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NC043760 | Death of an adolescent girl by hanging, in the early summer of 2011. FJ became known to agencies four months before her death when she disclosed a history of self-harming to mother and GP. FJ took a significant overdose of over-the-counter medication in the months preceding her death, resulting in an eight day in-patient hospital stay. Issues identified include: inadequate exploration of FJ's 'inner world'; lack of professional challenge; and insufficient importance attached to FJ's indications that she would self-harm if returned home and mother's indications that she could not guarantee FJ's safety. Makes various interagency and single agency recommendations, covering: police, educational psychology services, leisure services, child and adolescent mental health services (CAMHS), children's services, GP, community health and NHS services.
| Title: Serious case review: Child FJ: executive summary. LSCB: Wolverhampton Safeguarding Children Board Author: Fergus Smith Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 WWOOLLVVEERRHHAAMMPPTTOONN SSAAFFEEGGUUAARRDDIINNGG CCHHIILLDDRREENN BBOOAARRDD SSEERRIIOOUUSS CCAASSEE RREEVVIIEEWW CCHHIILLDD FFJJ EEXXEECCUUTTIIVVEE SSUUMMMMAARRYY PPUUBBLLIICCAATTIIOONN DDAATTEE 0044 NNOOVVEEMMBBEERR 22001133 1 INTRODUCTION 1.1 CIRCUMSTANCES PRIOR TO DEATH 1.1.1 FJ lived with her mother and other siblings. Her parents were separated though her father owned a house nearby and remained actively involved. All family members are White British and practicing Christians. 1.1.2 Some eight months before she died, FJ had begun to exhibit some difficult behaviour at home and her mother considered that she was the victim of some ‘cyber bullying’. 1.1.3 One evening in the early Summer of 2011, the parents found their daughter hanging from a wardrobe with a ligature around her neck. An ambulance was immediately summoned and FJ was transferred to hospital where life was formally pronounced extinct. FJ was then aged thirteen. 1.1.4 In the months preceding her death, FJ had: Taken a significant overdose of over-the-counter medication Some two weeks before she died, cut her wrist to an extent that required minor medical treatment 1.2 INITIATION OF THE SERIOUS CASE REVIEW 1.2.1 The then relevant statutory guidance (Working Together to Safeguard Children 2010) required a ‘serious case review’ to be initiated if a child has died (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in that death. Its purpose is to: ‘Establish what lessons can be learned about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result and As a consequence, improve intra and inter-agency working and better safeguard and promote the welfare of children’ 1.2.2 On 12.07.11 the chairperson of Wolverhampton’s Safeguarding Children Board (William Anderson) accepted the recommendation of the standing serious case review sub-group that a serious case review should be conducted into FJ’s death. Ofsted (the relevant regulatory body) and the Department for Education were immediately notified of that intention. 1.2.3 Serious case reviews are not inquiries into how a child died or who is culpable. Those matters are for Coroners and criminal courts respectively. The local Coroner has opened and adjourned an Inquest into FJ’s death. 1.3 INVOLVEMENT OF LOCAL AGENCIES 1.3.1 The following agencies were identified as having or likely to have information and opinions of relevance to the serious case review: FJ’s school Wolverhampton City Council Communities Directorate Safeguarding Service Health & Wellbeing: Wolverhampton City Council Communities Directorate Children and Families Division –Children’s Social Care (Child Protection & Family Support); Social Inclusion Multi Agency Support Team (MAST) (including educational psychologist and parent support adviser) Black Country Partnership Mental Health Foundation Trust hosting the Child and Adolescent Mental Health Service CAMHS (‘mental health practitioners’, ‘specialist practitioner’, consultant psychiatric and psychotherapeutic input and its ‘Crisis Team’) Wolverhampton City Council Communities Directorate: Safeguarding Service Health & Wellbeing, & Children and Families Division: Children’s Social Care (child protection and family support) Royal Wolverhampton Hospitals NHS Trust (in-patient paediatric, children’s liaison and school nursing services) West Midlands Police (jointly investigating alleged abuse, attending when FJ was missing and on the night of her death) Wolverhampton Primary Care Trust (commissioning GP services) 1.4 REVIEW PROCESS 1.4.1 Because there has been no concerns about her before FJ began secondary school the panel formed the view that it should explore the period from her move to her new school in Autumn 2009 to her date of death in 2011. 1.4.2 Members of the serious case review panel were as follows: Ms Nicki Pettitt (independent chairperson) Wolverhampton City Council Health & Wellbeing Directorate, Head of Service Safeguarding Wolverhampton City Council: Health & Wellbeing Directorate, Deputy Head of Service Safeguarding West Midlands Police: Detective Chief Inspector Public Protection Unit Wolverhampton City Council: Deputy Head of Child in Need & Child Protection Children and Family Division – for part of review Wolverhampton City Council: Head of Child in Need & Child Protection Children and Family Division – for part of review Wolverhampton City Council: Learning & Skills Directorate Black Country Partnership Mental Health Trust: Consultant Psychiatrist Youth Offending Team: Operations Manager Designated Senior Nurse Safeguarding Children Wolverhampton Royal Wolverhampton Hospital NHS Trust: Consultant Paediatrician & Designated Doctor for Safeguarding Children Wolverhampton Senior Inspector Education District Senior Educational Psychologist Staffordshire & West Midlands Probation Trust Youth Organisations Wolverhampton: Co-ordinator Safeguarding Children Board Training co-ordinator 1.4.3 The need for independence was recognised. No panel member had prior involvement with FJ or her family; the panel was chaired by an experienced independent person and the overview report drafted by an experienced author also with no connection with agencies or professionals involved. Each individual management review submitted was drafted by a suitably qualified individual with no line management or supervisory responsibility. 1.4.4 The independent chairperson Ms Pettitt is a General Social Care Council-registered freelance social work manager who qualified in 1989. The overview author is Fergus Smith of CAE (www.caeuk.org) who has thirty seven years post-qualification experience of social work, is the author of over twenty ‘Personal Guides’ to family and criminal law and is the co-author, author or chairperson of approximately forty serious case reviews. 1.4.5 The panel met on six occasions and devoted a further day to completion of a comprehensive action plan to ensure effective implementation of the changes identified as necessary during the serious case review. 1.4.6 FJ’s family was involved in formulating the terms of reference, updated during the course of the review (when some specific issues raised by them were also addressed). Following their acceptance by Wolverhampton’s Safeguarding Children Board, the parents were taken through the recommended changes. Sincere thanks are owed to the family for contributing at what remains a very difficult time for them all. 1.4.7 Both the family and staff affected by FJ’s death were offered support in coming to terms with the loss of this talented and much loved child. 1.4.8 Panel members were acutely aware of the ease of identifying FJ’s family and the potential harm to other vulnerable members by intrusive Media attention. On psychiatric and legal advice, the panel recommended that, following receipt of a response from Ofsted, only an executive summary should be published. This recommendation was accepted by Wolverhampton’s Safeguarding Children Board and this summary omits all identifying details. 1.4.9 It includes unchanged, conclusions, lessons learned and recommended improvements for local service (the majority of which have, as at June 2013 been completed). 5 2 AGENCIES’ CONTACT, CONCLUSIONS & LESSONS LEARNED 2.1 AGENCIES’ CONTACT 2.1.1 Until some four months before FJ’s death there had been no professional or parental awareness of any mental health difficulties or of any self harming. FJ then revealed to mother and her GP a history of self-harming. An immediate referral was made to the Child & Family Service of the Child & Adolescent Mental Health Service (CAMHS). The school also offered pastoral care and the services of an educational psychologist were engaged. 2.1.2 From that point on, several agencies were involved. 2.1.3 FJ went missing on one occasion following a row at home and her diary entry at that time indicated an intention to kill herself. 2.1.4 A scheduled appointment with CAMHS was consequently brought forward and a conclusion drawn that FJ’s continuing contact with an educational psychologist was sufficient. 2.1.5 Further family support was provided by Children’s Social Care and a Multi Agency Support Team. In the period to Easter, there was a good deal of liaison between involved professionals, though Children’s Social Care closed the case at this time. 2.1.6 In late Spring, FJ took a significant overdose of Paracetamol and Ibuprofen. In what was regarded by medical and other professionals as a deliberate attempt to kill herself. FJ was admitted to the children’s ward and spent eight days as an in-patient during which time there was some effective and some less effective liaison between paediatric, psychiatric, psychological and social care services. 2.1.7 The possibility of a transfer to a residential adolescent unit was considered but on her eighth day and without the benefit of a pre-discharge meeting, FJ was prescribed standard medication and discharged home to the care of her mother with ongoing support to be provided by the CAMHS Crisis Team. 2.1.8 The responsible psychiatrist wrote to the GP to advise of FJ’s return home and to request prescription of specified medication. FJ returned to school and was provided with substantial and valuable levels of support from staff there and from the involved educational psychologist. 2.1.9 In the middle of her school’s Summer term FJ informed her psychologist that she had had ‘slit her wrists’ and that voices had told her to do so. The psychologist initiated practical arrangements for the relatively minor treatment required and liaised with FJ’s psychiatrist and GP. 2.1.10 A multi-agency meeting at which FJ’s pattern of self-harm and attempted suicide could have been explored, would have been justified at this stage. 2.1.11 Some two weeks before FJ’s death, the treating psychiatrist changed her medication to a less orthodox one. Expert advice has confirmed that the choice was a reasonable one, but no rationale for it was included in the letter to the GP nor was any written information for parents provided as required by the National Institute for Health and Clinical Excellence (NICE) guidelines1. It anyway seems likely that FJ would not have experienced the full benefit of the new medication before her death about two weeks later. 2.1.12 The General Pharmaceutical Council has confirmed that its code of practice indicates that some doubts raised earlier by a local dispensing pharmacist as to the choice of the less orthodox medication, should have been raised by him directly with the psychiatrist. 2.1.13 Finally, a more detailed analysis is provided in the full report of some confusion on the night of FJ’s death, between Police and Ambulance Services centring on which hospital JF was to be taken to and its location. 2.2 CONCLUSIONS 2.2.1 Professionals involved appear to have approached their respective tasks in a conscientious and predominantly sensitive manner and most of the services provided were properly planned and efficiently and effectively delivered. 2.2.2 It is not possible to conclude that FJ’s tragic death was preventable by any simple alternative actions of professional staff. The evidence did though indicate she would further self-harm. If best practice had prevailed at all times, the risk of further attempts at suicide would probably have been better identified and more consistently evaluated. This in turn would probably have led to a more effective collaborative effort to keep her safe. SUB-OPTIMAL PRACTICE 2.2.3 There were a number of examples of individual sub-optimal practice: Children’s Social Care A failure by Children’s Social Care in February to seek further contextual information e.g. agency checks prior to completion of its core assessment A muddle about which member of the Family Advice & Support Team was to be allocated An apparent failure to circulate clear purpose, membership or outputs of a nonetheless useful ‘child in need’ meeting in March A failure to provide formal notification of case closure in April A muddle in May about whether Duty & Assessment or the Family Advice & Support Team should raise a referral 1 NICE Guidelines Depression in Children & Young People number 28 September 2005 CAMHS Insufficient weight placed by ‘consultant psychiatrist 2’, ‘mental health worker 2’ and by the ‘specialist practitioner’ on what FJ was saying ‘Consultant psychiatrist 2’s’ failure to convene a pre-discharge meeting ‘Consultant psychiatrist 2’s’ failure to initiate a dialogue with his paediatric peers during FJ’s period in hospital ‘Consultant psychiatrist 2’s’ failure to sufficiently involve the educational psychologist An apparent failure to adequately brief parents on what to do to keep FJ safe, to brief the GP or to provide written information to the family on prescribed medication or to record the rationale for the switch to the unorthodox Mirtazapine Community Services A failure at the Health Centre to pass on to the correct location notification of FJ’s overdose in May A school nurse’s failure to follow up her (belated) notification of FJ’s hospitalisation Police On the night of FJ’s death, poor communication between Police and Ambulance Dispatch centres, some officers of both services and the family SYSTEMIC ISSUES 2.2.4 Retrospective analysis of the effectiveness of the efforts made has also highlighted the following more systemic weaknesses that transcend individual agencies. Hearing the child’s voice 2.2.5 The reasons for FJ’s anxieties about home, her mother and what they represented do not emerge from available records. From the first assessment in March through to her discharge without a shared acknowledgment of her stated intention to self-harm again, coupled with all GP consultations being in the presence of mother, there was insufficient exploration of FJ’s inner world. 2.2.6 Though she was clearly ambivalent about her family, there was a consistency in the anxiety associated with it which was insufficiently recognised, explored or shared amongst involved professionals. 2.2.7 In the view of the overview author, FJ was as clear as she was able to be that a return home would lead to a further suicide attempt. 2.2.8 Observations of FJ’s instability of mood should not have offered as much reassurance about reduced risk as they did. 2.2.9 It is reasonable to conclude that there was undue optimism amongst the CAMHS staff who dealt with FJ after her initial assessment on the day of her hospitalisation. Such optimism also served to diminish the proper concerns of those who had heard FJ’s voice more clearly e.g. the consultant psychotherapist and educational psychologist. Practical arrangements for collaboration 2.2.10 Whilst there were many examples of sound inter-agency work, there were ‘system failures’ within the practical arrangements for collaboration: A faxed confirmation of the phone referral from the hospital apparently not being received by Children’s Social Care’s Duty & Assessment Team CAMHS’ mistaken reassurance about the current Family Advice & Support involvement when the hospital rang that agency A collective failure, albeit some individuals recognised the need, to ensure a pre-discharge meeting when FJ was in hospital The failed notification to the school nurse about FJ’s admission (a result of an erroneous address held by the hospital and compounded by an individual failure to forward the message) The fact that no written information was readily available to inform and facilitate the required briefing of GP and of parents with respect to the switch to Mirtazapine Record keeping & effective information sharing 2.2.11 A number of weaknesses in record keeping and information sharing seem to extend beyond the individuals involved and are probably systemic: The insufficient core assessment ‘completed’ in February – it seems likely that such a mistaken approach was not a ‘one-off’ and may have been accepted practice The absence of any agreed notes of the professionals’ meeting in early March which it is suspected may not be a ‘one-off’ The absence of standard elements for the child in need meeting in March (agenda, output notes kept / circulated) which again may well be more than a one-off failure Absent, poor quality or seriously belated records of contacts especially by several CAMHS staff The joint failure to ensure notes made by CAMHS staff at hospital are accessible at that location and at CAMHS CAMHS failure to offer the school directly or via the psychologist, guidance on how to respond to FJ on her return Sometimes illegible handwriting in some records of hospital staff Confident challenge 2.2.12 There were occasions when a professional became aware of a need to improve the plan or approach being adopted at the time but did not do so: The educational psychologist’s acceptance (even though she was the nominated ‘lead professional’) that there was no pre-discharge meeting ‘Consultant paediatrician 2’s’ acceptance that the February child protection enquiries adequately resolved any safeguarding concerns she had prior to FJ’s discharge The community pharmacist’s failure to make direct contact with the prescribing psychiatrist in spite of his concerns about the choice of medication 2.2.13 Though the reasons for respective actions may have differed, the implication for future practice is that, without regard to profession or rank within it, any individual who forms a view that an existing proposal or plan is not in the best interests of a child has an obligation to articulate that view. 2.2.14 Having initiated a challenge and failed to effect change, a responsibility remains to reflect on any counter arguments and (if the individual still believes change to be required) escalate the concerns through available channels. BEST PRACTICE 2.2.15 There was also good practice evident in this case of which the most commendable examples were the: Efforts of the ‘pastoral lead’ in an academic environment unused to addressing such significant emotional needs Educational psychologist’s commitment and willingness to be contacted at any time if FJ required it Joint approach adopted at the point of FJ’s admission to hospital of the consultant psychotherapist and psychologist Response of the practice nurse and receptionist in attending FJ’s home and waiting with her for an ambulance to arrive 2.3 FJ’S WORLD 2.3.1 Professional records and parental descriptions offered ‘external’ views of FJ’s world. Panel members sough to piece together and develop a coherent account of the expressed and implied wishes and feelings of FJ herself. The full report provided significantly more detail, much of it personal in nature. In essence, whilst apparently showing only limited signs of depression, FJ emerged as feeling lonely, helpless and stressed in the face of high levels of pressure from within her family. Observation of self-inflicted scarring on arms and abdomen by the GP and hospital respectively suggest also that FJ had found coping with her life more difficult than was obvious to others. 2.4 LINKS TO RESEARCH 2.4.1 Two sources of research potentially add to the learning arising from this tragic case. The first is the series of biennial analyses of completed serious case reviews published by the Department for Education (previously Department for Children, Schools and Families and before that the Department for Education and Science). The second source is the narrower and more specific knowledge-base derived from academic studies of self-harm and suicide in adolescents. Both are explored in the full report that has informed the Local Safeguarding Children Board’s responses. 2.5 LESSONS LEARNED Voice of child & mother 2.5.1 The feelings and opinions of daughter and mother were insufficiently heeded in this case by CAMHS staff. Though FJ’s mood state seemed to vary she was fairly consistent in offering verbal and non-verbal indications that she would self-harm or worse if returned home. 2.5.2 Similarly, and although insufficiently captured in CAMHS’ records, there seems little doubt that mother had clearly expressed doubts about whether she could keep her daughter safe if she returned home from hospital. 2.5.3 Mother has consistently recalled saying to ‘consultant psychiatrist 2 ‘I can’t be responsible for that thing’ [sic] [a reference to her self-harming daughter and the plan that she return home]. If that was indeed the expression used, the choice of words and its meaning required thorough exploration. 2.5.4 The practical result of assuming an ill-briefed mother could ensure acceptance by an increasingly reluctant FJ of the prescribed medications was to establish a further ‘battle-ground’ and risk further inflaming an already fraught relationship. Need for an holistic view 2.5.5 Any assessment of medical, psychological or social need or risk requires a holistic view of the child in her/his personal and social setting. For specialists in any given field to see ‘the whole child’ necessitates drawing upon information gathered and provided by others including the child. To ensure that such shared information is of value, it must be a complete, accurate and timely account of the results of professional contacts. 2.5.6 Though there were no examples of any deliberate refusal to share information, nonetheless there was insufficient information exchange. Key practitioners should have sat down together to compare, contrast and explore all that they knew during, or at worst after FJ’s hospitalisation. Had they done so, a clearer picture of the risk of suicide by FJ was more likely to have emerged. 3 RECOMMENDATIONS 3.1 INTRODUCTION 3.1.1 Mindful of the Department for Education research report2 that focused on recommendations from serious case reviews, the panel sought to minimise their number and maximise their specificity and achievability. 3.1.2 The panel has though found it necessary to formulate the following recommendations, most reproduced from individual management reviews (when necessary modified to render them more specific, measurable, achievable, realistic and timely) some identified by the overview author and/or health overview authors. These have been divided into those requiring action by: Wolverhampton’s Safeguarding Children Board or The agency specified 3.2 WOLVERHAMPTON LOCAL SAFEGUARDING CHILDREN BOARD 3.2.1 The Safeguarding Board should: Seek from Wolverhampton’s Children’s Trust Board details of the local provision for minimising amongst children and young people, self-harm and suicide and a reassurance as to the relative effectiveness of that provision Write to each member agency and ask them to issue a written reminder to all staff (and ensure their training programmes address) a): the need in law and best practice to include non-resident parents (especially, though not just those with parental responsibility and who are actively involved) in all assessments of need, planning and delivery of service and - b): the obligation of all professions without regard to discipline or rank within it, to offer respectful challenge to colleagues. Write to Wolverhampton PCT and ask that it remind all local community pharmacies of the professional expectation to make direct contact and query any proposed prescription which appears to the pharmacist in question not to be in the patient’s best interests. 3.3 SCHOOL 3.3.1 School 1 should review its outdated child protection policy so as to ensure it is rooted in the current 2010 version of Working Together to Safeguard Children. 2 A study of recommendations arising from serious case reviews 2009-2010 Brandon etc al DFE RR157 3.3.2 School 1 should seek from Children’s Social Care and partner agencies a simple description / illustration of the respective roles of local agencies and the established multi-agency infrastructure e.g. Common assessment Framework, lead professional, child in need meetings etc. 3.3.3 The school’s management team should reflect on why teaching staff did not involved the school nurse at any point and initiate in consultation with the Community Health Service any required organisational changes. 3.3.4 So as to achieve one of its key objectives in the 2011/12 School Development Plan (provision of effective training for pastoral staff in dealing with students who present with complex mental health issues, and the need to resource on-site counselling) a clear plan should be formulated with timescales and arrangements for monitoring progress and evaluation. 3.4 WEST MIDLANDS POLICE 3.4.1 ‘HQ Public Protection’ should instruct officers engaged in missing persons co-ordination duties to record all actions undertaken after a missing episode within retrievable police systems (the systems are already in place; Periodic dip sampling of systems will enable supervisory checks. 3.5 EDUCATIONAL PSYCHOLOGY SERVICES 3.5.1 Detailed plans should be prepared to improve the awareness of parents, schools and young people of self harm and the importance of early intervention. 3.5.2 Policy and procedural guidance for Children’s Social Care and MAST staff in relation to their respective responsibilities for overlapping areas of work should be developed. 3.5.3 A clear policy should be developed and supported corporately, for cover arrangements for staff absence in MASTs when casework involves significant levels of risk. 3.5.4 Multi-agency guidance on how staff should respond to suicide attempts and to self- harm should be developed. 3.5.5 Training to support the dissemination of the above guidance should be rolled out. 3.5.6 Practical arrangements need to be put in place so that messages can be left for educational psychologists. 3.6 LEISURE SERVICES 3.6.1 Youth services should be developed so as contribute to targeted work with those who self harm and those at risk of suicide. 3.7 CHILDREN’S SOCIAL CARE 3.7.1 In order to help achieve the delivery of planned help and measured outcomes to children and young people, social workers in the department should receive training in evidence-based approaches to assessment. 3.7.2 The Core Assessment should be redesigned to ensure social workers: Gather information from available sources including the use of assessment tools, such as those provided in the Framework for the Assessment of Children in Need and their Families, (DH, 2000) and Create a comprehensive chronology of salient information. 3.7.3 Policies and procedures about the management of s.47 enquiries should be well understood by the Duty & Assessment team, so should be reviewed at intervals of no more than three months as an agenda item in team meetings and supervision. 3.7.4 Recruitment of permanent staff should be achieved with minimum delay to avoid having a high ratio of agency staff in the department [completed]. 3.7.5 Induction processes in the Children and Family Support department should be reviewed and an inductions pack written and issued for new staff and supervising managers. 3.7.6 Departmental policy guidance should be updated to require that where forms are designed to be copied to service users and ask for service user signatures, practitioners must provide copies and gain those signatures or record why they have failed to do so. 3.7.7 Departmental policy guidance should be updated to require that key partners; specifically children, their families and referrers are written to when case responsibility is to transfer or close. 3.7.8 A memo should be sent by the Assistant Director of Children & Family Support, to all of the department’s staff supporting the Wolverhampton Safeguarding Children Board guidance ‘Children who Self Harm’: Practitioners’ supervision notes should record that they have read and understood that guidance. 3.7.9 A set of good practice exemplars for case note recording should be created and circulated to staff as an aide memoir. 3.7.10 Procedures for the ‘Resource Allocation Panel need to be amended to enable it to be able to become aware of and address ‘inter-panel’ events. 3.8 CAMHS 3.8.1 All CAMHS staff should attend record-keeping training. 3.8.2 The Deliberate Self Harm Assessment procedure should be strengthened to ensure that working practices between the hospital services and the CAMHS are robust, that there is consistency of record-keeping practices and that the explicit requirements for discharge planning are clearly defined (action plan provides details). 3.8.3 All electronic written details (in the form of e-mail information-exchange on case management relating to individual’ children’s needs) must be inserted into individual records which inform and evidence on-going case management within and across agency sites and are reflected as such within agreed standards of record-keeping and practice (action plan provides details). 3.8.4 A professionals’ meeting must be convened for all ‘high risk’ cases in which Children’s Social Care is not involved (action plan provides details). 3.8.5 Relevant enquiries regarding existing service involvement should be made by the CAMHS with key agency sites e.g. Community Children’s Nursing Service / Children’s Services, Local Authority following acceptance of a referral for service assessment of a child’s mental well-being, the details of which are to be fully documented. 3.8.6 When involved in care provision, the CAMHS should directly engage in multi-agency integrated service activities (Common Assessment Framework / Child in Need / Child in need of protection planning), ensuring that documentation is maintained which effectively informs on the progression and effectiveness of care delivery (action plan provides details). 3.8.7 All high risk cases must be brought to ‘peer meetings’ and key staff should receive minutes of those meetings. 3.8.8 A protocol should be developed for a high risk child wishing to disengage from service delivery (action plan provides details). 3.8.9 If a child is identified as a high risk suicide, the member of staff undertaking the initial assessment should be involved in subsequent assessments and case discussions. 3.8.10 A process should be developed to give staff guidance on ending a clinical session (action plan provides details). 3.8.11 All direct consultations with children should include an appropriate level of discussion with regard to: Their perspective on their needs Their opinions on care planning and needs’ management and Their impression regarding the impact on their well-being as a result of service intervention All of which should be accurately reflected within the records as maintained. 3.8.12 Safeguarding supervision needs to be embedded into practice by means of a review of existing clinical supervision and new arrangements made explicit. 3.8.13 Staff should undertake any required safeguarding children training as indicated by a review of the current in-service mandatory training. 3.8.14 In all cases of self-harm of children there must be robust multi-disciplinary liaison and in relevant instances a pre-discharge planning meeting must be convened. 3.8.15 Staff support should be offered in an appropriate and timely manner following the death of a child and its form determined by the results of reflection amongst and questioning of staff. 3.9 HOSPITAL 3.9.1 When children are in-patients hospital staff should ensure that their referrals to safeguarding services have been responded to before discharge and that they are included in any child protection discussions, strategy meetings and child protection investigations that take place. 3.9.2 In complex cases admitted to the ward for any length of time one named consultant paediatrician should take overall responsibility to ensure consistency rather than handing over care to the ‘out of hours’ consultant even if overall care is with the consultant child psychiatrist. 3.9.3 If there are child protection concerns about children on the ward consideration should be given to involving a consultant community paediatrician with expertise in this area at the outset. 3.9.4 When the CAMHS team considers that there is a suicide risk, senior hospital staff should ensure that parents have been given advice about keeping the young person safe and that their concerns have been addressed before discharge from the ward. 3.9.5 In all cases of self-harm of children there must be robust multi-disciplinary liaison and in relevant instances a pre-discharge planning meeting must be convened. 3.9.6 The hospital need to complete an exercise so as to verify that all details held of local liaison links are correct and introduce an expectation that all professional agencies which are known to be involved with a child-patient are informed of her/his admission and discharge. 3.9.7 All entries into the hospital records should be legible, signed with name and designation or registration number clearly stated and dated with the time for in-patients. 3.9.8 The Deliberate Self Harm Assessment procedure should be strengthened to ensure that working practices between the hospital services and the CAMHS are robust, that there is consistency of record-keeping practices and that the explicit requirements for discharge planning are clearly defined. 3.9.9 All direct consultations with children should include an appropriate level of discussion with regard to: Their perspective on their needs Their opinions on care planning and needs’ management and Their impression regarding the impact on their well-being as a result of service intervention All of which should be accurately reflected within the records as maintained. 3.10 COMMUNITY HEALTH 3.10.1 The systems and practice of information shared between the acute and community health services on presentation of children and young people with self-harming behaviour in the A & E should be reviewed. 3.10.2 The system and practice of collaborative working between the school and the school nursing service in the context of physical and emotional concerns for the welfare of individual children should be reviewed. 3.11 GP SERVICES 3.11.1 When there are concerns about a child and s/he is referred to another agency, there should be systems in place to ensure that the child attends the appointment and that the referrer is kept informed about the attendance. 3.11.2 When a health professional visits a patient this should be fully recorded as should the actions taken even if the care is passed onto another e.g. ambulance crew. 3.11.3 There should be specific recording of when and in what way the children’s wishes and feelings were ascertained and taken account of when making decisions about the provision of services. 3.11.4 All direct consultations with children should include an appropriate level of discussion with regard to: Their perspective on their needs Their opinions on care planning and needs’ management and Their impression regarding the impact on their well-being as a result of service intervention All of which should be accurately reflected within the records as maintained. 3.11.5 ‘Primary Care Services’ should be reminded of their responsibilities to identify vulnerable children without reliance on carers to pursue actions in response to their dependents’ health needs. 3.12 PRIMARY CARE TRUST 3.12.1 The Primary Care Trust or its successor organisation (Clinical Commissioning Group) should develop guidance to support the completion of independent management reviews with regard to Primary Care Service provision and which takes account of the management of serious case review requests for health information relating to adults. ………………………………………… SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 1 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome 1 MAST staff to be actively involved in improving the awareness of schools about self harm and the importance of early intervention. Social Inclusion Review of the MAST training that is currently provided to educational providers, including school governors, to ensure that self-harm and suicide prevention is appropriately included in training programmes. District Senior EP DSEP convened Psychology Service Special Interest Group to plan materials and training for schools. Guidance completed. Training and information in place. Completed 31.10.12. An increased awareness of the needs of these vulnerable students within school. 2 Development of youth services contributions to targeted work with self harmers and those at risk of suicide Social Inclusion Referral pathways to be developed. Training needs analysis of youth service staff to be undertaken to gauge their current and future capacity to undertake this work. Training plan to be devised and implemented. Head of Social Inclusion and Head of Youth Service Referral pathway and Training agreed between DSEP, Head Social Inclusion and Head of Youth Service. Completed 31.12.12 Head of Service agreement on an integrated approach involving Youth Worker and other Children & Family Support staff as an outcome of the Youth Service re-organisation when Youth Workers will be deployed to area teams. Youth Service staff given access to materials used to brief Children & Families staff. 3 Preparation of Policy and Procedures guidance for Social Care and MAST staff in relation to their respective responsibilities for overlapping Social Inclusion Develop a specific policy and procedure for relevant staff. Launch the policy and procedure at Head of Social Inclusion and Head of CIN/CP Materials developed into C&FSS Policy Guidance. Completed 31.12.2012 Presentation on self-harm delivered to Children, Young People and Families staff as part of staff briefings. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 2 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome areas of work. Joint Children’s Services event. 4 MAST staff to ensure that all child in need, and CAF plans should have clear detail and instructions about cover arrangements when the key worker/lead professional is absent. Social Inclusion All MAST staff to be informed of this expectation through management supervision and team meetings. Regular audits of plans to monitor this expectation. Deputy Head of SI Cover arrangements agreed and incorporated into Policy and Procedural guidance. Completed 31.12.2012 Policy established and in place. 5 Specialist Core assessments must provide a balanced analysis of the child’s story. Children’s Social Care Commission training to be delivered by the organisation - Child and Family Training in Evidence informed approaches to assessment. Head of Workforce Development and Head of Children in Need and Child Protection Child & Family Training was commissioned in November 2011 and is Now embedded using in-house trainers and provides the underpinning methodology for social work assessments in the city. Assessing Parenting and the Family Life of Children is part of our induction programme for new social Completed November 2011 A systematic and evidence-based approach to specialist assessments. This will result in practitioners providing improved analysis and more helpful plans being created with children and their families. It will help embed a good practice culture of analysis and critical thinking in the department. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 3 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome workers. 6 Core Assessment pro forma on Care First should be redesigned to ensure it encourages the gathering of information from all available sources and the completion of comprehensive chronologies Children’s Social Care Business Change Manager will be employed to consult with practitioners to review Wolverhampton Children’s Social care forms. Care First User Group (CFUG) chaired by Head of Looked After Children Development of New forms began in summer 2012 and were introduced in June 2013 and are being used by all social workers Completed June 2013. A pro forma which is easy to read and helps tell the child’s story. The needs of Children and their families will be better understood and help offered will target those needs. 7 Recruitment of permanent staff should be achieved with minimum delay to avoid having too high a ratio of agency staff in the department. Children’s Social Care All agency filled posts will be recruited to. Head of Children in Need and Child Protection When vacancies arise in social work posts they are recruited to without delay. The recruitment process is supported by robust HR processes. Completed July 2012 A stable and highly motivated workforce 8 Induction processes in the department should be updated and reviewed, identifying key policies and procedures in regular use and which require staff to demonstrate that they have read and understood them. Children’s Social Care An induction pack will be written and issued for new staff and their supervising managers to follow. The departments Child Protection policies and procedures will be reviewed and updated paying close regard to those available from the Head of Children in Need and Child Protection And Policies and Procedures Officer The induction policy, including the employee checklist, has been updated annually. Completed August 2012 Confident staff with: not only a clear understanding of their own department’s roles and responsibilities but also a clear understanding of other key partners’ roles and responsibilities. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 4 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome WSCB TriX online manual. 9 Copies of assessments and plans must be evidenced as having been received by service users and other agencies. Children’s Social Care Departmental policy guidance will be updated, to require that where forms are designed to be copied to service users and which ask for signatures that practitioners do so or record why they have failed to do so. Monthly auditing will include monitoring of this expectation. Head of Children in Need and Child Protection And Policies and Procedures Officer Department’s policies and procedures have been updated and staff forums utilised to embed responsibilities/ expectations. Social Workers record that service users have received assessments and plans on the Electronic Social care record. Monthly audits/thematic audits address information sharing. Completed – December 2012. Children and their families will be able to check out their understanding and relationships will be enhanced. 10 Key partners to always be informed when case responsibility is to transfer or close. Children’s Social Care Departmental policy guidance will be updated to require that key partners and most specifically children and their families and referrers are written to when Head of Children in Need and Child Protection And Policies and Procedures Department’s policies and procedures have been updated and remain under regular review. Most recent update October Completed 14.10.13 Well informed Children, Families and key partners. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 5 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome case responsibility is to transfer and close. Team meeting minutes and individual supervision records will record that practitioners have discussed and understood the importance of this communication standard. Monthly auditing will monitor compliance of this expectation. Officer. Head of Children in Need and Child Protection Head of Children in Need and Child Protection 2013 Since December 2011 Information sharing with partners is addressed within minutes.. Since March 2012 Monthly audits/thematic audits address feedback to partners regarding significant change/transfer. . 11 Children’s Social Care to ensure that there is an improved understanding by all staff of good practice in working with children and young people who self harm or threaten suicide. Children’s Social Care The Head of CiN and CP in Children and Family Support will write a memo to all of the departments’ staff supporting the WSCB guidance in section 5 sub section 19, Children who self -Head of CIN & CP Memo sent out to all staff outlining good practice Completed 08.12.12 Department staff to be given the opportunity to reflect on issues of self harm in supervision and as a team, particularly when they are in the role of lead professional. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 6 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome harm. Practitioners’ supervision notes will record that the memo has been discussed. 12 Quality of case recording must be improved. Children’s Social Care A set of good practice exemplars for case note recording will be created and circulated to staff. Auditing will monitor the effectiveness of this approach. Head of Children in Need and Child Protection New Carefirst forms contain links to good practice exemplars. Quality of recording monitored via monthly audit and supervision. Completed 08.08.13 Consistent clear case note recording standards across the department. 13 Provision of on-site counselling for students presenting with complex mental health issues. School 1 Seek governor approval for an increase in staffing. Ascertain level of need in order to determine amount of time required. Consider location for counselling service once established. Set protocols for student access to the counselling service. Headteacher / Deputy Headteacher Report completed and as a result, Counsellor employed by school 1 morning a week since October 2011 and 2 mornings a week from January 2012 In addition Counselling Psychologist attached to the school for 1 day a Completed 30.03.12 An additional resource is available for students and staff in school. Students and staff are able to access appropriate support to address specific needs. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 7 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome week ( from MAST 5) from September 2012 – July 2013. This service is well used by students. Referrals are made via Pastoral Leaders and students 16 years and over self- refer. 14 Provision of training for pastoral staff in dealing with students with complex mental health issues. School 1 Identify appropriate trainer. Book training. Deputy Headteacher Pastoral Leaders’ Training Day off site took place 16th January 2012. Included all Pastoral staff , 2 Learning mentors and School counsellor. Completed 16.01.12 Staff feel more confident and better equipped to support and address the needs of students with complex mental health issues. 15 Provision of parent support classes. School 1 Plan parent support classes to provide parents with greater insight into social networking sites in order to understand how cyber bullying happens, their Headteacher / Deputy Headteacher E-safety bulletins have been a feature of the termly school newsletter since September 2012. School has put in Completed September 2013. Parents feel better informed and better equipped to deal with these issues. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 8 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome responsibility to protect their children from it and how they can do so. Plan parent support classes on how to deal with issues of adolescent mental health, supporting parents to know how to address these issues. place Parental sessions for 2013/14 academic year including e- safety and cyber bullying (and adolescent mental health. In addition school has run ‘drop ins’ for parents to discuss any pastoral issues with a member of the SLT. 16 ‘HQ Public Protection’ should instruct officers engaged in missing persons co-ordination duties to record all actions undertaken after a missing episode within retrievable police systems (the systems are already in place and it is not onerous for officers to complete this task. Periodic dip sampling of systems will enable supervisory checks. West Midlands Police Missing persons coordinator practices to be revised to direct officers to appropriately record actions undertaken in a format which is readily available Force Lead Officer A new Force Policy on the Management, Recording and Investigation of Missing Persons was introduced in June 2013. It includes electronic recording on the COMPACT system of tasks and updates to be completed in the same tour of Completed June 2013 An improvement in the ability of officers to retrieve relevant information in a timely way. A more effective missing persons policy will be available to officers. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 9 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome duty. Missing enquiries are supervised by an Inspector and have an identified Officer in the Case. Debriefs following/ misper– absent episodes are recorded on COMPACT. All entries are searchable and retrievable. Bold italic is additional entry from HOR review of IMR Action Plan details AP No Recommendation / Issues Agency Source Specific Actions Responsible Lead Progress to Date Status including date for completion Outcome 17 To review the systems and practice of information shared between the acute and community health care services on presentation of children and young people with self-harming behaviour in the A & E department Community Services CLHVS, A& E staff, CAMHS, SN service 1. Response from CLHVS 2. Review notification procedure -form and timeliness 3. Standard operating procedure CLHV Pathways developed in partnership with Alcohol Liaison Nurse, Aquarius /Birmingham and Solihull Mental Health Trust (new providers since April 2013) and are working well. Named Completed July 2013 Improved Identification of need for young people presenting at A&E departments as a result of self-harming behaviour. Improved service delivery to these young people. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 10 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome Emergency Department[ED] Sister attends the alcohol steering group which monitors pathways. Verbal notification to services made by Paediatric Liaison Nurse. Independent Domestic Violence Advisor[IDVA] based in ED from October 2012 Specific training delivered to ED staff by Lead Nurse for Safeguarding Children with resultant improved training compliance. 18 To review the system and Community 1. Review SN attached System reviewed. Completed Form and function of SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 11 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome practice of collaborative working between School 1 and the SN service in the context of physical and emotional concerns for the welfare of individual children Services School 1 & SN service communication channels 2. Agree future systems of communication for urgent and non-urgent issues to School 1 School nurse (SN) now attends weekly for ‘drop ins’ for students. Students needing access to SN identified by Pastoral Leaders and referred to SN by Deputy Head. SN also delivers health sessions in PSHCE at KS3 – this has been ongoing for the last 4-5 years continues to be so. The Drop-in sessions provided by school nursing service is audited 6 monthly with positive findings 31.01.12 Drop-In sessions are understood by pupils and school staff Regular information-exchange takes place between health and education staff with regard to the health and well-being of pupils. Posters available in schools advertising school nurse drop ins School nurses advertise service during assemblies. Annual working together agreement completed with school nurses and individual schools. Safeguarding procedures followed and escalated appropriately. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 12 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome 19 Where there are concerns about a child and the child is referred to another agency, there should be systems in place to ensure that the child attends the appointment and that the referrer is kept informed about the attendance GP Review the records systems operated by GP practices which enable acknowledgement of all correspondence as received. Ensure systems are robust. Review the systems operated by GP practices which flag the need for referral follow-up. Ensure systems are robust. SC Commissioning Lead WCPCT Named GP for SC Letter sent to all GP’s and practice managers to ensure that each practice reviews its systems and procedures. Feedback to ensure that this occurred was received. Completed 30.9.13 Records systems are robust which ensure all correspondence is available to inform on-going care provision. Staff are alerted to the need to follow-up on referrals via established record-keeping systems. Named GP reports activities into the JHSCC Training events have been held across the city to highlight this issue and the named GP has circulated information to support the process. 20 Where a health professional visits a patient this should be fully recorded as should the actions taken even if the care is passed onto another eg ambulance crew GP Details to be forwarded to all GP Practices which inform on the expectation of record-keeping practices with regard to individual episodes of care provision. Expected record-keeping standards to be included in content of SC Training events for GP Practice staff . SC Commissioning Lead WCPCT Named GP GMC guidance sent to all practice managers and GP’s as well as a series of safeguarding training sessions detailing this issue and embedding this within practice Completed 30.06.12 Awareness-raising exercise is completed regarding record-keeping requirements. SC training programmes include information on record-keeping standards Named GP to report activities into the JHSCC SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 13 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome 21 There should be specific recording of when and in what way the children’s wishes and feelings were ascertained and taken account of when making decisions about the provision of services. Refer to Rec. HOR 6 GP Details to be forwarded to all GP Practices which inform on the expectation of record-keeping practices with regard to individual episodes of care provision Expected record-keeping standards to be included in content of SC Training events for GP Practice staff SC Commissioning Lead WCPCT Named GP All GP’s and practice managers sent the GMC guidance and a series of Safeguarding training sessions undertaken to fully embed this within their practice. Completed 30.06.12 Awareness-raising exercise is completed regarding record-keeping requirements. SC training programmes include information on record-keeping standards have been undertaken and area core part of the ongoing safeguarding training programme for the GP’s. GMC guidance has been circulated and highlighted to all GP’s and practices Named GP reports activities into the JHSCC HOR 1 Primary Care Services’ are to be reminded of their responsibilities to identify vulnerable children without reliance on carers to pursue actions in response to their dependents’ health needs. HOR For GP / Primary Care Services Details to be forwarded to all GP Practices which inform on responsibilities for identifying and attending to the needs of individual children Practice expectations are SC Commissioning Lead WCPCT Named GP Letter sent to all practices regarding this action and asking for assurance from practice managers. Completed 30.09.13 Awareness-raising exercise is completed regarding practice requirements. SC training programmes include information on SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 14 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome to be included in content of SC Training events for GP Practice staff practice requirements. Named GP reports activities into the JHSC HOR 6 All direct consultations with a child should include an appropriate level of discussion with regard to: their perspective on their needs, their opinions on care planning and needs’ management and their impression regarding the impact on their well-being as a result of service intervention, all of which should be accurately reflected within the records as maintained. HOR For GP / Primary Care Services Details to be forwarded to all GP Practices which inform on responsibilities for identifying and attending to the needs of individual children Practice expectations to be included in content of SC Training events for GP Practice staff SC Commissioning Lead WCPCT Named GP Letter sent to all practices regarding this action and asking for assurance from practice managers. Series of Safeguarding training sessions held across the city for Gp’s and their practice staff to ensure that this is addressed within all consultations with children and young people Completed September 2013 Awareness-raising exercise is completed regarding practice requirements. SC training programmes include information on practice requirements Named GP to report activities into the JHSCC SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 15 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome 22 When children are in-patients the hospital staff should ensure that their referrals to safeguarding services have been responded to before the child is discharged. Acute Trust This will be included in child protection audit. Re-distribute the ‘Management of Concerns’ Flow chart 6-monthly reports on referral activity to continue which includes detail on referral tracking and outcome. Ref Overview Report: The hospital is to complete an exercise to verify that details of local liaison links are correct and introduce an expectation that all professional agencies which are known to be involved with a child-patient are informed of his/her admission and discharge. Named Doctor for Safeguarding in hospital. Des Dr SC DSNSC DNSNC NNSC SC Strategic Lead RWHT Following a multiagency task and finish group an updated Self Harm policy has been written and ratified by the providers. The policy will be audited in Feb 2014 to ensure that it is working well for all providers. Finding will be reported through Joint Safeguarding Children Committee [JSCC] and to Commissioners. Completed 31.07.12 Safeguarding procedures followed and escalated appropriately. Training for ED staff to covers specific requirements of CAMHS patients. 23 Where there are child protection concerns regarding Acute Trust To discuss at peer review child protection Designated Doctor Flow chart redistributed to all Completed Ward staff have a full understanding of SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 16 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome children on the ward consideration should be given to involving a consultant community paediatrician with expertise in this area at the outset. departmental meetings Re-distribute the ‘Management of Concerns’ Flow chart Ensure that practice expectations are included in content of SC Training events for hospital staff Safeguarding Des DR SC DSNSC Des Dr SC DSNSC NNSC staff. Discussed at CP peer review meetings and embedded within the safeguarding training for paediatricians and paediatric nursing staff in all session 2013. 31.03.12 safeguarding children flow chart and of need to involve community paediatricians as required 24 When the CAMHS team considers that there is a suicide risk, senior hospital staff should ensure that parents have been given advice about keeping the young person safe and that their concerns have been addressed before discharge from the ward. Acute Trust To include in Discharge planning meeting Refer to Rec HOR 2 Clinical Director Discussed at CP peer review meetings and embedded within the safeguarding training for paediatricians and paediatric nursing staff in all session 2013. Completed - 30.04.12 Discharge planning meetings involving parents / carers is routine practice pre-discharge 25 In complex cases Acute Trust Refer to Rec HOR 2 Clinical Discharge Completed – Discharge planning SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 17 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome consideration should be given to holding a multi-disciplinary discharge planning meeting. Director planning meetings involving parents / carers is now routine practice pre-discharge and if this does not occur then clear rationale for the absence of a meeting is documented in the notes. This is embedded within training and the self harm policy. June 2012 meetings involving parents / carers is routine practice pre-discharge 26 All entries into the hospital records should be legible, signed with name and designation or registration number clearly stated. and dated with the time for in-patients. Acute Trust Staff to be issued with name and designation stamps with GMC/NMC nos. Practice expectations with regard to standards of record-keeping are to be re-issued Directorate manager Medical Director / Chief Nursing Officer All medical staff have received their name stamps Standards re-issued. Completed Completed 30.06.12 Standardised documentation / record keeping policy followed in in-patient, out-patient and Emergency department areas. Quarterly audit process in place which shows improvement in compliance. Trust audits 10 sets of case notes per month against NHSLA HOR 2 The Deliberate Self Harm Assessment is to be strengthened to ensure that HOR For Hospital Review and revise the existing procedure* Clinical Director RWHT Record keeping has been explicitly covered Completed 30.06.12 Discharge planning meetings held for CAMHS patients who required SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 18 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome working practices between the hospital services and the CAMHS are robust, that there is consistency of record-keeping practices and that the explicit requirements for discharge planning are clearly defined. Services Formulate a monitoring activity / audit of practice tool Complete 6 monthly audit and report into the JHSCC *ref Overview Report In all cases of self-harm of children there must be robust multi-disciplinary liaison and in relevant instances a pre-discharge planning meeting must be convened Deputy Chief Nurse RWHT within the safeguarding children training. A joint self harm policy has been written and ratified for use by BCPFT and RWT and is explicit in the expectation of record keeping and pre discharge planning meetings. enhanced care packages HOR 6 All direct consultations with a child should include an appropriate level of discussion with regard to: their perspective on their needs, their opinions on care planning and needs’ management and their impression regarding the impact on their well-being as a result of service intervention, all of which should be accurately reflected within the HOR For Hospital Services Details to be forwarded to all relevant hospital sites which inform on responsibilities for identifying and attending to the needs of individual children Practice expectations to be included in content of SC Training events for hospital staff Clinical Director RWHT Deputy Chief Nurse RWHT Safeguarding training delivered specifically for ED medical and nursing staff and Children’s Directorate staff on in-service study days – high 90% compliance Work continues to refine person centred care plans and user satisfaction Completed 30.06.12 Records of patients reflect improvement in recording of care planning SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 19 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome records as maintained. strategy design for autumn 2013. Monitored through JSCC annual schedule of work. 27 All CAMHS staff to attend Record keeping Training A more robust system be developed to ensure all contacts are inputted into case files in a safe and timely manner ie. electronic system. CAMHS Learning and Development (L&D) Review existing training arrangements and adjust according to need. Report submitted to management on numbers of staff attending training Random Case file Audits Discussions to take place in team meeting around how to ensure safe transferral of notes until a more robust system in place. Service Manager CAMHS team managers L & D Discussions taken place by NNSC with Service Manager who has disseminated to staff areas of concern. Random file audits are taking place. Specialised training has now been delivered for all relevant staff. Issues around appropriate input of contacts and safe transferral of notes have been discussed and made priority by staff. Notes that are written on the ward are now Completed 30.04.12 Good Practice in line with NMC / Trust Record Keeping Policy SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 20 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome scanned, with a copy filed into the Child and Family notes, ensuring mirror copies maintained within both. 28 A professionals meeting is called for all high risk cases where Children’s Services are not involved Refer to Rec. HOR 5 CAMHS Raise staff awareness of Common Assessment Framework (CAF) Monitoring of number of meetings that occur. Minutes documented accordingly in case file CAMHS team managers Staff have now completed or are booked on CAF training (some still those awaiting due to sessions being fully booked) The Deliberate Self Harm Policy has been amended to ensure multi-agency discussion takes place prior to young person being discharged from hospital. Policy has been agreed by RWT/BCPFT. NNSC continues Completed 30.06.13 CAF is utilised by Health professionals where Children’s services are not involved thus ensuring co-ordinated service delivery. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 21 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome to be informed via virtual fax of each self-harm admission to hospital. 29 All High Risk Cases to be brought to Peer Meetings. Key members of staff involved in the case should receive the minutes. CAMHS All staff involved in a child’s case should meet to discuss views on levels of risk, especially when there are inconsistencies around levels, or risk changes from high/low in a short period of time. Minutes of Meetings documented in both case file and Peer meeting file. Random case audits to identify high risk cases and monitor their discussion. Service Director All high risk cases discussed at weekly meeting which NNSC attends. Safeguarding issues are explored whether or not family known to CSC. Staff have received training regarding CAF process, NNSC/CAF co-ordinator offer refresher sessions. Staff are aware of internal escalation process and BCPFT Escalation Policy- this is monitored by the safeguarding links and NNSC at the Completed Dec 2011 Improved risk assessments and monitoring of activity to ensure children & Young People’s needs are being addressed. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 22 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome Crisis Team Meetings. 30 Protocol to be developed for when a child has been identified as high risk but wishes to disengage. This should stipulate that these children and their families are offered 2 weekly contact, even by phone call, and reviewed after following 3 months. In the case of a medicated child specific arrangements need to be made to carefully monitor adverse reactions in line with NICE guidelines. All correspondence to the GP needs to clearly state how and why decisions are made around the prescribing of medication. Refer to Rec. HOR 8 CAMHS Protocol to be developed and distributed to all staff. Audit to be completed of identified high risk cases and their care plans Audit of case notes Service Director Process in line with NICE guidelines has been informally developed and disseminated to staff via email, Process now ratified into service policy. High risk cases reviewed at weekly Crisis meetings and medication monitored in line with NICE guidelines. Included in Self Harm Policy. GP letter shares any information in relation to medication regime changes. Completed February 2012 A Protocol is in place and embedded to inform CAMHS staff of their responsibilities when Children disengage from CAMHS intervention. 31 When a child is identified as a high suicide risk the member of CAMHS Guidelines to be incorporated into Service Director These guidelines have now been Completed October 2012 There is clarity regarding actions to be taken SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 23 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome staff undertaking the initial assessment (Deliberate Self Harm Protocol) should be involved in subsequent assessments and case discussions. Should there be a variance in perceived risk between the initial assessment and the subsequent 2nd opinion, the clinicians involved should discuss together the concluding plan of care. Refer to Rec. HOR 2 Deliberate Self Harm Protocol. Audit of case files to ensure consistency of care Assessors invited to Peer meetings in high risk cases – this can be monitored through attendance list of Minutes. Staff conducting high risk assessments to ensure they are familiar with previous/on-going assessments by reading case notes and/or direct contact with each other. incorporated into the Self Harm Policy ( agreed by RWT/BCPFT) Initial assessors are invited to attend weekly meetings and contribute to case discussions. The escalation process has been disseminated to ensure staff are aware of where to take concerns should they feel perceived variance in risk needs addressing further. regarding children who are identified as being at high risk of suicide. 32 Process to be developed which will give staff guidance and enable them to end a session should they feel intimidated or the session exceeds the time allocated CAMHS The purpose and content, including time allocated, to be clearly explained to child and family before session begins. A contract agreeing to these terms to be signed by all involved. Awareness sessions to Service Director Team Mangers The F2F letter that is sent out clearly stipulates the time allocated and purpose of the meeting. Staff re-iterate this at the beginning of each session to ensure Completed 30.06.12 The effectiveness of increased clarity around times of sessions regularly monitored with any exceptions discussed within supervision. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 24 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome ensure staff are confident in assertion techniques. YP/and or parents understand the purpose and content of consultation 33 Safeguarding Supervision to be embedded into practice CAMHS Safeguarding Review the existing Clinical Supervision arrangements and guidance for staff Arrangements and expectations of practise to be made explicit Service Director NNSC It has been agreed that Clinical Safeguarding Children Supervision be integrated into existing Supervision Policy. Completed June 2012 SGC supervision takes place during internal clinical supervision and this covers the support they require. NNSC to offer additional support and advice when required, on both a 1-1 level, or by group discussion through our safeguarding link forums. A more robust system underway to ensure external supervision available on request 34 Staff to undertake mandatory Safeguarding Children training CAMHS Learning and Development NNSC Review the existing in-service mandatory training and adjust according to need. Accommodate needs, ensuring expectations of required levels are clear. Team Managers L & D NNSC Mandatory training passports have been developed through L & D to advise staff on required levels, act as on going Completed September 2013 Mandatory Safeguarding Training is embedded and available to all relevant staff. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 25 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome records and contain action plans for those whose training is outstanding. 35 Staff Support should be offered appropriately and timely following the death of a child. CAMHS Staff questionnaire/reflective exercise to understand individual needs and requirements and accommodate accordingly. To review existing processes and explore ways to enhance, including external support. Service Director Team Managers NNSC Support is offered by NNSC and CAMHS Managers to staff. This is available on an Individual and group reflection basis. Completed 31.03.12 Timely support is available to staff and the outline of this is embedded in policy and procedure. HOR 2 The Deliberate Self Harm Assessment is to be strengthened to ensure that working practices between the hospital services and the CAMHS are robust, that there is consistency of record-keeping practices and that the explicit requirements for discharge planning are clearly defined. Refer to Rec. 5 HOR For the CAMHS Review and revise the existing procedure* Formulate a monitoring activity / audit of practice tool Complete 6 monthly audit and report into the JHSCC *ref Overview Report In all cases of self-harm of children there must be Dir C & YP BCPFT The Deliberate Self Harm Assessment has been strengthened and completed through Task and Finish Group. Deliberate Self Harm Policy has been agreed by BCPFT/RWT. Completed 30.06.12 Deliberate Self Harm Assessment is effective and it’s effectiveness is measured via regular audit. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 26 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome robust multi-disciplinary liaison and in relevant instances a pre-discharge planning meeting must be convened HOR 3 All electronic written details (in the form of e-mail information-exchange on case management relating to individual children’s needs) are to be inserted into individual records which inform on and evidence on-going case management within and across agency sites and reflected as such within agreed standards of record-keeping and practice. The opportunity should be taken to make reference to information-exchange via SMS. HOR For the CAMHS Refer to CAMHS Rec. 1 Management of e-mail information exchange with regard to record-keeping practices is to be made explicit and incorporated into existing policies and procedures Dir C&YP BCPFT The BCPFT Information Governance Lead has reviewed current Record Keeping Policy to include these forms of communication. Completed 30.06.12 Records are fully informed on case management details which involve e-mail exchange. Expectations of record-keeping practices are explicit with regard to the use of e-mail information-exchange Relevant record-keeping audit activities to be reported into the JHSCC HOR 4 Relevant enquiries regarding existing service involvement are to be made by the CAMHS with key agency sites (eg Community Children’s Nursing Service / Children’s Services, Local Authority) following acceptance of a referral for service assessment of a child’s mental well-being, the details HOR For the CAMHS Existing policy and procedural documents are to be reviewed and revised to accommodate the need for enquiry with key sites. Local audit tool to be developed by which to monitor activity Dir C &YP BCPFT NNSC meets with staff (link/crisis team meetings) to ensure that appropriate liaison with relevant agencies is made. This has been included within updated Completed 30.06.13 Liaison and networking practices are enhanced. Practice expectations are explicit. Audit activity is to be reported into the JHSCC. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 27 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome of which are to be fully documented. Deliberate Self Harm Policy. HOR 5 When involved in care provision, the CAMHS is to directly engage in multi-agency integrated service activities (Common Assessment Framework / Child in Need / Child in Need of Protection planning), ensuring that documentation is maintained which fully informs the progression and effectiveness of care delivery. HOR For the CAMHS Refer to CAMHS Rec. 2 Existing policy and procedural documents are to be reviewed and revised to accommodate the need for practice expectations with regard to engagement in integrated multi-agency activities Local audit tool to be developed by which to monitor activity Dir C &YP BCPFT NNSC has highlighted need fro CAMHS to engage in multi-agency fora via link meetings etc. Staff are booked onto, or attended, Case Conference training. CAF training is embedded in service NNSC reports number of CAF’s raised/Conference invites/attendance into JHSCC Completed 30.06.12 Practice expectations are explicit. Engagement in integrated activities is enhanced. Record-keeping practices are robust Audit activity is to be reported into the JHSCC. HOR 6 All direct consultations with a child should include an appropriate level of discussion with regard to: their perspective on their needs, their opinions on care planning and needs’ management and their impression regarding the impact on their well-being as a result of service intervention, HOR For the CAMHS Details to be forwarded to all relevant CAMHS sites which inform on responsibilities for identifying and attending to the needs of individual children Practice expectations to be included in content of SC Training events for CAMHS staff Dir C&YP BCPFT Responsibilities have been forwarded to relevant CAMHS staff and are re-iterated via training programme. Impact to be Evidenced within records/supervisioCompleted 30.06.12 Awareness-raising exercise is completed regarding practice requirements. SC training programmes include information on practice requirements Activities to be reported into the JHSCC SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 28 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome all of which should be accurately reflected within the records as maintained. n notes. Quarterly audits to be presented to Care Governance Meeting. Relevant corporate record-keeping audit activities to be reported into the JHSCC. HOR 8 Existing systems and practices with regard to the prescribing of medication by the CAMHS and the associated care packages supplied by the service are to be audited with reference to compliance with NICE guidelines. HOR For the CAMHS Comprehensive audit to be undertaken with regard to level of compliance with NICE guidelines Dir C&YP BCPFT All high risk cases and care plans are reviewed weekly and medication monitored in line with NICE guidance. Completed 30.06.12 Status of local practices as compliant with national guidelines is explicit. Findings inform local action plan for on-going service development Audit activities to be reported into the JHSCC. Supplementary Recommendation HOR 7 Guidance is to be produced by which to support the completion of Independent Management Reviews with regard to Primary Care Service provision and which takes account of the management of Serious Case Review requests for health information as HOR Production of guidance to support process with regard to IMR of GP / Primary Care Services Awareness-raising of IMR process within GP SC Training events Dir. Primary Care Services WCPCT Des Dr SC DSNSC IMR process now included within the training of GP’s for safeguarding children training Dec 2012, Jan 2013, Feb 2013 Completed 30.09.13 Explicit guidance available to support the IMR process Effective and efficient engagement in the SCR process by GP Practices Activity is to be reported SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 29 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome relating to adults. SCR subgroup has developed IMR training for all agencies therefore no longer need full guidance specifically for Health professionals . into the JHSCC and the SCR Sub-committee WSCB. AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome Overview Report Recommendations OR 1 Wolverhampton Safeguarding Children Board should seek from Wolverhampton Children's Trust Board details of the local provision for minimising among children and young people, self harm and suicide and a Overview report A formal request to be made by the Chair of the WSCB to the chair of the WCTB for information. Report from the WCTB to be Head of Safeguarding Chair of the Sub group – Public Health has been requested to provide an update on source provision for YP + Self-Harm – Completed October 2013 The WSCB to be informed of local provision of services to this vulnerable group. A policy and procedure will be available to all SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 30 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome reassurance as to the relative effectiveness of that provision. considered by the Quality and Procedures Best Practice sub-group of the WSCB, who will then formulate a multi-agency policy and procedure for all staff who may work with children and young people who self harm or threaten suicide. Head of CIN and CP. Health and Wellbeing Board now responsible rather than CTB Letter re-sent to H&W Board in view of changes in Health economy. Self-harm Policy remains outstanding. agencies which will be based on local provision and will ensure best practice in this area. OR 2 Wolverhampton Safeguarding Children Board will write to each member agency and ask them to issue a written reminder to all staff (and ensure their training programmes address) a): the need in law and best practice to include non-resident parents (especially though not just those with parental responsibility and actively involved) in all assessments of need, planning and delivery of service; and b): the obligation of all professions without regard to discipline or rank within it, to Overview report Letter to be written, and to include the request that evidence of the impact of this request will be monitored through regular auditing and management oversight of case records. WSCB Quality and Performance sub-group to request regular updates on audits of practice in this area. Head of Safeguarding Chair of the Quality and Performance sub-group. Embedded in all relevant WSCB training and requested for inclusion in all partner agency training. Information only report to WSCB in November 2013. Information added to QA windscreen - 30 Completed March 2013 All staff to be reminded of expectations of good practice in assessment and planning. Managers to monitor this issue and address practice issues. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS Action Plan Updated 25 October 2013 31 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome offer respectful challenge to colleagues October 2013 OR 3 Wolverhampton Safeguarding Children Board will write to Wolverhampton PCT and ask that it remind all local community pharmacies of the professional expectation to make direct contact and query any proposed prescription which appears to the pharmacist in question not to be in the patient’s best interests Overview Report Letter to be written. Head of Safeguarding SC Commissioning Lead WCPCT Letter re-sent to CCG since the demise of PCT in April 2013. Completed October 2013 Awareness-raising exercise is completed regarding practice requirements. SC training programmes include information on practice requirements Evidence of completed action is reported into the Quality & Assurance Committee, WCPCT |
NC044609 | Death of a 4-year-old boy in December 2009, as a result of chronic neglect; Hamzah's body was discovered by police during a search of the family home in September 2011. Six of Hamzah's seven siblings were living in the family home at the time of the discovery of his body; all siblings under the age of 18 became subjects of care proceedings at this time. Mother was convicted of manslaughter and child cruelty in October 2013. Maternal history of: chronic alcohol dependency; depression; social isolation; domestic abuse; and reluctance to engage with services, including registering children with health and education services. Father was made the subject of a non-molestation order in 2008 following an arrest for assault against mother. Issues identified include: invisibility of children to services; failure to recognise the impact on children of living with domestic abuse; absence of enquiry into the cultural and religious complexity of the family; insufficient significance given to disclosure by adolescents; lack of professional curiosity and missed opportunities to conduct assessments; insufficient interagency cooperation and lack of an overall picture of family life. Sets out key findings using a systems model based typology developed by Social Care Institute for Excellence (SCIE) and raises issues for consideration in regards to identified themes for learning. Themes include: cognitive influence and human biases; viewing incidents in isolation and failing to identify patterns that represent harm to children; and tools for effective sharing and analysis of information. Includes a Learning and Improvement Report and statements from the Independent Chair of Bradford Safeguarding Children Board and the Independent Chair of the review.
| Title: A serious case review: Hamzah Khan: the overview report LSCB: Bradford Safeguarding Children Board Author: Peter Maddocks Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 89 A Serious Case Review Hamzah Khan The Overview Report November 2013 Page 2 of 89 Page 3 of 89 Index 1 Introduction and context of the review ..................................................................4 1.1 Circumstances leading to the serious case review......................................10 1.2 Rationale for conducting a serious case review ..........................................11 1.3 Reasons for the review and terms of reference...........................................11 1.4 The methodology of the serious case review ..............................................11 1.5 The scope of the serious case review .........................................................13 1.6 The terms of reference as described in national guidance ..........................14 1.7 Particular issues identified for further investigation by the individual management reviews: the key lines of analytical enquiry........................................15 1.8 The terms of reference for the health overview report.................................18 1.9 The terms of reference for the overview report............................................18 1.10 Membership of the case review panel and access to expert advice ............19 1.11 Independent chair of the serious case review panel and independent author of the overview report..................................................................................19 1.12 Parental and family contribution to the serious case review ........................20 1.13 Time scale for completing the serious case review .....................................21 1.14 Status and ownership of the overview report ..............................................21 1.15 Previous serious case reviews....................................................................22 1.16 Inspections of services for children in Bradford...........................................22 1.17 Synopsis and summary conclusion of the review panel ..............................23 1.18 The family and other significant people.......................................................32 1.19 Cultural, ethnic, linguistic and religious identity of the family and their community..............................................................................................................36 2 Overview of events.............................................................................................37 3 Synopsis of the learning and analysis from the individual management reviews. 40 3.1 Summary ....................................................................................................40 3.2 Significant themes for learning that emerge from examining the IMRs........40 3.3 Good practice identified through the review ................................................41 4 Analysis of key themes for learning from the case and recommendations ..........71 4.1 Issues for national policy.............................................................................82 5 APPENDICES ....................................................................................................85 Appendix 1 - Procedures and guidance relevant to this serious case review..........86 Legislation..............................................................................................................86 The Children Act 1989........................................................................................86 The Children Act 2004........................................................................................86 Safeguarding Procedures.......................................................................................87 The Bradford Safeguarding Children Procedures ...............................................87 National guidance...................................................................................................87 Working Together to Safeguard Children (2010) ................................................87 Framework for the Assessment of Children in Need and their Families 2001 .....88 Common Assessment Framework (CAF) ...........................................................88 Page 4 of 89 1 Introduction and context of the review 1. The serious case review examines, for the purpose of professional learning and service improvement, the involvement of agencies with Hamzah Khan who died as a result of the criminal neglect by his mother, Amanda Hutton who was convicted of manslaughter and child cruelty in October 2013. 2. The death of any child, whatever the circumstances is a traumatic and shocking experience and Hamzah’s is profoundly disturbing. Hamzah had been starved and neglected over a number of months. The full extent of his treatment was not known about until the evidence was laid before a judge and jury in the autumn of 2013 following an extensive criminal investigation. This detailed information was not available to the overview panel at the time that the serious case review was underway. The trial also revealed other significant information about the family and the circumstances of the children that had not been known until then. 3. The review examines what was known and understood by the different services at the time of events and considers what the tragic story of Hamzah represents for professional learning and future policy. In doing this, the review is focussed on how people doing difficult work, often as in this case with adults who are reluctant or unwilling to have help, can best be encouraged and supported in continuing to improve the opportunities and quality of contact with troubled families and vulnerable children. Simply saying that with hindsight, and if people had known what we all know now, they probably would have made some different decisions does not help with promoting effective improvement and learning. 4. One of the most singular aspects of this case is the degree to which there is very little recorded information about the children and particularly in respect of what they were thinking, feeling or saying at critical points such as the incidents of domestic violence. Hamzah together with some of his other siblings who had not ever got to school literally disappeared from the view of their extended family and community as well as from the view of universal services such as education and health. 5. When one of the children, then an adolescent, did speak out about his unhappiness it was heard and probably misunderstood as being solely symptomatic of adolescent and parent conflict and tension. 6. An important question from this review that is wider than just for the circumstances of one city and the local safeguarding children board is how children can be encouraged to talk about their home circumstances and for such information to be heard with sufficient curiosity, empathy and understanding that takes account of children’s overall well-being by people and organisations that have the capacity to do this. 7. Attention to collating information, showing thoughtfulness and reflecting on the significance of information is less likely to occur in conditions where workload, information systems and frameworks are not conducive to this and measures of what is satisfactory practice is not focussed on the experience and outcomes for vulnerable children. 8. It is now known that five children lived with awful physical and emotional conditions for many months as their mother’s emotional and mental well-being Page 5 of 89 was severely impaired and deteriorated. How can children living with such conditions have the confidence to talk with a trusted adult especially if they have been withdrawn from contact with services such as health visitors, GPs, early year’s services or school? These are not issues that are addressed through procedures or complex action plans. 9. Whether it is the professionals and other people who knew the family, the participants in the process of the criminal investigation and trial or the general public who have doubtless been very distressed by the information that has now been revealed about Hamzah’s circumstances, all will share a sense of anger, bewilderment and shock that a child can be so neglected as to die and then can be left undiscovered for almost two years whilst living in a major city in a country with one of the most developed systems for safeguarding children in the world. 10. The fact that Hamzah had been withdrawn from the usual and universal services such as early years, education and health and was therefore invisible for almost a lifetime is a significant factor. The overview panel received no information that suggested that there was one opportunity for a single individual to have done something to have saved this child. The information considered does not point to single acts or omissions but rather a constellation of factors that contributed to the circumstances. 11. Although some individual judgments with the benefit of hindsight can be seen to have been made without enough information or analysis, the invisibility of Hamzah is far more a reflection about how universal as well as specialist systems of help are delivered to vulnerable children and troubled families. 12. There is a danger in such a highly charged and emotional case such as this, that with the crude application of hindsight any genuine and more honest learning will be lost. Reliance on hindsight can wrongly infer that wrong personal or professional judgments were made rather than looking at what was known at the time and analyse how and why information was being processed by all of the relevant people (family and professional) and the reasons for it. Unless there is some understanding about how and why both professionals and families behave and act there will continue to be a preoccupation with looking at the wrong evidence and information that has limited value for improvement and learning in some of the most complex human and professional activity. 13. It is for this reason that the review examines for example whether there was sufficient understanding about the history and significance of domestic abuse, why assessments were approached in the way that they were rather than just stating that they could have been more effective, examining the impact and influence of contracting arrangements for GP services rather than just concluding the children should not have been taken off a GP register, the way in which people use and follow protocols for example in regard to finding children missing from education, the way in which enrolment of children with universal services such as school have been reliant on parents doing the right thing for their children and exploring issues such as why women who are emotionally and physically abused are so often unwilling and unable to co-operate or engage with help. 14. The person who could have prevented this death was Amanda Hutton who had the day-to-day responsibility for Hamzah and other siblings. She had become so overwhelmed with her own problems and needs that she was incapable of Page 6 of 89 adequately caring for herself let alone any dependent children. Nobody, save for the children who were living with her, will know when those conditions became so extreme and were in stark contrast to the conditions that were recorded by a succession of different services until some months before Hamzah’s body was discovered. However, Amanda Hutton was not always such an inadequate or a dangerous parent. 15. Amanda Hutton had first become pregnant as a teenager at a time when support for such young mothers was not as developed as it is now. There were not the specialist midwifes working with teenage parents, there were not Sure Start or Children’s Centre services. There would now be a far more active and informed approach to working with teenaged parents under current arrangements compared to the position over 20 years ago. 16. Little is known or recorded about the first pregnancies but the limited agency information from health visiting records for example and accounts from her family indicate that Amanda Hutton had applied herself with commitment and provided appropriate parental care for her older children; this is borne out by professional recording as well as the statements from different family members. She had cared for her step father after he had an operation. 17. Amanda Hutton had been capable of empathy and care to others. By the time she had neglected Hamzah to such an extent that Hamzah died having been denied nourishment, her circumstances had entirely changed as had her ability to function as an adequate parent as a consequence of her chronic dependency upon alcohol that had such appalling consequences. 18. That chronic dependency was not recognised or known about in the services that had been in contact with the family although there had been knowledge about drinking. Amanda even consulted her GP on at least one occasion in 2007 although the extent and degree of the dependency was not apparently as severe as became apparent in the later months of Hamzah’s life; some of that might indicate a minimisation on Amanda Hutton’s part as much as possibly a historical tolerance that is viewed differently by today’s knowledge and understanding about substance misuse and the impact it has on parents’ emotional and physical care of children. It also appears to be the case that for many years Amanda Hutton was able to maintain a better level of care that did not warrant more intrusive or assertive intervention when help was generally being declined. 19. The extent to which Amanda Hutton became isolated especially after the death of her mother was not properly understood and in truth was not disclosed either to the trial or in the agency information provided to the SCR. It simply was not known about. It is apparent that she was prone to depression and in 1999 had made threats to self harm. 20. It can now be seen that there was an effective and serious misdirection of services that had begun to make enquiries about the whereabouts of Hamzah and the other young siblings but this was after Hamzah had already died in December 2009. Amanda Hutton, with the apparent coercion of the children, had persuaded services such as education and health that they were living in an entirely different part of the country. What the trial established was that Amanda Hutton had been determined to keep the fact of Hamzah’s death a secret. Those threats that the trial were told about were sufficient to prevent Hamzah’s siblings from speaking out. Page 7 of 89 21. Although there were efforts to check information when for example a health visitor had become concerned in 2010 about the lack of contact with health services and subsequently both the enquiries by health, education and CSC as well as a referral that was made in early 2011 relied primarily on what the family said rather than getting to a point where Hamzah or the siblings who were subject of the inquiries had been seen. There was not a visit to the home because at the time it had not been regarded as necessary. It is one of the examples of where a decision has different significance with hindsight and knowledge about what the true picture was. 22. These events highlight the dangers of any decision making that relies on impressions of children being ‘safe and well’ rather than undertaking more inquisitive and reflective enquiries, either through a CAF (common assessment framework) or certainly when making enquiries and assessments in regard to whether a child is in need or at risk of significant harm1. People who are dealing with heavy workloads and have competing demands for their attention will have more limited opportunity to be curious, inquisitive and enquiring. 23. Neither the trial nor the SCR has satisfactorily reconciled how and why Hamzah’s disappearance for almost two years was not a matter of curiosity or inquiry for the father or any other adults in Hamzah’s family. 24. This SCR has considered the domestic abuse that occurred over very many years and probably predates the first recorded incident in 1996. The SCR also refers to Amanda Hutton’s history of depression and the traumatic isolation that she felt following the death of her much loved mother and the disintegration of her relationship with the children’s father over several years. 25. Some people will ask why help was not provided. Help was provided on several occasions and sometimes with great sensitivity and persistence. However, as will become clear through the report, that help faced many and significant barriers. These barriers included the extent to which neither parent felt able to acknowledge problems for much of the time and the emotional and psychological impairment that leads victims of abuse to refuse help partly because of concerns about exacerbating the situation. In addition, professionals faced problems of collating information from disparate sources. 26. The timeframe for when matters had got so entirely out of control or how some of the children were able to engage in Amanda Hutton’s account that Hamzah had gone to live with relatives are still not entirely clear although the trial heard evidence of coercion and threats of violence. It is also not clear why Amanda Hutton’s parenting of Hamzah was especially poor over and above observing that Hamzah appeared to have been a more difficult eater than the other siblings and this coincided with the escalating collapse of Amanda Hutton’s relationship, the escalating impairment of her ability to care for herself, her children or her home after she eventually left the abusive relationship. With hindsight it can be seen that this was the time when Amanda Hutton withdrew from community and professional contact. 1 The review analyses and comments on the lack of use of the CAF as well as the way statutory assessments were dealt with in later sections. Page 8 of 89 27. There has been reluctance from within the family to disclose or discuss information over and above what has been given in court and under oath. One of those witnesses had to be compelled to appear. Amanda Hutton was unwilling and unable to give a full account of how and why her life had been so transformed for the worse either to the trial or to the SCR. Amanda Hutton has chosen to have no contact with the SCR process. The trial established guilt for neglect and cruelty but not the reasons for it. What the trial and this SCR describe is a family where nobody was able to tell any service about the appalling conditions that had become prevalent by the time of the child’s death. 28. The non-molestation order that the children’s father was subject to from 2009 meant that he did not visit the property where Hamzah died although he continued to have full and shared parental responsibility with Amanda Hutton for his children. The case raises additional questions for how fathers who have been abusive or violent to their partners are able to have a role in the lives and upbringing of their children. 29. The only evidence that the children’s father disclosed a concern about the care of any children was when he had been taken into custody for assaulting Amanda Hutton. Although he was advised to tell CSC if he had concerns there is no record of this ever being done. The police did not have other direct evidence to support heightened concerns at that stage about the children. 30. This overview report gives an account of the detailed examination of several agencies knowledge of and contact with the family. The review acknowledges that some of those contacts could have been handled differently and explores why and the implications for learning by looking at the various contributory factors that influenced judgments, decisions and action of both professionals and other people as far as is possible. 31. The SCR examines the contact that took place at different times between the family and several agencies; this was primarily in regard to incidents of domestic violence. For the most part, Amanda and father were both resistant to professional contact. This is behaviour that will now be familiar to most professionals and services working with domestic violence and substance misuse and is explored in the analysis and findings of the report. 32. An account is also provided in the comment and analysis within the report about how the work of reviews such as this can contribute to the development of better informed practice as well as describing for example legislative changes in regard to domestic abuse being properly seen as causing significant harm to very young children in particular and the introduction of measures such as Domestic Violence Prevention Notices (DVPN) that are less reliant on victims co-operating with services such as the police. These are changes and developments that have occurred since the tragic death of Hamzah in 2009. 33. The case has raised important issues about how much responsibility is left to parents for example to register their children with health services or to ensure that they are enrolled for universal services such as education. The review considers for example issues such as the perverse incentives associated with primary health care patient contacts that create a disincentive to keeping reluctant or resistant people on GP register. 34. The SCR has coincided with a watershed in how reviews such as this have to better address the learning and improvement that needs to come from such Page 9 of 89 cases. The review has resisted a reliance on hindsight to judge the action and behaviour of all the parties, professional or others, to this tragic case. 35. The review has set out to understand what was happening and why and to explore the various influences and contributory factors. For example, mention is made in later sections of the report about how the aftermath of the “Baby P” case had very significant consequences in the increased level of contacts and referrals and how some of the measures designed to help ameliorate workload pressures had consequences in how information was being recorded at the time and the capacity to follow up less urgent or unresolved information such as when Hamzah was first identified as missing from education and health services. 36. The review panel has also taken account of the evidence that overly forensic overview reports and multiple recommendations that result in complex action plans have very little impact on wider learning and improvement in regard to the complex interactions that a case such as this illustrate. 37. It is for this reason that all agencies have considered what they need to change and do differently. However this overview report has not made recommendations but has instead provided a series of challenges and reflections for the Bradford Safeguarding Children Board (BSCB) to address in respect of the learning to be achieved from this review. Nobody should be under any illusion that by using such an approach it offers a far more substantial and onerous responsibility to the BSCB in responding to this tragic case than ratifying a set of recommendations and actions. 38. A significant theme in this review and for the trial was the extent to which Hamzah along with the younger siblings was unknown and invisible to services throughout his short life. The circumstances that caused Amanda Hutton in particular to withdraw increasingly from any contact with services are complex. A significant contributory factor appears to be the degree of domestic violence she suffered and the social isolation she felt. Associated with this was the reaction from some people in the community to a relationship that involved partners from different cultures and religions although the children’s father is less persuaded that this was a factor. 39. Hamzah was invisible to services largely because neither of his parents participated in the routine processes such as ensuring he saw health professionals on a regular basis or had been enrolled for early years or local educational provision. 40. The case has already prompted changes to the way in which services can be more proactive in looking for children who may be missing from such universal services although in the absence of an all embracing and comprehensive information system that records and tracks a child from birth, the primary reliance continues to rest on parents being responsible and enrolling their children where they retain sole parental responsibility (there is no statutory involvement through a care order for example). 41. There are important questions for local and national policy in regard to how many of the systems for the universal health care and education of children rely on parents registering their children for such routine services. Although this review describes the action already taken in Bradford to be more rigorous in identifying the children who either are not known at all or as in this case are Page 10 of 89 effectively withdrawn from view, is it realistically impossible to guarantee that a child will not remain hidden from universal or specialist services such as children’s social work services under current statutory arrangements. 42. The reflections and critical challenge are designed to provoke more enduring learning and improvement that applies across a wider range of services and children rather than being confined to the highly unusual circumstances of this one tragic case. 43. Regrettably, domestic abuse, child neglect, substance misuse and mental illness are the background to very many children’s lives. The work of a review such as this can only hope to inform and support the continued development of professional practice in a country where internationally, the UK is a bench mark for learning and improvement. 1.1 Circumstances leading to the serious case review 44. Hamzah (the index child for the review) had seven siblings, five of whom were living in the same household. The two eldest siblings lived independently. There was one other child (Sibling 3) who was younger. Hamzah’s body was discovered by police officers during a search of the house in September 2011. 45. The police were at the house following up concerns about anti-social behaviour and reports about very poor conditions in the home. The police were also trying to establish the whereabouts of several of the children who had not been seen for some time. Several visits had previously been made to the property by a police community support officer (PCSO) with a request for Amanda Hutton to make contact. During a visit earlier in the afternoon to the property Amanda Hutton had answered the door but had refused access to the house although the PCSO had noted the presence of a strong smell and the evidence of many flies. 46. It was the PCSO who showed great persistence in seeking further support from fully warranted officers and eventually secured access to the property that led to the discovery of Hamzah’s body. The action of that officer was commended by the judge and is also highlighted as one of the examples of good practice in this review. 47. It had not been possible to establish an exact date for Hamzah’s death when the SCR was being conducted in 2012 although as a result of the evidence given in the trial, it has now been established that Hamzah died on the 15th December 2009. Information provided through statements to the SCR and from the post mortem examination had indicated that Hamzah’s death might have occurred in December 2009 when Hamzah was aged four years old. The SCR panel was not told about the discovery of his body in a babygro for a child aged less than 12 months old; this was clear evidence that his physical growth had been severely impaired given the more definite date of death established by the criminal trial. 48. The parents had separated in October 2009. With the exception of the second eldest child (Sibling 6) who was 18 at the time of Hamzah’s death, all of the siblings were then living with Amanda Hutton. Sibling 7 was aged 19 at the estimated time of death. After the discovery of Hamzah’s body all of the children under 18 became the subjects of care proceedings initiated by the local authority and were placed with carers outside of the family. Page 11 of 89 49. The serious case review was commissioned on the 28th November 2011 by the independent chair of the Bradford Safeguarding Children Board. Work began on compiling a chronology in December 2011, which coincided with the appointment of the independent chair of the serious case review panel and of the independent author of this overview report. The panel chair has worked in Bradford but moved to other employment in 1993. The overview author has not worked for any of the services contributing to this serious case review. Further information about their relevant experience and knowledge is provided in section 1.11. 1.2 Rationale for conducting a serious case review 50. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with procedures set out in chapter 8 of Working Together to Safeguard Children (2010). 51. The LSCB should always undertake a serious case review when a child dies and abuse or neglect is either known or is suspected to be a factor in their death. 1.3 Reasons for the review and terms of reference 52. The reason for commissioning the review was that the circumstances under which Hamzah had died and the fact that the death had not been reported was indicative of Hamzah having been neglected. The information about the very significant impairment of physical growth was not known until the trial. There had been historical concerns including domestic violence and use of alcohol. The home conditions in which Hamzah and the siblings were living when the body was discovered were very poor. 53. The serious case review panel at their first meeting on the 10th January 2012 confirmed the scope and overall terms of reference for the review and established a timeline for the completion of work. The panel postponed agreeing case specific key lines of enquiry pending the receipt of the chronology and first drafts of narrative information from the authors of the individual management reviews (IMR) at the meeting of the panel in February 2012. 54. The overall purpose of the review is to establish the opportunities for learning and improvement from the case through a detailed examination of events, decision-making and action. In identifying what that learning and improvement is, to improve inter-agency working and to better safeguard and promote the welfare of children in Bradford. 1.4 The methodology of the serious case review 55. The serious case review was completed using the methodology and requirements set out in the national guidance (Working Together to Safeguard Children 2010) that applied at the time of the review being commissioned and completed. That guidance was extensively revised in March 2013 following the Page 12 of 89 publication of Professor Eileen Munro’s final report in 20112. The government had indicated that it supported the changes being recommended by Professor Munro that future serious case reviews should be conducted using systems based learning methodology; details about what that methodology and framework had not been agreed when the review was completed3. The BSCB was already working on how future serious case reviews in Bradford should be developed in order to provide a more informed inquiry into the local systems for safeguarding and protecting children4. 56. The analysis in the final chapter of this report uses some of the framework developed by SCIE (Social Care Institute for Excellence) in anticipation of the changes to serious case reviews to present key learning within the context of local systems. This also took account of recent work that had suggested that an approach of developing over prescriptive and SMART recommendations had limited impact and value in complex work such as safeguarding children5. The final chapter of the review for example explores the influence of family and professional interactions, the responses to incidents and crises and the tools that are used by professionals. The report also recognises that this is a very unusual case concerning the death of a child that was not discovered for several months. 57. This is not a review that has used systems methodology to collect and analyse the information from the people who had contact with the family, but the panel have worked to place the evidence that has been analysed within individual agency reports into a framework that begins to explore how the local systems both promote and in some circumstances inhibit professional practice and decision making. 58. The individual agency management review authors were briefed and encouraged to examine professional practice within the context of local systems operating at the time of the events that were being examined. A systems based review would have provided greater opportunity for the practitioners to be central to the process of the review in terms of collating information and helping to develop the analysis and collective understanding about why the case 2 Munro review of child protection: final report - a child-centred system; May 2011 3 The government started a three month consultation on the 12th June 2012 regarding the revised guidance for learning and service improvement that would change arrangements for the conduct of serious case reviews as well as abolishing much if the national guidance in Working Together and the arrangements for assessment of children in need. The revised national guidance was published in March 2013. 4 Analysis of clinical incidents; providing a window on the system not a search for root causes. CA Vincent; Quality and Safety in Health Care, 2004. The article argues that incident reports by themselves tell comparatively little about causes and prevention, a fact which has long been understood in aviation for example and is the basis of developing a systems learning approach to serious case reviews in England. 5 A study of recommendations arising from serious case reviews 2009-2010, Brandon, M et al, Department of Education, September 2011. The study calls for a curbing of ‘self perpetuating and proliferation’ of recommendations. Current debate about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans. SMART refers to strategic, measurable, achievable, realistic and timely. Page 13 of 89 developed in the way that it did. The revised national guidance gives greater freedom to LSCBs in regard to the methodology they choose to conduct a SCR. 59. A serious case review panel was convened of senior and specialist agency representatives to oversee the conduct of the review. The panel was chaired by an independent and experienced person who is also the independent chair of a LSCB in another part of northern England. An experienced and independent person has provided this overview report. Further information about their respective experience is provided in section 1.11. 60. The panel agreed case specific terms of reference that provided the key lines of enquiry for the review and were additional to the terms of reference described in national guidance. The panel established the identity of services in contact with the family during the time frame agreed for the review. For services that had significant involvement they were required to provide an independent management review (and are listed in the following section 1.4). These reports were completed by suitably experienced people who had no direct involvement or responsibility for the services provided to the children and their parents. 61. An overview of the health agencies was provided in a comprehensive health overview report. Health overviews are no longer a requirement for SCRs. 1.5 The scope of the serious case review 62. The period of the review was from the beginning of Amanda Hutton’s known pregnancy with Hamzah to the discovery of Hamzah’s body in September 2011. All information known to a service providing an IMR was reviewed. Any information regarding involvement prior to the period of the detailed chronology and analysis was summarised in the IMR and in the overview report. 63. All agency chronologies include detailed information about when the children were seen, spoken to or observations made about them. 64. Agencies that identified significant background histories on family members pre-dating the scope of the review have provided a brief summary account of that significant history. 65. Reviews of all records and materials that have been examined include; a) Electronic records b) Paper records and files c) Patient or family held records. 66. Individual management reviews were completed using the template provided by the Bradford Safeguarding Children Board (BSCB), and were quality assured and approved by the most senior officer of the reviewing agency. 67. The following agencies have provided an individual management review that was to be completed in accordance with Working Together to Safeguard Children (2010), Chapter 8 and the associated BSCB guidance and relevant procedures. a) Health services that include: o Bradford and District Care Trust (BDCT and provided health visiting services) Page 14 of 89 o Bradford Teaching Hospitals NHS Foundation Trust o Bradford and Airedale Teaching Primary Care Trust (PCT); general practitioner services and the Health Overview Report (HOR) o Yorkshire Ambulance Service b) Bradford Children & Young People’s Specialist Services commissioned the IMR on behalf of children’s social care services (CSC) c) Bradford Early Years Children’s Services (children’s centre) d) Bradford Education and Early Childhood Service commissioned separate IMRs in respect of education support services, school admissions and from schools the children attended during the period under review. e) Bradford MARAC (multi agency risk assessment conferences)6 f) Bradford Youth Offending Team (YOT) g) Voluntary organisations (Home Start, Hope Project and Staying Put7) h) West Yorkshire Police i) West Yorkshire Probation Service. 68. Bradford Metropolitan District Council had been made subject to a statutory direction to outsource its education services in July 2001; that direction was lifted from July 2011. This means that for the period that is the focus of this review, the provision of services was through an arrangement with Education Bradford an independent provider of education services in the city. 69. Information was also received from CAFCASS (children and families court advisory support service), the West Yorkshire Ambulance Service (WYAS), the Bradford Registrar and the Home Hunter service. Checks were also made with services in the east and south of England regarding information provided at various times by the family regarding the whereabouts of specific children. These checks confirmed that all of those children had always lived in the Bradford area. 1.6 The terms of reference as described in national guidance I. Keep under consideration if further information becomes available as work is undertaken that indicates other agencies should carry out individual management reviews. II. To establish a factual chronology of the action taken by each agency; III. Assess whether decisions and action taken in the case comply with the policy and procedures of the Bradford Safeguarding Children Board; IV. To determine whether appropriate services were provided in relation to the decisions and actions in the case; V. To recommend appropriate inter-agency action in light of the findings; 6 The MARAC is not an agency but is a multi agency framework for sharing information and action in response to identified risk; in this case it relates to incidents of domestic abuse. Although the abuse began in 1996 the MARAC was not established in Bradford until 2008. 7 Staying Put is a local domestic violence/abuse charity that helps up to 1,400 women and children every year across the Bradford District to stay in their own homes. Staying Put provided their IMR when the SCR panel had already prepared a draft overview report when the extent of the agency’s involvement was identified. Page 15 of 89 VI. To assess whether other action is needed in any agency; VII. To examine inter-agency working and service provision for the children; VIII. To establish whether interagency and single agency policies adequately supported the management of this case; IX. Consider how and what contribution is sought from the family members; X. To develop a clear multi agency action plan from the overview report. 1.7 Particular issues identified for further investigation by the individual management reviews8: the key lines of analytical enquiry 70. In addition to analysing individual and organisational practice, the individual management reviews should focus on: Recognition i. To what extent were any vulnerabilities or needs of mother recognised and taken into account in terms of any potential risks they posed for Hamzah and his siblings including any information about depression, domestic violence, social or family involvement or the use of alcohol or drugs; to comment in particular on any action taken to ascertain whether there were any issues of learning or other disability or impairment relevant to agency involvement, and comment on the extent to which any barriers may have contributed to mother’s reluctance to accept help or advice. ii. Provide information about any concerns that were reported by any member of the family and comment, where appropriate, on any action taken in response to such information. iii. Identify any opportunity for enquiring into the whereabouts and well being of Hamzah between June 2005 and September 2011. Assessment and Decision Making iv. The extent to which relevant historical information was sought, understood and considered in work with Hamzah and his family; IMR authors should include a summary of any relevant information known to their service about the parents or family that they judge relevant to the serious case review. v. The quality and timeliness of any assessments and the extent to which they took account of relevant family history, the cultural, ethnic and religious identity of the family, the needs of Hamzah and his siblings and the capacity of the parents (acknowledging they were separated) to meet the needs of their children; this should include comment about any extended family or others and their role 8 These are the detailed issues that are analysed by the IMRs and in the detailed analysis in chapter five of this report. Page 16 of 89 and impact in promoting the safety, well being and knowledge of Hamzah prior to the discovery of his death. vi. Consider and comment whether there were opportunities to use any arrangements such as the common assessment framework, team around the child or children going missing protocols to co-ordinate information and help at any stage. vii. Comment on the quality of judgments and decision making and the extent to which it reflected a focus on the needs of Hamzah and his siblings and represented appropriate professional standards and a competent understanding of any relevant theoretical and/or legal frameworks; particular attention should be given to how any evidence of neglect or impaired capacity to parent was collated and analysed. Using and Sharing Information viii. Identify whether information in respect of the family was shared among agencies to the best effect so as to inform appropriate help and interventions; in particular to identify when practitioners in contact with the family saw Hamzah and/or his siblings and recognised any evidence of neglect or other concerns and comment on what action was taken to protect him or a sibling. ix. To comment on the quality of reports and information provided for interagency enquiries and analysis including information provided in meetings of MARAC or the conduct of statutory assessments or for the purpose of identifying and tracing children who have gone missing. Engagement and acceptance of help and advice x. To what extent did either parent accept contact, advice or help from professionals in contact with the family between June 2005 and September 2011? xi. Was there any other action that could have been taken to achieve a better level of contact and engagement with the family? Planning and Help xii. Comment on the clarity and appropriateness of plans and actions undertaken made as a result of the discussion at MARAC, information about siblings missing from school or as a result of any statutory assessment. xiii. Identify what opportunities were taken to seek the views, wishes and feelings of any of the children and comment upon the extent to which the children may have felt inhibited to seek advice, information or help. Page 17 of 89 Practice Support and Supervision xiv. Consider whether all relevant single agency and multi-agency procedures were followed and comment on the extent to which procedures helped or inhibited appropriate judgments and action at the time. xv. Consider whether the policy, procedural, management and resource infrastructure that surrounded each agency’s involvement with Hamzah and his family promoted appropriate decision making; this should include evaluating the training, knowledge and experience of people working with Hamzah and his family, workloads and organisational stability; comment should also be made about whether any shortfall in resources were an impediment. xvi. Consider whether professionals working with Hamzah’s family had sufficient and appropriate supervision commensurate with their role and responsibilities, and the extent to which the case was subject to appropriate and effective managerial oversight and enabled critical reflection. Learning from SCRs and other review processes xvii. Consider relevant research or evidence from previous serious case reviews conducted by the Bradford Safeguarding Children Board; consideration may also be given to evidence from other LSCBs or evaluations of SCRs. Take into account any common themes and actions arising from that research and those SCRs that are relevant to the circumstances of this case and comment on what impact they had in this case. xviii. Consider previous reviews of single agency practice. Take into account any common themes and actions arising from those reviews that are relevant to the circumstances of this case and comment on what impact they had in this case. Agency specific key lines of enquiry xix. Police and children’s social care; report and comment on what information was shared and the actions taken between 12th September 2011 and the 21st September 2011 and whether there was opportunity to have discovered the body of Hamzah at an earlier stage in those enquiries. xx. Education and early childhood services; report and comment on the extent to which any of the children were missing from education or early years provision and the appropriateness of actions taken to ascertain the children’s whereabouts and attendance at school and other provision. Page 18 of 89 1.8 The terms of reference for the health overview report 71. The health overview report provided an overview of the information and analysis provided by all health services for the serious case review. In particular it addressed the following: i. Comment on the quality of information and analysis and identify significant themes and areas for learning; ii. Comment on any specialist referrals or assessments undertaken and the extent to which these contributed to appropriate decision making; iii. Provide comment on the extent to which evidence about neglect was identified and acted upon by various health services; iv. Comment on the extent to which the reports provided by health services have identified appropriate learning and have provided sufficiently informed analysis; v. Give particular regard to any implications for the likely reform of health arrangements in Bradford identified through the review regarding the capacity of primary health professionals to identify and follow up of children not presented for routine health advice or treatment; vi. The quality of action already taken in response to the serious case review and the recommendations and action proposed by the health IMR reports; vii. Identify any further themes to be explored within the overview report; viii. Make recommendations necessary to ensure appropriate implementation of learning across the health service in Bradford. 1.9 The terms of reference for the overview report 72. Provide a multi agency overview report in accordance with the national guidance in Working Together to Safeguard Children. 73. In addition to the requirements of Working Together to Safeguard Children (2010) and taking into account the specific issues identified above, the overview report author: I. Commented on whether the individual management reviews have addressed the terms of reference and all relevant issues; II. Examined the inter agency working and communication between all involved agencies; III. Determined whether services which were provided, actions taken and decisions made were in accordance with current policies, procedures and government guidance; IV. Considered whether different decisions or actions may have led to a different course of events; V. Provided an executive summary on behalf of the BSCB. Page 19 of 89 1.10 Membership of the case review panel and access to expert advice 74. An independent person was appointed to chair the case review panel from the outset; 75. The case review panel that oversaw this review comprised the following people and organisations; Position Organisation Professional Development Manager Bradford Metropolitan District Council (BMDC) Adult Services Designated Nurse Bradford and Airedale Teaching PCT BSCB Manager BSCB Medical Director Bradford and Airedale Teaching PCT Detective Chief Inspector West Yorkshire Police Manager Youth Offending Team Group Service Manager BMDC Children’s Specialist Services Assistant Director Access & Inclusion BMDC Access and Inclusion Independent ‘critical friend’ (Assistant Director Performance, Planning & Resources, Children's Services Department) Bolton Council Head of Midwifery Bradford Teaching Hospital Foundation Trust 76. The independent author of the overview report attended every meeting of the panel; 77. The panel had access to legal advice from a solicitor in the council’s legal service; 78. Written minutes of the panel meeting discussions and decisions were recorded by a member of the BSCB staff team. 1.11 Independent chair of the serious case review panel and independent author of the overview report 79. Nancy Palmer was appointed as the independent chair of the serious case review panel. Nancy is a psychology graduate and qualified social worker with a long career history in children’s services including the roles of child protection co-ordinator and service manager for child protection. Although she has worked mainly in the public sector she has also spent time in the voluntary sector and developed a career of increasing seniority in children’s services delivery and regulation. Alongside her employed role, she has also undertaken independent work chairing serious case and serious incident reviews, and delivering training on child protection and safeguarding. Following six years as a senior civil servant in the role of divisional manager with Ofsted, where she was instrumental in setting up and subsequently managing early years and children’s services regulation for the north of England, Nancy went on to spend 18 months as a government advisor on children’s services before becoming the Operational Director for the north of England with Cafcass. In July 2009 she Page 20 of 89 took the decision not to continue working full time and now holds a part time portfolio of work including the role of independent LSCB chair and other ad hoc work mainly in relation to children’s safeguarding. 80. Peter Maddocks was commissioned in December 2011 as the independent author for this overview report. He has over thirty-five years experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and was registered with the General Social Care Council now superseded by the Health and Social Professions Council (HSPC). He undertakes work as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several LSCBs in England and Wales. He has undertaken training in regard to systems learning and its application to serious case reviews. 1.12 Parental and family contribution to the serious case review 81. Amanda Hutton and father were made aware of this serious case review at the outset. In view of the separate investigation by the police as well as the coroner’s enquiry the serious case review panel had to ensure that any contact with the family was the subject of appropriate consultation and advice. The panel used the national guidance agreed between the Association of Chief Police Officers (ACPO), the Crown Prosecution Service (CPS) and the Directors of Children’s Services in England9. 82. Both parents initially confirmed that they wished to provide information for the review and had agreed to speak with the independent chair of the panel. Regrettably, in spite of several attempts to contact both parents it was not possible to speak with either of them during the course of the SCR apart from a brief conversation between the BSCB manager and Amanda Hutton that confirmed she was willing to speak with the panel chair. The chair of the panel and the BSCB manager each made several efforts to contact both parents by letter, telephone and text. The panel chair had a brief discussion with Amanda Hutton on the telephone and although a meeting was planned Amanda Hutton did not keep to that appointment. 83. Following the trial the children’s father agreed to meet with the manager of the BSCB. During that discussion the father made clear that he had been unaware that Hamzah had not been registered with a GP and had not had any immunisations. The children’s father denies responsibility for domestic abuse to Amanda Hutton although does acknowledge the conviction. He refutes that he was resistant to help for example in regard to the domestic abuse. The children’s father believes that although he has been subjected to racist attitudes he does not believe that his relationship with Amanda Hutton was a source of difficulty or hostility for some people in the community. The children’s father has expressed his surprise about the degree of resistance that Amanda Hutton had to offers of help. The children’s father has expressed his surprise that people 9 A Guide for the Police and the Crown Prosecution Service and Local Safeguarding Children Boards to assist with liaison and the exchange of information when there are simultaneous chapter 8 serious case reviews and criminal proceedings; April 2011. Page 21 of 89 did not contact him when there were concerns for example about the attendance of children at school. 1.13 Time scale for completing the serious case review 84. The case review panel met on seven occasions between January 2012 and September 2012. The initial chronology of services involvement was completed by January 2012. The first draft of the narrative agency reviews were completed in February 2012 although final drafts including agency analysis were finalised in March 2012. The first draft of the health overview report was completed in June 2012. The final report was presented to an extraordinary meeting of the BSCB on the 3rd October 2012. 85. There is an expectation that serious case reviews are completed within six months of being commissioned. A short extension to the timescale was agreed by the independent chair of the BSCB. This occurred as a result of several IMR authors and panel representatives being required to give priority to their participation in the statutory inspection of children’s services that took place in Bradford in May 2012. 86. Following the completion of the trial in October 2013, the chair of the BSCB arranged for a further examination of the information revealed during the trial prior to finalising the overview report for publication. That review involved the author of this report, the chair of the SCR panel and the BSCB manager reviewing what additional or new information that had become available through the trial with the assistance of a senior police officer. It was decided not to reconvene the full SCR panel to avoid undue delay to the publication of the overview report and executive summary. 1.14 Status and ownership of the overview report 87. The overview report is the property of the Bradford Safeguarding Children Board (BSCB) as the commissioning safeguarding board. Since June 2010, all overview reports provided to LSCBs in England are expected to be published. In view of the level of public interest that the case represents and the extent of the media coverage already given during the trial, the names of Hamzah and of the mother Amanda Hutton are used. 88. The overview report is primarily written with the intention of addressing professionals involved with the design, oversight or delivery of multi agency safeguarding services although it should also provide accountability and information to other interested parties. The executive summary provides a more accessible and shorter account of the key findings from the review. 89. The review aims to build on the considerable knowledge and expertise that has developed in relation to the safeguarding of children in the UK. In doing this work, the panel are mindful about how complex or opaque some of the information and events may have looked to practitioners at the time of the events. 90. The BSCB will determine how and what further information is provided to the family at the conclusion of the review and following the submission of the overview report and executive summary to the Department of Education. 91. The serious case review will not be the subject of a formal evaluation by Ofsted; that arrangement was ended in July 2012. The serious case review and the Page 22 of 89 associated action plans will be examined as part of the unannounced inspection of arrangements to protect children that takes place in all English local authority areas with children’s social care responsibilities. 1.15 Previous serious case reviews 92. The LSCB in Bradford has published executive summaries of four serious case reviews undertaken between 2006 and 201010. 93. Reference is made to these previous serious case reviews by several IMR authors and is also referenced where relevant in this overview report. The purpose of this is to highlight where similar issues or themes have been identified in previous reviews. This ensures that any action already recommended is not unnecessarily repeated. Themes relevant to this review include poor school attendance, domestic violence, the resistance of some families to professional help and support and the role of primary health professionals such as GPs in collating information and recognising safeguarding concerns. 94. There is evidence from other serious case reviews nationally that demonstrate a significance of injury to children from larger sibling groups. 95. Chapters four and five of this review describe in greater detail the specific lessons to emerge from a detailed analysis of this serious case review and include comments on how learning from previous reviews has been used. 1.16 Inspections of services for children in Bradford 96. All children’s services in England are subject to inspections. The local authority was subject along with all other local authorities in England to a Comprehensive Annual Assessment (CAA)11; in 2010 and 2011 the CAA annual rating given to children’s services in Bradford was adequate12. This meant that services were meeting minimum national standards. 97. The annual unannounced visit13 of inspection of contact, referral and duty arrangements for children that took place in late 2010 and 2011 judged 10 The coalition government’s notice issued on the 10th June 2010 under section 16(2) of the Children Act 2004 which amended the previous national guidance in Working Together to Safeguard Children requires that both the executive summary and the overview report with suitable redaction to provide confidentiality are published. The coalition government ended the formal evaluation of SCRs from the 5th July 2012. 11 The coalition government abolished the CAA from 2010. 12 This profile includes findings from across Ofsted’s inspection and regulation of services and settings for which the council has strategic or operational responsibilities, either alone or in partnership with others, together with data from the relevant Every Child Matters indicators in the new National Indicator Set (NIS). Every Child Matters was not continued as a policy framework by the coalition government. 13 The inspection was carried out under section 138 of the Education and Inspections Act 2006. It contributes to Ofsted’s annual review of the performance of the authority’s children’s services, for which Ofsted will award a rating later in the year, subject to any changes that the coalition government may introduce. The inspections are part of a national programme of enhanced inspection of children’s services introduced in 2009 following the death of Peter Connolly (Baby P) and the two subsequent serious case reviews in Haringey. Page 23 of 89 services to be adequate. That inspection reported that there were effective arrangements in place to refer and respond to concerns about children. The inspectors noted that the number of domestic violence notifications sent to social care by the police resulted in a higher than necessary workload for assessment teams and both of the services recognised the need to streamline this process so that referrals were clearly differentiated from notifications sent through only for information purposes. 98. Bradford’s children’s services were judged to be ‘good’ with ‘outstanding’ partnership working, following a two-week investigation carried out in May 2012 into how children in care, foster children and those leaving care are being looked after and how safeguarding services were working across the district to protect vulnerable children from abuse and exploitation. 1.17 Synopsis and summary conclusion of the review panel 99. Several aspects make this a most unusual case and therefore care has to be exercised in distinguishing between any lessons that are simply an application of hindsight with this one specific case and the more general areas of learning about how local systems for safeguarding children can be developed further. 100. A compelling aspect of the case for general learning is the extent to which none of the various organisations that came into contact with this family had enough information to form a view about what life was really like for any of the children in this household especially during the last few years. 101. The lack of focus on the needs, wishes and feelings of children is a consistent theme in serious case reviews. In this case there were specific occasions when some of the children expressed clear views and wishes that were given different inference by key services. One of the older children had been very unhappy although at the time it was interpreted as being the teenage angst of an adolescent rather than something more serious. 102. Information known to the various agencies at the time of the events that have been examined and analysed by the panel does not suggest that Hamzah’s death was a predictable event. Preventing his malnourishment required Hamzah to have been seen by professionals who could monitor his well-being.. Such monitoring should have resulted in his malnourishment and neglect being identified and would have been a cause to make referrals under the safeguarding protocols to CSC and the police. 103. The fact that Hamzah was not registered with a GP practice in the city had been noticed by a health visitor in 2010, who initiated enquiries into his whereabouts, and those of 2 other young siblings. However, this was after Hamzah had died. 104. The subsequent enquiries by health, CSC and education services did not establish as a matter of verifiable fact where Hamzah and the younger siblings were living, having been misdirected by Amanda Hutton. This extraordinary case will cause local and national agencies to consider how a child such as Hamzah can be kept in view of their community and local services. 105. The misdirection required Amanda Hutton to convince her older children about the account of the younger siblings staying with relatives in other parts of the country. The fact that the locations stated varied may have been a lack of Page 24 of 89 consistency in the story being told or the recording and sharing of the information by professionals. The ability to persuade several services that the younger children including Hamzah were no longer living in the city and had effectively disappeared will require thoughtful reflection in regard to the prevention of children going missing at local and national levels. 106. Hamzah’s absence from health visiting and GP services was being followed up in the summer of 2010 and advice was sought from the specialist safeguarding advisor. It was the health visitor’s enquiries that initiated the missing from education protocol in October 2010 when the health visitor was enquiring about the whereabouts of the youngest children. It is of course known now that Hamzah had already died and his death had not been reported by Amanda Hutton. 107. The pattern of Amanda Hutton avoiding health care professionals had been a longstanding pattern of behaviour that had she put down to being afraid of doctors. The reasons for Amanda’s reluctance to use health services were not explored at the time; at least there is no recorded evidence. The fact that she was a reluctant user of primary health care services was identified and was pursued by the GP and the health visitor for several months although the last time that the GP saw Amanda Hutton was in September 2006, although she had a telephone conversation with a GP in July 2007. 108. The fact that Hamzah was entirely “off the radar” of services for so much of his life was an indicator of concern although was not recognised until 2010 partly because nobody had a complete overview about the situation. The usual procedure for routine health care surveillance was undermined by Amanda Hutton’s complete withdrawal from every service. The extent to which the younger children were never seen by any health professional after the first birth contact is quite out of the ordinary. 109. A reluctance or lack of engagement with professionals such as midwives, health visiting and GP services are now more likely to be regarded as indicators of concern because these are some of the patterns that are increasingly understood to be contributory to a child’s safety and emotional well being (and was a factor in the health visitor initiating inquiries in 2010). 110. The GP practice had removed Amanda Hutton and the children from the register in October 2009 due to her persistent lack of response to appointments to have the children seen and to have the opportunity for routine care such as immunisations. If Hamzah had for example been seen by a GP prior to being removed from the register it would of course have been an opportunity for evidence about the extent of malnourishment that contributed to the death in December 2009 to be diagnosed. It is not a requirement for a GP to see a child before they are removed from the register. Hamzah had never received any of the routine immunisations which in itself was an indicator of concern. 111. There was a telephone contact with services in March 2011 which is analysed in greater detail in later sections that was also made after Hamzah had already been dead for several months. The checks made in response to the phone call relied on conversations with the older children at school. The checks that were made as a result of the phone call did not raise new or heightened concerns although if a home visit had been completed it would have clearly been an opportunity to check on the physical conditions within the home. Page 25 of 89 112. If the extent to which there was such a marked decline in the parenting provided by Amanda Hutton had been known, this would have provided a more focussed and concerning context for enquiry and assessment particularly by CSC or the police. Although the older children’s attendance at school was not consistent and they appeared neglected on occasions this was not a consistent pattern. There was contact with CSC again in July 2011 which reported the filthy conditions although as before in March there was an incorrect assumption that the youngest children were not living at the house. 113. There was one occasion when Hamzah’s father had expressed concerns about Amanda’s care of the children although this occurred after he had been arrested for assaulting her. He was advised to report his concerns to CSC but there is no record of this being done. 114. The evidence of domestic violence and the reluctance to engage with primary health care services were seen in isolation in large part because no single agency had a lead responsibility either by initiating a CAF (common assessment framework) or by a statutory route such as child in need (CIN). The lack of focus on what the children were saying or could have been encouraged to discuss more is also commented upon in other parts of the review. Matters are complicated in this case in as far as Amanda Hutton appears to have been a more caring parent at the outset with her older children but had clearly developed a chronic neglect in regard to the younger children. 115. Later chapters of the report provide the context for why the information that was reported and looked at was processed in the way that it was and considers what factors contributed. This takes account for example of the inherent barriers that professionals face when trying to respond to victims of domestic abuse, deal with substance misuse as well as the acknowledged shortcomings in how for example assessments were structured and conducted at the time, locally and through national systems. There were workload pressures that led to shortcuts in some aspects of the work. 116. The true extent of need within the family was therefore insufficiently known and the barriers for accepting professional help were not understood well enough at the time. None of the children’s views, wishes and feelings was given enough focus and priority even when some of the children explicitly sought help or came to the attention of support services. 117. Several professionals tried to offer help at different times although none were able to overcome the resistance that was exhibited by both of Hamzah’s parents. In regard to Amanda Hutton the behaviour is characteristic of women who have experienced abuse and violence over many years and presents significant challenges for professional practice. In regard to the father, he was reluctant to acknowledge his abuse and violence and sought to minimise it even after conviction. Again this is behaviour that professionals working with both victims and perpetrators will recognise. 118. The extent to which both of the parents were unwilling to accept help or advice and presented barriers to various professionals has become more apparent through the detailed collation of extensive information for the review. 119. A feature identified in other reviews nationally is how mind-sets can prevent a fresh look at information that appears to resemble or be consistent with previous reports which on their own do not arouse higher levels of curiosity or Page 26 of 89 concern and especially in services that are already under significant workload pressure. The mind-set that prevailed here was that Amanda Hutton had problems but was not considered to be a risk to her children. 120. The impact of domestic abuse on the emotional health of adults and children is becoming much better understood and for example national guidance emphasises that it is a source of significant harm for children and requires an appropriate response in regard to enquiry, assessment and the help that is provided. 121. Different factors influenced decision making at key moments. For example changes to working arrangements, the impact of events such as Baby P on the workload of local services as well as a genuine desire to try and support a family dealing with what were seen at the time as the tensions between adolescent development and parental control. 122. The three youngest children (Hamzah, Sibling 2 and 3) were never enrolled for education (including any early year’s provision14) and the primary health services had very limited contact. The implications of that are explored in the IMRs and the health overview report (HOR) and the later sections of this report. 123. When one of the children asked for help, this did not provide a clear enough opportunity to develop a better level of knowledge and understanding about the children’s needs and circumstances. There were opportunities to explore inconsistencies; for example the children could arrive in school clean and well-dressed whilst at other times displayed symptoms of neglect, the most acute being the physical condition of one of the children observed by the school nurse in regard to tooth decay which is indicative of longer standing and more persistent neglect. There was the limited understanding about the barriers (especially for Amanda Hutton in regard to the domestic violence and abuse) to accepting help or advice. Domestic abuse has a corrosive and long term impact on the victim as well as being emotionally damaging for any children living in the same household. 124. Other complications arose because information was inaccurately recorded or poorly shared; for example one of the IMRs comments on the number of people dealing with enquiries about the youngest children missing from education and how that contributed to fundamental misunderstandings. The children’s centre had wrong information about the age of Hamzah and Sibling 2 that contributed to them not having accurate reference points for judging the children’s social and physical development on issues such as using their fingers rather than a spoon to feed themselves. Now that the extent of Hamzah’s neglect has been revealed this takes on even greater significance. 14 The ESWS IMR explains that as Bradford adopts a rising fives admissions policy Hamzah and 2 would have been expected to start school in September 2009. By September 2010 Hamzah and 2 should legally have been in school. Sibling 3 would have been expected to start school in September 2010 but legally not required to be in school until September 2011. Page 27 of 89 125. The only multi agency discussion which was limited took place at MARAC15 and this was focussed on the risk to Amanda Hutton and not upon her children. There is a far better understanding now about the significance and implications of domestic abuse on the emotional, psychological as well physical health of children that has been enshrined in law and national guidance regarding significant harm. That level of understanding was different in 2008. 126. Not all of the relevant services such as the GP were aware of the discussion at MARAC or the decisions; if they had been there may have been a different approach to the lack of contact with Amanda Hutton and the children. The MARAC had only recently been established and for example CSC did not have consistent representation at the time. Other agencies such as education and early childhood services were represented but the people attending the meeting did not communicate information within their own service and did not apparently implement the actions that had been agreed. Some of this reflected insufficient understanding about the purpose of MARAC as well as understanding the heightened risk of further abuse that is associated with making disclosures of domestic abuse or trying to leave a violent relationship. 127. Domestic violence, depression and substance misuse were persistent features that are now revealed far more clearly as a result of the detailed work of the review in collating information from different services. There was for example a significant level of involvement by Staying Put services with Amanda Hutton for over two years in regard to the domestic violence and abuse but was not integrated and shared with other services. The involvement of Staying Put was largely unknown to other services and therefore the detailed information disclosed to that service was not shared with other professionals. 128. The absence of clear disclosures or not seeing the information such as the failure to attend immunisations as a source of harmful behaviour rather than isolated incidents contributed to the lack of assertive and pro-active approach in the case. 129. Achieving a better understanding about prevalence and significance of domestic abuse, depression and substance misuse as being a considerable and detrimental feature of life for children in the family requires time and patient persistence and represent a complex challenge for professionals who need to have time as well as the appropriate skill and resilience to have more quality contact with vulnerable children and troubled families. 130. Much of the characteristic behaviour associated with domestic abuse both on the part of perpetrator and victim are exhibited in this case; the lack of acknowledgement and responsibility for the violence by the perpetrator and the difficulty for the victim in accepting help or leaving the violent relationship. The reluctance to access or accept help arise from a complex number of factors such as fear of repercussions, complications arising from responsibility for children, fear of losing housing and income as well as reconciling emotions and feelings for a partner. The impact of long term abuse and coercion on victims is explored in the final chapter of this report. 15 MARAC is focussed on cases of higher risk of domestic abuse with the purpose of developing strategies to help the victim to be protected; it is often a moment of heightened risk when the perpetrator of domestic abuse knows that the abuse is being disclosed. Page 28 of 89 131. The context within which the services operated at different times are also a feature explored through the review. For example the publicity of the “Baby P” case in London had a profound impact on some services such as CSC. They were dealing with a significant increase in referrals that coincided with difficulties in retaining sufficiently trained and experienced staff; it also coincided with the implementation of new systems of working and information management. 132. The education welfare service describes how it was moving from a traditional school absence service that relied on threats of prosecution to a service that seeks to balance enforcement with support and engagement with vulnerable families that have a range of complex needs. 133. Some of the IMR authors also describe the very real dilemmas that are presented when for example a key professional who is crucial in terms of their knowledge and relationship with a family becomes ill, experiences bereavement or leaves a job. The report describes how for example Amanda Hutton had great difficulty in developing trust in professionals with some notable exceptions for example in relation to PC8 who supported her following incidents of domestic abuse. 134. The GP IMR discusses the changes that have occurred in general medical practice; ensuring that GPs have information about MARAC discussions, the introduction of new safeguarding training and systems for identifying information about the welfare of children; the IMR acknowledges the challenges of GP consultations that are based on time limited ten minute consultations especially with patients who only present at a point of urgent need. The manner in which services such as primary health care are commissioned and contracted are discussed in both the HOR and the later chapters of this overview report; for example, there are perverse incentives that can lead to disengaged and reluctant families becoming even more isolated from core and universal services as happened in this case. 135. The reluctance of Amanda Hutton in particular to have contact with any service and the degree to which this was able to dominate the interaction with different services who were unable to manage or overcome the resistance; a clearer focus on how the children were being effected and the need for clearer impetus to a more assertive approach. This is where structured multi agency discussion and seeking legal advice can be helpful and is something that is far better understood now and is enshrined for example in the revised local assessment frameworks. 136. Some professionals demonstrated a better understanding about the barriers facing Amanda Hutton for example by getting help in regard to domestic violence, although this was not collectively understood and in any event none of the agencies were able to achieve an appreciable engagement by either of the parents. Underlying patterns such as Amanda Hutton’s readiness to accept practical help in regard to matters such as housing but her rejection of the contact that made demands upon her in respect of issues such as improving school attendance were not recognised at the time. 137. Amanda Hutton’s reluctance to accept help was poorly understood in terms of what the barriers might have been especially in relation to the domestic violence she suffered. There was insufficient attention given to the implications of factors such as domestic violence and substance misuse on the children and Page 29 of 89 their emotional as well as physical care and well being. Reports that the children seem ‘safe and well’ address only that the children do not appear to be physically at risk rather than offering clearer insight about the emotional and psychological impact. The review discusses the limitations of some of the tools and frameworks available to help professionals make appropriate judgments. 138. Great reliance was given to Amanda Hutton providing consent for different interventions or support when a more assertive approach would have given more explicit consideration to the needs of the children and probably sought to override parental objections including if it had been necessary and subject to legal advice, going to court for an appropriate order. Legal options were not considered because key services never believed that the children were suffering harm at the time. 139. Amanda Hutton’s use of alcohol was not seen at the time as problematic and on some occasions there was an absence of certainty as to whether she was drinking or not. It was periodically observed when some agencies including the emergency services had access to the house or received third hand reports from members of the family including some of the children. The use of alcohol as well as the domestic abuse is a behaviour that adults will often want to disguise or keep hidden from view. 140. There are examples of good practice where for example individual professionals have sought to gain the confidence of Amanda Hutton and to offer considerable emotional and practical support far in excess of what would be expected from their professional or service remit, although this was not sufficiently coordinated across the different services that came into contact with the family. 141. Apart from the MARAC, there were no interagency meetings or formal discussions although there were discussions that took place over telephone or email or took place within single agencies; the consequence was that individual people and services were always dealing with incomplete information. When processes such as statutory assessments or the missing from education protocols were invoked they were not completed to the level of detail required; some of the factors that caused this have been referred to and are analysed in further detail later in the report. 142. The MARAC discussion was focussed on Amanda Hutton as a victim of domestic violence and there was insufficient account of the impact on her capacity to meet the needs of her children. 143. Safeguarding referrals that were made were then dealt with outside of the frameworks for strategy discussion and the information that was collated never triggered a threshold to convene a multi agency child protection conference. Recording of information was made using process logs rather than within needs assessment frameworks; some of this reflected taking procedural shortcuts to deal with workload demands. 144. When one of the children was physically assaulted and had sought help this led to a disagreement between the police and children’s social care services about what action was required. The outcome was that the child returned home. It was managed as a parent and teenager conflict. Page 30 of 89 145. Opportunities to engage father in terms of his violent and abusive behaviour were largely undermined by his reluctance and inability to acknowledge and to take responsibility for his behaviour. 146. There is fundamental learning to emerge for example in regard to applying procedures and protocols with a greater level of curiosity and understanding. This is not making a point about bureaucratic compliance. An example is the degree to which the reports of the children missing were largely treated as administrative liaison arrangements between different services within Bradford and with other areas in southern England rather than providing a ladder to escalate the level of enquiries. It not the following of the procedure but rather what the information has revealed that has to be the focus for deciding an adequate outcome has been achieved. 147. The BSCB and its partners will want to reflect upon the manner in which vulnerable families can disappear from the purview of essential services such as primary health, education and early childhood services and the manner in which commissioning and contracting arrangements can create perverse incentives in relation to providing access to services for vulnerable families and children. 148. The Munro Review commissioned by the Coalition Government in 2010 has stressed the importance of looking at such information within the context of people’s professional and organisational arrangements. Individual professionals are influenced and affected by the circumstances within which they work. 149. Such influences include the stability of the organisation they work in, the workload of individuals and their services, the quality of their training and knowledge, the clarity of working arrangements in matters such as how essential and relevant information is recorded and shared meaningfully. In this case there are specific issues such as how contracts are specified for the delivery of primary health services. There were the workload problems already referred to in some of the services that led to short term measures that contributed to insufficient analysis and collation of information. On a more limited scale there were also personal tragedies and difficulties that influenced the capacity of specific professionals. 150. Research and the evidence from other serious case reviews that is referenced in the IMRs and in later sections of this report shows that abuse is the product of several different factors and the complex interplay between them and the influence of family attitude and behaviour, professional reasoning and the action of all involved. Other serious case reviews identify the prevalence of depression, substance misuse and domestic violence as a background to many of the cases that involve the serious abuse or death of children16. 151. A more sceptical and enquiring approach combined with a predominant focus on the children creates an improved opportunity for better analysis about a 16 A national study in 2007 reported that domestic violence was a factor in 66 per cent of serious case reviews, substance misuse was a factor in 57 per cent and mental ill health was a factor in 55 per cent; overall over a third (34 per cent) featured all three factors combined and has been described as a ‘toxic trio’ by some commentators. Understanding Serious Case Reviews and their Impact 2005-7: A Biennial Analysis of Serious Case Reviews 2005-7, DCSF. Page 31 of 89 parent’s decision making and the extent to which they are able to put her children’s needs first. 152. Other serious case reviews locally and nationally also describe the extent to which help that is provided to vulnerable children or troubled families is delivered through a “silo” approach where individual people and services are focussed on their single agency issues, although there are instances in this case where individual professionals in the police and YOT for example tried hard to access other support from outside their own agency17. 153. Overcoming issues such as working in different agencies does require busy people having the capacity to talk with each other as much as doing their own core job. The factors are multi-facetted and includes over identification with the needs of Amanda Hutton, a lack of sufficient sceptical enquiry for example in regard to the disappearance of some of the children from health, education and social care systems, a reluctance to engage Amanda Hutton on anything more than a voluntary basis and an inability to identify the significance of the various and cumulative indicators of risk over time. 154. The importance of sharing information effectively and using it to think about what further enquiries should be made is highlighted in several of the IMRs. The majority of services had some knowledge of some indicators of potential risk and vulnerability but it did not lead to any further sustained concerted collective action. 155. Some of this reflected inadequate recording and gaps in information when practitioners were dealing with incidents. An example is one of the social workers not having full information about discussions at the MARAC; schools did not know about key decisions and the GPs were completely unaware. 156. There are other factors explored in the final chapter of this report in particular regarding the adequacy of tools that professionals have to make sense of opaque or contradictory information. Even when the assessment frameworks are used they represent considerable difficulty to practitioners in being able to describe and analyse risk. These frameworks have been abolished in national guidance since the death of Hamzah and work is already being completed on developing more appropriate single child assessment frameworks locally. 157. The only explicit risk assessments described in the IMRs was offence related; one was the OASys system18 in probation that is primarily focussed on father as the offender and his offence. The YOT also completed an assessment in regard to the work with Sibling 8. The assessments did not achieve a complete picture of information about the family but were consistent with national standards and 17 The limitations imposed if professionals are not able to look at aspects of the children’s needs outside of their own specific brief and is a significant theme identified in Understanding Serious Case Reviews and their Impact A Biennial Analysis of Serious Case Reviews 2005-07DCSF 18 OASys is the abbreviated term for the Offender Assessment System, used in the England and Wales by Her Majesty's Prison Service and the National Probation Service from 2002 to measure the risks and needs of criminal offenders under their supervision. Page 32 of 89 requirements for offence related work. The importance of ‘Thinking Family19’ was discussed by the probation IMR author and is echoed in the reflections of other agency reports from education and other disciplines. 1.18 The family and other significant people 158. Until the trial, very little information had been known about the history of Hamzah’s family or of either parent’s background and reflects the limited extent of enquiry, assessment and recording generally. 159. This had implications for aspects of practice and contact with the family. For example, the significance of the relationship between Amanda and her mother was not properly understood and therefore the traumatic sense of desolation and isolation that she felt particularly as the relationship with the children’s father became even more estranged. 160. The first record of domestic violence had been in May 1996. It is thought that there had been previous incidents that were not reported and this would be consistent with research evidence that disclosures of abuse are usually made only after several incidents20. There were ten specific incidents recorded by the police between 1996 and 2008 although there had been other contacts where more generalised comments about domestic violence were disclosed. 161. Hamzah’s mother is white British and father is Asian British Pakistani. Both parents speak English. They met as teenagers. It is believed that both had happy childhoods and they both have siblings. Father does not have any contact with any of his siblings. 162. Amanda Hutton became pregnant with her first child (Sibling 7) 18 months after she had met father outside a local night club when she was aged 16 in 1986. Amanda Hutton’s mother had just married her stepfather who Amanda Hutton had known since she was 13 years old. Amanda Hutton came from a relatively comfortable family and had attended a local grammar school. Amanda left school before completing any “A” levels and moved out of the family home into a local flat. She worked briefly for a printing company, and also worked in the distribution department of a major retailer. 163. The maternal grandmother maintained contact with her daughter and was a significant source of emotional and practical support until her death in December 2007. Amanda was in daily contact with her mother until then, sometimes phoning three or more times during a day and having long conversations with each other. 164. Amanda Hutton’s mother’s death which occurred after a long illness was especially traumatic for Amanda Hutton and coincided with what appeared to be a marked deterioration in the relationship with the father of the children. It is significant that during a conversation with a health visitor in 2008 Amanda 19 Think Family was supported by a toolkit published by the previous government in 2009; it has been withdrawn by the coalition government. 20 Research evidence shows that domestic violence has more repeat victims than any other crime; there will be on average 35 assaults before a victim calls the police. Page 33 of 89 Hutton stated that she had lost complete confidence in the health service when her mother died. 165. Although Amanda stayed in contact with her stepfather for a few months after the death of her mother, they gradually lost regular contact with each other. 166. According to third hand information from members of the family Amanda had been a typical teenager who had enjoyed music and had taken pride in her appearance. Although Amanda Hutton appears to have avoided health professionals for much of her life including ante-natal appointments she appeared to adapt to becoming a mother during her first pregnancies. Amanda’s step father was nursed by Amanda for about three months following an operation and she was caring and considerate. 167. Amanda had started drinking alcohol when she was a teenager although it appears to have become far more problematic as the relationship with the children’s father had deteriorated. 168. At the time of Hamzah’s death, the parents had already been separated for about a year. Amanda Hutton had been granted a non-molestation order in December 200821. 169. There had been concerns about domestic violence since 1996 although there had been several months between incidents being reported to the police. Significantly, the next incident reported after 1996 was in March 2003 when Amanda Hutton declined to make a statement and no further action was taken. 170. Professionals including specialist police officers will recognise that this is a common pattern of behaviour from women living with abuse who fear the repercussions of intervention although is behaviour that is less well understood by people who have less experience or specialist training and awareness. 171. Amanda was assaulted again in June 2003. In September 2004 Amanda Hutton was assaulted by father with a coin bag when there was no hot water for him to have a shower. Amanda Hutton again declined to make a statement or to accept help. Amanda Hutton made contact ten months later but not about specific incidents and also again in December 2005. There was a further incident in December 2006 when one of the children went missing. 172. In May 2007 one of the children complained that both parents assaulted them. In July 2007 there was a breach of the peace when Amanda Hutton stated that she felt trapped in the relationship, did not know how to get out and was described as very lacking in confidence. Amanda Hutton was unwilling to make any complaints to support a prosecution22. Amanda declined to go to a refuge 21 Reference is made in other parts of this report to other measure that have been introduced to help agencies such as the police deal with domestic abuse; an example is the use of domestic abuse prevention notices which were introduced this year. 22 Reference is made in other parts of this report to changes that have and continue to be made in relation to domestic abuse; for example the introduction of Domestic Violence Prevention Notices are one of the new powers given to police to take action against perpetrators without having to go to court or have the cooperation of a victim of abuse and violence. Page 34 of 89 for fear of reprisals. Amanda agreed to have a referral made to a local organisation working with women in abusive and violent relationships and she was also referred to the housing service and registered with the house hunter service. 173. In December 2007 there was an assault on Amanda Hutton by the children’s father in the family home. She provided contradictory information and the father denied assaulting Amanda Hutton. Amanda was contacted by a Staying Put worker who was told by Amanda Hutton that she was only allowed out of the house to do a brief shop of about 30 minutes each week and often had her telephone taken off her. 174. In February 2008 Amanda Hutton went to the police station to report that she had been physically assaulted. The domestic violence unit was unable to contact her subsequently because her phone was going to voicemail. 175. In May 2008 a police report refers to Amanda Hutton still living with her ex-partner when she reported being assaulted again at the house. Amanda Hutton was unwilling to speak to any police officer except to PC8 who had provided a response and support in previous contacts from as early as 2005 and had several contacts in the preceding months when Amanda Hutton had been unable to engage. That officer was not available. 176. The first referral to MARAC was made in July 2008 that collated information about 11 incidents since 200323. A further discussion at the MARAC in August was attended by PC8 who had managed to secure Amanda’s trust previously and told the MARAC that Amanda probably was at significant risk but was not disclosing information. At the end of November 2008 Amanda Hutton contacted PC8 saying that father was forcing her to leave the house. PC8 helped arrange interviews with housing services and encouraged Amanda Hutton to seek legal advice. 177. Under the arrangements that have been brought in now, the police would have the option of giving direction to the perpetrator and have powers to place restrictions on contact. Amanda Hutton was re-housed. Within 24 hours father broke into the property and assaulted Amanda Hutton as well as one of the children. Father was arrested and it was during the interview that he made comments about concerns regarding the children. 178. Father was subsequently convicted and a non-molestation order had imposed controls on him coming to house where Amanda Hutton lived. Father denies that there was domestic violence in the relationship in spite of the evidence from information such as police records. Although he attended meetings with his offender manager he was reluctant to acknowledge the domestic abuse and was disruptive when he did attend the integrated domestic abuse programme (IDAP). 179. For example, he attended the IDAP at the end of July 2010 and told everyone from the outset that he did not hit women as those men that do should go to prison. He blamed his partner and women in general because ‘they get you into trouble’. He was given the option to leave at the beginning and then at the 23 CSC was not represented at the MARAC. Page 35 of 89 break but he decided to stay. He was very vocal and had to be asked to be quiet and to listen24. 180. The parents had some contact with each other after their separation. For example in September 2009 father’s offender manager was told that Amanda Hutton had gone to father’s property following telephone conversations earlier in the evening. Amanda Hutton was described as very stressed. Father talked to the offender manager how Amanda Hutton and he had discussed how destructive their relationship had become and father was unsure how to be involved with his children. This contact occurred less than three months before Hamzah died. Before that contact, in June 2009 father had talked with the same offender manager about being uncertain about arrangements for contact with his children. 181. The family was removed from the roll of the GP practice in October 2009 after persistent non attendance for routine health appointments and had failed to respond to letter and other contact. 182. Five of the children had been enrolled at Bradford schools and had histories of problematic attendance at school. The three youngest children (including Hamzah) had not been enrolled at school or with any early years provision. No applications had been made. 183. The education welfare service (EWS) was significantly involved in attempts to achieve improved levels of school attendance and to establish the whereabouts of the three youngest children after the health visitor initially identified that Hamzah was not registered with any GP. 184. There had been some indication that Amanda Hutton experienced depression and had some reliance on alcohol. She was resistant to the involvement of professionals and this increased over time. 185. During the investigation into the circumstances surrounding the death of Hamzah, one of the older children stated that life ‘began to go downhill’ after the birth of Sibling 6, and from aged 11 years there were issues with Amanda Hutton’s use of alcohol and cannabis. He says that he was punched and slapped by his mother from the age of 12 years and that she drunkenly stabbed him with a kitchen knife when he was 13 years old, although this specific information about the use of a knife was not reported to the police at that time or to any other service. 24 He was suspended from IDAP because of the disruption and missed sessions. He was not happy about the suspension and thought he was being unfairly treated. Given the minimisation around the index offence of domestic abuse and the suspension, it was decided to take IDAP requirement back to court and have this removed which happened at the end of November 2010. The revocation application outlined the reasons for the request including the requirement being unworkable, owing to father’s disruptive behaviour at IDAP session, his minimisation and continuing denial. The report outlined that work would be carried out on an individual basis. His attitude did not change and by the last individual session in May 2011 he continued to blame Amanda Hutton for putting him ‘on probation’. Page 36 of 89 1.19 Cultural, ethnic, linguistic and religious identity of the family and their community 186. Hamzah’s father is British Asian and is Muslim. He has worked as a taxi driver and a mechanic. Amanda Hutton is white British. None of the agencies had information about any religious affiliation. 187. Just over 76 per cent of the population in Bradford is white compared to a national average of 97 per cent. Almost 34 per cent of 0 to 17 year olds are from black and minority ethnic backgrounds, the most significant group being of Pakistani heritage. Just over three per cent of the city’s school population describe themselves as dual heritage. 188. Bradford is amongst the most deprived districts in the country. It ranks as the 32nd most deprived out of 354 local authority districts in England and is in the most deprived ten per cent of local authority districts nationally. 40 per cent of areas in the district fall into the most deprived 20 per cent of areas nationally and the variance in deprivation is wide ranging, with five per cent of areas falling into the most deprived one pre cent of areas nationally and six per cent falling into the least deprived one per cent of areas nationally. 189. There are more children living in poverty in Bradford compared to the national average. A total of 61 per cent of children in the district live in low-income households, compared with 44 per cent nationally. 190. The uptake of formal pre-school childcare by low income families is lower in the Bradford district (14 per cent) than national (18 per cent) and is not increasing at an equivalent pace. Hamzah did not participate in any pre-school childcare. 191. The West Yorkshire Police deal with four incidents of domestic abuse every hour which cover other cities and towns as well as Bradford. The number of recorded domestic violence incidents in the Bradford district in the year to the end of April 2012 was 9,991, an increase of nearly 800 on the previous year. The police believe that is partly because victims feel more confident to report incidents. 192. 5,922 child referrals were made to Bradford Children’s Social Care in 2010-11. This is a rate of 460.86 per 10,000 population under 18 and was significantly lower compared to 7,547 in 2009-10 (587.3 per 10,000), this went against the national trend of a slight increase. The majority of referrals were due to concerns around abuse and neglect (85%) whilst approximately a quarter of referrals were for children who had been previously referred. Page 37 of 89 2 Overview of events 193. Amanda Hutton became pregnant with her first child (Sibling 8) 18 months after she had met father when she was aged 16 in the mid 1980’s. The parents stopped sharing the same house in 2008; the children’s father left the house after he was arrested for assaulting Amanda Hutton and he was made the subject of a non-molestation order although it clear from the information regarding the history of domestic abuse that has been summarised in section 1.18 that although they had been living in the same house they were effectively separated before then. With the exception of the two eldest children who were adults at the time of Hamzah’s death, all of the siblings lived with Amanda Hutton. 194. From the first pregnancy there was a pattern of avoiding contact with health services; the late notification of pregnancies had an impact on the planning of ante natal care. Amanda Hutton experienced low mood and depression with all of the pregnancies. The children’s father says that he was unaware of this25. By 2005 it was noted that there was some evidence of Amanda Hutton using alcohol to cope. 195. The first report of domestic violence was made in 1996; further detail of the domestic abuse that is already provided in 1.18 is not repeated in this summary. Amanda Hutton declined to make a formal complaint to the police; this was to be a repeated pattern. Further episodes of abuse and violence occurred. On at least one of those occasions it was one of the children who reported the violence and further information about domestic violence was provided by one of the children when he asked for help in 2007. 196. It is likely from information provided to the review that not all the incidents of violence were reported to services. Around the same time there were incidents in the community; the manner in which some of these were recorded and logged appeared to relate the parents being from different racial and cultural communities although the children’s father disagrees that this was the case. 197. With all of the children there were problems for the health visiting service and the GP in seeing the children (or parents). This became even more of a problem with the later pregnancies (that included Hamzah). 198. In December 2006 one of the children went to the police to talk about the situation at home and his distress about the domestic violence. The police used their powers of protection to try to arrange accommodation with CSC who were unable to find a placement. The child returned home. 199. Shortly after this there was a further incident when Amanda Hutton asked for police help although by the time they had arrived father had left the house. In February 2007 Amanda Hutton was at A&E with bruises and chest pains following an assault at home. She said that she had separated from father. 25 It is a consistent theme in reviews such as this that men are invisible to much professional practice and contact with vulnerable women or children. The lack of knowledge about Amanda Hutton’s emotional and mental well being invites refection about the degree of empathy between the parents. Page 38 of 89 There were further attendances at A&E one of which was via an ambulance that had been called to the house by one of the children. 200. At the end of March 2007 Child 8 appeared in magistrates court on charges of theft and deception and was remanded ‘as directed’ and placed with specialist foster carers for two nights before being returned home. The YOT (youth offending team) became involved. 201. In May 2007 Child 8 was injured having fallen when running away from father. The child went to A&E and whilst there asked for help to live away from the family. This led to involvement by CSC as well as the police. Child 8 was referred to the homeless service and provided with emergency accommodation. Child 8 returned home before the end of May 2007. 202. By the summer of 2007 Amanda Hutton was asking for help to find alternative accommodation away from father. Several services became involved in trying to help; this included YOT, the police as well as specialist services. In spite of Amanda Hutton asking for help, she was unable to take up appointments that were made for her. Further incidents of violence occurred later in the year. 203. It is known from information provided during the trial and from media information from members of the family that Amanda Hutton’s mother died just before Christmas 2007 which coincided with the anniversary of the death of Hamzah’s paternal grandmother. 204. There was further contact in 2008 from Amanda Hutton with the police; on more than one occasion one of the children had gone missing from home. In April 2008 Amanda Hutton asked to meet with a specific police officer (PC8) who had previously provided support. By the time the officer was able to contact Amanda Hutton she did not want to meet. 205. In July and August 2008 there was a discussion at the MARAC that had just been established26. In December 2008 there was a further incident at home when father forced an entry to the property and assaulted Amanda Hutton. He was prosecuted and received a community sentence with a requirement to attend sessions of a domestic abuse programme designed to help men to change their behaviour. He was asked to leave the group due to his disruptive behaviour and lack of cooperation. The children’s father disputes that he was disruptive and states that he was assaulted by Amanda Hutton on occasions. 206. In March 2009 Amanda Hutton moved to a new property. 207. In April 2009 three of the children were not collected from their primary school at the end of the school day. The police made a welfare visit that included checking all of the rooms in the house. One of the children did not have a bed and for another the arrangements were not clear. Amanda Hutton appeared to be under the influence of some unknown substance. The police sent information to CSC to suggest that a follow up visit by a social worker might be required. 26 Further information is provided later about the Multi Agency Risk Assessment Conferences (MARAC) that is designed to focus on addressing the cases of highest risk of domestic abuse through a coordinated safety plan. Page 39 of 89 208. In June 2009 the children’s father was convicted of an offence of battery in relation to his assault on Amanda Hutton in 2008. He was sentenced to a community order with a requirement to attend an integrated domestic abuse programme. 209. In October 2009 the children and Amanda Hutton were removed from the register of the GP practice. This followed a protracted period when Amanda Hutton had been asked to bring the children for routine health and developmental checks and immunisations and was after warnings of the intention to remove them from the practice list unless health professionals were able to see the children. 210. In late 2010 there was correspondence between health visitors, education and early childhood services and CSC which centred on the difficulties in seeing the children. By the end of 2010 and beginning of 2011 there were reports of some of the children living outside Bradford and school were noticing that at least one of the children who was attending the school was looking more neglected. Father told his offender manager at probation that the two eldest children were living with him. 211. There was an anonymous referral in March 2011 about the children. In July 2011 the school attendance service began making inquiries with the police about four of the children; this included Hamzah who had never been enrolled for education. Mother wanted services to believe that the children were living outside Bradford with relatives. Various places in the South of England were mentioned and inquiries made with another local authority that had no information; the children were never living outside Bradford. 212. In September 2011 there was a further referral to CSC. Over a period of several days a police community support officer (PCSO) made persistent attempts to see Amanda Hutton and the children without success. The PCSO made a child protection referral to CSC who requested a uniformed police officer to visit the property when Amanda Hutton had refused access to the PCSO. When the police gained access to the house Hamzah’s body was discovered. Page 40 of 89 3 Synopsis of the learning and analysis from the individual management reviews. 3.1 Summary 213. All of the individual management reviews were completed using Working Together to Safeguard Children (2010) which was also supported with additional local guidance provided on behalf of the BSCB. 214. Many of the services have already taken action or initiated action in response to improvements or areas of development identified through their individual review at the time that the SCR was being completed. 3.2 Significant themes for learning that emerge from examining the IMRs 215. The agency reviews identify themes that have implications for policy development and staff training that applies to all services working with children. In the summary of the review’s finding provided in chapter one there is acknowledgement that some of the issues to come out of this review are reflected in the finding of national evaluation and research. Important messages for learning from this review include: a) The importance of encouraging children to talk about their concerns, feelings or worries; b) Troubled families and parents who are suspicious or unwelcoming of contact from sources of help and support are also the most at risk of becoming isolated and invisible; c) Using phrases such as ‘safe and well’ to describe children’s circumstances based on short or superficial contact can create optimistic mindsets that can also influence how further information is processed; d) Ensuring that assessment practice is based on a thorough foundation of theoretical understanding and can show rigour in triangulating evidence from direct observation of children and what they say; previous history and chronology; and thorough and reflective enquiry with relevant third parties or professionals; e) Thorough and reflective practice requires people having time and capacity to spend time with children and for talking with each other in enough detail; f) Children need to be the focus of professional contact with vulnerable adults who may be reluctant to accept help or support; this means giving consideration to the influence, control and as in this case coercion that can be applied by adults determined to keep information secret; g) Concepts such as vulnerability and neglect do not reflect one off events or single behaviours; they represent a longer process of multi layered issues and patterns that will not be obvious through limited contact, observation, recording or partial sharing of information; h) Helping professionals to ‘Think Family’ and to see adult behaviour in terms of implications for their children; i) Workload pressure and contractual or commissioning arrangements can influence the capacity and focus of professional’s ability to respond to information or lack of engagement; j) Ensuring that procedures and processes that support the seeking and exchange of information in important areas such as identifying whether children are missing are not seen as substitutes for appropriate and curious professional enquiry; Page 41 of 89 k) The importance of primary health professionals in maintaining contact and oversight of pre-school children that extends further than administration of routine health care; l) The interplay of alcohol dependency, depression and domestic abuse increase the likelihood of child neglect and increase the risk of other abuse but does not predict such abuse; it therefore requires appropriately curious and proactive enquiry and assessment; m) Short cuts to systems and processes that may help ameliorate short term workload pressures may undermine the integrity and quality of critical activity such as assessment and information exchange and recording; n) Professionals are effected by the physical and emotional demands of their work that can be exacerbated by other temporary crises or difficulties that effect their performance such as the bereavement for one of the professionals in this case; o) Children may not feel able to articulate emotional and psychological distress and can face emotional and psychological barriers in providing full disclosure of information out of loyalty to their family or to other significant people in their lives; p) Emergency services such as the ambulance service (and by implication the fire and rescue services who are not involved in this case) may have significant information about families relevant to agency enquiries or MARAC discussions that is not routinely sought; q) Women who suffer domestic violence will face varied difficulties and barriers in being able to ask for and then use help and assistance; professionals need to be aware of relevant research as well as being empathetic; r) Men remain largely invisible to services that work with vulnerable children even when their behaviour as in this case is one of the sources of concern and risk for children; s) Responding to older children when they ask for help can present challenges to professional and agency orthodoxies; a teenager describing their home life as intolerable may not be describing the tensions associated with adolescent development but rather is describing harmful abuse. 216. The remainder of this chapter summarises key evidence relating to the terms of reference established for the IMRs. 3.3 Good practice identified through the review 217. To support the learning from the review the panel looked for examples of good practice. To constitute good practice, the panel looked for action or decision making that went beyond compliance with local and national policy, procedures and guidance. 218. Examples of good practice identified by the review include; a) The police took prompt action when Sibling 8 requested help because of the domestic violence; this included ensuring CSC became involved; b) The Registrar made a home visit to register Sibling 3’s birth when she was made aware of Amanda Hutton’s difficulty in being able to attend the office; Page 42 of 89 c) The police officer who gained the trust of Amanda Hutton tried to secure effective help and support in response to the domestic violence which included referral to housing and specialist advice services; d) The ambulance crew ensured that their concerns about the welfare of children was reported to CSC; e) The health visitor sought advice from specialist advisors when she was failing to get contact with Amanda Hutton and her babies in 2005; f) The discussion at the Primary Health Care Team involved the health visiting and GP service; g) The school nurse tried to make a home visit when she was concerned about lack of contact; h) When Sibling 8 attended with the injury to his thigh the A&E staff provided a place of safety and ensured that other services were contacted and continued to provide care and treatment while consultation and plans were made; i) The midwifery service arranged ante-natal home visits in one of the pregnancies in recognition of Amanda Hutton’s difficulty with attending hospital; j) The early childhood service secured access to the home after being asked to provide advice; this contrasts with the lack of success achieved by other services; k) The PCSO demonstrated very considerable persistence in gaining access to the house in 2011; they sought advice about the concerns they had and did not let the matter drop. 219. The remaining sections of this chapter summarise the most significant learning from the IMRs against each of the case specific terms of key lines of enquiry. Recognition To what extent were any vulnerabilities or needs of mother recognised and taken into account in terms of any potential risks they posed for Hamzah and his siblings and will include any information about depression, domestic violence, social or family involvement or the use of alcohol or drugs; to comment in particular on any action taken to ascertain whether there were any issues of learning or other disability or impairment relevant to agency involvement, and comment on the extent to which any barriers may have contributed to mother’s reluctance to accept help or advice. 220. With hindsight, the HOR comments that it can now be seen that the domestic abuse and isolation and the mental health issues and alcohol misuse suffered by Amanda Hutton were barriers which contributed to the family’s disengagement with services. 221. The MARAC report also refers to relevant research evidence about the severe impact of domestic violence on victims and the fact that in this case the known violence took place over more than 12 years. The MARAC author comments that ‘Low self esteem and confidence, feelings of helplessness, of being trapped and of feeling unable or unwilling to change the situation. This will have contributed to the mother being reluctant to accept help and support’. The police IMR also referred to the research evidence about the very negative impact on children of witnessing domestic violence. Page 43 of 89 222. The HOR comments on the extent to which IMRs from the community services (BDCT) identified the vulnerabilities of Amanda Hutton; these included recorded information about the domestic abuse, mental health difficulties, debt, isolation and lack of support, misuse of alcohol, managing eight children, at times as a single parent, and the lack of acceptance in some of the community where they lived as a white woman with an Asian partner. 223. All of these issues were recorded in isolation as separate events and there was little chronology within agencies linking them to reveal the picture of overall vulnerability. The authors comment about the absence of evidence that would suggest any in-depth analysis of these issues or any action planning or linking of information that would have highlighted the potential risk to Hamzah and his siblings. The HOR refers to evidence from Ofsted evaluations of SCRs nationally that describe the extent to which the child’s perspective is rarely evident and is reflected in this case. 224. Similar issues are identified with regard to the domestic abuse and possible post natal depression; there is no evidence that information was shared with other primary care professionals from midwives or that vulnerabilities were explored and help offered. The A&E department similarly appeared to take information about the assault of Amanda Hutton by a man in the street and at face value without any information gathering of family circumstances or referrals to other helping agencies or liaison with community staff. 225. In contrast to these issues the HOR points to the exceptional practice by YAS in 2007 when an ambulance crew remained with Amanda Hutton and her children for three hours after being called to help with a suspected drug overdose. 226. The author of the CSC IMR acknowledges that the information about Amanda Hutton’s vulnerabilities in regard to depression, domestic abuse and alcohol dependency combined with looking after a large family of children could have been given a higher order of significance. It is theme highlighted by other authors such as probation although the OASys assessment completed in May 2009 contained relevant information. 227. The BDCT author describes how the health visitor also identified Amanda Hutton’s vulnerabilities and that historical information had indicated a much higher level of post natal depression as far back as 2000. The high EPDS score was an indication that support was required. The issue of post natal depression was identified with the later births as well. 228. The BDCT author describes how a risk assessment was completed in 1998 and again in 2000 which both indicated low priority for support but was not updated when the evidence about depression and domestic abuse began to emerge. 229. The CSC author reflects upon how practice has changed in some important regards. For example, the significance of domestic violence and its impact on the emotional health as well as physical safety of children is better understood partly through the evidence and the learning generated through serious case reviews. 230. Although there was evidence about domestic violence going back to the 1990’s, agencies such as CSC only became aware through the routine reports (rather than specific referrals) from the police of incidents from 2003 onwards. Given the number of incidents each year, the services rely on frameworks or Page 44 of 89 thresholds that identify when domestic abuse is a risk to children. This relies on the people who are completing the reports being sufficiently aware and confident to report relevant and significant information without overloading systems and people; it also requires those people who receive and monitor such information to have a sufficient awareness and capacity to identify and prioritise appropriately. It requires a degree of insight and understanding about the damaging impact of domestic abuse that can identify risk and need in the absence of direct and tangible injury to a child. 231. The author of the CSC IMR describes how viewing successive incidents in isolation inhibited the identification of any underlying patterns; the incidents on their own might not meet a threshold of significant harm and therefore merit formal enquiry and assessment but the cumulative impact especially on young children was a concern that was not identified with sufficient clarity and focus. Even the older child’s report of physical assaults were not seen as having implications either for the child’s own well being or for the younger and more dependant and vulnerable siblings. 232. The extent to which domestic violence was a factor when the parents were living together and the pervasiveness of alcohol and depression were not sufficiently enquired into. This reflects an insufficient understanding about how the emotional and physical capacity of a parent is crucial to a child’s well being and safety. Without such understanding it is more likely that any help will be inadequate and insufficiently focussed. 233. Very little comment is made about how the different professionals interpreted Amanda Hutton’s reluctance to accept help or advice. Police and social care in particular have to balance the rights and ethics of parents and families to privacy and declining help against the consideration as to whether declining such help has negative implications for a child. 234. Amanda Hutton articulated a deep distrust about health professionals from her very first pregnancy although this was apparently not well understood at the time; the distrust extended to other people who became involved at later stages although it is of note that for a period the YOT had a member of staff who seemed more able to overcome Amanda Hutton’s reluctance to have contact with a professional. Amanda Hutton also developed particular trust in a specific police officer who tried to help her. 235. The IMR author for BTHT comments that maternity services recognised some of Amanda Hutton’s vulnerabilities in regard to depression that was apparently attributed to ‘baby blues’. There was no concerted exploration of Amanda Hutton’s depression or other vulnerabilities for example in regard to her increasing family and there was no recorded evidence of discussion with health visiting services. Amanda Hutton was never asked about whether she experienced domestic abuse. The author describes the improved changes that have been implemented since 2005 that ensure domestic abuse is subject of more assertive and enquiring practice and with the flagging arrangements for example in the electronic patient record system. 236. When Amanda Hutton attended at A&E it was not established that she was the mother of eight children. The first occasion occurred as a result of an alleged assault in the street that was accepted at face value; the second occasion that was identified as a physical assault by father, no further enquiries were made by the A&E about other vulnerabilities that the IMR author points out are Page 45 of 89 documented. Like many other areas Bradford has invested in training and awareness about domestic abuse especially since 2007. 237. The GP only saw one of the children during the timeframe for the review in March 2008 when Sibling 8 who was then aged almost 17 consulted the GP about chest pains. He described how he was living away from home ‘following difficult times’. This was a routine ten minute GP consultation and no further follow up was required. Sibling 8 did not raise any specific concerns about his own safety or well being or about his siblings. The IMR author comments that the introduction of the new Safeguarding Children SystmOne template27 across the district would probably alert a GP to broader issues within the family that was not available in 2008. The system allows potential and actual safeguarding concerns to be ‘flagged’ and linked to the patient record. 238. The YAS author comments on how when their crew responded in April 2007 and recognised Amanda Hutton’s mental health needs and radioed through to their communications centre for the number of the Crisis Team nobody had a contact number. This was overcome by contacting the police and CSC. 239. The MARAC in August 2008 provided a considerable history of domestic abuse. The MARAC was a new framework in Bradford in 2008 and the case was selected to help the police and other services improve responses to higher risk victims. The fact that the case was selected because of the history rather than as a result of a specific incident triggering a referral should have been an indication of vulnerability. The first meeting of the MARAC agreed that all services would research what information was known to each service and could have been an opportunity to have developed a more complete narrative of information and to have identified underlying patterns. CSC who had attended the first meeting was not at subsequent meetings. Provide information about any concerns that were reported by any member of the family and comment, where appropriate, on any action taken in response to such information. 240. Evaluations of serious case reviews in England and Wales supported by evidence from inspections and research frequently comment on the extent to which the level of concern about a child is frequently linked to how old they are. In other words there is an unspoken measure that infers greater concern when information is linked to very young children and decreases as children become older. 241. Some of this no doubt reflects a ‘common sense’ approach that regards older children as less dependent and able to show higher degrees of resilience. Although not completely without validity, such an approach can represent additional vulnerability for older children. 27 SystmOne, is an electronic patient records system being implemented within the NHS, and in Bradford has been rolled out across some community health services including GPs, Accident & Emergency departments, Drugs and Alcohol Teams (January 2012). In the coming weeks it will continue to be rolled out and made available to further services including health visitors, school nurses. The introduction of the system has already improved information sharing and provided greater clarity about which services are being provided to a family and helps improve the interface between adult and children’s services protecting children or vulnerable adults. Page 46 of 89 242. In this particular case Sibling 8 made very clear allegations of physical and emotional abuse in 2007. This was the only direct disclosure by a child. It is apparent that there was a difference of view between the police and CSC in particular about how best to respond. The approach taken by CSC and described in their IMR was to treat the incidents as a conflict between a teenager and his parents. The police were clearly not in agreement with this response. 243. The absence of significant injury to Sibling 8 combined with allowing the focus to remain on the behaviour of Sibling 8 rather than the parents and reluctance of Sibling 8 to pursue his allegations all contributed to CSC in particular not pursuing the matter as a safeguarding issue for Sibling 8 or the younger siblings. 244. Although the CSC IMR author does not refer to other factors, Sibling 8’s age may also have been a contributory factor; there would probably be a reluctance to become involved in making arrangements to look after an older child. Such reluctance highlights the dilemmas when older children move from their families at a point of crisis. The outcomes for older children in particular tend to be more negative in terms of their ability to settle into placements or to secure longer term educational and work prospects. There are often difficulties in reuniting older children back into their families. 245. Finding the best way to respond to the needs of older children can be complex; in this case there is little evidence that any support was provided once a decision was made to neither invoke safeguarding procedures or to make arrangements for Sibling 8 to be looked after for more than a few days. 246. The probation IMR author comments on the extent to which the OM remained focussed on father to the exclusion of taking a more holistic overview of the family’s overall situation. The OM was told by father of the late night visits to his property by Amanda Hutton between September 2009 and April 2011. The OM did not share this or related information with any other service either about the evidence of Amanda Hutton’s consumption of alcohol reported by father or the fact that the children were left at home when Amanda Hutton went to visit father’s home late at night. The focus on the domestic violence between Amanda Hutton and father did not appear to extend to a fuller consideration of the impact on the children. 247. The HOR points out that there was historical information in various health records about concerns that included the family’s isolation from either white or Asian community, disclosures of longstanding domestic violence in 2004 and indications of Amanda Hutton’s low mood and depression. Identify any opportunity for enquiring into the whereabouts and well-being of Hamzah between June 2005 and September 2011. 248. There were various contacts with the family over the six years. It is apparent with the benefit of hindsight and the collated evidence provided through such a detailed serious case review that Amanda Hutton in particular was both wary of contact and endeavoured to control any professional enquiries especially during the later timeline of this review and was generally proved effective up until September 2011. Page 47 of 89 249. The HOR comments that there were several opportunities where health staff could have been more proactive particularly when they received information from other services about issues such as domestic violence. 250. The GP service had made numerous attempts to contact the family by letter and by telephone; all of these contacts went unanswered. The GP made a home visit without success (this was not recorded in the children’s records). There was discussion between the GPs and the health visiting service who were also trying without success to make contact with the family. The IMR author for the GP review makes the point that there are no local or national standards in regard to the absence of contact between GP and children. The GP IMR author reflects on the value that the SystmOne will provide to health professionals dealing with similar circumstances now and in the future. 251. It is possible to see that Hamzah had disappeared from the view of services such as health from a very early stage and that some other siblings had not arrived in other services such as education and early childhood services. The author of the admissions IMR describes how the service were not aware of Hamzah and Sibling 2 leading up to the 2009 admissions and even if they had been, then current arrangements that comply with national requirements and standards do not require a follow up when an admission form for starting education is not returned; the national system is based on the assumption that parents will exercise proper responsibility in making appropriate arrangements for their children’s education. This assumption has implications in a city where there is a significant transient population of people not familiar with UK arrangements. 252. In October 2005 the nursery nurse attempted to make a home visit and was rebuffed by a hostile response from Amanda Hutton and an older sibling. The nursery nurse saw a child who looked pale and she consulted the health visitor. The BDCT author comments that this could have provided an opportunity to have inquired further and to have consulted other services at the time. CSC and the health visitor had discussed Amanda Hutton’s disclosure of domestic abuse prior to Hamzah’s birth in June. 253. The account in 2010 of the children going to stay with relatives was reported to various agencies with some variation about details such as location; Peterborough, Portsmouth and Southampton were variously referred to. Some embellishment was given for example in regard to plans for the whole family to relocate. 254. The fact that a child disappeared from routine health oversight and surveillance is an area of significant interest for the HOR and the IMR authors for those separate services. 255. CSC visited the home on four occasions between November 2006 and April 2007. On the first occasion SW1 saw Hamzah together with his siblings Sibling 2 and three; all three children were reported to be ‘looking well’. 256. The IMR author makes an important observation that on the three first visits to the house the various staff only saw the living room. They never saw any child on their own and they never visited bedrooms. The same author highlights that expected practice and standards required practitioners to speak with children and to visit sleeping arrangements. It is unclear if Amanda Hutton prevented such enquiries or they were simply not done. Page 48 of 89 257. In 2009 when the children were not collected from school the police made a home visit and reported that home conditions were acceptable. The police reported that Hamzah, Sibling 2, 3, 4, 5 and 6 had all been seen and looked well. 258. In March 2011 a neighbour made an anonymous referral; it is not clear why the referrer was advised to contact the police if they had concerns about the welfare of a child. At the same time CSC became aware through ESW1 that Hamzah and Sibling 2 had been ‘placed in Portsmouth’. CSC took reassurance from the ESW report that concerns did not appear substantiated; they made no enquiries of their own. 259. In July 2011 CSC were told of ESW4’s concerns about the filthy home conditions. However this information was never passed to a social worker or to a manager; a misunderstanding by CA6 believed that she had consulted and agreed an outcome with an unspecified social worker. 260. The referrals in March and July 2011 were opportunities for CSC to have inquired into the whereabouts of Hamzah. If more inference had been given to the vulnerabilities in this family it is more likely that more follow up would have been given to the reports of the children moving out of the area. The more substantial issue of how children who go missing are managed is explored in more detail in the final chapter. 261. Even if there had been a different response, it would not have provided a different outcome for Hamzah at that stage. Assessment and Decision Making The extent to which relevant historical information was sought, understood and considered in work with Hamzah and his family; IMR authors should include a summary of any relevant information known to their service about the parents or family that they judge relevant to the serious case review. 262. The extent to which information was known to any service about the wider family is very limited and reflects the fact that opportunities to make enquiries or conduct assessments were not sufficiently taken. Information that was known was generally accepted at face value. 263. The HOR reflects on the barriers in regard to accessing historical information in patient’s records. Health records are all written in chronological order, but every organisation organises them differently. They can be very long and complicated and there is no requirement for each and every record to contain a critical incident or summary sheet, which would highlight the more serious concerns and provide a basic chronology. 264. The widespread introduction of the new recording tool (SystmOne the safeguarding template) attached to every child’s electronic records will seek to improve this, as critical incidents which may indicate a child in need or at risk, and concerns and information about the child’s welfare and any actions can be recorded chronologically and kept separate to the main body of records to provide quick and easy access to the most pertinent information relating to safeguarding. Page 49 of 89 265. The SystmOne will provide primary health professionals with improved information about family information although in this case father was not registered at the same GP practice as his family. 266. The GP’s discussed the lack of contact with the practice and had meetings with the health visiting team. These discussions were not linked to the children’s records and the absence of immunisations and general health oversight do not appear to have been linked to other information known about incidents of domestic violence and depression. 267. Reference has been made in the previous section about the consultation that took place between CSC and the health visitor regarding Amanda Hutton’s disclosure of domestic violence prior to Hamzah’s birth. In general there was a high reliance on ‘agency checks’ which by and large recycle existing information already known to the services and were limited in their scope and nature. 268. For services such as health visiting, the information that was known about the family was not subjected to sufficient critical analysis in terms of understanding implications for Hamzah and his siblings. The difficulties in getting access led to a preoccupation with establishing contact rather than understanding the possible implications for the children and for other services. Amanda Hutton’s expressed reasons for not wanting contact with health professionals in general were taken at face value and were restricted to her feelings of distrust rather than what her children required. 269. The historical information held by the various services was not available as a unified source and even information held by individual services was not consistently and routinely accessed. 270. In December 2008 CSC updated their agency chronology records although the IMR author comments that this was largely confined to the episodes of domestic abuse. It was March 2011 when SW12 added a closing case note that referred to the ‘worrying history of mother’s ability to cope’. There was no further contact with the family until September 2011. 271. The CSC author observes that the reliance on routine agency checks left historical information largely unnoticed or unknown and therefore provided limited understanding regarding contemporary information and events. It is of note in the CSC report that for example agency checks with the health visiting service reported routinely that health visitors had not gained access to the home since 2005. Checks with the GP would have revealed that the GP had a similarly low level of contact with the children. The CSC author is struck by the absence of recorded consideration or analysis of historical information. Further analysis in later sections reveals that workload was an issue across the service and a contributory factor in how the enquiries were conducted and assessment was recorded. 272. The implications of such an approach is that unless a dramatic or tangible concern impels further enquiry or action, the vulnerabilities and risks for children remain largely unknown for example from the long and established pattern of domestic violence dating back to the 1990’s. 273. In probation, the OM was aware of the historical safeguarding concerns although when father provided new information about concerns for example Page 50 of 89 relating to the late night visits by Amanda Hutton these did not appear to have been understood for their significance according to the probation author. The quality and timeliness of any assessments and the extent to which they took account of relevant family history, the cultural, ethnic and religious identity of the family, the needs of Hamzah and his siblings and the capacity of the parents (acknowledging they were separated) to meet the needs of their children; this should include comment about any extended family or others and their role and impact in promoting the safety, well being and knowledge of Hamzah prior to the discovery of his death. 274. The quality as well as timeliness of assessments has been a significant issue for exploration in serious case reviews, inspections and academic research relating to work with complex families and vulnerable children. 275. The Munro Review provided fundamental criticism of the format and the conduct of assessment and made recommendations about changing the national framework for assessment with children in need in England that have led to revisions to national guidance. 276. It is widely acknowledged and is a focus of the Munro Review’s recommendations, that the national approach to assessment of children in need had become mechanistic and prescriptive with an unhelpful preoccupation with key performance indicators that have never really assisted in developing a better understanding about quality, relevance and outcomes to this important activity. 277. Recent studies have emphasised that although professionals such as social workers can be very effective at gathering information from a range of sources they face a far greater challenge in being able to identify ways to analyse the information for its relevance and significance in regard to risk and need for children, leaving assessment often to be ‘slightly better than guessing’ (Dorsey). 278. An evaluation of assessment tools by the Department of Education has identified and reviewed three systems of assessment tools. The study concludes that although there needs to be a move towards more structured analysis and decision making there is limited evidence about the effectiveness of available tools in child protection work28. 279. The extent to which fathers are absent from assessment and agency contact generally is another theme to emerge in national studies on a regular basis. Although father was sentenced to a community order for assaulting Amanda Hutton this did not overcome his reluctance to seek or accept help or advice. 280. This entire preamble is by way of providing some context for the analysis that is provided by the IMR authors and in the HOR. It would be surprising if the IMRs had been able to describe assessments that had achieved a proper balance of timeliness and scope. 28 Systematic review of models of analysing significant harm; Barlow J, Fisher JD and Jones D, Department for Education March 2012. Page 51 of 89 281. Although the lead responsibility for assessment within the context of work with children in need or at risk of significant harm will always rest with CSC and a qualified social worker, this does not remove the need for all the relevant services to have the capacity to both contribute meaningfully to formal assessments led by CSC as well as having frameworks to guide their staff in identifying and recognising need and risk appropriately. 282. Certain fundamental areas of knowledge are required across the whole community of services working with vulnerable children; these include for example appreciating the impact of domestic violence, substance misuse and mental health on the well being of children as well as of the adults concerned. It requires sensitivity to the cultural and religious traditions within which children are growing up. It requires an insight into why some families will have great difficulty trusting state services or organisations. It requires discrete areas of specialist expertise as it relates to professional disciplines for example in regard to children’s development, their learning capacity and their physical health. 283. The probation author describes that although the OASys assessment provided a ‘sound’ platform of understanding about father’s risk to known adults and children the assessment remained focused on the adults and on father in particular as an offender. 284. The CSC author describes the organisational arrangements in place particularly from August 2008 in regard to the implementation of the Integrated Children’s System (ICS)29 that was consistent with the national policies and frameworks in place prior to the election of a coalition government. The author summarises how the system creates the conditions within which key assessments as well as other tasks and activities are completed within a process that requires a managerial sign off; in other words if an assessment is required the case can only move forward even to closure once the assessment has been completed and authorised by a line manager. 285. The CSC author acknowledges the high reliance on third party checking with other agencies rather than taking more searching and direct enquiries characterised their approach. The same author also comments on the lack of use of the assessment templates for any of the information that was generally placed in case recording. Implied within the commentary is the fact that the structure of recording did not encourage or demand any degree of analysis. For example, Amanda Hutton’s symptoms of depression are recorded but there is not any consideration about the impact that the depression could have on Amanda Hutton’s capacity to meet the needs of four children all aged under three. 286. This process of relying on process case recording continued. Assessment was further inhibited by the absence of focussed attention on the children even to the extent of not seeing all rooms of the house or trying to speak with them. This contrasted with the police who did complete welfare checks that included checking all the bedrooms and other ‘non-public spaces in the home and on more than one occasion had for example identified issues such as inadequate bedding for some of the children. 29 ICS has been the subject of particular criticism and challenge by Professor Munro. Page 52 of 89 287. Much of the contact by CSC was conducted through ‘duty’ arrangements; this appears to have also contributed to the limited recording of information, the narrow focus of contact and the lack of enquiry into historical information or identifying any patterns. The CSC author acknowledges that the needs of the children were insufficiently identified and therefore recorded. Even Sibling 8 who made specific allegations about being assaulted was unable to elicit more concerted assessment and enquiries. 288. The cultural and religious complexity of the family was not enquired into. This is surprising for a service working in a metropolitan district with a rich history and diversity of culture, religion and language. It is of some note that there are occasions when Amanda Hutton appears to be the victim of racial or cultural inspired violence. The BDCT author comments that Amanda Hutton was isolated from both the white and Asian communities. 289. Health services had generally limited opportunity to undertake assessment with the children. Some of this reflected the episodic nature of services such as A&E or the YAS. Services such as midwifery faced problems in Amanda Hutton’s late notification of her later pregnancies. The health visiting service faced Amanda Hutton’s reluctance to engage with them. 290. The fact that the children were not presented for routine immunisations or other health care at the GP or with the health visiting service was recognised and discussed between the two services. That the children were not brought for routine immunisation and developmental checks is not unusual in some parts of Bradford and this on its own would not have aroused any particular concern or further interest. The same author also points out that the general health system operates on an assumption that an adult is taking responsibility for a child’s health (the education authors make a similar point in regard to enrolment for education). 291. The absence of contact meant that the child records were thin on detail and any information regarding Amanda Hutton’s depression and alcohol use was not linked. The one and brief consultation with Sibling 8 in 2008 would have taken place without any knowledge of other siblings or of the wider family circumstances. The new SystmOne referred to in previous sections provides improved opportunity for busy general practices to have access to fuller information assuming that the system is being routinely updated and used for the purpose of patient consultation. 292. The police IMR comments on the recognition by uniformed officers that Amanda Hutton did not want to speak to male police officers about domestic violence and describes the steps taken to provided a female officer. Consider and comment whether there were opportunities to use any arrangements such as the common assessment framework, team around the child or children going missing protocols to co-ordinate information and help at any stage. 293. The CAF was available from 2004. Some of the IMR authors refer to agency specific frameworks that with hindsight could have provided opportunity to explore Amanda Hutton’s support needs for example as part of her maternity assessment. There were several other occasions when the use of CAF could have provided an opportunity to collate information that may have led to more focussed and informed referral and enquiry by the statutory services. Page 53 of 89 294. None of the services used a CAF or other framework to co-ordinate information and help for the family. Several of the IMR authors are doubtful that such an approach would have improved outcomes in this case because of Amanda Hutton’s resistance to contact with services, although this should never be a reason to at least attempt to use the CAF. The CAF relies on parents giving their consent to participating in a CAF. The extent to which Amanda Hutton was able to keep various agencies away from her and the family is understood by the review panel and was clearly revealed as part of the criminal trial but was not so apparent to those working with Amanda Hutton at the time. If the CAF had been offered and refused this could have provided an opportunity for further reflection as to whether a more assertive approach was appropriate. 295. The CSC author believes that if a completed CAF had been used to support a referral it could have improved the response from CSC. Comment on the quality of judgments and decision making and the extent to which it reflected a focus on the needs of Hamzah and his siblings and represented appropriate professional standards and a competent understanding of any relevant theoretical and/or legal frameworks; particular attention should be given to how any evidence of neglect or impaired capacity to parent was collated and analysed. 296. The HOR describes professional judgement as generally being less than ‘optimal’ although also highlights some very good judgments such as the YAS handling of the emergency call out. The HOR author comments on factors such as the death of one of the health professionals being a possible contributing factor to the gaps in information being considered differently. The implications are that possibly a more questioning approach may have achieved a greater level of engagement with Amanda Hutton in particular. 297. The CSC author describes the involvement of CSC with the family as being ‘reactive’. Little opportunity was taken to explore the individual incidents or events either within a more adequate historical timeframe that could have shown up patterns or to consider the extent to which the presence of alcohol dependency, depression and domestic violence are all common factors in cases of children being neglected or abused. This does not assume that all adults who have alcohol dependency or are depressed will abuse their children; it does suggest that inquiries and assessment have to be sufficiently rigorous with a clear focus on what the information means for the child’s health and well being. 298. The fact that much of the agency response was conducted through duty arrangements and not creating the opportunity for more reflective enquiry and assessment meant that judgements were generally focussed on the immediate imperative of whether any other action was required. This approach of dealing in the ‘here and now’ could not identify the cumulative pattern and impact on the children never triggered the safeguarding thresholds of significant harm or other thresholds relating to need. The extent to which the children were in need was not explored. The Children Act 1989 not only defines duties in regard to helping children who can be seen to be at risk of abuse (s47) but also requires thought to be given as to whether ‘preventative services’ are appropriate to promote their well being and development and reduce the risk of significant harm (s17). Page 54 of 89 299. The CSC author concludes that the known presence of risk factors, the allegations made by Sibling 8 combined with the anonymous referral of the neighbour in March 2011 should have provided sufficient reasons to undertake an assessment of the children’s needs and circumstances. 300. The probation author refers to the development of mindsets that overlook the dynamic interplay of risk and the cumulative impact of repeated low level concerns. Another facet of such a mindset was making assumptions that because other services such as education welfare were involved with the children that any safeguarding issues were already being identified. This overlooked the information that the OM had that could help other professionals make more balanced and informed judgments. 301. The YAS author provides details of how appropriate referrals were made in April 2007 via the police about the children when Amanda Hutton was in a distressed condition. The author reflects on how ambulance crews’ thresholds of concerns can be different to other services levels and can result in challenge. The same author comments on a crew member describing conditions in the home as cluttered and the extent to which this was indicative of neglect or not. 302. The author for the GP IMR describes the decision by the practice to remove Amanda Hutton and her children from the practice register when they failed to be presented for appointments. GP2 who is the safeguarding lead within the practice deferred this decision but in October 2009 the family were removed when GP2 was away on holiday. The decision reflected a concern that they could be accused of maintaining ‘ghost records’ and be liable to allegations of fraud. If patients refuse to attend for appointments the practice is unable to provide the level of medical care expected and they also will not meet targets. 303. The GP IMR author points out that the decision to remove the family from the register did not breach any standards and concludes that clarification to local and national guidance would be helpful. 304. The fact that the family did not register with any other GP practice was not apparently flagged by any organisation. The GP author acknowledges that this represents additional vulnerability to a child in not having access to a full range of health advice and support and disappears entirely from an important part of the local primary health care system. Using and Sharing Information Identify whether information in respect of the family was shared among agencies to the best effect so as to inform appropriate help and interventions; in particular to identify when practitioners in contact with the family saw Hamzah and/or his siblings and recognised any evidence of neglect or other concerns and comment on what action was taken to protect him or a sibling. 305. There was a considerable amount of information sharing although the frameworks being used were at times unclear or informal and the outcomes that arose from the activity were limited. There were also inconsistencies in the quality of recording in and between services. For example, the children’s centre did not make any contemporaneous recording and did not seek any information from other services when they became involved for a few weeks in early 2009. Meetings such as MARAC were not consistently attended by the same agencies or their representatives; the MARAC author is confident that current Page 55 of 89 practice is much more secure from the arrangements in 2008 when MARAC was still a new arrangement in Bradford. 306. Some of the information that was shared between services arose because of routine or procedurally driven requirements. For example, incidents of domestic violence from 2003 were generally reported to CSC by the police although their purpose and intended outcome was not apparent between the two services. Given the number of domestic violence incidents, simply sending information through to another service can simply be stored and filed. It can be regarded as routine and administrative rather than a compelling record of concern being shared for the purpose of further enquiry and analysis. 307. The procedures for identifying children missing from education were largely managed as routine requests which did not trigger further levels of sharing or consideration of information. 308. In January 2011 the Year 8 pastoral manager reported her concerns to the school’s named person for child protection when Sibling 6's attendance had dropped to 51 per cent and despite letters and phone calls from school they had been unable to make contact with home. A home visit had been undertaken by school staff. They made contact with the children's contact point (social care). A common referral form to CSC was completed by the named person from the school who was informed by CSC that there was no role for the assessment team in this case because it was a school attendance issue. There are reports of Sibling 6 presenting at school in a physically neglected state. 309. School B reported that Sibling 5’s behaviour changed noticeably during 2010/11 in responses to school when they enquired about the reasons for absences from school. This suggests that the home circumstances were unsettling and beginning to impact on the children. However there is no evidence to suggest that this triggered further investigation by School B. 310. School B had believed that they had a good working relationship with the school nurse that provided an effective two-way communication process in which information was shared for individual pupils and their families. However, the IMR author comments about how indicators of concern were not discussed or reported and therefore undermined the effectiveness. Particular reference is made to information known to the school nurse in relation to Sibling 4; whilst the school nurse had clearly recorded information strongly suggesting chronic neglect of Sibling 4 of the type that would have been obvious to the school staff over a period of time (September 2011 a description of severe tooth decay and weight loss) there is no evidence that this important information was discussed with the head teacher. This leads the IMR author to question the quality of the information exchange between the head teacher and the school nurse. 311. By 2009 both schools were aware to some extent of the domestic violence incidents at home and there was knowledge of substance misuse by Amanda Hutton and one of the older children. However, at the same time School B reported the children as being well presented in school with no major concerns other than their habits of arriving late and of poor attendance. 312. The schools IMR concludes that School B did not fully recognise the potential impact that the domestic violence incidents might have had on the children nor did the school appreciate that the poor attendance was likely to be symptomatic of the home circumstances. Page 56 of 89 313. The YAS made a referral to CSC in April 2007 that outlined their concerns about Amanda Hutton’s mental health although they were unable to make direct contact with a mental health team. A copy of the patient report was provided to the hospital by the ambulance crew when they transported Amanda Hutton for medical treatment. 314. Further complications arose from the resistance particularly from Amanda Hutton but also on occasion from father to agency contact or involvement. There were also the apparently rehearsed recitals of family plans to move to other areas and the explanation of relatives looking after children to explain absences. 315. The CSC author reports on changes to the initial point of contact with services that is now seeing the piloting of integrated multi-agency teams designed to create better opportunities for seeing across boundaries and sharing intelligence with greater purpose; this reflects recommendations made by the Munro Review. Further changes have also been made to the management of ‘call handling’ 316. The discussions between the GP and health visiting service were not shared more widely with other services. This apparently reflected, at least for the GP practice, that they had no greater concerns than a family who were not attending for immunisations or appointments. It is an example of where the information in isolation had less significance until it is seen within the context of wider information about the family that is evident through the collated information presented to this review. It seems that no other agency ever sought information from the GP practice. 317. The BDHT highlights the contrast in how information was shared more effectively with other services when for example Sibling 8 attended at A&E compared to when Amanda Hutton had been to A&E on earlier occasions as a result of the assaults on her. The IMR author commends the persistence of staff in responding to Sibling 8’s needs especially within the context of a busy emergency treatment service. They ensured he remained on the unit while consultations took place with the police and CSC. Such decision making reflected a child centred approach. 318. The HOR comments on the evidence of communication between the community health services (health visitors and school nurses), CSC, schools, education social workers and agencies involved in MARAC; however, there is no evidence in the records that there was any multi-agency plans and interventions as a family in need. There was no evidence in the health records that the threshold was met for interventions regarding child protection even though there were concerns raised since 2006. GP services did not share information with any other agency except health visitors neither were they asked for any. Single and multiagency communication was erratic and inconsistent and was not seen in context as a whole picture but as a series of individual contacts and snapshots. To comment on the quality of reports and information provided for interagency enquiries and analysis including information provided in meetings of MARAC or the conduct of statutory assessments or for the purpose of identifying and tracing children who have gone missing. Page 57 of 89 319. The focus in MARAC was on the risk of violence to Amanda Hutton as the victim and did not sufficiently focus on the children. The changes that have been referred to in other parts of the report in regard to law and guidance, combined with the evidence of reviews such as this are giving a far clear focus and impetus to putting children central to risk assessment and management. The quality of reports and information were limited and was a reflection that the MARAC was just being established. Attendance by CSC was ‘inconsistent’. 320. The CSC author highlights significant issues in regard to how information historically was managed between key parts of the service and the extent to which this left practitioners with an incomplete picture. 321. The author describes how there were delays in placing information discussed at MARAC in 2008 onto the CSC electronic system until 2009. The paper record from MARAC contains more detailed information about incidents that were unknown to the area teams that responded to subsequent requests for information or referrals. 322. Changes to arrangements since 2009 have apparently addressed these deficits although the limitations of relying on pro-forma requests for information are still highlighted by this review. For example the education and early childhood author noticed that inquiries in regard to the children missing from education focussed on whether the children’s names, address and dates of birth could be confirmed and the date of last updating of information. The focus was on administrative functions rather than encouraging a more ‘intelligence led’ response. 323. It provides a good example of where unless people undertaking a task understand its purpose, the intended outcomes will be less secure. If individuals see the task as fulfilling an organisational and administrative requirement rather than seeing it as a means to an end in helping trace a child, they will display a lack of curiosity and the persistence that can transform both the activity and the outcome. 324. The CSC author comments that the quality and usefulness of much of the information provided was of limited value and provided little assistance to the practitioners dealing with events. 325. The YAS author comments on the potentially important information that YAS has following emergency response calls to family homes that is rarely sought by agencies or MARAC. The same author reports on the information sharing exercise between May and November 2011 organised by the Bradford Domestic Abuse Partnership (BDAP) that revealed that almost a third of cases discussed at MARAC had been visited by YAS. 326. The GP IMR author is unsure whether the GP practice remained unaware of the discussion at MARAC; there was no reference on the children’s records. The SystmOne should improve the sharing of information. 327. Most health services provided no written information although there were verbal exchanges of information. The health visiting service provided a written child protection referral to CSC in November 2006 that the HOR comments was clear and of good quality. The general lack of written information reflected the fact that none of the individual items of information known to various health practitioners had reached a formal threshold of concern. Page 58 of 89 Engagement and acceptance of help and advice To what extent did either parent accept contact, advice or help from professionals in contact with the family between June 2005 and September 2011? 328. The extent to which Amanda Hutton in particular displayed a distrust of professional services does not appear to have been evident to the various people in contact with the family. Although Amanda Hutton requested support on one occasion from CSC after Sibling 8 had made his allegations, this was principally in regard to managing his behaviour rather than addressing any of the issues that had an impact on her as a parent. However once the immediate crisis was over Amanda Hutton withdrew and refused further help or contact citing that she had sufficient support from the YOT. 329. The final meeting of MARAC in January 2009 was informed that Amanda Hutton had engaged well with services such as Staying Put and the Family Centre. 330. The HOR refers to the national and local evidence that fathers are frequently absent from contact with services. The author refers to current research and training into the engagement of fathers by the Fatherhood Institute30 to highlight the issues and improve this. The HOR author also reflects on the delays in responding to Amanda Hutton on the rare occasions she disclosed domestic abuse may have been a contributory factor in her disengagement. Was there any other action that could have been taken to achieve a better level of contact and engagement with the family? 331. The police IMR provided comment and information about the considerable efforts made by police officers in 2005 and 2008 to help Amanda Hutton to seek support in leaving the abusive relationship with the children’s father. It is apparent that Amanda Hutton developed a high degree of trust in one particular officer. In spite of the considerable efforts to support Amanda Hutton which included making contact with relevant services and arranging appointments Amanda Hutton felt unable to follow up on plans to leave. The same authors also comment on the difficulties in securing Amanda Hutton’s cooperation with the MARAC process. 332. The CSC author concludes that there was limited choice in the action that could have encouraged better contact and engagement with the family. This comment is a reflection of the fact that any help that was provided was on the basis of the voluntary arrangements under s17 of the Children Act 1989. 333. Although Amanda Hutton had demonstrated a long standing unwillingness to accept help, if practitioners had been better informed and equipped to take a more assertive and enquiring approach especially in regard to Amanda Hutton’s problems and again when Sibling 8 made his referral there remains a possibility 30 The Fatherhood Institute is a UK fatherhood think-tank. and registered charity that collate and publish international research on fathers, fatherhood and different approaches to engaging with fathers by public services and employers. Page 59 of 89 that an improved level of contact could have been achieved; it could certainly have been attempted. 334. Father displayed a similar unwillingness to accept professional involvement. Despite frequent efforts by the OM, father continued to minimise his offending and disrupted group activities that led to his suspension from the supervised programme. Amanda Hutton also showed a reluctance to receive any help through the Staying Put project and YOT or the police. She was willing to receive limited help for example in regard to benefit payments but was not willing to address other difficulties. 335. The GP practice did not discuss the case with CSC; as described in previous sections the issues in regard to the missed immunisations and developmental checks were not a cause for enhanced concern at the time but are an example of how the behaviour of the parents had an impact on the children. 336. The HOR acknowledges that all the health IMRs identify opportunities to have tried to secure improved engagement. A referral to the mental health crisis team from YAS may have improved engagement with mental health services (although they did contact the police when they had no contact details for other services). A decision not to remove this family from the GP list and improved multi-agency communication from the GP may have increased engagement. The hospital IMR author suggests that clarity as to why Amanda Hutton did not bring her children back to the hospital for various follow up appointments could have been investigated further with more direct contact, as arguably she was not acting in the best interest of her children at this time. Planning and Help Comment on the clarity and appropriateness of plans and actions undertaken made as a result of the discussion at MARAC, information about siblings missing from school or as a result of any statutory assessment. 337. The MARAC IMR describes action agreed at MARAC meetings as being appropriate referring to the arrangements made for support through Staying Put and the education welfare service. The author acknowledges that with the absence of CSC there was no opportunity to check and confirm if there was any follow up action being taken by that service. When MARAC were told that the health visitor was unable to gain access to the house the action agreed was to see the children through the school nursing service; this would not have provide opportunity to see Hamzah. 338. The police IMR authors report on the degree of concern there was on Amanda Hutton’s part in early 2009 that father might try to force his way into the family home and there was a high level of concern. 339. The author of the BDCT highlights how the fact that the family were subject of discussion at MARAC led the health visitor to mistakenly believe that Amanda Hutton was accepting help and support from other services. 340. The CSC teams who dealt with information requests and duty referrals had limited access to information that was discussed at MARAC. Arrangements have been improved since 2009 when area teams provide and receive information in regard to MARAC. Page 60 of 89 341. The HOR comments on the general lack of information about any statutory assessments although lists the various occasions when it could have been expected; after the physical abuse disclosure by Sibling 8 in May 2007, after more domestic violence in July and august 2008, following the MARAC in January 2009, following concerns of substance use by Amanda Hutton and older son and non collection of children from school in April 2009, following an anonymous allegation of shouting and swearing at the children in March 2011 and the increasing concern for the whereabouts of Hamzah and Sibling 2 throughout 2010 and 2011. 342. The HOR comments that the health visiting records are not clear about what assessment was completed after the child protection referral in November 2006. Identify what opportunities were taken to seek the views, wishes and feelings of any of the children and comment upon the extent to which the children may have felt inhibited to seek advice, information or help. 343. It is a recurring theme in serious case reviews, inspections and practice research that too little attention is given to seeking and recording evidence about children’s views, wishes and feelings. Children growing up in troubled families will face a range of difficulties in telling their story and it represents a significant challenge for people such as social workers and police officers as well as other people working in early years, education, health and criminal justice services. It requires appropriate skills, curious persistence and the time to do it adequately and it is often overlooked. It can be seen as being a lower value ‘talking’ activity compared to other tasks that demand time and attention. It is notable that the police IMR is the only report to include the reaction of the children ‘to a police presence’ in their home. It indicates sensitivity to how young children reacted to uniformed ‘strangers’ in their home. 344. The CSC author describes the limited opportunities taken by staff to seek the direct views wishes and feeling of children. The two occasions when Sibling 8 raised his concerns there appeared to be a high reliance on what he said to the police, which is indicative of a concentration on evidential disclosures rather than encouraging a fuller conversation about how he was feeling and what he wanted. The focus on allegations on the second occasion was halted when Sibling 8 withdrew his complaint. 345. The CSC author describes the visit to the house on five occasions between November 2006 and December 2008 and refers to the children being too young to speak but ‘had raised no concerns for the visiting social worker’. It would have been better practice if there had been more direct reporting of how the children had presented including their physical condition and emotional demeanour and how they responded to a stranger in their house. 346. When Sibling 4 and 5 were spoken to on other later occasions the CSC author reflects on whether both had been subjected to coaching or threats by their Amanda Hutton. The CSC author concludes that there was probably a naïve expectation that children would tell somebody if they were being harmed or would seek help; Sibling 8 tried to do this on two occasions and was unable to achieve a response. This would erode confidence in the willingness or capacity of the service to take their concern seriously and to act. Page 61 of 89 Practice Support and Supervision Consider whether all relevant single agency and multi-agency procedures were followed and comment on the extent to which procedures helped or inhibited appropriate judgments and action at the time. 347. The CSC author refers to the increased workload in Bradford that arose in the wake of the Baby P case in Haringey in early 2010. This had implications for some working practices especially in regard to the use of duty or welfare visits to respond to the lower risk cases. This was designed to avoid bottle necks and to create capacity to focus on cases that were seen to be of higher concern. The practice of relying on case recording rather than using an assessment framework reflects this workload management approach at the time. 348. These working practices appeared to have extended into areas prior to Baby P where there were queries and concerns regarding children’s welfare. For example, the decision by the police to invoke their powers of police protection in regard to Sibling 8 on the 9th December 2006 involved discussion with CSC although none of this was structured around the BSCB requirements in regard to strategy discussions or s47 enquires. 349. The significance of the BSCB procedures is to provide a consistent framework for sharing information and creating the circumstances under which judgements, decisions and action are likely to be properly balanced by looking at all relevant factors. There was disagreement between the police and CSC in regard to how the allegations by Sibling 8 were managed and they were never taken to a wider discussion that could have placed them in a better context of information about the family. 350. The reliance on information being presented at the point of initial contact or referral to allocate priority to a case represents systemic risk. This case has shown the importance of exploring underlying information and patterns that will be less likely to be identified by reliance single agency contact. The evidence of SCR’s nationally is that children are most vulnerable when their needs have not yet triggered a threshold requirement. 351. The probation author highlights a number of noncompliance issues identified by the agency review. These reflect issues highlighted by previous reviews. For example the use of CRAMS31 risk alert flags for the well being of children where drugs, alcohol, mental health or domestic violence are issues. The sentence plan included no objectives in regard to safeguarding children in spite of the offences and risk assessment32. 352. The GP Practice had a safeguarding policy in place that was compliant with the Royal College of General Practitioners guidance. The lead GP for safeguarding had participated in training and the action in relation to the family complied with standards. The author of the IMR identifies the value of further local guidance in regard to managing families who do not respond to appointments and managing the removal from practice registers. 31 CRAMS is an electronic case recording and management system used by the national probation service. 32 The IMR author includes information about serious personal difficulties that the OM was facing at the time that had an impact on their usual capacity and performance. Page 62 of 89 353. The police IMR authors note that in December 2008 when father was arrested for his assault on Amanda Hutton, a specific child protection referral should have been made in regard to the welfare of the children when father raised concerns about Amanda Hutton’s neglect of the children and her use of alcohol. The authors provide the context that when the officers had visited the house all the children appeared fit and well and by implication may have regarded father’s statements when he had been arrested for his physical assault on his wife as trying to deflect and divert attention. 354. In September 2011 when the PCSO was trying to gain access to the house and becoming increasingly concerned about the children, instead of consulting the CPPU they consulted a detective in an adjoining division who happened to be a personal friend. Although the detective friend provided advice about how to gain access to the house using a uniformed officer if necessary, the use of this informal source of advice was outside organisational protocols and meant that the CPPU were not alerted to the PCSO’s concerns. 355. Although this is not to criticise the officer who was trying to do the right thing it does invite reflection about why the PCSO did not seek advice from specialist officers within the division. It appears to be the consequence of being very new into post and uncertain about the inference being given to the growing sense of concern. 356. The HOR refers to the absence of robust procedures for any of the health services, except for YAS on action to take where there is disengagement and non-compliance and no access. It was after 2010 that more comprehensive and rigorous arrangements were introduced in regard to issues such as the disengagement of families. 357. The HOR refers to previous SCR’s that have increased the safeguarding training offered to staff either single agency or multi-agency, in domestic abuse, assessment and interventions, the impact of parental mental ill-health and substance use on children. There has been much activity in all the health services increasing the training levels of staff to comply with the recommendations in the intercollegiate document on competencies for staff in safeguarding children 2006 and latterly 2010. This is still in progress and is expected to be completed in 2012. 358. The ESWS author highlights how the CME protocols were incorrectly signed off. This resulted in the mistaken closure of the cases on Hamzah and Sibling 2 as ‘being found in another LA’. Specifically there were no checks made with Portsmouth Education to see if the children were in school; no known address for the children on closure and a lack of clarity of guidance on checking family fostering arrangements. No checks were made with Southampton and Peterborough. The IMR author reflects on the important function of managers satisfying themselves that the information they are being asked to base their own judgments is complete and clear for them to make a decision. Consider whether the policy, procedural, management and resource infrastructure that surrounded each agency’s involvement with Hamzah and his family promoted appropriate decision making; this should include evaluating the training, knowledge and experience of people working with Hamzah and his family, workloads and organisational stability; comment Page 63 of 89 should also be made about whether any shortfall in resources was an impediment. 359. The importance of organisational arrangements is increasingly understood in terms of how the quality of practice and outcomes is linked to the robustness of the organisation’s arrangements. It is also a fact that people undertaking difficult and complex work will face additional pressures such as bereavements or other disruptions in their personal as well as professional lives. One of the IMR authors describes how one of the professionals was affected by bereavement outside the workplace. Such personal pressures are exacerbated if individuals are also coping with excessive workloads. Good services rely on dedicated and appropriately trained people having the physical, psychological and emotional support and capacity. 360. The YAS author identified that several of the crew members responding to emergency calls had not completed level 2 safeguarding training and confirms action taken to address this. The author also describes other work being taken to help crew members in making judgments on what physical conditions might constitute neglect rather than lower level issues. 361. The CSC author describes how the assessment service was staffed by two experienced and qualified managers throughout the period under review and had the support of an experienced service manager. They had access to appropriate procedures and consultation was available. The practitioners who were involved with the family were level 3. 362. However there were a number of factors within CSC that represented a degree of vulnerability and impediment some of which have been commented on in previous sections. 363. There had been periods when sickness absence and annual leave had coincided, which left one manager in sole charge for some periods of time. This reflects an operational reality for any service. There were occasions when the assessment team has required support from agency staff which created some degree of instability and lack of consistency. 364. The introduction of an important system (ICS) in 2008 had placed some additional pressure on managers and practitioners before the system became established and familiar. The vulnerability of not having sufficient capacity to undertake assessments to a sufficient level of enquiry and consultation is that the hidden risk and need of children remains undetected and identified. 365. It was within these circumstances that working practice such as duty or welfare visits were used. 366. The admissions IMR author describes how access to independent choice for their children’s education has been removed as a requirement although acknowledge this was never available in regard to primary education. 367. The HOR provides commentary on the organisational arrangements for the various health services in Bradford. Of some particular relevance in this SCR are the arrangements for the delivery of GP services in the city that comply with national and regional requirements. Page 64 of 89 368. GPs are independent contractors. At the time of Hamzah’s death, GP services were commissioned by Primary Care Trusts (PCTs). A GP Practice that the family were registered with held a contract with Bradford and Airedale Teaching Primary Care Trust to deliver GP services. The type of contract was known as a Personal Medical Services (PMS) Contract, and was a form of contract used widely both locally and nationally. Under this contract there was a requirement for the practice as a whole to “give regard to the local safeguarding policy”. The commissioning body for GP services is no longer the Primary Care Trust since this was abolished at the end of March 2013. Since then GP services have been commissioned by NHS England. The West Yorkshire Area Team of NHS England oversees contracting and commissioning of GP services in the Bradford area. However it is noted that since 2013 all GP practices must be registered with the Care Quality Commission and this organisation mandates adherence to safeguarding policies and procedures through its registration and assessment process. Consider whether professionals working with Hamzah’s family had sufficient and appropriate supervision commensurate with their role and responsibilities, and the extent to which the case was subject to appropriate and effective managerial oversight and enabled critical reflection. 369. The CSC author comments on the absence of written consultation between practitioners and managers and is a reflection of some of the workload practice referred to in the previous section. 370. The GP IMR acknowledges that clinical records do not allow any judgement regarding the degree of critical reflection when discussions took place regarding the children not being presented for immunisations and developmental checks. Learning from SCRs and other review processes Consider relevant research or evidence from previous serious case reviews conducted by the Bradford Safeguarding Children Board; consideration may also be given to evidence from other LSCBs or evaluations of SCRs. Take into account any common themes and actions arising from that research and those SCRs that are relevant to the circumstances of this case and comment on what impact they had in this case. 371. The MARAC author comments on the changes made to the conduct of meetings following a SCR in 2010. The changes had put an emphasis on sharing information rather than more discursive case conference style discussion. Greater responsibility had been given to the designated officers attending the MARAC to ensure they had direct discussion with the staff member in their organisation that was in contact with the victim. Regular refresher training is also provided to the designated officers. 372. Two previous SCRs are referenced in the GP IMR regarding the importance of communication between primary health services. The introduction of the SystmOne is a response to that learning that is reflected in the historical case. 373. The police IMR authors refer to learning that had been identified in previous SCRs regarding the importance of all police officers having a clear understanding the importance of ensuring enquiries about the safety and welfare of relevant children should be a routine aspect of police work when responding to incidents. Although there are several good examples of where Page 65 of 89 police officers showed considerable awareness and persistence in following up concerns about the children the authors acknowledge that for a large and diverse police service the needs to ensure training and development is continually provided is an essential requirement for the service. 374. The HOR refers to learning from previous SCRs both locally and nationally. The similar themes and actions as identified in two previous SCR’s in Bradford. 375. The SCR AI in 2007 identified a lack of a co-ordinated response and support to mental health problems of a mother, which is echoed in this case. 376. The child J SCR in 2011 contained several themes also duplicated here. Firstly the lack of multi-agency assessment and planning which would have contributed to what the children’s life was like. Secondly, the lack of rigorous professional judgement and decision making which allowed this case to drift. Thirdly the invisible father, there is no evidence that any attempts were made to engage father and very little is known about him. Fourthly parental resistance to professional intervention is the key issue in this family and it appeared this was viewed as intractable and therefore contact was not pursued. Lastly there was no focus on the children’s wishes and feelings; Amanda Hutton was the focus of health professional activity. 377. Common themes in other SCR’s, national research and other documents has also been highlighted by the IMR authors, and these include: a) the failure to take into account the impact on children of living within an environment where there is domestic abuse and the emotional unavailability of the parents in this situation; b) no consideration of the presence of domestic violence, mental health issues and substance misuse as highlighted in Brandon et al (2009); c) Insufficient challenge to both family members and between professionals as highlighted in both the Victoria Climbié and Peter Connolly inquiries; d) Failure to register with a GP as in the Victoria Climbié case; e) Failure to record information from liaison and discussions in patient’s records. 378. The HOR describes the policy and practice changes and improvements from previous IMR’s and SCR’s which have been implemented: a) Written referrals to children’s social care within 48 hours were demonstrated in the IMR’s; b) There is now MARAC involvement from midwifery and A&E specifically; c) The development and launch of the district wide health services violence against women and girls strategy (2011); Page 66 of 89 d) Midwives are required to ask every woman at some point in the pregnancy about any domestic abuse; e) Failing to attend appointments and lack of engagement with services is an area in which Bradford teaching Hospitals in recent years have reviewed and developed a process for management around children who fail to attend appointments. Consider previous reviews of single agency practice. Take into account any common themes and actions arising from those reviews that are relevant to the circumstances of this case and comment on what impact they had in this case. 379. Previous SCRS had identified the importance of specialist safeguarding leads in GP practices and over 90 per have such a role established. All of those leads are trained to at least level 3. The GP practice had one of the more experienced leads. The implementation of the SystmOne referred to in several of the previous sections is also a product of previous agency learning. 380. The HOR refers to single agency reviews done as part of learning the lessons reviews and serious incident root cause analysis reports. Cross cutting themes are similar to those in this review and include, non co-operation with medical treatment, communication and recording practices, poor recognition of neglect and abuse and failure to challenge parents and professionals. These are being dealt with at present in terms of action planning and practice sharing events. 381. There are also issues highlighted in the YAS IMR which has come recently from another learning the lessons report with respect to ensuring all staff have level 2 training and also in recording those children in the household in any 999 visit where it is practical and possible. 382. The HOR identifies thematic learning from the health IMRs that can equally be applied to other services. 383. Professional judgement, assessment and decision making and single focus working (identified as silo working). Professional focus was on single issues within the family rather than looking at the whole picture. Any assessments were superficial and decisions made without a true picture of the family. Health professionals need to access and be knowledgeable about family history and historical information. Assessments need to be made on the basis of knowledge, observation and analysis and followed by action planning. Action plans should be reviewed regularly. 384. Lack of “think family” approach. There was never any sustained effort to get direct contact and assess the children. There is no evidence of what life was like for the children in this family and any information given was taken on face value and not explored or challenged. There was no consideration of what effect the toxic trio (domestic violence, mental health issues and substance use) had on the children. This also needs to be part of any information gathering and assessment. 385. Lack of engagement with the family. The family disengaged from all health (as well as other) services and as this became more entrenched it appears that the family’s non compliance was considered to be unchangeable. Professionals need to be aware through training and supervision of positive engagement skills to attempt to engage with non compliant families. The recognition of Page 67 of 89 opportunities to engage and intervene is crucial and professionals should be empowered through supervision and management oversight to engage with these opportunities. 386. Drift. The loss of focus, the difficulty in getting access to the family and their disappearance at times all contributed to the lack of action over many years. Supervision of staff is crucial and case audit of records and the production of chronologies would ensure there is focus on positive action. 387. Multi-agency information sharing, assessment and planning. The lack of joined up assessment, information sharing and thinking, meant there were missed opportunities for multi-agency action to help this family and protect the children. Health professionals should be clear in their written and verbal communication and in what action will be taken. They should also be supported and encouraged through supervision and training to appropriately challenge multi-agency colleagues to re-examine their decision making if necessary. 388. Invisible father. There is no evidence that any attempts to engage father was made and little is known about him other than the alleged assaults on his partner. Training and supervision should ensure that professionals are aware of the importance of fathers in children’s lives and the contribution they can make whilst at the same time assessing the well being and safety of children in circumstances where there are parental relationship problems. 389. Standards of recording and access to records. The importance of correctly recorded information in children’s records where it can be accessed when needed and form part of an assessment was an issue for several agencies. The use of the template for recording safeguarding information in the electronic records is vital and all efforts to implement it as quickly and thoroughly as possible should continue. The HOR comments that the improvements made at BTHFT have resolved the issue in the A&E department. Agency specific key lines of enquiry Police and children’s social care; report and comment on what information was shared and the actions taken between 12th September 2011 and the 21st September 2011 and whether there was opportunity to have discovered the body of Hamzah at an earlier stage in those enquiries. 390. The narrative chronology in chapter two describes the action taken by CSC and the police from the 12th September 2011. 391. The PCSO who initially dealt with the report from a neighbour about dirty nappies being thrown into his garden and stones thrown at his house and vehicle was new into post and had just completed their initial induction. The PCSO made five attempts to follow up the complaints by visits to the home prior to the 21st September 2011. After one of those unsuccessful visits the PCSO telephoned CSC to establish what information they had about the family; this contact was not recorded by the PCSO. 392. Around the 10th September 2011 the PCSO was in contact with CSC being aware of the state of the home and an ‘overpowering smell’. The PCSO left a card through the letterbox on the 12th September 2011 asking Amanda Hutton to contact her; Amanda Hutton subsequently made contact on the 15th September stating that she was no longer living at the property and that the Page 68 of 89 children were living with her eldest son. Although the PCSO attempted to make an appointment to speak with Amanda Hutton she ended the call. The PCSO made a visit on the 20th September 2011, again leaving a card. The PCSO was determined to make contact with Amanda Hutton. 393. On the 21st September 2011 the PCSO spoke with SW2 and they agreed to make a joint home visit. The PCSO visited with another PCSO and they shouted through the letterbox that they required Amanda Hutton to open the door or they would force an entry; the PCSO had previously sought advice from a detective. Amanda Hutton opened the door but refused entry. The PCSO consulted with SW2 to establish what concerns CSC had about the children. SW2 contacted the CPPU and was advised to request a uniformed officer to attend in order to force entry to the property. 394. The CSC author identifies that there was a delay in the team manager being made aware of the initial contact and the case was not allocated to a social worker until the 15th September 2011. There was an initial reluctance to treat the information as a safeguarding concern and there was a delay in making contact with the CPU and organising a strategy meeting. Significant factors appeared to be that this was initially treated as a report of a smelly house which had less priority in comparison to other cases that had clearer and more explicit safeguarding concerns being raised about children. It provides an example of how relying on presenting information can misinform and misdirect professional judgment. This is not intended to criticise an individual manager who doubtless had to balance competing priorities for allocating work to qualified social workers. 395. Although earlier discussion with the police and an earlier strategy meeting would probably have achieved a quicker entry to the house and the discovery of Hamzah’s body it would not have changed the outcome for him. The CSC author acknowledges that visits should have been made to the property and the fact that they were not reflected that other cases were taking priority at the time. Education and early childhood services; report and comment on the extent to which any of the children were missing from education or early years provision and the appropriateness of actions taken to ascertain the children’s whereabouts and attendance at school and other provision. 396. The schools IMR acknowledges that there were missed opportunities in September 2009 for School B, the Admissions Service and the CME Team to enquire about the whereabouts of Hamzah and Sibling 2 when they could have taken up their place in reception class at primary school. Similarly in September 2010 there was a missed opportunity to enquire about the whereabouts of Sibling 3 when he could have taken up his place in reception class at primary school. 397. With the benefit of hindsight more could have been done between the services to clarify the whereabouts of the missing children (Hamzah, Sibling 2, Sibling 3) and that this was a lesson for the local authority to learn from. There was a lack of connectivity between the authorities to clarify the whereabouts of ‘missing children’ and that schools can only be aware of missing children if they are informed of their existence. 398. There is no record on the Capita ONE system of any of the children in the family accessing early years provision. When dealing with school applications, Page 69 of 89 the Admissions Team is not aware of younger siblings who would be due to start school in future years. Therefore, because Hamzah and Sibling 2 were not in a pre-school setting, the team were unaware of their existence and therefore were unaware of them missing education. 399. The action taken by the admission officer regarding Sibling 5 was good practice, in this instance. From information provided by School B and the decision to allocate a school place without an application form being completed, the proactive action ensured that Sibling 5 was allocated the same secondary school as the older sibling. 400. Liaison between the admissions team and education social work service has improved since September 2010 when all local authorities became responsible for the co-ordination of in-year admissions. Prior to this, parents made direct contact with their preferred school when applying outside the normal admissions round. Since September 2010, processes for identifying children missing education has improved significantly, but again, this is mainly dependent on the parent making an initial application. Reference has been made that education social work service was informed that Siblings 1 and 2 were returning from Portsmouth but at no time was an in-year application for a school place submitted. Although the children were placed on the CME register by education social work service between October and November 2010 as ‘missing children’, there was no liaison between the two departments at that time. 401. The admission service IMR acknowledges that the primary school application process could be more widely publicised, for example regular articles in ‘Community Pride’ the Council’s publication that is sent to all Bradford district households three times each year. The IMR considers other avenues for obtaining details of children who are not in early years settings, such as Bradford Health Authority or Child Benefit data could be considered. 402. The arrangements put in place since December 2011 for the early years service to be notified about new births as a matter of course unless a parent decides to opt out provides stronger opportunity for improved inter-agency communication regarding all known vulnerable children, particularly those not yet in school and where parents tend not to engage with professionals. When these children are approaching school age, steps can be taken to ensure the family has engaged with the admissions process. Their details could be shared with the Admissions Team so that extra attention can be given to these children to ensure that a school application is made. 403. The DfE promotes the take up of online applications rather than the completion of paper application forms. Whilst this can be an easier process and more reassuring for parents that their application has been received, it results in the child's current nursery or primary schools not knowing whether an application has been made by the deadline date. Although the Admissions Team can inform the current school of this after all online applications have been imported into the admissions database, those parents disengaged in the process are not known until after the deadline date has passed. It is known that such families are less likely to complete a school application, so there is a need to improve their access to online facilities, such as drop in sessions within schools. 404. School A and School B followed the agreed systems and procedures in school at the time in terms of recording and monitoring attendance in relation to the Page 70 of 89 Family H children. However, recording and monitoring suggested a passive exercise rather than taking assertive action. Despite the actions and interventions described in the IMR that were put in place the impact was minimal in that attendance did not improve. Page 71 of 89 4 Analysis of key themes for learning from the case and recommendations 405. Any meaningful analysis of the complex human and professional interactions and processes for decision making that characterise multi-agency work with vulnerable children and troubled families has to understand why things happen and the extent to which local systems help or hinder effective work within ‘the tunnel’33. 406. The key findings in this chapter are framed using an adaptation of the systems based typology developed by SCIE. Although this serious case review has not used systems learning to collate evidence there is value in using the following framework to identify some of the underlying patterns that appear to be significant for local practice and which place individual action and behaviour within the context of agency and multi-agency working. a) Cognitive influence and human biases b) Family and professional contact and interactions c) Responses to incidents and information d) Longer term work with vulnerable children and troubled families e) Tools to support professional judgment and practice f) Management systems 407. The remainder of this report aims to use this particular case, to reflect on what it appears to reveal about areas for further development in the local safeguarding system and use it as far as possible as a window into those local systems. 408. In providing the reflections and challenges to the BSCB there is an expectation that the Board will provide a response to each of the key findings as well as to the recommendations and action plans that are described in the agency IMRs. As far as the key findings described in the remainder of this chapter it is anticipated that the Board will take the following action. a) An indication as to whether the BSCB accepts the findings; b) Information as to how the BSCB will take the findings forward; c) Information about who is best placed to do lead on any particular activity; d) An indication of the timescales for responding to the findings; e) Information about how and when it will be reported. 409. The BSCB will determine how this information is managed and communicated to relevant stakeholders. This report recommends that the BSCB discuss the key findings and makes a formal response that is also published. The reason for structuring this final and important part of the report in this way is that it gives responsibility and empowerment to the people who know their community and services to develop appropriate responses rather than to have action imposed. 33 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight and a far more detailed compilation of information. Page 72 of 89 Cognitive influence and human biases: developing mindsets that are open to fresh or different information; repeated exposure of professionals to intractable and long term problems contributing to a normalisation in their response; understanding the significance of deviant or risky parental behaviour. 410. This family were not regarded as the most vulnerable family known to the various services. Given everything that has been revealed since the discovery of Hamzah’s body this will be difficult to understand but it is important to consider what was known at the time and why, as well as understanding the implications. 411. The earliest and historical contact with the family, particularly by primary health care workers, described the parents as being supportive of each other and the maternal grandmother was also regarded as an important source of support for Amanda Hutton and her children. This picture clearly changed over time and the HOR in particular is able to reveal the pattern of increased disengagement from professionals although this was not recognised by most at the time; the initial impression of a supportive family continued to prevail. 412. Reports of domestic violence, the poor engagement with health professionals, Sibling 8 seeking help, inconsistent school attendance and the prosecution of father were all indicators of behaviour that represented risk to the children’s physical and emotional welfare. 413. Although there were discussions and consultations at various points as well as referrals to specialist services such as CSC none of this resulted in triggering either formal safeguarding protocols or other mechanisms such as CAF/TAC. Several of the IMR authors queried whether the use of such frameworks would have been any more effective in the face of the determined lack of engagement and cooperation from Amanda Hutton in particular. The value of using such frameworks would have been in highlighting more starkly the range of issues that were known to different people but were not collated and therefore seen in a more complete picture of the family’s deteriorating circumstances. The metaphor of people working with single pieces of a jigsaw has been used to describe how professionals often face a challenge in being able to see a child’s circumstances within the complete picture of their family and history and events. 414. Information about Amanda Hutton’s susceptibility to depression had been recognised during her first pregnancy and the use of tools to assess the extent of that depression during subsequent pregnancies identified concerns in the higher quartiles of the measurement. 415. Although both parents disguised significant issues such as their level of drinking which was only explicitly disclosed by Sibling 8 when he sought help there were occasions when staff especially from one of the emergency services observed Amanda Hutton under the influence of alcohol. 416. The domestic abuse was evident from as early as 1996 although it was from 2003 onwards that the incidents were reported to CSC and in 2008 father’s assault on Amanda Hutton was sufficient to require a non-molestation order and also resulted in criminal prosecution. Page 73 of 89 417. Father was able to minimise and deny his responsibility for the violence shown to Amanda Hutton and effectively limited his participation (through his lack of co-operation) in the court directed programme; it became primarily a matter of reporting to his offender manager at the office rather than participating in a group based programme designed to challenge attitude and behaviour. 418. The children missed routine health appointments and their attendance at school was problematic; the three youngest children never arrived in education or early childhood services and for the older children there were inconsistencies in their attendance. 419. The physical conditions in the home were described as poor in 2005 although on most occasions when a professional had access to the house, conditions did not cause concern. It was late 2011 when the neighbour made the referral that would eventually lead to the discovery of Hamzah’s body it was clear that the property had become almost uninhabitable. 420. Although there were occasions of individual professionals having concerns, this was more often focussed on Amanda Hutton as a victim of domestic violence rather than what the impact on the children’s emotional health was. Some concerted efforts were made to help her leave the violent relationship although it is clear that this was not successful. That is not especially surprising in itself; there is compelling evidence about the difficulties women face in fleeing abusive and violent relationships. 421. Although when the children were noticed as missing and there was contact and discussion between the various services the inquiries were largely misdirected by Amanda Hutton and by other family members who provided an account that some of the family had moved to other parts of the country. 422. When Sibling 8 sought help in December 2006 there was a disagreement between the police who initially used their police powers of protection to keep him at the hospital although CSC were unconvinced that Sibling 8 required protection. It was primarily managed as being symptomatic of a family dealing with adolescent behaviour. 423. At no point was there any discussion specifically about the children in a multi agency framework and only limited information was sought directly from any of the children. The MARAC discussions in 2008 were focussed on Amanda Hutton as a victim of violence. 424. The system (by which is meant the people and the processes for their communication, enquiry and assessment) is less able to deal with other more resistant aspects such as the depression, relationship difficulties and alcohol that were manifested in a more episodic manner and were not placed within a shared typology that could analyse and consider information with a greater degree of sceptical and informed enquiry and assessment. Further comments are made later in regard to the tools that support professional judgments. 425. Gaps in the sharing of information left all professionals without a complete picture but when episodic incidents occurred they were not apparently seen as symptomatic of longer term historic patterns or the implications for the children’s emotional as well as physical wellbeing. Page 74 of 89 426. Practitioners may come to tolerate neglectful behaviour in materially deprived communities and households; neglect is more common in poor and disadvantaged communities but poverty does not in itself cause the emotional and physical neglect of children34. 427. An NSPCC research briefing35 highlights the lack of consensus about what constitutes neglect that is reflected in the earlier finding in this report in regard to good enough parenting. The same briefing paper also describes the problems of coordinating help for families with complex problems that will, as in this case, involve several different services with different skills and professional backgrounds. 428. This process of normalisation has an impact on how professionals frame or categorise information and understand its significance and relevance. It has implications for how the style and quality of parenting is assessed as being good enough and is discussed in the last key finding. 429. A further feature in this case is the extent to which key professionals displayed a difference in their interpretation of thresholds of concern. For example, when Sibling 8 sought help it was evident that the police and hospital staff regarded the presentation of information by Sibling 8 as a safeguarding concern. This was interpreted differently for example by CSC who regarded it as more symptomatic of a parent and adolescent disagreement. The dispute reflects a difference of view in regard to how older children are assessed especially by services such as CSC. 430. Some of this reflects cultural assumptions that older children have greater resilience and can suffer ‘agency neglect’, some of it can reflect organisational anxiety that older children who leave their families and arrive in public care often face poor outcomes including a successful reunification; it can also be a reflection of the difficulties that professional generally have in identifying and assessing emotional neglect and abuse although in this case Sibling 8 had reported physical assaults and had suffered an injury to his thigh. Issue for consideration by the BSCB 1) Is the support for professionals from different professional backgrounds sufficiently rigorous and challenging to prevent inappropriate erosion of concerns especially in regard to older children? 2) Can professionals distinguish with sufficient clarity between indicators of neglect and other factor such as social disadvantage? 3) What is the capacity in terms of skills, knowledge and organisational capacity for services in being able to work effectively with resistant adults? 34 Stevenson O. Neglected children Issues and dilemmas Ch 3 pp20-29 Blackwell Science: London; 1999. 35 NSPCC. Child protection research briefing child neglect 2007. Page 75 of 89 Family and professional contact and interaction; putting children’s needs, views and wishes at the forefront of interaction and enquiry; achieving balance in how vulnerable parents are helped; recognition of barriers that inhibit engagement and implications for practice. 431. Throughout this case the parents remained the key influence in the interaction with professionals and services. The extent to which parents effectively control the attitudes and behaviour of key professionals is increasingly understood through research and the analysis of serious case reviews. The interaction and relationship between professionals and vulnerable families is the subject of complex ethical and legal issues. In cases where families are resistant to help or contact by services requires considerable empathy, professional knowledge and interpersonal skills as well as time and resilience. 432. The fact that this was a family that was resistant to involvement and contact is not unusual. There are several academic sources that provide support to what Egan described as being ‘impossible to be in the business of helping people for long without encountering reluctance and resistance’36. The behaviour which become acute when help is involuntary (for example the involvement of criminal justice in respect of father’s offence, referral to CSC) can be exhibited in a range of ways that have been categorised as being dependency, closure, flight, or ‘disguised compliance’37. 433. The first three behaviours were all displayed in this case at various times and served to keep professional focus misdirected and away from the needs of the children. Amanda Hutton’s antagonism to hospitals and health staff was generally known about from early on and was used to rationalise the absence of contact with the primary health services. It had implications for late ante natal care, post natal support and the on-going care and immunisations of the children. 434. The panel identified that more regard should have been given to the signs of vulnerability that have been described throughout the report. The panel have also identified the additional factors that need to be taken into account in regard to multiple births and the potential implications. 435. The information about domestic violence was primarily managed as a threat to Amanda Hutton and when there were occasions when she was seen to be unfit through drink to have responsibility for her children the responsibility was directed to one of the older children. 436. Evan Stark38 describes how domestic violence has to be understood more clearly as coercion in order to understand the impact on the women and to understand why these relationships endure, why abused women develop a profile of problems seen among no other group of assault victims. 36 The Skilled Helper: Egan, G. 1994. 37 The term is attributed to Peter Reder, Sylvia Duncan and Moira Gray who outlined this type of behaviour in their book: Beyond blame: child abuse tragedies revisited, 1993. 38 Coercive Control: How men entrap women in personal life Evan Stark: Oxford University Press 2007. Page 76 of 89 437. In this case Amanda Hutton was isolated from her wider community because some people in both the Asian and white community were unwilling to accept a relationship between two people from different cultural heritages. It is clear that she became more isolated after the relationship with father ended. 438. When health, education and early childhood as well as CSC all sought information about the missing children they were all misdirected. In late 2011 when the police and CSC were following up the referrals about home conditions the strategy used by Amanda Hutton was to close down any contact until the police overcame her resistance by use of their power of entry to the house. The investment in ‘Think Family’ in Bradford provides a framework for continuing to improve the response to vulnerable families in the future. Issue for consideration by the BSCB 1) How can professionals maintain an appropriate focus on the needs and risk for children when working with adults who have longstanding difficulties that can include depression, substance misuse or domestic abuse? 2) How can professionals identify evidence of inappropriate resistance? 3) How can professionals satisfy themselves that relevant children’s views, wishes and feelings are considered and influence judgements and decisions? 4) How can the revised arrangements such as Think Family be evaluated for their effectiveness and are there particular issues for children of multiple births? 5) How can professionals ensure that frameworks for responding to domestic violence recognise the barriers to effective help and what are the implications for offence management and social support and intervention? Responses to incidents and information; viewing individual incidents or crises in isolation; identification and clarification of patterns or inconsistencies that represent significant harm to children. 439. A consistent finding in this and other cases that have been the subject of serious case reviews is the extent to which new and emerging information is often not recognised and therefore not sufficiently understood within a context of previous information and events. Each incident was considered in isolation. This applied in regard to information and evidence about the use of alcohol and the recurrent episodes of domestic violence as well as for example how the request for help from Sibling 8 was managed. 440. The systems for judging the thresholds of concern appeared to offer limited encouragement and opportunity to identify or enquire into underlying patterns, attitudes and behaviours. This resulted in a reliance on whether a presenting issue represented a significant and current threat to the safety and well being of a child with a focus on physical or other tangible evidence of significant concern. Page 77 of 89 441. The ‘lower’ level of help was seen to be primarily as providing practical and emotional support, giving encouragement on an informal voluntary basis; to that extent it was effective although did hide underlying issues39. The help provided to Amanda Hutton with the intention of assisting her to flee domestic violence was done on a voluntary basis and sought to secure a place of safety for her. When the efforts were not successful, it did not lead to any further follow up action. 442. This case again reveals the pattern for services at all tiers to be preoccupied with responding to incidents on an event focused basis especially in regard to making judgments as to whether particular events represent significant harm for example. At no point did anybody think that any of the children were at risk of significant harm as a result of the pattern of violence and neglect. 443. There could have been a better appreciation of the emotional harm for the children (as well as for Amanda Hutton) and attention given for example to what Sibling 8 was saying. A number of factors are influential that range from individual events never meeting a sufficiently high threshold of concern especially for the higher tier and statutory services such as CSC through to the limitations of the systems tools described in the next finding. Reports and verbal information sharing can be routinely passed through to services but are not then analysed for relevance and significance in terms of the emotional health and well being of children. 444. Understanding the habitual and persistent behaviours associated for example with minimising and disguising the use of alcohol and domestic violence and the implications for parents’ emotional availability and capacity is not sufficiently embedded into practice. The complexity and ambiguity of such work is acknowledged but at present practice is apparently too reliant on what parents are willing to reveal and talk about. 445. The opportunities that were occasionally offered were not apparently recognised or followed up partly because they were seen at the time as a means of deflecting attention. For example, when father was arrested he wanted to talk about his concerns about Amanda Hutton’s care of the children although this was seen as deflecting from his violent behaviour. No follow up was made to the suggestion that father make a referral to CSC if he was concerned. Issue for consideration by the BSCB 1. How do the arrangements for responding to individual incidents or crises provide sufficient opportunity to place them within a context of previous history and to identify emerging patterns or dissonance /inconsistency? 2. How does the training and support provided to practitioners equip them to understand the importance of and have the capacity to identify 39 The panel noted for example that the children’s centre were invited to focus on practical issues such as budgeting; the younger children were eating ‘finger food’ for example which was probably an indicator of impaired social development; matters were compounded by the fact that they understood the children to be younger than they were. Page 78 of 89 underlying patterns such as emotional neglect as a result of issues such as alcohol dependence or domestic violence? 3. How does professional interaction in regard to contact, sharing information and making referrals consistently identify underlying concerns or patterns relevant to the development or vulnerability of a child over and above information about a specific incident? 4. How do practitioners have the guidance, confidence and skills to overcome the resistance of adults who may wish to divert or redirect professional focus or concern (that might include disguised compliance)? Longer term work with vulnerable children and troubled families; recognition of long term behaviours and changes to circumstances; multi agency understanding about what constitutes good enough parenting; systems that rely on parents doing the right thing. 446. The long history in this case of children being subjected to domestic violence, having their routine health needs neglected and their disrupted and impaired education and the extent to which the home conditions had deteriorated so badly in recent years invites reflection as to whether the various services have a good enough collective understanding about some fundamental frameworks such as what constitutes good enough parenting. 447. There were indicators of vulnerability when Amanda Hutton was pregnant on all the occasions. Providing effective help for children rests on professionals having the capacity to recognise early signs and having the ability to work with a parent. Being able to secure the confidence of a parent without becoming collusive requires well developed interpersonal skills, emotional intelligence and confidence. 448. In this case, there were isolated examples of individuals trying to help Amanda Hutton but none truly had a focus on the needs, wishes and feelings of any of the children until September 2011 when the police and CSC overcame Amanda Hutton’s resistance to allow anybody into the house. 449. Important issues such as the children’s absence from routine primary health care were noticed and were discussed by the primary health care team. The decision to remove the family from the GP register led to the removal of one important agency from the network of agencies that should be working together to share information. It is noted that the decision to de-register the family took place only about 6 weeks before the estimated date of Hamzah’s death. The review found no evidence of financial motivation for removal of the families, even though removal of patients from lists can have an effect on practice income. 450. None of the children were offered pre-school child care40. This could have been an important source of support both for the children’s development as well as providing practical support to a mother who was increasingly unable to cope. 40 The early years ‘offer’ has changed since the eldest children were born. The number of children’s centres has increased across the district and this has allowed a much wider and more comprehensive service to be offered. Page 79 of 89 451. The home conditions were noticed to be neglected and the children showed evidence of neglect in school. 452. A significant theme to come through in panel discussions is the extent to which national and local systems rely on parents acting responsibly and doing the right thing as good enough parents for their children. Many of the systems for example in regard to registering for statutory education or being registered with a GP rely on a responsible parent making the appropriate arrangements. This case shows the vulnerability of such an arrangement especially in a city with a significant transitory population. 453. The children’s centre IMR author describes that just over 70 per cent of children aged 0-4 are registered with a children’s centre in Bradford. The 30 per cent not registered included children such as Hamzah and his siblings. In 2008 the health visiting service began asking parents of newly born children to allow their details to be forwarded to the early year’s service. That has resulted in just fewer than 50 per cent of babies being notified to the service. 454. Since December 2011 the arrangement has been changed to an opting out arrangement and the proportion of babies notified to the service is now 90 per cent. This provides a more secure basis of knowing about children in local areas but as the children’s centre IMR highlights the practitioners need to have a proactive approach to engaging with families and especially those who for a variety of reasons are reluctant to have a service. Issue for consideration by the BSCB 1) Is the apparent level of uncertainty amongst different professionals about what constitutes ‘not good enough’ parenting acceptable? 2) Are local systems for ensuring children have access to appropriate health care and education (including pre-school) robust enough to compensate when parents are unable or unwilling to act in the interests of their children? 3) Are the increased rates of babies known to the early year’s service leading to improved access for the most isolated and vulnerable of children? Tools to support professional judgment and practice; availability and use of tools for collating, sharing and analysing information; promoting analytical discussion and revealing underlying and long term patterns such as neglect. 455. The effective sharing and analysis of information within a framework of appropriate and child focused assessment is a perennial challenge for multi professional teams or groups of workers and has been described and discussed in national research, inspections of children’s services as well as being a regular feature in serious case reviews. 456. The assessment of neglect is especially problematic in the information and professional systems that do not have the capacity to reflect upon the accumulated evidence of direct observation and professional reporting. Page 80 of 89 457. National efforts to achieve improved consistency have largely resulted in processes becoming ever more bureaucratised and process driven through computer based electronic recording frameworks. This has left professionals completing processes that have little apparent benefit for improving the clarity and insights regarding complex behaviours and family circumstances and their interplay. The tools focus on describing events or behaviour and offer limited opportunity to record reflection, hypothesis or analysis. In this case there were further factors that included using case recording rather than assessment frameworks for recording information. 458. Recent studies have emphasised that although professionals such as social workers can be very effective at gathering information from a range of sources they face a far greater challenge in being able to identify ways to analyse the information for its relevance and significance in regard to risk and need for children, leaving assessment often to be ‘slightly better than guessing’ (Dorsey). An evaluation of assessment tools by the Department for Education has identified and reviewed three systems of assessment tools. The study concludes that although there needs to be a move towards more structured analysis and decision making there is limited evidence about the effectiveness of available tools in child protection work41. 459. The current systems work with the greatest effectiveness when a tangible event or incident is being reported or recorded and this has encouraged a degree of reliance on the single record or event needing to provide a compelling and clear reason for a reaction especially from specialist higher tier services that are working with the most vulnerable of children. 460. The evidence from this case and from other reviews and studies show that formal assessments are largely a copy and paste of the same information recycled and reiterated; there is little sense of either a dynamic narrative or developing insight and analysis about needs, risks and motivations. There was very little information about the parents’ personal and family histories42. The current systems almost invite such an approach and especially in situations where workloads are high. The national frameworks for assessment have changed as a result of the abolition of the national assessment framework and will place a greater emphasis on local areas developing their own arrangements43. 461. The cumulative impact was that lower order information that is seen as either isolated or episodic as described in other findings is not shared and the underlying patterns are insufficiently revealed in regard to responding to events and incidents. The national assessment framework for children in need and their families was based on an ecological model that understands the 41 Systematic review of models of analysing significant harm; Barlow J, Fisher JD and Jones D, Department for Education March 2012. 42 Reder and Duncan found similar issues in their review of serious case reviews in 1999; Lost Innocents: A Follow-up of Fatal Child Abuse. It has become apparent in this review and is commented on by the HOR that the maternal grandmother was an important source of support and her death had a significant impact on mother. 43 The revised guidance is included in Working Together to Safeguard Children published in 2013. Page 81 of 89 importance of recognising that effective safeguarding relies on a dynamic interplay of multiple risk and vulnerability factors. Regrettably this has not translated into effective practice models and was acknowledged in the Munro Review referenced in earlier chapters. 462. In these conditions it is less surprising that much of the practice reflected through this case is a one dimensional and static approach to viewing the needs and circumstances of children and a preoccupation on physical conditions rather than the emotional needs and circumstances of children for example. In the absence of having a system that can offer better quality recording to the professionals, the completion of an assessment can be regarded as an administrative chore rather than being an important exercise of professional skill and judgment. 463. Another dimension revealed in this review and which is reflected in national studies44 concerns the extent to which questions about what a child means to a parent and what the parent means to that child in respect of their emotional care and security are not routinely explored. The same report offers reflection on the important relationship between having a good understanding about all aspects of maltreatment and its relationship with the development of children. Issue for consideration by the BSCB 1. To what extent is local assessment practice a reflection of a child focussed, professionally controlled activity rather than being driven by local and national bureaucracy? 2. Are the tools for collecting and recording information about children and their families adequate and able to promote sufficient interagency assessment? 3. How does the training and development of professionals undertaking assessments across all services provide sufficient understanding about child development and childhood vulnerability? Management systems; improving the local arrangements to use information about vulnerability to promote the well being of children (especially pre-school); developing models of help and support; moving to more assertive forms of help when required. 464. This serious case review has revealed that information that could provide indication of vulnerability (and indeed risk from significant harm) does not consistently lead to an appropriate escalation of concerns and follow up. Some of this is because different people have different parts of a child’s information or narrative which on it own is not regarded as being significant or concerning. 465. The review has also highlighted that a number of factors may be taken into account when a GP takes the decision to remove a person from their list. GP practices have to balance their duty to maintain accurate registration lists wherever possible, against the risk of making access to primary medical 44 Brandon, Sidebotham, Ellis, Bailey and Belderson. Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of serious case reviews Department for Education May 2011. Page 82 of 89 services harder for families who are de-registered. This review found no evidence that the decision to remove Hamzah’s family from the practice list was financially motivated, although it is recognised that GP practices receive payments that are both capitation based and performance based and in theory at least, financial factors could influence removal decisions. 466. The application of the missing children protocols within education, health and CSC all failed to confirm where the children were and yet did not trigger any other levels of enquiry. It is an example of where in the absence of evidence of specific harm the systems did not encourage any further progression. 467. There was evident confusion reflected in the IMRs about the application of particular aspects of legislation. A significant example was whether private fostering regulations were relevant to the information being provided by the family or whether there were other legal responsibilities on the part of any of the agencies. 468. Although this analysis has focussed on the younger children, there were issues in regard to how the concerns expressed by Sibling 8 were dealt with especially by CSC. Issue for consideration by the BSCB 1) Do professionals require written protocols and procedures to understand whether their action is appropriate and sufficient when enquiring into the whereabouts of a child? 2) How do professionals undertaking complex work that is subject to a great deal of primary legislation and regulation secure and maintain an appropriate level of knowledge and understanding? 3) Are there particular issues in a cosmopolitan city such as Bradford regarding how the community is kept informed about arrangements and agreements to look after children outside of their immediate family? 4) Are the current arrangements for permitting a child to be removed from a GP practice list appropriate? 5) Are the current arrangements for identifying any child living in the city not registered for school or for a pre-school service appropriate? 6) Does the BSCB have sufficient confidence in current arrangements for identifying children who are missing from home, education or health care and oversight? 4.1 Issues for national policy 469. GP practices, as contract holders, are mandated to follow local safeguarding procedures as part of the CQC registration and also through the terms of their contract for service delivery. With regard to individual GPs, the General Medical Council updated its professional guidance to all doctors in 2012 to indicate the responsibilities they carry as healthcare practitioners in considering and giving appropriate priority to the needs of children. Page 83 of 89 470. In terms of contractual obligations, GP practices with “open lists” should accept any patient onto their list and GPs should not remove patients from their list unless there is good reason, such as the patient no longer being in the practice area or there being a complete breakdown in the doctor-patient relationship. It remains a matter of some discretion however, whether to remove a patient or family if the exact address cannot be identified. Local guidance has been issued and consideration should be given to the need for any further local or national guidance on this issue. 471. The arrangements for the management of school admissions in Bradford are compliant with national requirements and standards. This review has identified how children who are never notified for admission to school can become missing without the knowledge of the authority. 472. The review has identified the importance of all public services having sufficient understanding about their role and responsibility in promoting the safety and welfare of children. The registrar of births in Bradford has highlighted the absence of guidance for that service at a national level. Peter Maddocks, CQSW, MA. Independent author November 2013 Page 85 of 89 5 APPENDICES Page 86 of 89 Appendix 1 - Procedures and guidance relevant to this serious case review Legislation The Children Act 1989 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act45 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need. Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm. These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a Baby Has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998. Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm. The Children Act 2004 Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate. The arrangements are to be made with a 45 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training. Page 87 of 89 view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes. This section is the legislative basis for children’s trusts arrangements. Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act46 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Safeguarding Procedures The Bradford Safeguarding Children Procedures The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this serious case review. National guidance47 Working Together to Safeguard Children (2010) 46 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. 47 The election of a coalition government in May 2010 has resulted in changes to guidance and policy that applied at the time. Page 88 of 89 The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable. The guidance was replaced in 2013. Framework for the Assessment of Children in Need and their Families 2001 The guidance in respect of the Framework for the Assessment of Children in Need and their Families was issued under section 7 of the Local Authority Social Services Act 1970 and was therefore mandatory. The guidance was replaced in March 2013. The framework set out the framework for ensuring a timely response and effective provision of services to children in need that applied at the time of the event described in this review. The framework is no longer national policy following the publication of Working Together to Safeguard Children in March 2013. It makes clear the importance of achieving improved outcomes for children through effective collaboration between practitioners and agencies. The framework sets out clear timescales for key activities. This includes making decisions on referrals within one working day, completing initial assessments within seven working days and core assessments within 35 working days. As part of an initial assessment children should be seen and spoken with to ensure their feelings and wishes contribute to understanding how they are affected. If concerns regarding significant harm are identified they must be subject of a strategy discussion to co-ordinate information and plan enquiries. Child protection procedures must be followed. Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should be a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention is required to secure the well – being of the child. Such intervention should be described in clear plans that include the services being provided, the people responsible for specific action and describe a process for review. Common Assessment Framework (CAF) The CAF is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The CAF is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. Page 89 of 89 The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions. All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008. Page 1 of 19 Bradford Safeguarding Children Board Serious Case Review Hamzah Khan (17.6.2005 – 15.12.2009) Learning and Improvement in response to the Serious Case Review Page 2 of 19 Page 3 of 19 Introduction: 1. On 3rd October 2012 the Independent Chair and Independent Author for the Serious Case Review (SCR) that was undertaken following the discovery of the death of Hamzah Khan presented the overview report to Bradford Safeguarding Children Board (BSCB). Members of BSCB accepted the report and its conclusions. Members of BSCB also accepted the Individual Management Reviews (IMR) which were submitted by each agency to the SCR overview panel. 2. The conclusions of the SCR set out in paragraphs 99 - 157 of the overview report are accepted as the basis for the further analysis within the overview report and as informing the subsequent learning and improvement work undertaken by BSCB and its member agencies. 3. The following specific conclusions are fundamental to understanding the challenges faced by BSCB, member agencies in Bradford and Local Safeguarding Children Boards (LSCB) and agencies in other areas: a. “Information known to the various agencies at the time of the events that have been examined and analysed by the panel does not suggest that Hamzah’s death was a predictable event.” (Paragraph 102). b. The panel concluded that Hamzah and his siblings could have received more coordinated support in response to the evidence of domestic violence and the indicators of neglect. This view is evidenced by the observations regarding aspects of practice in response to domestic violence that are described at a number of points on the overview report, in particular in paragraphs 141 and 145. c. “A compelling aspect of the case for general learning is the extent to which none of the various organisations that came into contact with this family had enough information to form a view about what life was like for any of the children in this household especially during the last few years.” (Paragraph 100). d. Another feature of this case is the manner in which the youngest three children including Hamzah were able to ‘drop off the radar’ of core universal provision such as primary health and education and early childhood services. There are a number of references to this feature in the overview report, in particular in paragraphs 39 and 109. It should be noted that Hamzah was not of statutory school age, and the focus for the review was to understand why he did not have access to early childhood services. 4. The significant themes for learning from the Individual Management Reviews (IMR) that agencies produced (section 3.2) and the examples of good practice identified through the review (section 3.3) are welcomed. 5. Chapter 4 of the SCR analyses the key themes of the case. The analysis of each theme concludes with a number of questions. These questions are challenges to all with responsibility for services to children and families in the Bradford District. The questions also provide a way for BSCB to critically apply the learning from this SCR when considering new safeguarding initiatives and holding existing services to account. 6. BSCB is committed to supporting the collective learning and improvement of all of its member agencies as a result of the lessons learned and the challenges identified by this SCR process. The SCR sub group of BSCB Page 4 of 19 actively monitors the progress of each agency’s improvement. Specific themes from the SCR have been, and continue to be, considered by the sub groups of BSCB and continue to guide safeguarding developments undertaken by BSCB and by its member agencies. Dynamic Learning and Improvement: 7. The obligation for LSCB to learn and improve is set out in chapter 4 of Working Together to Safeguard Children 20131 which was published after the conclusion of the SCR. This sets out how LSCB are required to develop a culture of continuous learning and improvement. This learning and improvement must be drawn from SCR, other reviews and audits, local and national research and the intelligent application of national policy initiatives to local circumstances. 8. The effective implementation of agency improvements resulting from the SCR process is a crucial mechanism for achieving much of the necessary changes identified from this case. The strong commitment of agencies to implement these improvements is welcomed by BSCB, and it is noted that many of the required changes identified have already been implemented. 9. However, there are other significant developments with origins independent of this SCR which also impact on the understanding and capacity of BSCB and its partner agencies to learn and improve. Many of these developments occurred after the death of Hamzah was discovered in September 2011, and some have occurred since the SCR was presented to BSCB in October 2012. Nevertheless the local implementation of these developments has been informed by the learning from this SCR, and the questions set out in chapter 4 have provided critical challenges to BSCB and each agency when considering how the developments may impact on children and families in the Bradford District. 10. Key relevant recent national developments have been: a. The Munro Review of Child Protection, the Government response and the subsequent progress report by the same author2. b. The national Troubled Families Programme3. c. NHS reform programme. 1 “Working Together to Safeguard Children - A guide to inter-agency working to safeguard and promote the welfare of children” was published by” was published by the Department for Education in March 2013. It came into force on 15th April 2013. 2 Professor Munro’s review of child protection was published by the Department for Education in 3 parts: • Part One:” A Systems Analysis” was published in October 2010 • The Interim Report: “The Child’s Journey” was published in February 2011 • The Final Report: “A Child Centred System” was published in May 2011. The Government response to the Munro Report was published by the Department for Education in July 2011 Professor Munro’s Progress Report: “Moving towards a child-centred system” was published by the Department for Education in May 2012. 3 The Troubled Families programme was launched by the Prime Minister in 2011 with the intention of assisting through targeted intervention an estimated 210,000 families in England. Page 5 of 19 11. Each of these developments has provided opportunities and challenges to BSCB and agencies that shape how local improvements have developed following this SCR. 12. The Munro Review of Child Protection and linked national policy developments are intended to create child and family services in which confident professionals exercise their informed judgement to ensure that children are safe and thriving, without being bound by unduly prescriptive regulations and procedures. In Bradford, the Local Authority and its partners have taken advantage of the new freedom and are re-designing key aspects of the Integrated Children’s System to ensure that professionals can more easily collate, share, and analyse information. 13. The national reforms to the child protection system also require each local authority and its partners to produce local protocols for the assessment of children and their families. In the Bradford District the Local Authority and its partners have developed the Bradford Single Child Assessment4 which is being piloted. An evaluation of the pilot will be considered by BSCB prior to full implementation. 14. Families First is the Bradford District implementation of the national Troubled Families Programme. This programme will work with 1,760 families (a figure determined by central government) in the District over a three year period from April 2012 – March 2015. Staff from seven statutory services and staff from voluntary sector agencies are working together to support families to address deep-rooted problems. 15. The Bradford Families First programme has been developed taking into account the lessons from both local and national serious case reviews. In particular the programme focuses on how agencies can better engage with families especially those who are either resistant or refuse the help on offer. 16. NHS Reform Programme: The ambition to ensure the effective safeguarding of children and adults is set out in “Safeguarding Vulnerable People in the Reformed NHS”5. This document sets out how the revised structures and commissioning arrangements of the NHS are expected to work together and with partner organisations to ensure the safety of children, setting the following expectation: “We expect to see the NHS, working together with schools and children's social services, supporting and safeguarding vulnerable, looked-after and adopted children, through a more joined-up approach to addressing their needs.” 17. It is in this context of change and opportunity that local and regional NHS bodies continue to work within an integrated framework with partners and are applying the learning arising from the SCR. Responding to the challenges raised by the Hamzah Khan SCR. 18. Chapter 4 of the Hamzah Khan SCR sets out a series of challenges grouped under six themes. In this section the themes are considered and examples of 4 The Bradford Single Child Assessment (BSCA) pilot began in October 2013 5 Safeguarding Vulnerable People in the Reformed NHS Accountability and Assurance Framework First published: 21 March 2013 Prepared by: NHS Commissioning Board Page 6 of 19 local improvements are described that have been completed or are under way which demonstrate responses to the challenges. 19. The first theme identified in Chapter 4 of the overview report is: Cognitive influence and human biases: developing mindsets that are open to fresh or different information; repeated exposure of professionals to intractable and long term problems contributing to a normalisation in their response; understanding the significance of deviant or risky parental behaviour. 20. As a result of the analysis undertaken in the SCR, specific challenges arise from this theme. These are: • The challenge of providing support for professionals from different backgrounds to prevent the erosion of concerns for children, especially older children; • Providing professionals with guidance and tools to distinguish between indicators of neglect and other factors such as social disadvantage; and • Equipping organisations to work effectively with resistant adults. 21. Ensuring that professionals from all agencies give appropriate weight to concerns about children, including older children requires individual agencies and BSCB to provide necessary support and challenge. This is assisted through clear single and inter-agency procedures, effective and testing supervision, providing structured opportunities for professionals to share information effectively and access to high-quality, relevant training. 22. Over the length of time that Hamzah’s family was known to agencies, all agencies have taken steps to strengthen support for professionals. The SCR demonstrated that this support has been uneven during the period considered. Agencies and BSCB need to continuously reinforce the emphasis given to such support and ensure that it equips staff to operate effectively in new structural arrangements and in the face of new challenges. 23. Each agency that participated in this SCR has reviewed its own child safeguarding procedures in the light of lessons learned from this case. The BSCB reviews and makes necessary revisions to its multi-agency child safeguarding procedures every six months, with the most recent revisions having been made in August 2013. 24. Regular, challenging and supportive supervision, focused on child safeguarding, is an important factor in enabling workers to maintain an appropriate understanding of the experiences of each child for whom they are responsible. BSCB requires all member agencies to complete a regular self-evaluation audit which includes questions about the frequency and effectiveness of supervision provided for their staff working with children and families. 25. A number of agencies have taken specific initiatives to improve further the quality of staff supervision. Local Authority Children’s Social Care Services train supervisors in the “4x4x4” supervision model developed and pioneered by Tony Morrison and Jane Wonnacott6. In addition, the Local Authority has a 6 Morrison, T. and Wonnacott, J. (2010) ‘Supervision: now or never. Reclaiming reflective supervision on social work’ Page 7 of 19 programme to provide independent management mentors to its first line managers in Children’s Social Care (CSC) to assist them in developing their supervision skills. 26. The Bradford Multi-Agency Risk Assessment Conference (MARAC), which provides a regular formal opportunity to discuss known domestic violence cases with a victim and child perspective, produced an IMR for the SCR. This highlighted that until 2010, the recently established Bradford MARAC did not have consistent appropriate representation by Children’s Social Care (CSC). This impacted negatively on the MARAC understanding of specific children’s experiences of domestic violence and on the quality of information sharing between CSC and other agencies in such cases. 27. National research and the evaluation of serious case reviews 7 indicates that some older children and young people in need of protection do not achieve good outcomes from the services provided by local authorities and their partners. 28. Local learning has been identified, through this SCR and case file auditing, that whilst agencies must respect the determined views of young people, it cannot be assumed that they are resilient to compromised parenting. 29. Local Authority Children’s Social Care has commissioned Professor Mike Stein to work with officers, to consider how to develop better responses to vulnerable young people based on interventions that are evidenced as being effective. Professor Stein is the co-author of “Neglect Matters”8. 30. A further challenge for agencies is to provide tools and support that enable professionals to distinguish between indications of neglect and other factors such as social disadvantage. 31. The new Bradford Single Child Assessment tool (BSCA) has been developed taking account of research evidence and the findings of serious case reviews, including the Hamzah Khan review. It focuses on the three domains considered in the previous assessment framework (child’s developmental needs, family and environmental factors and parenting capacity). 32. It is designed to support best practice; is less process driven but rather supports the intelligent questioning, understanding and analysis of information gathered that tells the child’s story. It is more child centred, focusing specifically on the child’s experiences and how these impact upon care, safety and development. It encourages greater participation of children and more direct social work time being spent with children. In this respect it significantly supports social workers and other professionals in addressing the initial challenge of giving appropriate weight to concerns about children, including older children. 7 Brandon, Belderson, Warren, Howe, Gardner, Dodsworth and Black: “Analysing Child Deaths and Serious Injury through abuse and neglect: what we can we learn? A biennial analysis of serious case reviews 2003 – 2005” (DCSF & UEA, 2008). 8 Hicks and Stein: “Neglect Matters: A multi-agency guide for professionals working together on behalf of teenagers” (DCSF and University of York, 2010). Page 8 of 19 33. In addition it draws on research evidence to require consideration of sources of vulnerability and resilience. Therefore the assessor is required to consider to what extent poverty and a run – down neighbourhood may be sources of vulnerability to neglect for a child. The assessor is then also required to consider the extent to which specific sources of resilience that reduce the risk of neglect may be evidenced, e.g. a committed adult, a good school experience, a strong community and good services and support. 34. The BSCA is currently being piloted and evaluated across the Bradford District. The evaluation will be presented to BSCB, and the extent to which the assessment tool assists in addressing this and other questions raised in the SCR will be considered. 35. High quality training for professionals and their managers assists in providing the necessary theoretical under-pinning to understand the complex causes and impact of neglect on children. In addition, training can provide practical skills and tools which professionals can develop further in their daily practice. 36. When delivered on a multi-agency basis training is particularly effective in developing, strengthened inter-disciplinary communication and understanding and a shared understanding of the evidence and research base that helps professionals to identify and respond effectively to neglect. Bradford Safeguarding Children Board (BSCB) is currently developing a new multi-agency training course focusing on recognising and responding to neglect. 37. The issue of child neglect is addressed in the content of a number of BSCB multi-agency training courses. The “Safeguarding Children: a Shared Responsibility” course has a particular emphasis on information sharing and the significance of effective interagency communication to safeguard children from abuse and neglect. This course is delivered 6 times a year to multi agency groups of 30 staff. In 2012 – 2013 staff from education (schools and support services), social care staff, probation, police, health staff (from the community and hospital trusts), early childhood services and staff from voluntary and community organisations have all participated in the training. 38. The course “Working with Resistant Families (Child Centred Practice)” was developed with an independent expert and has a particular focus on recognising the cumulative effect of neglect on older children. 39. Under this theme, the third challenge for BSCB and its partners is: What is the capacity to work effectively with resistant adults? 40. Each of the initiatives and support mechanisms for professionals described in response to earlier challenges under this theme apply to this question. Good quality supervision which assists the professional in understanding the nature of their relationship with resistant adults is essential. An effective supervisor will identify practical advice and assistance, for example by arranging for a joint visit with another colleague or professional from another organisation. 41. The BSCB multi-agency procedures contain a chapter on working with reluctant and hostile families. This chapter provides a framework for understanding the motivations and behaviours of families that appear reluctant to engage with services, outlines the responsibilities of staff and managers and provides good practice guidance. Page 9 of 19 42. The new BSCA (described in paragraphs 31 – 34, above) highlights parental suspicion of agencies as a vulnerability factor to be considered in assessment. 43. The multi-agency training programme delivered by BSCB contains two courses specifically designed to improve the skills and knowledge of professionals and their managers in order to work effectively with resistant adults. These have both been developed in conjunction with independent experts with learning from Hamzah’s case, and other SCRs, in mind. The two courses are: “Working with hostile or uncooperative families” and “Working with resistant families”. 44. “Working with hostile or uncooperative families” aims to help practitioners and managers to learn from practice and research, to understand how to overcome blocks and difficulties in relationships with families and to develop practical responses to overcome fear of intimidation, to be assertive and know what to say and do, and to work in an authoritative manner, focussing on the needs of the child. 45. In order to assess the impact of learning from “Working with hostile or uncooperative families“an evaluation session recently took place. All of the participants from each occasion the course has been delivered (approx 120 professionals) were invited. They were asked to reflect on the pledge they made at the end of the training session about how they have used the learning in their practice and provide evidence of impact of learning on their work with children and families. This evaluation has already demonstrated the need to develop a new training input on working with disguised compliance as a linked theme. The evidence from the evaluation will be collated and presented by the Learning and Development sub group as part of its quality assurance function. 46. “Working with resistant families” has a particular focus on the role of supervision in supporting workers faced with this challenge. It also focuses on developing an understanding of the impact of stress and fear on infant resilience and survival in such households and recognising the cumulative effect of childhood neglect on older children. 47. The second theme considered is: Family and professional contact and interaction; putting children’s needs, views and wishes at the forefront of interaction and enquiry; achieving balance in how vulnerable parents are helped; recognition of barriers that inhibit engagement and implications for practice. 48. Analysis of this theme resulted in a number of challenges for BSCB and its partners. These include: • The challenge of ensuring that professionals maintain an appropriate focus on the needs and risk for children when working with adults who have longstanding difficulties that can include depression, substance misuse or domestic abuse. • How can professionals identify evidence of inappropriate resistance? • Enabling professionals to satisfy themselves that relevant children’s views, wishes and feelings are considered and influence judgements and decisions. Page 10 of 19 • How can professionals ensure that frameworks for responding to domestic violence recognise the barriers to effective help? 49. The extensive training programmes provided both by single agencies to staff in their own organisations and on a multi-agency basis by BSCB play a significant role in ensuring that staff maintain focus on the needs and risk for children when working with adults who have longstanding difficulties. 50. The complex and multi-faceted nature of the difficulties experienced by members of some vulnerable families requires that agencies and services with a core focus on adults and those that focus on children take steps to ensure that their staff recognise the need to liaise and share information appropriately with all professionals engaged in helping a family. This requirement is emphasised in the BSCB multi-agency safeguarding children procedures, and is re-iterated in agencies own safeguarding children procedures. 51. Bradford District Care Trust (BDCT) sets out the safeguarding children obligations of its entire staff group in its publication “Safeguarding Children Information for Health and Social Care Workers”. Since 2011, BDCT and Bradford Council Children’s Social Care Services (CSC) have implemented a joint protocol intended to ensure that staff from both agencies co-operate to safeguard children through joint working, for example by visiting households together and both contributing to assessments of the needs of children living in vulnerable families. Audit of the implementation of this joint protocol has evidenced a significant rise in joint visiting and information sharing during assessments of the needs of children in vulnerable families. 52. It is important to recognise that work to resolve the problems faced by parents and care givers can make a significant contribution to improving the quality of life of children in the family. However, the work to assist parents must be informed by a sound understanding of the needs of the children, and of the impact of parental difficulties on children’s lives. The national evidence base that informs the principles and practices of the Bradford Families First programme (described in paragraphs 14 and 15, above) emphasises the effectiveness of multi-disciplinary family interventions in reducing domestic violence incidents and mental health problems. 53. The need to assist professionals to identify evidence of inappropriate resistance is emphasised in the review. The importance of equipping professionals with an understanding of this issue through good quality training has already been discussed, and the detailed and developing programme of multi-agency training in this area has been outlined. 54. Regular, challenging and supportive supervision is a key element of each agencies support to staff working with families that may exhibit inappropriate resistance. This supervision is most effective when combined with structured tools that encourage professionals to consider the nature and pattern of family engagement with services. 55. The new Bradford Single Child Assessment (“BSCA” described in paragraphs 31 – 34) specifically requires the social worker to consider the possibility that parents may be fearful of the stigma of needing help, or may be suspicious of statutory agencies. Reviewing records of contacts and a chronological history Page 11 of 19 of professional contact with families assists social workers and other professionals to identify patterns of resistance and non-compliance. 56. This review and other SCR have identified instances when professionals have had insufficient understanding of children’s lives and limited appreciation of their vulnerability. Such an understanding would be strengthened by more effectively gathering the children’s views, wishes and feelings, and giving proper consideration to these when assessing and making plans. 57. In 2012, BSCB audited its member agencies to establish how consistently the views of children were collected and considered in planning for individuals and developing services. A number of agencies identified the need to strengthen practice in this area. One consequence of this focus on engagement with children and young people was the decision by BSCB to establish a children and young people’s sub group, which will be in place by December 2013. 58. This focus has also influenced the development of the Bradford Single Child Assessment and tools used in agencies to gather and consider the views of children. 59. The BSCA requires that each child that is capable of expressing a view is given an opportunity to do so, both in terms of contributing to the information considered in the assessment, and in commenting on the outcome of the assessment. In Bradford a number of tools are available to support professionals in gathering and considering the views of children. Since 2012, Viewpoint, an interactive database, has been used to assist children in contact with Children’s Social Care (CSC) to share their views. 60. Viewpoint is an on-line, age appropriate questionnaire that enables children to answer questions and provide additional information to help professionals understand the child’s needs and to consider the effectiveness of help being given by professionals. It has been used extensively with Bradford’s Looked After Children, has recently been made available for use with children where there are child protection concerns, and will shortly be made available for use with all children in need. 61. Viewpoint makes a significant contribution to the development and review of plans for individual children. It Is also used to provide aggregated information for reports to BSCB, the Children’s Trust, Corporate Parenting Panel, the Children in Care Council and other strategic bodies in the District. 62. Developing effective frameworks for responding to domestic violence is a challenge for the District. There are strong links between BSCB and the Domestic Abuse Partnership (DAP) resulting in joint approaches to learning and training, joint protocols with partners and strengthened Multi-Agency Risk Assessment Conferences (MARAC). 63. A particular challenge for children’s services is to effectively screen the high volume of domestic violence notifications received from West Yorkshire Police and to ensure that help is effectively targeted at children affected. For the entire period considered by the Hamzah Khan SCR the practice was for West Yorkshire Police to send to Children’s Social Care (CSC) all notifications of incidents to which the Police were called, where there were children, including where there was no violence or abuse. Consequently CSC Page 12 of 19 used up significant resources in screening these notifications, rather than applying their resources more effectively to responding only to those that were appropriate referrals. 64. The numbers of domestic violence notification reports received from the police for the years 2006 - 2010 averaged at 5,850 a year, approximately 490 per month. In 2011-12 approximately 9,400 domestic violence notifications were received. 65. During 2012 CSC launched the Integrated Assessment Service, a multi disciplinary assessment team which receives and responds to all new referrals. A revised protocol was also agreed with West Yorkshire Police to put in place more effective shared screening of domestic violence notifications. 66. A police officer is located in the team, who screens all the police domestic violence notifications that are received by CSC. The police officer is able to access both police intelligence and any information held by CSC, which includes any previous incidents that may build up a picture of an emerging pattern. This integrated approach between CSC and the Police enables immediate access and the sharing of inter-agency information, which better informs CSC’s responses to DV notifications. Consequently numbers of notifications to CSC have reduced, with 4,600 being received in 2012-13. 67. The third theme considered is: Responses to incidents and information; viewing individual incidents or crises in isolation; identification and clarification of patterns or inconsistencies that represent significant harm to children. 68. Issues arise through analysis of this theme include the following. 69. How do the arrangements for responding to individual incidents or crises provide sufficient opportunity to place them within a context of previous history and to identify emerging patterns or dissonance/inconsistency? The BSCB multi-agency safeguarding children procedures have been revised to provide clearer expectations that assessments and child protection enquiries must gather information about the previous history of children and families and analyse present concerns regarding the well-being of children in the wider context of family history and functioning. The BSCA that is currently being piloted contains specific prompts to assist social workers and other professionals in to identify significant patterns in family histories. The practice standards developed within children’s social care requires that every child receiving a service has a properly maintained chronology to provide an overview of the child and family’s contact with agencies. This requirement is regularly audited by mangers at all levels of the service. 70. How does the training and support provided to practitioners equip them to understand the importance of and have the capacity to identify underlying patterns such as emotional neglect as a result of issues such as alcohol dependence or domestic violence? As a result of learning from this case and other reviews, revisions and additions have been made to the BSCB multi-agency training programme. Page 13 of 19 71. The substance misuse and parenting course has been revised following the completion of the review. This course provides participants with an opportunity to consider the issues related to parents who misuse substances and the impact on their ability to parent and ultimately the impact on the health and welfare of the child. This course is delivered twice a year to 30 participants on each occasion. Courses have been attended by midwives, teachers, health visitors, voluntary and community sector staff, specialist drugs and alcohol service providers, community resource workers, and probation staff. 72. The “Safeguarding Children: A Shared Responsibility” course has also been revised following the Hamzah Khan review. This course provides an opportunity for participants to share dilemmas and concerns when working on an interagency basis and to recognise the importance of effective interagency collaboration at the earliest opportunity. It includes specific material and exercises regarding neglect and emotional abuse as a consequence of parental mental health problems, substance misuse and domestic violence. This course is delivered on the annual programme 6 times a year to 30 staff on each occasion. Courses are attended by named teachers, other education staff, health visitors, school nurses, police, probation, midwives, youth service staff, connexions service staff, adult services staff, voluntary and community sector staff, early childhood practitioners and Families First staff. 73. “Child Protection Decision Making – Safeguarding Analysis and Assessment Training” is developed and accredited by Child and Family Training on behalf of the Department for Education. The mechanism for the delivery of this course in Bradford is specifically influenced by the challenge that this SCR raises regarding the need to support professionals from different backgrounds to share and jointly analyse information about children and families. Bradford is first LSCB to deliver this course on an inter-agency basis, and has made plans to ensure the sustainability of the course by developing a pool of agency based trainers who are accredited by Child and Family Training. The course is delivered 6 times a year for groups of 20 staff including social workers, midwives, health visitors, Connexions staff, Families First staff, police officers and education staff. 74. Two new courses have been commissioned for delivery to multi-agency groups as a result of learning from the Hamzah Khan case. The two courses are: “Working with hostile or uncooperative families” and “Working with resistant families”, and these courses, and the arrangements for evaluation, are described above in paragraphs 43 - 46. 75. How does professional interaction in regard to contact, sharing information and making referrals consistently identify underlying concerns or patterns relevant to the development or vulnerability of a child over and above information about a specific incident? 76. Bradford Children’s Social Care participated in regional research with Professor David Thorpe. It was commissioned across all 15 local authorities in the Yorkshire and Humberside Region in order to understand better how requests for help from social care are dealt with and whether there are ways in which the response to families can be improved A key question asked in the research was: “how do agencies know whether they are dealing effectively with initial child care enquires and the first stages of contact with people needing help? Are systems in place to spot those children at greatest Page 14 of 19 risk? And, when so many agencies are involved, is the focus on where it is most needed?” 77. This research and the subsequent action plan for Bradford was shared with and endorsed by BSCB. A new Integrated Assessment Service was developed with the Police, Health and Education which was launched in February 2012. 78. The agencies work together to ensure all safeguarding activity and intervention is timely, proportionate and necessary. Enquiries made to Children’s Social Care are screened by a qualified and multi-agency team, building on and enhancing good practice. This multi-agency team is led and managed within the Children’s Social Work Service. 79. The Integrated Assessment Team undertakes the following: • To screen all new Referrals that come into the team for the South and North East catchment areas; • To access and share all information about a child held by the individual agencies to inform professional judgement and decision making; • To provide a multi disciplinary consultation service to any professional who has a safeguarding concern about a child, providing advice and guidance and promoting preventatives services where appropriate; • To promote the Common Assessment Framework (CAF), directing appropriate contacts to preventative services & appropriate agencies through professionals’ own agency links & networks; and • To ensure that assessments and child protection investigations are carried out in a timely way engaging children and their families in the process. 80. Following feedback from the public and professionals, all referrers are now able to speak to a qualified professional within the multi disciplinary duty/screening team when making a child protection referral. This team includes an Education Social Worker, a Health Visitor, a Safeguarding Police Officer and Social Workers. 81. An evaluation of the Integrated Assessment Service showed significant improvement in the timely sharing of information held by and between agencies and also demonstrated that the quality of information sharing had improved, leading to better decision making for children. 82. External scrutiny has found that partners have developed a model that builds upon the existing, robust arrangements for safeguarding the District’s most vulnerable children. Two consecutive unannounced inspections by Ofsted of our child protection services in August 2009 and November 2010 focused on assessment arrangements. Both of these inspections were positive, identifying no areas for priority action. The Ofsted announced inspection of safeguarding arrangements and services to looked after children in May 2012 resulted in an overall good rating for services. 83. The fourth theme considered in chapter 4 of the overview report is: Longer term work with vulnerable children and troubled families; recognition of long term behaviours and changes to circumstances; multi agency understanding about what constitutes good enough parenting; systems that rely on parents doing the right thing. Page 15 of 19 84. Consideration of this theme results in three challenges, the first being: is the apparent level of uncertainty amongst different professionals about what constitutes ‘not good enough’ parenting acceptable? 85. The concept of “good enough” parenting is a challenging one for professionals to apply in some family situations. Both the needs of a child and parental capacity to effectively and safely meet those needs are dynamic and can change rapidly, sometimes in ways that are unpredictable. 86. Assessment tools including the Common Assessment Framework (CAF) and the Bradford Single Child Assessment (BSCA) assist professionals in gathering information with which to judge the quality of parenting. 87. BSCB has published a threshold of need document which has been in use in the District since 2010. Evidence from using the threshold document and from self-assessment audits of agency safeguarding arrangements show that this tool supports professionals in making judgements about children’s’ needs and parents’ capacity to meet those needs. However, for development and improvement have been identified in feedback from professionals and from this serious case review. BSCB has committed to revising the threshold in need document, in line with the expectations of Working Together to Safeguard Children 2013. It is anticipated that a revised threshold document will be published by April 2014. 88. The second challenge identified is: are local systems for ensuring children have access to appropriate health care and education (including pre-school) robust enough to compensate when parents are unable or unwilling to act in the interests of their children? 89. This SCR demonstrates the challenges faced by the universal services of health care, early childhood services and education in making contact with and providing services to children when faced with extra-ordinarily high levels of resistance by a parent. Primary health services to all of the children in the family were severely limited, and eventually they were removed from the General Practice register. 90. Hamzah and the other pre-school age children were not in contact with a children’s centre or any other pre-school provision. Whilst Hamzah and his youngest siblings were not of school age at the time of his death, it is reasonable to expect that applications would have been made for primary school places by that time. School attendance by Hamzah’s older siblings was variable, and at times fell to levels that resulted in the Education Social Work Service (ESW) becoming involved. 91. The improvements for Bradford District Care Trust (BDCT), which has responsibility for the Health Visiting Service, resulting from this SCR include a range of information, training, and practice issues. The records of all non-engaging families are now reviewed by the Health Visitor or other relevant health practitioner on a six-monthly basis to inform a risk assessment and action plan to minimise the risk of further drift. A pathway has been developed to ensure the prompt referral of non-engaging families where health professionals have identified safeguarding concerns. Page 16 of 19 92. General Practices (GP) across Bradford have been issued with robust guidance in relation to escalating any concerns that may arise from non-attendance for healthcare services, as well as the procedures to be followed if considering removal of children from their lists. GPs have also been reminded of their responsibilities to raise serious concerns in line with local multi-agency procedures 93. As part of this SCR, an individual management review (IMR) was completed by the Bradford Schools Admissions team. The improvements include a rolling programme of parental awareness-raising regarding the schools admission process. Regular articles are published in the newsletter which goes to every home in the District and a system has been agreed with early years settings, including children’s centres to ensure that clear information is given to all parents, with a particular focus on vulnerable children, to ensure that applications for school places are made. 94. The ESW service has revised the Children Missing Education procedure to ensure that managers regularly monitor and review each case. All Children Missing Education Cases must remain open until a school and home address in the UK is found, or until a manager agrees that all potential enquiries have been exhausted. The ESW service can now access the Bradford Council benefits database which has assisted in locating a number of families in the Bradford District whose children are not on a school roll. The Children Missing Education procedure has also been revised to those pre-school children whose sibling education history suggests they may be at risk of missing education. 95. The third challenge is: are the increased rates of babies known to the early year’s service leading to improved access for the most isolated and vulnerable of children? 96. The Bradford Early Years service manages and brokers provision for a large and diverse pre-school population, with a wide range of needs. The District’s Early Help Strategy is currently under review and BSCB is receiving regular reports on the progress of the review. From November 2013 the CAF Board and Parenting Board will be combined into one Early Help Board. 97. The service has identified the need to strengthen the documented requirements on children’s centres to link with other agencies when developing support plans for individual children. When completing a pre-CAF assessment children’s centres must link with other agencies to ensure that any identified additional needs are recorded and must review children’s support plans in consultation with these agencies. 98. To assist Early years Services and partner organisations in identifying vulnerable children an Integrated Care Pathway (ICP) model has been developed in Bradford District for children aged 0 – 4 and their families. The initial core services included in the model are; health visiting, children's, centres and midwifery services. The model has been developed through staff engagement sessions and through piloting 'segments' of the child's journey over a 6 month period in different parts of the district. A full time health visitor has been appointed to ensure implementation of the ICP model across all key services. Once fully embedded (anticipated date 01/06/14) the model will ensure the most effective use of current resources within these services and Page 17 of 19 will focus on improving outcomes for young children, especially those most at risk of poor health and well being outcomes. 99. The fifth theme identified and analysed in chapter 4 of the overview report is Tools to support professional judgment and practice; availability and use of tools for collating, sharing and analysing information; promoting analytical discussion and revealing underlying and long term patterns such as neglect. 100. Analysis of this theme results in three challenges for BSCB and local agencies. This first of these is: • To what extent is local assessment practice a reflection of a child focussed, professionally controlled activity rather than being driven by local and national bureaucracy? 101. The second challenge is: • Are the tools for collecting and recording information about children and their families adequate and able to promote sufficient interagency assessment? 102. The final challenge under this theme is: • How does the training and development of professionals undertaking assessments across all services provide sufficient understanding about child development and childhood vulnerability? These challenges arise from the specifics of this case, yet they are familiar to professionals who have followed the debate arising from Professor Eileen Munro’s review of child protection, and the government response to the review. The review concluded that a number of national constraints should be removed, including the requirements to adhere to nationally designed assessment forms and nationally prescribed approaches to IT systems for recording social worker activity with children. 103. This report has already described the work that is underway in Bradford to pilot the locally designed Bradford Single Child Assessment (BSAC). This is intended to be a child –focused tool that encourages the collection and analysis of relevant information within a time scale appropriate to the case. The report on the pilot of this tool will be presented to BSCB. 104. The freedoms to remodel the electronic recording system used to record social workers assessments, plans, interventions and case reviews has been welcomed by Bradford Childrens Social Care Services. Work is under way with the system provider to simplify aspects of the system, thus reducing bureaucracy, and to bring it in line with the BSAC tool. 105. As described in paragraph 73, BSCB is committed to delivering multi-agency assessment training to a minimum of 120 professionals each year. “Child Protection Decision Making – Safeguarding Analysis and Assessment Training” was developed on behalf of the Department for Education. An evaluation of the effectiveness of this training will be presented to BSCB during 2014. Page 18 of 19 106. The final theme analysed in the overview report is: Management systems; improving the local arrangements to use information about vulnerability to promote the well being of children (especially pre-school); developing models of help and support; moving to more assertive forms of help when required. 107. Six challenges arise from the analysis of this theme, the first of which is: do professionals require written protocols and procedures to understand whether their action is appropriate and sufficient when enquiring into the whereabouts of a child? BSCB and its partners accept that such written protocols and procedures are necessary. The development and strengthening of these procedures is described in paragraph 95 of this report. 108. The second challenge for consideration is: How do professionals undertaking complex work that is subject to a great deal of primary legislation and regulation secure and maintain an appropriate level of knowledge and understanding? This report has set out in some detail the work undertaken by BSCB and member organisations to assist professionals to maintain their knowledge and understanding of the legislative and regulatory framework within which they operate when working to safeguard children. This work includes the provision of extensive multi-agency safeguarding training (an annual calendar of 13 face to face course topics, 12 e-learning topics and additional bespoke learning events). 109. BSCB audits partner agencies to establish the effectiveness of safeguarding supervision provided to their staff. Information regarding supervision is set out in paragraphs 24 and 25. 110. The multi-agency safeguarding children procedures are reviewed by BSCB and its partners in the West Yorkshire Consortium every six months to ensure that they provide a user-friendly, up to date, legally compliant guide for professionals. The procedures were independently reviewed by a social work academic in 2009 and were found to be “User-friendly and thorough safeguarding procedures provided by knowledgeable and responsive providers”9. 111. The next challenge for BSCB and its partners is: are there particular issues in a cosmopolitan city such as Bradford regarding how the community is kept informed about arrangements and agreements to look after children outside of their immediate family? 112. In their work with Hamzah Khan’s family, professionals were diverted by the untrue assertion made at various times by mother and one of Hamzah’s adult siblings that he and other young siblings were residing, or would shortly be residing, in another local authority area. Although there was no evidence to support this, at one point one professional considered that a private fostering arrangement might be in place. 113. BSCB delivers a programme of modules to raise awareness of private fostering which is particularly targeted on education, early years and health professionals who have direct contact with most of the children and families 9 . Review of Safeguarding Procedures in Bradford Metropolitan District: Professor B. Featherstone Department of Social Sciences and Humanities, University of Bradford (2009). Page 19 of 19 in the District. In addition articles in community newsletters and the local newspaper have been used to promote awareness of private fostering, together with features on local radio stations. 114. Nevertheless, raising awareness of private fostering arrangements is a challenge in all local authorities, particularly in those, such as Bradford, where there are diverse cultural traditions of informal kinship care of children. 115. The fourth challenge is: are the current arrangements for permitting a child to be removed from a GP practice list appropriate? As described in paragraphs 92 and 93, the local arrangements for removing children from GP lists have been reviewed and revised. The impact of these revisions will be monitored by partners and reported upon to BSCB. 116. The fifth challenge to arise under this theme is: are the current arrangements for identifying any child living in the city not registered for school or for a pre-school service appropriate? Paragraphs 94 and 95 of this report describe a number of measures that have been taken with the intention of strengthening arrangements for identifying children not registered in school, or receiving a pre-school service. The effectiveness of these measures will be monitored by partners and reported upon to BSCB. 117. The final question for BSCB and its partners to consider is: does the BSCB have sufficient confidence in current arrangements for identifying children who are missing from home, education or health care and oversight? BSCB provides a programme of training regarding risks to children who go missing, factors that make children vulnerable to becoming missing, and explaining the protocols in place to reduce missing episodes. This training is delivered both face to face and via e-learning. 118. A regular report is presented to BSCB regarding children who are missing from home or education, and this will be developed to include information regarding children who are missing from health oversight. 1 Serious Case Review – Statement from the Chair of Bradford Safeguarding Children Board (BSCB) My name is Professor Nick Frost. I am Professor of Social Work at Leeds Met University. As Independent Chair of the Bradford Safeguarding Children Board (BSCB) I am responsible for overseeing review processes following the death of a child or after other serious incidents. The role is established by government regulations and this ensures my independence from all the agencies in Bradford. I have 35 years experience in practice, policy and research in children’s services issues. I wish to express my sincere regrets and sorrow about the death of Hamzah and the subsequent events. The death of any child is a tragedy and the fact that Hamzah’s body was undiscovered for a long period makes his death even more tragic. It is imperative that all agencies with safeguarding responsibilities, in Bradford and nationally, learn any lessons from his death and the fact that it was undiscovered for so long afterwards. The BSCB decided to initiate a Serious Case Review (SCR) following Government guidance as soon as possible following the events surrounding the discovery of Hamzah’s body. In accordance with the guidance I appointed an experienced person to independently Chair the SCR process (Nancy Palmer) and a well-qualified independent author to produce the report. Nancy is here today and will speak about the process of undertaking the review and she will outline the primary findings. BSCB has published three documents: the SCR, an Executive Summary of the SCR and a Learning and Improvement report produced by the BCSB. The SCR details significant events during Hamzah’s short life. The main aim of the report is to learn lessons from these unfortunate events so that professionals can change and improve their systems. The SCR is very clear that Hamzah’s death could not have been predicted but finds that systems, many of them national systems, let Hamzah down both before and following his death. It is my responsibility, as Independent Chair, to ensure that lessons are learnt. Very sadly I cannot give any assurances that a tragedy like this will never happen again in our country - as we can’t control or predict the behaviour of all parents, the vast majority of whom are doing their very best to care for their children. However, I can assure you that at this stage I am satisfied each agency is responding adequately: but this is an on-going process which requires constant monitoring. No child should go through what Hamzah experienced. I am satisfied that systems are in place today that minimise the chance of a situation such as this ever being repeated in Bradford. In this statement I wish to make a number of points. It is clear from the trial and the judge’s remarks that only one person is responsible for Hamzah’s death: that person is Amanda Hutton, Hamzah’s mother. At the trial, Judge Roger Thomas QC addressed how the mother had kept the death of her son a secret saying: “Your 2 deviousness was to keep various agencies away from you and your children.” The serious case review states: “Hamzah died because he was neglected by his mother.” Having established this accountability we need to know what the agencies in Bradford need to learn from the events. In my 35 years of involvement in children’s services I have never come across a case that can even be compared to this one. As the SCR establishes this was a unique combination of events: a mother who was determined not to co-operate even with the most necessary and essential services. She managed to mislead professionals and relatives about the whereabouts of Hamzah. Thus the SCR asks how a child could disappear ‘from the radar’ of the services. Certainly there was insufficient information and no evidence that would have allowed any agency to take statutory action to safeguard Hamzah. The SCR states that ‘there is nothing in the information examined by the panel to suggest that Hamzah’s death was predictable’. The SCR helps us to see how issues could have been handled more helpfully. For example, no thorough multi-agency assessment was undertaken - this is the usual way in which professionals build a full picture of what is happening in a household. Such an assessment may have given a comprehensive picture of circumstances in the household and should have led to a multi-agency meeting. One of Hamzah’s siblings could have been listened to more carefully on the two occasions where it was mentioned that all was not well in the family. However, when questioned about their home life at school the children appeared to be content. We have a duty to listen to children and young people. The SCR also finds that remarkably the siblings appeared well and cared for – but sometimes they did not. This inconsistency could have been explored more fully. Further mother was inconsistent in her stories about where Hamzah was following his death. Again some of her statements could have been followed up more fully. Now the system has been reformed fundamentally: to avoid children in the district disappearing from view all Bradford births are now notified to children’s centres by a health visitor – unless the parent explicitly opts out from this process. Additionally since Hamzah’s death, and drawing on research, the assessment process has been fundamentally reformed and involves a range of professionals working together. My independent view of services in Bradford has been they are good and sometimes excellent. This personal assessment was re-enforced by the Ofsted inspection of 2012 which is available on the Ofsted website. But lessons must and will be learnt and action will follow. Personally I will do all in my power to ensure that the contents of the Learning and Improvement document are fully followed through. I know I have the total commitment of all the agencies involved in the SCR to do this. __________ 1 Serious Case Review - Statement from the independent Chair of the review My name is Nancy Palmer, and I am the Independent Chair of this Serious Case Review. I am a qualified social worker with many years experience of children’s services. I have also held senior positions in both Ofsted and Cafcass. Since 2009 I have been an independent practitioner. Among my current responsibilities I am the independent chair of two Local Safeguarding Children Boards (LSCBs). I was commissioned to independently chair this review in December 2011. My colleague Peter Maddocks was commissioned as independent author of the overview report and executive summary. Peter has over 35 years experience of social care services and has held senior roles in local and national government, and in the voluntary sector. Peter is now an independent consultant and trainer, and has previously provided overview reports to several LSCBs. Peter Maddocks has never worked for any of the agencies involved in this review. I previously worked for Bradford Council, leaving that role in 1993. The other members of the overview panel for this review are senior officers of nine of the key local agencies involved in the case. None of these panel members had previously had any direct responsibility for the work undertaken with Hamzah and his family. The overview panel was strengthened by the participation of a Children’s Services senior officer from another metropolitan district council. This Serious Case Review was conducted in accordance with the statutory guidance contained within Working Together to Safeguard Children (2010). Individual Management Reviews were commissioned from 14 agencies listed in paragraph 67 of the overview report. The way in which reviews such as this are undertaken is changing to reflect the circumstances in which troubled families and vulnerable children are helped by services. It is for this reason that the overview report provides a series of challenges and critical reflections for Bradford Safeguarding Children Board and local agencies to enable them to implement learning and improvement. Shocking as the circumstances of Hamzah’s death are, it is important that all involved in a serious case review focus on what is to be learnt from the case, and how services can be improved for the future, in Bradford District and nationally. It is important to be clear that Hamzah died because he was neglected by his mother. The overview panel considered carefully all the information available to agencies at the time they were working with Hamzah’s family, and analysed how that information was used. The panel concluded that the information known to the various agencies at the time of the events does not suggest that Hamzah’s death was a predictable event. A significant finding in this SCR is the extent to which Hamzah was unknown and invisible to services throughout his short life. The report concludes that this was “largely because neither of his parents participated in the routine processes” the vast majority of parents do, “such as ensuring he saw health professionals on a regular basis or was enrolled for early years’ educational provision.” This meant none of the various organisations that came into contact with the family had enough information to form a view about what life was really like for any of the children in this household, especially during the last few years. 2 The review raises challenges for local and national policy makers to consider how far systems, such as provision of health care and enrolment for education, should rely on parents making the right decisions for their children. This review has found that there were occasions when one of the children spoke about the domestic violence in the family. On other occasions however the children said they were happy, for example, when questioned about their home life at school Children’s views, wishes and feelings must be focused on and understood. Children need to feel able to speak to people that they can trust, and those people need to have the time and capacity both to listen and respond to concerns and worries. The review highlights the corrosive impact of domestic violence and substance misuse and finds that at times there was insufficient attention given to the implications of domestic violence and parental substance misuse on the children in the family. The review notes that changes were made in Bradford to strengthen the multi-agency response to children living in households with domestic abuse. With the benefit of hindsight, the overview report provides a perspective not always available to professionals at the time that they were working with this family. For example, Amanda Hutton was able to care effectively for her older children, which made it more difficult for professionals to give proper weight to indications that her care for the younger children was inadequate, and becoming dangerous. Even in the later stages considered by the review, the presentation of the children was inconsistent, with significant tooth decay being noted in one child, but during the same time period another child being noted to have new clothes, neat appearance and healthy packed lunch and snacks. It is also important to draw attention to the good professional practice that was identified by the serious case review. This good practice included: persistent efforts by a police officer to encourage Amanda Hutton to accept help in response to domestic violence, the persistence of the PCSO in gaining access to the family home in September 2011 and the midwifery service arranging ante-natal home visits in one of the pregnancies. It is important that the learning from this review is disseminated and that actions to improve services result from this learning. I am pleased therefore that BSCB has accepted the overview report and the challenges contained within it. Some key developments have already improved services, for example, the establishment of a multi-agency assessment team that includes a police officer, education worker and health visitor working together with children’s social workers. I am also pleased that BSCB and its member agencies are committed to further changes such as piloting a new approach to assessments of children’s needs, the development of which has been informed by learning from this review, and from other reviews and research. Thank you. |
NC045799 | Suicide of a 17-year-old girl in April 2013. Child B was an inpatient in a specialist adolescent mental health clinic under Section 3 of the Mental Health Act 1983 at the time of her death. B was admitted to the clinic due to concerns that she had an eating disorder and because she had been self-harming. B lived with mother and step-father until January 2012 when she moved in with her boyfriend and then later her father. Although B's living arrangements were initially agreed by mother, she soon afterwards wanted B to return home. Family were known to services including Targeted Youth Support Service (TYSS) who worked with B, her mother and step-father to try to rebuild their relationship. Review was undertaken using the Partnership Learning Review model. Identifies areas for learning and development, including: contact with children's services should be considered when a young person presents with significant mental ill-health and where there are concerns about the impact of family dynamics on protective factors; and formal consideration should be given to sharing the details of Community Treatment Orders (CTOs) with agencies providing services to young people placed on CTOs, including schools and colleges. Includes Hertfordshire Safeguarding Children Board's response to the areas for learning and development.
| Title: Serious case review: re Young Person “B”: died April 2013 aged 17 years. LSCB: Hertfordshire Safeguarding Children Board Author: Ron Lock Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. HSCB – Serious Case Review re B – Overview Report July2014 Serious Case Review Re Young Person “B” Died – April 2013 Aged 17 years Independent Report Author – Ron Lock March 2014 – revised with the Inquest findings in May 2014 1 HSCB – Serious Case Review re B – Overview Report July2014 Contents Introduction 1.1 – 1.4 Page 3 Purpose of the Serious Case Review 2.1 – 2.2 Page 3 Summary of the facts 3.1 – 3.30 Page 4 Analysis: Knowledge of background information 4.1 – 4.7 Page 9 Effectiveness of services: - prior to mental health concerns 5.1 – 5.21 Page 10 - emergence of an eating disorder 5.22 – 5.27 Page 14 - safeguarding concerns 5.28 – 5.31 Page 15 The Use of the Mental Health Act 6.1 – 6.10 Page 16 Communication with the parents 7.1 – 7.15 Page 18 Inpatient care from Jan 2013 8.1 – 8.19 Page 21 Predictability and preventability 9.1 – 9.3 Page 25 Areas for learning and development 10.1 – 10.7 Page 26 The Serious Case Review Process – Appendix 1 Page 28 2 HSCB – Serious Case Review re B – Overview Report July2014 Introduction 1.1 This Serious Case Review was undertaken following the death in April 2013 of a young woman at the age of approximately 17 ½ years. The circumstances of her death suggested at the time that this young woman, who will be referred to as “B”, took her own life. 1.2 The Hertfordshire Safeguarding Children Board (HSCB) decided that the circumstances of B’s death met the criteria to undertake a Serious Case Review (SCR) and that it reflected relevant government guidance that “an SCR should always be carried out when a child dies…….including where a child died by suspected suicide,….. and where the child was detained under the Mental Health Act”1 1.3 At the time of B’s death in April 2013, she was an in-patient in a specialist adolescent mental health clinic under Section 3 of the Mental Health Act 1983 due to concerns that she had an eating disorder, but additionally that she had been self-harming. B had first been seen by a doctor because of possible anorexia in June the previous year and because of the seriousness of her condition, had been immediately admitted to the in-patient clinic (Care UK) where she remained for five months. Following a second admission in January 2013, it was considered during March and April 2013, that B was making progress with her mental health and accordingly had her supervision ratio reduced and had been allowed home to visit her father. Although presenting in good spirits on returning from the home visit, it was on the following day that B was found unconscious in a classroom where she was found with a ligature round her neck. Three days later she was pronounced dead. 1.4 The Inquest into B’s death was held in April 2014, after the work of this Serious Case Review had been completed. The Inquest recorded that the medical cause of B’s death was: - a) Hypoxic2 Brain Injury, b) Hanging, and c) Anorexia Nervosa and Depression. The Inquest’s findings in relation to the circumstances in which B came to her death were recorded as follows: “We are satisfied and so we are sure that on general observation the evidence presented demonstrates that (Young Person B) consciously and knowingly undertook an act with the intention of ending her life. This act occurred on the 14th April 2013 at Care UK by means of hanging, using bunting as a ligature and a locker handle as a ligature point.” The Coroner’s conclusion as to B’s death was “Suicide”. Purpose of the Serious Case Review 2.1 The purpose of a Serious Case Review (SCR) is to provide a “rigorous, objective analysis of what happened and why”3 and to “Identify improvements which are needed and to consolidate good practice”4. Additionally, SCRS should be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children; 1 Chapter 4, paragraph 12, Working Together to Safeguard Children – A guide to inter agency working to safeguard and promote the welfare of children – HM Government - March 2013 2 Brain Hypoxia is decreased oxygen in the brain – there is a risk of this condition if the person is choking, suffocating or in cardiac arrest 3 Chapter 4, paragraph 1, Working Together - March 2013 4 Paragraph 7, Chapter 4, Working Together - March 2013 3 HSCB – Serious Case Review re B – Overview Report July2014 • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data is collected and analysed, and • Makes use of relevant research and case evidence to inform the findings.5 The Local Safeguarding Children Board is then required to “translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children”.6 2.2 The details of how the SCR was conducted and of the process used, are contained in an appendix at the end of this report. Summary of the facts The factual information pertaining to B and her family falls into distinct periods of time. Autumn 2010 – end of 2011 3.1 This first period relates to when B was living at home with her mother and step-father and their children. She had been living with her mother since her parents’ divorce some years earlier, which had generally been acrimonious and for which a Children’s Guardian had been involved by the courts. 3.2 The first key event in the timeframe for this SCR occurred in the autumn of 2010 when B took a small overdose of Paracetamol following a family argument. She was just over 15 years old at this time. An appointment at the Child and Adolescent Mental Health Service (CAMHS) shortly afterwards, identified the overdose incident as “out of the blue”. B’s mother responded that there was no need for a follow up appointment and so CAMHS closed the case. At this time B was doing extremely well at the independent school she was attending. January 2012 – April 2012 3.3 During January 2012 B’s mother and step father raised strong concerns about B’s relationship with a new boyfriend, and the school became involved in trying to mediate, but shortly after, B moved in with her boyfriend’s family for weekdays, and at the same time B made contact with her father for the first time in two years, and then spent weekends with him. Although this arrangement to live with the boyfriend’s family was initially with B’s mother’s agreement, she soon afterwards wanted B to return home and tried to enlist the help of the school in this respect. 5 Paragraph 10, Chapter 4, Working Together - March 2013 6 Chapter 4, Paragraph 7, Working Together - March 2013 4 HSCB – Serious Case Review re B – Overview Report July2014 3.4 In March 2012, the head teacher sought advice from Children’s Services and they confirmed that B did not meet the child protection thresholds and that the school were responding appropriately in the circumstances to B’s mother’s concerns. Shortly after however, at the mother’s request, the school did make a referral to the Targeted Youth Support Service (TYSS), who then conducted a brief assessment of B’s circumstances. The outcome of the assessment was that B was happy continuing at her school (she was still attaining very good academic results) and living with her boyfriend’s family (she had her own room) until she could move to her father, with whom she had now resumed contact. The assessment also considered that there were no safeguarding concerns. In these circumstances, TYSS considered that they had no further role. B did not want the counselling she was offered and was clear that she did not wish to return to live with her mother and step-father. B was approximately 16 ½ years old at this time. 3.5 After the Easter holidays, B started living with her father full time, with plans to change to a new school in this new locality, following completion of her exams. May 2012 – November 2012 3.6 At the time when B was on study leave from school and only attending for examinations, B’s father sought advice from the school on 21st May 2012 because of his mounting concerns about B not eating and that she was starting to look visibly gaunt. On the 25th May 2012, the school applied for “special considerations” on behalf of B to enable her to gain some flexibility in respect of the examination arrangements whilst she was in need of medical attention. 3.7 At her GP appointment a few days later, it was recorded that B had lost approximately a stone in weight (based on B’s stated previous weight) and that she now had a Body Mass Index (BMI)7 of 14.6. An urgent referral was made to the local CAMHS. 3.8 Following two CAMHS appointments and an attendance at A&E department an urgent referral was made to a specialist in-patient clinic (for eating disorders) and B was admitted there on the 21st June 2012. As she had changed her mind about wanting to be admitted, and was attempting to leave and determined to be unsafe, B was detained in the clinic under Section 5(2) of the Mental Health Act8. An assessment was undertaken by the psychiatrist and on the next day, B’s in patient status was changed to Section 2 of the Mental Health Act9 3.9 Immediately prior to this, B started at her new school (a secondary school nearer to her father’s home) but just attended for a few days prior to her admission to the specialist clinic. 7 A widely used diagnostic tool, the body mass index measures the body fat based on the weight and the height of an individual. While a healthy BMI is in the range 19 - 25, a BMI index of 17.5 is considered to be an informal indicator of anorexia nervosa. 8 Section 5 (2) of the Mental health Act 1983 allows for compulsory detention for a person who is already an inpatient, for up to 72 hours by the doctor in charge of the case. 9 Sec. 2 of the Mental Health Act 1983 allows a person suffering from a mental disorder to be admitted to hospital for an assessment of their mental health and to receive any necessary treatment. The person can be detained for up to 28 days. 5 HSCB – Serious Case Review re B – Overview Report July2014 3.10 Later in June, there was communication between the 6th Form Heads of both B’s current new school and her former school, when arrangements were made for B’s file to be sent to the current school, once authorised by the head teacher to do so. Ultimately however, it was the academic reports only which were sent to the father. No other school records in respect of B were sent through to the new school although this school nevertheless made links with the specialist in-patient clinic in order to arrange for work to be sent for B to do. 3.11 On the 2nd July 2012, B agreed that her father could let her mother know that she was in the clinic, but that she did not wish to see her. Once informed of her inpatient care, B’s mother telephoned the clinic and requested contact with her daughter, but B was clear that she did not want her mother to know the details of her care and would need to think about contact. For the remainder of July there was communication between the clinic and B’s mother when she was appraised of her daughter’s wishes not to have contact, and B’s mother provided some background information about the family. 3.12 During the first two weeks of July 2012, B occasionally needed to be fed by a naso-gastric tube. She was still saying that she did not want to gain weight because she considered she was too fat. Whilst in the clinic, B was prescribed anti-depressant medication (Fluoxetine) and Olanzepine which is an anti-psychotic drug used to treat eating disorders where anorexic thinking is very fixed. 3.13 On the 17th July 2012 the specialist clinic wrote to Hertfordshire Children’s Services to inform them that B as a child/young person would be an inpatient with them for a period in excess of 12 weeks. On the 19th July 2012 B was placed on Section 3 of the Mental Health Act10 to enable her inpatient care to be extended beyond the 28 days. 3.14 There were some minor self-harm incidents (scratches on her arms) leading to B’s jewellery being removed by the clinic and she had also pulled out her naso-gastro tube. As a result of serious concerns for further self-harm and suicide on the 23rd July 2012, B was placed on Level 4 supervision11. A week later, the tube was removed because B had started eating solid foods – she was then placed on Level 3 supervision12. 3.15 At the beginning of August 2012 B agreed to speak with her mother on the phone which was the first direct contact between them since B had moved in with her boyfriend’s family approximately six months earlier. 3.16 B had not achieved the predicted A grades for her AS subjects studied at her previous school though achieved grades A, B and C and she requested to repeat Year 12 at her new school. B was now 17 years old. 3.17 B further self-harmed by scratching, and attempted to abscond from the clinic, but there had also been some successful outings with her father and boyfriend, and by September and 10 Sec. 3 of the Mental Health Act 1983 allows a person to be admitted (or retained) in hospital for treatment up to a period of 6 months, which is necessary for the person’s health and safety and for the protection of other people, and that the treatment cannot be provided unless the person is in hospital. 11 Level 4 supervision meant that at all times B had to be within arm’s reach of a member of staff. 12 Level 3 supervision meant that at all times B had to be within sight of a member of staff. 6 HSCB – Serious Case Review re B – Overview Report July2014 early October 2012 B had been compliant, with her weight continuing to increase. However, at a family session at the clinic on the 8th October 2012 B took the view that upon her eventual discharge from the clinic, she should again be able to reduce weight and was angry that she would be in receipt of after-care following discharge from the clinic. It was also discovered that B had again self-harmed at home at this time by cutting her arm. 3.18 Following some progress from that time, and no more self-harm incidents, by the 30th November 2012 B was discharged home to her father and placed on a Community Treatment Order13 (CTO) which included conditions to maintain her weight target and to work with the local CAMHS team. December 2012 – mid January 2013 3.19 During this seven week period, B remained at home with her father and siblings on the CTO apart from a brief return to the specialist clinic for three days in mid-December, because she was skipping meals and self-harming. Following an overdose and an attempt to hang herself at home approximately a month later, and with B’s continued concern about being overweight, she was admitted via the local hospital A&E Dept. for one night to an acute adolescent mental health unit before again returning to the specialist in-patient clinic. There was a discussion between the consultant psychiatrists from each of the units when it was agreed that the specialist clinic for eating disorders remained the most appropriate placement. B was readmitted to the clinic the next day on the 18th January 2013. January 2013 – March 2013 3.20 A few days after her return to the clinic B grabbed a shower hose with strength and force and tried to wrap it round her neck whilst showering. She was then supervised throughout the shower and the hose was replaced in the supervised bathroom by a fixed shower head. There were also instances at this time of B hitting her head against a wall and attempting to throw herself down the stairs 3.21 The CTO was revoked on the 24th January 2013 and B was once again detained on Section 3 of the Mental Health Act. She was again assigned Level 4 (1:1 supervision) and this was increased to 2:1 supervision when moving to different parts of the building as she had attempted to abscond at the beginning of February 2013 and needed three members of staff to restrain her. B was noted to have low mood, guilt and high suicidal ideation. Her medication was increased. 3.22 With B’s agreement, between 15th February and 1st March 2013, the clinic tried unsuccessfully to contact B’s mother in order to discuss with her whether direct involvement could now be established. 13 A Community Treatment Order (as part of a revision of the Mental Health Act 1983) enables a mental health patient to be discharged from hospital but where it is still appropriate for the person to receive treatment for their health, safety and the protection of others. Conditions are included for the person to be available for examination when requested. Discretionary conditions can also be applied where relevant. 7 HSCB – Serious Case Review re B – Overview Report July2014 3.23 On the 13th March 2013 B attended the first tier Mental Health Tribunal14 to appeal against her Section 3 detention in the specialist clinic. It was not apparent that B had modified her thinking in terms of her attitude to eating and her weight. The outcome of the tribunal was that the statutory criteria for her detention had been met and that B would remain on Section 3. 3.24 Following some improved behaviours and no further self-harming by B, it was agreed to allow her outside with staff for walks and also to allow her to attend a concert at the O2 Arena, with three members of clinic staff in attendance. This took place on the 22nd March 2013 and went well with no issues. 3.25 A decision was made two days later to allow B to have two visits home to her father for the up and coming bank holiday weekend at the end of March 2013. These were reported to have been successful with no issues and it was noted within the clinic that B’s mood was steadily improving. April 2013 - events leading to B’s death 3.26 By the 11th April 2013, it was decided that the supervision arrangements would be reduced in that B would be under normal staff supervision (general observation and checked hourly) for the period 8.00 a.m. to 9.00 p.m. and she would return to Level 3 supervision from 9.00 p.m. There was a supervised dormitory where staff could monitor the well-being of the patients constantly through the night. 3.27 There was a planned day home on the 13th April 2013 which both B and her father reported went well when she returned later that day to the clinic. Unknown to staff at that time, B attempted to use a shower hose that evening as a ligature but was interrupted by another patient on the unit. B and the patient agreed not to inform staff of the incident. 3.28 On the evening of the 14th April 2013, it was reported by staff at the time of handover at 7.15 p.m. that B was in a communal area and was settled with other patients and that they had no concern about her mental state at that time. She had been visited by school friends earlier in the day and this appeared to have gone very well – they had been laughing and joking and there was a pillow fight. B reported during the early evening that she felt she was managing her time off the Level 3 and 4 supervisions well and that her time at home with her father was very good. 3.29 Staff observed that B was still in the communal area at 8.00 p.m. and it was subsequently reported that she told another patient that she was going off to write a letter. When she did not return by 8.20 p.m., staff went to look for her. B was found in a classroom, having pushed a table behind the door. Staff gained access and found that B had used some bunting from the window as a ligature around her neck and tied it to a door on a cabinet 14 The Mental Health Tribunal hears applications for people detained under the Mental Health Act 1983 (as amended by the 2007 MH Act) or living in the community following the making of a conditional discharge, or a community treatment or guardianship order. The main purpose is to review the case to direct the discharge of a patient where the statutory criteria for detention are not met. 8 HSCB – Serious Case Review re B – Overview Report July2014 (three feet high from the ground) and had slumped forward. B was unconscious at the time and was transferred to hospital intensive care. 3.30 B was pronounced dead on the 17th April 2013 after failing to regain consciousness. _______________________________________________________________ Analysis 4. The extent to which B’s family background information was known and able to inform effective professional interventions 4.1 The family background of the parental divorce and of protracted disputes between them was generally known by the independent school which B attended, and of some of the impact this had had upon B and her siblings. 4.2 The detailed work by Cafcass15, following the appointment of a Children’s Guardian in 2005/06, ended in 2009, was not formally shared with any other agency. This was understandable in that it was court mandated work and there was no formalised process which required it to be shared with other agencies. However if the level of upset and anxiety to the children caused by their parents’ actions following the divorce generated significant concerns for their emotional well-being, then there could have been a referral to Children’s Services or to CAMHS. However, this period of professional involvement predates the period of analysis for this SCR although it did require extensive work with the family which tried to resolve family disputes about contact arrangements, and accusations and counter accusations about parenting behaviours. 4.3 Overall, this meant that for example, when B’s school made contact with Children’s Services in March 2012 to seek advice, (prior to the referral to TYSS), Children’s Services held no information about any previous family problems to inform their response at that time that B’s circumstances did not meet the threshold for their intervention. Based on what was known, this was an appropriate decision in the circumstances. 4.4 Similarly, at the time of the CAMHS appointment for B in October 2010 for an overdose, if the background information had been known, then there was the potential that this intervention may have taken a different focus. Ultimately however, the finding at that time was that it was a one-off incident and there had been no history of self-harming, so even with the benefit of hindsight, it is not possible to say what difference, if any, knowledge of the previous family difficulties, could have made. In effect, CAMHS closed the case on the advice of the mother, although B would have been separately communicated about this decision. With the presenting circumstances at the time, it would not have been expected for CAMHS to have acted any differently. 4.5 It was apparent that this background of disharmony between the parents continued and an acrimonious relationship between them was sustained, despite limited communication 15 “Cafcass” - Child and Family Courts Advisory & Support Service 9 HSCB – Serious Case Review re B – Overview Report July2014 between them. This undoubtedly had a continuing impact upon B and her siblings who all now lived with their father. This background and B’s estranged relationship with her mother was a feature of later therapeutic work for B and her father with CAMHS and with the specialist in-patient clinic. Therefore whilst the detail may not have been known of the past family difficulties, it was occasionally discussed in therapy sessions and so the impact of this background was known to the professionals providing the therapeutic input at this time. 4.6 The mother has maintained in her contribution to the SCR that her daughter’s care in the specialist in-patient clinic was based only on background information supplied by the father and by B herself, and that this information “might be economical at best and possibly misleading at worst”. Further communication from the mother to the clinic at this time did give other background information, raising concerns about the quality of the earlier father-daughter relationship. In their response on the 31st July 2012, the clinic stated that this background information had been passed on to the clinical team working with B. In this respect therefore, a potential gap in background information appeared to have been at least partially filled. 4.7 Clearly the disharmony between the parents, their very limited communication with each other, and the lack of contact between B and her mother from February until August 2012, presented a difficult situation for involved professionals to deal with, in their attempts to respond to B’s needs and difficulties. Nevertheless the first school worked with B’s mother and stepfather when B lived with them, and her father was the active involved parent whom professionals worked with once he had taken responsibility for his daughter in early 2012. This was in the context that the parents cared for B quite separately, and there was never any suggestion of a joint approach to parenting, and so in this way the professionals only ever worked with the parent who was responsible for B at that time. This was understandable and appropriate in the circumstances. 5. The effectiveness of services delivered to B and her family Professional interventions prior to the emergence of mental health/eating disorder concerns 5.1 B’s first school (an independent school) during the SCR period was a school where B worked to a high level academically and was very popular socially. In this way this school very much met B’s needs and she appeared to be enthusiastic and very settled there. 5.2 The school however were not aware of B’s overdose in October 2010 – neither CAMHS nor B’s mother informed the school at the time. There would have been no formal process whereby CAMHS needed to inform the school unless they considered that the school had a particular role to play, and there was agreement from the family to inform them. In fact within school, just a week after the overdose, B’s school report identified no concerns about her in Year 10 and for the year 2010. She had an excellent academic report at this time. B continued to progress within school and for example a year later the school reported that B “is grabbing all the opportunities that are offered to her and making the most of them”. Therefore, it appeared that there was nothing which would necessarily have been gained from the school knowing about the early overdose. 10 HSCB – Serious Case Review re B – Overview Report July2014 5.3 The school however became involved at a different level during January/February 2012 in trying to help resolve the relationship problems that emerged once B’s mother and step-father became very unhappy about B’s relationship with a new boyfriend. The outcome was that B would move to live with her boyfriend’s family – this had been initially agreed between the boyfriend’s mother and B’s mother. It was only immediately after this that B made contact with her natural father and also arranged to stay with him at weekends. 5.4 Because of the intensity of the concerns within the family and of the mother’s request for B to return home, the school head made telephone contact with Hertfordshire’s Children’s Services to seek advice. This was a very appropriate response to the situation and the contact was able to confirm that as a 16 year old, B had rights and that the child protection threshold had not been met. Private fostering arrangements were explained, which in essence meant that because of her age, formal legal requirements in this respect did not apply. 5.5 The school continued to be involved over the following month via numerous communications from the mother and some from the natural father and at one stage the school head offered to hold a meeting between the parents to discuss the problems. Overall however, the school were correct in their responses to the family that where B lived, and the parenting arrangements were a matter for them, and that the school’s prime concern was that these problems should not upset B’s academic progress. 5.6 The mother was concerned that the school had allowed B’s relationship with the boyfriend to continue, and she considered that he was a bad influence on her. It was not however the responsibility of the school to make decisions about B’s relationship with a boyfriend although they did in fact attempt to resolve the situation and responded to parental contact, but ultimately it was not a role which they were obliged to take on. There was no evidence to support the maternal concerns and B was continuing to do well at school. The agreement reached for the school to make a referral to TYSS was nevertheless a useful step forward in trying to bring some objective expertise into the process. 5.7 Whilst the mother apparently accepted that the referral was necessary, she made a formal complaint to the school about the delay in actioning this. TYSS became involved from the middle of March 2012. 5.8 The role of TYSS was to assess the situation and to try to support B and her mother and step father to try to rebuild their relationship. A major part of the mother’s concern was that B was in a sexual relationship with her boyfriend and that he may be using drugs. Whilst the maternal concerns about a sexual relationship existing were understandable, this was a matter for B who was over 16 at this time, and her boyfriend who was a little older. 5.9 The risk assessment completed over a period of approximately two weeks at the end of March 2012, was conducted in as sufficiently detailed a way as the circumstances required. B was seen on her own and the accommodation at her boyfriend’s family was also visited. The school gave their views and information to TYSS, who in summary had no concerns about the boyfriend and his family. The assessor spoke with B’s natural father but only had e-mail communication with B’s mother. The latter arrangement was not ideal, in that 11 HSCB – Serious Case Review re B – Overview Report July2014 although the mother did not apparently give her contact details to the assessor, without that direct contact it would have been difficult for the assessor to have really understood the dynamics between mother and daughter. In this way it would therefore have been difficult to have achieved the initial purpose of the intervention which was to try to build this relationship. 5.10 However, B presented as quite clear that she did not want to return to her mother’s care, though recognised that the arrangement at the boyfriend’s home was temporary to enable her to finish her exams and then move permanently to her father’s home. It was appropriate that B was offered counselling and mediation but she declined this. As part of the mother’s contribution to the SCR, she maintained that TYSS had incorrectly accepted everything at face value instead of being thorough, diligent and properly investigating her concerns. 5.11 There was no evidence that B’s mother’s suggestion of drug use by the boyfriend was pursued other than receiving the general reassurances from the school about him and the assessment that the relationship between the two young people appeared generally positive. The boyfriend was not the subject of the assessment and the work undertaken with B was sufficient in this respect for the assessor to reach the view that the relationship was not harmful to her. 5.12 Additionally the Individual Management Review (IMR) conducted by a senior manager within TYSS considering the quality of the assessment at this time, said that B was in good physical health and that there was no indication that B was suffering from any eating disorder. This statement was made in the later knowledge that B ultimately had an eating disorder. In fact such a concern had never been included in the original referral that was made, and there was no separate record that this was a concern of any professional at this time. 5.13 Although the mother’s concerns were understandable in that she had had no contact with her daughter for approximately two months, the level of concern about B’s situation did not meet a high threshold of concern for TYSS, and the assessor had been assured by three meetings with B, that she was not at risk of harm. Conversations with B’s father and with the boyfriend’s parents appeared to confirm they were happy with the arrangements and had made appropriate plans for the future after the exams had finished. In this scenario, there was little more that needed to be done. Overall this assessment was satisfactory, appropriate to the circumstances and the outcome was also appropriate – there was no evidence presented within the assessment which suggested that B was at any level of risk but that she was intelligent, thoughtful and clear about the decisions she was making to not return to her mother’s care, and to instead eventually live with her father. 5.14 As part of her contributions to the SCR, B’s mother said it was her belief that the boyfriend’s mother took B to the GP and that this was the beginning of B’s self-harming and eating disorder. The mother’s position is that she should have been told of these concerns and that more appropriate attention needed to be given to these concerns by professionals. 5.15 Whilst there were two occasions when B’s mother understood that B saw a GP in late February and late March 2012, when absent from school, there were no GP records to 12 HSCB – Serious Case Review re B – Overview Report July2014 substantiate that any attendance at the GP surgery took place. The father however recalled that B went to her GP in late March with an upset stomach which led to her initially cutting back on food, although not to any significant extent. Nevertheless, there was no record of any concerns about self-harming or eating problems at those times. The mother’s view is that these problems were known to the father and to professionals (i.e. the first school and the TYSS) but that the details of these were withheld from her and thereby meant that she did not appreciate the level of concerns and could not respond or intervene appropriately to help her daughter. 5.16 Within the chronology compiled by all involved agencies, there was no reference to B having an eating disorder or losing weight until the father formally reported this on the 21st May 2012. It was therefore not recorded as a formal concern to any professional until that time. There is however other information which could be construed as contradicting this position in that the CAMHS letter back to the GP in June 2012 after B’s first session there, said that regarding her weight, “there had been a rapid deterioration since her very distressing separation from her mother in February”. Also in a letter from the specialist in patient clinic in January 2013 to CAMHS, it stated that “Dad had noticed things developing significantly at the end of March 2012. Her significant weight loss of around 10 kg took place in the previous three months with her eating virtually nothing for the last month”. B herself claimed that her problems with eating began when she started secondary education, some years earlier. 5.17 What the father chose to do in respect of concerns for his daughter are not a matter for this SCR and in his contribution to this report, he is strong in his recollection that his daughter’s weight loss was a dramatic one over a short period at the end of May 2012, even though the stomach upset in late March 2012 led to her eating less. It was also not until May 2012 that the school expressed concern about B’s weight, though acknowledging that she had always been a slim young woman. 5.18 It was not therefore apparent that either the school or TYSS had any recorded concern about significant weight loss or regarding any eating disorder in respect of B from as early as February or March 2012. By the time that the eating disorder became a problem, TYSS were no longer involved, and the school made an immediate response in late May by their letter to try to relieve some of the pressures upon B of the school exams at that time. 5.19 I therefore find no evidence that any professional had any knowledge about an eating disorder for B, or self-harming prior to the end of May 2012. The content of the letters referred to above (Para 5.16) seemed to have reflected generalised comments taken from discussions with B and her father rather than the result of assessments on the basis of medical information. However, the details within the letters should have been much clearer about the evidence upon which they were making such statements. The problem of self-harming did not become known to professionals until late July 2012 and by this time CAMHS and the specialist in patient clinic were involved. Therefore I do not consider that any professional acted inappropriately at an earlier time as claimed by B’s mother. 5.20 B’s mother has also claimed that she was lied to by the school head teacher and not told of her daughter’s condition at the time of the school formally hearing her earlier complaint 13 HSCB – Serious Case Review re B – Overview Report July2014 (about the way that the head teacher dealt with their concerns at the time of B’s move to her boyfriend’s home) in late June 2012, and that in failing to do so, the head teacher abused her position of trust. It was the fact that there was no contact between mother and daughter or with B’s father which meant that B’s mother was unaware of the level of concerns about B’s weight loss at this time. However, it could not be expected that the school should be a go-between in this situation and it was not part of their professional responsibility to inform the mother of her daughter’s condition, who as far as they were concerned no longer had any involvement with B. The school had liaised fully with B’s father as her carer at the time of the concerns emerging and had acted appropriately in response to those at that time. Also at the time of this complaint hearing, B was attending a new school. Whilst B’s mother’s frustrations and anger can be understood that she did not know of her daughter’s worrying condition whilst the father and some professionals did, it cannot be said that the school failed to act appropriately in these circumstances by not informing her. 5.21 The school were informed by B and her father that B would be leaving the school at the end of the summer term - she was saying that she would prefer to live with her father and change to a school near his home. Professional interventions at the time that concerns of an eating disorder emerged 5.22 From the records available to this SCR, it was the father who was the first to express concern, initially via the school that B had not been eating much since she had moved to the boyfriend’s home but that she was now looking visibly gaunt. It was then a few days later (28th May 2012) that the GP identified loss of weight and an eating disorder. The school had at this time written to the GP to express their concerns about B’s recent weight loss. 5.23 As mentioned previously, it was difficult to accurately identify from records over what period of time B’s significant weight loss occurred, but it was clear that it was not until the father’s expression of concern that professional intervention commenced. 5.24 It was certainly true when B was seen by the GP, who then made an appropriate urgent referral to CAMHS, that her weight loss was already at a significant level with her BMI score very low and enough to reflect anorexia. It was noted in the referral that the speed at which the weight is lost can generate a high medical priority. Although it took more than a week before CAMHS received the GP referral and then a further week before the appointment was attended, this time period was not a significant issue in that ultimately B’s needs were appropriately assessed and responded to. It is understood that the system for dealing with eating disorders has changed since this time with a speedier referral process by the immediate use of fax now being in place. 5.25 The high level of concern for B’s condition at the CAMHS appointment attended by her and her father was that she needed to go straight to A&E for medical and physical checks. The hospital gave advice to B and her father about the level of nutritional drinks she needed to take. Overall the initial response to the weight loss was appropriate and focussed on the immediate need to get B’s weight increased. However, three days later it was very clear that B was very unwell at the CAMHS appointment, with her responses recorded as 14 HSCB – Serious Case Review re B – Overview Report July2014 “generally falling within the more extreme instances of anorexic thinking (denial)”. It was therefore appropriate that a referral was made for B to be admitted to the specialist in-patient clinic. In essence, attempts had been made for B to respond to the advice she had been given and to use the support of her father, in order to regain weight, but as this had clearly been unsuccessful, the referral for in-patient treatment was unavoidable and appropriate. 5.26 In the midst of these concerns, B started her new secondary school and from their perspective she presented as fine and happy although she was soon unwell and did not attend on her second day. Despite the level of concerns at her independent school, this new school had not received any information about B prior to her starting. Also this new school had not raised any concerns about B’s presentation or weight. It was the father who alerted the school about the CAMHS assessment and the low weight problems. The school were also informed of B becoming an in-patient at the specialist clinic and it was prompt and helpful for the school to arrange for work to be sent there for B. 5.27 There was a breakdown in communication between B’s schools in that the independent school failed to send information to the new school in respect of B even though the respective 6th form heads had agreed that this should happen. B’s stay in the new school was very limited because of her hospitalisation, and so ultimately this breakdown in communication had limited impact on the ability of the new school to provide the appropriate responses and care of B. However in other circumstances this could have been significant and it was a failing that the appropriate information was not transferred to the new school as part of good professional practice. It needs to be noted however that B was now over 16 years old and not of compulsory school age, so the transfer of information was not covered by normal procedures applicable for school age children. However, because there were considerable concerns about B’s well-being at this time, then from a safeguarding perspective, the transfer of information was important. Consideration of safeguarding concerns regarding the eating disorder. 5.28 During this period of time when B’s weight loss was very worrying, there was no consideration that the safeguarding aspect needed particular attention. For example, there was no record of whether a referral to Hertfordshire Children’s Services was discussed or thought appropriate from a safeguarding perspective, from the hospital or by CAMHS at the point when they first became involved with B. 5.29 The Hertfordshire procedures16 suggest that, if at any stage a professional is concerned that the child is in need of protection, a referral is made and that the usual child protection procedures would be followed whereby a child protection enquiry or an assessment will be conducted. B’s anorexic behaviour was in itself a form of self-harming, although both CAMHS and then the specialist in-patient clinic were endeavouring to address B’s needs at this time, and had done so as a matter of urgency. There was a professional view (which was confirmed by practitioners who attended the Learning Events) which was that the father 16–Paragraph 6.20; Self-harm and Suicidal Behaviour - Hertfordshire Safeguarding Children Board – Child Protection Procedures 2013 15 HSCB – Serious Case Review re B – Overview Report July2014 was caring and supportive to B and was doing all that was asked of him by the professionals. In this respect therefore B was not a child in need of protection that warranted a referral to Hertfordshire Children’s Services in that B’s current care was being managed with the appropriate level of intervention and urgency by the involved agencies. 5.30 Once it was clear to the specialist clinic that B would need to remain with them because of her eating disorder as an inpatient for a period greater than three months, they informed the local authority (Hertfordshire Children’s Services) of this by letter in mid-July 2012. This was a requirement under Section 85 of the Children Act 198917 and the letter was clear that it was for information purposes only and not a referral. Nevertheless the Act does require the local authority to take reasonable steps to enable them to determine whether “the child’s welfare is adequately safeguarded and promoted” whilst accommodated and “whether they should exercise any of their functions under the Act with respect to the child”18. As B had not by this time been an inpatient for three months, then the assessment team who received the letter considered that no assessment was required of Children’s Services and that they expected the clinic to inform them if B became an inpatient for longer than three months. 5.31 The clinic had met the requirements of the Children Act by informing the local authority in advance that B would be with them for more than three months and in fact included the discharge date of mid-November in the letter, meaning that B would be with them for five months. Therefore the Children’s Services decision to wait for the clinic to refer back to them after the three month period was incorrect as the clinic had already discharged its legal responsibility by informing them at an early stage. This meant that there was no further communication between the clinic and Children’s Services, and therefore that Children’s Services were not in a position at a later date to make any informed decision about whether they needed to become involved or not. As this period of B’s inpatient care increased, self-harming became a concern, which was something which Children’s Services were not aware of. Overall, therefore the legal notification process had no impact upon B’s care within the inpatient clinic and Children’s Services had not utilised the opportunity to consider whether their additional involvement was necessary or not. 6. The use of the Mental Health Act to provide services to B 6.1 The first use of the Mental Health Act 1983 was at the time of B’s admission to the in-patient specialist clinic on the 21st June 2012, when she changed her mind and wanted to leave. Her father wished her to remain and receive treatment although she remained determined to leave. Because of the seriousness of her condition, then to place B on Section 5 (2) of the act meant that she needed to remain for a minimum of 72 hours. This was an appropriate use of the Mental Health Act. 6.2 This arrangement allowed for a mental health assessment to be conducted which identified that she would need naso-gastric feeding if B did not manage her calorie intake herself. It 17 Sec 85 (a) & (b) states that “where a child is accommodated by any health authority for a consecutive period of at least three months or with the intention on the part of that authority of accommodating him/her for such a period, the accommodating authority will notify the responsible authority”. 18 Sec 85, (4) (a) & (b) Children Act 1989 16 HSCB – Serious Case Review re B – Overview Report July2014 was sensible in the circumstances to then place B on Section 2 of the Mental Act to assess her mental health and for her to receive the necessary treatment. B’s father was in agreement to this approach and confirmed in his contribution to this SCR that he considered the in-patient clinic to have acted responsibly and appropriately with B. 6.3 In November 2012, when it was reported that four consecutive week-ends home for B with her father and siblings had gone well, a further mental health assessment was conducted in the in-patient clinic when it was decided to place B on a Community Treatment Order (CTO) and to discharge her from in-patient care. 6.4 In the presenting circumstances, a CTO appeared to be an appropriate way to proceed as it would allow and encourage B to manage her own behaviours with her father’s and her siblings’ support, and would properly test out her ability to continue to increase her weight. 6.5 In effect, with B still maintaining that she was fat and then when some serious self-harming episodes took place, it was soon apparent that the CTO was not working and required her to be readmitted on two occasions back to the specialist in-patient clinic. It was concerning that on the first of these occasions when she returned for three days, the appropriate paperwork had not been completed by the psychiatrist, meaning that the return to the clinic was not compliant with the Mental Health Act. The subsequent letter to B to explain this mistake identified that the return to the clinic therefore needed to be viewed as voluntary on that occasion. Technically this was correct but it was not apparent that B experienced the short readmission as a voluntary episode. Neither she, nor her father challenged what had occurred and ultimately the mistake had no real significance on the treatment that B received – it was right that she needed to be back in the clinic at that time. The failure to sign the appropriate paperwork appeared to be an isolated incident, acknowledged by the psychiatrist, rather than any generic problem. 6.6 On the second of these occasions, on the 18th January 2013, B returned and remained resident in the clinic and this led to the CTO being revoked and again replaced with a Section 3 placement. In effect, B had only been resident at home for a short initial period of four days and then for approximately a month over the Christmas period before it became necessary to return her to in-patient care and revoke the CTO. 6.7 It therefore posed the question about the relevance of the CTO and that with such a serious suicide attempt being made whilst at home; whether it was appropriate to discharge B at that time. By then the Section 3 had been in place for four months so had just a further two months to continue and so it did seem that B’s progress needed to be tested. The week-end home success in November 2012 was no doubt a key determinant that a CTO was the appropriate next step. However it was on the later weekend that she self-harmed by scratching herself and on the previous week-end, had lost weight, so in this way, these weekends were not fully successful. 6.8 Nevertheless, the alternative would have been to continue with the Section 3 arrangement which would not have really tested any progress or change. Also B’s father utilised the services of CAMHS and the in-patient clinic at this time to get attention to any crisis during 17 HSCB – Serious Case Review re B – Overview Report July2014 the CTO, and the clinic were very prompt and appropriately responsive in re-admitting B for a short period so soon after the CTO had been introduced. 6.9 In many respects the CTO had little time to show its effectiveness but ideally for a community order to be successful, then those working with B in the community should be aware of the arrangements and requirements of the CTO, so as their interventions could support it. Whilst CAMHS were aware and integral to the work of the CTO in that they provided the therapeutic input to B and her family whilst under the auspices of the order, the new school was the other agency involved in providing input to B. This school however were not informed of the CTO and of its conditions and yet by this time, B had again started to attend there. 6.10 From the mental health perspective there appeared to be no appreciation of the need to involve the new school by, as a minimum, explaining the details of the CTO. There was no evidence that the matter had been discussed with B and her consent to share, sought. The reasons for not sharing this information appeared to be primarily because the school were not perceived as having a direct role in the implementation of the CTO. It was also unclear whether it was CAMHS or the in-patient clinic which had any responsibility for sharing information with other agencies involved with B in the community. As CAMHS were providing the mental health services in the community, then ideally it should have been them to share information with the school. To not to have done so meant that any observations of behaviours, peer relationships etc., and of any changes of these within school, were not available to add to any emerging picture of how B was managing day to day life. As far as the school were concerned, B’s discharge could have meant that she had conquered her problems and was no longer a concern from a mental health perspective, and yet this was some way from the truth. This was poor practice and appropriate communication should have taken place with the school in order to be able to gain a fuller picture of how B was managing her life outside of the clinic environment. 7. Professional involvement and communication with the parents 7.1 As part of their contribution to this SCR, B’s mother and step-father have raised concerns about the lack of engagement with them (and with B’s mother particularly) by professionals, especially with regard to the occasions when concerns began to emerge about B’s health and when the Mental Health sections were applied to ensure she remained in the specialist in-patient clinic. 7.2 At the time of the involvement of mental health services, it was apparent that B was residing with her father and she was clear that she had no intention to return to her mother’s care, and the lack of contact between B and her mother since she had moved out some four months earlier, reflected this position. Therefore in their early urgent dealings with B, it was only the father who was involved with the mental health practitioners in trying to resolve the presenting problems. 7.3 As there was an early decision to invoke the Mental Health Act in order to ensure that B was detained in the clinic, then the mother has maintained that it should have been her rather than the father who was involved in that decision. From her perspective she was clear that 18 HSCB – Serious Case Review re B – Overview Report July2014 it was she who had provided the longest period of day to day care for B and that it was therefore inappropriate to exclude her from any discussions about B’s care at this significant time. Her view was also that B had not suffered any mental health difficulties in her care, and that this meant that she could have provided some alternative solutions to the presenting difficulties. 7.4 Whilst it was very understandable that the mother felt that she should have been informed and consulted about the decisions to ensure that B received specialist in-patient treatment, in essence there is no formal or legal requirement for the mental health professionals to do so. They were working very closely with the father who had maintained a high level of involvement with the different professionals. Also, as he held Parental Responsibility (along with B’s mother), and was the current carer, it was viewed as appropriate that it was he, as the nearest relative, with whom these decisions needed to be made. There is no legal requirement that it is the parent who has had the longest period of care of a child who takes precedence, and in fact if two parents have Parental Responsibility, legally it is the elder who is deemed legally to be the “nearest relative”. (It is understood that the father is the older of the parents). Furthermore the Mental Health Act stipulates that if the patient is living with or being cared for by a relative, then that person would be deemed to be “the nearest relative”.19 Also the Children Act identifies that “where more than one person has Parental Responsibility for a child, each of them may act alone and without the other in meeting that responsibility”20. 7.5 Also, from the time of the admission, B was clear that she did not want her mother to know, was not intending to live with her, and would not initially give her consent for her to be informed of the admission. B had the legal right to make this decision and that “If a competent child (aged 16 and 17 years) requests that confidentiality be maintained, this should be respected unless a doctor considers that failing to disclose information would result in significant harm to the child.”21 7.6 It could be argued that B might not be “competent”, because she needed to be admitted to the clinic under a Mental Health section, but there was nothing to suggest that to not inform or consult the mother would have resulted in significant harm to B. It was also considered by the mental health professionals involved with B, that whilst B did not accept the seriousness of her eating disorder, she was in other respects able to make coherent decisions such as her wish for confidentiality. The position centres on whether or not B was Gillick/Fraser”22 competent and also importantly in B's case whether she had sufficient capacity to make the decision that she did. According to the evidence of B’s situation at the time, she was Gillick competent. In terms of the issue of Gillick/Fraser competency, if B was of sufficient maturity to understand the decision she was making and its implications, then 19 Sec 26, Mental Health Act 1983 20 Section 2(7) The Children Act 1989 21 Consent to Treatment in Children (Mental Capacity and Mental Health Legislation) – Patient Plus article written for health care professionals - 2013 22 “Gillick competency and Fraser guidelines refer to a legal case which looked specifically at whether doctors should be able to give contraceptive advice or treatment to under 16-year-olds without parental consent. But since then, they have been more widely used to help assess whether a child has the maturity to make their own decisions and to understand the implications of those decisions”. NSPCC Factsheet July 2012 19 HSCB – Serious Case Review re B – Overview Report July2014 legally professionals involved in her care would be obliged to abide by the decision not to inform other third parties including relatives.23 7.7 B would need at the time of making her decision sufficient capacity (capacity being situation specific) to make the decision not to allow her mother to have access to her information. In B's case this would be particularly important given that she was receiving in patient treatment for her Mental Health. The legal presumption in relation to capacity is that an individual has capacity to make a particular decision unless proven otherwise.24 7.8 Soon after the first admission, CAMHS discussed with the father that it would be relevant to inform B’s mother and he agreed to discuss this with B who then gave permission to inform the mother of the admission but not of the details of her condition. This occurred nine days after B’s first admission, and did demonstrate that the clinic professionals had considered B’s mother’s situation and that she should be made aware of her daughter’s admission. Although B’s mother then made immediate contact with the clinic, B did not want any direct contact at that time and her mother was duly informed of this by the clinic. 7.9 Relatives other than the “nearest relative” do have the right to apply to the county court to have the nearest relative displaced on certain statutory grounds, but even if B’s mother had taken this route, it would have been doubtful whether the grounds would have been met. Additionally insofar as matters of urgency, the Care Quality Commission recommend that mental health practitioners should consult with persons other than the nearest relative who are or have been involved in the patient’s care, and take their views into account. However, those involved in B’s care needed to respond to her wish for confidentiality from her mother, and they managed this in an appropriate way. Once B’s mother knew of the admission, she sent information to the clinic about family background matters, so ultimately this information and her views were considered in the treatment that B received. 7.10 Because B’s mother was not contacted at the outset of the mental health interventions and nor at subsequent key events when the Mental Health Act sections for detention or treatment were changed, then it is not possible to say whether her involvement would have made any difference to the success or otherwise of interventions that followed. In terms of capacity to consent to mental health treatment, there is reference in the relevant act to the need to consider the “best interests” of the patient, and that for a child this includes the “views of the parents”. However this still remained linked to the wishes and feelings of the patient, which were quite clear in these circumstances that B, as a person over the age of 16 years, did not want contact or to discuss her circumstances with her mother. 7.11 The Mental Health Tribunal, held in March 2013 ratified the current arrangements for B in that they remained necessary in order to meet B’s mental health needs. 7.12 Because of the continuing conflict between the natural parents, there was no communication between them at this time and the mother had no contact with her 23 Gillick v West Norfolk and Wisbech Area Health Authority and another House of Lords ( 1986) 1 AC 112, [1985] 3 All ER 402 24 Section 1 of The Mental Capacity Act 2005 A person must be assumed to have capacity unless it is established that he lacks capacity. 20 HSCB – Serious Case Review re B – Overview Report July2014 daughter and knew nothing of B’s problems until she was informed that she was resident in the specialist in-patient clinic. How the parents managed their joint parenting responsibilities and their communication was a matter for them. The main focus for the SCR process is whether the professionals acted appropriately within the law and in the best interests of B, in their communication with the two parents. Within the circumstances presented at the time, the actions by professionals were understandable and complied with relevant legislation and professional guidance. 7.13 In terms of the therapeutic interventions with B, it was unfortunate that the one telephone contact that she had with her mother whilst in the in-patient clinic seemed to unsettle B rather than aid her improvement. In the circumstances of the mother knowing so little detail of what had transpired with her daughter, it was difficult for her to know how best to respond to B. If one of the mental health professionals had helped prepare the mother for this first conversation with her daughter, without contravening B’s wish not to disclose the details of her treatment, this may have improved the outcome. 7.14 It was during her second admission to the clinic under the Section 3 arrangement that following therapeutic sessions with B, who expressed ambivalent feelings towards her mother, that it was considered it might be useful to involve the mother in future therapeutic sessions. Telephone calls and a letter were subsequently sent to ask B’s mother to get in touch and although the mother did not respond to these requests, it was nevertheless appropriate that such attempts were made as a means of trying to progress and improve B’s mental health. B’s mother felt that the lack of information in the letter and that she did not know that B was again resident in the clinic, led her to not know the full reasons for their wish to seek contact with her. 7.15 At the time when B placed the ligature round her neck, and which led to her death three days later, the father initially did not inform B’s mother but the clinic considered they had a duty of care to over-ride this. In the end the father did inform the mother, but it did show that the clinic had considered the importance of B’s mother being informed at this most significant time. 8. The period as an in-patient from late January 2013 under the final Section 3 arrangement 8.1 It was following serious suicidal behaviour of an overdose and an attempted hanging by B during four days in mid-January 2013 under the auspices of the CTO, when it was clear that she needed to be readmitted to a specialist hospital. By this time, B had lots of self-harm wounds on the arms, though these were generally superficial. It was from the A&E attendance at this time, that an assessment by the psychiatric team identified the need for B to be urgently admitted to a relevant adolescent unit. This was a very appropriate response, although there was poor recording of the actions and decisions within the hospital. 8.2 The situation was somewhat different than the earlier occasion in June 2012 when the hospital and CAMHS initially became involved, in that on this occasion, the presenting problems were significant suicidal behaviours rather than solely the eating disorder. It was clear that B’s urgent safety was the priority, and this was addressed, although there was no consideration by the hospital or by CAMHS whether a referral to Hertfordshire Children’s 21 HSCB – Serious Case Review re B – Overview Report July2014 Services would also be appropriate or helpful in these different circumstances. Whilst under the CTO it had not been considered appropriate to involve Children’s Services, it was now clear that use of the CTO had failed to address the presenting problems and so potentially a different approach was needed. 8.3 Because it was quickly very clear that in-patient treatment was necessary, involving Children’s Services would not have added to the decisions and actions which were being taken at that time and no doubt any advice from Children’s Services would have been to proceed with the plan to provide intensive in-patient mental health care. Nevertheless, whether to involve Children’s Services or to seek their advice, should have been given some consideration and recorded accordingly. Children’s Services had previously been informed of B’s earlier five month period of inpatient treatment in 2012, and made no response to that, so there could have been some consideration on this later occasion, with the situation clearly more concerning, whether there was now a need for their separate involvement and joint working with the mental health services. Nevertheless the role of a CAMHS social worker was already available and able to provide the duties and functions of a local authority social worker. B’s second period of admission from January 2013 was not for a consecutive period (there were periods of weekends at home) and was not greater than three months and so there was no legal requirement at that time for the clinic to again inform Children’s Services. 8.4 From the time of the CTO, a care coordinator from CAMHS had been appointed, whose role was to take an overview of what was happening and to coordinate services as necessary. However, the care coordinator role in effect became a passive one, being a recipient of information from the clinic, once B was again an inpatient there. 8.5 There was potentially a role for the care coordinator to sustain a role with the family outside of the work being undertaken in the clinic, to focus on the source of some of B’s difficulties and how the family could help to address these. This could of course also have potentially involved B’s mother and step-father at this time. However, it was understandable from this point on that the focus was very much on B within the specialist clinic and that the father was well engaged in this and in trying to support his daughter’s recovery. Work with the family would have been stepped up if there was a plan to discharge from the clinic, and it would not have been normal practice for a care coordinator to have significant direct involvement whilst the individual concerned was an inpatient. 8.6 The immediate response at the time of crisis in mid-January 2013 was for B to be admitted to an Adolescent Mental Health Unit, although she only remained there for one day where she refused to eat. A discussion was appropriately held between consultant psychiatrists from both this unit and the specialist in-patient clinic where B had previously stayed. As a result of this discussion it was agreed that to return to the clinic would be the most appropriate for B’s needs which were still seen as predominantly anorexia. The transfer arrangements were therefore quickly made. 8.7 Whilst it was apparent that the eating disorder was the main issue for B in that it appeared to be her distorted body image which led to the self-harming and suicidal behaviours, the suicidal behaviours had now reached a much more concerning level, for example with B 22 HSCB – Serious Case Review re B – Overview Report July2014 stating quite clearly that she wanted to hang herself. As part of the father’s contribution to the SCR, whilst he was very praise worthy of the work of the specialist in-patient clinic and in no way critical of them, he wondered whether the specialist focus needed to be on the self-harming and suicidal behaviour rather than the anorexia, and therefore whether the clinic remained the most appropriate placement. 8.8 It was clear that this issue had been the subject of discussion at the outset of the placement back to the specialist clinic, and that B’s refusal to eat when placed in the other unit had supported the decision that the clinic with the specialist anorexia knowledge and services would be more appropriate. Even though it was clear that B was unhappy about returning to the clinic, it was here that knowledge of her condition was known and that a relationship had been established with the father who had previously regularly attended family therapy sessions there with his daughter. Also, there was evidence that there were clear supervision arrangements in place to care for adolescents who were vulnerable from self-harming behaviours. 8.9 On balance therefore it appeared to be a reasonable decision that B was placed back into this clinic which specialised in eating disorders. 8.10 From the beginning of this final period of B’s inpatient treatment, it was clear that the self-harming and suicidal ideation was being taken seriously with periods of one to one and two to one supervision being put in place and her medication being increased appropriately. However, even as part of these strict supervision arrangements, B attempted to abscond and also tried to self-harm by using a shower hose, on two occasions putting her hand into a “fly zapper” and by picking at scabs. This tended to show the determination that B displayed in her behaviours for much of January though to mid-March 2013, but that overall the supervision arrangements had prevented any significant self-harm injury. 8.11 It will be a matter for the Coroner’s Court to consider the circumstances and cause of B’s death, although this SCR has had sight of the Serious Incident Requiring Investigation Report25 which has reviewed the circumstances of B’s care at this time in the clinic and of the events of 14th April 2013, when B was found with a ligature round her neck, and from which she did not recover consciousness. The overall finding of the investigation, undertaken by a non-executive director of Care UK, the umbrella independent organisation for Care UK (the specialist clinic for eating disorders) was that “It is difficult to identify how on the basis of the information available and the context in which the care was being provided, anything could have been done to prevent the patient committing the act of serious self-harm or this subsequently resulting in her death”. 8.12 As part of their contribution to this SCR, B’s mother and step-father strongly disagree with the way in which that investigation and review was conducted (partly in that it was not independent) and of its findings, and has claimed that information has been suppressed and that this potentially reflects criminal behaviour on the part of some professionals. This SCR has not identified such concerns. 25 Serious Incident Requiring Investigation Report – Dr Ian McPherson, Non-Executive Clinical Director 10 June 2013 23 HSCB – Serious Case Review re B – Overview Report July2014 8.13 It is important to note that whilst the investigation report identified that nothing different could have been done to prevent B’s death, it then goes on to make five recommendations for changes to practice within the clinic. These are: - 1. Clinical Care - It is recommended that Care UK Mental Health Division review the training they provide to staff in assessing and managing patients who present with risks of serious self-harm and ensure that a consistent model is used with appropriate adaptions for particular conditions and environments, reflecting current best practice. 2. Staff and multidisciplinary working – It is recommended that the review of staffing and multidisciplinary working already underway at Care UK prior to the incident, needs to take into account the possibility of large numbers of patients who may be admitted with more complex needs, including those at risk of serious self-harm. 3. Physical Environment – It is recommended that the review of potential ligature points at Care UK already undertaken since January 2013 needs to be considered in the light of this incident and agreement reached about any further action to remove physical risks, or in the event that this is not feasible or desirable in terms of the overall environment needed for therapeutic care, how these risks should be managed when caring for patients who present risks of serious self-harm. 4. Suicide Prevention Audits – it is recommended that regular Suicide Prevention Audits should be introduced across Care UK Mental Health Services, overseen by the Integrated Governance Team but actively involving managers and staff reflecting current best practice for inpatient care with appropriate adaptions for particular conditions and environments. 5. Arrangements for Shared Learning – The learning from this event needs to be disseminated across all units of Care UK’s Mental Health Division. As part of the clinic’s contribution to this SCR, we have been furnished with evidence of the positive progress of these recommendations. 8.14 The presence of bunting in a unit where self-harming was a concern in respect of its inpatients, did require explanation and whether it should have been in place. It is understood that the bunting which B used as a ligature had been put up as part of activities by other inpatients and that it was situated in a classroom that patients only usually attended when accompanied and supervised by staff. In this way the investigation report did not consider that it should have been removed and the bunting was not seen by clinic staff as presenting a significant self-harm risk. Nevertheless, B accessed the classroom unknown to any member of staff, so it clearly did represent a risk which should have been recognised. If the classroom was not meant to be accessed without staff in attendance, then it should have been locked. 8.15 Furthermore, recommendation number 2 above reflects the need to review how staff are trained in the assessment and management of self-harm. This training should be a fundamental component of staff knowledge and experience, so to request a review implies that staff may not have been sufficiently trained in this area. However the report does not go that far but identified the dilemma of treating high risk patients in that; “A highly risk averse approach could reduce the potential for incidents of self-harm but would also be 24 HSCB – Serious Case Review re B – Overview Report July2014 counter to giving the patient the opportunity to experience greater independence and to learn to manage their emotional stress”. The review of training should therefore consider how this dilemma can be addressed effectively by staff. The training matrix supplied by the clinic to inform progress against the recommendations and to inform this SCR, suggests that a comprehensive range of training is in place. 8.16 From mid-March 2013 there was some evidence of B making progress and this reflected a reduction of the supervision arrangements to level 3 and then just three days before the fatal incident, the supervision arrangements were again reduced to the normal level, meaning that B had to be seen and monitored at least hourly by a member of staff but that from 9.00pm she would need to be within sight of a member of staff. It was during the evening prior to 9.00pm that the incident of B accessing the classroom and using the bunting as a ligature took place. 8.17 In the long term it would not have been appropriate to sustain B to high levels of supervision, but also any decision to decrease this needed to be based on an accurate assessment of positive change. There was certainly evidence of a reduction in her self-harming behaviour and for example it was noted that on the 18th March 2013 that B had not self-harmed for ten days and that a few days after that she acknowledged wanting a life and to return home to her father. This was then supported by some successful weekends at home and attendance at a concert at the 02 arena with three staff members which appeared to go well. There was one incident of self-harming on the 26th March 2013 when she had used a paper clip to make superficial cuts to her arm and the response was to offer new strategies to B to cope with her desire to self-harm. 8.18 The timing of when to reduce supervision of B was therefore a crucial one and appeared to have been made within a context of diminishing risks of self-harm and some evidence of B making progress in respect of a possible return home in the future. The decisions to change the supervision arrangements were clearly made at regular team meetings between involved practitioners. No environment can be strict enough to eliminate all risks and the clinic, as well as needing to provide a safe environment for its residents, also had to provide a culture whereby its residents could progress towards discharge and a level of independence. 8.19 A Care Quality Commission unannounced Inspection26 occurred at the clinic a month after B’s death (it was not related to the death) found that the standards were met in the five key areas of service provision. 9. Prevention and predictability 9.1 Because B had self-harmed in the past and had demonstrated suicidal ideation, it cannot be said that the eventual tragic outcome was unpredictable – there was always a possibility that such an event could occur. What was important from the perspective of this SCR was 26 Care Quality Commission (CQC) Inspection Report – Care UK Clinic 17th May 2013 – 5 areas inspected “Respecting and involving people who use services”, “Care and welfare of people who use services”, “Management of medicines”, “Supporting workers” and “Assessing and monitoring the quality of service provision” - Report published June 2013. www.cqc.org.uk 25 HSCB – Serious Case Review re B – Overview Report July2014 whether the professional interventions were appropriate in the prevailing circumstances and throughout the time that B and her family were in receipt of services. 9.2 B was well liked by the professionals who came in contact with her and they were committed in their involvement in trying to help her. This SCR has not found that there were any occasions when procedures were not followed or legal requirements not addressed which adversely impacted the delivery of care and services to B. 9.3 Studies have shown that “most adolescent suicides are unplanned and that other studies have found that only 25% of completed suicides by adolescents show some evidence of planning”27. In the way that B presented on the evening of the 14th April 2013, there was no immediate indicator that she was contemplating suicide. 10. Areas for learning and development NB: It will be the Hertfordshire Safeguarding Children Board to decide whether and how to implement the areas for learning and development identified below. 10.1 Whilst not significant to the outcomes for B, if information is not promptly transferred about pupils at the time when they move schools, particularly when there are welfare concerns, then the new school’s ability to address any safeguarding concerns or to meet the pupil’s academic, social and emotional needs could be compromised. 10.2 There should always be consideration of the need to make contact with Hertfordshire Children’s Services when a young person presents with significant mental ill-health, especially in relation to self-harming and where there are concerns about the impact the family dynamics may have on the young person in terms of any risk or protective factors. This contact should include information gathering and discussion about whether there is a need to make a referral and how a full psychosocial assessment can be undertaken. 10.3 Hertfordshire Children’s Services should review its approach to dealing with notifications that children are likely to be detained by a health authority for at least three months. These are received under section 85 of the Children Act 1989. 10.4 For Community Treatment Orders in respect of young people to be as effective as possible, formal consideration should always be given to the details of the order being shared with those agencies providing significant services to the young person within the community, including schools and colleges which they attend. 10.5 It is important that A&E departments record decisions and recommendations made in respect of a young person’s attendance with mental health issues, to ensure records are available to support future treatment decisions and for reference if there are repeat A&E attendances. 27 Deliberate Self-Harm in Adolescence- Fox, C and Hawton, K – 2004 – Jessica Kingsley Publishers. 26 HSCB – Serious Case Review re B – Overview Report July2014 10.6 The recommendations and actions identified in Care UK own internal investigation contain significant learning for other similar establishments. The Hertfordshire Safeguarding Children Board should take the necessary action to ensure that they are brought to the attention of such establishments and that the LSCB in which Care UK is situated is made aware of these recommendations in order that their implementation can be monitored. 10.7 The findings from this SCR and the areas for learning and development need to be disseminated to relevant professionals in Hertfordshire working with young people with serious mental ill-health, and with the staff and management of Care UK clinic. Ron Lock 27 HSCB – Serious Case Review re B – Overview Report July2014 Appendix 1 The Serious Case Review Process 1. The HSCB chose to use a learning model to undertake the review consistent with the principles in the government guidance. This model is referred to as a Partnership Learning Review, and formed the basis of the work of the SCR and is attached as an appendix to this report. 2. An independent Lead Reviewer, Ron Lock, was appointed to lead the SCR and to compile the Overview Report. Ron Lock has considerable experience in safeguarding children and young people, including involvement in SCRs in other parts of the country, and had no connection in a professional capacity with the management of this case within Hertfordshire. 3. Senior managers from Hertfordshire were appointed to be part of the SCR Team, whose role was to assist with the scrutiny and analysis of professional practice in the case. They had had no direct involvement in the case and were the: - Named Nurse for Safeguarding Children, Hertfordshire Community NHS Trust - Head of Child Protection, Children’s Services, Hertfordshire County Council (later replaced for final meeting by the Service Manager North Hertfordshire and Stevenage, Hertfordshire Children’s Services. - Child Psychiatrist and Named Doctor for Safeguarding, Hertfordshire Partnership University NHS Foundation Trust - Business Manager, Hertfordshire Safeguarding Children Board 4. The SCR Team met on three occasions, chaired by the independent lead reviewer, in order to progress the SCR and to provide comment in respect of draft Overview Report. The independent HSCB chair was appraised of progress of the SCR and attended two of the SCR Team meetings to contribute to the analysis of practice. Members of the SCR team were also very active in their contribution to the two one-day Learning Events which were conducted with frontline practitioners and their line managers. These meetings were held in order for as many of the practitioners and line managers who had worked with the family as possible, to contribute to the SCR team’s understanding of the detail of the work that had been undertaken with the family and to contribute to the analysis of professional practice. The local agencies who had involvement with the family and who were represented by these professionals at the Learning Events, were: - Cafcass - West Herts Hospital NHS Trust - Hertfordshire Partnership University Foundation Trust - Hertfordshire Constabulary - Independent School (first school) - Hertfordshire Secondary School (second school) - Specialist In-Patient Clinic (for eating disorders) 28 HSCB – Serious Case Review re B – Overview Report July2014 - Solicitor (involved in early court proceedings in respect of contact and residency of the children) - Hertfordshire Children’s Services (Targeted Youth Support Services) - Children and Adolescent Mental Health Services (CAMHS) 5. The outcome from these Learning Events, which were chaired by the Lead Reviewer for the SCR, was clarification of the factual details of the work undertaken with the family as well as verbal and written contributions to the analysis of practice which in turn informed the key lessons learned from the work undertaken with this family. The findings from these Learning Events have been included within the body of the report in terms of both the factual and analysis components. Additionally to ensure greater understanding of particular parts of the work with the family, the Independent Author spoke individually with some of the practitioners and managers. 6. At the outset of the SCR process, detailed chronologies were requested from all of the involved agencies as identified above, of their involvement with the family from October 2010 which reflected the time when it was understood that Young Person B first self-harmed. Each person completing the chronologies (the Individual Agency Representative) was also asked to complete an additional summary of commentary and analysis of the professional practice within their agency. They also completed a separate document to identify any organisational or contextual factors which may have impacted on the work with the family. Relevant professional letters, e-mails and reports were also viewed as part of the SCR process, and a Serious Incident Investigation Report written after the death of Young Person B to review what transpired at the in-patient clinic, was also considered in detail. Furthermore, the Targeted Youth Support Services decided to conduct an Individual Management Review for their own purposes of learning, which was quite separate from the SCR process, although it was nevertheless viewed as part of the work of the SCR team. All of this material was collated and reviewed by the SCR Team, and the factual contents of the chronology were fully shared with all attendees at the Learning Events. 7. B’s parents were separately interviewed by the Lead Reviewer and the HSCB Business Manager, her father once and her mother and step father were seen on two occasions. E-mail and telephone contact also took place in order to check on facts and opinions as the SCR progressed. In this way, both natural parents have been actively involved in the process. Their contributions to the SCR have been included and identified within the body of the report where appropriate. __________________________________________________________ 29 Board Response to Serious Case Review - Young Person B Introduction The case of Young Person B, a 17 year old girl, was referred to the Hertfordshire Safeguarding Children Board (HSCB) in April 2013. The girl had been diagnosed with an eating disorder in 2012 which had resulted in her being detained under the Mental Health Act in a clinic outside Hertfordshire which specialised in managing eating disorders. Whilst detained, she committed suicide in that clinic. The national guidance for carrying out case reviews in (Working Together to Safeguard Children 2013) specifically requires that a Serious Case Review (SCR) is carried out when a young person dies while being detained under the Mental Health Act. In keeping with this guidance, Phil Picton, Independent Chair of HSCB commissioned an independent lead reviewer, Ron Lock, to complete a SCR for the case. His SCR Report was formally accepted by the Strategic Board of HSCB at its meeting on 23rd July 2014. The purpose of the SCR has been to investigate the circumstances of the case and to identify any areas for learning and development which would benefit the services provided by agencies to vulnerable children and young people. The Working Together guidance requires that SCR reports are published together with the Board’s response to the report. This document is the Board response to Young Person B’s SCR. The detailed process of the investigation carried out by Ron Lock is included as an Appendix at the end of the SCR report. In addition to professionals and managers from a number of agencies, B’s mother, father and stepfather contributed significantly to the development of the report and its areas for learning. The Board wish to thank them for their cooperation and contributions during a particularly difficult time. Since completion of the report, Young Person B’s mother has raised a number of concerns about the accuracy of the report as she disagrees with some of the comments and conclusions reached by the reviewer. These have been considered by the Independent Chair of HSCB and discussed with Board members but they are not considered to justify alteration to the report or reinvestigation of the case. It is Young Person B response to findings report final - Jan 2015 however, pointed out that where the phrase “family sessions” is used in the report for meetings between Young Person B and professionals in the residential clinic, these meetings did not involve B’s mother. In addition to the SCR investigation, the Coroner for the district in which B died, held an inquest into her death. This inquest took place over a number of days with a jury and legal representation. Before the inquest, the coroner and parties involved were provided with the draft version of the SCR report to assist in the hearing. The finding of the coroner was that B had intentionally ended her life and his verdict was ‘suicide’. In reaching the verdict, neither the coroner nor the jury made any adverse comment about the involvement of agencies, however the Coroner has written a formal letter to Care UK, the company which manages the clinic, asking them to require all staff to routinely carry ligature cutters to enable speedy assistance if there are future attempted hangings in the clinic. Section 9 of the SCR report starting on page 25, states that “This SCR has not found that there were any occasions when procedures were not followed or legal requirements not addressed which adversely impacted the delivery of care and services to B”. Section 10 of the SCR Report (page 26) summarises seven ‘areas for learning and development’ which have become apparent during the investigation. The Board’s response to each of these is set out below following each finding. The response to Findings 2 and 5 is contained in one section as the actions to address them complement one another. Findings and the Board’s Response Finding 1: “Whilst not significant to the outcomes for B, if information is not promptly transferred about pupils at the time when they move schools, particularly when there are welfare concerns, then the new school’s ability to address any safeguarding concerns or to meet the pupil’s academic, social and emotional needs could be compromised.” (Young Person B SCR Report, para 10.1) Board Response to Finding 1: Young Person B response to findings report final - Jan 2015 B attended two schools during the period of the review, firstly an independent school and then a state secondary school. As set out in the report, the first school did not effectively transfer information about B’s health to the second school when it was requested. Within a few days of starting the second school, B was detained under the Mental Health Act and did not go back to the school for some months. Owing to this detention, the lack of effective information sharing on this occasion did not affect her care. However, it was a potential problem for B’s care and anecdotal evidence provided to the Board by other schools suggests that difficulties in passing information between schools about transferring pupils’ health and welfare is not limited to this particular case. Without such information sharing, there is a risk that pupils will not be appropriately safeguarded and that schools may fail to fulfil their obligations under the Education Act. The Board has been assured that the two schools involved with B have both changed their approach to requesting and supplying such information as a result of this case. However the lessons need to be learned across all schools in Hertfordshire. In order to do that the Director of Children’s Services is discussing this finding with the Head Teachers’ Social Care Reference Group which she chairs. The Group, which includes Heads from a wide range of schools, is being asked to identify improvements to the systems used by schools to manage such information transfers. The Director of Children’s Services is also ensuring that the circumstances of the case and the need for effective sharing of the health and wellbeing information about a child at the time they transfer between schools is included in training and briefings for head teachers and other relevant members of school staff. This is being done through the existing arrangements for communications with head teachers on key issues. In doing this, schools will be referred to the Hertfordshire Children’s Services document, ‘School Safeguarding Practice Guidance on Pupil Safeguarding Records’ which is available via the Hertfordshire Grid for Learning. Whilst these guidelines are already included in the training for school’s ‘Designated Safeguarding Person (DSP)’, this case will be used to highlight the potential risks of not following the guidelines. All training and resources including a termly newsletter for DSP’s are available to all schools in Hertfordshire, including those in the independent sector. Monitoring and Evaluation of the Implementation of the Response to Finding 1 Young Person B response to findings report final - Jan 2015 Schools are supported in assessing their own effectiveness by a range of audit tools provided by Hertfordshire Children’s Services which enable them to monitor their safeguarding provision and to support their statutory requirement to provide a regular safeguarding report to their governing body. This is further supported by training for governing bodies on safeguarding issues. HSCB will require an update from Children Services during 2015 to assure it that these actions have been completed. It will then consider what means is most appropriate to collect information from schools to ensure that the transfer of information between schools on pupils health and wellbeing is taking place effectively. Finding 2: “There should always be consideration of the need to make contact with Hertfordshire Children’s Services when a young person presents with significant mental ill-health, especially in relation to self-harming and where there are concerns about the impact the family dynamics may have on the young person in terms of any risk or protective factors. This contact should include information gathering and discussion about whether there is a need to make a referral and how a full psychosocial assessment can be undertaken.” (Young Person B SCR Report, para 10.2) and Finding 5: “It is important that A&E departments record decisions and recommendations made in respect of a young person’s attendance with mental health issues, to ensure records are available to support future treatment decisions and for reference if there are repeat A&E attendances.” (Young Person B SCR Report, para 10.5) Board Response to Findings 2 and 5: Finding 2 highlights an issue for NHS service providers and particularly Accident and Emergency Departments (A&E). Finding 5 is specifically about attendances at A&E. They are jointly responded to because of this overlap. Young Person B response to findings report final - Jan 2015 Hertfordshire Partnership University NHS Foundation Trust (HPFT) provides specialist mental health services for children and young people (CAMHS) within the County. It works closely with hospitals, A&E departments and other practitioners to ensure that patients with mental health needs are effectively safeguarded. In doing this, it is usually the first specialist service to deal with mental health patients. The Managing Director of CAMHS has initiated an action plan to address Findings 2 and 5. The plan focuses on: • ensuring that whenever CAMHS professionals are approached to consider diagnosis and treatment for young people, they include the family context of the young person and the potential benefit of psychosocial assessments in their deliberations, • changing policies to ensure that referrals to Children’s Services are proactively considered and that this consideration and resulting decision is recorded. • A&E Departments improving recording when decisions are made about a young person who attends with mental health issues, so that better information is available if the young person re-visits A&E. Monitoring and Evaluation of the Implementation of the Response to Findings 2 & 5. The action plan will be monitored by CAMHS’ senior management team and hospitals will be required to confirm that they have implemented the changes and briefed staff on what is expected. Progress on the overall action plan will be monitored by the two Hertfordshire Clinical Commissioning Groups and will be reported to HSCB in February 2015. At that time the Board will identify any further auditing or sampling work needed to ensure the system is effective. Finding 3: “Hertfordshire Children’s Services should review its approach to dealing with notifications that children are likely to be detained by a health authority for at least three months. These are received under section 85 of the Children Act 1989” (Young Person B SCR Report, para 10.3) Board Response to Finding 3: Young Person B response to findings report final - Jan 2015 Hertfordshire County Council Children’s Services has reviewed the way it responds to notifications under section 85. These notifications are now being proactively considered by its Targeted Advice Service (TAS) with the purpose of effectively identifying if a Young Person is in need of support services. In addition, the circumstances of this SCR have been included in training for staff within TAS so that they fully understand the rationale for the new approach. Young Person B response to findings report final - Jan 2015 Monitoring and Evaluation of the Implementation of the Response to Finding 3 During February 2015, HSCB will receive a report on the numbers of section 85 notifications and the action taken in response to them. Finding 4: “For Community Treatment Orders in respect of young people to be as effective as possible, formal consideration should always be given to the details of the order being shared with those agencies providing significant services to the young person within the community, including schools and colleges which they attend.” (Young Person B SCR Report, para 10.4) Board Response to Finding 4: Hertfordshire County Council Health and Community Services (HCS) are responsible for the procedures around Community Treatment Orders (CTOs). They employ the Approved Mental Health professionals (AMHPs) who provide the ‘second opinion’ whenever a CTO is being considered as a means of re-introducing a patient back into their community. The Director of HCS is implementing an action plan to ensure that AMHPs prompt staff to involve all relevant agencies, including schools and colleges, in implementing the plans for CTOs. This includes sharing appropriate information about the patient’s needs and care plan. In doing this the AMHP Operational Group will specifically consider this SCR report. In considering the report and particularly this finding, HCS has suggested to the Board that the issue of involving schools and colleges in supporting students who are subject to a Community Treatment Order is wider than merely Hertfordshire. As a result, the Board will share the learning on the involvement of schools and colleges in Community Treatment Orders more broadly through such organisations as the Royal College of Psychiatrists. Young Person B response to findings report final - Jan 2015 Monitoring and Evaluation of the Implementation of the Response to Finding 4 The implementation of the action plan will be overseen by the AMHP Operational Group in Hertfordshire. That Group will report the progress on the action plan to HSCB in February 2015. Regarding the wider sharing of the learning from this finding, the Board will receive a report from its Business Manager in February 2015 explaining how that learning has been disseminated outside of Hertfordshire. Finding 6: “The recommendations and actions identified in Care UK’s own internal investigation contain significant learning for other similar establishments. The Hertfordshire Safeguarding Children Board should take the necessary action to ensure that they are brought to the attention of such establishments and that the LSCB in which the clinic is situated is made aware of these recommendations in order that their implementation can be monitored” (Young Person B SCR Report, para 10.6) Board Response to Finding 6: Clinics such as the one attended by B have patients placed with them by commissioners working on behalf of NHS England. A director from the South Midlands and Hertfordshire Area Team of NHS England sits on the HSCB Strategic Board. Together with the Chair of the Board, this representative is writing to all other NHS Area Teams which commission such specialist services. This letter is giving a synopsis of the case, the key findings of the SCR, the learning identified by Care UK in its internal report and the comments of the coroner about the benefit of carrying ligature cutters in such residential facilities. The Area Teams are being asked to inform their specialist providers of the learning so that others can take into account the issues raised by B’s case and to ensure that the appropriate issues identified in the case is included in commissioners monitoring of contracts with clinics. The letter will also be copied to the CQC (the inspection organisation for such clinics) so that CQC can consider the learning as it develops its own approach to inspection and standards in premises providing care. Young Person B response to findings report final - Jan 2015 The Board has already discussed the case with the Independent Chair and Business Manager of the Local Safeguarding Children Board for the area where the clinic is located. It is providing a copy of the SCR report and this response to that Chair for his information and to enable that Board to ensure that both the recommendations contained in Care UK’s internal report and the Coroner’s letter about staff carrying ligature cutters are effectively implemented. Monitoring and Evaluation of the Implementation of the Response to Finding 6 The circulation of the letters and any responses will be reported to the Board in February 2015. Finding 7: “The findings from this SCR and the areas for learning and development need to be disseminated to relevant professionals in Hertfordshire working with young people with serious mental ill-health, and with the staff and management of clinic.” (Young Person B SCR Report, para 10.7) Board Response to Finding 7: The SCR report is being used by the Board to develop both briefing and training material for the children’s workforce across the County. The training sub-committee of the Board is developing a plan to ensure that this is done comprehensively and delivered effectively. In some circumstances this will be by material solely focusing on this case and in others it will be incorporated into existing learning programmes which focus specifically on mental health issues or ‘lessons’ from case reviews. Both of these topics feature regularly in the Board’s own multi-agency training. The SCR Report and Board Response will be sent to the NSPCC for inclusion in their national repository of SCRs so that it is available for wider analysis and research particularly by those researching similar cases and developing new initiatives for young people’s health and welfare. Monitoring and Evaluation of the Implementation of the Response to Finding 7 The training sub-group of HSCB will report on the progress of the plan to the Board in February 2015. The outcome of this briefing and training work in affecting the Young Person B response to findings report final - Jan 2015 actions of professionals in carrying out their work will be included in the on-going programme of training evaluation which is reported annually to the Board. Conclusion The Case Review Group of HSCB will receive a full update on the progress on these findings in February 2015 and the following Strategic Board meeting will receive a summary report from that Group. An overview of the progress will be published in the HSCB Annual Report for 2014 -15 by the Autumn of 2015. Young Person B response to findings report final - Jan 2015 |
NC52374 | Attempted suicide of a boy aged under 16-years-old in 2019. Harry had experienced significant neglect, trauma, emotional and mental health difficulties whilst living with his mother, step-father and siblings in Scotland; subject to child protection plan in 2016. In 2017, Harry moved to live with his father in England. Incidents of self harm; suicide attempts on five separate occasions prior to the incident in 2019. Harry's recollection of the incident, resulting in him being admitted to Child and Adolescent Mental Health Services (CAMHS) is that someone tried to kill him, however there is no evidence to confirm this. Ethnicity or nationality of Harry is not stated. Learning includes: a greater appreciation of the impact of early childhood adversity and trauma and the importance of using this information to inform decision making and safety planning; importance of information sharing across borders and agency boundaries; the need for prompt action to secure the appropriate type of support and intervention when young people experience an acute and serious mental health episode. Identifies areas of good practice. Uses the SILP (Significant Incident Learning Process) methodology. Recommendations for the Safeguarding Partnership include: to inform the Child Safeguarding Practice Review Panel about the apparent lack of explicit guidance about the transfer of school records across borders in Scotland and England; to review and amend guidance and procedures on the management and information sharing practices between local community based child mental health services, acute health settings and community health services for situations where children re-present to an acute setting.
| Serious Case Review No: 2020/C8290 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. CLASSIFIED INFORMATION – FINAL VERSION Serious Case Review Review report Harry Independent Reviewer: Kevin Ball This report is strictly confidential and must not be disclosed to third parties without prior discussion and agreement with the Safeguarding Children Board. The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies involved. CLASSIFIED INFORMATION – FINAL VERSION Contents Page 1.Introduction 1 2. Process for conducting the review 1 3. Family composition & contribution to the review 2 4. Relevant case details 4.1. Relevant background information prior to the time-frame under review 4.2. Relevant information during the time frame under review 4.3. Key episode 1: September to November 2018 4.4. Key episode 2: January 2019 2 – 6 5. Findings & analysis 5.1. The use of history to inform risk assessment, safety planning & intervention 5.2. The quality of the strategy discussions & subsequent assessment and/or investigation - September 2018 Strategy discussion in response to Harry’s paracetamol overdose - January 2019 Strategy discussion in response to Harry’s suicide attempt 5.3. The quality & effectiveness of any cross border & transfer issues identified 5.4. The quality of information sharing between agencies 5.5. Evidence of the voice of the child being sought, heard and acted on 5.6. The effectiveness of maintaining a focus on the child’s safety & needs throughout 5.7. The provision of training & supervision to the workforce about the identification or & response to abuse, neglect & maltreatment, particularly relating to adolescents 5.8. The quality & effectiveness of the mental health pathway between services 6 - 22 6. Good practice 22 7. Conclusion 23 8. Recommendations 23 1 1. Introduction 1.1. A Local Safeguarding Children Board (LSCB) commissioned a Serious Case Review based on information which supported a professional view that a child, aged under 16 years, attempted to take his own life in early 2019. The child’s recollection of the incident is that someone tried to kill him however there is no supporting evidence to confirm this account. The child, who for the purposes of this review will be known as Harry1, had experienced a difficult childhood having suffered neglect, trauma, emotional and mental health difficulties whilst living with his mother in Scotland. Reports indicate that Harry tried to end his life on five separate occasions prior to the incident in 2019. 1.2. The response by those agencies in the run up to the suicide attempt as well as the immediate management of Harry at the time of the incident has come under the spotlight and as such, there are concerns about the way in which agencies worked together to safeguard Harry’s safety and welfare. 1.3. By way of a summary of the findings and learning, the following factors have emerged; - Harry had experienced significant abuse and neglect in his earlier childhood whilst living with his mother in Scotland. When he moved to live with his father in England information about Harry’s history was not effectively shared. Although this is unlikely to have altered Harry’s behaviours and attempts to self-harm or take his own life, it disadvantaged agencies attempts to support Harry at the times when he was most likely to have needed help. - The extent to which Harry’s earlier adverse childhood experiences were not fully appreciated by the professional network in the local area in England, resulting in further assessment opportunities not being prioritised – which, had they been, might have then informed safety planning. Practice was not fully informed by knowledge about the trauma he had experienced. - Following Harry’s serious attempt to take his own life, the initial response by services was quick and efficient however it soon became apparent that delays in securing him an appropriate placement in a specialist mental health provision began to impact on safety planning and care management. 2. Process for conducting the review 2.1. The LSCB agreed that this SCR would be undertaken using the SILP methodology2, which engages frontline staff and their managers in reviewing cases and conforms to the expectations as set out in statutory guidance3. The review was conducted by Kevin Ball who is an independent safeguarding consultant, an experienced chair and author of SCRs, and SILP associate reviewer. He is fully independent of the LSCB and its partner agencies. 2.2. Single agency reports4 were completed providing individual agencies with the opportunity to consider and analyse their practice and any systemic issues. In completing these reports it has 1 Harry is the pseudonym chosen by the child subject of the review. 2 SILP – Significant Incident Learning Process. 3 Working Together 2015 (under which this SCR was commissioned), HM Government. 4 Agencies that have contributed to this review are: - Children’s Social Care - County Education Department - NHS Trust - Adult Social Care - Children’s Services in Scotland - Local charity providing counselling - Clinical Commissioning Group - Specialist Hospital for Children - Police - NHS Foundation Trust 2 allowed agencies the opportunity to reflect on their practice, capture learning and make recommendations for improving their own practice. Following these reports being submitted practitioners, managers and agency safeguarding leads came together for a multi-agency workshop. All agency reports were shared in advance and the perspectives and opinions of all those involved at the time were discussed at the event. This group then reconvened to examine the first draft of the SCR report and further help shape the learning. 2.3. It was agreed that the time-frame under review would be from the May 2017 when Harry moved to the local area in England to live with his father until January 2019 following Harry’s most recent suicide attempt. Relevant background information is also captured. 3. Family composition & contribution to the review 3.1. Relevant family members in this review are: 3.2. Gaining the contribution of family members has been an important consideration for this review. The Independent Reviewer met with Harry’s father and his contributions have been helpful in shaping the learning from this review. In discussion, the father was clear about not knowing the full extent of Harry’s history from when he lived in Scotland having not had contact with him for a long time. He was also clear about the struggles of adjusting to living with, and caring for, Harry when he moved back to live with him from Scotland after a gap of seven years. These issues are expanded upon in the findings and analysis section. 3.3. The Independent Reviewer also met with Harry, who was keen to offer his perspective. In discussions, Harry described many of the highs and lows of his recent life and his thinking behind some of his actions. He also commented on some of the interactions he had with different professionals in recent times and how some were really helpful and others were less impactful. These are examined in the report. The Independent Reviewer and LSCB acknowledges the contribution of Harry and his father to this review and is grateful for their input. 4. Relevant case detail 4.1. Relevant background information prior to the time-frame under review 4.1.1. Concerns about Harry living with neglect are first recorded as emerging in 2012 whilst he was living with his mother, step-father and siblings in Scotland. Home conditions were described as poor and despite intervention by the local Children’s Services in Scotland, conditions fluctuated. 4.1.2. The first recorded suicide attempt by Harry (an attempted strangulation) was in March 2015 during which he had tied an electric cable around his neck. He was taken to Hospital in Scotland and subsequently received a psychiatric assessment which judged him safe to return home. Later that year concerns emerged about parent mental health, alongside ongoing concerns about the children living in a neglectful home environment and the mother being physically abusive towards Harry. Harry went to live with members of his extended family in Scotland for a few weeks in the local area to assist the situation but also began to seek contact with his birth father. 4.1.3. In September 2016 concerns reached the point that the local Children’s Services in Scotland convened an Initial Child Protection Case Conference which resulted in Harry and his siblings Family member: Known as: Subject child - Harry Father to subject child - Father Mother to subject child - Mother Siblings to subject child - Siblings 3 judged as at risk of suffering significant harm and that they would be subject to a child protection plan with their names of the Child Protection Register5. 4.1.4. In October 2016 Harry expressed a wish to return to live with his father. This request was alongside foster placements being sought for Harry in Scotland whilst him living with his extended family. Harry had had a seven year break in his relationship with his father, but was open to going into foster care if his extended family were unable to care for him and it was not possible to return to his father’s care. In November 2016 Harry and siblings were accommodated on a voluntary basis under section 25 of the Children (Scotland) Act 19956 due to the squalid and neglectful home conditions. Harry and siblings names were removed from the Child Protection Register in late 2016. 4.1.5. Harry spent Christmas of 2016 with his father in England with a view to a permanent move. In February 2017 the Children’s Social Care local to the review in England were requested by the Children’s Services in Scotland to conduct a home visit to confirm the father’s circumstances, who at the time was living with other adult family members. The father had voiced some early reservations about Harry coming to live with him however he had already approached a local school that Harry had expressed an interest in attending. Harry moved to the local area in England in May 2017, settled into school well, made friends and had joined local clubs. He remained concerned about his siblings’ welfare. 4.2. Relevant information during the time frame under review 4.2.1. In September 2017 a member of the school pastoral team noticed old cut marks on Harry’s wrists; these were reported to his Head of Year and was advised that these related to historical frustrations before moving to the area. 4.2.2. In November 2017 Harry was excluded from school for two days due to assaulting another pupil. In December Harry had a new patient examination at the GP Practice by a Health Care Assistant; there was no exploration about mental or emotional health as the template for recording such matters did not provide a prompt for asking these questions. 4.2.3. In June 2018 school records indicate that Harry disclosed to the member of the school pastoral team that he had tried to kill himself on many occasions, including an attempt at poisoning by taking 16 paracetamol tablets and hanging himself. The school response was swift in that an emergency GP appointment was sought for the following day; however Harry’s father was not made aware of these initial efforts by the school. Harry reported being unable to talk with his father about his feelings at this time. A member of the school staff took Harry to the GP appointment and he went into the appointment by himself. Once informed, the father was supportive and willing to work with the school. The GP made a referral to a local counselling service. Also in June, Harry came into school with a swollen eye and cut; despite efforts by school staff to elicit an explanation Harry would not account for the injury. This information was passed to the MASH7 with concerns about Harry’s mental health, his negative thoughts and being agitated, and reporting that the adults in 5 In Scotland children can be subject to a plan and their names placed on a Child Protection Register if they have suffered, or are likely to suffer, significant harm. 6 Section 25 - Children (Scotland) Act 1995 places a duty on a local authority to provide accommodation for any child who, residing or having been found within their area, appears to them to require such provision because (a) no-one has parental responsibility for him; (b) he is lost or abandoned; or (c) the person who has been caring for him is prevented, whether or not permanently & for whatever reason, from providing him with suitable accommodation or care. 7 MASH – Multi-Agency Safeguarding Hub 4 his life had let him down. The father was kept informed and was reported to be working actively with professionals to support his son. 4.2.4. In July 2018 Harry was seen by a GP and described feeling overwhelmed at times and that he had thought about harming himself. He was concerned about how this might impact on his career choices. The plan agreed was to review him in two weeks. At the two week review Harry reported feeling happier and more positive. By this time Harry had also engaged with the local counselling service following the referral by the GP. 4.3. Key episode 1: September to November 2018 4.3.1. In September 2018 Harry was taken to the local County Hospital having taken 30 – 40 paracetamol tablets. The overdose only came to light through the intervention of a friend whom Harry had messaged late at night. The friend then sent a text to Harry’s father telling him. There was also evidence of physical self-harm (cuts to his wrist with a knife and old burn marks on his arm). Harry had disengaged with the counselling service by this time, not attending scheduled sessions. CAHMS and Children’s Social Care were contacted and a Strategy discussion8 was held. Harry was assessed by CAMHS at this time and judged as at high risk of self-harm. Whilst in Hospital Harry disclosed multiple previous suicide attempts from the age of eight years, which included hanging and drinking bleach. He also alleged that his mother had tried to kill him by strangulation when living with her in Scotland. 4.3.2. The outcome of the Strategy discussion, further information gathering and risk assessment by Children’s Social Care, Police, CAMHS, the Hospital staff, and school was that Harry should be admitted to a tier 49 Child & Adolescent Mental Health Unit in another area. A place was found in a unit in a nearby city area however there was a delay in him being admitted. Harry has subsequently reported that during the intervening period whilst waiting to be admitted he had an accompanied outing from the Hospital with a Support Worker which allowed him plenty of opportunities to abscond to a bridge. Eventually Harry was admitted to the specialist tier 4 Unit on a voluntary basis. 4.3.3. Plans had been made to hold an Initial Child Protection Conference however this was later cancelled due to his admission to the specialist tier 4 Unit. 4.3.4. Harry was admitted to the specialist tier 4 Unit mid-September and then discharged mid-October, having benefitted from a phased return home and into school during this in-patient stay. Whilst in the Unit the local area community CAMHS service maintained contact by phone and attended a review. 4.3.5. In November Harry spoke to a Social Worker about his continued worries for his siblings. Harry also assaulted another pupil and was excluded for one day. The community CAMHS team had resumed their contact with Harry now he was back in the community setting. Records indicate that the case was closed to Children’s Social Care in mid-November following the completion of a Child & Family Assessment. 8 Strategy discussion is convened under Section 47, Children Act 1989; where a local authority has reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make such enquiries as they consider necessary to enable to them to decide whether they should take any action to safeguard or promote the child’s welfare. 9 A tier 4 provision is a specialist Child & Adolescent in-patient unit commissioned by NHS England. 5 4.3.6. During a residential school trip Harry was involved in an incident involving alcohol with some other pupils, for which Harry was heavily implicated. Harry was also concerned about his relationship with a girlfriend on this trip. 4.4. Key episode 2: January 2019 4.4.1. The day after the return from the school trip Harry was taken by air ambulance to a specialist Hospital for Children following a serious suicide attempt by hanging whilst at home. Police found unused prescribed anti-depressant medication, alcohol and a drug related item10 in his room; no cannabis was found. Following significant emergency medical intervention Harry recovered and was transferred to the local County Hospital. 4.4.2. At the same time as the transfer section 47 enquiries11 were initiated by Children’s Social Care alongside discussions by mental health professionals about the best course of action. Risk assessments were completed whilst Harry was in the Hospital and a plan was agreed that a specialist tier 4 bed was needed; ideally for a voluntary admission as the least restrictive option12. A referral was made to seek a bed. Advice was given to a Paediatric Consultant to apply section 5 (2) of the Mental Health Act 198313 and to call the Police if Harry attempted to leave the Hospital. A Registered Mental Health Nurse assessed Harry at this time as having no insight into his suicide attempt and likely to attempt suicide again; he was noted to be anxious and agitated and unable to sleep at night. In discussion with the Social Worker and mental health worker Harry stated he had no memory of the event and thought that someone must have tried to kill him; he maintains this perspective to this day. CAMHS expressed a view that the father was struggling to care for Harry, particularly given the trauma Harry had experienced in his earlier life and the impact this was now having on him. 4.4.3. Six days after this incident, and whilst still in Hospital, agency staff were providing staffing cover on a 1:1 basis however Harry went into an open outdoor play area on a third floor balcony on the Hospital Ward, having removed a glass panel from a play area, and attempted to abscond (or possibly harm himself); he was pulled back to safety by his father who was visiting at the time. Support from both the Police and Fire & Rescue Service was provided. Police remained on the scene for over three hours. Harry was given sedative medication to help him settle. The exact details of how this incident was then managed once Harry had been safely removed from the balcony are unclear with conflicting accounts of whether Harry was held using section 5 (2) powers or section 5 (4) powers14. The findings and analysis section examines this lack of certainty. 4.4.4. The following day Harry was found trying to interfere with window locks, position himself near exits and having a bottle of aftershave. At this stage the staffing ratio had been increased to 2:1 and keeping Harry in sight at all times. A specialist tier 4 bed was not available for another two days. 10 A grinder is an accessory often associated with drug use. 11 Section 47 – Children Act 1989, allowing a local authority which provides the local authority with a duty to make enquiries as considered necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare, where there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm. 12 Mental Health Act 1983: Code of Practice, Department of Health, 2015, HM Government, 13 Section 5 (2) is a temporary hold of an informal or voluntary service user on a mental health ward in order for an assessment to be arranged under the Mental Health Act 1983. This ensures their immediate safety whilst the assessment is arranged. This can last up to 72 hours. 14 A Section 5 (4) is a temporary nursing holding power to ensure the immediate safety of a hospital in-service user while assessment by a doctor is arranged. This can last up to six hours. 6 Harry stated that he planned to leave the Hospital later, resulting in agency nursing staff stating that they would need Police support to restrain him if required. Advice was given about increasing the use of sedatives if necessary. Harry attempted to leave the Hospital, as he had stated he would earlier. The agency Registered Mental Health Nurses refused to restrain him (despite being appropriately trained) which led to him kicking down the Hospital Ward’s locked doors and leaving the Hospital. Police found Harry in a public space later that night and returned him to the Hospital in the early hours of the morning under section 136 Police powers15. The plan was to assess Harry under the Mental Health Act about whether detention16 was necessary. The following day a tier 4 bed became available. Harry was admitted and went on to receive appropriate treatment. 5. Findings & analysis 1. The case is subject to review because there are concerns about the way in which agencies worked together to safeguard and protect Harry. This is against a background of known, and knowable, information about Harry’s history, namely one of experiencing significant harm and neglect whilst in his mother’s care in Scotland. Additionally, and with the benefit of outcome bias, questions have been raised about whether Harry continued to experience a degree of neglect having moved to live with his father. Questions have also been raised about the effectiveness of the arrangements to keep Harry safe whilst in Hospital following his serious and near fatal attempt to take his own life. 2. The following sections therefore examine these issues and seek to understand the quality and effectiveness of the multi-agency safeguarding response to Harry. It considers practice issues as well as drawing on systems thinking concepts17 as a way of making sense of some aspects of how this case was managed. Learning points for improving practice have been emphasised that can be used by practitioners, managers and trainers. 5.1 The use of history to inform risk assessment, safety planning & intervention 5.1.1. Statutory guidance18 at the time stated ‘… understanding risk involves judgement and balance. To manage risks, social workers and other professionals should make decisions with the best interests of the child in mind, informed by evidence available and underpinned by knowledge of child development …’. Statutory guidance also stated of assessment and analysis ‘… decision points and review points involving the child and family and relevant professionals should be used to keep the assessment on track. This is to ensure that help is given in a timely and appropriate way …’. 5.1.2. Although outside of the timeframe under review, the local Children’s Services in Scotland have reviewed their records and noted that there was no consideration given to seeking historical information prior to 2012 when they first became involved with the family, as preparation for the Initial Child Protection Conference held in 2016. They recognise that this was a missed opportunity to fully understand Harry’s early childhood history during a period of time when they had significant 15 Section 136 of the Mental Health Act 1983 allows a Police officer to move a person to place of safety, or detain them in a place of safety if they are already in one, if they appear to be suffering from a mental disorder and are in need of immediate care or control. 16 To detain someone under the Mental Health Act 1983 is to formally detain them if their own safety, of the safety of others, is at risk, and they fail to cooperate on a voluntary basis. 17 i) Systems thinking for safety: Ten Principles – A White paper, Eurocontrol, 2014 ii) A systems approach to policy evaluation, Caffrey, L., & Munro, E., The London School of Economics and Political Science, 2017, iii) Systems approaches to managing change: A Practical Guide, The Open University, 2010. 18 Working together to safeguard children, 2015, p.24, HM Government. 7 involvement with him and his family. Harry’s view of the social work services when in Scotland is one of them not offering much help or support. 5.1.3. Harry moved to England and to the area that commissioned this review in the spring time of 2017. This provided a natural point, in the overall process of case management for a handover of information between one local authority to another. This handover point can be viewed, as outlined by statutory guidance cited above, to provide an opportunity to ‘… ensure that help is given in a timely and appropriate way …’. The quality of this handover opportunity was poor, resulting in an ineffective transfer of information which could have been used to inform safety planning and intervention. 5.1.4. Prior to him attending the local school in England a meeting took place between Harry’s Social Worker from Scotland and school staff. No information regarding Harry’s prior attempts to self-harm were disclosed at this meeting, other than him potentially having some emotional needs as a result of earlier childhood neglect. Information shared gave no indication that a risk management plan would be required. So, although some information was shared by the local Children’s Services from Scotland it was incomplete and only went part of the way to assisting the School manage Harry. Critically, the local Children’s Services in Scotland did not advise the School about Harry’s status as a Looked after Child, nor of the historical episode of being on the Child Protection Register. There was also no formal notification19 to the local areas Children’s Social Care about this status. They acknowledge that this was not good practice, not their usual practice and that the matter is being addressed. This is further examined in section 5.3. Learning point: The handover of information from one team, service or authority creates an opportunity for risk management plans to falter or fail due to the transition from one system and set of professionals to another. Ensuring timely, well-coordinated and effective handover arrangements is important when managing risks to children. 5.1.5. In November 2017 Harry was excluded from school due to assaulting other students. The circumstances of the exclusion i.e. the assault were discussed with the MASH by the school. Records examined confirm that this was the first point that MASH became aware of Harry; having not received any information from the local Children’s Services in Scotland about Harry moving into their area several months earlier. On the basis of the presenting information the discussion with the MASH was treated as information only and understandably did not require further action from Children’s Services. No history was gathered at this stage as it was not considered necessary. Harry’s father has also relayed that he had little idea about the extent of Harry’s troubled past; knowing that he had attempted to self-harm but not attempted suicide. 5.1.6. In December 2017 Harry had a new patient examination with a Health Care Assistant. Whilst covering many subject areas the recording template used by the GP Practice did not offer a prompt for discussion of mental or emotional health. His mental and emotional health and history was therefore not discussed or considered. As a new patient, this triggered a request by the GP Practice for Harry’s previous GP record to be sent through from Scotland. Despite the request being sent, Harry’s previous GP records were not received until August 2019. Learning point: GP records can provide a valuable source of information, not only for the GP but also potentially for other professionals when concerns arise. Ensuring the timely exchange of information from one GP Practice to another, regardless of local authority area or geographical boundaries is important when working with vulnerable children. 19 A notification as might be expected under The Children Act 1989 guidance and regulations: Volume 2: care planning, placement and case review, June 2015, HM Government. 8 5.1.7. A referral was appropriately sent to MASH from Harry’s school in June 2018 following his disclosures about his past to the member of the school pastoral team but also the injuries; the referral alluded to some of Harry’s history which had been provided by the local Children’s Services in Scotland. In discussion, Harry spoke very positively about the school pastoral team, stating that their approachability was exactly what he needed at that time. MASH did not seek further information at this time as the outcome of the screening process and further discussion between the school and Harry’s father showed that the issues were being dealt with by the GP alongside consideration of him accessing CAMHS support. This point in time highlights a potential information gathering and assessment opportunity for the MASH and Children’s Services; however, it has to be weighed against the knowledge that there appeared to be a plan in place to support Harry, the father seemed supportive and at this time there was nothing to indicate Harry was in need of other services other than emotional/mental health support. 5.1.8. Harry also attended a GP appointment in June 2018 describing low self-esteem, low mood and that he had made plans to harm himself. Records and discussions indicate that the GP was not especially concerned about Harry’s presentation as he generally seemed ‘… chatty and cheerful and reported not to be actively suicidal ...’20. However, the records do not indicate whether Harry’s emotional or psychological history were explored to inform any assessment or intervention. This episode reflects conflicting and discrepant information; on the one hand Harry describing feeling low and making plans to harm himself, whilst on the other hand appearing cheerful. In such situations, for all professional involved, it is important to try to reconcile these contrasting accounts, especially when working with adolescents who display vulnerability. Whilst Gillick competence/Fraser guidelines21 and the involvement of Harry’s father were considered at the time by the GP this is not fully recorded. Harry attended a further two appointments in July during which he described feeling worse at the first, but then better at the second appointment. Harry confirmed that he was happy to talk with his father about his GP attendances but also gave consent for a referral to a local counselling service. At this stage Harry was not reporting he was considering actively harming himself and a priority referral to CAMHS was not judged necessary. In discussion with Harry, and with his benefit of hindsight, he felt that he was possibly looking for more from the GP, but he was uncertain about the exact nature of what he was looking for. As before, the GP notes from Scotland had still not been received so there was no historical context for the GP to place Harry’s presentation and their observations of him. This episode has resulted in a recommendation for the GP, and Practice, to ensure standards, as set out by the General Medical Council, are fully adhered to in terms of recording. The episodes also reflect that for Harry his emotional and mental health was somewhat erratic and unsteady. Given the fluctuations in Harry’s presentation a referral to CAMHS could have been considered alongside the referral to the counselling service, however the GP made a rational evaluation of the information presented. Information could also have been shared with the School Nursing Service. The reason given for not passing information to the School Nursing Service was knowledge that its resources were stretched. Learning point: One Service or professional cannot make a decision on behalf of another Service about whether someone in need of support will, or will not, be eligible for services. A needs led decision should be considered rather than a resources led judgement. 20 CCG submission to the review. 21 Like adults, young people (aged 16 or 17) are presumed to have sufficient capacity to decide on their own medical treatment, unless there is significant evidence to suggest otherwise. Children under the age of 16 can consent to their own treatment if they are believed to have enough intelligence, competence and understanding to fully appreciate what's involved in their treatment. This is known as being Gillick, or Fraser, competent, https://www.nhs.uk/conditions/consent-to-treatment/children/, accessed 03/06/2019. 9 5.1.9. As a result of the episodes outlined above, when Harry was first admitted to the Paediatric Ward in September 2018 following a paracetamol overdose very little was known about him (key episode 1). The MASH were contacted by the NHS Trust Hospital; this resulted in historical information being requested by the MASH, and received, from the local Children’s Services in Scotland within 24 hours. This information included history about him being looked after, child protection concerns in relation to the significant neglect he had experienced, information about his thoughts of self-harming, a brief chronology and some case notes which included information going back to 2015. This process worked well and clearly provided sufficient background information for services to risk assess and consider safety planning. A referral was then made to the local NHS Trust Child & Adolescent Mental Health Services (CAMHS) for a formal mental health assessment. 5.1.10. This series of events highlights that it was not until the occurrence of an acute episode that sufficient background information was gathered. Given the conflicting and inconsistent accounts Harry had given to the GP it underlines the difficulty and challenges professionals face when assessing risk and trying to make informed decisions about the management of risks – particularly mental health, which can remain somewhat hidden. Research22 notes ‘… Many of the stresses that contribute to suicide risk are common in young people, most of whom overcome them without too much difficulty. For a minority, however, the stresses are serious and the risks are real. For this reason, distress in young people should not be dismissed as transient or trivial. … The circumstances that lead to suicide in young people often appear to follow a pattern of cumulative risk, with traumatic experiences in early life, a build-up of adversity and high-risk behaviours in adolescence and early adulthood, and a "final straw" event. This event may not seem severe to others, making it hard for professionals and families to recognise suicide risk unless the combination of past and present problems is taken into account …’. 5.1.11. Research also highlights ten common themes in suicide by children and young people; emphasising the critical importance of needing to have access to historical information about an individual in order to provide the best opportunity to effective safety planning. A number of these are pertinent to this case. Themes include; - Family factors such as mental illness - Academic pressures, especially related to exams - Abuse and neglect - Social isolation or withdrawal - Bereavement experience of suicide - Physical health conditions with a social impact - Bullying - Alcohol and illicit drugs - Suicide-related internet use - Mental ill health, self-harm and suicidal ideas Learning point: Gathering information about a child’s earlier life experiences to inform assessment and decision making is crucial to providing the best possible response to a child’s distress. Examining this history may provide clues about the impact of cumulative risk factors, earlier trauma and events which may potentially trigger self-harm. 5.1.12. It is clear that from this point forward Harry’s history was taken into consideration to inform risk assessment, safety planning and intervention as it resulted in him being admitted to a specialist tier 4 Unit. It is however interesting to note that whilst Harry’s admission to the tier 4 Unit was correctly pursued on a voluntary basis (being the least restrictive option), from a community based GP perspective there were elements of biased thinking during consultations. These consisted of wishing to protect against any adverse impact any admission might have had on his intentions to pursue a particular career path; this is despite him reportedly continuing to express suicidal thoughts. The bias was in favour of supporting Harry’s career chances versus his more immediate needs. Although this 22 Suicide by children and young people, National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester: University of Manchester, p.7, 2017. 10 did not alter the pathway – which was the correct one at the time – it is important for non-specialists in community settings to reflect on this and learn when assessing mental health. Learning point: Risk management and decision making should be based on a comprehensive assessment of the situation, historical information, professional judgement and analysis, especially in situations where the stakes may be high. It is good practice to seek a fresh perspective to be a ‘devil’s advocate’ with your decision making. 5.1.13. In discussion, Harry spoke about the need for practitioners, no matter what their profession, to make it clear to young people that they were there to offer help and support when faced with a young person who was describing highs and lows in life. 5.2. The quality of strategy discussions & subsequent assessment and/or investigation 5.2.1. As cited above, decision and review points are important junctures to ensure case management is effective in meeting the safety needs of a child. The review has thus far confirmed that the handover of the case from one authority to another was not effectively used, and therefore as a decision and review point was a missed opportunity. In this case there were two Strategy discussions held; one in September 2018 and a further one in January 2019. These two points provided an opportunity to gather information and reflect on its meaning in order to inform next steps and any requirements for safety planning. September 2018 Strategy discussion in response to Harry’s paracetamol overdose: 5.2.2. From a procedural point of view the Strategy discussion was held within timescales and attended by the appropriate professionals, including children’s social care, Hospital staff, police, school and CAMHS. CAMHS provided a written report, as did the GP who was unable to attend the meeting in person. The CAMHS report states that Harry was receiving counselling at that time but was reportedly not finding this helpful. 5.2.3. Reports indicate that Harry had been open and forthcoming about his history and had also reported that he had been street homeless, using drugs and alcohol at one point in his life, but this was no longer an issue for him. The potential for this does not appear to have been factored into the safety planning or the assessment which followed nor is it clear if Harry’s self-reporting was followed up and verified. In discussion, Harry’s father has conveyed a sense of frustration around this time when Harry appeared to increasingly be taking more control of his life, with the father increasingly losing any sense of control he may have had with Harry. This reflects a struggle that many parents experience at a time of transition for a parent – child relationship, with young people increasingly becoming more autonomous. 5.2.4. Information that was included in the Strategy discussion appears comprehensive, and included; - History which included details about abuse and maltreatment suffered. - Harry’s father being somewhat resistant to social services involvement and there being relationship difficulties between him and Harry. 5.2.5. Information that was not included in the Strategy discussion, as recorded includes; - No explicit reference to Harry’s previously reported attempts to take his own life whilst living in Scotland. - No information about Harry’s home situation given the household composition. 5.2.6. The Strategy discussion record shows that the focus of discussion was about the immediate concern and needing to manage Harry’s safety. It concludes with an agreement that the threshold 11 had been met to conduct further enquires and assessment and with a recommendation that there should be an Initial Child Protection Conference. 5.2.7. The record shows that the immediate safety plan was for Harry to remain in Hospital and for further enquires to be made about a specialist tier 4 Unit. Otherwise there are six actions noted for the immediate and short term; these are quoted as; 1. Section 47 joint with health [this is procedurally incorrect] 2. Hospital discharge planning should he discharge into community 3. Flags on Police system 4. Police to be informed if he tries to leave Hospital [the interpretation of this has been questioned] 5. Ongoing assessment for tier 4 bed 6. ICPC date set to take place 14 days after the Strategy discussion (if needed) Learning point: It is important that records of meetings, and especially action points, are clear, not ambiguous and procedurally correct in order to avoid misinterpretation or confusion. All professionals responsible for Chairing meetings should be reminded about the need to check minutes and meeting records to ensure there is absolute clarity in the written word. 5.2.8. The assessment by the local area’s Children’s Services did not commence until November, two months after the presenting issue. The reason given for this delay is that the Social Worker had a high caseload at that time and needing to prioritise casework based on an evaluation of risk. As Harry had been admitted to a specialist tier 4 Unit the risk of further harm was being managed which also contributed to the decision not to prioritise the assessment. However, the assessment involved just one visit to see Harry and family in November, did not maximise the opportunities available to visit Harry whilst in the specialist tier 4 Unit, nor assess his family on their own before his discharge and be involved in discharge planning. The single assessment visit was also mostly conducted by a Social Worker but did include the contributions of a community CAMHS worker and a CAMHS Psychologist, who continued to work with Harry’s father and Harry’s school during this time. Despite this, it can be argued that this delay in assessment work was a missed opportunity for the local authority Children’s Social Care to mark a point in time in terms of Harry’s overall needs and safety, attempt to forge a positive working relationship with Harry’s father and inform any further intervention for all agencies involved. 5.2.9. The decision that an Initial Child Protection Conference was not necessary as Harry was in a tier 4 Unit is a debatable one. The decision was not based on an examination of the threshold as full enquiries had not been concluded, but because he was in a place of safety. Practitioners involved with Harry have confirmed that, on balance, this was the correct decision given the safety plan created however have expressed a view that rather than the child protection route being closed there was an opportunity to consider Child in Need or Early Help support as an alternative offer. Any alternative offer however had to be weighed with the need for consent but also knowing that the father and Harry were not asking for additional help. This is despite knowing that there were relationship tensions between themselves, and the father admitting to his struggles in adjusting to having Harry living with him. Learning point: Providing the right sort of help at the right time may make the difference to children and families. Working with parents and children to build an early help offer that is creative, tailored and flexible may reduce the need of further intervention at a later date. 12 5.2.10. From a system thinking perspective, this episode can be described as a trade-off23. Trade-offs are a system thinking concept. Work in complex systems is impossible to assign, predict and prescribe completely. Demand fluctuates, resources are often limited and goals often conflict. Frequently, the choices available to us are not ideal and we are forced to make trade-offs and choose sub-optimal courses of action. Trade-offs, such as these, help us understand system behaviour and system outcomes. The trade-off in this case was that the Social Worker prioritised other cases over beginning an assessment of Harry’s case because his immediate safety was being managed and there appeared to be balancing factors which seemed to mitigate against any future risk of harm. Management oversight at this time was inconsistent. Operating context is important; these practice issues had been identified by Ofsted in the inspections in recent previous years and, despite many improvements, also in 201924. 5.2.11. The balancing factors mitigating against further danger to Harry were; the family clearly stated that they did not want any additional support from Children’s Services; Harry was in a specialist tier 4 Unit for part of the time but then had committed to his engagement with CAMHS (who had reported that the suicide risk had reduced); Harry reported no concerns about living with his father and family and had returned to school and appeared to be enjoying it; and the father had developed a stronger relationship with the school. Harry’s father’s has described Harry being inconsistent in his behaviours and that he was trying to accommodate to Harry’s fluctuating behaviour by giving some leeway in his expectations of him. At times, he accepts that this stepped too far in the wrong direction with, for example, buying him some bottles of cider. The father’s view was that he was struggling to know how best to respond; this may, at times, have been viewed by professionals as not caring, not paying attention to Harry’s behaviour or being neglectful. The allocated Social Worker, through assessment work completed, expressed a view that ‘… Harry’s father on the one hand distrusted professionals and on the other hand wanted to be led by them, for fear of getting things wrong and the potential serious consequences in terms of Harry’s welfare ...’. This correlates with the view of others involved with the family but also that the father experienced some struggles in managing some of Harry’s behaviours and the circumstances in which he now found himself. Examples of these struggles included difficulty putting boundaries in place to manage Harry, managing work alongside caring responsibilities, Harry’s use of high sugar drinks, alcohol use, and Harry not adhering to taking his prescribed medication. 5.2.12. Given any remaining risk had the appearance of being managed, Children’s Services closed their involvement, however records and discussion confirm that the outcome of the assessment undertaken was not shared with partner agencies, nor were the Police informed of Harry’s discharge from the specialist tier 4 Unit. Given one of the agreed actions of the Strategy discussion (as worded in the record of the meeting) included keeping the Police informed, this practice fell short of expected standards and good practice. See learning point above at 5.2.7. 5.2.13. Harry’s father expressed pride and being impressed with the way Harry had recovered after his discharge from the specialist tier 4 Unit. Harry was described as achieving well at school, enjoying sport and appeared to be engaged with services. At this time Harry’s father thought progress was being made and the future was looking more positive. Harry himself has also described the following weeks as positive and feeling good. January 2019 Strategy discussion in response to Harry’s suicide attempt: 23 Trade-off - as cited a) Learning into Practice: improving the quality and use of serious case reviews, Masterclass 2: Systems thinking, SCIE & NSPCC, 2016 and b) Systems thinking for safety: Ten principles – A White Paper, Eurocontrol, 2014. 24 Ofsted inspection reports. 13 5.2.14. The Strategy discussion held in January 2019 provided the professional network with a second opportunity to evaluate the situation. A telephone Strategy discussion took place on the day of the incident and was then followed up two days later with a meeting – reflecting timely action all-round by relevant agencies. At the time Harry’s family were already engaged with relevant services i.e. the School and CAMHS and appeared to be managing the situation, and Harry appeared to be open with those adults he was having contact with. Only seven days before Harry had had a therapy session with CAMHS and had denied having any suicidal thoughts. Again, this highlights the difficulty for professionals and Harry’s father and other family members in predicting behaviour or self-harming attempts. 5.3. The quality & effectiveness of any cross border & transfer issues identified 5.3.1. Research25 about other serious case reviews states that ‘… multi-agency meetings with professionals involved in a case can encourage information to be shared and roles to be clarified, improving multi-agency working and allowing professionals to gain a holistic view of the case …’. 5.3.2. The local Children’s Service in Scotland Social Worker requested social work visits to Harry’s father to ascertain the suitability of the home environment should Harry move back to live with his father. These requests were made towards the end of 2016 and did not take place until early 2017. The local area Children’s Services visited and provided feedback to the Children’s Services in Scotland. This resulted in a telephone discussion between the two Services to verify information provided however there was no confirmation about a permanent move to live with his father. 5.3.3. The Social Worker from the local Children’s Services in Scotland visited the school in England in June 2017 when Harry was in transition. It appears some information was shared and there is reference to email exchanges about securing a school placement. However, with the benefit of hindsight the School’s perception is that the local Children’s Services in Scotland had not fully shared information with them in 2017, notably the gravity of Harry’s earlier abuse and life experience. Learning point: All professionals need to remain actively curious about information given to them that indicates harm and risk to children, and then sharing it with those who have responsibilities to keep children safe. Probing and seeking clarity about information which suggests future risks, is good practice. This is especially so at critical transfer points in case management. 5.3.4. It is evident that Harry remained a Looked after Child and there was no exchange of information or notification about his current status. Information about Harry’s background was not effectively transferred by the Children’s Services in Scotland to services locally during the timeframe under review until there was a serious incident in September 2018. Having reviewed their records the Children’s Services in Scotland have confirmed that they did not communicate directly with the local Children’s Services in England to confirm he had moved and was residing outside of their area. They have reported that it was their intention ‘… to keep the case open for at least 3 months and longer if required to ensure that his care was secured with his father ...’26 . Information transfer is documented as being fragmented and disjointed. The Children’s Services in Scotland have acknowledged that their management and practice of this transfer was not to the expected standard and that this is being examined with the relevant practitioners. The reason given for this not happening appear to be related to the belief that the Children’s Services Social Worker thought 25 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 116, University of Warwick & University of East Anglia, May 2016. 26 Children’s Services in Scotland submission to the review. 14 there was no longer a need to be involved so no action was taken to inform the local area of Harry’s move. 5.3.5. Practice for transfer of cases which relate to child protection issues within Scotland is supported by national guidance27, as is practice for transfer within England being supported by guidance28. Similar arrangements and expectations exist in relation to Looked after Children around placements across England and Wales based on guidance29. However this case has highlighted a potential gap in guidance for the transfer of case responsibility and notification from Scotland into England or Wales. 5.3.6. Additionally, it has highlighted the same lack of procedure of information sharing from a schools records perspective. Guidance in England30 refers to the need to share information if a child transfers to Scotland, but not if a child moves from Scotland into England. Scottish guidance31 only refers to practice within national borders, not across it. Harry’s school in England appeared to make reasonable efforts to seek previous information however this was not forthcoming. Learning point: Guidance and procedures already exist to support local authorities and professionals to exchange information across local authority areas. Good practice dictates that this should naturally be extended to cover the sharing of information across national borders within the United Kingdom. 5.3.7. The case has also highlighted that the local Children’s Services have reported experiencing significant problems in obtaining information from the Children’s Services in Scotland, citing numerous attempts, which have required escalation. Similarly, the Children’s Services in Scotland have also highlighted a problem in gaining information from the local Children’s Services in England about Harry’s current care arrangements so as to keep Harry’s mother informed. The reasons outlined above may be contributory factors, 5.3.8. The NHS Trust Hospital has highlighted information sharing problems following Harry’s discharge from the specialist tier 4 Unit in October 2018. No information about Harry’s mental health at discharge or an on-going management plan were received from the Unit, nor any update from local Children’s Services about the outcome of their assessment. This is despite the Hospital staff being involved in the initial Strategy discussion in September 2018. Hospital records do include a summary of involvement by CAMHS which include risks associated with Harry’s cannabis use, his potential for worsening suicidal ideations and conflict between Harry and his father. Again, this portrays fragmented information sharing practices. 5.3.9. The challenges associated with patient care when transfers across border and services have been raised by the review; in particular relating to the transfer between the specialist Hospital for Children and local Hospital outlined in key episode 2. At the point of transfer, Harry’s medical needs were mostly resolved however his mental state had yet to be assessed; the judgement and decision by the specialist Hospital was that Harry’s mental health needs were best assessed by the local service that knew him and who could then provide the consistency of care. This resulted in him 27 National Guidance for Child Protection in Scotland, 2014, p. 101, The Scottish Government. 28 Working together to safeguard children, chapter 3, 2018, HM Government. 29 The Children Act 1989 guidance and regulations: Volume 2: care planning, placement and case review, June 2015, HM Government. 30 Common Transfer file guidance, June 2019, HM Government, Common Transfer file: CTF 19 guide 31 Scottish Government: Children missing from education 15 being transferred to the local Hospital without having had any mental health assessment; however the local CAMHS was informed of the incident and issues. Given that Harry had made a serious, and near fatal, suicide attempt (although this was not his account of the incident) and required significant medical intervention to keep him alive, the appropriateness of the transfer decision has provoked much debate. This has prompted further impartial oversight; the decisions taken at this time have been judged as reasonable and appropriate, and in accordance with guidance32. 5.3.10. The local GP Practice had requested the previous medical notes held in Scotland. As stated above, the notes have only recently been transferred. The GP Practice has learnt from this episode and now has a system in place to ensure records are requested verbally by the safeguarding professional, and a verbal handover given regarding any concerns. It is hoped that even if there are significant delays in future, appropriate information is sought in a timely manner. 5.4. The quality of information sharing between agencies 5.4.1. Statutory guidance33 in place at the time for England refers to the need for effective information sharing practices between professionals and local agencies. 5.4.2. Information set out above has already highlighted a lack of information sharing between the Children’s Services in Scotland and the local Children’s Services in England. The crucial point where information sharing would have been the most valuable was once arrangements had been confirmed that Harry was to commence living with his father around June 2017. This may have resulted in a more timely opportunity to engage Harry and family with support services. 5.4.3. Harry’s School have examined their information sharing practices and judged them to be effective and robust, with clear systems and processes in place. There is no evidence to indicate this not to be the case, with the School being pro-active in their response to Harry when he made disclosures to the member of the school pastoral team, their subsequent response to ensuring he attended a GP appointment, their sensitivity in dealing with Harry participating in school trips, and their attendance at meetings. As stated, Harry’s view of the school was that they were very helpful and supportive. The school have reflected that they are clear that if they had known more about Harry they are likely to have offered him more support. The school has highlighted that they feel they were left managing risk and support for Harry around October 2018 when he had been discharged from the specialist tier 4 Unit and was reintegrated back into school. A multi-agency support plan, greater than just the involvement of mental health professionals would have been beneficial at this stage and reflects the point made above about a creative early help offer that might have been appealing to the father and Harry. 5.4.4. From a GP perspective information only became available about the extent and gravity of Harry’s troubles following the September 2018 paracetamol overdose incident. The GP provided a report for the September 2018 Strategy discussion and the NHS Foundation Trust CAMHS exchanged information in a detailed and timely manner and included a comprehensive mental health assessment, relevant family, psychiatric, educational and medical history. This is similarly the case following Harry’s suicide attempt in January 2019 with information from the MASH Nurse sharing information with the GP Practice resulting in Harry’s situation being discussed within the GP Practice at the multi-disciplinary meetings. A representative from the GP Practice was also invited and attended the Strategy discussion and received minutes afterwards. 32 National Clinical Guideline Centre - Major trauma: service delivery, NICE Guideline NG40, February 2016 & NHS standard contract for major trauma service (all ages), NHS England, 2013. 33 Working together to safeguard children, 2015, HM Government. 16 5.4.5. None of the local Children’s Services Social Workers have raised concerns about the quality or timeliness of information received from other agencies during the course of the involvement, other than the difficulties experienced in obtaining information from the Children’s Services in Scotland. 5.4.6. Based on the information in the Approved Mental Health Practitioners (AMHP) report it is clear that there was good information sharing between the CAMHS team and the AMHP Service. 5.5. Evidence of the voice of the child being sought, heard and acted on 5.5.1. Statutory guidance34 describes expectations about a child centred approach to keeping children safe; ‘… anyone working with children should see and speak to the child; listen to what they say; take their views seriously; and work with them collaboratively when deciding how to support their needs …’. 5.5.2. The Children’s Services in Scotland have considered their practice in their direct contact with Harry, highlighting that there is ample evidence of them noticing and hearing what he was saying. They have reflected that because Harry was an articulate and mature young man it is possible that some of the issues he shared were responded to in a similar fashion, with professionals missing the points that he, as a 14 year old child, was telling them. Examples of this include in September 2016 Harry reflected with the Social Worker about ‘becoming very like his father’, that that is the ‘root’ of the problem between him and his mother. He also talked about his ‘plan to assassinate his mother’. Harry had highlighted his pressing need for a decision about moving to his fathers in the consultation document used for his Looked after Review in March 2017, highlighting a further example of how Harry’s views were secured. 5.5.3. Harry’s school have conveyed a clear sense of working with Harry and ensuring his views and needs were considered. This has been evidenced by their records reflecting Harry’s comments, him being assigned a male sports mentor/key worker given his love of sport and expressed struggles with female members of staff. The school also supported attempts to deal with his anxiety about his younger sibling’s welfare by trying to contact the social worker in Scotland. As noted, from discussions with Harry he felt the school had a positive impact on his life and he spoke highly of their support. 5.5.4. The NHS Trust Hospital have confirmed many examples of them seeking and obtaining Harry’s views, wishes and feelings by both paediatric staff and agency staff. Recordings are made several times each day throughout each of the two admissions. This includes hearing his concerns about his younger sibling. 5.5.6. Following discussion with the GP Harry was referred to the counselling service in June 2018. The GP considered his competence and respected Harry’s wishes to be seen alone but also encouraged him to discuss the consultation with his father. 5.5.7. The local Children’s Services Social Worker allocated between September and November 2018 has cited examples of seeking and obtaining Harry’s views. This included capturing Harry’s ongoing worries for his sibling which resulted in the Social Worker discussing the issue with Harry’s father but also writing to the Director of the local Children’s Services in Scotland expressing Harry’s concerns about his sibling. A copy of this letter was shown to Harry. This was again followed up by the next allocated Social Worker in January 2019. 5.5.8. Although the Police had been aware of Harry since the September 2018 incident they only met with Harry once, in January 2019 when he absconded from Hospital. Police used their powers 34 Working Together 2015, p.10, HM Government. 17 under Section 136 of the Mental Health Act on this occasion, following information passed to them by the Hospital and from their previous knowledge of earlier incidents. They detained Harry and returned him to Hospital for his own safety clearly demonstrating having his best interests in mind. 5.5.9. The NHS Foundation Trust evidence that all interventions were informed by Harry’s views at the time, with opportunities provided to Harry during CAMHS therapy sessions and consultations. This also applied to joint work with the father. 5.5.10. One moment that does highlight learning is at the point that Harry took an overdose of paracetamol in September 2018 he informed a friend that he had done this. The friend sent a text to Harry’s father who then made arrangements for Harry to go to Hospital. The text was sent at around 11pm but not seen by the father until 3am, when he woke for work. Learning point: Children and young people should not be expected to hold information about actual or potential risk of others; supporting them to share information so that adults can act on it is an important message for parents, carers, schools and public health agencies to convey. Helping children and young people to understand the limitations of social media messaging and having a range of options to use when worried about something is an important life skill. Parents, carers, schools and public health agencies have a role to play in this education. 5.5.11. As cited in section 5.1 unless a child’s history and the cumulative impact of adverse life events is understood it can be very difficult to predict attempts to self-harm or end life. In this case Harry was inconsistent in his statements and responses indicating at times feeling settled and not having suicidal ideation but also openly stating he would try to take his own life if given the opportunity. Such situations reflect a real dilemma for professionals in knowing how best to respond, needing to balance the available evidence, the likelihood of self-harm with intent, with proportionate, legal and ethical interventions. Learning point: Often it is not possible to completely eliminate risk of harm to children and reduce it to something that can be controlled or predicated by a range of professional inputs. 5.6. The effectiveness of maintaining a focus on the child’s safety & needs throughout 5.6.1. Statutory guidance35 states, ‘… it is vital that every individual working with children … is aware of the role that they have to play and the role of other professionals …’. 5.6.2. Harry’s school have highlighted that up until the incident in September they had limited knowledge of Harry’s background and their focus was therefore on managing his emotional health. Following the paracetamol overdose and Harry’s reintegration back into school their focus shifted to being involved in the management of his mental health and safety – feeling like a step change and more serious than managing emotional health. They have expressed concern that they appeared to be operating in a relative vacuum for some of the time and that the situation needed a multi-agency risk management plan. Given the gravity of Harry’s overdose attempt and the unfolding realisation by agencies involved with the Strategy discussion that Harry had experienced considerable trauma in his earlier life, the hope for a multi-agency management, or support, plan is not unreasonable. Whilst the involvement of the NHS Trust Child Mental Health Services provided considerable support, the use of an Early Help Plan may have been better suited to managing the circumstances. This also needs to be placed in the context that Harry had only recently moved back to live with his father after several years of living apart, and that the level of parenting skill required by the father to support Harry would have been challenging for any adult. Agencies did 35 Working Together 2015, p. 9, HM Government. 18 not consider an Early Help Plan. The use of such would have provided a more co-ordinated response from agencies. Embedding the Early Help Pathway remains a priority for the Partnership. 5.6.3. The GP that met with Harry in June and July 2018 was not overly concerned about Harry’s presentation to believe more immediate action was necessary; this was based on Harry’s self-reporting and appearance as his previous medical records had not been received despite them being requested. The referral to counselling services can therefore be viewed as proportionate as there was no additional information available to the GP to consider an alternative pathway i.e. a referral to CAMHS. The need for safety planning and risk management was not obvious and the episode was not considered to be dangerous or high risk. On this basis the GP made a sound decision that was child focused based on the limited information available. 5.6.4. From the NHS Trust Hospital’s perspective the incident in January 2019 has confirmed a number of areas of learning for them, with three particularly standing out. 5.6.5. Firstly, Harry once admitted, went to the open outdoor play area where he considered absconding or harming himself. He had been left in his father’s care and without 1:1 supervision from a member of staff – despite the risk assessment that he needed an appropriate level of 1:1 care at all times by an agency Registered Mental Health Nurse. This care plan and expectation was known about by the member of staff being reinforced verbally on two separate occasions. However, review of the records and discussions with staff have revealed that there was no clear written care plan available resulting in a possible lack of clarity and certainty about what was meant by continual 1:1 observation – thereby compromising Harry’s safety. The standards of professional practice on this particular issue are being investigated in a parallel process to this review. Learning point: It is important that day to day management/ care plans are documented so as to achieve consistency of understanding across all staff who may be working with a child. This also ensures clearer handover to new staff and provides a benchmark about what is required and expected to keep a child safe. 5.6.6. Secondly, as part of the management of this incident once Harry had been talked down from the immediate risk on the balcony the on-call Psychiatrist advised using sedative medication. This was delayed it seems because the Consultant Paediatricians were not certain about a sedative being used in these situations. This has highlighted no clear process or policy about responding to such situations and resulted in an internal recommendation to remedy this gap. 5.6.7. Thirdly, Harry had openly expressed that if he had not been formally detained on the Hospital by midnight he would leave; supervision was increased to 3:1 of agency staff. He followed this action through with apparent relative ease, kicking the Ward door open and evading staff. The Trust have noted ‘… the hospital records made by an RMN stated that they would be unable to restrain and would require police support if Harry required physical restraint. The records give an insight to the reasons, for example they recorded they were concerned about physical harm to Harry and themselves. The internal review and discussions with ward staff indicate that staff were unaware that the RMN’s would not restrain Harry. The NHS Trust has asked the agency to investigate this as part of the complaint referred to earlier. In fact the paediatric ward staff on duty did try to physically restrain him from leaving but were unable to stop him …’36 . This episode has highlighted that Harry’s safety was compromised and there is a need to ensure all staff members are aware of the care plan, are suitably qualified and trained to perform the tasks and expectations associated with a care plan i.e. de-escalation and physical restraint, and that the Hospital need to develop a 36 NHS Trust submission to the review. 19 policy that supports staff in responding to threats of absconding from children but also actual incidents of absconding. 5.6.8. The Police response to the above incidents were timely, effective and child focused. They attended the Hospital when requested to assist with the management of the balcony incident although took advice from those staff dealing with the situation about the extent of their involvement with Harry so as not to inflame the situation. The attending Officer was asked whether the Police would detain Harry under Section 136 of the Mental Health Act for an assessment. This request was not supported as staff were advised that it was not appropriate given Harry was already in a ‘place of safety’. This request further reflects the confusion by Hospital staff about the use of legal intervention to safeguarding a person’s safety and welfare. 5.6.9. The Police’s response to Harry following absconding was again, timely, efficient and child focused with them returning him to the Hospital. Once returned to the Hospital it was clear that there was a lack of willingness, or understanding, by Hospital staff to detain Harry should he choose to leave again. The Officer therefore remained until the Mental Health Team arrived to conduct the relevant assessment on Harry. 5.6.10. Over the timeframe under review local Children’s Services have noted that Harry had three different Social Workers. One worker was allocated during the September to November 2018 episode (key episode 1) and then on re-referral two workers dealt with the case from point of referral through to allocation. In turn, this also meant different management oversight. Continuity of worker is an important principle when working with vulnerable children; it supports an opportunity to build more trusting and meaningful working relationships and is more child focused. Children and families should not necessarily be expected to understand the complexities of internal work load management systems. Experiencing continuity and the opportunity to build a rapport with those designated to offer support might be seen as a reasonable expectation from any child and family; reducing the number of workers involved from first contact to the point of ongoing support can be beneficial to all involved. Harry’s father has conveyed this as being something that would have made the whole situation around Harry’s two admissions to Hospital easier to deal with, highlighting that a single coordinated point of contact would have been helpful. Instead, having multiple practitioners contacting him was somewhat confusing. 5.6.11. From a system thinking perspective this can be described as organisations having to manage the interactions and flow of workload. From a service user perspective having a consistent flow to interactions and communications with professionals is desirable, regardless of the different function each worker may have. Where the flow is interrupted by changes in workers or new people entering the situation, it can cause confusion, frustration and anxiety; this was the father’s experience. In an ideal multi-agency partnership arrangement, and when a lead professional role may be designated, managing the flow of communications is a critical task. 5.6.12. In discussion, Harry was clear that having changes in Social Worker but also nursing staff was not helpful. It allowed little opportunity to build a relationship and often felt uncomfortable due to having to recount information. Of particular note, Harry reflected on the number of staff that were supervising him whilst in hospital and that it would have been preferable to have just one of two people watching him (when in bed sleeping) rather than a larger number. Learning point: Case management systems ideally need to support the principle of continuity of worker for children and families rather than multiple changes. Learning point: When there are multiple professionals involved in supporting a child and family it will be important for those professionals to reflect on the actual experience of the child, and family, 20 and whether it is possible to assign a lead professional who can act as a single point of contact across the multi-agency group. 5.7. The provision of training & supervision to the workforce about the identification or and response to abuse, neglect and maltreatment, particularly relating to adolescents 5.7.1. Statutory guidance37 sets out expectations relating to ensuring staff receive appropriate supervision, support and training to respond to their child protection responsibilities. 5.7.2. School staff, local Children’s Services, Adult Social Care, NHS Foundation Trust, the GP Practice and the Police have cited opportunities they have available to seek and acquire relevant training but also confirmed that staff involved with Harry were appropriately trained and supported. 5.7.3. Some aspects of information submitted to this review support a view about there being indicators of neglect in the parent – child relationship i.e. supervision of Harry’s medication. Generally though, evidence submitted describes a situation whereby Harry’s father, and other adult family members, were accommodating to having an adolescent in the family home who was struggling with a number of issues – and which are not necessarily directly indicative of neglectful parenting. Those involved in the review have reflected on the challenges of assessing such circumstances and the benefit of assessment tools to support and guide practitioners. The use of, for example, the Graded Care Profile which is used in the local area may not be the most appropriate assessment tool to help practitioners in such circumstances especially in situations where adolescent trauma38, impulsivity, emotional and mental health may be the presenting issues. 5.7.4. The Clinical Commissioning Group (CCG) Safeguarding team offers support and advice to GP Practices relating to safeguarding as part of a quality assurance programme. As part of this the CCG conduct dip sampling to evidence the effectiveness of training and interventions. Auditing, as part of this review process, has highlighted that there is no evidence to indicate whether supervision or support was sought about Harry. Whilst this may not necessarily be indicative of a trend it is important to learn from this. Learning point: Seeking a fresh perspective from a peer, or using a multi-disciplinary meeting forum to discuss complex, perplexing or cases of concern may be a valuable step to take in confirming the actions taken are positive, and/or opening new pathways which provide greater support and safety. 5.7.5.The NHS Trust Hospital have confirmed that there is a 94% compliance rate for paediatric nursing and medical staff to be appropriately trained and have the necessary skills and knowledge about safeguarding children. The Trust will want to ensure all staff are appropriately trained to achieve full compliance. The following other areas have been highlighted as needing further attention; - Clinical supervision arrangements for the nurses within the Emotional, Health and Well Being Team are lacking. - Specific training for medical staff in the use and prescription of sedative medication for acutely distressed children and young people. - The use of section 5 (2) of the Mental Health Act 1983. 37 Working Together 2015, p.53, HM Government. 38 Adversity and Trauma-Informed Practice, A short guide for professionals working on the frontline, June 2019, Young Minds, Adversity & Trauma-informed practice 21 - Specific training for staff concerning children’s emotional health and wellbeing, plus the use of de-escalation techniques, to increase staff confidence is needed. 5.7.6. The Children’s Services in Scotland have rightly identified that there is a training issue relating to transferring cases across geographical borders to other authorities in terms of good practice and the effective management of risk to vulnerable children. Learning point: Assessing, and responding to adolescent neglect, trauma, self-harm and attempts at suicide can be challenging. Learning39 from other Serious Case Reviews about adolescent suicides highlights the importance of working together and that ‘… behaviour should be viewed as symptomatic of other underlying problems and difficulties. The cause of the behaviour should be explored and addressed through multi-agency support …’. 5.8. The quality & effectiveness of the mental health pathway between services 5.8.1. From the GP perspective the referral pathway is clear; had Harry presented as needing a more immediate assessment the GP knew to refer to CAMHS. This pathway is available on the mental health NHS Trust website and work has been undertaken to ensure all GP Practices are aware of this procedural expectation. 5.8.2. Key episode 2 has highlighted a lack of clarity and knowledge by relevant professionals about paediatric mental health pathways. The episode has revealed confusion about the pathway, uncertainty about risk categorisation and disjointed working arrangements across different services based in the Hospital. 5.8.3. Considerable developmental work improving risk assessment, safety planning and interventions for children who self- harm or are in mental health distress, had taken place in the 12 months prior to Harry being admitted to Hospital in September 2018. Developments included extending the availability of CAMHS practitioners out of hours, new risk assessment processes and the introduction of a Hospital based health and emotional wellbeing team consisting of a Registered Mental Health Nurse (RMN), a trained paediatric nurse and emotional health and wellbeing support workers. As a result of these developments not all systems and processes had been fully embedded or tested, potentially accounting for some of disjointed practices occurring. 5.8.4. The NHS Trust Hospital have identified the following procedural points to learn from; - There is no defined process by which the nurse in charge assesses risk and documents decision making, including the escalation to Hospital managers, to determine when it is safe to admit a child if the risk assessment indicates a Registered Mental Health Nurse is required but not available. Practice at the time was that a risk assessment was made to determine the level of supervision and care required whilst awaiting a formal CAMHS assessment. This had been only recently implemented and Harry was assessed as being high risk and needing 1:1 support from a Registered Mental Health Nurse. As a RMN was not available at the time of admission the Nurse in charge made a decision that it was safe to admit Harry until a RMN became available. - There is an inconsistent understanding about when, and how, risk assessments should be used which results in uncoordinated care and a disjointed care plan potentially being created. Differences in understanding highlight that some staff believe that a risk assessment should end once a formal mental health assessment has been achieved whilst others believe it is an ongoing process and requirement. It has also revealed that two risk assessment processes could run in parallel with one another and potentially producing different outcomes and risk management plans; one being conducted by Hospital staff and the other by CAMHS staff. This 39 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 118, University of Warwick & University of East Anglia, May 2016. 22 is evidenced by the incident when Harry was judged by CAMHS as at high risk of self-harm in the community but was permitted out into town with a support worker; later Harry stated that he had opportunities to go to a bridge, presumably with an intent to jump. In this respect, care planning should make clear reference to; the level of supervision required; prescribed medication and include formal consultation between the Psychiatrist and the responsible Consultant Paediatrician. - The lack of a clear pathway, agreement and management strategies was also confirmed when a request for Harry to be moved to the adult psychiatric unit was refused, resulting in an increased staffing ratio to supervise Harry. The move was requested as a result of the delays in securing a tier 4 Unit bed and the challenges with keeping not only Harry safe on the children’s unit in the Hospital, but also other children who were also admitted at the time. There is a need to develop a clear protocol to determine under what, if any, circumstance it would be appropriate to admit a child onto an adult mental health unit. 5.8.5. This confirms not only a training need across all staff who will work with children in the Hospital and the need for a robust paediatric mental health care pathway for children admitted on to a Hospital, but also disjointed working protocols between CAMHS and the Paediatric Team in the Hospital, who have ultimate responsibility for the child patient. 5.8.6. A patient informally admitted to the Hospital does so giving consent and therefore is within their rights to choose to discharge themselves. The Section 5 (2) power of the Mental Health Act 1983 allows an informal patient to be detained for up to 72 hours. It would be used as a temporary measure if the patient’s mental health had deteriorated and they had become a risk to themselves and others and would be pending a further assessment by an approved mental health professional and two doctors i.e. a psychiatrist and a paediatrician. This was not used with Harry and it is evident that there was confusion about whether, and how, it could be used; ‘… there was considerable confusion about the use of Section 5(2) powers with NHS Trust staff being given conflicting information by CAMHS staff, the [clinical] director for the local Trust providing mental health services and the Local Authority Approved Mental Health Practitioner. This led to failure to apply powers and it could be argued that Harry‘s absconsion … may have been prevented if correct processes had been in place supported by training and education in the use of Section 5(2) …’40. The issue of when a child may, or may not, be admitted to an adult mental health ward should be clarified by the local NHS Trust. 6. Good practice 6.1. It is important to capture any good practice. Providing examples of good practice is a way of reinforcing positive behaviours and strategies so as to improve better outcomes for children. Examples include; - Harry was facilitated by the school to identify his own key person; a member of staff to whom Harry could go to if needed. In his father’s absence, a member of staff accompanied Harry to the GP Practice to ensure that he got there and went in to see the GP. - The school asked for support from CAMHS to write a support plan for Harry; this was widely shared to enable staff to understand his needs. - The quality of the partnership working – active, timely and regular – from the community based CAMHS service with Harry, Harry’s father and other agencies throughout. Harry was particularly complimentary about the psychological support offered to him. - The member of the school pastoral team noticing cut marks on Harry’s wrists and reporting these. Harry was very positive about this individual member of staff. 40 NHS Trust submission to the review. 23 - The NHS Trust’s Health and Emotional Wellbeing Support Worker’s prompt, calm and skilled approach to Harry during the incident where he was on the balcony edge, supporting the father, de-escalating the situation and returning Harry to the Hospital and seeking assistance. - The Police’s timely and sensitive response to Harry standing on the balcony whilst in Hospital. - The Police’s subsequent response to locating Harry once he had absconded from Hospital, returning him to the Hospital and waiting to offer support if it were needed. - A representative from the GP Practice attending subsequent Strategy discussions to share information, and ongoing review of Harry’s case at Practice multi-disciplinary meetings. - The actions of the first allocated Social Worker in responding to Harry’s worries about his sibling and spending time with him to gain his views, wishes and feelings. 7. Conclusion 7.1. This Serious Case Review has examined the circumstances around a child, under 16 years of age, who made an attempt to take his own life. Although the child’s account of the incident differs to that of the professionals involved it is clear that the child was vulnerable, unhappy and in need of support. The review has gathered and analysed documentary information from all of the agencies involved over a period of nearly two years, whilst also recognising relevant background information. It has benefitted from the involvement of many of the practitioners involved with the child and gained their perspectives about what happened, and why events may have occurred as they did. Positively, the review has also gained the child’s perspective as well as the father’s viewpoint. 7.2. The review has identified a number of areas where practice could have been strengthened. These include: - A greater appreciation of the impact of early childhood adversity and trauma and the importance of using this information to inform decision making and safety planning. - The importance of information sharing across borders and agency boundaries. - The need for prompt action, avoiding delay, to secure the appropriate type of support and intervention when young people experience an acute and serious mental health episode. 7.3. The review has captured learning points for use by practitioners, managers and trainers. As a result of this review agencies that have contributed have been able to identify learning that can be taken forward internally. Action plans have been provided by each agency involved, and where relevant and appropriate to do so, improvements have been initiated. It is the role and responsibility of the Safeguarding Partnership to monitor, scrutinise and challenge progress against single agency action plans. The report concludes with a number of recommendations for the multi-agency Safeguarding Partnership which may strengthen practice. 8. Recommendations 8.1. The following additional recommendations are made for the Safeguarding Partnership; 1. To ensure the learning from this Review is disseminated across the multi-agency safeguarding partnership to practitioners and managers. 2. To seek assurance that the actions identified by each partner agency, as a result of this Review, have been managed, implemented and embedded in a timely manner. 3. The Safeguarding Partnership to seek assurance from schools/colleges that they will raise children and young people’s awareness about the limitations of social media when worried about someone 24 else’s welfare and the need to consider a full range of options for getting help, advice or support. See section 5.5.10. 4. The Safeguarding Partnership to inform the Child Safeguarding Practice Review Panel of the specific finding about the apparent lack of explicit guidance about the transfer of school records across borders in Scotland and England. See sections 5.1.4. & 5.3.4. – 5.3.6. 5. The Safeguarding Partnership to inform NHS England regarding the findings of this review and the continuing issues regarding an apparent national shortage and challenges of availability of tier 4 beds. See sections 4.4.2. – 4.4.4. 6. The Safeguarding Partners to also contact NHS England and advise them regarding the difficulties in obtaining medical records from across national borders. See section 5.1.6. 7. The Safeguarding Partnership to request through the regional Partnership Board Business managers meeting that the regional ‘West Midlands Safeguarding Network protecting children who move across local authority borders’ guidance is reviewed and amended to reflect a wider set of circumstances in which children may move across national borders and where legislation, guidance and expectations may be different. See section 5.3.6. 8. To seek a review, and amendments where necessary, to the guidance and procedures around the management and information sharing practices between local community based child mental health services, acute health settings and other relevant community based health services for situations where children re-present to an acute setting. See sections 5.3.8 & 5.8.1 – 5.8.6. As part of the review of the guidance and procedures the Safeguarding Partnership should write to local commissioners and request i) they consider access to additional mental health support for children who are experiencing severe emotional and mental health issues when reviewing local commissioning arrangements for emotional help and well-being support services. Commissioners should consider the service response for children who do not engage with emotional help and well-being support services, requiring a more assertive engagement by local services to prevent escalation of risks. and ii)) request that local commissioners also consider options within future commissioning arrangements for appropriate step down provision for young people following discharge from tier 4 Units. See section 5.6.2. |
NC52429 | Death of 16-year-old boy in 2019 in an attack which is believed to be connected with rival criminal groups. Learning is embedded in the recommendations. Recommendations include: ask the Safeguarding Review Panel for guidance of serious youth violence incidents; review of practices on the provision of parenting support, where there is a perceived risk of involvement in youth offending; improve information sharing with schools and colleges in relation to children who are at risk as a result of serious youth violence or child criminal exploitation; ensure that youth offending service assessments consistently seek to identify and take full account of the child's background and relevant contextual factors and take full account of information from other localities when a young person is known to have links with services in other boroughs; consider making decisions to support or enable the relocation of family the responsibility of a manager at director level who should be reassured that all alternatives and risks present in the proposed area of relocation have been considered.
| Title: Serious case review: Child K and services to reduce serious youth violence. LSCB: Brent Local Safeguarding Children Board Author: Keith Ibbetson Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review: Child K and services to reduce serious youth violence Convenor - Brent Safeguarding Children Forum Mike Howard Independent Reviewer Keith Ibbetson Serious Case Review: Child K and services to reduce serious youth violence 1 INTRODUCTION 1 2 BRIEF NARRATIVE 9 3 EVALUATION OF THE SERVICES PROVIDED AND LEARNING 18 3.1 Introduction 18 3.2 The role of schools in educating and safeguarding young people who are affected by serious youth violence 19 3.3 The multi-agency response to murders and other serious incidents of youth violence 24 3.4 The relocation of young people and their families 28 3.5 The disparity between risk, the professional understanding of risk and action that could be taken to protect the young person and the public 36 3.6 Systems for identification of young people who are at risk because of gangs or serious criminality 43 3.7 The role of social care professionals, Youth Offending Services and youth-oriented services 46 3.8 The culture and practice of working with parents 50 4 RECOMMENDATIONS 52 Appendices 55 I Summary of views of Child K’s parents 55 II Review method and Terms of Reference 60 III Relevant findings and recommendations of the Child Safeguarding Practice Review (2020), It was hard to escape - safeguarding children at risk from criminal exploitation 65 1 | P a g e 1. INTRODUCTION Reasons for conducting the review 1.1. Between October 2019 and August 2020, Brent Safeguarding Children Board (the LSCB) carried out a review of the services provided for a 16 year old boy and his family. He is referred to in this report as Child K. He was murdered in 2019 in an attack which is believed to have been part of a series of connected violent assaults and deaths involving young people associated with rival criminal groups. 1.2. The review was carried out under the statutory guidance Working Together to Safeguard Children 2015. Its purpose is to undertake a ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’. The LSCB is required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’.1 This document sets out the review findings. 1.3. The death of Child K was brought to the attention of the LSCB which undertook the rapid review required by statutory guidance.2 The LSCB Independent Chair decided that a serious case review (SCR) was required, noting that concerns about serious youth violence fall within the definition of contextual safeguarding in the statutory guidance. 3 4 1.4. Child K’s murder has been the subject of a criminal investigation. One man has been convicted of his murder and another of offences linked to it. The report contains no further detail of the circumstances of Child K’s death. The SCR is aware of the highly-charged atmosphere that often exists around the killing of a young person, the risk of retribution and further serious violence. Only essential information about Child K, his family and his contact with professionals is included in this report where it supports the review findings. Sufficient detail is provided of the risk to Child K, the risk that he had posed to others and the services that had been provided, in order to learn lessons that can be applied to other young people. 1 Working Together to Safeguard Children (2015), 4.1 and 4.6. In September 2019 the statutory partners responsible for safeguarding children in Brent introduced new partnership arrangements, in line with the Children and Social Work Act 2017 and Working Together to Safeguard Children 2018. The LSCB is responsible for completing this work and publishing the finding and recommendations. Brent Safeguarding Children Forum will monitor the implementation of the recommendations https://brentsafeguardingpartnerships.uk/children/article.php?id=643&menu=0&sub_menu=2 2 Working Together to Safeguard Children (2018) Sections 4.20 – 4.21 3 In September 2019 the Independent Chair assumed the role of Independent Convenor of the Brent Safeguarding Children Forum, 2 | P a g e The scope of the review and the information considered 1.5. Child K and his family had been well-known to a number of services in Islington, Camden and Brent (where he was living at the time of his death). Initial review of the history suggested concerns about the way in which agencies had worked together to safeguard his welfare, noting that there may have been shortcomings in service provision because of the involvement of agencies in different London boroughs. 1.6. At the time of his death, Child K was the main suspect in the police investigation of the killing of another young person. The review has been told by the police that, had he not been killed, Child K would have been charged with the murder. The police were also investigating his involvement in other serious alleged offences. This made it important for the review to consider how the risk that he posed to other young people and the public more widely was understood and addressed, as well as considering questions about how he was being safeguarded. By the end of Child K’s life, there was a significant disparity between these risks and the interventions that professionals were able to make. This was recognised as a common challenge to families and professionals which the review could usefully explore. 1.7. Members of the LSCB, senior managers and the independent reviewer appointed to lead and undertake the review agreed initial terms of reference. These are set out in an anonymised form in Appendix 2. The original intention was to complete the review by the Spring of 2020. The Covid 19 lockdown caused the unavoidable postponement of interviews and meetings and delay in the agreement and publication of this report. 1.8. The review does not examine every episode in Child K’s life and contact with services in the same detail. Most attention is given to the issues which are believed to be of most value to agencies working with children affected by serious youth violence. Agencies involved and information obtained 1.9. The review has sought to obtain information from all of the agencies and contracted professionals that are known to have worked with Child K and his family including the following: • Local authority services (social care, housing, education services, and targeted youth support services) • Youth Offending Services • Metropolitan Police Service • Acute and community health services, including intensive care services 4 Working Together to Safeguard Children (2018) Sections 1.30 – 33. Contextual safeguarding refers to children and young people ‘vulnerable to abuse or exploitation from outside their families’. 3 | P a g e • Child and Adolescent Mental Health Services • Schools • General Practice 1.10. Agencies provided the review with chronologies that give factual accounts of their involvement with the family and other professionals as well as a brief commentary on the involvement. In addition groups of staff and managers who worked with the family have spoken directly to the independent reviewer in order to provide more detailed information about their work with Child K, reflect more widely on their experience of work with young people and their families, and suggest ways in which services might be improved. More senior or specialist staff have advised the review on relevant policies and procedures. Family involvement 1.11. Serious case reviews must involve family members. During the preparation of this report, the independent reviewer held a number of substantial discussions with Child K’s mother about the services that her son and the family had received. She later read a draft report and provided feedback. Unfortunately only phone conversations were possible because of the Covid 19 lockdown. The review has also taken account of feedback given by Child K’s mother directly to some of the agencies that worked with the family. The independent reviewer had a number of short phone discussions with Child K’s father via brief telephone call discussions. 1.12. The enormous pain caused to Child K’s mother and father by the loss of their son was apparent throughout these conversations. The reviewer is grateful for their contributions and has tried to reflect their knowledge and views in Sections 2 and 3 of the report. The SCR recognises that discussions with the family, and the other formal processes that follow from a violent death, such as criminal investigation, court hearings and the preparation and publication of reports, intrude on the ordinary process of grieving, bringing events to mind afresh. 1.13. Appendix 1 is a full summary of the parents’ contributions, but Child K’s mother wished that a number of points should be given particular emphasis. She wanted readers to understand that parents need to be informed about the challenges and the potential risks of knife crime, gang activity and criminal exploitation much sooner. Then, if their children are exposed to these issues as they become teenagers, they will be more prepared to deal with them. She believes that there is an urgent need for improvement in the relationships between the police and young people. This would increase the trust of young people in the police and enable police to investigate crimes and protect the public more successfully. This does not mean that young people who have committed serious criminal offences should not be held to account. One of her great 4 | P a g e frustrations was in the delay in action taken by the police over a number of incidents involving her son which all remained unresolved at the time of his death. The review has considered these further in Sections 3.5 and 3.8. 1.14. Child K’s mother cannot understand the need for families to be repeatedly assessed by different services, and struggles to understand why there are so often delays between assessment and action. She wants practical solutions to the problems that young people face. Reading the review, she said that Child K sometimes came across in a negative way. She wanted it to be understood that in the family he was ‘a loving boy with a big heart’. However she described him as ‘unhappy’ and reported that he ‘couldn’t find a way out of the situation he had put himself in’. 1.15. At some points the findings of the review and the views of the parents coincide. For example, the review agrees that the arrangements made to relocate the family in the months leading up to Child K’s death did not protect him and added new pressures on his mother. Elsewhere the review has reached different conclusions, reflecting the fact that they draw on different sources of information, experience and perspective. For example, the review is much less critical of the decision made by Child K’s school to permanently exclude him in 2018 than is his mother. This should not be a surprise. These are complex problems that are not amenable to simple solutions. It is inevitable that different views will be held and it is essential that they should be discussed in a constructive way. How can this learning review assist in improving services to reduce violent youth crime? 1.16. The review took place at a time when there was a considerable and understandable public and political concern about the large number of young people being killed or seriously injured, often by other young people or young adults. It therefore considered the services provided to Child K in this wider context, taking into account a growing recent body of research evidence and policy discussion about serious youth violence. 1.17. 23 teenagers were stabbed to death in London during 2019; the largest number of fatal stabbings since comparable records began in 2008.5 There were 14,590 recorded crimes involving the use of a knife in London in 2019-20, the highest figure since current records began in 2010-11.6 In England and Wales just under 4,500 knife and offensive weapon 5 https://www.bbc.co.uk/news/uk-england-london-50507433 one more was shot and there was one other recorded violent death 6 https://www.statista.com/statistics/864736/knife-crime-in-london/ These do not all involve young people and this includes domestic knife crime. 5 | P a g e offences were committed by 10-17 year olds in 2018-19. The number of these offences is lower than its previous peak which was in the years ending March 2009 and 2010. However until 2018-19, when there was a 1% fall, there have been year-on-year increases in these offences since the year ending March 2014, amounting to an increase of 64% compared with five years ago.7 Although the number of violent deaths of young people fell substantially during the first Covid 19 lockdown, levels of violence began to increase as it was relaxed. 1.18. In the year ending March 2018, 51% of children received a community sentence following conviction for a knife or offensive weapon offence. Although the number of children in custody has fallen consistently over recent years, the number of custodial sentences given to children for a knife or offensive weapon offence has been increasing, because the number of such crimes has been increasing. In the year ending March 2018, nearly 600 knife and offensive weapon offences resulted in immediate custody, which is nearly double the volume in the year ending March 2013. 1.19. The wider picture has prompted government, charities and ‘think tanks’ to publish large amounts of research as well as consultation papers and policy recommendations, identifying causes and advocating solutions. As would be expected when attempting to understand a social problem that has such devastating consequences, there are varying and strongly-held positions. Some thinking is highly critical of current policies. ‘Experts’ often disagree. Within the time available, this review has taken account of as much of this literature as possible. 1.20. Reports by two other safeguarding children boards in London that sought to build on a detailed knowledge of individual cases in order to reach wider thematic findings are relevant and have been referred to.8 The author of this report has conducted a number of reviews in relation to the death or serious injury of young people in similar circumstances and has drawn on this experience.9 7 Youth Justice Board Statistical Bulletin. These are offences resulting in a conviction or caution. The overall figure is 31% lower than 2009 8 Alex Chard (2015) Troubled Lives Tragic Consequences – a thematic review, Tower Hamlets Safeguarding Children Board, reviews the services provided to five young people convicted or victims of serious violence; Charlie Spencer, Bridget Griffin & Maureen Floyd (February 2019) Vulnerable Adolescents Thematic Review, Croydon Safeguarding Children Board, looks at the backgrounds and services provided to 40 adolescents deemed to be ‘vulnerable’ by locally determined criteria. Many, though by no means all, had been involved in youth crime. Reference to these reports should not be taken as an indication that either the author or the commissioner of this report endorses their thinking or findings. 9 For example: Hounslow Safeguarding Children Partnership (2020) Serious Youth Violence Systemic Review, Buckinghamshire Safeguarding Children Partnership (2019) Serious Youth Violence: Thematic Serious Case Review 6 | P a g e 1.21. Whilst this review was in progress, the Child Safeguarding Practice Review Panel published a thematic review of services provided to young people at risk of criminal exploitation, focusing on 21 adolescents from 17 localities (in England) referred to the panel in the 9 months between July 2018 and March 2019. These young people had died or were seriously harmed ‘within a context of criminal exploitation’.10 The thematic review was supported by a summary of relevant research.11 1.22. The national review covers some of the same areas of practice and this report refers to its findings at a number of points. Recommendations of the national review that appear directly relevant to Child K’s case are reproduced in Appendix 3 of this report. This is an important document that should be read by all those working in this difficult area of practice. 1.23. Taking the huge amount of information into account, one policy commentary summarises the position as follows: ‘The public debate about knife crime has intensified over the last two years but continues to generate single cause explanations, often overlooking the potential complexity and interconnectivity of the problem.’ 12 1.24. There is a consensus that there should be a collaborative approach to serious youth violence and for some time it has been government policy that a ‘public health approach’ is needed. However politicians and others contest what this means, how it should be implemented and how long it could take to succeed. The Association of Directors of Children’s Services believes that ‘at the most basic level we do not have a shared understanding and / or a clear definition of what constitutes a “public health” approach to reducing serious youth violence and knife crime’.13 1.25. To be successful, any collaborative approach must be developed and put into operation at a local level, informed by young people, families, communities and the professionals who are working with children. This includes understanding the services that have been provided for children and their families, what worked well, gaps and weaknesses in existing 10 The Child Safeguarding Practice Review Panel (2020) It was hard to escape - safeguarding children at risk from criminal exploitation, HM Government. page 12 11 N Maxwell et al (October 2019) A systematic map and synthesis review of Child Criminal Exploitation, Cardiff University. 12 Crest Advisory (2019) Serious violence in context: Understanding the scale and nature of serious violence, https://static.wixstatic.com/ugd/b9cf6c_654f5b6fab914780bd3f895df353e231.pdf?utm_source=Website&utm_medium=PDF&utm_campaign=Serious-Violence 13 The Association of Directors of Children’s Services Ltd (July 2019) Serious Youth Violence and Knife Crime, https://adcs.org.uk/assets/documentation/ADCS_Discussion_Paper_on_Serious_Youth_Violence_and_Knife_Crime_FINAL.pdf 7 | P a g e services and ideas about what might have been done differently. The purpose of a case review is to try to make sense of the experience of one young person and his family in a way that can contribute to that discussion. The focus on wider issues in the system 1.26. In keeping with the statutory guidance the purpose of this report is not to criticise the actions of individual professionals.14 It is likely that any group of professionals working with Child K would have struggled to respond effectively to his difficulties, not least of which was that for long periods of time, particularly towards the end of his life, he refused to cooperate with the efforts of his family and professionals to help him. Inevitably specific decisions and gaps in activity are highlighted, but at each point the intention of the report is that the focus of the reader should be on two questions: What do these events tell us about the strengths and weaknesses of the multi-agency systems that are in place to address the problems of serious youth violence? Are commonly-used practice approaches as effective as they need to be? 1.27. In any retrospective review of a child’s life and the services provided by agencies with welfare and safeguarding responsibilities, there is a danger of misusing the benefit of hindsight. This is particularly so when the review involves the life of a young person who was well-known to many professionals has been violently cut short. Because we know how Child K’s story ends, it is easy to be drawn to aspects of the narrative that seem to have pointed to its inevitability and asked why no one acted decisively to prevent the tragedy. This is referred to as ‘outcome bias’ and the review seeks to avoid it.15 1.28. In general, the review has sought to avoid this by focusing its attention on the choices that professionals faced and the information that they had at the time. It is only by understanding the real context in which professionals were working that the review can offer positive suggestions. There are however a number of points when the report consciously makes use of a degree of hindsight, because it would be foolish not to take advantage of the overview of events that is now available. Where this approach is being taken, it is made clear. Review of cases when a child has been killed or severely injured as a result of serious youth violence 14 HM Government, (2018) Working Together to Safeguard Children, Section 4.1 – 4.5 15 For a fuller account see, for example, James Reason (1997) Managing the risks of Organisational Accidents, page 38 8 | P a g e 1.29. This report is one of only a small number of locally-published serious case reviews or child safeguarding practice reviews in relation to the safeguarding of children from serious youth violence.16 Local safeguarding children partnerships respond differently to very similar incidents and often do not undertake or publish a detailed review. Case reviews are unlikely to be initiated by the statutory youth justice sector as there is currently no requirement for Youth Offending Services to review the provision made to those who have been convicted of serious and violent offences while under their supervision.17 1.30. The national child safeguarding practice review (Section 1.21 above) had a particular focus. All of the young people featured in the national study were male. While accurately reflecting the profile of the young people most likely to have been killed or to have seriously harmed another child, the review does not deal with the sexual and physical harm of young women linked to criminal exploitation. Nor does it address the role of young women as perpetrators of violence. While highlighting the disproportionate number of black and minority ethnic young people in its sample, neither the child safeguarding practice review nor the linked research summary offered specific insight into the factors that have influenced the lives of those children and their families, or the services they received. 1.31. Having conducted one national review on the topic of serious youth violence the Child Safeguarding Practice Review Panel is unlikely to do so again. Further local reviews will be needed to shed light on different aspects of this problem and to stimulate further debate and service innovation. It will therefore fall to local safeguarding children partnerships to judge the value of conducting a local child safeguarding practice review when a young person dies as a result of serious youth violence. Partnerships have considerable latitude to determine whether there will be useful local learning. Without further guidance they may not appreciate the possible contribution to further national learning and there is unlikely to be consistency in approach. 1.32. The Child Safeguarding Practice Review Panel is aware of the range of 16 A research summary found 4 SCRs published on youth homicides in London between 2016 and 2019, during which time 124 young people aged 16-24 had been killed. SCIE (2020) Analysis of statutory reviews of homicides and violent incidents: A report commissioned by the Mayor of London’s Violence Reduction Unit. Two more are known to have been published in 2020. See Waltham Forest Safeguarding Children Partnership https://www.walthamforest.gov.uk/sites/default/files/WFSCB%20-%20SCR%20Child%20C%20May%20final_.pdf and City and Hackney Safeguarding Children Partnership, http://www.chscb.org.uk/case-reviews/ 17 HM Prison and Probation Service guidance previously covered young offenders but since 2018 there has been no requirement to notify serious incident or reoffending to the Youth Justice Board, https://www.justice.gov.uk/downloads/offenders/psipso/psi-2018/pi-06-2018-sfo-procedures.doc.pdf 9 | P a g e incidents being reported, the number of reviews being initiated and the reasons for decisions about the need for a review. It is therefore well-placed to give more detailed guidance on the approach that it would prefer local partnerships to take when considering the need for reviews of practice in relation to children who are killed or badly injured as a result of serious youth violence. It might also usefully consider how it thinks the sector should learn lessons in relation to perpetrators of serious youth violence who are under the age of 18. 1.33. This report makes a recommendation on this. All recommendations are set out in Section 4 below. 2. BRIEF NARRATIVE Introduction 2.1. This section of the report provides an account of key events and the services provided to Child K and his family. This account is deliberately shortened in order to reduce the risk of compromising the privacy of family members. 2.2. It therefore does not set out the detail of every incident, all of the services provided or the reasons for decisions. Section 3 of the report evaluates the services provided by agencies in the areas that are judged to hold the most potential for learning. Family background 2.3. Child K was born in the UK. He had an older brother. The children’s father is black. Records provided to the review do not say anything more about the father’s history. He was noted to be unemployed in 2015 and reported to be frustrated about not being able to provide for his family. 2.4. Child K’s mother is from a Mediterranean country and came to the UK some years before the birth of her eldest son. The family lived in Islington until August 2019 when they were found temporary accommodation in Brent because of risks to Child K. Child K’s mother has always worked. When the family moved out of the borough, she had to pay the rent for two properties, and says that she barely qualified for housing benefit. 2.5. The parents separated in 2015, though they remain in contact. Child K’s father was involved with professionals during 2015, but subsequently there are only a small number of contacts with him recorded. 2.6. Some years before any significant professional contact in Islington, a teenage member of the father’s extended family was the victim of a fatal knife attack. This is now understood to have been a significant event in the life of Child K’s family, and might have influenced the response of family members to events in his life. Despite the extensive contact with 10 | P a g e professionals scrutinised for this case review, there is no record that this tragic event came to light in any professional involvement with the family until after Child K’s death. Child protection plan 2015 2.7. For 9 months in 2015 (when he was aged 12-13) Child K was subject to a child protection plan. This began because his father beat him with a belt when he learnt that his son had made offensive remarks to a female teacher. His father admitted the assault and accepted a police caution. Social care records note that Child K’s mother told professionals that she had already decided to separate from the father when this happened. She reported that the father had been verbally abusive to her, and there is one account in 2015 of the couple ‘pushing one another around’. It has been widely assumed by professionals involved that this was a family in which there had been domestic abuse, but there has been no allegation or record of any other incident. For professionals the focus of the child protection plan was: protecting Child K from further physical assault perceived risks of domestic abuse and mother’s concern to understand the reasons that Child K was having difficulties and to be able to parent him in a more authoritative way. 2.8. In late 2015 Child K’s mother was rehoused with her two sons, allowing the child protection plan to cease. The mother received some advice about parenting. She told the review that it was of limited use and at that stage she would have benefitted from the kind of advice she received later, which was more focused on specific problems of gangs and exploitation. The social worker recorded a number of individual discussions with Child K where he discussed his feelings about his school problems and his views of the family. 2.9. Although from a professional perspective this seemed to have been a successful intervention, and there is no doubt that it was in line with procedures and established approaches, both parents viewed it very negatively. Child K’s mother told the independent reviewer that she would never have considered voluntary involvement with social care after the child protection plan. His father said that the intervention had broken up the family and that the social worker had ‘undermined’ any authority that the parents had in relation to Child K. Transfer to Camden secondary school 2.10. At the beginning of 2016 (school year 8), Child K left the Islington school he had attended since secondary transfer. His mother said she had been unhappy with the school. He had not been permanently excluded but during 2015 he had been given a number of brief, fixed-term exclusions. Child K temporarily transferred to an alternative educational setting and 11 | P a g e then to a secondary school in Camden. The new school received very little information about Child K, except that he had been on a child protection plan and had been ‘aggressive’ in school on a number of occasions. 2.11. The school immediately recognised that Child K had a strong motivation to learn and considerable potential, but also the risk that his inability to contain his anger would harm his education. Over the next two years the school put a number of supports in place. These included: individual and small group teaching and mentoring regular contact with pastoral care workers motivational talks and leadership activities and help with strategies to manage his emotional reactions to events at school. Child K was allocated a sought-after place on a scheme run by a local football club and received good reports from his tutors and mentors. 2.12. A referral was made to Islington Child and Adolescent Mental Health Service (CAMHS) but Child K did not meet their criteria and passed the referral to the Youth Offending Service (YOS). The school believe he had mentoring sessions at the YOS but that organisation has no record of this. It therefore seems unlikely. In January 2017 the school referred Child K to the CAMHS outreach provided to Camden schools. The referral noted that Child K ‘becomes incredibly abusive verbally and his non-verbal body language is intimidating’. His mother’s main concern was ‘his inability to control his aggressive outbursts’. The CAMHS service was provided by the Tavistock and Portman NHS Foundation Trust, a different provider to the Islington CAMHS. 2.13. The CAMHS intervention consisted of an assessment, individual sessions with Child K and joint sessions with his mother, led by an experienced mental health practitioner. The 11 sessions focused on triggers for Child K’s behaviour at home and at school, the reasons for his responses and different ways of handling situations that were causing conflict and violence. Child K participated throughout and everyone involved believed that it had been a positive piece of work. 2.14. During 2017 Child K was involved in a series of violent assaults on school pupils. Child K was often in a leading role and it would be wrong to minimise the seriousness of these incidents. He also had a small number of contacts with the police, none of which were considered serious enough to merit a referral to the local authority. Murders of young people in Camden 2.15. In February 2018 there were a series of connected violent assaults on young people in Camden, resulting in three deaths and other young people being injured. All three young people had associations with Child K’s school and he is believed to have known one of them well. 12 | P a g e 2.16. Although there is no evidence that Child K was directly involved, and he did not feature in police briefings to other agencies at the time, these events had a significant impact on Child K (then aged 15½). In one incident (which the school reported to the police) he reported that he had been approached by a group of men and asked for information about the killings. 2.17. In April 2018 Child K started to attend evening sessions at a youth centre in Camden. He attended about once a month, engaged in lots of activities and caused staff no concern or difficulties. He stopped attending in January 2019, probably because of events in Islington (described below) and started to attend much more often in June 2019. 2.18. From this period his behaviour deteriorated and became marked by more violent episodes, a number of which occurred in and around the school. Positive sides to Child K’s behaviour became less apparent and his aggression increased, with little respect for previously accepted limits. He responded far less well to individual staff members who had previously been able to calm and reason with him. 2.19. Further pressure was added when the school admitted another pupil who had a known history of violence, having made it clear to Camden Council and to the child’s parents that the placement was unwise and risked harming the existing balance of relationships between a number of very difficult pupils in the school. Within a short time there was a violent conflict between Child K and the new pupil. Records show that the new pupil was permanently excluded. 2.20. Following an assault on a girl on a bus that the victim and her family did not want investigated by the police, Child K was referred via Islington MASH to the borough’s Targeted Youth Support (TYS) highlighting concerns that he may be involved with youths with gang associations. TYS contacted Child K and his mother to offer support services with a specific proposal that he would be referred to a charity, the Safer London Foundation for a mentor. Child K declined the offer. His mother was also offered a service. Records say that she declined, saying that she felt supported by the school. Stabbing and permanent exclusion 2.21. In May 2018 Child K was stabbed in Islington. He was admitted to hospital but his injuries were not serious. He gave no information about who was involved or the possible reasons for the attack. Islington social care convened a strategy meeting which resulted in a home visit at which all the family members were seen. Child K had returned to school and the social worker recorded being told that things were calmer at home. 13 | P a g e His previous refusal to work with a mentor was noted. A further social work visit was planned but there is no record that it took place. 2.22. The school stepped up support for Child K, enrolling him in a six week ‘intervention’ run by a former gang member. His mother was referred to a further parenting group, which she told the review was helpful as it directly addressed the problem of gang influence on young people. Another offer of involvement was secured from the football club. 2.23. Child K was involved in further violent incidents in and around the school, leading to the decision to exclude him permanently in early July 2018. His mother approached schools in a neighbouring borough but none was prepared to offer Child K a place. He started to attend the Islington pupil referral unit (PRU) in September 2018 (the beginning of school year 9). Social care and YOS assessment and intervention 2.24. In June 2018 Child K was arrested for committing a robbery. He was sentenced in July 2018 to a 9 month Referral Order, which is a community based penalty for young people who plead guilty to their first offence when appearing at Youth Court. Islington social care ceased its involvement, handing responsibility to the YOS to work with Child K under the order. The requirements placed on Child K were in keeping with the nature of the offence but did not reflect the concerns expressed about possible gang involvement or his previous violence and victimisation. 2.25. Child K largely complied with the requirements of the order. However it had little impact. The ability of the YOS to engage Child K, to judge the effectiveness of the order or to adjust its requirements was hampered by the fact that responsibility for oversight of the order was allocated to four different YOS workers during the first six months, in addition to other workers who were routinely involved in delivering different aspects of the programme. 2.26. In October 2018 Child K went missing for several days, the first time this had been reported. In interviews on his return, he gave no information as to his whereabouts. His YOS case manager referred him to social care but provided no other additional contact or involvement. 2.27. After a further assessment social care closed the case in early November 2018 on the basis that Child K had ‘engaged well’ with YOS and the mother’s parenting was ‘good enough’. There is reference in case records to a behaviour contract, presumably between Child K and his mother, but there is no evidence of its content or any work with the family to implement it. In late November 2018 Child K received a caution for assaulting a police officer and resisting arrest after objecting to a targeted stop and search which had been undertaken because the police had intelligence about a planned fight. 14 | P a g e Further episodes of serious violence 2.28. In January 2019 Child K is believed to have fatally stabbed a young person. This incident is not thought to have been connected to Child K’s stabbing in May 2018, the gang conflict in Camden referred to above, his subsequent stabbing in May 2019 or his murder in August 2019. 2.29. He was identified at a very early point as the most likely suspect and was arrested and questioned about this homicide. However the investigation was complex and the police took a considerable time to build their case. A large number of other young people were interviewed by the police as potential witnesses, or arrested and released under investigation. By August 2019 agreement was reached that Child K should be charged with the murder, but this did not happen before his death. 2.30. Child K was released on police bail for a month, later extended by two months. His bail conditions were specifically designed to keep him in the family home as much as possible in order to reduce the risk of retaliation or further conflict. They included a curfew. Professional concern focused on the risk of retaliation, as Child K had claimed responsibility for the killing on social media and was widely held to have been responsible. The YOS and social care developed a ‘safety plan’ with additional measures. 2.31. Continuing efforts were made to offer him education, though it was judged unsafe for Child K to attend the PRU and he was not motivated by online teaching. Efforts to make long term arrangements continued, taking into account his educational potential and previous enthusiasm to learn. 2.32. In March 2019 a Multi-Agency Risk Panel considered the safety plan and proposals to encourage the family to move. No application for rehousing was made at this point. Discussions continued as to how best to support Child K as YOS involvement would end once the Referral Order expired and there was no allocated social worker. The involvement of a mentor was suggested but at this point Child K continued to refuse help. Second stabbing in Islington and move to Brent 2.33. In early May 2019 Child K was stabbed and very seriously wounded during a confrontation between groups of youths and men in Islington. Again Child K gave no information about the reasons for the attack, telling the police and other professionals that he did not know who was responsible. Subsequent information points to it having been triggered by rivalry between Child K and a group of older, more established gang associates in the area where he lived. Weapons were found near the scene of the altercation. Again it is possible that charges would have been brought against Child K had he not been murdered. 15 | P a g e 2.34. Child K received treatment in adult intensive care for several days before discharging himself. He was a very difficult patient, being aggressive to hospital staff and to his mother when she visited. He refused to accept guidance about his behaviour from health professionals. Despite the gravity of his injuries, he continued to make and receive numerous phone calls from the hospital. 2.35. Hospital staff believe that Child K’s behaviour was due to a combination of his fear and uncertainty about what would now happen and the need to maintain a hard ‘persona’. One member of staff told the review that when not being aggressive, he seemed ‘sad and depressed… like a broken child’. 2.36. On discharge, Islington TYS again proposed the involvement of a mentor who it was hoped would be able to form a relationship with Child K so that he could begin to recognise the level of risk to which he was exposing himself. The mentor began to meet with Child K and became the most important professional contact for Child K and his mother until Child K’s death. The mentor told the review that when allocated responsibility for Child K he had little background knowledge about him or his family and was exclusively focused on protecting him from immediate harm. Islington social care assessed the case within the London child protection procedures and made plans to hold a child protection conference. Discussions about the about the allocation of a social worker began again, at this point both family and professionals believing that it should happen urgently. 2.37. Two weeks after his discharge Child K assaulted a teenage girl (in front of several witnesses). He is also known to have used indecent images to threaten her. This was investigated by the police, who ceased the inquiries when the alleged victim refused to give a statement. Social care managers made representations over this and a more senior police officer told the review that she had asked for the investigation to be reopened at the time of Child K’s death, though no further action had been taken. 2.38. Child K’s mother declined two offers of temporary accommodation (one was too far for her to continue to travel to work and the other was too small for the family) before accepting temporary accommodation in a three-bedroom house in Brent. The urgency with which this was approached meant that she accepted the offer without having the chance to see the accommodation or understand and work through all the practical and financial implications. The family moved at the end of May 2019. After extended discussions, social care case responsibility was transferred to Brent, which allocated Child K as a child in need case for assessment, believing that the level of risk was significantly lower now that Child K was living in Brent. This transfer took place in late June 2019 and Brent began a new social care child and family assessment. 16 | P a g e 2.39. The TYS arranged for a service to be commissioned by Brent from a charity working with young people affected by serious youth violence. A handover visit was made on 1 August 2019. Despite flexible offers of support being made, Child K refused any involvement. Arrests in Camden and Essex, murder of Child K 2.40. Child K’s mother had no effective authority over her son at this point. He continued to visit Camden and Islington regularly and did not hide this from either his Islington TYS worker or his Brent social worker. It is now known that in June and July 2019, after a break of five months, Child K regularly attended a Camden youth centre, more often than he had done during 2018. For as long as the TYS worker remained involved, Child K usually kept his appointments. They made positive agreements to work together, but Child K did not act on his advice. 2.41. In early July 2019 Child K was twice arrested in Camden on suspicion of possession with intent to supply Class A drugs, once in possession of a large amount of counterfeit money. He remained under investigation for these offences at the time of his death. The arresting officer completed a MERLIN (notification to the local authority) that flagged up the risk to Child K of involvement in a gang in Camden that had a history of serious violence. The officer appears to have been well enough informed to have had a specific gang in mind, but did not name it in the MERLIN. 2.42. This was the first event recorded connecting Child K to behaviour putting himself or others at risk in Camden since he had left his school there a year previously. Its significance was not appreciated or investigated further, in part because it had never been part of the professional narrative, developed in Islington and taken on by Brent, that contacts or risks to Child K in Camden would be significant. 2.43. The Brent social worker made two visits to the family in early July 2019, discussing this new information from the police with Child K and his mother on the second occasion. The child in need assessment and there was no subsequent change in the pattern of Child K’s behaviour. The next visit was on 1 August 2019 in order to help the proposed handover from TYS to the charity worker, which proved to be unsuccessful. In the meanwhile the focus of social work was mainly in working with Islington’s housing department to address the difficulties created for Child K’s mother because she was being required to pay rent simultaneously on two properties. The child and family assessment remained unfinished at the time of Child K’s death. 2.44. Although it is believed that he was regularly in Camden and Islington in July 2019, Child K did not come to police attention there again for another month. One professional told the review that Child K’s brother took him there. This would have reduced the risk to him of travelling on public transport, coming into contact with local youths, or being stopped 17 | P a g e by the police. 2.45. In early August 2019 Child K was arrested in Essex. He was reported by witnesses to have been part of a group of four young men who were trying to force entry to the home of a known local drug user. Child K’s specific role in these events is unclear and his associates were not identified or arrested. The police took him to hospital for the treatment of unexplained cuts and the hospital referred him to the local social services. 2.46. Essex Police arrested Child K on suspicion of possession with intent to supply Class A drugs, possession of a large knife and criminal damage. His mother and a solicitor were contacted and after giving a ‘no comment’ interview Child K was released into the care of his mother and helped to return to London. Because of the circumstances the police had no alternative but to release Child K on police bail while further evidence was gathered and analysed. The bail conditions were very limited, aimed to minimise the chances of Child K returning to Essex and committing further offences there. 2.47. Child K’s mother told the Essex police officers that he was well known to services in London. Neither she nor the solicitor raised concerns about Child K being at risk. Essex police did not contact social care about this episode and did not communicate with police colleagues in London until after Child K’s death. 2.48. Two days later Child K was fatally stabbed in Camden, in the locality of the youth club he had regularly attended for many months without incident. The murder is believed to have linked to violent local gang conflicts going back over at least two years. None of the Islington or Brent agencies involved with Child K or his family had ever explored his connections or friendships in Camden or risks that might arise from them. 18 | P a g e 3. EVALUATION OF THE SERVICES PROVIDED AND LEARNING 3.1. Introduction 3.1.1. This section of the report evaluates the impact of the services provided to Child K and his family. The evaluation is thematic and does not focus on specific incidents in chronological order. The aim is to highlight learning about the effectiveness of services that is more widely applicable. 3.1.2. Section 3.2 explores the role of schools in responding to young people who are affected by serious youth violence. The impact of school exclusion is frequently mentioned in both popular and professional discussions of serious youth violence. The review considers in detail the steps taken by the Camden secondary school to respond to Child K’s difficulties and to help him work within the reasonable expectations of a mainstream secondary school. 3.1.3. It also considers the wider role of schools, asking whether schools are sometimes being asked to accept an inappropriate level of responsibility for problems originating outside of the school that other agencies in the multi-agency safeguarding system are not responding to effectively. 3.1.4. Section 3.3 considers the response of agencies (individually and as part of the wider system) to murders and other very serious incidents of youth violence. Particular attention is paid to the impact of complex police investigations on a large number of young people, the time taken to complete enquiries and the working arrangements between agencies with different roles and responsibilities. 3.1.5. Section 3.4 explores the experience of Child K’s family and the approach taken by agencies in his relocation from Islington to Brent, underlining the complexity of these situations for both family and professionals. 3.1.6. Both sections 3.3. and 3.4 question whether current multi-agency child protection procedures offer an adequate framework for the assessment and management of risk in cases of serious youth violence, recognising that – definitely in London and almost certainly elsewhere – local authorities are adopting a number of very different approaches. Agencies that work across London, such as hospitals and the police, adapt case by case. The evidence is that non-compliance with procedures in one of the most risky and complex areas of safeguarding practice has become widespread. 3.1.7. Taking Child K as an example, Section 3.5 considers the ability of agencies to safeguard young people and to protect the public (including other young people) when a young person has become deeply involved in criminal activity, often including county lines drug dealing. This section of the report draws on recent academic research on organised criminal activity and gang violence. 3.1.8. Section 3.6 looks specifically at the identification of young people whose lives are affected by gang involvement and associations, particularly the effectiveness of the Metropolitan Police Service Gangs Violence Matrix 19 | P a g e (GVM). Considering the focus and limitations of the GVM, it asks whether wider multi-agency estimations of risk from gangs need to be considered in order to prioritise services from younger, more vulnerable children. 3.1.9. Section 3.7 discusses briefly the role of three key groups of professionals in working with serious youth violence: Social workers in children’s social care roles Youth Offending Service professionals Youth-oriented workers in targeted youth support services (in both local authorities and charities) It considers the strengths and limitations of approaches taken by staff in each of these services, drawing on Child K’s case history but also referring to other case reviews. 3.1.10. Section 3.8 considers the approach taken to working with parents, including the timing and content of parenting support. Examples of good practice 3.1.11. Inevitably a review of this nature focuses attention on areas in which improvement can be made. As much weight should be given to strengths in practice. The review briefly draws attention to the following: The sustained effort of Child K’s secondary school to draw out his considerable intellectual and personal potential, while seeking to understand and challenging aspects of his behaviour that were self-destructive and harmful to the safety and education of other pupils (this is discussed in more detail in Section 3.2) The clinical medical and psycho-social care provided by the London Ambulance Service and at Imperial Healthcare Trust by the staff in its intensive care unit at St Mary’s Hospital. It should be the cause of great sadness that colleagues in both of these services now have so much expertise in the management of seriously wounded young people. The practice is not discussed further in the review. It is assumed that the practice of this unit draws from and is disseminated among other ICUs and health safeguarding teams. The effort made by Islington TYS to continue to work with Child K and his mother after he had moved out of the borough to Brent 3.2. The position of schools in educating and safeguarding young people who are affected by serious youth violence Introduction 3.2.1. This section of the report considers a range of factors that affect the ability of schools to make the most effective response to the problems of serious youth violence, both in relation to their educational responsibilities and as part of the multi-agency network of agencies with safeguarding responsibilities. It asks whether schools are being asked to shoulder inappropriate responsibilities. 20 | P a g e The permanent exclusion of Child K from the Camden secondary school 3.2.2. Child K joined a Camden secondary school at the beginning of the second term of Year 8. Over the following two and a half years the school went to considerable lengths to develop his positive attributes, to help him reach his educational potential, and to help him deal with the ordinary demands and constraints of school life in a way that was not destructive or violent. These efforts drew continuously on resources from within the school (including mentors, teachers, senior members of staff, the safeguarding lead and the head teacher) and a variety of educational and specialist supports from outside the school, including an intervention from the CAMHS service. The school worked closely with Child K’s mother throughout and involved Child K, making genuine and repeated efforts to find out from him what he thought would help. 3.2.3. The final decision to exclude Child K permanently is one that the school regrets but at the time believed was unavoidable. It came at a point when Child K posed a risk to other pupils (evidenced by a large number of violent incidents) and staff could no longer exert a consistent, meaningful influence over his behaviour. Child K’s mother believes that the school should not have given up on her son and contrasts his behaviour at school unfavourably with his success at the project sponsored by a local football club. The reviewer believes that this comparison is not a fair one. In alternative settings many of the tensions that pupils need to deal with in mainstream school, in college, work and in ordinary life can be minimised. Disruptive behaviour is sometimes tolerated in a way that ordinary schools cannot. They may offer a temporary respite and a platform for reintegration and future progress but none of this is necessarily evidence of the failure of a mainstream school. 3.2.4. Child K’s Camden school has reflected in detail on the way in which it worked with him throughout his time there, as any school should do when it has permanently excluded a pupil. The review does not criticise the approach taken by the school and does not believe there was a viable alternative to its final decision. The school continues to be committed to the inclusion of the most difficult pupils and believes it is better equipped to meet their needs now than it was in 2018.18 It would be irresponsible of any school not to take account of the impact of disruptive and dangerous behaviour on all of its pupils. Not surprisingly the overwhelming majority of pupils support the use of exclusion for serious and repeated violation of school rules.19 18 This is borne out by discussions with school leaders and supported by the most recent Ofsted inspection report 19 HM Government (2019) Timpson Review of School Exclusion, CP 92. Research conducted by Coram cited in the review at Page 23. ‘Children also considered exclusion as the best option when a pupil had ignored repeated warnings from staff and other discipline methods 21 | P a g e 3.2.5. Public discussions about knife crime and serious youth violence often highlight concerns about exclusion, though research has identified a stronger association between weapon carrying and use by young people at the age of 14 and school truancy than with exclusion.20 3.2.6. It is recognised that permanent exclusion may be ‘a trigger point for risk of serious harm’, especially if there is a delay in making good alternative provision. Often it leads to a sense of rejection in the young person and their family and can seem to be a critical step in an irreversible exit from mainstream education. 21 22 Great emphasis is therefore placed on finding a viable alternative educational setting without delay. Child K’s mother approached a number of schools, but none was prepared to offer him a place. Islington Council made this arrangement for Child K, who attended the Islington PRU from the beginning of the next term and engaged well. 3.2.7. Child K’s mother did not want him to attend the PRU, but it was unrealistic to think that any mainstream school would accept him at that point, taking account of his history of violence and deteriorating relationship with teaching staff. It is a great regret that Child K received no education after January 2019, other than online teaching. This was the result of his suspected involvement in violent offending rather than any shortcomings in the PRU. The role of schools in the wider system to combat serious youth violence 3.2.8. Discussions about serious youth violence tend to focus on the role of schools for contributing to the problem by excluding pupils. An exclusive focus on internal school decisions draws attention away from wider factors that affect the ability of schools to work successfully with pupils affected by violence. It is equally important to explore the extent to which schools are currently being required to shoulder an inappropriate level of responsibility for managing the behaviour of young people who are involved in violence, because there is often no effective wider societal response. This is not what multi-agency partnerships would wish to happen, but it is what sometimes happens in practice. 3.2.9. Child K’s history shows how often violent assaults or robberies occur in or around schools, and on children’s journeys to and from school. As with had failed to improve their behaviour. This included “when people are constantly unaffected by regular school sanctions” or “when someone gets constant chances to behave, but continues to disobey” 20 Victoria Smith and Edward Wynne-McHardy (July 2019), An analysis of indicators of serious violence - Findings from the Millennium Cohort Study and the Environmental Risk (E-Risk) Longitudinal Twin Study (Home Office research report 110) page 9 21 Croydon Safeguarding Children Board, Vulnerable Adolescents Thematic Review 22 The Child Safeguarding Practice Review Panel (2020) It was hard to escape - safeguarding children at risk from criminal exploitation, HM Government 22 | P a g e many other reported criminal offences the police are often unable to act because victims are unwilling to name assailants or there is insufficient evidence to pursue a prosecution. More widely the police and other agencies are required to avoid drawing young people into the criminal justice system (termed ‘criminalising’ them) because youth justice research supports the view that early contact with the criminal justice system is associated with poorer long-term outcomes. Consequently youth justice system performance indicators place a value on reducing the number of first-time entrants into the system. 3.2.10. In Child K’s case, and in many instances known to the independent reviewer in other authorities, a violent incident led the school or the police to make a referral for diversionary activities to the YOS or to the local authority.23 If there have been no previous significant violent incidents and there are no explicit safeguarding concerns, such referrals will often be passed to the early help service (either in a family support team, the YOS or a charity) which will offer a voluntary assessment and support package. The more difficult or challenging the young person or his family, the less likely it is that this will be taken up, often leading to case closure. 3.2.11. In practice the problem is then passed back to the school. Schools can provide additional support for the pupil or supervise behaviour more closely (which they may have done anyway) but are left with a limited range of supports and sanctions. If the violence is serious or part of a series of incidents that is badly affecting other pupils, over time the sanctions open to the school inevitably include temporary and then permanent exclusion. The situation is particularly challenging when the school is left to handle conflicts between groups of youths in school, or there is repeated violence in the proximity of the school involving pupils. 3.2.12. Agency responses in these circumstances are being dictated not by the needs of the child but by thresholds for social care assessment and allocation, and the requirement for parental agreement and the young person’s engagement in early help. Child K’s mother challenged the review to explain why in this situation so much weight is given to the young person’s willingness to participate voluntarily. Information sharing with schools 3.2.13. While being asked to share a disproportionate burden in the response to youth violence, schools sometimes lack information about the involvement of their pupils in violent incidents that occur in the community. There is for example no system comparable to the arrangement that exists for 23 See for example Hounslow Safeguarding Children Partnership (2020) Serious Youth Violence Systemic Review 23 | P a g e informing schools when a pupil is present when there is domestic violence in the household. 3.2.14. From their perspective, schools (including PRUs) often have a lot of useful information about young people, both individuals and cohorts of young people. Sometimes schools are very aware of the relationships between children within the school and those outside it. Such information is often not taken on board by agencies that work with young people and their families at the individual case level. School admission criteria and ‘exclusion in all but name’ 3.2.15. The Timpson review of school exclusions documents in detail the way in which pupils are sometimes pressured to leave schools, without recourse to the use of permanent exclusion, a formal and time-consuming process that for a number of reasons both schools and parents sometimes wish to avoid.24 The use of informal processes (managed moves to another school or a PRU, home education or short term moves overseas for pupils whose families have strong links in another country) creates a group of pupils whose educational arrangements are sometimes not being tracked by any school or by the local authority. This can make it very difficult for schools to obtain information about the child’s background and likely needs when considering an admission or planning how best to educate the child. 3.2.16. Many of these factors are borne out by the educational journeys of Child K and that of a second pupil that his school agreed to admit in March 2018. The placement of this pupil proved to be extremely disruptive to Child K. 3.2.17. The Camden school received very little information about Child K when he joined the school in January 2016. In the experience of the independent reviewer this is a concern commonly cited by head teachers in secondary schools and pupil referral units when children have left another school as a result of behaviour problems. Child K’s mother told the review that she was not happy with how he had been getting on at his previous secondary school. It is now known that he had been excluded for short periods, but there was no formal, permanent exclusion. It is not clear whether it would be right to categorise this as what the Timpson enquiry into school exclusions termed ‘exclusion in all but name’. 3.2.18. The term can certainly be applied to the second very challenging pupil that the Camden secondary school agreed to admit in March 2018. His parents had been persuaded to remove him from his first secondary school, avoiding permanent exclusion. He was removed by his parents from a second school to be educated overseas before his permanent exclusion could be considered. He spent some months overseas, though it is unclear what happened to him while he was outside the UK or if he received any 24 HM Government (2019) Timpson Review of School Exclusion, CP 92 (pages 10 – 11) 24 | P a g e education. When his mother applied for a place at Child K’s school, the head received very little other information about this pupil, despite making concerted attempts to obtain it. 3.2.19. The school advised the parent and the local authority that the admission of this pupil risked upsetting ‘the precarious balance’ that it was currently maintaining between a number of pupils. The school could have refused to accept the pupil and made a formal appeal. This is a time-consuming process which the school knew from experience was extremely unlikely to succeed. The pupil was permanently excluded after only a very brief stay. The outcome was that a school that is strongly committed to educating very difficult pupils felt that it had no alternative but to permanently exclude two such pupils within a short period of time. 3.2.20. Child K’s school told the review that the current statutory arrangements for allocating places to children who have behaviour problems work against a school with its approach and philosophy. It has vacancies (because it is popular but not over-subscribed) and it is willing to work hard to integrate children with behaviour problems. Other schools, that are either over-subscribed or have a lower threshold for removing difficult pupils, shoulder less of the responsibility for educating the most challenging pupils. Recommendations 3.2.21. The Timpson enquiry report was published in May 2019 and made a number of recommendations on this, which were largely welcomed by schools and local authorities. There is currently no indication that these will be implemented by government and it must therefore fall to local authorities and schools to consider what practical, local measures should be taken to act on the recommendations, or take other additional steps that are in keeping with them. 3.2.22. The review has been told that all of the local authorities involved have taken action in relation to the findings of the Timpson review. Camden Council should consider whether this has been effective and what further action could be taken in relation to the schools in its area. As there are a considerable number of pupils living in Islington who are being educated in Camden schools the local authorities should consider what joint steps can be taken. Although Child K was not educated in a Brent school, Brent Council should consider the relevance of this finding for its schools. 3.3. The multi-agency response to murders and other serious incidents of youth violence 3.3.1. This section evaluates the response of agencies to fatal stabbings and other major incidents of serious youth violence. It draws on information about the following episodes described in Section 2 of this report: The fatal stabbings in Camden in February 2018 25 | P a g e The stabbing of a young person in Islington in January 2019 and Child K’s subsequent arrest The stabbing of Child K in May 2019 The murder of Child K in August 2019 It also takes account of the experience of the independent reviewer and participating agencies in dealing with other incidents. Each event highlights different issues, but in some instances there was a lack of joined-up responses taking sufficient account of the full range of young people affected by these incidents. 3.3.2. Decisions about whether to move young people or families are considered separately in Section 3.4. 3.3.3. The response to a major incident is likely to affect a large number of young people who may be the victim (or victims), possible witnesses or suspects. Incidents often have unpredictable repercussions. Individuals may be identified on social media (sometimes accurately, sometimes not) as having been arrested or spoken to by the police. Retaliation may be targeted at more vulnerable individuals loosely associated with a suspect, such as family members, girlfriends, school friends and others believed to be linked to a gang or group, whether or not that link is real. The direct impact of police enquiries 3.3.4. Investigations into the murders of young people are a priority for the police. There is an understandable and justified expectation to ensure that they lead to successful prosecutions. The police investigation into the murder in January 2019 (in which Child K was a suspect) was complex and necessarily involved the questioning of a large number of young people, a number of whom were released under investigation.25 It remained open some two years later. 3.3.5. Such delays are often due to the need to interview large numbers of people and to undertake forensic examination of weapons, clothing, drugs, mobile phones and social media in order to determine their evidential value. Officers involved in these investigations told the review that delays could be reduced if resources were available to process this work more quickly. Decision making by the Crown Prosecution Service also often adds to delay because consideration often needs to be given to the legal basis for bringing a range of charges against a number of individuals. 3.3.6. The police major investigation teams (MITs) responsible for such investigations will understandably focus single-mindedly on that crime and may not pay attention to, or even be aware of, safeguarding or welfare 25 Policing and Crime Act 2017. This places strict limits on the length of time for which police bail conditions can be applied but no limit on the length of time for which a person may be released under investigation 26 | P a g e concerns about young people involved. Information about these concerns may be held in a number of police teams and forces as well as in the YOS or social care. Schools may be dealing with very anxious children in any of the categories in Section 3.3.3 above. These episodes highlight the need to promote better coordination between different police teams (for example Major Investigation Teams and police in Basic Command Units with responsibility for child protection, gangs and public protection) and welfare agencies. It would not be right to expect the police to adopt a less effective approach to a criminal investigation, but better liaison may bring benefits to the investigation and to the welfare of the young people affected. There is a sensitivity about releasing information from an uncompleted investigation, but trust between criminal justice and welfare agencies needs to be established, as has happened historically in family child protection cases. 3.3.7. It would be helpful if officers in the major investigation teams were given briefings on the range of safeguarding issues considered in this and other reviews, including the national child safeguarding practice review. As well as ensuring that basic information is shared with the local authority via the MERLIN system, the Metropolitan Police should consider the appointment of a liaison officer from within the investigating team of detectives who will act as point of contact for other agencies who have concerns about the impact on any young person who may have been caught up in the enquiry. Local authorities should agree who will receive and hold any particularly sensitive information and whether it may be shared further. A joint protocol may be necessary. The review makes recommendations on this. Application of child protection procedures in cases of serious youth violence 3.3.8. These serious youth violence incidents reveal wide variation in the way local authorities are implementing (and sometimes not implementing) the pan-London child protection procedures, beginning with the organisation of strategy meetings and child protection investigations, but also later in the process, for example in relation to the thresholds for convening child protection conferences. No one in London would be able to provide an overview of the use of child protection plans for this group of children, or know whether other approaches are more effective. 3.3.9. This was highlighted by the major trauma unit that treated Child K in May 2019. The hospital deals with a number of badly-injured young people who are victims of youth violence and has developed good internal systems. Members of the hospital safeguarding team told the review that different local authorities adopt different approaches to basic safeguarding issues when children are admitted, despite there being an agreed set of procedures that were designed for intra-familial safeguarding. For example, this affects how quickly local authorities send staff to see young people and how strategy meetings are organised. 27 | P a g e 3.3.10. When a child is seriously injured local authorities have the responsibility to decide whether to convene a strategy meeting, make child protection enquiries under Section 47 to establish if a child is at risk of significant harm, and whether to convene child protection conferences.26 Some authorities convene strategy meetings promptly and they are well attended, others delay them and some now hold what are referred to as ‘contextual strategy meetings’ in the local authority office rather than at the hospital. Hospital staff are sometimes unable to attend these, reducing the effectiveness of information sharing.27 Usually agencies with cross-border safeguarding responsibilities (such as police and health providers) follow the local authority process, even if they find differences in approach confusing. This suggests that non-compliance with procedures in one of the highest risk areas of safeguarding activity has become common. 3.3.11. This should be addressed by the London Safeguarding Children Partnership. One way in which this could happen is through update of the London child protection procedures. These currently include practice guidance on safeguarding of children affected by serious youth violence. It is largely educational in nature and does not set clear parameters for multi-agency working.28 3.3.12. The term ‘contextual safeguarding’ is being used in different ways by different local partnerships, varying from an adherence to the particular model developed by the University of Bedfordshire, an approach loosely based on that model but given a specific interpretation by a local partnership, or as a term that is being used as a synonym for ‘extra-familial harm’.29 Both terms have been added to the definition of significant harm in the London child protection procedures (Core procedures - Section 1.3.13) without any indication that the detailed approaches set out in the core procedures may need to be varied. That however is what is widely happening. 3.3.13. Similar questions have been raised in Chapters 11 and 13 of the national child safeguarding practice review.30 That report points to the need for revisions to national guidance in relation to assessments and child 26 Section 47 Children Act 1989, Working Together to Safeguard Children 2018, Chapter 1 sections 43-53 27 See for example, City and Hackney Safeguarding Children Partnership, http://www.chscb.org.uk/case-reviews/ 28 Safeguarding Children affected by Gang Activity / Serious Youth Violence https://www.londoncp.co.uk/chapters/gang_activity.html 29 University of Bedfordshire Contextual Safeguarding, https://csnetwork.org.uk/ 30 The Child Safeguarding Practice Review Panel (2020) It was hard to escape - safeguarding children at risk from criminal exploitation, HM Government 28 | P a g e protection plans, implying that assessments may take more time than is currently normally allowed. 3.3.14. Whether or not there is a need to revisit the application of core child protection procedures and set out a different procedural framework is a matter for the London Children’s Safeguarding Partnership. The review will recommend that the London partnership discusses this as a matter of urgency. Broader coordination of responses at a strategic level by senior police and local authority officers 3.3.15. The first marked deterioration in Child K’s behaviour and emotional wellbeing occurred in the weeks after a series of violent incidents occurred in Camden in 2018. There was a coordinated strategic response to these events, but Child K’s school believed that if it had been more fully involved, it would have been better placed to respond to the needs of Child K and a number of other pupils. Part of the longer-term response to the events was the creation of a task force on youth violence, in which the school played a full part.31 3.3.16. A large number of young people were affected by the January 2019 Islington murder (as described in Section 2.31 above). Although meetings were held to consider the potential impact of the killing on the local community, there was no continuing sharing of information between the police and the local authority about the other children, many of whom were considered vulnerable or were receiving services from the YOS, TYS or social care. 3.3.17. The review will recommend that the Metropolitan Police Service and all three of the local authorities involved with Child K review their recent experience of complex or serious youth violence incidents to consider whether more could be done at a senior level to mitigate the impact of complex investigations into incidents of serious youth violence on the welfare of the large numbers of young people who are sometimes caught up in these investigations (while not jeopardising criminal investigations). 3.4. The relocation of young people and their families Introduction 3.4.1. This section of the report considers the decision to relocate Child K and his family after he had been badly wounded in a knife attack in May 2019. In hindsight it is clear that the move did not reduce the risks to Child K and that it created substantial, practical difficulties for his mother. It is clear 31 Camden Council (2018) Youth Safety Taskforce Report 2018, https://www.camden.gov.uk/youth-safety-taskforce 29 | P a g e from talking to the professionals involved that they were aware of the limitations of what might be achieved by the family moving. In hindsight more time should have been allowed to consider the implications more fully. 3.4.2. The difficulties associated with moving a young person who is at risk of serious youth violence (either alone or with his or her family) have been considered by the recent child safeguarding practice review.32 This further evaluation is designed to add detail to the analysis in that report in the hope that it will assist families and professionals in discussing and making these very difficult decisions in future. This report considers the following: Evaluating the relative risks and practical difficulties of moving a family The impact on professional relationships and working arrangements when a family moves Housing policies and procedures. 3.4.3. The review makes suggestions about the type of assessment that may work best and the arrangements for case transfer that might facilitate this. The focus here is on moving the whole family, rather than individual young people. The latter have been rehearsed extensively and the dangers of moving children into care placements far from their homes are well documented. The review does not consider the steps taken sometimes by families to move children abroad, which is anecdotally becoming more common and merits a separate discussion. Evaluating the relative risks and practical difficulties of moving 3.4.4. Discussions with the professionals involved with Child K confirm that they were aware of the potential negative aspects of the family relocating: as a key social care manager put it, there was ‘nothing in our remit or power that would guarantee to keep (Child K) safe’. However the circumstances in which the decision was taken made it less likely that alternatives would be fully explored. Initially moving was considered as a desirable, but not urgent, long-term plan. Later it came to be seen as a pressing emergency measure in which long-term arrangements were not the primary consideration. 3.4.5. The desirability of Child K and the family moving was first considered in February 2019, when Child K was arrested as a suspect in the murder of a young person. After arrest and interview the police gave Child K bail conditions designed to reduce the time he spent outside the family home, including a curfew. After his release from custody Child K told a YOS worker that he ‘wouldn’t mind (moving) as he doesn’t feel safe’. Encouraged by the YOS and social care, the family agreed to ensure that Child K was not alone 32 Child Safeguarding Practice Review Panel (2020) It was hard to escape - safeguarding children at risk from criminal exploitation, HM Government (page 21) 30 | P a g e away from the family home and he was told to reduce his social media presence. Alternative education arrangements were devised. 3.4.6. During March 2019 the level of concern increased as it was clear that Child K was continuing to claim responsibility for the murder on social media, bringing a high risk of violent retaliation. Records of professional meetings agreed the need to visit the family to help Child K’s mother complete a housing transfer application and for the police to release information to provide evidence of the justification for the move. Housing records do not identify any application from Child K’s mother at this point. Child K’s mother told the review that she received ‘no support’ about being rehoused during this period. Professional records suggest she did not believe that there was a threat and did not see the need to move. The review has not been able to explain these differences in expectations and understanding. 3.4.7. As there were no specific incidents or threats reported, the level of concern on all sides was reduced. Social care briefly closed the case assuming that an application would be made for the family to move out of the borough and that this work would be taken on by the Integrated Gangs Team once the YOS Referral Order had expired. 3.4.8. Everyone’s view changed in early May 2019 when Child K was seriously wounded. There was now a consensus that the family needed to move urgently. TYS staff involved told the review that moving out of the borough ‘was not a solution, but the family wanted it’. The social care team manager told the review that ‘at the time we felt we had to do something, even if the effect might be minimal’. There is no evidence that these reservations were openly discussed at the time. 3.4.9. Child K’s mother made a housing transfer application and Islington’s housing services took steps to identify potential properties. After discussion about two properties, considered by the family to be too small or too far away to enable Child K’s mother to travel to work, the family moved to temporary accommodation in Brent at the end of May 2019. 3.4.10. There is no evidence in these discussions of detailed consideration being given to the possible disadvantages of moving or of the specific additional risks that might come into play once the family had moved, for example the ease with which Child K could travel back to areas in which he might be at risk, or the prevalence of gang activity in the borough to which he was moving. Most professional discussion focused on the arrangements for the transfer of case responsibility between agencies in order to ensure some continuity of contact. Child K’s mother told the review that it would have been better if the family could have moved to short-term hotel accommodation and had time to make better decisions. In general local authorities are discouraged from placing families with children in hotel accommodation, as it is often unsuitable or of poor quality, but in principle this approach will have much to commend it in some cases. 31 | P a g e Case transfer – the impact of moving on professional involvement and relations 3.4.11. While conducting a child protection investigation into the risks arising from the May 2019 stabbing and the wider risks of violence, Islington decided to hold a child protection conference to which professionals from Brent would be invited. This was scheduled to take place in June 2019, roughly two weeks after the family had moved. This would evaluate the type and level of risk in detail, make a child protection plan if that was agreed to be necessary and secure the smooth transfer of the case between the local authorities. Islington’s plan was that it would convene and chair the conference and that Brent would attend the conference and immediately take on responsibility for the work. The management decision on the Islington social care assessment was that the ‘the only way forward is to try and manage his risks to self, others and wider community under a child protection plan’. 3.4.12. The Brent social care team that would have held responsibility for the work after transfer declined to attend the conference, but asked to be informed of the outcome. The specific reasons were not recorded but are likely to have included uncertainty about whether the family’s move to Brent would be a permanent one. This had been a difficulty in some previous, similar cases. 3.4.13. Actions taken by Brent social care staff suggest that they believed that having moved out of Islington the risks to Child K would be substantially reduced. This was reflected in the initial screening carried by the department which considered the risk to Child K as 5/10 while he was living in Brent (a score of one being the highest), consistent with classification as a child in need. Initially Islington challenged the Brent decision not to attend the proposed conference, citing the relevant sections of the London child protection procedures. Subsequently Islington agreed to cancel the conference and instead to transfer the family as a child in need case, in line with Brent’s request. This was now viewed as the quickest way of arranging the transfer of the case since if Child K had been made the subject of a child protection plan without Brent’s involvement, a further ‘transfer in’ conference would have been required, causing several weeks further delay. 3.4.14. After transfer as a child in need, Brent would undertake a reassessment of Child K’s needs and any risks. Instead of all the involved professionals meeting at a child protection conference, separate transfer processes were arranged, including a joint meeting between social workers and a joint meeting between the TYS worker and a worker from a voluntary organisation commissioned by Brent with whom Child K refused to work. 3.4.15. A Brent social worker was allocated who made visits to Child K and his mother and an assessment continued for some weeks. The social worker discussed the continuing risks to Child K, being aware that he continued to 32 | P a g e travel into Islington and Camden, but the main focus of the social worker’s activity was the practical and financial difficulties that the housing move had created for Child K’s mother. Child K’s mother was understandably frustrated, seeing the further assessment as a waste of time when no additional services were being provided. The national experience of moving young people and their families 3.4.16. The difficulties associated with moving a young person who is at risk of serious youth violence (either alone or with his or her family) were considered by the recent government child safeguarding practice review.33 The national report considered information about 21 young people who had been killed or seriously wounded, eight of whom had been moved (six with other family members, two to local authority care placements). The review also studied a comparator group of children who had not been killed or seriously wounded. A similar number of the young people in both groups had also been moved to new homes, suggesting that the need to consider moving young people or their family is not uncommon. 3.4.17. The national review identifies a number of potential negative features of such moves, however well-organised. Although the intention in moving a young person is to break links with criminal associates or those who have threatened violence, communication between the young person and associates in the original location often remains easy and there will often be factors strongly pulling the young person back to their home area. Young people may become involved in criminal activity in the new area, for example dealing drugs to provide a basic income, which may prompt conflict with local groups. One recent study identified young people relocated from cities as one of the models used by criminal gangs in the establishment of new county lines.34 There is no evidence that Child K made any local criminal connections or came into conflict with local young people. He remained in close contact with young people from Islington and Camden, as he had always said he would. According to one professional he was taken there regularly by his brother. 3.4.18. The national study also identifies the risk of placing new strains on the family, and weakening or breaking links between the family and the existing professional network. The professional network around Child K was weakened in a number of ways, the clearest indication of this being the widely differing perceptions of risk after the move. In Islington there was a clear understanding that Child K was the suspect in a murder investigation and had been stabbed twice. Consequently he would have been the subject 33 The Child Safeguarding Practice Review Panel (2020) It was hard to escape - safeguarding children at risk from criminal exploitation, HM Government 34 Simon Harding (2020) County Lines: Exploitation and Drug Dealing among Urban street Gangs, Bristol University Press 33 | P a g e of a child protection conference and legal advice had been taken to explore whether there were legal steps that could have been taken to protect him. In Brent these issues were much less immediate. The screening score and the time taken to update the social care assessment indicate that the risks were believed to have been made considerably less significant by the move. 3.4.19. In Islington faith had been placed in the Islington TYS sessional worker allocated after Child K was stabbed. Despite making considerable efforts, he had never been able to establish the level of contact with Child K that had been planned. After May 2019 he had been the main and most regular contact with Child K and his mother, but his involvement came to an end because Islington TYS could not fund work with a young person living outside the borough for more than a short period of time. After the family moved the contacts with the TYS worker were infrequent and he had no significant influence over Child K’s behaviour. Transfer to a similar service based in Brent failed because, after an initial meeting, Child K refused to have contact with the new organisation. 3.4.20. After Child K’s move to Brent some police contacts continued to be routed via the Basic Command Unit covering Camden and Islington, causing delay in information sharing. Child K had been well known to the police in Islington but police teams in Brent do not seem to have had an awareness of his presence. His arrests in July 2019 triggered no specific action by the police in Brent or multi-agency consideration. The links to Camden presented an additional difficulty, though in this case they would also have been easier to handle from Islington because of the shared police BCU. 3.4.21. The national child safeguarding practice review advocates the relocation of young people and their families as an effective short-term strategy, ‘providing an immediate reduction in risk and a breathing space’. It suggests that this can only be successful as ‘part of a clear and consistent strategy for protecting and supporting that child’.35 The emphasis on the use of relocation as a ‘breathing space’ suggests that attempts should be made to keep the professional network in place and that professionals who know the family should continue to be responsible for developing the long-term plan during this period. The ability of different agencies to do this will vary as they have different rules and guidance governing the retention of cases. Further difficulty may arise because this approach does not sit entirely comfortably with the requirement for the local authority in which the child is found or usually lives to take statutory action under the Children Act 1989. 3.4.22. This is an area that would benefit from agreed approaches at least between London authorities. The review has made a recommendation on this. 35 Page 21 34 | P a g e Housing 3.4.23. The national child safeguarding practice review also reports the views of practitioners that ‘housing policies should be amended to include children at risk of criminal exploitation as a high priority group for rehousing or transfer’. There are inherent difficulties for local authorities. They can support applications for mutual exchange or transfer, but are unlikely to be able to arrange a housing transfer sufficiently far from the original location to achieve the objectives of the move. 3.4.24. Islington identified short term accommodation for the family but Child K’s mother was placed under considerable financial stress because, until an agreement for exceptional payment was reached with Islington Council, she remained responsible for paying the rent on two properties, or risked having to give up her original tenancy. The review has been told that this exceptional payment can only legally be made for a limited period and that, regardless of the intention of local policy to help families affected by serious violence, there are considerable practical difficulties in relocating a family without jeopardising their potential right to permanent housing. 3.4.25. The position of Child K’s mother was unusual in that she had a reasonably high, stable income and received no housing benefit. Other families will be affected in different ways; but every family should understand exactly what its financial position will be when making decisions about whether or not to move. In genuine emergencies accommodation could be provided for a period of no more than a few weeks, while longer term plans can be developed. Learning and recommendations 3.4.26. There is a growing recognition, shared by all the professionals who have contributed to this review, that relocating families because of the risk of serious youth violence is not always the best solution. 3.4.27. This being the case, an approach is needed that takes account of the relative and specific risks of a family moving or not moving, both in principle and in relation to specific locality. This should include the topics identified in this report and other case reviews, as well as the national child safeguarding practice review: Likelihood that the young person’s behaviour does not change because their most important social connections will remain in place Risks in the locality to which the child is moving Risks of weakening professional networks so that there is less professional knowledge and oversight Practical difficulties (including financial difficulties) created for other family members. 35 | P a g e It may not always be possible to be certain whether relocation is an emergency short-term measure (managed by the existing professional network) or part of a worked out long-term plan. 3.4.28. At the time professionals had no framework for undertaking the comparative assessment of risk in two localities. This may be a feature of the fact that safeguarding professionals dealing with families usually assess current risk and propose solutions that are assumed to be better. There is less experience of risk-assessing alternative plans. 3.4.29. Assessment of risk in these cases must be the assessment of risk in context and as such is very different from the assessment of clinical or medical risk (which is unlikely to vary greatly from one locality to another). This points to the value of professionals from two localities being involved simultaneously: those from the original location being fully aware of the history and the reasons for risk; those from the proposed relocation locality able to complement this assessment with their own local knowledge of the environment in which the child will be living, local criminal activity, school cultures and strengths etc. 3.4.30. Part of the more structured approach to assessing both sets of risks would be to understand the extent to which the young person and his family would accept and implement any measures. Efforts to reduce risks to Child K over several months had failed, in part due to his inability to change his behaviour. In this type of assessment that factor would strongly indicate against a plan that relied in a high level of cooperation. 3.4.31. The nature of the risk that exists when a young person is involved in youth violence severely tests the models of case handover and transfer that have been applied to intra-familial child protection work, favouring as they do transfer of cases at a specific point in time supported by written summaries of the history, sharing of records and a one-off transfer meeting. It is also not best resolved through the model, adopted in this case, of reassessment by the new professionals. This risks ‘starting again’ and losing sight of the seriousness of the original issues and risks delaying provision. 3.4.32. If part of the problem is that a young person will continue to return to their home locality, it suggests the need for some professionals in that area to continue to be involved for a longer period of time, even if case responsibility in some agencies sits elsewhere. It was always likely that Child K would continue to spend time in Islington (and as it turned out Camden) and that regardless of the move, steps would need to continue to be taken to safeguard him there. This was inevitably going to be much more difficult for professionals based in another borough to arrange. In this case for example Brent Council might have agreed to continue to fund the Islington TYS worker and to concentrate on meeting Child K in Islington or Camden, given that it was known that he would continue to go there. A framework is needed within which a flexible transfer can happen at different 36 | P a g e points in different agencies but within which there is still clear accountability. 3.4.33. The review makes recommendations on these issues 3.5. The disparity between risk, the professional understanding of risk and action that could be taken to protect the young person and the public 3.5.1. This section of the report compares the evidence of risk to Child K during the last 12 months of his life with the action that professionals took to safeguard him and to protect the public. It considers both the actions possible within the criminal justice system and under children’s safeguarding arrangements. Information from the narrative 3.5.2. It is useful to summarise the key events. In June 2018 Child K committed a robbery and was sentenced to a nine month Referral Order. Although external inspectors have found Islington YOS assessments to be ‘generally good’, the assessment made in this case failed to take account of the depth of Child K’s difficulties and possible gang influence on his life. This was because it took insufficient account of associations in Camden that had developed over time as he had attended a Camden secondary school. This gap in the assessment was never subsequently recognised or addressed. 3.5.3. In late 2018 the order was extended by three months because Child K was convicted of assaulting a police officer; however but no changes were made to the requirements of the order 3.5.4. Records show that Child K complied with the terms of the order but the likelihood that he would benefit from the activity or develop links with adults who might positively influence his behaviour was reduced because over the period of the order four different YOS case workers were allocated responsibility for the work with him. 3.5.5. Until January 2019 Child K attended and worked well at the pupil referral unit (PRU), though his reported interactions with others in the vicinity of the PRU point to tensions between groups of young people. 3.5.6. In late January 2019 Child K was suspected to have murdered a young person. He was questioned and released on police bail with conditions designed to protect him from reprisals and to restrict his contact with other young people. These were extended for a further two months, the maximum allowed without a charge being brought. He was then released under investigation as charges were not ready to be brought.36 The murder 36 https://www.cps.gov.uk/legal-guidance/bail 37 | P a g e investigation continued and it is understood that Child K would have been charged with the murder had he not been killed. 3.5.7. Within days of the bail conditions expiring, Child K was stabbed and admitted to hospital with very serious wounds. There is no known connection between the January and May 2019 events, though it is likely that the ending of his bail conditions reduced pressure on Child K to comply with requests to stay at home. The circumstances of this incident remain unclear and a number of weapons were found near the scene of the incident, suggesting an armed affray. The incident remained the subject of a criminal investigation at the time of Child K’s death. 3.5.8. Shortly after his release from hospital Child K physically assaulted a young woman and threatened to blackmail her with indecent images. Initially the police investigation was dropped due to lack of cooperation from the alleged victim, though a more senior officer told the review that she had asked for it to be re-opened following an approach from social care and given the gravity of the alleged events. 3.5.9. At the end of May 2019 Child K moved to Brent and from that point appears to have spent increasing amounts of time in Camden, avoiding the area in Islington where he had been stabbed. 3.5.10. In early July 2019 Child K was twice arrested for possession of drugs with intent to supply and the possession of counterfeit money in Camden. Again he was released under investigation. The police MERLIN noted that he was associating in Camden with known gang members who had a recent history of involvement in serious violence. The Brent social worker discussed this with the family and no other action was taken. Child K continued to travel to Camden but did not come to police attention in London again until his death. 3.5.11. In early August 2019 Essex Police arrested Child K for possession of a knife and for possession of drugs with intent to supply. Along with other youths he was suspected of attempting to break into the home of a known local drug user. The details of his involvement and relationship to the other youths or the drug user were never established and the investigation was closed when Child K was murdered. The circumstances bear the hallmarks of ‘county line’ criminal activity. Child K received minor injuries, though it was never clear how. The hospital emergency department referred him to the local authority emergency duty team, which noted the information. 3.5.12. Child K was released while enquiries were undertaken to establish if there was a forensic connection between Child K, the knife and the drugs. He was given bail conditions to ‘live and sleep in London’ and ‘not to enter the county of Essex’, the focus being on reducing the risk of further local offences rather than his general welfare. Prior to his release he denied being threatened or coerced in any way. When asked Child K, his mother and his solicitor raised no concerns about his welfare. Child K and his mother were 38 | P a g e escorted to a station and put on a train to London. Neither his role in these events, nor the nature of his link with the other young people, was ever clear. 3.5.13. He was murdered shortly after this, a killing that was part of a continuing feud between gangs, one of which Child K was believed to be linked with, though the nature of that association is unclear. Learning and recommendations Situating Child K’s behaviour in our current understanding of gang activity and organised criminal behaviour 3.5.14. Child K’s behaviour put him at a high level of risk over this period. By the time of his death it is believed that he had been in conflict with: Youths from a gang in another part of Islington (because of the murder and his assault on a girl) Older Islington gang members from a locality near to his own neighbourhood Members of a gang in Camden who were in long term conflict with associates of Child K. Any of these might have posed a serious threat. 3.5.15. As well as being a risk to himself, Child K posed a substantial risk to other young people and the wider public: He was suspected to have been responsible for a murder and involved in an armed affray He had assaulted and threatened a teenage girl He was suspected to have been involved in dealing drugs in London (and possibly Essex) and laundering counterfeit currency. 3.5.16. Discussions about the risk to young people often focus on the formal identification of gang involvement. However this may not be the sole or main determinant of risk. The way in which Child K would be viewed and treated by others depended on his reputation: what other young people believed he had done, or he could credibly claim to have done, and who his associates were believed to be. Research suggests that a rapid and serious acceleration in violent behaviour in some individuals is increasingly common and is a feature of the dramatic changes in drug markets and urban street gangs associated with the growth of county line drug dealing.37 3.5.17. In the past drug trading based on estates and defined localities gave rise to conflicts over market share and prestige that could be violent but were also usually self-limiting. In contrast, the rapid expansion of county lines drug dealing has created intense competition between groups and individuals to maximise markets and profits. Child criminal exploitation is a feature of this 37 See for example the description in Simon Harding (2020) County Lines: Exploitation and Drug Dealing among Urban street Gangs, Bristol University Press. 39 | P a g e activity, but there are also significant opportunities for young people who are prepared to be ruthless to operate across a number of groups and localities, with much more fluid loyalties to associates, sometimes seeking to outmanoeuvre more established older criminals. The short-term rewards in terms of money and standing can be substantial but the risks are extremely high. 3.5.18. These new patterns of criminality are a challenge both to the criminal justice system and to the ability of agencies to use safeguarding measures to protect young people who are considered vulnerable. We do not know what factors were motivating Child K, but there was a significant disparity between the risk posed by his behaviour and the response, particularly after he moved to Brent. Response possible within safeguarding procedures and approaches 3.5.19. While he lived in Islington, after each major episode professionals took steps to establish what had happened and to understand the risk, including a discussion of Child K at the borough’s High Risk Vulnerability Panel, strategy meetings, a proposed child protection conference and a legal planning meeting. 3.5.20. These efforts were not successful. For the reasons described in Section 3.4 the child protection conference did not take place. A legal planning meeting was held but could not identify steps within the family law that could protect Child K. The civil law framework includes measures that allow young people to be protected from adult exploitation or the consequences of their own behaviour (for example Secure Accommodation Orders, other types of abduction or retrieval orders) but they are often not relevant because they were not designed with this type of situation in mind. 3.5.21. After he moved to Brent, the risks described above (Section 3.5.14-15) were believed to have been mitigated by the family moving home. The child and family assessment that began in June 2019 was to be completed within the statutory timescale (35 working days) so it was not finished by the time of Child K’s death in August 2019. It may not have provided a more detailed understanding of Child K’s long-term risk level, or any additional plans to address it. At the time of his death Child K was receiving services as a child in need and the family were receiving periodic visits from a social worker. Despite new recent concerns and outstanding historical events, the support provided focused mainly on the financial problems caused to his mother by the relocation of the family, rather than on Child K’s safety. Responses possible within the criminal law 3.5.22. When a young person has been arrested because of suspicion that he has committed a crime (even a very serious, violent crime) the legal framework leans heavily towards release of the person under investigation (RUI) pending completion of the investigation and determination by the police or 40 | P a g e the Crown Prosecution Service as to whether or not there is sufficient evidence to bring charges. Bail may still be granted even when serious charges are brought. In Child K’s case, none of the other investigations merited his detention, even though the number of serious, alleged offences under investigation was large and growing. Child K’s mother expressed her frustration to the review that it had taken so long for these suspected offences to be investigated and that in the meanwhile he remained living in the community with few (and sometimes no) measures that restricted his liberty or helped her to keep him safe. 3.5.23. Action by the police in relation to Child K was determined by the length of time taken to complete complex investigations and the requirement (beyond brief periods when it is possible to impose bail conditions) to release suspects under investigation. The police officers involved in investigating the January 2019 murder were focused exclusively on that case and had no specific additional interest in Child K’s further alleged offences, except insofar as they might provide evidence in relation to the murder. Steps taken by them were dictated by the needs of their investigation and not influenced by the overall level of risk to any individual child. Had he been charged with the murder (which seems to have been very likely) Child K is likely to have been remanded in custody.38 3.5.24. The Essex police officers who arrested Child K were aware that the circumstances pointed to a possible county lines drug-selling operation and of the steps that can be taken under the National Referral Mechanism (NRM) to collate information about young people who are vulnerable to criminal exploitation.39 The police officers had dealt with similar cases before and understood the pattern of risks. To demonstrate that such risks were present on this occasion would have taken considerable further multi-agency information gathering, which was not triggered by the episode. 3.5.25. Essex Police recognises that there were shortcomings in the action taken. 38 The number of young people who are remanded in custody by the courts has fallen by more than half in the last decade from 5,663 to 2,370 between 2007/08 and 2017/18 (58%) Manon Roberts, Gemma Buckland and Harvey Redgrave (November 2019) Examining the youth justice system: What drove the falls in first time entrants and custody, and what should we do as a result?’, Crest Advisory (page 27). In the introduction to Examining the youth justice system Anne Longfield, the Children’s Commissioner writes that she has ‘serious concerns about the number and treatment of children on custodial remand, 63 per cent of whom were not subsequently given a custodial sentence last year’. (page 5). There is determined pressure on the part of policy advocates, researchers and academics to further substantially reduce or end altogether the use of custody for young people in almost all circumstances. See for example Tim Bateman (2020) The state of youth justice 2020 - An overview of trends and developments, National Association for Youth Justice (Chapter 8). 39 The National Referral Mechanism allows those who are identified as victims of criminal exploitation (for example). Information about the NRM is available at: https://www.gov.uk/government/publications/humantrafficking-victims-referral-and-assessment-forms/guidance-on-the-national-referral-mechanism-for-potential-adult-victims-of-modern-slaveryengland-and-wales 41 | P a g e Sole reliance should not have been placed on reassurance from Child K and his mother that he was not acting under duress. Direct contact should have been made with social care services in Child K’s home borough, though it is very unlikely that any alternative action would have been taken before Child K’s death which occurred only days after the episode. 3.5.26. The recent review of the death of another child highlighted a similar response from a county police force.40 This suggests that there is a need for greater awareness of the steps that can be taken under the NRM, and of the Rescue and Response system that has been commissioned by the Mayor of London. 3.5.27. There is also a need for a more thorough review of this legal device. Harding’s research, citing National Crime Agency reports, is positive about the legislation. He reports police officers being keen to bring prosecutions for trafficking offences but realistic about the extent of evidence required. The child safeguarding practice review found that ‘the NRM’s original purpose does not always fit well with the circumstances of (criminally exploited) children and that understanding and use of the NRM was patchy’.41 Some police officers are sceptical about the widespread application of the NRM, believing that organised criminals understand the legislation and will organise their activities in a way that creates a class of young people who are immune to criminal investigation and sanctions and therefore even more vulnerable to exploitation. This is arguably only an extension of the factors that encouraged wide exploitation of young people in recent years because there is a large supply of young people available to involve in criminal activity who professionals seek to avoid bringing within the criminal justice system. There are other ways in which designation under the NRM can make young people more vulnerable, for example when the removal of a tag to enforce a curfew means that children cannot be traced and go missing more often. 3.5.28. No additional recommendation is made in relation to this, as both the national child safeguarding practice review and the Waltham Forest review of the death of Child C have already made recommendations on this issue. The case review assumes that the Mayor of London actively promotes information about the existence of the London Rescue and Response system with police forces outside London. The Metropolitan Police Service has introduced Operation Harbinger which provides for the rapid sharing of information about all children in custody. 40 Waltham Forest Safeguarding Children Board (May 2020) Serious Case Review - Child C, a 14 year old boy 41 Child Practice Safeguarding Review (op cit) page 9, discussed in more details at page 48 42 | P a g e The gap between public expectations and the approaches favoured by professionals 3.5.29. As well as highlighting gaps and weaknesses in the current criminal and civil legal frameworks, Child K’s history highlights gaps between public perceptions (including those of many parents) about what professionals should be able to do, what professionals are able to do, and what professionals and policy makers think should happen. Given the number of serious incidents in which Child K had been involved, members of the public might be surprised or disappointed that the police were not able to detain him and that local authorities were unable to safeguard him, especially as throughout the last 9 months of his life Child K was at risk of harm, his own behaviour put him in harm’s way and he posed a risk to the wider public, including to other young people. He had consistently refused any offer of help and, to his mother’s frustration, no effective restriction could be imposed on his movement or behaviour. 3.5.30. The wider context of this discussion is set out in Section 1 of this report: The growth in knife and offensive weapon crimes being committed by young people in the last five years The historically large numbers of young people who have been killed or seriously injured by other young people In addition, in London at least, black children and children from some minority ethnic backgrounds appear to be heavily over-represented among victims of knife crime.42 To this can be added recent evidence about dramatic differences in homicide victimisation rates for different ethnic groups, especially young people. 43 3.5.31. Professionals also find the lack of effective powers extremely frustrating, adding to the sense of hopelessness that some already experience. At the same time, those who seek to influence the direction of policy in relation to serious youth violence focus almost exclusively on the need for more therapeutic and preventative responses to serious youth violence, focusing on young people’s experience as victims. Youth Offending Services, youth and crown courts operate within a framework that strongly discourages the use of custody, either for remand or sentencing, as is evidenced by the 42 Young black people and those of mixed backgrounds are significantly over-represented among victims of all crime. See Youth Justice Board presentation (August 2020), ‘Exploring racial disparity - How it affects children in their early years and within the youth justice system’, https://www.gov.uk/government/news/to-end-racial-disparity-we-require-your-absolute-focus 43 S Kumar et al, (2020) ‘Racial Disparities in Homicide Victimisation Rates: How to Improve Transparency by the Office of National Statistics in England and Wales, Cambridge Journal of Evidence-Based Policing, https://doi.org/10.1007/s41887-020-00055-y In the most extreme example, for young people aged 16 to 24, the 2018-19 homicide rate was 24 times higher for black people than for white people. 43 | P a g e steep decline in the numbers of young people in youth custody in the last decade.44 3.5.32. Inconveniently, preventive services aimed at reducing risk factors associated with serious youth violence can only be successful in the medium to long term and there are already some young people who are beyond their reach. These young people are likely to be placing themselves at the most serious risk and causing the greatest harm to others (including to the most vulnerable young people). At the very least professionals need to be prepared to engage in an open-minded discussion with the wider public about the validity of current thinking and approaches. 3.6. Systems for identifying young people who are at risk because of gangs or serious criminality 3.6.1. This section of the report explores the way in which professionals make use of information about the influence of gangs or organised criminal groups on young people and how the impact of these is understood, taking the information that was known about Child K as an example. 3.6.2. There is continuing debate about whether it is useful to focus on the role of gangs. Some pundits and academics oppose this, almost as an article of faith, believing that it distracts from efforts to address the vulnerability of young people and illegitimately labels young black men. They argue that only a small percentage of knife crime is attributable to gangs and see the focus on gangs as a form of ‘moral panic’. Others point to the evidence of young people themselves, significant academic research, high levels of retaliatory violence as well as social and cultural indicators of gang allegiance such as social media posts. 3.6.3. Any discussion about the significance of gangs and criminal groups must be prefaced by a recognition that professionals often do not have reliable information about gang involvement or influence because these matters are, by their nature, secretive and are discussed in terms that adults (including professionals) often struggle to understand. Research suggests that gang and organised criminal activity are rapidly changing. In some circumstances, beliefs about a person’s criminal involvement and status are critical (particularly for other young people) but may not accurately reflect actual membership of a criminal group. 3.6.4. Using the broadest criteria, gang or organised criminal influences on Child K’s life might have been identified at the following points: 44 Gemma Buckland and Harvey Redgrave (November 2019) Examining the youth justice system: What drove the falls in first time entrants and custody, and what should we do as a result?’, Crest Advisory 44 | P a g e • February 2018 – events in Camden linked to killings were believed to be impacting on his life, behaviour and education • May 2018 – victim of a stabbing in Islington, which is unlikely to have been a random event • January 2019 - suspected murder of an associate of an Islington gang, although the trigger is believed to have been personal rather than linked to gang associations • May 2019 – victim of a second stabbing in Islington • Reported assault on young woman who had associations with a rival gang • Involvement in county lines type criminal activity in Essex. The Metropolitan Police Gangs Violence Matrix (GVM) 3.6.5. Given the circumstances of his death and knowledge of some of the events listed above, some professionals were surprised to hear that Child K had not been identified by the police as what is termed a ‘gang nominal’. This is a result of the specific approach taken by the Metropolitan Police Service to the identification of gang members and associations, and the role of the Gangs Violence Matrix (GVM). 3.6.6. The GVM has a controversial history and has been modified after criticism of its failure to identify and include older, established gang members alongside the disproportionate inclusion of young people from black and some minority ethnic backgrounds.45 It was also not clear to the public how names were added or removed and whether consistent criteria applied across London. 3.6.7. The police have responded to this criticism by making public much more information about the purpose of the GVM and the criteria for inclusion.46 The police told the review that the purpose of the GVM is ‘to reduce gang-related violence, safeguard those exploited or used by gangs and prevent young lives being lost’. It aims to achieve this by identifying ‘the most violent gang members who need enforcement action against them and gang members who have been repeat victims of violence and therefore need support to safeguard them from being further victims and to divert them away from gangs’.47 45 Amnesty, ‘Trapped in the gangs matrix’ https://www.amnesty.org.uk/trapped-gangs-matrix?utm_source=google&utm_medium=grant&utm_campaign=AWA_HRUK_gangs-matrix&utm_content=%2Bgang%20%2Bmatrix 46 This and substantial amounts of other information can be found at https://www.met.police.uk/police-forces/metropolitan-police/areas/about-us/about-the-met/gangs-violence-matrix/ Information about the breakdown of people on the GVM is now regularly updated by borough. 47 Submission to the review from the Metropolitan Police Service 45 | P a g e 3.6.8. In order to achieve consistency and greater reliability the police only include a person’s name on the matrix when there are two pieces of verifiable intelligence to confirm membership of a known gang. The individual is then further assessed according to information about known use of violence and weapons, suspicion of involvement in crime and experiences as a victim of violence. The GVM is then used to target police activity at the most serious offenders and the most vulnerable victims. As a result, incidents involving young people who are on the GVM will automatically be checked. In some boroughs the police work as part of a multi-disciplinary gangs team so the review will involve members of the team from other agencies such as youth workers and social workers. 3.6.9. It is understandable that the MPS is required to use strict criteria that can be verified, can be applied consistently and focus on those who pose or are at the highest level of risk. At the same time this will not collate softer information (such as the examples set out in 3.6.4 above) which may build a cumulative picture of organised criminal influence on a vulnerable young person. According to the research supporting the child safeguarding practice review, for example, ‘police services do not use a vulnerability flag for child criminal exploitation, meaning that children who are arrested for possession with intent to supply class A drugs may not be treated as vulnerable’.48 3.6.10. This prevents the inclusion of many young people whose lives have been affected by organised criminal gangs, or perhaps have looser or more fluid affiliations, but do not meet the criteria. One effect of this is that when lists of the names of children considered to be vulnerable, based on police records, are searched, they are likely to focus on those on the GVM, rather than the larger number of young people who (while not having a proven association with an identified gang) may still be heavily influenced or affected by violent criminality. In some instances this will lead professionals to miss the involvement of young people in events that have taken place outside the child’s home borough. 3.6.11. Some local authorities have already developed their own list of children about whom there are welfare concerns because of suspected gang influence to complement the GVM. If such a list were developed the inclusion of the child’s name, details of information held and who has access to it should be known to the young person and his or her parents. The reasons for inclusion of a name might provide a useful focus for frank discussion about behaviour and risks. The review makes a recommendation in relation to this. 48 N Maxwell et al (October 2019) A systematic map and synthesis review of Child Criminal Exploitation, Cardiff University 46 | P a g e 3.6.12. More broadly, much of the discussion about the GVM and other such lists has focused on their disadvantages and negative effects. If it is to have any positive impact for the young person or assist professionals, inclusion as a ‘gang nominal’ or on a vulnerability list or matrix should attract specific additional resources from agencies. 3.7. The role of social care professionals, Youth Offending Services and youth-oriented services 3.7.1. This section highlights areas of potential learning for social care professionals, Youth Offending Services and youth-oriented services (such as targeted youth support services). The evaluation takes account of the author’s experience of conducting reviews in other local authority areas. In particular the findings have a substantial overlap with a review commissioned by Islington Safeguarding Children Board.49 3.7.2. Although these comments are organised by service, senior managers and leaders need to consider the way in which the three types of service respond together as a system to problems of serious youth violence, including the allocation of responsibility for work with young people between services and the way in which services coordinate their activity when more than one is involved. Social care 3.7.3. Child K received an assessment or service from local authority social workers during the following periods: 2015 – 2016 – under a child protection plan focused on dealing with physical abuse by his father May 2018 – Child K’s school made referral to the MASH, which was screened and passed to TYS and then closed because neither Child K nor his mother wanted to receive a service May 2018 - following an incident in which Child K was stabbed – a child and family social work assessment was undertaken and it was proposed to hand responsibility for work to be undertaken by the YOS which was beginning to work with Child K under the terms of a Referral Order January 2019 – following the incident in which Child K was suspected to have killed another young person –strategy meetings were held and the case was closed in March 2019 as the risk to Child K was believed to have diminished May 2019 – following the incident in which Child K was stabbed and very severely injured, strategy meetings were held and a child protection 49 Islington Safeguarding Children Board (2021) Services Provided for Child P and his family (forthcoming) 47 | P a g e conference was scheduled, a legal planning meeting was held, the family was encouraged to move and the case was transferred to Brent July – August 2019 – Child K was allocated as a child in need in Brent following transfer from Islington, the main focus of work was the financial difficulties created for the mother by the housing move. 3.7.4. After the most serious incidents (January and May 2019) social workers and their managers worked diligently to find ways to safeguard Child K. The key Islington social care manager told the review that Child K was ‘the case with the highest profile, over and above all others in the team’. But at the same time there was ‘nothing in our remit or power that would guarantee to keep (Child K) safe’. The decision to hold a legal planning meeting to ensure that every possible action had been considered on a case that was going to be transferred to another local authority, demonstrates this commitment. 3.7.5. At other points social workers struggled to know what to do. The pattern of brief assessment followed by referral to early help services, followed by case closure has been frequently observed by the author in work where the risk to young people arises because of serious youth violence. When a specific practical or procedural task has to be accomplished (such as moving a family, holding a strategy meeting or placing a child in accommodation) there is an obvious task for the social worker. Otherwise local authority social workers frequently say that they find it hard to define their role or to point to stories of successful interventions. Some believe that their training and skills are less relevant and that they have nothing to add to the work being undertaken by youth workers, relying on them and in some instances closing cases when high levels of risk remain. This is a reversal of the normal approach which allocates responsibility for lower risk cases to staff and managers without social work qualifications. 3.7.6. There may be genuine, practical reasons for this difficulty in finding a role. Social workers who have substantial and complex caseloads often spend considerable time in court or writing reports and inevitably have less time for direct work with young people. Sometimes the YOS is required to be involved, leading social workers to close cases because their participation can seem to be an unnecessary duplication. However there may be deeper reasons. Difficulties may also arise because there now is a tension between currently-favoured ways of working with young people and the fact that social workers and their managers who have roles, responsibilities and statutory duties requiring them to hold and exercise authority on behalf of the state and the wider community. 3.7.7. Relationships that acknowledge this authority recognise that one party has a status based on accumulated knowledge, greater life experience, a greater understanding of the consequences of young people’s actions, and also holds statutory powers and duties. In contrast contemporary approaches now often strongly emphasise engaging with young people and pay little attention to the ownership and use of authority, despite this being 48 | P a g e an ordinary and important part of relations between adults (including parents) and young people. For example, a highly influential report on working with adolescents focuses heavily on engagement, using the terms ‘engage’ or ‘engagement’ 43 times, almost always positively.50 It makes no use of the term ‘authority’ or ‘authoritative’. 3.7.8. This approach has implications. Relationships that rely exclusively on engagement will inevitably require repeated renegotiation of objectives in order to win trust; inevitably they place great store on not alienating the young person. Professionals focused on engagement will tend not to make judgements or set firm boundaries. Engagement is a legitimate and important objective but an exclusive reliance on engagement, if accompanied by a reluctance to make use of personal, professional and statutory authority, may not serve young people well. Social workers and others involved in safeguarding could usefully reflect on their approach, especially when the strategy of engagement is failing. The implications for work with parents are discussed further in Section 3.8. Targeted Youth Support (TYS) 3.7.9. Child K was referred to the Islington TYS in early 2018 following a referral from Islington social care. TYS proposed to allocate a place on a voluntary organisation mentoring scheme, which Child K declined. The records note his mother’s statement that she did not want any additional support at that time, as she was being helped by Child K’s school. 3.7.10. As the end of Child K’s Referral Order approached, the YOS and TYS identified the need for a worker to continue to meet regularly with Child K, either from TYS or the Integrated Gangs Team. It was not clear from the records what criteria pointed to one being the preferred option over the other. After some discussion a sessional worker was allocated from TYS who had had brief contact with Child K the year before, on the basis that he would be best placed to form a positive relationship with Child K. For about four months he became the most important member of the professional network and was able to meet with Child K (and his mother) about once a week. This was far less often than had been hoped and his influence on Child K’s behaviour was limited. An attempt to hand over the work to a charity commissioned by Brent Council, which takes a similar approach to the work, was refused by Child K. 3.7.11. In contrast to the social work approach where – in theory at least – interventions are based on an assessment of need and risk and take a full 50 E.Hanson and D.Holmes (2014) That Difficult Age: Developing a more effective response to risks in adolescence, Research in Practice / Association of Directors of Children’s Services. The word ‘authority’ is found only when referring to ‘the local authority’. https://www.researchinpractice.org.uk/children/publications/2014/november/that-difficult-age-developing-a-more-effective-response-to-risks-in-adolescence-evidence-scope-2014/ 49 | P a g e account of the history, the TYS worker was focused exclusively on the perceived current practical risk to Child K, i.e. that he had provoked at least one group of gang members and would be at risk if he visited Islington from his home in Brent. The stated objectives in May 2019 were to ‘support the goals of recovery and safety’. It is not certain what this meant. Critically, the TYS mentor told the review that he had not known that Child K had been to school in Camden or might have important connections there. He told the review that later he had not understood why Child K was visiting Camden, as well as Islington. 3.7.12. This episode illustrates the way in which TYS or similar voluntary services can be asked to play a leading role in this work, because their approach is viewed as more likely to lead to engagement, but do not undertake a detailed assessment on which to base the intervention and rely on others to provide important history. It suggests a lack of a structured and systematic approach to supervision and management oversight which makes the expectations that are sometimes placed on TYS and similar youth-oriented services too high. Arrangements for joint supervision and planning between social care, TYS and / or YOS need to be in place and operating effectively. These are issues that Islington Council has begun to address, but they may apply equally in any local authority where reliance is being placed on youth-oriented service commissioned from the voluntary services. Youth Offending Services 3.7.13. Child K was made the subject of a Referral Order in July 2018 having pleaded guilty to committing a robbery. The supervision began in September because he was allowed to go on holiday to see his mother’s family for a month in August. The order ended effectively in April 2019 when the work was handed over to TYS as described above. 3.7.14. Islington has recognised that the July 2018 assessment took insufficient account of the risks of exploitation and gang association that were already apparent at the time. The Referral Order intervention and plan which followed were appropriate to the specific offence and not to the whole picture and context in which Child K’s offending was taking place. This was a missed opportunity for concerted multi-agency intervention with the family, particularly as there was a social care assessment at the same time. 3.7.15. It was easy for Child K to attend sessions and appear to comply with the terms of the Referral Order, in part because little was done to explore or challenge the difficulties in his history that contributed to his offending. But he also had four different YOS workers with responsibility for oversight of his order during a period of a few months, effectively spoiling any chance of effective, personal engagement. Islington has recognised that this level of staff turnover, in a service that seeks consistency and engagement, is 50 | P a g e unacceptable and has made proposals to reduce changes in staff allocation in future. Collaborative working between the three services 3.7.16. There were only brief periods when professionals from more than one of these services were actively working with Child K. Between February and April 2019 professionals from YOS and social care attended strategy and planning meetings and made separate visits to the family before it was agreed that the case would best be dealt with by the TYS worker. Had there been longer periods of case allocation to more than one service, joint supervision and planning of the work would have been of benefit. 3.7.17. The review has been told that Islington Council has begun to address this issue which may also equally apply in any local authority where reliance is being placed on youth-oriented service commissioned from the voluntary services. 3.8. The culture and practice of working with parents and young people 3.8.1. This section considers the work undertaken with Child K’s parents, mainly his mother. Research commissioned by the safeguarding practice review confirms the importance of work with parents of young people affected by serious youth violence: ‘Parental engagement is nearly always a protective factor. Parents and extended family members need effective support in helping them manage risk from outside the home. This is skilled work and requires building good relationships with parents. A number of parents we spoke to felt blamed and therefore alienated from attempts by services to help.’ 51 3.8.2. There were spasmodic attempts to work with the mother, but no coherent approach spanning the period under review. From 2017 the Camden secondary school engaged Child K’s mother closely in its work to support Child K, involved her in the referral to the Camden CAMHS outreach service and referred her to a parenting programme in June 2018, shortly before Child K was permanently excluded. This and other parenting programmes are discussed below. 3.8.3. There was then a gap in work with the mother as there is no evidence of Islington YOS working with the mother under the terms of the Referral Order between August 2018 and February 2019. From then home visits were made to discuss safety planning for Child K and the family when he was suspected of killing another young person. From May 2019 the TYS 51 N Maxwell et al (October 2019) A systematic map and synthesis review of Child Criminal Exploitation, Cardiff University 51 | P a g e worker tried to work with her and it appears that his individual support was valued. After the case transfer in May 2019 the Brent social worker was in touch with Child K’s mother but (according to her) made no positive or practical suggestions. At this point Child K’s mother understandably resented the need for the family to be re-assessed and was disappointed that professionals had no other practical suggestions as to what she should do. Professionals were relying on Child K changing his behaviour and were encouraging him to take up an offer of education in September 2019. 3.8.4. The records suggest that professionals may have underestimated the extent of the pressure on Child K’s mother. It is difficult to imagine any situation worse for a parent than to know that your son has been arrested as a suspect in the murder of another child and that (regardless of whether he committed the crime or not) there is a risk of violent retaliation. Shortly after this, Child K was nearly killed in an apparently unconnected attack. This must have had a devastating effect on Child K’s mother and wider family, evidenced by comments recorded that ‘I no longer know my son’ and an acknowledgement that she could not influence his behaviour. Such statements are found in the records over several months; however the records do not appear to show that the impact on her was fully appreciated and assessments do not draw any clear conclusions from this. Perhaps it was underestimated because Child K’s mother was articulate and always willing to cooperate. It is noted that she had ‘good enough’ parenting skills, though in the context of the problems she faced, this meant very little. 3.8.5. This may reflect a wider difficulty in relation to professional ownership and use of authority, referred to in Section 3.7. It is difficult to see how progress can be made in such cases unless parents (including members of the extended family however defined) develop the confidence to be able to relate to young people in a more authoritative way. It is hard to see how professionals can enable parents to be more authoritative if professionals do not feel comfortable responding in an authoritative way. Parenting support 3.8.6. Child K’s mother said that she valued the 2018 parenting programme as it focused attention on the stresses that she was facing at that point and dealt frankly with topics such as gangs and why children might choose to carry a knife. In contrast earlier programmes had been less specific in their focus, concentrating on the problems of younger children. Child K’s mother told the review that it would have been helpful to have had this input sooner, so as to be able to anticipate the difficulties likely to be faced when looking after an adolescent. This echoes the views of other parents. The review makes a recommendation on this. 52 | P a g e 4. RECOMMENDATIONS Guidance on the review by safeguarding partnerships of serious youth violence incidents 4.1.1. Brent Safeguarding Children Forum should ask the (national) Child Safeguarding Practice Review Panel to give guidance to local safeguarding children partnerships on the following: How the panel intends to undertake further enquiries into the areas of serious youth violence and child exploitation In what circumstances local child safeguarding practice reviews of practice in relation to children who are killed or badly injured as a result of serious youth violence should take place so that they can contribute to national as well as local learning. How it wishes the guidance to be interpreted in relation to perpetrators of serious youth violence who are under the age of 18. Parenting and early intervention 4.1.2. Brent and Islington Councils should review their practice on the provision of parenting support, where there is a perceived risk of involvement in youth offending, to ensure that it covers issues that are likely to emerge in adolescence, such as risk from gangs and knife-crime, and to ensure that it is provided at an early point School roles in safeguarding children at risk of serious youth violence 4.1.3. In the absence of central government action, Brent, Camden and Islington Councils should review the effectiveness of the steps already taken to act on the recommendations of the Timpson review of school exclusion and consider what further practical, local measures should be taken to and take additional relevant steps that are in keeping with the recommendations. 4.1.4. Brent, Camden and Islington Councils should consider what practical, local measures should be taken to improve information sharing with schools and colleges in relation to children who are at risk as a result of serious youth violence / child criminal exploitation. Youth Offending Service assessments 4.1.5. Whilst recognising that Islington YOS assessments have been found by external inspectors to be ‘generally good’, the partnership should ensure that YOS assessments consistently seek to identify and take full account of the child’s background and relevant contextual factors and are not focused narrowly on the circumstances of a specific offence. When a young person is known to have links with services in other boroughs, supervisors should ensure that assessments seek out and take full account of information from other localities. 53 | P a g e Application of child protection procedures when children are at risk of significant harm as a result of serious youth violence 4.1.6. Brent Safeguarding Forum should ask the London Safeguarding Children Partnership to determine the suitability of existing core child protection procedures to this area of practice and, if necessary, set out a different procedural framework for children at risk of extra-familial harm, including serious youth violence. 4.1.7. Brent Safeguarding Forum should ask the London Safeguarding Children Partnership to consider the value of developing a common approach to the production of a list of young people who are considered to be at risk because of the influence of gangs or violent criminality. This would be used to supplement the police GVM in order to make regular checks of police records of incidents. The focus would be on evidence of risk of harm to the young person rather than gang membership or known criminal association. Relocation of young people and their families because of the risk of serious youth violence 4.1.8. Brent Safeguarding Forum should ask the London Safeguarding Children Partnership to address the issue of relocation of families in its procedures so that there are shared expectations about practice across London boroughs. 4.1.9. Pending development of a cross-London approach, Islington Council should develop a template, capturing the issues set out in this report, to be used by professionals in their discussions with families and young people when considering the relocation of a family. The council should consider making decisions to support or enable the relocation of family the responsibility of a manager at director level who should be reassured that all alternatives and risks present in the proposed area of relocation have been considered. 4.1.10. Brent Council should review its internal procedures for the transfer in of serious youth violence cases. In future an invitation to attend a child protection conference on a child already living in the borough or where a plan is in place to move to the borough should only be declined by a senior manager. 4.1.11. Brent should carry out an audit to check that its initial screening of cases properly reflects the level of possible risk in youth violence cases. Screening and assessment should not assume that relocation has reduced risk. The impact of complex and serious investigations on young people 4.1.12. The Metropolitan Police Service should confirm its commitment to providing a MERLIN report on all young people affected by incidents of serious youth violence. It should sample a range of incidents to assure itself and partners that the system is effective. 54 | P a g e 4.1.13. The Metropolitan Police Service should (in collaboration with local authority representatives) consider whether more should be done to safeguard the welfare of young people affected by complex criminal investigations into incidents of serious youth violence. In relevant cases the police should appoint a liaison officer from the Major Investigation Team to work closely with the relevant local authorities and youth offending services over the course of the investigation and taking into account all young people affected. The police should provide briefings on the range of safeguarding issues considered in case reviews, including the national child safeguarding practice review on child criminal exploitation to major investigation teams and to senior investigating officers as part of their training. Collaboration between services 4.1.14. Brent Safeguarding Children Forum should promote arrangements for joint supervision and case planning in serious youth violence cases involving, as a minimum, social care, the Youth Offending Service and other commissioned interventions for high-risk young people. 4.1.15. Brent Safeguarding Children Forum should seek assurance from member agencies that staff working with young people affected by serious youth violence (including youth-oriented services) receive structured supervision to enable them to plan and review their work effectively. 55 Appendices Appendix I Views of Child K’s parents Appendix II How the review was undertaken and Terms of Reference Appendix III Relevant findings and recommendations of the national Child Safeguarding Practice Review Appendix I Summary of discussions with Child K’s parents The following is a summary of the views of Child K’s parents, transcribed from notes of discussions. The views expressed here do not necessarily coincide with those of the independent reviewer or the multi-agency safeguarding partnership. Child K’s father 1. The independent reviewer had two brief phone conversations with Child K’s father during the lockdown. He sounded distressed during both. The focus of his attention was on the role of Islington social care during 2015 when Child K had been made the subject of a child protection plan. He felt that the social worker undermined the family’s authority over Child K by asking him to report any further incidents of physical punishment to her. She should not have done this and after that Child K went downhill. Child K’s mother 2. Child K’s mother spoke twice at length to the independent lead reviewer on the phone during the first Covid-19 lockdown. She had twice previously met Islington’s Director of Social Care and a senior housing manager, and was informed that a letter summarising her views expressed in those discussions had been made available to the review. The views of the mother as expressed in these interviews overlap and are combined in Sections 3 – 27 below. After Child K’s mother had seen a draft report, two further discussions were held, which are summarised in Sections 28 - 37 below. Points repeated in the second discussion are not all included in the second part of the summary. Child protection interventions in 2015 3. The child protection and domestic abuse intervention (described in Sections 2.7 – 2.10 of this report) was negative and intrusive and Child K’s mother said that she felt 56 judged all the time. This was why when the child protection plan ended, she would never have considered having further contact with social care Child in Need services Educational difficulties 4. Child K’s mother believes that his secondary school did not react when he started to go downhill (in early 2018). The school could have done more and been better trained to respond and have services in place. 5. Permanent exclusion was the key point that Child K’s life changed for the worse. His mother believes that Child K’s school got fed up with him, felt that they were not getting results. They should have kept trying. She asked why Child K was able to work and succeed in one environment (a specialist project) and not in other environments (the school). The problem must therefore be the school and not the child, and schools need to make more allowances. 6. Child K’s mother did not want him to go to the Pupil Referral Unit. Child K lacked motivation there. There should be more resources for excluded children. 7. She believes that there aren’t enough male role models in schools, among social work and Youth Offending Services for mixed-race kids. Police interventions 8. Child K’s mother believes that the police didn’t investigate the stabbings properly. Young people don’t trust the police so won’t tell them anything. Police have to change and should police communities in a more sympathetic way. The police aren’t visible in the community and they need to be. Moving out of Islington 9. Child K’s mother stated that it was her idea to move to Brent. She agreed it had been a good idea to move, but she expected more support. When professionals ask families to move urgently due to risks, and parents work, they are trapped in paying double rent (one for their permanent property which they can’t give up otherwise they lose all rights) and one for their temporary accommodation. How can this realistically work paying for 2 properties? 10. If you are on benefits and have to move you do not have to pay two rents. If someone works it is impossible to survive financially having to pay two sets of rent. No one explained this. She could not afford this and the additional pressure this causes at an already very stressful time is not acceptable. 11. When a family is assessed as being at risk in their family home, the housing department and social care work together to offer solutions. Social care expecting a family to move immediately is a high-pressured situation and very stressful. Child K’s mother felt that she was not offered any choice. Also she had not seen the place that the family were going to, which was in a very poor condition. 57 12. Asking a family to uproot is an overwhelming thing, even by itself, let alone with all the other factors and information that the family had to take in at that time. Child K’s mother suggested that hotel accommodation should be provided even for a few days, somewhere you knew would have clean bedding, food and so that you are your family could be safe from harm. She had not been afforded this time by being told you needed to take Temporary Accommodation immediately. 13. Child K’s mother expressed concern that moving away may actually increases risk to young people as they go missing for longer, not knowing the area and relationships with key professionals are broken. Social work interventions 14. Child K’s mother believed that when Child K was stabbed (in May 2019) social workers didn’t know what to do. This was disappointing. Aren’t they supposed to? Child K’s mother said that they kept asking her what she thought should happen. Professionals are meant to make suggestions about the kind of things that will help. 15. Child K’s mother said that the changeover between different groups of professionals was the cause of a lot of difficulties. Why if you have a perfectly good assessment in one borough and you go to live in another borough, they have to do a 4-6-week assessment? Why can’t they just use the other borough’s assessment and get on with the work? 16. To lose all the professional connections moving to a new area was very difficult for Child K and you as a family. Child K had told some professionals that he felt she had been bullied to take the temporary accommodation offer. You wondered whether social care services questioned whether you were able to protect your son and the implications of this. Whereas really you just needed time to think, rather than being hurried into a decision. 17. At one point professionals were repeatedly introducing new professionals to the family and this impacted negatively. Youth Offending Services and support 18. Child K’s mother said that he had had 4 workers from YOS in 9 months. Staff need to be more committed – they shouldn’t keep leaving. The changes of workers don’t help children talk to professionals or trust them. It is impossible for a child to think that professionals actually care if there is a constant change. You repeat your story again and again. 19. Child K had built a relationship with TYS worker but this had to change when the family moved to Brent and the service was no longer on offer. Parenting support 20. Child K’s mother said that the parenting support work who became involved in 2018 was good – but why was this not provided sooner? The parenting support work in 2015 was little use – it did not recognise how serious the issues were. 58 21. A charity worker spoke to Child K about the risk of carrying knives after he was first stabbed. Child K’s mother said that she was in shock thinking why would a child who has just been stabbed carry a knife. The charity worker explained it to her. More education for parents is needed about knife crime. 22. Child K’s mother said that more parenting work is needed. Parents don’t know what is really going on in communities with young people and said that services needed to undertake prevention work very early on e.g. Year 5 with parents advising them about social media, community risks, grooming. She had done a parenting course but would have preferred this to be earlier on in Child K’s life. Local authority services for the young people who killed Child K 23. Child K’s mother felt the system had failed the young people who had killed her son. She understood that one of them had been excluded at the age of 14 and that he had never had a job or education since but had 21 convictions. Child K’s mother said the he must have been known by social services. How is this possible? There should be more openness about what services had been offered to young people such as him? Response after the death of Child K 24. F Child K’s mother said that following the death no one helped her. She was completely overwhelmed and in grief and without her brother and sister-in-law who had sadly lost their son many years earlier to knife crime she wouldn’t have known what to do. 25. Child K’s mother said that there were many aspects of the response to the death that made it more difficult. It was only the next day that she had confirmation of what had happened from a police Family Liaison Officer. 26. Child K’s mother said that – with the exception of a worker from the YOS - she had received no contact from anyone in Islington that had worked with her son, not even a text sending their condolences or to ask how she was? Could they do anything for me or support me in any way? To her this was unacceptable. Some months later she had received a lot more empathy and support from a senior social care manager. Do all professionals know how to respond after a death of a young person? Working with young people 27. Child K’s mother questioned why young people have to consent to services and why parents can’t override this when they know it will do their child good in the long run? Summary of Child K’s mother’s comments on the report – February 2021 28. Child K’s mother said that it was hard to read the report because it made the memories come flooding back. The report was quite dense and there was a lot of information. Sometimes it was hard to follow. There are some technical aspects to the report, which describe the procedures for the child protection system, which are hard to understand. 59 29. Child K sometimes comes across in a negative way, but his mother you would want everyone to understand that in the family he was a loving boy with a big heart. He was unhappy and couldn’t find a way out of the situation he had put himself in. 30. Child K’s mother believed that there are too many different services involved and there is not enough leadership provided by senior managers. These problems seem too difficult for people at the lower levels in organisations to solve, but they do not seem to involve more senior people. That is what you would do when you have a problem that you cannot solve in a business or a company and it is hard to understand why that does not happen in this work. As a result there is not enough leadership provided and no one has oversight of everything that is happening for a young person and their family. 31. As Child K’s mother experienced it, there were sometimes three or four people dealing with the problems at the same time. When you face this as a family it takes too long to get anywhere and professionals don’t seem to have any practical solutions. Why did the family have to be reassessed by Brent social care when there had already been assessments, and why this should take so long? You introduce a new person. Everyone becomes tired of telling the story. And this assessment did not result in anything happening. 32. A young person cannot deal with delays. The longer you leave it the less likely it would be that Child K would engage. Time is important and there is no time for lots of meetings. There was talk about finding an apprenticeship, or a college place. Three months after something has happened, a teenager will not be interested in what you are going to say. 33. There are three references to the police not taking action to prosecute Child K before his death, but saying that they intended to do so (i.e. the murder of another young person, the assault on a girl and the possession of drugs and a knife in Essex). Child K’s mother said that this makes it sound as if they were all waiting for something to happen. It is very frustrating that there was such a long delay before any firm action was taken. If he had been dealt with sooner the outcome might have been different. 34. Child K’s mother said that it was not good enough of Essex Police to say that she did not think her son as at risk. Was it not their role to look into that? She felt that generally the police did not deal with these issues well. 35. Child K’s mother noted the time in hospital when a professional had said that he ‘was sad and looked like a broken child’. She agreed and she had been trying to make sure he had a mental health assessment, but with no success. 36. It is very frustrating that social workers are not able to make more practical suggestions. Really you wonder what the point is of social care being involved? It is intrusive if they come to your house and ask questions that are intrusive, write it in your record but don’t do anything. There are too many meetings, which result in nothing. What is the point of workers who come – like admin workers making a list of problems – if they don’t have any practical solutions? This is a difficult thing for 60 parents. You are somehow expected to open up about your problems to someone as if they are your friend. But they are not your friend. 37.Child K’s mother would like to know about what happens to the recommendations and that some things at least will change. Appendix II Principles from statutory guidance informing the review method The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. Reviews should also: Recognise the complex circumstances in which professionals work together to safeguard children. Seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. Seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. Be transparent about the way data is collected and analysed. Make use of relevant research and case evidence to inform the findings. Working Together to Safeguard Children 2015 (Sections 4.9 and 4.10) 61 Child K – REDACTED Terms of reference / lines of enquiry for the Serious Case Review 1. Purpose and scope of the review 1.1. The review is being carried out under the statutory guidance Working Together to Safeguard Children 2015. Its purpose is to undertake a ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’. The Brent Safeguarding Children Forum (now undertaking the review) is required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’. 52 1.2. Brent’s partnership will lead the review which will also consider provision made by services in Islington, Camden, Westminster and Essex. 1.3. There are too many separate incidents and actions – some taken by Child K and other family members and the decisions of a large number of professionals – for the review to be able to answer the question of whether this death could have been predicted or prevented. It is clear even from an outline of the history that during the last months of his life Child K was at a very high level of risk. 1.4. The review should consider services provided to Child K up to his death ……. Bearing in mind the need to undertake a proportionate piece of work and to focus the review on current / recent practice, the review will evaluate in detail services provided from January 2016. …The review should receive and consider summarised information about significant earlier events and service provision as this may point to antecedents and risk factors in Child K’s earlier life. 2. The overall approach 2.1. In relation to the most important episodes and themes, the review will seek to understand both: the provision made in this specific case and the underpinning policies and procedures 52 Legally Child P was a child throughout the period under review, although some aspects of the legal framework change as children become more mature or reach certain ages below 18. The review will use the terms ‘child’, ‘young person’ and ‘young adult’ flexibly so as to communicate its findings as clearly as possible. 62 evidence of wider effectiveness / impact of these services so that recommendations do not rely just on the findings of one case history 2.2. The review will identify evidence of good practice and effective service provision so that this can be encouraged and promoted. 3. Episodes and themes emerging from the initial chronology and discussions that the review needs to understand 3.1. The child’s educational ‘journey’, in particular change of secondary schools his move to the Islington Pupil Referral Unit 3.2. Engagement and continuity in support: the type of services that were offered actions taken by agencies when services were not taken up or children were not brought to appointments what happened at the end of a period of service provision? 3.3. Quality of assessments. For example: does assessment consider contextual risks?53 does it consider the full history of attempts to provide services? does it take account of changes in circumstances? were the case closure decisions subject to a risk assessment? 3.4. Categorisation as a gang member or affiliate. For example: how was this done? what are the thresholds? is there one system or more than one system? how is it communicated to the professionals involved? how does it affect the way in which young people are seen and understood? 3.5. Management of the highest level of risk – including: evidence of a young person’s involvement in organised criminal activity or serious crime taking discharge against medical and other professional advice decisions to facilitate relocation to a new area 53 The term ‘contextual safeguarding’ is now commonly used. The review uses this to refer to the safeguarding of children when risks arise from their contacts in the community (including from gang affiliation) as well as, or rather than, from the family, and when the behaviour of the young person itself may pose a risk to others in the community. Whilst the term would not have been used during some of the period under review, these concerns are relevant. 63 missing episodes or evidence of involvement in criminal activity outside of London (county lines) extent to which police intelligence is used to safeguard children. 3.6. Liaison between health providers (including acute hospital trusts that are major trauma centres) and local authorities in an emergency, both during 9-5 working hours and out of office hours. 3.7. Arrangements for inter-agency working across borough, including when agencies from two boroughs are involved or agencies have facilitated the relocation of a child or family to another area for his or her protection. This would include: continuity of provision (including health services) arrangements for the sharing of information case responsibility and transfer legal responsibilities and procedural aspects 3.8. The role and effectiveness of voluntary sector and commissioned services. 3.9. Response to incidents of domestic abuse involving intimate partners, both historically and in the recent case history. 64 Appendix III Child Safeguarding Practice Review Panel (2020) It was hard to escape - safeguarding children at risk from criminal exploitation, HM Government Section 16. Local learning points 16.3 We recognise that many safeguarding partnerships are already constructing their responses to the issues, although some are further ahead than others. Through this review, we have identified a series of questions and challenges in four key areas that we believe every partnership should be working on and be able to answer. 1 Problem identification Do you know the size and nature of the problem in your area? Do you know which are the most vulnerable neighbourhoods and community spaces? Which children are predominantly affected in your area? Are they all boys? Are BAME children disproportionately affected? What is your response to your local dynamics? 2 Supporting your staff Do you know the levels of risk your front-line staff are routinely managing? Do you know how well they are supported and supervised in this work? Have you articulated an approach to risk management that is shared across all agencies? 3 Service design and practice development Are your services flexible enough to respond to the critical moments in children’s lives? Is there sufficient emphasis on relationship-based work and on the value of trusted relationships? How are individual risk management plans for these children constructed? Are all local agencies contributing as needed? Are risk management plans regularly monitored to respond to changing levels of risk? How well are families being engaged in the joint protection of their children? How is the balance between understanding these children as both victims and perpetrators understood locally? Are adult and children’s services working together where needed? Are you satisfied with the approach in your local area to prioritising housing for families who face a serious threat as a result of criminal exploitation? 65 What is the pattern and trend in school exclusions? What is the nature of alternative provision available? Is there a sufficient focus on disruption of criminal activity as well as support for victims? How well co-ordinated are you with your neighbouring partnerships? If your police service covers more than one area, are you as integrated with those other areas as possible? Are you confident that information follows children and families who are moved out of your area for their own safety and that there is continuity of support? 4 Quality assurance How are your independent scrutiny arrangements focused in this area of work? Have you developed a sense of what ‘good’ looks like in this work? Are the voices of children and their families helping inform your responses and your quality assurance? National recommendations Recommendation 1: Trial a practice framework which can respond to children at risk of serious harm from criminal exploitation. 17.8 Key features of a practice model to respond to children at risk of serious harm from criminal exploitation 17.8.1 Identification of individual children who are at risk of serious harm through use of data, mapping exercises, local practitioners’ knowledge and work with communities to get a detailed picture of those at risk. This group of children would be those who are identified as being at the most extreme risk, where criminal exploitation is known to be a feature and they are involved in county lines and gangs. 17.8.2 Intensive and dedicated work with individual children and their families to build good relationships. A specialist team (perhaps part of an existing service) comprising practitioners from a mix of disciplines and with significant experience of working with adolescents. The most important qualities are persistence, tenacity, creativity, flexibility and ability to respond quickly. 17.8.3 Team make-up will vary but could include both part-time and full-time staff from the following disciplines: police, youth offending, social work, clinical expertise, voluntary sector, youth work, teachers, family support workers. 17.8.4 Members of the team who can work closely with parents and provide dedicated support to help them manage the risk in a way which is perceived to be supportive and empowering. Family group conferences and group work with parents are a strong feature of this work. 17.8.5 Use of a shared practice model which is known to be effective, such as systemic practice. The seven features of practice described in the evaluation of the Innovation Programme outline the key factors which have been found to be associated with positive outcomes. |
NC52281 | Death of a 12-year-old boy in 2020 due to multi-organ failure, sepsis and cerebral palsy. Concerns were identified regarding neglect. Child M had significant disabilities and complex chronic medical needs. Learning includes: a need to better understand child M's lived experience and his family's coping mechanisms; insufficient case co-ordination and development of agreed ways to maintain health and minimise risk of harm; a need for a review of the respective roles of school nursing assistants and school nurses; a need for debate about the extent to which existing service user information systems support or constrain information exchange; a review of the extent to which education, health and care plans (EHCP) or non-school attendance policies are being applied to those in special education facilities. Recommendations include: develop child-centred guidance on the meaning and application of 'mechanical' and 'physiological or medical' restraint to children in the community who are vulnerable by virtue of physical or learning disabilities; ask agencies to remind professionals of the existence and importance of compliance with the existing 'was not brought' policy; review special schools to provide confirmation that non-school attendance responses are of comparable or superior standards than those applied to non-disabled pupils; children's social care disability service to discuss and agree the co-ordination role that it could play in complex cases.
| Title: Child safeguarding practice review: ‘Child M’. LSCB: Harrow Safeguarding Children Partnership Author: Fergus Smith Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. HARROW SAFEGUARDING CHILDREN PARTNERSHIP CHILD SAFEGUARDING PRACTICE REVIEW ‘CHILD M’ PUBLICATION VERSION FERGUS SMITH 24.06.21 CAE 1 1 INTRODUCTION 1.1 SCOPE & PURPOSE OF REVIEW 1.1.1 This review was triggered by the unexpected death in early 2020 of 12-year-old ‘child M’. Child M (a British-born male of Pakistani ethnicity) had significant disabilities and complex chronic medical needs. The eventual conclusion of a post-mortem some months later was that he had died as a result of ‘multi-organ failure, sepsis and cerebral palsy’. 1.1.2 Initial agency responses included (in accordance with statutory ‘Child Death Review Guidance’1) a ‘Joint Agency Response’ on 06.02.20 and on 17.02.20, notification of the National Child Safeguarding Practice Review Panel as well as initiation of a local ‘Rapid Review’. 1.1.3 In the course of discussion amongst those participating in the ‘Rapid Review’, concerns were identified relating to child M’s medical / dental care, attendance at his special school and reported use of physical restraint. It was concluded on the basis of the then available facts that child M might have experienced ‘neglect’2 i.e. ‘a persistent failure to meet a child’s basic physical and/or psychological need, likely to result in the serious impairment of the child’s health or development’. 1.1.4 A recommendation that a child safeguarding practice review be completed was accepted by the independent chairperson of Harrow’s Safeguarding Children Board and supported by the National Panel. The review was completed between September 2020 and May 2021 with the purpose of identifying any required improvements in the local planning and delivery of services intended to safeguard and promote the welfare of children. 1.1.5 Independently authored reports were obtained from all involved agencies and a comprehensive merged chronology of service delivery developed. An experienced independent author was commissioned to evaluate overall service delivery and, supported and advised by a panel of relevant managers, formulate any justified recommendations. 1.1.6 Relevant professionals were convened for a discussion of the initial findings of this case review and their opinions, experiences and ideas are reflected in this final publication summary. Panel members are grateful for the commitment of time that practitioners’ attendance represented. Child M’s parents were informed of this review and encouraged to contribute their views and comment on a final draft of this report. Regrettably, they have not responded to those offers. 1.1.7 As illustrated overleaf, child M lived at home with his mother and father and two younger siblings. His condition mean that he required feeding via a ‘percutaneous endoscopic gastrostomy’ (‘Peg –fed’ is the commonly used abbreviation) . Child M was wheelchair-dependent and unable to speak. 1 See http://www.gov.uk/government/publications/child-death-review-statutory-and-operational-guidance-england 2 Page 105 Working Together to Safeguard Children 2018 CAE 2 1.1.8 For the period selected (September 2017 to February 2020) the following ‘lines of enquiry’ were pursued: • Use of restraints on children in Harrow apparently contrary to Government guidance – and attitudes towards their application to children with disabilities or communication difficulties • Effectiveness of the review system for Education, Health and Care Plans (EHCPs) • Any need for a ‘was not brought’ (WNB) policy for Harrow • Whether the threshold for safeguarding is being applied properly to children with disabilities • Whether prolonged school absences for disabled children are managed in accordance with local procedures • Identification of the partnership’s response to child M’s reported mouth pain and dental care • How well child M’s voice was heard, understood and taken into account in assessment and planning • How well was the culture of child M’s family understood and taken into account in assessment and planning • Reasons why child M’s death was not initially dealt with as an ‘unexpected death’ 1.1.9 Section 2 summarises what was for child M’s family and the professional network, a very demanding period and the substantial efforts expended to meet the many medical, emotional, care and social needs of child M. Section 3 provides responses to the review’s lines of inquiry and recommended changes to service design or delivery. Father Mother Child M Sister Brother CAE 3 2 SUMMARYOF SERVICE DELIVERY 2.1 RECOGNITION OF & RESPONSE TO HEALTH & OTHER NEEDS WHILST AT PRIMARY SCHOOL Restraints & Medication 2.1.1 Though significant scope was found for improving the recording of prescribed medication, there is ample evidence of sensitive practice by school nursing assistants, teaching staff as well as speech and language therapists, occupational therapists and physiotherapists. Child M’s complex needs required the ongoing involvement of a local paediatrician as well as the expertise of several specialist functions. 2.1.2 By half-term in Autumn 2017 involved agencies were aware of the use of ‘soft restraints’ used to prevent dystonic3 movements that might cause involuntary self-harm i.e. he could, as well as scratching face and eyes, potentially become stuck in a painful position. The class teacher responded by making large jumper sleeves to be slipped over her pupil’s arms and the arms of his wheelchair for use on home-school journeys. Child M could ask for them if they were needed during the day and was able to ‘eye point’ to either ‘sleeves’ or a symbol for ‘no’. The sleeves were thought to have a similar effect to a weighted blanket. Use of ‘soft restraints’ is also captured in the medical records of the consultant paediatrician in October 2017. Comment: the intentions of father, school staff, consultant paediatrician and GP were positive and sought to incorporate the child’s wishes; there existed though, scope for further multi-agency debate and better co-ordinated responses 2.1.3 Joint and ultimately successful efforts were made by the paediatrician and occupational therapist to request the Housing Department to relocate the family so as to enable installation of a permanent hoist. Initial Reports of Oral Discomfort 2.1.4 Community Children’s Nurse Team records of late 2017 include a reference by the school to ‘intermittent mouth ulcers’. Practical advice was offered by the nurse who also recommended a ‘mouth area review’ by GP or specialist dentist. Her advice was not followed. In December 2017, a multidisciplinary therapy report for transition to Secondary School and a standard review of prescribed medication was completed. Arrangements were made for an appointment at the ‘Paediatric Neurodisability Unit at Great Ormond Street Hospital for an initial assessment and injections (under anaesthetic) of Botulinum Toxin4 to arms and legs. Planned Transition to Secondary School 2.1.5 In late March 2018, an annual review meeting was attended by father 3 Dystonia is a movement disorder in which muscles contract involuntarily, causing repetitive or twisting movements; the condition can affect one part of the body (focal), two or more parts (segmental) or all parts (general) 4 Botulinum toxin-A injections are designed as a temporary treatment to reduce muscle spasticity and works by weakening or paralysing muscles, thus decreasing pain CAE 4 and Secondary School senior staff. Child M’s needs and a plan for his transition were agreed and included a referral (Common Assessment Form - CAF) to be sent to Harrow’s Multiagency Safeguarding Hub (MASH) seeking carer support at home. School staff believed that it would help the family if there were support with child M’s personal care and the value of holiday play-schemes was recognised by all. By May 2018 the family had moved to its new home. Physiotherapy staff discussed with child M’s father possible use of ‘night splints’ – their purpose to enable prolonged stretching. In the event, father’s concern about the impact on child M’s sleep prompted him to decline their use. Comment: though intended to be therapeutic and their use discussed with father, there may have been little difference from child M’s perspective, between ‘night splints’ and ‘soft restraints’ to prevent accidental self-harming. 2.1.6 In mid-May 2018, during what was to be the final medical review by the school’s linked consultant paediatrician, increased dystonia was reported by father over the past 2-3 months and a second reference to mouth ulcers appeared, albeit said to be reduced in their impact. Classroom staff remained concerned about the severity of dystonia and the paediatrician planned to pursue further specialist opinion. This action and others identified at the above review were progressed. Comment: the number of specialists from Health, Education and Social Care agencies rendered overall co-ordination of child M’s complicated needs challenging; sufficient recognition of the pressure on his parents and siblings is not apparent in agencies’ records. Planned Support over Summer & Handover to Secondary School 2.1.7 Failed attempts were made by a newly allocated social worker in the Children’s Disability Team to organise respite care over as well as a review of occupational therapy needs over the Summer. By way of transition planning, a learning support assistant from the Secondary School began to visit him and develop a rapport. A ‘liaison morning’ with a family worker from the next school was also convened in late June. Comment: arrangements negotiated between schools illustrate a high level of sensitivity and forethought. 2.1.8 Concerns about child M’s gastrostomy emerged during the final week of term and would have benefitted from School Nursing Service involvement and a lead health professional to coordinate responses to a child with complex medical needs and apparently in pain. In late August, the GP Practice asked its administrative staff to follow up (by means of inviting a phone consultation) the parental failure to present child M at a scheduled ‘Spinal Assessment’ appointment earlier that month, or to respond to phone calls or messages left on father’s phone. No record of that action or its results have been located. CAE 5 2.2 SECONDARY SCHOOL & CONCERN ABOUT ‘RESTRAINT’ Internal Safeguarding Referral 2.2.1 Child M achieved full-time attendance for a week in early September 2018 before being admitted via A&E and spending 4 days in hospital. Later that month, the assistant head teacher queried the use of restraints on school transport. A Community Paediatric Nurse initiated a safeguarding referral and alerted her deputy head teacher and ‘safeguarding lead’. She did not escalate the case via her Health hierarchy, apparently because of an understandable (misguided) reluctance to add to the heavy workload of their senior colleagues. 2.2.2 There were in late October, extensive discussions and negotiations within the school and with other involved agencies about the need to resolve ‘seating’ and other needs before child M would resume attendance. After a half-day attendance in early November, child M was not seen again there until mid-May 2019. Comment: the complexity of this situation and unmet need for co-ordination across the local network would have justified escalating the case. 2.2.3 A Personal Learning Plan (PLP)5 in December 2018 was unable to set new targets because of child M’s ongoing absence, though it was recognised that father was struggling to get his son into the current wheelchair. Child M was not present at a planned medical review which involved paediatrician, paediatric physiotherapist and neurodisability consultant. Recognising there were behavioural as well as medical issues associated with child M’s difficulties, it was agreed a referral would be made to CAMHS. Also ‘urgent’, though not achieved for 9 months, was a follow up to the neurodisability consultant at Great Ormond Street Hospital. 2.2.4 Early in Spring 2019, a meeting of teaching staff and physiotherapist acknowledged child M’s reluctance to leave his house and use his wheelchair, which was thought to be ‘behavioural’ as opposed to ‘medical’. In a rare acknowledgement of the family context, a sibling with additional needs was reported to live at home, with another ‘in and out of hospital’. Review of Education, Health & Care Plan (EHCP) 2.2.5 Though there was an attempt on 12.02.19 by physiotherapist and occupational therapists to formulate a plan, the more formal annual review of child M’s EHCP was not completed. Extensive debate about child M’s absence and the underlying reasons followed. The need for a slow transition was agreed. Father was in agreement with the proposed way forward. A week later and again on a second occasion, father consulted a GP and reported that child M had a raised temperature and white spots / pus on his tonsils. The doctor diagnosed tonsillitis and prescribed antibiotics. 2.2.6 The potential benefit of a school-based dietetic appointment in early 5 A pupil has a PLP which outlines targets for the term; targets are set which will enable her/him to make progress towards their EHCP outcomes, build on prior knowledge, understanding and skills, address any gaps in learning and focus on specific areas which are relevant to the individual. CAE 6 May was lost as child M’s non-attendance continued. Records confirm attempts made by staff working in the ‘Family Liaison’ role to develop with father, a plan for child M’s gradual return to school. He managed only an hour-long session in mid-May 2019 and, after a renewed agreement about ongoing time-limited sessions, was absent for the remainder of that school year. School and CAMHS subsequently struggled to contact the family and the Family Liaison staff were ‘contemplating’ a referral to Children’s Social Care. Because he was not, after an unexplained delay of 10 months, presented to an Ear, Nose and Throat (ENT) appointment in March or again in June, child M was removed from its list. The clinic failed to notify the GP Practice of that action. 2.2.7 At a ‘team around the family’ (TAF) meeting in school in late June 2019 father described an improvement in child M’s distress level, which he attributed to changes in diet. A ‘transition plan’ (seeking to avoid known triggers for distress whilst in school) was outlined by CAMHS. In late July, a planned ‘speech and language therapy’ session was cancelled by father and although re-scheduled for an earlier date was not, as result of non-school attendance, completed until October 2019. 2.2.8 In mid-September father described ‘really bad’, albeit improving, mouth ulcers. Records of late September reflect child M’s return to school for about a week. Consideration was given to how medication at school needed to be sent home if he was absent, lest the stock at home be insufficient. It remains uncertain whether, with minimal school attendance, parents held sufficient supplies and made full use of the prescribed medication. 2.2.9 In late September 2019, a ‘case closure’ letter was sent to the parents by Children’s Social Care. The decision apparently reflected father’s failure to respond to an undated phone call from a duty officer, though it also included a reference to a conversation in which father had reported resumption of part-time school attendance. Comment: inadequacy of records renders it difficult to be confident about events, the Service response though, suggests a reluctance to acknowledge and carefully assess the self-evidently high level of support needs; even taking into account the insufficiency of co-ordinated multi-professional efforts, it must have been clear by then that the parents were struggling to respond to health-related appointments; addressing that issue head-on could have enabled a better appreciation of how (quite understandably) overwhelmed, the family may have actually been. 2.2.10 From late October until the end of term, child M achieved 2 half-days at school per week. In the school nurse assistant’s records, she captured the first reference father made to child M showing signs of pain because (he thought), of emerging teeth. Safeguarding Referral to Children’s Social Care 2.2.11 At the end of October during a pre-arranged home visit for a nursing re-assessment, restriction of child M’s hands and arms was observed. Socks had been slipped onto on his hands and the right hand looped in a scarf and tied (albeit not tightly) to his leg. This action was reported by father to prevent scratching of head, eyes and mouth. The community CAE 7 paediatric nurse’s view was that the parents were struggling to cope. She consulted her agency’s safeguarding nurse and it was agreed that child M’s father should be informed and a safeguarding referral made to Children’s Social Care. 2.2.12 Upon receipt of that referral by the Multi-agency Safeguarding Hub (MASH), the details provided by the community nurse were noted and the case passed to the Disability Service to explore child M’s lived experience and parental ability to manage the demands his disability represented. Comment: the reported facts would have justified a strategy discussion / meeting under s.47 Children Act 1989 involving health professionals; even operating under s.17, there was a clear need to explore the needs of the whole family not just those of child M. 2.2.13 No feedback to the referrer was provided and it would appear that this procedural failure was not escalated by the Nursing Service. The social worker allocated to complete an assessment, seems to have made no response until a home visit 6 weeks later when no record of his actions has been located. In response to notification of the above referral, a GP undertook a home visit and noted that ‘child M has thick gloves covering both hands with a soft cloth to his inner thighs that allows enough traction to prevent him hitting his face and lips and not a tight cloth tying his hands and feet together which was the impression he got from the email received. The GP noted that the family is caring and can see it is a challenge to manage this difficult and unpredictable situation. Comment: the actions of the nurse were commendably cautious and provided an opportunity to better appreciate the lived experiences of child M and family. 2.2.14 On 03.12.19 the physiotherapist during a school-based review, responded to father’s report of continuing mouth ulcers by initiating a referral to the Community Dental Service6. This was received on 05.12.19, and included a description of the patient being a child with special needs experiencing pain and the need as ‘urgent’ (the expectation being that it would be triaged on the same day, the patient contacted by phone within 24 hours and an appointment offered within a week - in the event of difficulties in establishing contact by phone, a letter would be sent). 2.2.15 In this instance however, no response was made until early January 2020 when an appointment was offered for early February. The contractual expectations, case triaging by ‘an experienced referral management lead’ and quality assurance systems appear sound. It may be that unrecorded attempts were made by phone to contact the parents. Prompted by its shared concern about the delay, the Dental Service has taken steps to optimise responses to the intrinsically 6 NHS England commissions Whittington NHS Trust to provide community and specialist dental services to children with complex or additional needs who are unable to get appropriate care from a general dental practitioner. CAE 8 complex needs of a patient such as child M. 2.3 CHILD M’S DEATH & SUBSEQUENT RESPONSES 2.3.1 In response to a telephone notification of death on a date in mid-January 2020, a detective sergeant from the Metropolitan Police Service (MPS) attended and was briefed on the reasons for his admission and observations of medical staff. The attending officer noted that the cause of death was at that time ‘unknown’ though thought likely to have been from non-suspicious medical causes. He liaised with the Children’s Social Care Emergency Duty Team where staff confirmed involvement of an allocated social worker. The sergeant and a second officer attended the hospital, spoke with the physician in charge who confirmed the earlier description of events. Having consulted the on-call detective inspector, it was agreed the matter could revert to the standard hospital protocol, in the knowledge that the death would be considered by the local Child Death Overview Panel (CDOP) and that the Coroner’s office had already been notified. Comment: the immediate Police response to the tragic death was commendably cautious and sensitive. 2.3.2 The GP Practice was notified promptly of child M’s death (cause at that time ‘unknown’) and next day the standard ‘form 1’ sent by the Practice to the Coroner’s office. Apparently in consequence of unfamiliarity, the named doctor did not notify Harrow Clinical Commissioning Group of child M’s death. Though Police were not invited, a first ‘Rapid Response’ meeting was convened in early February and a further ‘Rapid Response’ meeting, attended by the detective inspector convened 11 days later. 2.4 RESPONSES TO LINES OF ENQUIRY USE OF RESTRAINTS Law / Regulation / Guidance for Professionals 2.4.1 Desk-top research of the lawful / professional expectations of community staff working with highly dependent children highlights: • ‘Use of Reasonable Force: Advice for Head Teachers, Staff and Governing Bodies’ published in July 2013 cited s.93 of the Education and Inspection Act 2006 which allows the use of ‘reasonable force’ in specified circumstances e.g. prevention of harm to an individual • More recent (27.06.19) non-statutory government guidance is to be found in ‘Reducing the Need for Restraint and Restrictive Intervention of Children and Young People with Learning Disabilities, Autistic Spectrum Conditions and CAE 9 Mental Health Difficulties in Health and Social Care Services and Special Education Settings’7 and • ‘Keeping Children Safe in Education’ (2020) also provides updated statutory guidance for schools and colleges though contains no reference to use of physical restraint 2.4.2 Other older regulations or Department for Education (DfE) guidance apply to specific settings such as Children’s Homes or Foster Homes. The use by or consent of, a person with parental responsibility to the use by another person, of proportionate and reasonable force to restrain a child who might otherwise injure her/himself or another individual is not proscribed in legislation unless or until its nature or frequency were to cause a local authority to conclude that there existed ‘reasonable grounds for suspecting that s/he is suffering or is at risk of suffering ‘significant harm’.8 Nonetheless, without regard to parental wishes or gaps in the currently published advice, it is clearly of vital importance that the most vulnerable of children are protected from all unintended consequences of well-meaning restraint as well as any deliberate harm. Use of Restraint in Child M’s case 2.4.3 Use of ‘soft mechanical restraints’ was well intentioned and entirely supported by father (and possibly mother). From late 2017, until the referral by the community nurse in late 2019, the practice was accepted by school, community paediatricians, GP, CAMHS (from an unrecorded date in 2019) and father. It may also be that the Children’s Social Care Disability Team knew of and accepted the practice. Whether the use of the ‘soft restraints’ was always justifiable is more debatable and an important example amongst many, of why there needed to have been a comprehensive, coordinated multi-agency approach to planning and reviewing child M’s needs. If professionals had been able to interpret more holistically, his unspoken wishes and feelings, an equivalence between the mechanical restraint represented by a large woollen sleeve and the medical restraints of which splints and administration of Botox injections were examples might have emerged. 2.4.4 It is clear that health and education staff at the Primary School were committed and sensitive to his many needs. Some initiatives shown e.g. home visits to follow up absences, accessing father via a relative suggest action ‘above and beyond’ expectation. Involvement of family at the Secondary School was, reflecting chronic absence, more limited. Though monitored internally, it does not seem that formal notification was made to the local authority. It is likely that if child M not been disabled, the response of a mainstream school would probably have been different. Effectiveness of the review system for EHC plans ? 2.4.5 Insofar as school attendance was not at that time seen to be problematic, the last annual review at child M’s Primary School was held in March 2018. This involved parents and senior staff from the 7 S.47 Children Act 1989 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/812435/reducing-the-need-for-restraint-and-restrictive-intervention.pdf CAE 10 current and future planned school as well as those providing therapy to child M. It had the advantage of a well-completed ‘All About Me’ report (likes, dislikes, methods of communication, equipment, strengths and achievements, calming strategies etc). A further annual review report was drafted in January 2019 by occupational, speech and language and physiotherapists and a multi-agency meeting convened in mid-February. There was no Children’s Social Care representation and its value was limited by child M’s ongoing non-attendance. 2.4.6 Child M’s Secondary School report that the annual review documentation received made no reference to self-injurious behaviour, need for restraints or the child’s high level of anxiety or gastric distress. This case review has been advised that the absence of any reference or contribution to the EHCP in child M’s school nursing records does not justify a recommendation with respect to their greater involvement. An assurance has been given that because the service with respect to pupils with complex health needs, is now being delivered by specialist nurses this will ensure sufficient information sharing. NEED FOR A ‘WAS NOT BROUGHT’ POLICY FOR HARROW ? 2.4.7 A report provided by the Central & North London NHS Foundation Trust provides confirmation of the existence of a ‘Was Not Brought’ (WNB) policy and an expectation that all staff should be familiar with it. The Trust’s report highlights the need to recognise the relative isolation of school nursing assistants and, in consequence of less intense and specified training, insufficient recognition of the significance of non-compliance with medication / medical intervention. This is arguably more obvious if a child patient is not presented to a clinic appointment and less when it is a secondary consequence of non-school attendance. 2.4.8 The above report also highlights a further important, albeit less tangible, reason why the ongoing unreliability of child M’s medication was not better recognised. The report makes reference to what may usefully be distinguished from one another. The ‘written / formal contract’ of employment meant that the assistants could consult more senior registered school nurses for advice and support as/when required. The ‘psychological contract’ reflected both ambiguity (were Education staff rather than school nursing assistants responsible for taking the initiative?) and ambivalence (school nursing assistants were sensitive to the heavy workload of their senior colleagues). The absence of an ‘overview’ of all the abortive contacts reflected the lack of overall coordination reported elsewhere in this report and within the Trust, an unhelpful mixture of paper and electronic records. A single shared database would obviously ensure the possibility of better informed and more timely responses. THRESHOLD FOR SAFEGUARDING CHILDREN WITH A DISABILITY 2.4.9 Some suggestions of unconscious bias or more arguably, institutional ‘disablism’9 can be found in the relatively passive responses of the GP Practice in May 2018 when father failed, having sought medical 9 ‘Disablism’ is the consequence of disability as oppression, whereby negative attitudes, disablist policies, discriminatory practices and environmental barriers prevent the full participation and inclusion of people with disabilities in everyday society (Oliver 2009). CAE 11 assistance, to follow up on child M’s reported mouth ulcers. The GPs knew each family member well and might usefully have better appreciated that child M’s health and well-being depended entirely on the actions / inaction of others. A second example is offered by the relative passivity of response when the MASH relayed the community nurse’s referral of November 2019 to the Children’s Social Care Disability Team. No feedback to the referrer was provided and little action taken for some 6 weeks. The legal foundation of the belated response was not confirmed as being either s.17 (in need) or s.47 (significant harm). It seems likely that the response provided, had it involved a non-disabled child, would have differed and might have prompted a ‘strategy discussion’. 2.4.10 A health-related example of a possibly differentiated response may be found in October 2018 when the school nursing assistant’s sensitivity to her observations were relayed by way of an internal response only to the senior leadership team, rather than her Health seniors (possibly reflecting a sense that she belonged to the school ‘team’). PROLONGED SCHOOL ABSENCES FOR DISABLED CHILDREN MANAGED IN ACCORDANCE WITH LOCAL PROCEDURES ? 2.4.11 It appears that no formal quantification or notification to the local authority of the extremely extensive (and possibly ‘authorised’) periods of child M’s absence from Secondary School was completed. The practitioner event highlighted the challenge of balancing attendance with the complex and frequently changing needs of pupils with a significant levels of disability. A positive organisational response has been to ensure all future ‘attendance panels’ include a representative of the Children & Young Persons’ Disability Service. WHY THE PARTNERSHIP’S RESPONSE TO CHILD M’S MOUTH PAIN & DENTAL CARE NEEDS FELL SHORT OF EXPECTATIONS 2.4.12 During the course of this CSPR, the contractual obligations and expectations of the NHS England-commissioned Whittington Health NHS Trust’s Community Dental Service were provided and confirm the existence of clear, coherent requirements for service delivery including suitably informed / qualified and timely responses to referrals. It may be that further attempts to make telephone contact with child M’s parents were made and failed. Such efforts were not then recorded but in response to this case, a log of such efforts has been established. WHY CHILD M’S DEATH WAS NOT INITIALLY DEALT WITH AS AN UNEXPECTED DEATH 2.4.13 A delay and uncertainty about describing the death of child M as ‘unexpected’ reflected the manner in which the original notification of the event was provided by the hospital. Whilst the Coroner had been appropriately informed of the event, Harrow Clinical Commissioning Group had not been informed. The consequences of the delay were compounded by an inability to access the family home until members returned from a trip abroad. The existence currently, of a dedicated ‘Child Death Overview Team’ precludes the need for a local recommendation though (given that Child Abuse Investigation Teams are now managed within each Borough Command), it would be useful CAE 12 to confirm that all Boroughs are positioned to be compliant with all required responses to unexpected child deaths. HOW WELL WAS THE ‘VOICE’ OF CHILD M UNDERSTOOD & TAKEN INTO ACCOUNT IN ASSESSMENT & PLANNING ? 2.4.14 During his attendance at Primary School, there are numerous examples of educational and therapeutic staff involved in the provision of education, medication and therapies demonstrating a careful and sensitive approach to the pupil’s immediate feelings and preferences. As a result of his vastly reduced attendance from July 2018 onwards, the advantages of coordination and care, skill and commitment from those who had related directly to child M was largely lost. Instead, his day to day care became almost entirely dependent upon his parents (the balance of responsibility between mother and father remains unknown). Though no evidence exists to suggest that parents were anything but caring and committed, they may often have been overwhelmed by the totality of child M’s needs as well as the care of younger siblings. Setting aside the fact that the practice had been known to many in the network for some two years, the initiative shown by the children’s community nurse in recognising and responding to her observations in late 2019 was commendable. HOW WELL WAS THE CULTURE OF THE FAMILY UNDERSTOOD & TAKEN INTO ACCOUNT IN ASSESSMENT & PLANNING ? 2.4.15 In spite of the considerable sympathy and respect for the efforts made by his family to care for child M, few attempts were made and minimal progress achieved in understanding the reality of day to day life. Even basic information remained unrecorded e.g. neither Children’s Social Care, School Nursing or CAMHS records captured names, dates of birth of younger siblings, their respective individual needs or their wishes with respect to the impact of their profoundly disabled brother. 2.4.16 The reality of frequent lifting, providing total personal care for child M and trying to present him at dozens of appointments must have placed huge and (as he grew older) increasing pressures on the adults within the household. Some recognition of this can be found in the referrals to Harrow Children’s Social Care in March 2018 and June 2019. 2.4.17 Child M’s mother appears only once within the extensive records seen. Health records did capture the fact that her use of English may have been limited which offers one explanation about her very limited involvement in contacts with the professional network. A little more professional curiosity amongst any of the involved professionals might usefully have explored her experiences of caring for child M as well as possible explanations for father’s lead role in agencies’ contacts. 2.5 EMERGING LEARNING 2.5.1 Transcending the specific ‘lines of enquiry’ above, it is possible to identify some overarching opportunities for organisational learning. LISTENING TO CHILD M 2.5.2 Several examples of ‘best practice’ emerge from the material examined. CAE 13 Primary School staff, involved therapists and the CAMHS behaviour analyst were sensitive to child M’s feelings. The former professionals especially showed a willingness to interpret his responses in a manner which may have been inconvenient in relation to completing a proposed assessment of need, but sought to recognise the child’s rights. INSUFFICIENT CASE CO-ORDINATION 2.5.3 Material provided to this CSPR demonstrates that there were weaknesses in the following specific functions and interfaces: • Ensuring reliable administration and recording of medication whether child M was in school or at home • Ensuring that the information and expertise accrued by teaching staff, medical practitioners, therapists and (to a lesser extent) Children’s Social Care, were all factored into the review of the Education and Health Care Plan (EHCP) • Drawing upon the above to debate and determine the optimum way of protecting child M from any risk of harm 2.5.4 The magnitude of challenge for professionals is made clear if one recognises the involvement of 15+ agencies and many more individuals within those organisations. Though the community paediatrician or GP Practice might have had some potential value at the coordinator of child M’s multitude of mostly health-related needs, the more obvious candidate for this unfilled role was the Disability Service within Children’s Social Care. By definition, a child with a disability is a ‘child in need’10. An assessment apparently begun in April 2018 at about the time the family moved to larger and more suitable accommodation failed to capture any detail of child M’s siblings or how the family was coping. Subsequent opportunities in June and November 2019 were also missed. MORE EFFECTIVE SCHOOL NURSING / ASSISTANT ROLES 2.5.5 A lack of oversight of record keeping and insufficient supervision of complex cases meant that issues that needed to be addressed in relation to child M’s care, absences, medication etc were not explored further. In addition, documentation in or instead of the use of SystmOne, 10 A child is ‘in need’ if s/he is unlikely to achieve or maintain, or have the opportunity to do so, a reasonable standard of health or development without provision of services by a local authority, or if her/his health or development is likely to be significantly impaired or further impaired without such services, or s/he is ‘disabled’ [s.17(11) Children Act 1989. CAE 14 was often poor. 2.6 CONCLUSIONS 2.6.1 The overall learning emerging from this review suggests: • An unmet need to better understand child M’s lived experience at home and his family’s coping mechanisms • Insufficient case co-ordination and development of agreed ways to maintain health and minimise risk of harm • A need for a review of the respective roles of school nursing assistants and school nurses • A need for debate about the extent to which existing service user information systems support or constrain information exchange • A need for enhanced appreciation / application of existing ‘was not brought’ policies • A review of the extent to which Education, Health and Care Plans (EHCP) or non-school attendance policies are being applied to those in special education facilities 2.7 RECOMMENDATIONS HARROW SAFEGUARDING CHILDREN BOARD 2.7.1 The Board should develop child-centred guidance on the meaning and application of ‘mechanical’ and ‘physiological / medical’ restraint to children living in the community (other than in regulated environments) who are additionally vulnerable by virtue of physical / learning disabilities 2.7.2 The Board should ask each agency in the local partnership to take steps within routine communications and training programmes to remind professionals (including those in community settings such as GP Practice and School Nurses) of the existence and importance of compliance with the existing ‘Was Not Brought’ policy. CAE 15 CENTRAL & NORTH WEST LONDON (CNWL) NHS FOUNDATION TRUST 2.7.3 Health visiting and School Nursing ‘Units’ on SystmOne should be amalgamated into a single ‘Harrow 0-19 Unit’. 2.7.4 The Trust need to review and distinguish the respective roles of school nurse and school nursing assistants ensuring that in both cases, appropriate levels of supervision are provided and recording requirements made explicit and monitored. [the panel has been informed that as of September 2021, Harrow as part of the North West (NW) London CCG, will be commissioning a specialist school nursing service provided by fully qualified children’s nurses, thus ensuring that expertise and professional oversight is maintained across the service]. 2.7.5 The Trust should formulate proposals for addressing the risks associated with records fragmented across connected functions e.g. School Nursing & Community Services. 2.7.6 Seek confirmation that the current arrangements for ensuring School Nursing Service perspectives (e.g. missed appointments) that inform annual EHCP Plans are robust. HARROW EDUCATION SERVICE 2.7.7 A review across all special schools is required to provide confirmation that non-school attendance responses are of comparable or superior standards than those applied to able-bodied pupils. 2.7.8 Special schools should explore the possibility (understood to work well in neighbouring Brent) of seeking advance parental agreement to dental screening via ‘blanket consent’ obtained at the start of the school year. CHILDREN’S SOCIAL CARE DISABILITY SERVICE 2.7.9 On the basis of inadequate responses to child M’s situation (recorded and otherwise), there is a need to: • Review lawfulness, purpose and processes followed with respect to a ‘child in need’ (s.17(11) Children Act 1989) who is already known, or referred to the Disability Service • In consultation with partner agencies, discuss and agree the co-ordination role that the service could play in complex cases [‘remote working’ practices could facilitate the required service changes] Overview Child M Publication Version 24.06.21 A&E Accident & Emergency Department MARS Medicine Administration Record Sheet CAMHS Child & Adolescent Mental Health Service MASH Multi-agency Safeguarding Hub CCNT Community Children’s Nurse Team NICE National Institute of Clinical Excellence CDOP Child Death Overview Panel OT Occupational therapy CSPR Child Safeguarding Practice Review PEG Percutaneous endoscopic gastrostomy CAF Common Assessment Framework PLP Personal Learning Plan DfE Department for Education PT Physiotherapy EHCP Education, Health & Care Plan SLT Speech & language therapy ENT Ear, nose & throat TAF Team Around the Family GOSH Great Ormond Street Hospital SNA School nursing assistant LSA Learning support assistant WNB ‘Was not brought’ |
NC049429 | 15-year-old child, Perry, who suffered a serious injury in April 2015 as a result of poor physical care and hygiene. Perry's father was convicted on four counts of neglect and sentenced to four years imprisonment in February 2017. Perry and three siblings went to live with their mother and received support as children in need. Perry's parents separated in 2008 and the children lived with father who refused to allow them any contact with mother. Siblings were subject to a child protection plan for neglect between December 2010 and July 2012. Referrals in 2014 resulted in further involvement by social workers and other professionals through a child in need plan. There were allegations of sexual assault of one of the siblings by a young adult male living in the household and concerns around poor living conditions and the physical care of the children. Key findings include: the need to recognise the potential for harm from neglect; the need to have high expectations; collating evidence about risk, vulnerability and resilience more systematically; having strategies to respond to parental resistance; identifying who is living in households; avoiding the use of euphemistic language which obscures professional communication and understanding; and listening to the views of children and assessing their level of understanding. Makes recommendations for the LSCB to consider including: do they have sufficient information about the use and effectiveness of local assessment resources, including guidance on identifying and responding to children at risk of significant harm from neglect?
| Title: A serious case review under Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006: ‘Perry’: the overview report. LSCB: Nottinghamshire Safeguarding Children Board Author: Peter Maddocks Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. FOR PUBLICATION Page 1 of 56 A serious case review under Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006 ‘Perry’ The overview report Commissioned by the Nottinghamshire Safeguarding Children Board August 2017 FOR PUBLICATION Page 2 of 56 Index 1 Introduction ................................................................................................... 4 1.1 Context of the serious case review ............................................................... 4 1.2 Rationale for conducting the serious case review............................................ 5 1.3 The methodology and scope of the serious case review ................................... 6 1.4 Information about Perry and the family ........................................................ 8 2 Summary of contact by services and significant events ......................................... 12 2.1 Summary prior to January 2013 ................................................................. 12 2.2 January 2013 and CAF ............................................................................. 12 2.3 Referral to MASH and social work assessment ............................................. 13 2.4 Referral to the Supporting Families Service.................................................. 15 2.5 Involvement of MAT and education welfare service in Derbyshire ................... 16 2.6 Referral to Nottinghamshire MASH from Derbyshire MAT .............................. 19 2.7 Completion of assessment and allocation as CIN December 2014 .................... 20 2.8 February 2015 concerns increasing about neglect and Perry feeling scared of males in the house ............................................................................................ 21 2.9 Contact by school with children’s social care services .................................... 22 2.10 Perry presented at hospital by school ......................................................... 22 2.11 Referral to GP ........................................................................................ 24 2.12 Strategy meeting .................................................................................... 24 2.13 Decision that children cannot remain with father ......................................... 24 2.14 School report further concerns and Perry presented at hospital ...................... 25 2.15 Summary of contact with Humberside social care services ............................. 26 3 Appraisal of professional practice in this case ..................................................... 28 3.1 Responding to neglect ............................................................................. 29 3.2 Voice of the child and understanding their personal and family history ............. 31 3.3 Risk from inappropriate contact and relationships ........................................ 32 3.4 Communication between professionals ...................................................... 34 3.5 Use of legislation and safeguarding pathways .............................................. 35 3.6 Quality of assessment and plans ................................................................ 39 3.7 Parental resistance ................................................................................. 41 3.8 Use of the local escalation processes .......................................................... 43 4 Analysis of key findings for learning and improvement ......................................... 44 4.1 Cognitive influence and human bias in processing information and observation . 44 4.2 Family and professional contact and interaction ........................................... 46 4.3 Responses to information and incidents...................................................... 47 4.4 Tools to support professional judgment and decision making ......................... 48 4.5 Management and agency to agency systems ............................................... 49 4.6 Issues for the Nottinghamshire Safeguarding Children Board to consider in regard to learning and improvement ............................................................................. 51 4.7 Recommendations .................................................................................. 51 4.8 Issues for national policy .......................................................................... 52 Appendix 1 Terms of reference identified by the serious case review team for further investigation by the key lines of enquiry: .................................................................. 53 Appendix 2 Membership of the case review team ...................................................... 55 FOR PUBLICATION Page 3 of 56 Appendix 3 Biographical summary of the independent reviewer ................................... 56 FOR PUBLICATION Page 4 of 56 1 Introduction 1.1 Context of the serious case review 1. This serious case review examines the appropriateness of professional support given to a 15 year old child (referred to as Perry for the purpose of the review1) who was diagnosed with a serious injury in April 2015 arising from emotional abuse and neglect. 2. Finalisation of this serious case review and publication of this overview report was postponed pending the outcome of the parallel criminal process associated with the events and information described in this report. The father, with whom Perry and the three other siblings were living up until 2015, was convicted in January 2017 on four counts of neglect and was sentenced to four years imprisonment in late February 2017. Up until that point it had not been possible for the independent reviewer or for any other member of the review panel to have any contact with Perry or any sibling or with either of the parents. This was at the request of the Crown Prosecution Service and of the police to avoid compromising what had been a long investigation. After the criminal proceedings had been concluded, Perry and mother agreed to a meeting with the independent reviewer and the Nottinghamshire Safeguarding Children Board Development Manager in late April 2017 and the finalisation of this report. 3. In the spirit of candour, the nature of the injury to Perry, occurring as result of extended poor physical care and hygiene that was in plain sight of several people and organisations, put this into the category of an injury that could and should have been prevented. Several professionals recognised that neglect was a serious threat and several individuals were working diligently and beyond the remit of their professional roles to improve Perry’s circumstances over several months. Some other professionals did not share the same level of concern as others. 4. The review’s task, in compliance with government guidance set out in Working Together to Safeguard Children (2015), is to address why, despite concerted effort on the part of individual professionals, it was not more effective and what can be done to improve future arrangements and inter-agency working and to better safeguard and promote the welfare of children. 5. A key learning message from this review is the importance of all professionals understanding and having the confidence to use and to navigate the relevant escalation processes to ensure that the most appropriate response is being given by the correct professionals in a timely fashion. Individual professionals can become overloaded or disorientated by a variety of factors that can include workload pressures as well as for example the cognitive and emotional challenges associated with dealing with the complex and chronic neglect2. This was a parent who appeared 1 To help give confidentiality and privacy to the children, there is no reference to the gender of any of the siblings. Perry is a unisex name. The usual pronouns of ‘he’ or ‘she’ are substituted with ‘they’ or ‘their’ for example (and the subsequent impact on grammatical convention is acknowledged). 2 Chronic neglect being is defined and understood as one or more needs basic to a child’s healthy development not being met, the neglect is perpetrated, by commission or by omission, by a parent or caregiver and the neglect happens on a recurring or enduring basis. FOR PUBLICATION Page 5 of 56 to the various professionals to love his children despite his haphazard parenting, the quality of which he appeared able to improve temporarily when sensing there was an escalation of likely intervention, for example through the possibility of court action or other measures. 6. Another key learning message is that whatever the motive or circumstances of a child’s neglect, it can pose a serious threat of emotional and physical harm, and in a minority of cases can even be life threatening. 7. The review describes and analyses the extent and quality of contact and involvement of services with Perry and the three siblings who had been the subject of historical concerns about neglect. There had been a child protection plan between 2010 and 2012 as well as involvement through child in need plans up until December 2012 and the case being formally closed by children’s social care services in January 2013. 8. For the purpose of clarity the use of acronyms is kept to a minimum that is possible. Family members are referred to by their relationship to Perry such as mother, father or sibling. The eldest sibling is Sibling 1 and the youngest of the four siblings is Sibling 3. Perry is the second eldest. Professionals are referred to by their roles such as teacher, school nurse, GP, police officer or social worker for example. Four adolescent males (Boy 1 through to Boy 4) are also referenced in the report and their relationships and the significance for including in the report is described at the relevant points. 9. Two areas are identified in the report. Nottinghamshire is where the children lived with their father and the majority of services contributing to this review are located in that county. School 1 is a primary school and School 2 is a secondary school both of which are located in Nottinghamshire. Derbyshire is the second area identified. Sibling 2 attended a secondary school (School 3) in Derbyshire and there was involvement by the multi-agency team (MAT), education welfare and school nursing services. 10. A third area is generically referred to as Humberside. This is the area where mother lives and where the siblings have moved to. In the interests of giving the siblings confidentiality in their new location and the fact that the review is not focussed on any significant input from that area, the particular local authority is not identified in this report. 1.2 Rationale for conducting the serious case review 11. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires local safeguarding children boards to undertake a review in accordance with the criteria and procedures that are set out in chapter four of Working Together to Safeguard Children (2015). 12. A local safeguarding children board should always undertake a serious case review when a child has been seriously harmed and abuse or neglect is either known or is suspected and there is cause for concern as to the way the authority, the local safeguarding children board or other relevant persons have worked together. FOR PUBLICATION Page 6 of 56 13. The circumstances of Perry’s injury and admission to hospital was discussed by the serious incident review sub group of the Nottinghamshire Safeguarding Children Board on the 9th September 2015. The panel agreed that the criteria for a statutory serious case review were met. The serious harm to Perry appeared to be the result of neglect and there were issues to be examined in regard to what different organisations had known about Perry. 14. The recommendation was ratified by Chris Few, the independent chair of the Nottinghamshire Safeguarding Children Board, on the 14th September 2015. Ofsted and the National Panel were advised of the review being commissioned on the 16th September 2015. 15. The expected timeline for completion of a serious case review described in national guidance is six months from the date of commissioning. The timeline for completion of the review is determined by the independent chair of the local safeguarding children board who can take account of factors that may have an impact on the timeline. This includes parallel processes such as the police investigation of the circumstances of Perry’s injury described earlier in the report. 16. The overview report is the property of the Nottinghamshire Safeguarding Children Board as the commissioning board and will be the final and public record when it is published. 1.3 The methodology and scope of the serious case review 17. The review was conducted from the outset on the basis that this overview report would be published in full and without redactions. 18. The methodology used to conduct the serious case review draws on best practice in proportionately balancing the need for sufficient rigour in regard to investigating the circumstances of professional involvement with Perry and siblings given the public interest issues associated with the case3, taking account of the parallel criminal investigation and securing the level of appropriate and informed reflection about the complex human, legal and organisational systems for the purpose of learning and improvement. 19. The methodology combined an investigatory model for collating information from agencies with elements of a learning review model for analysing the latent underlying conditions and contributory factors that are influencing local systems and practice and reflected in the final chapter of the report which describes findings and recommendations. 3 The public interest relates to the circumstances under which the injury developed over time to a child who was the subject of extensive multi-agency contact and there had been longstanding concerns about neglect that had involved the use of child protection plans historically and is the subject of a statutory serious case review. FOR PUBLICATION Page 7 of 56 20. The timescale of the review is from the beginning of 2013 when Perry and the three siblings were no longer subject of either a child protection or child in need plan until Perry’s admission to hospital in April 2015. 21. All services who had contact with Perry were required to provide a chronology of relevant and significant contact or information. 22. Organisations who were identified as having significant involvement with Perry were required to provide a written account of contact and agency analysis against terms of reference set out in the appendix that included an appraisal of learning for that service together with any action for implementing learning and improvement. These reports were provided by the following agencies: a) Nottinghamshire Healthcare NHS Foundation Trust (NHCFT) regarding the provision of school nursing services; b) Nottinghamshire Police in regard to contact with the family and associated people and the criminal investigation of the circumstances of Perry’s injury; c) NHS Nottingham West Clinical Commissioning Group (CCG) in relation to the delivery of GP based health care services; d) A report was provided on behalf of the three schools and associated educational support services in relation to Perry and siblings; e) Nottinghamshire Children, Families and Cultural Services Children’s Social Care in relation to contacts, referrals and assessments in relation to child in need and child protection plans; f) Nottinghamshire Supporting Families Service who attempted to provide support in the summer of 2013; g) Nottinghamshire Youth Service in regard to Sibling 1, Perry and Sibling 2’s respective participation in activities at a local young people’s centre between January 2013 and November 2014; h) Nottingham University Hospitals NHS Trust (NUHT); provided hospital treatment to one child in January 2013 (Sibling 3) for a broken toe before the admission of Perry in April 2015. 23. CAFCASS4 provided a summary of information about their brief contact in 2010 when father made a private law application to the family proceedings court in 2010. Information was sought from the multi-agency team (MAT) and school nursing service in Derbyshire. Information was also provided by the school in Derbyshire. 4 The Children and Family Court Advisory and Support Service. FOR PUBLICATION Page 8 of 56 24. Information was collated about; a) The extent to which circumstances of the children were sufficiently known about and understood in regard to the needs, views, wishes and feelings of the children commensurate with their age and understanding; b) The extent to which evidence of neglect was observed, recognised and understood by professionals in regard to promoting the safety and well-being of the children; this includes the clarity of understanding and knowledge about any relevant and significant history in regard to similar concerns over a longer time period; c) The quality and rigour of professional response at a single and multi-agency level; this will include how significant information or incidents were dealt with through contact, assessment or enquiry and action planning; d) The level of understanding about any factors related to culture, cognitive understanding or disability that had a bearing on engagement and interaction between the children and their father with different professionals; e) The quality of advice, support and supervision for professionals and the oversight of arrangements for children at risk of significant harm; f) Identification of any issues in regard to the capacity or resources of agencies across the continuum from delivering appropriate early help through to more assertive and statutory intervention when required. 25. The panel supporting the work of the review was comprised of senior and specialist agency representatives to oversee the collation and analysis of information and outcomes of the review and reporting to the Nottinghamshire Safeguarding Children Board. The panel representation encompassed senior and specialist professionals from children’s education and social care services, criminal justice and health organisations. Information is included in an appendix to this report along with the relevant biographical details of Peter Maddocks the independent reviewer and author of this report. 1.4 Information about Perry and the family 26. Perry has three siblings, one of whom is older and two are younger. Father is long term unemployed. The area that Perry was living when with father is a predominantly white population as is Nottinghamshire as a whole compared to England. The area does not have a high concentration of deprivation. 27. Surprisingly, and in spite of the statutory involvement through a child protection plan and child in need plans, little information had been recorded by local services regarding the family circumstances before moving to Nottinghamshire or about the mother or the reason for the separation and her absence from the children’s lives. The school nursing service in Derbyshire who saw Sibling 2 at drop in sessions at the school FOR PUBLICATION Page 9 of 56 had the only record of any of the children regarding contact with mother which described them as having occasional contact which they looked forward to. 28. The parents have been separated since 2008/09 (the exact date is not recorded in documentation provided to the review) when the children were brought to live in Nottinghamshire in a rented house by their father who has an extended family living in the county. The parents had met when father was working in the Humberside area. The circumstances of the separation were not recorded in any assessments; mother told the independent reviewer that father left Humberside with the children after their relationship had broken down. Mother was staying with friends when father took the children to Nottinghamshire. According to mother the relationship had been in difficulty for several years and the pregnancies and birth of the children had been an effort to keep the relationship going. Father refused to allow any contact and had, according to Perry and to mother, told the children that mother did not want any contact with them. He threw away any birthday and Christmas cards sent to the children. He would visit friends in Humberside but never made arrangements for the children to see their mother during those visits. Perry and sibling 2 who met with the independent reviewer say that they just stopped asking about their mother. 29. Mother was living on benefits at the time of the separation and says that she had no help from any agency to secure a large enough property to be in a position to have the children returned to her. When the children returned to mother’s care in April 2015 she was able to acquire a four bedroom property within weeks. 30. While Perry and the siblings were living in Nottinghamshire mother was sent minutes of meetings such as the child protection conferences but no direct contact was discussed. Mother was told that services were working with the children and their father in Nottinghamshire; no help was provided to promote contact or to seek the views of the children or explore returning them to Humberside. Mother had contact with several different social workers although felt that it was only the final social worker in Nottinghamshire who spoke to her in clear terms and made things happen. 31. Perry’s family’s cultural and ethnic heritage is white British and English is their language. There is no record of any religious affiliation. There is no record of any assessed learning or physical difficulty or disability on the part of either parent (although in November 2014 father referred to having learning difficulties but this does not appear to have been followed up and explored). Apart from some mild post-natal depression for mother, there is no record of any mental health difficulties or illness and neither parent have any record of misusing alcohol or drugs (although there are references later in the report to some unresolved queries about father’s possible use of alcohol and drugs). 32. The children were the subjects of a child protection plan for 18 months between December 2010 up to July 2012 when the plan was stepped down to a child in need plan that ended in December 2012 (although the case was not formally closed by children’s social care services until January 2013). Concerns were focused on neglect. More recent referrals in 2014 had resulted in further involvement by social workers FOR PUBLICATION Page 10 of 56 and other professionals through a child in need plan. There had been allegations of sexual assault of one of the siblings by a young adult living in the household and there were concerns about the continuing poor condition of the home and the physical care of the children. 33. Sibling 1 the eldest sibling left School 2 in July 2014 and was not in employment or further education. Perry attended the same school. Sibling 2 the third sibling attended School 3 (located in Derbyshire) having transferred in September 2013 from School 2. Sibling 3 the youngest sibling attended a junior school (School 1) in Nottinghamshire. 34. When Sibling 1 arrived from Humberside they came with a partially completed formal assessment of special educational needs. Nottinghamshire ‘adopted’ this assessment and issued a statement of special educational needs describing Sibling 1 as having ‘significant learning difficulties in all areas.’ Sibling 1 was placed at School 1 with additional support. At transfer to secondary school father expressed a wish that Sibling 1 went to School 2 and this was agreed. At School 1 and School 2 the SENCOs5 worked with class teachers and education support services to plan and monitor Sibling 1’s educational progress. Sibling 1’s progress appears to have been in line with their abilities. Sibling 1’s statement was discontinued in April 2011 but additional support continued to be made available. 35. Perry also has general learning difficulties. Perry was given support throughout their time at School 2 and appears to have made educational progress commensurate with their abilities. The implications of Perry’s learning difficulties on the events leading to their hospital admission are discussed later. 36. Sibling 3, the youngest sibling, has moderate learning difficulties and followed an individualised curriculum at school with both academic and social targets. Sibling 3 had substantial support within school and Sibling 3’s needs were planned and monitored through an individual education plan. School maintained an individual education plan that was regularly reviewed and Sibling 3 had additional support funded from the High Level Needs Panel. 37. Sibling 2 the second youngest sibling is described by staff at School 3 as a child of around average ability. With appropriate attendance and support the school expected Sibling 2 to be capable of achieving five GCSEs at A-C level. 38. All four siblings appeared to enjoy attending their respective schools although there were concerns about Sibling 2’s late arrival (when taking the younger sibling to their school). There were attendance issues for Sibling 2 in 2014 and for Perry in March 2015 in the weeks prior to the diagnosis of injury which is described in the narrative of the next chapter of this report. 5 Special education needs coordinator (SENCO) is a teacher who is responsible for special educational needs at school. All schools have a SENCO and they work with other teachers and with parents to make sure that pupils with special educational needs get the appropriate support and help they need at school. FOR PUBLICATION Page 11 of 56 39. There have been three different young males living in the household. Limited information was recorded about any of these males in regard to Perry and the three siblings although there was significant involvement by children’s social care services with two of the males. In addition, the siblings had contact with unknown adult males outside of Nottinghamshire via social networking websites. Further information is included in the following narrative summary. FOR PUBLICATION Page 12 of 56 2 Summary of contact by services and significant events 2.1 Summary prior to January 2013 40. Historical records held by the universal health services describe a history of concerns about children’s developmental delay, neglect and not going to health appointments for the children when they were living with both parents in the Humberside area before the parents separated and father and the children moved to Nottinghamshire in 2009. Further information is included at the end of this chapter given to the independent reviewer as a result of inquiries for this review through the Humberside area’s local safeguarding children board. 41. Perry and the siblings have been known to universal and specialist services since coming to live in Nottinghamshire. There were recurring concerns about the quality of father’s parenting and the poor home conditions and services attempted to work with father. 42. In December 2010 the circumstances of the children were discussed at a child protection conference which decided that the children were at risk of significant harm due to the poor physical conditions of the home and the emotional neglect of the children. In July 2011 the continuing lack of improvement led to a decision to invoke the public law outline (PLO) process with a view to putting the matter before a court6. Legal advice was that an emergency application would fail for lack of evidence. There is no comment recorded in regard to an application by notice. 43. The invoking of the public law outline (PLO) and the prospect of legal proceedings apparently generated some progress and in July 2012 it was judged appropriate to step down from a child protection plan to a child in need. The review child protection conference that made this decision was not quorate being attended only by the social worker, a SENCO from one of the schools and father7. A child in need meeting was scheduled for September 2012. No minutes are recorded for this meeting although there is evidence of the meeting having taken place. 2.2 January 2013 and CAF 44. In January 2013 children’s social care services formally closed their involvement on the basis that father had achieved ‘sustained significant improvements’. There was 6 The PLO is a national procedure for when social workers concerned about the welfare of a child may be thinking about taking the case to court so that they can ask the court to make orders to protect the child. In most cases (that do not involve emergency protection for example) the Public Law Outline requires the social workers to arrange a meeting with the parent(s) to see if it is possible to reach agreement about what needs to happen to protect the child from harm, so that court proceedings can be avoided if appropriate and if not will then begin a formal process of giving notice. The PLO falls outside of the scope of the review’s timeline although comment is made later in the report. 7 The NSCB procedure requires as a minimum that at every child protection conference there should be at least two other professional groups or agencies in addition to children’s social care that have had direct contact with the child who is the subject of the child protection conference. FOR PUBLICATION Page 13 of 56 continuing support primarily through the school using what was then called the common assessment framework (CAF). Nationally, the CAF has subsequently been replaced by early help arrangements. These are usually, although not exclusively, deployed before difficulties escalate to requiring more intensive involvement such as child in need or child protection. The use of CAF in long-term neglect cases can unwittingly disguise inadequate care. 45. The CAF was opened on the 14th February 2013 by the SENCO at School 2. This described father as ‘caring, loving but struggling with domestic chores’. The siblings were described as ‘self-sufficient and able to take care of themselves in terms of washing and dressing’ although it was noted that one of the siblings had ‘matted hair and grubby clothing’. 46. A multi-agency meeting at School 2 on the 14th February 2013 was attended by the school nurse and was informed that the youngest sibling (Sibling 3) was needing help with self-care such as showering and hair brushing and that father was amenable to this help through School 1. 47. The meeting was told that the case was closed to social care and that school were going to lead on a CAF. It was agreed that a CAF review would be held on 27th March 2013. That review appears to have been postponed until the meeting in June 2013 that is described in the later paragraph below. 2.3 Referral to MASH and social work assessment 48. On the 5th June 2013 a youth worker made contact with the MASH (multi-agency safeguarding hub) to discuss concerns about the neglect of Perry and Sibling 1 whose spectacles had been broken for six weeks; both of the siblings’ clothing was dirty which made them the target for bullying. Father had also cut Sibling 1’s hair. Sibling 1 was also talking with a 60 year old male on a social networking website. The school was reported as having similar concerns. 49. There was discussion in the MASH with the former allocated social worker who advised the MASH that there was an ongoing CAF in place with the school acting as lead professionals. It was recorded that contact could not be made with school (although no reason is recorded). It was judged that the information was not ‘new’, the situation was of a ‘chronic nature’ and that the family function at a ‘low but adequate level’. It was recommended that the CAF would continue. 50. On the 10th June 2013 the MASH wrote to School 2 informing them about the concerns passed on by the youth worker regarding ‘Sibling 1’s unkempt appearance and possible contact with an older male’. The letter confirmed that MASH had decided to take no further action and asked the school to ‘address these concerns within the CAF’. 51. Two weeks later on the 19th June 2013 the youth worker made a second enquiry with the MASH. Sibling 1 had disclosed being hit by father the previous evening and had FOR PUBLICATION Page 14 of 56 also been pushed down the stairs. The spectacles were still broken. The siblings were suffering bullying and there were concerns about ‘mild learning difficulties and head lice’. 52. Three days later, on Friday the 21st June 2013, the team manager agreed that an assessment was required. The referral information recorded in MASH included a ‘copy and paste’ of the original concerns at the initial child protection conference in 2010 (and therefore querying the sustainability of father’s ‘improved parenting’). There is no reference to the social network contact with a much older male (and the implications for whether this was an indicator of potential abuse; it represented an inappropriate contact given the absence of any other apparent relationship). 53. A CAF meeting on the 27th June 2013 discussed ongoing concerns about the cleanliness of the siblings’ clothing. Father was invited and expected to attend the meeting but did not and neither did children’s social care services. The school nurse had phoned father to remind him about the meeting although had not got an answer. The school nurse was identified as the lead professional for the CAF. The school nurse updated the information in the CAF to create a ‘family CAF’ which was sent to all the professionals on 3rd July 2013. A further meeting was scheduled for 12th September 2013. 54. A social worker made a home visit on the 4th July 2013 for the purpose of speaking to father and the children in regard to the assessment that had been decided by the team manager two weeks previously. The social worker reported that that there was no disclosure of physical harm during the visit and that the children stated that father did not hit them. It is not clear if all the children were spoken to or whether father was present throughout during their discussion. 55. The social worker spoke with the school nurse on the same day and described finding the home cluttered and bedding that was dirty with mattresses that needed replacing. The school nurse had already been helping to clear clutter from the home (and is an example of a professional going beyond the remit of their role and considering the size of caseload for a school nurse). The social worker raised a query about Sibling 1’s level of learning and understanding. Father had raised whether Perry’s two other siblings had ADHD (attention deficit hyperactivity disorder) although the school nurse had no information about such a diagnosis although there was ‘global developmental delay’. The social worker planned to recommend that a core assessment should be completed; this would require allocation to the area social work team. 56. Coincidentally, father consulted the GP on the same day (4th July 2013) in the company of his mother presenting with symptoms of tiredness and a low mood. His mother suggested that he needed anti-depressants. Blood tests revealed no physiological illness and although he was offered a follow up consultation with the GP he did not attend. There was no contact between children’s social care and the GP and indeed no requirement for such contact to be made. FOR PUBLICATION Page 15 of 56 2.4 Referral to the Supporting Families Service 57. A referral was made on the 5th July 2013 to the Supporting Families team (which was the targeted support service which no longer exists but had then just been established in October 2012. It is now a Family Service incorporating early help functions)8. The social worker apparently made the referral, in consultation with the health visitor, in regard to improving home conditions, developing boundaries and guidance, social isolation, developing routines and providing advice and support in regard to sexual health and development. 58. A joint visit was made to the home by the Supporting Families district co-ordinator and the social worker on the 23rd July 2013. They found the house to be ‘cluttered, dirty and untidy’. Father agreed that improvements needed to be achieved in regard to the children’s hygiene and he agreed to work with the Supporting Families service. 59. The core assessment was to be undertaken by an area based social worker who, according to a phone discussion on the 24th July 2013 with the school nurse, planned to close the case when the assessment was completed feeling that a CAF should be an appropriate level of help for the family. The school nurse did not know what the circumstances of the referral had been or who had made the referral. 60. On the 29th July 2013 the first visit to the home by the Supporting Families service found the home to be even more untidy than on the initial visit with litter and food debris in the lounge. All the children were present with their father and the siblings were described as being ‘adequately presented’. All of the siblings were seen on their own as well as with their father and they discussed improvements they wanted to achieve. When the family support worker made the follow up scheduled visit to the home on the 5th August 2013 they could not get a response but left a card. The worker attempted a further visit the same day but again with no response. The worker informed the social worker and apparently there were further unrecorded and unsuccessful attempts made to visit. 61. In July 2013, according to school nursing records, a transfer out to another school was completed for eleven year old Sibling 2 to move from School 2 to School 3 in Derbyshire in September 2013. 62. This was confirmed when the assessment was completed on the 23rd August 2013. The assessment noted that school attendance was good, there were no concerns about the siblings’ physical presentation and there was ‘acceptable’ improvements in the home conditions. The assessment noted that a referral had been made to the 8 The Supporting Families Service had a prescribed remit to deliver improvements to families with children who presented with at least three of the four factors that were being targeted by the government’s Troubled Families programme. The factors were; receipt of state benefits as a result of not working; children persistently absent/excluded from school; children involved in anti-social behaviour; a local criteria which in Nottinghamshire included social care involvement. The Troubled Families service has continued into a second phase and been incorporated into early help provision. FOR PUBLICATION Page 16 of 56 Troubled Families’ Service (which father never engaged with). The assessment recommended that a CAF was appropriate. 63. When the children returned to school in September 2013, although there was some improvement in the cleanliness, some clothing was ‘inappropriate’ (this apparently referred to size). Hair cleanliness also remained an issue. 64. On the 9th September 2013 the siblings (with the exception of Sibling 2 who at their request was now attending school in Derbyshire) were discussed with the GP at a ‘Red Card’ multi-agency family liaison safeguarding meeting9. There are no written records of that discussion. 65. On the 18th September 2013 the Supported Families service spoke to the head teacher for the junior school who confirmed Sibling 3 was attending regularly although there were continuing concerns about hygiene. 66. On the 4th October 2013 children’s social care services were informed by the Supporting Families service that they had closed the referral as the father had not responded. 2.5 Involvement of MAT and education welfare service in Derbyshire 67. On the 6th March 2014 Sibling 2’s school (located in Derbyshire) requested support from the Derbyshire education welfare officer located within the multi-agency team (MAT) for the locality (there are local MAT services located across Derbyshire). Sibling 2’s school attendance had been poor for some time and had declined to just over 70 per cent by the end of February 2014. The Department for Education define school attendance of less than 85 per cent as representing persistent absence and therefore a matter for concern. 68. The referral from the school reported that they had tried to provide support to father who had told them he had three other children to look after and had admitted finding it ‘hard’. The school reported that no improvements had been achieved and that father was not responding to telephone calls or to letters. The school stated in the referral that they had been in contact with School 2 to inquire if they had observed any concerns in regard to Sibling 1 or Perry. School 3 had been told that there were no concerns about the older siblings (this contact had been made in February 2014). 69. The education welfare officer made an unannounced home visit on the following day to discuss the possibility of Sibling 2 moving to a school closer to home. There is little 9 The multi-agency family liaison safeguarding meetings (also referred by some people to as Red Card meetings) are held between GP’s, health visitors and school nurses to discuss children where there are identified concerns and take place within agreed timescales that are held at least quarterly and are deemed as good practice. Practice nurses should be involved and any discussion should be documented within the child’s electronic patient SystmOne record and for this record to be flagged. There is further guidance being developed in the county which is discussed in the final chapter. FOR PUBLICATION Page 17 of 56 detail recorded of that visit or even who was present. There is no record about home conditions, adverse or otherwise. 70. The education welfare officer made a follow up home visit ten days later on the 17th March 2014 and spoke with father about achieving an improvement to the morning routines in regard to Sibling 2 arriving at school on time. There was another discussion about the option of Sibling 2 moving to a school closer to home. Father was warned that if school attendance did not improve there would be further action. The record is unclear about what action was proposed although the inference is enforcement action through the court. There is no record of what the condition of the home was like. There was no further contact by the education welfare officer before they closed the case on the 19th June 2014 after Sibling 2’s school attendance had improved. 71. Just over three weeks later the school emailed the education welfare officer to report further concerns about Sibling 2’s attendance at school which had again declined (to 86 per cent) and homework was not being completed. The case was reallocated to another education welfare officer. There is no explanation about why a different officer was allocated the referral given the recent contact in June 2014. School 3 reported that Sibling 2 was not attending school due to stomach pains and headache and had been throwing their lunch away. An attendance warning letter was issued to father on the 8th July 2014. 72. The letter was followed up by a prearranged visit to the home by the education welfare officer to discuss attendance and strategies for getting Sibling 2 to school on time. Perry was seen during the visit and was described as being well presented. There was no further contact with the education welfare officer until late October 2014 when school again were reporting attendance issues. 73. On the 13th September 2014 (a Saturday), the emergency duty team (EDT) received a fax from the Nottingham City EDT. The fax concerned a referral from an anonymous referrer who knew the family, believing that Sibling 2 was in a relationship with an 18 year old male and that on a social networking internet site there had been a mention of rape. 74. The Nottinghamshire EDT worker telephoned the referrer in order to clarify details. The referrer stated that Sibling 2 was 12 years old and that her boyfriend (Boy 4) was 18 years of age and had previously been in a relationship with Sibling 1. The referrer stated that there were pictures on the social networking site of Boy 4 and Sibling 1 and of Boy 4 and Sibling 2, and that there were comments about rape and ‘ragerape’. 75. The EDT worker looked at the internet pages and felt that the words were used in ‘the context of slang’. There were photographs but ‘they were not of concern and there was nothing to suggest rape or a relationship between Sibling 2 and Boy 4 although Sibling 2 did have a picture of a male asleep’ with a caption ‘Boy 4 sleeping awww’. The matter was discussed with the EDT team manager who stated that the case needed to be investigated further by the district team. FOR PUBLICATION Page 18 of 56 76. On 15th September 2014, the team manager of the district team recorded that the social worker needed ‘to triage, speak with parents’ (sic) and it was rated amber priority as there was ‘no evidence to believe that Sibling 2 was at risk of immediate harm’. Attempts were made that day to telephone the father but were unsuccessful. It was therefore agreed with the team manager to write to father asking that he make contact with the team. It was recorded that there was ‘not enough evidence to progress otherwise’. No further action was taken and father did not make contact with the team. 77. Perry who had been a regular attendee at the local young people’s centre since December 2012 stopped going to the centre in October 2014. Sibling 1 who had also been a regular attendee since January 2013 stopped her attendance in November 2014. Sibling 2 had been a less regular attendee. 78. On the 28th October 2014 the education welfare officer and a MAT worker (multi-agency team) from Derbyshire made a home visit. The education welfare officer had attempted to visit four days previously but the door was not opened despite people being thought to be inside. 79. Sibling 2 had a bandaged knee and was limping. The lounge was described as cluttered, the carpets were dirty and the house smelt musty. Father agreed to let the two practitioners look around the house. Sibling 3’s ‘bed’ was a dirty mattress with a duvet and no cover. Sibling 3 said one of the siblings slept on the settee in the lounge. During the visit, Sibling 2 and Sibling 1 were in a bedroom with ‘a male friend’ who was not identified playing a computer game. 80. Sibling 3 was dirty and their hair was matted. In addition to the general clutter and dirt there were trip hazards all around the house. Father showed little engagement with the concerns. He did not want support and he declined subsequent contact with the early help service that was arranged after the visit. 81. A further visit on the 31st October 2014 by the education welfare officer raised ‘further concerns about conditions’. This was discussed with a manager in the MAT who instructed that a referral should be made to the MASH in Nottinghamshire. This was not actioned until the 13th November 2014. 82. The head teacher for the youngest sibling asked the school nurse to see Sibling 3 on the 11th November 2014 because of concerns about home conditions, poor hygiene and persistent head lice. Sibling 3 reported that conditions at home had got ‘messy again’ and that Sibling 2 was doing all the clearing up and Sibling 1 was bringing Sibling 3 to school. Sibling 3 was dressed in clean clothes although their hair was greasy and there was still evidence of head lice. According to the school nurse’s record the school were aware that the Derbyshire Targeted Support Service had made a referral to MASH (two days later on the 13th November 2014). 83. The following day, 12th November 2014, Sibling 2 told staff at School 3 that Sibling 1 had been raped by their boyfriend (Boy 1) during the summer school holiday (when FOR PUBLICATION Page 19 of 56 aged 16 years old). He had been allowed to stay in the house by their father. Boy 1’s sibling (Boy 2) had also been staying at the house and the two males had been ‘going out’ with Sibling 1 and 14 year old Perry. It was reported that initially Boy 1 had been going out with Perry but had turned his attention to Sibling 1. 84. Sibling 2 also reported that a pair of 11 year old Sibling 3’s knickers had been found in father’s car after Boy 1 had been working on the vehicle. 85. When the assistant head (who was also the safeguarding lead for the school) phoned father he had said that he believed that there had been ‘consensual sex’ involving 16 year old Sibling 1. Father said that that the matter had been dealt with by the parents and that the police had not been informed. 86. The school reported this information to the MAT and to the Nottinghamshire MASH on the 12th November 2014. The school also reported concerns about the home conditions. The school’s referral also reported that one of the siblings had been seen (by a targeted support work during a home visit) to kiss father ‘inappropriately on the mouth’. Children’s social care services decided that an initial assessment was required. 2.6 Referral to Nottinghamshire MASH from Derbyshire MAT 87. A referral by the Derbyshire MAT to the Nottinghamshire MASH was sent by secure email on the 13th November 2014. The referral states that the parents had separated six years previously. Father reported that he had learning difficulties and was taught how to do things by his father. Father had also described Sibling 1 and Perry having learning difficulties and that Sibling 3 had ‘global delayed learning’. The referral described a range of concerns in regard to neglect and father’s lack of engagement with help and support. 88. On the 17th November 2014 a youth worker had reported that Sibling 1 had disclosed that Perry had taken naked photographs of them self and sent the images to a 19 year old in the south west of England. 89. The social worker who made a home visit to speak to the children on the 19th November 2014 was prevented from speaking to Sibling 1 by father on their own. Very poor home conditions were described, and it was difficult to access the downstairs rooms. The social worker discussed with father the concern regarding Sibling 2 having reported that 16 year old Sibling 1 had been raped. Father stated that Sibling 1 was not raped but that there had been ‘sexual activity’ with a 17 year old who was a boyfriend. Father insisted that he had spoken to the boy’s parents and had ‘sorted’ the situation. He refused to allow the social worker to speak to Sibling 1 and asked the social worker to leave the property. 90. On the 25th November 2014 a strategy discussion between the police and children’s social care services agreed that children’s social care services should undertake a single agency enquiry ‘unless Sibling 1 wished to speak with the police’. It is not apparent that the obstruction of the social worker by father was discussed. FOR PUBLICATION Page 20 of 56 91. On the 2nd December 2014 a parent of another child at the school reported an online posting by Perry on a social networking website about having sex with dad. The social worker spoke with Perry who reported that it was only Sibling 1 who used the account (the siblings apparently all had access to each other’s online accounts). 92. On the 6th December 2014 a referral was sent to Nottinghamshire Police from Derbyshire to report an historical allegation that Sibling 3 had been indecently assaulted. The allegation had originated with Boy 2 telling his then girlfriend (Sibling 1) in September 2014 that Boy 1 had indecently touched Sibling 3. 93. This information was logged against the name of the male rather than Sibling 3 and therefore was not known about until the review identified the third party reference to it. There is a discrepancy in the record of information between the police and children’s social care services about this information. The police have described written and telephone communication about the allegation of indecent assault which was not explicitly recorded in children’s social care services. What has been established is that Sibling 3 along with the siblings were interviewed by a social worker and no disclosure or allegation was made about Boy 1. It is also apparent that the specific allegation was not explored in any interview. 94. The information was the subject of a strategy discussion between the police and children’s social care services although there was not an agreed record of what was discussed and agreed. 95. The police and children’s social care services concluded in December 2014 that Sibling 1 had not been raped although had experienced sexual contact that had ‘caused distress’. Children’s social care reported that all of the children had been spoken to individually at school although there is no detail recorded. Sibling 1 and father did not want the police to be involved. 2.7 Completion of assessment and allocation as CIN December 2014 96. The core assessment that was completed on the 22nd December 2014 following the s47 enquiries noted the number of previous assessments in regard to neglect and poor home conditions and that it was a persistent and continuing cycle of limited improvement. There is reference to Sibling 1 and Perry using the internet (although no detail is recorded or evidence of referencing back to the transfer of inappropriate photographs over the internet). Father was also said to be using cannabis although, again, no detail is recorded. 97. It was decided that an initial child protection conference should be convened if there were ‘any issues with engagement or concerns regarding home conditions and parenting boundaries’. 98. The assessment recommended that a child in need (CIN) plan should be developed; this was written the same day and apparently as a desk based activity (as opposed to FOR PUBLICATION Page 21 of 56 working with father, children and others). The plan identified the following requirements; the siblings to be ‘presented appropriately in order for them to feel confident and prevent social isolation and resolve recurring head lice, self-protection on the internet, self-protection around relationships, self-esteem and vulnerability, building trusting relationships to gain the children’s wishes and feelings via direct work, to supervise the children on the internet, to attend school on time, consider father’s low mood and his learning capacity, management of the home conditions to an acceptable level and promoting contact with mother’. All of the actions were to be reviewed in six weeks. 99. The case was transferred back to the area social work team where it was allocated on the 29th December 2014. Other professionals were informed of the transfer almost two weeks later on the 12th January 2015. 2.8 February 2015 concerns increasing about neglect and Perry feeling scared of males in the house 100. There was no contact by children’s social care services with the family until February 2015. A letter sent on the 11th February 2015 to arrange a social worker’s visit to the home for the 20th February 2015 referred to attempted contact by phone although there are no dates recorded. Father refused to allow the social worker into the home on the 20th February 2015 because he ‘had company’. There is no further information about who this was. 101. A follow up visit on the 23rd February 2015 found the home conditions to be poor. The smell in the house was ‘very strong’ with a general body odour and the children were all in dirty unwashed clothes. The social worker attempted to go through the child in need plan that had been written by the social worker in December 2014 but father minimised the concerns. 102. Further concerns that were recorded during February 2015 included Sibling 2 arriving late at school, the children being in dirty clothing and smelling and being socially isolated by peers, being hungry and their (unsupervised and unrestricted) use of the internet. Father was also reported to be misusing alcohol (although nothing specific is recorded). He made clear he had no intention of working with social workers and would not attend meetings. He initially gave consent for the social worker to work with the children although later stated that the children wanted nothing to do with the social worker. The concerns were discussed at an ‘informal’ multi-agency meeting on the 4th March 2015 that was not attended by father. 103. A supervision discussion between the social worker and their manager on the 12th March 2015 agreed that if father was unwilling ‘to address the concerns a strategy meeting would take place’. 104. On the 24th March 2015 a member of School 2 raised concerns because Perry was smelling strongly of urine and had greasy hair. Perry was walking ‘as if in pain’. Perry reported that Sibling 1’s boyfriend (Boy 3) was always at the house and ‘lies on top of FOR PUBLICATION Page 22 of 56 the bed with Sibling 1’. Perry said that he was calling Perry names and alleged that he was asking Perry to have sex with him. Perry disclosed feeling scared of him and hated going home when he was there. 2.9 Contact by school with children’s social care services 105. The information was reported to children’s social care services by the senior teaching assistant. The social worker was on leave and the teaching assistant therefore asked to speak with the duty manager who was ‘not available’. It was a support officer who dealt with the telephone contact and advised the school that the social worker was scheduled to visit on their return from leave in nine days’ time and that there were plans to convene a child protection conference. This reference to plans to convene a child protection conference does not appear to have been based on advice or direction from a social worker or a manager. 106. Later the same day the deputy head teacher who was on gate duty at the end of the day observed Perry ‘clearly in pain, appeared to be shuffling along’. 107. Perry returned to school the following day and was still in considerable pain. Perry had not washed or changed their clothing and was walking with difficulty. Perry said that they had a pain in their stomach and confirmed that father had not given them any medication to manage the pain or made arrangements for Perry to see the GP. 108. The school decided that Perry needed to be taken to the hospital emergency service by a teacher for assessment and treatment and informed father accordingly. 2.10 Perry presented at hospital by school 109. Perry, accompanied by a teaching assistant, was presented at the hospital with abdominal pain and was at the hospital for some nine hours having first of all been seen in the emergency department and then transferred to the paediatric ward to provide further time for assessment. Perry was examined around the abdomen but no clothing was removed. Perry was diagnosed with a urinary infection and prescribed anti-biotic medication. Perry was examined by a consultant paediatrician who also saw father as well as Perry and discussed the current involvement of social work services. Father who was described as unkempt ‘was unclear’ about why children’s social care services were completing an assessment. There was telephone contact between the hospital and children’s social care service duty social worker although, as previously mentioned, the allocated social worker was on leave. The consultant paediatrician asked to ensure that the social worker made a home visit on their scheduled return from leave four days later. No referral was made to children’s social care. There was no contact between children’s social care services and the school until the 31st March 2015. 110. Perry did not attend school the following day; a home visit was made by the school attendance officer who saw Perry at home with father. Sibling 1 answered the door. FOR PUBLICATION Page 23 of 56 Perry returned to school on the 1st April 2015 saying that they felt better but ‘did smell really awful’. A teaching assistant took Perry home to have a shower and a change of clothing. The teaching assistant spoke with father to point out the very poor hygiene and advised that Perry should be seen by a doctor. Perry was expected to return to school later that day. 111. Children’s social care services undertook a visit to the home the following day, 2nd April 2015, and found the home conditions to be poor and father ‘taking no responsibility’ and was unwilling to work with social workers and refusing to allow contact with the children. He was advised that there would be no option other than to ‘escalate to an initial child protection conference’. 112. A subsequent discussion with the team manager over a week later on the 10th April 2015 agreed that a joint visit would be made to the home with a view to convening a legal meeting to discuss options through the court. The team manager agreed to speak with the service manager. 113. The social worker made a home visit on the 17th April 2015. Perry was in the shower and was not seen by the social worker. The social worker was told that Perry was off school with a urinary infection. Father confirmed that he had not taken Perry to the GP stating that he had bought over-the-counter ‘remedies’. He was advised to contact the GP. 114. The joint home visit that had been agreed over a week earlier on the 10th April 2015 was made on the 20th April 2015 by the team manager and social worker who found conditions to be ‘exceptionally poor’, describing debris everywhere, an infestation of flies, food on the floor, dirty crockery and their feet ‘sticking to the floor’. The smell of urine was ‘overpowering’. The team manager was particularly shocked by the amount of flies in the house. There was nowhere to sit in the living room and there were a number of trip hazards, including a chainsaw on the kitchen floor. The team manager tripped in the hallway. The level of uncleanliness in the kitchen was ‘extreme’; no work top was clear and it looked as if rubbish had just been thrown around the room. One ground floor room was totally full with furniture and clothing and was not accessible. Only the front room and kitchen were accessed during the visit. 115. The social worker stated to the author of the agency report that the father’s demeanour changed during that visit and that the social worker had felt quite intimidated by him. The social worker recalled that the home conditions had deteriorated since the previous visits. 116. Perry had not returned to school effectively since the 25th March 2015 when they had been taken to hospital from school and had not been taken to the GP or any other health centre. 117. Father maintained that he did not need to change anything and was in denial that any of the children were being neglected. He was asked to consider having the children FOR PUBLICATION Page 24 of 56 looked after under a voluntary arrangement (s20 of the Children Act 1989) and was informed that legal advice was to be sought about securing court orders. 118. The team manager and social worker contacted the police to request that photographic evidence was secured; they were advised that taking photographs was not a service provided by the police10. It was agreed that the team manager would convene a strategy discussion. This was done the following day, 21st April 2015 and arranged for the 22nd April 2015. 2.11 Referral to GP 119. Perry was taken to the GP on the 21st April 2015 prompted by the home visit the previous day as well as contact from the school nurse who had phoned to check on whether father had taken Perry to see the GP given the non-attendance at school since the Easter break. The social worker ensured that a GP booking had been made and informed the practice about the home visit and concerns which were entered on to the electronic patient record system. Perry was not physically examined by the GP during the consultation. 120. Perry was unable to produce a sample of urine to be tested (not unusual in itself) and arrangements were made for Perry to bring a sample in the following day. In the event it was delivered by the social worker when father had failed to bring a sample in; (there is of course no way of knowing if this was actually a sample from Perry and it is highly unlikely given the condition that it is now known that Perry was in by this stage). According to the receptionist, the smell from Perry was ‘like nothing (the receptionist) had smelt before’. The GP claims not to have smelt an odour. 2.12 Strategy meeting 121. The strategy meeting on the 22nd April 2015 agreed that a joint enquiry would be conducted by the police and children’s social care services. The meeting felt that an initial child protection conference would be of little value given father’s attitude and should proceed with a legal strategy meeting. 122. Father refused permission for social workers to look around the home when they visited on the 23rd April 2015. He claimed that Perry was better. He would not allow any photographs to be taken of the conditions in the house. 2.13 Decision that children cannot remain with father 123. The team manager discussed the case with the service manager on Thursday the 23rd April 2015 and agreed that making arrangements for the children to be placed with 10 If there had been a strategy discussion the police could have been party to the investigation and the collation of evidence including photographs. FOR PUBLICATION Page 25 of 56 mother in Humberside should be pursued otherwise a legal planning meeting should be arranged. The checks with Humberside did not begin until the following week. 124. On 27th April 2015 a police check on the mother was returned to children’s social care. It stated that on 14th August 2001 there was a child abuse record following an anonymous caller reporting having seen various bruises on Sibling 1; that the house was chaotic, lots of dirty nappies had been seen and the caller felt that Sibling 1 lacked supervision. No action was taken by the police in 2001. 125. There is a discrepancy between Humberside and Nottinghamshire social care services about when checks in Humberside were started in April 2015. According to Nottinghamshire on the 28th April 2015, the Humberside social care service were telephoned following the emailed request for information. Due to a shortage of staff in Humberside no information was exchanged. According to Humberside the first contact was not until the 29th April 2015. 2.14 School report further concerns and Perry presented at hospital 126. On the 28th April 2015 the school contacted the social worker. Perry had returned to school; this was the first attendance since the 25th March 2015; she had a smell described as being ‘like sewerage’ and ‘rotting fish’. Perry was very pale. It was agreed that father would be asked to take Perry to the hospital. 127. Father took Perry to the hospital. He also smelt. Perry was wearing several layers of clothing and was resistant to removing any. Perry was admitted and the following day was persuaded by the school nurse who visited Perry at the hospital to allow a proper examination and the removal of clothing. Perry told the school nurse that a fear of being in trouble was the reason for the reticence in allowing an examination. 128. Perry had to be taken to an operating theatre for the removal of clothing and examination. Perry was wearing multiple layers of clothing and underwear, and had been urinating and defecating through them for several days (the exact number is unknown). Perry had head lice, was unkempt, and had very poor hygiene. Extensive and severe wounds were uncovered encircling the tops of both legs, cutting through skin/tissue/fat down to the muscle layer, with the underwear completely embedded and stuck in to the wounds. Paediatric staff have commented that the condition of Perry was outside of anything they had previously observed in a child and were very distressed by the severity of the injuries. 129. Perry remained an inpatient, requiring plastic surgery, intravenous morphine and antibiotics until ready for discharge several days later. 130. On 29th April 2015, Humberside social care were again contacted. They stated that a response would be made that day. A police check was also requested on the mother’s partner, and it was confirmed that there was no trace of him on police systems. FOR PUBLICATION Page 26 of 56 131. On 30th April 2015, the social worker transported Sibling 1, Sibling 2 and Sibling 3 alongside their mother to Humberside. The home address was seen, as were the sleeping arrangements. The home conditions were recorded as being ‘not of concern’. 2.15 Summary of contact with Humberside social care services 132. In interview with the agency reviewer for children’s’ social care services in Nottinghamshire the social worker stated that it was difficult to get information from Humberside social care services but that the information shared by Humberside was that the case had been opened and closed due to ‘low level s17 concerns’ (reference to section 17 of the Children Act 1989 and child in need) with some mention of head lice and smacking but a lack of evidence. This information exchange was not recorded in the file but the social worker confirmed in interview that they knew this information prior to taking the children to Humberside on 30th April 2015. 133. The author of this overview report has made his own inquiries of the Humberside social care service through the local safeguarding children board. In a letter from Humberside the independent reviewer was told that the first contact from Nottinghamshire was on the 29th April 2015, to outline the circumstances of the case and ask whether there were any concerns known about the children’s mother who lived in Humberside. 134. Humberside say they were told that in view of the serious neglect suffered by Perry and the three siblings there was a possibility that the four children would move to Humberside to live with her. There is no reference to the contact by email and phone prior to the 29th April 2015 recorded by Nottinghamshire. 135. Humberside say that their worker provided what information was known to them at that time, which was limited to three contacts in 2000, 2004 and 2007. Supporting information was only available in relation to the 2004 and 2007 contacts, both of which were initiated by school services. 136. On 19th March 2004 Sibling 1 and Perry’s head teacher had contacted Humberside children’s social care to express concerns about both children. They were said to have some learning difficulties, appeared unkempt and regularly suffered with head lice. Sibling 1 was described as often being late for school and had said that this was because the parents slept in. The head teacher making the contact felt that the parents were not coping, having phoned the family at 11.00 and they were all still in bed. This information reflects the pattern of concerns that had been evident when the siblings were in the care of their father. 137. The children’s mother, had told the head teacher that Sibling 1’s behaviour was difficult (damage to house, swearing and drawing on the walls) and that Sibling 1 was sent to her bedroom in response to this behaviour. The head teacher also said that other parents had informed the school that Sibling 1 was sometimes locked in the garden and that the siblings had been seen hanging out of a bedroom window. Advice FOR PUBLICATION Page 27 of 56 was offered to the school, but there is no further detail in the record in relation to the content of this advice. 138. On the 4th July 2007 the Behaviour & Educational Support Team (BEST) contacted Humberside social care services in relation to Sibling 1 with whom they had involvement. The BEST team had visited the family following an incident which was described by Sibling 1 as resulting from mother brushing Sibling 1’s hair due to Sibling 1 having itching of the scalp. The brushing was hurting Sibling 1 who was trying to get mother to stop. Mother pushed Sibling 1 who fell. The BEST worker stated that both mother and Sibling 1 were ‘ok’, the worker had addressed the issue with mother and she had agreed that this should not happen again. The BEST team were ‘to continue to offer support to the family if needed’ and agreed to make further contact with the social care service if there were any further problems. 139. There were no further contacts or referrals about the family, and Humberside social care services have no knowledge of the circumstances surrounding the children’s move from Humberside to the care of their father in Nottinghamshire. 140. According to the letter, following the contact from Nottingham on 29th April 2015, and in view of the seriousness of the children’s circumstances, Humberside children’s social care was ‘very keen to be as fully involved as possible in planning for them if they were to return to live with mother on a permanent basis’. They arranged for a consultant social worker (a specialist and experienced social work practitioner) to attend a multi-agency strategy meeting that was scheduled in Nottingham on 7th May 2015, where further information was to be shared. However, Perry’s three siblings were transported to Humberside on 30th April 2015 by the Nottinghamshire social worker to live with their mother; therefore by the time this strategy meeting took place three of the children were already living in Humberside. Perry was still in hospital in Nottinghamshire. 141. Humberside social care services say that they were not asked to make any further checks, neither were they invited to be involved in making or assessing these arrangements. The position was subsequently clarified by Nottinghamshire social care services as one in which the mother had ‘exercised her parental responsibility in respect of the children, as opposed to social care services having placed the children in their mother’s care’. Perry joined the siblings in Humberside when Perry was discharged towards the end of May 2015. 142. Following the strategy meeting on the 7th May 2015 the consultant social worker and the Humberside locality group manager were in contact with the Nottinghamshire social care team in relation to the details of the assessment of mother carried out by Nottinghamshire. There was no record of an assessment being completed by Nottinghamshire. A transfer meeting between Humberside and Nottinghamshire was held on 8th June 2015, since which time the children have been supported by Humberside children’s social care as children in need. FOR PUBLICATION Page 28 of 56 3 Appraisal of professional practice in this case 143. Several people from different services tried hard to provide support. Good relationships were made between the siblings and particular professionals. All of the children went to schools with good pastoral care and all of the schools were active in making contact with other professionals. They were prepared to take action when they became very concerned about Perry’s physical health and presentation. There was for example a good working relationship between School 2 and the school nurse who also took a close interest in the family and at one stage took responsibility for the CAF. 144. The youth workers made relationships with three of the siblings and made them feel welcome. These are the universal services that are so important in helping create resilience for children like Perry living in adverse circumstances and are in a position to raise concerns with specialist services. 145. There was effort to give support to father on several occasions and the referral to the Supporting Families service was an example of a service reaching out to work with father in spite of rather than because of any legal or service thresholds. 146. Although all of these services contacted children’s services at different times, this did not lead to action that was prompt and rigorous enough in really dealing with the neglected circumstances of Perry and siblings. None of the people who had concerns and were reporting these apparently knew how to escalate them when they were not getting the response they felt was required11. An example is the teaching assistant who despite asking to speak with a duty manager was only able to speak with a support officer. Similarly a consultant paediatrician who wanted to speak with the social worker (who was on leave) left a message and was neither informed about the background concerns of Perry or making a referral about Perry’s condition. 147. Some of the initiatives by professionals in daily contact with the siblings, well intentioned as they were and with Perry’s interests at heart, did not have the outcome that was required. Examples include using the CAF so soon after the CIN arrangement had been closed by children’s social care. The CAF, undertaken by professionals who had little or no previous contact or involvement, was undertaken on the premise that father was able to take concerns seriously, that he was ‘trying’, a ‘devoted and loving father’ and was putting his ‘needs ahead of the children’. In truth, the CAF helped disguise the fact that neglect was entrenched and that father was displaying resistance to professional concerns over many years. When contact was made with children’s social care early in 2013 the prevailing mind-set expressed through the MASH referral was that nothing had changed to require an escalation, at least initially. 148. A mind-set that saw neglect as a lower order concern, combined with the evident workload issues in children’s social care at the time created latent conditions in which 11 None of the services appear to have been aware of these processes despite recent communication strategies in the form of briefings to schools for example. FOR PUBLICATION Page 29 of 56 at every point that a contact was made the response lacked urgency, even in March and April 2015 when it was increasingly clear that children’s social care professionals were becoming concerned enough to raise the possibility of the siblings being looked after (although only with the consent of father). This slowness also characterised the making of referral for example from Derbyshire in October 2014. 149. The decision to take Perry to hospital in March 2015 to have medical treatment was a clear recognition about the extent of worry at school. The fact that this was done outside a safeguarding pathway involving the statutory agencies meant that the hospital staff were not sure who or what they were dealing with. A clear request for a safeguarding medical was what was required at that time with a summary of the background concerns. This required children’s social care to be taking a lead. 150. The assessments that were undertaken at different times were not detailed enough in several important respects and are described later on. Significantly, the neglect was never defined and analysed clearly enough; this had already an impact on the PLO proceedings back in 2011. 151. The primary focus remained on physical neglect and missed a better more holistic enquiry into the emotional care of the siblings. The significance about information suggesting inappropriate and abusive relationships with non-related adults was not recognised within children’s social care and was not apparently shared with the police. The obstruction by father of social work inquiries was not discussed with the police. Children’s social care did not initiate strategy discussion with the police to discuss the concerns being reported and allow an opportunity to plan joint investigations. 152. A combination of factors that include the impact of long-term neglect on professional cognitive processing of information, flaws in how professionals escalate concerns effectively, the use of euphemistic language and workload contributed to the response given to Perry and the other siblings not being effective in preventing the injury. 3.1 Responding to neglect 153. Occasional lapses in hygiene have a distressing consequence for any child but are of a different order to the persistent and chronic neglect that erodes self-confidence, isolates a child and for Perry resulted in what should have been a preventable injury (or at least prevented its severity). 154. The consequence of neglect for Perry and the siblings was not sufficiently assessed and analysed by the services that had the statutory power and responsibility to intervene. In this case the police were given limited opportunity to consider the information that children’s social care were receiving. 155. Social care professionals not in daily contact with the children or their father, were less able to understand the significance of emotional and physical neglect in this household and the impact that it was having on the children. Knowledge of the family over several years developed a mind-set that this was a family that straddled the FOR PUBLICATION Page 30 of 56 boundary of just good enough care. Rather than seeing further reports of neglect in the context of cumulative abuse for a child it was initially processed as being consistent with the known and established history. This is important because it is social workers who are in a position to escalate intervention, using the courts if necessary to present evidence to secure legal powers and authority, and ultimately assume greater control and responsibility for children when parents cannot or will not address legitimate issues of concern. The use of legal proceedings is not restricted to circumstances when a child needs to be removed but can for example involve the use of supervision orders. When social care recognised that they needed to escalate their response it was delayed more than once. 156. Looking back through the information collated for the review it is difficult to determine what had ever changed in regard to the conditions of the children and the attitude of their father to any of the help provided by such a variety of professionals over several years and it seems had begun before the children ever came to Nottinghamshire. Although there were marginal improvements, made usually as a result of threatened escalation in regard to school attendance for example, these marginal improvements were only ever short-lived. 157. Associated with this was the evidence of father becoming less co-operative and more confident about obstructing certain professionals such as social workers particularly from December 2014 onwards. These factors were not recognised at the time. These are issues that are regularly identified through reviews such as this. 158. The discussion and processing of information about neglect generally focussed on the physical condition of the children and of their home. In itself not very surprising given this is the tangible and observable evidence. It is less apparent how the emotional care of the children was inquired into and assessed. Too much reliance was given to the children not disclosing anything untoward and father giving positive reassurances on important issues such as the reports of sexual activity. 159. Superficially, the children and father were observed to have a good rapport. There is no record of exploration about what the children meant to father and what had motivated him to bring them to Nottinghamshire. 160. There is little information about the quality of emotional attachment of the children to their father (or to the absent mother) and what either parent meant to each of the children. 161. There is information that father found the emotional care of his four children as challenging as giving them good enough physical care. He does not appear to have been very engaged either in the physical care of his children, meeting their needs in regard to routines such as feeding them and getting them to school or in supervising them in the house. There is no information about social activities that he encouraged although there is evidence he used withdrawal of social activities such as the young people’s centre as a sanction. FOR PUBLICATION Page 31 of 56 162. The children showed considerable resilience in spite of the deficient parenting they received. Some of that deficit in parenting was apparently ameliorated by the children, and in particular Sibling 2, taking on care tasks abrogated by their father. Sibling 2 does not have the level of additional needs that the three other siblings have in regard to cognitive and learning difficulties and it was Sibling 2 who was seen to be taking on adult responsibilities such as getting a younger sibling to school that involved a walk of several miles and contributed to Sibling 2 often being late for school. Given Sibling 2’s quasi-carer responsibilities that were having a direct impact on important aspects such as educational attendance and participation, this deserved discrete assessment. 163. The children were often dirty and did not have regular meals. They lived in what is described as dirt and clutter. They were unsupervised at home, had unregulated access to the internet and some of the siblings were exposed to inappropriate sexual behaviour by young males allowed unsupervised access to the house. There is evidence that some of the siblings were vulnerable to sexual abuse and exploitative behaviour in regard to issues such as the transmission of inappropriate images over the internet. The siblings were socially isolated and subject to some bullying. 164. An important factor in dealing with child neglect is exploring the tangible aspects of care being given (or not given) to children. A recurring theme in this family is the extent to which throughout the children’s lives they have been denied appropriate access to health care when required. The GP for example had very little contact with father or the children. This in turn also meant that there was little recorded base line information about the children’s physical health and development. 165. Denying access to appropriate health care throughout childhood in regard to routine developmental checks and immunisations as well as to consultation and treatment in regard to illness or injury is evidence that should have been considered in regard to neglect. 3.2 Voice of the child and understanding their personal and family history 166. Children and young people generally face internal and external barriers in talking openly about their feelings or disclosing difficult information about themselves or their circumstances. Additional complications arise when there are additional levels of difficulty associated with learning and cognitive functioning and the implications this has in achieving clear accounts. 167. The children’s difficulty in communication is referred to on more than one occasion although it is less clear how these were then considered in the organisation of important disclosure discussions. There is no record of an assessment of the respective learning and cognitive ability of the individual children and their respective level of understanding for example in regard to what are appropriate and inappropriate relationships. Too much reliance appears to have been given to the absence of disclosures (for example regarding allegations of sexual assault) and on more than one occasion a child refers to not wanting to get into trouble for sharing FOR PUBLICATION Page 32 of 56 information. It is not so much what children actually say, but rather what they are not willing to talk about. 168. Often, the behaviour of children and their physical presentation (clothing, cleanliness, weight, and demeanour) reveals what they might be experiencing, thinking, feeling or hoping for rather than any more explicit statements or disclosures. Children who suffer chronic neglect are far more likely to have feelings of low self-esteem, of feeling unloved and unwanted and this also has implications for disclosure. 169. The physical presentation of the siblings has been described in some detail already. There has also been reference to the developmental delays observed in the early years of the siblings and the ongoing global and learning difficulty of three of the siblings. Evidence about the degree of isolation the children appeared to experience has also been referenced. 170. Most if not all of the professionals who had contact with the siblings were largely unaware of any significant history of the children. There was an apparent absence of curiosity about the children’s relationship with their mother or her circumstances since the children moved to Nottinghamshire. Despite mother routinely receiving copies of minutes of meetings there was no other work or enquiries with mother. When the children were reunited with their mother in April 2015 it took place at the hospital where Perry had been admitted. The three children who met with the independent author described that meeting as very rushed. 171. Access to the children at important moments was controlled by father. For example when allegations about unwanted sexual behaviour or the use of the internet for transmitting inappropriate images were being reported. There was contrast between what the children disclosed away from home and how they presented when at home or when interviewed by a social worker for example. 172. Father was highly influential in persuading the siblings were doing nothing that was without their consent. There is little recorded evidence about how professionals developed an understanding about how far each of the siblings had an understanding about consent taking account of their respective ages and cognitive development. 173. High reliance was given on the children having a ‘warm relationship’ with their father but less sceptical attention given to other indicators such as his control of the children and their access to key professionals and the children’s ability to speak freely. 3.3 Risk from inappropriate contact and relationships 174. Several occasions when information was recorded indicated that the siblings could be at risk from inappropriate contact or relationships via the internet or in regard to young adults having access to their home. This information was shared with the police investigation during the review. FOR PUBLICATION Page 33 of 56 a) The youth worker reporting information on the 5th June 2013 to the MASH (multiagency safeguarding hub) that Sibling 1 was talking with a 60 year old male via a social networking website; b) The enquiry on the 13th September 2013 to the EDT about 13 year old Sibling 2 possibly being in a relationship with an unknown 18/19 year old. c) Sibling 2 telling staff at School 3 on the 12th November 2014 that her sibling, Sibling 1, had been raped by Sibling 1’s boyfriend (Boy 1). Sibling 2 also referred to his younger brother (Boy 2) who was also living in the household and was described as being in a relationship with 14 year old Perry. Father refused to allow social workers to speak to Sibling 1. The strategy discussion between the police and children’s services in December 2014 concluded that Sibling 1 had not been raped but ‘had experienced sexual contact that caused distress’. d) Sibling 2 also reported that Boy 1 had been working on father’s car and afterwards a pair of Sibling 3’s (youngest sibling) knickers were later found in the vehicle. e) School 3 reported on the 12th November 2014 that one of the siblings had been seen (by a targeted support worker during a home visit) to kiss father ‘inappropriately on the mouth’. f) The youth worker reported on the 17th November 2914 that Sibling 1 had disclosed that Perry had taken naked photographs that had been sent to an unnamed 19 year old living in the south west of England. There was further reference to concerns about the use of the internet in late 2014. g) A parent of another child at the school reported on the 2nd December 2014 a posting by Perry on a social networking website a comment about having sex with dad. The social worker spoke with Perry who reported that it was only Sibling 1 who used the account. h) On the 24th March 2015 Perry who was smelling strongly of urine and was walking as if in pain at school told school staff that Sibling 1’s boyfriend (Boy 3) was always at the house and lies on the bed with Sibling 1. Perry said that this boy was calling them names and alleged that he was asking Perry to have sex. Perry reported feeling scared of him and hated going home when he was there. 175. Father’s obstruction of social workers in talking with the siblings was not discussed with the police and the majority of the incidents or information summarised in the previous paragraph were not reported to the police until this serious case review had collated information. Father claimed that at the time any sexual relationships were consensual although this was contradicted by his assertion that he had spoken to the family of a young male to warn him off. 176. The allegation of rape by one of the boys was discussed by the police and social workers although it was only social workers who undertook any formal enquiries that were obstructed by father. Given the nature of the criminal allegation the police should have ensured they were leading the enquiries; it was inappropriate to delegate it to social workers. FOR PUBLICATION Page 34 of 56 177. There is no recorded evidence about the circumstances of the respective incidents were investigated and no recorded evidence about how the different siblings cognitive and learning difficulties were considered in regard to issues about consent. It is apparent that at least two of the siblings were the subject of behaviour that made them feel afraid and upset. 178. The possibility that the siblings were at risk from potentially inappropriate contact and relationships was not recorded in any assessment or enquiry. 3.4 Communication between professionals 179. Achieving clear enough communication between busy professionals working different shift patterns using different IT and other information systems and across several different worksites is a recurring theme in reviews. 180. Significant communication between professionals is described in the previous chapter. This included the schools who had day-to-day contact with Perry and siblings and who recorded their concern about the physical neglect of the children and attempted to engage father with support from the school nurse. Sibling 2’s school involved the education welfare officer and MAT service. The school that Perry attended with a sibling communicated a great deal with education support services. The youth service also contacted children’s social care services to report information. 181. The status of the information sharing was not always explicit. Was a specific phone a call an enquiry, a contact or the intention to make a referral? There is a pathway to provision framework that guides decision making which is intended to guide and inform all professionals about how decisions will be made in regard to information. However, some professionals probably assume that if they have contacted children’s social care and it is their intention to make a referral that this is how it will be managed. In fact, the decision as to whether information is to be processed as a contact or referral by the MASH or by children’s social care lies with that service. It is for this reason that clarity about the use of escalation processes are important and is discussed later. 182. The manner in which information was categorised and managed by children’s social care was influential on more than one occasion. 183. The referral in June 2013 was regarded by children’s social care services as not being new information. Some of this reflected a difference of view between social care services and other professionals about the seriousness and significance of neglect. Information about the children being subjected to unwelcome and inappropriate contact by adults was not sufficiently recognised partly because of the assurances that father gave. 184. The phone call on the 24th March 2015 made by the senior teaching assistant to children’s social care services provides an important learning point. Despite asking to FOR PUBLICATION Page 35 of 56 speak with a duty manager it was a support officer who took the call. The issue was not apparently escalated to the designated senior in school to pursue and equally there was no formal escalation to children’s social care services. 185. The police should have been party to the escalating pattern of concerns about the physical condition of Perry in March and April 2015. The condition of the children constituted a potential offence for the police to be aware of and the father’s pattern of obstructing access and enquiries with the children should also have been discussed with a view to the police supporting the investigation. 186. The home visit made by the social worker and team manager that resulted in a request to the police to take photographs should have instead have been a referral to the specialist public protection unit with a view to agreeing a strategy for joint investigation. If there had been a strategy discussion with the police prior to that home visit there would have been an opportunity to discuss whether a joint visit by police and social workers was appropriate. 187. The GP service was never approached for information during the assessments. The GP service should have been aware of the child protection plan that had been in place historically although would not have been updated about the subsequent referrals and assessments. If the GP practice had been updated, and if the GP had consulted those records, would there have been a different mind-set to the consultation in March 2015 for example. The level of contact by the youth service with three of the siblings was apparently unknown and they were not invited to participate in any multi-agency discussion. 188. The referral from the MAT in Derbyshire to the MASH in Nottinghamshire was almost two weeks after the home visit in October 2014 despite the manager in MAT issuing an instruction that the referral should be processed. There was change in management between the instruction being made and the new manager recognising that the referral was still outstanding two weeks later. 3.5 Use of legislation and safeguarding pathways 189. The decision to step down to a child in need plan in March 2012 was taken at a child protection conference that was not quorate; it was only attended by the social worker, the SENCO from School 2 and father (and chaired by an independent reviewing officer). Information provided by children’s social care services appears to have been more optimistic about conditions compared to the views of other professionals. 190. After children’s social care services closed their involvement in January 2013 the school and school nurse became the primary professional support to the children through a CAF. Arguably, this helped to disguise the significance of the neglect at least initially. None of these professionals had been part of the previous core groups. This contributed to a new set of professionals starting afresh with father who gave them an optimistic impression of a parent who was a ‘devoted and loving father’ and ‘was putting the needs of his (children) first’. It remains unclear the extent to which any of FOR PUBLICATION Page 36 of 56 the professionals who were directly in contact with father and the children from January 2013 onwards had a good enough knowledge about prior history. 191. In order to protect children, important powers are given to police and social workers in particular to conduct formal enquiries and take action to ameliorate any identified risk to a child. The effective implementation of those legal powers relies on a good understanding and application of the relevant frameworks and pathways for the police and social care professional staff to follow. 192. Some of those powers require authorisation through an application to court whilst others describe duties to make enquiries and in the case of the police will allow temporary removal of children12 when there is immediate concern about the safety or well-being of children. The point has been made that the police were not sufficiently informed by social care services about relevant information and therefore were not involved as much as they should have been in the enquiry processes in this case. 193. The spirit and the structure of the relevant legislation and statutory guidance is upon professionals exercising their powers when required in a timely manner. In examining Perry’s circumstances there was significant inertia during critical periods. 194. In November 2014, when a decision was made that a strategy discussion was required to discuss the allegation of rape made on Sibling 1’s behalf by Sibling 2, it was six days before the strategy discussion took place that decided on a single agency investigation by children’s social care rather than a joint investigation. The decision to conduct a single agency investigation was not appropriate given the nature of the allegation. There was a further week before the siblings were talked to individually by the social worker at their schools. A delay in undertaking any disclosure work with a potential victim and particularly for a child reduces the likelihood of information being given for any number of different reasons. More than once, one of the children referred to their concern about getting into trouble over information being given. 195. The delay to the making of enquiries has implications in regard to important issues such as any forensic evidence as well as increasing the likelihood of vulnerable child witness with a learning difficulty not being able to provide information. 196. The section 47 enquiry which only involved social workers was not completed for a month. Given the history of neglect and other information indicating inappropriate and unwelcome contact from young adults, it seems perverse that an initial child protection conference was not considered appropriate. It is not confirmed if a manager’s advice and direction was sought on this; none is recorded. The absence of a child protection conference removed an important opportunity to bring different 12 Section 46 of the Children Act 1989 provide police powers of protection (PPOP) to remove a child to a place of safety for up to 72 hours. The powers are intended to be used for exceptional circumstances that by definition are unforeseen. They are not intended to be used as an administrative convenience of not having to make an emergency application to a magistrate. FOR PUBLICATION Page 37 of 56 services including the police to a round table discussion about the various risks to the children. 197. The decision to transfer the case to an area social work team in order to provide statutory help through a child in need plan was a continuation of involvement although nothing happened until March 2015 when there were further concerns being raised primarily by the school. 198. Although the case was promptly allocated to an appropriately experienced and qualified social worker it took their personal caseload up to 25 cases, 13 of which were children already subject to a child protection plan. Additionally, the social worker was on leave at the beginning of January 2015 when the case was transferred in to the team. Shortly after their return to work the social worker was allocated a further complex case which resulted in the child being removed, and it was this other case became the focus of the social worker over those weeks. There is further analysis in the findings later in the report. 199. Although it is apparent that a decision to undertake further section 47 enquiries was made in late March 2015 in response to the information coming into children’s social care these did not start until the 22nd April 2015. 200. The police were not party to the escalating concerns about neglect and were therefore not primed to participate in the process of making enquiries and collecting of evidence. This is not procedural convention; it is about jointly considering what information or evidence has been discovered so far and planning a strategy for making further enquiries and investigation. 201. The purpose of a strategy meeting between the police and social care professionals is intended to highlight the nature of concerns and risk and to agree a strategy for conducting enquiries and to review information from those enquiries. 202. If the police had been party, through a strategy discussion or meeting, to the concerns in March and April 2015 they would have in a better position to allocate resources to secure evidence in the home. Warranted police officers have powers to overcome obstruction that are not available to other professionals such as a social worker. In April 2015 that father prevented social workers from seeing Perry when they visited the home. Perry had also not been sent to school and father was reluctant to seek medical attention for the child. In cases where there are concerns regarding sexual abuse the on-call paediatrician for sexual abuse should be involved in the strategy discussion. This is a concern that has been raised in audit and in a previous serious case review (IN14) and has been raised at the Board. 203. Although social workers and other professionals clearly wanted to secure the engagement of father, this approach had shown little progress over several years. If social workers are unable to get sufficient cooperation and engagement by an adult with parental responsibility in making required improvements to keep a child safe, the social workers can seek additional powers through the court and involve for example FOR PUBLICATION Page 38 of 56 acquiring shared parental responsibility through a care order. These are usually done by giving notice and using the public law outline framework although there is provision for emergency applications ex-parte without notice. 204. There were two significant episodes where the use of legislation was considered by social workers prior to the diagnosis of Perry’s injuries in late April 2015. On both of those occasions it was apparent that there was concern about the children remaining in the care of their father. 205. The first occasion occurred outside the time line for the serious case review but is nonetheless relevant to later events and identifying learning for professional practice. 206. Legal advice was sought in July 2011 and it was agreed that the legal threshold for neglect was met although a court would need evidence regarding the impact on the children. The fact that evidence could not be identified reflected a weakness in the quality of information being collated and the analytical rigour in understanding the implications on the children rather than a lack of evidence. It highlights a weakness in how assessment of the neglect was undertaken at that time (information is provided in the final chapter about the subsequent work on assessment in the county). 207. The second episode occurred in April 2015. It began on the 2nd April 2015 when the social worker had returned from leave having been told about the school taking Perry to the hospital emergency service on the 25th March 2015. 208. The social worker clearly felt that the situation had reached the point of requiring a more authoritative approach through the safeguarding procedures although did not apparently discuss the concerns with the team manager until the 10th April 2015. 209. The social worker had a complex workload and was involved in legal proceedings with one of the other allocated cases. Whether it was the social worker having other more urgent demands or whether it was the unavailability of the manager for example is not clearly established. Information from the service has not clarified the reason for this delay. The agreement to make a joint home visit was not executed until the 20th April 2015. It was during this visit that the team manager and social worker attempted to persuade father to allow the children to be looked after. 210. An option available to the team manager and social worker would have been to consult a solicitor about grounds for either an emergency protection order or seeking an order by notice given they had clearly wanted to have the children taken out of the household. Other legal orders could also have been considered. In order to do this it also requires consultation with a senior manager. As events over the next few days demonstrated, their concerns were well founded although at the time they did not have evidence from other professionals or their own contact to suggest that any of the children were at immediate risk of significant harm. If there had been legal consultation it is unlikely that an emergency application would have been supported; the injury to Perry had not been diagnosed that that stage. FOR PUBLICATION Page 39 of 56 211. The police, having not been involved in any strategy discussion about the evidence of neglect that was becoming more concerning by the end of March 2015 were not in a position to support an investigation and collate evidence until after a strategy meeting two days later. Arguably, an emergency strategy discussion should have happened on the same day as the visit had taken place. The lack of apparent urgency infers a degree of disconnect between the original objectives of creating procedural pathways that promote timely liaison between services that can then become routine and viewed as an administrative function. 212. After Perry had been diagnosed with an injury the local authority arranged for the children to go to their mother. Although there were checks with the other local authority, these were the minimum and there was no other assessment undertaken. Given the information provided in some agency reports for this review about historical concerns about neglect, combined with the fact that the siblings had all experienced neglectful care over several years, further information about the mother’s circumstances and capacity to meet the needs of her children should have been sought before the children moved to Humberside. 3.6 Quality of assessment and plans 213. Assessment of a child’s needs and circumstances is the foundation upon which effective statutory professional help is provided when a child is in need or requires safeguarding from significant harm. Several assessments were completed at different times and by different social workers. The fact that the assessments did not identify sufficient history about the children including their relationship with their mother, did not identify more clearly the significance of neglect and the father’s resistance has to invite reflection about the adequacy of assessment practice. Were the deficiencies due to workload pressures or do they reflect the expectations and standards expected of social workers? 214. A starting point for the assessment has to be securing a sufficiently complete narrative about the history of the child and family which should include the personal history of significant adults taking responsibility for caring or parenting. There were gaps in the narrative for Perry and siblings that have already been commented upon. 215. An assessment cannot just be a narrative. It requires professionals to analyse the significance of information that is collated (and the significance of any information that is not available or cannot be verified). 216. The point has been made that the family history of Perry is largely unknown in spite of extensive statutory involvement for child protection and the conduct of assessments. In developing an insight into the level and nature of risk there has to be an exploration of what protective factors or sources of resilience can be identified alongside the factors that indicate vulnerability for a child. 217. For example, research indicates that older children with good attachment, good self-esteem and a good relationship with a sibling combined with a higher IQ will indicate FOR PUBLICATION Page 40 of 56 higher levels of resilience compared to another child. In this case the assessments have not revealed and explored this sort of information clearly enough. 218. Similarly, parental history of domestic abuse, significant substance misuse, chronic psychiatric illness, isolation, experience of being abused as a child, having been looked after and had multiple placements or are fearful of the stigma or suspicious of statutory contact are contra indicators to consider alongside protective factors that include positive social support, a positive parental childhood, good parental health (mental and physical), education including workplace qualification and stable employment. The assessments do not provide sufficient information on these various factors. 219. Family and environmental factors that are significant in regard to indicators of vulnerability include a run-down neighbourhood, a poor relationship with school, poor social support, poverty and social isolation. The factors in regard to protection and resilience include a committed adult for the child, a good school experience, strong community and good services and support. The assessments do not provide sufficient information about these various factors. 220. Assessment, as described in national guidance, should be a dynamic and ongoing process that has the capacity to analyse information and respond to the changing needs or risk faced by children. A good assessment helps avoid delay in providing help and can monitor and record the impact of any services delivered to the child and family. The focus should be on the child. The assessment needs to show appropriate rigour in checking relevant information and providing a record of evidence that can demonstrate appropriately balanced judgments are being made. 221. The assessments were characterised by being episodic, did not establish a clear enough history of the children, focussed on physical presentation of the children and their home conditions and did not describe clearly enough the views, wishes and feelings of the individual children about their circumstances and about important issues such as their mother or about the presence of unrelated young adults in the household. 222. The children had discernible differences regarding their development, their personal level of understanding and the roles they had in the family. Sibling 2 for example was clearly taking on carer responsibilities for aspects of her siblings’ daily routines and father was abrogating tasks and responsibilities he had as a parent. 223. The assessments were limited in collating evidence from outside of children’s services and do not appear to have sought information from important professionals such as the GP or other professionals such as the youth service who had significant contact with three of the siblings. If health professionals had been approached this could have shown up the extent to which the siblings had not been seen by health services. FOR PUBLICATION Page 41 of 56 224. Neglect was a persistent feature in the presentation of the children at school and for three of them at the local youth centre, along with the poor conditions of the home although this was not explored in regard to the impact it was having on the children. The children suffered isolation, showed evidence of developmental delay, lacked important social and emotional skills, were often hungry and were exposed to sexual activity that was unwelcome for Perry, was opportunist and exploited the siblings’ vulnerability. It was this type of information that an assessment should have been collating. 225. Although workload has clearly had an impact on some aspects of how the case was managed, the case has identified other issues for development and improvement. 226. Neglect is notoriously difficult for professional practice and makes assessment even more critical. There is the dilemma of different professionals having their own thresholds and frameworks for making judgments about what constitutes neglect. Neglect is persistent and rarely has one catastrophic and defining event that can clearly push professional judgement over a multi-agency threshold of common concern. 227. The threshold of concerns relating to the neglect of children therefore can and do differ between different individuals and organisations. Some of this reflects different types of knowledge and expertise. An example might be a paediatrician having a much clearer medical understanding about the impact of neglect on very young children’s neurological and physical development compared to another non-medical professional for example. Neglect requires a different approach in regard to how enquiries and assessment is conducted. For example, it has to establish what the deficits and identify how it is having an impact on the child. Neglect can also appear to represent less urgent risk compared to other forms of abuse when for example social workers and the police are having to prioritise how they will respond to individual incidents of information and the amount of resource in terms of professional experience and time is allocated. 228. The issues highlighted in regard to assessment are contributory to the plans more often than not being characterised by an absence of clear enough objectives or tasks. The final child in need plan written in December 2014 is described as being very long and was not implemented. 3.7 Parental resistance 229. Serious case reviews consistently comment upon the importance of professionals being able to distinguish between families who are genuinely engaged in a necessary process of change and intervention and those that are resistant to professional concern and interventions. 230. The evidence of research and from reviews of practice identify three broad types of uncooperative behaviour. FOR PUBLICATION Page 42 of 56 a) Hostile and threatening behaviour; which produces damaging effects, physically or emotionally, in other people including professionals; b) Non-compliant behaviour; involves proactively sabotaging efforts to bring about change or alternatively passively disengaging; c) Disguised compliance (manifested as disguised resistance); involves significant adults in a child’s parenting and care not admitting to their lack of commitment to change but working subversively to undermine the process. 231. The types of behaviour are not entirely or necessarily exclusive from each other in their use by resistant adults although the first two behaviours are more explicit and discernible. Accepting the need for change in response to concerns about significant harm to a child is often a complex journey. Tony Morrison (2006)13 adapted Prochaska and Di Clemente’s (1984)14 model of change by describing seven sequential elements of motivation, which, he argued, are necessary for genuine and lasting change to begin: a) I accept there is a problem; b) I have some responsibility for the problem; c) I have some discomfort about the impact, not only on myself, but also on my children; d) I believe things must change; e) I can be part of the solution; f) I can make choices about how I address the issues; g) I can see the first steps to making the change/can work with others to help me. 232. Parental non-acceptance of the stages identified by Morrison produces different forms of resistance and, indeed, even parents within one household may respond differently to accusations of maltreatment. In several works, Bentovim (198715 and 200416) argues that parents’ failure to take responsibility for their children’s maltreatment, their dismissal of the need for treatment, their failure to recognise their children’s needs and the maintenance of insecure or ambivalent parent and child attachments are all key indicators of a poor prognosis in regard to a diagnosis that a child has or is at risk of significant harm. 233. To complicate matters considerably, parents may say that they accept the need for change, and can even appear motivated towards that end, whereas, in reality, they are actually opposed or indifferent. 13 Morrison, T. (2006) Staff supervision in social care: making a real difference for staff and service users, third edn, Brighton: Pavilion. 14 Prochaska, J.O. and DiClemente, C.C. (1984) The transtheoretical approach: crossing traditional boundaries of therapy, Homewood, IL: Dow Jones-Irwin. 15 Bentovim, A., Elton, A. and Tranter, M. (1987) ‘Prognosis for rehabilitation after abuse’, Adoption and fostering, vol 11, no 1, pp 26–31. 16 Bentovim, A. (2004) ‘Working with abusing families: general issues and a systemic perspective’, Journal of family psychotherapy, vol 15, no 1/2, pp 119–135. FOR PUBLICATION Page 43 of 56 234. Father never accepted that any of the siblings were at risk from neglect and minimised the concern of professionals. His level of understanding was not explicitly explored. The lack of sustained improvement in his parenting and his obstruction of social workers in particular was not discussed in multi-agency meetings with the police or with other services. 3.8 Use of the local escalation processes 235. As with all human behaviour and interaction, people can make ill-informed judgements or do not take the correct action for a variety of reasons. A great deal of child protection work and especially in regard to issues such as neglect and emotional abuse rely on nuanced professional judgment. The same legal system that gives powers and responsibilities to protect children also sets out legal protection for parents and families on matters such as privacy. A great deal of child protection work is not about gross acts of cruelty that can be seen for what they are but rather are far more nuanced and opaque. 236. The Nottinghamshire Safeguarding Children Board recognises that professionals can disagree about a judgment or decision and has published a policy and pathway for professionals to escalate their concerns if they believe another professional is taking a wrong decision and is unwilling to discuss it17. The procedure sets out the following advice. 237. ‘Problem resolution is an integral part of interagency working to safeguard children. It is often a sign of developing thinking within a dynamic process and can indicate a lack of clarity in current procedures or approach. Professional disagreement is only dysfunctional if not resolved in a constructive and timely fashion. 238. Effective working together depends on an open approach and honest relationships between agencies and a commitment to genuine partnership working. As part of this there needs to be a system in place to enable disagreements to be resolved to the satisfaction of practitioners and organisations involved. The aim should be to resolve difficulties at practitioner level between organisations, where this is possible, but where not the disagreement should be escalated until a resolution is achieved. Disagreements should not be left unresolved. 239. Disagreements could arise in a number of areas, but are most likely to arise around thresholds, roles and responsibilities, the need for action and communication. 240. Although it is apparent that several professionals had misgivings about the slow pace of response at critical moments, none of them used the escalation procedure which was updated in July 2015. 17 Resolving Professional Disagreements (Escalation Procedure) FOR PUBLICATION Page 44 of 56 4 Analysis of key findings for learning and improvement 241. Meaningful analysis of the complex human interactions and decision making processes that are integral to multiagency work with vulnerable children and troubled family’s has to understand why things happen and the extent to which the local systems (people, work processes, organisational arrangements) help or hinder effective work locally within ‘the tunnel’18. 242. In keeping with models of best practice for conducting serious case reviews, the findings use a systems based typology developed by SCIE to identify some of the underlying patterns that appear to be significant for local practice: a) Cognitive influence and human bias in processing information and observations; b) Family and professional contact and interaction; c) Responses to significant incidents and information; d) Tools and frameworks to support professional judgment and practice; e) Management and agency to agency systems. 243. The aim is to use this particular case to reflect on is revealed about gaps or areas for further development in the local systems for vulnerable children and young people. 244. In providing any recommendations, reflections and challenges to the Nottinghamshire Safeguarding Children Board there is an expectation that there will be a response to the key findings in regard to the following: a) An indication as to whether the Nottinghamshire Safeguarding Children Board accepts the findings; b) Information as to how the Nottinghamshire Safeguarding Children Board will take any particular findings forward; c) Information about who is best placed to lead on any particular activity; d) An indication of the timescales for responding to the findings; e) Information about how and when it will be reported. 245. The Nottinghamshire Safeguarding Children Board will determine how this information is managed and communicated to relevant stakeholders. The formal response should form part of the publication of the serious case review. 4.1 Cognitive influence and human bias in processing information and observation Dangers of a mind-set that cannot recognise the potential for harm from neglect; not seeing information with fresh eyes; neglect that can prove fatal; dangers of low expectations and professional overload; professional open mindedness and vigilance; understanding the 18 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight. FOR PUBLICATION Page 45 of 56 significance and risk of neglect for particular children requires knowing the child well; guarding against flight from judgement 246. Neglect can be life threatening or cause significant physical injury, as demonstrated in this case, and needs to be treated with as much urgency as other categories of maltreatment. The possibility that in a very small minority of cases neglect will be fatal, or cause grave harm, should be part of any practitioner’s mind-set. This is not to be alarmist and is not suggesting that predicting or presuming that where neglect is to be found, the child will be at risk of death. However, practitioners, managers, policy makers and decision makers have to be discouraged from minimising or downgrading the harm that can come from neglect and discouraged from allowing neglect cases to drift especially in busy services dealing with competing categories of abuse and concern. Drift was a significant issue in this case and although workload (discussed later) was a significant factor it is unlikely to have been the only ‘latent condition’. 247. The age of children can also have an impact on the sense of urgency that professionals give to information. Older children can be seen to have more opportunity to take care of themselves compared to a younger more dependent child. Age related bias was apparent in how for example the role of one of the siblings as a carer for a younger child was not the subject of any significant enquiry and assessment. 248. It should remain a key objective for professionals to ensure that a child is living in a sufficiently healthy environment and has appropriate relationships that promote the child’s proper development and well-being. Professionals should be striving to do this in partnership with parents and care givers using mechanisms such as early help (historically CAF) where and when it is appropriate and does not require a more authoritative and assertive strategy. 249. However, it is essential that professionals are able to recognise the significance of neglect either in regard to extreme forms such as in this case from the spring of 2015 and when it is persistent and long-term (and also demonstrated in this case). 250. Professionals are expected to form judgements about what is good enough care and this is different and distinct from being judgmental. Some professionals can struggle to reconcile what they feel might be imposed standards when working with families from socially or economically challenged circumstances. 251. It would be foolish to adopt a stance that says any child who has recently been subject of a child protection plan or been a child in need should not then be supported through an early help plan but Perry’s case invites reflection as to whether anybody was adopting a sufficiently robust mind-set that queried what had really happened to the neglect that had been talked about for so long. 252. In this case there was a distinct difference between professionals who were able to see the neglect for what it was and others who exhibited a lower threshold of expectation and were distracted by the parent’s general disguised resistance FOR PUBLICATION Page 46 of 56 (discussed later) and the belief that the siblings had a positive relationship. This led to some professionals to optimistically interpret the siblings’ behaviour when they were living in an unsafe home which have been described. The poor developmental progress of two siblings in particular were not explored robustly in any assessment. 253. Not enough attention was given to collating systematically the evidence about risk, vulnerability and resilience. Without having any reference points key professionals lacked vital compass reference points against which to judge the children’s circumstances. 254. In order to judge the degree of risk to an individual child requires assessments to be informed by people who know the child well. It is clear from the information collated by the review that Sibling 2 did not share some of the learning and developmental concerns of the siblings. This had consequences for Sibling 2 that was not explored in any of the assessments for example. 4.2 Family and professional contact and interaction Recognising and having good enough strategies to respond to parental resistance; clarity about the respective roles of police and social workers in the conduct of enquiries; identifying who is living in households and the dangers of inappropriate adults hiding in plain view; 255. The extent to which father was demonstrating disguised resistance (in contrast to the more often referenced ‘disguised compliance’) was not recognised until April 2015 when the social worker noted a change in father’s attitude. It was apparent that as the contact and enquiries by children’s social care were escalating (albeit not quickly enough) father was increasingly showing a determination to not cooperate with enquiries. 256. Superficial engagement by parents with concerns and doing just enough to reduce the level of concern by professionals who then close their involvement that leads to a pattern of opening and closing intervention in long-term neglect cases has been a recurring theme in serious case reviews examining injury (or death) of children subject of long- term neglect. 257. Relying on voluntary and partnership based agreements to work with parents or care givers who are resistant to concerns about children (as father was on a consistent basis) creates the latent conditions for collusion between professionals and the resistant parent. 258. Relying only on a voluntary arrangement for removing the children from their unsafe home in April 2015 was inappropriate and delayed arrangements. This does not mean that children’s social care had sufficient evidence to have persuaded a court to grant an emergency protection order but it merited discussion with a lawyer as to whether there were grounds for proceedings through notice given the social worker’s clear instinct that alternative care was becoming necessary. Contemplating court FOR PUBLICATION Page 47 of 56 proceedings also has additional workload implications for any professional who is already trying to respond to a busy and complex workload. 259. Given the evidence presented in this report about neglect in the children’s early childhood and the extent of it whilst in Nottinghamshire and the implications for their longer term development, relying on mother just exercising her parental responsibility without clearer inquiries is questionable. It suggests that there may be factors associated with an apparent lack of confidence in using legal frameworks. Is it confidence and court related skills or is it the values and attitudes towards working with parents? 260. Being aware of the potential parental resistance has implications for how enquiries and assessments are conducted. Social workers and supervisors need to understand the distinct role that police have in child welfare enquiries and the powers that they have to support the conduct of enquiries and if necessary assisting in the removal of children. 261. The dangers of hidden men in households where vulnerable children live is a recurring theme in reviews such as this. The importance of identifying who is spending time in the household of a vulnerable child, not just relying on a parent for essential information where there are concerns, not overlooking the parent who is estranged from the household and listening to children who are stating that they are unhappy or afraid. 262. The absence of curiosity about the young males who were allowed to live in the house is a concern. There was evidence of sexual activity which was not welcomed by Perry who made clear that they were afraid at home. The evidence of unsupervised use of the internet and its use in transmitting inappropriate images and facilitating contact with males in different parts of the country were not investigated and most were not reported to the police. 263. All of the siblings were vulnerable to exploitation by virtue of their age or specific cognitive and learning difficulties, their isolation and the absence of supervision by their father. Issues such as consent need more meaningful exploration than was achieved in this case. Father was highly influential in those decisions. 4.3 Responses to information and incidents Purpose of assessment in revealing information about the child and accessing to resources; euphemistic language obscuring professional communication and understanding; prompt and rigorous enquiries and investigation of neglect; establishing the views, wishes and feelings of children and assessing their individual level of understanding; 264. Workload influenced how busy social workers in particular approached tasks such as assessment. The principles of an assessment framework should be to discover and reveal information about a child that goes beyond proving or disproving an allegation or specific concern. It has to be multi-dimensional as described in the appraisal of practice. FOR PUBLICATION Page 48 of 56 265. The use of ‘copy and paste’ to populate the assessments has the effect of reinforcing previous mind-sets and deficits and is evidence of people taking short cuts. Is this just the behaviour of people feeling too busy or does it indicate a need for more fundamental development of assessment capacity in regard to practitioner understanding about what assessment should be. 266. The euphemistic use of language is common. Examples have been provided in the previous chapter. This combined with the deficits in the quality of assessment. 267. Understanding the significance of neglect requires the focus of professional enquiry and assessment to be on the child and not to be distracted by optimistic promises to change behaviour. The cleanliness of children, their weight, their language and social development represent opportunities to record factual information about a child against which to map where they are in regard to expected milestones and are ongoing reference points to help inform whether the circumstances of a child are improving or not. 268. It remains unclear if at any stage a professional had a frank discussion with father about issues such as body odour, the appalling conditions in the home and the extent to which the children’s physical presentation was isolating them. Professionals need to feel confident about tackling sensitive and personal issues. The only person on record as having explicitly raised the issue in a direct manner was the teaching assistant. Some professionals may feel more inhibited about direct speaking on personal issues. 4.4 Tools to support professional judgment and decision making Use of tools and frameworks in the assessment of neglect; dangers of support strategies minimising or disguising entrenched neglect; robustness of assessment frameworks that provide sufficient historical context, triangulation of evidence and information and explore risk and resilience; exploring what the child means to a parent and what a parent (absent or otherwise) means to a child; 269. Practitioners need to be sensitively attuned to the relationship between parents and children, even where parents present as loving but may be failing to cope such as in this case. Nobody has explained adequately what the obstacles were in regard to father being able to parent more effectively. It is known that as the siblings became older he was facing difficulties in dealing with issues such as sexuality and made such a risky combination with the presence of males in the household and over the internet. 270. Parent–child relationships are often highly complex and practitioners need to be sensitively attuned to this relationship, even where parents present as loving but may be failing to cope. Neglect of medical care as demonstrated in this case can become fatal or cause life-long damage. 271. The fact that so many areas of information are unknown despite involvement over several years and the fact that assessments were completed in 2013, 2014 and again FOR PUBLICATION Page 49 of 56 in 2015 invites reflection about the systemic arrangements for enquiry and child assessment. Do the systems encourage the type of reflective and ecological enquiry that is required in complex child safeguarding work described in the appraisal of practice?19 272. None of the services have made reference to local toolkits and frameworks designed to assist professionals in assessing and responding to neglect. This seems paradoxical given that Nottinghamshire have developed and published a detailed and well referenced assessment framework that includes links to a wide range of toolkits and other resources to assist social workers in particular when conducting an assessment of a child. 273. Similarly, there has been significant work undertaken in regard to the neglect of children specifically and in June 2014 the local authority published a social work practice briefing entitled Working with Children at Risk from Neglect. It is less apparent how the framework applies to or includes other relevant services or professionals. Are these seen as relevant to the work of other relevant professionals such as designated lead professionals in other workplaces across the county and are social workers using them appropriately and consistently? 274. The formats for collating and presenting assessments need to encourage practitioners to develop both a sufficiently comprehensive narrative and to also provide a structure for analysing the information. The point being made here is whether practitioners regard the type of assessment that was completed for Perry as the type that is expected by the revised local arrangements and if so does it assist them in carrying out complex judgments and actions and help them make enough sense of how to most effectively help a child? 4.5 Management and agency to agency systems Ensuring that the police are involved and take the lead in investigations that relate to allegations of crime; encouraging and increasing the use of resources to support professional judgment; ensuring all professionals have knowledge and confidence to use escalation procedures; common understanding about what is contact, enquiry or a referral; having a common record of critical discussion such as strategy discussions; ensuring final child protection conferences are quorate. 275. Although the police were not made aware of all information relating to the neglect or other concerns they did have information about the allegation of rape and participated in the strategy discussion. That resulted in the decision to investigate without direct police involvement. Recent audits indicate that the majority of strategy discussions are resulting in single agency investigations by children’s social care services. 19 Ecological enquiry refers to the informed understanding about how a child’s development is effected by its family and wider community environment. FOR PUBLICATION Page 50 of 56 276. Reference has been made to the considerable investment in providing access to materials and resources that support assessment work with vulnerable children. This is most evident in children’s social care services where social workers have access via the local authority intranet to a wealth of material. There is also practice guidance provided in regard to recognising and responding to neglect published by the NSCB. This range of resource may appear somewhat overwhelming for professionals unfamiliar with using the material. This is an example of where line managers have a role in encouraging and directing attention to particular resources and ensuring, to paraphrase Professor Eileen Munroe that intelligent use is made of smart resources rather than random and uninformed application of forms by practitioners uncertain about their purpose or their application. 277. Not all of the material is exclusively the domain of a qualified social worker and there is merit in developing the knowledge and skills across the workforce of relevant professionals working with vulnerable children. Universal services are critical in identifying children who are being abused through neglect and have a role in ensuring effective advice and help is provided and securing the safeguarding of children at risk of harm. There have been pilot projects in the county to improve the identification and response to children at risk from neglect. 278. Contact from other services with children’s social care was described as being enquiry, contact or referral. Some professionals followed up their initial contact with children’s social care whilst others did not. Professionals need to know with certainty how their information is to be processed by children’s social care services; whether it is being managed as a simple enquiry or contact or whether it will be managed as a referral. 279. A further complicating factor in the case was that Perry was already known to social care services and had a social worker allocated. This in itself should not deter a professional making a referral when they have concerns. The Nottinghamshire procedures are explicit that any referral regarding an open case should be made to the social worker allocated for the case (or in their absence to their manager or a duty social worker. 280. Professionals need to know and understand the purpose of escalation procedures if and when they feel their information is not being processed correctly either in regard to being defined as a referral or there is a delay in allocating and processing enquiries or assessment. Escalation applies when for example CAF or child in need are being considered in circumstances where a multi-agency child protection conference should be meeting to make decisions. It also applies when final child protection conferences are deciding to end a child protection plan and ensuring that the conference is quorate and been seen to consider all the relevant professional information and judgment. 281. It should be an expectation that all professionals who have a designated safeguarding role in their agency or workplace are familiarised and updated in regard to safeguarding policies, protocols and practice learning. FOR PUBLICATION Page 51 of 56 282. Professionals who are not sufficiently versed in the processes may resort to personal initiative when concerned about a child as occurred in this case. Such action, although well intentioned, can contribute to systems not working effectively enough. An example in this case was a teacher taking Perry to hospital but having no legal role in pursuing enquiries. 283. Reliance on individual practitioners and agencies to record critical discussion and decisions such as strategy meetings is unreliable and susceptible to misinterpretation and assumptions being made. 4.6 Issues for the Nottinghamshire Safeguarding Children Board to consider in regard to learning and improvement 284. Individual services will use the review as an opportunity to examine other aspects of policy, practice or processes in responding to vulnerable children at risk from neglect and other abuse. 1. Does the Nottinghamshire Safeguarding Children Board have sufficient information about the use and effectiveness of local assessment resources, including the guidance on neglect in identifying and responding to children at risk of significant harm from neglect? 2. Is the Nottinghamshire Safeguarding Children Board sufficiently informed about the circumstances and reasons for the low proportion of s47 investigations that involve the police? 3. Is the Nottinghamshire Safeguarding Children Board sufficiently informed about the conduct and quality of assessments of neglect? 4. How can the Nottinghamshire Safeguarding Children Board ensure that the arrangements for escalating issues and concerns about individual children are known and used by professionals? 5. Has the review identified any additional training requirement in regard to parents who are absent from households where children are subject to child in need, child protection or looked after arrangements? 6. Has the review identified any additional areas for quality audits or evaluation? 7. Has the review identified any additional training or development needs in regard to recognising and responding to resistant parents? 4.7 Recommendations 1. The Nottinghamshire Safeguarding Children Board should ensure that appropriate professional briefings and practitioner learning events on the findings from this review are completed. FOR PUBLICATION Page 52 of 56 2. The Nottinghamshire Safeguarding Children Board should ensure that the use of local escalation procedures are monitored as part of the quality assurance arrangements and commented upon in the annual report. 4.8 Issues for national policy 285. The serious case review has noted that the use of the ‘Red Card’ family liaison meetings are not a national framework or requirement for GP practices. FOR PUBLICATION Page 53 of 56 Appendix 1 Terms of reference identified by the serious case review team for further investigation by the key lines of enquiry: 1. In response to observations and concerns around home conditions, care of the children, their health and welfare did agencies: - a) Follow relevant law, procedures or professional standards that were in place at the time? b) Complete appropriate assessments? c) Recognise risks and respond appropriately to them? d) Apply thresholds for services appropriately and in line with the Pathway to Provision. When decisions were taken to step down or step up, was the transition managed effectively and what was the impact on the children? e) Provide services and support appropriate to meet the needs of the children and any risks identified? f) Communicate effectively within and between agencies and where appropriate escalate any professional disagreements? g) Is there evidence of effective working together to safeguard and promote the welfare of the children? h) Use effective strategies to deal with resistance shown at times by the father? If not, why was this the case? 1. Plans: a) Were appropriate plans developed in response to information and observation of the children? b) Did professionals work effectively to implement and monitor the plans? c) Was appropriate advice and action taken? d) Was consideration given to legal planning processes? If not, why? 2. Did agencies hear the voice of the child and was it acted upon by staff working with the family? If not, what were the barriers to them doing so? FOR PUBLICATION Page 54 of 56 3. Were there any racial, cultural, linguistic, faith or disability issues that needed to be taken into account in the assessment and provision of services? How were these issues managed by agencies? 4. Did professionals working with the family receive appropriate supervision and support? Was there adequate management oversight in this case? 5. Were there issues in relation to capacity or resources in agencies that impacted on the provision of services? FOR PUBLICATION Page 55 of 56 Appendix 2 Membership of the case review team Service Director Children’s Social Care Nottinghamshire County Council Inspector Nottinghamshire Police Service Director Education, Standards and Inclusion Nottinghamshire County Council Associate Director for Safeguarding and Social Care Nottinghamshire Healthcare NHS Trust Director of Quality and Performance Mansfield and Ashfield Clinical Commissioning Group (CCG) Associate Designated Nurse for Safeguarding Children NHS Newark and Sherwood CCG (working on behalf of NHS Newark and Sherwood CCG, NHS Mansfield and Ashfield CCG, NHS Nottingham West CCG, NHS Nottingham North and East CCG and NHS Rushcliffe CCG) Medical Director Nottinghamshire University Hospital Named nurse Nottinghamshire University Hospital Safeguarding Group Manager Nottinghamshire County Council Board Manager Nottinghamshire Safeguarding Children Board Development Manager (child deaths) Nottinghamshire Safeguarding Children Board Independent reviewer (author of this report) Professional support Child Death Administrator Nottinghamshire County Council FOR PUBLICATION Page 56 of 56 Appendix 3 Biographical summary of the independent reviewer The safeguarding children board commissioned Peter Maddocks as the independent reviewer who has written this overview report. He has over thirty-five years’ experience of social care services the majority of which has been concerned with statutory services for children and families. He has experience of working as a practitioner and senior manager in local authority services and of working in national inspection services and with the voluntary sector. He has a professional social work qualification and MA and is registered with the Health and Care Professions Council (HCPC). He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and statutory inspections in relation to the safeguarding children. He has undertaken independent agency reviews and has provided independent overview reports to several local safeguarding children boards in England and Wales as well as regularly working on domestic homicide reviews for several community safety partnerships. He has not been employed by any of the services contributing to this serious case review. He has completed training for overview authors and independent reviewers including the application of systems learning and participation in masterclass professional development |
NC52726 | Stabbing of boy by his mother in December 2021 when she suffered from an acute and transient psychotic episode. Learning includes: the importance that professionals working with children have the skills and knowledge to identify parental alcohol misuse and neglect and intervene for children who are not able to voice their experiences; there tends to be an over optimism about parent's self-reporting and that quite often substance misuse is known about but not seen as excessive; in instances where an individual smells of alcohol but there is no evidence of intoxication this may reflect that they have a tolerance for alcohol at harmful or dependent levels. Recommendations include: assurance that practitioners have sufficient training and development to enable professionals that work with children to understand the impact of parental alcohol misuse and recognise and respond to children exposed to parental alcohol misuse; assurance that local education settings have an effective policy and systems in place to ensure that information is available to inform decision making by the MASH during school holidays; and ensure that children are put on school roll immediately that a place is accepted and that this is not a systemic problem in their area.
| Title: Report of the safeguarding children practice review regarding C92 and C93. LSCB: Torbay Safeguarding Children Partnership Author: Siobhan Burns Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child Safeguarding Practice Review C92 C93 October 2022 REPORT OF THE SAFEGUARDING CHILDREN PRACTICE REVIEW REGARDING C92 & C93 Independent Safeguarding Consultant and Author Siobhan Burns Report completed 28th October 2022 2 Child Safeguarding Practice Review C92 C93 October 2022 CONTENTS Content Page number The trigger incident that led to the review 3 The review process 3 The family composition 3 Background history 3 Lived experience of the children 4 The views of the family 5 Analysis – reachable periods in the family history 5 Identified good practice 10 Lessons learnt and recommendations 10 Appendix Appendix 1 – Background to the review Appendix 2 – Terms of Reference 14 3 Child Safeguarding Practice Review C92 C93 October 2022 1. THE TRIGGER INCIDENT THAT LED TO THE REVIEW: 1.1 On the 17th of December 2021, the boy’s mother suffered from an acute and transient psychotic episode. 1.2 During this episode, she developed the belief that C92 was the devil. C93 came home and found the mother holding C92 on the bed and trying to force him to take a liquid substance. The mother stabbed C92 multiple times in his back and once to the front of his torso. C93 intervened to protect his brother and received a small wound in doing so. 1.3 C92 ran to his neighbour’s home and sought help where emergency treatment was sought for both boys. 1.4 The mother was arrested, placed into custody and later transferred to a secure mental health hospital. 1.5 The children’s father had died from coronavirus shortly before the trigger incident in December 2021. 2. THE REVIEW PROCESS 2.1 The background to the review, terms of reference and a description of how the review was carried out are shown in the Appendix to this report. 3. SUMMARY OF FACTS 3.1 FAMILY COMPOSITION Family member Relationship Ethnicity C92 Child concerned White British C93 Child concerned White British -- Mother White British -- Father White British -- Maternal aunt White British 4. BACKGROUND HISTORY OF THE REVIEW 4.1 Neither of the children were open to children’s services before the trigger incident. 4.2 There were two reports of domestic abuse in 2008 which took place in a neighbouring authority. One of these reports made reference that the parents had been drinking. 4.3 The mother and father had an ‘on-off’ relationship until 2021 when they decided that they would marry and live together. The family lived together between November 2011 and June 2014 and again in 2021 for periods of time leading up to the 8th of December 2021, when the father died. 4.4 The father had a manual job and the mother was employed in a local hospital. During the Covid 19 Pandemic, she was considered a key worker. 4 Child Safeguarding Practice Review C92 C93 October 2022 4.5 Both boys attended local schools and their education was unremarkable in that neither of the boys had any additional needs. C93 was removed 3 times from school to home educate him, this resulted in him missing school for 7 months. He also had some time out of school due to school refusal and anxiety linked to a phobia he experienced. 4.6 There were periods in the family history where the mother appeared to be struggling. At these times she took time off work due to stress and professionals observed that she smelt of alcohol, she self-reported that she was drinking too much and also posted videos on social media, very intoxicated. At one time she sent C93 to live with his father in a neighbouring authority. 4.7 There were three referrals made to children’s services during the children’s lives. In two instances this was in relation to injuries the children had received and one referral about the mother’s drinking. Another separate report was made by a member of the public to the police that the mother was very intoxicated and was driving whilst drunk. 4.8 In September 2021 the mother stole some medicines and equipment from work. This included the remains of a small vial of a controlled drug. 4.9 The family experienced multiple stressful events in 2021. The mother was a health key worker and was working in a stressful environment, due to the impact of the coronavirus. In February 2021 the maternal uncle had a serious accident and was partially paralysed. In March 2021 the boys’ father had a heart attack, in August 2021 the mother’s close friend died of cancer. In early December 2021, the father and C93 contracted the coronavirus and were hospitalised, the father died from the coronavirus in hospital. 4.10 At the time of writing this review, both children were safe and their permanent placement had been secured. 5. LIVED EXPERIENCE OF THE CHILDREN 5.1 Both boys have a very good sense of humour and were described by their social worker as “vibrant”. C93 was protective of C92, even more so following the trigger incident. He was described as “delightful, sociable, polite and caring”. He enjoys football. His teachers observed that he had a close friendship group at school. 5.2 C92 is less mature, likes playing video games and enjoys imaginative play. He was always very close to his mother and was treated as a child younger than his years by his mother. He is an articulate boy who can express his emotions well. He didn’t experience any interruptions in his school attendance and has a close group of friends. His school is a source of support and stability for him. 5.3 C92’s lived experience differs from C93’s. There was a degree of protection for him as the ‘baby’ of the family. 5.4 C93 has shared his view that his mother’s drinking had been problematic for some time and it had become worse after his father’s death. 5.5 He recalled a period in September 2020 where his refusal to go to school resulted in his mother taking him to live with his father, in a neighbouring authority. He had not had consistent contact with his father before this. This was a very significant life event for C93, who felt abandoned by his mother. 5 Child Safeguarding Practice Review C92 C93 October 2022 5.6 C93 is aware that his mother’s drinking sometimes took priority over meeting his and his brother’s basic needs. He recalled having an ill-fitting school uniform but felt that his mother always had money for cigarettes and alcohol. His recollection of not having the right size school uniform was corroborated by the school. C93 recalls that they didn’t have boundaries put into place by their mother and that they didn’t do homework or online work during the closure of schools during ‘lock down’1. Again, this recollection was corroborated by the schools. The lack of home support for the children’s education had an impact on their attainment. 5.7 C93 recalled being punched in the chest by his father, whilst his mother was out at a nightclub. He felt that after he told his mother about this that she didn’t care. The children’s father returned to his home in the neighbouring authority the next day. C93 was returned to his father’s care a few weeks later. 5.8 From C93’s description of his life, living with his mother was unpredictable and although being sent to his father’s care was a traumatic event for C93 he felt that living with his father was more predictable. His description of his mother was a view shared by some of the professionals working with the mother. 6 THE VIEWS OF THE ADULT FAMILY MEMBERS The maternal aunt shared her view that it would have been helpful if the hospital had made a referral to children’s services when the mother discharged C93 in December 2021. 6.1 The independent author met with the mother in the secure hospital setting. Unfortunately, the meeting was cut short due to her feeling very angry. She was angered by the content of the report. She did not agree with the description of the events on the 17th December 2021, or that C93 had been removed from school by a parent. She did not accept that she had removed C93 from school in October 2020 with the intent to home educate him or for him to be taught at home in February 2021, due to health vulnerabilities that would have made him more prone to coronavirus infection. 6.2 She felt that she had not neglected the children’s needs and did not have any issues with alcohol. 6.3 Despite her views she agreed with the recommendations for practice improvements arising from the report. 7. ANALYSIS 7.1 The analysis of the family history shows some opportunities where agencies could have gained a greater understanding of the lived experience of the children, specifically concerning the children’s exposure to maternal alcohol misuse. Whilst these are missed opportunities, it is clear that the events of the 17th of December 2021 were not preventable. The mother experienced an acute and transient psychotic episode which developed rapidly in the context of extreme stress. This was the first psychotic episode that the mother had experienced, which developed a few days after the death of the father. There were clear signs that the mother was experiencing acute stress in December 2021, but there were no opportunities to anticipate the extreme nature of her psychotic episode. 7.2 REACHABLE PERIODS Reachable period 1: September 2012 to April 2013 1 Schools closed when the prime minister imposed domestic restriction to curtail the spread of coronavirus 6 Child Safeguarding Practice Review C92 C93 October 2022 In September 2012 C93 had been in school for approximately a year. At this time school staff noticed that the mother smelt of alcohol. In November 2012 C93 told staff at the school that he had been hit by his father which had caused a bruise on his ear. A child protection investigation was commenced. When interviewed, C93 described that his father had not hit him but pushed him off the sofa, this account was corroborated by the father’s account. C93 also said that his parents ‘fight’. He was five years old at this time. A decision was made by children’s services that no further action was required. 7.3 It is positive that a child protection investigation was commenced. However, there was a lack of analysis in the assessment and a lack of understanding of the lived experience of the child. 7.4 In the days following the start of the child protection investigation there were a further 3 observations that the mother smelt of alcohol and 1 observation that C93’s personal hygiene needs were not being met. These factors were not considered in the assessment which was concluded in December 2012. This assessment did not identify the neglect and domestic abuse safeguarding concerns. The early signs of neglect alone should have triggered a referral to early help. Given the additional concerns about the mother’s drinking, it seems highly likely that this would have resulted in the threshold being met for children’s services to carry out an assessment of the children’s needs. It has not been possible to establish why these factors were not taken into consideration in the assessment due to the historical nature of this investigation. 7.5 Reachable period 2: October 2016 to August 2018 Between October 2016 and August 2018, the mother was signed off sick for several short-term periods. In total, she had 11 periods of short-term sickness and 1 extended period of certified sickness2. 7.6 This coincides with the start of new observations that the mother smelt of alcohol when collecting the children. There were 5 instances in this reachable period. The school did speak to the mother about their concerns. She responded that she would often go for a drink with her mother after work but would never drink and drive. On one occasion, she gave a rationale for drinking that she had received bad news about her sister. On another occasion she reported not feeling well and told staff not to get too close to her. 7.7 In August 2018 there was an anonymous referral made. The mother reportedly told the referrer that she was a “self-confessed alcoholic” who “often drank and drive”. This triggered a MASH enquiry3 and checks were carried out with a range of agencies. However, this referral was made in August and the schools were closed for the summer holidays. This resulted in the assessment being completed without the observations of the school who had noted that the mother had smelt of alcohol on the following occasions: • October 2016 • November 2016 • December 2016 • June 2017 • July 2017 7.8 This was critical information for the assessment. 2 Certified sickness refers to sickness certified or validated by a medical professional. 3 Where information is collected from agencies that sit in the Multi agency Safeguarding Hub 7 Child Safeguarding Practice Review C92 C93 October 2022 7.9 In total the school had noticed that the mother smelt of alcohol on 11 occasions between 2012 and 2018. The school did speak to the mother about their concerns in June 2017 but she was not signposted to any local alcohol support services. Practitioners that took part in the review reflected that, as the mother did not present as intoxicated, they did not feel that the threshold was met for a referral to children’s services. Practitioners knew about local support services for alcohol misuse but did not refer her to this service as they believed that this was a self-referral service only, which is not correct. 7.10 A referral to early help was not considered an option at the time as it was believed that the mother would not take up services. Early help services are only provided to parents who consent to receive services. In this case, it was believed that she would not give her consent for a referral early help. 7.11 Practitioners reflected that there was not a strong early help offer in 2018 and at that time services were not provided promptly. This meant that by the time families were provided with services, their crisis had passed and parents tended to withdraw. The combined belief that the mother would not consent to services and a lack of confidence in the early help offer at the time, resulted in the family not being referred for early help. 7.12 Had the assessment taken in all the available information about the family this would have highlighted the risk to the children from the mother’s use of alcohol. If this risk had been appropriately assessed this would have triggered a referral to the Local Authority Designated Officer (LADO) whose role is to consider risks where adults are employed in positions of trust that come into contact with children. Procedures set out that the LADO should be alerted to cases where a person who works with children has: • Behaved in a way that has harmed, or may have harmed a child • Possibly committed a criminal offence against, or related to, a child • Behaved towards a child or children in a way that indicates they may pose a risk of harm to children • Behaved or may have behaved in a way that indicates they may not be suitable to work with children Including: • The person's behaviour with regard to his/her own children • The behaviour in the private or community life of a partner, member of the family or other household member • A person's behaviour in their personal life, which may impact upon the safety of children to whom they owe a duty of care. 7.13 The referral in 2018 links to concerns about the mother’s use of alcohol in her private life which had potential risks to her own children and the welfare of children in her employment. The combined information from the school and the anonymous referral would have painted a picture of problematic alcohol use which would have triggered a referral to the LADO. This did not happen as the information available to the MASH at the time did not show that the mother had been drinking excessively. Therefore, the referral was closed with a recommendation for no further action. 7.14 The outcome of the assessment which was skewed due to missing information and the subsequent failure to refer to the LADO was a significant reachable moment. This was important as from 2018 C93 moved up to secondary school and C92 began to walk to school with friends. This resulted in much less face-to-face contact with the mother. The reduction in the observations about the 8 Child Safeguarding Practice Review C92 C93 October 2022 mother’s presentation in the next part of the family history was likely to be due to a reduction in face-to-face contact rather than a change in the mother’s alcohol use. 7.15 Reachable period 3: September 2020 to May 2021 C93 went to live with his father in a neighbouring authority in October 2020. His mother removed him from school stating that she intended to home educate him. Thereafter the Elective Home Education team in Torbay were informed by his Torbay school and his school place ceased in Torbay. 7.16 By December 2020 the Torbay Elective Home Education team were concerned that no school place had been secured for C93 and they wrote to the mother twice. They had not been informed that C93 had gone to live with his father. 7.17 The parents applied for a place in a college near the father’s home address in February 2021 but this was full. Until February 2021 the neighbouring authority was not aware that C93 was in their area. 7.18 A place was offered for C93 in a local school at the end of February 2021. The parents were concerned about C93’s clinical vulnerability4 in March 2021, following the school reopening after closures due to the coronavirus. The parents requested that he be educated at home, online, despite the school being open. 7.19 In March 2021 the father suffered a heart attack and both he and C93 reunited with the mother and C92 in Torbay. Although C93 was offered a school place in February 2021, he was not placed on the school roll until May 2021 by which time he had moved back to Torbay. C93 was not placed on the school roll as he was being educated at home via online teaching methods. This was due to a clerical error. When a child is not on roll with a school and not in education this means that they are not visible. 7.20 More localised learning for the neighbouring authority is the need to place a child on the school roll as soon as a place has been accepted. If this had happened the receiving school would have been responsible for C93’s education from February 2021 and not May 2021 and their performance would have been judged on the basis that one of their children had not attended school for 3 months. 7.21 Statutory guidance concerning children who are missing education sets out that local education departments should have joint working and information sharing arrangements. In this case, this did not happen effectively and C93 got lost between the two local education authorities. 7.22 Reachable period 4: August 2021 to 17 December 2021 During this period the family were living together following the father’s heart attack in March 2021. That August the mother told her doctor that she was concerned about her drinking. She reported drinking 20 units a week and was worried that she was drinking too much and struggling with her mental health. This was a missed opportunity to signpost the mother to early intervention services concerning her alcohol use. She was drinking above the recommended levels of 14 units per week and had expressed concern about her drinking. The records suggest that she was not referred to alcohol support services as she was considered to “have insight”. 4 Clinical vulnerability to coronavirus refers to individual with health conditions that resulted in a higher risk of severe illness from coronavirus. 9 Child Safeguarding Practice Review C92 C93 October 2022 7.23 The mother reported she was drinking 20 units a week when she was actually drinking very heavily, having ‘cut back’ to 7 bottles of wine per week, spread over 3 days5. This equates to 2.3 bottles of wine per day and approximately 70 units of alcohol per week. She did not fully disclose the extent of her drinking to her doctor and therefore this information was not knowable at the time. 7.24 C93 was assaulted by his father in September 21 but did not tell anyone about this at the time. In the same month, the mother took the vial of controlled drug from the hospital. She took a range of medication and equipment from the hospital. It is not known why she took the drugs. Medical practitioners that took part in this review indicated that the amount of the controlled drug that was stolen would not have any impact on a person’s wellbeing, mood or functioning, due to it being a small amount. 7.25 The taking of this controlled drug was not detected. This was due to the previous system by which controlled drugs were signed for when they are taken, but the remainder of any vials of controlled drugs were not signed back in to be disposed of. This system has since been reviewed and there is a signature required by two health practitioners when taking the drug and a signature required by two health practitioners confirming the disposal of any unused controlled drugs. 7.26 In November 2021 there were clear signs that the mother was struggling and this was impacting on the care of the children. There was a referral from a member of the public to the police that the mother was driving whilst under the influence of alcohol. Officers in the local area were made aware and requested to look out for the mother’s vehicle. She was not seen driving. This referral was not linked to the children as it pertained to an adult only and was not linked to an address. 7.27 Colleagues of the mother noticed posts on social media where she was extremely intoxicated. The mother tended her resignation on the 25th of November as she planned to move to a neighbouring authority. She never presented as intoxicated at work or smelt of alcohol. Most of the observations of her being intoxicated happened outside of work and tended to coincide with periods of sickness. 7.28 C93 was removed from school by his parents in November 2021. This was the third time that he had be removed from school to be home educated. He remained out of school until the trigger incident. There was no follow-up from the neighbouring authority after he was removed from school. The importance of C93 being removed from school was not apparent to the neighbouring authority. They were not aware that he had been previously taken out of school on 2 occasions in Torbay. Therefore, the significance of this was lost and C93 fell through the gaps between the two local authority education departments. 7.29 In December both C93 and his father contracted the coronavirus. This marked the start of a period of acute stress and distress for the family. The mother was able to see C93 in hospital but not her partner. C92 remained at home and due to the coronavirus self-isolation requirements the mother was unable to ask for help caring for C92 from her wider family and she could not bring him into the hospital. He was left home alone with neighbours ‘looking out for him’. He was then aged 10 years old and immature for his age. The mother has described how she was torn between her partner who was gravely ill in intensive care, her son who was very ill and her youngest son at home. On the 7th of December 2021, the mother told staff at the hospital that she was “having a meltdown”. 7.30 The father’s health deteriorated quickly thereafter and he died on the 8th of December. The same day the mother discharged C93 from hospital. The hospital did consider making a referral to children’s 5 Taken from an expert report in the Care Proceedings. 10 Child Safeguarding Practice Review C92 C93 October 2022 services but did not. Contact was made with the family GP to share concerns that the family would likely need additional support. The GP did not share any concerns at this point. By contacting the GP and not children’s services this created a missed opportunity. 7.31 If a referral had been made to children’s services the following information could have been pieced together to develop an understanding of their needs: • Historical domestic abuse. • Mother struggling with C93 as a young baby. • History of alcohol concerns. • A child protection investigation into an injury which resulted in no further action. • C93 significant periods of missed education and being removed from education 3 times by his parents. • An anonymous referral that the mother was a “self confessed alcoholic”. • Concerns that the children’s basic needs were not being met. • The mother’s report to the GP that she was drinking too much. • A report to the police that the mother was drink driving, “stank of” alcohol and was “staggering”. • C92 being left at home unsupervised. • The stress caused by the illnesses of the father and son and subsequent death of the father. • The mother’s decision to remove C93 from hospital against medical advice. 7.32 . With the information contained in paragraph 7.31 and the stress the family were experiencing, it is highly likely that if a referral had been made to children’s services that the threshold to carry out a child and family assessment would have been met. 7.33 Interventions from children’s services and other agencies at this time would not have prevented the mother’s psychotic episode, but it could have resulted in supportive services being offered to children in acute distress. 8. IDENTIFIED GOOD PRACTICE There was evidence of good joint working by Torbay education professionals in February and March 2019. The mother withdrew C93 from school stating that she intended to home educate him. The school promptly informed the Elective Home Education team who made timely contact with the mother. It became clear that she had concerns about C93’s school rather than wanting to home educate him. By working closely together the school, Elective Home Education Team and Admissions team found a new school and C93 had a school place within 20 days. 9. LESSONS LEARNT AND RECOMMENDATIONS The purpose of a child safeguarding practice review is to establish if there are lessons to be learnt for agencies, to prevent children from experiencing abuse or harm and to highlight good practice. 9.1 It is difficult to see how the actions or inactions of any of the agencies could have anticipated or prevented the mother from developing the acute and transient psychotic episode, or the subsequent physical harm and trauma the children experienced. 9.2 However, there were missed opportunities in respect of the mother’s alcohol use and the impact of that on her capacity to parent. The boys have described the care given by their mother as unpredictable, they have been exposed to seeing their mother very intoxicated and out of control. 11 Child Safeguarding Practice Review C92 C93 October 2022 Their basic needs were not always met, including protection from harm of C93 when hurt by his father. 9.3 Research shows that parental alcohol misuse can lead to parents having “chaotic, unpredictable lifestyles” and that they may “struggle to recognise and meet their children’s needs6. This echoes the experiences of the boys. 9.4 Neither boy disclosed any concerns about their mother’s drinking to professionals until after the trigger event. Her drinking had likely become normalised for the children, given there were patterns of excessive drinking dating back to September 2012. 9.5 Children living with alcohol dependent parents can feel stigma, shame and guilt and feel reluctant to betray their parents7. It is therefore important that professionals working with children have the skills and knowledge to identify parental alcohol misuse and neglect and intervene for children who are not able to voice their experiences. 9.6 Learning from other case reviews shows that there tends to be an over optimism about parent’s self-reporting and that quite often substance misuse is known about but not seen as excessive8. In this review, practitioners reflected that they were aware of the mother smelling of alcohol but as she was never observed to be drunk. As a result, they did not consider it to be an issue requiring a referral to children’s services. 9.7 Substance misuse practitioners that contributed to this review stated that to be smelling of alcohol in the morning is a sign of significant consumption of alcohol, whether this is linked to morning consumption of alcohol or excess drinking the night before. In instances where an individual smells of alcohol but there is no evidence of intoxication this may reflect that they have a tolerance for alcohol at harmful or dependent levels. The more alcohol that is consumed, the higher a person’s tolerance is. 9.8 The regularity with which the mother was drinking during the day was also a flag to indicate that she was drinking to excess and had a high tolerance9. Local specialist substance misuse practitioners have also shared that any person drinking in excess of 20 units per day (in this case it was estimated to be 25 units; 2.5 bottles of wine) is at significant risk of developing physical alcohol dependency which has an associated high tolerance and risk of death and seizures upon immediate cessation. This situation requires specialist intervention to manage and alcohol dependency is not conducive to sole parenting of any children. 9.9 There were opportunities in 2012, 2013, 2016, 2017, 2018 and 2021 to identify and intervene concerning parental alcohol misuse. It will be important going forward that professionals working with children in schools, GPs, children’s services and police use professional curiosity and identify and understand the impact of parental alcohol misuse on children. If a referral had been made to 6 Parental substance misuse | NSPCC Learning accessed on 22.07.2022 7 Rossow I, Felix L, Keating P & McCambridge J (2016); Public Health England (2016); 57 Rossow I, Keating P, Felix L & McCambridge J (2016); Kelly, Y.J. et al. (2016; Whiteman S, Jensen A, Mustillo S & Maggs J (2016) cited from Houses of Parliament Postnote Feb 2018, Parental Alcohol Misuse and children. 8 Learning from case reviews briefing: parents who misuse substances (nspcc.org.uk) accessed 22.07.2022 9 Alcohol addiction | Signs & symptoms of alcoholism (ukat.co.uk) 12 Child Safeguarding Practice Review C92 C93 October 2022 local substance misuse services, they would have been in a position to show professional curiosity about the mother’s reported levels of drinking and to assess this against objective measures such as breathalyser readings, when it is felt that inconsistencies are present. As an adult with parenting responsibilities the impact of the alcohol use upon parenting capacity would have been routinely assessed within the first 12 weeks of any treatment episode. Linked recommendation 1: For Torbay Safeguarding Children Partnership to seek assurance that practitioners have sufficient training and development to enable professionals that work with children to understand the impact of parental alcohol misuse and recognise and respond to children exposed to parental alcohol misuse. 9.10 The anonymous referral in 2018 was a reachable moment for the children. Children’s services carried out checks with the police and health colleagues. Health colleagues were able to check if the mother was open to substance misuse services or if there was a history of alcohol misuse known by the family’s doctor. These checks did not indicate any concerns. The omission of information from the children’s school was a significant one. If information had been taken from the school, it would have shown evidence of problematic drinking from 2012 and a pattern of increased concerns from 2016 to 2018. This level of concern would have triggered an assessment and intervention from children’s services. 9.11 There are some schools in Torbay that are contactable during the school holidays but this is not consistent across all education settings such as schools, early years and further education. Linked recommendation 2: For the Torbay Safeguarding Children Partnership to seek assurance from TESS, that local education settings have an effective policy and systems in place to ensure that information is available to inform decision making by the MASH during school holidays. 9.12 This review has shown that there was low confidence held by practitioners about the early help offer and concerns that when referrals were accepted, services were not being offered in a timely manner. The Torbay children’s service inspection carried out in May 2022 complimented the early help offer and the timeliness of the provision of services. There have been improvements to the early help offer since 2018 and therefore there is no linked recommendation in relation to early help. 9.13 There has been learning in this review about children missing education. Torbay education services worked effectively to get C93 into school in 2019. However, he fell between the two education departments when he was taken to live with his father in a neighbouring authority. As a result, he did not receive any education for 4 months. C93 is significantly behind in his reading attainment and this gap in his education contributed to him falling behind. 9.14 The issue of children missing education and the risks associated with children moving between education authorities undetected are well recognised and there is evidence that children with poor school attendance have fallen through the gaps in the education system even more so following the 13 Child Safeguarding Practice Review C92 C93 October 2022 pandemic10. There has been a call to develop a national database for children that are missing education. Linked recommendation 3: The findings of this review to be highlighted to the National Panel and Children’s Commissioner as further evidence to support the development of systems to track children moving between education authorities. 9.15 C93 was given a school place in a neighbouring authority. He did not start classroom based learning immediately due to his parent’s concerns that he was clinically vulnerable to the coronavirus. Despite being given a place in this school he was not placed on the school’s roll which is not in line with expected procedures. Linked recommendation 4: That the Torbay Safeguarding Children Partnership contact the neighbouring education authority and request that they carry out assurance activity to ensure that children are put on school roll immediately that a place is accepted and that this is not a systemic problem in their area. 9.16 The detection of the controlled drug in the children’s home raised questions in this review as to how this could be taken from the hospital. There are strict procedures in hospitals relating to how controlled drugs are accessed and administered. This review has shown that the correct procedures were followed when the drug was signed out by two healthcare professionals. At the time there was no procedure in place to control how the remains of vials of controlled drugs were disposed of. Since this finding was highlighted there has been a procedure put into place which requires two healthcare professionals to sign for the disposal of the remainder of any vials of controlled drugs. As a result of the new procedures, there is no linked recommendation in relation to the disposal of controlled drugs. 9.17 The mother was a healthcare professional that come into contact with children in her role. Where there are concerns that an individual’s conduct in or out of work could compromise the safety of a child, it is expected that this risk is referred to the Local Authority Designated Officer. The referral in 2018 was not shared with the LADO. The assessment missed critical information from the school. Due to this, the threshold for making a referral to the LADO was not met as there was no evidence available to the MASH that the mother was misusing alcohol. The failure to report the mother’s alcohol misuse to the LADO at this point was not indicative of a poor understanding of the LADO's role or compliance with procedures, but more reflective of the poorly informed assessment. As a result, there is no linked recommendation about awareness of and compliance with LADO procedures. 9.18 Finally, there was an opportunity for the children to be offered support immediately after the father’s death. It will be important that the learning from this review is shared, to emphasise the importance of the role MASH in bringing multi-agency information together and building a holistic picture of children’s needs. 10 Children Commissioners report: Voices of England’s missing children. June 2022 14 Child Safeguarding Practice Review C92 C93 October 2022 Appendix 1 PRACTITIONER INPUT TO THE REVIEW Individual agency practitioners met with the reviewer in 1:1 meetings. The draft report was shared with practitioners to ensure that their contributions had been accurately represented. PARALLEL PROCESSES The conclusion of the care and criminal proceedings coincided with the drafting of the final report. This is significant as it impacted the levels of participation by the family and the children. The care and criminal proceedings were extremely stressful and demanding for all the family members so sensitivity was shown to their views that they wanted limited participation in the review. FAMILY INPUT TO THE REVIEW Despite this sensitivity around the timings of the conclusion of the proceedings, some views were obtained from the wider family. The boy’s views were gathered extensively by their social worker, Guardian and experts that were commissioned in the care proceedings. Their views have been taken from these professionals and their reports. The review report draft was shared with family members. They did not make any further comments or corrections to the final draft. The mother was met by the author. She was provided with a copy of the report in advance of the planned meeting. Unfortunately, she was very angered by the contents of the report which limited her contribution to the review. Comments that she had made on the report were given to the author at the end of the meeting. These comments, where they could be, have been incorporated into the final draft. She was invited to make any other comments on the review by email. At the time this review was signed off, no further communication had been received by the mother. Appendix 2 TERMS OF REFERENCE |
NC045933 | Death of a 6-year-old boy and his mother and the attempted suicide of his father in April 2013. Father pleaded guilty to manslaughter on the grounds of diminished responsibility. He was diagnosed with a psychotic mental illness and detained under the Mental Health Act 1983. Child L and parents were not known to any specialist services. Previous contacts with health services for injuries to Child L and Adult L were judged to be accidental. The day before the incident, father consulted his GP about feeling in low mood and hearing voices; there had been no previous mental health issues. GP requested an assessment by a mental health practitioner and a meeting was scheduled for the next day. Identifies good practice including the GP's referral to mental health services and school support to pupils and families after the deaths. Issues identified include: missed opportunities for sceptical and curious enquiry by health professionals; no enquiry about Child L by GP; 'shortcoming of human inference' leading mental health specialists to think a GP would rate a case high risk to get a quick assessment; and use of a telephone triage system for mental health assessment. Uses a systems methodology based on the Social Care Institute for Excellence (SCIE) framework to present the key learning. Questions for consideration cover: overcoming cognitive influence and human bias in information sharing; ensuring sufficient enquiry and recording of any presentations for medical treatment; and use and availability of tools and frameworks for assessing risk.
| Title: A serious case review: ‘Child L’: a domestic homicide review: ‘Adult L’: the overview report. LSCB: Lancashire Local Safeguarding Children Board Author: Peter Maddocks Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Lancashire Safeguarding Children Board Lancaster District Community Safety Partnership A Serious Case Review ‘Child L’ A Domestic Homicide Review ‘Adult L’ The Overview Report April 2015 Index 1 Introduction and context of the review ..................................................... 4 1.1 Rationale for conducting a serious case review and a domestic homicide review 5 1.2 The methodology of the combined serious case review and domestic homicide review ....................................................................................... 6 1.3 Reasons for the review and terms of reference for the review ................ 8 1.4 The scope of the review ................................................................... 8 1.5 Particular issues identified by the panel for further investigation by the individual management reviews: ............................................................... 11 1.6 Membership of the case review panel and access to expert advice ........ 11 1.7 Independence and experience of the lead reviewers ........................... 12 1.8 Parental and family contribution to the review................................... 13 1.9 Timescale for completing the review ................................................ 16 1.10 Status and ownership of the overview report ..................................... 16 1.11 Previous serious case reviews and domestic homicide reviews in Lancashire 17 1.12 Summary conclusion of the review .................................................. 17 1.13 The family and other significant people ............................................ 23 1.14 Cultural, ethnic, linguistic and religious identity of the family ................ 24 2 Synopsis of agency involvement ............................................................. 26 3 The critical reflection and analysis obtained from the individual management reviews. ................................................................................................... 29 3.1 Summary .................................................................................... 29 3.2 Significant themes for learning that emerge from examining the individual management reviews .............................................................................. 29 TOR 1 What knowledge or information did agencies have that indicated the adult victim might be a victim of domestic abuse, or that child L might be at risk of significant harm? .................................................................................... 30 TOR2 What services were offered to the adult victim, the perpetrator and child L and were they accessible and sympathetic?................................................. 34 TOR 3 What information did family and friends have that might have indicated the adult victim and/or child L were at risk of abuse? ......................................... 39 TOR 4 What knowledge did agencies have that the perpetrator might be a perpetrator of abuse and pose a risk of significant harm to Child L or the adult victim? ................................................................................................. 40 TOR 5 Were there any risks in relation to resources or capacity that had an impact on how services were provided to the victims or to the alleged perpetrator or that impacted on agencies’ ability to work effectively with other services? .............. 41 4 Analysis of key themes for learning from the case and recommendations ...... 44 4.1 Learning from previous serious case reviews ..................................... 45 4.2 Cognitive influence and human bias and its influence in judgments and decision making ..................................................................................... 45 4.3 Responses to incidents or information .............................................. 48 4.4 Tools to support professional judgment and decision making ............... 50 4.5 Issues for national policy ................................................................ 50 5 APPENDICES ....................................................................................... 52 Appendix 3: Single Agency Recommendations.............................................. 53 1 Introduction and context of the review 1. This combined domestic homicide and serious case review examines the death of a 40 year old mother (the victim) and her six year old child (Child L) and the attempted suicide of the 34 year old father (the perpetrator) who had killed them both and then had attempted to take his own life in April 2013. It is a tragic and highly unusual incident that has caused great distress and confusion for the family, friends and other people who knew the family. It has also caused ongoing emotional and mental trauma for the perpetrator. 2. The taking of life is the most serious of crimes. This tragic incident occurred shortly after the perpetrator had first experienced symptoms of psychosis and he was due to participate in a mental health assessment just a few hours after he took the lives of his family and attempted to take his own. The perpetrator had no prior thoughts or motivation to harm himself or to cause injury to anybody else. He had no prior history of mental illness and no history of substance misuse 3. The deaths are highly distressing for the family and friends and for the professional services such as school and primary health services who knew the family. The review has been assisted by the participation of those people in providing information to help understand what occurred and to support professional learning in regard to a very rare and unusual set of circumstances. 4. The consistent information and evidence provided for the review is that the killings were entirely out of character and are difficult to comprehend for the family and friends as well as for the perpetrator himself. Such deaths which are variously referred to in research and other literature as family annihilation or familicide are very rare within the UK as well as in other countries. 5. It was a late morning in early April 2013 when the police were summoned to a domestic property in the county. On arrival they found the adult victim and Child L already deceased and the perpetrator suffering from self-inflicted multiple and life threatening stab wounds in several locations on his body. He was arrested on suspicion of murder and was taken to hospital where he survived his self-inflicted injuries. His general physical fitness combined with the speed and quality of the medical treatment including paramedical care at the scene was a significant factor in saving his life. He subsequently appeared in court charged with two counts of murder and was remanded in custody although was transferred to a secure hospital to receive ongoing assessment and treatment. 6. The perpetrator subsequently pleaded guilty to manslaughter on grounds of diminished responsibility. He has a psychotic mental illness, a delusional disorder to which both the prosecution and the defence agreed on the diagnosis. The perpetrator is to remain in hospital indefinitely under S37 of the Mental Health Act 19831. He will also be subject to a restriction order under section 41 of the same legislation. 7. Child L and the adult victim were not known to any of the specialist services in the county. They were both registered with the GP as was the perpetrator. Child L attended a local primary school. 8. Less than 24 hours before the deaths, the perpetrator had consulted his GP about feeling low in mood and had reported hearing voices in his head. He had been accompanied by the adult victim to the surgery who was concerned about her partner’s behaviour. There had been no previous mental health difficulties. 9. The GP who had recent experience of working in psychiatric services took a detailed history and contacted the single point of access to mental health services requesting a prompt assessment of the perpetrator’s symptoms. An initial assessment was conducted by telephone the same day and a follow up face-to-face meeting was arranged for the following day with an experienced mental health practitioner (MHP1)2. The mental health practitioner is a health practitioner who has undertaken specialist training. 10. This appointment was not kept due to the events already described in the first paragraph. 1.1 Rationale for conducting a serious case review and a domestic homicide review 11. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board to undertake a review of a serious case in accordance with procedures set out in chapter 4 of Working Together to Safeguard Children (2013). 12. The local safeguarding children board should always undertake a serious case review when a child dies and abuse or neglect is either known or is suspected to be a factor. 13. The circumstances under which a domestic homicide review must be carried out are described in legislation and national guidance. The relevant legal requirement is the Domestic Violence, Crime & Victims Act (2004) Section 9 1 This is a court order imposed instead of a prison sentence, if the offender is sufficiently mentally unwell at the time of sentencing to require hospitalisation. The psychotic illness was diagnosed several weeks after the killings. 2 The single point of access is through telephone, fax or post. The referral was triaged by a mental health practitioner (MHP1) who made contact with the service user the same day the referral was received. that came into force on the 13th April 2011. The national guidance is described in Multi-agency statutory guidance for the conduct of domestic homicide reviews. 14. A domestic homicide review must review the circumstances in which the death of person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a person to whom they were related or with whom they were or had been in an intimate personal relationship, or a member of the same household as themselves. 15. The Lancashire Safeguarding Children Board and the Lancaster District Community Safety Partnership took advice respectively from the Department of Education and from the Home Office and made a strategic decision to combine the reviews to ensure that information was coordinated and that analysis would identify learning for the two boards responsible for the statutory reviews. The decision to combine the reviews also ensured there was no duplication and made best use of the combined resources of the organisations involved in the review. 16. The two boards agreed to commission the independent lead reviewers to coordinate the work of the joint review. Neither of the lead reviewers has worked for any of the services contributing to this review. Further information about their relevant experience and knowledge is provided in section 1.8. 17. One of the lead reviewers, Annie Dodd, took principle responsibility for chairing panel meetings and facilitating case groups and managing the review process including liaison with the family, the different services and with the police major inquiry team through the senior investigating officer (SIO) and the panel police representative. 18. The second lead reviewer, Peter Maddocks, took principle responsibility for writing the combined overview report. 19. The reviewers shared responsibility for collation and analysis of information and presenting the findings of the review to the joint boards and to practitioners and other stakeholders in the county. 1.2 The methodology of the combined serious case review and domestic homicide review 20. This review was completed using the methodology and requirements set out in the relevant government national guidance in respect of serious case reviews and domestic homicide reviews. 21. A case review panel was convened of senior and specialist agency representatives to oversee the conduct and outcomes of the combined review. 22. Work began on compiling a chronology in June 2013, which coincided with the appointment of the lead reviewers. 23. The panel established terms of reference, identified key lines of enquiry for the review and set a timetable for submission of reports and other evidence and information. This included seeking appropriate contributions from family and friends. 24. The panel established the identity of services in contact with the family during the time frame agreed for the review. For services that had significant involvement they were required to provide an independent management review in accordance with Home Office requirements3 (and are listed in section 1.4). These reports were completed by senior people who had no direct involvement or responsibility for the services provided to the child or adults. 25. The local safeguarding children board in Lancashire was already working on how future serious case reviews in the county could be developed in order to provide a more productive window into the local systems for safeguarding and protecting children4 and have participated in regional and national pilot work on using system learning within serious case reviews developed by SCIE (Social Care Institute for Excellence). 26. The review panel decided to build on the learning that had been developed from two previous SCRs in the county; one of those had been wholly conducted using the SCIE framework and another SCR had used the framework to present the findings from the review. 27. The analysis in the final chapter of this report uses some of the framework developed by SCIE to present the key learning within the context of the local systems. This also takes account of recent work that suggests that an approach of developing over prescriptive and SMART recommendations have 3 The revised Working Together published in 2013 removed this as a prescribed requirement for SCRs. 4 CA Vincent, (2004) Analysis of clinical incidents; providing a window on the system not a search for root causes. Quality and Safety in Health Care. The article argues that incident reports by themselves tell comparatively little about causes and prevention, a fact which has long been understood in aviation for example and is the basis of developing a systems learning approach to serious case reviews in England. limited impact and value in complex work such as safeguarding children5. The final chapter of the review for example explores the influence of professional self-confidence and calibration of risk and the tools that are used by professionals to help inform their judgments and decisions. 1.3 Reasons for the review and terms of reference for the review 28. The reason for undertaking a serious case review is that Child L died as a result of non-accidental injuries. The reason for undertaking a domestic homicide review is that the adult victim was killed by her partner with whom she was living when she was killed along with her son. 29. The deaths were reported to the Lancashire Safeguarding Children Board on the 10th April 2013 and the case was considered by the serious case review (SCR) group on the 7th May 2013 who recommended to the independent chair of the local safeguarding children board that the circumstances of Child L’s death met the criteria for a mandatory serious case review. The Chair of the community safety partnership was notified on the 11th April 2013 and community safety partnership was notified on the 13th April 2013. 30. The serious case review was commissioned by Nigel Burke, the independent chair of the Lancashire Local Safeguarding Children Board on the 7th May 2013. The domestic homicide review was commissioned by City Councillor David Smith, the Chair of the community safety partnership on the 7th May 2013. 31. The first meeting of the panel for the combined review on the 24th June 2013 confirmed the scope and terms of reference for the review. The scope and terms of reference of the review was routinely discussed and updated at subsequent panel meetings to take account of any new or emerging information and reflection. 32. The purpose of the review is to establish what lessons are learned from the case through a detailed examination of events, decision-making and action. In identifying what those lessons are, to improve inter-agency working and better safeguard and promote the welfare of children and adults who are vulnerable to or victims of domestic abuse in Lancashire. 1.4 The scope of the review 5 Department for Education (2011), A study of recommendations arising from serious case reviews 2009-2010, Brandon, M et al, The study calls for a curbing of ‘self-perpetuating and proliferation’ of recommendations. Current debate about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans 33. The review covers the time from when the adult victim and the perpetrator had first met, and includes the lifetime of Child L. The period under review is therefore from January 2002 until the day of the deaths in April 2013. 34. Organisations were asked to review any earlier information about both parents and check if it had any bearing on understanding their capacity as parents, including any evidence of violent or sexual behaviour, mental ill health or substance misuse. 35. All information known to a service providing an individual management review was reviewed. Any information regarding involvement prior to the period of the detailed chronology and analysis was summarised in the individual management review. 36. All agency chronologies included detailed information about when the child was seen or observations were made about them. 37. Agencies that identified significant background histories on family members pre-dating the scope of the review provided a brief summary account of that significant history. 38. Reviews of all records and materials were considered including; • Electronic records • Paper records and files • Patient or family held records. 39. Individual management reviews were completed using the template provided by the Lancashire Local Safeguarding Children Board, and were quality assured and approved by the most senior officer of the reviewing agency. 40. The review was completed in compliance with relevant local and national guidance. For serious case reviews the national guidance is set out in Working Together to Safeguard Children (2013), Chapter 4. There is local associated local safeguarding children board guidance and relevant procedures. Individual management reviews were completed in accordance with Multi-agency statutory guidance for the conduct of domestic homicide reviews. The following agencies have provided information for the review. a) Blackpool Teaching Hospital NHS Foundation Trust (provided health visiting and school nursing services) b) NHS England (GP services for the whole family) c) Lancashire Care NHS Foundation Trust (provided the single point of access to mental health services) d) Lancashire Constabulary (historical information and investigated the circumstances of the killings and the subsequent attempted suicide) e) Southport and Ormskirk Hospitals NHS Trust (services provided in July 2010 by the accident and emergency department at Southport and Formby District General Hospital to the adult victim and Child L and the services provided by the paediatric accident and emergency department at Ormskirk District General Hospital to Child L in regard to scald injuries that occurred during a camping holiday)6. f) The independent kindergarten service where Child L attended a nursery until he began school g) Two primary schools attended by Child L (second primary school because of the house purchase and move) h) University Hospital Morecambe Bay (provided midwifery and accident and emergency services) 41. Information that was sought from other services at the outset of the review is described in the appendix to this report. Written information was received from a Walk In Centre that provided treatment for Child L when had a scald injury. 42. Information was also sought from members of the families and is described in section 1.9. 43. The revised national guidance for serious case reviews allows the local safeguarding children board to use any learning model which is appropriate to the case. The guidance requires the review to a) recognises the complex circumstances in which professionals work together to safeguard children; b) seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; c) seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; d) is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 44. The national guidance in regard to domestic homicide reviews provides advice on issues that the review should consider. This also includes a requirement for the panel to establish terms of reference for the review and the provision of reports from agencies with significant contact or involvement. 6 The adult victim’s foot was dressed for a scald injury and she and father were advised to attend the paediatric accident and emergency department with Child L who had a blister on the abdomen as there are no paediatric emergency facilities at Southport Hospital; the paediatric accident and emergency department is based at Ormskirk Hospital. 1.5 Particular issues identified by the panel for further investigation by the individual management reviews7: 45. In addition to analysing individual and organisational practice, the individual management reviews should focus on: a) What knowledge or information did agencies have that indicated the adult victim might be a victim of domestic abuse, or that Child L might be at risk of significant harm? b) What services were offered to the adult victim, the perpetrator and Child L and were they accessible and sympathetic? c) What information did family and friends have that might have indicated the adult victim and/or Child L were at risk of abuse? d) What knowledge did agencies have that the perpetrator might be a perpetrator of abuse and pose a risk of significant harm to Child L or the adult victim? e) Were there any risks in relation to resources or capacity that had an impact on how services were provided to the victims or to the alleged perpetrator, or that impacted on agencies’ ability to work effectively with other services? 1.6 Membership of the case review panel and access to expert advice 46. The case review panel that oversaw this review comprised the following people and organisations; Position Organisation Annie Dodd Independent reviewer and chair Early Years Lead Quality and Continuous Improvement Service (LCC) Named Nurse Safeguarding Children University Hospital Morecombe Bay Assistant Director of Nursing – Safeguarding Adults Lancashire Care Foundation Trust Review Officer Lancashire Constabulary Quality and Review Manager Safeguarding Unit Schools Safeguarding and Children's Social Care (CSC), LCC Safeguarding Manager Fylde and Wyre and Lancashire North Clinical Commissioning Groups Acting Principal Social Worker Children’s social care services (LCC) Designated Doctor Safeguarding and NHS North and East Lancashire 7 These are the detailed issues that are analysed by the individual management reviews and in the detailed analysis. Children Looked After County Head of Active Intervention and Safeguarding Adult Social Care, LCC Named Nurse Safeguarding Children Blackpool Teaching Hospital NHS Foundation Trust (health visiting and school nursing) Safeguarding Practitioner Blackpool Teaching Hospital NHS Foundation Trust (Acute) Named Nurse Safeguarding Children Southport and Ormskirk Hospital Peter Maddocks Independent reviewer and author of the overview report Panel Observers/Support Business Manager Lancashire Safeguarding Children Board Community Safety Officer Lancaster City Council Community Safety & Justice Coordinator Lancashire Community Safety Partnership 47. The independent author of the overview report attended every meeting of the panel. 48. The panel had access to legal advice from a solicitor in the council’s legal service. 49. Written minutes of the panel meeting discussions and decisions were recorded by a member of the local safeguarding children board staff team in Lancashire. 1.7 Independence and experience of the lead reviewers8 50. Annie Dodd chaired the review and was previously employed as an assistant director with a local authority children’s social care service and has over 30 years’ experience as a qualified social worker and is registered with the Health and Care Professions Council (HCPC). Ms Dodd is now self employed as a consultant. She has previously chaired a serious case review for Lancashire SCB but has no other connection with Lancashire Safeguarding Children Board and has not been involved in any aspect of the management of the case. 51. Peter Maddocks is the author of this report and has over thirty-five years’ experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and 8 National guidance set out in Working Together to Safeguard Children 2013 refers to lead reviewers whereas Home Office guidance for the conduct of domestic homicide reviews refers to the distinct and separate roles of chair of the panel and the author of the overview report; both sets of guidance require independence. MA and is registered with the Health and Care Professions Council (HCPC). He undertakes work as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several local safeguarding children boards in England and Wales as well as work on domestic homicide reviews as a chair and author. He has undertaken work as an overview author on previous serious case reviews in Lancashire. Apart from this, he has not worked for any of the services contributing to this review. He has participated in training and professional development as a reviewer; this has included specific training in the use of systems learning applied to serious case reviews. 1.8 Parental and family contribution to the review 52. The perpetrator and other members of the extended families were made aware of this review when it was commissioned. A letter was initially sent by the lead reviewer who chaired the review panel, who in consultation with the police ensured that the relevant national guidance was complied with9. 53. The perpetrator’s mental health deteriorated following the killings. He was initially judged to be unfit to enter a plea for the purpose of the criminal proceedings. In view of his mental health it was considered inappropriate to seek any direct contact with him. This decision was taken in consultation with the medical team providing care and treatment. Information was sought from people who know the perpetrator and the family. 54. After the completion of the criminal proceedings further contact was made with the perpetrator through the consultant supervising his ongoing treatment and care and the perpetrator confirmed that he was willing to participate in a discussion with one of the lead reviewers. 55. That discussion took place in late 2013 and included one other professional member of the review panel along with a member of the professional team working with the perpetrator. 56. During that meeting the perpetrator talked about his relationship with the adult victim and Child L and his recollection of events and circumstances leading up to the deaths. He was not asked about the reasons or for details about the killing of the adult victim and Child L. 57. The perpetrator recalled feeling very down and depressed; paranoia and anxiety were also symptoms that the perpetrator had felt. The perpetrator 9 A Guide for the Police and the Crown Prosecution Service and Local Safeguarding Children Boards to assist with liaison and the exchange of information when there are simultaneous chapter 8 serious case reviews and criminal proceedings; (April 2011). was very distressed by events and still could not believe what had happened. The perpetrator said that the house move had been very stressful. It had coincided with him being unable to work in his landscape gardening business because of the severe weather at the time. The perpetrator acknowledged that he had always been a bit of a worrier and could get anxious about ‘nothing’; for example dealing with the routine tax returns, ensuring that they had enough money (which they did). 58. The perpetrator did not know why he began to feel paranoid and thought that people were after him. He felt generally closed in, lost and scared and when he began to hear voices he had sought advice from the GP. The perpetrator had felt fine about talking with the GP and about the referral to psychiatric services. He had become anxious when the meeting did not happen the same day as seeing the GP and because the hospital was located close to a prison the perpetrator had begun to have feelings of being sent away and possibly locked up. 59. The perpetrator described having a happy childhood with a supportive family. He had a happy childhood. He had a small group of friends at school. He had not been very confident. He had two girlfriends before meeting the adult victim in 2003. His first relationship had lasted about 30 months and the second for about 12 months. 60. The perpetrator met the adult victim after he moved to eastern England after being made redundant from a factory. He described getting on very well from the start and that he had loved her and both had been devoted to Child L. 61. The perpetrator and victim were both quiet individuals who enjoyed each other’s company. They occasionally went out to a pub for example. The victim had friends at work with whom she socialised sometimes. 62. Almost all relatives and friends who were contacted for the review indicated their willingness to contribute information. All were consistent in describing the family as being apparently happy and were all deeply shocked by the incident. 63. A maternal aunt to the adult victim explained that the adult victim was a very quiet girl, as were her parents. They had kept themselves to themselves. She is very sad about what happened and described Child L as a beautiful little boy. She said that she cannot understand how the perpetrator could have done what he did to him. This aunt had never met the perpetrator, but did meet his parents at a memorial service the family had for the adult victim’s mother for those that couldn't attend the funeral. She confirmed that the perpetrator's parents were very upset about what had happened and told her they didn't understand why it had happened. 64. A paternal aunt to the adult victim had known her since her birth. This aunt explained that the adult victim had been very quiet and didn't speak until she was five years old and had started school, but since then she was a ‘very sunny person’. She was chatty when she came to visit (last visit from the adult victim, the perpetrator and Child L was during the autumn school half term 2012). There were no issues that the aunt knew about, nothing at all to suggest what happened would happen. The aunt described the perpetrator’s parents as lovely people, and described how they attended the memorial service in the east of England following the death of the maternal grandmother. The aunt mentioned a pastor who managed a shop in the adult victim’s original home town outside Lancashire where the adult victim had worked for 15 years. 65. A paternal aunt to the adult victim who lives outside Lancashire and therefore had less contact with the family recently commented that they had always seemed to be a lovely family; the adult victim and Child L appeared very happy and described the perpetrator as a bit quiet. 66. The parents of the perpetrator and the perpetrator’s sister have had extensive contact with the family since the start of the perpetrator’s relationship with the adult victim and the subsequent birth of Child L. They also confirmed the description provided by other relatives and friends that the relationship between the perpetrator and the adult victim had been good and described a loving family who were well supported and in contact with the extended family. They share the shock experienced by others. 67. The paternal family had thought that the perpetrator had a medical problem when it was noticed that he was showing unusual symptoms such as drinking an excessive amount of water a few days before the killings. They thought that he possibly had developed a physical ailment such as diabetes for example. They had also become aware that other aspects of his behaviour had become unusual. For example, he thought people were being ‘funny’ with him. Initially this was not severe but increased over a period of several days. The perpetrator knew he had some sort of problem but could not identify what it was. The appointment with the GP was made on the expectation that the perpetrator had developed a physical condition such as diabetes and this was having an impact on him along with the usual stress of going through a house purchase and the house move that had been completed three weeks previously. 68. Some of the family felt that the visit to the GP had inadvertently exacerbated the perpetrator’s feelings of anxiety (and this was subsequently confirmed when the perpetrator spoke with the reviewers). The GP had asked lots of questions and completed a physical assessment which had not identified any physical problems. The perpetrator was advised that a referral had been made to a local psychiatric hospital service. It is the family’s perception that this appeared to have shocked the perpetrator and the adult victim with the suggestion that the perpetrator was mentally ill and a possible expectation that he was to be admitted to a psychiatric hospital. 69. After the GP consultation it seemed to the family that the phone ‘never seemed to stop ringing’ and this apparently added to the sense of heightened stress. The first phone call from the mental health practitioner included the question about whether the perpetrator felt suicidal. The paternal family feel this should not have been asked over the phone. 70. A further call to rearrange the scheduled face-to-face assessment with a male also inadvertently troubled the perpetrator who had been having thoughts that other people thought he was gay and therefore the suggested arrangement implied additional meaning for the perpetrator. 71. The family felt that the perpetrator had developed a fixation that there was a plan to keep him in the psychiatric hospital. He could not understand why he should be going there otherwise. He had talked a lot about the scheduled appointment. 1.9 Timescale for completing the review 72. The case review panel met on six occasions between June 2013 and October 2013. The initial chronology of services involvement was completed by July 2013. The first draft agency reviews were completed in August 2013. The first draft of the overview report was completed in September 2013. The overview report was presented to an extraordinary meeting of the local safeguarding children board and community safety partnership in January 2014. 73. The report could not be finally published until the completion of all parallel processes in April 2015. 1.10 Status and ownership of the overview report 74. The overview report is the property of the Lancashire Safeguarding Children Board and the Lancaster District Community Safety Partnership as the commissioning boards. 75. Since June 2010, all overview reports provided to local safeguarding children boards in England have to be published in full. The same expectation is also made in national guidance for overview reports for domestic homicide reviews. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Child L and the adult victim. 76. The report has to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible level of learning. 77. An executive summary was provided at the conclusion of the review. This provides a brief summary of events and the most significant points of learning identified as a result of the review. The local safeguarding children board and community safety partnership will determine how and what further information is provided to the family at the conclusion of the review and following the submission of the overview report and executive summary to the Department of Education and the Home Office. 1.11 Previous serious case reviews and domestic homicide reviews in Lancashire 78. The local safeguarding children board in Lancashire had undertaken nine previous serious case reviews between 2008 and 2013. 79. This is the fifth domestic homicide review in Lancashire since the statutory implementation in April 2011 although this is the first review that involves a familicide and it does not involve any history of abuse or substance misuse. As there are 14 community safety partnerships within Lancashire, a consistent approach to domestic homicide reviews has been developed with all relevant agencies based on the serious case review process. 80. Reference is made by several individual management review authors to relevant findings in serious case reviews completed locally or in other parts of the country and is also referenced where relevant in this overview report. The purpose of this is to highlight where similar issues or themes have been identified in previous reviews. This ensures that any improvement or learning action already recommended is not unnecessarily repeated. 81. Subsequent chapters of this review describe in greater detail the specific lessons to emerge from a detailed analysis of this review and include comments on how learning from previous reviews has been used. 1.12 Summary conclusion of the review 82. Cases where people kill their families and then commit suicide are thankfully rare in the UK and in other similar countries. 83. Familicide is defined as “a multiple-victim homicide incident in which the killer's spouse or ex-spouse and one or more children are slain10”. It remains 10 Wilson, M., Daly, M., & Daniele, A. (1995). Familicide: The Killing of Spouse and Children. Aggressive Behavior, a relatively understudied phenomenon and there is very limited information or research in regard to family annihilation or familicide. 84. In domestic abuse there is more usually some prior indication of potential harm and a pattern of escalating behaviour. In regard to domestic and child abuse there is a considerable range of information and research evidence to inform the analysis and development of learning. Because familicide is a rare event there is relatively little data and limited research that can help professionals identify factors that might indicate a heightened risk of it occurring and therefore preventing it. 85. The research indicates there are numerous motivations for the crime of familicide. Harper and Voigt’s (2007) study found that familicide is typically carried out by the head of the household whose motivation is the belief that they no longer can care for their families11. This appears to have been a significant factor in this case when the perpetrator feared that he might not have the capacity to care for his family; it is not certain whether this related to the onset of his psychosis or reflected concerns for example about his business. 86. Research concerning familicide has also identified several other characteristics with respect to perpetrators; familicide is a particularly male dominated crime; men were responsible for 95 per cent of all familicidal killings (Wilson et al, 1995). 87. Researchers have also found that intimate crimes rarely take place in public locations, and that most familicides take place in residential settings such as in this case at the family home. Harper and Voigt (2007) found most familicide victims are victimized in their own bedrooms and “the majority of incidents take place in residences located in middle-class suburban communities”. 88. There is a high prevalence of suicide among the offenders of familicide12. A larger proportion of genetic parents commit suicide following filicide, parents who kill multiple victims are more likely to commit suicide than those who kill a single victim, and parents are more likely to commit suicide after killing an older child than parents who kill a younger child. There is no significant difference in suicide rates between filicidal killings. Wilson et al’s (1995) study observed that half of the male perpetrators of familicide committed suicide. 11 Harper, D. W, & L. Voigt. (2007). Homicide followed by suicide an integrated theoretical perspective. Homicide studies, 11, 295- 318. cited by Bartholl and Sheldon 12 Shackelford, T. K., Weekes-Shackelford, V. A., & Beasley, S. L. (2005). An Explanatory Analysis of the Contexts and Circumstances of Filicide-Suicide in Chicago, 1965-1994. Aggressive Behavior, 89. The research that is available in the UK draws a distinction between groups of killings. These are described by Yardley, Wilson and Lynes13 as revenge killings and a second group that is ‘altruistic’ where the killing serves ‘a necessary even if distasteful means towards a desired outcome’ or from ‘a warped sense of love and loyalty’. Within the group the same researchers go on to describe four categories that are anomic, disappointed, paranoid or self-righteous. This case appears to have the characteristics of an anomic killing described in more detail in paragraph 88. 90. The limited study of UK deaths identifies some common traits. These include that many of the men who kill in these circumstances are from lower socio economic backgrounds, are underemployed and have histories of disruption and offending in childhood that might continue into adulthood. The mean age of the adults who killed was 38 and the children killed were a mean age of 6 years old. Almost a third (32.2 per cent) were stabbed, the child was killed by their biological parent and the killings occurred in a private place (home or secluded location) rather than in any confrontation with services such as the police. 91. The research evidence that is available identifies some risk factors that may predict more severe domestic violence. Amongst these is over enmeshment which might possibly be a factor in this particular case. 92. Over enmeshment is a condition identified by academics such as Professor Gelles of the School of Social Policy & Practice at the University of Pennsylvania, USA in which perpetrators either view “their family members as possessions that they control or [they] don’t see any boundaries between their identity, their wife and their children. And so these are suicides of the entire family, where the anomic, overly enmeshed individual can’t bear to leave the pain behind and so takes his wife and children with him”14. 93. Anomic suicide which is also described in the UK study published in the Howard Journal and by other academics including Professor Gelles reflects an individual's moral confusion and lack of social direction, which is related to dramatic social and economic upheaval. Social norms become unclear during times of change. Individual behaviour is less susceptible to social norms and can induce feelings of threatened masculinity. In this case for example the perpetrator had developed concerns that other people might think he was gay (the perpetrator explained that he did not have a girlfriend until relatively late adolescence that had been the source of some joking by family members but had surfaced in his memory when he became unwell). 13 Elizabeth Yardley, David Wilson and Adam Lynes. A Taxonomy of Male British Family Annihilators, 1980–2012;; The Howard Journal 2013. 14 Bernie Auchter, Men Who Murder Their Families: What the Research Tells Us; NIJ Journal / Issue No. 266 94. People (and men in particular) do not know where they fit in within their communities or societies. This can occur when an individual goes through extreme changes in wealth; while this includes economic ruin, and it can also include windfall gains. In both cases, previous expectations from life are pushed aside and new expectations are needed before an individual can judge their new situation in relation to the new frameworks. 95. In this case the family had moved into a new area having purchased their home with a bequest from the death of the maternal grandmother a month before the killings. The perpetrator had set up a gardening business. The police investigation following the killings has not identified any significant financial difficulties although a colleague of the adult victim’s has mentioned feeling that the family did have financial worries perhaps associated with the seasonal nature of the perpetrator’s business and the adult victim working only part time. The perpetrator confirmed that he had worried at times about business and the house move had been very stressful for him. 96. The perpetrator reported feeling that one of his regular customers was ‘being funny with him’. He began to feel that other people were talking about him. On the day that the perpetrator went to the GP to discuss his symptoms that would lead to his urgent referral for a mental health assessment, a relative had been sentenced to six years imprisonment; the offence had no direct connection with the family. The relative had bullied the perpetrator although this was not the reason the relative went to prison. 97. In the evening of the same day of the GP consultation the perpetrator had expressed his concerns that Child L would be bullied and that other people would think he was a paedophile (which has no substantiation but reflected the perpetrator’s mental and psychological distress at the time). In a statement to the police after the killings the perpetrator also described his concern about the possibility of becoming a hospital in-patient as result of the mental health assessment and that he would be unable to care for his family. 98. Very little if any of this information was known to any of the services that have participated in this review. Even if they had known all of the information, there was little to indicate from the perpetrator’s behaviour or conversation or from his partner to indicate a risk of significant or immediate harm. 99. Although the review has examined the onset of mental health symptoms for the perpetrator just before the killings and with the benefit of hindsight is able to identify important learning especially in regard to early response to the emergence of those symptoms, there was no opportunity for either family and friends or the professional services that were in contact with the family to have predicted and therefore prevented what happened to Child L and the adult victim. 100. Until the untimely and tragic deaths this was a family who were living quietly and without any exceptional or unusual incidents or the involvement of any specialist services or from the police. The perpetrator and his family had become aware that he was not feeling well and had sought advice and help and he was co-operating with the assistance and support being offered. 101. The information for the review describes how the adult victim moved to Lancashire after she and the perpetrator had developed a relationship and had quickly planned to have a child. The information provided to the review and analysed in later sections includes reflection about how the potential social and economic isolation of women is not part of routine health screening for example when registering as a new patient. 102. The review reinforces the importance of routine checking for potential indication of domestic abuse especially when any injuries are observed in or outside clinical settings. For example, both the adult victim and Child L had treatment for different injuries that were described as accidents although there were shortcomings in the level of detail that was checked at the time. There were also gaps in how some of this information was then passed to services such as the GP. 103. This is not to suggest that abuse or violence was confirmed or missed as a feature in this family but it does reinforce the importance of professionals maintaining an appropriate level of sceptical curiosity. 104. The review has examined the referral to mental health services on the day before the killings. Although there was a prompt response and practitioners complied with the relevant protocol for the initial and immediate response and contact with the patient there is learning and improvement identified, for example in regard to risk assessment and management in new cases with active and untreated psychosis. 105. The review panel agrees with the individual management review provided on behalf of the mental health service that a face-to-face mental health assessment should have been given even higher priority with the perpetrator if it had been correctly understood that he was experiencing a first and untreated episode of psychosis; there was a difference of professional opinion between the GP and the mental health practitioner (MHP1). 106. The risks associated with the first episode of untreated psychosis had been a factor identified in a regional domestic homicide review that had led to implementation of clinical guidance in the health service in the county. The protocol was not implemented in this case because although the GP thought that the perpetrator might have been showing symptoms of psychosis the subsequent assessment by the specialist mental health practitioner did not identify symptoms to confirm such a diagnosis. 107. This is not a criticism of either professional who both had relevant training and experience and can both be expected to make a professional judgment of their own. The review explores some of the factors and influences that contributed to how judgments were made for the purpose of identifying learning. 108. The perpetrator had been the subject of a face-to-face assessment by the GP who made the referral to the mental health service and there was a telephone consultation between the GP and MHP1 and a telephone triage assessment by the mental health practitioner on the same day that he had first disclosed his symptoms. 109. There was a differential diagnosis as to what specific mental health symptoms the perpetrator was experiencing which is described and analysed in later sections of this report. Not unreasonably some of the relatives have queried whether the killings could have been prevented if the perpetrator had been seen by a psychiatrist. Regrettably, even if the face-to-face assessment had occurred the same day, this would not have necessarily prevented the killings and the perpetrator’s attempted suicide. This would have only been prevented if there had been a decision that the perpetrator required in patient treatment either as a voluntary patient or if the legal thresholds had been met for detention under the mental health legislation, or the perpetrator had felt less anxious about no longer being able to care for his family. 110. This would have required evidence that the perpetrator posed a risk of harm to himself or to others. No evidence has been found to indicate that any professional had grounds for such a concern and there was never an indication from the adult victim or from Child L that they had ever felt threatened by the perpetrator at any time. 111. It is impossible and unwise to second guess what symptoms would have been diagnosed in a face-to-face assessment for example with a consultant psychiatrist or what treatment plan might have been identified. There was agreement in the panel and with the benefit of expert advice and opinion that in the presentation of symptoms to the GP and the MHP1 there was no basis to think that in-patient treatment would have been a likely outcome. 112. The purpose of conducting a statutory review is to undertake a detailed examination of the events within the context of understanding how the judgements, decisions and actions were taken by the various professionals involved with the family for the purpose of drawing out learning to inform future policy, service development and individual practice. The rest of this report describes in detail the interaction and information that different services had with the family and identifies the key learning. 1.13 The family and other significant people 113. The adult victim was aged 40 years old when she and Child L died. the perpetrator was 34 years old. Child L was an only child. Both of the adult victim’s parents had died, her mother relatively recently. The perpetrator has siblings and his family live locally and there had been regular contact. 114. There had been no evidence of any relationship difficulties. This was confirmed in the contact and conversation with family friends and relatives who contributed to this review and is consistent with the recollections from various professionals who came into contact with them. The hospital sister at Ormskirk remembered the family’s attendance because of the fact the family was on holiday camping and remembered having a conversation about their holiday. The interaction between all family members was good and they were ‘chatty’ with each other. 115. The adult victim and the perpetrator had first met when the perpetrator was working in the east of England where the adult victim was living at the time. He had been working in a factory in Lancashire until he was made redundant and had moved to the east of England following a break up with a previous girlfriend. The perpetrator’s father had known people in the east of England. The perpetrator met the adult victim in 2003 aged 24 years old. The perpetrator described the relationship as really good and how he had loved the adult victim getting on really well from the moment that they had met. They moved to Lancashire. They decided they wanted to have a child. The perpetrator described Child L as the ‘best son (he) could ever have had’. 116. On moving to Lancashire the perpetrator had found work as a gardener and the adult victim worked part time as a sales assistant. In 2012 the perpetrator had set up his own business as a self-employed gardener. 117. The perpetrator and the adult victim were quiet individuals; they did not go to pubs often and preferred doing activities together. 118. The paternal family describe the perpetrator as having always been quiet since childhood with a few friends. The family said that he was not bullied at school and the perpetrator confirmed this. 119. The perpetrator had two previous relationships. The second relationship had ended by the end of 2002 and coincided with the perpetrator being made redundant. This previous girlfriend had made a complaint to the local police when she reported being ‘pestered’ by the perpetrator when she had told him that she wanted to end their relationship. This had involved the perpetrator making unwanted phone calls to her. There was no physical violence ever reported although she did say that her mobile phone had been damaged by the perpetrator. The police had not introduced the DASH protocols15 at the time and the information was not screened as a domestic abuse incident. The information came to light as a result of the major inquiry by the police investigating the killing of the adult victim and Child L. Once the perpetrator had been advised by the police he had desisted from any further contact. 120. Child L had required eight days care in a neo natal ward following his birth. He was slow to put on weight and had been assessed for hearing difficulty after he started statutory education; the hearing assessment concluded that Child L did not have a hearing difficulty. Before starting school he was enrolled with a local children’s centre between March 2008 and April 200916. 121. There was one occasion when a health visitor observed a bruise to the adult victim’s face in June 2009. She denied that it was anything other than an injury caused when gardening17. Less than a week after this visit the adult victim took Child L for one of his regular nursery sessions by which time the bruise was not visible. The paternal family mentioned that the adult victim had been injured on one occasion when she had an epileptic fit in the bathroom. 122. There were no other injuries or concerns identified until the presentation at the GP surgery the day before the killings to discuss the mental health symptoms. At that consultation, the adult victim did say that she was becoming worried about the perpetrator’s behaviour although did not give any indication that she was worried about any immediate or significant risk of harm. 123. The perpetrator enjoyed his work as a gardener and had regular customers. The winter was less busy although the family managed their finances and the ability to purchase their house outright shortly before the killings had represented a reduction in their monthly outgoings. 1.14 Cultural, ethnic, linguistic and religious identity of the family 124. The maternal and paternal families are both white British. Their first and only language is English and there is no record of any physical or learning 15 The DASH (domestic abuse, stalking and honour based violence) risk assessment is a tool used by police services throughout the UK to assess the risk that a victim is exposed to and can help in identifying the action required to manage risk. 16 These are centres that are open to all parents, carers and children under five years of age and many of the services are free. 17 After the killings and the review was commissioned members of the family have mentioned that they thought the bruise had occurred during an epileptic fit in the bathroom. disability18. In late 2012 the family purchased outright the home where the killings took place. The house move resulted in Child L changing to a different primary school in the county. 125. Both adults were in employment. The perpetrator was self-employed in his gardening business. The adult victim worked part-time as a retail sales assistant. 126. Lancashire has a population of 1.16 million, which is projected to grow by almost eight per cent to 1.23 million by 2028. The county comprises a mixture of urban, rural and coastal communities and covers twelve district councils four of which (Burnley, Hyndburn, Pendle and Preston) rank in the top 30 most deprived districts in the country (Index of Multiple Deprivation 2007). 127. Five per cent of the population are from minority ethnic backgrounds, predominantly Pakistani and Indian, clustered mainly in parts of the east of the county and in Preston. More recently, small but growing numbers of people from Eastern Europe have begun to settle across the county, with concentrations in Lancaster and Preston. 128. A total of 20 per cent of children across the county are income deprived according to the Index of Multiple Deprivation 2007. Six areas (three in Burnley, two in Preston and one in West Lancashire) are ranked in the two per cent of the most deprived in England for child poverty and 9.5 per cent of children in Lancashire live in super output areas ranked among the 10 per cent worst nationally for income deprivation. 129. In contrast, the area that the family had moved to in late 2012 has low levels of crime and is above the median in terms of deprivation and health. 18 There is a reference later in the report to the GP records having some information that the adult victim had received remedial education support as a child although the records provide no other detail. 2 Synopsis of agency involvement 130. This narrative summary of professional contact with Child L and the adult victim provides an account of the most significant events and decisions from the different services involved with them during the timeframe established for the review. 131. This summary, and indeed the whole overview report, has to strike a balance between protecting the confidentiality of the child, their family and the various people who were in contact with them whilst providing a sufficiently detailed account of events in order to draw out the points for learning and development in the later chapters. Therefore, the summary does not contain every contact with the family. 132. In late 2002 a previous girl friend of the perpetrator had made a complaint to the police that he had taken her mobile phone. He had been making unwanted calls to her. The phone was returned to the partner and no further action was taken. The police have taken a statement as part of their investigation in which the ex-partner confirmed that she had never been subject of domestic abuse by the perpetrator and that he had stopped trying to contact her after she had contacted the police. 133. the perpetrator had left Lancashire less than a week later and moved to the east of England. Less than a month later, in late January 2003 the paternal grandparent (PGP) reported that the perpetrator had caused damage to the front door of the PGP’s home. He did not want to make a formal complaint and no further action was taken. 134. In June 2003 the perpetrator’s sister contacted the police to say that the perpetrator had returned home just before midnight and had ‘gone berserk’. Five minutes later the paternal grandmother called to say the police were not required and that her daughter had got too excited about her brother. The police attended. No complaint was made and no offence was recorded and the perpetrator was transported to the great grandmother’s home. 135. There was routine contact with GP services and in October 2005 the adult victim was diagnosed with epilepsy following two episodes of losing consciousness in June and October 2005 respectively. It was around this time that the adult victim mentioned that she had plans to start a family the following year. The diagnosis of epilepsy had implications for this plan in regard to the medication that she was prescribed to manage the condition. There are associated issues in relation to an enhanced risk of depression that are discussed in the individual management review from the GP practice. 136. In July 2006 the adult victim’s pregnancy was confirmed. Child L was born in February 2007. He was born in a poor condition requiring resuscitation and admission to the neo natal ward where he remained for eight days. The adult victim was discharged from hospital on the day of the birth. Child L made progress. In November his weight was below the ninth centile19. the adult victim had continuing physical health problems following the birth associated with the pregnancy. 137. Between March 2008 and April 2009 Child L was enrolled with the local children’s centre where he attended sessions with the adult victim. 138. In June 2009, the health visitor made a routine home visit during which the adult victim was noted to have faint bruising below her left eye although she was wearing makeup. The health visitor was unable to ask directly about the bruise as the perpetrator was present. Opportunity was given to contact the health visitor if the adult victim wanted to talk about diet or “anything else”20. 139. Three weeks later, the adult victim contacted the health visitor by phone to change the venue of a planned appointment to take place at the paternal grandmother’s home as Child L had stayed overnight the previous evening. During the phone conversation, the health visitor enquired about the bruising she had seen at the last visit. The adult victim explained that this had occurred when she had been sweeping up leaves. She made clear that it was not the result of any domestic violence. Child L’s dietary intake had improved and the health visitor was happy that Child L’s weight was now above the 2nd centile. The adult victim reported that Child L’s diet had improved because he was eating a greater variety of foods. Child L had also started going to a nursery. He had been initially shy and had gravitated towards adults. The adult victim felt that Child L was enjoying nursery. 140. In March 2010, three year old Child L was taken to the local hospital emergency department by a grandparent with a ‘head injury’ having fallen from a buggy. This attendance at the hospital was not notified to the GP. Child L was seen and documented as ‘walking, talking and playing normally’. Further analysis is provided in later sections in regard to the level of detail that was recorded in regard to the circumstances of this injury. 141. In July 2010 the adult victim and Child L both had treatment at a hospital emergency department in Southport for scald injuries. The adult victim had an injury to her foot and Child L had a small blister to the abdomen. The 19 A centile chart is a size for age chart that is used to decide whether the size of a child falls within the normal (average) range or whether the child is larger or smaller than normal. Centile charts show the position of a measured parameter within a statistical distribution. They do not show if that parameter is normal or abnormal. They merely show how it compares with that measurement in other individuals. They are called centiles and not per centiles. If a parameter such as weight is on the 3rd centile, this means that for every 100 children of that age, three per cent would be expected to be lighter and 97 heavier. On the 9th centile, 9 would be lighter and 91 heavier. 20 The nursery staff never saw any injury or bruising to the adult victim. perpetrator had accompanied them and they are remembered by the hospital sister who was on duty as having been chatty. The injuries were reported to be the result of an accident while they were on a camping holiday. Both the adult victim and Child L had treatment at the hospital and on the advice of the sister Child L was taken by the parents to another hospital in Ormskirk that had a paediatric service. 142. In September 2011 Child L started school. A month after enrolment his teacher suggested that his hearing should be checked. An assessment in January 2013 did not identify any hearing loss. 143. In April 2012 Child L was treated at a hospital emergency department for an injury to his head. It is documented that Child L was ‘hit on forehead by handle of walking frame’ causing a lump on the left side of the forehead. Child L was described as being ‘happy, alert and playful’. The safeguarding children section of the patient documentation was not completed and no discussion with the school nursing service was apparently considered. Further analysis is provided in later sections of the report. 144. In January 2013 Child L was transferred to a new school because the family had bought a house and moved to another area in the county. 145. In early April 2013 Child L’s parents went to the GP to discuss the perpetrator’s mental health symptoms. The GP took a detailed history and promptly referred the perpetrator to the single point of access service and a duty mental health practitioner (MHP1) quickly contacted the perpetrator by phone within an hour of receiving the referral and completed an initial assessment by phone. An appointment was made to see him the following day. The referral and initial assessment confirmed that there was no history of self-harm and no suicidal ideation currently. Further information and analysis is provided in later sections. 146. The adult victim and Child L were killed overnight and the appointment was therefore not kept. 3 The critical reflection and analysis obtained from the individual management reviews. 3.1 Summary 147. The individual management reviews were completed using national guidance set out in Working Together to Safeguard Children (2013) and Multi-agency statutory guidance for the conduct of domestic homicide reviews which was also supported with additional local guidance provided on behalf of the local safeguarding children board. The individual management reviews included action plans for implementing recommendations. All the individual management reviews are countersigned by the senior manager for the individual commissioning agency. 148. Many of the services have already taken action or initiated action in response to improvements or areas of development identified through their individual review. 149. For some of the authors, they were simultaneously working on other individual management reviews for other serious case reviews. All of the authors were also undertaking their usual range of professional roles and responsibilities. 150. The national guidance has removed a requirement to provide a health overview report (HOR). No HOR was provided in this review. 3.2 Significant themes for learning that emerge from examining the individual management reviews 151. The agency reviews identify themes that have implications for policy development and staff training. In the summary of the review’s finding provided in chapter one there is acknowledgement that some of the issues to come out of this review are reflected in the findings from national evaluation and research. 152. The good practice identified by the review included: a) The extended consultation with the GP which had lasted 20 minutes was followed immediately by the GP personally making a telephone referral to mental health services; b) Prompt and sensitive arrangements were made by the school following the death of Child L to provide support to the school community and information provided to families; this included the provision of additional pastoral support at school and work with the local church to have playground support; involvement by the critical incident team to support the school staff and anticipating the possibility of the traumatic incident prompting disclosures or requests for specific help from other families. c) The hospital sister in Southport referred Child L to another hospital for a paediatric assessment and treatment after the scald injury. 153. The remainder of this chapter summarises key evidence relating to the terms of reference established for the individual management reviews. TOR 1 What knowledge or information did agencies have that indicated the adult victim might be a victim of domestic abuse, or that child L might be at risk of significant harm? 154. The killing of a domestic partner and a child is a distressing and shocking experience for the family as well as for other people including professionals who were in contact before the deaths. Relatives and friends who have contributed information to the review have consistently described a family that was content and committed to each other. None of them had concerns in regard to the safety or wellbeing of any family member. They were a family who sought help and advice appropriately in regard to their health and wellbeing and of Child L. 155. The individual management review from the schools provided information about the extent of support that was provided to pupils and other members of the school community after the death of Child L. The two schools have been rated as good or outstanding by Ofsted that includes their work in regard to safeguarding children. 156. The same report describes the attention and awareness given to identifying children who may be exhibiting signs or symptoms of distress or abuse. Child L was a quiet child but showed no indication of being unhappy or being a child at risk of harm. The other services, primarily health that came into contact with Child L and the adult victim had similar views. 157. It is not uncommon in reviews that are required to collate and analyse a great deal of information following a tragic incident to identify with the benefit of hindsight, the occasions when there may have been opportunities to identify signs or symptoms of concern or abuse. The level of detailed enquiry and analysis required by a SCR and domestic homicide review can often reveal information that was either not identified at the time of events taking place or had a different interpretation. 158. In this case there was one occasion when a health visitor had noticed during a home visit in June 2009 that the adult victim had a bruise which was still visible through make up. The perpetrator had been present and therefore the health visitor had not asked any direct questions about the bruise although when she left the house she had made a point of encouraging the adult victim to speak with her if there was anything she needed to talk about. 159. The health visitor had followed up the bruise although this did not happen for three weeks when the adult victim had called to change the venue for the health visitor’s scheduled home visit; the adult victim then stated that the bruise had been caused accidentally by a garden rake when she had been gardening. The individual management review acknowledges that this was too long a delay given the information that is known about following up evidence of injuries quickly to encourage disclosure and to secure evidence for further enquiries. 160. The only other occasion when the adult victim was seen with a physical injury was when she presented with a scald burn at another hospital emergency department in July 2010 when the family were on holiday locally. Although the adult victim and Child L initially went to the same emergency service, Child L was treated separately at another hospital’s paediatric emergency service in regard to the same accident. The injuries were reported to have occurred whilst the family were camping although there was no detailed history recorded in regard to the particular circumstances under which the injury had been acquired. 161. The individual management review author from the Southport and Ormskirk Hospital NHS Trust observes that if the hospital sister had not still been employed in the Trust and had such a clear recollection of the presentation at the hospital there would have been little other information to know about the incident. The fact that the family presented in such a positive fashion was the reasons that little inquiry was made about circumstances or the recording of information. The hospital sister did ensure that treatment was prompt and liaised with the other hospital paediatric service to ensure that Child L attended. 162. There were two other occasions when Child L was taken for hospital treatment. In March 2010, three year old Child L was taken to the local hospital emergency department by a grandparent with a ‘head injury’ having fallen from a buggy. This attendance at the hospital was not notified to the GP. Child L was seen and was documented as ‘walking, talking and playing normally’. Child L was attending a nursery at this time where there is no record of an injury to Child L and the nursery was not aware of any hospital treatment. Further analysis is provided in later sections of the report in regard to the level of detail that was recorded about the circumstances under which injuries occurred. 163. In April 2012 Child L was treated at a hospital emergency department for an injury to his head. It is documented that Child L was ‘hit on forehead by handle of walking frame’ causing a lump on the left side of the head. Child L was happy, alert and playful. There is limited documentation as to how Child L had sustained the injury. The safeguarding children section of the patient documentation was not completed and liaison with the school nursing service was not apparently considered. Further analysis is provided in later sections of the report. 164. Care needs to be taken in not applying a hindsight bias that because of what happened to Child L and the adult victim begins to ascribe these presentations as missed opportunities that could have prevented their deaths. It remains probable, based on what is known from the information collated and analysed for the review and during the police inquiry, that these were accidents. However, it would be expected practice to have seen a higher level of professional curiosity and recording than was achieved and would also have given greater confidence that abuse was not missed. 165. The individual management review on behalf of the GP service discusses other learning to emerge from a detailed examination of the patient records. For example, the individual management review highlights that the adult victim moved to Lancashire after meeting the perpetrator when he was temporarily working in another part of the UK. When she registered as a new patient, there was no consideration as to whether she was socially isolated or where her support was located over and above her relationship with the perpetrator. The same individual management review also highlights that epilepsy carries a heightened chance of depression which was not apparently considered when the adult victim sought advice about pregnancy. The individual management review draws attention to the prevalence of social isolation and depression in child injury and domestic abuse. 166. None of the services were able to provide information as to whether a learning or cognitive difficulty was an issue for the adult victim although the GP report highlights that the adult victim had remedial education support when she had been at school although her medical records for that period are missing and therefore no more detailed information is available. 167. The GP consultation on the 8th April 2013 had resulted in a referral being made to the county mental health services through the Single Point of Access. Although there was nothing in the demeanour of either parent to cause immediate concern about the perpetrator being at risk of self-harm, it is apparent that the perpetrator was experiencing what the GP thought could be a psychotic episode and was the reason the GP made an urgent referral by telephone in spite of having other patients already waiting for their consultation. The individual management review describes how the GP had recent experience of working in psychiatric services for six months. 168. Neither the GP nor MHP1 who initially dealt with the referral had inquired about Child L. Although the GP had spent 20 minutes talking with and assessing the perpetrator’s mental and physical health, neither the GP nor the MHP1 during their telephone discussion with the perpetrator later the same day used a depression assessment tool such as the PHQ-9 to collate information about the perpetrator’s mood and general mental health21. The individual management review on behalf of the mental health service confirms that the PHQ-9 is rarely completed until a face-to-face assessment is completed by the MHP1. 169. The referral from the GP was recorded by the duty mental health practitioner (MHP1). There is inevitably a degree of risk in information being misunderstood or being given differential inference between the person providing information and the individual recording it. Some of this reflects a fundamental attribution for example in regard to recording evidence of risk; on the form there is a section asking for information about risk screening where the tendency is to look at the safety of practitioners which is valid but also requires a conscious consideration of risk on a broader front. Experienced practitioners will assert that this is integral to their practice although their recording may not explicitly reflect this. 170. There is also what is described in research literature as the ‘shortcomings of human inference’. This can help describe how judgments can be influenced by inference where for example the mental health service know that GPs will almost certainly allocate a judgment of high risk to their referral and that this is understood as trying to give their patient a higher priority for attention rather than reflecting a more objective assessment of concern22. 171. The service may therefore be less bound by a third party judgment and especially if that third party is seen to be ambivalent. The judgment in regard to risk is decoupled from the data and intelligence about the subject of the risk. None of this should be read as a criticism of the GP or the mental health practitioners but rather is intended to develop an insight into how important aspects of roles and functions are carried out. 172. The mental health service responded promptly to the telephone referral. Having taken the call from the GP and tried to contact the perpetrator through the telephone landline MHP1 successfully made contact through the adult victim’s mobile phone. The parents were in a local public park at the time. The mental health practitioner completed a telephone triage and having concluded that the perpetrator was not requiring an immediate face-21 The individual management review on behalf of the GP practice discusses the various tools that are available to general practitioners that included the PHQ-9 assessment tool that has been validated for use in primary health care settings. The tool is designed to assess the patient’s mood over the previous two weeks rather than relying just on immediate observation and self-reporting of current mood. 22 Nisbett & Ross, (1980). Human inference: Strategies and shortcomings of social judgment; Prentice-Hall to-face assessment then made arrangements for this to be completed the following day. 173. During the referral discussion and the triage conversation, no information was disclosed that indicated there were any historical or current concerns about domestic abuse. TOR2 What services were offered to the adult victim, the perpetrator and child L and were they accessible and sympathetic? 174. Until the perpetrator began to experience his first disclosed episode of mental health symptoms to the GP and the subsequent referral to the mental health services by the GP, the family had not come to the notice of any other services other than those providing health care for the family and the early years care and education provided for Child L. Child L was a regular attendee at nursery and at primary school and was meeting the recognised developmental milestones. 175. The provision of services to the family was largely routine and unremarkable. This included appropriate contact with the family GP services, midwifery and health visiting services as well as presentations at hospital emergency services following accidents. Contact with the school was also routine in as far as Child L was a regular attendee at school and his parents participated in parent evenings and attended school events. 176. The purpose of the review is to allow reflection and analysis about whether any aspect of services could be improved. This does not imply people were not doing their jobs correctly but rather looks at how the service can be improved or can be provided with enhanced levels of awareness or sensitivity. 177. The GP individual management review comments about the gap in historical patient records for the adult victim that cannot be explained; the time period is from when she was living in another part of the country although it would be expected practice for records to be transferred to a new practice when a patient has registered with a new GP. 178. The individual management review comments that although a routine patient check was completed when the adult victim transferred to the GP practice, the framework of the patient check still does not prompt inquiry about wider social and emotional issues and which may or may not have been significant factors for the adult victim. The individual management review makes reference to community and social isolation as factors that can be associated with domestic abuse (and forms of child abuse). 179. The GP individual management review also discusses the fact that the reviews of the adult victim’s epilepsy did not include questions about depression although there is an associated life time prevalence of between six and thirty per cent for patients diagnosed with epilepsy. The same individual management review also points to depression as being a factor identified in incidents of domestic abuse (and is also a factor in child maltreatment and abuse). 180. The same individual management review also comments that there were not routine screening questions about domestic abuse; this is not a local or national requirement in GP contracts and there is research still being undertaken in the UK to establish whether there should be changes to the policy. 181. The presentations at the hospital emergency services by the adult victim and Child L were opportunities for a more sceptical and curious enquiry about the circumstances under which the injuries had occurred. Child L was twice presented with an injury; on one of those occasions it was because he had fallen from a buggy and on another he had a bump to his head. The GP was only told of one of those presentations and also had incomplete information in regard to the adult victim receiving hospital treatment. The GP also received incorrect information about a presentation for Child L at hospital that referred to a scald when in fact Child L had an injury to his head. 182. The individual management review on behalf of UHMB describes the historical systems for notifying the GP services about any hospital attendance by a patient relying on practitioners generating a letter; this appeared to be the case in regard to Child L but this was overlooked. The current electronic patient information system generates a notification when a patient is presented for hospital treatment. In many parts of England hospital trusts have well established paediatric liaison services that have responsibility for overseeing information about hospital admissions or treatment of children and young people and have a critical role in coordinating information. UHMB will have established a paediatric liaison service from September 2013. This service will have oversight of gathering of hospital and treatment information in respect of all children aged 18 and under who have been presented and admitted for treatment. They will also be responsible for communicating the collated information to the relevant primary and community care professionals such as GPs and health visiting and school nursing services. 183. One of the hospitals has been subject of critical inspection reports and changes have already been instituted in regard to how history is taken and communication with primary health services such as the GP. 184. In regard to the perpetrator, when he consulted his GP regarding the onset of his low mood and other symptoms, the GP took a thorough history with regards to the voices that the perpetrator was hearing. the perpetrator was clear that the voices were not talking to him, but were rather talking about him. The GP asked specifically whether the voices were asking him to do anything and the perpetrator’s reply was that they were not. The GP asked specifically whether he had any thoughts of self-harm or suicide and the perpetrator had said he did not. 185. The GP did not think that there was an immediate risk to the perpetrator or to the adult victim who was present throughout the consultation. The GP had not appreciated at the time that the couple had a child although even with the benefit of hindsight, there was nothing in the initial assessment to indicate risk of significant harm and injury to any of the family. 186. The GP contacted the Single Point of Access, which is the correct referral mechanism for urgent mental health problems. The GP explained the situation to them and asked for ‘a quick assessment’, given the perpetrator’s recent onset of mental health symptoms. There was an initial assessment over the telephone that same day by a mental health practitioner and a face-to-face appointment was given for the following day. This was the day on which the killings took place; they had not attended the hospital appointment. 187. The perpetrator had been called by telephone immediately after the referral was made by GP by the same mental health practitioner who had received the referral from the GP; the individual management review described this as timely and provided consistency. The practitioner followed the referral pathway in Lancaster and Morecambe for urgent assessments. Two attempts were made to call the perpetrator on his landline before a successful attempt via the adult victim’s mobile phone. The perpetrator was in a local park when he took the phone call. The practitioner discussed with him the concerns the GP had relayed and explored the nature of his voices. The perpetrator agreed to a face-to face assessment with the practitioner the following day which continued to offer consistency. 188. Telephone triage is the standard practice across the Trust for all referrals marked urgent made to the Single Point of Access as a way of clarifying the referral and “gate keeping” the allocation of assessments. The Single Point of Access in Lancaster and Morecambe receives approximately 25 referrals a day and these are processed by the duty worker. 189. The individual management review on behalf of the LCFT discusses the shortcomings of a telephone based triage service drawing attention to research and other evidence. The individual management review is concerned that a telephone triage for symptoms of mental disorder has limitations as it relies only on sound. No other senses can be used such as body language or demeanour and eye contact observations are not available to a telephone triage. Likewise, the full range of interpersonal communication is not available to establish rapport and establish patient confidence and trust to disclose their symptoms. When he responded to the telephone triage, the perpetrator was in a public place and may not have had sufficient privacy for a confidential discussion of his symptoms. In this case the GP had had opportunity of face-to-face contact in the privacy of a consulting room which concluded in the immediate and urgent referral for a mental health assessment. 190. The duty mental health practitioner recorded that the GP had stated that the perpetrator was “? Hearing voices” and “paranoid people are talking about him”. Following the telephone conversation with the perpetrator the mental health practitioner concluded that the voices were ‘an internal dialogue’ rather than instructions or incitement to act in particular ways23. The mental health practitioner was therefore not working on a premise that the perpetrator was presenting with symptoms of untreated psychosis. 191. With the benefit of hindsight and the detailed analysis provided in the individual management review, this working hypothesis may have represented a degree of over confidence. This is not a criticism of any individual specialist practitioner. The judgement they arrived at was consistent with what they ‘heard’ during the telephone referral and the triage telephone assessment. 192. The individual management review on behalf of the mental health service offers an analytical commentary about the shortcomings of the referral process, the reliance on a telephone based triage service and the other influences such as cognitive and human inference. This is explored further in the later chapter that presents key findings from the review. 193. The decision to arrange the face-to-face assessment meant that using tools such as the PHQ-9 and completing a more detailed history were postponed, albeit for less than 24 hours. The delay had been an additional source of anxiety for the perpetrator. Even if the face-to-face assessment had been completed that same day it would be false to conclude that the awful events overnight could have been prevented. The perpetrator would have been free to remain at home unless there had been any evidence to support either voluntary or compulsory in patient treatment. The pace and scale of crisis and deterioration in his emotional and mental condition was not indicated in the information presented. 194. The individual management review from the LCFT draws attention to Blue Lights and an internal briefing that had been published following a domestic homicide review in a neighbouring authority. Blue Lights are applicable to all mental health clinical staff and are a method of sharing learning from incidents across Lancashire Care NHS Foundation Trust. 23 The individual management review explains that internal dialogue refers to the general experience of most people thinking in their own words their internal thought processes rather than being auditory or hallucinatory and therefore more distressing for the patient and indicative of for example a psychotic episode. 195. Blue Light 71 was issued in October 2011, and concerns the treatment of first episode psychosis. This was produced following a post incident review (PIR)24 of a domestic homicide where it was found that a person experiencing first episode psychosis who was not assessed by the appropriate service for her needs in a timely manner. It recommended that where an individual is actively psychotic and untreated, and therefore is at risk to themselves or to others, they will require an emergency assessment on the day of presentation involving a senior member of medical staff. Therefore all such presentations must be referred through the Crisis Resolution and Home Treatment Team for comprehensive assessment and formulation of a treatment plan. 196. There is further analysis in the individual management review and in later sections of this report. The mental health practitioner did not feel that the perpetrator’s symptoms were indicative of active psychosis or represented a source of risk. The mental health practitioner felt that the adult victim could have alerted the mental health practitioner to a risk of harm because the contact was made through her mobile phone although it is acknowledged that in compliance with maintaining patient confidentiality the mental health practitioner did not identify them self to the adult victim when they made contact with the perpetrator on her mobile phone. There are also issues to be considered in regard to the relationship and working arrangements between the single point of access team and the Crisis Resolution and Home Treatment Team. 197. The conclusion therefore for the panel is that although the response by all services to the different members of the family can be described as sympathetic and prompt, particularly in regard to the onset of the perpetrator’s symptoms, there are aspects of learning that will be looked at in later sections of the report. 198. When the police interviewed the perpetrator after the killings and he had made some physical recovery from his own self-inflicted injuries, he described how worried he had been about the prospect of being hospitalised and feeling his family would be unable to cope. This anxiety was not known and therefore was unrecognised to the GP and to the Single Point of Access practitioner at the time. The paternal family have also provided information to the review about how the GP consultation and referral to the mental health service inadvertently exacerbated the symptoms. 24 A post-incident review (PIR) is an evaluation of incident response used to identify and correct weaknesses, as well as to determine strengths and promulgate them through organisations and is used in health trusts across the UK. PIRs are normally used to support revision to services or clinical practice. TOR 3 What information did family and friends have that might have indicated the adult victim and/or child L were at risk of abuse? 199. Several of the individual management reviews acknowledge that analysis of the case provides an opportunity to reflect on whether their staff had enough or sufficiently recent training to develop their awareness about domestic abuse. For example about making more rigorous checks into the circumstances of accidents and the barriers that face women living in coercive and abusive relationships. There is no evidence that the adult victim ever indicated that she was the victim of abuse or coercion. 200. Research as well as the findings of reviews into child abuse and domestic homicide highlights the heightened risk of domestic abuse for example during pregnancy. This is not to suggest that every pregnant woman is at risk of domestic abuse or that even the adult victim was a victim of domestic abuse. 201. The point is to create awareness on the part of professionals to screen and look for indicators of domestic abuse rather than rely on explicit disclosure or other evidence. The GP individual management review makes the point that a killing is often not a first attack and is often preceded by psychological or emotional abuse that is not identified by primary health services in contact with the victim or abuser. 202. The GP individual management review acknowledges that there were gaps in information provided to the practice from the hospitals that provided treatment to Child L when for example Child L had fallen from a buggy. The GP practice was told about the scald injuries although these were recorded in the barest detail and did not record any further enquiries that would be expected in accordance with clinical guidelines such as those published by NICE25. 203. The individual management review on behalf of UHMB comments that there had been delays in implementing national guidance on screening women during pregnancy for evidence of domestic abuse26. The same individual management review also acknowledges that the more limited local procedures that had been in place for considering potential safeguarding issues were not fully complied with; a significant factor was judged to be 25 The individual management review has commented that nowhere in the GP records is it documented that there were any further inquiries made into the circumstances surrounding these injuries. NICE Clinical Guideline 89 When to suspect child maltreatment (2009) recommends that practitioners should seek an explanation for injuries. This should be done in an open and non-judgmental manner. There is no evidence to suggest this was done in this case. 26 The UHMB author points out that NICE guidance published in 2006 was not introduced to the Trust and it was in 2012 when the current guidelines and staff development was implemented. workload associated with the closure of a hospital emergency department in Cumbria and staff shortages. 204. The bruise to the adult victim in June 2009 was the only record of an injury being observed outside of a hospital emergency service. Although this was followed up and the adult victim confirmed that it was nothing more than a gardening accident, the follow up occurred almost three weeks later. Research shows that women in particular are reluctant to disclose domestic abuse and that on average up to 35 incidents will have occurred before such a disclosure is made. 205. The reasons for not disclosing abuse include social isolation and economic dependency including housing; the adult victim had moved to Lancashire and with the exception of her elderly mother, had no family although she did make friends with a colleague at work and appeared to have a good relationship with family relatives. TOR 4 What knowledge did agencies have that the perpetrator might be a perpetrator of abuse and pose a risk of significant harm to Child L or the adult victim? 206. The police had historical information about a previous partner of the perpetrator following his harassment of her when she ended their relationship at the end of 2003. This was stopped when she reported it to the police and he had been advised about his conduct. His father (paternal grandfather) had ensured that a mobile phone was returned to the ex-partner. 207. the perpetrator met the adult victim very soon after this relationship ended and there were never any reports of concerns about their relationship to the police or to any other service. 208. When the perpetrator experienced the onset of psychosis, the adult victim arranged for him to be seen by the family GP. During the consultation the adult victim did not disclose any concerns about her own safety or to Child L. The GP individual management review comments that the history taken by the GP included exploration about the perpetrator’s threat of harm although this was focussed primarily on whether he had any thoughts of self-harm (which he did not). He was not asked about any thoughts of harming other people. Although he appeared unkempt, he kept good eye contact with the GP who made a referral immediately to the local mental health service. 209. With hindsight, aspects of decision making in response to the GP referral was not based on complete information or sufficient consideration of other relevant factors. This is not to blame or place responsibility for what happened on any individual. Even if the perpetrator had been invited to a face-to-face assessment on the day of the referral from the GP it does not then infer that he would have been diagnosed as requiring inpatient treatment. 210. The local protocol for treatment of first episode psychosis recognises that analysis of serious untoward incidents has identified an emerging theme in regard to people who are actively psychotic and have not been treated are always at risk in the first episode. 211. The protocol stresses the importance of a same day assessment to also consider urgent treatment and other intervention if necessary and for the assessment to involve a consultant psychiatrist or their deputy. 212. This reinforces the view that a primary threat will be from the person with the symptoms being a risk to their own safety. In terms of what is understood about the circumstances of the killings and attempted suicide, it appears that this is a case of familicide triggered by the psychiatric and psychological crisis rather than being the product of an escalation of abuse. TOR 5 Were there any risks in relation to resources or capacity that had an impact on how services were provided to the victims or to the alleged perpetrator or that impacted on agencies’ ability to work effectively with other services? 213. With the exception of the individual management reviews from the UHMB and the LCFT mental health service, resources are not identified as a significant factor in how the case was dealt with at the time. 214. The individual management review from UHMB describes significant historical problems that may have been contributory factors to how for example some aspects of inquiry and recording of information about the accidents described in earlier sections. These included low levels of safeguarding training (but rapidly improved and at the time of submission of the individual management review for this review was at required CQC levels27), the absence of paediatric liaison arrangements and children’s nurses (addressed following Ofsted and CQC visits), and reorganisation of services. 215. The individual management review also describes the extent to which significant turnover of staff has had an impact that has included the degree to which organisational memory is limited. The individual management review describes very considerable improvement work and acknowledges the need to complete the required improvement actions in safeguarding arrangements in regard to for example establishing safeguarding champions. 27 Care Quality Commission that is responsible for checking that national standards are met in health services. 216. The LCFT individual management review explores the various factors that had an influence on the practitioner’s decision not to offer a same day assessment, some of which reflect local working arrangements. The practitioner made the decision not to apply the Blue Light protocol based on their assessment that he was calm, there were no indications of thoughts of harm to himself or others, and it was their opinion that the possible voices described in the GP referral were the perpetrator’s own internal dialogue. 217. Had the practitioner followed the Blue Light they would have needed to contact the Crisis Resolution Home Treatment Team who have the resource and responsibility to provide same day assessments. The author of the individual management review interviewed the Single Point of Access practitioners and the review established that there are interface issues between Crisis Resolution and Home Treatment Team and Single Point of Access and that the Single Point of Access practitioners report inconsistent responses and thresholds when referring to the Crisis Resolution and Home Treatment Team. This may have impacted on the practitioner’s decision making in respect of the timing of the assessment. 218. The mental health practitioner stated that they were confident in their clinical judgement, that had the perpetrator needed it the mental health practitioner would have contacted Crisis Resolution and Home Treatment Team but that they felt the perpetrator did not require the protocol / referral to Crisis Resolution and Home Treatment Team as they had assessed that the perpetrator was not a risk to himself or to others. 219. As stated in previous paragraphs, the process of telephone triaging urgent referrals is a standard practice in the Single Point of Access. The use of such telephone triage in mental health has been subject to a research study in Australia and the individual management review author is able to draw some parallels with its use and access to resources in this case. The individual management review includes a reference to a particular study28 from 2007 (although not in Lancashire): “One of the central themes to emerge from the interview data was that the gate keeping of resources is intrinsic to the mental health triage role, and that decision making in triage is typically influenced by the availability of resources such as inpatient beds and access to crisis teams. The interview data established that nurses commonly experience ethical tension between the interests of economics underpinning the mental health triage model, and the provision of equitable, ethical, quality mental health care”. 28 Sands N (2007); Mental health triage: towards a model for nursing practice, Journal of Psychiatric and Mental Health Nursing, 14, p243–249 220. The individual management review author is concerned that the decision not to follow the Blue Light protocol was affected by the Crisis Resolution and Home Treatment Team relationship. Had the perpetrator been assessed that day by a psychiatrist, the GP’s referral information would have been clarified on a broader range of evidence and directly observable cues. In this case the GP’s referral information suggesting that he might have been hearing voices and was therefore a “high risk” was replaced by the self-report of the perpetrator in the telephone triage assessment. 221. The individual management review author considers whether urgent referrals should receive a telephone triage as part of the process and the need to ensure that it remains clinically-led. The system of telephone triage is a nationally recognised and implemented system. The individual management review author confirmed that the mental health practitioner completed a thorough telephone triage, but does draw the attention to the managers in LCFT as well as to the review panel of the limitations of the telephone triage for example in a practitioner not being able to observe non-verbal information about the patient’s demeanour or presentation. 222. The individual management review explains that the LCFT has adopted a stepped care model of service29. This ensures that the expertise and resources of the Trust are offered to match the needs of patients; the patients with the most complex needs receive a service commensurate to their needs. Alongside addressing the needs of patients, the model addresses the reality that the resources that can be made available are finite. Therefore patients are only referred to be stepped-up when their needs have been clearly assessed and considered, and when sufficient efforts have been made to manage at the lower step of provision. 223. The individual management review considers that the experience of MHP1 and their colleagues combined with interface issues may have contributed to misplaced confidence in the telephone triage process and the development of a culture of self-sufficiency to manage within the single point of access. Additionally, the team is made up of mental health nurses with limited input from a psychiatrist; the single discipline may reduce the availability of sufficiently rigorous challenge that can be present within teams where there are more than one discipline with different perspectives and expertise available and a culture of sceptical inquisitiveness. 29 Step care mental health services are a system of delivering and monitoring treatment designed with the intention to deliver the most effective but least resource intensive services that are provided promptly and that patients only ‘step up’ to more intensive or specialist services when clinically required. 4 Analysis of key themes for learning from the case and recommendations 224. Any meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable individuals or families has to understand why things happen and the extent to which the local systems (people, processes, organisations) help or hinder effective work locally within ‘the tunnel’30. 225. In this chapter the panel set out key findings that are designed to offer challenge and reflection for the local safeguarding children board and community safety partnership and their partners. The emphasis is not on the more traditional formulation of SMART recommendations. The key findings are framed using a systems based typology developed by SCIE. Although this review has not used systems learning to collate evidence, there is value in using the following framework to identify some of the underlying patterns that appear to be significant for local practice in Lancashire; a) Cognitive influence and human bias b) Responses to incidents and information c) Tools to support professional judgment and decision making. 226. The remainder of this report aims to use this particular case, and to reflect on what this reveals about gaps or areas for further development in the local child protection system and use it as a limited window into the local systems. 227. In providing the reflections and challenges to the local safeguarding children board and/or the community safety partnership there is an expectation that there will be a response to each of the key findings as well as to the 31 recommendations and the associated action plans that are described in the agency individual management reviews. As far as the key findings described in the remainder of this chapter it is anticipated that the local safeguarding children board or the community safety partnership will take the following action. a) An indication as to whether the board(s) accepts the findings; b) Information as to how the board(s) will take the findings forward; c) Information about which board and who is best placed to lead on any particular activity to promote improvement and learning; d) An indication of the timescales for responding to the findings; e) Information about how and when it will be reported. 30 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight. 228. The local safeguarding children board and community safety partnership will determine how this information is managed and communicated to relevant stakeholders. This report recommends that a formal response is also published. 4.1 Learning from previous serious case reviews 229. The local safeguarding children board in Lancashire had undertaken nine previous serious case reviews between 2008 and 2012. This is the third domestic homicide review in Lancashire. Reference has been made to the domestic homicide review completed in a neighbouring area that led to the development of the Blue Light guidance mentioned in the previous chapter. 4.2 Cognitive influence and human bias and its influence in judgments and decision making Self-confident practitioners working within imperfect systems; the influence and shortcomings of human inference in risk assessment; the calibration of risk. 230. In this case there was relatively little involvement or contact with services and only a brief period of less than 24 hours between the perpetrator first disclosing his symptoms with the GP and the tragic deaths occurring. 231. The individual management reviews from the GP and from the LCFT in regard to the Single Point of Access Service provide information and analysis in regard to how the process of referral was handled from the GP to the mental health practitioner on duty. Both individual management reviews confirm that both services and the individual professionals involved have complied with the relevant professional standards and local protocols. Further, even if there had been any different decisions or action taken, it would not have resulted in the perpetrator being anywhere other than at home with his family on the night that the killings and attempted suicide took place. 232. A review such as this is required to analyse how decisions and action are taken for the purpose of learning. For that reason, the panel with the help of the agencies individual management reviews has looked at why there was an apparent discrepancy between the GP concluding that the perpetrator was exhibiting symptoms of psychosis and the mental health practitioner who did not. If the mental health practitioner had agreed with the GP that the perpetrator was exhibiting the onset of a psychotic condition his referral would have been managed in compliance with the Blue Light protocol described in an earlier section of the report for all first and untreated episodes of psychosis. 233. Although this would have meant that the perpetrator would have been seen by a consultant psychiatrist the same day that the referral had been received, this would not necessarily have been able to prevent the tragic events without in-patient assessment and treatment. The perpetrator’s presentation during the contact with the GP and the mental health practitioner suggests that this would have been an unlikely outcome. 234. The influence of human bias in how information is processed and analysed in complex processes such as a mental health referral is an area that a learning based review attempts to explore in order to understand how people make their judgments and decisions. 235. In this case the GP’s referral information suggesting that the perpetrator might be hearing voices and was a “high risk” was replaced by the self-report of the perpetrator in the telephone triage assessment. The individual management review author draws attention to the tensions of managing finite resources (such as consultant psychiatric expertise) and making clinically led judgments. 236. The individual management review highlights that GP referrals to the service are invariably marked as high priority and it is widely assumed within the service that this is an effort to give the patient priority in what is known to be a busy referral service (over 25 a day). In this case the referral was a telephone call made by the GP with MHP1 recording the information. There is an assumption that the GP will have a more generalist knowledge of mental health (in this case the GP had recent experience of working in a psychiatric setting although this would not give the depth and level of training and experience of mental health professionals working longer term in specialist services) and conditions such as psychosis and the referral is the opportunity to subject the information to a more expert mental health service. 237. There are also interface issues between the Single Point of Access Service and the Crisis Resolution and Home Treatment Team in regard to differing interpretation on thresholds for urgent referrals and inconsistencies in response which was encouraging the mental health practitioner duty team to not make referrals until they had completed an assessment. 238. Within this context the individual management review analyses whether the mental health practitioner was over-confident in their judgement that the perpetrator was not displaying psychotic symptoms based on the telephone triage discussion. This is not a criticism of the mental health practitioner by either the individual management review or by the author of this report but is more an analysis of how working practices and cultures have developed. 239. There has been a lot of research on the overconfidence effect in decision making and judgements31 reviewed for example by Lichtenstein, Fischhoff, & Phillips. People are generally unaware of the "shortcomings of human inference" thus they rely on biased or selected samples of data, over-rely on their personal traits or ‘pet’ theories and use subjective calibration strategies32. As people are generally unaware of these inferential errors they tend not to adjust their subjective confidence and thus are overconfident in their judgment. 240. In this case, there was a tendency to give greater weight to the telephone call than the information and professional judgment being offered by the GP. This is not a statement that says one professional got the judgement right and another got it wrong. Instead, it is to understand how specialist practitioners working in a busy and pressurised setting are processing information that is opaque and nuanced. 241. The most consistent finding in relation to the overconfidence effect has been that people generally are not well calibrated, they tend to have too strong a belief in the correctness of their judgements and they are too confident. 242. This can be especially the case when one person feels they are more expert than another person. When people are overconfident they believe that they know more than they in fact do know, or believe their accuracy to be higher than it in fact is. Over-confidence was referred to as a “cognitive conceit”33. This can be particular phenomena in single discipline teams or services that regard themselves as the expert. 243. The LCFT report considers whether the initial information in the referral urgent referrals should receive a telephone triage as part of the process and whether this is a resource-led process rather than clinically-led. The author is not suggesting the worker did not carry out a thorough telephone triage, but is drawing attention to the limitations of telephone triage. Issue for consideration by the local safeguarding children board and community safety partnership 1. Are there any specific issues to be addressed by local organisations in the development of referral, risk assessment and information sharing 31 Lichtenstein, S., Fischhoff, B., & Phillips, L. D. (1982). Calibration of probabilities: The state of the art to 1980. In D. Kahneman, P. Slovic, & A. Tversky (Eds.), Judgement under uncertainty: Heuristics and biases, (pp. 306-334). Cambridge, England: Cambridge University Press. 32 Nisbett, R., & Ross, L. (1980). Human inference: Strategies and shortcomings of social judgment. Englewood Cliffs, NJ: Prentice-Hall. 33 Block, R. A., & Harper, D. R. (1991). Overconfidence in estimation: Testing the anchoring-and-adjustment hypothesis. Organizational Behavior and Human Decision Processes, between the specialist mental health services and other professionals in the county? 4.3 Responses to incidents or information Injuries may be accidental but abuse must be considered and also take account of the potential barriers for victims to disclose information; ensuring that there is sufficient enquiry and recording of information about the circumstances of any presentations for medical or health treatment. 244. The panel found no substantiated evidence that either the adult victim or Child L were ever subjected to abuse by the perpetrator and have noted the extent of remorse, confusion and distress he has experienced since the killings. In terms of that incident none of the services had any indication that this was a possibility and the information shared from the police investigation confirmed that there was no apparent premeditation. 245. The previous section of these findings discussed the influence of cognitive factors such as overconfidence and the shortcomings of human inference when assessing evidence as in this case from another professional. In this part of the report the focus shifts to looking at whether medical practitioners showed enough rigour in how they managed presentations by the adult victim and Child L for treatment following injury. It is clear that they were all regarded as accidents but there was an over-reliance on the information presented to the clinicians and not enough evidence that more sceptical and research informed history taking and assessment was taking place. 246. The individual management review from the Southport and Ormskirk Hospitals NHS Trust describes how the cognitive influence of how the family presented was an influence in not taking a more sceptical approach to the taking of a history. This was not confined to that service or that one occasion. Even though this is not a case that has involved coercion or abusive behaviour, the review is an opportunity to improve the opportunity for identifying potential indicators and symptoms. 247. For example, the adult victim was observed with a bruise to her eye. It was understandable that the health practitioner did not want to be more assertive in her enquiries during the home visit; if it had been an injury caused by her partner there was a strong likelihood that the adult victim would not disclose information or that the possibility of disclosure would increase risk. Although the practitioner tried to show empathy and encouragement to contact her, she did not make any follow up enquiries until three weeks later. 248. Research and the evidence from reviews such as this reinforce the importance of grabbing moments of possible disclosures of abuse. Children and adult victims of abuse face many and diverse barriers to disclosing abuse and therefore sensitive but prompt follow up is required. Delay in follow up will compromise other processes such as securing forensic and medical evidence as appropriate for effective investigation and intervention. 249. The adult victim stated that the injury had been the result of a gardening accident and apart from the scalding injury, there were no other occasions when either physical injury of or other indicators seen to suggest that the adult victim was subject to domestic abuse or coercion. 250. The adult victim and Child L were treated for scald injuries. There is little information recorded about how the scalding occurred. They were also treated at separate clinical locations which represent potential vulnerability in clinicians being able to identify patterns. There were two other occasions when Child L was seen at hospital following accidents and again there was little information recorded in regard to circumstances. There were also gaps in making sure the GP practice were informed about all presentations and having accurate details about circumstances. 251. Recognising and identifying evidence of abuse relies on respectful and sceptical inquiry and taking of history until the deaths of Child L and the adult victim, this was a family who were never a concern for any service in the county. Although there is no evidence that either the adult victim or Child L had suffered abuse there had been occasions when they had been seen by health professionals who could and should have been more curious when for example the adult victim was seen with a bruise and both had suffered scald injuries. 252. Although there is nothing to indicate that the injuries were not caused by the accidents that were reported at the time, there was a naïve approach to taking histories and sharing information with the GP practice for example. 253. There have been previous serious case reviews that highlighted similar shortcoming in emergency care settings. 254. The follow up to the bruise was done three weeks after it had been first observed. A central theme of the serious case review is the extent to which the opportunities for making sufficient enquiries and sharing of information were not sufficiently exploited. The considerable history of the perpetrator in particular remained undiscovered for many of the services. Issue for consideration by the local safeguarding children board and community safety partnership 2) Are the local safeguarding children board and community safety partnership sufficiently confident that current arrangements for recognition and responding to indicators of child or domestic abuse in emergency health settings? 4.4 Tools to support professional judgment and decision making The use of tools or frameworks to make referrals and conduct triage and allocate priority is susceptible to human biases and organisational pressures 255. The review with the help of the agency individual management reviews has looked in detail at the mechanisms for making and managing referrals. Under current arrangements there is a high reliance on the quality of information passed over to the Single Point of Access and the use of the telephone based triage. 256. The GP individual management review discusses the absence of any recommended tools or frameworks for GPs to use when being consulted by a patient and assessing risk. For example, there is a patient health questionnaire (PHQ-9) that gathers information about mood and thoughts of harm over a preceding two week period rather than just being focussed on symptoms during the consultation. This assessment is not used uniformly or indeed any other framework. 257. Mention has already been made of the cognitive influence arising from the mental health practitioner seeing a variety of referrals and inconsistent information. In this case, the perpetrator’s GP had recently completed working in a psychiatric setting. 258. The report has also discussed the analysis provided in the individual management review from the LCFT in regard to the shortcomings of a telephone based triage system. Allied to this is overall rate of referrals and managing the pathways through the stepped care model of accessing assessment and treatment services. Issue for consideration by the local safeguarding children board and community safety partnership 3. Are the local safeguarding children board and/or the community safety partnership satisfied with current arrangements described in this review for the identification, assessment and management of risk associated with the onset of psychotic or mental health crisis? 4. How can the learning from the review be transferred into professional risk assessment and practice? 4.5 Issues for national policy 259. There are no nationally recommended risk assessment frameworks for health professionals to use when assessing and managing risk of harm from patients experiencing emotional or mental health crises. Peter Maddocks, CQSW, MA. Independent author December 2013 CONFIDENTIAL 5 APPENDICES Appendix 1: list of agencies contacted for the review University Hospital Morecambe Bay General Practitioners Blackpool Teaching Hospital Trust (health visiting and school nursing) Lancashire Care Foundation Trust Constabulary Primary schools Morecambe Kindergarten Early years Probation Trust Women's Aid Southport and Ormskirk Hospital Adult social care Lancaster City Council Lincolnshire agencies (all agencies contacted to request any known historical information) Appendix 2: family and friends contacted for the review Maternal Aunts to mother Paternal Aunts to mother Cousin of mother Work Friend of mother School Friend of mother Paternal Uncle to child Paternal Aunt to child Paternal Grandparents to child 2015LancashireChildLOverview Page 52 of 57 CONFIDENTIAL Appendix 3: Single Agency Recommendations a) Education: No recommendations b) General Practitioners: 1. Screening for domestic violence Currently the practice does not screen for domestic violence. The guidance for conducting Domestic Homicide Reviews states that "murder is often not the first attack and is likely to have been preceded by psychological and emotional abuse" and it is recognised that most of those experiencing abuse are not identified by their GP (Richardson et al. BMJ 2002). One study conducted in primary care in the USA put the figure of those identified at fewer than 10%. Questions on domestic violence are now incorporated into antenatal care but as yet there is no consensus on the benefits of routine screening for all. The National Screening Committee found that it did not meet the criteria for a national screening programme, one reason being that there is a lack of evidence on effective interventions for those who do identify themselves. Nevertheless routine reviews such as new patient and post-natal checks may represent the only chances a victim of abuse has to attend the surgery without arousing the partner's suspicion and safeguarding concerns should be borne in mind. There are a number of screening tools for domestic violence. These include some general, well phrased questions which could be incorporated into routine checks. I would recommend that the practice considers incorporating these into its computer templates. This should be preceded by general training on identification and management of disclosures of domestic violence so that the questions would only be asked in the appropriate setting and manner. Mother's possible social isolation following her move from Lincolnshire may have increased her vulnerability. Such risk factors may be picked up if enquiries are made about wider social circumstances at routine checks and again I would recommend that consideration is given to the incorporation of this. 2. Depression screening for all chronic diseases Currently screening for depression is only performed for patients with Coronary Heart Disease and Diabetes as part of the Quality and Outcomes Framework. As shown in the critical analysis other chronic diseases (including epilepsy and asthma as suffered by mother and father respectively) are linked to varying degrees with depression and I would recommend that consideration is given to incorporating the two screening questions into all chronic disease reviews. 3. GP Practice/Health Visitor communication When Child L was discharged from hospital a copy of the discharge letter was sent to his health visitor recommending that his weight gain be monitored. There is no further record of his weight until 2011. It may be that this information is contained in Child L's Red Book but I do not have a copy of this. There is no record of any communication about Child L's weight gain between the surgery and Health Visitors. Currently the practice has neither a formal nor informal arrangement for regular 2015LancashireChildLOverview Page 53 of 57 CONFIDENTIAL information sharing with the attached Health Visitors. Consideration should be given to implementing regular two way communication 4. Further exploration of psychological symptoms Father presented on 29/3/10 with chest pain. During the consultation he disclosed that he was under some stress due to the poor weather as he worked as a self-employed gardener. This is the only mention in the medical records of any psychological symptom prior to 8/4/13. The focus was, as is appropriate, on father's symptom of chest pain but there does not appear to have been any further exploration of his stress. This may have been due to time constraints or it may have been done but simply not documented. It may have been appropriate to explore this further, perhaps at a separate appointment and I would recommend that consideration is given as to whether disclosures such as this should prompt any further enquiries. I am well aware that I have the considerable benefit of hindsight when making this recommendation and I would again stress that in my opinion this would in no way have prevented the tragic events that took place three years hence. 5. Emergency Department attendances I feel that the circumstances surrounding the scald to mother and Child L should have been explored in greater detail. It is unclear whether this was not performed due to time constraints, a training issue or requires a change in practice policy. It may be that it had been done but not documented. This case shows us the importance of recording such discussions. Emergency attendances for certain types of injury or frequent attendances may indicate abuse and NICE guideline 89 (2009) recommends we seek an explanation for any injury in an open and non-judgemental manner. Currently the urgent care dashboard will flag up frequent attendees but presumably this would only cover a single hospital trust and an abused child may be taken to a number of different locations for treatment in an effort to allay suspicion. I discussed this with the practice's nurse team leader who felt that the urgent care dashboard could be configured to flag up multiple attendances at different locations. I would recommend that practitioners when they receive an Emergency Department discharge for a child or adult ask themselves whether there may be safeguarding concerns. In the case of injury to an adult which arouses suspicion of domestic violence the "child behind the adult" should be considered and an appropriate risk assessment made. 6. Assessment of risk to others and recording thereof in Mental Health consultations There is no mention in the records as to whether the GP made an assessment of the risk father posed to others. GP 1 felt it was not necessary to specifically question father on his intent to harm others as his mental state examination and observation of father did not give any indication that this was at all likely. As discussed below there is evidence to support this approach. However he did not document it. As GPs we are trained to always ask about thoughts of self harm when a patient presents with a Mental Health issue but under normal circumstances we would not usually ask about intent to harm others. No assessment tool was used in the consultation as this was an episode of psychosis for which no general practice 2015LancashireChildLOverview Page 54 of 57 CONFIDENTIAL assessment tool exists. In consultations for depression without psychosis there are a number of possible assessment tools - the Patient Health Questionnaire (PHQ 9), Hospital Anxiety and Depression scale (HAD) and the Beck Depression Inventory being the most commonly used. None of these includes a question on intent to harm others. GP 1 did not ask mother about her feelings in relation to the risk of self harm or harm to others posed by father. He had already ascertained whether father had any intent to self harm and it would not have been appropriate to put these questions to mother in his presence. Vinestock (1996) states that when assessing risk to others "the patient's own statements tend to be less reliable and the emphasis is more on behaviour and collateral information". I reviewed a number of mental state examination templates. Some asked questions about thoughts or intent of harming others and some did not. Although not qualified to comment on whether specific questions should be asked to assess risk to others, I would recommend that risk to others is not only considered but specifically documented in Mental Health consultations as we already do for risk of self-harm. It is important to remember that risk cannot be completely eliminated and accurate prediction is never possible for individual patients (RCPsych 2008). Information regarding more advanced risk assessment tools can be found in the documents listed in the reference section. 7. Consider whether there is a child safeguarding issue when a parent presents with a Mental Health problem Quite correctly the focus of the consultation was on father who was presenting with a serious mental health problem. However, parental mental health problems are well known to be a significant factor in child abuse, being one-third of the "toxic trio" of major risk factors. We need to be aware when dealing with an adult patient that there may be a "child behind the adult" and ensure that the needs of the child are not overshadowed by the needs of the parents (Keep Me Safe RCGP, 2005). The RCGP Curriculum recommends that physical, psychological, social, cultural and spiritual issues should be considered in the assessment and management of mental health problems. In the case of Child L the GP was not aware that a child lived with father and mother. In my opinion it would be good practice to make inquiries as to who lives in the household as this may raise safeguarding issues. I must stress that in my opinion GP 1's management of the case remains appropriate despite not being in possession of this information and having this knowledge would have made no difference to the tragic outcome. All practice staff should have the relevant safeguarding training as recommended by the Intercollegiate Guidance for Safeguarding Competencies (2010). Staff should have training commensurate with their responsibilities - level 1 for all practice staff, level 2 for practice nurses and although GPs only require level 2 training for revalidation it is recommended that they undergo level 3 training as this includes multi-agency working relevant to their everyday practice. 2015LancashireChildLOverview Page 55 of 57 CONFIDENTIAL 8. Communication between Primary Care and Mental Health practitioners GP 1 made an urgent referral to the Mental Health team via the single point of access. This was done immediately after father and mother left the consulting room. He was told that father would be assessed that same day but as we know father was actually given an appointment for assessment the following day. In my opinion where there is a change in the original care plan such as this, then that information should be communicated back to the referrer to ascertain whether this is acceptable as the referrer is the person who has actually seen the patient. I do not believe this is the responsibility of the GP and therefore this recommendation would apply more to the Mental Health service. I do feel that communication in general between the practice and Mental Health team should be looked at to enable any other potential problems to be identified. 9. Support for GPs and practice staff During my interviews at the surgery it became clear that although GP 1 had had significant support from his colleagues in the practice, there was no formal support structure in place at a higher level to help surgeries when affected by such a tragedy. This could perhaps involve a debriefing exercise or counselling support. I would recommend that the responsible CCG considers implementing this as a matter of urgency. c) Blackpool Teaching Hospital NHS Foundation Trust 1. If bruising is noted that indicated a suspicion or potential domestic abuse, questioning of the victim should happen as soon as possible. 2. Domestic abuse training that will address the importance of providing contact details of Women's Aid when domestic abuse is suspected but denied. 3. Ensure all health visitors and school nurses aware of the most recent guidance from DOH 2013 health visiting and school nursing programmes, no.5 Domestic Violence and Abuse Professional Guidance 4. Record keeping training - looking at basic entry details such as time of visits/contacts and also completion of the record regarding information about fathers/significant males living in a household. d) Southport and Ormskirk Hospitals NHS Trust 1. Continue to raise awareness of signs of domestic abuse via safeguarding training 2. Ensure information is available regarding domestic abuse for patients in the accident and emergency departments. 3. Staff are aware of the importance of documentation and the need for a full history and details of attendance. 4. To develop the Domestic Violence Link Nurse at Southport Accident and Emergency Department 2015LancashireChildLOverview Page 56 of 57 CONFIDENTIAL 5. Review the Accident and Emergency Domestic Violence protocol to include routine questioning e) Lancashire Care NHS Foundation Trust 1. The referral form is in need of review to ensure areas of identified risk are focussed and of an assured standard. This will include recording and training aspects. 2. That triage information is recorded on the clinical record system (rather than added to referral form). Citing who has provided the information. 3. That consideration should be given to the use of multi-disciplinary working, increased access to clinical discussion. 4. To review the potential for isolation in the current environment of the Single Point of Access team in Lancaster and Morecambe – small office, lone working 5. To review the interface with CRHT re referrals for urgent assessments. 6. To understand the capacity of urgent referrals and the use of telephone triage 7. Consider whether the Blue Light 71 needs to be revised to ensure risks and vulnerabilities are understood. 8. To review stepped care model and the concept of resources influencing pathways. f) Kindergarten 1. Awareness raising session for staff on Domestic Abuse and the effects on children especially early years children and babies and the effects on women. (How to spot potential signs and gain support access for parents and children.) 2. E learning CP training for all staff annually rather than the 3 yearly updates at present this would go above and the current recommendations within the EYFS guidance g) Constabulary Third party reporting of Domestic Abuse to be written into the new DASH Policy and Supporting Procedures currently under review. h) University Hospitals of Morecambe Bay NHS Foundation Trust 1. To set up archive evidence index for safeguarding. 2. Specific training from Woman’s Aid on domestic abuse to continue to support A+E staff and Midwives and develop skills in the issue of Domestic Violence. 3. UHMBFT A+E to work with Lancaster Women’s Aid to raise the awareness of the support available to victims of Domestic abuse. 4. UHMBFT clinical service team to work with the local MAPPA coordinator to strengthen information sharing of individuals who pose a risk to the others who may access care from UHMBFT. 2015LancashireChildLOverview Page 57 of 57 |
NC52341 | Extensive non-accidental injuries to a 2-year-old boy in March 2018. Mother and her partner both admitted to physically harming George during care proceedings but a police investigation found insufficient evidence to establish who had caused the injuries. Mother became pregnant with George at age 17. She was assessed as a child in need during her pregnancy and George was made the subject of a child protection plan prior to his birth. Mother had a history of substance misuse and mental health issues and experienced insecure housing throughout this period. In November 2017, concerns were raised about Mother's new partner at a review child protection conference but it was concluded that he posed low risk and George was stepped down to a child in need plan. In March 2018, Mother and her partner took George to the GP and he was diagnosed with a viral illness. Later that day, George was taken to hospital and a child protection medical found several non-accidental injuries. Uses the Significant incident learning process (SILP) methodology. Learning includes: information about adults in a child's life needs to be analysed by all agencies; there are barriers to information sharing, including time, staffing and concerns about consent; and professionals need to be supported to reconsider their position when new information is shared. Recommendations include: professionals need to exercise respectful uncertainty and healthy scepticism; families should be made aware if they are likely to require ongoing involvement with support services; and local escalation policies for dealing with professional disagreement should be promoted.
| FINAL FOR PUBLICATION 1 Serious Case Review George REVIEW REPORT Lead Reviewer: Nicki Pettitt Accepted by the CLSCB: 19 March 2019 This report is strictly confidential and must not be disclosed to third parties without discussion and agreement with the CLSCB prior to publication. The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies involved. FINAL FOR PUBLICATION 2 Contents 1 Introduction to the case and summary of the learning Page 2 2 Process Page 2 3 Family structure Page 3 4 Background prior to the scoped period Page 3 5 Key episodes Page 4 6 Analysis by theme and learning Page 5 7 Conclusion and Recommendations Page 13 1 Introduction to the case and summary of the learning from this review 1.1 This Serious Case Review (SCR) is in respect of a two-year-old child to be known as George. He suffered extensive injuries while in the care of his mother and her partner. George was the subject of a child in need plan that was about to be closed. He had twice previously been the subject of a child protection plan with the category of neglect. The parents initially stated that the injuries were both self-inflicted and accidental1. 1.2 Mother’s partner had lived with George and his mother for around six-months, initially part time. George had occasional contact with his father. He was an only child at the time. 1.3 The response to his injuries resulted in George being appropriately safeguarded and he is currently doing well in foster care. The CPS originally decided that Mother and/or her partner should not be prosecuted for the injuries due to conflicting medical opinion. Care proceedings concluded in February 2019 with a full care order being made. During the proceedings Mother and her partner both admitted they had physically harmed George. They chose not to implicate the other for any specific injury. The court made a finding that one or both of them caused the injuries. The police reopened their investigation in light of the admissions however following a review by the CPS, it was found there was insufficient evidence to establish who had caused the injuries. 1.4 A summary of the learning identified is: The need for professionals to challenge themselves and others, particularly when a decision has been made but new information emerges. Professionals require support to enable them to challenge family members, themselves, and other professionals. There is a need for improved knowledge of and use of the CLSCB escalation policy, to be used when there is a professional disagreement or to challenge another agency. Even when improvements are seen, professionals need to be clear themselves, and with parents, that when the parents have a number of pre-disposing vulnerabilities and adverse childhood experiences, there is likely to be a need for on-going support throughout their child’s life. 2 Process 1 Two medical experts had differing opinions, so the CPS decided not to pursue a prosecution. FINAL FOR PUBLICATION 3 2.1 The CLSCB recognised the potential to learn lessons from this review regarding the way that agencies work together to safeguard children2. It was agreed that this SCR would be undertaken using the SILP methodology, which engages frontline staff and their managers in reviewing cases and focuses on why those involved acted as they did at the time. Agency reports are completed where agencies have the opportunity to consider and analyse their practice and any systemic issues. They provide details of the learning from the case within their agency. Then a large number of practitioners, managers and agency safeguarding leads come together for a learning event3. All agency reports are shared in advance and the perspectives and opinions of all those involved at the time are discussed and valued at the event. The same group then come together again to study and debate the first draft of the SCR report. Later drafts are also commented on by all of those involved and they make an invaluable contribution to the learning and conclusions of the review4. 2.3 It was agreed that the review would consider in detail the period from November 2017 which was the date that Mother’s partner was known to be having contact with George who was on a child protection plan at the time, until 22 March 2018 which was the date his injuries were seen by professionals. Detailed case information will not be disclosed in this report5, only the information that is relevant to the learning established during this review. 2.4 Early family engagement is required as part of the SILP model of review. The lead reviewer met with Mother, whose views are included in the report. She will be updated on the conclusions of the review prior to publication. The lead reviewed spoke briefly to Father and had hoped to engage with him further prior to publication, further attempts were made to contact Father but these were unsuccessful. 3 Family structure 3.1 The relevant family members in this review are: Family member To be referred to as: Subject child George Mother of George Mother Father of George Father Mother’s partner Mother’s Partner 3.2 Any other relevant family members will be referred to by their relationship to George. 4 The background prior to the scoped period 4.1 Mother became pregnant with George when aged 17, while she was living in hostel accommodation. She was homeless due to a breakdown in the relationship with her own mother and her recent move to Cumbria from another area. She had lived in Cumbria 2 The decision was based on: a past history of agency concerns resulting in Child Protection Plans; evidence that there are concerns as to how agencies worked together; the nature of the injuries, the conclusion that it is highly unlikely the injuries were self-inflicted; and the probability that George will be impacted emotionally in the future. 3 The Chair of the CLSCB agreed the SCR, the lead reviewer was appointed, the terms of reference were agreed, agency reports and a chronology were requested, and two events were held to engage with staff in November 2018 and January 2019. The lead reviewer is Nicki Pettitt, an independent social work manager and safeguarding consultant. She is an experienced chair and author of SCRs and a SILP associate reviewer. She is independent of CLSCB and its partner agencies. 4 Working Together 2015 (the legislation in place at the time the review was agreed) states SCRs should be conducted in a way that; recognises the complex circumstances in which professionals work together; seeks to understand precisely who did what; considers the underlying reasons that led to actions; seeks to understand practice from those involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. This review has achieved these objectives. 5 Statutory Guidance expects full publication of SCR reports, unless there are serious reasons why this would not be appropriate. FINAL FOR PUBLICATION 4 before and had family members locally. Cumbria Children’s Social Care (CSC) assessed her as a Child in Need (CiN) at the time of the pregnancy, due to her own vulnerabilities. 4.2 Prior to his birth, George was made the subject of a Child Protection Plan (CPP) and pre-proceedings work was started under the Public Law Outline (PLO). The pre-birth assessment undertaken identified risks including Mother’s substance misuse, her mental health, rejection from her own family, Father’s poor experience of being parented, and the parent’s relationship. 4.3 Mother worked with professionals and the PLO concluded as it was agreed that the threshold for care proceedings was not met. George remained on a CP plan until Mother left Cumbria to live with her own mother in another city at the end of 2016, when George was around 18 months old. Despite the recommendation from CSC in Cumbria that George remain on a CP plan, the new local authority undertook an assessment and the transfer-in child protection conference agreed that George should be the subject of a CiN plan. Mother told the review that a plan was never made and that she only saw a social worker once while she resided outside of Cumbria. 4.4 Around six months later Mother and George returned to Cumbria, homeless and with no money. They approached CSC as they were staying with Father whose accommodation was unsuitable. An Initial Child Protection Conference (ICPC) was held and a further period of child protection planning commenced in March 2017, due to concerns about Mother’s associations with risky people and the difficult relationship between Mother and Father. 5 Key episodes 5.1 The time under review has been divided into three ‘key episodes’. These are periods of intervention that are judged to be significant to understanding the work undertaken with a child and family. They are key from a practice perspective rather than to the history of the child. They do not form a complete history of the case but summarise the relevant activities that occurred, and are a brief outline of the information that informed the review and helpful to the reader of this report. Key episodes 1. Child protection planning 2. Child in need planning 3. Response to injuries Key episode 1: (child protection planning) 5.2 The decision to place George onto a CPP for the second time on his return to Cumbria was difficult for Mother to accept, as the other area had previously agreed that a CiN plan was suitable. Practical help and support was provided on George’s return to Cumbria, including help with housing. Professionals worked with Mother with the aim of George being removed from a CPP and positive changes were seen. Father had little involvement with George. Mother told the review that George had a number of different social workers and health visitors, and that it was difficult having to go over her background information again on her return. 5.3 At a Core Group on 1 November 2017, around eight months after the family returned to Cumbria, it was noted that Mother had entered a new relationship and was spending considerable time with her new partner. The initial social work observations of him with FINAL FOR PUBLICATION 5 George were positive. George was described as a happy boy with a good and increasing vocabulary. 5.4 A Review Child Protection Conference (RCPC) was held two weeks later and it was unanimously agreed that the CPP should be stepped down to a Child in Need (CiN) plan. This was despite the police seeking information during the meeting about Mother’s Partner, and finding historic concerns about his mental health, and criminal convictions for arson, violence, and drug related offences. Intelligence was also available about drug taking, domestic abuse, and that he had been remanded in custody but no further action taken for suspected sexual activity with a 14 year old child. This had not been shared with the social worker by Mother’s Partner when she had asked him about his history. The social worker later discussed the concerns about the 14-year-old with Mother’s partner and it was concluded that he posed a low risk to George. Key episode 2: (CiN planning) 5.5 Mother and her partner moved with George into a larger home together in December 2017. The CiN planning continued and it was evident that Mother’s Partner had an increasing role in caring for George. CiN meetings were held and Mother completed play-based work with Barnardos. There were no significant concerns although Mother’s partner lost his job shortly after the move and was stated to be very low due to this, the resulting financial strain, and difficulties in claiming Universal Credits. At the same time Mother informed the social worker that she was no longer taking her ante-depressants6. It is now known that Mother briefly separated from her partner early in 2018 following a domestic abuse incident, but this information was not shared with any professionals at the time. 5.6 It was agreed in a CiN meeting on the 9 March 2018 that all of the identified needs had been met and that CSC involvement should cease. Mother did not wish to receive early help support, so George would have only received universal services support. The social worker had not yet closed the case at the time of George’s admission to hospital on 22 March 2018. Key episode 3: (response to injuries) 5.7 The Nursery that George attended was informed on 20 March 2018 that he would be absent for the week as he had ‘a sickness bug’. On 22 March 2018 he was taken to the GP by Mother and her partner with concerns about conjunctivitis and a cough. A viral illness was diagnosed. George had bruising to his head and it was explained by Mother that he had fallen in the bath. The GP listened to George’s chest but did not remove the clothes from his upper body so missed the other bruising later seen at hospital. As the GP was aware of the history of safeguarding concerns for George, they contacted the Strengthening Families worker after the consultation. They felt reassured that George was no longer on a CPP and the risks were felt to have reduced, and that George often had bumps and bruises. Mother told the review that the GP did not take George out of his buggy and that they listened to his chest through his clothes, including his coat. 5.8 Later the same day Mother contacted 111 stating that George had been seen by the GP that morning following a head injury, that he remained drowsy, and that he had slept for most of the day. 111 sent an ambulance and George was transported to hospital with Mother and her partner. A child protection medical was completed and a number of non-accidental injuries were identified. Mother and her partner later provided differing and inconsistent explanations for the injuries, but both suggested they were self-inflicted by 6 First Step had advised her to continue taking her Sertraline (antidepressant). FINAL FOR PUBLICATION 6 George. The injuries were not thought to be consistent with the explanations given. George was taken into police protection and both Mother and her partner were arrested. 6 Analysis by theme and learning 6.1 From the information gained from the agency reports, from the discussions at the learning events, and from meeting with Mother, several key themes have emerged. The following are judged to be most significant and enable us to identify learning for the CLSCB and its partner agencies: Themes Predisposing risks Parental self-report Step down to child in need 6.2 Each theme identifies learning, and each learning point is linked to a recommendation in either this report or within the agency reports. It will be stated if the learning is being addressed elsewhere. Theme: Predisposing risks 6.3 Pathways to Harm, Pathways to Protection; a Triennial Review of SCRs 2011–14 was published in 20167 (to be referred to as the Triennial Review) and states that consideration of a wide range of SCRs shows that there are factors in a parents’ background which potentially may present a risk to a child. These include: Domestic abuse Parental mental health problems Drug and alcohol misuse Adverse childhood experiences A history of criminality, particularly violent crime Patterns of multiple, consecutive partners Acrimonious separation The Triennial Review points out that these factors ‘appear to interact with each other, creating cumulative levels of risk the more factors are present’. In George’s case a number of these were present in regard to Mother, Father and Mother’s Partner. They needed to be assessed and considered regularly when working with the family. Other factors are included in the Triennial Review as significant and include; young motherhood; estrangement from the new mother’s own parents; temporary housing or supported accommodation; lack of support from the baby’s father and/or an unstable relationship with the father.’ These were also present in George’s case and required consideration. 6.4 None of the relevant adults had positive childhoods. The CSC agency report found that what was missing from the assessments regarding George is the particular consideration of what risk these adverse childhood experiences posed to George. Despite the proactive use of child protection planning, there is no evidence that a thorough assessment was undertaken, including when Mother’s Partner joined the family. All three had been living independently by the age of 16 and had limited, if any, family support. Mother’s history included neglect, living in a home where domestic abuse was an issue, sexual abuse, and exploitation. Father has a history of parental bereavements and was a victim of interfamilial 7 P. Sidebotham and M. Brandon et al. (2016) FINAL FOR PUBLICATION 7 sexual abuse at a young age. In the case of Mother and Father there was good knowledge of their histories. In the regards to Mother’s Partner key information was not initially known and then was not considered adequately. This included his mental ill-health, violence to his mother and siblings when he was a child, and evidence that he used cannabis and illegally sourced prescribed medications. 6.5 The available information about Mother’s Partner was not known until after the RCPC as checks had been undertaken within CSC using the wrong spelling of his name. As he was not living with the family police checks had not been prioritised earlier. It was good practice that the decision was made that police checks should be undertaken while the conference was taking place. The issue regarding what information was actually shared by the police at the RCPC is considered below. It is clear from the agency reports that other agencies had access to much of this information, and this was not sought or shared by them when it was known that he was in a relationship with Mother. It is not only the responsibility of CSC to check their records to see what historic information is available, and all professionals working with a family should make relevant and proportionate checks within their own agency records. 6.6 Verbal arguments were a regular feature of the relationship between Mother and Father. This was largely seen as a historic issue as Mother and Father were not a couple for much of George’s life. Mother had also had other relationships where domestic abuse was a feature. It is known that domestic abuse can feature in further relationships if work has not been undertaken to address the issue. It now appears that the relationship between Mother and her partner was difficult on occasion as she left him shortly after they moved in together, although this was not known at the time. 6.7 Mother had a history of depression, anxiety and panic attacks. She was receiving drug treatment via her GP practice/s for this8. The assessment process undertaken by the health visitor identified that Mother suffered with moderate post natal depression following the birth of George and Mother saw her GP regarding this as advised. In November 2017 Mother self-referred to First Step9 for support with her emotional and mental health. Mother told First Step that she had suicidal thoughts and they thought she likely had some symptoms of PTSD.10 Mother attended four out of seven sessions offered and First Step did not feel that they had the opportunity to pursue the work required to address Mother’s mental health, as the focus of the early appointments was to build a relationship. Mother disengaged from the service and she was discharged before George was injured. First Step believed Mother was self-aware, was managing, and that her issues would not have an impact on her care of George. None of those working with George were aware of Mother’s work with First Step, but her mental health issues were known to them and at no stage was there an assessment of the impact of Mother’s mental health issues on her parenting by any of those involved with George, including when Mother stated she intended to stop taking her anti-depressants in January 2018. Those involved appropriately supported Mother with her own issues however. 6.8 Mother’s Partner had not seen his GP for a number of years, but historic information is available from 2014 that he was assessed by the mental health crisis team for low mood, self-harm and suicidal thoughts. Anger management and substance misuse were also issues 8 Mother told the review that she was prescribed with a number of different anti-depressants over time, but she found the side-effects difficult to manage particularly feeling sleepy and the weight gain. 9 First Step Cumbria provides free, talking therapies for a range of common mental health problems including depression and anxiety. 10 Post-traumatic stress disorder FINAL FOR PUBLICATION 8 known to the GP, although it was not stipulated what substances he misused. This was not known by those working with the family at the time. 6.9 During the timescale of the SCR Father was referred to First Step for support with his mental health needs. He engaged with an initial assessment by the Urgent Care Team but did not engage with First Step when ongoing support was offered. There was no consideration of the impact on George of his difficulties. This may have been, in part, because his cooperation with the CP plan and contact with George was inconsistent. It was known however that Mother took George with her to live with Father after her return to Cumbria, and there was the possibility she would do so again. 6.10 Drug and alcohol misuse was an issue identified pre-birth. Mother admitted to drinking and to using cannabis, cocaine and plant food11. Father was known to misuse alcohol. Mother’s Partner admitted to misusing cannabis, although he stated he had not done so for around 4 months prior to moving in with Mother and George, having ‘grown out of it’. It was not known at the time that he also misused illegally sourced prescription drugs such as Diazepam. There was no evidence that there was on-going substance misuse by Mother at the time of George’s injuries. 6.11 George had a number of moves when he lived with Mother, and much of their accommodation was insecure and inappropriate. The local authority intervened and provided support to ensure that Mother was adequately housed when they were made aware of the situation. As will be shown below, Mother was not always open with the professionals involved, and there was a feeling that she would only share significant information when pressed or if she required assistance. This included where she was living with George. 6.12 Mother was 17 years old when she had George. The Triennial Review states that the average age of first time mothers whose children were the subject of a SCR was age 19, compared to the national average of age 28 for first time mothers. It is noted that in parts of Cumbria the average age of a first time Mother is also age 19. Mother’s young age, the absence of reliable family support, and the family’s transient lifestyle and house moves may have adversely impacted on George’s health, safety, and wellbeing. The practical help and support provided by professionals was good, but there was not always a step back to consider the likelihood of this pattern continuing and the impact this would have on George going forward. However with an improving picture there was understandable optimism around the time that George was injured. In this case, where the historic concerns and parental vulnerabilities are extensive, there should have been an understanding that the family will require support throughout George’s childhood, and to be transparent about this with the parents. 6.13 The predisposing risks were acknowledged and George spent much of his early life on a child protection plan. Care proceedings were considered following his birth via the PLO because of the extent of the concerns. Over time however, and particularly following the involvement of Mother’s Partner, the risks to George were thought to have reduced. There were no concerns about his presentation, there had been no specific incidents of concern, and Mother appeared to be cooperating with support. Barnardos had noted improvements and Mother was described as happier. There was evidence she was working on the Barnardos play advice between the play sessions, which is unusual and very positive. It was 11 Plant Food is the street name of a drug called mephedrone, which is a powerful stimulant that’s often compared to drugs like cocaine and ecstasy FINAL FOR PUBLICATION 9 understandably believed by all involved that a safeguarding response was no longer required. Learning: Information held about parents and those living with or having extensive contact with a child, including historic information, needs to be analysed by all agencies and considered in respect of the risks and on-going impact on the child at all relevant points of the case. Any new information emerging requires thorough consideration, which may lead to a change in the plan for the child. Families like this one should be made aware that they are likely to require on-going involvement with support services due to the challenges they will face because of their own history. Theme - Parental self-report: 6.14 For most professionals it is standard practice to take the word of a parent who is acting in the best interests of their child. When considering if there is a safeguarding issue, or when providing a child protection response, there needs to be respectful uncertainty and a consideration of whether the parent is providing all of the information. There were a number of occasions in this case where Mother was felt to be either saying what professionals wanted to hear or where she didn’t share information. For example she did not tell professionals that she was moving home, she resisted giving the social worker the name of her landlord, she didn’t tell them she was seeing First Step, and she did not disclose her pregnancy with her second child until explicitly asked by the social worker. 6.15 When Mother was receiving maternity care very little was recorded about Father other than his name, age and that he was no longer in a relationship with Mother but wanted contact. The social worker involved during the second period of CP planning tried hard to engage with Father but he was avoidant and having limited contact with George, so he wasn’t particularly considered in assessments and interventions. Mother and George had lived with him on their return to Cumbria however and there were a number of indicators that they remained in a relationship or at least that there was contact throughout 2017. 6.16 Mother’s Partner was not always open and honest. He told professionals (and indeed Mother) that he was the father of two children, and he did not disclose his previous contacts with the police when asked. It has taken a number of months, post George’s injuries, for professionals to establish the extent of his deceit. He was seen, at the time, to be a positive influence for Mother and potentially a good carer for George. He appeared to provide the stability that had not been consistently evident prior to his involvement. 6.17 Once a professional has a view of a person or situation it can be difficult for them to change this view, even where there is evidence emerging that it might be based on incorrect information. In this case during the RCPC the police officer in attendance undertook checks on Mother’s Partner as it was clear that he was spending a lot of time with Mother and George. Those involved in the case were aware that although the family said he was staying three nights a week, this is a common statement when the family is in receipt of benefits. He may actually have been staying more often or living in the home. In this case however the fact that he was not ‘living with the family,’ also had an impact on the decisions made, as will be shown below. 6.18 Mother often got angry with professionals. She had been known to shout and swear when she was upset or didn’t get her own way. She was very angry when she moved back to FINAL FOR PUBLICATION 10 Cumbria and George was put onto a CPP. During this conference she was abusive and aggressive; screaming at one of the workers and calling her a liar. Mother was not seen as manipulative at the time but there were signs of avoidance and use of anger and aggression which could enable her to successfully deflect or diffuse concerns. The social worker largely handled these outbursts well, letting Mother rant then persistently returning later to explain what was required. 6.19 Mother’s Partner had admitted to using cannabis in the past, but told the core group he had grown out of it and had given it up prior to meeting Mother. There is no evidence that when he lost his job and was feeling down in late 2017 that it was explored with him that he may feel tempted to start using cannabis again. It was not known at the time, but it has since emerged that Mother’s partner also misused illegally sourced prescription medication. Mother’s history of misusing substances was well known to agencies prior to the birth of George and in the first year of George’s life, and this was a concern which was part of the CPP. More recently there were no concerns in this area. However there were occasions where it was known she had been drunk and in the strategy meeting held in March 2017 when she returned to Cumbria with George, it is recorded that on a home visit that Mother had looked “doe eyed” and she had been asked if she was using drugs. She had stated that she was taking codeine for a back condition and this made her drowsy. It is recorded that the social worker was not convinced by this explanation, but there is no evidence this was checked with the GP or that the danger of misusing prescribed or over the counter drugs was considered. 6.20 Mother opened up to an extent to the GP and to First Step about her mental health issues, but she underplayed it with those involved with George and found it difficult to accept that her behaviour could have a negative impact on her son. Mother’s mental health was considered as part of the CP and CiN plans, however the core group did not have all of the relevant information and largely relied on Mother’s report. She did not tell the social worker or core group that she was being seen by First Step, and did not initially tell First Step about the involvement of CSC with her child. They wrote to Mother’s GP asking for any information to be shared around any safeguarding, risks, and history, but did not receive a response at that time. There is reference made to George within the risk assessment undertaken by First Step, highlighting that he is no longer on a CPP but is open as a Child In Need and that risks have reduced as Mother is engaging well with services including mental health. This appears to have been the report given by Mother in her first face to face session. This was not checked with CSC as would normally be the case. 6.21 A report was made by Mother to First Step of an incident where Mother’s Partner had had to take a knife away from her as he was worried she may hurt herself. This was discussed with Mother and appropriate techniques to manage difficult feelings and the support she required were explored. Mother presented her partner as protective and said to First Step that he was instrumental in ensuring she did not harm herself. No discussion was had with her about whether George was present at the time of the knife incident however and whether any consideration was given to the potential impact of Mother’s fluctuating low mood and thoughts of harming herself on George. 6.22 Mother told the professionals involved with George that she had PTSD, although she had not been explicitly told this, just that she had some of the symptoms. This may have been an understandable mistake, but it was not clarified with Mother or with mental health professionals what the impact may be on George. It is known that children living with a parent who has or shows signs of PTSD can be adversely affected, either due to exposure to FINAL FOR PUBLICATION 11 the parent’s behaviour or because the parent is likely to be absorbed by their own difficulties and the child can be emotionally neglected. It is a complicated issue that was not considered as George appeared to be living in a more stable environment when the CPP was stepped down. 6.23 George had a number of minor injuries over time that were either sustained at the nursery or seen by the nursery and others involved. George was thought by some to be a slightly clumsy child who often fell over and bruised easily, and it became expected that he would have a certain amount of injuries. The nursery said however that George’s coordination and physical development were within the normal age bands for his age/stage, and they did not find him clumsy. The Strengthening Families worker said she observed bruising and she gave Mother advice about safety in the home. Her concerns were more about lack of supervision than physical abuse. Bruises and bumps are common in children of his age in areas that are bony prominences such as knees, shins and foreheads. The social worker has witnessed George head banging when he didn’t get his own way at home. The nursery did not see this behaviour in their setting. 6.24 George had changed nursery in around October 2017. Mother informed the new nursery on the registration form that George had a social worker, but when they asked Mother for the name and contact details they were told by Mother that the case was being closed. There was no evidence of contact from the social worker to the new nursery until February 2018, although there was a CPP and then a CinN plan in place at the time George was at the nursery. The nursery told the review they had tried to make contact with the social worker, but found this difficult due to the telephone system in place. The new nursery asked the old nursery for George’s record and when they received it there was no reference at all to there being a social worker or George’s status as a child on a CPP. The new nursery shared during the review that they had no concerns and that they were aware who the Strengthening Families worker was. The Strengthening Families worker was told by Mother that she had moved George’s nursery on 30 October 2017, prior to the RCPC where the step down took place, but the nursery were not invited. Mother also shared her reasons for moving George at the RCPC. 6.25 When George was taken to the GP and the injury to his head was observed, the GP was satisfied that the bruising was consistent with the mechanism of injury reported by the adults, however there was obviously a degree of concern as the GP spoke to the Strengthening Families worker. The GP notes provide very little detail about the injury and the history given. The GP documented that the child was not in distress when he attended with his “parents” and he appeared well in himself. The GP Practice did not receive any minutes from the conferences in June or November 2017, so the GP decided to speak to the Strengthening Families worker which was good practice. After this discussion the GP decided not to make a safeguarding referral, and neither the GP or Strengthening Families worker spoke to the social worker although it was an open case. 6.26 In 2014 the NSPCC published a summary of learning from SCRs about disguised compliance. This involves parents giving the appearance of co-operating with agencies to avoid raising suspicions and to allay concerns. This can be an effective way of ensuring that professionals delay or avoid interventions. Professionals need to ensure they triangulate what parents are saying by establishing the facts, gathering evidence about what is actually happening, and communicating well with all involved. While there were examples of good information sharing in this case, there were also areas where this could be improved and where Mother’s reports could have been checked with other professionals. FINAL FOR PUBLICATION 12 6.27 It is important that professionals share information and communicate to ensure that they do not rely on self-report. If information is not shared, professionals need to question this and challenge each other. This includes using the Cumbria LSCB escalation of professional disagreement policy if required. There were a number of times in the case where respectful challenge could have occurred. First Step did not receive a response from the GP when enquiring about Mother and the GP did not receive minutes from the June and November 2017 conferences. Neither were challenged at the time12. It is noted that CSC in Cumbria sought information from Children’s Services in the previous local authority following the return of Mother and George, but it was not provided. The relevant police force also declined to share information with the social worker, stating that Cumbria Police needed to request this. This did not happen and this was not escalated. There was also a general concern voiced during the review meetings regarding how agencies such as nurseries can find out which social worker is involved13. 6.28 Understanding of pressures across services can stop professionals escalating disagreements and make them less likely to complain about the system or practice of others involved in a case. In this area of Cumbria there are GP vacancies, capacity issues for Health Visitors, Social Workers and the Strengthening Families service. All of those involved are aware of this and do not wish to add to the difficulties by raising issues and taking exception with other agencies. It is understood that the time it takes to recognise issues, take up concerns and use the escalation process is also an issue. Those involved reporting the lack of time even for reflection. Practice needs to be child focused however and appropriate challenge improves services for children. The review found that those involved worked very hard with the family within the context of high demands on their time. 6.29 Learning: Professionals working in safeguarding need to exercise respectful uncertainty, healthy skepticism and be supported to always consider if they have the whole picture. Good information sharing is key, as is professional curiosity. However there are a number of barriers such as time, staffing, data systems, protocols and concern about consent. Not all practitioners are aware of, or use, the CLSCB escalation policy14. Theme: Step down to and closure of child in need 6.30 During the RCPC that unanimously agreed George should be on a CiN plan rather than a CPP, information about Mother’s Partner was established by the police who undertook the required checks during the conference. The minutes show all of the relevant information was shared verbally towards the end of the meeting by the police officer attending. Most of those present only remember that the issues regarding an alleged sexual assault on a 14 year old, that now appear to be unfounded, were disclosed and discussed. The minute taker confirmed that the minutes only reflect what was said at the conference, as they operate on a ‘if it’s not said, don’t put it in’ basis. The focus of the discussion following the sharing of the information was on the allegation made by a 14 year old girl, and did not include a robust consideration of the other information shared. All of the police information 12 The GP agency report noted that there has been a reduction in the number of Vulnerable Child Meetings happening within GP Practices in this area of Cumbria which has an impact on information sharing and professional challenge. 13 Other information sharing issues were identified. George presented with a head injury in July 2017 for which he attended the Emergency Department at the hospital and was referred on for a Paediatric assessment. The information from the discharge letter indicated that the Safeguarding Hub had been contacted but the hospital clinician had been told that there were no safeguarding concerns. This was not the case, as George was on a CP plan at the time. 14 http://cumbrialscb.proceduresonline.com/chapters/p_conflict_res.html FINAL FOR PUBLICATION 13 had previously been concealed by Mother’s Partner from the professionals and from Mother herself. Despite the potential for the information to be significant, the fact that it had not been shared previously, and the need for it to be considered in light of any risk to George, the decision to step down was made. There was no suggestion of a shorter period of on-going CP planning while the new information was assessed. 6.31 The conference was chaired by a different IRO to the one who had chaired the previous meetings, and they told the review that this had an impact on the lack of challenge. However the IRO had been in post for four months and was an experienced chair, and although the previous chair remained in the service, no hand over took place. The new chair remembers it being a very positive conference and had no reservations about agreeing to the CPP ending, having stipulated that an assessment of the new information available about Mother’s partner must be part of the CiN plan. 6.32 Mother’s Partner was seen as a positive and stabilising factor for Mother and George by all those involved. The required CSC checks had previously been completed on him but using the wrong spelling of his name. The checks showed no previous involvement with the department, which was not the case. Despite the involvement of a new adult in the life of a child on a CPP, no updated Child and Family Assessment was undertaken before or after the RCPC. It was acknowledged in supervision in October 2017 that the presence of a new male in the home “increased the vulnerability for George” but no re-assessment was commenced. This was largely because things were thought to be going well and because George was observed to be comfortable and happy when in the care of Mother’s Partner. In this case the social worker was newly qualified and this was her first allocated child protection case. She had inconsistent managerial support, having had a number of agency team managers over the course of the case and very few formal supervision sessions. 6.33 In the months that followed, no concerns emerged, until immediately prior to Christmas of 2017 when the social worker visited and was told that Mother’s Partner had lost his job. He was observed to be feeling very down and they were waiting for a Universal Credit payment. Despite this George was physically well cared for, the home was in a good condition, and there was a Christmas tree and Christmas presents evident. This was reassuring to the social worker, who ensured the family had food bank vouchers to use on Christmas Eve in case the benefit payment did not arrive. This was good practice. 6.34 The conference agreed that when the CPP ended that there should be on-going CiN support, and an assessment should be completed regarding the new information available on Mother’s Partner. A clear plan to discuss the full police history and Mother’s partner’s lack of candour regarding this history needed to be fully considered following the conference. It was agreed that the CiN plan needed to be in place for three months and Mother was focused on this timescale. She was determined that there would be no further social work involvement following this time. A CiN meeting was held after three months and concerns remained, these included Mother being pregnant and the fact that she was not on the tenancy agreement for the new accommodation, leaving her and George potentially vulnerable to becoming homeless. The Strengthening Families worker15 had assessed George’s development and identified a need for monitoring in a couple of areas. He was also observed to be head banging and biting. This information was not discussed with the nursery or with Barnardos who continued to be involved however. They reflected during the 15 The health visiting role was provided via the Strengthening Families Team who deliver a holistic health service to families including parents/carers, children and/or young people, aged pre-birth to 18 and in some instances to age 25, that according to the CLSCB multi-agency threshold guidance ‘require a statutory intervention’. FINAL FOR PUBLICATION 14 review that this would have been helpful information so that they could pursue these issues in their work with the family. The Strengthening Families worker missed two of the CiN meetings. Firstly due to not being told the family had moved (the meetings were held in their home) and then because of the delayed start to one of the meetings. There are capacity challenges for both health visitors and Strengthening Families workers in this part of Cumbria and this wider issue is being reviewed. Learning Professionals need encouragement, support and confidence to reconsider their position when new information is shared during a meeting. 7 Conclusion and recommendations 7.1 George was injured while in the care of his Mother and her partner. While Mother acted protectively by taking George to hospital, he had injuries that had been sustained over at least a 4 week period. It is not known what impact the abuse will have on George as he grows up. He had injuries that shocked and upset those involved in the case. The care proceedings found that George had suffered significant harm from either Mother or her partner and that he should not return to Mother’s care. 7.2 There is a local context, parts of Cumbria have a high number of young parents where there are predisposing vulnerabilities and risks evident. This poses a challenge for the partner agencies of the CLSCB due to the resources required to manage the demand. This has been identified in other SCRs undertaken locally and continues to be an issue. 7.3 Good practice has been identified in this case both in the agency reports and during discussions with the professionals involved in the case. They include: George had continuity of health visitor (who moved into a Strengthening Families role at the time) and social worker following his return to Cumbria. Cumbria CSC challenged the decision to step down to child in need when the family moved to another area. There was a timely strategy meeting and child protection conference on George’s return to Cumbria. Despite George’s young age, there was a lot of direct interaction with him. The social worker, who remains involved, was in her first year of practice and this was her first child protection case. She has shown an excellent commitment to George and has managed to maintain a challenging yet supportive relationship with Mother. There was a timely response from First Step following Mother’s referral. The care George received at the hospital was excellent and timely. George was protected quickly. An Emergency Protection Order was obtained the next day and Interim Care Order 5 days later. 7.3 There has been a high degree of cooperation and engagement from agencies with the SCR process, which has been important in identifying the learning. 7.4 It is recognised that actions have already been taken in relation to some of the individual agencies’ identified learning, and that changes have been made which will be outlined in the CLSCB’s response to this SCR. For example First Step and health visitors (both those providing a universal service and those within Strengthening Families) have an improved relationship and have developed expectations and a system for information sharing. FINAL FOR PUBLICATION 15 7.5 The agency reports have made recommendations which have largely been completed by the conclusion of the SCR. Some of the learning identified within this report will have been addressed by the single agency actions plans. For example the nursery now ask explicitly, on their Registration Form, for the name and contact details of any other agency involved with the child. 7.6 The purpose of providing additional recommendations is to ensure that the CLSCB and its partner agencies are confident that any areas identified as being of particular concern, and not included in the single agency plan, or which require an interagency or LSCB action, are addressed. Recommendation 1: The learning from this review should be disseminated widely. Recommendation 2: This report should be shared with the LSCB in the area where Mother and George lived prior to time period considered by this SCR. Recommendation 3: The CLSCB to seek assurance from partner agencies regarding their promotion of and confidence in using the CLSCB policy for escalating professional disagreements. Question for the CLSCB: How can you be assured that the level of service provision to children with young parents who have predisposing vulnerabilities is sufficiently focused and resourced to meet the need in certain areas of Cumbria with high needs? |
NC044949 | Death of a 19-month-old child in April 2013, as the result of a non-accidental head injury. Child A's mother and partner were arrested but it was not possible to establish who caused the injury; legal proceedings in relation to the future care of Child A's younger half sibling concluded that mother and/or partner caused the injury. Child A's parents were planning to separate and had decided to have a termination before discovering mother was already 30 weeks pregnant. Parents separated almost immediately after Child A's birth and mother entered into a new relationship when Child A was 8-weeks-old. Parents separation was acrimonious; during private law proceedings allegations of domestic abuse were made against father and allegations of aggressive behaviour and alcohol misuse made against mother. Identifies issues including: preconception of father as controlling leading to his concerns over mother's parenting being minimised; insufficient challenge to information provided by mother, which was later found to be untrue, including false allegations made against father; and drink-driving allegations made against mother not being shared with the police agency responsible for assessing potential harm to children. Uses the Social Care Institute for Excellence (SCIE) systems model to identify learning, covering: risks associated with delayed first presentation in pregnancy; and the mechanism for identifying and sharing safeguarding issues raised via Crimestoppers.
| Title: Serious case review: Child A1301. LSCB: Bedford Borough Safeguarding Children Board Author: Jane Wiffin Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Bedford Borough Safeguarding Children Board Serious Case Review Child A1301 October 2014 2 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential CONTENTS Section Page Executive Summary 3-7 1. Introduction Reason for the Serious Case review 7 Time scale for the SCR 8 The Family 8 Succinct summary of case 9 Timeline of critical incidents 10-12 Methodology 12 The Lead Reviewers 13 The Review Team 13 The Case Group 14 Family Involvement 14 Structure of the Review process 14 Sources of data 14 2. Professional Practice Appraisal 15-19 3. The Findings Analytic process for establishing systems findings 20 Categories of underlying patterns 20 Finding 1 22-25 Finding 2 25-27 Finding 3 27-29 Finding 4 29-30 Finding 5 30-32 4. Additional learning 33-34 5. References 35-37 3 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Executive Summary Reason for the Review This Serious Case Review is about Child A, a white British child who died at the age of 19 months as a result of an unexplained non-accidental head injury. Child A’s Mother and her partner (father of Child A’s younger half sibling) were arrested, but it has not been possible to establish who caused the fatal injury. The legal proceedings regarding the future care of the surviving half sibling concluded that Mother and /or her partner had caused the injury. There is no evidence to suggest that any professional could have predicted or prevented this sad death. Review Process This Serious Case Review has been undertaken using the SCIE Learning Together methodologyi. The process was led by two reviewers, one of whom was independent from all agencies, and the other an experienced safeguarding professional whose agency services were not part of the Review. These reviewers were responsible for writing the report. A panel of senior managers and many of the professionals who had direct involvement with Child A and their family oversaw the Review. The Review Panel made a significant contribution by taking part in interviews and attending meetings. We are grateful for their thoughtful and open contribution, and their willingness to learn lessons from this sad incident to improve future practice. Child A’s Father also made a significant contribution to the Review and we want to also thank him for this. Child A’s Mother and her partner were invited to contribute their views, but no response was received from them. Child A Family Circumstances Child A lived for the first four weeks of life with both parents, but they separated acrimoniously when Child A was 4 weeks old. Mother and Father are both White British and they both experienced reasonable economic and social circumstances, and had supportive and available families. Mother started a relationship with a friend of both parents soon after she separated from Father and they had a child when Child A was 18 months old. There is little information about Mother’s partner, except that he is also White/British and worked full time. Contact with Professionals Child A’s parents were on the point of separating when Mother discovered she was pregnant. She initially decided to have a termination, but discovered that she was already 30 weeks pregnant, and the parents decided to remain together. Child A was born, and the parents almost immediately separated. The parent’s relationship was acrimonious and there were allegations of domestic disputes by Mother, which were not substantiated by the police and one allegation was found to have been falsely made by Mother which led to police action. Mother started a new relationship soon after she and Father had separated. There were then consistent disputes regarding contact arrangements for Child A. An anonymous caller to Crimestoppers in November 2011 alleged that Mother was drink driving with Child A in her car and using a false driving licence. When Child A was three months old Mother sought help from her GP regarding anxieties about returning to work which she claimed was caused by Father’s abuse. 4 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Father took legal action regarding the difficulties with contact and also sought a shared Residence Order through Private Law proceedings. During these proceedings Mother told the CAFCASS worker that Father was a cannabis user, and Father said that Mother misused alcohol. These allegations were taken seriously, but subsequent drug and alcohol testing were negative. The issue of contact was seemingly resolved, but it remained acrimonious. Father provided a large amount of information as part of the Private Law proceedings that Mother had been aggressive and violent in the past and, had problems with alcohol. She disputed these issues, and the shared residence was not granted. Mother became pregnant when Child A was 10 months old and she did not seek antenatal care until very late into her pregnancy. The reason for this remains unclear, but she said that she had again not realised that she was pregnant. The Midwife who saw her had concerns that she smelt of alcohol, and made a referral to Children’s Social Care. They carried out an Initial Assessment which led to no further action, because the concerns were not substantiated and there was no evidence that Mother needed further support. Mother and her partner had routine contact with health professionals, and there was no reason for any other professional contact with Child A or their half-sibling in the weeks before the critical incident. Up until Child A’s death there were no concerns about Child A or the half-sibling, and there is no evidence that professionals could have predicted or prevented Child A’s death. What this case does highlight is the professional response to families involved with universal services, about which there are low level concerns and the importance of professional curiosity. It also raises the importance of good quality information sharing to form a holistic picture of a child’s life. If some of the gaps highlighted in the Findings below had been addressed a fuller picture of this family’s life would have been known. Finding 1: The acceptance of parental explanations has prevented professional curiosity and challenge Partnership practice with parents and building relationships is an important part of safeguarding and support because parents are often experts in their child’s life. However, it is critical that professionals maintain a level of healthy scepticism and respectful uncertainty in their work (Laming 2003). In order to achieve this professionals need to think about the information parents provide and challenge discrepancies and inconsistencies. In this case Mother provided discrepant and inconsistent information to a number of professionals, which was not actively checked or challenged. For example, during the Initial Assessment undertaken during Mother’s second pregnancy, she disputed information that the midwife had provided, asserting that it was the midwife that was mistaken; she gave untrue information about Child A’s contact with their Father, saying she had organised it because she believed that it was important they developed an effective relationship and she denied having drunk any alcohol, despite smelling slightly of alcohol being the reason for the assessment. This information was recorded in the assessment without comment, or a professional view being provided. It is much safer for children, young people and their families if challenge of what is reported by parents is built into processes such as supervision and decision making, but also into cultural expectations which recognise that asking questions and seeking explanation from parents is something to be valued. A high reliance by professionals on self-report by parents brings with it significant risks of proceeding on false information. The Bedford Borough Safeguarding Children Board is asked to consider whether there is a collective view about the prevalence of this issue and the scale of change needed around challenge with families; whether there is enough known about the perspectives of the workforce on this issue and how the Board could promote a culture where professionals are supported to be challenging when necessary. 5 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Finding 2: Recognising the potential consequences of Mothers who book late into their pregnancy is important Delayed antenatal booking presents medical and service challenges, leaving only a short window for the relevant health checks to be undertaken, and arrangements for the birth to be made. This case represents the paradox whereby women who delay booking for antenatal care – for whom there may be increased psychological and other risk factors – are less likely to have their emotional and psychological needs investigated and responded to, due to the urgency of their medical needs. There is no evidence that Mother was asked follow up questions about the delay or whether the issue of a concealed pregnancy, ambivalence about this baby or being a parent were considered and assessed. There are significant potential risks for babies if we do not balance the need for medical issues with psychosocial ones where women delaying booking for antenatal care. The Bedford Borough Safeguarding Children Board is asked to consider whether any previous work has been carried out in this area, whether there is a clear pathway for professionals to follow regarding delayed first presentation/ late booking and what action can be taken to address these issues. Finding 3: The Importance of routine enquiries regarding domestic abuse in the pre and post natal period can get lost where there are no other obvious risk factors The Department of Health introduced Routine Enquiry regarding domestic abuse in all health settings because the risk of women being subject to domestic abuse is heightened when they become pregnant or immediately after childbirth and the potential impact on the baby and mother is significant. There is no evidence that Mother was asked by health professionals about domestic abuse, and the Review Panel were told that this was in large partly because there appeared to be no other relevant risk factors present. Given the long term impact of domestic abuse on children and adults it is essential that domestic abuse is detected early on and that those affected are provided with an active and sensitive response. The Bedford Borough Safeguarding Children Board is asked to consider whether they are confident that all antenatal and postnatal professionals are aware of the importance of the sensitive and routine asking of all men and women about domestic abuse, whether those professionals feel equipped to ask these questions and how to respond appropriately and what action they could take to address these questions. Finding 4: Preconceived ideas about fathers as either “good” or “bad” and the influence on the professional response There is evidence from research that suggest there is ‘fixed thinking’, in the professional response to men in safeguarding and support services which has led to fathers or father figures being perceived in polarised ways as either primarily ‘good’ men (good dads) or ‘bad’ men (bad dads). The research showed that beliefs linked directly to whether fathers were thought of by professionals as reliable or unreliable, trustworthy or untrustworthy and therefore the extent they were included as sources of knowledge about children’s lives, in assessments and in decision making. Child A’s Father was at times viewed as abusive and controlling in his contact with professionals. For example, in the Private Law application to the Courts for a Residence Order Father provided a large amount of information to the court about his concerns about Mother’s drinking, mental health and aggression. This was viewed as evidence by the Court of his controlling behaviour, and not taken account of. Fathers are important to children, and it is critical they are given a voice. It is therefore imperative that fixed views about men do not get in the way of providing an individual response based on the needs of children. The Bedford Borough Safeguarding Children Board is asked to consider whether they have any existing data about the involvement of fathers in decision making from early intervention to safeguarding, whether they are aware of the Father 6 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Matters Initiative introduced by the coalition Government to address these issues nationally and what the Board could offer in terms of addressing this issue. Finding 5: Professionals missed opportunities to share information with health colleagues This Review highlights the important role that GP’s, Health Visitors, Midwives and all other health professionals’ play in sharing information which will aid other professionals to undertake the early identifications of need. Mother shared with her GP that she wanted a termination, but she found that her pregnancy was too far advanced. Although this was an extremely personal decision for her, it was the view of the Review that the GP should have assessed whether it was appropriate to share this information with Health professionals because these parents had not intended to be parents, and were due to take on this role in a matter of weeks. The impact of this on attachment and relationships may need to have been assessed. The Bedford Borough Safeguarding Children Board is asked to consider whether they are aware that information sharing by GPs to the wider multiagency network is an issue of concern beyond this case, how they might establish whether this is the case and what strategies they might employ to address it. Alongside these Findings there were three additional issues that the Bedford Borough Safeguarding Children Board was asked to consider: The acknowledgement of the emotional impact of child deaths and subsequent Serious Case Review on professionals: The professionals who were involved in this case felt that the way in which they were informed about the death of Child A and the subsequent instigation of the Serious Case Review was unsupportive, unconsidered and disjointed leaving them feeling upset and deskilled. There was the exception of the Midwifery staff who felt well supported by their manager. The Bedford Borough Safeguarding Children Board were asked to consider what could be done about this for future reviews. In this case the Father felt unable to share his concerns about Mother’s parenting and the potential impact on Child A because he was worried about being involved with “social services”. If this information had been shared early on it may have influenced the professional view of this family. The Bedford Borough Safeguarding Children Board is asked to consider whether this is an issue beyond this case which requires action. Crimestoppers – Clarification is required about to properly identify, utilise and share safeguarding intelligence raised via this mechanism. In November 2011 Crimestoppers received information that Mother was drink driving in the local area, with a child in the car. There does not appear to be a mechanism for ensuring that this information is shared with the appropriate police section who can address the safeguarding aspects. This was a serious allegation about the needs and circumstances of a child and there should be a mechanism for Crimestoppers intelligence reports to go to the appropriate police section. 7 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential 1 INTRODUCTION Reason for the Serious Case Review 1.1 This Review was instigated because Child A1301 (hereon referred to as Child A) died at the age of 19 months as a result of an unexplained non-accidental head injury. On the 16th April 2013, the Mother took Child A to the GP surgery with a three day history of diarrhoea and vomiting. Child A was seen again later the same day at the out of hours GP service with the same complaint. The examination of Child A on both occasions was reported as normal and the Mother was advised to give Child A additional fluids. Child A was admitted to Hospital on 21 April 2013 after being found in the cot by Mother’s partner possibly fitting. A CT scan was undertaken and revealed a severe head injury. Child A was promptly transferred to Addenbrooke’s Hospital where they underwent surgery to reduce the pressure on their brain. Child A was subsequently transferred to their paediatric intensive care unit, and died on 24 April 2013. The medical view was that the injury was likely to have been caused by extreme force, akin to a car travelling at 60 miles per hour and stopping suddenly. Neither Child A’s Mother nor Mother’s partner could provide an explanation for this injury which had occurred whist Child A was at home cared for by them. They were arrested, and bailed, and they currently do not face any criminal charges. It has not been possible to establish who caused the injury to Child A. The legal proceedings regarding the future care of the half-sibling concluded that Child A had suffered non-accidental head injuries caused by the Mother or Mother’s partner. This hearing also concluded that both had lied about the circumstances leading up to Child A being hospitalised, Mother’s alcohol misuse, and also concluded that there was no evidence that either adult had not provided appropriate care for Child A or their half-sibling prior to the incident. There is also no evidence to suggest that any professional could have predicted or prevented this sad death. 1.2 The Bedford Borough Safeguarding Children Board (BBSCB) Serious Case Review Panel and Independent Chair of the Bedford Borough Safeguarding Children Board agreed that this case met the criteria for a Serious Case Review as per Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 because Child A had died and abuse was suspected. 1.3 Working Together 2013ii requires that Serious Case Reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • Makes use of relevant research and case evidence to inform the findings. 8 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential LSCBs may now use any learning model which is consistent with the principles in the guidance, including the systems methodology recommended by Professor Munroiii. The BBSCB agreed to undertake a review using the SCIE (Social Care in Excellence) Learning Together ivmethodology. Time scale for the SCR 1.4 It was agreed that the Review would cover the period of time from when Mother came into contact with professionals because she was pregnant with Child A, in June 2011, to the day of the critical incident, 21 April 2013. The Review was commissioned in October 2013 and completed in October 2014. The Family 1.5 Relationship to Subject Age at time of critical incident Ethnicity Child A1301 Subject of the review 19 months White/ British Child B1301 Half-Sibling 1 month White/ British Mother 26 White/ British Father 28 White/ British Mother’s partner, Father of Child B1301 21 White/ British Maternal Grandmother (MGM) White/ British Paternal Grandmother (PGM) White/ British Paternal Grandfather (PGF) White/ British Succinct summary of case 1.6 The family was largely known to routine, universal services and as a result little was known by professionals about the lived experience of Child A, their relationship with Mother, Father, Mother’s partner and extended family. The parents were involved with routine services, except for some contact with the Police and an Initial Assessment undertaken in April 2013. Child A therefore had little direct contact with professionals, and when seen for routine health appointments and the Initial Assessment undertaken in April 2013 the available evidence was that Child A was well looked after, had a good relationship with their Mother and engaged with professionals. Mother’s partner had no contact with professionals when he was caring for Child A so no agency was able to comment on his relationship with Child A. Mother’s partner started a relationship with Mother when Child A was 8 weeks old. With the exception of maternity staff, who described their contact as routine, no 9 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential professional had any contact with him or saw him with Child A and his half-sibling who is the partner’s biological child. 1.7 Mother reported during the Initial Assessment that she had a good relationship with her own extended family and it became clear during the contested residence order proceedings in May and October 2012 that she had a close relationship with her Mother, Child A’s Maternal Grandmother. Mother also reported at this time that she was living in the village where she had been brought up and had friends and accessed local resources such as the mother and toddler group, but there was no objective evidence of this. She also said she had a horse which she had owned for 23 years and which was stabled in the village. 1.8 Father reported a close relationship with his parents, and they tried to help when Mother and Father were separating. The Paternal Grandparents subsequently supported Father during contact and Father reported that they were subjected to aggression by associates of Mother during contact visits. No professional had contact with the extended family. 1.9 Child A’s parents were on the point of separating when Mother discovered she was pregnant. She initially decided to have a termination, but discovered that she was already 30 weeks pregnant. Child A was born, and the parents almost immediately separated. The parent’s relationship became acrimonious and there were allegations of domestic abuse by Mother. 1.10 Mother started a new relationship soon after she and Father had separated. There were then consistent disputes regarding contact arrangements for Child A. An anonymous caller to Crimestoppers in November 2011 alleged that Mother was drink driving with Child A in her car and using a false driving licence. 1.11 Father took legal action regarding the difficulties with contact and also sought a shared residence order through private law proceedings. The issue of contact was seemingly resolved, but it remained acrimonious. Father provided a large amount of information as part of the Private Law proceedings that Mother had been aggressive and violent in the past, had problems with alcohol. She disputed these issues, and the shared residence was not granted. 1.12 Mother became pregnant when Child A was 10 months old and she did not seek antenatal care until very late into her pregnancy. The reason for this remains unclear, but she said that she had again not realised that she was pregnant. The Midwife who saw her had concerns that she smelt slightly of alcohol, and made a referral to Children’s Social Care. They carried out an Initial Assessment which led to no further action, because the concerns were not substantiated. Mother and her partner had routine contact with health professionals, and there was no reason for any other professional contact with Child A or their half-sibling in the weeks before the critical incident. Timeline of Key Professional Contacts Date Incident September 2010 Father and Mother started a relationship. 13 June 2011 Mother went to GP 1 because she had discovered she was pregnant. Mother provided information to GP 1 who calculated that she was 19 10 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential weeks pregnant. She requested a termination and the GP organised this. June 2011 Mother and Father attended a private clinic as a result of GP referral and were told that because the pregnancy was of 30 weeks gestation it could not be terminated. The parents had been due to separate, but they agreed they would remain together and be parents for the unborn baby. 21 June 2011 Mother went back to her GP surgery and saw GP 2 who she told that she was unable to terminate the pregnancy and GP 2 made a referral for antenatal care. 7 July 2011 Mother was booked for antenatal care at 32 weeks pregnancy. 1 September 2011 Child A was born. 6 September 2011 Midwives visited and there were no concerns, Mother, Father and Child A was seen and all was described as well. 22 September 2011 Health Visitor – routine visit. Only Father seen, Mother and Child A not present. October 2011 Mother and Father separated acrimoniously. November 2011 Mother started a new relationship with an old friend of both parents. 16 November 2011 Mother telephoned the Police alleging that Father had been outside her house, had scratched her car, and harassed her through text messaging. Father was arrested and charged with criminal damage, which he was later exonerated of, and Mother was subsequently charged with providing a false statement. 16 November 2011 Father was arrested and charged with the use of threatening behaviour. 18 November 2011 The Police made a referral to Children’s Social Care regarding the two incidents in November. In line with the existing threshold criteria it was agreed that no further action was necessary and Father had bail conditions imposed not to contact Mother. 30 November 2011 Mother and Father had a dispute regarding contact arrangements and Mother called the Police. No action was taken and the bail conditions remained. 30 November 2011 Anonymous information was received by Crimestoppers alleging that Mother was driving with Child A in the car after consuming two bottles of wine and using a counterfeit licence. This information was passed on to the Traffic Police who looked for her and the car, without success. 25 January 2012 Mother visited GP 3 and asked for a sick note because she said she had separated from her partner who had been abusive to her. She said that she could not return to work because her partner worked in the same place and she was having panic attacks. She was diagnosed with an anxiety state, given a two week sick certificate and Propranololv was prescribed. She was seen twice more by the same GP, and her sick certificate was extended to May 2012. 30 March 2012 Father made a private law application for a shared residence order. 11 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential 30 April 2012 Father was interviewed by a CAFCASS (Children and Family Court Advisory and Support Service) Officer. He discussed the conflicts regarding contact and provided details of an incident where he was threatened by a group of men when he went to collect Child A. 30 April 2012 The Police were made aware of allegations regarding Father’s cocaine use, and a referral was made to Children’s Social Care. This was reviewed by a Team Manager and led to no further action. 16 May 2012 Mother was interviewed by a CAFCASS Officer. She alleged that Father had used cocaine in the past, and was concerned he still did. She agreed to regular contact, but said she was against shared residency, saying it was not in Child A’s best interest. 22 May 2012 The parents were seen by a CAFCASS Officer at Bedford County Court at the First Hearing. Father made allegations regarding Mother’s alcohol use. They attended a Separated Parents Information Programme and a way forward for contact was agreed. The shared residency order application could not be completed because of the allegations of Father’s drug use, and counter allegations of Mother’s alcohol use, tests for both were agreed. Father filed an extensive body of evidence for the Hearing, making significant allegations about Mother. 26 May 2012 The Police were called by Mother regarding Father taking photographs of her car. No action was taken and a domestic abuse referral was sent to Children’s Social Care. Seen as routine reporting and no action taken by Children’s Social Care. 17 August 2012 Mother was arrested for making a false statement regarding the car scratching incident in November. No action taken. 10 October 2012 Final Court Hearing. Father filed a large number of responses to existing queries, on top of the file he had already submitted. He provided further information regarding concerns about Mother and her alcohol use. This was viewed by the court as evidence of his controlling nature. The Judge found in favour of Mother regarding the shared residency order. The financial cost to both parties was significant. 26 February 2013 Mother went to the maternity unit of the local hospital at 35 weeks pregnant because she was concerned about reduced fetal movements and backache. Mother reported that she had been aware of the pregnancy for two months and had seen the community Midwife three times. There was no record of this. The Midwife was concerned that Mother smelt slightly of alcohol and she made a referral to Children’s Social Care using the Common Assessment Framework (CAF). 27 February 2013 CAF sent to Children’s Social Care outlining Mother not seeking antenatal care despite knowing she was pregnant for two months and also smelling slightly of alcohol. 5 March 2013 Home visit made by a Social Worker to carry out an Initial Assessment. Mother disputed the information about the delay in booking or alcohol use. Child A was seen, good attachment with Mother noted and home conditions assessed as suitable. Mother’s partner not present. Case closed. 12 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential 7 March 2013 Social Worker telephoned the Midwife and said that the Mother had disputed the information provided regarding the delay in booking and case to be closed. 22 March 2013 Child B born. 23 & 27 March 2013 Midwives visited and there were no concerns, Mother, her partner (father of the baby) and baby all seen and all was described as well. 16th April 2013 Child A seen by GP with diarrhoea and vomiting Later on the same day Child A was seen by the out of hours GP services with diarrhoea and vomiting. The examination on both occasions was normal and Mother was advised to give Child A additional fluids. 19 April 2013 Father attended GP to follow up communication he had with the surgery about wanting knowledge of Child A’s medical care and to be involved in decision making. He confirmed he had parental responsibility and his solicitor followed this up. April 2013 Father wrote to Mother and her partner suggesting that he will be undertaking a further private law application. 21 April 2013 Child A was taken to hospital by ambulance after he was found in their cot by mother’s partner. It was thought he was ’fitting’. 21 April 2013 Child A transferred to Addenbrookes. 24 April 2013 Child A died from a significant head trauma. Methodology 1.13 This Serious Case Review has been undertaken using the SCIE Learning Together methodologyvi. The focus of a case review using a systems approach is on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – what happened and why – to identify the deeper, underlying issues that are influencing practice more generally. It is these generic patterns that count as ‘findings’ or ‘lessons’ from a case, and changing them should contribute to improving practice more widely. Data comes from semi-structured conversations with the involved professionals, case files, contextual documentation from organisations and the family who are the subject of the review. A fundamental part of the approach is to talk with staff to understand what they thought and felt at the time they were involved in the case, avoiding hindsight as much as possible. It is vital to try and make sense of what factors contributed to their actions at the time and to the decisions they made. This is known as ‘local rationality’. The appraisal of practice is then made in the context of those contributory factors. The Lead Reviewers 1.14 This review was undertaken by Jane Wiffin who is a SCIE accredited Lead Reviewer and Anneliese Hillyer-Thake who has undertaken the SCIE training and has been mentored by Jane Wiffin throughout the process. Jane Wiffin was the independent Lead Reviewer. She is a qualified Social Worker who has extensive experience of working in safeguarding. She is an experienced Serious Case Review Author and Chair, having undertaken 22 reviews. She is an accredited SCIE Learning Together Reviewer. She is independent from all the agencies involved in this review. 13 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Anneliese Hillyer-Thake is Head of Safeguarding for the East of England Ambulance Service NHS Trust. In this role she is responsible for contributing to Serious Case Reviews for Local Safeguarding Children's Boards across the Eastern Region. She has considerable experience in undertaking Serious Case Reviews. The Review Team 1.15 The Review Team consisted of a team of senior representatives from local agencies who had no direct dealings with the case. They analysed the conversations and documents, identified key practice episodes and contributory factors and helped to make sense of the key Findings. This report is the shared responsibility of the Review Team in terms of analysis and conclusions, but was written by the joint Lead Reviewers. The Case Group 1.16 The members of the Case Group are the professionals who worked with or made decisions about the family, and who had individual conversations with the Lead Reviewers. The Case Group comprised of 20 people (although not all these people attended case group meetings). They met with the Review Team on four occasions to share in the analysis, identification of contributory factors, and to comment and contribute to the final report. Individual sessions were held with some professionals, either because they could not make the case group meetings or to clarify data. Name Agency Roseanne Johnstone Interim Head of Social Work, Bedford Borough Council Helena Hughes Designated Nurse for Safeguarding Children, Bedfordshire Clinical Commissioning Group Karena Thomas Detective Superintendent, Bedfordshire Police Dr Wendy Kuriyan Designated Doctor for Safeguarding Children, Bedfordshire Clinical Commissioning Group Dr Abdullah Khan Named GP for Safeguarding Children, NHS England / Bedfordshire Clinical Commissioning Group Dawn Andrews Head of Service for Safeguarding Children, South Essex Partnership Trust Jackie Scott Matron Paediatric Named Nurse Safeguarding Children, Bedford Hospital Sally Stocker Business Manager, Bedford Borough Safeguarding Children Board 14 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Family Involvement 1.17 Mother, Father and Mother’s partner were all invited to contribute to the review. Mother and Mother’s partner did not reply and therefore they have not contributed. The Lead Reviewers met with Father on three occasions and he provided a great deal of information as well as written material, based on his correspondence with professionals and particularly material related to his private law application. He also read the final report. Structure of the Review Process 1.18 The Review Team met on five occasions, including four times with the Case Group, and worked on the data, analysis of practice and the identification of the Findings and issues for BBSCB consideration. Sources of data 1.19 • Semi-structured conversations between the Lead Reviewers and 16 members of the Case Group; • The semi-structured conversations with Father and materials provided by him and his solicitor; • Documentation: All necessary documentation was made available to the Review Team ranging from case files, procedures, and police attendance records. This meant that the reviewers did an in depth review of all the relevant information held during the period under review by Children’s Social Care, GP surgery, Police, CAFCASS, Health Visiting and Maternity Services. 15 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential 2 PROFESSIONAL PRACTICE APPRAISAL 2.1 This case involves the routine response of agencies to Child A from when his Mother discovered she was pregnant in June 2011 to Child A’s death in April 2013. The Author begins by capturing the appraisal that the Review Team made about the practice response to this case, given what was known and knowable at the time. The Findings that follow hope to provide an explanation of the “why” questions, outlining what got in the way of professionals being as effective as they wanted to be. 2.2 It is always difficult for those professionals who were directly involved with a child who dies unexpectedly. The professionals we spoke to expressed this very clearly and these feelings were compounded for them by the news that there would be a Serious Case Review. This caused anxiety for many and many of the professionals told the Review Team that this anxiety was not sufficiently acknowledged or addressed by their organsiations see the additional learning section. Despite this, all the professionals who had contact with Child A and the family took part willingly and intelligently, because of a keen desire to understand what had happened and improve practice for the future. The Review Team is grateful to them for being open and helping to make sense of the case and the context in which practice took place. 2.3 It is quite clear that this was an unexpected death and there were no indications that either Mother or her partner was likely to harm Child A. The circumstances which led to Child A’s sad death remain unknown. In the recent Finding of Fact Hearing for the care proceeding regarding the half sibling, the presiding Judge concluded that Mother and Mother’s partner had not given a true account of the events that led to the death, and that Mother had lied about her alcohol misuse and her partner had not been honest about his knowledge of this. 2.4 Mother went to her GP in June 2011 and said was pregnant. She provided information which led GP 1 to assess that she was 19 weeks pregnant and she asked GP 1 to organise a termination. There is little information about why she decided to have a termination and the GP did not record information about this. Father told the reviewers that it was because the relationship had become fractious and they were about to separate. When Mother and Father attended the termination of pregnancy services, Mother was found to be 30 weeks pregnant and therefore they could not terminate the pregnancy. 2.5 Mother returned to her GP surgery and saw GP 2. There is no recorded conversation between the GP and Mother about how she felt about the pregnancy continuing or, her and her partner’s emotional readiness to be parents. This should have taken place. An antenatal referral was made, which did not include the information regarding Mother planning a termination, but being too late into her pregnancy and consequently no other professional knew about this start to Child A’s life or had an opportunity to consider its meaning for Child A or Mother. Although this was an intensely personal issue, the GP should have made an assessment of whether sharing this information as part of the health response to antenatal care would be appropriate in the context of Mother and the unborn child’s wellbeing. (See Finding 5). The Healthy Child Programmevii alongside NICE Guidanceviii makes clear the importance of the early assessment of maternal and paternal emotional wellbeing (see the additional learning section). This should include a consideration of the early risk factors associated with impaired outcomes for children later in life, such as ambivalence about a pregnancy, unstable partner relationships and intimate partner violence. It is unclear how well Mother and Father were 16 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential prepared for parenthood, and there should have been a greater consideration of the implications for the care of this baby, the potential impact on the attachment relationship and Mother and Father’s health and well being. 2.6 Mother saw a Midwife at 32 weeks pregnancy. She explained that she had not realised that she was pregnant, which was why she was booking her antenatal care so late. The Midwife was not aware that Mother had sought a termination. All action was taken to ensure Mother’s medical needs were met, but there is no recorded discussion or assessment of the implications of delayed first presentation/late booking, or exploration of the reasons for it. Delayed first presentation/late booking is known to be a significant risk factor, and even in the context of a Universal provision there should have been more professional curiosity about this very delayed first presentation/ late booking and the potential impact on parent-child attachments and the potential impact on Mother’s mental health. (See Finding 2). 2.7 When Child A was born, the family were visited by health professionals as would be expected. These were routine visits where family relationships appeared to be positive, and the evidence was that Mother was coping well with the new baby. There is no recorded evidence of whether she was asked about her emotional wellbeing, in line with NICE Guidelinesix or whether she was asked about domestic abuse (See Finding 3). Father described later in his court statement that at this time Mother was drinking, and there were fights between them. He did not share this with any professionals at the time (see additional learning). 2.8 The parents separated a month after Child A was born, and Mother started a new relationship with mother’s partner who was an old friend. There were tensions between Mother and Father about contact arrangements, and Mother called the Police twice to report text and verbal harassment and damage to her property by Father (which was subsequently proven to be untrue). Father confronted mother’s partner about an allegation that he had attempted to defraud him regarding the sale of his house (mother’s partner was an estate agent at this time) and Father was arrested for threatening behaviour. These incidents were dealt with appropriately by the Police, and they shared information with Children’s Social Care as would be expected. This was routine reporting and in line with the existing thresholds for the provision of services this led to no action beyond being held on file. During this time Crimestoppers received an anonymous referral regarding Mother drinking and driving (two bottles of wine) with Child A in the car. This was sent to the traffic division, who immediately looked for Mother on the road, but this information was not shared with the Public Protection Unit, the Police agency responsible for addressing potential harm to children, as would be expected, given the risks this posed to Child A. It was a missed opportunity to develop a clearer picture of the circumstances in which Child A lived. Despite extensive efforts to make sense of why this gap exists, it has not been possible to do so. (See additional learning). 2.9 When Child A was three months old, Mother told GP 3 that she was having panic attacks, which she said were caused by the Father threatening her. Mother said that she and Father had separated, but she was worried about returning to work because he worked for the same organisation. She was diagnosed as having “an anxiety state”, medication was prescribed, and a sick note given, which was subsequently extended for four more months by GP 3. The GP ascertained that Mother was in a safe place, living with Maternal Grandmother and the police were involved. There is no recorded discussion of the implications of either the anxiety state, or the allegations regarding threats on the wellbeing of a three month old baby as would be expected. This information was not shared with the Health Visitor and it is the view of the Review Team that the Health Visitor should have been told of the pressures 17 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential on this new Mother with a young baby (see Findings 3 and 5) . This was a missed opportunity to develop a clearer picture of the circumstances in which Child A lived and the support that might be needed. There was no reason for Mother and Child A to have contact with any other professional during this time. The GPs later explained, as part of this review, that they no longer have the same contact or alignment with Health Visitors as in previous years, where they would have regularly met with Health Visitors assigned to the practice. The national health visiting specifications states that the service should be delivered so that there is a named Health Visitor linked to each GP practice and that they will facilitate an agreed schedule of regular contact meetings for collaborative service delivery. This review has enabled the practice to strengthen information sharing with the Health Visitor and Midwife. 2.10 In March 2012 Father made a Private Law application for a contact order and a shared residence order, (and he paid all of his own legal costs). This was prompted by the difficulties he was having in seeing Child A, and indeed he alleged that on one occasion he was threatened by a group of men when he attended an agreed contact session. Mother and Father were assessed promptly by CAFCASS and interviewed by a CAFCASS Officer at the first hearing in May 2012. Mother made an allegation that Father had used cocaine in the past, and she was concerned he was still doing so. Appropriately, a drug test was ordered (paid for by Father), and was subsequently found to be negative. There is no evidence that Father ever used cocaine. Father made allegations about Mother’s alcohol misuse, and she was also tested, and this also proved to be negative. The contact arrangements were agreed and CAFCASS closed the case, as would be expected, at this point. 2.11 The first hearing for the Shared Residence Order was heard in May 2012 and Father made a number of allegations about Mother to the court. This information included allegations of Mother’s misuse of alcohol, her lying about when she discovered that she was pregnant and that she had attacked Father physically and self harmed with the intention of telling the Police that Father had hurt her. He also provided a large quantity of texts from her – he did not provide the corresponding replies, personal letters and pornographic pictures of Mother he had found on his computer. Mother made allegations of domestic abuse by Father. Father was told by his solicitor that the evidence that he had provided was viewed within the court proceedings as further evidence of his controlling behaviour in the context of domestic abuse. It is of concern to the Review Team that the court did not ask for an assessment (Section 7 report) to be undertaken, given the concerns raised about both parents. The implications for the care of Child A do not appear to have been sufficiently considered, and Father appears to have been sidelined, and his concerns dismissed. This was not appropriate. (See Finding 4). This was a further missed opportunity to develop a clearer picture of the circumstances in which Child A lived. 2.12 In February 2013 Mother went to hospital, said that she was pregnant and concerned about reduced fetal movement. This was the first that any professional knew of the pregnancy which was assessed as being of approximately 35 weeks gestation. She told the Midwife that she had discovered that she was pregnant two months earlier, and had seen a Community Midwife on two occasions. This was checked with the Community Midwife a few days later who said that she had not had any contact with Mother. The issue of Mother’s delayed first presentation/late booking for pregnancy was not explored further with her (see Finding 2) and there was no evidence that her emotional wellbeing was explored; in line with existing guidancex or whether she was asked about domestic abuse (See Finding 3). The Midwife was concerned about this delayed first presentation/late booking and the fact that Mother smelt “slightly” of alcohol. She decided that a referral to Children’s 18 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Social Care was needed, and this was done via the Common Assessment Framework (CAF) the next day. This was a clear and proportionate response; however the Midwife did not have an opportunity to inform Mother that she was making a referral. The current concerns were clearly outlined, but the previous delayed first presentation/late booking for her first pregnancy was not mentioned as would have been expected. 2.13 The referral was responded to promptly and an Initial Assessment started. Mother was seen at home with Child A. Information about past concerns regarding the police notifications of domestic abuse was discussed, and the GP was asked for information regarding the wellbeing of Child A, but not asked about Mother’s background. The assessment relied too heavily on Mother’s own version of events – her “self report” that she did not drink alcohol, that the information from the Midwife was incorrect regarding how long she had known about the pregnancy, that Child A had regular contact with his Father and she had ensured that this took place. These were all unsubstantiated assertions (See Finding 5). 2.14 This Initial Assessment was only focused on the risk to the unborn baby, and not Child A. Father was not aware that the assessment of Child A had been undertaken. His views were never sought, despite him having parental responsibility, and at this point he had made allegations to court about his concerns regarding Mother’s drinking, mental health and her potential aggression. This information would have challenged Mother’s own self report of her circumstances, and would have provided a different picture regarding the risks faced by Child A and the unborn baby. The assessment concluded that there was no role for Children’s Social Care and the case was closed. Given the information collected this was an appropriate response. The referring Midwife was informed of the outcome, of the history of domestic abuse, and that Mother disputed what the Midwife had said about the delayed first presentation/late booking. This dispute was not discussed, and therefore the likelihood that Mother was not telling the truth about her circumstances was not considered and the implications for the needs of either child not assessed in the light of this. 2.15 Child A’s half sibling was born, and Mother and her partner were visited as would be expected by health professionals. There were no concerns raised as a result of these visits, which were described as routine with evidence that Mother was coping well with the new baby. Child A was seen and described as “lovely” and “thriving”. Mother did not share that there was continued conflict with Father, or the threat of further costly legal action by Father. 2.16 Child A was brought to hospital with a slow heart rate and seizures in April 2013, and Child A was discovered to have a serious head injury. Although this review does not cover the care provided to Child A before they died, there is significant evidence that this was of a consistently high standard, and both hospitals Child A attended tried to do all they could to save Child A. The half-sibling was immediately safeguarded, and care proceedings sought. 2.17 It was a shock to all those professionals who had contact with Child A that they had died and that Child A’s Mother and mother’s partner were arrested on suspicion of having caused the injury that caused Child A’s death. The impression was that this was an ordinary family who were respectable, and the available evidence was that both children were well cared for by Mother and Father and subsequently Mother and Mother’s partner. The contact the family had with professionals was of a largely routine nature, and the only concerns were regarding disputes and harassment which led to Police action and one allegation regarding Mother smelling of alcohol 19 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential during her second pregnancy. In reality it has emerged that there were some concerns about Mother’s alcohol use, about anxiety and aggressive disputes about contact, with both Father and Mother alleging domestic violence. It is the task of this review to try and understand why such a false image of Child A’s circumstances remained. It appears that it was in part caused by some gaps in information sharing across the multi-agency network; (see Finding 5). Mother lied consistently about her circumstances, and she was not challenged about inconsistencies in the information she gave to professionals (see Finding 1). Father had concerns which he initially did not share because he did not want his child known to “social services” (see the additional learning section) and when he did provide information to court he was perceived as controlling, and so his concerns were minimised (see Finding 4). He was not included in the Initial Assessment that took place during Mother’s second pregnancy and thus an opportunity to form a more holistic view of Child A’s life was missed. These are important learning points for future practice, but there is no evidence to suggest that any professional could have predicted or prevented this sad death. 20 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential 3 THE FINDINGS In what ways does this case provide a useful window on the system? 3.1 The outcome of this case is unusual. Around 1 – 2 children a week are killed by their parents or carersxi. There is growing evidence regarding the profile of parents who kill their children, and there is often a coexistence of serious psychiatric disorders, violence and significant substance misuse. This blended family does not fit this profile. They lived in reasonable economic and social circumstances, and had supportive and available families. There were some known issues about conflict, alcohol misuse and a brief spell of anxiety as well as Mother’s delayed first presentations/late bookings for her pregnancies. Up until Child A’s death there were no concerns about Child A or their half-sibling, and there is no evidence that professionals could have predicted or prevented Child A’s death. What this case does highlight is the professional response to families involved with universal services, about which there are low level concerns and the importance of professional curiosity. It also raises the importance of good quality information sharing to form a holistic picture of a child’s life. Analytic process for establishing systems findings 3.2 The aim of a Learning Together case review is to use a single case as a ‘window on the system’, to uncover more general strengths and weaknesses in Child A protection system. A four-stage process of analysis is used to articulate how features of the case can lead to more general systems learning. The first is to look at how the issue manifested in the case, this will often be presented as one example, even if there are several such examples. This evidence comes from the analysis of the case and examination of key practice episodes. 3.3 The second step is to consider whether the issue observed in this case is ‘underlying’. That is, that it is not a ‘quirk’ of the case, but is likely to represent practice in other cases and by other practitioners. The third step is to consider how geographically widespread and numerically prevalent the issue is within the system. Sometimes it is not possible within the scope of a review to establish this data. The sources for these steps will be information from the Review Team and Case Group, any performance data, national research and other reviews in a variety of combinations. 3.4 The last step is to articulate why this issue matters, what are the risks to the safeguarding system. Based on this finding, questions and considerations for the BBSCB are formulated. 3.5 Alongside the systemic Findings there was also some additional learning that emerged from this review and this is covered in section 4. Categories of underlying patterns 3.6 The systems model that SCIE has developed includes 6 broad categories of underlying patterns. The ordering of these in any analysis is not set in stone and will shift according to which is felt to be most fundamental for systemic change. Not all the typologies will have a finding associated with them but they are designed to allow for structured enquiry as to what the data has revealed: 21 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential • Human biases (cognitive and emotional): Are there common errors of human reasoning and judgement that are not being picked up through current case management processes? • Family-professional interaction: What patterns are discernible in the ways that professionals are interacting with different family members, and how do they help and or hinder good quality work? • Communication & collaboration in responses to incidents: Are there particular good or bad aspects to the patterns of how professionals respond to specific incidents (e.g. allegations of abuse)? • Communication and collaboration in longer term work: Were any good or bad patterns identified about ways of working over a longer period with children and families? • Tools: What has been learnt about the tools and their use by professionals? • Management system: Are any elements of management systems a routine cause for concern in any particular ways? 22 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential This review has prioritised five findings for the BBSCB to consider: Finding Category Finding 1: The acceptance of parental explanation has prevented professional curiosity and challenge. Family Professional Interaction Finding 2: There is insufficient knowledge and understanding about the potential consequences of delayed first presentation/late booking on the welfare and mental health of the family. Communication & collaboration in response to incidents Finding 3: The message about the importance of routine enquiries to be made about domestic abuse in the pre and post natal period may have got lost where there are no other obvious risk factors. Communication and collaboration in longer term work Finding 4: Preconceived ideas about fathers as either “good” or “bad” influences potentially whether they are involved in assessments regarding their children. This means that important information about risks may be lost. Human biases (cognitive and emotional) Finding 5: Opportunities were missed to share information with health colleagues which would have allowed other professionals to undertake a more comprehensive assessment of the family’s wellbeing and the couple’s readiness for parenthood. If appropriate information is not shared with the multi-agency network this could lead to instances where there is an incomplete assessment of a child’s wellbeing. Communication and collaboration in longer term work Additional Learning There is insufficient acknowledgement of the emotional impact of child deaths and subsequent Serious Case Review on professionals. In this case the Father felt unable to share his concerns about Mother’s parenting and impact on Child A because he was worried about being involved with “social services”. Does the BBSCB consider that this is an issue beyond this case which requires action? Crimestoppers – Clarification on how internal mechanisms properly identify, utilise and share safeguarding intelligence raised via this mechanism. 23 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Finding 1: The acceptance of parental explanation has prevented professional curiosity and challenge. How did it manifest in the case? 3.7 Partnership practice with parents is important where there are concerns about children’s welfare. Munroxiixiii in her review of child protection system highlighted the importance of developing effective relationships with parents, to achieve better outcomes for children. The concept of partnership practice has recently been defined as “Authoritative Practice” where professionals treat parents/carers with respect and empathy, but are also clear about appropriate and positive challenge.xiv 3.8 In this case there were a number of incidents where professionals relied on the self-reporting by Mother without challenge or without a clear search for corroborative evidence. 3.9 In February 2013 Child A’s Mother attended hospital and told health professionals that she was pregnant with her second child and was worried about reduced foetal movement. At this time she was 35 weeks pregnant. Mother reported that she had not known she was pregnant until 8 weeks earlier, and she had seen a Community Midwife on two previous occasions. This was not the case, and although the Midwife who saw her could not find any information regarding these previous contacts, she did not challenge Mother about this discrepancy. The Midwife made a referral to Children’s Social Care, because of the delayed first presentation/late booking and concerns that Mother smelt of alcohol. She included the information in the referral that Mother had reported seeing a Community Midwife but that there was no evidence that this had taken place. This information was provided without any professional comment or analysis and was not contextualised alongside her previous delayed first presentation/late booking. 3.10 The Social Worker discussed with Mother the issue of her delayed first presentation/late booking and how long she had known she was pregnant. Mother disputed the information provided by the Midwife. This issue was not analysed and the possibility that Mother was not telling the truth not acknowledged. Subsequently, the Social Worker contacted the Midwife to tell her that Mother disputed the information she provided, and said the Midwife had obviously misunderstood her. There was no discussion or analysis of this information, or discussion about what this might mean. This lack of reflection meant that Mother was seen as reliable, well engaged and trying her best to be helpful. 3.11 In reality, during the assessment interview, Mother provided information that was not true. She said that she did not have a problem with alcohol and that she had only smelt of alcohol because she had been to the pub, but not consumed alcohol, and this was believed. She also said that she had organised contact for Child A with Child A’s Father because she recognised that it was important and that it was going well. This was also not true, and if contact had been made with Father or CAFCASS this would have been apparent. It is not always possible to triangulate all information provided as part of these routine assessments, but where this is the case, it must be made clear what the parents view is, and what the assessing Social Worker believes about it. What their professional judgement is about it. This is where “healthy scepticism” and “respectful uncertainty” (Laming 2003) plays a part. 3.12 There was a further opportunity to check the issue of parental self report in the Initial Assessment if it had been shared with the Midwife to check and confirm the content and analysis. She was the referrer and her agency was due to continue working with 24 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Mother and her partner. The Midwife did not ask to see the assessment and it was not shared with her. The issue of partnership with parents has meant that there is a mistaken belief that parents must give permission for the assessment to be shared. In fact national guidance makes clear that the assessment is focussed on Child A and that if there are agencies who will remain involved after the assessment has completed, that information regarding the assessment should be shared with them, to enable them to complete their work. How do we know that it is an underlying issue and not something unique to this case? 3.13 The Case Group told the Review Team that a reliance on parental self report was a key issue in their work. They told us that giving parents a voice in records and assessments was important, but they reflected that this might lead to a lack of healthy scepticism and respectful uncertainty (Laming 2003). How common and widespread is this? 3.14 It is unclear how common and widespread this issue is in Bedford Borough as no data is collected about the extent of parental self report and its influence on decision making. This is a not an issue which is part of current auditing practice. Why is it important? “Working with family members is not an end in itself; the objective must always be to safeguard and promote the welfare of a child. The child, therefore, must be kept in focus” 3.15 Partnership practice with parents and building relationships is an important part of the assessment process, as parents are often experts in their child’s life. However it is critical that professionals maintain a level of healthy scepticism and respectful uncertainty (Laming 2003). This is an active process of triangulating the information from different sources, and establishing ether there are discrepancies and what those discrepancies might mean (Morrison) for the child. Finding 1: The acceptance of parental explanation has prevented professional curiosity and challenge. It is much safer for children, young people and their families if challenge of what is reported by parents is built into processes such as supervision and decision making, but also into cultural expectations which recognise that asking questions and seeking explanation from parents is something to be valued. A high reliance by professionals on self-report by parents brings with it significant risks of proceeding on false information. Arrangements put in place to recognise when there is insufficient challenge, and to increase the value given to challenge, are in the interests of families and professionals. Such arrangements can include ensuring time for in depth supervision, ensuring an independent uninvolved voice at key decision making meetings, managers modelling that challenge is acceptable, and showing how it can be done in a constructive way so that workers have more confidence in challenging parents. Questions for the BBSCB Is there a collective view at the Board about the prevalence of this issue and the scale of change needed around challenge with families? 25 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Is enough known about the perspectives of the workforce on this issue? Is there a view that to challenge parents is to be judgemental? How could the Board promote a culture where professionals are supported to be challenging when necessary? Is there clarity about when assessments can and should be shared with multi-agency colleagues? Finding 2: There is insufficient knowledge and understanding about the potential consequences of delayed first presentation/ late booking on the welfare and mental health of the family. 3.16 There is general recognition that delayed first presentation/late booking for antenatal care is a potential risk factor for the health and wellbeing of mothers and babies (Calder 2013). Despite this, there is a lack of both quantitative and qualitative research which addresses the phenomenon of delayed antenatal attendance. Where small scale research exists it shows that delayed first presentation/late bookers tend to come from disadvantaged groups such as Black and Minority Ethnic communities, women who are single and unsupported and women who are more socially deprived. The reasons for the delayed first presentation/late booking are often connected to this disadvantage, or a lack of knowledge or information about antenatal care. Mother and Father were not in any of these disadvantaged groups. 3.17 Research does also suggest the reason why some women fail to access antenatal care could be a rejection of the pregnancy or concealment. There is limited research into concealed pregnancy and even less into the link between this and child abuse. The reality is that women may have a variety of reasons for their behaviour. Reder et al (1993) in their overview of 35 Child abuse enquires highlighted that an ambivalence to or rejection of pregnancy and delayed antenatal care was an important risk factor for child abuse and neglect. Where guidance exists (see for example West Sussex policyxv) professionals are encouraged to explore the reason for this if an appointment is made very late for antenatal care (after 24 weeks of pregnancy). 3.18 One of the primary ambitions of the Healthy Child Programme is to ensure that all parents are well prepared for parenthood. Mother started to access antenatal care about 8 weeks before she and Father became parents. They had not attended any parent craft classes, and had not actually prepared themselves psychologically for this role. 3.19 Delayed antenatal booking also presents medical and service challenges, leaving only a short window for the relevant health checks to be undertaken, and arrangements for the birth to be made. This case has represents the paradox whereby women who delay booking for antenatal care – for whom there may be increased psychological and other risk factors – are less likely to have their emotional and psychological needs investigated and responded to, due to the urgency of their medical needs. 3.20 It is essential that the meaning of delayed first presentation/late booking is assessed, and its meaning explored in all cases, regardless of whether there are other obvious risk factors. 26 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential How did the issue manifest in this case? 3.21 Child A’s Mother delayed first presentation/late booking for both her pregnancies. She said on both occasions that she did not know she was pregnant because she had irregular periods, and so would use a pregnancy test to see if she was pregnant. On both occasions she gave a different story to different professionals, and there were clear inconsistencies. One Midwife noted that in her second pregnancy, it was obvious that she was pregnant, which called into question her assertion that she had not known. This was not addressed, and did not lead to any questions or analysis about the meaning of the delayed first presentation/late booking. 3.22 There is no evidence that Mother was asked more questions about the delayed first presentation/late booking, or that the issue of a concealed pregnancy, ambivalence about this baby or being a parent were considered. The issue of the lack of preparation for this new role was not covered, and it remains unclear what the meaning of this was for the care or wellbeing of Child A. How do we know it is an underlying issue? 3.23 Mother delayed booked for both her pregnancies and received a similar response each time. The meaning of her delayed first presentation/late booking was not assessed. How prevalent and widespread is the issue? 3.24 There is no precise information about how many women delay booking for their pregnancies, although it appears nationally to be a small percentage of births. At a local level it was reported by the Clinical Business Unit Manager for Women and Children’s services, Bedford Hospital that it was common to have a number of delayed bookers in the maternity unit every month. It is however a significant issue which needs further discussion. Finding 2: There is insufficient knowledge and understanding about the potential consequences of delayed first presentation/late booking on the welfare and mental health of the family. Delayed first presentation/late booking is recognised as a risk factor for babies, and as a potential indicator of emotional/psychological issues in women and needs careful discussion and thought. The recent research review completed by the NSPCC highlights particularly the vulnerability of young babiesxvi, and the recent Ofsted review of Serious Case Reviews noted that a significant number were held for babies under 1 year old. There are significant potential risks for babies if we do not balance the need for medical issues with psychosocial ones where women delaying booking for antenatal care. Questions for the BBSCB Does the Board recognise late booking in any context as is an important issue? Has the Board done any previous work on exploring this issue within the multiagency children’s workforce? How can the Board be assured that this issue will be addressed and lessons shared? Is there a clear pathway for professionals to follow regarding delayed first presentation/ late booking? 27 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential If the Board decides to take action in this area, what measures will it put in place to test whether it has been successful? Finding 3: The message about the importance of routine enquiries to be made about domestic abuse in the pre and post natal period may have got lost where there are no other obvious risk factors. 3.25 Domestic abuse has a profound impact on women, men and children. International research suggests 4–8 per cent of all pregnant women are victims of domestic abusexvii. One study suggested rates of domestic abuse (severe to moderate violence) increase after birth compared to the antenatal periodxviii. The same study found that 40–50 per cent of women who experienced physical abuse also experienced sexual assault. The Psychiatric morbidity survey estimates 33,000 babies under 1 in England, equivalent to around 39,000 in the UK, are living in a family where there is domestic abuse. There is now increased understanding that the consequences of heightened maternal stress during pregnancy as a result of domestic abuse extend to the foetus – and later to the newborn infant as young as one year old can experience trauma symptoms as a result of witnessing domestic abuse. There are significant long term negative outcomes for a child living with domestic abuse and early identification and the provision of safe and caring opportunities for disclosure are an important part of a universal response. 3.26 The Healthy Child Programme makes it clear that all parents should routinely be offered the opportunity to discuss domestic abuse as part of a broader strategy of a preventative health programme for children. This routine enquiry, alongside other health issues, is important because domestic abuse affects women and men from all sections of society, and is often an issue where no other obvious risks exist. How did the issue manifest in this case? 3.27 Mother made allegations to the Police that Father was domestically abusive soon after Child A was born. These were addressed by the Police, and referrals were made to Children’s Social Care, and these were recorded, and led to no further action. 3.28 This information was not known to the antenatal or postnatal professionals that Mother came into contact with, and there is no evidence that she was asked about domestic abuse by them. Father also alleged that Mother had been domestically abusive to him. This was not known by professionals until much later, but there is no evidence that he was asked about domestic abuse. 3.29 Mother told the GP in January 2012, when Child A was 4 months old, that Father had been threatening to her. There is no evidence that the GP discussed the impact of this on Child A or considered talking to another professional, such as the Health Visitor, to see if further support was needed. Given the potential impact of domestic abuse on the emotional wellbeing of an infant, and parent - child attachments, this was a missed opportunity. It remains unclear what the impact of these early conflicts were on Child A’s emotional wellbeing. How do we know it is an underlying issue? 3.30 The Case Group expressed surprise that Mother had not been asked about domestic abuse, because their sense was that this was well embedded in practice. However, they recognised that they are often influenced by the circumstances of parents. The Review Team and Case Group concluded that asking about domestic 28 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential abuse was well embedded in practice where there were clear risk factors, but that with parents who present as coping and no obvious concerns, it was less so. How prevalent and widespread is the issue? 3.31 Current research suggests that 1 in 3 women and 1 in 7 men will experience domestic abuse in their lifetime. This risk is significantly heightened during pregnancy and in the early days of parenthood. Research also makes clear that domestic abuse affects people from all sections of society, and is often hidden where parents live in reasonable economic and social circumstances. It is therefore a significant issue in the context of pre-and postnatal care. Finding 3: The message about the importance of routine enquires to be made about domestic abuse in the pre and postnatal period may have got lost where there are no other obvious risk factors. Domestic abuse is a serious issue during pregnancy which can have a profound negative impact on women and the health and wellbeing of the unborn baby. It can affect the development of positive parent-child relationships, which are the cornerstone of children’s wellbeing. There is also clear evidence that domestic abuse has profound long term negative consequences for children, with their health, mental health, success at school and ability to build good relationships with others. It is essential that domestic abuse is detected early on and that those affected are provided with an active and sensitive response. Questions for the BBSCB Is the Board confident that all antenatal and postnatal professionals are aware of the importance of the sensitive and routine asking of all men and women about domestic abuse? Are the Board aware of whether professionals feel equipped to ask these questions and how to respond appropriately? What strategies can the Board employ to address this issue? If the Board decides to take action in this area, what measures will it put in place to test whether it has been successful? Finding 4: Preconceived ideas about fathers as either “good” or “bad” influences potentially whether they are involved in assessments regarding their children. This means that important information about risks may be lost. 3.32 Children Act 1989 and the Human Rights Act 1998 makes clear that fathers have a right to be centrally involved in decision making, planning and services regarding their children. Research suggest that fathers have a significant role to play in children’s lives and as part of his review of child protection systems Laming said "Particular mention should be made of the part to be played by fathers, not least as good role models”. 3.33 Researchxix and Serious Case Reviewsxx have shown that fathers and father figures are often invisible to professionals, and are not always successfully included in work regarding their children. 3.34 There is evidence from research that professional perceptions of men in child protection work appear to be “as a threat, as no use, as irrelevant or absent”xxi. This ‘fixed thinking’, means that men were perceived in polarised ways as either primarily 29 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential ‘good’ men (good dads) or ‘bad’ men (bad dads). The research showed that beliefs linked directly to whether fathers were thought of by professionals as reliable or unreliable, trustworthy or untrustworthy. When professionals adopted this restricted way of thinking they could discount a ‘bad’ dad’s concern about the welfare of children (Brandon et al 2009xxii). 3.35 Ferguson and Hogan (2004)xxiii found that stories about fathers ‘float around the system’. In their study of fathers’, men’s identities were sometimes constructed by professionals in collaboration with family members, and fathers were often labelled as dangerous without the professional having had any direct contact with them. Based upon this fathers were often excluded from decision making. The use of negative stories about fathers has also been found by Scourfield xxiv(2003) to influence whether they were included in assessment, plans and decision making. 3.36 This “fixed” thinking runs contrary to the ambitions of the Governments “Fathers Matter campaign” which was launched in 2008, alongside a best practice framework to help agencies and LSCBs develop effective practicexxv. How did it manifest in this case? 3.37 In March 2012 Child A’s Father initiated a Private Law application regarding contact and a shared Residence Order for Child A. Early in the process both parents made allegations about the other. Mother said that Father had used cocaine in the past, and she was concerned that this remained as an issue which might impact on his care of Child A. This allegation influenced thinking about the contact arrangements, and it was felt necessary to ask Paternal Grandmother to be present. Father took a drug test, which proved negative, and no other evidence about drug taking emerged. 3.38 Father made counter allegations that Mother had significant problems with alcohol and she took a liver function test which provided negative. 3.39 Mother shared during the first hearing for the shared Residence Order that Father had been violent to her; in fact there was never any evidence of this. She had reported a number of incidents of harassment and that Father had damaged her car. This was subsequently shown to be a false allegation, and Mother was subsequently arrested, but not charged, for perjury. 3.40 Father provided a large amount of information to the first hearing, which included allegations of Mother’s violence and aggressions, her alcohol misuse, self harm and he produced vast quantities of texts from her to him, and photos of a pornographic nature, which he found on his computer. These were significant concerns which had the potential to have an impact on Mother’s ability to provide safe care to Child A. These concerns were dismissed in court, and were seen as evidence of Father’s controlling behaviour in the context of domestic abuse. This meant that these allegations were never assessed, and the implication for the parenting of Child A never established. The information was never shared outside of the court arena, and Father’s concerns were never acknowledged. 3.41 In March 2013 Father was not included in the assessment that took place regarding the half-sibling but which also related to his child. This assessment included information about him being domestically abusive, and that Mother had established a pattern of appropriate contact arrangements, because she was aware of the importance of the relationship between Father and Child A. This was far from the truth, and an opportunity to provide Father with a voice was lost. 30 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential How do we know it is an underlying issue? 3.42 The Case Group recognised that fathers are often marginalised, particularly when there are concerns about domestic abuse. Research and Serious Case Reviews support that this is an underlying issue nationally. The Case Group recognised that fixed thinking about violent men influenced the extent to which they should and could be involved in decision making. It has not been possible to talk to those involved in the court process, or to establish the extent to which this is an underlying issue in private law applications locally. How prevalent and widespread is the issue? 3.43 Nationally, there is considerable evidence that fathers are marginalised from decision making about children, and court processes. Finding 4: Preconceived ideas about fathers as either “good” or “bad” influences potentially whether they are involved in assessments regarding their children. This means that important information about risks may be lost. Fathers are important to children, and it is critical they are given a voice. There have been a number of high profile Serious Case Reviews where fathers have tried to alert professionals to concerns about a mother’s care of children and have been disregarded because of perceptions that they were unreliable (Hamza Khan, Baby Peter). It is imperative that fixed views about men do not get in the way of providing an individual response based on the needs of children. Questions for the BBSCB Does the Board agree this is an issue? Does the Board have any information about the involvement of fathers in decision making from early intervention to safeguarding? Is the Board aware of the Father Matters Initiative, and what it could offer in terms of addressing this issue? If the Board decides to take action in this area, what measures will it put in place to test whether it has been successful? Finding 5: Opportunities were missed to share information with health colleagues which would have allowed other professionals to undertake a more comprehensive assessment of the family’s wellbeing and the couple’s readiness for parenthood. If appropriate information is not shared with the multi-agency network this could lead to instances where there is an incomplete assessment of a child’s wellbeing 3.44 The wellbeing of children depends on appropriate joint working between agencies and professionals that have different roles and expertise. Individual children and their families need support from health, education, early years, children’s social care, the voluntary sector and other agencies. 3.45 GPs are an extremely important element of this network. They are well placed to recognise when a parent or other adult has problems that may affect their capacity as a parent or carer and is crucial that the optimum possible use is made of their skills and experience. Part of this is an informed approach to effective information 31 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential sharing which underpins integrated working and is a vital element of early intervention. How did it manifest in this case? 3.46 Mother went to see her GP in June 2011 because she thought she was pregnant. This was confirmed, and she asked her GP to organise a termination. An appointment was made by the GP at a termination of pregnancy services clinic, where Mother was assessed as being 30 weeks pregnant. As a result of the late stage of pregnancy, the Mother subsequently returned to her GP and an antenatal referral was completed. The information about the termination request was not included in the referral. The termination request was viewed by the GP as an adult decision, and a personal one for the Mother involved. In this situation Mother and Father had made the decision to terminate the pregnancy, but the significant issue was that they were not able to do so, and this therefore also became about the needs and circumstances of the unborn child. In these situations, in line with the Healthy Child Programme it is essential that all health professionals There is no evidence that the GP assessed the potential psychological impact this may have had on the Mother and Father, or discussed with the Mother, her relationship, or attitudes to the baby who at this stage could be unwanted. This was a significant gap and meant that the Midwife who saw her next did not know that the baby was potentially unwanted. 3.47 There is no evidence that the GP discussed the reason for the termination with Mother, they did not know that that Mother and Father were about to separate because of the volatility of their relationship and that they had never planned to be parents. Research suggests that unwanted pregnancies are linked to potential physical and emotional harm as well as poor quality care/neglectxxvi. This was important information that should have been shared and would have contributed to a fuller picture of the family circumstances in which Child A lived. 3.48 Mother did not tell the Midwife that she had wanted to terminate the pregnancy, and instead she chose to say that she did not know she was pregnant, but when she discovered she was, she was delighted to be so. The Midwife could not consider the meaning of this change in story or consider why Mother chose not to discuss the planned termination, because she did not know about it. In fact this was the beginning of a pattern of Mother giving different stories to professionals about why she delayed first presentation/late booking for both pregnancies. If the information had been shared, this pattern might have been recognised and addressed. 3.49 Serious Case Reviews demonstrate that it is often only when information, which is seemingly unimportant, is brought together from a range of sources, does a holistic picture of a child’s life emerge. This good information sharing is important for their future healthy development, as well as to keep them safe. How do we know that it is an underlying issue and not something unique to this case? 3.50 The GPs who were seen as part of this review felt that terminations were a private matter for women, and they did not routinely share this information with others. In this case there was a second example where information about Mother’s anxieties, and allegations of domestic abuse were not shared with any professionals, despite Child A being 4 months old at the time. The Case Group told the Review Team that this was not a quirk of this case, but that they had encountered previously problems regarding information about adults, which related to the needs of children, which GPs in other circumstances had not shared with them. Research suggests this is a 32 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential widespread problem, and national inquires such as Victoria Climbiexxvii highlighted the need for GPs to take a child centred approach to information sharing. How common and widespread is this? 3.51 There is no available information locally about this issue, and no work has been done to establish how widespread it is. However, the Review Team and Case Group attested to this being an important issue. Finding 5: Opportunities were missed to share information with health colleagues which would have allowed other professionals to undertake a more comprehensive assessment of the family’s wellbeing and the couple’s readiness for parenthood. If appropriate information is not shared with the multi-agency network this could lead to instances where there is an incomplete assessment of a child’s wellbeing Information sharing across the multi-agency network is essential to ensure the wellbeing and protection of children. Serious Case Reviews show us that when information shared from a range of sources can the overall meaning for the child be understood effectively, and true picture of a child’s life emerge. It is essential that professionals do not make these decisions in isolation, because they have decided that it is not relevant or proportionate to share. This is particularly critical in the pre-birth period and the first year of life. Research suggests effectively assessing and meeting the needs of parents and children at this time has a long term positive benefit for children and their families. Research also suggests that the first year of life is when children are most likely to be harmed. It is essential that all relevant information is shared to enable professionals to make appropriate decisions about the necessary support. Questions for the BBSCB Are the Board aware that information sharing by GPs to the wider multiagency network is an issue of concern? How will the Board establish this? What are the strategies that the Board could employ to address this? If the Board decides to take action in this area, what measures will it put in place to test whether it has been successful? 33 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential 4 ADDITIONAL LEARNING 4.1 Alongside the Findings, there were three significant issues which emerged from this review which the Board need to be aware of. Significant Issue 1: There is insufficient acknowledgement of the emotional impact of child deaths and subsequent Serious Case Review on professionals 4.2 The Case Group told the Review that they felt that the way in which they were informed about the death of Child A and the subsequent Serious Case Review was unsupportive, unconsidered and disjointed allowing professionals to come away from those discussions feeling upset and deskilled. Several members of the Case Group told us they heard this news of Child A’s death when they had just experienced some personal loss. They said they were expected to simply carry on with their job, without sufficient of what had happened. There was the exception of the Midwifery staff who felt well supported by their manager. 4.3 The Biennial Review of Serious Case Reviews xxviiihighlighted the impact of being involved in a Serious Case Review for Professionals who talked about feelings of failure, guilt or being made a scapegoat and the words ‘upset’, ‘traumatic’, ‘devastating’, ‘under scrutiny’ and ‘vulnerable’ were all used . Another recurring theme from the Biennial Review was the lack of support and supervision of practitioners involved in Serious Case Reviews and the need for an immediate support service. Practitioners feel ‘out on a limb’ and isolated. There can be a lack of knowledge and understanding of what will happen next in the review process, and a “period of uncertainty whilst awaiting outcomes; a step into the unknown”. “The length of time the review goes on, one is carrying anxiety for a length of time, especially if court case or media involvement”. Member of staff. Significant Issue 2: In this case the Father felt unable to share his concerns about Mother’s parenting and impact on Child A because he was worried about being involved with “social services”. Does the BBSCB consider that this is an issue beyond this case which requires action? 4.4 Serious Case Reviews have highlighted that observations and information from family, friends and neighbours may provide vital insights into the workings of families (Laming, 2003). They are a vital source of information. A review of families’ perceptions of the child protection system (Wiffin 2010) suggest that there is a general lack of confidence in child protection processes, and a concern that to alert professionals to concerns is to open a family up to critical scrutiny where families have no control about the outcome. 4.5 There were a number of opportunities where the Father could have shared his concerns about Mother’s alcohol misuse and violence, but he chose not to do so. He had contact with a number of health professionals, and presented a picture of a harmonious family when Child A was first born. He told the reviewers that this was because he did not want his child to be known to “social services”. He agrees that he underestimated the impact of his silence, and when there were some concerns he was not then asked his view. 34 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential Significant Issue 3: Crimestoppers – Clarification on how internal mechanisms properly identify, utilise and share safeguarding intelligence raised via this mechanism. 4.6 In November 2011 Crimestoppers received information that Mother was drink driving in the local area, with a child in the car. All Crimestoppers intelligence reports go directly to the Police Central Intelligence Bureau (CIB) Intelligence group email list and can be picked up by any of the staff on the 24/7 CIB Intelligence desks. All submitted intelligence, regardless of its source is viewed by the CIB Operations team to ensure that all actionable intelligence is attended to appropriately. There are 3500 logs per month and a grading system is used to prioritise those items that merit greatest attention and which have the highest degree of credibility. The content of the report regarding Mother was sufficiently detailed to allow action to be taken and was passed to Traffic Policing for their attention and action. There does not appear to be a mechanism for ensuring that this information is shared with the Public Protection Unit. This was a serious allegation about the needs and circumstances of a child. Despite the high volume of information, there should be a mechanism for Crimestoppers intelligence reports to go to the appropriate place. 35 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential References i Fish, S. Munro, E. Bairstow, S. (2008) Learning Together to Safeguard Children: developing a multi-agency systems approach for case reviews. SCIE: London ii Education Department (2013) Working Together to Safeguard Children: a guide to interagency working to safeguard and promote the welfare of children. London. iii Munro, E. (2011) The Munro review of child protection: final report: A child centred system. London:TSO. Fish, S. Munro, E. Bairstow, S. (2008) Learning Together to Safeguard Children: developing a multi-agency systems approach for case reviews. SCIE: London. v A beta-adrenoceptor blocking drug (often referred to as a beta-blocker) Anxiety: anxiety can cause physical symptoms such as a fast heartbeat and trembling. Propranolol slows the heart rate to relieve these symptoms. (However it does not relieve the emotional symptoms associated with anxiety, such as stress or fear, so these symptoms should be treated separately.) vi Fish, S. Munro, E. Bairstow, S. (2008) Learning Together to Safeguard Children: developing a multi-agency systems approach for case reviews. SCIE: London vii Department of Health (2009) Healthy Child Programme – pregnancy and the first five years of life viii Antenatal and postnatal mental health: clinical management and service guidance, NICE Clinical Guideline (2007) ix Antenatal and postnatal mental health: clinical management and service guidance, NICE Clinical Guideline (2007) x Antenatal and postnatal mental health: clinical management and service guidance, NICE Clinical Guideline (2007) xi Dale, P., Green, R. and Fellows, R. (2002) What really happened? Child protection case management of infants with serious injuries and discrepant parental explanations. London: NSPCC. [NSPCC Policy Practice Research Series]. xii Davies C. & Ward H. (2013), Safeguarding Children Across Services: Messages from research on identifying and responding to child maltreatment, London, Jessica Kingsley Publishers xiii Munro, E (2011) Munro review of child protection: final report - a child-centred system; Department of Education. https://www.gov.uk/government/publications/munro-review-of-child-protection-final-report-a-child-centred-system xiv The term authoritative practice is referred to in the most recent biennial review and specifically in the Baby Peter executive summary which describes the approach as challenging and confronting about parenting, setting clear targets with short timescales and discovering motivation and capacity to be a responsible parent 36 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential xv WEST SUSSEX LOCAL SAFEGUARDING CHILDREN BOARD (2007) Child protection good practice guide: Concealed pregnancy and birth: http://www2.westsussex.gov.uk/yourcouncil/ppri/sci/PDF_files/cs48_concealed_pregnancy.pdf xvi Cuthbert, Chris, Rayns, Gwynne and Stanley, Kate (2011) All babies count: prevention and protection for vulnerable babies: a review of the evidence: NSPCC, xvii Gazmararian, J. (1996) Prevalence of violence against women. xviii Geilen, A. (1995) Interpersonal conflict and physical violence during Child Abearing year. xviii Manning, V. (2011) Estimate of the numbers of infants (under the age of one year) living with substance misusing parents, NSPCC. xviii Bogat, G.A. (2005) Trauma symptoms among infants exposed to interpersonal violence, CAB. xix Ryan, M. (2000). Working with fathers. Radcliffe Medical Press, Oxon. xx Brandon, M., Bailey, S. Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, J. and Black, J. (2009) Understanding Serious Case Reviews and their impact: A Biennial Analysis of Serious Case Reviews 2005-7, Research report DCSF-RR129, London, DCFS. xxi Scourfield, J. (2003) Gender and Child Protection, London, Palgrave Macmillan. xxii Brandon, M., Bailey, S. Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, J. and Black, J. (2009) Understanding Serious Case Reviews and their impact: A Biennial Analysis of Serious Case Reviews 2005-7, Research report DCSF-RR129, London, DCFS. xxiii Ferguson, H. and Hogan, F. (2004). Strengthening families through fathers: Developing policy and practice in relation to vulnerable fathers and their families - WIT Repository. xxiv Scourfield, J. (2003) Gender and Child Protection, London, Palgrave Macmillan xxv The Think Fathers campaign aims to bring about a sea-change in British culture, politics and public services, whereby fathers’ significance in their children’s lives is fully recognised and acted upon. The campaign has three goals: • To transform children’s, family and health services, including maternity services, pre-schools/nurseries and schools into services which systematically engage with fathers and support father-child and parental relationships. • To promote public understanding and debate about fatherhood and how we can all support fathers’ positive involvement in their children’s lives. • To develop father-inclusive approaches at work – for example, flexible working and leave arrangements for men and women which take account of fathers’ roles in bringing up children http://www.fatherhoodinstitute.org/2009/about-the-think-fathers-campaign/ 37 Serious Case Review: Bedford Borough Safeguarding Children Board Confidential xxvi Reder, P. and Duncan, S. (1999) Lost Innocents: A Follow up Study of Fatal Child Abuse: London: Routledge xxvii Laming (2003) Victoria Climbie Inquiry: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273183/5730.pdf xxviii Brandon, M., Bailey, S. Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, J. and Black, J. (2009) Understanding Serious Case Reviews and their impact: A Biennial Analysis of Serious Case Reviews 2005-7, Research report DCSF-RR129, London, DCFS. |
NC51821 | Death of a 10-week old boy in 2017 as the result of non-accidental head injuries. Forensic post-mortem found two injuries: one several days prior to death and another closer to time of death. Father convicted of manslaughter and grievous bodily harm; custodial sentence. Family known to universal services only; no vulnerabilities in family background. Ethnicity or nationality not stated. Lessons: preparation for parenthood needs to involve: both parents learning practical and emotional aspects of caring for a new born baby; managing crying; access to advice and support when needed; when a baby is taken to hospital with symptoms indicating potential harm, consider the possibility of non-accidental injury. Recommendations include: Safeguarding Partnership should continue to use ICON: Babies Cry, You Can Cope! and DadPad (prevention of abusive head trauma tools) and evaluate these programmes; medical professionals should provide documented analysis of any symptoms of non-accidental head injury.
| Title: Serious case review report: Baby T. LSCB: West Sussex Safeguarding Children Board Author: Jane Wonnacott Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Official: Sensitive West Sussex Safeguarding Children Board Serious Case Review Report Baby T Report Author Jane Wonnacott MSc MPhil CQSW AASW Director, Jane Wonnacott Safeguarding Consultancy Ltd Official: Sensitive Serious Case Review Baby T 6.2.20 Page 2 of 10 Contents 1 INTRODUCTION ........................................................................................................... 3 2 REVIEW PROCESS ...................................................................................................... 3 3 FAMILY BACKGROUND .............................................................................................. 4 4 INVOLVEMENT WITH SERVICES IN WEST SUSSEX ................................................ 4 5 FINDINGS ..................................................................................................................... 7 6 CONCLUSION ............................................................................................................ 10 Official: Sensitive Serious Case Review Baby T 6.2.20 Page 3 of 10 1 INTRODUCTION This serious case review was commissioned by West Sussex Safeguarding Children 1.1Board following the death of a baby, known throughout this review as Baby T. Baby T died in a regional hospital in 2017 of injuries which were thought at the time to be suggestive of non-accidental injury. He was 10 weeks old and lived with his parents. Baby T’s mother had called an ambulance after Father had alerted her that Baby T 1.2was unresponsive and had stopped breathing. Baby T was taken to a local hospital and on the same day transferred to the regional paediatric intensive care unit. Investigations confirmed that Baby T was suffering from severe retinal bleeding and bleeding on the brain, injuries which were identified at the time as potentially being caused by shaking and/or impact. Baby T subsequently died of his injuries. Statutory guidance1 at the time required Local Safeguarding Children Boards to carry 1.3out a serious case review when a child has died, and abuse and neglect are known or suspected. The death of Baby T fulfilled the criteria for a serious case review and the previous Chair of West Sussex Safeguarding Children Board commissioned this review. An independent lead reviewer and serious case review panel made up of senior 1.4managers from agencies within West Sussex were appointed. The first phase of the review took place in parallel with police enquiries. Family members were informed that the review was taking place but were not offered an opportunity to contribute, pending decision by the Crown Prosecution Service as to whether any member of the family would be charged with an offence. During the initial phase of the review, further forensic reports confirmed the traumatic 1.5nature of Baby T’s injuries and that they must have been as a result of considerable force. It was also suggested the injuries may have occurred over a period of time and later forensic examination confirmed that Baby T had suffered two events causing injury, one several days prior to death and another closer to the time of death. A decision was made to prosecute Baby T’s father and he was convicted of Manslaughter and Grievous Bodily Harm and received a custodial sentence. 2 REVIEW PROCESS The primary questions agreed for the review by the LSCB Case Review Group and 2.1amended at the first serious case review panel meeting were: For the agencies involved with this child and family, what was the quality and effectiveness of the response in recognising and responding to vulnerability factors? How well did this inform any assessment and intervention? To what extent did professional curiosity inform assessment and intervention? 1 Department for Education (2015) Working Together to Safeguard Children Page 75-6 Official: Sensitive Serious Case Review Baby T 6.2.20 Page 4 of 10 How was information used and shared to inform assessment and intervention and were there any barriers to sharing information? What are the similarities with any findings and themes from recent serious case reviews in West Sussex (N, O and S) and what is the relevance of these for the findings and recommendations of this review. Chronologies/ reports of involvement were received from: 2.2 Sussex Police Primary Care Services (GPs) Sussex Community NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust South East Coast Ambulance Service The Regional Paediatric Intensive Care Unit. It was agreed that the lead reviewer should meet with practitioners who had contact 2.3with the family along with the relevant chronology author. Meetings took place with: 2.4 Consultant Paediatrician at the local hospital GP Health Visitor Midwife Whilst waiting for the conclusion of the criminal proceedings an interim report was 2.5presented to the LSCB in order that any immediate learning could be considered, and action taken. Following conclusion of the proceedings Baby T’s mother (known as “Mother” throughout this report) was offered an opportunity to contribute to the review. She agreed to do so and met with the lead reviewer and chair of the panel and we are very grateful for her helpful observations. Father was also offered the opportunity to contribute and spoke to the chair of the panel. 3 FAMILY BACKGROUND There is nothing within any agency records indicating any vulnerabilities within the 3.1background of Baby T’s mother or father. Mother comes from a local family who were considered by practitioners to be 3.2supportive. Father had moved to West Sussex from another area and this review has received no information indicating any vulnerabilities in his history. Mother and Father lived together in well maintained, privately rented accommodation. 4 INVOLVEMENT WITH SERVICES IN WEST SUSSEX Up until the death of Baby T there had been no involvement with the family other 4.1than routine services. Official: Sensitive Serious Case Review Baby T 6.2.20 Page 5 of 10 In August 2016, Mother was pregnant, saw the GP and was referred to the midwife. 4.2 Mother was seen at home by the midwife at eight weeks and six days gestation. This 4.3booking appointment was not carried out by the usual midwife due to the usual midwives’ maternity leave and records show that Father was present at the booking appointment. It is expected practice that midwives ask fathers about their alcohol use, smoking, employment and whether they have other children. It has not been possible to confirm from the records whether Mother was asked if she had ever felt threatened or vulnerable, but again this would be expected practice. When the usual midwife picked up Mother’s care at 16 weeks gestation, no concerns were passed on either verbally or in the records. Midwifery care was unremarkable, and it was good practice that Mother saw the 4.4same named midwife from 16-week gestation onwards. All parents are offered an ante-natal class on a Saturday focused on birth and labour and in addition there is a two-hour “Baby Matters” class on a weekday. This was attended by Mother and included information on: Breast feeding & hand expressing The first 10 days and what to expect emotionally and physically for both mum & baby Five to thrive and brain development Safe sleeping How to deal with crying and unsettled babies Who will visit & when they will visit Who the maternity support workers are & the support they will provide. Mother also recalls attending the Saturday morning class with Father and that this 4.5mainly focused on practical matters such as bathing the baby. Father remembers attending a class and hearing about crying babies, different cries and being told not to shake or shout at the baby. Baby T was born in 2017. Emergency procedures were followed for shoulder 4.6dystocia2 but examinations by midwife and paediatrician post-birth found the baby to be in good condition. Shoulder dystocia is a relatively common occurrence and midwives would be very familiar with the procedures necessary to assist the birth. An appointment was made with the physiotherapist, as is usual practice. Baby T was visited at home in line with usual practice by the community midwife. The 4.7midwife recalls that the final visit (with a student midwife) on day 11 was “textbook” and very thorough. Both parents were seen, and no concerns noted. Baby T was seen the same day by the health visitor and noted to be gaining weight and doing well. The health visitor has told the review that she understood Mother and Father to be in 4.8a stable relationship and both parents were very welcoming at the new birth visit. The health visitor described Father as physically strong and Mother as quiet, unassuming, 2 Where the baby’s shoulders become stuck Official: Sensitive Serious Case Review Baby T 6.2.20 Page 6 of 10 but confident. There were no concerns at either the new birth visit, the baby clinic or the six-week contact. The six-week contact took place in the family home with Mother and included all the expected advice, including prevention of sudden infant death, feeding and general health promotion. The usual enquiries were also made about maternal mental health and domestic abuse. It was expected practice that there should be a discussion with the health visitor 4.9about managing crying and avoiding hurting your baby, although Mother does not recall this being discussed at that visit3. Within West Sussex the Integrated Prevention and Earliest Help Service4 promote ‘Five to Thrive’ which is a social modelling tool promoting attachment and the underlying workbooks discuss support with a crying baby. Health visitors are also being trained in the use of promotional guides, which also contain specific reference to crying babies and each practitioner has access to a reference copy of the NSPCC ‘Coping with Crying’ leaflet. In June 2017, Mother called the GP surgery and described Baby T as being unwell 4.10for 14 hours – vomiting, one wet nappy, red eye, floppy, reduced oral intake. Mother was advised to take baby into the GP surgery which she did 35 minutes later. The GP provisionally diagnosed bronchiolitis and appropriately referred Baby T to the paediatric department at the local hospital. One doctor at the hospital recalls Father getting cross about not being seen quickly 4.11enough (which was not felt to be justified) but this was not significant enough to be documented in the records. Baby T was admitted to the ward and both Mother and Father stayed with him overnight. He was found to be suffering from a childhood illness and was discharged home with open access to the hospital for the next 72 hours and advice on “red flag” features was given. Three days later, Mother and Maternal Grandmother took Baby T back to the 4.12assessment unit at St Richard’s hospital due to concerns about the way he was feeding, and he was admitted to the ward. Father joined Mother in the ward later in the day. During examinations Baby T was also found to have a (non-significant) heart murmur. There is nothing of concern in the nursing notes. The review was told that nurses would have documented if they had any concerns about any rough handling or the parents were particularly anxious about crying. Baby T was discharged home the next day. Mother has told the review that from her 4.13perspective she would have liked the opportunity to give one more feed before discharge and felt that they were being sent home due to pressure on beds. This is not the perspective of the hospital and it is impossible to verify either account. Even if this was not the intention of the hospital to ask Mother to go home before she felt ready, it is important to understand that this is how Mother recalls feeling at the time. She also does not recall being told about the heart murmur and feels that she should have received a letter about this and a follow up visit from a health professional. 3 The recent core descriptor in the health promotion guidance clearly states a requirement to discuss crying babies. Page 29 of the Personal Child Health Record lists crying babies as a discussion point at the new birth visit and there is a field to complete on the new birth visit template. 4 This was the name of the service at the time of this review, it is now known as Early Help Official: Sensitive Serious Case Review Baby T 6.2.20 Page 7 of 10 Nine days after his discharge from hospital, at 13.01, Mother called the ambulance 4.14describing Baby T as in cardiac arrest. The history given was that Mother had fed him at approximately 12.00 and Father then tried to settle him in his vibrating chair. Father had noticed that his eyes had rolled back, he was unresponsive and had stopped breathing and called Mother. Baby T was taken to the local hospital where, because of the seriousness of his condition, he was transferred to the Regional Hospital paediatric intensive care. At this stage the paediatrician believed that Baby T would be unlikely to survive but the transfer to the regional hospital would allow further investigations to take place and would give the family time to adjust. The paediatrician at the local hospital recalls Father asking on more than one 4.15occasion whether they knew what had caused the injury. This was unusual behaviour of a parent in these circumstances. There was little time to take a full history at the local hospital and a more detailed medical history was obtained by the intensive care team from the regional paediatric intensive care unit. The paediatrician from the local hospital had suspected possible non-accidental 4.16injury and when she heard about the retinal haemorrhaging she was not surprised. With hindsight she feels that she could have been clearer about her suspicions with the police when concerns about Baby T were first raised, as the police were not treating the injuries as suspicious at that stage. 4.17 Baby T died of his injuries the next day and Sussex Police began their investigation. 5 FINDINGS Finding One Preparation for parenthood needs to provide adequate opportunity for both parents to learn about the practical and emotional aspects of caring for a new-born baby and access adequate advice and support as and when this becomes necessary. No vulnerability factors were obvious and in fact, the case history outlines generally 5.1good care from community health services. There was continuity of midwifery care, midwives work closely with GPs and are located within the GP surgery. Health visitors are also located within the GP surgery. There are monthly meetings between GPs and health visitors where there is an opportunity to discuss any concerns about families registered with the surgery. All antenatal and postnatal checks were completed with opportunities to see both parents in the family home. There is the offer of one antenatal and one baby matters class. It is less clear to what extent both parents are routinely given the opportunity to 5.2discuss in any depth how to manage when babies cry and the prevention of abusive head injury. The Baby Matters sessions provide little opportunity for this as they cover several topics in a short space of time and are held on a weekday when fathers are unlikely to attend. The weekend class focuses on practical issues and only Official: Sensitive Serious Case Review Baby T 6.2.20 Page 8 of 10 Father recalls managing crying being mentioned. The Lead Reviewer has been told that practice has now developed and managing crying is now promoted as a vital aspect of health promotion. Health visitors are expected to discuss this at the new birth visit. It will be important to make sure that discussion of this sensitive topic is being embedded into day to day practice across all partner agencies as appropriate. One way in which new parents may be offered advice and support is via children and 5.3family centres. As noted in a previous serious case review within West Sussex5, this provision is actively promoted, and health visitors are charged with asking parents at ante natal and pre-birth visits whether they would like to be registered with their local centre and assisting them with registration. The take up rate for this service is 85%.6 . However, there is no centre within the town where Baby T lived, and the nearest centre is not easily accessible on public transport. This would not have been thought of as a cause for concern in this case as the extended family lived locally and were understood to be very supportive. Within West Sussex, “Family Assist” has been developed which may have been 5.4helpful in a situation where either parent was worried about caring safety for a young baby. Family Assist is an online communication and information tool and has the potential to deliver public health messages to women and families from pregnancy to 19 years. Family Assist can be used universally as it has two functions; one is the delivery of timed and relevant public health messages to those registered; the other is a web-based information platform available to all. It is promoted by the Healthy Child Programme across the county but maternity providers other than those in the west of the county have not yet signed up to the service so in those areas it is only accessed after the birth. Women and those they wish to nominate (importantly fathers) can sign up at booking 5.5with a midwife and from then the system generates e-mail communication relevant to the age of the child. It is possible to see whether e-mails have been opened and to target information as needed. The system includes a live chat function which enables families to ask for advice before difficulties escalate. In this case it may be that such a system would have provided additional advice and support although Mother was unsure whether Father would have accessed such a tool had it been available at that time. As a result of a serious case review7, a new initiative within Hampshire addresses the 5.6topic of abusive head trauma and Hampshire are promoting the roll out of ICON, a whole system approach to preventing abusive head trauma, nationally8. This is a programme of intervention based around coping with crying and is based on research into abusive head trauma which shows that crying is a known trigger, 70% of perpetrators are males and incidents increase in the first month of life with a peak at six weeks and a decrease during three to six months. These factors would seem to 5 West Sussex LSCB Serious Case Review Baby O 6 West Sussex Child and Families Centres Management Report 2017 7 Hampshire LSCB serious case review Baby U 8 https://www.hampshiresafeguardingchildrenboard.org.uk/toolkits/abusive-head-trauma/overview/ Official: Sensitive Serious Case Review Baby T 6.2.20 Page 9 of 10 be relevant to this case. The programme requires the same messages being shared with parents and carers at different stages by different professionals and has now been taken forward by West Sussex Safeguarding Partnership as a means of extending their on-line provision. They have also included “DadPad”9 which is specifically targeted as a support to fathers. Recommendation One The West Sussex Safeguarding Partnership should continue to develop a whole system approach to the prevention of abusive head trauma and evaluate progress of the tools (ICON and DadPad) that are being implemented to develop this. Finding Two It is good clinical practice to consider the possibility of non-accidental injury when a baby is taken to hospital with symptoms that might indicate they have been harmed. Vomiting is one symptom that should prompt this analysis. It is important to stress that this is not a case where there were obvious missed signs 5.7and symptoms when Baby T was taken to hospital two weeks prior to the serious incident. It is only as a result of the forensic post-mortem, that we are aware that there was an injury that predated his death. There is however nothing in the records to indicate that non-accidental injury had 5.8been considered and discounted. This would have been good practice and consideration of both medical and social factors should automatically be included in the analysis and recorded in the hospital notes. Recommendation Two Medical/health professionals should ensure that medical assessments where a baby presents with any symptoms associated with non-accidental head injury/abusive head trauma (NAHI) include a clearly documented analysis considering the possibility of NAHI. NAHI should be considered as an important cause of babies presenting with any of the following features - apnoea, seizures, vomiting, irritability/drowsiness and reduced feeding, even in the absence of any external injury. 9 https://thedadpad.co.uk/ Official: Sensitive Serious Case Review Baby T 6.2.20 Page 10 of 10 6 CONCLUSION There is nothing to suggest that the severe injuries to Baby T could have been 6.1predicted. There were no obvious signs that would have indicated that this was a vulnerable family who may need help beyond the services that would be offered to all new parents. Services were delivered to expected standards and community services exceed those found in other areas of England with, for example, one named midwife caring for the mother throughout pregnancy. There are opportunities at the local surgery for GPs, midwives and health visitors to communicate about vulnerable families, all visits expected by the Healthy Child Programme took place and the family and baby were seen within the home environment. There are opportunities to develop support services to all new parents including a 6.2specific focus on managing babies when they cry. There are also opportunities to make sure that support reaches fathers and these services are currently being developed within West Sussex. There was an opportunity to improve documentation in hospital when Baby T was 6.3admitted with vomiting and other symptoms indicative of usual childhood illnesses. This does not show that non-accidental injury was actively considered and discounted. Although conclusions and treatment may have been the same, this is an area for practice improvement. |
NC042952 | Executive summary of a review into the serious injury of 6 1/2-week-old twin babies, who were admitted to Somerset hospital and found to have serious head injuries and body bruising. Father was convicted of unlawfully and maliciously inflicting grievous bodily harm and received a sentence of 45 months' imprisonment, Mother was found not guilty of any offence. Mother and Father known to have had troubled childhoods and history of paternal mental ill health and conviction for violent offences. Family had contact with a number of services, including 7 local authority areas, 29 health agencies, 3 police forces and 7 housing authorities/agencies. A strategy discussion had been held by Somerset children's services and plans were in motion for a child protection conference at the time of the incident. Considers issues of: pre-birth assessments and rights of the unborn child; the role of police welfare checks; the need for professionals to challenge each other appropriately; working with mobile families who regularly cross organisational boundaries; and the use of research to inform practice. Makes interagency and various single agency recommendations covering children's social care, housing services, legal services, GPs and NHS Trusts and the police.
| Title: Serious case review: overview report: executive summary: in respect of Baby A and Baby B LSCB: Somerset Local Safeguarding Children Board Author: Jane Wonnacott and Gillian Earl Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Executive Summary 21.03.13 Page 1 of 27 Somerset LSCB Serious Case Review Overview Report EXECUTIVE SUMMARY In respect of Baby A and Baby B Report Authors Jane Wonnacott BA MSc MPhil CQSW AASW Director In-Trac Training and Consultancy Ltd Gillian Earl RGN RHV MA Associate In-Trac Training and Consultancy Ltd Executive Summary 21.03.13 Page 2 of 27 1.INTRODUCTIONCircumstances leading to this serious case review 1.1 Twin babies aged six and a half weeks were admitted to a Somerset hospital and found to have serious head injuries and body bruising. The babies had moved to Somerset from Nottingham with their parents eleven days previously and were living with family in the area. Both parents were arrested and charged with Grievous Bodily Harm. The result of the criminal trial was that Father was convicted of unlawfully and maliciously inflicting grievous bodily harm and received a sentence of 45 months’ imprisonment. Mother was found not guilty of any offence. 1.2 Mother and Father had received services in seven different local authority areas and had been in contact with a significant number of health providers, both during the pregnancy and following the birth of the twins. 1.3 In view of these circumstances, the chair of Somerset Safeguarding Children Board decided that the case met the criteria for a serious case review under statutory guidance1, which requires that a review should be considered where a child sustains a potentially life threatening injury and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children. 1.4 In line with national guidance, Somerset LSCB took the lead in convening the review since the babies were resident in Somerset at the time of their injuries. As information emerged that there had been significant prior involvement by agencies in other areas of the country, information was sought from the relevant organisations and they were invited to participate in the review process. This included attending panel meetings and commenting on drafts of the report. 1 HM Government (2010) Working Together to Safeguard Children London: DCSF. Chapter 8, paragraph 8.11. Executive Summary 21.03.13 Page 3 of 27 2. THE SERIOUS CASE REVIEW PROCESS 2.1 John Snell, Somerset Safeguarding Children Board Independent Chair, was appointed to chair the serious case review panel and oversee the process. 2.2 Members of the serious case review panel were: Somerset LSCB Co-ordinator Somerset LSCB Deputy Chair Service Director, Safeguarding and Care Designated Doctor Somerset and North Somerset Local Safeguarding Children Boards Designated Nurse Somerset Local Safeguarding Children Board Detective Inspector Avon and Somerset Police Principal Educational Psychologist Somerset County Council LSCB Audit Officer 2.3 Independent authors Jane Wonnacott and Gillian Earl were appointed to prepare the overview report. The authors attended panel meetings in order to ensure that the views of the panel were taken into consideration in the preparation of the final report. 2.4 Following careful consideration of the facts, full individual management reviews were requested from: • Oxfordshire County Council. • Oxfordshire General Practitioner Services. • Avon and Somerset Police. • Nottingham CityCare Partnership (Health). • Nottingham City Children’s Social Care. • Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. • Derby Hospitals NHS. • Nottingham University Hospitals. • Somerset Social Care. • Somerset GPs. • Somerset Partnership NHS Foundation Trust (formerly Somerset Community Executive Summary 21.03.13 Page 4 of 27 Health). • Derbyshire Social Care. • Somerset Health Overview Report. 2.5 Supplementary information and reports for information from organisations who had limited contact with the family were received as requested by the panel. 2.6 During the latter stages of the review process information was received from Somerset County Council Legal Department regarding the estimated timings and nature of the injuries to Baby A and Baby B. This information noted metaphyseal fractures present in both babies that were likely to have occurred sometime prior to the final serious injury. Terms of reference and scope of the review 2.7 The terms of reference for the review were agreed by the panel chair. The timescale for the review was established as beginning when Mother met Father, moved to North Somerset, and became pregnant, and ending following the twins’ admission to hospital with serious injuries and non accidental injury was established to be the most likely cause. 2.8 It was agreed that the overall aim of the serious case review process would be as described in Working Together to Safeguard Children 2010 Chapter 8, section 8.5. In addition, authors were asked to consider the earlier childhood history of each parent in order to understand the attributes they brought to parenting. Each author was also asked to assess whether any information their organisation held about either parent, outside the prescribed timescale, was relevant to any issues raised and lessons learnt. Family involvement 2.9 The Serious Case Review Panel was advised by Somerset Police that family members should not be contacted until after criminal proceedings had been completed. Letters were sent to both parents and paternal grandmother outlining the serious case review process, explaining that they could immediately submit any comment in writing to the serious case review panel. This letter was copied to the family social worker as a point of contact should the family request further explanation. Following conclusion of the trial Mother, grandmother and Father were contacted and asked whether they wished to contribute to the review. Father did wish to see the overview author and he was Executive Summary 21.03.13 Page 5 of 27 therefore visited in prison and his views sought about the help offered to the family. 3. FAMILY AND PROFESSIONAL CONTEXT 3.1 Both parents of Baby A and B are White British. Father lived in the south west region until moving to Oxfordshire and Nottingham following his relationship with Mother. Mother grew up in Derbyshire, moving to North Somerset once she began the relationship with Father; together they then moved to Oxfordshire, Nottingham and most recently Somerset. 3.2 Mother, following a troubled childhood, was living in a hostel in for vulnerable young women in Derbyshire immediately prior to meeting Father. She has several siblings, one of whom lived in the Oxfordshire area. There have been frequent suggestions that the Mother may have a learning disability but there is no evidence of any formal testing to confirm this. 3.3 Father’s childhood was also troubled, having spent time in the care of Somerset County Council as a young person. There is some evidence of mental health problems and he was also known to the police following violent incidents resulting in a number of criminal convictions. 3.4 Father met Mother when she was visiting North Somerset on holiday; she moved in with him a week later and shortly afterwards it was confirmed that she was pregnant with twins. 3.6 Following confirmation of Mother’s pregnancy in North Somerset: • Mother moved to Oxfordshire to stay with her brother, citing domestic violence from her partner. Mother reconciled with Father, was evicted from her brother’s home and moved with Father into a tent in Oxfordshire. Health, Children’s Social Care, Police and housing agencies had contact with the family at this point. • Mother and Father moved to Nottingham, moving in with a friend until they obtained their own accommodation. Nottingham Children’s Social Care, housing organisations and health agencies were all involved with the family during this pre-birth phase. Children’s Social Care completed assessments but at no time Executive Summary 21.03.13 Page 6 of 27 was the case considered by them to meet the threshold for child protection enquiries. • Mother went into premature labour ten weeks before her estimated date of delivery and was admitted to hospital in Nottingham before being transferred to hospital in Grimsby (where the twins were born) due to lack of Neonatal Intensive Care cots in Nottingham. • The twins (together with both parents) were transferred to Derby hospital’s Neonatal Intensive Care Unit, then back to Nottingham where they were discharged into the community. During their time in hospital concerns were expressed to the social worker by hospital staff about the parents’ care of the twins, however, the case continued to be assessed as falling below the threshold for child protection. • Within forty eight hours Baby A was re-admitted to hospital in Nottingham and discharged the following day. Nottingham Children’s Social Care continued to be involved at this point and liaised with Somerset Children’s Social Care once they were aware that the family were planning on visiting Paternal Grandmother in the Somerset area. • A few days later, the family moved to Somerset without telling professionals that they were leaving. According to Father, their intention at this point was to find somewhere to live where they felt safer than they did in Nottingham. • During the eleven days the family spent in Somerset a strategy discussion was held and plans were set in motion for a child protection conference. Daily visits were set up and they were visited by professionals from three services (Police, Health and Social Care) on seven occasions. A number of planned visits to the family were unsuccessful. The babies were also seen by the GP and were taken to Accident and Emergency on one occasion prior to their final admission with unexplained injuries. 3.7 As demonstrated by the above history, Mother and Father have had contact with a number of services beyond universal provision, both prior to and during the period covered by this review. This has therefore been an extremely complex review involving seven local authority areas, twenty-nine individual health agencies, three police forces and seven housing authorities / agencies. Executive Summary 21.03.13 Page 7 of 27 4. SUMMARY OF LESSONS LEARNT Protecting babies’ pre-birth. 4.1 Many of the lessons from other reviews, in relation to babies under one year, apply in this case, particularly in the pre-birth period. An important factor appears to have been a lack of understanding of the implications of a multiple birth, the likelihood that the babies would be premature and the possibility of medical complications making the babies more vulnerable. The delay in completing a robust pre-birth assessment was therefore particularly significant and resulted in over-optimism that the parents would be able to provide safe, appropriate care. Caring for twins provides a number of challenges and for these parents, with their own vulnerabilities and needs, a comprehensive pre-birth assessment should have highlighted the risks and resulted in a coherent multi-agency plan before they were born. 4.2 The issue of the right of unborn babies to protection is fundamental here. The legal and statutory definition of a child does not include the unborn and there is, therefore, a case to consider amending this definition in order to protect the rights of the unborn child. Using professional knowledge to inform assessments 4.3 There is evidence that assessments failed to identify the interaction of a number of known risk factors that should have concerned professionals. These included mental health problems, a history of violence, substance misuse, possible domestic violence and parents who had received compromised parenting themselves. These were not properly assessed and did not result in a coherent plan to protect the babies. 4.4 At no time, particularly pre-birth, were professionals explicitly utilising any frameworks to assist them in identifying risk. The PAM (Parenting Assessment Manual) assessment’s primary focus was on parental functioning and, in conjunction with a good core assessment, may well have contributed to an understanding of risk. 4.5 However, there was no core assessment and the PAM assessment was unfinished. Ward et al (2010)2 suggests that utilising a simple methodology developed by Jones et 2 Ward, H., Brown, R., Westlake, D., and Munro, E. (2010) Infants suffering, or likely to suffer, significant harm: A prospective longitudinal study. DfE Research Brief DFE-RB053 Executive Summary 21.03.13 Page 8 of 27 al (2006)3, and underpinned by research evidence, has proved a useful means of identifying which children are at greatest risk of suffering significant harm in the future. Another useful framework both pre- and post- birth is the signs of safety approach4. The explicit use of such frameworks might have assisted in the consideration within Nottingham and Somerset as to the level or risk and whether the threshold for legal intervention had been met. Daily Visiting 4.6 One response to the concerns in the case was to set up a daily visiting schedule both in Nottingham and Somerset. Any plan for daily visits needs careful consideration as, unless the purpose and limitations of the visits is clear, it may result in a false sense of security across the professional network. As this case demonstrates, it is likely that the babies had suffered during the period that visits had occurred and the visiting schedule did not prevent the final severe head injuries. In fact, it is possible that the visits themselves raised the parents’ anxieties. Where daily visiting is taking place, it is important that the purpose is made explicit to families and the professionals who are carrying them out and there are clear contingencies in place if visits are not achieved. Police Welfare Checks 4.7 Linked to daily visiting is the issue of ensuring the right people with the right qualifications and experience are carrying out tasks. For example, the police officer asked to carry out a welfare check had limited operational experience. They were asked to undertake a potentially complex task and to offer an opinion as to the health and welfare of the babies, an opinion that was likely to have been given considerable weight by others. As a result of this case and others, Avon and Somerset Police are working on a protocol which will clarify the role of welfare checks and who should be charged with carrying them out. Attendance at meetings 4.8 Other issues have emerged concerning roles within the system, including ensuring that the right people (i.e. those with direct knowledge of the parents’ capabilities) attend discharge planning meetings and the need for strategy discussions to include health personnel, particularly where there are young babies with medical issues. 3Jones, D., Hindley, N., and Ramchandani, P. (2006) ‘Making Plans: Assessment, Intervention and Evaluating Outcomes, in Aldgate, J., Jones, D., and Jeffery, C. (eds) The Developing World of the Child. London: Jessica Kingsley Publishers 4Buffa, J., and Podesta, H. (2004) ‘Partnership and Risk Assessment in Child Protection Practice Protecting Children 19 (2) 36-48 Executive Summary 21.03.13 Page 9 of 27 Professional Challenge 4.9 The need for professionals to challenge each other appropriately has been a feature of many serious case reviews. In this case there appear to have been a number of factors that prevented constructive challenge at various points, most notably during the time the twins were in hospital, post-birth. The overriding impression is that there was a reluctance to challenge social workers who were perceived to have more expertise in child protection matters. This reluctance was compounded by the communication style of one social worker. This was particularly crucial at the point of the discharge planning meeting, when it is now known that despite escalation polices within the LSCB, the disquiet of nursing staff was not conveyed to the chair. LSCBs, therefore, need to take steps to move beyond policies and procedures in this area and to examine the health of interagency relationships on a regular basis. Working with mobile families 4.10 This case has clearly highlighted the challenges associated with working with mobile families who regularly cross organisational boundaries. As well as the practical issues relating to information transfer, the review has also identified that mobility needs to be treated as information in its own right. In this case, for example, it is possible that the sudden move to Somerset may have been triggered by the parents becoming aware that there were developing concerns about their parenting. The reason for mobility therefore needs to be questioned and understood within the context of an assessment of risk. 4.11 Professionals also need to be careful not to increase mobility inappropriately, such as when Mother was encouraged to move from North Somerset to her brother’s home in Oxfordshire. Additionally, in this case, the lack of suitable neonatal intensive care cots resulted in these vulnerable babies moving through three hospitals in the first few weeks of their life. The number of moves immediately following their birth appears to have reflected the mobility of the family generally, and may have reinforced this behaviour and led them to believe that practitioners were not robustly managing the case and therefore that they should move to one (Somerset) which could meet their needs. Working with complexity 4.12 The importance of reflecting, throughout any assessment on the dynamics of family/ Executive Summary 21.03.13 Page 10 of 27 professional interaction, is evidenced throughout this review. At times the parents appeared to be engaged with professionals, drawing them in as a source of support, mainly with practical matters. On other occasions they were openly hostile although there is also evidence that they gave clear warnings to professionals that they did not feel able to cope with the babies and would have agreed to s20 accommodation. In Nottingham this option was not considered, as the focus was on the inappropriateness of using section 20 for what was perceived to be housing rather than a child protection issue. This option was again not considered in Somerset, this time because the parents were not requesting it and appeared to be coping, with support. The importance of listening to parents who, through their behaviour, are giving clear warnings that they are not coping needs to be recognised, as a failure to respond at that point may mean the opportunity for intervention is lost. 4.13 Relationships between professionals and the family were therefore complex and there is little evidence that supervision in any agency enabled professionals to reflect on the dynamics of the relationship they had with the family and the meaning of their behaviour. Staff supervision 4.14 The need for effective supervision is therefore a key lesson from this review. Effective supervision would have enabled professionals to stand back from the day to day case management, focus on the risk factors present in this case and consider their likely impact on outcomes for the babies. Effective supervision would also have focussed, whilst the babies were in Nottingham, on the dynamics of family / professional relationships as well as relationships between professionals and the impact these might be having on outcomes. 4.15 One important lesson particularly relevant within health agencies is the need to use consultation with named and designated professionals, combined with escalation processes if necessary, when there is concern regarding the actions or decisions of others within the professional network and constructive challenge has not resulted in the desired outcome. Executive Summary 21.03.13 Page 11 of 27 5. CONCLUSION 5.1 In this case, Baby A and Baby B were injured whilst living in a family situation which, when all the facts are taken into account, could have predictably led to a less than optimal outcome. Whilst the severity of the injuries could not have been predicted, there were clear signs that Mother and Father were struggling to provide the care needed by two vulnerable, premature babies. An important issue is therefore whether there were opportunities to prevent the injuries. 5.2 The most obvious opportunity was during pregnancy in Nottingham, when a comprehensive pre-birth assessment would have revealed family histories indicative of parents who, at best, would need a great deal of support to care for twins. The combination of a twin pregnancy, two vulnerable parents, Father’s history of violence and few support structures should have led to a structured assessment of risk prior to the birth. 5.3 The second opportunity to prevent the injuries was during the immediate post-birth period when both parents were giving clear signals that they were finding it difficult to cope, with the father at times being especially vocal about his concerns. A combination of a discharge planning meeting that did not include information from concerned health professionals, and a failure to really listen to what the parents were saying, both verbally and through their actions, meant that there was a focus on practical issues such as housing, rather than potential risk. Health staff remained concerned, but failed for whatever reason to escalate their concerns to senior management. 5.4 The final opportunity was following the parents’ sudden move to Somerset, when the earlier failure to conduct a full assessment resulted in a paucity of relevant information being passed to Somerset. Although the case at this point was immediately identified as high risk, again historical information that should have been available about Father, including his criminal background involving violence, was not integrated into the ongoing assessment, nor did it inform a discussion with the legal team regarding whether the threshold for legal intervention had been met. 5.5 Although there was well co-ordinated professional activity providing intensive visiting to the family at this point, it is likely that both babies had already received some injuries. It Executive Summary 21.03.13 Page 12 of 27 is possible that the final serious injuries could have been prevented by greater clarity regarding the purpose of the welfare visits and a more intrusive approach by professionals. In addition, a greater recognition and acknowledgement of the risk posed by Father might have resulted in a more proactive management of risk action plan. 5.6 The preventability of the final injuries through a differing approach to visiting in Somerset is by no means certain. The main conclusion from this review must be that the failure to prevent the injuries stemmed from the cumulative effect of a number of organisations over time, failing to: • Integrate all known information about the family. • Recognise risk, including the particular issues relating to a multiple birth. • Fully assess the impact of a parent’s own life experiences on their parenting capacity. • Work together effectively across professional and area boundaries. 5.7 It should be noted that this was a particularly challenging situation due to the number of moves, some of which were precipitated by organisations themselves. Managing such cases requires strong, effective management, supervision and support for professionals to enable them to stand back, reflect and identify risk whilst working with constantly evolving complex situations on a day to day basis. 5.8 The most important element of any review must be whether it has a positive impact on future practice. Individual management review authors have considered their involvement in this case and made many recommendations for practice improvement which have been accepted by senior managers and are in the process of being addressed. A number of additional recommendations are made by this overview report that require either a multi-agency approach to service improvement or a shared vision of good practice across LSCB member agencies. These relate to pre-birth assessment practice, staff supervision, inter-professional relationships and use of research to inform practice. It is the view of the serious case review panel that these recommendations address key issues which are at the heart of practice in this case. Executive Summary 21.03.13 Page 13 of 27 6. OVERVIEW REPORT RECOMMENDATIONS All LSCBs involved with this review are asked to consider the recommendations from the overview report, health overview report and individual management reviews relevant to their area. The chair of Somerset Safeguarding Children Board will write to the chairs of Nottingham, Derbyshire, North East Lincolnshire, Oxfordshire and North Somerset, in order to bring to their attention the findings of this review and invite them to develop and monitor action plans which will address the lessons learnt. 6.1 LSCBs should review their pre-birth assessment guidance to ensure that it highlights the particular risks that need to be considered in the case of multiple births and the need to gather and analyse all relevant historical information. 6.2 LSCBs should ensure that an audit of pre-birth assessments takes place, in order to ascertain whether they are fit for purpose, in line with the guidance and adequately analyse the potential risk to the unborn child. 6.3 LSCBs should review supervision arrangements across the partnership and establish, implement and audit a core standard for safeguarding supervision. The standard should: • Focus on the quality of supervision delivery. • Take account of differing governance arrangements, supervision cultures and organisational structures for the delivery of supervision. • Take account of Working Together to Safeguard Children (2010 para 4.51) and promote a style of supervision which: � Keeps a focus on the child � Avoids drift � Maintains a degree of objectivity and challenges fixed views � Tests and assesses the evidence, based on assessments and decisions � Addresses the emotional impact of work. 6.4 LSCBs should ask agencies to review their internal escalation and resolution processes and ensure that policies are combined with regular activity to evaluate and review the health of relationships at the front line and first line manager level. 6.5 LSCBs should review and monitor single agency or multi-agency safeguarding training strategies to ensure the promotion and embedding of relevant research, in relation to the assessment of risk and young babies, the importance of cumulative histories in Executive Summary 21.03.13 Page 14 of 27 analysing risk and working with resistant and/or mobile families. 6.6 Somerset LSCB should raise with the appropriate Government department the issue that unborn children currently do not have the same right to protection in law as children post-birth, and ask that Government child protection guidance should adequately address the rights of the unborn child. 7. HEALTH OVERVIEW RECOMMENDATIONS It is recognised that only the Somerset Local Safeguarding Children Board and partners can implement an action plan; however, it is highly recommended that these recommendations are disseminated to all NHS Clusters and Local Safeguarding Children Boards for both their consideration and implementation as standards of good practice. 7.1 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to recommend that NHS Trusts have in place, a policy for multi-agency pre-birth planning between 18-20 weeks gestation, where there is recognition of parental risk factors and/or safeguarding concerns to the unborn/newborn child • Early identification of high-risk families must include a holistic evaluation of any risk factors to unborn children, particularly where there is known domestic violence and parental mobility. • There should be recognition of the likelihood of early delivery for all pregnancies but particularly when the mother is expecting twins. • Safeguarding concerns to the new born child should be identified through holistic assessment by 18-20 weeks gestation and a multiagency pre-birth planning meeting held to develop a pre-birth plan with additional measures in place in the event of premature birth. • GP record keeping policies should require all vulnerable families’ records to be ‘flagged’ with born/unborn children. Record keeping policies should be amended Executive Summary 21.03.13 Page 15 of 27 to include unborn child in line with the Children Act 1989 despite foetuses having no legal status. 7.2 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to ensure that all health provider services have a Did Not Attend/Missed Appointment policy with reference to children where there are safeguarding concerns across all health specialities, including where children and pregnant mothers may attend. • All NHS Providers to have in place a Did Not Attend/Missed appointment policy for all health services accessed by antenatal mothers and children 7.3 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to recommend that all Obstetric/Neonatal health services should review policies to ensure clinical need, vulnerability and safeguarding concerns are included in the decision making for hospital transfer and discharge, ensuring both family history and documentation are provided in a timely manner, and there is clarity of purpose for discharge planning and strategy meetings. • When unborn infants are transferred out of area in order to access specialist neonatal care, further transfers must be limited to transfer back to the local area to promote continuity of care, information sharing and child protection planning. All transfers should be made on the basis of clinical need only. • Unborn babies/children should not be transferred to other hospitals out of area when there is no identified clinical need for this transfer. Where transfers are required for a clinical need proper documentation and transfer of full ‘social information should be made by direct telephone communication to the receiving on-call Community Paediatrician/Paediatric Consultant. If this is not received, it should be ‘chased up’. • Where there are safeguarding concerns, weekend/bank holiday discharges should be avoided if possible to minimise the involvement of staff that are unfamiliar with highly complex families, avoiding ‘start again’ assessments. There must be clarity of the status of all professional and discharge meetings with appropriate attendance from all agencies. Professionals with key Executive Summary 21.03.13 Page 16 of 27 information who consider they should attend should request an invitation. The meeting should incorporate: • good preparation • practitioners prepared and empowered to challenge decision making • good minutes including appropriate and timely distribution 7.4 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that NHS Trusts review information sharing pathways and escalation policies to ensure health professionals are clear about their duty to share information when there are child protection concerns, and the process to escalate these concerns, to include the secure and prompt transfer of information when families move out of area. • Health professionals must be clear about their duty to share information, escalate cases and refer to Children’s Social Care, if necessary, without the consent of parents where the welfare of children or UNBORN children is likely to be compromised. Designated and Named professionals should facilitate this if necessary. • There must be careful and concise sharing of concerns about parenting ability and risks to the unborn child between agencies and health services when families move areas. • All practitioners are accountable for their practice and must challenge other agencies’ decisions when required. Designated Professionals must be accessible for advice and support to assist staff to use the escalation process where there are appropriate concerns. • There must be consideration of a clear policy for prompt and secure transfer of children’s health records to the receiving authority for both children in need or subject to a child protection plan. Transfer of information through Named Nurses should also be used. • When new services are set up to provide urgent care services such as the Executive Summary 21.03.13 Page 17 of 27 acute care GP, there must be consideration of the pathways for information sharing to health visitors on attendances by children. 7.5 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that early identification of high-risk families must include a holistic assessment, targeted history taking and the evaluation of the risks and protective factors to the unborn children. • Sufficient consultation time for all health professionals should be allowed for holistic and complete history taking especially at first contact, and ‘patterns’ of behaviour and risk factors noted where there are concerns. Every effort should be made to confirm information given in a history independently and to contact/receive information from previous health workers responsible for parents, unborn babies and children, where they may be parenting concerns. • Nursing observations as to parental management skills and their behaviour is an important CONTRIBUTION to a “Parenting Assessment” but because of the artificial environment of a hospital setting cannot replace it. There needs to be clarity that such information does not form a complete formal parenting assessment as understood by other agencies. • There should be consideration of the appropriate policy for admission of children with faltering growth/neglect in specialist children hospitals to an appropriate ward with due regard to safeguarding concerns • Where parents are recorded as having “learning difficulties” early “baby handling” teaching skills should be instigated with sufficient time for reinforcement of lessons. • Professionals should expect to see and check vulnerable children and not be inhibited by parental excuses to not disturb, particularly when ‘serious neglect’ issues are identified. Executive Summary 21.03.13 Page 18 of 27 7.6 NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that all NHS Trusts review their training materials and give consideration to the need to be amended such that the learning points which have emerged are clearly embedded in professional training. 8. INDIVIDUAL MANAGEMENT REVIEW RECOMMENDATIONS Derby Hospitals 8.1 That medical and nursing staff are supported and developed by a programme of further specific training in identification of attachment issues in the NICU environment, adult risk issues, parenting assessment, recording and communication of concerns. 8.2 Safeguarding team to facilitate involvement of learning disability liaison nurse or safeguarding adult officer with LD background in cases of concern where parents have a learning disability 8.3 That Derbyshire County Council Children and Younger Adults Department review the protocol for sharing information with other Local Authorities to ensure a timely response North Lincs and Goole Hospital 8.4 To review the protocol and name of the child protection care pathway 8.5 To review the current level 3 safeguarding training to increase course content in relation to recognition and impact of parental learning disability 8.6 Develop specific child development training for staff groups working on neonatal units across the hospital sites 8.7 Develop a formal communication process for transfer / handover of care from midwifery to neonatal units ensuring the inclusion of all family / social history 8.8 Develop a timely records transfer process between midwifery and neonatal unit to ensure no loss of information Executive Summary 21.03.13 Page 19 of 27 8.9 Develop a process of parental assessment for parents of children on neonatal units NHS North Somerset 8.10 Safeguarding Training for all GPs to encompass their role as gatekeepers of information, and that they need to take a more holistic view of patients as parents. 8.11 GP training is audited on an annual basis 8.12 Pre-birth planning arrangements are audited Nottingham Support Service 2 8.13 All Access Point staff undertake in house safeguarding training Nottingham Support Service 8.14 Work between agencies to be further examined internally and areas for improvement identified 8.15 Handling of complaint: there is evidence to indicate that communication between the social worker and manager was good through the investigation and the complaint was resolved to everyone's satisfaction. However, records of the contact could be better, which needs to be addressed with manager of Nottingham Support Service 1. 8.16 Contact following on from the complaint was with the manager but records are not clear. This will be addressed with manager Nottingham University Hospitals NHS Trust 8.17 Complete the planned update of the existing Trust policies (Safeguarding Vulnerable Adults; Mental Capacity Act) 8.18 Update the In-utero Transfer Guideline to include safeguarding 8.19 Update the Trusts Transfer & Discharge policy to include safeguarding 8.20 Have a debriefing meeting between NUH and Social Care once the SCR is completed Executive Summary 21.03.13 Page 20 of 27 to identify lessons learned regarding the interagency relationship 8.21 At that meeting it should seek solutions to the need for formal communication regarding risk issues, particularly category and severity, between Social Care and NUH 8.22 Produce guidance clarifying roles and responsibilities for ward staff regarding parenting observation and assessment 8.23 Ensure that all staff attend safeguarding training according to Trust Policy 8.24 Ensure that the nature of the individual’s safeguarding responsibility is reviewed at annual appraisal (appraisers therefore need to be trained accordingly) 8.25 Re-emphasise the need of internal escalation to the responsible consultant when there are safeguarding difficulties 8.26 Ensure that the staff who attend Discharge planning meetings are the appropriate staff and that they understand their role and understand that the organisation should support discharge only when it is satisfied that a satisfactory plan is in place 8.27 Ensure that where care is provided at home by NUH staff that there are clear roles and responsibilities in place for escalating safeguarding concerns 8.28 Ensure that the staff of the Family Health Directorate, have Learning Disabilities training 8.29 Continue its current work on Information Governance and address this issue particularly with the Family Health Team 8.30 The Family Health Directorate should work with their neonatal consultant team to review how they discharge their responsibility on the postnatal wards for babies with social concerns which are often outside the overview abilities of medical registrars 8.31 The Family Health Directorate should ensure that the feeding charts identify who has fed and provided care to babies on our wards Executive Summary 21.03.13 Page 21 of 27 8.32 The Family Health Directorate should emphasise to its ward managers their oversight role in cases of complex social issues, in particular where non-registered staff have been involved 8.33 The Family Directorate should re-emphasise the importance of adhering to policy for parents being resident of the wards 8.34 The Family Health Directorate should work with the Obstetric team to review how the outcome of referrals to the perinatal mental health team is communicated to the mother’s NUH record 8.35 The Family Health Directorate should re-emphasise to its staff the importance of adhering to its In-utero transfer policy with respect to completing incident forms 8.36 The Safeguarding team should address training issues in those areas where communication with them was not timely 8.37 The Safeguarding documentation should be reviewed to ensure that the paperwork supports ready access to the correct “Risk” Information 8.38 ED should explore what processes they have in place to deal with patients who present with complex social issues and are not already known to Social Care locally 8.39 The Family Health Directorate should ensure that there is appropriate advise/support given to the Safeguarding Team should issues arise that they cannot manage. Nottingham CityCare Partnership 8.40 Nottingham CityCare Partnership will arrange training for frontline staff in relation to Parents with Learning Disabilities and the impact upon children. 8.41 The Nottingham CityCare Partnership Named Nurse for Safeguarding Children will ensure that all the Safeguarding Children Nurse Specialists and the Domestic Abuse Nurse Specialist in the Safeguarding Children Service are fully aware of the Escalation Process where there may be immediate concerns for the safety and well being of a Executive Summary 21.03.13 Page 22 of 27 baby, child or children and know what immediate action to take 8.42 A review of the Escalation Process by Nottingham City Safeguarding Children Board Nottinghamshire Healthcare NHS Trust 8.43 That the ‘trilogy of risks’ are added to the screening tool for post natal depression 8.44 That the Trust’s DNA policy is used in all directorates 8.45 All Perinatal Mental Health Practitioners have a knowledge of the usage of the CAFs Nottingham City C&F 8.46 Where families have been known to previous local authorities, Social Care Team managers will ensure that background information is sought from those authorities prior to authorising a Core Assessment 8.47 In the case of pre-birth assessments where there are identified safeguarding risks / indicators, an initial planning meeting to commission the assessment must be chaired by a CTM or a CSCTM. This meeting should allocate key tasks, record risks and identify the timescale and review process. 8.48 All contact with a Service User, even via text message, will be recorded and form part of the child’s case file 8.49 An electronic recording system is developed for the Family Community Teams which complements and has a clear interface with the social Care Carefirst and Castle systems. 8.50 Supervision case discussion records will be amended to include a section on ‘current assessment of risk, if any’. 8.51 All discharge planning meetings will consider a current assessment of risk 8.52 Social Care will develop a policy regarding highly mobile families Executive Summary 21.03.13 Page 23 of 27 8.53 The outcome of a CRIMMs check will be copied directly to the team manager who must make a written acknowledgment on the file that he/she has read the contents and a managerial view of risk. 8.54 Training is developed in respect of pre-birth planning and rolled out across social care and family community teams. 8.55 Concerns about individual issues of competence should be addressed within the appropriate line management arrangements. Oxfordshire Health NHS Foundation Trust 8.56 To improve the level of knowledge regarding Child Protection processes for General Practitioners 8.57 To improve communication between Midwifes, General Practitioners and Health Visitors 8.58 To formalise the process to follow up complex / high risk pregnant women who do not attend appointments / move out of area 8.59 Social Services telephone calls to be managed by the respective Named General Practitioner 8.60 Improved use of General Practitioner codes and flagging system 8.61 To ensure that all staff working in a PHCT have received a commensurate level of Safeguarding training 8.62 To ensure that the correct advice is given to patients who present as ‘homeless’ Oxfordshire County Council: Children, Education and Families Directorate 8.63 Domestic Abuse training and guidance is reviewed to ensure that the cycle of abuse and reconciliation is adequately reflected and that an understanding of reactions to abuse are included. 8.64 The ‘pre-birth referrals’ procedures and protocol for children moving across boundaries are reviewed and updated to ensure that pre-birth cases are referred quickly and not Executive Summary 21.03.13 Page 24 of 27 held open without active assessment or support being provided . 8.65 Where a third party moves in to a household where there is active CEF involvement guidance is developed to assist practitioners in knowing when to refer to the assessment team. 8.66 An audit and dip sample of referral recording and address checks is undertaken . 8.67 CEF to explore how the relevant aspects of the course ‘Principles of learning disability support’ can be delivered to CEF staff. Thames Valley Police 8.68 Thames Valley Police to review the initial training of PCSOs to ensure the inclusion of guidance on how to correctly record and refer (internally) safeguarding concerns. 8.69 Thames Valley Police to circulate a bulletin to PCSOs containing guidance on how to correctly record and refer (internally) safeguarding concerns. 8.70 Thames Valley Police to review their Domestic Abuse Policy and Operational Guidance to ensure sufficient guidance is provided in relation to what may constitute an ‘incident’. (Any changes to be published) 8.71 Thames Valley Police to issue a bulletin to the Domestic Abuse and Child Abuse Units reminding them to create a CEDAR record whenever an intelligence report results in further Police action and in particular a referral to another agency. 8.72 Thames Valley Police to review the management of intelligence reports once received within the Child Abuse Investigation Units, Domestic Abuse Units and by the Vulnerable Adult Co-coordinators to ensure compliance with the ‘Management of Police Information’ guidance in terms of creating an audit trail. 8.73 Thames Valley Police to review their Child Abuse Investigation Policy to ensure it contains reference to the importance of considering the welfare of unborn children. (Any changes to be published) Executive Summary 21.03.13 Page 25 of 27 Somerset County Council Children and Young People’s Directorate 8.74 If another local authority or agency requests a welfare visit or other task, expectations for this visit or task should be agreed and sent out in writing. 8.75 Somerset Direct (SD) should always advise the caller of the secure email facility. 8.76 Somerset Direct should always clearly identify advisors by their full name, whilst ensuring personal security. 8.77 Somerset Children's Social Care should have clear guidance relating to failed home visits including contingency and reporting arrangements. 8.78 Somerset Children's Social Care, in conjunction with LSCB partners, should set out clear criteria relating to welfare visits specifying roles and responsibilities. 8.79 Somerset Children's Social Care should in consultation with partners clarify: ●When a strategy meeting must be face to face ●When it is appropriate to have a telephone conference ●When a respective specified agency (e.g. health) must be included in the strategy. 8.80 Somerset Children’s Social Care, through the Somerset LSCB, to share the above with the South West procedures group as examples of good practice. Avon and Somerset Constabulary 8.81 All ‘Welfare checks’ should be carried out be qualified Child Protection professionals with police attendance reserved for occasions only where police powers are required. 8.82 Where 5.1 is not possible, by virtue of the fact an emergency check is required, a strategy discussion should take place between a CAIT supervisor and the agency before the checks are carried out. The risks can then be analysed and a considered plan agreed prior to the visit taking place. The officer attending should ideally be a CAIT officer; if another member of staff attends they should receive a briefing direct from the CAIT supervisor. The results of the visit should then be subject of a further strategy discussion. Executive Summary 21.03.13 Page 26 of 27 8.83 Protocol agreed between Social Services and police to reflect procedures to follow in the event of emergency checks being required by police. 8.84 ISO procedure to be introduced into Force Communications to reflect an appropriate response to such requests in the future. 8.85 All Avon and Somerset Constabulary staff likely to come into contact with the public to receive appropriate child protection training, including risk indicators of abuse. This should be by delivery of the existing NCALT training module in the first instance. 8.86 Where a need for an Initial Child Protection Conference is highlighted there should be ability to fast track those where children are at most risk. 8.87 All police contact with children about whom there are concerns should be reflected in a comprehensive intelligence report that should be submitted in a timely manner and shared with CAIT staff for analysis. Taunton and Somerset NHS Foundation Trust 8.88 Clinical case to be used in the Trust ongoing Safeguarding training programme. 8.89 Recommendations from this SCR to be incorporated into Trust Safeguarding procedures and audit programme as appropriate. 8.90 Learning from this SCR to be used Trust ongoing Safeguarding training programme. Somerset County Council Legal Services 8.91 Submit e-mail to every lawyer within the Social Care team, strongly urging them to maintain a record of any conversation with client(s) where it could be construed that legal advice has been given (even if no matter subsequently arises as a result of that advice). 8.92 Message to instruct that where such records are created, they should be added to the Norwel case management system on every occasion in the event that a legal matter does arise (i.e. the Service is formally instructed to take further action). Executive Summary 21.03.13 Page 27 of 27 8.93 The format of any such record is to be at the discretion of the lawyer providing the advice, provided that it clearly details any recommendations provided, even if that recommendation is to take no further action at the time. The recommended (but not mandated) format is an e-mail to the recipient of the advice as soon as is practicable after the event. Somerset Partnership NHS Foundation Trust 8.94 A review of the processes currently in place to ensure professional records of high risk cases are transferred swiftly between organisations must take place. Consideration must be given to how information from outside Somerset is obtained in order to guarantee the seamless provision of key services to families; consistently delivered, ensuring children remain safeguarded. 8.95 A Significant Event Audit meeting should take place with the health visitor team involved in this case. The Area Manager, Locality Safeguarding Children Nurse and Named Nurse should attend to discuss all the issues in this case and to identify any individual learning required from the individuals involved. 8.96 The lessons learnt from this review must be disseminated to the individuals concerned, the health visiting team and the wider organisation, illustrating the concerns identified and reiterating best practice processes. The relevant local and national policies and guidelines should be referenced and their usage reiterated to all staff. |
NC045050 | Serious injury of a 4-year-old girl of mixed heritage, in March 2013. Zara was admitted to hospital suffering from stomach pains. Ruptures to her duodenum, thought to be non-accidental, were identified following surgery. Criminal charges have been brought against suspected perpetrators (not mother). Maternal history of challenging behaviour, drug misuse, social isolation, financial problems and homelessness. Paternal history of drug misuse, prolific offending and imprisonment. Family were known to a number of agencies, including children's social care, housing services, police and probation services. Approximately a year prior to the incident, mother was the victim of what the Police described as a racially aggravated common assault, which included a threat to burn mother's flat down with Zara inside. Issues identified include: mother's intelligence, unusually good level of education and articulacy diverting the attention of professionals; insufficient exploration of the impact of ethnic, cultural and religious factors; assessments being treated in isolation leading to a limited understanding of cumulative risk; and insufficient exploration of the significance and impact of father. Uses some elements of the Learning Together methodology. Makes recommendations, covering early years services, schools, children's social care, health visiting, housing and rent collection services, probation, hospitals and GPs.
| Title: Serious case review: ‘Zara’. LSCB: Wandsworth Safeguarding Children Board Author: Fergus Smith Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CCOONNFFIIDDEENNTTIIAALL WWAANNDDSSWWOORRTTHH SSAAFFEEGGUUAARRDDIINNGG CCHHIILLDDRREENN BBOOAARRDD SSEERRIIOOUUSS CCAASSEE RREEVVIIEEWW ‘‘ZZAARRAA'' July 2014 Contents 1 INTRODUCTION 1 1.1 Detection of injuries to Zara & response of the Local Safeguarding Children Board (LSCB) 1 1.2 Arrangement of the overview 2 2 REVIEW PROCESS 3 2.1 Relevant agencies 3 2.2 Timetable for serious case review 3 2.3 Conduct & critique of process 4 2.4 Family details 7 3 AGENCIES’ CONTACT WITH FAMILY PRIOR TO REVIEW PERIOD 10 3.1 Introduction 10 3.2 Mother’s final year of education: 2007/08 10 3.3 Ante-natal period May- December 2008 14 4 PERIOD OF REVIEW: BIRTH TO CRITICAL INCIDENT 18 4.1 Introduction 18 4.2 1st year of Zara’s life: December 2008 – December 2009 18 4.3 2nd year of Zara’s life: December 2009- December 2010 22 4.4 3rd year of Zara’s life: December 2010- December 2011 26 4.5 4th year of Zara’s life: December 2011- December 2012 30 4.6 5th year of Zara’s life: December 2012 - incident in March 2013 34 5 ANALYSIS 37 5.1 Introduction 37 5.2 What were the key relevant opportunities for assessment? if opportunities were missed please state what they were & your understanding of why they were missed. 37 5.3 Was consideration given to the impact of cultural / racial & other equalities issues in any assessments? 40 5.4 Do assessments & decisions appear to have been reached in an informed & professional way? 41 5.5 Did actions accord with assessments & decisions made? 42 5.6 Were appropriate services offered / provided or relevant enquiries made, in light of assessments? 44 5.7 Were practitioners aware of & sensitive to the needs of the child in their work? How did practitioners establish the child’s view about what was happening in her life & how was this recorded? 46 5.8 Were professionals knowledgeable about the potential indicators of abuse or neglect & about what to do if they had concerns about a child’s welfare & was this evident in their practice? 48 5.9 Were senior managers or other organisations & professionals involved at points in the case where they should have been? Was there sufficient management accountability for decision making? 50 5.10 Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisation? there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave impact on the case 52 5.11 Did the organisation have in place policies & procedures for safeguarding & promoting the welfare of children & acting on concerns; was the practitioner aware of their existence & Was the work in this case consistent with each organisation & the WSCB’s policy & procedures for safeguarding & promoting the welfare of children, & with wider professional standards? 53 5.12 Additional case-specific issues 54 5.13 Missed opportunities for best practice 60 6 CONCLUSIONS 62 6.1 Introduction 62 6.2 Findings 62 Good individual practice 62 Sub-optimal systems 62 6.3 Predictability & preventability 63 7 RECOMMENDATIONS 64 8 GLOSSARY OF ABBREVIATIONS / NAMES 68 9 BIBLIOGRAPHY 70 1 1 INTRODUCTION 1.1 DETECTION OF INJURIES TO ZARA & RESPONSE OF THE LOCAL SAFEGUARDING CHILDREN BOARD (LSCB) 1.1.1 At the time of the incident in March 2013 that triggered this serious case review (SCR) child Zara was a four year old female of dual heritage (White / Black Caribbean) living in social housing with her twenty one year old White British single mother. 1.1.2 Zara was admitted to the local hospital suffering from stomach pains and vomiting. Following extensive surgery, two ruptures to her duodenum (the short part of the small intestine connecting it to the stomach) were discovered. During surgery, Zara experienced cardiac arrests and required life-saving resuscitation. The injuries were believed by attending surgeons to be the result of trauma. Criminal charges have been brought against suspected perpetrators. 1.1.3 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 (SI 2006/90) requires LSCBs to undertake reviews of serious cases in accordance with the principles set out in Working Together to Safeguard Children HM Government 2013. A serious case review (SCR) must be initiated when abuse or neglect of a child is known or suspected and either the child has died or has been seriously harmed and there is cause for concern as to the way the authority, LSCB partners or other relevant persons have worked together to safeguard the child. 1.1.4 Its purpose is: To establish what lessons can be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children To identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result and As a consequence, improve intra and inter-agency working and better safeguard and promote the welfare of children 1.1.5 Following consideration by the ‘Serious Case Improvement and Learning Sub-committee on 24.04.13 and 02.05.13, members concluded the case satisfied the criteria for a serious case review. This recommendation was put to and agreed by the independent chairperson of Wandsworth’s Local Safeguarding Children Board (LSCB) immediately after the second meeting and the Department for Education (DfE) was subsequently informed. 1.1.6 On 12.09.13 Zara’s mother was informed of the initiation of this SCR and her involvement in its conduct sought as described later in this report. Zara’s birth father (currently in prison) was also informed and invited to comment on services provided to his daughter. 2 OVERVIEW AUTHORSHIP & CHAIRING OF SCR PANEL 1.1.7 An independently authored overview report was commissioned from CAE Ltd (www.caeuk.org) (a social work consultancy with experience of over fifty SCRs). It was agreed that upon submission of all relevant material, author Fergus Smith would, in accordance with the detailed terms of reference appended to this report: Collate and critically appraise all individual management reviews (IMRs) and other documents Develop for consideration by the panel, an analysis, conclusions and recommendations for action by Wandsworth’s Safeguarding Children Board, member agencies and (if relevant) other local or national agencies 1.1.8 The SCR panel was chaired by the independent chairperson of Wandsworth’s Safeguarding Children Board (Ms Nicky Pace) and the panel consisted of professionals with expertise in Health (health visiting and GP), Education, Children’s Social Care, Police and Housing. 1.2 ARRANGEMENT OF THE OVERVIEW 1.2.1 In an attempt to render more accessible what is a significant amount of detail, the remainder of the report is laid out as follows: A description and commentary on the effectiveness of the methodology adopted and conduct of the SCR Family details including a genogram of relevant family members A more detailed chronological account of agencies’ involvement with the family during the review period, highlighting key events and professional decisions An analysis of the extent to which records demonstrate best practice with respect to the issues in the terms of reference Overall findings and conclusions Practical recommendations for the LSCB and member agencies that are specific, measurable, achievable, realistic and timely A glossary of abbreviations A bibliography of general and case-specific literature of relevance 3 2 REVIEW PROCESS 2.1 RELEVANT AGENCIES 2.1.1 The following agencies were identified as having or likely to have information and opinions of relevance to the serious case review: Wandsworth Education & Early Years Service (providing secondary education and education welfare services to mother and nursery provision for Zara) Wandsworth Children’s Social Care (initial and other assessments, ‘ad hoc’ responses and inter-agency liaison) St George’s Healthcare NHS Trust (health visiting services ) Wandsworth Housing (provision of tenancies & tenancy support) Wandsworth Rent Collection Service (a part of the Finance Department responsible for pursuing tenancy-related debts) Chelsea & Westminster Hospital (provision of midwifery and paediatric A&E and urgent care centre services) London Probation Trust (completing offender assessments and pre-sentence reports on Zara’s father) Metropolitan Police Service (investigating crimes committed by Zara’s father and mother and notifications of incidents involving potential risk to a child) GP Practices (providing community based medical services) 2.2 TIMETABLE FOR SERIOUS CASE REVIEW ORIGINAL & REVISED 2.2.1 The SCR panel agreed a clear timetable which was later adjusted. Actual achievement of each specified task is (where dates differ from the original) shown in parentheses: 20.06.13: Sub-committee planning meeting with IMR and overview authors to agree membership and dates for meetings 01.07.13: Chronology from each involved agency to be submitted to SCR co-ordinator (MPS chronology received on 10.01.14) 09.07.13: Integrated chronology for panel members (22.08.13, updated 04.09.13, 20.09.13, 26.09.13 and a final version including Police entries provided on 10.01.14) 16.07.13: Set-up meeting with IMR and overview author to decide on ‘key lines of enquiry’ and revise the terms of reference 19.07.13: Learning exercise 1 with practitioners 19.08.13: Draft 1 IMRs to be submitted to co-ordinator (27.08.13 for all but Housing which arrived on 29.08.13 and Police on 21.02.14) 4 05.09.13: ‘Challenge meeting’ for panel to consider IMRs submitted by that date (05.11.13) September: Overview author to meet with parent/s (deferred pending receipt of final IMRs – father seen in November and telephonic contact with mother in February 2014 respectively) 23.09.13: Final IMRs to be submitted to co-ordinator (St George’s Hospital & Early Years Service, Housing including tenancy support + Rent Collection Service and health visiting all on 30.09.13, Probation & Chelsea & Westminster received 03.10.13; Clinical Commissioning Group 09.10.13, and a final MPS IMR on 27.02.14) 30.09.13: ‘Sign off’ of IMRs and discussion of a ‘draft 1’ of an overview (05.11.13; 26.03.14) 14.10.13: Learning exercise 2 with practitioners (postponed until 21.11.13, 28.02.14, 15.05.14 and finally held 11.06.14) 11.11.13: Draft 2 overview report to be submitted (was to be 29.11.13, 19.03.14 and became 04.04.14) 21.11.13: Executive of LSCB to sign off overview and support recommendations to the LSCB (05.12.13 and became 14.07.14) Publication of final version (due December 2013, will be after conclusion of criminal proceedings November 2014) 2.2.2 Following discussion at the panel it was determined that reports from the two Housing Associations would be useful and these were made available in mid-February. It became apparent that their value was seriously limited. Apparently archived records were no longer available and the accounts provided had been written largely from the memories of individuals. For that reason, those reports have not been used and a recommendation about the need to ensure the production and retention of professional records amongst commissioned service providers has been included in section 7. 2.3 CONDUCT & CRITIQUE OF PROCESS TRANSPARENCY 2.3.1 The SCR panel was clear from the outset that in order to maximise learning opportunities, make agencies’ self-examination transparent, and to satisfy the legitimate right of the public for professional accountability, the final overview report would be published in its entirety. 2.3.2 This report therefore provides a comprehensive account of events and professional actions, though details about people and places that would lead to the identification of individuals in the family or within involved agencies have been minimised. 5 METHODOLOGY 2.3.3 The panel determined that its approach would incorporate some elements of the ‘Learning Together’ methodology currently being promoted by the Social Care Institute for Excellence. Thus, in advance of drafting IMRs, an early meeting with involved practitioners was convened and their perspectives on roles played and the context within which they were operating were sought. 2.3.4 Following debate amongst panel members about the IMRs received and the development of some tentative conclusions, a follow-up meeting with practitioners was held and helped to refine the final conclusions and recommended service improvements. SCOPE OF REVIEW & QUALITY OF PROCESS 2.3.5 Aside from adding authenticity to the retrospective examination of services, closer involvement of staff in the SCR served to facilitate an appreciation of the need for and commitment to required changes. In the author’s view, the value of the first meeting with involved staff would have been greater if panel members had been as informed then about the case as they subsequently became. 2.3.6 In the light of what was known about child Zara and her family, the span of the SCR was appropriate. The terms of reference (each element of which is addressed in section 5) also explicitly allowed for the possibility of an agency addressing any event that fell outside of the defined review period. 2.3.7 The integrated chronology of all agencies’ contacts was very well presented and the standard of final versions of individual management reviews generally good, though the variation in some from established terms of reference rendered aggregation and comparison more difficult. The final draft of the health visiting IMR remains difficult to interpret reflecting a confusion in the period under review about which health visitors were responsible, difficulties in transition from paper-based to electronic records, organisational re-structuring and the introduction of ‘corporate case loads’. 2.3.8 The SCR process was delayed but not otherwise reduced in value by significant resource difficulties within the Police Service which meant that its chronology and IMR were made available considerably later than all others. 2.3.9 All the IMRs were written by sufficiently independent and suitably experienced authors who based their reports on relevant records and when necessary, interviews with specified staff. Initial versions of chronologies lacked sufficient detail and premature and different ascription of anonymised labels for professionals in some reports made it difficult to determine identities. Following confirmation of names and roles, a common nomenclature has been used in this overview. 6 FAMILY INVOLVEMENT Mother 2.3.10 Zara’s mother was informed in person by Wandsworth’s head of safeguarding that a SCR was being conducted and was invited to meet with the overview author. An offer to meet was emailed in October and a further reminder sent in November. An email response was received in early December and a provisional arrangement made to meet in early 2014 by which time it was anticipated the final overdue IMR would have become available. 2.3.11 Liaison with the Police senior investigating officer (SIO) ensured that the focus of discussion with Zara’s mother was on services received. Subjects that might generate evidence for the ongoing criminal investigation were avoided 2.3.12 On two occasions the author travelled some distance to a pre-arranged venue chosen for its convenience to Zara’s mother. On both occasions, Zara’s mother when contacted, reported that she had ‘forgotten the appointment’. Further negotiations via email established that mother would make herself available for a discussion by phone. Four calls were made at agreed times and none answered. Messages were left. Finally in mid-February, mother initiated a call and spoke at length to the author. Her memories and opinions are woven into the narrative at relevant places. Father 2.3.13 The father of Zara is serving a long custodial sentence for numerous offences unrelated to Zara’s injuries which were committed during the period when he and the mother Zara were intimate partners. He agreed to meet and provide his perspectives. At that meeting Zara’s father confirmed that his relationships with Zara’s mother and (he reported) his daughter are over. 2.3.14 Father confirmed what records indicate i.e. although in an intimate and ongoing relationship with her, he had not co-habited with mother. The pregnancy in 2008 was unplanned but he said, was welcomed by them both at the time. Zara’s father reiterated what he had previously claimed to a probation officer viz: that the birth of Zara was sufficient incentive to give up use of cocaine. 2.3.15 Father indicated that because they had never lived together and because he kept his criminal activities hidden from his own and from Zara’s mother, he had never met any professionals such as midwives, health visitors, housing personnel or social workers. Thus, he was unable to comment on any services that may have been offered or provided. He was able to confirm that Zara’s mother spent significant time with his mother. 7 2.3.16 Father did indicate that he was wholly unaware of any threat from gangs perceived by his ex-partner and assumed that any such claims might have simply reflected her wish not to be housed in certain areas. 2.3.17 Father (whose name appears on Zara’s birth certificate and who in consequence has parental responsibility) was keen to have sight of a copy of the published report. Security considerations at his prison preclude accessing the Wandsworth LSCB website so the author undertook to seek agreement to father being given of a copy of this report. Confirmation that such an arrangement would, in due course be made, was relayed back to father by the Probation Service. Zara 2.3.18 Zara was adjudged to be too young to contribute directly. A conversation with her foster carer provided a glimpse into her formative experiences and how they may have impacted upon her presentation and performance. 2.3.19 Zara was described by her carer as a bubbly, confident, inquisitive and affectionate child who relates well to other children and to adults. She still relates more readily to younger men than to older ones with whom it appears a degree of mistrust remains. Zara has begun to speak more openly about the reality of living with her mother and of ‘being hurt’. 2.3.20 An unsurprising wish to be with her mother and yet to be safe is illustrated by Zara’s recent and touching proposal that her mother moves to the carer’s home and that they all live together. The child has coped well when, on several occasions, mother has failed to attend the supervised contact and instead, members of the extended family have come in her place. 2.3.21 Zara has a memory and (according to her mother) affection for her birth father. She has described visiting him ‘in a castle’ (possibly a reference to Wandsworth Prison where he spent time on remand). 2.4 FAMILY DETAILS Name Gender Relationship Year of birth Ethnicity Child Zara Female Subject 2008 White / African Caribbean Female Mother 1991 White Male Father 1983 White / African Caribbean Male Maternal uncle Not known White Addresses Actual / estimated dates 1. Mother: with MGM Wandsworth 2.Mother: with MGM Early 2008 :Pimlico Westminster 3. Mother: short-term emergency B&B 17.01.08 -21.01.08 Wandsworth 4. Mother: own unknown accommodation 21.01.08 may have been at MGM where she was located by 08.02.08 (deduced) 5. Mother: 2nd short-term emergency B&B 19.03.08 – 13.04.08 Wandsworth 6. Mother: temporary accommodation specialist supported housing for 16/17s 14.04.08 – 01.06.08 Wandsworth 7 Mother: Housing Association medium level 02.06.08 – 19.04.09 (abandoned because of ‘mice 8 support mother & baby Unit infestation’ triggering formal notice to quit) 8. Mother & Zara at MGM address 19.12.08 – January 2009 9. 2nd Housing Association high level support mother & baby teenage parent unit 26.03.09 – 23.05.10 prior to awaited permanent accommodation - actually on/off with PGM and awaiting a ‘move to Tooting’ according to mother 10. Mother & Zara: permanent 2 bed flat 24.05.10 – 25.11.13 [current address unknown] 9 Father of Zara Child Zara Boyfriend of Zara’s mother ? 2 Maternal grandfather MGF PGF Maternal grandmother MGM PGM Paternal aunt Mother of Zara Maternal uncle 1 3 10 3 AGENCIES’ CONTACT WITH FAMILY PRIOR TO REVIEW PERIOD 3.1 INTRODUCTION 3.1.1 The terms of reference allowed for the possibility that a number of agencies held historical information about Zara’s mother. It was felt that they might, in combination, offer a useful background picture of relevance in evaluating the support services offered to child Zara and her still very young mother. 3.1.2 Thus, section 3 offers a summary of the period from Zara’s mother first coming to the attention of Wandsworth agencies through to the period of formal review i.e. Zara’s birth to the incident in March 2013 that triggered the SCR. 3.1.3 The author’s comments on a number of individual events or decisions are provided in italicised paragraphs. Section 4 aggregates these and addresses and analyses a wider range of issues. 3.2 MOTHER’S FINAL YEAR OF EDUCATION: 2007/08 3.2.1 Having been privately educated at an independent boarding school located outside of London (school 1) for several years, mother was withdrawn in late 2006 reportedly because of a financial crisis in the family. Mother confirmed to the author that this event thrust her ill-prepared into a tougher environment than that to which she was accustomed. Her personal resentment of the parents’ decision was magnified because her sixth form brother was allowed to remain at the school. 3.2.2 An application to a local school was initially unsuccessful because there were no vacancies in the relevant year group. A second application in June 2007 succeeded. Though reports from school 1 had been positive, there were within weeks, reports of challenging conduct e.g. illicit smoking and in the Autumn, lateness, a failure to work, poor attitude and low attendance (only 75% in the final term of 2007). Mother described examples of ill-discipline at the school and a frightening sense of ‘survival of the fittest’. In retrospect she feels that she coped by lowering her standards of conduct to that of the worst around her. 3.2.3 The Wandsworth Early Years & Education IMR refers to involvement at this time of a member of the Youth Offending Team YOT1 (who mother has stated was much valued) seconded to the ‘Battersea Early Intervention Team’. 3.2.4 Offers of support, offer of part-time schooling and a warning letter about court action for non-school attendance seem to have made little difference. A local alternative education provider was considered and after initial uncertainty mother said she would attend. Fulfilment of her apparent agreement later became contingent upon a named friend also being allowed to accompany her. 11 MOTHER’S INITIAL CONTACT AT MEDICAL CENTRE 1: 3.2.5 A review of earlier paper records held by the GPs revealed nothing of note from her own earlier childhood and the first relevant contact was in late October 2007 when Zara’s mother (then aged 15 years 10 months) was taken to medical centre 1 by her own mother (Zara’s maternal grandmother, hereafter referred to as MGM). 3.2.6 MGM was concerned about her daughter’s reaction to imminent parental divorce. She reported her missing school, staying out late and presenting challenging behaviour. Zara’s mother acknowledged past sexual activity though denied that she was sexually active at the time of her presentation to GP1. 3.2.7 GP1 initiated a referral to the local Child and Adolescent Mental Health Service (CAMHS) (where the young woman was placed on an eleven week waiting list) and to Wandsworth Children’s Social Care. Comment: the referrals and her initial follow up suggest a doctor sensitive to this adolescent’s psychological and social needs. The waiting period was long but not unusually so. 3.2.8 In mid-November 2007 mother was reported by her mother as ‘missing’. She had left for school but failed to attend. After some text communication with MGM indicating that she was safe but unwilling to disclose her location, mother returned safe and well of her own accord two days later. Police officers had made routine enquiries and subsequently conducted an un-informative de-brief upon her return. 3.2.9 In the late evening of the day of her return, mother again walked out and within minutes had (she later admitted) stolen from MGM’s account in a local cash machine. MGM did not wish to pursue a prosecution and mother returned home next day. 3.2.10 In mid-December 2007 a letter from the local authority warning of legal action consequent on poor school attendance was sent to MGM (attendance in early 2008 was only 37%). 3.2.11 Zara’s mother failed to attend any of three CAMHS appointments, or to respond to follow-up letters sent after each. In February 2008, following discussion and agreement with her then social worker, a letter confirming case closure was sent to her and to the GP. Upon receipt of her letter, mother made an appeal (which was accepted) to keep her case open. 3.2.12 Children’s Social Care had responded to GP1’s phone referral by deploying an ‘initial contact worker’ (ICW1) who in turn initiated contact with the MGM. The MGM went on to report her daughter as missing on two occasions in late 2007. MGM believed she was using harder drugs in addition to an acknowledged use of cannabis. MGM also reported the fraudulent use of her debit card by her daughter. 3.2.13 Information gathered during this period referred to the brother still at boarding school and to an aunt with whom Zara’s mother was ‘close’ but (according to mother) drank to excess. The young woman also referred to a fear of her father though why remained unexplored. Comment: the issue of mother’s stated fear of her father may have been an important missed opportunity to better understand her needs. That said, in her conversation with the author, mother has no recollection of this disclosure or why she might have made it. 12 3.2.14 The case was transferred to the ‘Diversion from Care’ team with a recommendation of a core assessment (an in-depth assessment of family functioning and significant environmental factors). Some assessment was undertaken but apparently not written up. Allocated SW1 in consultation with team manager TM1 planned work around housing, liaison with other agencies and a referral for a family group conference. A planned case closure in consequence of mother’s lack of engagement was postponed in response to a request from MGM for the team to remain involved. Comment: reasons why no core assessment was completed or why medical centre 1 received no feedback from its referral, have not emerged from the Children’s Social Care IMR. Mother’s recollection of this period is incomplete but her strongly held overall memory is of insufficient support. MOTHER’S INITIAL BID FOR ACCOMMODATION: JANUARY 2008 3.2.15 In mid-January 2008 mother (aged just over 16) was referred on by Children’s Social Care to the Housing Department following unsuccessful attempts by the former agency to mediate between mother and daughter. In retrospect mother acknowledges that MGM’s apparently rejecting behaviour may have been an attempt to shield her youngest child (then aged 10) from the influence of mother’s challenging conduct. 3.2.16 At that time there was a joint protocol in place to try to ensure that responses of Housing and Children’s Social Care to such young people were compatible. By the following year, a ‘Youth Homelessness Prevention Team’ had been put in place specifically to deal with 16/17 year old homeless individuals and by March 2012 explicit procedures produced to inform the responses of practitioners and managers in both departments. 3.2.17 On this occasion mother was accepted as being homeless and initially provided with a place in a bed and breakfast establishment. One IMR suggests that she may actually have spent a proportion of her time in this period living with a ‘27 year old brother (actually a step-brother) in Hampstead’. Mother anyway left behind her an unpaid bill of £125 and ignored advice about how to get the Housing Department to settle it. 3.2.18 Records indicate that MGM mentioned a [named] friend of mother’s and that he and her daughter smoked. MGM also confirmed that her husband had flown to South Africa. 3.2.19 In late January education welfare officer EWO1 sought a professionals’ meeting prior to a family group meeting on the grounds that her experience of the family was that its members kept changing their plans for this young woman. Early in February 2008 Zara’s mother returned to MGM’s address. 3.2.20 The Diversion from Care team received a notification from Wandsworth Housing Department that Zara’s mother had moved out of the first B&B in late February. An incident in early March where MGM reported finding Zara’s mother in the bath with her boyfriend at 05.00 suggests that by then anyway, she was back at MGM’s home address. 13 FAMILY GROUP MEETING 3.2.21 On a date in mid-March MGM reported to the Diversion team that she had returned home to find her bedroom door smashed and a laptop stolen. She had notified Police and suspected the then unnamed boyfriend of Zara’s mother. 3.2.22 A family group meeting was convened a few days later. Relatives involved included the maternal great grandmother (MGGM), MGM, an aunt (of Zara’s mother) and mother of child-to-be Zara. These attempts to reconcile MGM with her daughter were unsuccessful and in spite of efforts by the social worker, several failed appointments and phone calls to her cut off by Zara’s mother, prompted Children’s Social Care to close the case on the basis of a lack of engagement. 3.2.23 Zara’s mother tried (presumably after the family meeting) to persuade Housing to offer accommodation and was advised, since she had quit her previous accommodation, to call her Diversion worker and make a fresh application. Further contact three days later with YOT1 focused on her entitlement to benefits and a need to prove she was still in education. 3.2.24 A record of supervision of the above worker indicated a place in a second B&B had been provided in mid-March 2008 and that EWO1 and the Connexions Service were being supportive. It also indicated that her father i.e. Zara’s maternal grandfather was ‘in receipt of [specified] medical treatment in South Africa. Comment: no further information about Zara’s grandfather has been provided by any agency. 3.2.25 In early April father was arrested and admitted burglary. He appeared in court, was remanded into custody and subsequently sentenced in May 2008. 3.2.26 At about this time, there was a phone discussion between consultant psychiatrist (psych.1) and a social worker (presumed to be SW1) when they discussed the family background and hypothesised the origins of its difficulties. 3.2.27 A Diversion team record of early April 2008 indicated mother still living (and reportedly happy in) a ‘bed and breakfast’ establishment (where she stayed for about a month according to Housing records). She reported that she did not wish to attend her appointment with psych.1 at Adolescent Services. The social worker concluded that as Zara’s mother had rejected all suggestions, there was no future role for his service. 3.2.28 A record of supervision within the same team dated mid-April indicated that a planned family group review meeting was to be cancelled (in fact it actually went ahead on a few days later). EWO1 confirmed that Zara’s mother was now on a school roll. 3.2.29 Children’s Social Care records of the family group meeting review indicate that mother ‘had moved into accommodation in a [named] road’ and now ‘had a career plan’ (which was train as a lifeguard). Mother’s account to the author referred only to starting a childcare course later abandoned as a result of her pregnancy. 3.2.30 The Police IMR confirms a prison visit by mother to father in mid-April. 14 3.2.31 The above move of accommodation has been confirmed by the Housing Department and a record of supervision of the social worker dated May also refers to a move to a ‘hostel for young people’ said to be supported by Connexions. 3.2.32 On a date in late April, in spite of a phone message cancelling her appointment MGM appeared and was seen by psych.1. He took a detailed family history and undertook to write to Zara’s mother and to convene a ‘large family meeting’. 3.2.33 On the recorded basis that mother stated she no longer required Diversion team support, the manager decided to close the case. The fact that mother was at that point pregnant with child-to-be Zara was unknown to this agency (and possibly to mother herself). 3.2.34 Housing records indicate that mother may have made a phased move into her hostel in the period from mid-April through to early June. Comment: it seems as though from her initial request for accommodation in January to recognition of pregnancy as described below, mother lived in 5 different locations. 3.3 ANTE-NATAL PERIOD MAY- DECEMBER 2008 3.3.1 Mother presented to hospital 1 A&E in mid-May and was discovered to be 9 weeks pregnant. Records indicate she informed staff she was ‘in care and in a youth hostel’. Recognition of the young woman’s vulnerability prompted a ‘maternity meeting’ convened at the hospital 4 days later. The medical staff informed mother’s medical centre 1 GP of the A&E presentation and their medical / social observations. The record within Children’s Specialist Service of notification of this contact is dated late June. Comment: the elapse of some 6 weeks before a record is made of the notification may reflect delayed reporting from the hospital and/or tardy inputting to the client information system of Children’s Social Care. 3.3.2 The Practice nurse met mother for purposes of ante-natal care and re-booked her with GP2. The GP practice had not by then received a discharge summary later received from the specialist registrar from hospital 1 A&E and indicating his view that mother was pregnant. COURT APPEARANCE OF ZARA’S FATHER 3.3.3 Meanwhile in mid May 2008 probation officer PO1 prepared a pre-sentence report by means of a video link to the prison in which Zara’s father was being held on remand. The account she was given indicated that although nominally living at his mother’s address, her disapproval of his lifestyle meant that he often stayed with Zara’s mother ‘whilst he was using’ (he later clarified with his supervising probation officer that although he was spending time with the mother of Zara she was not allowed overnight visitors). In his meeting with the author, Zara’s father confirmed that he had never actually cohabited with her mother. 3.3.4 Zara’s father claimed his awareness that his partner was expecting their baby motivated him to relinquish crime and settle down. The sentence passed next day entailed 36 weeks custody suspended for 2 years, a 2 year Supervision Order and an Attendance Centre requirement of 60 days duration. 15 3.3.5 Later that week Zara’s mother (aged 16 and living in what was described as a hostel) was seen by GP2 for antenatal booking. The age of the father of her child was not determined. The subsequent referral by GP2 to hospital 2 noted that the young woman was ‘vulnerable’…naïve as to what pregnancy is going to entail’……and ‘in need of a lot of support’. Comment: this GP’s referral helpfully highlighted the anticipated additional needs of mother. The hospital records do not acknowledge the risks referred to by the GP. Mother re-iterated that (with the advantage of hindsight) she was very naïve and vulnerable at this stage of her life. 3.3.6 Medical centre 1 records indicate mother was not seen again during pregnancy and no confirmation of ante-natal care (usually shared with the GPs) or of Zara’s birth or discharge from hospital was received. Comment: although the reports from the hospital indicate that health visitors were alerted to mother’s discharge from hospital, the failure to involve GPs from medical centre 1 during mother’s pregnancy suggests a systemic weakness and a missed opportunity for provision of support by those with some knowledge of the family. 3.3.7 In June 2008 mother attained the statutory school-leaving age having attained an average attendance rate of only 24% in her last year. 3.3.8 In early June mother left a message with CAMHS claiming she was ‘visiting family in New York’ and was unable to attend a scheduled session. At the end of June, continuing efforts by the agency to engage with Zara’s mother resulted in it being given the misinformation (presumably by Zara’s mother herself) that she was going to live in South Africa with her father. Comment: during mother’s conversation with the author, she denied that there was ever the possibility of her going to South Africa. Constraints of time and circumstance inhibited any further challenge about whether the above reported claims confabulations or deliberately deceitful. 3.3.9 At the beginning of July, the case was allocated to a hospital 1 social worker SW2 to complete an ‘initial assessment’1. Comment: allocation of a social worker took over 5 weeks from mother’s presentation at A&E and then led only to the much delayed ‘initial assessment’ described below. 3.3.10 In late July father was again arrested having been detained on a stolen motorcycle. He was in possession of a CS spray and 2 wraps of cocaine. He was sentenced in December 2008 for these offences and for breaching his earlier suspended sentence. 3.3.11 Mother’s initial antenatal consultation at hospital 2 was in late July when 20 weeks pregnant. Records indicate that she said that she had a ‘youth worker’. Presumably in consequence of this contact, a home visit was undertaken a week later, by a Children’s Centre midwife and information leaflets were provided. No concerns were raised. A follow up support visit was arranged for September. 1 An initial assessment was a standardised instrument used by Children’s Social Care departments across the country. It should capture all basic biographical information, offer an initial analysis of its significance and recommend any further required action. 16 3.3.12 In early September Zara’s mother presented herself at Wandsworth’s ‘Referral & Assessment Service’ and sought what she described as ‘support’. She indicated she was ‘isolated and living in supported accommodation’ provided by a Housing Association. Because she was already an open case, Zara’s mother was directed toward her allocated worker at hospital 1. Comment: records accessed for the purposes of this SCR suggest that the unknown number of occasions on which SW1 tried to contact mother were unrecorded. It seems possible mother had not understood that she had an allocated social worker at hospital 1. Mother’s recent recollection of this period was simply of seeking and being refused support. 3.3.13 At her scheduled home visit by a Sure Start Children Centre midwife in mid-September, a good relationship with the father of Zara was reported. Further information about support and smoking cessation was provided. However, at an ante-natal consultation 3 days later, mother reported headaches and nausea. She also referred to starting a university course ‘the next week’ though no further reference to that has emerged from material made available to the SCR. Mother made no reference to any such course when speaking with the author. 3.3.14 Mother cancelled a pre-arranged home visit by SW2 and was admitted next day to an ante-natal ward complaining of abdominal pains. Nothing abnormal was found and she was discharged a day later and asked to return in a week for test results. She failed to do so. 3.3.15 By November and early December 2008 and at 34, 36 weeks and 38 weeks into pregnancy, further antenatal follow ups revealed nothing of significance. 3.3.16 Zara’s father was again arrested in late November and found to be in possession of crack cocaine. A warrant for his arrest also existed as a result of him failing to appear at court in early November. He was eventually sentenced to 30 months imprisonment and released in September 2010. 3.3.17 Meanwhile, the initial assessment initiated in July was ‘completed’ in late November 2008. The target for completion of such assessments at that time was 7 working days. The significant delay in this instance is explained within the IMR for Children’s Social Care as being a reflection of the difficulty presented to the social worker of getting Zara’s mother to engage in the process. The assessment concluded that in spite of mother’s age, strained relationship with MGM and that she was relatively unsupported, the housing support worker was sufficient input and there was no need for Children’s Social Care input. Comment: the conclusion of that assessment was at odds with its contents. Mother is clear she needed a lot more support than was given though clearly, her willingness or ability to take up what was offered was then (and remains) poor. 3.3.18 The school nurse service reportedly received a Police notification of an incident in early November 2008. The record kept by the school nursing service does not explain to which incident the notification referred and no other agency refers a notification in November. The MPS chronology confirmed that mother had been present during an argument between two others and had felt contractions. An ambulance had been called but no treatment was required and Police took no further action. 17 BIRTH OF ZARA & CONTEXT OF FURTHER PROFESSIONAL ACTIVITY 3.3.19 A ‘false alarm’ in mid-December was followed next day by a further self-referral to the labour ward and Zara was born without complications a few days before Xmas. Because her mother was still very young, the midwifery team notified the ‘safeguarding midwife’ and liaison with community midwife, health visitor as well as Children’s Social Care was initiated. Comment: involvement of the safeguarding midwife was commendable. No reason why the GPs at medical centre 1 were not notified has been provided though the account from the health visiting IMR below offers some indication of confusion about addresses. 3.3.20 Following a discharge meeting involving (it has been deduced) a student social worker from hospital 1, allocated midwife and the safeguarding midwife, mother and baby were discharged to MGM’s address in Westminster. The intention declared by mother and MGM was that mother and Zara would remain there for 2 weeks and then return to what was recorded as her ‘supported lodgings’. 3.3.21 The home address recorded for mother was an address in Wandsworth (which appeared in no other IMR) and the birth notification was sent to a [named] health visiting team. At a new birth visit neighbours suggested that mother had moved out a year previously. A check with hospital 2 revealed the address of MGM in Westminster and the birth notice and records were in consequence sent to health visitors in that borough. Those health visitors in turn confirmed that mother and baby were now living in Tooting and ‘may have been visited by a health visitor there’. 3.3.22 An unnamed health visitor for the homeless made contact with mother and visited her next day. Comment: subject to further clarification, these events may explain in part why the referring GP was told nothing of the birth or what followed. An absence of names in the IMR provided prevents triangulation and confirmation of accounts. 3.3.23 The IMR evaluating the provision of health visiting services points out that in the period 2008-2010 the transition from paper to electronic records had a number of unintended consequences. Whilst clinic staff recorded their work on Rio, the health visitors for the homeless used paper until May 2009 when they moved across to a Tooting team (and even then scanners were not made available until 2010). Whilst the service was moving toward an electronic system, child health records team would have recorded birth notification and blood spot (for phenylketonuria) results on the new electronic RIO system but the health visiting teams might not have been able to directly access this information themselves Comment: the above description offers a poor impression of the management of the transition, a difficult environment for staff to work in and one in which the completeness of health records could apparently be compromised. 3.3.24 Whilst the above efforts were being made to trace mother and baby and offer health visiting services, a further initial assessment had been begun on 19.12.08 by a student social worker who was supervised by SW2. 18 4 PERIOD OF REVIEW: BIRTH TO CRITICAL INCIDENT 4.1 INTRODUCTION 4.1.1 Section 4 considers year by year, events and professional judgements in the period from Zara’s birth in December 2008 to her hospitalisation in late March 2013. The most significant periods and events are highlighted by means of headings and sub-headings respectively. 4.2 1ST YEAR OF ZARA’S LIFE: DECEMBER 2008 – DECEMBER 2009 4.2.1 Within 6 days of the birth of Zara, her father appeared at Crown Court charged with the offences for which he was arrested in July and for breaching his earlier suspended prison sentence. His was imprisoned and not released until March 2009. 4.2.2 A community midwife CM1 informed the hospital 1 Social Work team of her belief that Zara’s mother was not in fact staying with the MGM for 2 weeks as understood by the hospital at point of discharge. Nonetheless a week later on 29.12.08 a home visit to that address was completed by the student social worker from hospital 1. This individual may have made a further visit in January. 4.2.3 At this first post-natal contact by a professional, the mother of Zara reported that she had been coping well though was a bit tired. Mother reported that Zara was feeding and sleeping well and the MGM reinforced her daughter’s claim to be caring well for the baby. 4.2.4 MGM and mother described Zara’s father as ‘bad’ and there was a discussion about his future role in the care of his daughter when he was released. Records provided do not provide the content of these discussions. 4.2.5 By the second week of January an un-identified midwife was satisfied that Zara (an alert and responsive baby) and mother were well enough to be discharged from her care, though records refer also to a follow up visit. The midwife noted mother’s comments that she was happy at the accommodation provided by the Housing Association and got on well with her key worker. Mother said she would not be staying in Wandsworth, was receiving support from her own and her partner’s mother, Mother also reported that her partner was in Wandsworth prison and due out in March 2009. The student social worker’s attempt to glean information was thwarted when she offered the wrong surname to prison staff. The IMR indicates SW2 agreed to write up her student’s assessment but did not do so. 4.2.6 In mid-January 2009 mother and baby Zara registered at an alternative medical centre 2. Records indicate mother was concerned about a red mark on Zara’s neck and was offered an appointment next day. Mother subsequently rang to say she had overlooked the time given and was offered another one a few days later. She arrived 35 minutes late, was offered an appointment if she waited but was ‘unhappy’ and left the surgery before Zara was examined. Comment: the episode illustrates mother’s motivation to care for her baby as well as the limits on her ability to do so, perhaps in consequence of poor organisational skills / impatience / impulsivity. 19 4.2.7 A record from hospital 1 suggests that HV2 made an opportunistic home visit on the same date as the above event but did not meet mother or child. 4.2.8 SW2 or probably her student (records offer no certainty) spoke by phone and was told by mother that she and her baby were doing well but that she had been told by her Housing ‘case worker’ (presumed to be same unidentified individual as her key worker) that she would not be given permanent accommodation and would instead be referred to a ‘mother and baby unit’. Zara’s mother was not keen on that option. A home visit for late January was agreed. 4.2.9 At the planned home visit the worker from hospital 1 was told that Zara would be brought to the medical centre 2 next day for Zara’s primary immunisations2. Mother referred also to a visit ‘the previous day’ by a health visitor (though records from that agency suggest no contact had at this point been established). Mother indicated that her boyfriend was at that time a category C prisoner in a Cambridgeshire prison. Comment: it remains unclear whether mother’s reported reference to a visit by a health visitor was an attempt to deceive or an inaccurate record. Her conversation with the author included a comment that she had at that time no idea what service to expect from a health visitor. 4.2.10 Records of supervision of SW2 / student social worker in late January 2009 refer to the ‘Housing Association worker’ having agreed to mother and Zara moving on from her supported accommodation. The agreed plan was completion of the initial assessment and, subject to mother’s agreement a referral to the ‘Early Years Multi-Agency Panel (EYMAP). If mother declined such support, no further follow up was considered necessary. 4.2.11 A subsequent phone conversation with the Housing Association worker confirmed that, aside from rent arrears, ‘no other concerns existed’. Comment: the report latterly provided by this provider reported that it had been observed that during her stay, mother ‘appeared not to want anything to do with the baby although she bought a lot of nice things for her’. 4.2.12 In early February 2009 Child Health provided HV2 with an address for mother and Zara and provided her with a parent-held ‘red book and labels. Which address was provided has not been shared with the SCR panel. 4.2.13 Mother failed to bring Zara to an appointment with a GP3 made for unknown reasons in mid-February. 4.2.14 Zara had not been seen by a health professional since the midwife discharged her from her care over a month previously. On 19.02.09 the baby was seen by an unidentified GP. The doctor recorded no health-related concerns, noted that mother was breast-feeding Zara and that they were living in temporary accommodation spending much of the time with the mother of the imprisoned boyfriend. A plan was made for health visitors to follow up on weight and review the domestic situation. The Practice nurse gave Zara her first set of primary immunisations. 2 A primary immunisation is a vaccine to protect against Diphtheria, Tetanus, Whooping Cough, Polio and Haemophilus influenzae type b (Hib) [DTaP/IPV/Hib] 20 4.2.15 Next day HV2 received a phone call from the Housing Association where an unnamed member of staff was concerned that mother was spending little time at the property; was tearful and depressed. A request for the health visitor to visit was made. 4.2.16 The health visitor phoned mother who sounded to be, and said she was, well. Mother confirmed her visit the day before to the GP who had said she was not depressed. Comment: mother’s reference (if accurate- GP records do not confirm the subject being discussed) to the GP’s view imply the subject of depression had been discussed at her visit to medical centre 2. 4.2.17 The health visitor called and met mother, Zara and the MGM. Mother confirmed that Zara had received her 8 week check and immunisations and was reported to be very receptive to ideas and seen to be handling her baby well. MGM was noted to be offering good support. Zara was by this stage reported to be receiving breast and bottle milk. 4.2.18 The ‘Home Detention Curfew Report’ being prepared in March required PO3 to complete a home visit to Zara’s paternal grandmother. The address was well known to Police and because a number of the associates of Zara’s father were confirmed drug dealers, MPS officers questioned the suitability of the address for curfew purposes. 4.2.19 In a phone call to mother in late March 2009 by the student social worker from hospital 1 she was told mother’s key worker ‘had been fired’ and ‘everything was messed up in regards to her accommodation being sorted out’. Mother reported she was no longer at her accommodation because of an infestation of mice. Mother indicated that she was now staying at the home of her boyfriend’s mother and that her own mother MGM ‘had gone to Spain to get married’. In her conversation with the author mother confirmed as accurate her account of an infestation of mice. 4.2.20 An email exchange later between the social work team at hospital 1, initial contact worker ICW2 and the Homeless Persons’ Unit clarified mother had not been evicted but had been given a ‘notice to quit’ which was to expire in mid-April as she had essentially abandoned the property. 4.2.21 Next day mother phoned the student social worker and told her that Housing would be allocating her temporary accommodation and that a housing officer HO1 would contact her. Mother was indeed provided with an alternative place to live where its records indicate the tenancy began on 20.04.09 though where (according to Housing records) mother remained until her move to her permanent accommodation a month later. 4.2.22 Other agencies’ records suggest mother’s place had been allocated from a date in late March. Mother revealed to the student social worker that she was anyway still staying with the mother of her imprisoned boyfriend. Comment: mother and Zara clearly spent substantial amounts of time with the associates of Zara’s father. The report provided by the Housing Association claims that ‘concerns were raised with social services [sic] regarding mother’s non-engagement with the service as well as health professionals; baby not residing at the premises and rent arrears’. These may be a reference to contacts made with the health visitor and/or to the hospital student social worker. No record of the reported meeting and a requirement that mother committed to being at the unit for 2 days per week has been located. 21 4.2.23 In late March 2009 Zara was seen by the Practice nurse for her second set of ‘primary immunisations’. During the remainder of her registration at medical centre 2, correspondence relating to 2 recorded attendances at Accident and Emergency (A&E) was received (one for diarrhoea and the other for a viral infection). No concerns were raised about general welfare in either. Zara’s father was released from prison at this time. 4.2.24 In late April 2009 HV2 tried to contact Zara’s mother and establish her latest address. HV2 noted concern about the frequent moves by this young mother. She forwarded records to Tooting-based health visitor colleagues. Upon receipt, an invitation for a ‘transfer-in’ appointment a week later with HV6 was immediately sent. The system then in place meant that this individual would be the named health visitor until Zara was 1 year old (at which stage a child would ordinarily become part of a corporate case-load). 4.2.25 Supervision notes from the social work team at hospital 1 dated 07.05.09 indicate that the student social worker was to follow up with mother her anticipated housing move and check that she (and presumably Zara) had registered with a GP. It was noted that Zara had been reported to appear healthy and well on the last visit. It was agreed that the supervisor SW2 would write up the initial assessment and complete a closing summary. 4.2.26 The closing summary referred was completed and described mother as ‘vulnerable, supported by her mother (MGM) and housing support worker who is ensuring she had good enough independence skills before moving into her own accommodation. No need for further Children’s Services was identified’. Comment: the impact of Zara’s father’s release from prison was not addressed. 4.2.27 Meanwhile, efforts continued to be made by HV2 to contact mother who did not respond to cards left at what was understood to be the relevant address or to messages on her mobile. 4.2.28 In early June 2009 PO2 who was writing a ‘pre-sentence report’ faxed Children’s Social Care to ask whether Zara was ‘known to the agency’. 9 days later SW2 left a phone message for the probation officer in which she confirmed that Children’s Social Care had, in consequence of mother then being only 17, been involved in a pre-birth assessment. The social worker reported that mother was now in high support accommodation designed for use by mothers aged less than 18 and that the child’s MGM was supportive. Comment: no good reason for the delay in responding to Probation has been provided. 4.2.29 It seems likely there was a follow-up conversation between social worker and probation officer in that PO2 records she informed the social worker of father’s drug abuse history and of the crimes for which he was awaiting sentence. PO2’s report does not explicitly address any implications of him spending time with mother and Zara, and indicates an assessment by Children’s Social Care of 6 month old Zara was being completed. 4.2.30 PO2’s assessment of the ‘risk of serious harm to children’ was assessed as ‘low’. Comment: the extent of harm of relevance to Children’s Social Care is encapsulated by the term ‘significant’ defined in s.31 Children Act 1989 as amended by s.120 Adoption and Children Act 2002. How the term ‘serious’ is defined by probation officers i.e. does it differ from significant harm? may be a significant factor in evaluating respective understandings of risk to Zara (and others). 22 4.2.31 Mother was due to meet with the Practice nurse on 17.06.09 although neither confirmation of the reason for the appointment, nor whether she attended has been found. IMPRISONMENT OF ZARA’S FATHER 4.2.32 Zara’s father at the end of June, received a 30 month custodial sentence for the offence of possession with intent to supply a class A drug. 4.2.33 In mid-August 2009 MGM reported to the Practice nurse that her daughter (mother of Zara) had attended A&E where swine flu had been diagnosed and Tamiflu administered. 4.2.34 A phone call from an unnamed professional at medical centre 2 in mid-September elicited from Zara’s mother than she was planning to register at an ‘Upper Tooting Practice ‘soon’. FIRST & SECOND PRESENTATIONS OF ZARA AT A&E 4.2.35 Later in September 2009 mother brought Zara to hospital 1 A&E where her baby was diagnosed as having a viral infection and sent home in her care. No other concerns were noted 4.2.36 At a second presentation Zara was diagnosed as having an upper respiratory tract infection and diarrhoea. The discharge letter notes no other concerns. Details of this event were only scanned into the patient information database ‘Rio’ about 3 months later. Comment: the delayed inputting of this routine notification may have been a one-off or represent a more systemic problem. 4.2.37 Contact with the health visiting service had been very limited. A very brief contact occurred in early November when mother reassured health visitor HV3 who seems to have made an opportunistic home visit that she was fine and that Zara was attending a nursery. 4.2.38 At medical centre 2 it was recognised that Zara was overdue her 3rd set of immunisations and an invitation was sent out. Neither mother nor Zara were seen again that this centre. 4.3 2ND YEAR OF ZARA’S LIFE: DECEMBER 2009- DECEMBER 2010 4.3.1 Available records suggest that local agencies had no further involvement with Zara and her mother until February 2010. ASSESSMENT OF NEED / RISK DURING THIS PERIOD 4.3.2 In early February 2010 a ‘risk assessment summary’ within the social work team of hospital 1 noted that no member of the household (defined as mother, Zara and the child’s father) was on the local authority ‘aggressive persons’ register nor on the sex offender register. According to the guidance on this pro-forma, if any of a number of factors were present a full risk assessment would have been required. Comment: the motivation for such a register is understandable, the wide range of (some subjective) criteria that justify inclusion suggest to the author that interpretations will vary considerably. 23 4.3.3 Mother with others and accompanied by Zara was caught shoplifting in early February 2010. Zara appeared well and the MPS records indicate a notification was sent to Children’s Social Care. 4.3.4 A week or so later Police were called to the mother and baby unit. A named woman who claimed to Godmother to Zara was proposing to take care of Zara because her mother was unwell. The named individual was for unknown reasons, banned from the unit and a row ensued. With mother’s consent, this woman did later take Zara (noted by officers to be wrapped up warm with a bottle). 4.3.5 Later that month a ‘move-on’ assessment was completed by the supported housing provider and confirmed that it would be appropriate to offer mother permanent accommodation. This assessment notes Zara’s father as mother’s partner. The records note mother’s objection to moving to the proposed area because the [named] gang could cause problems for her partner which in turn could impact on the safety of her child. Comment: No evidence for mother’s assertion was sought or provided. In conversation with mother, she confirmed she had wanted accommodation in a more salubrious area but accepted that she had never been threatened by any gang member and denied any personal involvement in gangs. 4.3.6 Mother was contacted again in March by Housing Lettings and indicated that Roehampton and Putney would be inappropriate areas because of the gang connections of Zara’s father but that certain estates in Battersea would be acceptable. 4.3.7 A week after the above exchange mother was asked by the temporary accommodation officer to attend a meeting where she was given a verbal warning for (an unspecified) breach of house rules. This may refer to an incident in the MPS chronology where mother and two others attended the flat of a friend who subsequently realised £100 had gone missing. 4.3.8 The day after her verbal warning PO2 called and spoke with SW2 who confirmed that the case was closed shortly after Zara’s father had been sentenced and that there was no ongoing Children’s Social Care involvement. SW2 is recorded as having indicated that there were no concerns about Zara in her mother’s care. Comment: Children’s Social Care IMR reports this significant exchange was not recorded by SW2. 4.3.9 The social worker had no current information about the status of mother’s relationship with Zara’s father e.g. whether there had been contact with him during his imprisonment. Her advice was that a new referral would be required in order to obtain an updated assessment in the event that father lived with mother after his release. This advice was reflected in PO2’s ‘home detention curfew report’ drafted by her in late April 2010. Comment: the fact and nature of any ongoing relationship would have been significant information insofar as father might, upon release have had a high level of contact with Zara. 24 OFFER OF PERMANENT ACCOMMODATION & CONTACT WITH CHILDREN’S SPECIALIST & HEALTH & HOUSING SERVICES 4.3.10 In early April 2010 Mother was offered the tenancy of what remained until November 2013 her address. The policy then should have ensured that being less than 18 years of age, she was offered ‘tenancy support’. Mother was not offered it. The reason for this oversight has been attributed to a problem with the use of the Housing Department’s software. Comment: the oversight had no adverse impact on Zara’s mother and what is clearly a useful system has since been extended to tenants aged less than 20 years old. 4.3.11 Mother made a visit to the Referral & Assessment Team of Children’s Social Care on 10.05.10 where she was seen by an unnamed initial contact worker (ICW). She reported that as a result of her passport and bank cards being stolen some 3 months previously she was experiencing difficulties obtaining Benefits. The ICW liaised with mother’s accommodation providers and obtained confirmation of the difficulty of obtaining a loan or grant without adequate identification. Records supplied do not indicate what further action if any was taken. Mother mentioned that she was planning to move to her permanent accommodation a week later though in fact her move was completed a few days after that. 4.3.12 A check in late May by a service manager in Children’s Social Care SM1 identified a number of tasks not completed before the case was closed e.g. a chronology, list of all involved professionals, details of religion and GP and a closing summary. Comment: it is unclear whether the case had been closed (with the specified tasks incomplete) or would not be authorised for closure unless they were completed. 4.3.13 During a visit to the clinic mother sought information about local services indicating she ‘will [sic] be moving soon’ to [name provided] Road. Mother was advised to register as a temporary patient with a GP. If this record of when she moved is accurate, mother might in fact have delayed her move into the permanent accommodation provided. 4.3.14 By early June her rent arrears triggered an initial alert and a request she contact Housing. Perhaps in response to this warning, mother attended and asked for forms for a ‘management transfer’. She is known to have sought legal advice from a local law firm citing harassment from some individuals in the area as a justification for a transfer to Westminster. The law firm was unable to follow up mother’s request for help because the numbers she provided were unobtainable. Comment: it seems that mother was unable to sustain engagement even when she had the possibility of representation from a source of local expertise. 4.3.15 Mother persisted in her attempt to be re-housed and at a meeting in early July asked for a letter she could present to Westminster to confirm she was unsafe in Wandsworth. During the author’s interview with the father of Zara he doubted that his ex-partner was fearful of any gang-related issues (and mother later confirmed that in conversation with the author). 25 4.3.16 Mother anyway offered no evidence at the time for her contention and was advised she could apply for a different property in Wandsworth or (if she continued to feel unsafe) to approach the ‘Housing Options Service’ (a service for those claiming to be homeless). Mother was unwilling to pursue that possibility and no further action was taken. THIRD PRESENTATION OF ZARA AT A&E & FOLLOW-UP 4.3.17 In late August 2010 and accompanied by an unidentified friend, mother presented Zara at the paediatric A&E department of hospital 2. The toddler was reported to have pulled a small cup of hot water off a table. The injuries were judged to be consistent with the account provided. 4.3.18 Mother volunteered that she was known to Children’s Social Care though her case was closed. She also accurately reported that Zara’s father was in prison and that the child was not registered with a GP; nor were the child’s immunisations up to date. 4.3.19 The hospital’s liaison health visitor was informed of the circumstances though her records do not provide confirmation that she in turn linked with the health visitor for the family to address GP registration and follow-up of overdue immunisations. 4.3.20 The injuries required only routine follow-up and during the course of the first contact a day after Zara’s visit to A&E, mother suggested that her relationship with the child’s imprisoned father was over. The reasons for father’s imprisonment were apparently not sought. Comment: insufficient curiosity about significant males / biological fathers is a common finding in SCRs. The available evidence suggests some form of relationship with Zara’s father did continue e.g. she visited him in prison in September 2012 and regular letters have been exchanged. 4.3.21 Because Zara was not registered with a GP, there was no relevant community location to which to send the medical records of the child’s treatment. 4.3.22 Medical centre 2 had in January 2010, noted Zara was overdue her 3rd set of immunisations and sent a letter inviting attendance. Zara was not seen again. 4.3.23 HV4 followed up the August A&E presentation. In a phone call she was told that although MGM had advised against immunisations, Zara had received 2 immunisations and that mother was hoping to arrange her 3rd. A home visit was agreed though mother was not in when HV4 called at the end of the month. There was no further follow-up. HOUSING RELATED DIFFICULTIES & FATHER’S RELEASE FROM PRISON 4.3.24 By late September 2010 records of liaison between HO2 and rent collection officer RCO1 confirm mother’s growing rent arrears and refer also to ‘anti-social behaviour issues’. The outputs of the meeting held in early July 2010 were shared with the RCO. 4.3.25 In late September Zara’s father had been released from prison and he sought to convince his probation officer PO4 that his ongoing relationship with Zara’s mother and determination to be a positive role model for his daughter would help him lead a law-abiding life. Father indicated to PO4 that he has ceased to use crack cocaine and any other drugs in 2008. 26 4.3.26 In late October 2010 the RCO made an unsuccessful home visit to mother’s address. RCO left a card and about a fortnight later mother rang back promising to make payment of rent. 4.3.27 Mother attended the Housing Department office in November and spoke with her previous temporary accommodation officer HO1. A referral was apparently made to ‘Centrepoint Floating Support’ and an appointment was made for mother to meet with the senior estate manager next day so as to discuss again a management transfer. The relevant form was not completed and it is assumed that mother remained unable to evidence risk and that in consequence no further action was taken. 4.3.28 The Rent Collection Service records indicate numerous attempts by phone, letter and visits from this period until Spring of 2011 to collect rent owed. 4.3.29 Mother, Zara’s father and three others were stopped in a stolen car in November 2010. There was insufficient evidence of guilty knowledge so no further action was taken against them. Comment: this was the first and only time that mother and father appear to have been operating together. Father assured the author that he kept his criminal life well away from his ex-partner. 4.3.30 In mid-December 2010 there was an altercation at mother’s flat involving a friend of Zara’s father who assaulted a female friend of mother. Police attended but the victim did not substantiate the allegation. Neither mother nor father was interviewed. 4.3.31 Zara’s father had further supervision appointments in December. At the former he provided accurate details of his daughter when told that Children’s Social Care would need to be notified of his involvement with her. At the latter session with PO4, father referred also to a son whom he saw weekly. When interviewed by the author of this report, Zara’s father stated clearly he has no other children and had no recollection of the claim referred to here. Comment: a delay of more than 6 weeks ensued before communication with Children’s Social Care was made. No other reference has been found to a son. If he did make such a claim it should also have been explored and followed up. 4.4 3RD YEAR OF ZARA’S LIFE: DECEMBER 2010- DECEMBER 2011 MORE HOUSING-RELATED DIFFICULTIES & FATHER’S RETURN TO PRISON 4.4.1 On a date in mid-February 2011 it is now known that Zara’s father robbed a pregnant woman. He was later arrested and charged with that and 20 other similar offences between 2007-2011. 4.4.2 On 17.02.11 a request from PO4 for information on the family was made to Children’s Social Care. The officer confirmed that father was serving a sentence for possession of class A drugs with intent to supply and that Zara was child living at the home address. Comment: it appears that PO5 (who dealt with father’s recall to prison the following month – see below) left it to PO4 to update Children’s Social Care; in the context of a demanding workload, he accepts that he overlooked the task. 27 4.4.3 In late February father committed a further robbery also involving significant violence. 4.4.4 Although Probation records do not confirm receipt of a response from Children’s Social Care, PO4’s fax was apparently responded to by an ICW who reportedly indicated ‘family known, no child protection concerns. S/he recommended case closure and this was later ratified by a manager. Comment: the term closure probably refers to ending this specific duty episode but might reflect an uncertain status following the manager’s identification of a number of tasks that required completion before case closure. 4.4.5 As result of breaching his licence conditions (in consequence of a series of robberies on lone females for which he had been arrested in February 2011), Zara’s father was recalled to prison. He was sentenced in September 2012. 4.4.6 By late April court action for non-payment of rent was being contemplated by the ‘Rent Collection Service’ (RCS) within the local authority Finance Department and any relevant information held by Children’s Social Care was sought. An unnamed ICW was asked to respond to the request and then initiate case closure. The ICW wrote to mother informing her of the contact from the RCS and invited her to meet. 4.4.7 The ICW also informed Housing of her action and confirmed there would be no further involvement of that agency. No record of subsequent case closure has been provided. An unnamed RCO who checked ‘Framework I’ and thought the case was still active queried if there was current involvement and was told the case had been closed in May 2009. Comment: it remains unclear precisely when the case was closed by Children’s Social Care. 4.4.8 By early May, given the threat of eviction, the Finance Department’s Rent Collection Service, referred to Housing’s Tenancy Support Service. Staff from the latter service tried to contact mother by means of phone calls, letters and a visit. All attempts proved unsuccessful failed and the case was closed. DRUGS RAID & FOLLOW-UP 4.4.9 In late June 2011 Children’s Social Care was notified by Police about a drugs raid on the home of a man described as ‘mother’s boyfriend’. Mother was found in bed with a named man and a large quantity of drugs was found in that bedroom, a bathroom and in a drawer in the bedroom where Zara was sleeping. 4.4.10 Mother and her friend were arrested for possession with intent to supply and later bailed. Further information from Police confirmed that mother had been previously caught shoplifting with friends whilst Zara had been present. The male was known for criminal damage, dangerous dogs and had received warnings for drug possession. Mother was arrested and made ‘no comment’ at interview. After investigation and CPS advice, no charges were preferred. 28 4.4.11 The duty manager TM3 (actually a ‘principal social worker’) required an initial assessment to be completed to ascertain the impact on the child of exposure to drug use. Checks with health and drug services were also requested and the issue of mother’s association with drug users, personal use and financial management were to be established. The manager also indicated there might need to be s.47 enquiries in the event that significant concerns about Zara’s living arrangements were revealed. Comment: this manager’s careful response illustrates good practice. 4.4.12 Responsibility for completion of the initial assessment was allocated next day to a social worker SW6 who liaised with DS1. That police officer was able to confirm that Zara had been within easy reach of a wrap of cocaine and that mother and boyfriend had been arrested for possession with intent to supply and had been bailed until a date in early September. Mother had been bailed to her Tooting address. 4.4.13 SW6 tried to contact mother by phone and made a home visit where s/he left a note. Over the course of the next few days SW6 repeated her/his attempts to contact Zara’s mother. A phone call to the Tooting Health Clinic revealed that the allocated health visitor was HV5. 4.4.14 Mother together with a relative believed to be her aunt attended the Referral and Assessment Team at the end of June 2011. She denied use of drugs or being in a relationship with the male [who according to the MPS was ‘known to be her boyfriend’ at this time]. The record of this meeting noted that Zara appeared happy and well cared for. 4.4.15 Next day in response to the Police notification of the drugs raid, HV4 made an appointment to meet with mother. The details noted in that agency’s records refer also to a lock knife found during the raid. A call by her to Children’s Social Care confirmed an assessment was being conducted but that ‘no CP plan will be instigated’. Comment: it is unclear how the result of an assessment could be known before its completion. 4.4.16 In July 2011 supervision records in Children’s Social Care suggest that the social worker was completing a core assessment. The rationale for switching to a core assessment has not been traced. 4.4.17 In a phone conversation with SW6 mother indicated that Zara ‘might be registered with a surgery ‘off [a named] road’. She could not recall the name and suggested the member of staff call again later. Mother indicated her intention to register herself at a new local GP that day (which she did – see below) 4.4.18 At the suggestion of the supervisor, SW6 had contacted medical centre 3 to seek information. The response next day from a GP4 confirmed that Zara was registered there as a temporary patient and that she had been seen twice (once for conjunctivitis and once for swelling of a toe on her right foot). The surgery had no concerns about Zara. GP4 confirmed that mother was not registered at the centre. 4.4.19 Though the time of either visit is unclear, it seems the social worker completed a home visit and met mother and Zara (said to look ‘happy and well’) and HV4’s visit failed to locate mother and daughter. 29 REGISTRATION OF MOTHER AT MEDICAL CENTRE 4 4.4.20 On 06.07.11 Zara’s mother (though not Zara) registered at the medical centre 4. 4.4.21 A call was made a week later to GP5 at medical centre 2. She recalled an altercation with staff when mother had arrived late for an appointment and confirmed that mother and Zara was registered with the Practice though neither had been seen since 2009. No concerns about care of Zara or about drug misuse had been noted. 4.4.22 A call to GP6 at medical centre 4 was made by SW3 (why SW6 had ceased involvement is unclear) who informed them of the drugs raid and Zara’s access to class A drugs. 4.4.23 The social worker was asked to encourage mother and Zara to register and the child protection lead at medical centre 4 (GP6) was informed of the exchange. Comment: in fact mother (though not her daughter) was already registered here. 4.4.24 Zara went on to be registered at medical centre 4 on14.07.11 but was not seen during the timeframe of this SCR. Further correspondence was sent to mother in 2012 encouraging her to present Zara for her overdue immunisations. Comment: it appears that the information provided by Children’s Social Care was not acted upon. COMPLETION OF CORE ASSESSMENT & ONGOING CONTACTS WITH AGENCIES 4.4.25 In the core assessment completed in July 2011 mother denied that the man with whom she had found during the drugs raid was her boyfriend. He was she claimed ‘just an acquaintance with whom she stayed one night’ and she denied any knowledge of his use of drugs. The social worker provided a letter to support her to obtain a community care grant and offered advice about ‘acquaintances’. The recommendation of this assessment ratified by the manager TM5 was to close the case. That decision was phoned through to HV4 next day. Comment: were the risks of her toddler accessing lethal drugs explored and was mother’s account credible? 4.4.26 HV4 managed to complete a home visit in early August 2011 and noted that the flat was strewn with toys. Mother expressed no anxieties about Zara and, in discussing her arrest in June, the health visitor was offered mother’s reassurance that she was going to now focus on the care of her child. Mother was encouraged to bring Zara who was ‘lively but thin’ to clinic for weighing and to put the child’s name on a waiting list for a school. 4.4.27 Later in September mother sought help from Children’s Social Care when she claimed her cooker had broken down. Aside from the fact that she was given a £5 voucher, nothing else is recorded about this office visit. About a month later mother again sought financial help this time because she claimed, her (unnamed) cousin had withheld Benefit money from her. She explained that her Benefits were being paid into the account of that cousin because she owed her money. Unspecified advice was given and no further action taken. Comment: the arrangement sounds fraudulent. 30 FURTHER CRISES INVOLVING POLICE 4.4.28 In early October mother became the victim of what was described by Police as a racially aggravated common assault which had included a threat to burn the flat down with Zara in it (a friend’s boyfriend was arrested for the offence which had been committed at Zara’s home with her present). A Police notification (Merlin) was completed though its receipt was not confirmed in the Children’s Social Care IMR. 4.4.29 Some 2 weeks later Police were called again to Zara’s home. A friend was staying and her ex-boyfriend made threats against her mother and against child Zara. The man was subsequently arrested. 4.4.30 A month later, officers attended the home address at the request of the London Ambulance Service. A man there was becoming violent. He was later taken voluntarily to hospital. On this occasion it is unclear whether mother and child Zara were present. 4.5 4TH YEAR OF ZARA’S LIFE: DECEMBER 2011- DECEMBER 2012 MOTHER’S ARREST 4.5.1 A further (Merlin) was received by Children’s Social Care in December 2012. It indicated that mother had been arrested for taking prohibited articles into Wandsworth prison and a maternal great aunt of Zara was looking after Zara. The notification referred to Police suspicion (reinforced by comments of the aunt) of mis-users of drug and alcohol frequenting mother’s home and that Zara’s mother might be a drug user. 4.5.2 In response the duty manager instigated an assessment under s.17 Children Act 1989 i.e. to establish whether Zara was a ‘child in need’ in consequence of maternal neglect or insufficient parenting capacity. The manager raised the possibility of a child protection conference if concerns about mother’s misuse of drugs or her inability to make changes were substantiated. The case was allocated to SW4. 4.5.3 A supervision record dated specified the checks amongst local agencies required by the team manager and include asking a health visitor to see Zara. The family network was also to be explored. A second record of supervision (3 weeks after receipt of the notification from Police) seems only to repeat what needed to be done. Comment: the delay in completing (clear and sensible) tasks specified in supervision may have reflected overload and/or lack of organisational skills or commitment by SW4 and/or the fact he left during the course of this assessment. The work was then allocated to SW5 (who also failed to liaise with Probation and the health visiting service). 4.5.4 A phone call to the maternal aunt of mother confirmed her familiarity with Zara’s mother from the age of 3, and elicited the advice that the MGM was in Spain and would not want to know about her daughter or granddaughter. Mother’s contact details were provided. 4.5.5 Mother’s aunt reported that Zara’s mother was not drug or alcohol dependent but was in with the ‘wrong crowd’. A home visit later that day by SW5 found her in the company of a female who was described as her best friend. 31 4.5.6 Zara was observed to be comfortable and have a good relationship with her mother. The child was observed to be able to communicate very clearly. Mother indicated that she was awaiting confirmation from the Police about charges arising from her visit to Zara’s father in prison. Mother referred also to her daughter’s use of a nursery ‘until she had graduated from College’. Comment: the record is written in a manner that suggests mother had at that point graduated and that the need for and use of a nursery had consequently gone. In fact mother did not and has not gained any further / higher or vocational qualifications. Concerns about drug and alcohol misuse in the flat seem not to have been raised. 4.5.7 On 11.02.12 medical centre 4 wrote to SW4 to confirm that Zara was a registered patient though had not been seen at the Practice and that there was no known ‘PMH’ [presumed to mean ‘previous medical history] Comment: it is unclear whether the acronym PMH was used in real time in the letter or just in the development of the chronology for this SCR; either way, it represents an unhelpful obstacle to clear inter-agency communication since many non-medical recipients would not be familiar with the term. 4.5.8 The IMR from hospital 1 confirmed that the Police notification about mother’s attempt to convey illicit articles into Wandsworth person was sent also to medical centre 4. Comment: No record of receipt or of a subsequent communication between an unnamed duty health visitor and an aunt of mother was inputted to the agency’s database (though paper records exist). 4.5.9 SW5’s supervision in mid-March 2012 reaffirmed the need to complete the tasks begun by SW4. An additional need identified at this point was that of an unannounced home visit. SW5 tried to visit mother at home later that day but got no response and left a letter inviting mother and Zara into the office. It would appear that this was followed up by a further letter and a successful home visit on 22.03.12. Comment: the home visit was by appointment not unannounced. CASE CLOSURE BY CHILDREN’S SOCIAL CARE & FURTHER EVENTS 4.5.10 A closing summary in late March 2012 confirmed a belated referral to health visiting services, an understanding Zara would be attending (an unnamed) nursery and is reported to have included advice to mother not to engage with friends who abuse drugs and alcohol. SW5 in a phone conversation with GP8 that day, was informed about the overdue immunisations. 4.5.11 A manager TM4 ratified SW5’s recommendation for case closure and mother was (in accordance with best practice) informed in writing and provided with a copy of the completed assessment. Comment: the IMR author pointed out that in spite of tasks specified by the manager in supervision with SW4 and SW5, neither had informed the health visiting service of the assessment whilst it was being conducted or sought information from that source. HV4 was sent a copy of the completed assessment. She does not recall seeing it and it was not inputted to Rio. 32 4.5.12 Children’s Social Care received a prompt response from HV4 who undertook to follow up the health-related issues with Zara’s mother (though no record of this conversation was found on Rio). At about this time mother dropped in to a local Montessori nursery and completed a registration form. She claimed she would be attending [a named] College but failed to make any further contact. 4.5.13 Approximately 2 months after case closure, PO6 sought information for his court report about father. ICW3 cited the previous contacts i.e. the agency had been involved in a pre-birth assessment of mother who lived in supported accommodation for under 18 year olds; that she had the support of MGM and appeared to be coping well with Zara. ICW3 also confirmed the case was closed following safeguarding concerns explored and resolved in January of drug and alcohol misuse at the home address. 4.5.14 Probation records indicate father’s history of drug misuse had been previously shared with relevant agencies. It seems though that details of current offences in particular children witnessing robberies, was not shared. Comment: by mid-2012 the level of support being provided from MGM to Zara’s mother would have been unknown. The fact children were present when their mothers were assaulted / robbed could have informed thinking by Children’s Social Care. 4.5.15 Though not of direct relevance to mother or child Zara, a friend called Police from the home address on 14.04.12 to inform Police of her assault by a boyfriend. The male concerned was arrested at another location. 4.5.16 By May 2012, an un-attributed suggestion is that the home address was being used by Tooting gang members for purposes of class A drug supply. ZARA FOUND IN STREET 4.5.17 A further significant incident occurred in early June 2012 when Zara (then 3.5 years old) was found by a neighbour wandering the street unaccompanied. The explanation provided by Zara was consistent with that offered by mother and her aunt with whom Zara had been left. 4.5.18 Because there had been 3 previous assessments, the manager decided to instigate an assessment and, according to its conclusions consider the need for a transfer to a child in need (CIN) team for ongoing support. The case was allocated to SW6. Comment: the decision by the manager was a commendably cautious one that took account of known history. The need to treat the incident seriously had also been reinforced in a supervision session at which time the possibility of an initial child protection conference was mooted. 4.5.19 A planned home visit had been cancelled because SW6 had been delayed and she instead met in the office with the mother of Zara and her aunt. A credible explanation of how Zara had managed to exit the house was provided. Zara was noted to be a chatty and engaging child about whom no other concerns were recorded. A phone conversation with HV4 elicited the facts that she had last seen Zara in August 2011 and had had no concerns. HV4 reported that Zara had had her primary immunisations and ‘just needed pre-school boosters’ so as to be fully up to date 33 Comment: the response to the Police notification was justified and proportionate and conclusions drawn about the incident within reasonable limits and therefore justified. In that almost a year had elapsed since her last sighting of Zara, HV4’s observation could offer only partial reassurance. 4.5.20 Presumably triggered by SW6’s contact, opportunistic visits were made by an unnamed medical centre 4 duty health visitor. A letter was also later sent inviting mother to make an appointment for Zara and providing times of clinics. Rio was not updated with the Merlin received from MPS but a health review was booked for 31.12.12. 4.5.21 On 19.07.12, a member of staff at nursery 1 (a friend of Zara’s mother and ‘Godmother’ to Zara) asked for an application form. A subsequent response from the nursery thanked mother for returning the waiting list application and offered a 3 year old grant-funded place from September 2012 on 3 afternoons a week term time only. Comment: a Godmother for a nominally Moslem child seems unusual. The same staff member was amongst those authorised to collect Zara from nursery implying a trusting relationship with mother. 4.5.22 The case was formally closed to Children’s Social Care on 30.07.12. IMPRISONMENT OF ZARA’S FATHER 4.5.23 A pre-sentence report dated 31.07.12 by PO6 assessed the ‘risk to children’ represented by Zara’s father’s offending as ‘low’. He made reference to the information provided by SW2 at hospital 1 in 2010 and the more recent notification of case closure. Comment: it seems likely that the ‘risk to children’ evaluation did not address the possible physical and probable psychological impact of seeing one’s mother violently assaulted and robbed [the method favoured by father and his associates was to target visibly wealthy women, some pregnant, who were additionally vulnerable because they were accompanied by children]. 4.5.24 The father of Zara was sentenced in September to an extended sentence for public protection which took account of robberies committed during the period of his relationship with Zara’s mother [he asked for 256 other offences including an attack on a Post Office van to be taken into account when being sentenced]. 4.5.25 Meanwhile, Zara had begun part-time attendance at nursery 1 (by November this had become full-time because mother said she would be attending college). The arrangement ended in late November when Zara was withdrawn with unpaid fees of £416. 4.5.26 Staff at this nursery have reported Zara presented as a very tall and mature child who was well cared for and wore designer clothes. Good interactions between her and mother were observed. Mother although reserved in manner, was articulate and appeared affluent. 4.5.27 Zara herself was described as strong willed having good listening skills and very chatty, a bit of ‘Tom boy’, independent, full of life, active and outgoing; a child who did not cry. 4.5.28 Mother had picked up her daughter only during her first week at this nursery; thereafter Zara was taken home by staff member nursery worker 1. Staff report that they did not know about Zara’s paternity or that her father was imprisoned at this time. 34 Comment: there were no aspects of Zara’s appearance or behaviour or her relationship with mother that should have aroused any concerns, though the fact that staff were unaware of the identify of Zara’s father or that he was in prison is surprising. 4.5.29 A review at the end of October at medical centre 4 flagged up that Zara’s immunisations were still not up to date. The health visiting service was alerted and reported on the several unsuccessful attempts to contact Zara’s mother. Comment: the administrative system for acting upon overdue immunisations seemed to work well. PRESENTATION AT URGENT CARE CENTRE 4.5.30 On early November 2012 Zara was brought to the paediatric urgent care centre by MGM because of abdominal pain and headaches. Paracetamol reduced the level of reported pain and Zara was discharged. Records of this visit indicated that Zara was now registered with a GP and that immunisations were up to date. Comment: this may have been an example of a clinician accepting at face value what an apparently reliable and concerned caregiver was saying. 4.6 5TH YEAR OF ZARA’S LIFE: DECEMBER 2012 - INCIDENT IN MARCH 2013 4.6.1 In early January 2013, a review at medical centre 4 picked up that Zara was not yet on a list for a school. Her mother was noted to be registered with a GP in a [named] area (it was actually medical centre 2) and the difficulty in making contact noted. A plan to contact ‘Schools Admission Service’ and to liaise with involved health professionals was made and followed up in an email to HV4. She in turn sought and obtained confirmation of mother’s current address from Children’s Social Care where a manager subsequently determined ‘no further action’. Comment: such a review was useful but partly misinformed in that mother had been registered at medical centre 4 since 06.07.12. That centre was able to supply an email address for mother as her mobile number no longer supported calls, texts or voicemails. SUSPICIOUS CHARITY COLLECTION 4.6.2 In early January 2012 mother and an un-named male were stopped by Police whilst acting as charity collectors for ‘Kids Integrated Cancer Treatment’ (a genuine registered charity). Both were wearing purple jackets carrying a logo and had collection boxes. Neither possessed accreditation. Aside from a warning, no further action was taken. 4.6.3 By the middle of that month increasing levels of rent arrears triggered the serving of a ’notice of seeking possession’. Next day Zara’s mother called the Rent Collection Service and reported that she had a baby, was working part-time and that her Housing Benefit had been cancelled. She was advised to initiate a new claim and keep the office informed. Comment: no IMRs have confirmed that mother was in work of any description. It is uncertain whether the term ‘baby’ referred to Zara or whether mother was seeking to deceive. 35 4.6.4 Liaison between staff at the prison where father had begun his sentence and local Probation staff identified as a central part of his ‘sentence plan’ the objective of maintaining contact with family. Zara’s father reported regular contact with his family. Comment: it is unclear if this referred to his mother and/or to Zara and her mother. 4.6.5 Following an introductory visit at which her father’s imprisonment and Zara’s visits to him were acknowledged, Zara started to attend on an afternoon-only basis a nursery class at nursery 2. Zara’s attendance rate diminished over the following 6 weeks and some 4 days before the incident triggering this SCR, she ceased attending. 4.6.6 Staff reported that, aside from mother, 3 other adults (including MGM) were authorised by mother to collect Zara. Zara herself was described by staff as being popular, having a strong character, leading the play of others and one who was missed even months after her withdrawal. Staff were unaware of Zara’s previous attendance at nursery 1. Comment: as was the case at her previous nursery, no aspect of mother or child’s appearance or behaviour aroused any concerns or suspicions. A passing reference by mother of previous use for a year of a fee-paying Montessori nursery was checked during the course of the SCR. She had been offered but failed to take up a place. 4.6.7 By 08.03.13 Children’s Social Care had been notified of the pending court proceedings and an (unnamed) initial contact worker was asked to respond and offer advice. An attempt to advocate for mother was unsuccessful and this was relayed to her by phone. Mother’s proposal to pay £20 per week toward arrears and submit fresh Housing Benefit claim was noted and passed on to the Rent Collection Service. The duty task was then considered completed and no further role identified for Children’s Social Care. 4.6.8 The Police IMR revealed that child Zara apparently fell over and grazed her knee whilst taking MGM’s dog for a walk after nursery of 21.03.13. The injury was reported to have appeared trivial. However, Zara later complained to MGM twice that day and again on 22.03.13 that she had a stomach ache. 4.6.9 The Police report also relays detail of importance to the issue of culpability for the injury suffered by child Zara. The following analysis in this report however, has relayed and addresses only those issues that reflect the services offered and provided to Zara and her family. 4.6.10 A&E PRESENTATION 4.6.11 Zara was taken to A&E at hospital 1 on 26.03.13 and subsequently admitted with a perforated duodenum thought likely by medical staff to have been caused by trauma. The safeguarding nurse notified Children’s Social Care and medical centre 4 was sent written confirmation. 4.6.12 Discussions between Police and attending registrar at the Paediatric Intensive Care Unit (PICU) noted the preceding 24 hour history – ‘Zara said to have complained of stomach pain and vomited; no external trauma, 1 small mark in the middle of her back and another behind an ear; ? small vaginal discharge (swabs from surgery and from examination sent for analysis)’. 36 4.6.13 Upon notification of the incident Children’s Social Care liaised with the Rent Collection Service and recovery of rent arrears action was suspended. 2 weeks later on SW7 from hospital 1 contacted the Rent Collection Service, referred to what was recorded as a ‘chest injury’ and said Zara would be in hospital for some weeks to come. She indicated mother had not caused the injuries but that there were going to be legal proceedings and mother and Zara might need to leave their current address. 4.6.14 SW7 also indicated that mother and Zara had not anyway been living there ‘due to safety issues’, so that mother would not have been receiving her post. SW7 was asked to prompt mother to initiate a Housing Benefit claim. The unnamed rent collection officer (RCO) asked to be kept informed and subsequently left a message for SW7 on 12.04.13 to which she received no response. Comment: aside from the anatomical inaccuracy with respect to the injury, the term ‘safety issues’ reportedly used by SW7 had no meaning without explanation. A failure to respond to a message suggests poor individual practice. 4.6.15 The RCO persisted in her attempt to get an update and on 19.04.13 reached SW7 who informed her that a SW8 was now allocated and that legal proceedings had begun, SW7 agreed to ask SW8 to liaise with the rent collection officer. 4.6.16 Medical centre 4 received a phone call on 23.04.13 from a SW10 who confirmed that Zara’s injuries were considered non-accidental and were being investigated by Police. Zara, now subject of an interim Care Order, was to be discharged to a foster home. Comment: it is presumed that SW10 was a member of hospital 1. 4.6.17 The rent collection officer emailed SW8 on 24.04.13 and confirmed that because mother had not been awarded Housing Benefit and has paid nothing toward her rent debt, legal action was planned to recover monies owed. 37 5 ANALYSIS 5.1 INTRODUCTION 5.1.1 Section 5 addresses each element of what are regarded as generic terms of reference for SCRs and then the case-specific ones identified by the SCR panel. It then lists a number of missed opportunities for what could have been ‘best practice’. 5.1.2 Naturally the degree of relevance of each of the 11 elements of the main terms of reference varies across agencies with the result that for some, the comment made is very brief. 5.2 WHAT WERE THE KEY RELEVANT OPPORTUNITIES FOR ASSESSMENT? IF OPPORTUNITIES WERE MISSED PLEASE STATE WHAT THEY WERE & YOUR UNDERSTANDING OF WHY THEY WERE MISSED. Education & Early Years 5.2.1 The opportunities for action by Education Services in mother’s final (poorly attended) year of statutory education were very limited. The approaches taken e.g. part-time and alternative schooling were reasonable responses, though they failed. In the circumstances, the proceedings initiated by the Education Welfare Service were justified albeit also ineffective. 5.2.2 With respect to Zara’s time-limited attendance at nursery 1 and nursery 2, feedback from staff confirm the formal records that indicate nothing of significance emerging. 5.2.3 Nursery staff would have had no knowledge of any previous Children’s Social Care involvement and poor or erratic attendance for a pre-statutory school age child would not of itself prompt sufficient concern to prompt action. 5.2.4 As indicated earlier, it would be helpful for those arranging admission to early years provision to agree with a parent (when relevant) why a child had not received all recommended immunisations and what information e.g. an absent father, could be shared with those staff dealing with a child; also that admitting staff ensure they receive or seek from known previous settings information of relevance to current care and education. 5.2.5 The recommendations in section 7 reflect the above needs. Children’s Social Care 5.2.6 The IMR author counted 6 significant referrals all leading to an assessment, though only the first led to any service or plan. Each assessment the author noted, was focused on a particular incident and did not reflect adequately on the pre-existing records i.e. no cumulative picture of mother or Zara’s life emerged. 5.2.7 The 3 assessments that were undertaken in 2011 / 2012 all concluded that if there were further concerns s.47 enquiries would be considered. In the event, no such action was taken and the IMR author was unable from records found to discern why not. 38 5.2.8 What was lacking in each assessment was an analysis of the known or suspected facts e.g. the significance of the radically changed personal circumstances of mother. The IMR author wondered if this was a function of the involvement of an initial contact worker rather than a social worker. However, the failure in early 2008 to complete the then scheduled core assessment involved a social worker and a manager which suggests a more systemic issue of ‘limited expectations’. 5.2.9 The price paid for not completing an effective core assessment was insufficient understanding of her needs at a time before mother’s life was rendered even more complicated by pregnancy and Zara’s birth. 5.2.10 The pre-birth initial assessment was based on very limited contact with mother, minimal information about father and was unduly optimistic in its conclusions. 5.2.11 The 3rd assessment led by a student social worker was characterised by the IMR author as more about support than assessment and took over 4 months to ‘complete’. The significance of the tension between mother and MGM and father’s behaviours and anticipated role remained unaddressed. 5.2.12 The remaining 3 assessments were responses to MPS notifications and mother’s powers of persuasion seemed to be enough for an acceptance that the grounds for concern were erroneous. The IMR author cites Brandon et al 2005 [see bibliography] who in their biennial evaluation of SCRs referred to a tendency to accept parental assurances rather than exercise professional judgments. 5.2.13 The chance to challenge mother’s inaccurate assertion she had no health visitor and was at a disadvantage in sorting out Zara’s pre-school booster, was lost in January 2012 when neither SW4 or SW5 complied with the manager’s instruction to contact the health visitor. Health Visiting 5.2.14 Early assessments were deemed sufficient and adequate but later the significance of mother’s apparent compliance may have been underestimated as a result of her assertive presentation. Housing Service 5.2.15 The assessment of entitlement to accommodation in early 2008 was managed effectively in close collaboration with the Diversion team of Children’s Social Care. 5.2.16 When the Rent Collection Service referred mother in May 2011 with a view to being offered ‘tenancy support’, the response of 3 attempts to make contact was consistent with the policy in place at the time. Rent Collection Service 5.2.17 This service, when contemplating eviction in 2011 initiated an appropriate referral to the tenancy support service within Housing. The service also showed sensitivity and persistence in April 2013 when it was seeking to re-assess its next steps following the incident leading to this SCR. 39 Hospital 2 5.2.18 The vulnerability of mother spelt out by GP1 in his referral to this hospital was not reflected in ante-natal records subsequently maintained. However, the recognition that as a consequence of mother’s age and circumstances, a pre-discharge meeting was required was commendable. Probation 5.2.19 The types of assessments of the father of Zara accorded with the Probation Trust’s expectations at the time but there was scope for improving the quality of some. 5.2.20 The records maintained of family contact (in person and by phone) did not adequately distinguish contact by mother or by Zara. 5.2.21 PO7’s assessment of father’s risk to children as ‘medium’ is considered an underestimate and on the basis of the details of the robberies justifies a ‘high risk’ rating. 5.2.22 The IMR provided acknowledges that in February 2013 when PO7 formulated her ‘start custody’ assessment (a requirement for an offender assessed as high risk of serious harm to the public and serving a custodial sentence of more than 12 months) she did not seek a further update from Children’s Social Care. This would have enabled the question of potential risk associated with his contact with Zara to have been explored. 5.2.23 Feedback from the prison concerned has subsequently provided reassurance that the potential risk has been assessed in accordance with that institution’s ‘public protection manual’ and that because contact is supervised, no restrictions are required. Police 5.2.24 Each occasion officers had contact with mother and/or Zara represented at least a potential opportunity for an assessment of need. They responded appropriately on each occasion. GP Service 5.2.25 The initial assessment of need by GP1 in October 2007 was thorough and child-focused and informed timely referrals to CAMHS and to Children’s Social Care 5.2.26 Initial follow-up was also good but confirmation that mother had failed to use the offer of help from CAMHS did not prompt a formal review with her or her family and uncertainty about mother’s psychological and social needs remained. 5.2.27 The referral for ante-natal care in May 2008 was accurate and sensitive and the primary responsibility for initiating liaison and shared care lay with the hospital. Nonetheless the medical centre might (ideally) have reviewed the case and sought an explanation for the absence of feedback from hospital 2. 5.2.28 Zara’s 8 week check in early 2009 offered an opportunity that was not fully exploited to recognise and respond to a very young mother in temporary accommodation with her baby’s father in prison. The possibility of a review of Zara following the drugs raid in July 2001 was not pursued. 40 5.3 WAS CONSIDERATION GIVEN TO THE IMPACT OF CULTURAL / RACIAL & OTHER EQUALITIES ISSUES IN ANY ASSESSMENTS? Education & Early Years 5.3.1 Though such details may have been captured by the settings concerned, the IMR supplied did not confirm that Zara’s ethnic origin or ascribed religion was known to staff at nursery 1 or nursery 2. Children’s Social Care 5.3.2 The ethnicity of Zara’s father was not captured in any of the assessments undertaken and the significance of his family’s origins, experiences and their religious affiliations and how these might impact on behaviours remained un-explored. 5.3.3 Mother’s stated intention that Zara (to be coached by her father upon release from prison) would be raised as a Muslim was not addressed at the time nor when mother later claimed that her relationship with Zara’s father was over. 5.3.4 Mother’s stated determination that her daughter should live in a better area than their current accommodation also remained un-explored. The IMR indicates that (possibly reflecting her own affluent upbringing) mother did not want Zara playing with local children. Observations of the nursery staff were that Zara experienced no difficulty or maternally-imposed constraint in relating to peers, but mother’s aspirations and what she was prepared to do to achieve them would have been a productive avenue to explore. Health Visiting Service 5.3.5 Records confirm mother is of White British origin and comes from an affluent background; child Zara’s father was of dual heritage (White/African Caribbean) and a Muslim. According to her mother, Zara was to be raised as a Muslim. The IMR provided does not explain how the services were influenced by this knowledge of ethnicity, culture or Faith. At his meeting with the author, Zara’s father acknowledged that his commitment to his Faith was limited. Housing Service 5.3.6 Whilst the services provided (offers of accommodation and ‘tenancy support’ to sustain it) were generally provided in an efficient manner, no evidence has emerged to indicate any particular recognition of needs associated with ethnic or cultural origins. 5.3.7 The question of needs related to gang affiliation or avoidance is addressed below. Rent Collection Service 5.3.8 In April 2011 the Rent Collection Service appropriately sought confirmation of any ongoing involvement of Children’s Social Care. The possibility of mother’s fear of gang-related responses became apparent to this Service only in April 2013 (after the incident that triggered this SCR) when mother reported that she had not been living at her allocated property. 41 Hospital 2 5.3.9 The records kept by staff and evaluated by the IMR provided, suggest no appreciation of the significance of the ethnic or broader cultural origins of mother or daughter. Probation 5.3.10 With respect to the agency’s work with Zara’s father, Probation’s records initially mis-recorded his ethnicity as ‘Chinese and no Faith’ before correcting it to ‘dual heritage White British / Black Caribbean and Muslim’. Nothing seen suggests that the significance of his ethnicity or Faith was sufficiently recognised or addressed with him e.g. how did he personally reconcile his Islamic Faith with the crimes he committed? Police 5.3.11 There is no indication that issues of race or culture impacted upon responses given. Police actions with respect to Zara’s father were entirely a function of the extensive investigations of the many serious crimes it is now known he committed whilst in a relationship with the mother of child Zara. GP Service 5.3.12 Nothing in the medical records suggests an appreciation of how the racial or cultural origins, beliefs and practices or experiences of MGM, mother or Zara’s father might have been impacting, or might in the future impact upon their behaviour or personal development 5.4 DO ASSESSMENTS & DECISIONS APPEAR TO HAVE BEEN REACHED IN AN INFORMED & PROFESSIONAL WAY? Education & Early Years 5.4.1 Both nurseries clearly had and were able to share comprehensive accounts of Zara’s attendance, appearance and behaviours whilst in those settings. Children’s Social Care 5.4.2 As detailed in section 5.2 above, the consistent weakness in all assessments undertaken by Children’s Social Care was a near-exclusive focus on the here and now, rather than considering events in their historical context coupled with an unquestioning overdependence on mother’s responses. Health Visiting Service 5.4.3 The failure by a health visitor in Tooting in March 2012 to record the Children’s Social Care assessment and her discussions will have reduced the value of the electronic records for future users. 5.4.4 Similarly, the later failure to record the MPS notification (Merlin) received in June of that year reduced the accuracy and validity of the records 42 Housing Service 5.4.5 Housing Service determinations of need and co-ordination of provision appear to have been completed in an informed and professional manner consistent with current policies. Rent Collection Service 5.4.6 Officers from this service acted in an informed and professional manner, were clear about their central task and liaised as required with colleagues in Housing and Children’s Social Care. Hospital 2 5.4.7 Following Zara’s presentation at paediatric A&E in August 2012 the opportunity for exploration with mother and liaison with the relevant health visitor about overdue immunisations, lack of GP and father being in prison was not taken. Probation 5.4.8 The ‘pre-sentence report’ of July 2012 should have evaluated Zara’s father as more than ‘low’ risk to children and the ‘start custody’ report of February 2013 should, given what was known of the family have included a complete risk screening and analysis section reflecting that knowledge and assessing risk to children including Zara. Police 5.4.9 All actions within the chronology supplied and explained in the Police IMR appear to have been informed by the information available at the time and shared appropriately when in the interests of safeguarding child Zara or others. GP Service 5.4.10 The assessment of mother when in the care of MGM was an informed and thorough one. The ability of those GPs to contribute further was constrained by the absence of feedback from hospital 2 or Children’s Social Care and the IMR supplied notes that no post-natal assessment of risk or post-natal depression was recorded. 5.5 DID ACTIONS ACCORD WITH ASSESSMENTS & DECISIONS MADE? Education & Early Years 5.5.1 Nursery 1 and nursery 2 acted in accordance with the (unremarkable) needs of Zara. The recommended changes to practice in section 7 do not represent a criticism of their good work; rather an opportunity to further enhance it. Children’s Social Care 5.5.2 There were several examples where actions did not follow decisions or assessments e.g: A 5 week delay at hospital 1 social work team between the decision to initiate an ‘initial assessment’ and actually doing so 43 A period of almost 5 months to complete that initial assessment (the required time limit was then 7 working days) and a conclusion at odds with the needs described in it The failure of SW2 to write up her student’s initial assessment begun following the birth of Zara An unexplained delay in June 2009 for SW2 to respond to PO2’s request for information about father The failure of SW2 to record her (out of date) reassurance to PO2 in March 2010 that there were no concerns about Zara in her mother’s care The check by a service manager in May 2010 revealed a number of tasks that should have been / still needed to be completed before case closure (no proof has been found that the tasks were then completed) Following mother’s arrest in January 2012 SW4 and SW5 failed to liaise with Probation and health visiting services as instructed by the manager Health Visiting Service 5.5.3 The failure to input the MPS notification of mother’s attempt to convey illicit articles into prison served to reduce the value of the electronic records for subsequent users. Housing Service 5.5.4 The only exception to what was otherwise efficient and effective service delivery was overlooking the need to offer tenancy support to mother (then aged less than 18). The oversight made no difference in practice to mother and Zara. The IMR reports that a subsequent recent policy shift has extended the age range and increased the reliability with which those who are eligible are identified. Rent Collection Service 5.5.5 The limited involvement of this service indicates that all their actions were in accordance with assessments and decisions made. Hospital 2 5.5.6 In the ante-natal period, the hospital failed to engage with the referring medical centre 1. Post-natally, although mother’s discharge was handled carefully, there was further scope for involvement of health visiting colleagues in the community. 5.5.7 Further contacts led to responses that accorded with assessments of need. Probation 5.5.8 The potential for heightened recognition of potential risk to children within assessments completed by Probation staff has been outlined above Police 5.5.9 Decisions made by the Police followed logically from assessments made by officers. The author has no criticism of the manner in which this was done. 44 GP Services 5.5.10 Assessments made by GPs involved generally resulted in appropriate actions and decision making although there was an apparent lack of response at medical centre 2 to do more than alert health visitors to the domestic situation reported at the post natal check. 5.5.11 At medical centre 4, there could have been a more prompt follow up on the information provided at registration that Zara was behind on her immunisations or to ‘code’ the concerns that were reported by Children’s Social Care. 5.6 WERE APPROPRIATE SERVICES OFFERED / PROVIDED OR RELEVANT ENQUIRIES MADE, IN LIGHT OF ASSESSMENTS? Education & Early Years 5.6.1 Services provided by both nursery 1 and nursery 2 were entirely appropriate. Children’s Social Care 5.6.2 The initial collaborative approach between Children’s Social Care and Housing in response to mother’s request for accommodation was commendable. IMRs provided have not included the detail of precisely what mother sought and how the distinction was drawn between a need for somewhere to live versus a potential need to be accommodated under the provisions of s.20 Children Act 1989 (and becoming a looked after child with associated ‘after care’ advantages). 5.6.3 The critical difference between each status was spelled out the following year in the ‘Southwark Judgement’ R (On the Application of G (FC) (Appellant) v London Borough of Southwark (Respondents) 2009. Insofar as the evidence supplied refers to no disagreement between MGM, mother and both Wandsworth Departments about the nature of need, it is assumed that there was a consensus that mother merely required somewhere to live independently. 5.6.4 The subsequent vulnerability of mother and later her daughter casts doubt on the presumption that mother was ready to cope with the level of independence implied by forms of accommodation provided. Also assessments undertaken in 2009 should have anticipated and explored the implications of the anticipated release from prison of Zara’s father. 5.6.5 The response to notification of the Police raid in June 2011 (including confirmation of Zara’s exposure to Class A drugs and mother’s arrest) was rightly upgraded to a core assessment (though not re-defined as one being undertaken under s.47). The assessment seems to have been closed off with insufficient challenge about the immediate and indirect risks to Zara of exposure to drugs and drug dealers. Health Visiting 5.6.6 The provision of effective health visiting services was inevitably rendered more difficult because of mother’s initially frequent moves, changes of GP registration for herself and for Zara and by mother’s ongoing unreliability in responding to offers of help. 45 5.6.7 However, it appears that those difficulties were compounded by organisational change and consequent muddle which is reflected in the IMR provided. Had the level of confusion been less, it seems likely that the overall health visiting service offered (though possibly not accepted by mother) would have been of a better quality, Housing Services 5.6.8 There were few opportunities for improvements in the services provided by or via the Housing Department. Arguably, further advice might have been sought when mother claimed to be in fear of violence from a local female gang Rent Collection Service 5.6.9 The actions of rent collection officers were consistent with the functions of that service and showed an appropriate sensitivity following the trauma experience by Zara in March 2013. Hospital 2 5.6.10 The ante-natal services provided to mother were appropriate (the failure to liaise with medical centre 1 is commented upon elsewhere). 5.6.11 It remains uncertain whether reassurances provided by MGM at the visit to the urgent care centre on 08.11.12 about Zara being up to date with immunisations were accurate. Probation 5.6.12 Appropriate forms of assessment were applied on the several occasions that the courts required advice or information. Missed opportunities for making some of those assessments more precise and child focused are commented upon elsewhere. Police 5.6.13 Responses made followed appropriately from the facts as they were known at the time. GP Services 5.6.14 GP assessments resulted in referrals to CAMHS, Children’s Social Care and antenatal care for mother, all which resulted in appropriate services being offered. 5.6.15 At the postnatal check it was established that mother and Zara remained vulnerable but the only action initiated at that point was to ask health visitors to follow up. 5.6.16 It is a matter of speculation what might have been possible with more multi agency collaboration. The fact that there was no feedback from Children’s Social Care or from Midwifery to inform a more thorough risk assessment and that this information was not actively sought by GP was characterised by the IMR author as relative ‘blind spot’. 46 5.7 WERE PRACTITIONERS AWARE OF & SENSITIVE TO THE NEEDS OF THE CHILD IN THEIR WORK? HOW DID PRACTITIONERS ESTABLISH THE CHILD’S VIEW ABOUT WHAT WAS HAPPENING IN HER LIFE & HOW WAS THIS RECORDED? Education & Early Years 5.7.1 The descriptions of Zara relayed by the IMR author and provided directly at the practitioners’ learning events by staff who worked with the child, offer reassurance that Zara was developing normally and manifesting no signs of abuse or neglect. Descriptive records including a photograph illustrate a pretty, confident and popular child always well-presented and exhibiting no more reserve about family than many others. 5.7.2 Unless specifically commissioned e.g. following a child protection conference, staff should not ‘push’ a child to reveal more about home than s/he might do spontaneously. Children’s Social Care 5.7.3 The independent IMR author acknowledged and commended the fact that when MGM first sought help from the agency, mother (then aged 15) was given an opportunity to be seen alone. The focus on and to some extent sympathy for her was subsequently lost at the time of the unsuccessful family group conference. The IMR author also formed the view that the circumstances in which Zara was living and her needs were effectively lost in the assessments undertaken following her birth e.g. The initial assessment immediately after Zara was born failed to explore mother’s reasons for quitting her property nor explore the suitability for Zara of her father’s home The core assessment following the drugs raid did not challenge mother’s denials and address head-on the life –threatening exposure of her daughter to Class A drugs or the associated chronic risks if mother and/or her boyfriend and associate were dealing Consideration of the potential for Zara to lose her mother if she were to be imprisoned for attempting to convey illicit articles into prison was subverted by mother’s blunt denial of culpability 5.7.4 The day to day experiences of Zara e.g. how often did she stay with her mother’s aunt, how often did she see her father (in and out of prison) do not emerge from any assessments and it seems that Zara was never spoken to alone. 5.7.5 All agencies agreed that Zara related positively to her mother but the IMR author refers to the need (in addition to offering good enough physical care) also for ‘reflective functioning’ in a good parent i.e. a capacity to keep the emotional needs of her/his child in mind and to be empathetic to her/his feelings. 5.7.6 Mother’s criminal behaviours and association with serious offenders suggest that her own needs often outweighed her ability to award priority to those of her daughter. 47 Health visiting 5.7.7 The fragmentation of health visiting services across place and time significantly reduced the extent to which any one health visitor was able to get to know Zara and evaluate what impact her mother’s chosen lifestyle was having on her and whether there were explicit indicators of risk that required action. 5.7.8 The current national approach of corporate caseloads further reduces the probability of a relationship-based service and critically depends upon accurate evaluation of need / risk in attributing families to the 3 categories that now exist viz: ‘universal’, ‘universal plus’ and ‘universal partnership plus’. Housing Services 5.7.9 The opportunity for sensitivity to the needs of mother (still technically a child until 18) and later Zara were limited to the provision of suitable accommodation. In spite of mother’s abandonment of some, she never produced evidence to support her contention that what was provided was unsuitable. Rent Collection Service 5.7.10 This service showed sensitivity to Zara’s needs when it initiated contact with Children’s Social Care in early March 2013 and again in its exchanges after her assault later that month. Hospital 2 5.7.11 Whilst the individuals no doubt acted in good faith, the confusion that ensued around the time of Zara’s discharge from hospital remains insufficiently understood and was clearly not in Zara’s best interests. Probation 5.7.12 The primary focus of the Probation Service was naturally on Zara’s father. As indicated elsewhere in this overview, what may usefully be described as the ‘mind-set’ in relation to the notion of ‘risk to children’ was directed toward children in general rather than the narrower and more immediate issue of Zara or indeed the son father is reported to have claimed to have. Police 5.7.13 On each occasion that child Zara was present at an incident, the standard procedure for notifying Children’s Social Care was followed. GP Services 5.7.14 The sensitivity to the needs of a vulnerable child was more obvious when medical centre 1 was dealing with mother (then aged 15). The extent to which GPs pursued the lack off their involvement by hospital 2 pre and post-natally or the issue of overdue immunisations was reasonable but could (ideally) have been improved upon. 48 5.8 WERE PROFESSIONALS KNOWLEDGEABLE ABOUT THE POTENTIAL INDICATORS OF ABUSE OR NEGLECT & ABOUT WHAT TO DO IF THEY HAD CONCERNS ABOUT A CHILD’S WELFARE & WAS THIS EVIDENT IN THEIR PRACTICE? Education & Early Years 5.8.1 To the extent that an Ofsted evaluation may be regarded as a useful indicator, both nursery 1 and nursery 2 are rated ‘good’ and this would have included an evaluation of their safeguarding arrangements. 5.8.2 The ability in practice to discern and act upon suspected abuse or neglect was untested during the short periods that Zara attended (7 and 11 weeks respectively at nursery 1 and 2). Children’s Social Care 5.8.3 There are no indications that staff lacked knowledge of what to do in the event of clear indicators of abuse or neglect. The challenge presented in this case was that the indicators were not clear. 5.8.4 Given the context of what might be labelled ‘understandable uncertainty’ and the reasonable presumption that staff were busy enough and not seeking additional work, the best hope of the agency achieving a level of objectivity was through regular effective supervision. The nature and value of the supervision actually provided is explored below. Health visiting 5.8.5 The IMR provided to the SCR confirmed that staff were sufficiently trained and that protected time for supervision was available. However, the author’s experience of other comparable situations raises the question of the usefulness of supervision (regardless of its intrinsic quality) if it is only provided with respect to cases identified by the supervisee? 5.8.6 The dilemma is comparable to that observed in the evaluation of risk by probation officers (and discussed elsewhere). If the determination of threshold for discussion / supervision / ratification of a recommendation by a more senior colleague, remains with the less experienced, how does an agency ensure that less obvious but nonetheless high risk cases are nor overlooked or otherwise down-graded ? In other words, self-selected cases taken to safeguarding supervision may identify some but not all those which carry the highest risk of significant harm. Housing Services 5.8.7 The IMR of Housing-related services provides evidence that staff are sufficiently aware of indicators of abuse and neglect and that none emerged in the time mother spent in specialist mother and baby units. Rent Collection Service 5.8.8 This service initiated a check in April 2011 with the intention of establishing any ongoing contacts between Adults’ or Children’s Social Care and in the author’s view took sufficient account of safeguarding issues in their responses. 49 Hospital 2 5.8.9 Hospital 2 was formally committed to the London Child Protection Procedures and recognised the expectation of a pre-discharge meeting for this vulnerable young mother. 5.8.10 The extent to which the omission of the referring GPs and relevant health visitors was a function of misinformation provided by the family had yet to be determined. Probation 5.8.11 Staff initiated several contacts with Children’s Social Care from June 2009 onwards suggesting an awareness of required responses if there are concerns about a child’s welfare. 5.8.12 The IMR author was able to confirm the attendance of PO4 and P6 on safeguarding children training but was unable to confirm attendance by other colleagues. The recommendations in section 7 address this uncertainty. Police 5.8.13 The responses of officers indicate that they were aware of and acted upon indicators of neglect or abuse. GP Services 5.8.14 There is evidence that GP staff had knowledge and understanding of potential indicators of neglect and acted to address them e.g. the insufficiency of immunisations was conveyed to Children’s Social Care and health visitors. 5.8.15 GPs appear to have actively sought, been aware of and acted sensitively towards the needs of mother in the early period of this SCR. 5.8.16 There was though, insufficiently assertive outreach during mother’s pregnancy and in the postnatal period. 5.8.17 Zara appears to have been a ‘hidden child’ with whom GPs were unable to establish face to face contact. In the absence of direct contact little more could have been done to determine a response to mother’s lawful and not uncommon failure to ensure her daughter’s receipt of all recommended immunisations. 50 5.9 WERE SENIOR MANAGERS OR OTHER ORGANISATIONS & PROFESSIONALS INVOLVED AT POINTS IN THE CASE WHERE THEY SHOULD HAVE BEEN? WAS THERE SUFFICIENT MANAGEMENT ACCOUNTABILITY FOR DECISION MAKING? Education & Early Years 5.9.1 There was no occasion when involvement of a manager was required in either nursery. Children’s Social Care 5.9.2 All the assessments undertaken were signed off by a manager. None seemed to have discerned the extent to which their conclusions were rooted in mother’s denial of any responsibility for matters that had led to Police involvement. 5.9.3 The decision of more than one manager that any further concerns should lead to consideration of more formal safeguarding action was justifiable but was overlooked when the opportunity to do just that arose. 5.9.4 A multi-agency meeting could usefully have brought together and clarified mother’s chosen lifestyle and its current and future impact on Zara. 5.9.5 The IMR author believes that some current developments should serve to enhance quality of future assessments i.e. a new single assessment focused on professional judgement and the use of ‘signs of safety and of wellbeing’. 5.9.6 Without regard to the intrinsic values of these initiatives, monitoring by local managers and audits by more senior staff will remain necessary if sufficient quality is to be assured. Health visiting 5.9.7 In contrast to the arrangements within Children’s Social Care, unless a case is identified as being of particular concern, there is no requirement or expectation within health visiting services that it should be brought to supervision. Hence, until the incident in March 2013 Zara’s case had never been discussed with a more experienced and objective practitioner or manager. 5.9.8 The effectiveness of a system of ‘exception reporting’ is that it depends upon sufficiently complete and accurate records and having practitioners able to recognise and raise the cases that trigger their concern. In this instance some inadequacies and fragmentation of records and organisational muddle (transition from paper to electronic records and shifting lines of accountability) represented an unfavourable professional environment. Housing Services 5.9.9 The IMR provided confirmed that managers were involved at each required stage of the involvement of Housing Department staff. This SCR has highlighted a need for a review of the current expectation within the tenancy support service of a standard 3 attempts to contact a tenant. The intention is to develop an approach that better recognises the vulnerability of some young tenants and is especially alert to the potential need to engage other agencies if they are parenting a child. 51 Rent Collection Service 5.9.10 Managers were involved appropriately by the Rent Collection Service staff. Senior managers have though identified a need for further child protection training and for a procedural change such that cases where a concern has been identified will be regularly reviewed with senior managers. Hospital 2 5.9.11 The involvement of the safeguarding midwife at the time of Zara’s birth offers evidence of a readiness amongst staff at that time to involve more senior staff. The failure in the ante and post natal period to liaise with medical centre 1 remains unexplained. Probation 5.9.12 In accordance with policy, the decision to recall father to prison in 2011 was made by a senior manager. There were no other occasions when a manager was supposed to be consulted and was not. 5.9.13 Probation has a similar system to that which exists with health visiting services i.e. only if a case if considered ‘high risk’ must it be discussed with a senior colleague. Because father had been assessed as a ‘high risk’ to the public, both the ‘start custody’ and ‘pre-sentence reports of February and July 2012 respectively were countersigned by a senior probation officer. Earlier reports deeming father to be ‘low risk’ did not require countersignature by a manager. 5.9.14 The inbuilt weakness of such an arrangement is that if the level or nature of risk a client poses is underestimated by a practitioner, the potential check and balance that could be provided by a senior colleague is absent. 5.9.15 The IMR author illustrates this issue well when he suggests that the risk of serious harm to children in the pre-sentence report of July 2012 should have been more than ‘low’. Police 5.9.16 Until the serious assault that triggered this serious case review, incidents had not required the involvement of more senior managers. Though strictly beyond the scope of this review, it appears that senior officers have been involved in supervising and supporting the criminal investigation of Zara’s injuries. GP Services 5.9.17 GPs are self-employed and are not accountable to senior managers. Their contractual obligations to provide a service was (until April 2012) to the local Primary Care Trust and is since then to the ‘Local Area Teams’ of NHS England. Nothing in this SCR suggests any actions by GPs that were inconsistent with standard contractual arrangements. 52 5.10 WERE THERE ORGANISATIONAL DIFFICULTIES BEING EXPERIENCED WITHIN OR BETWEEN AGENCIES? WERE THESE DUE TO A LACK OF CAPACITY IN ONE OR MORE ORGANISATION? THERE AN ADEQUATE NUMBER OF STAFF IN POST? DID ANY RESOURCING ISSUES SUCH AS VACANT POSTS OR STAFF ON SICK LEAVE IMPACT ON THE CASE Education & Early Years 5.10.1 There were no operational difficulties with either involved nursery or between them and other agencies. Ofsted’s evaluation of both settings as ‘good’ suggests an adequate number of staff and the ability of those who worked directly with Zara to provide for the IMR author and at the practitioners’ events, a comprehensive and sensitive account suggests Zara’s early years experiences were very positive. Children’s Social Care 5.10.2 The IMR author who conducted some interviews for the purposes of compiling her report, and provided an opportunity to comment on the issue, was not made aware of any shortfall of staff or any comparable resource constraint within the settings involved. 5.10.3 Given the uncertainty about precisely when the case was closed, the author has though speculated about how clear a distinction there is between the role of the Referral & Assessment Team and that of the team within hospital 1? e.g. for how long is a case which is opened at hospital 1 dealt with from that team and at what point might it transfer elsewhere. Health Visiting 5.10.4 The IMR provided does not suggest that any absolute shortage of health visitors adversely impacted upon the service provided but does make it clear that the context in which staff from different locations operated was rendered more difficult by a (slow and varying across workplaces) transition from paper-based to electronic record keeping in 2008 and the re-structuring and re-allocation of accountabilities in 2010. 5.10.5 As highlighted by some practitioners interviewed, the position that still pertained at the time of their interview (but which has since been resolved) whereby a family could be allocated to more than 1 ‘cluster’ was a recipe for confusion. Housing Services 5.10.6 There is no suggestion within the IMR submitted or seen in the reports of others that there were any organisational difficulties or capacity-related constraints to the service provided by the Housing Department including its Tenancy Support function. Rent Collection Service 5.10.7 Nor is there any indication of organisational difficulties or capacity-related constraints with the Rent Collection Service. 53 Hospital 2 5.10.8 In the relatively brief and limited period of involvement of hospital 2, no shortage of resources or other organisational difficulty is believed to have constrained the actions taken. Probation 5.10.9 At his interview PO4 referred to a significant overload of work when he joined the agency in July 2010 and indicated that this explained the later delay in him contacting Children’s Social Care instructed by the senior probation officer in December of that year and to a failure to visit father at home. It should be noted that the senior probation officer does not agree with those views. 5.10.10 PO4 also referred to some difficulty in obtaining information from the local MPS Intelligence Unit but provided no examples from this case. It would therefore be wrong to draw any conclusions about this important example of inter-agency co-operation. Police 5.10.11 No resourcing difficulties were identified in the Police IMR and none is apparent from the whole picture that emerges from collation of all available material. GP Services 5.10.12 The GP IMR reports that until April 2012 there was no ‘named GP for child safeguarding’ (a formal role offering support and advice to GPs) and that this might have impacted upon the readiness or confidence of doctors to escalate their concerns. 5.10.13 The author agrees that the unfilled post represented a theoretical risk but has seen no evidence that it did in fact constrain the actions taken by involved GPs. 5.11 DID THE ORGANISATION HAVE IN PLACE POLICIES & PROCEDURES FOR SAFEGUARDING & PROMOTING THE WELFARE OF CHILDREN & ACTING ON CONCERNS; WAS THE PRACTITIONER AWARE OF THEIR EXISTENCE & WAS THE WORK IN THIS CASE CONSISTENT WITH EACH ORGANISATION & THE WSCB’S POLICY & PROCEDURES FOR SAFEGUARDING & PROMOTING THE WELFARE OF CHILDREN, & WITH WIDER PROFESSIONAL STANDARDS? 5.11.1 All the agencies involved were formally committed to the London Child Protection Procedures and no IMR has suggested that staff were insufficiently trained or aware of them. 5.11.2 The various lost opportunities identified by this SCR did not represent gross breaches of any lawful or procedural requirement; rather they reflected judgements being made on the basis of less than all potentially available information. 54 5.11.3 Some obstacles preventing access to the whole picture of Zara’s life were contextual / systemic and some more individual; they included: Poorly planned transitional arrangements within the health visiting service to support staff in the move from paper-based to electronic records and from traditional relationship-based health visiting to the phenomenon of ‘cluster working’ and ‘corporate caseloads’ – the net result being uncertainty about accountability Insufficient quality control within Children’s Social Care such that tasks identified at case closure-related audit as ‘incomplete’ could continue to be so A self-imposed constraint amongst probation officers limiting their consideration of the impact of father’s behaviours and accomplices on Zara’s welfare A traditional role distinction whereby even sensitive and caring GPs tend to be relatively passive and await incoming information 5.12 ADDITIONAL CASE-SPECIFIC ISSUES Were agencies aware of the mother’s lifestyle & connections with gang & criminal activities when making assessments of the child? 5.12.1 Mother was recognised by several agencies as different from other young mothers in local temporary accommodation. Though the impact on involved professionals of such factors was insufficiently explored, it seems likely that mother’s intelligence and an unusually good standard of education provided her with a level of confidence and articulacy which she applied to denying and diverting attention from a significant level of personal need. 5.12.2 Mother’s pursued her position on certain issues without regard to an absence of evidence (e.g. mice infestation of accommodation, threats from local gangs). She also bluntly denied events or allegations for which evidence did exist (shoplifting, attempting to smuggle illicit goods into prison, an awareness of drug and alcohol misuse by boyfriend and others). These observations illustrate her ability and tendency to block professional attempts to form open and honest relationship with her. 5.12.3 Her ability to argue for and obtain what she wanted e.g. accommodation was matched by her success in avoiding adverse consequences when she failed to act responsibly e.g. no payment of fees to the nurseries nor rent to the Housing Associations. 5.12.4 Aside from Police and Probation where Zara’s father was clearly the respective officers’ central concern, other agencies held very limited information about him and made little effort to find out more. Hence the GP on learning of mother’s pregnancy did not seek the identity, age or ethnicity of the father; similarly hospital 2 lacked curiosity about the paternity of Zara and what impact he might have on his daughter’s welfare; nursery 1 staff also remained unaware of the identity of Zara’s father or of the fact he was in prison. 5.12.5 This apparently widespread insufficiency of curiosity was reinforced by mother’s reluctance to acknowledge too much about Zara’s father. Given the duration (albeit interrupted by spells of incarceration) of their relationship, the large number of father’s crimes and the observed affluence implied by the way mother and Zara were dressed, it seems unlikely to Police and this author (though mother claims it to be so) that she was unaware of at least a proportion of her partner’s offences. 55 5.12.6 Clearly, mother would not have wanted to draw attention to her lifestyle and the ability to present herself and Zara well in social situations coupled with an observed disinclination to get involved at the nursery (where many young parents form significant and mutually supportive relationships) served her well. 5.12.7 Mother did cite a fear of a female gang in Summer 2010 but when asked by a generally attentive and efficient Housing Service produced no evidence to substantiate her stated fears. When asked by the author in the course of compiling this report, mother did not press her historic claim of a fear of gangs. The Police IMR confirms that none of the contacts with mother or her child reveal any link or association with gangs. 5.12.8 Even the Probation Service with its focus on Zara’s father remained unaware of any gang affiliation Zara’s father had / has. 5.12.9 The net result of all the contacts and assessments completed is that there was insufficient exploration of the way mother and Zara were living, no agency knew or indeed knows now to what extent it was being financed or otherwise shaped by drug dealing. 5.12.10 In hindsight, a multi-agency meeting could have pulled together the many and separate strands to formulate a more complete picture. Was information appropriately shared about the drug culture & impact of this on Zara’s development? 5.12.11 In spite of her parents’ concerns about possible use of hard drugs (her cannabis use seemed to have been an accepted ‘given’) there was limited early challenge about mother’s possible usage. Because the issue of drug mis-use was not addressed in either the pre-birth or immediate post-partum initial assessments, the implied risks to baby Zara in utero or subsequently as a baby remained uncertain. 5.12.12 The MPS had expressed doubts to Probation in February 2009 about the suitability of the home of the paternal grandmother’s home as a base for purposes of a court-imposed curfew. This was based on awareness within the MPS that a number of his associates were drug dealers. 5.12.13 This information was not shared with Children’s Social Care at the time nor was the potential impact on them of Zara and her mother spending time at the address reflected in the pre-sentence report later prepared by PO2 in June 2009. 5.12.14 Although her place had been allocated in late March it seems likely that mother and Zara actually remained at the above location (and were thus exposed to father’s associates and the drugs they possessed / traded) for several further weeks. 5.12.15 Almost a year later there was a further phone exchange between SW2 and PO2, with the former indicating that a new referral would be required to prompt an updated assessment if father, upon his scheduled release in September, moved back to his mother’s address. 5.12.16 In February 2011 PO4 sought information from Children’s Social Care and reported that father was serving a sentence for possession of class A drugs and that Zara was living at his home address. 56 5.12.17 Police notification to Children’s Social Care of the drugs raid of June 2011 revealed a new and significant intimate relationship (albeit one denied by mother) as well as the fact that Zara (aged 2.5 years of age) had been directly exposed to potentially fatal drugs and a weapon. 5.12.18 Mother’s arrest implied that she was aware of the drugs and had placed her own personal needs above those of Zara. Aside from her reserved manner and limited personal involvement with nurseries, nothing (setting aside her failure to pay any fees) untoward was noted. Zara’s appearance, affect and conduct all fell well within normal parameters and gave no cause for concern. 5.12.19 No information about drug culture and its impact on child Zara has emerged that had not been shared between individual agencies. Was sufficient consideration given to the impact of cultural / racial & other equalities issues in any assessments? 5.12.20 Across targeted agencies, aside from recognition of an obvious difference (mother being more articulate and better educated than most comparable service users) there seemed to be little appreciation that behind those features lay potentially more significant issues e.g. What were the parental aspirations and expectations when they paid substantial fees for a private boarding school education for Zara’s mother? How did Zara’s mother respond when she was removed from the boarding school she ‘loved’ and a brother remained to complete his schooling? (her conversation with the author suggests that ‘jealous and resentful’ were amongst the feelings she experienced) How did mother feel about the parental separation and father’s move to South Africa Why did she say she feared her father? (mother now says she has no recall of that) Did her claim to be moving to live with her father represent a fear or a hope? To what extent was entering into intimate relationships with those involved in crime and anti-social behaviour chance and/or a rejection of parental values? What was the cultural / religious background/s of the parents of Zara’s mother? What were mother’s religious beliefs and how did they influence her day to day life? Was MGM pleased or distressed about her daughter’s pregnancy and was the ethnicity of Zara’s father important to her or her ex-partner? What implications for mother and Zara did MGM’s new partner have? How did mother feel about MGM’s new relationship? Of what significance was the fact that Zara’s father was a Muslim to mother and/or her parents? What were mother’s expectations of the ‘Godmother’ nominated by Zara’s mother? 5.12.21 Records supplied offer no answers to these and many more questions that together identify a proportion of the cultural / religious / racial context in which a distressed and challenging adolescent became a teenage parent with a very dangerous partner. Mother’s own vulnerability was probably greater than she herself appreciated. 57 5.12.22 The Children’s Social Care IMR points out that even basic data was not captured e.g. ethnicity of Zara’s father and his family (a further example of his ‘invisibility’ as a parent). 5.12.23 With respect to its work, Probation’s records initially mis-recorded father’s ethnicity as ‘Chinese and no Faith’ before correcting it to ‘dual heritage White British / Black Caribbean and Muslim’. The significance of ethnicity or Faith remained un-explored. 5.12.24 Passing references to the maternal grandfather receiving specified medical treatment in South Africa also raised the possibility of certain issues, which remained unexplored. Was consideration given to the escalation of the lack of response by mother to immunisation & developmental assessment opportunities? 5.12.25 The issue of delay is Zara receiving all the standard pre-school immunisations needs to be placed in the context of law and national policy. There is overwhelmingly sound evidence of benefit to the individual and to wider society (through herd immunity) of maintaining a high take up rate for immunisation. However, (with respect to a child too young to make her/his own informed decision) whether s/he does receive any or all such immunisations is at the discretion of a parent. A failure or refusal to allow such interventions is neither unlawful nor (unless other evidence points that way) necessarily irresponsible. 5.12.26 The evidence within the IMRs suggest that although her own mother (MGM) was opposed in principle to such interventions, mother was at worst ambivalent and at best willing but too distracted by a chaotic lifestyle to ensure that it happened. 5.12.27 Thus, in January 2009 Zara was given her first set of DTaP/IPV/Hib and in March that year received her 2nd set of primary immunisations. 5.12.28 Monitoring of the issue in medical centre 2 picked up by January 2010 that Zara was overdue her 3rd set of immunisations and a letter was sent. It remains unknown whether mother received that correspondence. 5.12.29 When Zara was seen at paediatric A&E department in August 2010 (at which point neither mother nor Zara were registered with a GP) the fact the child was overdue for further immunisations was picked up but was not pursued with the relevant health visiting service. 5.12.30 Zara remained registered with medical centre 2 for only a further 6 months after its attempt to contact mother by letter. The fact that she was overdue her further immunisations emerged again only after the drugs raid in June 2011. It was not raised as a concern with SW6 in her phone conversation in early July 2011 with GP4 at medical centre 3 (where Zara had been registered as a temporary patient), nor by GP5 from medical centre 2 a week later. 5.12.31 The phone conversation between SW5 and GP8 in late March 2012 probably occurred after the decision had been made in Children’s Social Care to close the case. Had the health visiting service been involved in the formulation of that core assessment, the scope for persuading and assisting mother to organise Zara’s 3rd set of immunisations would clearly have been greater. 58 5.12.32 Following Zara’s registration at medical centre 4 in July 2012 further efforts were made to encourage mother to bring Zara in for the overdue immunisations. In fact the child was not seen for that or any other health-related issue in the 18 months before the incident triggering this SCR. 5.12.33 The average annual rate at which under-fives are seen at Wandsworth GP Practices is 5.It is a matter of speculation as to whether Zara was unusually healthy, her mother more confident in management of or less sensitive about, day to day morbidity or whether a combination of such factors prevailed. 5.12.34 The GP Service IMR author evaluated the efforts made to ensure Zara’s full set of immunisations as ineffective and the involvement of health visitors belated. In the author’s view however, the absence of other grounds for concern rendered the responses made proportionate to the perceived need. 5.12.35 The author does concurs with the suggestion that a consultation with the named or designated doctor for safeguarding children could have been useful but otherwise concludes that the issue of mother’s overall care of her daughter would best have been addressed in the context of a multi-agency meeting. As discussed below, such a meeting was never convened. Were historic records systematically reviewed to evaluate & assess risk? 5.12.36 The IMR that evaluated the responses of Children’s Social Care highlighted that there were 6 formal assessments and that all lacked a clear purpose; that little use was made of previous assessments with each incident being treated in isolation. In consequence there was limited cumulative understanding of risks or strengths. 5.12.37 The IMR author also found little evidence of formal reviews of records. An audit undertaken by a service manager in May 2010 helpfully identified a number of uncompleted tasks and agreed that these were to be pursued with the relevant social worker. There is no documentary evidence to confirm that they were. 5.12.38 Regular supervision was provided to allocated social workers. The focus of that supervision though was on immediate tasks rather than on critical reflection on the developing picture. 5.12.39 There is also evidence of insufficient rigour with respect to follow-up of overdue or incomplete pieces of work e.g. failure to complete the requested core assessment in 2007, the write up of the initial assessment begun after Zara’s birth and (by two social workers) to comply with the instruction in January 2012 to liaise with Probation and health visitors. 5.12.40 The result of the insufficiently reflective approach was to reinforce the tendency of practitioners to react to the latest event without placing it in its historical context. Thus, a number of decisions by managers along the lines of ..’if there are further referrals about Zara, safeguarding responses should be considered’; were made but not then enacted. 5.12.41 A balance is required between supervision as a means of progress chasing and its potential to offer space to step back and invite examination of the impact on a developing child of all known relationships, circumstances and events. 59 5.12.42 Within Probation records a good deal of repetition was apparent and levels of understanding about father’s thinking or offending do not seem to have risen over time. 5.12.43 The IMR evaluating health visiting services attributes failures to take full account of existing records to the disruption in the period 2008/2009 when paper-based systems were gradually replaced by electronic records and to a contemporaneous reorganisation. 5.12.44 Best practice would have prompted nursery 2 to seek a transition report from nursery 1 though not doing so caused no obvious problem in this case. 5.12.45 All Police response seems to have appropriately drawn upon its available databases. This case did not meet the criteria for services from a number of agencies; if all information had been shared about this case, would this have met criteria & services provided or risk assessment made? 5.12.46 It is significant that at no time in the 5+ years considered within this overview, was there any face to face meeting of all involved professionals. 5.12.47 The early efforts made when mother was first referred to Children’s Social Care to understand and meet the family’s needs quickly became focused on satisfying mother’s insistent demand for her own accommodation and upon other related practical matters such as Benefit entitlement. 5.12.48 There were potentially useful individual exchanges e.g. SW1 and psych.1 in April 2008 who had then sought to develop hypotheses about the origins of the difficulties within the family. In essence though, each event or crisis from then till March 2013 was handled by a specific agency (sometimes in consultation with or informed by the records or views of another). 5.12.49 The discharge meeting held in hospital 2 immediately after Zara’s birth in December 2008 might usefully have been enlarged in its scope and membership to address the high level of vulnerability reported by GP1 a year previously and reinforced by the pre-birth initial assessment (albeit the conclusions of the latter could see no role for Children’s Social Care). 5.12.50 A further chance to pull together and better understand the respective concerns, risks assessments and efforts of health visitors, probation officers and staff from the social work team at hospital 1 emerged in early Summer of 2009. Instead of any such meeting, the initial assessment begun by a student seems to have remained unwritten and the case closed off by her supervising social worker SW2. 5.12.51 Zara’s 3rd A&E presentation (the first at hospital 2) in August 2010 could have been more effectively handled by the liaison health visitor who could usefully have sought a multi-agency meeting to address GP registration, overdue immunisations and the stated termination of relationship with the then imprisoned father of Zara. 5.12.52 The last clear chance for a full exchange of information, concerns and proposals could have followed the drugs raid of June 2011 when reported events may well have justified awarding enquires s.47 status (Zara could easily have accessed and died from ingestion of the illicit drugs) and convening an initial child protection conference. 60 5.12.53 The author of the IMR evaluating health visiting services is of the view that if that agency’s records had been better kept and applied, there would have been a recognition that mother and Zara required more than ‘universal’ level of support i.e. would have become eligible for ‘universal plus’ status. Had the health visiting service attributed a ‘universal plus’ status, it would naturally have served to raise the profile of the case. 5.12.54 Without regard to that agency-specific issue, the value of a multi-agency meeting would have been to aggregate and evaluate the variety of apparently low level concerns and probably to better recognise the risks to Zara inherent in mother denying and diminishing crime and drug related conduct by herself or her associates. 5.13 MISSED OPPORTUNITIES FOR BEST PRACTICE 5.13.1 The following section lists actions or decisions that fell short of accepted ‘best practice’. Its length is misleading. It does not indicate that services offered or delivered were generally of a poor standard; rather that an honest, thorough and self-critical examination has unsurprisingly, found many ways in which quality of service might have been improved. GP1 (whose initial referral was commendable) did not follow up Zara’s failure to engage with CAMHS A reference by mother in early 2008 to Children’s Social Care’ initial contact worker, about her fear of her father (now denied or forgotten by mother) remained unexplored Children’s Social Care failed to involve GP1 in its assessment of need (indeed it appears not to have completed the core assessment deemed necessary at that time) In June 2008 PO1 when preparing the pre-sentence report, did not establish that his girlfriend (mother of Zara) was less than 18 thus denying herself the opportunity for recognising that it would be appropriate to liaise and share information about drugs misuse / potential risks to mother The impact of father’s release from prison on Zara was not addressed in the closing summary completed by SW2 in May 2009 The delay of 9 days in SW2 responding to Probation’s request for information to inform the pre-sentence report in June remains unexplained There was a significant delay before information about Zara’s presentation to A&E in December 2009 was actually inputted to the Rio database In February 2010 mother’s objection to being housed in a proposed area because of gang-related fears remained unexplored and un-challenged SW2 apparently failed to record a significant exchange with PO2 on 26.03.10 The failure to automatically offer tenancy support in April 2010 was unfortunate but had no impact in practice PO4 was slow to involve Children’s Social Care in December 2012 and failed to initiate any response with respect to father’s reported claim (denied him) to have a son with whom he had weekly contact PO4 should have updated Children’s Social Care in March 2011 about the victim being a pregnant woman with a small children following father’s recall to prison on a ‘conspiracy to rob’ charge Zara’s presence and exposure to class A drugs (and a weapon) at the drugs raid in June 2011 merited a more significant multi agency response 61 Medical centres 2 and 4 could have tried to engage and persuade mother to complete Zara’s immunisations by earlier involvement of health visitors rather than depending upon written invitations The initial and core assessments undertaken by SW4 and SW5 in early 2012 both failed to involve (as directed by the team manager) health visitors or Probation PO6 in his exchange with Children’s Social Care in May 2012 could usefully have informed that agency of the presence of young children at the series of violent robberies father was by then known to have committed Children’s Social Care case closure in July 2012 might usefully have been managed in a more incremental manner and a level of ongoing support been negotiated PO7 in February 2013 when preparing the ‘start custody’ OAsys could usefully have sought an update from Children’s Social Care and sought an opinion as to any risks in ongoing contact between Zara and her father 62 6 CONCLUSIONS 6.1 INTRODUCTION 6.1.1 This section encapsulates the learning from this case for the way in which agencies worked to safeguard and promote Zara’s welfare. It offers a brief summary of good and sub-optimal responses (individual and systemic). 6.2 FINDINGS GOOD INDIVIDUAL PRACTICE 6.2.1 Examples of ‘good’ practice by professionals (i.e. exceeding what would be expected in comparable cases) were as follows: The response of GP1 and GP2 at medical centre 1 in late 2007 showed a sensitive awareness to the vulnerability of Zara’s mother The flexibility of CAMHS in responding positively to mother’s plea not to close her case in early 2008 The involvement of the safeguarding midwife at the point of Zara’s birth Children’s Social Care Diversion and the Housing Options Teams worked well together in responding to mother’s initial request for accommodation in 2008 The initial response of the manager in Children’s Social Care in response to notification about the drugs raid in June 2011 (though conversion to s.47 status did not take place) The careful response of another team manager in June 2012 to the report of Zara being found alone on the street 6.2.2 The IMR author who evaluated the service provided by GPs to mother and Zara was able to report upon and commend an internal reflective exercise conducted by staff within medical centre 4. The suggestions for improvements are consistent with those of the independent IMR author and are reflected in the recommendations in section 7 of this report. SUB-OPTIMAL SYSTEMS 6.2.3 Section 5.13 above listed opportunities where the possibility of best or optimum practice was missed by individuals. Of greater significance for local systems, the following provide examples of agency responses which fell below the minimum standard a service user might reasonably expect: Hospital 2 failed to notify medical centre 1 of mother’s attendance for ante natal care or about Zara’s birth and discharge from maternity services Children’s Specialist Care failed to provide any feedback to GP1 who had initiated a helpful referral of mother in October 2007 A delay of some 5 weeks before case allocation and then of over 18 weeks to complete an initial assessment by hospital 1 Social Work Team (the then target time was 7 working days) 63 Inadequacy with respect to its first initial assessment in 2007 (scope, depth and recording), the family group meetings in early 2008, initial assessments of Summer and Winter 2008 and the further 3 triggered by Police notifications, undertaken by Children’s Social Care A failure across most agencies to explore the significance and possible impact on Zara of her father (or later the man described by Police as mother’s boyfriend) The (undetected) failure of SW4 and SW5 to complete the tasks required by their team manager in January 2013 following mother’s arrest The failure within Children’s Social Care to reflect on or follow-up on the conclusions of previous assessments that further incidents should prompt s.47 enquiries An (undetected) failure by an unidentified duty health visitor in the first half of 2012 to enter relevant records into the information system 6.3 PREDICTABILITY & PREVENTABILITY 6.3.1 On the basis of known history (her relationship with Zara’s father throughout a lengthy period of very serious offending) it was predictable that this vulnerable young woman could become involved in relationships with other men involved in anti-social and/or criminal conduct. However, her visible care of Zara remained adequate. 6.3.2 Limited evidence existed (e.g. arrest for possession with intent to supply in 2011 when Zara was exposed to class A drugs) to suggest that she knowingly neglected, abused or allowed the neglect or abuse of Zara by others to the extent of causing ‘significant harm’. 6.3.3 The assault on Zara by an individual yet to be identified and tried in court could not therefore have been predicted by those professionals who had contact with mother and daughter, nor is it clear that any action that might reasonably have been predicted by a local professional could have served to prevent what appears to be a spontaneous event. 6.3.4 Current Care Proceedings will judge the extent to which the significant harm suffered by Zara is a function of inadequate parental care and where the best interests of this little girl now lie. Similarly, the criminal process will determine culpability for the physical harm suffered by Zara. 64 7 RECOMMENDATIONS RECOMMENDATIONS INTENDED OUTCOME SAFEGUARDING CHILDREN BOARD 1. Wandsworth Safeguarding Children Board should complete an exercise to gather and evaluate intelligence from all member agencies about the perceived effectiveness with respect to ‘inter-agency information sharing’ of existing: Policies Procedures Practice (by means of case audits) - the results of the above exercise should inform any further action required A clearer, more consensual and more reliably implemented approach to involvement of other agencies and sharing of relevant information 2. Wandsworth Safeguarding Children Board should seek confirmation from member agencies that any services that may be commissioned are being required to satisfy the obligations of s.11 Children Act 2004 Ensuring the retention across time of accurate records of service providers’ contacts with service users SERVICE DELIVERY BY LOCAL AGENCIES Wandsworth Education 3. Early Years Service & Schools should issue guidance to: Clarify that relevant information should be shared (i.e. passed over by the originating setting or if necessary, sought by the new one) in unplanned as well as planned transfers / transitions Recommend that existing attendance rate monitoring (even for pre-statutory school age children) is used to inform discussion with parent/s and (if concerns about welfare arise) to inform any request for early help support services Encourage the capture of reasons why a child may not be up to date with all her/his recommended immunisations e.g. parental choice Staff will have a more complete understanding of history of early years experiences and be better able to interpret a child’s appearance, affect and behaviour A more evidence-based approach to working with parents and other agencies Acceptance of lawful parental choice and an enhanced opportunity to recognise and support those parents wanting their child to be immunised and whose organisational ability needs support 65 4. Compliance levels with existing systems for responding to children / young people who go missing from education (including sensitivity to the risk of sexual exploitation) should be confirmed by audit More effective multi-agency services Wandsworth Children’s Social Care 5. Children’s Social Care should develop guidance about ‘adolescent neglect’ to complement existing training Improved recognition by practitioners 6. The existing audit of assessment schedule should be amended to include a section on parental self-report Increased likelihood of respectful uncertainty and confidence to challenge – leading to better informed assessments 7. The results of all audits so far completed in 2013 should be circulated Learning derived from identification of themes and issues identified in the report 8. Develop practice guidance for initial contact team / Referral & /Assessment Service duty that clarifies type and quality of information to be shared with other agencies More informed, efficient and confident information sharing (the current development of a multi-agency safeguarding hub should facilitate this) 9. Children’s Social Care should require each person who provides professional social work supervision to include in their reflective practice, the following 3 questions: Have we taken sufficient account of known personal history (including development and maintenance of a chronology)? Do we know enough about the father or significant other males in the case? Would our understanding be enhanced if we convened a multi-agency meeting? St George’s Healthcare NHS Trust (health visiting) 10. St George’s Trust should: Review the Rio cluster system to ensure clarity about which health visiting team is responsible for a child Implement a robust record-keeping methodology Introduce mandatory record keeping training for all community health care practitioners working with children Introduce a procedural expectation that all cases where a Police notification (MERLIN) has been evaluated by the Safeguarding Team as requiring specified action is taken to safeguarding supervision Clearer accountability Clearer distinction between facts, self-reporting etc Up skilling the workforce Enhanced risk management 66 Review and re-launch the policies / procedures associated with ‘no access’ / ‘did not attend’ Wandsworth Housing 11. Wandsworth Housing should: Remind all staff of the availability of multi-agency safeguarding children training Organise refresher safeguarding training for all staff to include the implications of gangs Review tenancy support procedures to under 20s especially in relation to case closure following a failure to locate or engage a tenant Complete the already scheduled review of the joint working protocol between with Children’s Social Care (ensuring that gang-related issues are reflected in it) Better informed workforce Heightened awareness of a contemporary challenge A more sensitive service Revised arrangements informed by experience Wandsworth Finance (Rent Collection Service) 12. The Rent Collection Service should: Confirm that the ‘rent collection manager’ is the lead officer for safeguarding of children and accountable for ensuring all cases of concern are referred to ‘Tenancy Support’ and/or Children’s Social Care Deliver training to officers to enable identification of cases of concern Require the rent collection manager to introduce stringent procedures for follow up of safeguarding referrals initiated by rent collection officers Clarity about accountability Better informed workforce A safer and more rigorous service London Probation Trust 13. London Probation Trust should brief all relevant staff in the borough’s local delivery unit so that: Communications with Children’s Specialist Care distinguishes provision of versus seeking information and a referral A referral is initiated in every case where a service user is assessed as presenting a risk to any child Referrals include all available details The age of a service user partner is always checked since it may prompt a need for a referral They become familiar with the Prison Service policy on contact with children (chapter 2 Public Protection Manual) More precise identification of need, enhanced clarity and quality of information provided and requests made for a response 67 Chelsea and Westminster Hospital 14. Chelsea & Westminster Hospital should: a. Ensure that GP lists are available in all paediatric clinical areas b. Require A&E staff to cross check between the current two electronic systems for attendance c. Require health visitor referral forms to be completed electronically d. Require records of immunisation status to be added to health visitor referral form e. Sustain the existing monthly meetings with community and hospital midwifery team, named midwife, and health visitors To more accurately identify and share approaches to the most vulnerable patients General Practice It is essential that a robust system of information sharing is put in place to ensure that the ‘full story’ is available to all practitioners involved in a child’s care. GPs must receive case based training on the importance of information sharing and assertive seeking of information which is not immediately available to them. All agencies must ensure that their information sharing is maintained throughout their involvement and not only in times of crisis The establishment of regular links with Health Visiting and Children’s Services representatives have already been recommended in other reports for the borough. This practice is evolving but must be further established and embedded and needs to be encouraged and facilitated at a level that makes it standard practice independent of practice size, location or population demographic 7.1.1 Each agency has a detailed ‘action plan’ including allocation of responsibilities, deadlines and agency-specific means of monitoring progress toward, completion of specified tasks. Final overview child Zara 01.07.14 68 8 GLOSSARY OF ABBREVIATIONS / NAMES Abbreviation Meaning EYMAP Early Years Multi Agency Panel IMR Individual management review MPS Metropolitan Police Service PMH Previous medical history SCR Serious case review UTD Up to date [used by health professionals in referring to immunisations] Title Meaning GP1 GP2 GP3 GP4 GP5 GP6 GP7 GP8 PN1 Health visiting HV1 HV2 HV3 HV4 HV5 HV6 Midwifery HV TL CM1 CM2 CM3 CM3 CM4 Mental Health Psych. 1 Children’s Social Care ICW1 ICW2 ICW3 SW1 SW2 SW3 SW4 SW5 SW6 SW7 SW8 SW9 SW10 69 TM1 SM1 TM3 TM4 TM5 Student SW FGC1 Education EWO1 YOT YOT1 Probation PO1 PO2 PO3 PO4 PO5 PO6 PO7 Housing Pathway/ Notting Hill Housing Association HO1 HO2 Finance Department RCO1 Metropolitan Police MPS DS1 Places School 1 mother School 2 mother Nursery 1 for Zara Nursery 2 for Zara 70 9 BIBLIOGRAPHY General Working Together to Safeguard Children, HM Government 2010 & 2013 Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial study of serious case reviews 2003-2005 Marian Brandon, Pippa Belderson, Catherine Warren. David Howe, Ruth Gardner, Jane Dodsworth, Jane Black, DCSF 2008 A Study of Recommendations Arising from Serious Case Reviews 2009-2010 M Brandon, P Sidebotham, S Bailey, P Belderson University of East Anglia & University of Warwick Understanding Serious Case Reviews and their Impact a Biennial Analysis of Serious Case Reviews 2005-07 Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren & Black DCSF 2009 Building on the learning from serious case reviews: A two-year analysis of child protection database notifications DFE – RR040 ISBN 978-1-84775-802-6 2007-2009 Learning Lessons, Taking Action: Ofsted’s evaluations of serious case reviews 1April 2007 to 31 March 2008 Published December 2008 Ages of Concern: learning lessons from serious case reviews: a thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 Learning Together to Safeguard Children: A ‘Systems’ Model for Case Reviews March 2009 SCIE New learning from serious case reviews: Marian Brandon et al RR226 DfE 2012 Case-specific ‘Southwark Judgement’ R (On the Application of G (FC) (Appellant) v London Borough of Southwark (Respondents) 2009 |
NC52301 | Death of a 3-month-old girl in March 2019. Emily's mother was convicted of infanticide and given a hospital order under section 37 of the Mental Health Act. Learning includes: the need for the local safeguarding system to be more effective in working with parents who have previous mental health conditions, taking account of factors that might make parents reluctant to talk about their past; improving responses to an overdose by a parent, prioritising responses to mental health concerns of parents with babies and small children; where parents of young babies have emerging mental health concerns, health visitors should be utilised to provide support and assess potential risk; the system designed to make sure that a surviving sibling is safe needs to include effective co-ordination within the police and between agencies. Recommendations include: agencies providing services to families review the use of interpreters, ensuring that provision is adequate; practitioners are encouraged to obtain relevant information from outside the UK and incorporate the information into their assessment practice; children's services work with mental health services to develop the role of the MASH mental health worker; comprehensive guidance is available to professionals when a child has been killed by a family member, including clarification of agencies' roles and responsibilities, and addressing the issue of emotional support for a bereaved parent.
| Title: Serious case review ‘Emily and Jack’. LSCB: Croydon Safeguarding Children Partnership Author: Jane Wonnacott Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Croydon Safeguarding Children Partnership Serious Case Review ‘Emily and ‘Jack’ Report Author Jane Wonnacott MSc MPhil CQSW AASW Director, Jane Wonnacott Safeguarding Consultancy Ltd Serious Case Review Page 2 of 28 Contents 1 INTRODUCTION ........................................................................................................... 3 2 THE REVIEW PROCESS ............................................................................................. 3 3 CASE SUMMARY ......................................................................................................... 5 4 FAMILY PERSPECTIVES ............................................................................................ 9 5 FINDINGS & RECOMMENDATIONS ......................................................................... 10 6 SUMMARY OF RECOMMENDATIONS ..................................................................... 21 7 APPENDIX 1 – TERMS OF REFERENCE ................................................................. 23 8 APPENDIX 2 – DETAILS OF LEAD REVIEWERS..................................................... 27 Serious Case Review Page 3 of 28 1 INTRODUCTION 1.1 This serious case review was commissioned following the death of a three-month old baby girl in March 2019. The baby’s mother admitted killing her child and in July 2019 appeared in court and pleaded guilty to infanticide. She was convicted of this offence and given a Hospital Order under Section 37 Mental Health Act 1983.1 1.2 Due to the circumstances of the death Croydon Safeguarding Children Board carried out a rapid review of the information known to local agencies about the family. The review concluded that the case met the criteria for a serious case review under statutory guidance2. 1.3 The decision to carry out a serious case review took place before 1st September 2019 when Croydon Safeguarding Children Board became Croydon Safeguarding Children Partnership (CSCP). In line with statutory transitional guidance3, arrangements for initiating and publishing the review remain with the Local Safeguarding Children Board who commissioned two independent lead reviewers, Edi Carmi (review chair) and Jane Wonnacott (report author) to carry out the review.4 Responsibility for responding to the review and implementing recommendations will lie with the new safeguarding partnership. 1.4 The baby who died will be referred to as “Emily” throughout this review report and her brother, who was thirteen months older than her, as “Jack”. 2 THE REVIEW PROCESS 2.1 A panel was appointed to work with lead reviewers during the review process. The panel comprised: Designated Doctor, Croydon Clinical Commissioning Group Head of QA and Safeguarding, Children, Families and Education Named Nurse Safeguarding Children, South London and Maudsley NHS Foundation Trust Serious Case Review Team representative, Metropolitan Police Safeguarding Lead, London Ambulance Service Named Nurse for Safeguarding Children, Croydon Health Services Safeguarding Children Board Manager, Croydon Safeguarding Children Board (CSCP) Administrator, Croydon Safeguarding Children Board (CSCP) 1 The courts will issue a hospital order under Section 37 of The Mental Health Act (MHA) if the person concerned has (a) been convicted of a crime that is punishable with imprisonment, (b) has a mental disorder and the court believes they should be in hospital instead of prison. 2 This guidance was Working Together to Safeguard Children 2018. 3 HM Government (July 2018) Working Together Transitional Guidance 4 Information about the lead reviewers is set out in Appendix 2 Serious Case Review Page 4 of 28 2.2 Terms of Reference were agreed and attached at Appendix One. These were extended beyond the time of Emily’s death to examine the effectiveness of the system in safeguarding Jack and meeting his needs in the immediate aftermath. 2.3 Chronologies of involvement were requested from the following agencies and authors of the chronologies joined a meeting of the review panel to discuss their findings: London Ambulance Service (LAS) Police GP Health Visiting Midwifery Children’s Social Care (CSC) and Early Help South London and Maudsley NHS Foundation Trust (SLAM) (including the Peri-natal Mental Health service) 2.4 In addition to providing a chronology, South London and Maudsley Mental Health Trust (SLAM) conducted a serious incident investigation and their report was made available to the review. 2.5 The lead reviewers met with the father of Emily and Jack and also with Mother. We are very grateful to them for their willingness to help with this review and share their perceptions of the way in which practitioners had interacted with them before Emily’s death. The perspectives of the family are summarised in section 4 and noted wherever relevant to events throughout this report. 2.6 In order to understand further what happened but also why decisions were made and the factors affecting practice at the time, the lead reviewers met with practitioners who knew the family. Discussions took place with: Emergency department medical and nursing staff Midwives Health visitors and nursery nurses Social workers and managers Police officers Mental Health clinicians and service leads GP Practice 2.7 A final draft of this report was agreed with the panel and shared with practitioners before being finalised, shared with Mother and Father and presented to the Croydon Safeguarding Children Partnership. Limitations 2.8 Not all practitioners who had made decisions in respect of the family or known and worked with them were available to contribute to the review. This was due to a variety of reasons including moving employment and being no longer contactable and sickness. This has left some unanswered questions as to why decisions were made at the time. Serious Case Review Page 5 of 28 3 CASE SUMMARY Events prior to the death of Emily 3.1 The parents of Emily and Jack originate from Eastern Europe. Father has worked in England for several years and Mother joined him in 2016 after their marriage. Most people who have met them consider both Mother and Father to have adequate English language skills on a day to day basis, although complex discussions are best conducted through an interpreter. 3.2 Mother disclosed to the midwife who booked her for her first pregnancy that she had a significant mental health history in her home country. The information that she gave included that she had received in patient treatment. Information obtained since the death of Emily has confirmed that this included multiple admissions and a diagnosis of Bipolar Affective Illness, but this level of detail was not known to professionals before to Emily’s death. 3.3 Mother’s disclosure prompted a referral by the midwife to the peri-natal mental health service5. The referral was not accepted, and a letter was sent to the GP (copied to Mother and the community midwives) to this effect. The reason given for rejection wad that Mother’s current mental state was stable, and she did not meet the criteria for secondary care services. The GP was asked to monitor her mental state during the perinatal period, the team offered to see her in the future should input be needed and prescribing guidelines were given for antidepressants pre or post-delivery of the baby. Discussion with current managers has confirmed that a referral which cited previous in-patient treatment should have attracted a red flag and been an assessment and this would be current practice. 3.4 The issue of the use of interpreters is discussed further in Finding One, particularly in relation to how far an apparent grasp of English may have masked both parents’ difficulty in understanding more complex information. Practitioners have commented that their decision not to use interpreters at all appointments was because Mother’s command of English seemed good and Mother confirmed this, telling the review that it did not occur to her to ask for one as she had studied English at university. As a result, an interpreter was not used for the meeting with the midwife. The parents do not remember a referral being made to the perinatal service, nor the letter explaining that the service would not be offering an appointment. They have told this review that in their home country they would have received a copy of the referral letter and did not realise that this is not the case in England. 3.5 Mother did not refer to her previous mental health history again although this was on her midwifery records and available to the health visiting service when she later declined an ante natal visit from the health visitor. Mother stated that she does not 5 The Croydon Perinatal Community Service helps women who have mental health difficulties during pregnancy and after the baby is born. These include depression, anxiety or disturbing thoughts and can sometimes affect the mother and baby relationship Serious Case Review Page 6 of 28 recall declining this visit and both she and Father have stressed that they believed that they had accepted all help that was offered to them. The most likely explanation for this discrepancy is a misunderstanding about the offer of a visit from a health visitor; a role that they were not familiar with from their home country. In Croydon resources do not allow for ante-natal visits to all women and Mother had been offered the visit because of her disclosure about her mental health. Ante-natal visits are an opt-in service and it would have been assumed by the health visitor that the midwife was managing the situation. 3.6 There were no further alerts from midwifery and Mother accessed the necessary ante-natal care. Use of interpreters throughout this period was inconsistent, with them more generally being used for medical procedures such as scans. Mother has told the lead reviewers that she accessed her own support with preparing for the birth via the local Eastern European community. 3.7 Following Jack’s birth, Mother and Jack were seen for a new birth visit by the health visitor. At this visit Mother’s previous mental health history was discussed but as Mother seemed well and spoke of having a good support network she was assessed as needing a universal service. This meant that she would next be seen four weeks later in the child health clinic by a nursery nurse. In a busy clinic where parents attend without appointment there is no opportunity for in depth discussions and the nursery nurse would not have access to previous records. There is no record of a six-week check by the health visitor; most likely because only targeted checks were being undertaken at that time and Jack was in receipt of a universal service. 3.8 About three months after Jack’s birth the family moved to another area of Croydon and changed GPs, to a practice with a GP who spoke their language. 3.9 Mother received routine ante-natal care during her pregnancy with Emily. She did not speak about her previous mental health problems or Bipolar diagnosis and told this review that this was deliberate as she thought that if social services knew that she had taken medication in the past they would take her children away. With hindsight Mother now feels that her fears may have been linked to her declining mental health. 3.10 Emily was born by a planned caesarean section and for a short while following the birth Mother had the support of Maternal Grandmother who had come to England to help her. At the new birth visit by the health visitor Mother was reported to be happy, caring well for Emily and the notes record that when asked, Mother told the health visitor that she had no history of depression. Mother told this review that she does not recall being directly asked this question. The health visitor had not had time to read the previous notes where Mother’s previous in-patient treatment was recorded but told the review that since a number of years had now passed this information would not have changed the decision that Emily should receive a universal service. Mother and Emily were seen at six and eight weeks after birth and all seemed well. 3.11 When Emily was twelve weeks old Mother was taken to the local acute hospital emergency department by ambulance, having contacted a neighbour to say she had taken an overdose of ibuprofen tablets. The London Ambulance Service completed Serious Case Review Page 7 of 28 an information sheet for the Emergency Department (ED) and provided a verbal handover to the triage nurse. It is usual that this verbal handover informs next steps within the Emergency Department as, due to time pressures, there is no time to read paper records. This issue is discussed further in Finding Two 3.12 The Ambulance Service also made a child safeguarding referral to Croydon MASH6 which noted that the information from Mother was that she had taken a previous overdose when living in her home country. This had not been recorded on the information sheet given to the Emergency Department and the triage nurse does not recall being informed of this at the point of verbal handover. 3.13 Mother was seen in hospital by the triage nurse who carried out an initial assessment and then was seen later by a doctor. Mother explained that she had not intended to kill herself, but she had a sleepless night, woke up drowsy, took the tablets for pain and, when she realised that she had taken twelve tablets she ran to a neighbour. This explanation resulted in the overdose as being described as “accidental” within the health records. 3.14 The triage nurse made an immediate referral to Croydon MASH and recommended that Mother should be seen by the hospital mental health team. After further assessment, the doctor decided that Mother did not meet the criteria for mental health assessment, and she was discharged home with a diagnosis of depression. The doctor spoke to Father over the telephone asking him to take Mother to the GP the next day to obtain medication as medication would not be prescribed within the Emergency Department. Usual practice within the Emergency Department is that a discharge summary is sent to the GP electronically and it is expected that GPs will screen these summaries on arrival at the surgery. There is no system for marking summaries as urgent. In fact, GPs receive numerous discharge summaries and the system at the GP surgery has to prioritise those that are urgent, and these are seen by a GP the same day. Those not identified as urgent will be placed in a box for GPs to review within a week. Mother’s situation was not regarded as urgent as she had not been referred to the psychiatric team and there was no mention of the MASH referral. The discharge summary was not seen by the GP before she attended the GP surgery the next day. The issue of communication within the health system is discussed further in Findings Two and Three 3.15 The next day the GP prescribed anti-depressant medication having been told by Father that the hospital doctor had said that Mother had “mild depression”. This GP was not aware of Mother’s previous mental health history as the family had not mentioned this and the letter from the perinatal service that had been sent to the previous GP had not migrated across into a new information system installed by the surgery. The health visitor was not notified by the GP but has informed this review that any parent taking an overdose would have received a priority visit from a health visitor. From Father’s perspective the events surrounding the overdose were an 6 The Multi Agency Safeguarding Hub. Serious Case Review Page 8 of 28 opportunity to understand the seriousness of Mother’s mental health condition and this episode is discussed further in Finding Two. 3.16 Two days after the overdose and as a result of the MASH referral a social worker spoke to Mother on the telephone and the case was allocated for a home visit within 72 hours to see the children, explore support networks, obtain permission for wider agency checks and agree a safety plan. At the first visit which took place one week after the overdose, the social worker agreed with Mother that a second visit was needed with an interpreter. This took place two days later. Following the home visit there was no contact with the health visitor or GP, but a referral was made (three weeks after the overdose) to the community mental health team via e-mail. This referral noted she presents as tired, slow in speech with shoulder slouched forward, in my view she seems depressed. 3.17 The referral from the social worker was discussed at the mental health assessment and liaison referrals meeting the next day (a Thursday). A new record had been opened as Mother’s date of birth was incorrect and did not match the previous referral to the perinatal mental health team. The team were not aware of the previous referral and the plan was to: Telephone risk screen with an interpreter Refer to the perinatal team and if the referral was not accepted to discuss with the team leader The team leader to discuss with the Clinical Safeguarding Lead To update the referrer. 3.18 The referral was sent to the perinatal mental health team on the morning of the Saturday, the same day of the fatal incident. The death of Emily and responding to the needs of Jack 3.19 The events following Emily’s death are explored further in Finding Three. 3.20 On the Saturday morning Father left work early to return home having been unable to obtain a response from Mother via the phone. On arriving home, he called the London Ambulance Service and the Police to attend. On arrival uniformed police officers and ambulance crew heard Mother comment that she had killed her baby. An officer who could speak the same language as Mother was requested and was available to the family both at the home and later at the hospital although no Family Liaison Officer was allocated as at this stage events surrounding the death of Emily were not confirmed. The Metropolitan Police safeguarding team were notified by the officers at the home as were the homicide team. 3.21 Due to Emily’s condition she was taken by ambulance as an emergency to the local acute hospital where she was pronounced deceased. 3.22 Mother, Father and Jack were also taken to the hospital where Mother was later arrested on suspicion of murder. Serious Case Review Page 9 of 28 3.23 The Children’s Services Emergency Duty Team had been notified by the Police and discussed with them the welfare of Jack. By this time Father was not thought to be implicated in the death of Emily and was deemed to be able to meet Jack’s needs. A social worker from the Emergency Duty team briefly visited the hospital and at that time Jack was in the care of a uniform police officer as Father had been taken to the police station for questioning. The need for Jack to be medically examined was considered and took place the next day. 4 FAMILY PERSPECTIVES 4.1 From the perspective of Father, the main opportunity to help Mother and identify how ill she was, came at the point she took the overdose and he does not understand why she was not sent to a specialist at this point. He told the reviewers that he had no previous experience of psychosis and he believes that the hospital should have seen the signs that something was not right as contrary to the hospital’s understanding, his perspective was that she did not know why she took the medication. He did know that she had suffered from depression a few years ago and was in hospital before coming to England and this was because of the loss of her job at the time. Father also knew Mother was missing her home country although family visited to help after the birth of Jack and Emily. 4.2 At no time did Father suspect that Mother would do anything to hurt their children, but he was very worried about Mother’s own mental state as she was tearful after the overdose and a “bit down.” 4.3 Father felt that midwives, health visitors and the baby clinic were helpful and both he and mother described the GP in very positive terms. At no time did Mother ask for an interpreter for these appointments as she had studied English at university and believed herself to be proficient enough to talk to professionals. She did however ask for an interpreter for ultrasound examinations and this was arranged. 4.4 Mother described feeling very positive about both pregnancies and also telling the midwife when pregnant with Jack that she had suffered from depression in the past. By the time she was pregnant with Emily she felt that she had no depression after having Jack and did not therefore think it would be possible to suffer with depression for her second child. She also believed by this point that if she mentioned taking medication social services would take her children away. 4.5 Mother also told the review that she had enough support from the local community although she was sad that her mother had to return home early after Emily’s birth due to illness. She also feels that the one opportunity to help her more was after the overdose and that possibly being kept in hospital for observation and monitoring might have prevented Emily’s death. She recognises that it would have been helpful to go back to talk to the GP as she began to feel worse just prior to the tragedy but by this point she was really incapable of doing so. Serious Case Review Page 10 of 28 5 FINDINGS & RECOMMENDATIONS 5.1 The analysis of information in this case identifies three areas where there are lessons for practice: The initial response to Mother during her first pregnancy and the subsequent assessment of her mental health needs taking account of her history and cultural background. This is a theme though Findings One and Two and the important role that Health Visitors can play is discussed in Finding Three. The response by practitioners both in hospital and the community when Mother was seen in the acute hospital having taken an overdose when Emily was twelve weeks old. This is a key point in the case and is discussed in Finding Two. The effectiveness of the system in ensuring that Jack was safe, and his needs were met after the death of Emily. This is discussed in Finding Four. Finding One The safeguarding system in Croydon needs to be more effective in working with parents who have previous mental health conditions, taking account of factors that might make parents reluctant to talk about their past and where appropriate facilitate relevant sharing of information between professionals. 5.2 This review has grappled with sometimes competing views as to how far parents should be responsible for sharing of information about themselves, particularly in the light of previous contact with mental health services. The significance in this case was that had there been a more consistent knowledge across the network about Mother’s in-patient history in her home country, a different analysis of her needs might have ensued. 5.3 This was not a situation where Mother never spoke about her past, but she did vary in the degree to which she shared information. For example she was open about her past mental health history when she booked with the midwife for her first pregnancy, told the ambulance crew when she was being taken into hospital after her overdose, but then according to GP records did not tell the GP when asked about whether she had any previous history of depression. The panel have discussed the stigma surrounding mental health that can prevent sharing of information, but it is not clear that this was perceived as a main inhibitor by Mother. Instead, she told the review that when she was reluctant to speak openly, the main driving factor was a fear that her children would be taken away. She attributes this reaction to her declining mental health and disordered thought processes. The reasons for her responses in specific situations cannot be determined by this review but it does serve to remind agencies of the need to promote an environment where parental mental health can be discussed openly with a focus on helping parents to access services that can support them in their parenting role. Further work needs to be done to understand how best to facilitate discussion with parents and their families about mental health issues, the Serious Case Review Page 11 of 28 need for additional support with parenting and whether there are cultural factors that might provide additional challenges in this area of work. 5.4 In relation to cultural factors, since the family are an important source of information the review panel have considered whether inconsistency in the use of interpreters has influenced practice in this case, particularly in facilitating Mother’s disclosure of her full family and medical history. There is evidence, confirmed by the lead reviewers meetings with the family that although Mother and Father give the impression of having a good understanding of the English language this is not always the case where complex issues are being discussed or the discussion relates to services and systems that would have been unfamiliar to them. It is important that assumptions are not made about expectations of services by people who have lived outside England, or the degree to which parents whose first language is not English understand technical issues relating to the way systems operate. 5.5 In this case, important information about Mother’s mental health history was obtained from her home country after the death of Emily. The review panel were unsure how far this would have been easily obtainable to professionals assessing Mother’s needs without the catalyst of such a serious incident. The events described in this review confirm the importance of obtaining such information and systems need to be in place to facilitate this. 5.6 Responsibility for sharing and making sense of information must not sit with parents alone. The professional system needs to make sure that information is shared properly with the appropriate consents, and that other information that indicates a parent may need additional support to care for their children is recognised. This is did not always happen in this case due to a combination of factors including: Different criteria being used to judge whether a perinatal service was required than would be used today. IT system errors resulting in not all information being transferred between GP surgeries Difficulties in identifying all relevant factors within an electronic health record Difficulties in identifying where an interpreter is necessary when a parent’s first language is not English. 5.7 When Mother shared information about her history, the midwife appropriately referred to the perinatal mental health team and recorded that Mother had in-patient treatment in her home country and there was a family history of mental illness. The referral was rejected by the perinatal mental health service although the lead reviewers have been assured that practice today would be to always accept a referral where a Mother has previous in-patient treatment. The importance of this being established practice is confirmed by this review, as there is now evidence that the extent of Mother’s mental health treatment in her home country was significant and that her support needs during pregnancy needed to be assessed. 5.8 The lack of perinatal mental health assessment at an early stage had a significant impact on later events. Serious Case Review Page 12 of 28 During Mother’s first pregnancy the health visitor was not concerned when she understood that Mother had declined an ante-natal visit (as discussed in paragraph 3.5) and assumed the midwife was managing the situation. Had there been more involvement by the perinatal service it is likely that there would have been liaison between the perinatal service and the health visitor and more consideration of support needs beyond universal provision. If Mother had received “Universal Plus” support for the first pregnancy as result of concerns about her previous mental health, this should then have meant that similar support would have automatically been in place for her second child. The note in the midwifery records regarding Mother’s history, including inpatient treatment, was not obvious within the acute trust electronic records and did not therefore inform the decision making of the emergency department doctor after Mother’s overdose. The doctor accepted Mother’s comment that she had previously suffered from depression but was no longer on medication, as being indicative of a non-serious episode. An assessment by the perinatal service may have been more obvious within health records and should have provided more detailed information about Mother’s mental health condition. The health visitor carrying out the new birth visit for Emily who had not met Mother before, did not have time to read all the records and was not alerted to previous concerns about mental health. By the time of the second pregnancy, practitioners told the review that even had they known, because time had passed and Mother had managed well with Jack, they would not have automatically considered the need for further monitoring and review beyond universal provision. This is not in line with expected practice set out in the perinatal pathway7 and is an area for learning and practice development. It should not have automatically been assumed that because Mother had managed well with one child, all would be well with a second baby born only fifteen months later. 5.9 The GP at the time of the overdose should have been aware of the previous referral to the perinatal mental health team and that Mother had not met the criteria for a service. However, this GP had no information at all about Mother’s mental health history as the original letter declining the referral had not migrated into the new electronic records. The GP did ask Mother about any previous mental health issues and she did not tell the GP about her past history. 5.10 The review panel has considered the suggestion from midwives that a history of mental health problems should attract a flag on the records which would be easily identifiable should Mother present at hospital. This is worthy of further discussion but there are several issues to consider: What the threshold would be to apply a flag as too many factors warranting a flag in the records might result in a loss of meaning 7 Croydon Health Services NHS Trust (2016 and 2019) Perinatal Pathway for Health Visitors. Serious Case Review Page 13 of 28 The organisation needs to agree who can flag and this must be administered properly There would need to be discussion about who should be authorised to add a flag about parental mental health Any use of flags should not detract from the professional responsibility that practitioners have to read past records in order to inform current decisions. Recommendation One Health partners should work together to establish a system to alert practitioners where a parent has previous in-patient treatment for a mental health condition. Recommendation Two Croydon CCG should remind Croydon GPs of NICE guidance and best practice in the use of structured risk assessments in situations of parental mental ill health, and their use should form part of the next CCG self-assessment of GP practice. Recommendation Three Partners providing services to children and families in Croydon should review the use of interpreters and ensure that provision is adequate and is being used appropriately. Recommendation Four The CSCP should seek reassurance that practitioners are encouraged and supported to obtain relevant information from outside the UK and incorporate the response into their assessment practice. Recommendation Five Croydon Public Health should work with Mental Health Services and parents to understand any obstacles to sharing information about previous mental health conditions and use this information to develop a positive public health message. Finding Two The response to an overdose by a parent must include: an adequate mental health assessment effective liaison between acute and community services the prioritisation of responses to mental health concerns of parents with babies and small children. effective multi-agency assessment 5.11 The episode when Mother presented at the acute hospital with an overdose highlights several areas for practice improvement and development as well as aspects of good practice by individuals within the system. Despite this good practice the overarching picture is of a system under pressure where “process” and “throughput” was dominating practice with limited critical thinking and discussion with colleagues. 5.12 There was good practice on the part of the London Ambulance Service who submitted a child safeguarding referral to MASH which clarified Mother’s previous mental health history. However, neither the ambulance handover sheet given to the Serious Case Review Page 14 of 28 emergency department, nor the verbal handover included information about the history or that a MASH referral had been made. This was particularly significant in this case as knowledge of a previous mental health history would have changed later assessments and highlights the need for attention to be paid to information exchange at the point of handover. 5.13 The review has been told that although the Ambulance Service procedure is to complete written information to pass to staff in the Emergency Department, the reality is that there is no time in a busy department to read this and the verbal handover is the prime route for information transfer. This appears to be an example of a system developed within one organisation which may not have its desired impact due to the way it is received. A similar dynamic occurred at the point of information transfer out of the Emergency Department to the GP as described in paragraph 3.14 above and discussed in paragraph 5.21 below. 5.14 When Mother was first seen in the Emergency Department the triage nurse was expected to start the completion of the risk assessment matrix and then hand this on to the treating doctor for finalisation and decision making. In this case the triage nurse made appropriate recommendations regarding her medical care based on known information and it was good practice that this assessment noted that that she should be seen by the mental health team and a MASH referral made. The nurse immediately completed the MASH referral form to alert Children’s Social Care; this document did not include all the information contained within the London Ambulance Service referral which had also been made to MASH, as Mother had not disclosed previous mental health issues to the triage nurse. Mother does not recall being asked about any previous problems at this point. 5.15 It is of note that this experienced nurse was influenced by her gut instinct which told her that there were underlying issues – she recalls that Mother did not look her in the eyes or engage well and this raised concerns. This serves as a reminder of the importance of integrating intuitive responses with hard information when assessing any form of risk. 5.16 Within the hospital, once the triage nurse made the decision to make the MASH referral, the system within the adult emergency department did not include discussion with the hospital children’s safeguarding team who could have then liaised with the health visiting service. The assumption was that a MASH referral would automatically trigger health visitor notification and input. 5.17 Following triage, there was no further discussion between the nurse and the treating doctor. The doctor within the Emergency Department who was responsible for assessing Mother used the same hospital mental health risk matrix as the nurse (which includes a set of risk factors rated red/amber/green) and decided that there was no need for referral to the liaison mental health team within the hospital. The rationale for this decision is not recorded, including why the recommendations of the triage nurse were not followed. From discussions with staff in the Emergency Serious Case Review Page 15 of 28 Department, expectations about the way in which decisions about risk are recorded needs clarification. 5.18 In this case there was no discussion at the time with anyone from the psychiatric liaison team to confirm that discharge home and a GP appointment was the right decision. The doctor concerned was hesitant to refer every overdose to the mental health team feeling that this would not be welcomed unless clear risks were identified. It appears that there was an over reliance on an understanding that the overdose had been “accidental” and Mother had not intended to take her own life. This analysis does not consider the need to understand the mental state of any parent who takes an overdose when caring for very young children, whether or not this was intentional self-harm. 5.19 A discussion with psychiatrists from the liaison team at the acute hospital confirmed from their perspective it is recommended practice that even where an assessment is rated “green” and the patient has taken an overdose and/or is a parent who has self-harmed there should be, at a minimum, a discussion with the mental health team. In fact, in this case there could have been a direct referral from the hospital to the perinatal mental health team. 5.20 One factor underlying decision making in this case appears to be opportunities for doctors in the emergency department to receive training and ongoing consultation in the management of mental health patients. The review was informed that previously consultant psychiatrists had provided input to the induction training programme for emergency doctors and there had been regular group supervision sessions. Both these practices had stopped as due to work pressures it has been increasingly difficult for staff to attend the training. As a result, emergency doctors may not be aware of expected practice and have limited opportunities to develop their knowledge and skills in this area. 5.21 The standard discharge summary that was received by the GP practice from the hospital had no prompt to identify it as urgent (as is usual practice) and was not seen by the GP before Mother’s appointment. Information to this review from the Emergency Department is that there is no system for flagging letters as urgent and an assumption is made that GP surgeries screen all discharge summaries on arrival in the surgery. This is not the case and within Mother’s surgery only those clearly identified as urgent will be looked at by a GP immediately. The hospital letter noted the overdose but because Mother had not been referred to the psychiatric team and the letter did not mention the referral to MASH there was nothing to alert the GP to the possible seriousness of the situation. 5.22 The GP carried out their own risk assessment which is not based on any recognised guidance and from this concluded that Mother did not need a referral to mental health or other services. Mother said she had no previous mental health problems and felt that Father was able to offer enough support. The GP has informed the review that counselling was offered which Mother refused, preferring regular sessions with the GP who spoke her language. The GP is not a trained counsellor and these sessions Serious Case Review Page 16 of 28 were intended to provide general support. From mother’s perspective she does not recall being offered counselling by the GP at this stage. 5.23 The specific response to the MASH referral within Children’s Services is discussed further in Finding Three below. Once allocated to a social worker it is positive that there was a referral to the mental health assessment and liaison team; although the referral also lacked a reference to Mother’s mental health history in her home country which had been contained in the referral from the London Ambulance Service. A more appropriate course of action at that time would have been a direct referral to the perinatal service. This would not be an issue today as the current system in mental health provides a single point of access which would have allowed for a quick decision to be made within mental health services as to the most appropriate team to respond to the referral. 5.24 The referral from the social worker contained enough information to prompt a speedier response by mental health services than occurred at the time. Within the mental health assessment and liaison team there was no link made with the previous referral to the perinatal service as Mother’s details (date of birth) on the social work referral did not match. The review has not found that this was anything other than a genuine mistake. The review of mental health services carried out under the NHS serious incident framework8 confirms that the teams screening tool was not used and there was no follow up with either the social worker or the GP to clarify the nature of the overdose and how medication was being managed. The significance of a referral from a social worker (which is an unusual event) in relation to a Mother with two small children was not recognised as a priority and was instead discussed at the regular referrals meeting the next day (Friday) and the plan actioned on Saturday; the same day as the incident. The reason for the slower than expected response is identified in the serious incident review is that the team were under pressure and only had capacity to respond to severe presentations. The referral from the social worker did not reach that threshold. Action has now been taken to improve staffing and the protocol has been updated to ensure that any referrals that should be assessed by the perinatal team are sent the same day. Recommendation Six The risk assessment matrix used in the emergency department should be reviewed and amended to specify that where a patient presents with post-natal depression and/or an overdose there must be a referral to the psychiatric liaison team. Recommendation Seven Protocols and training within the emergency department should be revised to ensure that where a MASH referral has been made by the emergency department due to concerns about a patient’s mental health, there should always be a referral to liaison psychiatry and notification to the hospital safeguarding team. The MASH referral should always be noted in discharge notifications to GPs. 8 Mental Health Investigation Report (September 2019) South London and Maudsley NHS Foundation Trust. Serious Case Review Page 17 of 28 Recommendation Eight Within the Emergency Department all staff, including junior doctors on rotation, should receive mandatory training in expected practice where a patient presents with mental health concerns and ongoing opportunities for reflection and practice development in this area. Recommendation Nine Croydon Health Services should review points of information transfer to make sure that assumptions about the way information is being received are realistic and understood by all involved. Specifically: Discharge summaries sent by the Emergency Department to GPs. Written information given by the Ambulance Service to staff in the Emergency Department. Recommendation Ten Croydon Children’s Services should work with mental health services to review and develop the role of the MASH mental health worker in order to support effective decision making at the point of referral. Finding Three Where parents of young babies have emerging mental health concerns, the skills of health visitors should be recognised by the professional network and utilised as part of a plan to provide support and assess potential risk. 5.25 In this case there were three opportunities for health visitors to be made aware of Mother’s overdose, but information did not reach the health visiting service prior to the death of Emily. The opportunities were: When Mother was seen in the Emergency Department When Mother visited the GP the next day When the social worker responded to the MASH referral. 5.26 Had health visitors been aware of a parent with a young child presenting at hospital with an overdose they would have prioritised a home visit to assess what support might be required. 5.27 Within the hospital, the system for notifying the safeguarding team where the concern is about an adult as a parent does not work as effectively as the system where the child is the focus of the concern. In this case there was no automatic notification to the safeguarding team who could have then liaised with the community health visitors. This issue has been addressed in recommendation six above. 5.28 The MASH referral was assumed by hospital staff to trigger a multi professional response including notification of the health visitor. In fact, there was no contact by a social worker with either the GP or the health visiting service as part of the information gathering process, or later once the case was allocated for assessment. Information given to this review suggests that social work practice in Croydon does not always adequately involve communication and discussion with GPs and health Serious Case Review Page 18 of 28 visitors. These discussions appear to be constrained by concerns about permission to share information. Government guidance on information sharing9 promotes a positive approach to sharing information, seeking consent as appropriate but always considering the safety and wellbeing of the child. The GDPR and Data Protection Act2018 place duties on organisations and individuals to process personal information fairly and lawfully; they are not a barrier to sharing information, where the failure to do so would cause the safety or well-being of a child to be compromised. Similarly, human rights concerns, such as respecting the right to a private and family life would not prevent sharing where there are real safeguarding concerns. (p7) 5.29 Information gathering from partner agencies should therefore always be possible with parental permission and practice standards within Croydon Children’s Social Care state that: All assessments will include multi-agency contributions and participation…and…Partner agencies are part of all ongoing planning and intervention for the family10 There is little evidence that these standards informed practice in this case either at the point the MASH referral was received, or during the Child in Need assessment process. As a result, this contributed to the health visitor and GP not having the full picture. Further work is needed to understand whether this is a more general social work practice issue in Croydon. 5.30 The review has also been informed that there is a mental health practitioner whose role is to work closely with MASH, but they were not involved in discussions about this referral because it is not a full-time post. 5.31 The GP who saw Mother the day after the overdose did not consider involving the health visitor in a situation such as this and health visitors told the review that they have only tenuous links with GPs. The GP practice does not hold multi professional meetings where patients with vulnerabilities can be discussed and the role of health visitors in working with parents with emerging mental health issues is an area for development. Recommendation Eleven Health visitors in Croydon should be supported and given permission to take the time required to review family history prior to a new birth visit. Recommendation Twelve Children’s Social Care should improve the information sharing culture by clarifying expectations and promoting a positive approach to information gathering, information 9https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721581/Information_sharing_advice_practitioners_safeguarding_services.pdf 10 Practice Standard 2 Serious Case Review Page 19 of 28 sharing and collaboration with families and professionals within the safeguarding network. Recommendation Thirteen The Safeguarding Partnership should ask relevant organisations to test the current relationship between health visitors and GPs and develop a consistent approach across Croydon for information sharing and face to face discussion about children who may need a service beyond universal provision. Finding Four The system designed to make sure that a surviving sibling is safe needs to include effective co-ordination within the police and between police, health and children’s social care. 5.32 In this case Father has provided good care for the surviving sibling but on the day of the incident, although individuals did their best, here was insufficient co-ordination and planned focus on making sure Father was both physically and emotionally able to ensure Sibling’s needs were met. It was not always clear to everyone who had overall responsibility for coordinating the response within the hospital and the situation was affected by a lack of presence by the police safeguarding team. This issue was compounded by the fact that the incident took place at a weekend when there is minimum social work cover. 5.33 From the perspective of the Consultant Paediatrician the protocols for managing the suspicious death of a baby in Croydon, including the relative roles and responsibilities of the various police teams and health and social care staff are not clear and easily accessible at a time of crisis. The detectives from the homicide team cover the whole of London and may take some time to arrive, and this left the paediatrician in this case with uncertainty as to how to proceed. This would have been clearer had there been an officer from the police safeguarding team available at the hospital. 5.34 Expected practice within the Metropolitan Police in these circumstances is that a Detective Sergeant from the safeguarding team should attend the scene and/or the hospital until such time as the homicide team can arrive. This did not happen in this case and as a result uniformed officers were left managing a complex situation involving a murdered baby plus a surviving sibling, although they did request the presence of safeguarding officers. There were no system pressures on that day that should have prevented this happening and action has now been taken by the police to make sure that relevant individuals are aware of expectations. 5.35 There is a record of a telephone strategy discussion between the Police Sergeant and the children’s out of hours team which confirmed that there were no immediate safeguarding concerns in relation to Father, he could continue to care for his son and Children’s Social Care would arrange emergency accommodation near the hospital. However, at this stage no safeguarding professional had seen Father, the full facts of Serious Case Review Page 20 of 28 the case were not known, and this should have informed the plan. In any event, Father was in a state of severe shock and had no family support nearby and the impact on him of the death of his baby could not be known, including how this might affect his emotional capacity to care for his son. 5.36 In addition, access to interpreters via language line could have assisted the out of hours social work team as they were communicating with Father over the phone at a point when he would have been very distressed. Language line is available to social workers only during office hours which results in service users who need this service out of hours receiving an inferior response. 5.37 The decisions at this stage did not set out a clear plan for a medical check and when Father was taken for questioning at the police station it was assumed by the Detective Sergeant that Sibling at been admitted to hospital and was therefore the responsibility of medical and nursing staff. In fact, Sibling remained for some time in the care of a uniformed police officer until Father returned. He then went into hostel accommodation with Father (as the home was a crime scene) and was medically examined the next day. Medical and nursing staff were not aware that Jack had left the hospital with Father and at first were not sure where he was. Jack was safe but this might not be the case in other similar situations, and it is important that there is greater clarity as to who has overall responsibility for coordinating the plan and communicating with relevant staff. 5.38 The hostel accommodation provided for Father and Jack is approved by Croydon Housing as suitable for emergency housing for families. Although practitioners acted with the best of intentions the description of the hostel given by Father is of accommodation that was unsuitable for a recently traumatised parent who was caring for his young child. No one accompanied Father to the accommodation to check its suitability or that he had the necessary money and clothes. The system at this point did not have sufficient resources or flexibility to respond to these unusual circumstances in a way that provided good standard accommodation and made sure that father had all he needed to care for his child. 5.39 It is important to stress that the above analysis does not blame any individual but is intended to highlight a potential gap in the system. Steps were taken to provide practical support to Father and there is no suggestion that he could or should not care for his child. However, he had no family support and in addition to the practical response provided, no one person had the role of providing the emotional support that a bereaved parent might need in these circumstances. Recommendation Fourteen Croydon Safeguarding Children Partnership need to ensure that comprehensive guidance is available to all professionals when a child has been killed by a family member and that professionals are trained in its use. This must include clarification of roles, responsibilities and expectations of staff from the Metropolitan Police, Children’s Social Care and all relevant health professionals in acute and community services and address the issue of emotional support for a bereaved parent. Serious Case Review Page 21 of 28 6 SUMMARY OF RECOMMENDATIONS Recommendation One Health partners should work together to establish a system to alert practitioners where a parent has previous in-patient treatment for a mental health condition. Recommendation Two Croydon CCG should remind Croydon GPs of NICE guidance and best practice in the use of structured risk assessments in situations of parental mental ill health, and their use should form part of the next CCG self-assessment of GP practice. Recommendation Three Partners providing services to children and families in Croydon should review the use of interpreters and ensure that provision is adequate and is being used appropriately. Recommendation Four The CSCP should seek reassurance that practitioners are encouraged and supported to obtain relevant information from outside the UK and incorporate the response into their assessment practice. Recommendation Five Croydon Public Health should work with Mental Health Services and parents to understand any obstacles to sharing information about previous mental health conditions and use this information to develop a positive public health message. Recommendation Six The risk assessment matrix used in the emergency department should be reviewed and amended to specify that where a patient presents with post-natal depression and/or an overdose there must be a referral to the psychiatric liaison team. Recommendation Seven Protocols and training within the emergency department should be revised to ensure that where a MASH referral has been made by the emergency department due to concerns about a patient’s mental health, there should always be a referral to liaison psychiatry and notification to the hospital safeguarding team. The MASH referral should always be noted in discharge notifications to GPs. Recommendation Eight Within the emergency department all staff, including junior doctors on rotation, should receive mandatory training in expected practice where a patient presents with mental health concerns and ongoing opportunities for reflection and practice development in this area. Recommendation Nine Croydon Health Services should review points of information transfer to make sure that Serious Case Review Page 22 of 28 assumptions about the way information is being received are realistic and understood by all involved. Specifically: Discharge summaries sent by the Emergency Department to GPs. Written information given by the Ambulance Service to staff in the Emergency Department. Recommendation Ten Croydon Children’s Services should work with mental health services to review and develop the role of the MASH mental health worker in order to support effective decision making at the point of referral. Recommendation Eleven Health visitors in Croydon should be supported and given permission to take the time required to review family history prior to a new birth visit. Recommendation Twelve Children’s Social Care should improve the information sharing culture by clarifying expectations and promoting a positive approach to information gathering, information sharing and collaboration with families and professionals within the safeguarding network. Recommendation Thirteen The Safeguarding Partnership should ask relevant organisations to test the current relationship between health visitors and GPs and develop a consistent approach across Croydon for information sharing and face to face discussion about children who may need a service beyond universal provision. Recommendation Fourteen Croydon Safeguarding Children Partnership need to ensure that comprehensive guidance is available to all professionals when a child has been killed by a family member and that professionals are trained in its use. This must include clarification of roles, responsibilities and expectations of staff from the Metropolitan Police, Children’s Social Care and all relevant health professionals in acute and community services and address the issue of emotional support for a bereaved parent. Serious Case Review Page 23 of 28 7 APPENDIX 1 – TERMS OF REFERENCE CSCB TERMS OF REFERENCE Serious Case Review Emily & Jack 1. SCR decision Following presentation to the March 2019 Serious Case Review Sub Group, consultation the SCR National Panel and feedback from SCR sub-group agencies, it was agreed that a Serious Case Review should be undertaken. 2. Child & Family details Emily Jack Mother Father Address: Croydon. First language: Eastern European 3. Circumstances In March 2019 London Ambulance Service received a 999 call regarding a three month old baby not breathing. The baby was found to be in cardiac arrest. The baby was pronounced dead at the Hospital and the summary of the cause of death is Suffocation, although the Post Mortem results are awaited. Mother reportedly told LAS staff ‘I’ve killed my baby’. 4. Serious Case Review Criteria & Purpose In accordance with the Local Safeguarding - Transitional Arrangements 2018 Croydon Safeguarding Children Board continues to have a statutory duty to commission Serious Case Reviews. The criteria for serious case reviews are detailed in Regulation 5 of the Local Safeguarding Children Boards Regulations 2006:- 5 (2) A serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or Serious Case Review Page 24 of 28 (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Working Together (2015) states: Reviews should be conducted in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 5. Learning outcomes To gain an understanding of the factors that led to this child’s death To identify learning from all aspects of the history and engagement with the family To promote any learning from this SCR across the safeguarding partnership Specific Questions: How well are Professionals in all agencies equipped to assess need and provide resources for people from different cultures. How do Professionals and services assess what support within the community is being accessed by a family. What consideration is given to ante and post-natal support, and what knowledge do Practitioners have of the range of services available locally? How confident are Professionals in exploring physical and mental health history in ante and post-natal care and subsequently assessing need. What is the level of understanding of mental health issues in Midwives, GPs and Health Visitors? Was mother’s history taken into account in SLAM’s decision to reject the perinatal referral? Was father engaged with agencies? Was there an understanding of any need for and use of interpreters? Was there an over-reliance on father to be the interpreter? What is the quality of multi-disciplinary working within Health agencies as regards information sharing and the coordination of services, and the responsibility of agencies when cases don’t meet threshold for service provision (both the referring agency and the agency that declines to provide a service). How well did the agency respond to the safeguarding needs of the family in the immediate aftermath of the tragedy. What factors help and what gets in the way of good practice? Serious Case Review Page 25 of 28 6. SCR Author and Chair Independent Consultant Jane Wonnacott has been appointed as SCR author. Jane is an SCR author recommended by the National Safeguarding Review Panel and a recognised expert in safeguarding and in conducting reviews. Edi Carmi, Independent Consultant has been appointed as Chair of the SCR Panel. Edi has extensive experience in Safeguarding Children with specialist knowledge in Serious Case Reviews and has led other case reviews and studies of local authority systems and practice. 7. SCR Review Panel The SCR Review Panel will play a pivotal role in providing scrutiny and challenge to the review, of both their own agency and that of partners. They will ensure their agency is complaint with the requests of the SCR and within the specified timescales. They will actively contribute to the SCR report and assist in the identification of relevant practitioners for any practitioner enquiries and learning events. SCR Panel Membership is drawn from representatives from all relevant agencies: Croydon CCG & CHS – Designated Doctor for Child Protection (incl. GP) Croydon CHS – Head of Safeguarding South London and Maudsley London Ambulance Service Met Police Croydon Social Care & Early Help Any other relevant agency 8. Methodology This SCR will use a hybrid model which includes: Chronology of individual agency involvement with the family using the Chronolator tool, Summary of findings and learning from each Agency Individual agency staff groups meetings with Chair and Author Practitioner Learning Event Scrutiny of SCR report Learning event - Practitioners Participation/learning events will be held for those involved from the relevant services, with the aim of capturing multi-agency views about the learning areas outlined above. It will also provide an opportunity for reflection and constructive ideas about these complex issues. Serious Case Review Page 26 of 28 Timeline Partners are asked to record their engagement with the family for the period 1 January 2017.to 6 March 2019 using the Chronolator Tool Partners are asked to summarise, in bullet point form, any contact with the family for the month after 6 March 2019, using the Chronolator Tool Partners are asked to include any other relevant information outside this timeline, again using the Chronolator Tool 9. Family The family will be informed of the Serious Case Review and invited to take part in the Review with a view to gaining their views about services or support provided or that have engaged with them over the review period. This will be facilitated by the CSCB team and undertaken by the Chair and Author. This is likely to include both parents and relevant grandparents. 10. Password Please ensure that any confidential documents transmitted electronically are protected using this password. 11. Appendix Information gathering documents included in the first SCR panel meeting: London Ambulance Service Police GP Health Visiting Midwifery Children’s Social Care & Early Help Questions If you have any questions about this process please contact Maureen Floyd (CSCB Manager) on [email protected] or Board Administrator Nia Lewis on [email protected] Serious Case Review Page 27 of 28 8 APPENDIX 2 – DETAILS OF LEAD REVIEWERS Edi Carmi (review chair) Edi Carmi, qualified as a social worker in 1978 and after a career as a practitioner and manager in both statutory and voluntary sectors, has worked independently for 19 years. During that time she has focused primarily on the safeguarding of children, undertaking serious case reviews as well as writing policy and procedure. She was the lead author of the first pan London child protection procedures, as well as the procedures throughout the South East. Since 2009 she has been working with the Social Care Institute for Excellence (SCIE) in the development and implementation of the Learning Together methodology for learning from practice and more recently leading the national audit of diocesan safeguarding for the Church of England and author of the 3 published overview reports. She has considerable experience on learning from reviews where there are multiple victims, involving both non recent and recent abuse; this has included reviews into cases of child sexual exploitation, child on child abuse, the early deaths of 13 care leavers in Somerset and the abuse of children within adopted families. She has a particular interest in institutional abuse and was the author of a report for the Diocese of Chichester, subsequently known and published in 2014 as the 'Carmi' report, into the abuse of choristers. She was also a joint lead reviewer, with Jane Wonnacott, on the serious case review into Southbank International School London and was Chair of the St Paul’s School Serious Case Review. Jane Wonnacott (report author) Jane qualified as a social worker in 1979 and has an MSc in social work practice, the Advanced Award in Social Work and an MPhil as a result of researching the impact of supervision on child protection practice. She has significant experience in the field of safeguarding at a local and national level. Since 1994 Jane has completed in excess of 150 serious case reviews, many of national significance. She has a particular interest in safeguarding practice within organisations and was the lead reviewer for two reviews into abuse in nurseries and the serious case reviews into St Paul’s School and Southbank International School London. She has contributed to the literature exploring effective safeguarding education settings. Jane is a member of the national Child Safeguarding Practice Review Panel pool of reviewers. As Director of In-Trac Training and Consultancy, Jane has been instrumental in developing a wide range of safeguarding training and oversaw In-Trac’s contribution to the development of the “Achieving Permanence” training materials for the Department of Education. She has a long-standing interest in supervision and developed a national supervision training programme for social workers with the late Tony Morrison. She has recently worked with colleagues to apply this model in school settings. Serious Case Review Page 28 of 28 |
NC048201 | Two siblings, Child A and Child B, both under 5-years-of-age, removed from the care of Special Guardians after the male partner was found to be seriously physically and sexually abusing them, in May 2015. There had been concerns for the welfare of both children throughout their lives. They both had special needs, as did their birth parents. There had been extensive involvement with health and social care agencies and the Family Court, which had placed the children with a couple, Mr K and Ms L, under a Special Guardianship Order. A number of criminal charges were brought against Mr K and he received a lengthy custodial sentence. Ethnicity or nationality is not stated. Findings: there were overall concerns about the way the local authority approached the task of planning the care of the children; neither of the Special Guardians had any experience of parenting nor with looking after children with disabilities; the particular vulnerabilities arising from these children should have been given greater weight; there were reported injuries which were not investigated. Recommendations for the LSCB: to highlight the particular vulnerabilities of children with disabilities; to require the local authority to look at its arrangements for working with families where there have been long standing child care concerns; the use of family group conferences; the arrangements for assessing whether siblings in care should be placed together or separately; and the use of Special Guardianship with particular reference to the involvement of the Permanent Placements Panel.
| Title: Child A and Child B: a serious case review. LSCB: Oxfordshire Safeguarding Children Board Author: Kevin Harrington Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 28 Serious Case Review, Published 01 03 17 Oxfordshire Safeguarding Children Board CHILD A AND CHILD B A SERIOUS CASE REVIEW Kevin Harrington JP, BA, MSc, CQSW Page 2 of 28 Serious Case Review, Published 01 03 17 1. INTRODUCTION 1.1 This Serious Case Review (SCR) concerns two siblings, referred to in this report as Child A and Child B, who were both under 5 years old at the relevant times. There had been concerns for the welfare of the children throughout their lives. They both had special needs, as did their birth parents. They had lived, separately and together, with a number of different carers. There had been extensive involvement with health and social care agencies and the Family Court. 1.2 That involvement had led to the placement of the children with a couple, Mr K and Ms L, under a Special Guardianship Order (SGO) made by the Family Court. They lived with them for about a year but were removed when evidence emerged suggesting they both had been seriously sexually and physically abused by Mr K. A number of serious criminal charges were brought against him, some of which were found proved. He received a very lengthy custodial sentence as a result. 1.3 These matters were brought to the attention of the Oxfordshire Safeguarding Children Board (OSCB). The Chair of that Board at the time, Ms Maggie Blyth, having consulted the relevant agencies, decided that the circumstances of the case met the criteria for an SCR, in line with the government’s guidance1. This is the Overview Report from that review. 2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 2.1 This SCR was formally initiated by Ms Blyth on 29/7/15. The OSCB appointed an experienced independent person – Kevin Harrington2 - to act as Lead Reviewer and to write this report. Mr Harrington has been supported by the officers of the OSCB and a panel (the Panel) of senior representatives from the agencies which had been involved in the children’s lives. 2.2 All those agencies were required to submit an Individual Management Review (IMR), either containing a narrative and an analysis of their involvement where that had been substantial, or a narrative account of events where involvement had been less significant. Those agencies are detailed in the table below. AGENCY NATURE OF INVOLVEMENT Children, Education and Families Services, (CEF) Oxfordshire County Council (OCC) The County Council, through its children’s social care services (CSC) was the lead statutory agency, responsible for protecting the children and promoting their best interests. Thames Valley Police (the police, TVP) TVP were involved in a number of relevant criminal investigations 1 “Working Together to Safeguard Children” (2015), referred to in this report as Working Together 2 See Appendix A Page 3 of 28 Serious Case Review, Published 01 03 17 Law and Governance, Oxfordshire County Council (Legal Services) Legal Services provided advice and representation in bringing the concerns for the children to the Family Court Oxford City Council Oxford City Council was consulted in making arrangements for the SCR but had no continuing role. CAFCASS Cafcass represents children in the Family Courts Oxford Health NHS Foundation Trust This Trust provided health visiting and a range of specialist therapeutic services Oxford University Hospitals NHS Foundation Trust (OUH) OUH provided emergency and continuing specialist health services to the children Oxfordshire Clinical Commissioning Group (OCCG) OCCG has reported on the involvement of General Practitioners (GP) Adult Services, Oxfordshire County Council Adult Services had been in contact with the birth parents of the children as a result of their learning disabilities 2.3 Agencies were asked to review their involvement from January 2013, when the family requested that there should be a Family Group Conference, until the end of May 2015, when the abuse of the children came to light. 3. METHODOLOGY USED TO DRAW UP THIS REPORT 3.1 This report draws on the content of the IMRs, dialogue with IMR authors and other staff, and family members. 3.2 This report consists of A factual context and brief narrative chronology. Commentary on the family situation and their input to the SCR. Analysis of the part played by each agency, and of their submissions to the review. Identification and analysis of key issues arising from the review. Conclusions and recommendations. 3.3 The review has been carried out in accordance with the underlying principles of the statutory guidance, set out in Working Together: The review “recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Page 4 of 28 Serious Case Review, Published 01 03 17 seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight3; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings”. 3.4 The government has introduced arrangements for the publication of Overview Reports from Serious Case Reviews, unless there are particular reasons why this would not be appropriate. This report has been written in the anticipation that it will be published. 4. KEY EVENTS 4.1 Introduction 4.1.1This section of the report briefly summarises the care arrangements made for these children. Further detail is then provided where appropriate throughout the report. The family composition, and the various care arrangements for the children, are complex. 4.1.2 Child A and Child B are siblings, born in 2010 and 2012. Their parents are Mr C and Ms D, who were in their twenties when the children were born. Both Mr C and Ms D have at times received services as adults who have a learning disability. 4.1.3 Ms D had a child, Child E, with another partner two years before the birth of Child A. There had been concerns about the care of Child E who, as a consequence, lives with Ms D’s parents, under an SGO. 4.1.4 Child A and Child B have a younger sibling, Child P, who also lives with a member of the extended family under an SGO. 4.1.5 Child A was the subject of a Child Protection Plan before birth. Mr C and Ms D then cared for Child A until the age of two, when they said that they were unable to continue to do so. CSC had been extensively involved and Child A was then admitted to the care of the local authority. Child A remained in care, at two placements, until moving to live with Mr K and Ms L in March 2014, aged nearly three and a half. The first placement was terminated in October 2013 following allegations, which were not eventually substantiated, of physical abuse by the foster-carer. When the matters leading to this review came to light Child A returned to live with the second set of foster-carers and remains there. 4.1.6 Child B lived with Mr C and Ms D from birth for 10 months, before moving to live with the paternal grandmother, PGM. PGM wanted to continue to care for Child B but it was decided that she could not meet Child B’s needs 3 This review does not rely on hindsight, and tries not to use hindsight in a way that is unfair. It does use hindsight where that promotes a fuller understanding of the events and their causation. Page 5 of 28 Serious Case Review, Published 01 03 17 in the long term. Child B remained with her until moving to live with Mr K and Ms L in April 2014. During the period with Mr K and Ms L Child B also spent time in a respite placement with the carers who had most recently cared for Child A. When it emerged that Mr K had been abusing the children, Child B returned to those foster-carers with Child A, and remains there. 4.2 The placement with Mr K and Ms L 4.2.1 In March 2013, following the suggestion of a family member, a Family Group Conference (FGC) was held to discuss the various concerns for the children and what plans might best be made for them. An FGC is a process led by family members which can plan and make decisions for a child who is at risk in some way. Ms L is a distant relation, by marriage, of the maternal family – her maternal uncle is married to the sister of child A and child B’s paternal grandfather. She and Mr K, her partner for some three years, were said to be involved in supporting the birth parents in their care of the children and attended the FGC. 4.2.2 Mr K and Ms L expressed an interest in caring for the children. CSC carried out a “viability assessment” which did reveal some causes for concern. There were criminal records for offences of dishonesty. Ms L had experienced some sexual abuse within her family as a child. The records note that this left her “more determined to ensure that children are listened to and protected from any form of harm”.. 4.2.3 Ms L was “upfront” about her lack of child care experience and the support she would need, from both her partner and the child care agencies. She had previously made an application to adopt, with a former partner, but withdrew because, she said, that partner was not sufficiently committed to adoption. The local authority decided to carry out a full “Connected Persons Assessment4” of the couple, which proceeded over the coming months. 4.2.4 Meanwhile the local authority had concluded, through due process, that neither birth parent could meet the children’s needs. The local authority initiated care proceedings in the Family Court and both children were made subjects of an Interim Care Order in September 2013. A permanency planning meeting was held to consider where the children should live. At this point the assessment of PGM for Child B was still underway. The assessment of Mr K and Ms L had been completed and it was agreed that they could be considered as carers for both children if necessary. 4.2.5 It was then in October 2013 that allegations were made of physical abuse of Child A by the foster-carer so that Child A moved to a second foster-placement. Soon after that, in December 2013, the local authority Fostering Panel concluded that Child B could not, in the long term, remain with the paternal grandmother because of concerns about PGM’s ability to provide 4 This refers to the placement of a Looked After Child with a relative or friend who is not already approved as a foster carer at the time of the placement. Page 6 of 28 Serious Case Review, Published 01 03 17 care adequate to Child B’s needs. Child B remained with PGM on a short term basis. 4.2.6 By the end of 2013 the plan was to reunite the two children and place them with Mr K and Ms L, with a view to seeking an SGO. Child A was placed with them in March 2014 under “regulation 24”5 arrangements. The Family Court, at the beginning of April 2014, agreed with the local authority’s recommendation and made the SGO, leading to the immediate move of Child B to join Child A in the care of Mr K and Ms L. The Family Court also made an order that the local authority should continue to supervise the children for the following 12 months. 4.3 The Special Guardianship placement: April 2014 to March 2015 4.3.1 The agencies involved put in place or maintained a range of services and support arrangements for the newly constituted family, including some day care provision. From the local authority the ATTACH6 team became involved, a specialist local authority service supporting the placements of children looked after, or placed with a view to adoption, by the authority. The children continued to be seen formally as “children in need” and monitored under those provisions7 as well as the requirements of the Supervision Order. 4.3.2 The children, and particularly Child B, were reported to have displayed some unsettled behaviour from the outset. Child B was said often to scream for long periods and to upset Child A. In July 2014 Child B was noted to have a number of bruises. This led to an Initial Child Protection Conference where all agencies eventually agreed that the bruising could have been caused accidentally. This incident is discussed further below. Case management continued through the “child in need” planning arrangements. 4.3.3 Through the enquiries arising from the bruising it emerged that Mr K was under investigation by police. He had been involved in the criminal misuse of a debit card belonging to a colleague. In due course he admitted offences and received a Conditional Discharge from the courts. 4.3.4 The children’s behaviour continued to cause concern. Child B’s reported behaviour included self-harm, head banging and hair pulling, and pinching different areas of the body. Child A was observed to be exhibiting ‘unco-operative” behaviour at nursery. Mr K was the carer most involved in working with the ATTACH Team. 5 Regulation 24 of the 2010 Care Planning Regulations provides for the temporary approval as a foster-carer of someone known to a child in exceptional circumstances for up to 16 weeks to allow an immediate placement and sufficient time for appropriate further steps to be taken. 6 The ATTACH Team (Attaining Therapeutic Attachments for Children 7 Section 17 of the Children Act 1989 defines a child in need as a child who is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision of appropriate services; or a child whose health or development is likely to be significantly impaired, or further impaired, without the provision of services; or a child who is disabled. Page 7 of 28 Serious Case Review, Published 01 03 17 4.3.5 In late 2014 one of the children was seen at nursery with facial bruising. Mr K said that this had been accidentally caused. The nursery contacted the social worker who advised that no further action was necessary on the basis that there were often injuries because the child’s behaviour was difficult to manage. 4.3.6 There was a similar incident involving the other child in January 2015. Again facial bruising was noted at a Children’s Centre, a social worker was informed and advised that no further action need be taken for the same reason. 4.3.7 It was decided that some “respite care” arrangements should be introduced for Child B. In January 2015 Child B spent about two weeks with the foster-carers who had most recently cared for Child A. They were very concerned at Child B’s presentation and behaviour when placed but the child was reported to settle well with them. 4.4 The discovery of Mr K’s abuse of the children 4.4.1 Towards the end of March 2015 Ms L contacted Thames Valley Police. She had become concerned that Mr K might be having an affair and had covertly placed a recording device in their home. When she had listened to it she heard both children crying and Mr K making violent threats, sexual comments and noises. Police responded promptly and Mr K was arrested that same night. 4.4.2 In the following days medical examination revealed multiple bruising to both children. Ms L told police that she had not been aware of the extent of the bruising, nor how it had been caused. Child protection procedures were initiated and, with the agreement of all professionals involved, the children were brought back into the care of the local authority and placed with their current carers, the same foster-carers referred to in paragraph 4.3.7 above. 4.4.3 Mr K was released from custody on conditional bail, and remained on bail until November 2015 when he appeared in court to face a number of charges of sexual and physical abuse of both children. He admitted all the charges of physical abuse / cruelty. He denied all the sexual charges but was found guilty of the rape of one of the children. He received a lengthy prison sentence for the sexual offence and cruelty. 4.4.4 The SGO was formally discharged by the Court in January 2016. Page 8 of 28 Serious Case Review, Published 01 03 17 5. THE FAMILY 5.1 The birth parents, the former female Special Guardian and the current foster-carers agreed to speak to or meet with the author of this report. Their comments are summarised below. 5.2 The birth parents 5.2.1 A meeting was arranged with the birth parents but, on the day, they felt unable to attend. They receive continuing support from Mencap, whose staff are talking to them about the SCR and its findings. 5.3 The female former Special Guardian 5.3.1 Ms L no longer has any contact with Mr K. She was keen to contribute to the SCR and has submitted a detailed statement. She had become and remains very dissatisfied with the local authority’s input and management of the case. Some of the points she has made are echoed in this report, particularly the decision to place both children with inexperienced carers. There was little preparation or contact with Child B before that child was moved to the Special Guardians. She also expresses dissatisfaction with the continuing support provided by the local authority though that is not so well evidenced. 5.3.2 It was as a result of speaking to Ms L that it emerged that there had been two incidents where the local authority had received reports of facial bruising to the children. She herself had accepted Mr K’s account that the injuries were caused in day care settings. The way in which the local authority dealt with these incidents, and the fact that they were not reported by the local authority to this review, are considered in section 6.2 of this report. 5.3.3 Ms L’s dissatisfaction with the local authority continued after the children had been removed from her care. She found herself in the position of being a party to the legal proceedings through which the Special Guardianship Orders were discharged. She reports that she felt personally severely criticised by the local authority, when, prior to her disclosure of Mr K’s abuse, “there had been nothing but positive comments and praise”. 5.3.4 Ms L had made a complaint through the statutory complaints arrangements for local authority children’s social care services in June 2015. The complaint had been concluded in February 2016. There are various aspects to the complaint but essentially it is about Ms L’s feeling that she and Mr K had been inadequately supported by the local authority before and during the placement. 5.3.5 When the complaint was being concluded Ms L was told, in respect of certain issues, that “The (Complaints) Panel are aware that this case is now subject to a Serious Case Review and that this matter may be part of the considerations of that Page 9 of 28 Serious Case Review, Published 01 03 17 comprehensive multi-disciplinary enquiry, and do not wish to comment further”. 5.3.6 It would have been appropriate that the local authority advise the SCR that a complaint had been made, the substance of which might overlap with the SCR process, and that the complainant had been given an indication that the SCR would deal with matters originally raised as complaints. 5.3.7 The local authority may wish to clarify this with her and ensure that there are no outstanding matters of complaint which she expected this process to deal with. 5.4 The foster-carers 5.4.1 The foster-carers have been keen to contribute to the SCR. They had very serious concerns when they provided respite care for Child B. The child had substantial areas of bruising when arriving at their home. The child settled very quickly with them and there was no evidence of screaming, crying, headbanging or any of the reported disturbed behaviour which had led the Special Guardians to seek a respite placement. The foster-carers were concerned that the child’s presentation might be linked to maltreatment and spoke to social workers about this but this did not lead to any action. The foster-carers asked that the local authority should look again at what it does to equip foster-carers in such a situation to express and pursue such concerns. The local authority has agreed to follow these matters up. 5.4.2 The foster-carers shared concerns about Special Guardianship which echo some of the points made in section 7.6 of this report. They feel that it can be used as a “cheap option” and one that lacks the thoroughness of the processes of assessment and review for foster-carers and adopters. In this case they remarked on the very tenuous nature of the family connection between the children and the carers, yet that connection served to carry a degree of legitimacy in the placement arrangements. 5.4.3 At some point in the future they would like to be able to tell the children that their experiences have led to improvements in services to children in need. Page 10 of 28 Serious Case Review, Published 01 03 17 6. THE AGENCIES 6.1 Introduction 6.1.1 These children have a wide range of special needs and their lives, from birth, have been troubled. This has brought them into contact with many health and social care agencies, providing some very specialised services. The “parent agencies” for all these services have evaluated their overall involvement with the family and the following sections of the report briefly summarise and consider that evaluation. 6.1.2 It is inevitable, and appropriate, that such a comprehensive analysis will identify learning points and things which could have been done better. However it is right to say that the overall picture that emerges is one of agencies and individuals working together with a real commitment to promoting the best interests of two very needy children. 6.2 Oxfordshire County Council, Children’s Social Care Services 6.2.1 CSC is the agency at the centre of this review. Their involvement with the family as a whole is long standing. They have had the most significant role in respect of planning and managing the care of the children who are the subjects of the review, and ensuring that those children were properly protected, wherever they have been living. 6.2.2 In terms of protection from the serious harm inflicted by Mr K, for CSC as for the other agencies, it is accepted that the matters leading to this SCR could not have been anticipated. However there are learning points arising from the way in which the agencies, and particularly CSC, responded to injuries to the children. The events of July 2014 have implications for a number of agencies and are discussed separately in section 7.3 of this report. Events in late 2014 / early 2015, in which the actions of CSC are particularly significant, are considered in paragraphs 6.2.9 to 6.2.12 below. 6.2.3 The quality of CSC’s longer term work, planning and managing the care of the children, also raises concerns. That is evidenced firstly in the decision, in February 2011, that child protection planning was no longer needed for Child A. This was a decision taken with proper process – independently led and supported by all agencies – but the lead responsibility sits with CSC. Their report to this review accepts that it was perhaps an “over optimistic” decision. That degree of optimism continues throughout these events. 6.2.4 Soon after that decision Ms D was pregnant again, with Child B. That pregnancy did not lead to a pre-birth risk assessment, nor any formal review of the decision to end child protection planning. Child B was born in February 2012 and it was not until December of that year that it was accepted that the care provided by the birth parents was inadequate so that Child B could not stay with them. Page 11 of 28 Serious Case Review, Published 01 03 17 6.2.5 Child B moved to live with the PGM, effectively a family initiative to which CSC acceded. This was despite the well known problems PGM had experienced in caring for her own son, Child B’s father, which were also raised as a concern by MGM. Moreover PGM’s problems were not solely historical. Agencies were also involved in supporting her in the care of Child B’s paternal aunt and, in October 2013, one of those agencies raised concern about PGM’s use of alcohol and a violent partner living in the home. 6.2.6 Despite the concerns about PGM a LAC review in early October 2013 concluded that she should be supported as a long term carer for Child B. However a further assessment, carried out to meet the requirements of Regulation 24, 2010 Care Planning Regulations8 recommended only the following month, November 2013, that PGM should not continue to care for Child B in the long term. That position was supported by a Fostering Panel in December 2013 which confirmed that she should not care for Child B. Nonetheless the child did remain with PGM until moving to live with Mr K and Ms L in April 2014. 6.2.7 It is always necessary in these exercises to keep in mind the clarity that hindsight brings. It is also right to acknowledge the hard work of the staff involved in trying to work out the best options for these children from a range of more or less unsatisfactory choices, in what can be a confusing legal context. But, standing back now, one is struck by the extent to which care planning was reactive rather than driven by a dispassionate assessment of what these children really needed most. They do not live with their birth family now and it may be that the option of removing them from their birth family should have been given greater weight at a much earlier stage. 6.2.8 The weaknesses in proactive planning are further illustrated in the decision whether the two children should be placed together. These were very young siblings who had never lived together for very long. Yet one cannot see evidence of any measured, structured consideration of the potential benefits of placing them separately. This had appropriately been raised as a concern with the local authority by the Children’s Guardian. The local authority has now reflected on this and accepts that there was a “lack of rigour” in their approach to this issue. Key Issue Finding a permanent home outside the children’s birth family, and placing them separately, should have been given greater thought. 6.2.9 Two further issues arise from the local authority’s response to the two incidents, in late 2014 and early 2015, when the children had facial bruising. The various accounts of these incidents are not consistent but the crux of the 8 Regulation 24 of the 2010 Care Planning Regulations sets out arrangements for the temporary approval of a “connected person” as a foster carer in exceptional circumstances for up to 16 weeks. Page 12 of 28 Serious Case Review, Published 01 03 17 matter is that on both occasions, when the day care provider informed CSC of the bruising they were advised that Mr K’s account of accidental causation was reasonable and no further investigations were necessary. 6.2.10 There was clearly a possibility in both instances that these were inflicted injuries – the day care providers were sufficiently concerned to report them. But the social worker failed to initiate child protection enquiries and failed to consult anyone else about what had been reported. The local authority has now agreed that “…our response was not adequate and that procedures and protocols for responding to such concerns were not followed”. 6.2.11 There is a clear picture throughout these events of staff working hard for these children in the face of a series of challenges and obstacles. But that picture also includes elements of an approach which follows events rather than leads, underpinned by an insufficiently questioning optimism. 6.2.12 The second concern is that these two incidents were not reported by the local authority to this SCR. They came to light only as a result of the contact between the author of this report and Ms L. I do not think the local authority deliberately sought to conceal these matters but this does indicate a lack of thoroughness in the authority’s approach to this aspect of the Review: any incidents suggestive of inflicted injury during the relevant period should have been identified and analysed in the report received from CSC. 6.3 Thames Valley Police 6.3.1 TVP has had relatively little involvement with this family. There have been three key contacts in respect of the children. The first of these contacts arose from the allegations in October 2013 that Child A’s foster-carer was rough and unkind to him. From a police perspective “A police investigation … found this case to be one word against the other without any corroborative evidence”. 6.3.2 The second contact relates to the concerns in July 2014 that Child B may have been physically abused. The immediate operational response from police, in conjunction with the local authority’s EDT, was prompt and thorough. However this thoroughness is not entirely reflected in the subsequent follow up from police. The IMR notes that police did not interview Mr K or Ms L and withdrew from the enquiries prematurely, at a point when it had not been demonstrated or concluded that no crime had been committed. The IMR illustrates how, across the agencies, the emphasis drifted away from the protection of the children from harm, and towards the need to support the carers in the difficult task they had taken on. 6.3.3 Finally police were of course involved in responding to the abuse that has led to this review. They were the first agency to be involved and went on to pursue a very efficient, comprehensive investigation, while giving an appropriate weight to the needs of the children throughout. Page 13 of 28 Serious Case Review, Published 01 03 17 6.4 Oxford University Hospitals NHS Foundation Trust 6.4.1 OUH was principally involved as a result of the special health and developmental needs of the children. The Trust’s IMR describes the process of assessment, provision of services and review which was systematic and thorough, appropriately involving the range of other agencies that could contribute. The Trust was also involved in the multi-agency response to the injuries to Child B in July 2014, discussed below. 6.4.2 The IMR highlights two key themes emerging across the agencies: that children with special needs can display similar behaviour to children who are distressed as a result of abuse, and that the issue of Special Guardianship in this case illustrates the diverse and complex range of ways in which the courts can become involved in the lives of children. Non-specialist agencies may sometimes need assistance in understanding that complexity, for example in respect of determining who has parental responsibility. 6.5 Oxford Health NHS Foundation Trust 6.5.1 This Trust provided health visiting services and a range of specialist therapy services for both children. Some of this provision was unavoidably disrupted when, for various reasons, the children’s addresses changed, so that a large number of professionals saw the children. During the periods when the children were in the care of the local authority the Trust also provided services through its Looked After Children team. 6.5.2 The Management Report demonstrates good, well co-ordinated professional involvement across this range of services, and with the other agencies: “both children received a high level of input from both the health visiting and the children’s integrated therapy services in order to ensure their development progressed and their needs were met”. 6.5.3 There are some learning points and instances when best practice was not maintained – for example, not submitting a written report to the Child Protection Conference on Child B in July 2014 – but, again, the overall standard of work, and the commitment of practitioners to these children is clearly evidenced. Page 14 of 28 Serious Case Review, Published 01 03 17 6.6 Oxfordshire Clinical Commissioning Group 6.6.1 The CCG has reviewed the involvement of the children’s General Practitioners during the period under review. Because of changes of placement a number of GP practices were involved but this did not lead to any significant difficulties. The GP was central to the events leading to the Child Protection Conference in July 2014, which is discussed separately. The overall level and quality of service from all GPs was good apart from some issues relating to documentation. 6.7 Children And Family Court Advisory And Support Service (CAFCASS) 6.7.1 Cafcass became involved when the local authority initiated care proceedings in the Family Court in the summer of 2013. This prompted the appointment of a Children’s Guardian by Cafcass. Their Management Report explains that “The core functions of a Children’s Guardian are to provide the court with an independent overview of the child’s situation and of options available to the court; to critically appraise the work of other agencies; and to make recommendations to safeguard and promote the welfare of the child. Ensuring that the ‘voice of the child’ is represented during the proceedings is another key role of the Children’s Guardian”. 6.7.2 The Children’s Guardian (the guardian) was fully and appropriately involved throughout the journey of the children through the legal proceedings. There were a number of points at which issues arose between the guardian and the local authority in relation to the care planning for the children. Ultimately an overall consensus was reached and the guardian supported the placement of the children with Mr K and Ms L. 6.7.3 However the guardian remained concerned about the use of SGOs in this situation, particularly in view of the young age of the children and the inexperience as carers of Mr K and Ms L. Issues related to the legal management of the case and the use of SGOs are considered separately below. 6.8 Oxfordshire County Council, Legal Services 6.8.1 Legal Services’ role was to give advice to inform the key decisions to be made in planning the long term care of the children. Their involvement is also considered below in relation to the relevant terms of reference. 7. THE KEY ISSUES 7.1. A focus on the child How were the children’s wishes and feelings assessed and considered? Were services sensitive to the possible causes of evidence of unhappiness and disturbance after the placement which has led to this Page 15 of 28 Serious Case Review, Published 01 03 17 review? Were specialist services, such as the ATTACH team, appropriately and productively involved? 7.1.1 It was difficult for all the agencies to assess the wishes and feelings of these children because of their young ages, disabilities and communication difficulties. There was always good reason to believe that disturbed behaviour was a consequence of early neglect. OUH reports, in respect of Child A, that “Behaviour such as head banging, biting the tongue and grinding the teeth were noted in the records (and)… the Clinical Psychologist confirmed that, given the previous social history, this would not be unusual behaviour for a child with attachment difficulties”. 7.1.2 The guardian has reflected on whether she might have done more, perhaps by arranging an observation while Child A was getting to know the Special Guardians. The IMR from Cafcass accepts that this might have been helpful, but only to a limited extent: “there were limitations, in that Child A was getting to know both adults through weekly visits whilst the primary carer remained his foster carer. The weekly meetings were activity based and would not, I believe, have provided robust evidence as to how Child A would relate to the Special Guardians once placed full time in their care”. 7.1.3 The IMR from CSC also identifies how behaviour can be interpreted so as to fit with assumptions made about the children: “If they appear to be comforted then this is viewed, understandably, as a sign of positive attachment. If Child B is observed crying and head banging and unable to be comforted by Ms L, then this is interpreted as due to previous experiences with the parents and paternal grandmother”. 7.1.4 The prevailing specialist advice was that the reported disturbed behaviour of the children could be explained as a consequence of early neglect and attachment issues. This was the view taken by ATTACH, a local authority specialist team of professionals with backgrounds in clinical psychology and therapy. They provide assistance and support in a range of situations where children are living away from their birth parents, and overall the team’s involvement was helpful. However, as the IMR comments “there should have been more critical reflection between professionals as to the likelihood of other causes of this disturbed behaviour”. 7.1.5 The IMR from CSC appropriately concludes that “some of Child B’s behaviours can also be viewed as classical signs of abuse. Very calm behaviour with a new carer was perhaps an indicator of a missed opportunity to spot this earlier”. The advantage of hindsight bias is accepted but, ultimately, SCRs do have that benefit. No criticism of those involved at the time necessarily arises from the opportunity to view these events in the light of what we know now. Page 16 of 28 Serious Case Review, Published 01 03 17 Key issue The children’s distress was too easily ascribed to negative experiences in their earlier lives. Professionals might have been more alert to the possibility of other causes. 7.2 Were agencies sensitive to any significant issues of diversity in their involvement in this case? Did interventions take full and proper account of the disabilities and disadvantages which these children had? 7.2.1 Both of these children had very significant disadvantages. They were not always well cared for by their birth parents, nor by some subsequent carers. They both have global developmental delay. Child B has a degree of physical disability. Both have needed a range of therapeutic services. Their ethnicity is also complex. 7.2.2 All of the participating agencies have been able to demonstrate that they took account of the children’s special needs, and those of their birth parents, in their delivery of specialised services to the family. 7.2.3 Research9 tells us that disabled children are three times more likely to be abused than non-disabled children. The agencies, and particularly CSC with its lead responsibilities for the children, have recognised that they could have been more alert to the possibility of abuse of these children. Again, this is not a conclusion solely informed by hindsight. Closer observation and analysis of Child B’s reported behaviour – screaming in distress for long periods when in the care of the Special Guardians but not doing so when going to the foster carers for “respite” – might have suggested cause for concern. The inexperience of the Special Guardians as parents might also have been kept more closely in sight. Key issue The vulnerabilities of the children, and particularly their disabilities, did not always prompt the level of professional watchfulness that they might have done. 7.3 Were assessments carried out and decisions taken and followed up in an appropriate way? In particular were child protection concerns identified in July 2014 appropriately assessed and followed up? 9 See, for example, Jones, L., Bellis, M.A., Wood, S., Hughes, K., et al. (2012) Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. The Lancet July 2012 Page 17 of 28 Serious Case Review, Published 01 03 17 7.3.1 Because of their special needs, and the requirements of child care planning, there were very many assessments carried out by the agencies. Generally there are no concerns about the quality of those assessments and how they were followed up and reviewed. However a number of issues arise from the agencies’ response to the child protection concerns in July 2014. 7.3.2 Mr K took Child B to the GP on a Friday evening. Child B had bruising to the forehead which Mr K said he had noticed a couple of days previously and could not explain. The GP assessed Child B carefully and found further bruising to the legs. He judged that the possibility that these were inflicted injuries, particularly the bruising to the legs which was unusual, needed to be assessed. He allowed Mr K to take the child home judging, appropriately, that there were no acute concerns. After some difficulty in making contact the GP spoke to an “out of hours” social worker from the Emergency Duty Team (EDT) who agreed to follow up. 7.3.3 The social worker contacted the family and secured an agreement that another adult (Mr K’s sister) would stay with them overnight to provide a degree of supervision. The social worker then referred the matter to police, for information at that stage. The following day social workers arranged for Child B to be seen at hospital. Child B was admitted for observation and Mr K remained on the ward throughout. The social worker and uniformed police went to Mr K and Ms L’s home and satisfied themselves that there was no cause for concern for Child A. 7.3.4 A Strategy Meeting under child protection arrangements was convened at the hospital on the Monday. The results of some medical tests were still awaited but the Paediatric Consultant raised concerns at the meeting. The number and nature of the bruises and the lack of any adequate explanation for them was of concern. 7.3.5 The consultant and nursing staff, and the EDT social worker, had also been concerned about Mr K’s attitude and presentation: he seemed nonchalant and distant from Child B and at one point had complained to staff that Child B had “been more trouble than they knew”. 7.3.6 The Consultant was also surprised that apparently no-one caring for the child had heard any cry of pain, which he would have expected, given the nature of some of the bruising. 7.3.7 Police decided at that stage to take no further investigative action unless it were demonstrated more clearly that there were non-accidental injuries. A second Strategy Meeting was held the following day. Results of a full skeletal survey did not reveal any further concerns, nor any underlying organic cause for the marks and bruises. Child B was discharged although it was judged that Mr K should not have unsupervised care of Child B until the matters were concluded (though he could have unsupervised care of Child A). Page 18 of 28 Serious Case Review, Published 01 03 17 7.3.8 It was decided that there should be a Case Conference under child protection procedures. CSC had initially felt this was unnecessary but the Independent Chair for the meeting, having discussed the situation with the Consultant Paediatrician, decided that there should be a conference. 7.3.9 That meeting now received information from Child A’s nursery. Staff there had seen a lump on Child A’s thigh during the week before the admission to hospital and had noted this on a body map. The body map did not show subsequent bruising though it was later confirmed that nursery staff had seen bruising to the head and had not felt that these injuries were of concern. 7.3.10 Mr K had by this time suggested that the bruising to the legs was probably caused when Child A had been sitting in a shopping trolley during a recent trip to a supermarket. The social worker for the children accepted this as a possible explanation, as did the Consultant, with some reluctance. 7.3.11 The conference concluded, unanimously, that there should be no further child protection action. Key factors in that decision were that The injuries had not been conclusively demonstrated to have been inflicted. A wide range of services was already involved with the family and would be continuing to see the children. 7.3.12 When these events were considered during the SCR, the significance of hindsight bias was acknowledged: it was important to assess what had happened with the perspective of what was known by the staff dealing at that time, before the perverse cruelty of Mr K had come to light. In that context the SCR judged that, overall, the decision not to pursue these matters further under child protection arrangements was reasonable. There had also been some good and thorough practice by the GP and EDT in responding to the initial concerns, and by the Independent Chair in challenging the CSC reluctance to pursue the matter under child protection arrangements. 7.3.13 However some concerning learning points were identified. Agencies need to keep sight of the well-evidenced high frequency of non-accidental injury in children with disabilities, who are often least able to explain or demonstrate what had happened to them. Police too quickly came to the conclusion that they could withdraw from the enquiries: there was still a clear possibility that the injuries were non-accidental and relevant further enquiries should have been made – interviewing Mr K and Ms L, for example. The unusual, disaffected behaviour demonstrated by Mr K on the ward was too easily set aside. The medical opinion of the paediatrician, indicating non-accidental causation, was also too easily set aside – by all concerned, including the paediatrician himself. The GP did not attend or report to the meetings held, and the Health Visitors did not submit a written report. 7.3.14 The review has identified some factors which may have affected the outcomes of the conference. There were so many attendees at the meeting - twenty-two - that it was difficult to have a sufficiently full discussion. The Page 19 of 28 Serious Case Review, Published 01 03 17 carers were in attendance throughout which may also have inhibited discussion. Overall the desire for the placement to be successful, especially for staff with a continuing relationship with the children, may have obscured their judgment. Key issue Formal child protection procedures were not followed with sufficient rigour. Further investigative steps should have been taken and fewer people should have attended the Child Protection Conference. 7.4 How were Family Group Conferences used? Was this helpful? 7.4.1 A Family Group Conference is a process led by family members which can plan and make decisions for a child who is at risk. In Oxfordshire they are facilitated by a dedicated service located within CSC. 7.4.2 Most of the agencies involved in the SCR were unable to comment on this issue as they played no part in two FGC’s which were held in March and June, 2013, and which led to the initiative to place the children with Mr K and Ms L. These conferences arose from a request by the MGM of the children. The report from CSC judges that they were “useful in galvanising the role of the wider family in working together to support the children (and considering)… viable long term solutions”. 7.4.3 It was through the FGCs then that Mr K and Ms L almost drifted into the lives of these children. They were brought to the meetings by a distant relative. As discussed below there are a number of factors that might lead one to question whether they were properly equipped to become their parents. Their lack of any experience of bringing up children is the most obvious one. 7.4.4 It was not the role of the FGC to assess them as parents – that came later. But that FGC process must own some of the responsibility for the initial suggestion that they could and should look after two exceptionally needy children. Once an idea like that is mooted it can take on its own momentum. The FGC process may have given it a degree of legitimacy it would not have owned, had they come forward in different circumstances. The IMR from CSC appropriately raises the question: “Should there be some safeguards as to who is invited to FGCs and the role they can assume based upon these meetings?” Key issue The FGC could have been facilitated in a way that enabled a more robust challenge to a proposal that adults with no experience of parenting and some problems of their own could offer a permanent home to two children with very special needs. Page 20 of 28 Serious Case Review, Published 01 03 17 7.5 Are there any lessons to be learned from the conduct of the overall legal proceedings throughout the period under review? 7.5.1 The legal proceedings were complex and changing. There are a number of detailed matters and considerations which consumed time and energy, but do not need to be set out in this report. The following summary of the process and progress of the legal proceedings is drawn from the submission to this review from Legal Services. 7.5.2 Following the initiation of proceedings in August 2013, Interim Care Orders (ICO) were made (unopposed) at the first hearing in September 2013 together with various directions involving a comprehensive timetable up to a final hearing. The final hearing was originally listed for five days commencing in February 2014. 7.5.3 There were a number of matters that arose following the issue of proceedings: The birth of a third child, Child P The capacity of both birth parents The paternity of birth father The care of Child B by the paternal grandmother 7.5.4 Proceedings were also issued and consolidated with the proceedings concerning Child A and Child B following the birth of Child P in September 2013. There was a contested ICO hearing with an ICO being made in favour of the Local Authority. Arrangements were made for Child P to be cared for by the maternal grandparents. These arrangements were made permanent following the final hearing. 7.5.5 In October 2013 the Local Authority had adopted a position that Child P remain in the care of the maternal grandparents Child A move to the care of the newly proposed special guardians in a planned way within four weeks Child B remain in the care of the paternal grandmother 7.5.6 The case summary submitted by Legal Services to the Court indicates that the IRO was content with this plan but the Guardian had some concerns and needed further time to consider the SGO. 7.5.7 Concerns then arose about the care afforded to Child B by the paternal grandmother and the local authority became unwilling to approve Child B’s continuing placement with her. In December there was a contested ICO regarding Child B. The matter was adjourned to January 2014 and an Interim Supervision Order granted in respect of Child B. In addition, there were further directions for the Local Authority to file and serve final evidence, care plans and SGO assessments by the end of January 2014. The final hearing was also moved to the end of March/beginning of April 2014. Page 21 of 28 Serious Case Review, Published 01 03 17 7.5.8 In mid-January the Local Authority’s adjourned application for an ICO in respect of Child B was refused, the test for interim removal having not been met – essentially that at an interim stage the removal of children from their carers is not to be sanctioned unless the child’s safety requires interim protection. 7.5.9 At a further hearing in March 2014 the Local Authority was directed to provide an addendum SGO Support Plan, together with the Support Plan in relation to Child B in the event that the child remained with PGM. The Special Guardians were requested to set out their position as to whether they put themselves forward as carers for Child B and alternative proposals in relation to contact should both children not be placed with them. 7.5.10 Following a final hearing that concluded at the beginning of April 2014 SGO’s were made in relation to Child A and Child B, together with Supervision Orders for twelve months. 7.5.11 There was some delay as a result principally of the challenges arising from the learning difficulties of the birth parents, the birth of Child P and the decision to be reached as to whether Child B should remain with PGM. The Court acknowledged these issues and sanctioned the delay in the proceedings. 7.5.12 As indicated above there remained some areas of disagreement between the Guardian and the local authority as to the most appropriate order to be made by the court. The sad events leading to this review could not have been foreseen but the Guardian’s caution is understandable, particularly given the inexperience as parents of Mr K and Ms L. Ultimately, as Legal Services now advise in their report to this review “These matters were then considered fully before the Court and the competing arguments assessed and determined in (the local authority’s) favour”. Key issue The legal proceedings were particularly complex but their overall conduct was satisfactory. Differences of opinion between agencies were resolved as they should have been. 7.6 Were the relevant agencies clear about when and how Special Guardianship should be considered, what enquiries should be made and what assessments should be carried out? Are there satisfactory arrangements for following up children who have been made subject to Special Guardianship Orders? Is the guidance provided to staff adequate? 7.6.1 Special guardianship was introduced in 2005. It could be seen to fit broadly between a residence order and an adoption order in terms of the new carers’ responsibility for the child. Special guardianship offers greater security Page 22 of 28 Serious Case Review, Published 01 03 17 than long-term fostering but does not require the absolute legal severance from the birth family that can stem from an adoption order. 7.6.2 It was introduced to some extent in the light of research indicating that a significant group of older children do not wish to make such a complete break from their birth family. The introduction of the new order also recognised some special circumstances such as the situation of prospective carers from some minority ethnic groups who may have religious and cultural difficulties with adoption as it is set out in law. Similarly, unaccompanied asylum-seeking children who need secure, permanent homes may have strong attachments to their birth families. 7.6.3 A fundamental aim of special guardianship is to meet the child’s need for a legally secure relationship with their carer. An SGO gives the special guardian parental responsibility for the child, with some limitations and, unlike adoption, the birth parents also retain parental responsibility. 7.6.4 Where an SGO is made in respect of a looked after child, the child will no longer be considered to be in the care of the local authority. A Supervision Order to the local authority may be made. There is a requirement to undertake an assessment for a Special Guardian Support Plan. That support may include some or all of the following provisions: Counselling, advice and information Financial assistance Mediation with parents in respect of, for example, contact arrangements Therapeutic provision Training for Special Guardians to meet the child’s needs 7.6.5 So, these children became subject to SGOs. The court made a Supervision Order, to provide oversight by the local authority for one year. This was part of the local authority’s plan submitted to court. There was a Special Guardianship Support plan in place. The Special Guardians subsequently complained (to the Children’s Guardian) that they had not been provided with enough information about what they were committing to and, particularly, the differences between being an approved Kinship Carer and a Special Guardian. CSC point out that, as is required, they had ensured that independent legal advice was provided to the Special Guardians but have accepted this as a learning point. In future they will ensure that the advice provided does clearly explain the differences between different sorts of legal order and status. 7.6.6 There is no other indication that the local authority failed to meet any statutory or good practice requirements in respect of the decision to place these children under Special Guardianship arrangements with Mr K and Ms L. Our Terms of Reference query whether the guidance to staff about when and how to use Special Guardianship arrangements is adequate. The local authority has reviewed this and confirms that Page 23 of 28 Serious Case Review, Published 01 03 17 “The online procedures are easily accessible to staff and outline the ‘Special Guardianship process and Tracking’ process and provides links to supporting procedures and information”. 7.6.7 However, the very fact that this review is specifically tasked with considering the use of Special Guardianship indicates a degree of concern. That concern arises from the fact that these were two very needy young children and their placement was with two people who had no experience at all of being parents. They did not know the children before becoming involved, through the Family Group Conference, in making arrangements for their future. Any family connection was tenuous. There were criminal records for offences of dishonesty. The assessment process used was not as rigorous as the arrangements for permanence through adoption – there is no requirement that a proposed Special Guardianship arrangement be considered by the Permanence Panel. Special Guardianship did not guarantee that the local authority had a continuing significant role in supervising and planning the care of these young children, for whom the local authority had some parental responsibility. 7.6.8 While plans were being made for these children the government was also reviewing the use of Special Guardianship. That review was prompted by widespread concerns about, to quote the final report from the government’s review10 “Rushed or poor quality assessments of prospective special guardians, for example, where family members come forward late in care proceedings; where there has been inadequate consideration early on of who might be assessed; when assessments have been carried out very quickly to meet court timelines; or when the quality of an initial assessment is challenged, requiring the reassessment of a special guardian. Potentially risky placements being made, for example, where the SGO is awarded with a supervision order (SO) because there remains some doubt about the special guardian’s ability to care for the child long-term. In the …case file analysis (which informed the report), almost half of the 51 cases considered had a SO attached to the SGO. This is particularly concerning where the child is not already living with the guardian, or where there is no or little pre-existing relationship Inadequate support for special guardians, both before placements are finalised, and when needs emerge during the placement, for example, where the special guardian has not received the information or advice to make an informed choice about becoming a special guardian, or where they receive little or inadequate support post order to ensure they can support the child’s needs” 7.6.9 The correspondences between these national concerns and some features of the case under review are self-evident. The government has made a number of changes to the arrangements for Special Guardianship which will address some of these issues, and they are detailed in the national review. 10 SGR_Final_Combined_Report.pdf Page 24 of 28 Serious Case Review, Published 01 03 17 7.6.10 This report has stressed that we have the advantage of hindsight. Those repeated references are made because it is very important to be clear that the grotesque abuse of these children could not have been foreseen. However, judgments about the overall placement decision, the choice of new carers and the legal arrangements used, do not rely on hindsight. This was a risky placement choice which, in my view, was more likely than most to fail. It is not clear that placement options outside the birth families of the children were given enough consideration. Key issue There are clear correspondences between features of this case and the concerns which have led to a national review of Special Guardianship. 7.7 Were there any organisational difficulties within or between agencies? If so, how were these tackled? Has this review found evidence of good practice? 7.7.1 The report from community health services describes the challenges arising when dealing with children who have a diverse range of disadvantages and who move relatively frequently so that “new” professionals inevitably become involved. “Frequent changes in professionals can prompt a ‘start again process’, in other words the children are re-assessed by every new professional and former behaviours and adaptation to different environments can be missed. The loss of this vital information with regards to behavioural changes may prevent deeper analysis of the case”. 7.7.2 In fact the agencies generally responded well to this challenge and their reports do not indicate any unusual problems of communication or collaboration. Indeed, there is quite a lot of evidence of productive working across agencies. This can be found both in the ongoing work with the children and in the agencies’ responses to the significant events which arose during the period under review. As the report from CSC judges: “There was good multi-agency working and co-operation during the period in question”. 7.7.3 There are two well evidenced examples of good practice emerging from this review. The first is the response across all the agencies to the evidence of the abuse which has led to the review. That response was swift and well thought through. Police and CSC were decisive and thorough in balancing their safeguarding responsibilities with the requirements of the criminal investigation. They were supported in that by the other relevant agencies. 7.7.4 The second body of evidence of good practice lies in the agencies’ ongoing work. The special needs of these children, social, medical and developmental, constituted a significant challenge to the agencies. For the most part those agencies worked together well. Page 25 of 28 Serious Case Review, Published 01 03 17 8. SUMMARY OF CONCLUSIONS 8.1 A number of learning points and concerns about practice within and between agencies are identified in the SCR. However it is right to say at the outset that there was no indication that the children might be abused, so seriously and extensively, within the Special Guardianship placement. It is also right to note that the SCR recognised that many individual staff across the agencies had displayed great commitment and compassion in their work with these children. 8.2 The SCR identified an overall concern about the way in which the local authority approached the task of planning the care of the children. There was an unevidenced optimism that various arrangements within the children’s family would meet the children’s long term needs, which were special and demanding. The review found that the possibility of seeking to remove them from their birth family should have been given greater weight at a much earlier stage. There was also a lack of rigour in the Council’s approach to determining whether the children should be placed together, when they had spent little time together before living with the Special Guardians. 8.3 Neither of the Special Guardians had any experience of parenting, nor any experience of looking after children with substantial disabilities and disadvantages. They almost drifted into the children’s lives yet became their legal parents. The SCR expressed some concerns about how this had happened, firstly in respect of the FGC. The FGC process may not have adequately challenged that plan and in fact may have provided an unwarranted degree of legitimacy to the proposed arrangements. 8.4 The legal proceedings which culminated in the Special Guardianship Orders were complex. This was related to associated developments across the extended family, and some disagreements between the Council and the Children’s Guardian. Ultimately however it is agreed that all matters were considered fully and properly by the Court before making those orders. There is no indication that the local authority failed to meet any significant statutory or good practice requirements. 8.5 However, while plans were being made for these children the government was also reviewing the use of Special Guardianship. That review was prompted by a range of factors including evidence of some matters identified in this review insufficient assessments of prospective Special Guardians SGOs being awarded along with a Supervision Order, suggesting a degree of ambiguity about a permanent placement inadequate support / intervention from agencies post-placement, particularly when new needs or concerns emerge The government has made a number of changes to the arrangements for Special Guardianship to address these issues. 8.6 The particular vulnerabilities arising from these children’s disabilities should have been given greater weight. Children with disabilities are known to Page 26 of 28 Serious Case Review, Published 01 03 17 be much more likely to be abused than non-disabled children. There were concerning aspects of the children’s’ presentation after the placement with the Special Guardians which might have given greater cause for concern. There was a tendency too readily to conclude that distressed behaviour was an inevitable consequence of early neglect and then the changes in the arrangements for the children’s care. Agencies need constantly to remind staff that children with special needs can display similar behaviour to children who are distressed as a result of abuse. 8.7 There was a specific missed opportunity across the agencies, when one of the children was found to have suspicious bruising and formal child protection procedures were initiated. Aspects of those events, including medical evidence and concerns about the presentation of the male Special Guardian, might have prompted more thorough investigation. Police too quickly withdrew from the investigation when there was still a clear possibility that the injuries were non-accidental and further enquiries could have been made. There was a Child Protection conference where there were so many attendees at the meeting, including the carers, that it was difficult to have a sufficiently full discussion. 8.8 There were other occasions when a day care provider reported bruising but the local authority made no enquiries about this. Overall the desire for the placement to be successful inappropriately affected child protection processes. Page 27 of 28 Serious Case Review, Published 01 03 17 9. RECOMMENDATIONS TO THE OXFORDSHIRE SAFEGUARDING CHILDREN BOARD 9.1 The Board should use its arrangements for disseminating the learning arising from Serious Case Reviews to highlight the particular vulnerability to abuse of children with disabilities and special needs. 9.2 The Board should require the local authority to demonstrate that it has used the findings of this review to inform its arrangements for care planning for “looked after” children with particular reference to: Working with families where there have been long standing child care concerns Responding to new child protection concerns The use of Special Guardianship, with particular reference to the involvement of the Permanent Placements Panel The use of Family Group Conferences The arrangements for assessing whether siblings in care should be placed together or separately Page 28 of 28 Serious Case Review, Published 01 03 17 APPENDIX A THE LEAD REVIEWER Kevin Harrington Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has worked on some 50 Serious Case Reviews in respect of children and vulnerable adults. He has a particular interest in the requirement to write SCRs for publication and has been engaged by the Department for Education to re-draft high profile Serious Case Review reports so that they can be more effectively published. Mr Harrington has been involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council, and has undertaken investigations commissioned by the Local Government Ombudsman. He served as a magistrate in the criminal courts in East London for 15 years. |
NC046111 | Life imprisonment of a 15-year-old boy convicted of killing a 21-year-old man. CH stabbed Mr Z, a stranger, following a confrontation on a residential street. CH was subject to a child protection plan at the time of the incident. His case was being coordinated by Haringey children and young people's services as a transfer case conference had not been arranged following family's move to Enfield one year earlier. Family history of: mental health problems; alcoholism; domestic abuse; criminal behaviour and anxiety around their immigration status (they were originally from Jamaica). CH had a history of offending, self-harming; and running away from home. He had previously been subject to a care order. Findings include: mother's problems distracted from the needs of her children; support for the family ended abruptly following the cessation of a care order; and domestic abuse between mother and female partner was not treated as seriously as heterosexual partner violence. Makes recommendations, including: information coordinators should be appointed within teams working with families with complex needs, to compile a family history and facilitate information sharing; the Safeguarding Board should create a simple chronology tool that could be completed across agencies; and the Safeguarding Board should explore custodial and residential approaches to working with young people with severe behavioural problems.
| Title: Serious case review overview report: Child ‘CH’. LSCB: Enfield Safeguarding Children Board Author: Alyson Leslie Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW OVERVIEW REPORT Child ‘CH’ Alyson Leslie - Independent Overview Author May 2015 CH Overview Report Final Page 2 of 22 Contents 1. Incident Leading to the Serious Case Review ................. 3 2. Summary of Critical Failings ................................................ 4 3. The SCR Process .................................................................... 10 4. Discussion of Key Themes and Going beyond Learning Lessons ..................................................................................... 12 5. Thinking Differently about Capturing Children's Experiences ............................................................................ 13 6. “The Child's Needs v the System's Needs" .................... 15 7. Summary of Good Practice ................................................ 16 8. Perspective of Mrs H and of CH ........................................ 17 9. Findings and Conclusions .................................................. 18 10. Recommendations from this Serious Case Review ... 19 11. Appendix A – Terms of Reference ................................... 21 CH Overview Report Final Page 3 of 22 Incident Leading to the Serious Case Review 1. On 31 August 2011 CH, then aged 15 was with another male and two female teenagers in a residential street in North London. It was around 7pm and daylight. They were generally playing around with each other and then started targeting a passer-by, Mr Z, a 21-year-old student who was unknown to any of them. The facts established in court were that Mr Z remonstrated with CH who, egged on by his friends, confronted him. A heated argument ensued during which Mr Z was seen trying to placate CH. The other male youth joined CH in lashing out at Mr Z, punching and kicking him. Mr Z raised a skateboard he had picked up. A knife was produced and CH stabbed Mr Z with a single wound to the chest. Mr Z collapsed and residents who had witnessed the events summoned assistance. Despite prompt medical attention and emergency surgery, Mr Z died the following day. 2. CH later claimed he acted in self-defence by punching Mr Z after Mr Z attacked him with the skateboard and claimed that the fatal blow was struck by the other male youth present. CH was identified by witnesses as the assailant by his distinctive clothing which was captured on CCTV and by his street name which a female companion had used. 3. On 13 June 2012 CH was sentenced to life imprisonment with a minimum term of 10½ years. The sentence was increased to a minimum term of 12 years imprisonment by the Court of Appeal on referral by the Attorney General on 9 October 2012. 4. In his sentencing remarks, the trial judge described Mr Z as "an outstanding human being" and he was described by his mother as "caring and respectful". Mr Z was due to have enrolled at university the following day to study architecture and was on his way home from collecting the passport he needed for matriculation, from his grandmother's home, when he encountered CH and his companions. 5. Both Mr Z and CH came from families which had migrated to the UK. Both had spent time growing up in North London and their lives shared some common features. One of the purposes of this review is to gain an understanding of how CH came to be on the trajectory which led to the events of 31 August 2011, culminating in the profound tragedy of Mr Z's death and the ruinous consequences for CH. Other objectives of this review are to understand how public services interacted with CH and his family and to determine the extent to which his actions could have been prevented or predicted. The loss of Mr Z's life was a devastating and unnecessary tragedy. Part of its legacy must be turning a better understanding of how an adolescent boy can become a lethal threat to a stranger on a quiet London street, into effective interventions for deflecting other young men from similarly dangerous trajectories. 6. CH admits to being present when the altercation with Mr Z took place but maintains he was not carrying a weapon and that the fatal blow was struck by the other male. His appeal against conviction has been heard and was turned down at the end of 2014. CH Overview Report Final Page 4 of 22 Summary of Critical Failings 7. Any detailed scrutiny of a case going back over ten years will inevitably find shortcomings in systems and practice, some of which may be reflective of policy and attitudes of a different time. In some cases it is no longer relevant to focus on the issues as law, guidance, policy and practice have changed. This case has highlighted a number of general issues, such as the unrealistic expectations of case conferences and a lack of awareness of the significance of emotional neglect, which impacted across both single agency and inter-professional working. 8. Individual agency shortcomings are addressed in the recommendations made by individual agencies in IMRs, along with proposals and timescales for addressing them. Overarching recommendations for the Boards are made at the end of this report. 9. There are, however, a small number of "critical failings" at individual practitioner or agency level, from various stages of this case, which had a significant or potentially significant impact on the quality of service provided or outcomes for family members. These are summarised in Table 1 below. CH Overview Report Final Page 5 of 22 10. Table 1 PERIOD/AGENCY FAILINGS REASON (if known) COMMENT Early 2004 Sheffield Children's Services Continuing vulnerability of family in period after withdrawal of intensive support and ending of care order was not fully addressed. After loss of contact with family, Agency then did not follow-up and confirm family whereabouts resulting in loss of professional continuity when family moved within South Yorkshire and then to London. Agency was influenced by letter from UKBA advising that family was being deported to Jamaica. Family was keen to disengage from contact with social services agencies and avoid further involvement. Families must be considered vulnerable for a pre-determined "amber" period following cessation of registration/care order. This must be agreed prior to expiration of order/registration and must be recorded and notified to any agency making child protection related inquiries. Move of vulnerable families overseas should be followed-up with the same thoroughness in transfer of information as within the UK and contact made with authorities in country to which they move. Importance of follow-through in child protection work. 2004 onwards Most GPs Failure to identify and communicate history of child protection concerns which were recorded in medical records of Mrs H and AH when invited to contribute to assessment of children's needs / requests for information by social services. Resulting in superficial and/or inaccurate information and reassurances being conveyed to case conferences and to social workers undertaking assessments. Failure to be pro-active in relation to child welfare in light of knowledge of Mrs H and AH's psychiatric conditions, Mrs H, AH, GK Reliance on self-reported patient information which was not checked against records. Failure of GPs to familiarise themselves with family history. Over a period of 10 years GPs received presentations and notifications of clinic attendances for CH's health yet no-one made the link with stresses in his home environment. Similarly, regular A&E attendances for trauma injuries, including a bullet wound and burns, were not explored in relation to child welfare. GP records had information about Sheffield child protection concerns that was otherwise unavailable to social workers but was never shared in the period before Sheffield records were obtained. The attitude of London GPs contrasted sharply with that of Sheffield GP1 who was proactive in identifying potential child protection issues in relation to parental health issues and who liaised closely with health visitor. Individual presentations at surgery or notifications from A&E/clinics were not CH Overview Report Final Page 6 of 22 and CH attendances at A&E and clinics. Failure to link GK into health visiting system. Insufficient clarity about statutory child protection responsibilities and need to be proactive in evidencing that no child was at risk. contextualised and the worrying picture of family violence and stress was not acknowledged. Late 2006 - early 2010 Haringey CYPS Failure by Haringey CYPS to respond to repeated referrals and requests for investigation, initiation of multi-agency case conferences and intervention in the light of multiple and escalating concerns about the care of CH and about the children of AH. Assessments were used as a form of intervention that ultimately delayed intervention and failed to grasp the significance of the family's history, the patterns of violence or the likely impact on the children of years of emotional abuse and neglect. The context of the prevailing culture, inconsistent standards of practice (particularly in relation to assessment) and failures of leadership in Haringey 2006 onwards have been highlighted above. Staff appeared sometimes to treat each new referral about the H family as a new referral rather than contextualising it within an extensive history. Staff had inadequate management support and management oversight of the case was poor. Management of the department was woefully inadequate, allowing poor standards of practice to prevail. Poor assessment skills resulted in inadequate assessments which were not subject to proper oversight or challenge. Even when circumstances began to improve in Haringey under new leadership, the oversight of the case was inadequate. 2010-2011 Haringey CYPS Poor case management by Haringey CYPS. Failure to follow up actions from case conferences in core groups or through review meetings and allowing the case to drift, compromising the welfare of CH and GK in particular. There was a failure throughout to envisage what experiences of "emotional abuse/neglect" meant for the children and what measures were needed to mitigate them. The complexity of the case was too much for one worker to handle and a different approach could have been adopted that allowed sufficient attention to be given to the differing needs of each child. See above 2010 -2011 Core Group The Core Group did not meet sufficiently regularly and were not always well-attended. The Core Group failed to Poor management and oversight of the Core Group meetings and insufficient challenge and follow-through by CYPS Poor channels for accountability for Core Group and lack of clarity about who should be monitoring efficacy and how this should CH Overview Report Final Page 7 of 22 recognise that it was overwhelmed by the complexity of the case and unable to give sufficient attention to the diverse needs of the children of Mrs H and of AH. The Group allowed its agenda to be dominated at times by issues of Mrs H's sexuality and her immigration worries. The Group put forward a poorly formulated request for secure accommodation for CH in May 2010, as a response to escalating concerns about his behaviour and well-being. When this request was rightly rejected, no alternative was considered, although the Group was concerned that CH was at risk of harming or being harmed if he continued on the same trajectory. supervisor who should have been alert to drift in the case. be done. Clearer protocols needed for overseeing/auditing work of core groups. 2010-2011 Haringey CYPS Failure by HSW1 to transfer the case to Enfield CSC after the family moved in August 2010 caused difficulties for multi-agency working and resulted in Enfield professionals who encountered CH to have an incomplete history on which to base their assessments of risk. Poor practice combined with insufficient supervision and oversight. Failure to recognise the need to plan and implement a careful transfer of a volatile and complex case. New protocol for transfer of cases with CPP in Haringey needs to be devised and strictly monitored for agreed period. 2010 -2011 Haringey YOS Retention of CH's case by Haringey YOS after CH moved to Enfield was initially justifiable but as time passed became a barrier to effective integrated working and added to the confusion over curfew orders and breaches, and affected case planning and management. Original decision to retain till end of order was understandable but once a second court order was made, case should have been transferred. YOS officer seemed to lose track of what was happening. Protocol should be established to ensure timely transfer of cases where offender has moved between authorities. Transfer should be made for cases with more than two months of order to run and cases where a new order comes into force before the end of an order with less than two CH Overview Report Final Page 8 of 22 months to run. March-June 2011 Haringey CYPS Failure to respond to referrals and information, including the report of 60+ injuries, suggesting GK was at risk of physical and emotional harm. Failures to follow safeguarding procedures in relation to investigation compromising criminal investigation and resulting in GK being placed with Mrs H who was known to have physically abused a child previously and who was a potential suspect in relation to the injuries to GK Emphasis appears to have been placed on GK's retraction of allegations rather than the physical evidence of non-accidental injury. There was an inexplicable failure of management and professional standards in the handling of this case. One possible explanation is that CYPS staff had come to accept high levels of violence in this family as normal. Mechanism is needed for professionals other than CYPS to initiate a case conference. July 2011 Haringey CYPS Failure to follow through on actions of review case conference and legal planning meeting in relation to accommodating GK and securing supervision orders for CH and DH. No obvious explanation apart from a lack of diligence and absence of a mechanism for identifying and monitoring significant actions from case conferences and legal planning meetings. Mechanism needed for identifying and monitoring key actions from case conferences and legal planning meetings. August 2011 Enfield YOS Insufficiently robust case management and oversight by EYOS2 meant CH was not seen sufficiently frequently, that he was not assessed at a high level of risk of harm and that the confusion about orders, breaches and curfews was unresolved. The standard of the case officer's practice was not sufficiently high. Case officer did initiate a number of actions, including referral to psychologist and support agencies with potential to assist CH. Some of the shortfalls arose because of the timing of the order at the end of July with several staff including EYOS2 being on leave in this period This was an unusual departure from Enfield YOS's usual good standard of practice and robust oversight systems. CH Overview Report Final Page 9 of 22 Failings in Context 11. While some of these failures are particularly grave, notably the poor assessment practice in Haringey CYPS over a prolonged period of time, it is important to note that none of the deficits noted above contributed directly to the death of Mr Z. It can be argued that had CH been removed from the community and accommodated elsewhere, he would not have been present at the fateful encounter with Mr Z on 31 August 2011. CH, however, maintains he was not carrying a knife that evening, and the court determined that it could not be proved otherwise, leaving open the likelihood that the knife was being carried by one of the other young people present. Even if CH had been absent, there is a possibility therefore that Mr Z would have encountered the other young people, one of whom may have had a lethal weapon. 12. Even if CH's presence alone did not guarantee the development of events that led to Mr Z's death, the above failings are still significant. CH was a troubled, displaced and stressed young man with a growing history of aggressive actions and criminal behaviour. He was adjudged, in keeping with his history of emotional trauma, to have little concept of the link between actions and consequences. He had a particularly disrespectful attitude to females and had been alleged to have subjected girls in school to aggressive, sexualised assaults; he consorted with youths who had histories of violent crime, and had allegedly been implicated in crimes involving knives and guns. Aside from his convictions for burglary and assault, he had been arrested or interviewed by Police in relation to 14 other incidents, including drug-related incidents, theft of property, assaults, and crimes involving guns and knives. He had run away from home several times and in early March 2011 had deliberately injured himself, following an incident in his home. He was vulnerable, unstable, and rootless. Without the kind of rigid, structured, intensive programme advised by the Enfield YOS psychologist, CH was in a highly vulnerable state and in all likelihood was going to harm someone or be seriously harmed. 13. Had the events of August 31 2011 not happened, or had CH's case been transferred earlier from CYPS and from Haringey YOS to Enfield CSC and Enfield YOS, the more structured, co-ordinated support and more insightful assessments evidenced by Enfield services might have secured CH the intervention he needed. Much would have depended, however, on the cooperation of CH and the ability of professionals to persuade him to separate from his destructive peer group, and to provide him with a more stable living situation than with his mother. While Mrs H's view is that her son should have been removed from the family home and sent to a boarding facility with a "strict discipline" regime, CH's own view is that nothing would have persuaded him voluntarily to leave his home and family, that he had no desire to lose his social group and that no professional had ever been able to help him. 14. Two further issues are important to consider in looking at the history of professional contact with this case. First, Mrs H and AH were serial offenders over many years. Their offences related mainly to shoplifting but also included acts of violence. Despite frequent court appearances, only once did either of them receive a custodial sentence. Mrs H's role as a mother, her anxieties about her immigration status and her health were regular factors put forward in mitigation when she was in court. CH was also questioned about or suspected of being involved in over a dozen crimes for which he was not charged or brought to court. The CH Overview Report Final Page 10 of 22 SCR panel did invite the Crown Prosecution Service to contribute to this Review, but they declined to do so. Their contribution might have helped explain why members of this family avoided more robust prosecution of offences and more serious consequences. 15. Second, it is not clear whether the serial offending by Mrs H and AH, and the catalogue of over 40 incidents of household violence and violence against others in which they were implicated, have been fully considered in relation to their applications for asylum. The delay in resolving Mrs H's asylum case meant the family were able to accrue further periods of residence in the UK by default. The UKBA IMR does point out however, that, in the light of the features of the case and the capacity of UKBA to manage it, had a final decision been concluded earlier it would not necessarily have led to steps to enforce the removal of the family from the UK. The UKBA’s opinion was provided before the collation in this review of information that later emerged which calls into question some of the narrative which was the basis of Mrs H and AH's original application for asylum which has not, prior to this review, been available to UKBA or its predecessor agencies. The SCR Process Terms of Reference 16. The terms of reference for this Serious Case Review are set out in Appendix A. The Serious Case Review Process 17. At the time of Mr Z's death, CH and his family were living in Enfield. Enfield Council was responsible for his educational provision and he had been supervised by criminal justice services in Enfield for just over a month. His family had moved to Enfield one year previously from neighbouring Haringey where they had lived for over five years. CH was subject to a child protection plan and his case was open to and being coordinated by Haringey CYPS because, although Enfield had been alerted to the family's presence in their area, a transfer case conference had never been arranged by Haringey. 18. Following discussion between the LSCBs from Haringey and Enfield it was agreed that a joint Serious Case Review (SCR) would be undertaken. The Review was chaired by the independent Chair of Enfield LSCB, Geraldine Gavin, while the administration of the process was undertaken by Haringey. The review commenced on 4th December 2012. 19. CH's family moved to Haringey in 2005 from the Sheffield area where they had lived for over four years. Sheffield LSCB undertook a review of the family's time in Sheffield and provided a comprehensive overview report. The family spent several months in Barnsley between living in Sheffield and moving to Haringey. Barnsley were invited to contribute to the SCR process but decided not to do so, Children's Services there having had no contact with the family, although the family did access housing and health services 20. IMRs have been prepared by a mixture of independent writers and senior staff from within the agencies. CH Overview Report Final Page 11 of 22 Elements of Independence /Overview Report Writer 21. The SCR Panel comprised members of Haringey and Enfield Local Safeguarding Boards and was chaired by Geraldine Gavin, Independent Chair of Enfield LSCB since 2010. The Overview Report has been written by Alyson Leslie of the University of Dundee, working in an independent capacity. Approach to this Serious Case Review 22. Setting the parameters and making arrangements for the review across two Boards, with the involvement of over twenty agencies, was a complex task. Slippage occurred initially in arrangements, meaning IMRs did not get underway until around March 2013. There were difficulties for the production of the Overview Report when the original schedule changed from spring to autumn 2013, and the availability of the writer has been a delaying factor. Other considerations have been the participation of family, which was secured late in the process (July and November 2013) and CH's appeal against conviction which was rescheduled from October to December 2013 and was finally heard at the end of 2014. Scope and Timescale of the SCR 23. This review covers the history of CH and his family from the arrival of his mother and sister in the UK in July 2000 up until the death of Mr Z. Originally it was intended to review the family history from November 2001. In order to contextualise material from that time, it was necessary to start the review period just over a year earlier, when family members first arrived in the UK. Structure of Overview Report 24. The family history falls into four periods: The early years (2000 - 2004) from Mrs H's arrival in the UK until the family left Sheffield The "missing" years (2004 - 2005) when the family moved around and had intermittent contact with statutory agencies The London years early phase (2005 - 2008) The London years gang phase (2009 - onwards) 25. Within this report and within the chronology is sensitive information about individuals in the family group which has been disclosed by them about themselves or other family members in confidence to health and social work professionals. Some of this information shared with professionals has not been more widely shared by the individual disclosing it. It is imperative that in sharing the contents of this report and in its publication, safeguards are in place to protect the privacy of the persons affected. 26. The events discussed cover a period of eleven years. Significant changes have taken place in policy, practice and leadership in fields and in agencies. For example, when the first Initial CH Overview Report Final Page 12 of 22 Child Protection Conference took place in Sheffield, the new Working Together guidance had only been published a few weeks earlier and new assessment frameworks and practice guidance were unavailable to professionals. In the early period, therefore, professionals were sometimes working in the context of processes which were unfamiliar and not fully bedded in. 27. A crucial period in the family's contact with Haringey CYPS came in 2006-2009. This is the same period that staff in Haringey were working with the family of 'Child A' (Peter Connelly) and dealing with the aftermath of that case. Three reviews of the Child A case have documented the apparent lack of leadership, evidence of poor standards, insufficiencies in supervision and under-resourcing in children's social care services in Haringey at that time. In that context, it is unsurprising that subtleties and complexities of CH's circumstances and the potential risks within them were not recognised or addressed. As the situation in Haringey stabilised during 2009, engagement with the family did increase and Mrs H speaks highly of some of the involvement and people from CYPS, particularly HSW1, in that period. The case, however, was only intermittently seen as a high priority. Discussion of Key Themes and Going beyond Learning Lessons 28. In a case of this complexity, the traditional concept of "learning lessons" is not helpful. It suggests professionals and agencies finding out things of which they were unaware or being reminded of things they had forgotten. The traditional approach to "learning lessons" also creates a danger of particularising issues at the level of individual professionals or agencies and reducing outcomes of the exercise to remedial actions that can be check-listed. As a result, systemic and wider policy issues can be overlooked and no room left for truly creative and pro-active initiatives. 29. Agencies completing IMRs have made recommendations in relation to areas of practice and administration where these are still relevant. These are adjudged by the people who know the agencies, their management and systems best, to be sound, achievable and relevant. It is suggested that individual agencies should develop and implement action plans in relation to these recommendations and that the Haringey and Enfield Boards should focus on addressing a small number of broad policy areas which can have a wider impact on safeguarding complex families and which are discussed below. Issues of Communication, Information Transfer and Assessment 30. Given the distance of many of the events in this case, it is not particularly helpful to engage in a detailed critique of all the issues of communication, information transfer and conclusions of assessments arising from professional engagement with the H family. These are covered in detail in IMRs with particularly thorough and detailed analysis in the Health Overview and the CYPS IMR. 31. The broad lessons to emerge are extremely familiar to everyone involved in safeguarding children and do not need elaboration: Assumptions must be avoided in child protection work as they only introduce more uncertainty into an already uncertain situation; CH Overview Report Final Page 13 of 22 Professionals can readily mistake parental participation for co-operation and engagement; Focus on a child can be easily lost due to parents employing deliberately distracting techniques or due to parents being so pre-occupied with their own concerns and demanding of professionals' attention; Follow-through is critical when dealing with information, responsibility or concerns in child protection cases: a good metaphor is the transferring of a baton in a relay race, it should only be released when its secure reception has been acknowledged; Safeguarding is everyone's responsibility. There are some good examples of professionals who were working with the adults in the H family being sensitive to the impact on the children of AH's and Mrs H's health and lifestyle, and many examples of this being overlooked. Thinking Differently about Capturing Children's Experiences 32. The most important theme to emerge from the extensive documentation of this review is the importance of understanding and responding to the child's perspective. This is perhaps a more helpful way of thinking about "listening to the voice of the child". 33. The term “listening to the child's voice" has three limitations. First, it puts undue onus on the child to do something difficult and counter-intuitive and speak out (by implication within earshot of an adult). Second, it implies a conversational context. Children do not find it easy to articulate their worries and fears, particularly when talking might make things worse or hurt a parent about whom they have confusing feelings of affection and fear. Children are also unlikely to express their feelings, fears, needs and wishes to an unfamiliar adult. Third, the term can suggest passivity by the hearer and does not capture the necessity of a response to what the child is saying. 34. In all the documentation available to this review, the "voice" of CH on his home circumstances was rarely heard. The only direct examples are from the Sheffield period where his voice is directly heard three times, and each time he is saying that someone has hurt him, that his home is a scary place or that he wants to leave it. The courage that it took him and BH to confide these things to an adult cannot be underestimated. Each time CH said these things it was to a trusted, friendly and familiar adult at school. Each time there was an immediate response and steps were taken to keep him and his brother safe in the short term. In the longer term, little changed in a house where people sometimes hit him, hit each other, harmed his mother, and came into and left his life in a bewildering way. A child inevitably becomes dispirited when the supreme and frightening effort he has made to get adults to change something he cannot, ultimately makes no difference. 35. In Sheffield CH and BH told adults about their home life and how it affected them and that they wanted to leave there. The adults who listened then appeared to do the opposite of what the boys asked. BH only succeeded in his attempt to get away from the unpleasantness at home by displaying more forceful and distressed behaviour. For CH who was younger and quieter, nothing changed except that he no longer had the comfort and companionship of his CH Overview Report Final Page 14 of 22 older brother for a period. Later the children rarely responded to inquiries about their home life. 36. In safeguarding, the occasions when children directly articulate abusive experiences, worries, fears or needs to professionals are relatively rare. Opportunities for busy professionals to build the quality of relationship and level of trust necessary for a young person to feel safe and confident talking about their lives and feelings can be equally rare. Professionals cannot overly rely on these rare occurrences to deliver a child's perspective on events. A child's story, experiences and needs can more often be deduced where they cannot be voiced. 37. The Health Overview Report argues that throughout CH's life there is little evidence of professional curiosity about or response to the impact of events and traumas on the children, including the level of violence witnessed by the younger family members, the verbal and physical abuse they endured and the effect on them of their mother experiencing unstable and sometime violent relationships. 38. Professionals must be attuned to understanding the impact on a child's experiences of the places where and people with whom they spend most of their time (household, school, gang activities, online). 39. When CH or BH found their voice, they described a chaotic existence, severe physical punishment, unpredictability and the fear of violence in their household. Some of the underlying causes of these traumas, such as Mrs H's dangerous lifestyle and health issues did not change; professionals, therefore, could reasonably deduce that these elements continued to cause distressing experiences, even when BH or CH were not complaining of them. 40. It was accepted that the children were exposed to unpredictable incidents of violence, family instability and emotional unavailability. Children cannot be expected to articulate the physical, emotional and cognitive impact of living long-term with such stresses, though they will express it through distressed, aggressive or overly-compliant behaviour. Professionals need to be alert to the severe and enduring impact of the continuous stress of emotional neglect, exposure to violence and chaotic family systems on children and anticipate and articulate it. On-going emotional trauma experienced by children requires as careful assessment and as clear a response as the episodic traumas of physical abuse. 41. Since their arrival in the UK, nothing in the H family situation has improved for the children. A new generation is now enduring the same abuse and turmoil with which their uncles and aunt grew up. There are now three more children in the household, AH's sons and daughter, GK, EJ and FJ (11, 5 and 4). History suggests they may face a bleak and traumatic childhood. The pattern of instability, the impact of severe health problems, criminality, violence and aggression, transient and volatile relationships and lack of emotional nurture has continued to dominate the children's lives. 42. Extraordinary levels of violence, emotional and physical abuse and criminality were accepted by many professionals as the norm for the household with no consideration of its long-term impact on the children. In particular, incidents of domestic violence made known to police, medical and social work professionals were not followed-up in terms of child welfare as they should have been. Because several incidents involved Mrs H and a female partner or CH Overview Report Final Page 15 of 22 girlfriend, there seems to have been an assumption by professionals that they were less serious and less harrowing to the children than heterosexual partner violence. 43. Despite thousands of professional hours provided by nearly 70 people, and provision of multiple forms of support to different family members, little changed for CH or his siblings over their time in the UK. Assessments and reviews confused activity with progress and failed to address the basic questions of "What is changing and to what end?" and "If nothing is changing, what must we do instead?" Review processes throughout became activity planning sessions and failed to address the quality or effectiveness of interventions or take stock of how and whether the children's lives were improving. 44. There was clearly no lack of innovative schemes to support and assist CH, from Boxing Academy as a school alternative, to mentoring schemes that would give him positive black male role models. When one form of intervention was unsuccessful it tended to be replaced with another solution without the underlying issues that it was intended to address having been fully identified and quantified. There was no objective way, therefore, of monitoring the effectiveness of intervention and no sense of coherence, integration, or clear purpose. 45. What is evident in this case is the absence of a mechanism for recognising the futility of approaches and activities which are not making a difference to children and replacing them with something that will. Reviews had become so formulaic that they missed the obvious and did not deliver what was required to make a difference. In this case, none of the resources being committed to the case were improving the children's situation; removing them from that situation should have been a serious consideration from 2006 onwards. “The Child's Needs v the System's Needs" 46. The reluctance to consider residential options for CH may have been in some part attributable to external pressures rather than the child's needs determining available options. There is considerable pressure on YOS teams not to recommend custodial sentences. Some of the performance measures of YOS teams are linked to securing non-custodial outcomes. This means that the specific needs of some young people, such as CH, for whom a psychologist had recommended a structured environment with strong routine, may be subsumed by policy imperatives. As the government's emphasis on restorative justice initiatives is developed, this dilemma may become more pronounced. 47. Some of the assessments of CH undertaken in the youth justice system, using standardised tools, failed to identify the high level of risk he presented. On each occasion this happened, the professional judgement of staff tended to recognise the levels of risk present, which the national measures they used failed to capture. It has now been recognised nationally that tools, such as those used in this case, are not fit for purpose. A new framework of standardised assessment is being introduced in criminal justice which places more emphasis on the judgement of professionals. 48. While recognising that a residential placement or custodial outcome might have been the most appropriate recommendation for CH at various times in 2010-11, given the risks he presented to himself and others, the risks attendant on such placements must be recognised. CH Overview Report Final Page 16 of 22 The rate of reconviction of offenders sentenced to custody in England is over 70%. Young people who have spent time in residential institutions have some of the lowest levels of educational attainment and highest levels of homelessness, destitution and mental illness in our society. This is not an inevitable outcome of removing a young person from their unsatisfactory home environment but rather reflects the features of the residential/youth custody system in the UK. Countries such as Norway, for example, have less than half the UK's reconviction rate. Summary of Good Practice 49. This review has of necessity focussed on the deficits in the handling of in this case in order to identify gaps and learn lessons. The summary of critical failings has been set out at para 10. Exceptional practice has been noted also in a number of instances: The proactive work and responsiveness of GP1 in Sheffield who recognised the implications of Mrs H's and AH's health for the welfare of their children; The intensive work carried out by family support staff in Sheffield in the autumn of 2003 which provided a settled period for the children; The diligence of CP2, the consultant who quickly identified safeguarding issues in relation to Mrs H's parenting capacity and took steps to ensure these were followed through; The exceptional practice of TSW1 whose assessments were thorough and insightful and who made sustained efforts to secure the engagement of Haringey CYPS in relation to the children's well-being; The diligence of probation officer, PO18, in sharing assessments and concerns with health and other agencies in the absence of CYPS intervention; The exemplary practice of staff at NMT A&E in following child protection protocols and identifying the children of Mrs H and AH as subject of child protection plans and following through their concerns; The thoroughness of the documentation by CPaed1 of Whittington Health of over 60 injuries to GK and the clarity of recommendations for follow-up; The work of School 1 which recognised and tried to address CH's deteriorating behaviour and engagement and were responsive to child protection concerns; The accurate and detailed assessment by SnPr2 of Haringey CYPS of the risks and concerns in the family situation and her persistence in attempting to alert senior managers to the dangers of the case being left unallocated; The responsiveness of Haringey FIP to concerns about gang related activity and, in conjunction with Housing, the swift intervention when Mrs H and AH were perceived to be at risk following their altercation with gang members in July 2010. CH Overview Report Final Page 17 of 22 The insightful and thorough PSR compiled by EYOS1 despite considerable lack of engagement from the H family and extremely short timescales. Perspective of Mrs H and of CH 50. Mrs H's view is that all the issues relating to child protection concerns over many years arose from a single misunderstanding and from BH's misbehaviour. Mrs H's states that the allegations made by BH in Sheffield about her lifestyle and physical abuse of BH and CH were untrue. She says they were fabricated by BH because she would not allow him to have a dog and that they set off a chain of events which meant that for many years she and her family were pursued and scrutinised. She asserts she loves her children and would not harm them. Mrs H acknowledges that her lifestyle was previously unsettled and that she had a serious drink problem but she feels she has not been given enough credit by professionals for having tackled her alcoholism and stopped drinking and for having ceased offending behaviour. 51. In Mrs H's view, her contact with social work services has never been satisfactory in relation to her children. Either she was being pestered unnecessarily about their welfare and living under, what she saw as, the threat of them being removed, or when she sought help about CH being caught up in gang culture, she was not given sufficient support. Mrs H does have a high regard for HSW1 whom she said spent a lot of time with the family and tried to help CH. She believes, however, that CH should have been "sent away to a boarding school" to break his links with the area and with the people with whom he was offending. 52. CH, in contrast, states that nothing would have persuaded him to move out of his home. His loyalty was first to his family and he feels the need to protect his mother and would not have willingly left her and his siblings. He does not think he would have settled anywhere else like a residential school or foster care. CH has a strong affection for his family and a need to feel part of them. He remembers his time in Sheffield at school as being happy, although things were more unhappy and unsettled at home then than they were in London. His perception seems to be linked to the presence and absence of people who hurt his mother. 53. CH does not feel anyone he encountered understood his life and he did not feel confident talking to anyone. He did not like the ethos of Boxing Academy. He does not like boxing and felt the regime there was oppressive. At times his life seemed full of professionals who came and went but nothing changed and he wanted to be free of them. His view is that what are needed to divert young men from crime and gang activity is lots more structured sports and leisure activities to fill up their time. CH denies he has ever been involved in knife crime and maintains his innocence of Mr Z's murder. CH Overview Report Final Page 18 of 22 Findings and Conclusions 54. The following is a summary of the findings and conclusions of this review. a) At the time of Mr Z's death, CH was on a worrying trajectory of violence, offending, disengagement and rootlessness and he was seeking increasingly to identify with gang culture. He was at risk of harming someone or of being harmed. b) The circumstances of the death of Mr Z, and CH's involvement could not have been predicted. c) CH was not breaking curfew when he had a dispute with Mr Z and fatally stabbed him. CH was on a curfew order covering the period from 9 pm to 7 am on the day Mr Z died. The incident which led to Mr Z's death happened just before 7pm in the evening. d) The seeds of the recklessness and inability to conceptualise consequences which appear to have influenced CH's actions on 31/8/11, were sown over a decade earlier and flourished in the atmosphere of poor nurture, inconsistent parenting and emotional trauma he endured from early childhood to adulthood. e) An opportunity may have been missed in Sheffield to remove the children from the care of Mrs H and provide them with stable environments, while allowing her to be helped to sort out her own overwhelming difficulties and needs. The main factors in Mrs H retaining care of her children were her successful challenge in court to the local authority request for a care order, her subsequent short period of intense compliance with parenting support programmes and the deregistration of the children's names and premature closure of the case in the erroneous belief the family were returning to Jamaica. f) Families subject to child protection plans and measures do not recover stability or safety quickly. The H family should have been considered vulnerable and at some risk for a period of two years after deregistration and liaison made with whichever location they moved to, including if necessary with Jamaican authorities. g) Professionals frequently failed to recognise the patterns of Mrs H's behaviour, her constant need to move house, her manipulation and her placing of her immigration status needs and other issues before her responsibilities as a parent h) The failure by Haringey CYPS to respond to the repeated requests by TSW1 and others for intervention was an unacceptable level of performance and put CH and other children in the family at risk. i) The failure by Haringey CYPS to follow safeguarding procedures and to ensure the safety of GK in March 2011, after he was found to have suffered a large number of non-accidental injuries, put the child at unacceptable risk and was woefully inadequate and unsafe practice. j) Assessment appeared to be used at times as an alternative to action / decision-making, even in the face of evidence of risk of harm to the children CH Overview Report Final Page 19 of 22 k) The case conference process delivered mainly general aspirations rather than workable strategies linked to key outcomes. There was a lack of follow through of key decisions and few systems for monitoring them in place. l) Astonishing levels of violence perpetrated within and against the H household were normalised and tolerated unchallenged. Same sex intimate partner violence appeared not to have been evaluated and responded to as robustly as similar violence might be in a heterosexual relationship. m) CH should have been removed from the H household at least two years before the tragedy of Mr Z's death. This could have been achieved by a number of approaches including residential schooling and need not have necessitated secure accommodation. GK should not have been allowed to remain in the care of Mrs H or AH following CPaed1's report of a series of non-accidental injuries in March 2011. n) DH's compliant nature and near invisibility in the H household narrative may mask equally significant levels of emotional trauma occasioned by her upbringing. o) Despite some improvements in aspects of the family situation it is unlikely that life in the H household will be any more stable or safe for the current generation of children. Recommendations from this Serious Case Review Introduction 55. These recommendations to the Board reflect the key lessons to be learned from this review. They draw on the views of the SCR Panel and the author of this report. 56. The review does not make a recommendation for every point of learning that has been identified. These recommendations are complemented by more detailed recommendations, specific to each agency, contained in the IMRs from those agencies. 57. It is over three years since the events leading to this Serious Case Review. Agencies have not awaited the completion of this review in order to tackle issues arising from these events. Many of these recommendations, or aspects of them, have been identified and addressed already. Recommendations to the Haringey and Enfield Safeguarding Children Boards 58. The Boards should explore through discussion, debate and professional development initiatives ways of improving professional competence in assessment. One of the mechanisms used should be the sharing of good practice. In this case, the work of TSW1, SnPr2 and EYOS1 are commended for discussion and learning. 59. The Boards should explore and devise local arrangements for reviewing decisions by Children's Services not to progress to S47/ICPC potential child protection cases referred by partner agencies. CH Overview Report Final Page 20 of 22 60. The Boards should draw on learning from Troubled Families and TAF work to establish models of working with families with complex needs, specifically families where there are both mental health and child protection issues. The key elements of the models should be that professionals have time and scope to deploy their professional skills, that a discrete team work with the family and that an information co-ordinator be appointed from within that team, whose role is to compile and understand the family history and to facilitate the flow of information amongst professionals. 61. The Boards should look to establish a Practice Working Group to look at creation of a simple chronology tool that could be completed across agencies. 62. The Boards should support efforts to review YOS national performance indicators to ensure they do not risk compromising outcomes for individual children. 63. The Boards should support efforts to explore custodial and residential approaches which have low rates of reconviction. 64. The Boards begin a dialogue across professions about shifting the emphasis from "listening to the voice" to "capturing the experience" of the child, with particular consideration of what a child's behaviour tells us about their experience. CH Overview Report Final Page 21 of 22 Appendix A – Terms of Reference The following terms of reference (TOR), covering 13 areas of professional activity were agreed at the start of the process Terms of Reference 1. An examination of any issues, in communication, information sharing or service delivery, within or between services. To include those with responsibility for working out of hours as well as those working in normal office hours and with particular reference to their knowledge of the process of escalation on intra and inter agency concerns in accordance with paragraph 18.5 of the London Child Protection procedures. 2. Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children and with wider professional standards? 3. What were the key relevant points/opportunities for assessment and decision-making and effective intervention in this case in relation to the children and family? What was the quality and timeliness of decision-making and did subsequent assessments and decisions appear to have been reached in an informed and professional way? What was the quality of multi-agency risk assessments? 4. Did actions accord with assessments and decisions made, taking into account the previous court intervention? Were opportunities for effective intervention, such as Section 47 investigations, multi-agency strategy meetings, Family Group Conferences, Child Protection conferences or effective Looked After Child reviews taken? Were appropriate services offered/provided and/or relevant enquiries made, in the light of assessments? 5. What did each agency know about the history of each of the parents and or any other significant adults in the household? Consider whether both the mother’s and the fathers' presentation and experiences in the light of their childhood and previous relationships was appropriately identified, acted upon and has any relevance. 6. What training has been provided in adult-focussed services to ensure that, when the focus is on meeting the needs of an adult, this is done with regard to the duties to safeguard and promote the welfare of children? 7. Were practitioners aware of “what it was like to actually be that child”, sensitive to the needs of the children in their work, and knowledgeable both about potential indicators of abuse, specifically physical abuse or neglect and about what to do it they had concerns about a child’s welfare? 8. Did practice in the period show any lessons learned from previous Serious Case Reviews? If not, what were the barriers? 9. Was practice sensitive to and/or influenced by the racial, cultural, gender, sexuality, linguistic and religious identity and any issues of disability of the child and family, and were they explored, taken on board and recorded? 10. Was there sufficient management accountability for decision-making? What was the quality of supervision? Were senior managers or other organisations and professionals involved at points in the case where they should have been? CH Overview Report Final Page 22 of 22 11. How effective was management support and supervision in countering the impact of parental hostility and deflection. What evidence is there of reflective and authoritative practice of both supervisors and supervisees? 12. Evaluate the impact of any organisational change and challenge over the period covered by the review and establish the capacity of front-line services for effective response. 13. In addition to the above, IMR writers are asked to comment on any other children in the household. |
NC045595 | Death of a 15-year-old in early 2014, as a result of complications caused by a chronic health condition. Child BR was receiving care from a tertiary health centre, geographically remote from their home town. Child BR was made subject to a Child Protection plan on the grounds that Child BR was resisting medical intervention, concerns of parental neglect and parental inability to endorse attendance at medical appointments. A Child Protection plan and later a Child in Need plan were implemented, which maintained the same level of support from practitioners. Parents had agreed to a bespoke residential plan to improve Child BR's access to health care but Child BR died before the plan could be implemented. Uses the Welsh Child Practice Review model to identify learning points, including: scope for exploring joint working practices between tertiary and primary health services, including the role of the GP as the repository of all health information; when brief interventions are successful ways to maintain them should be explored; and commissioners of specialist health services should consider prompt access to psychological services for children and young people with chronic conditions.
| Title: Concise child practice review: Case reference: Child BR. LSCB: Blackpool Safeguarding Children Board Author: Rachel Shaw Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final November 2014 Page 1 of 16 CASE REFERENCE: Child BR Blackpool Safeguarding Children Board Concise Child Practice Review Review Process Circumstances Resulting in the 12 month Review The death of a child is always a tragedy. Formal and effective systems are required to review what has happened and to learn from the experience so that inter-agency arrangements or services can be further improved where this is thought to be necessary. At the beginning of 2014 Child BR age 15 years was found dead at the family home. The Home Office Pathologist concluded in the Post Mortem Report that Child BR’s cause of death was Methoxetamine (Synthetic Class B Drug) Toxicity, Chronic Renal Failure and Hypertensive Heart Disease. Child BR was of Caucasian descent and lived at the family home with siblings. Child BR suffered with a significant chronic health problem, which without medical intervention would be life limiting. In addition there had been previous concerns about parental neglect which had led to a multiagency response by agencies. Specialist health care services were being provided by a geographically remote tertiary health care provider to manage and treat the condition. Following an early referral from the tertiary health care provider Child BR was being supported by social workers from the local Children’s Social Care Service. Attempts to ensure Child BR accessed health care proved challenging initially when as a young dependent child who relied on parental compliance to attend and later as a teenager exerting self choice in refusing to consistently access health care. Attempts to work with Child BR and family were intermittently successful. Prior to Child BR’s death a bespoke residential placement had been identified and plans were in place to introduce this to Child BR. The aim was to offer Child BR intensive support in order to improve access to essential health care to maximise health outcomes. Unfortunately Child BR died before this was implemented and it remains unknown if this intervention would have been successful or in fact provided further challenge. Final November 2014 Page 2 of 16 Background Information for the period prior to the 12 month Review: Child BR was born with a health problem requiring immediate surgical treatment and follow up. It appears that Child BR was lost to follow up due to Child BR and family moving house to another area. Child BR next came to the attention of health services at the age of 11, which was 3 years 9 months prior to the review timeline, and was diagnosed with a life threatening illness which was a consequence of the original condition. This acute episode of ill health necessitated health care provision from a tertiary centre which was geographically remote from Child BR’s home town. The centre made an early assessment that if Child BR did not access appropriate treatment this would lead to deterioration in health and subsequent death. This coupled with concerns that Child BR was resisting medical intervention and parental inability to endorse attendance resulted in an appropriate safeguarding referral from the tertiary centre to Social Services Child Care Team in April 2009. The health care providers recognised that Child BR and family required additional support to meet health needs. This resulted in Child BR being subject to a Child Protection Plan, the category of which was neglect, with intensive multi agency support. Successful compliance with the Child Protection Plan resulted in both Child BR’s health and welfare needs being met more consistently and a Child in Need Plan was then implemented which maintained the same level of support from practitioners. Child BR’s health condition required regular treatments each week which were delivered both at the tertiary centre and also at home, facilitated by a parent, following extensive training. From August 2013 onwards home treatments were no longer appropriate and visits three times a week were required at the tertiary centre. The family and Child BR required intensive family support from services. Child BR was displaying challenging behaviour within and outside of the home including refusal to attend for health treatment and resistance to attend school. Alternative education provision was made at two or more different specialist educational establishments in an attempt to meet Child BR’s educational requirements whilst maintaining regular health care interventions. The Police and local council worked together to assist the family in improving their home environment by clearing the house and garden and agreeing ground rules for interaction with neighbours following disputes. Legal Context: A Serious Case Review was commissioned by Blackpool Safeguarding Children Board (BSCB), in accordance with Working Together to Safeguard Children (Department of Education 2013). Regulation 5 of the Local Safeguarding Children Boards Regulation 2006 sets out the functions for LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5 (1) (e) and (2) set out an LSCBs function in relation to serious case reviews, namely: 5. (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. Final November 2014 Page 3 of 16 (2) For the purposes of paragraph (1)(e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. BSCB considered that the death of BR met the criteria for undertaking the SCR because there had been concerns that neglect had been a feature over a number of years prior to death. This review was undertaken in line with the principles of learning and improvement set out in Section 9 of Working Together to Safeguard Children (Department of Education March 2013). The methodology used was the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012). The Child Practice Review process was introduced in Wales in January 2013 to replace the Serious Case Review Process. This is an innovative formal process that allows practitioners to reflect on cases in an informed and supportive way. Documenting the history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for Local Safeguarding Children Boards to use where it is more important to consider how agencies worked together. The detail of the analysis undertaken of the case is not the focus of the reports which are succinct and centre on learning and improving practice. However, because a review has been held, it does not mean that practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice. The role of Safeguarding Boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the review can be used to inform systems and practice development. In so doing the Board may identify additional learning issues or actions of strategic importance. These may be included in the final child practice report or in the action plan as appropriate. Methodology: Following notification of the tragic death of Child BR and agreement by the chair of BSCB to undertake a Child Practice Review, a Review Panel was established in accordance with guidance. This was Chaired by a member of Blackpool Safeguarding Children Board, an NSPCC Service Manager, and included representation from relevant organisations from Health, Police, Education and Social Care. Rachel Shaw, Designated Nurse, Safeguarding Children Service, was commissioned from Public Health Wales NHS Trust to work with the panel and to undertake the review. The time period for this review is between the 1 January 2012 and 1 January 2013 also taking into account the services provided prior to this 12 month timeline. Full Terms of Reference are included in Annex 1. Final November 2014 Page 4 of 16 All agencies reviewed all their records and provided timelines of significant events and a brief analysis of their involvement for the 12 month period of the review and the preceding years. These were considered by the Reviewer and Review Panel and provided opportunity for panel members to raise questions, clarify understanding of the circumstances of the case, services provided and identify good practice and areas for improvement. The agency timelines were merged and used to produce an interagency timeline. This was carefully analysed by the Reviewer with the Review Panel to identify the areas that required further exploration and consideration. The process also identified key practitioners to be invited to attend a learning event, the purpose of which was to understand the involvement of services with BR and family. The 12 month summary timeline is attached as Annex 2. The Chair of the Panel and reviewing officer met with Child BR’s family to gain an understanding of their experiences of the services offered. This was shared with the panel and with practitioners attending the learning event held on the 10 July 2014, facilitated by the Reviewer and attended by the Chair of the Panel and Business Manager of the LSCB. The learning event was organised in line with Welsh Government guidance (Child Practice Reviews Organising and Facilitating Learning Events, December 2012). Following the learning event, the reviewer collated and synthesised the learning to date for discussion with the review panel, the panel gave consideration about what could be done differently to further improve future practice. Draft reports were provided to the Review Panel and a Final report was agreed on the 17 September 2014. The Reviewer and Chair of the Review Panel arranged to meet again with the family to share the learning identified from the Review. Once agreed by Blackpool Safeguarding Children Board the full report will be made publically available by the Board. Analysis, Practice & Organisational Issues Identified Analysis: The challenge for practitioners and managers was that of a young person presenting with a serious health problem who was resisting regular specialised health treatment coupled with parental inability to enforce attendance. Despite attempts by practitioners Child BR persisted in accessing health care on an intermittent and unpredictable basis often displaying verbally aggressive and disruptive behaviour towards health care staff, other patients and parents when attending. The challenge of managing a young person living in crisis who is insistent on not accessing life saving treatment is an unusual scenario. The age of Child BR during the 3+ years leading up to the time period of the review provided practitioners with additional challenge. Initial engagement was with a young person reliant on those with parental responsibility for ensuring Child BR was presented for treatment. As Child BR advanced in years and Final November 2014 Page 5 of 16 became competent to make self choices about accessing health care the challenge of ensuring access to that health care was further compromised. Child BR was supported via a Child in Need Plan for an extensive period. During this time there were periods of improvement when there was intensive support and then issues arose again as professionals stepped back. Legal options were considered by Children’s Social Care including making Child BR a ward of court. However, managers in Children’s Social Care did not think that this would have provided the method to enforce attendance for treatment and it was not pursued despite practitioners challenging the decision making of their managers. Leading up to the time of death there was a decision to pursue a Residential Placement. There had been previous parental refusal for a Residential Placement utilising voluntary arrangements under Section 20 Children Act 1989 but parental agreement was forthcoming in the weeks before Child BR’s death and a bespoke residential placement had been located. The next steps would have been to discuss with Child BR. It will remain unknown if this would have elicited any change in BR accessing essential health care. Evidence of consideration for a ‘half way house’ between being supported at home and being accommodated under Section 20 was not apparent during the review. This may have been achieved through innovative ways of maintaining intensive support to the family which had proved successful via the Child in Need Plan. This review identified some key learning points and areas of effective practice which focussed on the following main areas: Communication: There was excellent communication between all practitioners involved in supporting Child BR including social workers, social work support workers, education workers, Consultant and Specialist Nurse from the tertiary centre and the Police. Staff worked well together and shared information appropriately. Staff should be commended on their tenacity in seeking to develop and maintain communication and a relationship with Child BR who was displaying very challenging behaviour towards staff visiting at home and when accessing health care provision. Their passion to work together to secure positive outcomes for Child BR was undeterred. A gender appropriate Social Worker was introduced at one stage in an attempt to provide a gender specific role model to improve outcomes but unfortunately this made no impact on the situation. All practitioners who worked with Child BR and family remained constant throughout the time period from diagnosis to death which provided continuity of care to BR and family. While health care was very specialised and being managed by the tertiary centre it was noted that there was little or no input from the local primary and community health services. Although this is unlikely to have impacted on the outcome there may be learning for BSCB to explore this issue further. Woodman J et al (2014) state because general practice is a universal service which can take a longitudinal view of families, GP’s are well placed to enact direct response to the children and families they see as well as participate in existing systems to Final November 2014 Page 6 of 16 safeguard and protect children. Learning Point 1: Scope and improve, as appropriate, the current joint working between tertiary centres and local primary/community health services for children/young people with chronic health conditions. To include: • Local community health support to the child/young person/family (Community Nursing/School Nursing • GP health support to the child/young person/family • Information sharing between health services including electronic information sharing • Accessing GP resource as the repository for all health information In relation to GP input this may be assisted by reference to a recent publication The GP’s role in responding to child maltreatment: London: NSPCC Interagency working: There was evidence of excellent interagency working between all professionals. Successful implementation of a Child Protection Plan (which predates the review period) and then a Child in Need Plan which maintained the same level of intervention to Child BR leading to improved access to health care. The Consultant and Clinical Nurse Specialist from the tertiary centre attended Child Protection and Child in Need meetings and an extraordinary meeting with the Head of Children’s Services due to levels of concern for Child BR. There were periods when brief but intensive interventions from specialist services within children’s social care were mobilised for time limited periods which resulted in improved outcomes for Child BR. There may have been an opportunity to maintain these interventions and thus sustain this change over a longer period of time. Learning Point 2: When brief interventions from specialist services are successful explore ways to maintain these interventions over a longer/permanent period of time. There were however also periods where there was no progress in accessing health and education services. This was the source of anxiety for practitioners who were concerned with the decision of managers within Children’s Social Care not to pursue a legal route to make Child BR a ward of court. Managers based this decision on their view that this would not have been an effective method to enforce treatment or act as a stabilising factor in BR’s life. Although practitioners felt confident to challenge the manager’s decision, which is good practice, they were left feeling anxious and vulnerable in being asked to continue to manage Child BR in the same way. Practitioners would have benefitted from additional support from their managers at this time. Final November 2014 Page 7 of 16 Learning Point 3: All agencies to ensure that staff are supported appropriately particularly at periods of increased anxiety eg when a child/young person dies, or at particularly challenging periods for a caseload holder. Learning Point 4: Blackpool LSCB to ensure there are arrangements in place to facilitate locally for multi agency professional forums for ‘stuck cases’. The Consultant and Specialist Nurse considered whether discharging Child BR to adult services would be beneficial because the specialist health care services required could be delivered more locally. However, it was concluded that the follow up for non attendance would not have been so rigorous and that this would have been a more risky option for Child BR. Education partners worked together with other agencies well and responded to Child BR’s needs and sought to provide education in a variety of settings to suit need at the time. This included education provision in specialist educational establishments and home education and although Child BR only accessed such provision intermittently education staff persisted in trying to engage the young person to engage. Assessment: It was noted that the Core Assessment undertaken by Children’s Services for Child BR would have benefitted from being updated regularly as new events/challenges arose. This would have provided opportunities to assess his changing needs over time and analysis of risk. Learning Point 5: Children’s Social Care to ensure that Core Assessments for long term cases are reviewed following new events in that child/young person life. Child BR displayed challenging behaviour towards professionals and was also challenging for parents. Examples of this were refusing to attend school, refusing to attend for health treatment being verbally abusive towards staff and other patients and causing disruption in health settings. Despite attempts from family to support sensible decision making Child BR continued to make poor decisions about access to both health and education provision which was being offered. Parenting children can make many demands on adult carers but staff working together with this family tried endlessly to suggest positive parenting techniques to parents who in reality had lost parental authority. Specific input from a Child Psychologist may have helped Child BR come to terms with a chronic life threatening disease which in turn may have influenced decision Final November 2014 Page 8 of 16 making. Psychological services for children and young people with chronic health needs is intrinsic to helping children/young people and their families deal with such enormous health issues and is often part of an in house service provision aligned with specialist health services. It will remain unknown if this would have helped in the case of Child BR as such services were not available as part of the tertiary health service provision. Learning Point 6: Commissioners of Specialist Tertiary Health Care Services consider prompt access to psychological services for children/young people and their families for children/young people with chronic long term life limiting health conditions. Consent issues for young people making decisions about accessing health and other services: The crux of the analysis of this case surrounds the ongoing dilemma facing families and professionals when children/young people are perceived as competent in making choices about whether they access services but make decisions which adults and professionals consider poor choices. It is not possible to force children/young people to access services against their will and there is no legal route which would enforce this. The tertiary health provider did seek legal advice in managing Child BR’s non compliance but the advice was unforthcoming perhaps because there were no legal solutions available. In the case of Child BR it was hoped that the option of becoming accommodated would have provided some additional support and stability to encourage better decision making and secure Child BR’s agreement to treatment. A real and difficult ethical dilemma arises for professionals when a young person, who is informed and understands about health care treatment and the consequences of not accepting treatment, continues to refuse. Professionals can only continue to guide and advise the young person in question and need to be supported by their managers in so doing. This appropriate support will be different in each organisation ranging from manager’s support, multi agency professional forums for ‘stuck cases’, supervision from safeguarding teams within health settings etc. Conclusion: From the analysis it is apparent that professionals and family worked tirelessly to try to influence Child BR to make appropriate choices about accessing health care. The process of the review has identified some learning points for BSCB to consider but the application of these is unlikely to have altered the outcome for Child BR. The view of the family was that there was nothing else that professionals could have done to change anything and the family considered that all professionals involved went that extra mile to support them. The challenge to professionals and families alike in supporting children/young people who make poor health/education decisions is likely to persist and there is no quick fix. Final November 2014 Page 9 of 16 Improving Systems & Practice In order to promote the learning from this case the review identified the following actions for Blackpool Safeguarding Children Board and its member agencies: Communication: 1. Scope and improve, as appropriate, the current joint working between tertiary centres and local primary/community health services for children/young people with chronic health conditions. To include: • Local community health support to the child/young person/family (Community Nursing/School Nursing) • GP health support to the child/young person/family • Information sharing between health services including electronic information sharing • Accessing GP resource as the repository for all health information In relation to GP input this may be assisted by reference to a recent publication The GP’s role in responding to child maltreatment: London: NSPCC Interagency working: 2. When brief interventions from specialist services are successful explore ways to maintain these interventions over a longer/permanent period of time. 3. All agencies to ensure that staff are supported appropriately particularly at periods of increased anxiety eg; when a child/young person dies, or at particularly challenging periods for a caseload holder. 4. Blackpool LSCB to ensure there are arrangements in place to facilitate locally for multi agency professional forums for ‘stuck cases’. Assessment 5. Children’s Social Care to ensure that Core Assessments for long term cases are reviewed following new events in that child/young person life. 6. Commissioners of Specialist Tertiary Health care services consider prompt access to psychological services for children/young people and their families for children/young people with chronic long term life limiting health conditions. References: Protecting Children in Wales: Guidance for Arrangements for Multi- Agency Child Practice Reviews. Welsh Government 2012. Woodman J, Hodson D, Gardner R, Cuthbert C, Wooley A, Allister J, Rafi I, de Lusignan S, Gilbert R ( 2014) The GP’s role in responding to child Final November 2014 Page 10 of 16 maltreatment. London. NSPCC Statement by Reviewer REVIEWER Statement of independence from the case Quality Assurance statement of qualification I make the following statement that prior to my involvement with this learning review:- • I have not been directly concerned with the child or family, or have given professional advice on the case. • I have had no immediate line management of the practitioner(s) involved. • I have the appropriate recognised qualifications, knowledge and experience and training to undertake the review. • The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference. Reviewer 1 (Signature) Name Rachel Shaw Date 20 November 2014 Chair of Review Panel ( signature) Name Linda Evans Date 20 November 2014 Final November 2014 Page 11 of 16 Annex 1: Terms of Reference Final November 2014 Page 12 of 16 TERMS OF REFERENCE FOR CHILD PRACTICE REVIEW Child BR Introduction • This Serious Case Review has been commissioned by Pauline Newman, Chair of Blackpool SCB on the recommendation the Case Review Sub-group of BSCB. It is in accordance with ‘Working Together to Safeguard Children’ March 2013 which has been adopted by BSCB and underpins it’s Learning and Improvement Framework • A multi-agency Review Panel and Review Panel Chair has been identified and an External Reviewer has been commissioned to undertake the review. The Chair of the Review Panel will regularly report progress to the BSCB. • Review Panel Members: (Chair) Service Manager NSPCC Designated Doctor for Child Protection Blackpool Teaching Hospitals Designated Nurse for Child Protection Blackpool CCG Principal Social Worker Children’s Social Care Review Officer Lancashire Constabulary Named Nurse Central Manchester University Hospital Named Nurse Safeguarding Blackpool Teaching Hospitals Head of Access and Inclusion Children’s Services Purpose Final November 2014 Page 13 of 16 • Establish whether there are lessons to be learned about the way in which local professionals and agencies work together to safeguard children. • Identify clearly what those lessons are, how they can be acted upon and what is expected to change as a result. • As a consequence, improve inter agency working and better safeguard children. • Identify examples of good practice. Terms of Reference The terms of reference agreed for this review are: 1. The following services will produce a 12 month timeline of actions taken by each agency going back 12 months from the date of Child SB’s death • Blackpool Children’s Social Care • Blackpool Teaching Hospital NHS Trust • Blackpool Children’s Services – Education • Royal Manchester Children’s Hospital • Lancashire Constabulary • Blackpool Clinical Commissioning Group 2. A summary/analysis of each services involvement will also be produced by the above services. This will include additional background information from outside the timescale for the review as well as initial analysis of the key issues involved, an indication of further issues for consideration by the Reviewer and any recommendations if appropriate. This should be brief (no more than 2 sides of A4) 3. Other services may be asked to provide a timeline following review of the information provided. 4. Determine whether decisions and action taken in the case comply with local and national policies and procedures 5. To examine inter-agency working and service provision for the Child 6. To determine the extent to which decisions and actions were child focussed. Final November 2014 Page 14 of 16 7. The Reviewer will meet with the family to seek contributions to the review and keep them informed of key aspects of progress. 8. Identify any features of the case, which indicate that any part of the review process should involve, or be conducted by an independent party. 9. Identify any parallel investigations of practice and determine if a co-ordinated approach will address all the relevant questions. 10. To hold a learning event for practitioners. 11. The Reviewer will produce a succinct Review Report with recommendations which will constitute the Overview Report and Executive Summary under the current regulations in accordance with Working Together to Safeguard Children March 2013. The Reviewer will share the Review Report with the family. 12. The review panel will agree an BSCB action plan from the recommendations 13. The Review Report will be presented by the reviewer and Chair of the Review Panel to the BSCB and it will then be made available to the public on the BSCB website. 14. The Chair of Blackpool SCB will be responsible for making all public comment, and responses to media interest concerning the review until the process is completed. It is anticipated that there will be no public disclosure of information other than the Review Report. A media statement will be prepared and approved by the BSCB Chair for use at publication of the Review Report, if required. She will be assisted in this role by Blackpool Council Communications Team. 15. The BSCB and Panel will seek legal advice on all matters relating to the review. In particular this will include advice on: o Terms of Reference o Disclosure of Information Final November 2014 Page 15 of 16 Appendix 2: Summary Timeline Blackpool Local Safeguarding Children Board Summary Timeline Re: Child BR Type of activity 2013 Jan Feb March April May June July Aug Sept Oct Nov Dec Local Health Services from DGH/Community Paediatricians Admitted to DGH with Pneumonia Health Visitor/School Nursing Service Tertiary Health Centre Attended for treatment(2) Attended for treatment(1) Attended for treatment(2) Attended for treatment(2) Attended for treatment(1) Attended for treatment(1) Attended for treatment (4) Absconded during visit Hospital Safeguarding team contacted for advice CAMHS referral advised Attended for treatment(3) DNA 1 Attended for treatment(4) DNA 1 Behaviour abusive and aggressive Attended for treatment Behaviour abusive and aggressive Attended (5) for some treatment DNA 1 Behaviour abusive and aggressive Attended (2) for some treatment DNA 1 Police GP Social Services Legal advice sought by team manager. Wardship advised. HOS advises not to pursue wardship CIN Meeting Permission sought to seek a residential placement under Section 20 Children Act 89 Refused by parent CIN Meeting Meeting between Team Managers over recent deterioration Revisit section 20 accommodation with parent CIN Meeting SW to discuss Section 20 accommodation with parent Parent informed a residential Placement had been found SW visits but parent unable to attend Final November 2014 Page 16 of 16 Type of activity 2013 Jan Feb March April May June July Aug Sept Oct Nov Dec Housing Education Education provided from different centre Education meeting to discuss attendance issues Home Visit – no reply Several attempts made to contact home for tuition Contextual issues Detailed timelines were produced by the relevant services for the purposes of the review to assist the understanding of the complex interactions between events and services in this case. This summary and partial timeline contains limited and annonymised details and is provided to supplement the outline of circumstances in the Child Practice Review report. |
NC52228 | Serious injuries to a 6-year-old child in 2018. History of domestic abuse between Child R's parents, resulting in a Child in Need Plan and Child Protection Plans until parents separated. Child R had experienced 13 injuries over a nine-month period, mainly in the form of bruises to his face. In 2017 and 2018 Child R made disclosures about being hurt by mother's partner. Child protection medical examination found that one injury was non-accidental and caused by someone hurting him but no protective action was not taken. Injuries were attributed to poor parental supervision, but this was not in line with the medical findings. In October 2018, Child R attended the emergency department with a serious head injury and significant bruising, which later required neurosurgery. Mother's partner was sentenced to nine years for grievous bodily harm against Child R; Mother charged with neglect. Ethnicity or nationality not stated. Learning focuses on compliance with child protection procedures and the arrangements for the child protection medical examinations; assessment of risk, the impact of confirmatory bias and misunderstanding of terminology; the transfer of cases. Recommendations include: ensure that multiagency child protection procedures are effective in respect of strategy discussions and child protection medicals; chronologies should be completed as part of the referral to Social Care to highlight patterns of physical injury; consider an awareness raising campaign within the wider children's workforce focused on physical harm in children and consider whether the terminology around non-accidental injuries should be changed.
| Title: Serious case review: Child R. LSCB: Nottingham City Safeguarding Children Partnership Author: Hayley Frame Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Child R Author: Hayley Frame Completed: 22.08.2019 Published: 01.04.2021 2 Forward This Serious Case Review was completed in the summer of 2019. The content remains as written by the author and as signed off by the Childrens Safeguarding Board which was the governing body for Serious Case Reviews at the time. Publication was delayed whilst we awaited the conclusion of associated criminal proceedings. In the intervening period, in response to Working Together 2018, there have also been statutory changes in local safeguarding arrangements, with the introduction of Statutory Partnerships and the disbandment of Safeguarding Boards. Due to the extended delay and statutory changes a decision has been made to publish this report without attempts to update or amend in any way. This allows for full transparency and reflects the learning and actions undertaken in response at the time. 3 Contents 1. Introduction 2. Purpose and Principles of the SCR 3. Methodology 4. Time period for SCR 5. Parallel processes and investigations 6. Overview report structure 7. Summary of Historical Information 8. Summary of Information Known to Agencies and Agency Involvement in Respect of Child R 9. Analysis including lessons learned 10. Changes in Practice and Actions Already Taken 11. Conclusions 12. Recommendations 4 1. Introduction 1.1. Serious Case Reviews (SCRs) are always carried out by a Local Safeguarding Children Board (LSCB), when a child dies or is seriously injured and abuse or neglect is known or suspected to be a factor. This procedure is laid out in the NCSCB Safeguarding Children Procedures and is in accordance with the expectations set out in the Government guidance, ‘Working Together to Safeguard Children’ 2015, chapter 4. This SCR has been commissioned following the completion of a Rapid Review compliant with Working Together 2015 (as per current DfE transition guidance published July 2018). 1.2. This report summarises the findings from the SCR that was established to consider the professional interventions in respect of a child, who will be referred to as Child R, who was seriously injured whilst in the care of his mother and her partner. In October 2018, Child R attended the emergency department with a serious head injury and significant bruising. This later required neurosurgery. 2. Purpose & Principles of the SCR 2.1. The purpose of the SCR is to establish any lessons to be learnt from the case; to identify how these will be acted on and lead to sustainable improvements, the prevention of death, serious injury or harm to children. 2.2. The NCSCB and partner organisations will translate the findings of this SCR into programmes of action, which lead to sustainable improvements in practice and service delivery, to improve outcomes. 2.3. The following principles will be applied to this SCR: a culture of continuous learning and improvement across partner organisations identifying learning and promoting good practice; the review will be proportionate according to the scale and level of complexity of the issues being examined; the review will be led by an individual who is independent of the case under review and of the organisations whose actions are being reviewed; professionals will be involved fully in the review and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; the final report of the SCR will be published, including the NCSCB’s response to the review findings, in order to achieve transparency, unless a reason not to do so is identified within the process improvement will be sustained through regular monitoring and follow up so that the findings from the SCR makes a real impact on improving outcomes for children recognition will be given to the complex circumstances in which professionals work together to safeguard children 5 the review will seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; the review will seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; the NCSCB and partner agencies will be transparent about the way data is collected and analysed; and relevant research and case evidence will be used to inform the findings 3. Methodology 3.1. An Independent Reviewer, Hayley Frame, was commissioned to undertake the SCR. Miss Frame is an independent safeguarding consultant and as such is independent of all agencies contributing to the SCR. She has 24 years’ experience within safeguarding, as a practitioner and as a manager at various levels, and is a qualified and registered Social Worker. Miss Frame is experienced in completing serious case reviews, safeguarding adult reviews and domestic homicide reviews. 3.2. This SCR was commissioned following the completion of a Rapid Review and submission to the National Panel which agreed with the recommendation for a Serious Case Review. As such the project plan and methodology took into account: That there was already a detailed rapid review report available that highlights key learning and practices episodes which has been used to inform this report. That organisations had already completed and submitted internal case review reports. That the SCR needed to be proportionate in recognition of learning already identified and potential for additional learning. That there was a need to engage the workforce, specifically those involved with the family in the process, via the convening of a reflective learning event. There was a need to engage the family in the process subject to police approval given ongoing criminal investigations That the process was compliant with Working Together 2015, (as per current DfE transition guidance published July 2018.) 3.3. Agency submissions were provided by: Nottingham City Council - Children’s Integrated Services Nottingham CityCare Nottingham City Clinical Commissioning Group (for GP contracted services) Nottingham Emergency Medical Services (NEMS) School Nottinghamshire Police 6 Nottingham University Hospital NHS Trust East Midlands Ambulance Service 3.4. In order to ensure that the SCR considered not only what happened but why, the NCSCB SCR standing panel agreed to adopt an approach that engaged directly with practitioners involved in the case. As a result, a practitioner event was held, to which all practitioners and their line managers who had direct involvement in the case were invited. The practitioner panel ensured that opportunity was given to fully understand practice from the viewpoint of the individuals involved at the time. 4. The time period over which events were reviewed 4.1. 1st October 2017 to 2nd October 2018 (date of incident that led to the decision to hold a SCR) 5. Parallel processes and investigations 5.1. The involvement of family members has not been possible at this stage due to the ongoing criminal investigations, which includes Child R’s mother. The CPS have authorised a charge of neglect on Child R’s mother on the grounds that she left her son with a known dangerous man. The mother’s partner was sentenced to 9 years for Grievous Bodily Harm against Child R. 5.2. There are no other reviews currently taking place in relation to this case. 6. Overview Report Structure 6.1. The Overview Report provides a summary of the information contained within the agency submissions, ensuring that key events and issues are captured and analysed. Author’s comments are set out in bold, including findings ascertained from the practitioner event held as part of the review. 6.2. The analysis includes a summary of the author’s comments, analysis of the case against the identified key issues and the themes that have emerged from this SCR. 6.3. There have been a number of developments and actions already taken and these are set out in section 11 prior to the conclusions and recommendations of the report. 7. Summary of historical information 7.1. In 2012 concerns were raised regarding domestic abuse between Child R’s parents. This led to a Child in Need Plan commencing. In January 2013, a child protection enquiry 7 under section 47 of the Children Act 1989 was undertaken which concluded that the children were at ongoing risk due to domestic abuse. An Initial Child Protection Conference took place and the children were made subject to child protection plans under the categories of physical and emotional abuse. This plan remained in place until April 2014, when the case closed as the parents had separated and it was felt that the risk of domestic abuse had reduced. 7.2. In November 2014, it was confirmed that the couple had resumed their relationship and in May 2015, the children were again made subject to child protection plans. The child protection plan ceased in November 2015. Following the child protection intervention, the family continued to receive support and intervention from the Children’s Targeted Family Support Team until January 2017. 7.3. The parents were no longer in a relationship during the scoping period for this review. 8. Information Known to Agencies and Agency Involvement in Respect of Child R 8.1. On 30th November 2017, Child R informed school staff that his mother’s partner had punched him in the arm ‘the other day’ and given him a ‘dead arm’. A concern form was completed by the school and the mother was spoken to who said that she did not recall her partner punching Child R’s arm and stated that having previously been in a violent relationship that she would not condone this kind of behaviour. The review has concluded that in the circumstances the school’s response was proportionate however it is of concern that Child R may have felt disbelieved and that his voice went unheard. There was no change in his presentation however following this incident to trigger further concern. 8.2. Similarly, on 31st January 2018, Child R informed school staff that his mother’s partner had shot him with a nerf gun (a toy gun that fires foam darts) causing a bruise to his cheek and a cut to his forehead. Again, a concern form was completed and his mother was spoken to. It does not appear that this injury was considered in the context of the previous injury. The school have acknowledged that they could have done more to ascertain who the mother’s partner was. Had this injury been referred to Children’s Social Care, the details of the partner could have been established. 8.3. On 14th February 2018, Child R had bruising to his face which was allegedly caused by play fighting. A concern form was completed and his mother was spoken to who agreed to take Child R to the GP. 8 The review has established that Child R’s mother came into school in the morning, saying that she was thinking of taking Child R to the GP due to the bruising. The school have reflected as part of this review that they should have made a referral to Children’s Social Care but the explanation seemed reasonable and they were reassured that she was taking him to the GP. 8.4. Child R was seen by the GP that day, at 6pm, who made a referral to Children’s Social Care the next day after having reflected upon the presentation and feeling concerned about Child R’s injuries. The GP informed the mother. The review has questioned whether the GP had considered whether Child R was safe to go home that night and whether a referral should have been made to the out of hours Emergency Duty Team. 8.5. The referral was screened by Children’s Social Care on 15th February 2018 upon receipt and it was agreed that there was a need for a child protection investigation and that the child needed to be seen that day. . Despite this, no strategy discussion took place with the police and s47 (child protection enquiries) did not commence. Expected practice is that the social worker will speak with the Police and health professionals to have a strategy discussion. The police are based in the same office. In situations where it is not clear-cut whether a child protection medical is needed and therefore the social worker will go out to see the child first, they will still have a discussion with the Police beforehand. This ensures that S47 enquiries have already been agreed in advance with the Police and that any child protection medical occurs within that framework. In addition, a strategy discussion provides an alert to the police of an injury to a child and allows them to consider the potential for a police investigation at the earliest opportunity. In this case the police were denied the opportunity to consider the need for a police investigation as they were unaware of Child R’s injuries. 8.6. The child was seen by a social worker and attempts were made to arrange a child protection medical. However the Non Accidental Injury clinic was closed and so it was agreed that a child protection medical would occur the following day. The review has considered what should happen when a child protection medical is required but the clinic is closed. It would be essential to ensure that a risk assessment was agreed through a strategy discussion; that the child was medically safe and that a safety plan was in place given the potential for non-accidental injury. In this case, there was no adequate safety plan in place as it was assumed that the mother was a safe person. 9 8.7. The child protection medical occurred on Friday 16th February 2018 and it found that the injury was non accidental in nature, as the bruises were in areas of soft tissue that are not usually injured accidentally. The information was recorded on a summary form and handed to the attending social worker which she signed. This was a different social worker to the one who had visited Child R at home, due to her being on annual leave. The form states the views of the Paediatrician: ‘I am concerned that this is a non-accidental – i.e. that this was caused by someone hurting him’. The review has established that the social worker took this paper form away with her. The Paediatrician has informed the review that the mother walked out of the clinic in distress and that the social worker was intending to speak to her manager. There is no record of any discussion taking place, or of the paper copy of the report being shared with the Team Manager. However, the tone is set by the safety plan agreed on 15th February 2018, which assumes that Child R’s mother is a safe person, and so she leaves the hospital with Child R. Expected practice would be that after a child protection medical, the Team Manager would record on the child’s file the outcome of the medical examination; the immediate safety plan for the child and why they have determined it is safe for the child to go home. 8.8. It wasn’t until Monday 19th February 2018 that the Team Manager informed the social worker that a strategy discussion with the police was required. In addition, the Team Manager ticked the relevant boxes on the child’s electronic file for a strategy discussion to be held and S47 enquiries to commence. This strategy discussion did not occur. The review has established the allocated Social Worker subsequently cancelled the strategy discussion from the electronic file on 5th March 2018. This cancellation is not easily visible to a Team Manager when closing a case. This has been raised with the system provider Liquidlogic as a risk within the system. The review has not been able to establish why the Social Worker cancelled the strategy discussion. In addition, this must question the administration rights within the system that allow a Social Worker to cancel an action that has been initiated by a Team Manager. 8.9. On Wednesday 21st February 2018, the full child protection medical report is emailed to Children’s Social Care. It was electronically copied to the GP. The report is clear regarding the concerns that the injuries are likely to have been caused non-accidentally. The report also details that Child R was to be subject of an s47 enquiry. The full medical report was emailed to the Children and Families Direct inbox. At that time the business support officers would then email the report to the social worker. There is no record of a Team Manager having seen either the interim report (paper copy the social worker would have been given at the end of the medical examination) or the full report once it was received later. This protocol 10 has now changed in that the report is emailed to both the social worker and team manager to ensure management oversight. 8.10. On 28th February 2018, the school recorded that the social worker shared the outcome of the medical with the school as being ‘NAI due to poor supervision’. The review has considered the issue of terminology across the wider workforce, and the school have reflected that not all school staff would fully understand that NAI means the child has an inflicted injury. Also, the injury was not due to poor supervision – the medical report was clear that the concern was that someone had harmed the child. 8.11. On 15th March 2018, Child R was seen at school with further bruising to his head, allegedly from falling from his bed. The school informed children’s social care but no action was taken. On 20th March 2018, he had bruising to his waist. The school informed Children’s Social Care and a social worker visited Child R and felt that it appeared accidental and that she was intending on closing the case. On both occasions, a medical view should have been sought regarding Child R’s injuries. 8.12. The following day, 21st March 2018, Child R was seen at school to have fresh bruising to his face. The social worker was informed but she was unable to visit until the following day. Also on the 21st March the social worker contacted, and spoke with the GP. The GP advised that there was no medical condition that would suggest a predisposition to bruising. The GP was of the belief that s47 enquires were being undertaken. 8.13. On 26th March 2018, the children’s assessment was concluded and the case was closed to children’s social care. The authorising Team Manager wrote that ‘The assessment has not raised any further concerns since the medical that was undertaken from the referral. Agency checks have not raised concerns. No concerns raised about the children in the home. Appropriate supervision of the children has been raised. Mother has taken on board all concerns and worked with the assessment.’ It is of note that the Team Manager made reference to the medical yet did not identify that this had occurred outside of established safeguarding procedures, and specifically that a strategy discussion and s47 enquiries had not taken place. In addition, the case was allocated to the social worker from 19th February 2018 until 26th March 2018. No supervision between the social worker and team manager occurred during this time, which should have been monthly as per the supervision policy, and there is no recorded management oversight. 11 8.14. The following day, 27th March 2018, Child R had further facial bruising which was referred by the school to children’s social care. He was seen in school by the same social worker who felt that it was accidental. This was the third report of bruising in 6 weeks. 8.15. On 29th March 2018, Child R was tearful in school and limping. The social worker visited him in school again but no action was taken. School records show that they discussed with the mother that Child R should be taken to the GP. 8.16. Child R had further facial bruising on 16th April 2018. The information was recorded by the school staff and his mother was spoken to. Again on 23rd April 2018, a mark was seen to Child R’s back and the school spoke to his mother. The review has established that the school did not refer these injuries to children’s social care because the assessment outcome was that the injuries that occurred had resulted from poor supervision and not inflicted harm. They felt that the mother was plausible in her accounts. 8.17. On 15th May 2018, Child R had bruising to his face and neck. His sister informed the school that she threw a car at him. A concern form was completed. 8.18. On 17th May 2018, the social worker finalised a second assessment and stated that the case should be transferred to Targeted Family Support Services. The authorising Team Manager wrote that ‘It is a concern that Child R has presented with a number of different injuries, however there have been consistent explanations for this and there is a concern regarding a lack of supervision within the household. I am therefore in agreement with the social workers recommendation for the case to be stepped across to TFST for the identified work to be completed. Should there continue to be concerns regarding injuries to the children following work being completed with mother a referral to CSC to be made and consideration to S.47 enquires being initiated’. The social worker report does not identify the pattern of bruising and the view taken is that the bruising is caused due to a lack of supervision. The first and second assessments are virtually identical however they were signed off and authorised by 2 different Team Managers. 8.19. The case was considered by the Targeted Family Support Manager who felt that the case would be best met by Early Help services (a lower tier of intervention). The review has considered that this should have prompted a discussion between the Children’s Social Care Team Manager and the Targeted Family Support Team Manager due to a differing view regarding the threshold met for services. 12 8.20. On 7th and 12th June 2018, further facial bruising was seen at school. After the second incident the school contacted the social worker who stated that the case was going to be allocated within Targeted Family Support Services, which was inaccurate information. School records show that the social worker spoke to a staff member and informed them that the case was closing and transferring to Targeted Family Support Services– when the case was actually fully closing with no further action. The social worker is also reported to have said that a discussion had taken place with the Team Manager and they agreed that if an adult was intentionally harming the child, that they would have hurt the child on their body and not their face so as to hide the abuse. This provided the school with reassurance. The Team Manager was present at the practitioner event held as part of this review and was clear that this conversation did not occur and that the Team Manager does not agree with the view that people who hurt children would never hurt a child on the face in order to avoid detection. 8.21. Despite the Targeted Family Support Team Manager’s earlier view, a home visit was undertaken by a Family Support Worker on 22nd June 2018, however the mother refused Targeted Family Support Services and the case was closed. There was no referral made to Early Help, no consideration of escalating the case to Child in Need status given the mothers refusal to engage with Targeted Family Support Services, and as such the case was closed to all of Children’s Integrated Services. 8.22. On 25th June 2018, Child R was seen by the GP with back ache. No marks or bruises were noted. This was a different GP to the one that made the earlier referral to Children’s Social Care. 8.23. On 11th and 24th July 2018, Child R was seen at school to have bruising to his arms. The mother was spoken to by the school and the explanation given by the mother and by the child himself was that he had been wrestling with his cousin and it caused the bruising. The school advised not to wrestle and to find alternative ways to play. The review has established that the school were not fully convinced that the injuries were linked to poor supervision but as Child R was known to be a boisterous and clumsy child at school there was some plausibility that he had sustained the injuries due to poor supervision. At this point school were not aware that the case would not be transferring to Targeted Family Support Services as planned, and still believed that a family support worker would be allocated. 13 8.24. Child R attended the Urgent Care Centre on 25th August 2018 with an ankle injury and multiple facial bruising. The GP was informed. The explanation that he had fallen from his bike was accepted. The urgent care worker had a very clear memory of Child R as he was limping badly and as his mother was heavily pregnant, the worker carried Child R down the corridor. The worker did not have any concerns about Child R’s presentation and he appeared happy and boisterous. In hindsight, the worker has reflected that bruising to both sides of his face would be unlikely after a bike fall. The urgent care worker also looked at the safeguarding note held on the system, and saw that the case was closing to social care, and felt reassured by this. The presentation was not referred to children’s social care as would be expected practice. 8.25. On 2nd October 2018, Child R attended the emergency department with a head injury and significant bruising. This later required neurosurgery. Following disclosures, the mother’s partner was arrested for assaulting Child R. 9. Analysis including lessons learned 9.1. Compliance with child protection procedures and the arrangements for the child protection medical examinations 9.1.1. As was established within the rapid review, it is clear that the social work response to the concerns raised for Child R was not in line with both national and local safeguarding procedures. This was compounded by a lack of management oversight. It has been established that there were no contextual issues such as the allocated social worker’s caseload being high that might have provided some explanation for the failure to comply with established procedures. Unfortunately the social worker is no longer employed by the Local Authority and therefore it has not been possible to engage her in the Serious Case Review. 9.1.2. As part of the Rapid Review process, an individual reflective session was held with the social worker with regard to the case management and responses to Child R’s repeated presentation with injuries. This was held prior to the social worker leaving the Local Authority and the notes of the session were made available to the Independent Reviewer for this Serious Case Review. The social worker is recorded as having stated that the mother was very engaging and that she spoke to the children alone who had not made disclosures, and had also undertaken direct work with Child R in school. She could not recall why a strategy discussion did not occur and did not mention that she had cancelled it. She confirmed that she had undertaken visits that had not been recorded. She was able to articulate the process for child protection enquiries but was not able to explain why the process had not been followed in this case. An audit of twenty cases held by the same social worker was completed to ascertain if these practice issues were present in other cases. No practice concerns were identified through this audit. An audit of 10 cases for each Team Manager was also completed to ensure that there were no practice concerns about their decision making. 14 9.1.3. The strategy discussion is a pivotal part of all safeguarding procedures. It allows for information sharing between key statutory agencies and ensures agreed decision making where there are concerns regarding a child experiencing significant harm. It also allows for consideration at an early stage for the potential for criminal investigations to be undertaken by the police. Despite this Serious Case Review, it remains unclear why a strategy meeting did not occur in this case. 9.1.4. In November 2018, Ofsted undertook an inspection of the Local Authority and found that ‘child protection enquiries are swift and well-coordinated, including when concerns are received out of hours. Co-location of police, health and probation agencies with children’s social care supports timely strategy discussions and appropriate decision-making. Children at risk of significant harm are urgently seen and risk is quickly assessed. A small minority of enquiries take too long. This leaves some families with prolonged uncertainty. Social workers’ timely assessments of children’s needs are thorough and provide a clear view of risks to children. They are informed by good-quality direct work, which means that children are contributing to and influencing their own plans’. These inspection findings support the view that the failures in this case relate to individual practice errors rather than systemic difficulties within children’s social care. 9.1.5. The child protection medical examination that was held should have occurred within the context of agreed s47 enquiries with the police following a strategy discussion held with them, and health colleagues. It is not clear, despite this review, why this did not happen in this case and how the child protection medical examination occurred outside of agreed pathways. The review has considered how child protection medical examinations are arranged and the process is that the social worker will call the on call paediatrician for advice and if agreed that a medical is required, then the social worker completes a form and sends it to business support staff at the hospital. The review has suggested that the form is amended to include whether a strategy discussion has been held and whether s47 enquires have been initiated. If not, then a child protection medical cannot go ahead and be booked. 9.1.6. Arrangements have been made to ensure that the full medical examination report is now given social care team management oversight as they receive an emailed copy, within one working day There is currently no similar way to ensure that the hand held paper copy of the interim report completed at the time of the examination is seen by the Team Manager as it is given to the attending social worker. However the form itself could be amended to include the details of the interim safety plan and the name of the Team Manager who has agreed it. If this is completed by the on call paediatrician this will ensure that there is discussion of the findings immediately, appropriate management oversight and a safety plan for the child agreed between the paediatrician and the Team Manager. 9.1.7. Standard safeguarding procedures were not followed when Child R presented to the Urgent Care Centre and social care were not informed of his attendance. The GP who was in receipt of the information regarding the presentation did not inform social care either however the information would likely have been filed in the GP notes by an 15 administrator and without reference to safeguarding concerns is unlikely to have been flagged with the GP. 9.1.8. The review has recognised that within the Urgent Care Centre there is, by the very nature of the work, a fast turnaround and workers have very little time to look at the history of a presenting patient, and even if they did would not necessarily understand all the acronyms and terminology used. The Urgent Care Centre have completed work with staff on different social care terminology and acronyms to support them when looking at notes, have compiled a ‘top tips for bruising in children information sheet and have also considered how they use body maps. This may have assisted the worker in considering fully whether the mechanism reported was in line with the presenting injuries. 9.1.9. The school have acknowledged that there were several occasions where multiagency safeguarding procedures were not followed and they should have referred Child R’s injuries to Children’s Social Care. They have reflected on how they accepted the position of the social worker in that the injuries were due to poor supervision and that they were reassured by the mother’s presentation. In addition, they believed that the case was awaiting allocation of a family support worker yet did not pursue when this was going to occur. 9.1.10. Despite the review process and the scrutiny of the Independent Reviewer and the NCSCB SCR Standing Panel, it has proved to be very difficult to understand and make sense of the sequence of events and agency responses in this case. As the Review has not been able to seek the contribution of the social worker nor the mother, this has also made the challenge of understanding why even more difficult. 9.1.11. There is a clear failure to recognise a catalogue of injuries suffered by Child R. Within the practitioner event held as part of this Review, the Independent Reviewer compiled a basic list of all injuries sustained by Child R. This made for stark reading and the impact of this upon those in attendance was significant. Had a similar brief chronology been completed as part of Child R’s case management, this may have led to a different conclusion of the assessment and response as the evidence is overwhelming. 9.2. Assessment of risk, the impact of confirmatory bias and misunderstanding of terminology 9.2.1. The assessments completed by the social worker were not of a high standard. Although two were completed they were virtually identical. The assessments did not clearly identify the worries and what was expected to keep the child safe, in line with well-established Signs of Safety guidelines. Child R’s father was not approached as part of the assessment and there was no information regarding the mother’s partner. It appears that the social worker developed some fixed thinking in relation to the cause of injuries for Child R, believing them to be due to poor supervision. This bias then impacted upon her decision making and the actions taken. More robust management oversight could have challenged this stance. In addition, the use of a chronology listing all of Child R’s injuries would have been a key tool to challenge fixed thinking. 16 9.2.2. The review has established that there were opportunities for escalation of concern regarding Child R. Professional challenge is a key safety net in the delivery of multiagency safeguarding procedures. The paediatrician undertaking the examination did not have input into the proposed safety plan despite their findings. The school were informed wrongly by the social worker that the outcome was ‘NAI due to poor supervision’ - yet this is clearly a contradictory description for the cause of an injury to a child. 9.2.3. The review has discussed the impact of the misunderstanding of terminology and that the term Non Accidental Injury is not particularly helpful, although widely accepted within the child protection arena. To reconsider rewording the term to be that of ‘inflicted or deliberate injury’ would alleviate any confusion regarding injuries that arise as a result of poor parenting such as poor supervision, and put the focus upon who caused the injury and not just how. New categories have been established within the paediatric service, yet these specialist categories would not necessarily be easily understood by the wider workforce. 9.2.4. The review recognises that it takes time to embed new terminology across a multiagency safeguarding partnership, yet this has been seen already to be successful with regard to ‘DNA’s’ now being referred to as ‘was not brought’; which again is a good example of where a change in terminology can lead to a change in focus, the focus being upon the child’s experience. To change widely accepted terminology will be a strategic challenge however the driver for this comes from the practitioners themselves who were clear that a change to ‘inflicted or deliberate injury’ would leave no room for misunderstanding or ambiguity, and it is imperative that this Review listens to the voice of the practitioners on the front line. 9.3. The transfer of cases 9.3.1. Previously when a case was being transferred from children’s social care duty teams to the Targeted Family Support Teams, and Targeted Family Support Team decided that the case should not sit with them then the case would electronically be referred back to the social worker. This has now changed so there would be a discussion between the Social Care Team Manager and the Targeted Family Support Team Manager or Family Support Practice Specialist. If TFST are not going to take the case then it will be for the Social Care Team Manager to decide on what to do next. This will ensure that the case can be escalated where needed and not result in case closure to all parts of Children’s Integrated Services, as occurred in this case. 9.4. Child R’s lived experiences 9.4.1. Child R was, at the time of the significant injury, a 6 year old child who had experienced thirteen injuries over a nine month period. These injuries were mainly, though not exclusively, in the form of bruises to his face, often in areas that are not commonly injured during accidents. A child protection medical determined that one of these was likely to be non-accidental. He had been seen and treated by medical professionals for back pain 17 and ankle pain. He has also received a serious head injury, requiring neurosurgery, and all current available evidence indicates that this was the result of a serious assault. Child R is a child that has experienced significant pain, apprehension and fear as a result of these injuries. Despite good support in school, access to a specialist counsellor and direct work with the allocated social worker, Child R was not able to tell professionals involved with him how he received the injuries. 9.4.2. All indications are that Child R enjoyed school. He was a popular pupil with a solid friendship circle. He presented as happy and confident in class and had excellent attendance. He was seen to be an active and sometimes boisterous boy who engaged well in school life. Observations of him with his mother raised no concern in the way they related to each other. His mother’s presentation also served to reassure professionals in contact with her, apart from that of the consultant paediatrician who undertook the child protection medical as it would appear that she saw a different presentation of the mother, who was not accepting of the medical findings regarding the cause of Child R’s injuries. 10. Changes in Practice and Actions Already Taken Childrens social care have completed the following activity: A development session has taken place with all team managers from the duty service in respect of section 47 procedures, strategy discussions and child protection medicals. In addition, it has been reinforced to social care staff that following a safeguarding concern any safety plans implemented are discussed with a Team Manager and that when a child protection medical has confirmed child abuse, before the child leaves the hospital, the social worker must agree the safety plan with the Team Manager and place this on the child’s file. The Children’s Integrated Services case transfer policy has been updated to capture the actions to be taken if a family do not engage after the case has stepped across to Early Help or Targeted Support services. The School: The school involved have already implemented some procedural changes. This has included the use of provision mapping which identifies the school’s key vulnerable children, and the application of signs of safety to the weekly safeguarding meeting; in order to provide a better oversight and monitor progress. This will also provide the opportunity for the regular review of children’s chronologies to identify any patterns of concern. Each child will have an action plan which will be regularly reviewed. The school has a weekly staff briefing where safeguarding is a standing agenda item. The school have altered their policy so that only a Senior Designated Safeguarding Lead can close down an internal concern form. This will provide appropriate management oversight. 18 This learning is to be shared within the DSL wider schools network. Team Around the school: Children’s Integrated Services have developed their offer to schools where the school may be worried about children who attend their provision. All schools have been given the contact details for the Targeted Family Support Team Manager and Family Support Practice Specialist in their area. All schools across the city will have a named Family Support Worker who will meet with the school on a termly basis (three terms a year) to look at the most concerning children, and offer a Family Support clinic if require to offer advice and support the school if a request for a service or a referral is required. The managers and specialist will have on average 16 schools per Targeted Family Support Team area and they will meet with the schools on a termly basis to look at concerns and emerging themes. Health agencies The designated safeguarding professionals for Nottingham City CCG have produced a communication to remind all health professionals about their responsibilities to promote the welfare of all children. This will also include challenges to the outcome of contacts that are disputed and should this not be resolved the escalation process must apply. Within the Urgent Care Centre, when professionals see children with marks/ bruises (multiple in nature, following a late presentation, not consistent with the mechanism of injury or raises any concerns) a body map should be completed as it is considered to be a tool to promote good practice of record keeping. The body map should also be part of any referrals made to assist in the understanding of what has been visualised. The Nottingham CityCare Partnership have also compiled a terminology/acronym glossary to be used across all agencies. 11. Conclusions 11.1. It is evident that Child R has experienced significant physical harm. He had multiple bruising to areas that are uncommon for accidental injury. Child protection procedures were not followed and despite a clear medical view regarding one injury being non accidental and caused by someone hurting him, protective action was not taken. The belief that the injuries were caused by poor supervision was not in line with the medical findings and the evidence/assessment completed to support this hypothesis is weak. The individual practice issues of the allocated social worker shaped the progress of the case and there was an absence of management oversight to challenge her beliefs. 11.2. Measures were taken following the incident to provide assurance that case management within the relevant social work teams was effective and of the required standard. The 19 Ofsted inspection of Children’s Social Care in 2018 supported the view that the systems within the duty teams were effective. There is no evidence to support a view that the failures within this case are as a result of organisational or systemic issues. 11.3. However, it would appear that Child R’s positive presentation and the plausibility of his mother influenced the decision making. The application of the framework for child protection, its associated policies and procedures, should have provided a safety net to challenge fixed thinking and look objectively at the evidence. This did not occur and Child R remained at risk of, and suffered, significant harm. 12. Recommendations 12.1. The LSCB should be assured that the existing multiagency child protection procedures are effective in respect of strategy discussions and child protection medicals. This should include: A review of access rights within the social care electronic case management system That no Child protection medical examination can take place without a strategy discussion being held and S47 enquiries having been agreed as per established procedures. A review of the arrangements for child protection medical examinations is completed. This should include the means by which safety plans are agreed by all relevant agencies. 12.2. Chronologies should be completed as part of the referral to Social Care to highlight patterns of physical injury. Chronologies should also be completed by social care as part of the children’s assessment and shared with the Community Paediatrician where appropriate to ensure that they have all relevant information. 12.3. The LSCB should consider an awareness raising campaign within the wider children’s workforce focused upon physical harm in children and consider whether the terminology used within the workforce should be changed. |
NC047217 | Serious head injury of a primary-school-aged child in October 2014. Parents reported that Child A had fallen from a height in the early hours of the morning whilst trying to reach a cupboard. A subsequent visit by the police to the family home raised concerns about the safety of the conditions. The children were removed to foster care. At the time of the incident Child A and siblings were subject to child protection plans under the category of neglect. Family had significant contact with a wide range of agencies and were receiving support from a Team Around the Family (TAF) due to concerns about home conditions and the childrens failure to thrive. Mother had previously had two children removed from her care and adopted. Mother had a history of childhood sexual abuse, a lack of emotional warmth towards her children and suspicion of services and professional involvement with her family. Father had a history of alcohol misuse, domestic violence and controlling behaviour. Findings for learning include: parents were able to dominate and manipulate TAF meetings by disputing points, creating diversions and feigned compliance with recommendations; no formal parenting assessment was made of parenting capability or motivation to change; professionals struggled to distinguish between parental neglect and emotional abuse; assessment tools were not always used effectively; and the escalation policy was not used by professionals to challenge decision making following referrals. Uses a systems based approach to analyse information and present the findings. Poses questions for the Local Safeguarding Children Board to address.
| Title: Serious case review: Child A: overview report LSCB: Cheshire West and Chester Local Safeguarding Children Board Author: Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 CHESHIRE WEST AND CHESTER LOCAL SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW CHILD A OVERVIEW REPORT Date endorsed by LSCB 19th November 2015 Date of Publication 24th March 2016 2 Index Page No 1. Introduction and Background to the Serious Case Review 3-11 2. Brief Summary of Agency Contacts and Key Practice Events 12-20 3. Professional Involvement and Analysis of Practice 21-25 4. Findings and Questions for the Board 26-31 5. Wider Learning 30 Addendum AM’s comments on the report 33 3 1. Introduction to the Serious Case Review 1.1 Family Names, Pseudonyms and Confidentiality To protect the identity of the family in this case all family members and professionals re-ferred to in this report are anonymised. The report does not refer to individual children within the family; the subject child will be referred to as Child A throughout the report. Child A’s gender is not referred to in this report and any gender references will be neutral (i.e. through the use of ‘they’, ‘their’ or ‘them’). Child A’s parents will be referred to as AM (mother) and AF (father). 1.2 Decision to Conduct a Serious Case Review In December 2014 the Cheshire West and Chester Local Safeguarding Children Board Seri-ous Case Review Panel considered information regarding an incident involving Child A dur-ing which Child A sustained an injury that later required hospitalisation and surgical inter-ventions. After considerable discussion and debate the Panel concluded that the case met the criteria for the conduct of a Serious Case Review (SCR) as set out in Working Together to Safeguard Children (revised 2015). The incident leading to this SCR occurred in October 2014. At this time the family were sub-ject to Child Protection planning with the children being registered under the category of neglect. Child A is the second oldest sibling amongst a large sibling group. 1.3 Rationale for conducting the review The Local Safeguarding Children Board Serious Case Review (LSCBSCR) panel felt that, due to current concerns, historical contacts and the number of agencies involved with the family, significant learning could be gained by conducting a SCR. It was noted that this is a com-plex case involving a large number of partnership agencies that are both local and regional. 1.4 Family History There had been significant historical contact with a range of agencies. AM had previously had two children removed and subsequently adopted prior to her being in a relationship with Child A’s father. The oldest child in the family had been subject to Child Protection planning in 2004 under the category of neglect. All the children were referred to Children’s Social Care in 2010 when the Health Visitor made a referral in relation to a man who was thought to have been involved in sexual abuse (it has been established that there were no convictions against this individual) visiting the family home. 4 It was agreed by the LSCBSCR panel that contextual information regarding the parents’ ex-perience in their own childhoods and the circumstances surrounding removal of AM’s first two children would be of benefit to the review. 1.5 The Incident On the morning of the incident that led to this SCR, Child A had attended school as usual without any report from their parents of Child A having sustained an injury at home. Whilst away from the school premises, Child A became unwell and required hospitalisation and emergency treatment. This treatment was the evacuation of a left sided sub-dural haema-toma (bleed on the brain), which was the result of a head injury sustained in a fall earlier that day. The hospital reported that a subsequent conversation with the parents described the mech-anism of the injury as being that Child A had a habit of coming downstairs at night to watch TV. In the early hours of the morning in question Child A’s father (AF) was asleep on the sofa and was woken by Child A saying that they had hurt their head, and that they would not let father look at their head. AF also reported that Child A had told him, whilst on the intensive care ward, that they had got up to watch a TV programme and that they had climbed onto a kitchen work-surface, then on to the refrigerator to reach a high cupboard to get sweets. They had fallen from the refrigerator onto the hard surface kitchen floor, hitting their head on the floor. Child A’s parents were contacted and attended hospital where they were informed that fur-ther enquiries would be made by police and Children’s Social Care (CSC) who were con-cerned about the safety of the family home and of Child A and their siblings. Police were asked by CSC to attend the family home and photograph the home conditions, to assess the suitability and safety of the conditions. Based on photographic information it was deemed that the conditions were unsuitable, and that a police protection order (PPO) should be sought to enable the children to be taken to a place of safety pending further in-vestigations. That same day Child A’s siblings were removed to foster carers, whilst Child A remained in hospital. Child A was discharged six days later to foster carers. At the time of writing, Child A and their siblings are currently residing with foster carers un-der an Interim Care Order. 1.6 Background - Child A and their Family Child A is the second oldest child amongst a large sibling group. Child A was described by professionals as being a lively and active child. Child A appeared to have difficult relation-ships with their siblings; one relationship being of particular concern to professionals with high levels of aggression and anger being present between the two siblings. 5 During the period under review Child A and their siblings were subject to Team Around the Family (TAF) assessment (and later to Child In Need (CIN) and Child Protection (CP) plan-ning). Child A was referred to specialist services in relation to concerns about faltering weight and growth, and behavioural difficulties - recorded as anger and hostility towards their siblings, inability to control their temper, and other behaviours of concern. The siblings in the family were all subject to concerns by professionals in relation to their failure to maintain weight gain; there were also issues in relation to speech and communica-tion with some of the siblings. Child A’s parents were reported by professionals involved in the TAF to have chaotic rela-tionships with the children. They appeared unable to establish routines and boundaries. All professionals involved with the family noted that AM lacked emotional warmth and was un-able to maintain an emotional bond with the children, particularly as they grew older. AM acknowledged this and attributed it to her childhood experiences. AM disclosed to professionals that she had been the victim of sexual abuse in her childhood, she recounted that she had been abused from a young age and had been abused by her fa-ther and other males who were part of a ‘paedophile ring’. She reported that she was made to perform sexual acts with these males from the age of two years. She said that she had told people at her school about this and that she was taken to a police station in the area but no charges were brought. The review tried to find further information about these events via police sources but could find no records. The removal and subsequent adoption of her two children had led AM to be suspicious of services and professional involvement; this was noted by all professionals involved in the review, and was most apparent in relation to the involvement of CSC. AF was perceived to be the primary carer by some professionals. He appeared to have the main responsibility for taking the children to school and collecting them. AF worked which meant that the family were not entitled to benefits, resulting in some financial hardship. AF was reported to drink excessively on occasion. His behaviours when intoxicated were of concern to professionals. There had been two recorded incidents of domestic abuse between AM and AF going back several years. There had also been a suspected incident of physical violence during the pe-riod under review, however, AM denied that there was any abuse when she was asked by professionals. There was no formal assessment conducted (such as a CAADA DASH risk as-sessment, as the first two incidents pre-dated the introduction of this tool and AM denied the more recent incident). Some professionals observed controlling behaviour from AF to AM in the way they interact-ed with each other; AF was reported to keep control of the finances. AM had spoken to health professionals about feeling under pressure in their sexual relationship. 6 In 2012 the family were placed on Team Around the Family (TAF) following concerns raised by the Health Visitor about the home conditions and the children’s failure to thrive. This review begins at that point. 1.7 Methodology A Serious Case Review team was convened of senior agency representatives from Cheshire West and Chester agencies. The review was co-ordinated and managed by the LSCB Busi-ness Manager and a Lead Reviewer who was appointed following a commissioning process. The review used a systems based approach to analyse information and present the findings. A multi-agency chronology was compiled in March 2015 from which the Review Team drew the key lines of enquiry and terms of reference (research questions) see 1.9. The Review Team identified the services and individual practitioners that would provide in-formation and participate in the review. A briefing session for practitioners was held in April 2015 which was followed by individual conversations with practitioners from a range of agencies. These conversations were conducted by members of the Review Team and the Lead Reviewer. The Review Team used the information from the conversations and other evidence to iden-tify key and significant episodes of practice in the case from which the findings are drawn. The review gathered written and electronic information and documentation for analysis; this included all relevant documents and reports from services working with the family in regard to assessments, agreements and plans, minutes of meetings and other relevant re-ports. The review also received written reports from two hospitals that had contact with Child A on the day the incident took place. The findings in the final chapter of this report use an adaptation of the framework devel-oped by SCIE to present the key learning within the context of the local arrangements. The work of the review is exempt from the Freedom of Information requirements that apply to public bodies. There is case law in regard to the information that can and should be dis-closed to coronial and police criminal proceedings. The review was conducted on the basis that the overview report would be published in full. 1.8 Scope of the Review The period to be reviewed was agreed as 31st March 2012 to 31st October 2014. Relevant information prior to 31st March 2012 was considered by the Review Team where this added to understanding of the case. 7 This report does not focus on events subsequent to 31st October 2014 in relation to any civil or criminal proceedings. 1.9 Issues identified for further exploration (research questions) The LSCBSCR panel identified a number of areas for further exploration during the SCR, as follows: Is the approach to dealing with neglect sufficiently outcome focused? Is there evidence of any issues identified within local learning guidance that is rele-vant in this case? Is there a sufficiently clear contemporary definition of neglect being used within all partner agencies that needs to underpin collaborative work? How did practitioners working with the family consider and hear the voice of the child? To what degree was this case appropriately stepped up and down through the con-tinuum of need? Were relevant assessment tools appropriately applied and of good quality? Did safe-guarding processes, including recording systems support information sharing and decision making in this case? Does the existing suite of training to partner organisations sufficiently cover the knowledge, skills and guidance staff require to identify and manage cases of neglect and is there evidence of learning being applied to practice? Is there evidence of managerial oversight and supervision of practitioners within the case? These questions will be reflected in the findings of the SCR detailed in Section 4 of this re-port. 1.10 The Review Team and Case Group The Review Team was made up of members of the Serious Case Review Panel, all of whom were selected on the basis of their seniority within relevant organisations. One of the Re-view Team members had direct contact with the family in a previous role. This was declared at the outset and did not present any conflict of interest. The Review Team met on three occasions to oversee the review and contribute to and ap-prove the final SCR overview report presented to the LSCB. 1.10.1 Membership of the Review Team Position Organisation SCR Chair Designated Nurse Safeguarding Children (Chair) NHS West Cheshire Clinical Commissioning Group and Vale Royal Clinical Commissioning Group Business Manager Cheshire West and Chester Local Safeguarding Children Board Team Manager, Access to Re-sources Team Cheshire West and Chester Children’s Services 8 Senior Manager, Integrated Early Support Cheshire West and Chester Children’s and Young People’s Ser-vices Detective Constable, Major Crime Review Team Cheshire Police Head of Safeguarding Safeguarding Unit, Cheshire West and Chester Children’s Ser-vice Operations Manager Cheshire West, Halton and Warrington Youth Offending Ser-vice Designated Doctor Safeguarding Children NHS West Cheshire Clinical Commissioning Group and Vale Royal Clinical Commissioning Group Safeguarding Children in Educa-tion Service Manager Cheshire West and Chester Education Service In Attendance Independent Lead Reviewer 1.10.2. Services and Practitioners Involved in the Review Practitioners were identified at the ‘scoping’ stage of the review. Each agency submitted a detailed chronology to the Serious Case Review Panel, from which practitioners were se-lected to participate in face to face or telephone conversations with the Lead Reviewer and members of the Review Team. The following practitioners participated in the Review. A brief description of services is given below. ESAT (Early Support Access Team) IES Integrated Early Support Case Management Teams based within localities – ESAT and IES are elements of the Early Support Offer in Cheshire West and Chester CART – Contact and Referral Team is the front door to level 4 services (CP and CIN). Quarriers is a commissioned service offering support to children affected by Domestic Abuse at level 3 on the Continuum of Need. Core Assets works with families across Levels 2, 3 & 4 of the continuum of need. Role Pseudonym GP GP1 Community Midwife CM1 Health Visitor HV1 Head-teacher, Primary School 1 HT1 Head-teacher, Primary School 2 HT2 Family Support Worker 1 FSW1 Family Support Worker 2 FSW2 Integrated Early Support (IES) Manager IESM1 Integrated Early Support IESM2 9 (IES) Manager Team Leader School Health Service SHC1 Speciality Doctor SD1 Dietician D1 Quarriers Manager QM1 Family Support Worker Core Assets FWS3 Core Assets Manager CAM1 Early Support Assessment Team (ESAT) Manager EM1 Playgroup Manager PG1 Playgroup Manager PG2 Early Years Worker ESW1 Social Worker SW1 Social Worker SW2 Social Work Manager SWM1 Independent Reviewing Of-ficer Service IRO1 Police Officer PO1 Police Officer PO2 NB: The Health Visitor who worked with the family for the first part of the period under review has now left her post and was not interviewed as part of this review. She is re-ferred to in this report as ‘the Health Visitor’. 1.11 Other Sources of Information All relevant agencies were asked to provide a chronology of their involvement within the period under review. A comprehensive multi-agency chronology was compiled. In addition to information provided during the course of professional conversations, written reports were received from two hospitals that treated Child A for the head injury. The Review Team accessed a range of written and electronic records including minutes of meetings, assessments, records of referrals and responses. 1.12. Family Involvement Child A’s parents were informed of the SCR at the beginning of the review process and were invited to participate. However shortly after this a criminal investigation commenced and consequently this precluded them from making a contribution as the review progressed. The Review Team agreed to keep parental involvement under consideration until the final report was signed off by the LSCB and submitted to the National Panel. 10 In late 2015 the criminal proceedings concluded and the Review Team re-visited the oppor-tunity for the parents to contribute albeit the review had been completed. In early February 2016 parents were provided with a copy of the report. The LSCB Business Manager on be-half of the review team visited AM to discuss the content. AF could not be present but had made notes on the report for the LSCB Business Manager. AM and AFs responses are set out in the addendum of this report at Page 33. Where rele-vant, AM’s comments are also noted in the main body of the report. At the outset, the Review Team discussed offering Child A and their siblings an opportunity to participate in the Review; however due to the circumstances outlined above, a decision was taken to revisit this proposal once police had finished their enquiries. By this time, the report was finalised, but discussions are taking place between the LSCB and professionals working with Child A and siblings to share the report and provide an opportunity to respond should they wish. 1.13. Parallel Processes At the time of writing there is an ongoing criminal investigation which may lead to a crim-inal case being submitted to Crown Prosecution Service for prosecution. 1.14. Timescale for completion The Review Team agreed a completion date of 30th May 2015 with the final overview review being presented to the LSCB on 8th June 2015, followed by submission to the National Panel. 1.15. Diversity Factors The adults and children in the family are ‘White British’. No specific diversity factors were identified. 1.16. Background to the Family AM had been previously known to CSC, having had two children removed and subsequently adopted some years previously. At this time AM was in a different relationship and none of the siblings involved during the scope of this review had been born, there are references to this throughout the narrative as it was referred to with frequency by professionals and was seen to be a key factor in the relationship between AM and professionals. AM disclosed to professionals that she had been the victim of sexual abuse in her childhood, she recounted that she had been abused by her father from a young age and had been abused by other males who were part of a ‘paedophile ring’. She reported that she ‘had to’ perform sexual acts from the age of two years. She said that she had told people at her school about this but that nothing had ever been done. There were no formal allegations made and there is no police record of these events. 11 The oldest child of AM and AF was subject to a Child Protection plan in 2004 under the cate-gory of neglect. In 2007 it is recorded on police CAVA that AF had allegedly had a knife and ‘nicked’ AM to the neck. AM was not prepared to follow up a complaint about this incident and it was not pursued. AM had also been victim of assault in 2002 by a different partner. In 2010 the Health Visitor made a referral to CSC reporting that a male was present in the family home who had allegedly been involved in sexual behaviour with a child. The parents were advised that this was inappropriate and the referral did not progress beyond checking. 1.17 Child A Child A was known to the majority of professionals involved in the review. Child A was the second oldest child in the family and was noted to be a lively child who interacted with their siblings in a chaotic way. Child A was reported to have a particularly difficult relationship with one sibling with whom they often fought and argued. This behaviour was observed at school and at home. Professionals commented that Child A seemed to get most of the attention from their par-ents (although this was largely negative attention). Chid A was referred to services in rela-tion to behavioural problems, undiagnosed ADHD and failure to gain weight. Some profes-sionals observed that Child A appeared to be constantly hungry. When they were referred to the dietician in August 2014 Child A attended with their father; HT2 noted that Child A seemed to be accompanied by their father on most occasions which she found to be unusu-al. It was noted that Child A appeared to have few boundaries when they were with their sib-lings; the siblings appeared as a chaotic group who seemed to ‘egg each other on’ to bad behaviour. Child A was described by HT2 as coming across as quite dominant when seen with their parents and the rest of the siblings and that this felt like an unusual dynamic. There were concerns about sexualised behaviours and a lack of parental control over what Child A viewed on television early in the morning when they were unsupervised. HV1 had raised with the parents that Child A may be accessing TV programmes containing ‘adult’ ma-terial. 12 2 Brief Summary of Agency Contacts and Key Practice Events During the period under review there were numerous contacts between the family and pro-fessionals involved in the case. The integrated chronology details around 350 recorded con-tacts; the Review Team consider it is likely that there were other contacts and communica-tions with the family during this period. FSW1 reported that AM made frequent (daily) visits to the local Children’s Centre and spoke to professionals and other staff there on many oc-casions. An overview of professional contacts is provided below; fifteen of these contacts have been identified as key practice events (i.e. pivotal points in the progression of the case). 2.1 Contacts Between March and December 2012 During this period the main contacts with professionals and the family were with the Health Visitor, the Community Midwife and the Community Paediatrician in relation to routine and non-routine health appointments for the children. No specific safeguarding concerns were noted by professionals until, in October 2012 AM disclosed to the Health Visitor that AF comes home ‘drunk’ and urinates in inappropriate places. NB AM disputes that she said this. It was noted by the Health Visitor that the chil-dren appeared to be experiencing inconsistent care and that there were no routines or boundaries in the home. It was recorded that AM said she did not want family support. The Health Visitor recorded her concerns and spoke to a Family Support Worker FSW1 about trying to engage with the family. During October 2012 Child A had two appointments with the GP, one in relation to an acci-dent where they had fallen downstairs; the second regarding a referral to the Community Paediatrician for undiagnosed ADHD. In November 2012 the Health Visitor noted that she had been told by AM that Child A and another sibling were copying their father and not using the bathroom and toilet appropri-ately and that bedrooms were sometimes soiled. In December 2012 it was again noted that the family did not want TAF support and that par-ents were reluctant to engage. FSW1 had conducted a joint home visit with the Health Visi-tor to try to get the family to engage. FSW1’s first impression was that the family was cha-otic and that the issues they presented were ‘huge’. FSW1’s first priority was to establish a relationship with the parents to begin to address the needs of the children. 2.2 Contacts from January 2013 Onwards Key practice event 1: In January 2013 a professional’s meeting was held to discuss concerns about the family which included long standing issues in relation to parenting, AM’s disclo- 13 sure of historic sexual abuse as a child. The removal of two older children and concerns about negative parenting. The result of the professional’s meeting was to initiate a TAF and allocate FSW1 as support worker to the family. Later that month a TAF meeting was held where it was noted that Child A could be frustrat-ed and angry and that they showed some sexualised behaviours. Health issues in relation to other siblings were also discussed at the meeting. Between late January and September 2013 TAF meetings took place on a regular basis, the family appeared to be engaging with FSW1 and the TAF plan was being followed. The par-ents attended a Webster Stratton parenting course and conditions in the home appeared to be improving. On one occasion in April 2013 AM asked to see the Health Visitor and told them that she had no money to buy food as AF was unable to go to work after falling of his bike whilst ‘drunk’. In August 2013, whilst AM was in hospital, the children were being looked after by AM’s mother who reported that AF had not returned home. Police looked into the report, how-ever AF returned home later that same day and no child welfare concerns were noted by police. Key practice event 2: Towards the end of September 2013 a TAF meeting was held at which all professionals agreed that the family had been provided with sufficient ongoing support and advice to manage routines and boundaries, and that a period of time was required to assess whether parents were able to manage independently. A decision was taken to close the TAF as there were no current significant concerns – there had been no incidences over the summer holidays and parents reported they had had positive experiences with the chil-dren. The School Nurse was to continue to monitor the height and weight of the children. Key Practice Event 3: In November 2013 a new baby was born. Whilst AM was in hospital police received a 999 call from one of the children. An older child and an adult could be heard in the background. There were no requests made and no disturbance heard. Police attended family home and found no concerns. The Hospital would not release AM until they knew she was safe as they had a record of historic domestic abuse by AF. The hospital team noted previous safeguarding concerns and took robust action to ensure that recent and historic concerns were addressed prior to discharge, this included consulta-tion with ESAT. Following AM’s discharge from hospital with the new baby HT1 noted concerns regarding the children’s appearance and behaviour. It was noted that the children appeared hungry, that Child A was thin and pale and that one of the siblings appeared to be ‘sad and quiet’ in the classroom. HT1 raised these concerns with the parents and arranged a meeting to dis-cuss the issues with them; the parents queried whether this was a TAF meeting, although at that time the TAF had not been re-opened. 14 HT1 telephoned ESAT to share her concerns and it was suggested that the FSW conduct a home conditions assessment and complete a graded care profile and that consideration be given to re-opening the TAF. A post-natal visit conducted by CM1 noted the room to be dirty and cold, dogs were barking loudly, the children were disruptive and the parents were shouting. Key practice event 4: In late November 2013 a professional’s meeting was held at which concerns were discussed regarding the children’s emotional wellbeing, lack of food and eat-ing patterns, tiredness, clothing and behaviour. The children had been asked about why they were urinating in their room, they said they were afraid of the two dogs so would not go to the toilet. It was agreed that a TAF assessment would be completed by FSW1 and FSW2. It was also agreed that 1:1 work would take place with children to discuss their wishes and feelings. The TAF was re-opened. One week after the TAF was re-opened FSW1 and FSW2 visited the family at home. The vis-it was said to be a very difficult one. AF was shouting at the children and Child A was seen to be very angry; they said that one of their siblings did not use the toilet properly. The FSWs were struck by the way the parents engaged with Child A as if they themselves were children – arguing with Child A rather than setting boundaries. The situation became worse and the parents did not appear to grasp that they were responsible for Child A’s behaviour. Following this visit a Home Conditions Assessment was completed with a score of 23 from a possible score of 90. Key practice event 5: A few days after the home visit a TAF assessment was completed. This included a ‘My Views’ assessment with the children. Two of the older siblings, including Child A said that they fight and don’t use the toilet properly as they are scared to go down-stairs because of the dogs. Child A said that they hated their siblings and wanted to be the only child. The parents disputed what Child A had said. The children’s weights were record-ed and Child A was recorded as not having gained weight, and was referred to the Communi-ty Paediatrician. A further TAF meeting took place in mid January 2014 where concerns regarding the behav-iour of Child A and a sibling was discussed. It was noted that the children were receiving the same meals cooked by parents and that they should be weighed again in March. It was also noted that sessions with Child A and their siblings were ongoing, with the aim of improving their relationships, and that Child A preferred to have sessions on their own. A referral to the Quarriers service was agreed to undertake further work with the children re-garding their wishes and feelings and relationships. It was noted that the children appeared unkempt and not always clean. Key practice event 6: One week after the TAF meeting Child A was seen by the Community Paediatrician, having been referred by the School Nurse for faltering growth and behavioural difficulties. Both parents attended the appointment with Child A and reported that they were concerned about Child A’s anger, violence towards one of the siblings and that Child A was using other rooms instead of the toilet. The Community Paediatrician noted Child A’s 15 weight and made a referral to the Consultant Paediatrician to establish whether there may be a medical reason for Child A’s faltering weight and growth. The Community Paediatrician also made a referral to Child and Adolescent Mental Health Services (CAMHS) regarding Child A’s behavioural difficulties. (CAMHS saw Child A with their parents in March 2014. They did not receive a full assessment as they were not found to have any mental health needs, and was discharged without any further appointments). Key Practice event 7: In early February 2014 FSW1 and FSW2 visited the family at home. The home conditions were observed to be cold, dirty and cluttered. A referral to CSC was dis-cussed with the parents. FSW1 later observed AM with Child A at the Children’s Centre, they were being roughly handled with AM saying that it was because of Child A’s behaviour that the children would be removed by Social Care. Key Practice event 8: The following day FSW1 and FSW2 made a referral to CART (Contact and Referral Team), they had consulted with senior managers who felt the case should be escalated to Level 4. The referral set out the TAF’s ongoing concerns about the home condi-tions, presentation of the children, behavioural issues and faltering weight. The referral also set out concerns about parenting capacity and capability, capacity to change and disguised compliance. The referral stated that there were ongoing issues of neglect and emotional harm to the children. The referral made specific reference to Child A’s behaviour towards their siblings, their anger and aggression towards them and their lack of remorse when they had hurt them. The refer-ral stated that Child A only received attention for negative behaviour which perpetuated these behaviours. The referral also made reference to AM’s disclosure that she had been a victim of sexual abuse as a child and that she had an inability to form emotional bonds with the children. There was also reference to historic domestic abuse within her relationship with AF. In summary the referral stated that despite a TAF being in place for 18 months there had been minimal change or improvement and that the TAF group felt that a Level 4 assessment was required. Key practice event 9: CART’s response to the referral was to seek a further rationale from the TAF. A senior manager from the Integrated Early Support (IES) service expressed her concerns by email that the referral had not been accepted, and received a written response. The written response stated that the case was not considered by CART to be at Level 4 (it was acknowledged that the case was at ‘complex Level 3’) as parents were engaging with the TAF process and some improvements had been made. The response suggested that the TAF should continue, that unannounced visits should be put in place and that a graded care profile should be completed. The response included an offer to reconsider the referral if cir-cumstances changed. Over the next month professionals involved in the TAF continued to engage with the par-ents and some improvements were seen in safety and in engaging with the children’s health 16 appointments. It was noted that areas that needed to improve were physical care, hygiene, clothing, approval and responsiveness. In early March 2014 Child A was seen by the Consultant Paediatrician who could find no un-derlying cause for faltering growth and discharged Child A from the general paediatric clinic with a requirement for height and weight to be monitored on a 6 monthly basis. Child A was also seen by CAMHS and it was felt that they did not have any mental health needs, Child A was therefore discharged by the CAMHS service. Over the next few weeks unannounced visits took place to the family home, where some improvements to the home conditions were noted, however, Child A and a sibling were not using the toilet appropriately and fighting between them was noted (AM reported that Child A had ‘strangled’ the sibling the day before). An appointment was made for Child A to meet the Quarriers worker to begin work around wishes and feelings, to which both parents agreed. Over the next four weeks Child A and both parents met with the worker and appeared to engage well. A TAF meeting was held in late May 2014 at which the parents discussed the behaviour of Child A and their sibling, saying that things had deteriorated and that they were taking food out of cupboards. Parents refused to take responsibility for the behaviour of the children, saying that it was the children’s ‘fault’. The parents asked if the TAF would be closed as they were feeling pressurised by having services involved. Key Practice event 10: In early June 2014 a professionals meeting was held at which FSW1 reported to the Quarriers worker that a man who had allegedly been involved in sexual be-haviours with children had been in the family home. This information had been gained from CSC who had raised the issue of the man having visited the family home in the past. They had advised parents that the man should not be in the family home with the children. Two days earlier FSW1 had reported to the Quarriers worker that there had been domestic abuse in the family and that AF had been arrested in 2008 for threatening AM with a knife. Key practice event 11: Three weeks later the children were weighed by the School Nurse and all had lost weight. This was discussed with FSW2 and a referral was made to CART the fol-lowing day. Later that week Child A attended a further appointment with the Community Paediatrician where it was confirmed that they had lost weight, the advice was to keep a food diary and a referral was made to the Dietician. A letter was sent to parents and school with regard to the need to complete and return a ‘Connors 3’ questionnaire with regard to behavioural is-sues. The day after the referral was received by CSC police received notification from them that a strategy meeting was to be held a week later. The meeting took place and it was agreed that CSC would begin a single assessment. 17 FSW3 from Core Assets was allocated to the family. FSW3 visited the family one week later with SW1. The parents were advised that the FSW3 would be providing regular support to the family particularly in relation to home conditions and mealtimes. The parents were asked what support they thought they required and said that Child A was really naughty so support with that would be useful. Over the next four weeks the family continued to receive intensive family support from FSW3, contact with SW1 and SW2 and with Quarriers, who were now also working with Child A’s siblings. The family moved house to a larger property in early August 2014, condi-tions in the new property were initially poor with no cooker or carpets. AM was engaged with the local church who were providing assistance. Key Practice Event 12: Nine days after the family had moved house, FSW3 visited the family at home. On entering the home FSW3 found that one of the younger siblings was choking and appeared to have something stuck in their throat; parents were not responding to this and FSW3 had to take control of the situation. Whilst FSW3 was there SW2 arrived and was informed of the choking incident. SW2 went to speak to one of the older siblings upstairs and found writing on a bedroom wall about AM hurting one of the children, this read ‘I hate my mum because she hurts me every day – and that’s true’. Key practice event 13: The following day SW2 visited the family home and found the young-est sibling face down on the floor of the lounge fast asleep, SW2 said he feared that they might be dead. AF’s reaction was one of unconcern saying about the child that ‘they would sleep anywhere’. Key Practice event 14: SW2 raised his concerns with his manager and initiated a strategy meeting with police that took place the following day. Concerns were discussed and were felt to have escalated in the last week. The decision of the strategy meeting was that the threshold for referral to child protection was met. Only police and CSC were involved in this strategy meeting. The following day during a home visit FSW3 noted that the parents said that the children had been stealing from the fridge. It was also noted that some of the children had minor in-juries, cuts and scratches. This was discussed with the parents who could not account for these injuries, but gave an unconvincing account of bruising to one of the older siblings. FSW3 informed AM that she would be reporting these injuries to CSC. In early September the older siblings, including Child A, started at Primary School 2. HT2 felt that the parents had been open and honest about their involvement with services. The school identified that, although parents had expressed concerns about Child A’s behaviour, they had more significant concerns about one of Chid A’s siblings who appeared to be a sad and isolated child. Key Practice Event 15: In mid September an Initial Child Protection Conference was held at which the family were present. The Conference Chair requested that Core Assets provide vis- 18 its on seven days per week; this was felt to be excessive as it is unusual to have more than two visits per week in most cases. It was agreed that five visits per week be provided. The meeting discussed TAF having been in place for 18 months with minimal change. Parents disputed all the points made by professionals. The risks identified were poor supervision leading to fighting amongst some of the children, lack of routines and boundaries, basic needs not consistently met, weight loss, the size of the family, emotional impact on the chil-dren of being told they will be taken into care by parents, parents displaying no motivation to change and being defensive and uncooperative. There was a unanimous decision to continue Child Protection planning under the category of neglect and a core group meeting was set for late September. Over the next three weeks the family continued to receive intensive support and an-nounced/unannounced home visits. Primary School 2 reported to CSC that one of the chil-dren had sent a letter to a fellow pupil saying that they wanted to ‘have sex with them’ – it appears that the older siblings had colluded in sending the letter. The same sibling was also excluded from school for two days for hitting another pupil. Key practice event 16: On the day that the incident leading to this review took place, Child A reported for school as usual, accompanied by AF. There were no signs that Child A was un-well and no report from AF that an incident had occurred at home in which Child A had hurt their head. Whilst away from the school, Child A became unwell and was taken to a local hospital, from where they were transferred to a specialist Children’s hospital where they underwent emer-gency surgery to evacuate a left sided sub-dural haematoma (bleed on the brain). That same day CSC and police held a strategy discussion regarding the safety of the siblings and discussed invocation of a Police Protection Order (PPO). Police visited the family home and reported poor conditions; a further discussion was held with CSC and it was decided to invoke a PPO. The children were removed from the family home and placed with foster car-ers. Child A was discharged from hospital six days later to foster carers. 2.3 Summary of Key Practice Events Date/Event Significance January 2013 – Professionals Meeting fol-lowing concerned raised by Health Visitor This brought the family to the attention of a wider group of professionals and was the catalyst for the TAF September 2013 – TAF was closed Professionals agreed that the family had been offered all relevant support and that time was needed to see how they could cope without professional support (this was a missed opportunity to explore why there was minimal change) November 2013 Police received a 999 call from the children whilst AM was in hospital This alerted concerns amongst health staff however police noted no safeguarding con- 19 cerns (this was an indication that AF was not addressing the needs of the children) November 2013 Professionals agreed that the TAF should be reopened Concerns were discussed which led to the TAF being re-opened, this was an opportuni-ty to evaluate whether a higher level of in-tervention was required November 2013 A TAF assessment was completed The assessment contained both positive and negative factors and reinforced the view to continue with TAF December 2013 Child A was seen by the community paediatrician Faltering weight and behavioural issues were discussed. Referrals were made to Hospital Paediatrician and CAMHS February 2014 A home visit by the FSWs raised their concerns The home conditions were observed to be poor, both FSWs felt that a referral to CART was necessary and informed AM of this February 2014 A referral was made to CART requesting Level 4 A detailed referral was submitted on behalf of the TAF expressing concerns about the wide range of issues and lack of progress in achieving change February 2014 CART assessed the referral and rejected it CART asked for a further rationale for the referral, ultimately rejecting the referral and proposing that the TAF continue and put in place additional checks and assessments, including the graded care profile June 2014 New information is shared about a man accused of sexual behaviours with a child having visited the home in the past. This information was shared by FSW1 with Quarriers (however it does not appear to have been shared with the TAF group?). This was historic information, not related to any recent events, however, it was deemed to be of enough significance for some profession-als to share June 2014 The School Nurse makes a refer-ral based on concerns about Child A and other siblings weights The school nurse discussed her concerns with the TAF lead and it was agreed that a referral should be made to CART asking for a single assessment to be put in place. The referral was accepted and a single assess-ment commenced. July 2014 FSW3 visited the family home and found one of the younger siblings choking with little response from the parents SW2 visited the family home whilst FSW3 was present and found writing on the bed-room wall of one of the children This raised FSW3’s concerns about safety in the home, it was noted and communicated to CSC SW2 went to speak to one of the older chil-dren in an upstairs room and found writing on the wall about mother hurting the child. SW2 spoke to the children and parents about this, the children denied having writ- 20 ten it and tried to blame each other July 2014 SW2 visited the family home and saw one of the babies lying face down in the middle of the room SW2’s immediate reaction was that the child appeared lifeless. They were in fact asleep but the unconcern showed by AF was of concern to SW2. SW2 returned to the office and initiated a strategy meeting that took place the following day July 2014 SW2 initiated a Strategy Meeting A strategy meeting took place between CSC and Police where it was decided that the case met the threshold for child protection. No other professionals were involved in this strategy meeting. September 2014 An Initial Child Protection Conference was held that was attended by the parents. Core Assets were brought in to provide additional support sessions for the family. The meeting was observed to be ‘long and very difficult’. October 2014 Child A presented to school as usual with no report that they had hurt their head earlier that day. Whilst away from school Child A became unwell and was hospitalised for emergency treatment. 21 3 Professional Involvement in the Case and Analysis of Practice 3.1 Synopsis of Professional Observations Professionals had been involved with Child A and their family over many years. CSC were briefly involved in 2004 when the oldest child in the family was subject to Child Protection Planning under the category of neglect. Professionals saw the family as having multiple issues and as being ‘very complex’. Despite their engagement with the TAF it was felt that AM and AF were largely resistant to profes-sional involvement. AF was said to be opposed to any form of support at the outset, but appeared to accept this once the TAF had begun. Professional observations were that AM presented differently to different agencies, some found her to be co-operative in terms of engagement with services, whilst others found her to be constantly on edge and never at ease. AM was highly suspicious of professionals, which was attributed to her previous experience of two children having been removed and subsequently adopted. AM’s GP noted that AM was a feisty individual who was not afraid to challenge professional views. Her main contact with the GP was when the children were young, bringing them in for the treatment of childhood illnesses. AM mostly saw the GP with pregnancy related issues, GP1 and the other professionals in the practice tried to get AM to think about preventing pregnancies as her own physical health was beginning to suffer as a result of numerous pregnancies. She was prescribed a range of contraceptives, none of which seemed to be effective at preventing pregnancy. AM does not appear to have ever discussed any issues relating to the disclosure of sexual abuse in her childhood with GP1, nor did she seek any advice or support in relation to emo-tional or mental health issues. GP1 recalled that she could appear stressed and sometimes angry but he associated this with having to cope with a large family. CM1 had known AM for some time but had not been required to visit her at home until 2012. CM1 considered her relationship with AM to be open and honest; AM attended ante-natal appointments and CM1 had no difficulty in engaging her. Prior the period under review, in an historic pregnancy, CM1 saw a footmark on AM’s stom-ach and enquired about domestic abuse. AM denied that there was any domestic abuse in her relationship with AM at that time. CM1 acted appropriately in recording that she had raised the matter with AM and discussed it with her supervisor, which resulted in a contact to CSC. When the TAF began in 2012 the aims were to improve home conditions, the presentation of the children and their behaviours and to strengthen emotional bonding in the family. Professionals were aware of other issues emerging within the family, including sexualised behaviours that were observed at school and in the home. These issues were raised at TAF meetings although there is no evidence of actions to investigate or address the causes. 22 The majority of professionals found AM to lack emotional warmth with the children which AM herself attributed to the childhood experiences she had disclosed. Although she had received ‘low level counselling’ AM did not seek any additional psychological support for these issues, reporting that she found it too difficult to cope with. FSW1 felt that AM had benefitted from counselling, AM attended twenty sessions following which AM did appear to show some empathy with Child A when they were unwell, which had never been wit-nessed before. Some professionals observed that AM appeared to be ‘controlled’ by AF - asking his permis-sion to do things. However professionals also observed her asserting herself with AF in the home environment. At meetings they appeared as a couple but displayed distraction behav-iours, being argumentative and walking in and out of meetings. AM often displayed physical symptoms of being unwell during meetings. Professionals noted that AF appeared to be the parent who took responsibility for the chil-dren. He took the older children to school and to health appointments. It was noted by professionals from the nursery that he had a very strong bond with the child attending nursery and this was apparent when he was taking and collecting them from nursery. How-ever, it was noted by some professionals that AF did not bond with the children when they were babies, that he did not make eye contact with the babies and that he only began to interact with them when they were around six months old. NB This is professional opinion and is disputed by AM. Following the re-opening of the TAF in November 2013 professionals observed a decline in home conditions and parenting. When the decision was taken to refer to CART in February 2014 the two FSWs and the TAF group felt that it was no longer appropriate to continue with TAF and that a higher level of intervention was required. When CART proposed that the case continue to be managed at TAF professionals in the TAF felt demoralised and un-sure as to what they could do next. It is of note that all professionals observed distracting and diversionary behaviours by the parents at meetings; AM appeared to respond to suggestions to make improvements in the home conditions and in relation to managing the children, however, these were not sus-tained. TAF meetings were often disrupted by the parents who refused to accept the responsibility they had for managing the children. The parents blamed the children for their behaviours and argued about the best way to improve things at home. All professionals felt that the family stood out and that they were unusual. This was be-cause of the size of the family and also because of the interactions observed between them. The majority of professionals observed a lack of warmth and emotional bonding between AM and the children. This was particularly apparent when AM was observed with the older children, although some professionals also noted that AM was negative towards the unborn during later pregnancies. 23 PS1 had been very involved with the family for a number of years having had the children with them since nursery. When the family engaged with TAF PS1 continued to have signifi-cant involvement in the process, with FSW2 leading the TAF. FSW2 had known the family for some time. FSW2 began leading the TAF and found that the family engaged very well with agencies. There were several professionals involved with the family, the aim of the TAF was to achieve an improvement in home conditions, to ensure that the children were doing well and that school attendance was good. Both parents seemed to find it difficult to praise the children; this was particularly marked with AM. It was noted that AF appeared to have a stronger bond with some of the children than others. FSW1 noted that AF did not bond with the children when they were first born and did not show much interest in them, he didn’t make eye contact with them and attend to their needs. It was only when the children reached the age of around 6 months that AF began to bond with them. Both parents seemed to withdraw emotionally from the children when they were around age 5 or 6, this was particularly apparent with Child A and one of their older siblings. When Core Assets received the referral neither alcohol abuse or domestic abuse was men-tioned. FSW3 recalled calling to the house on a Sunday and hearing there was a commotion inside, AM handed the baby to FSW3 and said, just take them I can’t handle it any more. FSW3 went into the kitchen with AM after sorting the children out; AM said AF ‘comes in drunk; he is useless most of the time’. Two professionals separately made reference to a specific event where they felt that one of the children had been intimidated by AF in a particular way; when asked about this event the parents had said that this was a prank and should not be taken seriously. However, pro-fessionals described the child as visibly distressed and affected by the incident. This had giv-en rise to concern by these professionals and was felt to be indicative of a neglectful ap-proach to the emotional wellbeing of the child. NB. At the point of discussion with the LSCB Business Manager the parents continued to dispute the circumstances of this inci-dent. When observed together by professionals, both in the home and in other settings, the older children were often said to be out of control, wild, chaotic and ‘almost feral’. When the children changed school in September 2014 parents had said to HT2 that they were most concerned about Child A’s behaviour, however HT2 felt more concerned about one of the other siblings who was described as being ‘a very sad child who had no self-esteem or sense of self-worth’. The relationship between Chid A and this sibling appeared to be hostile; they fought and argued a great deal. HT2 observed the relationship between AM and AF to be tense at times. AF appeared to be controlling of AM with AM ‘checking out’ decisions with him all the time. When SW1 and SW2 had become involved with the incident that led to this review, both parents had become hostile towards professionals, they were constantly complaining about professionals and reporting them to other agencies, saying that professionals were not turn- 24 ing up to appointments to support them in the home. The children appeared to be afraid to speak in front of professionals, having been told by their parents that they would be taken away if they said anything. This created a tense and difficult situation between parents and professionals which continued until the children were taken into foster care. 3.2 Analysis of Professional Practice in the Case There is clear evidence that professionals involved in the case worked hard to support the family. There were no issues of professional misconduct or malpractice. Professionals worked well together although the large number of professionals involved with the family may have enabled AM and AF to cause distractions and feign compliance. The nature of parental engagement and disguised compliance was recognised by the majori-ty of professionals working with the family and was discussed at professional meetings and cited in the referral made to CSC in February 2014. Because the parents appeared to make occasional improvements (although these were not sustained) this led to an over-optimism in relation to parenting capability and motivation to change. There was no formal assessment of parenting capacity or capability conducted which would have enabled professionals to measure motivation and change over time. There was a strong focus from professionals on the home conditions, the presentation of the children and their physical health. Professionals also shared concerns about the lack of emotional warmth, specifically from AM towards the children. This may have had the per-verse effect of professionals not exploring the underlying causes of neglect, emotional abuse and the behavioural problems of the children. The majority of professionals were aware of AM’s disclosure of sexual abuse and her inabil-ity to show emotional warmth to the children. AM was offered ‘low level’ counselling to explore the impact of her childhood experiences. Professionals did not know what else could be offered to AM, particularly as she told them that she did not want to think about what had happened to her as a child. It was recognised by professionals that AM attributed her lack of emotional warmth to her earlier experiences, and that this had an impact on her relationship with the children, however, there seemed to be nothing more that profession-als could do to address these issues. Interactions and information sharing between professionals was of an expected standard. In general meetings were well attended and actions were followed up and completed. The interaction between TAF group and CART was described by members of the TAF group as being hierarchical. The escalation policy was not used by the TAF group to challenge the decision not to accept the referral in February 2014, although professionals in the TAF were aware of the policy and procedure. IESM1 did challenge the decision made by CART in Feb-ruary 2014 but this was not taken any further. Professionals referred on more than one occasion to the recent transformation programme and noted that the structure of services had changed significantly over the past 18 months. Whilst there were some benefits to this restructure, which was becoming apparent to pro- 25 fessionals now, there had been some early difficulties in communication between services. This was particularly the case where Level 3 services had been decommissioned from Chil-dren’s Social Care and a new provider, Core Assets brought in. It was not clear to the Review Team how assessment tools such as the Edinburgh Depres-sion Inventory, Domestic Abuse Risk Assessment tools and other risk/harm assessment tools were used by professionals to build a complete picture of risk/harm and protective factors within the family. All professionals received management and supervision within their own agencies, and managers were appropriately consulted in relation to safeguarding and referral decisions. However oversight of the TAF group was lacking. Professionals were focused on the needs of the children and ensured that their wishes and feelings were considered at all meetings, and through referrals to commissioned services. 26 4 What does the case tell us about the local system for safeguarding children 4.1 Analysis of key themes from the case and description of findings for learning and improvement Meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable children needs to understand why things happen and the extent to which the local systems (people, work processes, organisational arrangements) help or hinder effective work locally within ‘the tunnel’1. This section sets out the key findings designed to offer challenge and reflection for the Cheshire West and Chester LSCB and partners. a) The key findings are framed using a systems based typology devel-oped by SCIE to identify some of the underlying patterns that appear to be significant for local practice in Cheshire West and Chester, these typologies are: b) Cognitive influence and human bias in processing information and ob-servation; c) Family and professional contact and interaction; d) Responses to significant incidents and information; e) Tools and frameworks to support professional judgment and practice; f) Management and agency to agency systems. The remainder of this report uses this case to reflect on what this reveals about gaps or are-as for further development in the local safeguarding system. In providing the reflections and challenges to the Cheshire West and Chester LSCB there is an expectation that there will be a response to the key findings in regard to the following: a) An indication as to whether the CWACLSCB accepts the findings; b) Information as to how the CWACLSCB will take any particular findings forward; c) Information about who is best placed to lead on any particular activity; d) An indication of the timescales for responding to the findings; e) Information about how and when it will be reported. The CWACLSCB will determine how this information is managed and communicated to rele-vant stakeholders. The formal response should form part of the publication of the SCR. p 1 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the per-spective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight. 27 4.2 Finding 1 TAF Meetings and Process (typologies Family and Professional Contact and Interaction; Responses to Information and Incidents; Tools to Support Professional Judgment and decision making; management and agency to agency systems) TAF provided a useful process by which to engage the family and establish professional relationships with them. However, the TAF lost impact over time, primarily because the family’s needs and complexities required a higher level response. Professionals involved in the TAF attempted to escalate the case on two occasions, on the first occasion without success. 4.2.1. TAF was in place for 18 months (other than a break of two months between Sep-tember and November 2013). It is the view of the Review Panel that a quality assur-ance process needs to be in place to ensure that TAF is running effectively and that the case is still appropriate to be managed at TAF level. 4.2.2. The parents engaged in TAF meetings however they appeared to dominate the agenda and manipulate the meetings by disputing points raised by professionals, us-ing diversionary behaviours and feigning compliance with recommendations made by the TAF. Questions for the Board to address: What can be done to improve quality assurance of TAF? How can professionals be supported in discussing concerns at TAF level where par-ents are disruptive and distracting in meetings, thereby stifling debate and divert-ing focus? What can the Board do to enshrine review of TAF referrals to CART to quality as-sure decision making? 28 4.3 Finding 2: Parenting Capacity, Capability and Motivation to Change (typologies Family and Professional Contact and Interaction; Tools to Support Professional Judgment and de-cision making) All professionals judged parenting capacity and capability to be poor; however no formal parenting assessment was ever undertaken, there was no assessment of motivation or capability to change, nor any formal assessment of causal factors such as disclosures of historic sexual abuse. Parenting capability and motivation to change was a key factor in this case, professionals appeared disarmed by factors such as historic sexual abuse, potentially abusive relation-ship between parents and sexualised behaviours 4.3.1. It was apparent throughout involvement with the family that parents lacked capacity and capability and that motivation to change was low. 4.3.2. Factors influencing parenting capacity such as disclosure of historic sexual abuse, domestic abuse and alcohol misuse were known but not explored fully. 4.3.3. There is no evidence that a formal parenting assessment took place, although parents were referred to, and completed a ‘parenting course’. Questions for the Board to address: Are professionals working at TAF level equipped to address issues of parenting ca-pability and causal factors? What professional support exists for discussion of causal factors where these re-quire specialist consideration (e.g. historic sexual abuse)? Are the tools for parenting assessment easily available and understood? What quality assurance measures are in place to ensure that parenting assess-ments take place and are acted upon? 29 4.4 Finding 3: Neglect and emotional abuse are one and the same in the mindsets of some professionals. This resulted in the clear issues of emotional abuse being obscured by responses to neglect that were focused on seeking visible improvements. 4.4.1 Despite all professionals identifying emotional abuse having a profound impact up-on the children the causal factors and impact of emotional abuse was not fully ex-plored. 4.4.2 Categorising the presenting issues under the banner of ‘neglect’ created a tendency to become focused on evidence and events 4.4.3. Professionals found it difficult to separate neglect and emotional abuse, it may be helpful to revisit these categorisations to support the hypothesis that emotional abuse can stand alone from neglect and has a significant and ongoing impact on out-comes for children 4.4.4. It appears that CAMHS focus on identifying a recognised mental health condition re-sulted in the causal factors for Child A’s behavioural issues remaining unexplored 4.4.5. The causal factors for the sexualised behaviours of the children were not fully ex-plored Questions for the Board to Address What can be done to strengthen focus and responses to emotional abuse? Is the current ‘neglect strategy’ sufficiently clear in guiding professional decision making? What can be done to strengthen assessment of behavioural problems in non-specialist services to ensure that causal factors and behaviours are fully assessed? Do professionals have the knowledge, skills and support to assess sexual abuse (as opposed to Child Sexual Exploitation)? 30 4.5 Finding 4: The use of tools to assess and refer lacks rationality; some tools are per-ceived to be intrusive and lacking in usefulness whilst other are useful but require integra-tion 4.5.1. The Graded Care Profile was not implemented when first recommended by CART. This is because it was seen as being intrusive and too detailed. This may be profes-sional bias or choice but is an important indicator of the interpretation of this tool and its application 4.5.2. The Home Conditions Assessment was used on several occasions and appears to be a useful tool but needs to be seen in context with other assessments to make it mean-ingful 4.5.3. Some agencies using different assessment tools (e.g. Core Assets – Signs of Safety), this may add to depth of understanding and guide responses, however these tools should be integrated into the wider system to ensure that they have legitimacy and authority 4.5.4. The quality of the initial referral via MARF has a significant bearing on whether refer-ral to Level 4 is accepted. Further training on the completion of MARF may be re-quired to enable professionals to best represent their concerns in this format. There was a feeling from professionals of this being a process of ‘trying to get something over the threshold’ 4.5.5. Domestic Abuse Risk assessments do not appear to be formally used or integrated alongside other risk/need assessment tools. Questions for the Board to Address What steps can be taken by the Board to ensure that the current suite of assess-ment and referral tools being used are fit for purpose, clearly understood by pro-fessionals, quality assured and integrated? 31 4.6 Finding 5: The escalation policy was not used to challenge decision making in this case; this is reflected in other Practice Learning Reviews conducted by the Board, suggest-ing that there is a systemic issue in relation to escalation. 4.6.1. Although a challenge was made in relation to the decision not to accept the case at Level 4 following referral to CART in February 2014 this did not follow the policy in relation to escalation. When the challenge was rejected there was no further action to escalate the decision despite professional dissatisfaction and concern. Questions for the Board to Address What action can the Board take to ensure that escalation is seen as a positive ac-tion to protect children? What support do professionals require to enable them to use escalation appropri-ately? 32 5 Wider Learning 5.1 Sharing of Information across all agencies Although information sharing in this case was generally of a good standard, there were two areas in which professionals suggested that information sharing could be improved. These were (i) Sharing of safeguarding concerns and other relevant information with the Nursery. The Nursery in this case had been operational for around 18 months and was run by a not for profit provider, which was relatively new to the local community. It was felt that it had tak-en some time for the Nursery staff to become known and ‘embedded’ in the local communi-ty and professional network, which may have contributed to them being outside of the in-formation sharing network. However, the importance of involving Nurseries in safeguarding practice and systems has been highlighted in this case. (ii) Sharing of intelligence and relevant police information with schools. HT2 felt that shar-ing of this type of information did not take place routinely. This may be because PS2 is lo-cated outside of the host Local Authority area. 5.2 Involvement of All Agencies in Strategy Meetings and Discussions The strategy meeting called by CSC in August 2014 included only police and CSC. Whilst this may not be a systematic issue, it is important to reinforce the need to include all agencies in such meetings and discussions to ensure that all aspects of the case are considered. 5.3 Responding to Domestic Abuse Responses to domestic abuse are often ‘incident’ led. Domestic abuse was recognised by professionals in this case (both as a historic and current issue) however it does not appear to have featured as a significant factor in discussions at professional, TAF or other meetings. 5.4 Impact of Service Redesign Joint working and reintegration following major service redesigns is becoming stronger, however further work is required to integrate new services following restructure and rede-sign. 33 6.1 Addendum – AM’s Comments on the Report 6.1.1 On behalf of the review group, the LSCB Business Manager delivered a copy of the re-port to AM and AF. A follow-up visit was scheduled to give parents an opportunity to discuss the content of the report and provide their perspective. AM was present and provided a re-sponse of behalf of both parents. AF although unable to be present, provided a written re-sponse to aspects of the report that were discussed more fully with AM. 6.1.2 Specific feedback was received in relation to the following: 6.1.3 AM said the report suggested that the family had received a lot of support and that this was not the case. AM specifically challenged the statement that the family sup-port service was provided on a frequent basis and that the family did not receive seven or even five visits per week. This does not correspond with information re-ceived from the agencies who report high levels of contact and support. 6.1.4 AM has been provided with information to enable her to complain about the service in question as this is not within the remit of the review. 6.1.5 AM disputed that the parents had been told about poor home conditions when they received notification of Child A’s accident. This does not correspond with profes-sional accounts of the information provided. 6.1.6 AM highlighted that the move to another property took place at only one day’s no-tice and that this impacted the home conditions. 6.1.7 AM felt that the wording of the report implied disbelief of her disclosures in relation to historic sexual abuse. It was agreed that this would be reviewed as there was no intention to suggest that AM had not been telling the truth about these events. The author has reworded sections of the report as appropriate to ensure that no bias is implied. 6.1.8 AM said that references made to an incident of a child ‘choking’ were untrue and that the child was not in distress. Two professionals were present when this event took place, their recollection of events is different to AM’s. 6.1.9 With regard to writing on the wall of the bedroom about ‘mummy hurting me’ AM said that this was already present in the house when they moved in and that it was inside a wardrobe. The professional recollection of this is different to that of AM and is documented in professional records. 6.1.10 AM disputed the account of the incident when SW2 said he saw one of the siblings asleep on the floor and thought he was dead. This differs from the professional’s recollection of this event. 6.1.11 AM disputed the accuracy of events described on Page 23 of the report as follows: 34 6.1.12 AM disputed that AF did not bond with the babies. The text has been changed to illustrate that this is professional opinion. 6.1.13 AM disputed that she told a professional that AF came home drunk. This is not the recollection of the professional. 6.1.14 AM disputed the professionals account of the incident referred to in Section 3.1, page 23 or that AF had intimidated the child. A note has been made in the body of the report that AM disputes this. |
NC043938 | Death of a baby as a result of a traumatic head injury, which the postmortem concluded could not have occurred without some force. The immigration status of mother was that she had limited leave to remain in the UK following her marriage to father. Father had some learning difficulties, which was not known to mother before the marriage. Prior to Child 1s birth mother, father and Child 2 lived with father's extended family. After moving to their own accommodation mother and father reported that paternal grandfather was physically abusive and controlling and managed their finances, including father's disability allowance. Mother had previously disclosed domestic abuse and unhappiness with father to her GP. Identifies lessons learned, including: significance of mother's vulnerabilities in relation to her arranged marriage, father's learning difficulties, her social isolation and her immigration status; and recognition of the importance of domestic abuse disclosures however low-key they may appear. Makes recommendations covering children's services, GPs, housing, hospital and ambulance services.
| Title: Serious case review overview report in respect of Child 1. LSCB: Bolton Safeguarding Children Board Author: Hester Ormiston Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW OVERVIEW REPORT In Respect Of Child 1 Overview report prepared by:- Hester Ormiston, Independent Author Signature:-_________________________ Overview Report Endorsed by:- Mike Tarver, Independent Chair, BSCB Signature:-_________________________ EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1. Introduction: 1.1 Circumstances that led to the Review Page 3 1.2 Terms of Reference Page 4 1.3 Timescale for the Review Page 5 1.4 Panel Membership Page 5 1.5 Individual Management Reviews & Page 6 Additional Information 1.6 Involvement of other LSCBs Page 7 1.7 Family Composition Page 8 1.8 Genogram Page 9 1.9 Family Involvement Page 10 1.10 Issues of Race, Language, Culture, Religion Page 11 and Disability 1.11 Media Interest Page 11 2. Overview of what was known Page 11 3. The Individual Management Reviews (IMRs) Page 12 4. Conclusions and Analysis Page 33 5. Summary Page 44 6. Lessons Learned from this SCR Page 46 7. Recommendations: 7.1 Summary of SCR Recommendations Page 47 7.2 Summary of IMR Recommendations Page 47 7.3 Summary of PCT Commissioning Page 49 Health Overview Report 2 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1. INTRODUCTION 1.1 Circumstances that led to the Review 1.1.1 Child 1 was taken to the GP’s surgery by the father, Adult 2 as the child appeared unwell. The advanced nurse practitioner at the practice examined the child, gave advice and the family returned home. Once at home, while the mother (Adult 1) was upstairs with Child 2, Adult 2 made himself a drink in the kitchen. He heard Child 1 crying. When Adult 1 came downstairs she found Child 1 appeared to have stopped breathing and was floppy. She ran with the child into the road and a neighbour, who was in the road at the time, rang for an ambulance. Child 1 was taken by the neighbour back into the family home, Address 4 where he started CPR. Child 1 was taken with Adult 1 to Hospital 1. The child was, later that evening, transferred to Hospital 3 and supported by a life support machine but reported to be unresponsive. 1.1.2 The following evening Child 1 was reviewed by an eye specialist who identified evidence of retinal bleeding. At that stage it could not be confirmed whether it was a consequence of medical intervention or non-accidental injury. Child 1 died shortly after 9 pm. 1.1.3 A post mortem was conducted and revealed a 4 x 5 cm bruise under the skin on the right hand side of Child 1’s skull. Under this was a 4 cm linear fracture of the skull. The brain had haemorrhaged to both sides and blood was evident in both optic nerves. There were also calcified nodes on the third and fourth ribs at Child 1’s spine on the left hand side. These appeared to be old injuries but it was not known whether or not they were due to non-accidental injury. 1.1.4 The provisional post-mortem findings suggested that Child 1 suffered a fatal traumatic head injury which could not have occurred without some force being applied to an immobile baby. Neither parent had an adequate explanation for the injuries. 1.1.5 The information in paragraphs 1.1.1 to 1.1.4 was notified to the independent chair of Bolton Safeguarding Children Board who considered that the circumstances of Child 1’s death were likely to meet the criteria set out in the first part of Working Together to Safeguard Children 2010, namely:- When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a SCR into the involvement of organisations and professionals in the lives of the child and family. This is irrespective of whether local authority children’s social care is, or has been, involved with the child or family. 3 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.1.6 Ofsted was notified of the details of Child 1 and that a Serious Case Review (SCR) may be held. An Initial SCR Panel was convened and the information shared at that meeting did suggest that Child 1 died as a consequence of suspected non-accidental injury. This recommendation was endorsed by the Independent Chair of BSCB and this was shared with Ofsted in writing. 1.2 Terms of Reference (ToR) 1.2.1 Initial agency reports had been prepared by:- • Greater Manchester Police • Bolton NHS Foundation Trust • General Practitioner, NHS Bolton • Bolton Children’s Services Staying Safe • Bolton Children’s Services, Children and Families Support Service (Children’s Centres) • Bolton Council, Community Housing Services • Bolton at Home 1.2.2 Using the information available from these reports, the Panel agreed the following questions were appropriate as key lines of enquiry in agency individual management reviews (IMRs). 1. To what extent did agencies/services/individuals recognise and take account of Adult 1’s potential vulnerabilities, in particular:- • Age • Language and literacy needs • Immigration status • Marital status • Level of isolation or integration within the local community • Relationship and support offered from wider family members And what impact did this have on assessments, planning, intervention and outcomes 2. To what extent did agencies/services/individuals recognise and take account of Adult 2’s potential vulnerabilities, in particular:- • Age • Learning disability/difficulty • Marital status • Parenting capacity • Level of isolation or integration within the local community 4 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • Relationship and support offered from wider family members And what impact did this have on assessments, planning, intervention and outcomes 3. What opportunities did the agency have to observe parenting capacity and interaction between Adult 1 and Adult 2 with Child 1 and Child 2? What impact did this have on assessments, actions and services offered at the time? Is there anything that could have been done differently? 4. To what extent have assessments and interventions considered diversity issues, including ethnicity, religion, language, disability and cultural issues? 5. What opportunities did the agency/service provide to Adult 1 and Adult 2 to speak independently of one and other about any concerns or worries they had prior to the birth of Child 1? On reflection can you identify any learning points? 6. To what extent did the agency have awareness of domestic abuse issues within the nuclear and extended family? What was the response of the agency and how did this feature in assessments, planning and interventions? 7. On reflection were there any opportunities or indicators that suggest CAF processes could have supported multi-agency work? 8. On reflection were there any signs or indicators that Child 1 was at risk of suffering significant harm or other missed opportunities to safeguard this child? Where signs and indicators are identified, please clarify any action that was or was not taken and the reason for this. 1.3 Timescale for the Review 1.3.1 The timescale for the review was agreed from the point the family moved to Bolton until the outcome of the post-mortem. 1.4 Panel Membership 1.4.1 The SCR Panel comprised:- • Vlasta Novak, Independent Chair • Hester Ormiston, Independent Report Author • Assistant Director, Bolton Children’s Services • Detective Inspector, Serious Case Review Team, Greater Manchester Police • Bolton Council of Mosques 5 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • District Manager, Bolton Children’s Services • Associate Director Safeguarding (Designated Nurse), Bolton PCT • Consultant Paediatrician, Designated Doctor for Safeguarding, Bolton PCT • Head of Personalisation & Inclusion, Adult Community Services • Housing Options and Advice Services Group Manager, Bolton Council Community Housing Services The Panel was supported by:- • Safeguarding Board Officer (Advisor) • Senior Administrator, Safeguarding Children Board (Minute Taker) • Solicitors from Legal Services, Bolton Council The Panel met on five occasions on. The Overview Report was presented and endorsed by BSCB within the required six month timescale. 1.4.2 IMR authors were invited to attend in turn on two occasions for discussion and feedback on each agency report. The NHS Overview report was discussed at a subsequent meeting. 1.5 Individual Management Reviews (IMRs) & Additional Information 1.5.1 The following agencies were asked to provide IMRs:- • Bolton NHS Foundation Trust (to include midwifery, health visiting and Hospital 1) • General Practitioner services • Bolton Council Community Housing Services • Bolton at Home • Children’s Services Staying Safe and Children’s Centres (combined report) • North West Ambulance Service, • North West Transport Service, and • NHS Commissioning Health report 1.5.2 All the IMRs have been prepared by staff or managers who have not had direct or line management contact with the family prior to the death of Child 1. Each one has been countersigned by heads of service or equivalent. The panel has considered each IMR, in conversation with the author, offered comments and following some revisions found that they meet the expectations of Working Together 2010. One IMR is in a different format but provides all the necessary information and analysis to contribute to the overview report. 6 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.5.3 BSCB procedures include an expectation that all IMRs will be closely scrutinised, and if not of sufficient quality will be returned for ‘revision’ to the agency. This process has been followed by each agency and the reports have been completed to a high standard in written styles which are clear and informative. 1.5.4 In addition to IMRs the SCR Panel requested information from:- • Greater Manchester Police • Bolton Council Adult Services • Bolton Legal Services • Hospital 3 NHS Foundation Trust These services were asked to provide a letter or report to outline any involvement with the child or their family. 1.5.5 As there was a possibility that the immigration status of Child 1’s mother, Adult 1, could have had some impact on family relationships the United Kingdom Border Agency (UKBA) was asked for any relevant information on her stay in the UK. 1.6 Involvement of other LSCBs 1.6.1 Panel discussed that although the SCR should focus on Child 1’s life it would be useful to have background information from Area 4 where the family had lived prior to Child 1’s birth. In particular Area 4 services were asked to provide a summary of their knowledge in relation to:- • Adult 1’s immigration and marital status • Adult 2’s learning disability/difficulties assessments, service provided and outcome • Wider family relationships, tensions within these relationships and any domestic abuse issues • Opportunities for agency’s to observe parenting capacity and outcomes from these • Services offered and accessed by the family • Profile of BME communities in Area 4 and how this family functioned within the community or accessed support to meet any diversity needs • Any additional vulnerability issues identified by services in Area 4 This information was requested and submitted by Area 4 LSCB to the SCR Panel. 7 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.7 Family Composition Anonymised Name Relationship to subject (if applicable) Address Ethnicity or diversity issues Child 1 Subject Address 1 Pakistani/British Muslim Child 2 Sibling Address 1 Pakistani/British Muslim Adult 1 Mother Address 1 Pakistani Muslim Adult 2 Father Address 1 Pakistani/British Muslim Adult 3 Paternal Grandmother Address 2 Pakistani Muslim Adult 4 Paternal Grandfather Address 2 Pakistani Muslim Adult 5 Paternal Aunt Address 3 Pakistani/British Muslim Adult 6 Maternal Uncle Address 3 Pakistani/British Muslim 8 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.8 Genogram Child 1 Child 2 Deceased Adult 1 Mother Adult 2 Father Adult 6 Maternal Uncle Adult 5 Paternal Aunt Adult 3 Paternal Grand-mother Adult 4 Paternal Grandfather Not Known 9 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.9 Family Involvement 1.9.1 The panel considered that it would be appropriate to ask Child 1’s parents, Adults 1 and 2, and the close family members living in Bolton if they wished to make any comment on the services provided across Bolton. 1.9.2 As it was important that any legal process should not be compromised, it was agreed that the independent SCR chair would write initially to Adults 1 and 2 via their solicitors to inform them of the SCR process. On police advice a list of questions was submitted to the Senior Investigating Officer who confirmed that they were unlikely to elicit responses which might compromise any criminal proceedings. These were sent with a further letter to the solicitors of Adults 1 and 2. 1.9.3 A letter was also sent to Adult 5 to invite her comments. Adult 5 contacted the Safeguarding Unit, asking to meet with a Panel representative and BSCB officer. The Panel Chair and BSCB Safeguarding Officer met with Adult 5. 1.9.4 Adult 5 considered that the services provided to the family had been good. She commented that perhaps more practical information could have been given to Adult 1, who may have found it more difficult living as a ‘single’ family; that is, not living with the extended family who would ordinarily provide care to any child in the household. Additionally Adult 5 noted that the service provided at Children’s Centres is good, but could provide more focussed support for parents while the children play together. It would also be useful if the service was specifically extended to fathers as well. It was agreed that further contact would be made with the family prior to publication. 1.9.5 Following endorsement by Bolton Safeguarding Children Board and in preparation for publication further engagement was undertaken with the family. Adult 1, Adult 2 and Adult 5 all had the opportunity to read the report in full before publication. In response to their feedback it was agreed with Bolton Safeguarding Children Board Independent Chair that all dates, as well as gender references relating to the children would be removed from the report. It was agreed this did not detract from the learning. 1.9.6 Adult 1 also wished to state she disputes the record that she was not happy with the second pregnancy. She has reported that this was a planned pregnancy, she was happy about this but she was unhappy with the circumstances between her and Adult 2. In response to this feedback it was agreed with Bolton Safeguarding Children Board Independent Chair that this would be noted in the report but this is what she is believed to have said at the time. 10 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.10 Issues of Race, Language, Culture, Religion and Disability 1.10.1 Adult 1’s immigration status was that she had leave to remain in the UK for a period. The family are Muslim with Adult 1 speaking both Urdu and Hindi. The marriage between Adults 1 and 2 took place in Area 3, possibly by Sharia law, with no UK civil marriage; Adult 2’s family live in Area 4. Adult 2 has been in receipt of some disability benefits because he has a learning difficulty. 1.11 Media interest 1.11.1 There was local and national media interest on the day Child 1’s parents were interviewed by the Police, following a Police press statement about a murder investigation. The Panel considered there was likely to be further significant media interest in the SCR and any enquiries would be dealt with jointly via the Council and Greater Manchester Police’s press offices. 2. OVERVIEW OF WHAT WAS KNOWN 2.1 Background information provided by Area 4 Safeguarding Children Board indicates that Adult 2 lived with his extended family from birth in Area 4. As a child he had few health needs but details of his education are held in some health, education and Connexions records as from the age of twelve he attended a school for pupils with moderate learning difficulty. In particular Adult 2 was unable to read, write and communicate in line with his chronological age, and had poor concentration. 2.2 Both Adult 2 and his father, Adult 4, have a police record, each having one offence relating to motor vehicles; Adult 4 also has a conviction for Possession of a Controlled Drug and Adult 2 was interviewed for supplying a controlled drug. 2.3 Adult 2’s sister, Adult 5 also lived with the family, and her husband, Adult 6, joined them when they married. The records suggest that Adult 2 had another sister, as there is a note of her alleging rape when she was seventeen years old. Adult 6 was arrested and charged but the statement was withdrawn. 2.4 Adults 5 and 6 left the family home in Area 4 at some point that predates the Terms of Reference and moved to Bolton. They reported that they found Adult 4 intimidating and controlling. 2.5 Adult 1 had joined the extended family from Area 3 and Child 2 was born. Adults 1 and 2 moved to Bolton, asking for assistance from the police to collect their belongings and Child 2 from the family home. At the time Adult 1 reported that she was not allowed to contact her family in Area 3; later the couple told agencies in Bolton that Adult 2’s father used to hit him, as well as dictating what they could and could not do and managing their benefits, including Adult 2’s disability allowance. 11 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 2.6 When Adults 1 and 2 moved to Bolton they lived with Adults 5 and 6. Adult 5 provided them with support to apply for their own tenancy. They presented as homeless, accepting that immediate homelessness was not likely. However the couple presented a second time, as the lodging arrangements were no longer sustainable. A house was allocated, which the family moved into after refurbishment. As part of the housing application Bolton Community Housing Services checked the immigration status of Adult 1 and were told of her ‘limited’ leave to remain; they also confirmed via routine checks that Adult 2 was entitled to additional benefits because of his disability. 2.7 Child 1 was born eight months after Adults 1 and 2 moved with Child 2 into their furnished home rented from Bolton at Home. The tenancy was in Adult 2’s name only possibly as a consequence of Adult 1’s immigration status. As Adult 2 was aged under 25 years, the family had a Tenancy Action Plan as part of the Tenancy Sustainment Service. This meant the family had regular visits from a Support Officer. 3. INDIVIDUAL MANAGEMENT REVIEWS 3.1 Bolton Community Housing Services 3.1.1 Community Housing Services provides a range of housing and access related services including management of the housing register and choice based lettings, homelessness and housing advice. It is the first agency any person seeking housing in Bolton would attend. 3.1.2 The IMR has been prepared by the Head of Community Housing and countersigned by the Chief Planning and Housing Officer. The author has an overview of all housing services that would have been relevant to the family. 3.1.3 The report uses information from case notes and staff interviews:- • Homelessness presentation case file • Homelessness presentation case • Homelessness prevention case file • In electronic records (OHMS, the Integrated Housing Management system). This system holds details of housing applications, allocations and rent accounts • Interviews with two staff members who provided the service to the family; one staff member has retired but had maintained detailed case notes 3.1.4 The front page of the report gives a brief profile of the agency responsibilities giving context to the rest of the report. The report includes responses to a number of standard questions for an IMR which are helpful, but leads to some repetition of information which specifically addresses the key lines of enquiry. 12 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.1.5 Community Housing Services had four direct contacts with Adults 1 and 2. Three were at the Housing Options Centre, where Adult 2 was helped to make an application for housing and when homelessness was imminent, documents were checked and a tenancy offered. The family was visited at Adult 5’s home to confirm the circumstances of the potential homelessness, and to clarify immigration status and any specific needs. Adult 2 was advised to attend the appointment to check he had the capacity to sign a tenancy agreement. 3.1.6 The involvement of Community Housing Services ended prior to the family’s move to their own tenancy and Child 1’s birth. 3.1.7 The service had limited opportunity to observe the family. However the records on the family’s presentation show how the agency systems, training and supervision support staff to record contacts in a manner that takes account of abuse both to children and adults, as well as consider any disability or cultural needs. 3.1.8 The IMR concludes that the service provided to Child 1’s family followed all procedures, in a ‘professional but attentive and caring manner’. There is one recommendation that in all contacts a record of all people present should be maintained. 3.2 Bolton at Home 3.2.1 The agency is a registered social housing provider, having taken over ownership and management of Bolton local authority housing. It provides a range of housing services to 18,000 tenants. 3.2.2 The IMR has been prepared by the Customer Support Manager who has responsibility for services to older and vulnerable customers and countersigned by the Director of Housing Services. 3.2.3 The report has been prepared from paper records:- • The Tenancy Sustainment Service agreement • Home visit records • Customer overview records detailing all contacts • Introductory Tenancy Progress checklist • Initial STeP assessment completed by Adults 1 and 2 • Tenancy records held in the local housing office • Notes from an interview with a staff member after the notification of Child 1’s death Computer records consulted were:- • OHMS allocation of tenancy records • Repairs lists 13 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • Tenancy records on ethnicity, and • CORE lettings log 3.2.4 The author was unable to interview the two staff members who provided services as one had retired and the other (Support Officer 2) had left for another post. However the staff member who has retired (Support Officer 1) had all but one of the contacts with the family and was interviewed as noted above, prior to the SCR but after the serious incident notification to local services from BSCB; the notes provide some detail for the IMR. 3.2.5 Additionally because Adult 2 was aged under 25 years, the family was referred to the Tenancy Sustainment Service and, following completion of an assessment, a ‘Successful Tenancy Plan’ (STeP) was completed. However the paper record of the assessment and plan completed when the tenancy was taken up cannot be found after a search in the agency. These documents would have provided more detailed information given directly by Adult 1 and Adult 2 and their acceptance of a level of support. 3.2.6 Initial contact with Adult 2 was in writing when he accepted the offer of the tenancy. When the tenancy was ready for use Support Officer 1, assisted Adult 2 to apply for a furniture package and completed the STeP. 3.2.7 Support Officer 1 visited three times soon after the family moved in but had no contact, leaving a card asking them to make contact. 3.2.8 Support Officer 2 visited for a two month review and noted that although the family had not responded to the request for contact, the tenancy was well maintained and the family reported they had support. Over the next nine months Support Officer 1 made eight visits, of which the family were at home for five. In addition to this Adult 1 proactively sought advice from Bolton at Home to:- • Obtain a back door key • Resolve an issue with housing benefit • Additionally over the months, some nearby trees had to be cut down, and then damp appeared in the kitchen and later in one of the bedrooms. Adult 1 telephoned to say that no progress had been made on treating the damp. This was the day after Child 1’s birth. 3.2.9 The records note that during the visit Adult 2’s sister and husband with their baby were present and had been for all visits to date; it is noted that Adult 1 is looking forward to the birth of Child 1; and when the damp was noticed in the kitchen, that the baby was due. 14 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.2.10 The records do not always note who was present when contact was made, but they suggest that the family have good support from Adult 2’s sister and from neighbours. However the notes also indicate that Support Officer 1 may have thought that Adult 2 was in breach of his tenancy agreement by allowing his sister and family to live with them. Adult 2 denied this and Adult 5 was not seen following the comment. 3.2.11 The report concludes that the service monitored and offered support appropriately to Adult 1 and Adult 2, but that there are three areas for improvement, forming recommendations. These are that:- • Key documents like the assessment and STeP plan should be computerised • Where there is a ‘no contact’ visit, procedures should be reviewed to ensure there is regular contact with tenants • Records of home visits should record who is present with more description of the conversation and observations 3.3 Children’s Services – Staying Safe 3.3.1 The Staying Safe Division of Children’s Services has responsibility for Children’s Centres, Family Support Teams and all Social Work teams (including Referral and Assessment (R&A), Safeguarding, Looked After Children, Emergency Duty team (EDT), Leaving Care, Youth Offending Team (YOT), Independent Reviewing Officers (IROs) and other Child Protection workers (including Local Authority Designated Officer for safeguarding, Local Safeguarding Children Board Officer, Safeguarding in Schools Officer, CAF Co-ordinator). The work spans levels 2-4 of Bolton’s Framework for Action; however, the Family Support, Social Work and IRO teams only work at levels 3 and 4. 3.3.2 The IMR has been prepared by the Head of Service, Child Protection and Leaving Care, who has responsibility for Safeguarding, Common Assessment Framework (CAF), IROs and the Leaving Care Service. It is countersigned by the Director of Children’s Services. The report reviews services provided by Children’s Centres, the R&A Team and the EDT. 3.3.3 The report has used electronic social work records of case notes, emails, contact records, initial assessment and strategy discussions, as well as paper and electronic records from two Children’s Centres:- • IT records of registration and attendance • The registration form • Records from the crèche • Multi Agency Resource Panel (MARP) referral and panel minutes Additionally two Children’s Centre managers and a family worker, three social workers and two emergency duty social workers were interviewed. 15 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.3.4 The first contact with Children’s Services was when Adult 1 and Child 2 registered at Children’s Centre 1, the nearest centre to their address while living with Adult 5. They attended nine drop in activities. After a four month gap, they attended one more drop in activity and Child 2 went into the crèche while Adult 1 attended one ESOL (English for Speakers of Other Languages) class. There was no concern reported from any of these sessions and this pattern of attendance is normal. The service is available for parents (usually mothers) to use when they wish with no action if they do not attend. It was also noticed when preparing the IMR that Adult 1 had attended once at Children’s Centre 3. 3.3.5 Adult 1 began attending for ante-natal care at Children Centre 2 coming five times until a week before the birth of Child 1. At Children’s Centre 1, Adult 1 used the name she had used for her Children Centre registration but at Children’s Centre 2 she sometimes used a different name, but the same as the one she used for NHS records. 3.3.6 About two weeks after Child 1 was born, a referral was made to the MARP for family support from Children’s Centre 2. When the family worker contacted the home to arrange a visit, Adult 2 answered the telephone and only said ‘No, No, No’. The family worker then agreed to make a joint visit with the referrer, Midwife 8, but for personal reasons was not able to contact Adult 1 before Child 1’s death. 3.3.7 The referral had not indicated a level of priority at a time when the Children’s Centre resources were stretched. A follow up to the brief details originally recorded on the referral noted that:- • Adult 2 had learning difficulties not known to Adult 1 at the time of their marriage • Child 2 also had some developmental delay • Child 2 was in receipt of Speech Therapy services • Child 2, Adults 1 and 2 all slept in one bed in the lounge because of damp in the bedroom • The family was struggling financially as they were repeatedly repaying money claimed from Department for Work and Pensions by relatives in their name • Adult 1 was isolated and struggling without support 3.3.8 On the day of Child 1’s admittance to hospital, the R&A social work team was contacted by Hospital 3 notifying of the imminent death of Child 1, with brief details of the circumstances of admission to the local hospital, medical condition and that at present the cause of death did not appear suspicious. 16 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.3.9 Hospital 3 notified the emergency duty team that because of the retinal bleeding found by an eye specialist, non-accidental injury could not be ruled out. Later EDT was notified that Child 1’s death had occurred. Senior managers were informed of the death. Following senior manager’s discussions and decisions the GMP Public Protection Investigation Unit was informed. Both GMP and Children’s Services knew that a post mortem would be conducted and no action would be taken until information was available from it to confirm the cause of Child 1’s death. 3.3.10 As soon as the EDT knew that Child 1 had died, agency checks were made with Area 4 Children’s Services as Hospital 3 indicated that the family had returned there with Child 2. Following some negotiation and when the death of Child 1 was identified as potentially non-accidental, Area 4 Children’s Services’ EDT visited the family with the local police. They observed that Child 2 was safe and well. The negotiation for a home visit by Area 4 Children’s Services was supported by GMP PPIU. Adult 1 and Adult 2 were advised to return to Bolton (and that they cannot have direct care of Child 2). 3.3.11 The R&A team and EDT only had contact with the family from the time of Child 1’s admission to hospital and the procedures were followed properly with senior managers informed and updated appropriately. 3.3.12 The review of the Children’s Centre services has raised some suggestions for change. The agency is conscious that the service is a universal service provided with the intention of welcoming parents from the community who may be less willing to attend if they thought their parenting was being monitored. However the IMR makes four recommendations that:- • Staff should be trained to ensure that registration details are completed more fully or with explanations for any gaps • The signing in sheet should note if the person attending is registered or not (registration is not required to attend) • The service should consider the development of a brief record for each session, noting the title, learning for the parents, and which adults and children were present • The referral process for MARP should be reviewed to ensure a CAF is completed if more than one agency is in contact with the family 3.4 Reports included in the NHS Bolton Commissioning Report General Practitioner 3.4.1 Child 1’s family were registered with two different general practitioner practices (GPs), the first was close to the address of Adult 5. They registered with the second practice which is close to Address 1 after they moved into their own tenancy. 17 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.4.2 The IMR was prepared by the GP clinical advisor for NHS Bolton and countersigned by the Associate Medical Director, NHS Greater Manchester. The author interviewed two GPs and the Advanced Nurse Practitioner (ANP) from the current practice, and read the records for Child 1 and Child 2, and Adults 1 and 2 from both practices. The chronology only contains contacts directly involving Child 1, but the narrative includes some historical information from the first GP practice where it is relevant to the key lines of enquiry. 3.4.3 Child 2 had been diagnosed with an iron deficiency as part of routine health visiting screening and had been referred to dietetics. Child 2 was also receiving speech and language therapy input. The GP notes do not indicate any concern for wellbeing. 3.4.4 Historically Adult 2 had input from his GP in Area 4 for his learning difficulty but there were no recordings linked with this in the Bolton records. 3.4.5 The only significant record for Adult 1 was a record made (in the first Bolton practice) where she had told the GP that Adult 2 had hit her and she did not want another pregnancy. She was given advice and a telephone number to ring if she wanted support. 3.4.6 Child 1 was seen three times at the surgery. The first occasion is recorded as a query about jaundice and the midwife visiting the surgery agreed to follow up as a routine part of their service. The second visit resulted in an admission to Hospital 1 as the child was vomiting and had ‘motley’ skin which can be an indication of a serious illness. Child 1 was discharged the same day with a prescription for anti-reflux treatment which the parents collected from the GP practice two days later. 3.4.7 The day of Child 1’s final admission to hospital parents had earlier requested a GP appointment. Following the request for a same day appointment, the Advanced Nurse Practitioner (ANP) saw Child 1 with Adult 2. She saw from the notes that there had been a previous concern with vomiting and she concluded that the problem was a continuation of reflux. She examined Child 1’s chest and abdomen but did not remove all clothing. She advised a review if the condition deteriorated. 3.4.8 None of the practitioners considered that there were any cultural or language issues, with both parents communicating clearly and understanding responses. There was also no evidence of Adult 2’s learning difficulty noted in the records. 3.4.9 The narrative picks up two issues that should have been responded to differently. The first is that with such a young baby, the ANP should have removed the clothing to examine fully and have made an accurate record of alertness. The post mortem of Child 1 suggests that the death would not have been prevented by such action, but it is good practice. 18 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.4.10 The second issue is that GP Practice 1 gave advice to Adult 1 about seeking help when she revealed some domestic abuse, but did not note it in the records in such a manner that it would alert other practitioners in the practice, and did not notify the health visitor. This should be a routine response especially as there was a pre-school child in the family. If the health visiting service had knowledge of the issue more enquiries probably would have been made when Child 1’s pregnancy was known. 3.4.11The IMR suggests that cultural issues could potentially have prevented Adult 1 from seeking further help or advice. It is known that the GP gave Adult 1 a Children’s Services telephone number to ring for advice. It would have been more appropriate if details had been given of culturally appropriate services which are available in the local community. The records do not note if the GP explored further the content of the information, for example the frequency or severity of the abuse. 3.4.12 The IMR notes that both GP practices provided a good quality primary care service to the family; in particular good practice in guaranteeing that young children are seen on the same day and that practitioners are all well qualified and experienced in paediatric health. However the IMR identifies the issues in paragraphs 3.4.9, 3.4.10 and 3.4.11 as recommendations to share with all Bolton GP practices. 3.5 Bolton NHS Foundation Trust 3.5.1 Bolton NHS Foundation Trust was created from local community and hospital based services. This SCR is the first completed since the services came together under one management structure. The IMR has used the SCR opportunity to check consistency of understanding and use of procedures within different sectors of the organisation. This means that some learning is not directly linked to the SCR but will contribute to improved safeguarding responses across the new Trust Arrangements. 3.5.2 The IMR has been prepared by the Trust’s Named Nurse Safeguarding Children and countersigned by the Associate Director of Patient Safety/Deputy Chief Nurse, Bolton NHS Foundation Trust. To complete the report, the author has read:- • The health visiting records (including those from Area 4) for Child 1 and Child 2 • The midwifery records for Child 1 and Adult 1 • Hospital 1 records of Child 1’s admission • Accident and Emergency records for Child 1 from Hospital 1 The author interviewed the health visitor, the health visiting staff nurse, the midwife and paediatrician. The author did not review the records of the therapy services provided to Child 2, and the panel confirmed that sufficient detail of service delivery and parenting of both children had been gained from the primary health service records and interviews. 19 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.5.3 The records from the health visiting and midwifery service are completed to a good standard, and include good detail of who was present, the focus of the contact and a summary of discussion. 3.5.4 The health visiting service contacts mainly concerned Child 2 starting with a detailed assessment being completed. Both adults reported they were in good health and Adult 1 said she had no concerns in relation to personal safety or domestic abuse. It is not known if Adult 2 was present while domestic abuse and personal safety issues were discussed. The family was not unusual in that Adult 2 was present less often, but when there he demonstrated appropriate care and concern for Child 2. 3.5.5 The focus of most visits was attention to some developmental needs of Child 2, linking with speech, diet, play and sleep pattern. Appropriate referrals were made to specialist services and when the health visitor was giving detailed advice on diet, she arranged to visit with an Urdu speaking interpreter. However the record confirmed that Adult 1 spoke English sufficiently well to understand the content of health visiting and midwifery contacts. 3.5.6 Discussions covered matters concerning benefits, progress on audiology and speech therapy appointments and encouragement to attend activities at the local children’s centre to give Child 2 more opportunities to play. 3.5.7 Adult 1 attended all her ante-natal appointments and was well during the pregnancy. It was recorded that both adults were happy to be having a second child. The records note however that there were continuing difficulties with Child 2’s development and behaviour. Child 2’s blood count had improved with a varied diet and medication. 3.5.8 Adult 1 indicated that she and Adult 2 planned to separate as he was reported to have started a new relationship. In the same conversation Adult 1 said she was concerned that if Adult 2 took Child 2 to the family in Area 4 when she went into hospital for the birth of Child 1, she may not be able to get Child 2 back. Adult 1 reported that Adult 2 planned to return to live with his family, but that he would look after Child 2 in Bolton during her hospital admission. 3.5.9 Towards the end of the pregnancy Adult 1 discussed finding a nursery placement for Child 2. Just before Child 1’s birth, Child 2 missed some routine health appointments but this was not considered an indicator of compromised parenting, but rather due to the imminent birth. 3.5.10 Child 1 was born by normal delivery at Hospital 1 and was discharged home. When the midwife visited the family was sleeping downstairs as they said the bedroom was damp. Child 1 was over wrapped and advice on safe sleeping was given as expected in BSCB’s recent initiative called ‘Sleep Safe’. 20 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.5.11 Adult 1 took Child 1 to the surgery. She saw the GP about a concern that Child 1 had jaundice, and separately she saw Midwife 1 about the umbilicus. The records note that Adult 1 was tearful. Adult 1 described the earlier abuse from Adult 2’s family and said she wanted her family to come to stay from Area 3. The midwife reported this information to her colleague who visited the family, but had no further discussions about family circumstances. 3.5.12 Child 1 developed well, putting on weight appropriately. Just prior to discharge from the midwifery service to the health visitor and GP, Midwife 8 discussed the issues Adult 1 had raised with her colleague. Following this discussion Midwife 8 made a referral for family support. 3.5.13 Health Visitor 2 completed her primary visit and recorded discussion of key issues on safe sleeping, feeding, immunisation and skin care, as well as the family situation. The adults reported they were applying for rehousing as a family. 3.5.14 The records indicate no concern of the care of either Child 1 or 2. Child 2 was referred by an ophthalmologist to a paediatrician because of some unusual behaviour, for example hand flapping, limited language, tantrums and repetitive behaviour. Child 2 had not been seen by the paediatrician at the time of Child 1’s death. In line with the universal service as part of the Healthy Child Programme, Health Visitor 2 had no further direct contact with the family, but kept in touch by telephone and from records received from the GP practice. 3.5.15 Other than the birth of Child 1, Hospital 1 had contact with the family when Child 1 was admitted following presentation at the GP surgery with vomiting. Child 1 was discharged the same day with a prescription for anti-reflux therapy. The final contact was the admission of Child 1 for cardiac arrest. 3.5.16 The IMR acknowledges the wide range of issues discussed by health visitors and midwives with Adult 1. While there were some clues that Adult 1 felt isolated there were also a number of protective factors, including attending the Children’s Centres for activities, attendance at ante-natal care, family members visiting and using community resources. 3.5.17 Staff Nurse 1 took care to ensure that an interpreter was present to speak in Urdu when she was giving detailed information but Adult 1 had a good understanding and kept dietary records in good English. Other than the abuse in Area 4 the staff had no concerns about the adults as parents. When matters of diet or over wrapping were pointed out, the family responded appropriately and immediately. Adult 1 found it more difficult to consistently implement the advice given in respect of Child 2’s routines but she co-operated with staff at all times. 21 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.5.18 While Adult 2 was seen less often (four times), there were no concerns about his parenting; he demonstrated a good relationship with Child 2. Importantly none of the staff identified any issues as a result of him having a learning difficulty. Learning difficulty was not evident in his ability to manage and respond to the needs of Child 2. This was a professional judgement made from a number of observations and not formal assessment or further enquiry being undertaken to consider if his learning difficulty had any impact on his parenting. 3.5.19 The only indicator of risk noted was that both parents were young, but both approached parenting with maturity. Adult 1 had three opportunities to talk about domestic abuse from Adult 2, but on each occasion said she had no concerns for her personal safety. At the last direct contact, both adults seemed relaxed and comfortable with each other. Staff are experienced in signs of abuse or difficult relationships, but did not find this to be the case for Adult 1 and 2. 3.5.20 The IMR identifies three areas where the service could have made further assessments or enquiries. These are:- • The impact of Adult 2’s learning difficulty on his parenting • The family isolation, especially Adult 1 • In the context of the social isolation, how extensive was the support provided by the wider family when Child 2 was born Overall however there was no evidence of significant harm. 3.5.21 The report notes that the family were provided with good health services, with a child centred focus, good relationships with community NHS staff, referrals as needed for other services, and attention given to culture and language. However as noted in paragraph 3.5.1 the SCR has given an opportunity to consider the provision of a child focussed service in the context of the whole Bolton NHS Foundation Trust. 3.5.22 The recommendations relate to:- • Awareness of the vulnerability of infants to include all services in community and acute setting • All services have up to date knowledge and skills about domestic abuse • Raise awareness with relevant staff about the CAF process specifically when to start a CAF and CAF skills • Exploring children’s identity issues when health services are provided • Assessment and recording in relation to attachment • Review of oversight of the work of support staff in health visiting teams- specific to health visiting Teams • Consider implications of research and practice developments in other areas for keeping infants safe 22 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • Remind relevant Foundation Trust staff of the SUDC process in relation to ensuring that contact has been made with the police 3.6 North West Ambulance Service (NWAS) 3.6.1 NWAS provides emergency and non-emergency pre-hospital medical care to all patients throughout the North West Region. It also provides patient transport services for those patients unable to travel independently to and from hospital. 3.6.2 The IMR has been prepared by the Safeguarding Practice Manager and countersigned by the Head of Clinical Safety. The report is written using the electronic records from the Sequence of Events (SOE) of the Emergency Service Control and Command System and the clinical record completed by the attending crew with details of the incident, patient observations, clinical interventions and treatment. The three staff who attended the emergency call were interviewed by the police and the records of these have contributed to the IMR. 3.6.3 NWAS has maintained two separate databases of vulnerable children and adults since 2006. There had been no referrals for any adult or child from Address 1. 3.6.4 An emergency call made by a passer-by was received (this was about seventy minutes after the appointment, in paragraph 3.4.7 above at the GP practice). The address was logged and the patient identified as a child of a few months who was in the mother’s arms but not breathing or conscious. The call was coded as ‘urgent’ using standard government codings and initially a single crew Rapid Response vehicle was allocated. The coding was then upgraded to ‘priority’ and a two person ambulance allocated. A different Rapid Response vehicle with a paramedic who had paediatric training and a different ambulance with two staff became available closer to Address 1. 3.6.5 The vehicles arrived at the address. The Rapid Response paramedic found Child 1 inside Address 4 receiving cardio-pulmonary resuscitation from the male caller. He picked up the baby and proceeded to the ambulance and, with the ambulance senior paramedic, continued to provide treatment using a bag valve mask and then a defibrillator. 3.6.6 Initially Adult 1 was in the ambulance with Child 2, but she took Child 2 back into the house, and was taken back to the ambulance by the Emergency Medical Technician to travel to the hospital. 3.6.7 The ambulance crew alerted the hospital of the nature of the emergency, arriving at Hospital 1 shortly after. 23 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.6.8 During the journey the Emergency Medical Technician asked Adult 1 what had happened. The conversation was difficult because of Adult 1’s limited English at that time, but by asking ‘yes/no’ questions and with gestures, a picture of events was described, of the visit to the GP, and Adult 1 coming downstairs and seeing that Child 1 ‘wasn’t right’. 3.6.9 At the hospital the technician stayed with Adult 1 until a nurse came to take over her care. 3.6.10 The IMR notes that the service met all expected practice standards, notifying NWAS Support Centre of a possible Sudden Untoward Death of a Child. The exception was that the records show that the Emergency Control Centre did not notify the police. 3.6.11 The IMR makes two recommendations. The first is to remind all staff that Language Line is available as an emergency service to ensure crucial information can be noted prior to arrival at hospital; the second is to ensure the review of Sudden Untoward Death of Children procedures are urgently updated to stress the need to notify the police when the service takes a child to hospital when there is an Acute Life Threatening Event or a Sudden Untoward Death. The failure to report to the police has been noted in a previous SCR by NWAS. The importance has to be stressed as it prevents contamination of a possible crime scene. 3.7 North West and North Wales Paediatric Transport Service (NWTS) 3.7.1 NWTS was set up to transport by ambulance any critically sick or injured child from general hospitals to the nearest paediatric intensive care unit (PICU). The service provides paediatric specialist NHS staff (doctors and nurses) to manage the care during transport, as well as advice support on patient management before transfer or when transfer is not possible. 3.7.2 The IMR was written jointly by the lead consultant and lead nurse and countersigned by the Clinical Nurse Manager. The report is based on written reports, telephone records and interviews with staff. 3.7.3 The service contact with Child 1 was brief from the first contact to when the handover to Hospital 3 PICU took place. The timing of the call meant that two teams of staff were involved, the daytime team handing over to the night team. The first team spoke to the family on arrival at Hospital 1, and the night team spoke to them on arrival at Hospital 3. 3.7.4 The narrative in the IMR notes that the consultant at Hospital 1 was asked to check if Child 1 was known to the local safeguarding team, because of the uncertainty of the cause of the cardiac arrest although the notes of examination are clear that there was no external sign of NAI. It is noted in the chronology as well as the narrative that the possibility of NAI was discussed at handover to Hospital 3. 24 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.7.5 The service always follows up to find out the progress of patients within 24 hours of the transfer. NWTS was told Child 1 was very poorly and later notified of the death, and the referral to the Coroner. 3.7.6 The IMR notes that recording for Child 1 did not meet the expected standard, as two sets of documents had been completed. The second set made an assumption that history taking and examination had been completed prior to arrival at Hospital 3. Also the paperwork, although safeguarding concerns had been highlighted as a possibility, did not record what action had been taken to refer to the relevant agency. Additionally the review identified that the driving staff at present do not have any safeguarding training. 3.7.7 All three of these points have been included as recommendations for the service. 3.7.8 The IMR is not presented in the same format as other IMRs, but because of the limited contact with the family, all the necessary information is evident in the report. 3.8 Hospital 3 NHS Foundation Trust 3.8.1 Hospital 3 NHS Foundation Trust is one of two specialist Paediatric Tertiary Centres in the North West of England providing medical care for very sick children. The paediatric intensive care unit regularly manages the care of children who then become the subject of SCRs and so has in place procedures that recognise the uncertainty that can surround the cause of admission. 3.8.2 The addendum IMR was prepared by a Nurse Consultant, the named nurse for Safeguarding Children and countersigned by the acting Director of Nursing and Executive Lead for Safeguarding. It was agreed that Terms of Reference used by other IMR authors were not fully relevant; instead the IMR (referred to as an addendum IMR for this reason) used the following questions for analysis:- • What opportunities did the agency have to observe parenting ability and interaction between Adult 1 and Adult 2? • What impact did this have on assessments, actions and services at the time and were these all appropriate? • On reflection were there any signs or indicators that Child 1 was at risk of suffering significant harm? • Did all agencies and professionals give due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration? • Did all agencies keep the child and their experiences at the centre of their assessments of and interventions with the family? • Were information sharing and communication systems within and between agencies and across boundaries effective? 25 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • Was record keeping and documentation of an adequate standard? To prepare the report the author used the paper and electronic records created at the hospital and the NWTS transfer information. 3.8.3 The report gives in detail not only all the medical interventions and notes of Child 1’s deteriorating condition, but also every communication between staff and between staff and the family. Child 1 was admitted and died shortly after with parents present. 3.8.4 The report demonstrates the care taken to ensure all possible causes of Child 1’s collapse could be investigated, including non-accidental injury, at the same time allowing the family members to be with Child 1 and to grieve. 3.8.5 On admission it was known that because it was 50 minutes before Child 1 could be resuscitated following the cardio respiratory arrest, it was unlikely that the child would live. The family had been prepared for this by staff at Hospital 1 and this continued at Hospital 3. Adult 1 stayed with Child 1 during the night, while the rest of the family (Adult 2, Adult 3, Adult 4 and Child 2) returned home. 3.8.6 As part of normal procedure for an unexplained collapse, Child 1 was referred to the ophthalmologist. This showed evidence of retinal bleeding that was not caused by the prolonged resuscitation. Hospital 3 had already notified Bolton Children’s Services of the life threatening condition, that Child 1 was likely to die and that the SUDI protocol would be followed. During the afternoon, a further call was made to Bolton Children’s Services. The checks showed that neither Child 1 nor Child 2 was known to Social Care. 3.8.7 The specialist resource at Hospital 3 means that very poorly children are regularly admitted in unexplained circumstances. Experience has shown that preparing staff and the family for any type of investigation into the causes prevents both distress to family members, and possible interference of evidence at an early stage. This has led to the inclusion of action to be taken in the SUDI protocol called the Acute Life Threatening Episode (ALTE). This addition, with an ALTE pro-forma to complete is accepted across the Area 5 authorities. 3.8.8 Hospital 3 began the implementation of this procedure with notification to Safeguarding Consultant 1. The purpose of the procedure was explained to the family and information collected (by Safeguarding Consultant 1) from them to contribute to the records. Later in the day, Safeguarding Consultant 3 explained that the matter would be referred to Children’s Services and the police. Safeguarding Consultant 3 telephoned Bolton Children’s Services on the morning to confirm the information about Child 1’s death, referral for a post mortem and notification to the Coroner, following the SUDI protocol. 26 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.8.9 Child 1’s family were only in contact with Hospital 3 for 24 hours. During that time, Adult 1 and Adult 2 spoke freely of their life when living with Adult 4 and their concern that he would take over the arrangements for their baby. Adult 2 was described by Adult 4 as having the mental age of 12, but Adult 1 described him as ‘lagging behind by two years’. During all the conversations, Adults 1 and 2 seemed to understand the staff concerns, and presented as caring parents. 3.8.10 The report demonstrates that staff were aware of Adult 2’s learning difficulty, and that English is not Adult 1’s first language. All communication was given in a simple form, in Hindi when requested and was only shared with the wider family with the consent of Adult 1 and 2. 3.8.11 Hospital 3 has a Child Protection policy ensuring the needs of any child are paramount; as Child 1 was very poorly from admission, nursing was provided on a one to one ratio, so care was safeguarded at all times. However this is balanced by the Trusts challenge to meet the twelve principles of a good death as defined in their hospital procedures. As Child 1 could not communicate in any way, the staff ensured that parents were in close contact at all times. Also the bereavement policy ensured the parents were able to cuddle, wash, take photographs, and take away imprints of Child 1’s hands and feet. 3.8.12 Overall the IMR demonstrates full adherence to the procedures, inclusion of the family and sensitivity to the issues presented by the extended family, while remaining focussed on nursing and treating a very sick baby who was likely to die. 3.8.13 The review of records identified two inappropriate records. One staff member, Safeguarding Consultant 2, had recorded them as ‘lovely and devastated’. The IMR notes that this is a subjective statement, which should not be part of the factual record. A second concern was an electronic entry by a nurse that there were no safeguarding concerns when an earlier paper record notes the query of the retinal haemorrhages in the right eye. 3.8.14 Hospital 3 had notified Bolton Children’s Services early that the SUDI protocol would be implemented following the death of Child 1. However when the call was made to notify of some safeguarding concerns following the Area 5 ALTE procedure there was an expectation that Children’s Services would notify the local police to ensure consideration of protection of a possible crime scene. There is no similar protocol in the remainder of the North West and the response in Greater Manchester is to wait until the notification of death or confirmation of NAI before involving the police. 3.8.15 The IMR has two recommendations linked with the points made in paragraphs 3.8.13 and 3.8.14, to improve standards of record keeping by including such examples within the safeguarding training, and to work with agencies in the North West, including NWTS to adopt the principles and actions from the Area 5 ALTE procedure. 27 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.9 The NHS Bolton Commissioning Report 3.9.1 The NHS Bolton Commissioning report has been jointly prepared by the Associate Director of Safeguarding (Designated Nurse) and a Consultant Paediatrician (Designated Doctor) from NHS Bolton and countersigned by the Interim Accountable Officer from the Commissioning Group for Bolton. 3.9.2 The authors have used the five NHS IMRs as the basis of the NHS Commissioning Health Report as well as:- • Feedback and comment from panel discussions on each IMR • A training meeting for NHS IMR authors • Discussion with the Lead Commissioner for the regional PICU service to gain agreement to include the Hospital 3 IMR in the report • An analysis of the integrated health chronology • Consideration of practice standards • Additional review of health visiting records, particularly those transferred from Area 4 to clarify how care was provided to Child 2, prior to the move to Bolton 3.9.3 The authors note at the beginning of the report that it had been difficult to prepare the NHS chronology as the region uses a different template from Bolton. Following discussion at panel, it was agreed that the differences should be discussed at the LSCB and any relevant action taken. 3.9.4 The NHS Commissioning Health report is written in a clear, simple style. It outlines the contact the family had with NHS services and where appropriate considers whether the service has fully met practice standards. Any evidence of not meeting standards is limited but is important to consider. The report considers as more than meeting practice standards:- • Quality of the health visitor ‘movement in’ visit • Service provided by both GP practices, especially the prompt appointment service for babies and young children • Wider assessment provided by the ophthalmologist leading to a referral to a paediatrician • Role of the health visitor in making referrals for therapy services and follow up on progress • Transfer and communication between health visiting and midwifery services • Quality of the midwifery service • Quality of the primary health visiting visit following Child 1’s birth • Emergency services provided by NWAS and NWTS, including excellent response times • Services provided by Hospital 3 28 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.9.5 Overall the authors are able to report that the family was provided with a good quality service, and a particularly sensitive service during the time of delivering acute emergency services. 3.9.6 The NHS Bolton Commissioning Report, following the commentary on the description of events, identifies five themes for consideration that link with the terms of reference. These are:- • Communication • Plurality of vulnerability factors in the family and assessment • Cultural issues • Learning difficulties • Domestic abuse 3.9.7 In the introduction to the Themes, the authors note that while within the review, participants can use hindsight, it is important to only make judgements on practice based on the information available at the time. Within the comments against each theme the authors cross reference them against each of the eight terms of reference. However the terms of reference are not specifically addressed limiting cross reference in section 4 of this report. 3.9.8 In the commentary the report notes that the majority of contacts and service provision met all expected standards, for example the detail recorded in health visiting assessment visits, referrals for speech and language therapy, specialist dietary advice, and checking how well the family were able to follow advice. The Commissioning Report commented on this good practice, but notes three areas where judgements could have been different as described in paragraphs 3.9.10 to 3.9.15 below. 3.9.9 The information recorded by the GP about domestic abuse was not given to the Health Visitor, nor coded as an alert, or referred to Social Care. During health visiting visits the matter of personal safety was properly raised but without Adult 1’s disclosure, or some indication of her situation, the health visitor was not in a position to pursue Adult 1’s responses. 3.9.10 One of the authors of the Commissioning report has checked carefully the notes transferred from Area 4. There is no indication of any domestic abuse between the adults in the extended family. With hindsight, the information suggests a level of acceptance within the family of some violence. The Commissioning Report notes that the GP IMR identifies that some action should have been taken, and recommends closer liaison between Health Visitors and GPs as there should have been some consideration of the impact of the domestic abuse on Child 2. 29 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.9.11 The omission of giving information to the health visitor was further exacerbated when during the pregnancy of Child 1, both parents were reported to be pleased. Not knowing that Adult 1 had told the GP that she did not want another pregnancy, while Adult 2 did, prevented the midwife from checking more carefully with Adult 1. In hindsight, staff can see that potentially Adult 2 had a controlling role. 3.9.12 The point in paragraph 3.9.9 is also pertinent for NHS staff responses when Adult 1 discussed that Adult 2 was seeing someone else and that they were planning to separate. Community NHS staff had established a good rapport with both adults, and Adult 1 and 2 began to talk about their experiences with the extended family in Area 4. The staff would have had a more complete picture if they had known about Adult 1’s separate concerns and they would have been able to consider the impact on Child 2 and the expected baby. The NHS Bolton Commissioning Report notes that no other agency had either alerted the staff to any concerns or asked for information as they were concerned. 3.9.13 However, while the omission was regrettable, it is not the view of the NHS Commissioning authors, or the panel, that even with greater efforts to check that Adult 1 was able to talk about any difficulties in her marriage, there would have been a different outcome. 3.9.14 In relation to NHS community staff the last area considered is the lack of information on Adult 2’s learning difficulty. Again the authors checked the information transferred at the time from Area 4 Community NHS records. There was one reference, within the notes to his learning difficulty, but the information was not included in the summary as a factor relating to his parenting capacity. This summary is used to highlight any particular needs, issues or concerns. None of the NHS staff who met Adult 2 were aware that he had a learning difficulty, and there is no suggestion that the difficulty had an impact on his parenting. In fact there are positive comments on the relationship between Adult 2 and Child 2. 3.9.15 The NHS Bolton Commissioning Report comments on the prompt and responsive service provided in the emergency by both NWAS and NWTS. However there was a delay in notifying the police of the unexplained injury as it was not done by NWAS as expected. Hospital 1 did not check the notification had been made by NWAS, nor did NWTS. The police only became aware of the possibility of an unexplained serious injury or death when Children’s Services notified them. While in this instance the timing was not crucial, in some circumstances the police can only complete investigations properly and promptly if a notification is made at the earliest opportunity. This is recognised in the individual IMRs and the Commissioning report. 30 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.9.16 When Child 1 was transferred to Hospital 3, because of the unexplained nature of the cardiac arrest, the hospital followed their procedure for ALTE. As noted in paragraph 3.8.14, this procedure is not in place across the whole of the North West. This led to a misunderstanding between Hospital 3 and Bolton Children’s Services. In discussion in panel, there seemed to be a further lack of clarity in the procedure. The notification from Hospital 3 to Bolton Children’s services, after the ophthalmologist had identified retinal haemorrhaging, was intended to trigger notification to the police. In fact the notification to the police was only made after Child 1’s death. The detail of the expectations of the pro-forma will need to be clarified, if as recommended it is accepted as a regional procedure. THEMES EMERGING FROM THE NHS BOLTON COMMISSIONING REPORT 3.9.17 Theme 1 – Communication The conclusions identify some lack of communication which can be improved. These are:- • Information sharing between GP, the health visiting service and Children’s Social Care should include key factors that could impact on parenting; the GP IMR has a recommendation to remedy this point and since the death of Child 1, this is included in the NHS Bolton Safeguarding Policy • Notification to the police when a baby has an unexplained condition that could have been caused non-accidentally. As non-accidental injury must always be a possibility, individual IMRs have made recommendations, and the NHS Bolton Commissioning report makes two recommendations linked with this issue. One is that BSCB and NHS Bolton should ask Greater Manchester to adopt a similar ALTE pro-forma, and the second that NHS Bolton should use the pro-forma within local services. 3.9.18 Theme 2 - Plurality of vulnerability factors in the family and assessment The report considers the strengths of both parents observed by NHS staff. Until Adult 1 talked to the health visitor about her marriage, and her loneliness, there was little indication of vulnerability. The report refers to research that indicates the vulnerabilities known to the service, even with the additional information from the visit to the GP, it would not reach a threshold for a family action or child protection meeting, but did meet the threshold for additional support. 3.9.19 The report also comments that most of the health visiting visits were undertaken by a staff nurse. Supervision from the health visitor should have reviewed the support needed by the family and the health visitor should have considered completing a CAF. This is included as a recommendation in the Bolton NHS FT IMR. 31 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.9.20 Theme 3 - Cultural issues The report notes that information on the extended family in Area 4 which would have provided a fuller context for the situation of Adult 1 in particular but also Adult 2 was not included in the transfer notes. However even though the extent of Adult 2’s learning difficulty was not known or the degree of isolation Adult 1 was experiencing, NHS staff could have provided some information and guidance on community support. In Bolton with a large and mixed cultural population there are many opportunities for women to gain support from the community in culturally sensitive groups. 3.9.21 All the NHS staff recorded good language skills, and the health visitor checked that Adult 1 could understand the more complex information in the dietary advice with the use of an interpreter. In Area 4, the records indicate Adult 4 translated for Adult 1, but with hindsight this is noted as a possible controlling action. 3.9.22 There are no recommendations linked with cultural issues, as the staff recognised the needs of Adult 1 and had taken action to support her. 3.9.23 Theme 4 - Learning Difficulties The report notes that no health professional observed any concern about Adult 2’s ability to parent. He had sole care of Child 2 on a number of occasions. Learning difficulty is not a key indicator of safeguarding concerns, (noted the overview of Serious Case Reviews, found it a factor in 15% of cases), and the conclusion is that it did not have an impact with Adult 2. However his learning difficulty may have had an impact on Adult 1’s feelings of isolation. A wider conclusion is that fathers should be routinely included more in discussion of child health. 3.9.24 Theme 5 - Domestic Abuse The response to the one record of domestic abuse does not meet the expected standards within the LSCB procedures. The omission of not passing on the information has been noted in detail in the report, but the NHS Bolton Commissioning Report concludes that it also points to the wider concern of the lack of engagement by GP practices in child in need and child protection procedures. In this case the lack of information about the behaviour of Adult 2, and the experience of abuse in Area 4 meant that assessments of Child 2 did not take any account of domestic abuse but that the service offered to Adult 1 and the children would not have differed. Adult 1 was asked at least twice if there was any domestic abuse, and had the opportunity to speak more easily when the interpreter was present. 3.9.25 The NHS Bolton Commissioning Report draws some general conclusions that are reflected in the individual IMRs and makes four recommendations, linked with the commentary in paragraphs 3.9.10 to 3.9.13. These are:- 32 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1. Greater Manchester LSCBs and NHS Greater Manchester amend the current Protocol “Sudden Unexpected Deaths in Childhood to include guidance on the management of a child suffering from an ‘Acute Life Threatening Event’ (ALTE). This will ensure a consistent response by agencies to notifications of children experiencing a life threatening event where non accidental injury is always a differential diagnosis. 2. Bolton Foundation Trust to consider adopting the ALTE pro forma for use in children who remain in Bolton for their investigation and treatment. This should specify explicitly who will be contacting each agency involve and when this has been done so that there is no delay in involvement of any individual agency. 3. Hospital 3 to review the ALTE pro forma to include an explanation about what ALTE protocol requires for areas that do not have an operational ALTE protocol and agree and document which agency will take responsibility for notifying the Police as the existing protocol only states that the Police must be informed. 4. Raise awareness of the impact of additional stressor including poor housing, social isolation, poverty and domestic abuse on parents with particular regard to parents with learning difficulties. This recommendation relates to frontline health workers responsible for assessing children and family’s needs and also managers responsible for clinical supervision. 4. CONCLUSIONS AND ANALYSIS 4.1 To what extent did agencies/services/individuals recognise and take account of Adult 1’s potential vulnerabilities? In particular:- • Age • Language and literacy needs • Immigration status • Marital status • Level of isolation or integration within the local community • Relationship and support offered from wider family members And what impact did this have on assessments, planning, intervention and outcomes? 4.1.1 Generally agencies consider that staff in contact with Adult 1 had an understanding of her vulnerabilities. However when each of the bullet points is taken in turn, much less was known than emerged in the SCR process. 33 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.1.2 The only agency to comment on the young age of Adult 1 was Bolton at Home. Because of the ages of both Adult 1 and Adult 2, they were offered additional support as part of the STeP programme to help maintain the tenancy, as young people rather than as young parents. The visiting officer had recorded brief details of visits and contacts, which suggested the couple, were managing the tenancy well and asking for help when it was needed. 4.1.3 All the agencies who met Adult 1 knew that English was not her first language, but their records show that her spoken, and when seen, her written English is of a good standard. The Children’s Centre registration details record her first language as Urdu and her English as ‘basic’ but it is not known if this was her judgement or a staff member’s. She did attend an ESOL on one occasion. It is not known if her failure to attend more classes was due to her assessment of them not being necessary, or for other reasons. As the service is available for those who wish to use it, rather than as part of a plan, it was not appropriate to follow up any non-attendance. 4.1.4 As part of the service for Child 2, the health visitor wished to ensure Adult 1 understood detailed dietary information and advice. For this visit an interpreter who spoke Urdu accompanied the health visitor, but at the visit it was agreed that Adult 1 had no need of the service and clearly understood the information and advice being shared. 4.1.5 However when Child 1 was taken to hospital and Adult 1 was distressed, she did wish to revert to her first language. The staff member in the ambulance was able to talk by use of closed questions and gestures, but could have used Language Line. At Hospital 3 one of the consultants spoke Hindi and by choice she used this language to speak to the family on admission. At other times all staff members used English and considered Adult 1 understood. 4.1.6 Once again, the only agencies that were aware of Adult 1’s immigration status (discretionary leave to remain) were the housing agencies. Her status had been confirmed as part of the housing application. NHS agencies only record immigration status if the person is recorded as either an asylum seeker or refugee as there are specific health arrangements for people with such status. 4.1.7 The UKBA notes that at the time of Child 1’s death her immigration could not be described as ‘precarious’, but a mother of two small children, only having eighteen months security remaining, may have a different view. However agencies providing universal services had not asked her about this. 4.1.8 The only agency in Bolton who had any details of Adult 1’s marriage was Bolton NHS Foundation Trust. Adult 1 told her midwife after the birth of Child 1 that it had been an arranged marriage that took place in Area 3. However staff also viewed Adult 1 as mature and engaging well with services. 4.1.9 The background details from Area 4 give this information as it had been recorded by Area 4 Police when Adult 2 had been interviewed in relation to supplying a controlled drug but was not known generally to agencies in Bolton. 34 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.1.10 In relation to the last two bullet points, I have taken them together. The housing agencies knew of the support offered by Adult 5, both in providing accommodation when the family moved to Bolton because of the abuse from Adult 4, supporting the housing application and providing support after the family moved into Address 1. At one point a Bolton at Home staff member asked if Adult 5 and her family were living at this address as they had been present each time she called. Adult 1 had also told the agency she had good contact with neighbours. The STeP service was intended to ensure the family had sufficient support to maintain the tenancy, but that is the whole extent of their interest. 4.1.11 Children’s Centres are part of Bolton’s universal provision to support families. While their remit is to help parents to parent well and provide opportunities to mix and socialise, it is specifically not a service which asks for any personal details unless the adult offers the information or there are child protection concerns. When the midwife made the single agency referral, there was no indication that Adult 1 was socially isolated, but just that she would benefit from some support. 4.1.12 Within the NHS, the first GP in Bolton probably had the best indication of Adult 1’s isolation, when she told him that her husband had hit her, she was lonely and she did not want another baby. The GP notes also included some information about the abuse in Area 4. However this was not coded for future practitioners to see; this meant that when Adult 1 began to talk to other health services her conversation was not seen in the context of her earlier conversation. Direct information about Adult 1’s experience in Area 4 was only given by her to Midwife 1 (at GP). It was when Midwife 8 followed up this discussion on her visit that the single agency referral was made as Adult 1 had said she felt isolated. 4.1.13 Staff Nurse 1 had noted when she was working with the family to improve Child 2’s diet, that Adult 6 was visiting to help reinforce the programme of change. This was recorded as positive family support. 4.1.14 When the family was at Hospital 3, the vulnerability of Adult 1 was recognised, first by the staff member from NWTS who stayed with her, and then by Hospital 3 staff. They fully understood her need to be fully included, respected her request for all information to be given to her and Adult 2 before discussion with the wider family, and consulted when decisions about withdrawal from life support had to be made. 4.1.15 On reflection, agencies have identified that their services could further improve by:- • NHS community staff have a wider understanding of the range of stressors that can cause vulnerability within a family • Children’s Centres ensure full and accurate factual details are taken when families register for attendance 35 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • NHS agencies use Language Line for emergencies as well as for more routine • Ethnicity is recorded, including first language 4.1.16 However, as will be noted later in the report, there is a balance to be made of intrusion into the lives of those who do not ask or appear to need support, and the need to know so that support can be offered and made available. 4.2 To what extent did agencies/services/individuals recognise and take account of Adult 2’s potential vulnerabilities, in particular:- • Age • Learning disability/difficulty • Marital status • Parenting capacity • Level of isolation or integration within the local community • Relationship and support offered from wider family members And what impact did this have on assessments, planning, intervention and outcomes 4.2.1 For Adult 2 comments made in paragraphs 4.1.8 and 4.1.10 above also apply. He still met the criteria for inclusion on the STeP programme. Other than the note about his age from Bolton at Home, no agency had recorded any comment about his age. 4.2.2 English is Adult 2’s first language but he also speaks Urdu and Punjabi. The cognitive assessment completed as part of the court process notes that Adult 2 ‘can express himself quite adequately and although he sometimes uses words idiosyncratically his meaning is generally quite clear’. This is relevant for the agencies responding to any recognition of Adult 2 having a learning disability/difficulty. 4.2.3 As part of the housing application Community Housing Services checked the status of Adult 2’s learning difficulty with him, his sister, and the GP. The notes state he has a ‘relatively low level raising no significant concerns for independent living nor in terms of parenting capacity’. Any further comment is not available as it would be on the assessment that cannot be found in Bolton at Home records. 4.2.4 Children’s Services only knew that Adult 2 had a learning difficulty from a note on Midwife 8’s single agency referral. When the Family Worker telephoned to arrange to visit in response to the referral, her assumption at his response was that he did not speak good English. On reflection it may have been because he knew nothing of the referral, or didn’t want any agency involved in the family. 36 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.2.5 While Bolton NHS FT knew from Adult 1 and Adult 2 that Adult 2 had a learning difficulty, both had described as ‘difficulty in reading and writing’. Adult 5 had told Bolton Childrens Services that Adult 2 had a learning difficulty, and described it as ‘being about seven years younger than his chronological age’. It was only when the family was at Hospital 3, when Adult 4 described him as having a mental age of 12, while Adult 1 described him as two years behind that there was any suggestion that his capacity as a parent might be limited. The staff at the hospital recorded that when the family was arranging to leave, he seemed confused about where he should go, but this is the only recording that suggests he was unable to understand fully expectations and his responsibilities. The panel considered Adult 2’s response could equally be a response to an emotional and draining situation. 4.2.6 In relation to Adult 2’s parenting capacity, observations from the health visiting service, who saw him four times, the midwife and Bolton at Home staff were all positive. He was seen to care for and play with Child 2, and when Child 1 was ill the second time, it was Adult 2 who took the child to the surgery. All the staff who observed Adult 2 were trained in Child Protection and were aware of which signs to look for to identify any safeguarding concerns. The NHS Bolton Commissioning Report concludes that more information would have been helpful in the context of including fathers more in child health assessments. This has been identified in a number of Serious Case Reviews, and noted in the fourth Biennial study of SCRs published by Ofsted in June 2009. It had studied 189 SCRs completed between 2005 and 2007. Two of the key findings were that there was a dearth of information about men in most serious case reviews, and a failure to take men into account in an assessment. 4.2.7 Adult 2 was not considered to be socially isolated. The housing agencies noted that he had and appreciated support from his sister. Support Officer 1 also found the whole family was out on six of 12 visits, suggesting they had people to visit or places to go. NHS community staff found he was often out when they visited and assumed he was not isolated. 4.2.8 In summary, Adult 2 presented as an adult who was able to communicate with staff from the different agencies, was an active parent to Child 2, and after the birth, to Child 1, and appeared to have support both from family and the community. 4.3 What opportunities did the agency have to observe parenting capacity and interaction between Adult 1 and Adult 2 with Child 1 and Child 2? What impact did this have on assessments, actions and services offered at the time? Is there anything that could have been done differently? 4.3.1 Records and staff interviews confirm that observation of Adult 1 and Adult 2 as parents were positive. Some agencies (Community Housing Services, Bolton at Home, Children’s Services) only saw the adults with Child 2, but it was noted in particular that Adult 2 had a good relationship with this child, with a note from Staff Nurse 1 that Child 2 was missing Adult 2 when he was absent from the home. 37 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.3.2 The GP record indicates that they were seen as a normal, caring family; the limited observation at Hospital 3 gave no indication of anything different. 4.3.3 The more detailed records are from the two Health Visitors and the two midwives. Adult 1 is recorded as mature and in control of family matters, but showing warmth and with a positive relationship with Child 2. This assessment was confirmed by observations from ward staff when Adult 1 stayed with Child 1 in Hospital 1 during admission. When Adult 1’s demeanour was different, it was recorded, as ‘tearful’ and ‘sad’. The conclusion that both parents were competent is based on the full health visiting assessment, and then working with the adults using the Solihull Resources (a Parenting Support Programme) to help make changes with Child 2. 4.3.4 Adult 2 was seen by Community Health staff four times, and was not seen alone; however his parenting was observed to be appropriate with good interactions with Child 2. 4.3.5 When Adult 1 and Adult 2 first moved to Bolton their relationship was assumed to be a strong one. Together they had defied Adult 2’s family and left the extended family home to live as a family unit. The first indication that their relationship had some difficulties was, when Adult 1 told GP1 that she did not want another baby, that Adult 2 had hit her a few times, she felt lonely, that her parents were abroad and that Adults 3 and 4 had thrown them out. This was not explored further by the GP and not coded in the notes to draw the attention of later practitioners. 4.3.6 Further information was given when Adult 1 told Staff Nurse 1 that Adult 2 was ‘seeing someone else’ and they had discussed separating after Ramadan. She was also concerned that Adult 2 would take Child 2 back to Area 4 when she was in hospital for the birth of Child 1, and that he would not bring Child 2 back to her. 4.3.7 Adult 1 told Staff Nurse 1 that they were planning a separation by mutual agreement. Just after Child 1’s birth, Adult 1 revealed some of her isolation when she told Midwife 1 of the reason for the move from Area 4. She also wanted her mother to come from Area 3 to help her. When Midwife 1 asked her about the conversation she said she felt isolated. 4.3.8 This conversation prompted the single agency referral to MARP. However when Health Visitor 2 made the primary visit following the birth of Child 1, the plans had changed to seeking rehousing as a family. At no time was there any negative interaction between the adults, and it is possible that the disclosures could be seen as more associated with Adult 1’s greater vulnerability immediately before and after the birth of Child 1. 4.4 To what extent have assessments and interventions considered diversity issues, including ethnicity, religion, language, disability and cultural issues? 38 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.4.1 On the whole agencies had recorded diversity issues. Community Housing Services had confirmed the immigration status of Adult 1, checked with family and GP for information on Adult 2’s possible disability, noted both adults had a good standard of spoken English and recorded all the basic monitoring information. It is expected that similar records would have been made by staff at Bolton at Home but the STeP documents are missing. 4.4.2 It has already been noted in paragraph 4.1.11 that Children’s Centres provided by Children’s Services are a universal service which is non-intrusive. However the records were not sufficient to give basic factual information which would demonstrate how well it was reaching out to isolated communities. 4.4.3 Attention was given by most agencies to language, with either records that both adults communicated well in English, or in a couple of cases more specific support before making the judgement. Staff Nurse 1 used an interpreter in Urdu when she wanted to ensure more complex information was understood, but following that visit it was noted the service was not needed again. 4.4.4 The Children’s Centre provided ESOL classes, but because of the emphasis on people attending when they wished Adult’s 1 attendance at only one class was not questioned. It may have been that she appreciated her English was of a good standard. 4.4.5 There is evidence that agencies considered culture more widely than just language. However one element of this may have been the health visiting and midwifery services interpreting Adult 2 being absent on many visits as him taking a ‘traditional role’ in parenting, rather than checking more about the impact of his learning difficulty on his role in the family. 4.4.6 Hospital 3 however had clear records of understanding the wider cultural needs with discussions about funeral arrangements, accepting the role of the wider family and also some use of Hindi, when a consultant was able to do so. 4.4.7 It has been noted in paragraph 4.1.5 that NWAS did not use Language Line, but it could have been inappropriate given the critical circumstances and with Adult 1 able to understand sufficiently. Hospital 3 had been told by Adult 1 and separately by Adult 4 that Adult 2 had a learning difficulty, and so ensured that all communication was in simple terms and that he understood. 4.4.8 Although the Area 4 records indicate some learning difficulty, the GP found no difficulty in communication with Adult 2 either because of learning difficulty or language. Bolton NHS FT has included a recommendation that includes ensuring staff have wider understanding of identity within the cultural and ethnicity context. This recommendation is endorsed by the NHS Bolton Commissioning Report. 39 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.5 What opportunities did the agency/service provide to Adult 1 and Adult 2 to speak independently of one and other about any concerns or worries they had prior to the birth of Child 1? On reflection can you identify any learning points? 4.5.1 Few agencies had opportunities to see either Adult 1 or Adult 2 alone and Bolton at Home notes in the IMR that as a housing agency, staff do not try to do so. 4.5.2 Children’s Services only saw Adult 1, but always in activity groups when the opportunity for staff to speak alone to any adult would have been limited. The Children’s Centre had recorded Adult 1 as an Urdu speaker, and possibly did not appreciate the standard of her English. Only the administrative staff member spoke Urdu, and the IMR suggests that Adult 1 spoke in Urdu to other parents. 4.5.3 The NHS records show that when Adult 1 was in a situation when she could speak freely (GP1, Midwife 1, Health Visitor 2 and at Hospital 3), she did reveal her concerns about Adult 2, Adults 3 and 4, and her feeling of loneliness. However when asked as part of the health visiting initial assessment, Adult 1 had said she had no concerns about personal safety or domestic abuse. If the GP record had been appropriately coded other practice based staff would have known of the history of domestic abuse. Also if the GP had notified the health visitor of the information it is possible Health Visitors 1 and 2 would have asked further questions when Adult 1 knew them better. Adult 1 had spoken to Staff Nurse 1 about financial concerns as well as the plan to separate, but had not spoken of any concern about having a second child. 4.6 To what extent did the agency have awareness of domestic abuse issues within the nuclear and extended family? What was the response of the agency and how did this feature in assessments, planning and interventions? 4.6.1 Community Housing Services were the first agency to have contact with Adult 1 and Adult 2. They were accompanied to their appointments by Adult 5, who confirmed the account of abuse they had experienced from Adult 4. It is expected that Bolton at Home also had this information. Both agencies did not consider the family to be at risk as they had taken steps to come to live in Bolton. This information was also held in a brief note in the GP records. 4.6.2 In addition, Adult 1 had told Staff Nurse 1 that Adult 4 was claiming Adult 2’s benefits. Staff Nurse 1 recognized this as a concern and although not constituting physical violence was evidence of controlling and intimidating behavior of wider family members. Adult 1 told Midwife 1 that the family had moved to get away from Adult 4 and the staff member understood the family was not in contact with the extended family in Area 4, but had support from an uncle (Adult 6) in Bolton. 40 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.6.3 Adult 2 gave Health Visitor 2 the same information some days later, but the record says the abuse was when he was a child. When the family was at Hospital 3, staff there recorded the historical abuse and respected the wish of Adults 1 and 2 that they only speak to Adults 3 and 4 with their permission. 4.6.4 In relation to abuse within the nuclear family, Adult 1 was asked about this directly on 2 occasions but she denied that there was any. As indicated previously, if the GP record had been known, Health Visitor 2 may have asked this question in a different manner, and received a different reply. 4.6.5 The midwifery notes also indicate that questions were asked about emotional well-being which include prompts about personal safety and relationships during the ante-natal period. No concerns were reported by Adult 1 at that time. 4.6.6 When Adult 1 spoke to Staff Nurse 1 about the plan for separation, Adult 1 was clear that the plan to separate was mutual and amicable. 4.6.7 The last time Health Visitor 2 saw Adult 1 and 2 together they were described as ‘being relaxed with each other and there was not an awkward or uncomfortable atmosphere. Adult 1 was not seen to be intimidated by Adult 2 and appeared to make decisions about the family.’ 4.6.8 Health staff interviewed stated they are aware of domestic abuse issues and how they impact on children and high risk factors, but they did not detect any high risk factors for Adult 1. 4.7 On reflection were there any opportunities or indicators that suggest CAF processes could have supported multi-agency work? 4.7.1 Housing agencies in Bolton are fully included in the arrangements for CAF, but in all their contacts found the family did not appear to need more support than that offered by Adults 5 and 6. Adult 2 has additionally reported good relationships with neighbours. 4.7.2 Community NHS staff completed detailed assessments when the family moved into Bolton, and after the birth of Child 1. However these staff did not have the benefit of the information given by Adult 1 to the GP. It is possible/probable that when Adult 1 and 2 began to disclose some details to Staff Nurse 1 and then to Midwife 1 an earlier referral would have been made for support from MARP. With information on the abuse in Area 4, Adult 1’s loneliness, and her not wanting a second pregnancy, the health visitor would have understood that Adult 1 has some long standing concerns, and was missing her family and the support they would offer. 41 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.7.3 Communication between health visiting and midwifery services was good, and the services although child focussed, included discussions on other family matters. Health Visitor 2 on reflection, without the information from the GP, considered she could have completed a CAF just before Child 1’s birth. Midwife 8 did make a referral, but using the single agency form, when with the additional information a CAF may have been more appropriate to access family support. This view is supported in the NHS Bolton Commissioning Report. 4.7.4 The Children’s Services IMR notes that the services should have insisted on a CAF because when the midwife sent in the referral, the family was known to health visitors, Children’s Centre, speech therapy, and the STeP housing programme. In this instance the referral could have led to a more robust response. Completion of the CAF process would have included the historical information from Area 4 giving a full picture of the family situation. 4.7.5 This point was discussed in panel, but panel members who are familiar with CAF thresholds considered that with all the information, and with hindsight, meeting the criteria for CAF was borderline. 4.8. On reflection were there any signs or indicators that Child 1 was at risk of suffering significant harm or other missed opportunities to safeguard this child? Where signs and indicators are identified, please clarify any action that was or was not taken and the reason for this. 4.8.1 The housing agencies only had contact with the family prior to Child 1’s birth, but both confirm they had no concerns from their observations of the care given to Child 2. Additionally the family had recognised the negative impact of abuse and fled to protect themselves and their child. 4.8.2 Children’s Services Children’s Centres also only saw Adult 1 prior to Child 1’s birth. The staff had no concerns about the safety of a child cared for by Adult 1 from her presentation at the Children’s Centres. 4.8.3 In the GP IMR, the author interviewed the doctors and ANP who saw Child 1. They conclude that there was nothing to indicate that Child 1 was at risk of significant harm. These staff also would not know of the information recorded by the previous GP about Adult 2 hitting Adult 1, or the abuse from Adult 4, as the records had not been coded to draw attention to it. Even with this information the panel agreed that there was no evidence of significant harm to either Child 1 or 2. 4.8.4 The community health records are detailed and were used to apply the Significant Harm checklist. The chronology indicates a family who asked for appropriate services and who responded to the planned care for Child 2. The records also show that the staff informed each other as new information was given particularly by Adult 1, and that a wider picture was building up. 42 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.8.5 However the Bolton NHS FT IMR also highlights two points. The first is that even though full assessments were completed these were focussed and did not explore how Adult 2’s learning difficulty could impact both on his parenting and Adult 1’s feeling of isolation. In the absence of usual risk factors of substance misuse, mental health issues and domestic abuse only known of in the wider family, the learning difficulty of Adult 2 did not appear to be a significant risk factor. These comments lead to a recommendation in the NHS Bolton Commissioning Report that frontline NHS community staff and their managers who provide supervision should have improved awareness of how additional stressors can have an impact on young parents, especially when one parent has a learning difficulty. 4.8.6 The second point is that assumptions may have been made about Child 1 as this was not a first baby. However no one has recorded any assessment of how much care was provided by the extended family in Area 4, and then Adults 5 and 6 in Bolton. This information may have been significant in understanding any pressures for Adults 1 and 2 caring for two children independently. 4.8.7 However on the positive side, there was no evidence of previous injuries to either child, and the parents were seen to interact appropriately and with emotional warmth to the children. While the parents were receiving support from an increasing number of agencies, there was no evidence to suggest risk of significant harm. 4.8.8 This TOR is targeted to Child 1, but the IMR from Hospital 3 has raised an important issue for children’s services and the police where there is a life threatening illness and one or more other children in the family. All LSCBs have Sudden Unexplained Death of a Child/Infant (SUDC or SUDI). However there are no shared protocols for similar action when a child might have a serious or acute life threatening event but not die. 4.8.9 Hospital 3 has developed a protocol that has been accepted by all the Area 5 local authority LSCBs. This is known as Acute Life Threatening Event (ALTE), and is set out within the SUDI protocol, the difference being that in the instance of an infant death, the matters are within the remit of the Coroner. 4.8.10 The definition used to initiate ALTE is:- ‘Any sudden/unexpected collapse of an infant requiring some form of active intervention/resuscitation and subsequent intensive care/ high dependency unit admission and [the collapse] remains unexplained.’ The protocol expects hospital staff to notify the local Children’s Services for any child where the injury is either suspicious or unexplained. The early notification is to allow local procedures to follow through with checks of other children in the family and notification to the police should there be a need to secure the scene of a potential crime. 43 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.8.11 When Hospital 3 notified Bolton Children’s Services it was with the expectations in that the actions in paragraph 4.8.8 would be carried out. However in the absence of such a procedure in Greater Manchester, the accepted practice in Bolton is only to take any action when it has been confirmed that there is evidence of NAI. In fact the pro-forma does not assign specific tasks to be completed, but lists collection of contact telephone numbers and if the agency is included in the discussion. This SCR has identified that the pro-forma if adopted should be amended to provide clarity. 4.8.12 Discussion in the SCR panel confirmed that there had been a genuine misunderstanding, with Bolton Children’s Services accepting the information as an early alert to a child death with no apparent suspicious circumstances. However this delayed and confused the welfare check on Child 2, and delayed notification to the police. This second delay was further exacerbated by NWAS not notifying the police of the emergency call as is expected. The Bolton NHS FT IMR recommends Hospital 1 A&E department should check that a police notification has been made. 4.8.13 When Bolton Children’s Services were notified later in the day of the retinal haemorrhage, the senior manager made the decision to wait until the morning to notify the police of developments. However this decision was made with the expectation that NWAS would already have notified the police of the circumstances of the admission to Hospital 1. 4.8.14 The panel agreed that wider acceptance of the ALTE protocol would be beneficial for all LSCBs where infants could be admitted to Hospital 3 and also to Hospital 2. It is included as a recommendation of the NHS Bolton Commissioning Report as well as within the Hospital 3 report. Additionally the NHS Bolton Commissioning Report recommends introducing a similar protocol for children who remain in Bolton for investigation and treatment. 5. SUMMARY 5.1 The narrative on each IMR and the responses to the Terms of Reference indicate that agencies worked competently, mainly meeting expected standards of practice and with an understanding and respect for the cultural identity of the family. The records also describe a young couple who showed maturity, ability to manage the household, and a warm and caring approach to parenting. 5.2 The main service providers were staff from NHS services provided universally, but with increased support and specialist services when assessments demonstrated the need. The Ofsted Biennial review referred to in paragraph 4.2.6 also notes: Almost half of 189 children were under one year of age and a third were very young babies under 3 months. This repeats the findings of the last biennial analysis and reinforces the importance of the safeguarding role for health staff (especially midwives and health visitors) working with young babies and their families, as noted by Lord Laming (2009). 44 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 ‘Progressive universalism,’ offers a more targeted health visiting service to families assessed as having a higher level of need. But if this need is not identified in the antenatal period, or soon after, the children will not get access to this additional support and monitoring by health professionals. It is the view of the panel that NHS community staff provided this service. 5.3 When Adult 1 used services at the Children’s Centres she was able to meet with other parents who spoke Urdu. Her attendance with Child 2 was not consistent, but the reason for this is not known. 5.4 Housing services provided a prompt assessment of need, recognised when the family’s needs became more urgent and as part of the STeP programme provided more support to maintain the tenancy because of their young age. 5.5 When Child 1 was in cardiac arrest, emergency services and both hospitals provided prompt, specialist, and sensitive care. 5.6 The IMRs identify some occasions of poor or missed communication, (specifically the GP not passing on information from Adult 1, the health visitor not considering a CAF, transfer between the teams in NWTS, NWAS not notifying the police of the unexplained cardiac arrest and the misunderstanding between Hospital 3 and Bolton Children’s Services), but on the whole communication within and between services was good, and recorded in detail. 5.7 The key area where, with hindsight, agencies acknowledge a better service could have been provided is understanding the context of the capacity to parent. Assessments did not complete the picture of Adult 1 needing more personal support and her possible acceptance of domestic abuse and Adult 2 possibly needing more direct input to help him to parent because of his learning difficulty. Equally, except for housing agencies, it was not known for some time that the family had fled from abuse within the extended family. 5.8 Panel had discussion about the level of need demonstrated when information from all agencies was combined into the chronology and IMRs. As the NHS Commissioning Health report notes the service did not offer Adult 1 information and guidance on the opportunities to get more support from within the community. 5.9 However panel agreed that even with the information combined the family needs did not meet the threshold for formal co-ordination of multi-agency working using the CAF and Child Action Meeting process as detailed in Bolton’s Framework for Action. 5.10 It is within this context that the panel concluded that the death of Child 1 was neither predictable nor preventable. In fact, the Panel acknowledged the challenges all workers face when assessing risk, managing resources and getting the right balance between support and the need to respect private family life. This case has highlighted this, particularly as this family generally offered a good standard of care and were responsive to their children’s needs. 45 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 6. LESSONS LEARNED FROM THIS SCR 6.1 Each agency has identified individual recommendations, mainly linked with improving records or direct communication. The panel considered that apart from these the recommendations led to three main areas of learning from the SCR. They are:- 6.2 Recognition of the importance of domestic abuse, however low key the disclosure appears to be, when there are children in the household. The GP did not liaise with the health visitor about Adult 1’s disclosure of domestic abuse, nor did he code that disclosure on her records so that it would be seen immediately if there were further disclosures. With this information, when Adult 1 was asked about her safety, the question could have been phrased acknowledging a history of abuse, making it easier for her to disclose any further concerns. It is possible that Adult 1 would have disclosed information about the family in Area 4 much sooner, giving a clearer picture of her life. 6.3 Recognition of the stressors contributing to the vulnerabilities of Adult 1 and Adult 2. There was only partial recognition of Adult 1’s vulnerabilities in relation to a number of circumstances: her arranged marriage; her suggestion that the pregnancy was not wanted by her; her husband’s learning difficulties; her abusive and controlling father-in-law; her isolation after leaving Area 4; financial issues; her immigration status and her need for support from her own family in Area 3. 6.4 Also Adult 2’s learning difficulties were not understood or fully explored. Agencies provided services based on their expectation that Adult 2 was the head of the household, in a traditional cultural model when in fact Adult 1 was in control. If staff had employed a more challenging assessment of family functioning, these elements may have been known earlier. Some understanding of Adult 2’s limitations caused by his learning difficulties would have completed the picture of Adult 1’s situation. 6.5 With all the information now gathered about the two adults, it is accepted that it would have been appropriate for a CAF to be made, so that all options to support the family could have been considered between all the agencies. 6.6 Use of ALTE protocols. On the day the child presented at hospital, there was a sequence of not notifying the police of the unexplained cardiac arrest of Child 1. It is expected that the person taking the call at NWAS headquarters will notify. This was not done, and on arrival at Hospital 1 there was no check that it had been done. The ALTE protocol in use at Hospital 3 intends that when a child has a life threatening illness or injury the local children’s services are notified, who should in turn notify the police. This pro-forma should be explicit about who has specific responsibilities for each action. 46 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 6.7 Bolton Children’s Services were notified of Child 1’s admission to Hospital 3 and that Child 1 was unlikely to live. Initially it was notification only. After there was a possibility that this cardiac arrest was unexplained a further notification was made. The expectation at Hospital 3 was that Children’s Services would notify the police. The ALTE protocol is in place to ensure that all agencies are alert to the possibility of beginning procedures linked with safeguarding. 6.8 These three areas of learning are reflected in the recommendations in the NHS Bolton Commissioning Report and the GP IMR. The recommendation on adopting the ALTE pro-forma at Hospital 1 would ensure clarity on who should make the appropriate notifications. The SCR panel has fully discussed the individual agency and NHS Bolton Commissioning report recommendations and fully endorses them all. The panel has no further recommendations. 7. RECOMMENDATIONS 7.1 Summary of IMR Recommendations • This review has found a good standard of practice in all agencies. The family were provided with a range of universal services that met their needs, taking account of their culture and language. Within the NHS in particular the agencies can be proud of the quality of service provided as a routine and at the time of the emergency. However, as always when services are examined in detail, there is learning leading to some recommendations to improve practice or develop services further. • Bolton Safeguarding Children Board will request and require all agencies who contributed to this SCR to provide six monthly progress on the implementation of their action plans until all elements have been completed. 7.2 Summary of IMR Recommendations Hospital 3 recommended that:- • Record keeping issues highlighted within the addendum report shall be used as a basis for learning with both the health professionals directly involved in the care of the child and as part of the mandatory safeguarding training provided to all health professionals across the organisation • Health Overview Author makes a recommendation to the Northern Strategic Health Authority to request all LSCB’s across the region review and amend their current SUDI/SUDC protocol to include guidance on the management of a child suffering an ALTE, which would include triggering a referral to Children’s Services and the Police 47 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 Bolton at Home recommended that:- • Introduces electronic storage of STeP assessments • Reviews its contact processes for customers • Reviews the collation and recording of customer information as part of home visit process Bolton NHS Foundation Trust recommended that:- • All services have up to date knowledge and skills about domestic abuse • Awareness is raised with relevant staff about the CAF process specifically when to initiate CAF and develop CAF skills • Children’s identity issues are explored when health services are provided • Assessment and recording in relation to attachment is further developed • Review oversight of the work of support staff in Health Visiting teams- specific to HV Teams • Consider implications of research and practice developments in other areas for keeping infants safe • Remind relevant Foundation Trust staff of the Sudden Unexpected Death of Children process in relation to ensuring that contact has been made with the police • Increase awareness of the vulnerability of infants to include all services in community and acute setting Children’s Services recommended that:- • To ensure the registration forms in the Children Centres are fully completed at the time of registration. To check details are up to date on the registration form if families present at a different centre • Review the signing in process, to ensure all names are captured and match with the registration forms • Consider a general overview recording of each session and to think about how learning can be transferred into the home • Review the referral process to the MARP 48 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 Community Housing Services recommended that:- • Case record/Visit forms should be amended to indicate all individuals present during contacts • Briefing note to staff regarding change to record keeping GP recommended that:- • Promote as good practice referring cases of domestic abuse to Health Visitors where preschool children are in the family and code the domestic abuse in the records • Promote as good practice stripping off babies fully for examination by GPs North West & North Wales Paediatric Transport Service (NWTS) recommended that:- • Ambulance staff to undertake safeguarding training North West Ambulance Service (NWAS) recommended that:- • NWAS Safeguarding Children Policies and Procedures are strengthened in relation to taking into account issues of ethnicity, diversity, culture and language which may pose barriers. Current policy and procedures due to be updated • Specific reference to ‘language- line’ will be added into the policy and procedures to ensure staff can communicate effectively with patients and relevant others • Update the Sudden Untoward Death of Children Procedures to ensure that during any Acute Life Threatening Event (ALTE) or sudden untoward death of a child, the police must be notified by the relevant Emergency Control Centre Call Taker 7.3 Summary of PCT Commissioning Health Overview Report The PCT Commissioning Health Overview Report recommended that:- • Greater Manchester LSCBs and NHS Greater Manchester to amend the current Protocol “Sudden Unexpected Deaths in Childhood” to include guidance on the management of a child suffering from an ‘Acute Life Threatening Event’ (ALTE). This will ensure a consistent response by agencies to notifications of children experiencing a life threatening event where non accidental injury is always a differential diagnosis 49 EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • Bolton Foundation Trust to consider adopting the ALTE pro-forma for use in children who remain in Bolton for their investigation and treatment. This should specify explicitly who will be contacting each agency involved and when this has been done so that there is no delay in involvement of any individual agency • Hospital 3 to review the ALTE pro-forma to include an explanation about what ALTE protocol requires for areas that do not have an operational ALTE protocol and agree and document which agency will take responsibility for notifying the Police as the existing protocol only states that the Police must be informed • Raise awareness of the impact of additional stressors including poor housing, social isolation, poverty and domestic abuse on parents with particular regard to parents with learning difficulties. This recommendation relates to frontline health workers responsible for assessing children and families’ needs and also managers responsible for clinical supervision 50 |
NC041418 | Review into the death of a 6 month old infant at the family home in July 2010. Emergency services had been called by father after he was contacted by neighbours. Mother found unwell and needing medical treatment. Cause of death unascertainable but mother was convicted of one count of neglect and sentenced to 2 years in prison, later reduced to 16 months. Mother had history of medical ill health and concerns had been raised by father. Police called to an incident at family home in May 2010. Issues include: lack of adequate priority given by agencies to address mother's illness; the availability and adequacy of specialist health services; use of the common assessment framework; and need for appropriately qualified staff to carry out assessments.
| Title: Child D a serious case review: executive summary LSCB: Havering Local Safeguarding Children Board Author: Kevin Harrington Date of publication: 2011 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD D A SERIOUS CASE REVIEW EXECUTIVE SUMMARY Kevin Harrington JP, BA, MSc, CQSW On behalf of the Havering Local Safeguarding Children Board Completed 25th January 2011 1. INTRODUCTION 1.1 The London Ambulance Service was called to an address in the London Borough of Havering in July 2010, in the early hours of the morning. They found Child D, who was nearly 6 months old, showing no signs of life. There were indications that he had been dead for some hours. His father, Mr E, had just returned from work. His mother, Ms F, was unwell and required medical treatment. 1.2 The circumstances of the death of Child D led the Havering Safeguarding Children Board (HSCB) to conduct a Serious Case Review (SCR) in line with statutory requirements, as set out in the government’s guidance1. 1.3 This is the anonymised Executive Summary of the Overview Report arising from that Serious Case Review. This report contains An account of the reasons for conducting the review and its process A summary of the key events A summary of the findings and lessons to be learnt from the Serious Case Review 2. DECISION TO CONDUCT THE SERIOUS CASE REVIEW 2.1 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Boards to undertake reviews of serious cases. The Regulation defines a serious case as one where (a) abuse or neglect of a child is known or suspected; and (b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 2.2 In this case, the decision to conduct a SCR was based on the death of a child in circumstances giving cause for concern that he had been neglected. The key issues identified as indicating that a SCR was necessary were: the period of time that elapsed before emergency services were contacted. the presentation of the child when found by emergency services. the presentation of the mother when emergency services attended. there had been significant contact between the family and some local services before the death of Child D. 2.3 The purposes of SCRs are set out in “Working Together” (Paragraph 8.5). They are to 1 Working Together to Safeguard Children (2010) – referred to in this report as “Working Together” establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and improve intra- and inter-agency working and better safeguard and promote the welfare of children. 2.4It was determined that the following agencies should contribute to the Review: AGENCY NATURE OF CONTRIBUTION Barking Havering and Redbridge University Hospitals NHS Trust (BHRUT) Individual Management Review North East London NHS Foundation Trust (NELFT) Individual Management Review Outer North East London Community Service (ONEL CS) Individual Management Review London Ambulance Services NHS Trust (LAS) Individual Management Review London Borough of Havering, Social Care and Learning – Children and Young People Services (CYPS) Individual Management Review Metropolitan Police Service (MPS) Individual Management Review NHS Havering Health Overview Report2 2.5 Individual Management Reviews (IMRs) and the Health Overview Report were drawn up by officers who had had no previous involvement in the case. The parents of Child D did not respond to invitations to participate in or contribute to the Review. 2.6 A Panel was established to manage and assure the quality of the review process. In order to provide impartial leadership and appropriate challenge, the Panel was chaired by Ms Sue Dunstall. Ms Dunstall formerly chaired Northamptonshire Area Child Protection Committee. She was a non-executive director of Northampton General Hospital Acute Trust (1997-2005); and an elected member of Northampton Borough Council (1995-1999) and Northamptonshire County Council (1997-2001). She currently holds a substantive part-time post as policy advisor with the NSPCC, alongside which she acts in an independent capacity as Chairperson of the Havering LSCB. 2.7 The composition of the Panel was as follows: 2 “Working Together”, Para 8.30, requires that all SCRs should include “an integrated health chronology and a health overview report focusing on how health organisations have interacted together”. Name / Designation Organisation Role Ms Sue Dunstall Independent Independent Chair Service Manager North East London Foundation Trust Panel Member Interim Assistant Director of Non-acute Commissioning NHS Havering Panel Member Designated Nurse Consultant NHS Havering Panel Member Service Manager Safeguarding and Service Standards L B Havering Children’s Social Care and Learning Panel Member Head of Patient Experiences London Ambulance Service Panel Member DI Child Abuse Investigation Team Metropolitan Police service Panel Member Director of Nursing Barking, Havering and Redbridge University Trust Panel Member Head Nurse Safeguarding Barking, Havering and Redbridge University Trust Panel Member Additional Educational Needs Services Manager Children Social Care and Learning Panel Member Commissioning Manager3 NHS Havering Panel Member Legal Services Manager L B Havering Legal Advisor 2.8 Kevin Harrington was appointed to draw up an integrated chronology of events during the period under review and to produce this Overview Report, with an accompanying Executive Summary and an Action Plan, integrated across services. Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has a particular interest in Serious Case Reviews, in respect of children and vulnerable adults, and has worked on more than 30 such reviews. Mr Harrington is also involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council. He has served as a magistrate in the criminal courts in East London for 15 years 2.9 The SCR Panel determined that agencies should provide detailed accounts and analysis of their contact with the family from May 2009, when Ms F became pregnant with Child D, until his death, and should provide summary accounts of any relevant contact outside that period. 3 This officer was unwell and did not attend any Panel meetings, but was represented by a number of deputies. 3. SUMMARY OF EVENTS 3.1 Ms F received medical treatment between 2005 and 2007. She subsequently moved to Romford and, in April 2009, her pregnancy with Child D was confirmed. The GP with whom this was first discussed was a doctor in training, who did not pick up the issue of her previous contact with health services. 3.2 However, in June 2009 she again approached her GP, saying that she was concerned that she might again develop health problems, and wanted advice. Her GP referred her to a local NHS service, provided by the North East London Foundation Trust. An officer from that service telephoned her and she was given contact details for a local service. No further action was taken, other than to report back to the GP. 3.3 Ms F was generally compliant with ante-natal care arrangements and, at her first appointment, discussed her health problems. The midwives referred her to a Consultant Obstetrician with specialist responsibilities. However, the appointment with this obstetrician was delayed and the assessment eventually carried out was not sufficiently thorough. The obstetrician concluded that Ms F was able to ask for help if necessary and did not require consultant care. She did not refer Ms F to any other services. 3.4 Ms F was employed in a civilian capacity by the Metropolitan Police Service. She saw an occupational health adviser several times. The occupational health adviser tried, with Ms F’s consent, to draw together information from her GPs and the hospital where she was due to have her baby, but the responses from those services were slow and incomplete. 3.5 When Child D was born he was healthy except that his weight was low. Mother and baby were both judged to be well and were discharged after a couple of days in hospital. Community midwives, who had not been made aware of her medical history, visited twice and had no concerns, before routinely transferring care to the Health Visitors. 3.6 A Health Visitor, who again had not been made aware of the history, visited promptly and recorded no concerns. The Health Visitor called again a week later and, on this occasion, Ms F spoke about some aspects of her medical condition. The Health Visitor called the midwife who had been visiting, who said that she had not felt any concerns about the family. 3.7 The Health Visitor returned the following week, finding Ms F’s presentation and confidence much improved. However, Child D’s weight gain was slow and the Health Visitor arranged for them to be seen by the GP the following day. The GP carried out a full assessment of the child but found that no action was necessary, except that he be kept under review. 3.8 When the Health Visitor called again, a week later, Ms F seemed well and the flat was tidier than when she had last visited. During March and April Child D was seen several times at clinic and had two sets of immunisations. There was nothing in his presentation to give cause for concern. 3.9 At the beginning of May, just after midnight, emergency services were called to a domestic disturbance involving Ms F and Mr E. Ms F had called the London Ambulance Service, who attended and in turn called police. Police officers took Ms F to a local hotel to stay overnight. Mr E told police that he believed that his partner was unwell but that she was unwilling to admit this and seek support. Child D was described as well looked after, in a clean and secure environment, and there were no immediate concerns for his safety. 3.10 This attendance was routinely notified by police to Havering Children & Young People’s Services (CYPS). This notification was reviewed by a manager who detailed an unqualified Family Support Worker to undertake a home visit. The Family Support Worker made an unannounced visit, accompanied by a student social worker. 3.11 Ms F told the two workers that she had been unwell previously and had been helped by specialist services. She denied any current ill health and said she had support from relatives. However she acknowledged feeling low and isolated, with no friends in the local area, and was home alone a great deal because Mr E worked six days each week. 3.12 The flat was found to be warm, clean and tidy with appropriate toys for Child D. Ms F agreed to a referral to a Children’s Centre, which would offer general support and contact with other parents. She agreed to allow information to be shared with the Health Visitor and the Family Support Worker spoke to the Health Visitor the following day. This was the first time that the Health Visitor was made aware of Ms F’s history of ill health. 3.13 The Family Support Worker subsequently spoke again, by telephone, with Ms F and with Mr E, who said that he remained concerned about Ms F. He also said that he was doubtful that Ms F would make use of services. The Family Support Worker suggested various voluntary services which might assist and indicated that the local authority CYPS would not be taking further action. 3.14 The following day the Health Visitor saw Ms F who told her she was feeling unwell and now disclosed her medical history. The Health Visitor advised that she would discuss the situation with the GP and subsequently arranged a GP appointment for Ms F. She also made a Children’s Centre referral, but did not detail the nature of Ms F’s medical history. 3.15 A CYPS manager reviewed the findings of the Family Support Worker and decided that the family situation did not meet the threshold for the completion of a formal assessment by CYPS but that the family should be referred to a Children’s Centre for family support services. That referral had in fact already been initiated by the Family Support Worker (who recorded that the analysis of risk level was “low”). CYPS then formally terminated their involvement. 3.16 In June Child D had his third immunisations and his weight was noted to be improving. However, when Ms F saw her GP, who carried out a very full review, she was referred to a specialist service as the GP was very concerned by her presentation. In response to this referral the specialist service did not take any direct action but, instead, contacted the Health Visitor and asked her to refer Ms F to another service. 3.17 The Health Visitor did as she had been asked and made the referral, setting out the situation as it had been described by the GP in the initial referral, but without using the word “urgent”. She faxed this referral two days after the GP had made the original referral. The fax was recorded as received six days after it was sent, and reviewed five days after that. It was given a lower priority because it contained no indication of urgency. In due course Ms F received a letter inviting her to see a doctor from the specialist service towards the end of July. 3.18 Child D was seen at clinic routinely in the first week of July and satisfactory weight gain was noted. However, later that day Mr E called police. He had been contacted by a neighbour after Ms F had knocked on the neighbour’s door, asking for help. Emergency services attended the family home, arriving at around the same time as Mr E. Ambulance staff have documented that Child D was in cardiac arrest, showing no signs of life and was beyond resuscitation. He had been dead for several hours. 3.19 Ms F was arrested and taken to a police station, where she was judged to be unfit for interview. Subsequently she was bailed by the Metropolitan Police Service to reside at a hospital. A post -mortem was conducted the next day and found that: cause of death was unascertainable there was no evidence of injuries indicating abuse there was no evidence of disease, infection or illness found. 3.20 The Serious Case Review was initiated without delay and concluded in February 2011, within the government’s target timescale of six months. 3.21 Ms F was charged with and admitted one count of neglect, eventually receiving a sentence of 16 months in prison. 4. CONCLUSIONS: LEARNING POINTS AND MISSED OPPORTUNITIES 4.1 Before his death there had been no evidence that Child D was not being adequately cared for, and the Review found that there were never concerns which should have led to any child protection intervention. 4.2 However, there was a great deal of evidence that his mother was unwell, including repeated direct requests from her for help. There were weaknesses in the sharing of information but all the “treating” agencies had some knowledge of the problem, and the consequent risks to Child D, but failed to give adequate priority to the need to address her illness. 4.3 Specialist health services had a particular responsibility to address this concern but failed adequately to do so. Their response to the referral from primary health care services in June 2010 was disappointingly weak: no assessment was carried out in the community and there was avoidable delay in offering a specialist appointment, in response to a referral the GP had described as “urgent”. There is no evidence that these services took account of there being a vulnerable child in the family. 4.4 Initially the GP failed to ensure that maternity services were aware of Ms F’s full medical history. Maternity services picked this up anyway but there were delays and weaknesses in the assessments carried out by obstetricians. Then all the other health services involved failed to ensure that the Health Visitor was aware of the relevant history. 4.5 The Health Visitor only became aware of that history after the one occasion, in May 2010, when Ms F came to the attention of police. Nonetheless, although she was always prompt and sympathetic in her dealings with the family, the Health Visitor did not carry out comprehensive assessments. 4.6 Children and Young People’s Services were only briefly involved, following up the incident involving police. They should not have deployed an unqualified officer to carry out an assessment of a child’s safety. There was then avoidable delay in making child-focussed support services available to the family. 4.7 The Common Assessment Framework (CAF) was established as the appropriate process to follow where the “universal” agencies identify that a child might have “additional” needs - such as those which might arise from Ms F’s situation. This was the appropriate inter-agency procedure to be followed to flag up and begin the analysis of the additional needs of Child D which arose from his mother’s problems. The GPs, maternity services or Health Visitor might have made use of this “tool” but none of them did so. 4.8 Through her employment Ms F was in touch with impressive occupational health services. However, the contribution from those services was undermined by slow and inconsistent feedback from other health services. 4.9 Agencies have found a number of themes in this Review which were also identified in a previous Serious Case Review in Havering in 2009. It is consequently necessary to check that lessons learned from that Review have been thoroughly followed up. 4.10 The principal learning point relating to the process of this Review was that some agencies failed to submit reports which were concise, punctual and in the standard format which had been agreed. This meant that the process of analysing and cross-checking those reports was more complicated and time-consuming than necessary. Page 10 of 10 5. OUTCOME OF THE SERIOUS CASE REVIEW 5.1 This Review involved brought to light a number of issues about the ways in which agencies work, individually and together, to protect children. Those issues have led the Havering Safeguarding Children Board to draw up an Action Plan, which aims to ensure that the lessons learnt from this Review are taken fully into account in managing and delivering services to children and their families. 5.2 The principal issues tackled in that Action Plan are Giving appropriate weight to the needs of children when working with parents who are unwell. The availability and adequacy of specialist health services. The use of the Common Assessment Framework. Ensuring that assessments are carried out by appropriately qualified staff. |
NC52443 | Death of an infant girl and serious injury to a 2-year-old-girl. These were two separate cases that involved child neglect. Learning includes: consideration is needed of the parents history and on-going vulnerabilities and the impact this can have on children; a pre-birth social work assessment should be undertaken where there are risks and vulnerabilities that warrant involvement from childrens social care; clarity around the roles of all professionals involved with a family such as recognising that support for care leavers from a Pathway Worker may not extend to the care leavers child; a need for professionals to meaningfully consider and involve fathers in assessments and plans in respect of their children; professionals need to use specific neglect tools and understand the root causes of neglect and the impact on a child over time; and there is a need for professionals to robustly challenge themselves, each other and parents/carers when it comes to managing cases of neglect. Recommendations include: ensure that professionals are aware of and use the local neglect strategy; assurance from the local authority regarding improvements in the use of the Graded Care Profile and evidence based practice in neglect cases; all plans for a child in need or for child protection need to provide a clear and detailed description of who is undertaking what work with the family, which takes their role and its limitations into consideration.
| Title: Child safeguarding practice review: Kingfisher. LSCB: South Tees Safeguarding Children Partnership Author: Nicki Pettit Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final 1 Child Safeguarding Practice Review Kingfisher Author: Nicki Pettit Final 2 Child Safeguarding Practice Review Kingfisher Contents 1 Introduction to the review Page 1 2 Process Page 2 4 Identification of learning Page 3 5 Conclusion and Recommendations Page 16 Introduction to the review 1. This review considers systems and practice within and between partner agencies in the South Tees area specifically with regard to the assessment and safeguarding of children where there are concerns about neglect. 2. In order to identify learning and good practice, and to consider the need for improvement action, the review reflected on two cases where the neglect of young children featured. 3. The learning identified is in relation to: The importance of knowing and considering a parents history and vulnerabilities Recognising and working effectively with families where neglect is an issue Pre-birth assessment Involving fathers The role of pathway (leaving care) workers Impact of audits Professional challenge Impact of COVID 19 Process 4. Following rapid review processes1 and consultation with the Child Safeguarding Practice Review Panel, the STSCP identified that lessons could be learnt regarding the way that agencies work together to safeguard children where neglect is a concern2. 5. The CSPR was conducted in accordance with the requirements set out in: 1 A rapid review is undertaken in order to ascertain whether a Local Child Safeguarding Practice Review is appropriate, or whether the case may raise issues which are complex or of national importance and if a national review may be appropriate. The decision is then made along with the national Child Safeguarding Practice Review Panel. 2 It was agreed that this learning review would be undertaken rather than individual child safeguarding practice reviews after consultation with the National Child Safeguarding Practice Panel in December 2020. Final 3 The Children Act 20043 (as amended by the Children and Social Work Act 20174) Working Together 20185 Tees Multi-Agency Children’s Safeguarding Policy and Procedures 6. In order to identify learning and consider the need for improvement action, the review considered two cases. One where a young baby died, and one where a two year old was seriously injured. Both of the families were well known to statutory agencies and on either a child in need or child protection plan at the time of the incidents. Lucy6 was two years old when she was injured in an accident that was contributed to by parental neglect. Her mother was receiving support as a care leaver and Lucy was on a child in need (CIN) plan at the time of the incident. Mia was less than a month old when she died. The cause of death is not yet known7. Mia was on a child protection plan (CPP) due to neglect concerns for her older siblings. Her father misuses drugs and is on a drug treatment programme. 7. Consideration of these cases enabled the review to focus on the systems that were in place and what works well in a strengths-based approach, alongside an exploration of where there may be learning for the system and for multi-agency practice. 8. In respect of the cases considered, personal family details will only be disclosed in this report where it is essential to the learning established during the review. 9. An independent lead reviewer8 was commissioned to work with a panel of local safeguarding professionals from the key agencies. The lead reviewer facilitated practitioner events,9 made contact with the families and produced this report. The lead reviewer and the panel collaborated on identifying the learning and agreeing recommendations from this CSPR. 10. All of the parents received two letters asking them to speak to the lead reviewer about their experience of professional involvement with their families. Only Lucy’s father agreed to speak to the lead reviewer and his views are included in the report. Prior to publication of the learning from the review, all of the parents will be updated. 11. Agency involvement at the time was considered by each individual agency through the completion of case specific chronologies, which included analysis and the identification of any single-agency learning. From these chronologies and the rapid review information, themes were identified for discussion with the professionals involved in the cases at the practitioner events. The events also considered wider practice with children and families where neglect is a concern in South Tees. 12. An OFSTED inspection in December 2019 found that Middlesbrough Children Services was inadequate and a key focus of the improvement plan is about recognising risk and the need to improve the 3 http://www.legislation.gov.uk/ukpga/2004/31/contents 4 www.legislation.gov.uk/ukpga/2017/16/contents/enacted 5 https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 6 Both children have been given alternative names to ensure confidentiality and aid the learning from the review. 7 Toxicology tests were negative 8 Nicki Pettitt is an experienced lead reviewer and has been undertaking serious case reviews and CSPRs since 2009. She is entirely independent of all partner agencies in South Tees. 9 This was by virtual meeting technology due to the impact of Covid-19 Final 4 management of cases of long-standing neglect. This review was therefore also seen as a way of checking on the multi-agency response to the neglect evident in the two cases being considered. Analysis and identification of learning 13. Through the detailed consideration of both cases, the review has established the following learning: Learning point 1: When assessing if children require additional support or if they are at risk, it is important to always consider the parent’s history and on-going vulnerabilities and the impact on the children. 14. Lucy’s mother had been in care from the age of 7 due to her own experience of neglectful parenting. She had a large number of care placements, police and youth offending service involvement and periods of being missing from her placements. She was 18 years old and open to Pathways (the leaving care service) at the time of her pregnancy. Her midwife made a referral to children’s social care stating that she was a vulnerable care leaver and had a history of violence when younger. The Youth Offending Service (YOS) confirmed to the review that this was related to behaviour in her residential placement and that they had had no involvement for around 4 years. Lucy’s mother had a history of depression and self-harming which was not felt to be an issue by the time of Lucy’s birth when she was 18 years old. Routine questions about mental health were asked and the mother stated she was well. By this time she had reconciled with her mother, Lucy’s maternal grandmother (MGM) and was living back in the family home. 15. There was limited contact with the child’s father either during the later part of the pregnancy or post birth. He told the review that he was not invited to any meetings and had very limited contact from professionals in respect of his daughter. He was not thought to have been known to children’s social care during his childhood, but at the practitioners event undertaken for this review the GP confirmed that father’s notes held information on a child protection plan for neglect in his early childhood, This was not known to those currently working the case, as it appears that GP checks had not been undertaken. This information should also have been available to CSC but changes of IT system seem to have led to it not being readily available. Father was also known to the YOS, but these checks were not undertaken. The Pathways worker knew Lucy’s mother well and had met her father. She had concerns about their relationship, lifestyle and their capacity to safely care for a baby. Lucy’s father told the review that they smoked cannabis regularly but denied that had ever been any domestic abuse in the relationship. 16. In contrast, Mia’s family were not well known to professionals in Middlesbrough. They did not move in to the local authority area until early in 2020. It soon became apparent that there were indicators of neglect of the children in this large family10. A child protection plan was made in March 2020. The concerns were specifically about the impact on the children of Mia’s father’s11 significant and long-term substance misuse12 and the ability of their mother to protect them from the effects of this. Mia’s father was on a treatment plan but continued to misuse drugs, including crack cocaine and heroin. The relationship between Mia’s parents was relatively new and he was not the father of the older children. In 10 In order to protect the identity of the family, the number of siblings will not be specified in this report. However Mia had a much higher than average number of older brothers and sisters. 11 The older children have a different father. 12 Mia’s father also has older children who live in another area and there is no contact, they are not considered further by this review. Final 5 the previous local authority area, which was the same health authority area, they had received a universal health visiting service. During the review professionals involved with them reflected that mother’s wider family tended to live in households with poor levels of hygiene, but that none would meet the threshold for professional involvement due to neglect. 17. It appears that the concerns in relation to the care of the children did not start until after their mother began her relationship with the father of baby Mia, following her split from the father of the older children. Mother reported struggling with depression following the break-up of this long-term relationship and this continued to be an issue at the time of their move to Middlesbrough. She was also noted to be stressed and frustrated by her new partners drug use, although it was felt that she did not fully understand or acknowledge the impact on the children, including the cost of his habit which was estimated to be at least £120 per week13. 18. Mia’s father is reported to have had a difficult childhood and to have started misusing drugs at age 12. Little was known at the time about his more general childhood experiences, but he had physical health issues as well as the ongoing substance misuse concerns and required a lot of help and support from his partner, and to an extent her older children. There were occasions known to professionals where one of the children would be sent out with mother’s partner to ensure he did not use drugs. While the focus of the professional’s parenting concerns was this drug use, it was expected that the children’s mother would be providing the majority of parenting. This was not going to be easy with a large number of children, her depression, a lack of local family support, emerging difficulties in the relationship with Mia’s father and reportedly poor quality private-rented housing, even before the Covid-19 pandemic. The need for a child protection plan was established and processes were followed. 19. Pathways to Harm, Pathways to Protection; a Triennial Review of SCRs 2011–14 was published in 201614 (to be referred to as the Triennial Review) and states that the SCRs considered show that there are factors in a parents’ background which potentially may present a risk to a child. These include: Domestic abuse Parental mental health problems Drug and alcohol misuse Adverse childhood experiences A history of criminality, particularly violent crime Patterns of multiple, consecutive partners Acrimonious separation The Triennial Review points out that these factors ‘appear to interact with each other, creating cumulative levels of risk the more factors are present’. Other factors are included as significant; young motherhood; estrangement from the new mother’s own parents; temporary housing or supported accommodation; lack of support from the baby’s father and/or a new or unstable relationship with the father.’ The average age of first-time mothers whose children were the subject of a SCR was age 19. Lucy’s mother was 18 when she was born. This is compared to the national average of age 28 for first 13 Mother told professionals that she did not give money to her partner, however they had a joint benefits claim which would have made this difficult. Was this questioned enough, particularly in light of the lack of food etc in the home? 14 P. Sidebotham and M. Brandon et al. (2016) Final 6 time mothers. There were also housing issues, family conflict and difficulties with her previous partner. At one stage Lucy had three different homes in two weeks. 20. For Mia and her siblings a number of these issues also co-existed. For example, housing was an ongoing issue and the relationship between Mia’s parents was very new when mother became pregnant. Both cases show that it is essential that anyone undertaking an assessment or working to support a family understands the importance of considering their current situation, but also that consideration is given to the potential impact of the parent’s childhood experience, relationship/s and their specific vulnerabilities on their parenting and risks to their child. 21. The mental health of a parent should be considered in the context of the impact on the care provided to the child. In the cases considered there had been insufficient consideration or overly optimistic consideration of this impact by professionals working with the families. Both mother’s in these cases had some mental health concerns that do not appear to have been fully explored. There was no evidence that the impact of Lucy’s mother’s anxiety on her parenting was considered and Mia’s mother’s depression was seen as a reaction to her circumstances and its impact on the children was seen to be in terms of her not being able to practically care for her large family, particularly while pregnant. The impact on the children of these mental health issues required much wider understanding and assessment. Learning point 2: A pre-birth social work assessment should be undertaken in cases where there are predisposing risks and vulnerabilities that warrant involvement from children’s social care. This includes if there is involvement with the parent or other children in the immediate family. All professionals need to be aware of this procedure and should challenge a lack of assessment. If no assessment is to be undertaken when the parent is receiving a service from pathways, as could be appropriate, there needs to be clear reasons recorded about why this is the case. 22. In Mia’s case there was a pre-birth assessment as her siblings were on child protection plans at the time. While this was undertaken the analysis could have been stronger, particularly in respect of the parenting capacity of both parents and the likely life experience of Mia following her birth. A pre-birth child protection conference was held, although it was delayed due to COVID-19. It specifically considered if the baby was likely to be at risk of significant harm from neglect, and a child protection plan was made. At the time there was little improvement noted in the home conditions, which were described as extremely poor. Concerns remained about the ability of mother and her partner to manage the behaviour of the children, despite a period of child protection planning for the older children. It was right that the baby was made subject to a child protection plan. The challenge was to ensure that the plan considered each individual child and their needs. 23. In Lucy’s case no further action was taken in respect of the pre-birth referral from the midwife during mother’s pregnancy, despite the unborn baby procedures stating that an assessment will take place “where the expectant parents are currently active to CSC and/or they have children who are currently active to CSC” and because of the specific vulnerabilities that the midwife outlined. Lucy’s mother was receiving a service from Pathways as a care leaver and therefore technically open to CSC so a pre-birth Final 7 assessment needed to be considered, or at least there should have been a clearly recorded reason why the procedures were not being followed which was shared with other professionals. There is no evidence that the midwifery service challenged the decision. 24. The Pathways worker made a new referral around a month later, raising concerns about the expectant mother and father’s drug misuse, lack of settled accommodation, domestic abuse in the relationship and the potential difficulties the expectant mother may have in caring for a baby. A single assessment was appropriately completed on this occasion and it was decided that the baby should be on a child in need plan following birth. Learning point 3: Clarity is required regarding the roles of all professionals involved with a family and assumptions should not be made. If a parent is receiving support from a Pathways worker, this does not mean they will be providing support to the care leavers child or specifically monitoring their wellbeing. They may have no contact with the child. 25. Lucy’s mother received significant support from her Pathways worker during the pregnancy. Information shared with the review noted that there were over fifty separate contacts during these months. The main areas of need were in respect of accommodation difficulties, the fragile relationship between mother and MGM, difficulties in the relationship with the baby’s father and general anxiety about the pregnancy and birth. There was a good relationship and there is no doubt that Lucy’s mother benefited from this. 26. The focus of a Pathways Worker is on the care leaver and their needs in respect of health, education or employment, housing and financial/benefit issues. While a number of care leavers are also parents, the Pathways Worker is not responsible for the children, even if they are on a child in need plan as Lucy was following her birth. The decision to close this plan appears to have been made largely due to the on-going involvement of the pathways worker with her mother however. There were outstanding issues, particularly in respect of suitable housing for the young family, the relationship with MGM and contact with Lucy’s father. The recording of the decision states that the case was closed as there were no safeguarding concerns identified. This was despite limited evidence of work being undertaken to support the mother with the concerns identified during the assessment. It is important that support to care leavers who are parents and their children includes a consideration of the support they require, rather than a deficit model where support is only provided if there are safeguarding concerns. 27. It was noted that the Pathways worker would continue their involvement with Lucy’s mother, which was seen as a safeguard to the baby. The only professional involved specifically for the child was the health visitor and there is no evidence that consideration was given to the need for on-going parenting support to pre-empt future referrals, and to what early help services could provide to a vulnerable mother with a new baby. This was in part due to assumptions that the pathways worker was responsible for the baby, and also due to the mother previously stating that she did not wish to engage with early help support. 28. Professionals need to be curious about what the involvement of another professional actually involves. For example it is common for professionals to assume that if a care leaver is a parent, that the pathways worker’s role will provide a safeguard to the baby. While this is true to an extent, there may actually be Final 8 very little involvement between the care leaver and their own worker, there may not be home visits and they may not actually ever see the baby. In this case, and generally, questions should be asked about the extent of a professional’s involvement, including the level of contact, where they are seeing people, whether they undertake home visits, and what happens if their service is declined. When care leavers become parents there needs to be a recognition, clarity and full understanding of the different roles that professionals have in relation to the family / unborn. Learning point 4: It is important that professionals understand the need to meaningfully consider and involve fathers in assessments and plans in respect of their children. 29. In 2020 the South Tees partnership completed a CSPR called Stork that considered systems and practice with families with young babies in the area. It concluded that a child’s father needs to be seen as an equal parent in order to ensure that the needs and risks to a child are met and known. It stated that professionals need to give separate consideration to how they can meaningfully engage with fathers, including those who do not live with the child. It also recognised that this can pose a challenge to professionals. In respect of both Lucy and Mia challenges were evident. 30. In Lucy’s case there were concerns about the child’s father but these were not assessed at the time. The mother’s assertions about him were accepted and there was no evidence of any meaningful attempts to involve him in the child in need plan made prior to Lucy’s birth or later when a new plan was made. It appears he continued to have contact with Lucy at the time, and although there is evidence of some on-going difficulties regarding comments on social media it was largely said to be positive by Lucy’s mother. At one stage, when Lucy’s mother had housing issues, Lucy went to stay with her father and his parents. There was still no attempt to undertake a proper assessment of him, to involve him in the child in need plans, or to consider what help and support his side of the family could provide to Lucy. It is now known that prior to Lucy’s accident her mother had started a new relationship and was expecting a baby. Nothing was known about her new boyfriend and the impact his presence in the family may have on Lucy and on the mother’s care of her daughter. 31. The father of Mia’s siblings lived in another area and there was a view that he wanted no involvement with his children following his move to Middlesbrough. Some attempts were made to contact him but largely the children’s mother’s assertion that he would not cooperate was accepted. As well as posing a potential risk to children, fathers can also be a protective factor. For example fathers who do not live as part of the immediate family may be capable of caring for and protecting a child if this is required, as he may have been for the older siblings of Mia who were on a child protection plan due to concerns about neglect and the impact of their mother’s partner drug misuse. Case reviews show that fathers are often overlooked by professionals15, often along with the wider paternal family. This was potentially the case for both Lucy and Mia. 32. In Lucy’s case her father is now her full-time carer. This review was provided with very little information about Mia’s sibling’s father, who appears to still be absent from their lives and the work being 15 Hidden men: learning from case reviews. Summary of risk factors and learning for improved practice. NSPCC April 2015 Final 9 undertaken with them, which is ongoing. Sandstrom et al16 made specific recommendations about identifying fathers and male carers, including: ‘being explicit with mothers about the importance of speaking to the father and including him in the process, while also ensuring that she would not be put at risk; speaking separately to the father rather than gathering information solely through the mother; and arranging separate home visits if necessary to explain the relevance of his involvement with the child, communicating a willingness to include him in decisions.’ Lucy’s father told the review he knew little about professional involvement with his daughter and that he was not invited to be involved in any planning. 33. As noted in the Stork review, learning has been identified nationally about the requirement for meaningful involvement with fathers by professionals working with children, and the national Child Safeguarding Practice Review Panel is due to publish a national CSPR that will consider this issue. Two recommendations were made in the Stork review. Firstly that the STSCP take the learning from the national CSPR when it is published and explore further what can be done to improve the involvement of fathers in work undertaken with families where there is a new baby. Secondly that a piece of work is undertaken to provide a better understanding from professionals in partner agencies of the role of fathers, the need to engage with fathers and to consider projects in other parts of the country that are making a difference. These recommendations will also be beneficial in light of the learning from Lucy and Mia’s cases. Learning point 5: Professionals need to use specific neglect tools and ensure that they understand the root causes of neglect and the impact on a child over time 34. Although in many ways Lucy suffered from lower level neglect throughout her life prior to and immediately following the serious incident when she was two years old, the risk from neglect was not identified at the time. A second single assessment was completed when she was around a year old following allegations shared by a family member about the home conditions at MGM’s home, where Lucy and her mother were living. Concerns were also shared about Maternal Grandmother’s alleged long term and ongoing misuse of amphetamines. No further action was taken by CSC following the assessment and again it was recorded that due to the Pathway’s worker and health visitor involvement there was no need for social work involvement with Lucy. This was not challenged by the pathways worker or the health visitor and there is no evidence that cumulative risk or the need for early help was considered. MGM had always been seen as a positive safeguard for the child and an assessment was required to ensure that this was actually the case in light of the new information shared. There was no consideration of using any neglect tools, such as the graded care pathway (GCP) in the case. The GCP is an assessment tool which helps practitioners measure the quality of care a child is receiving. The NSPCC state that it is effective in helping identify whether a child is at risk of neglect. In Middlesbrough there is currently improved access to training for social workers in the GCP, with course availability throughout the second half of 2021. There is also a plan to ensure wider professional training across agencies if issues with licencing are successfully addressed. Until then, the increased use of chronologies, genograms and ecograms to guide practice would be a positive step. 16 Approaches to father engagement in home visiting programs. 2015 Final 10 35. A strategy meeting was held in January 2020, when Lucy was around 18 months old. This was following an incident where MGM was allegedly physically assaulted by Lucy’s mother and aunt, both of whom had been drinking and possibly misusing drugs. The assessment that followed identified that there had been significant instability for Lucy in where she lived and who cared for her, and that she presented as unkempt. This incident was treated in isolation and not considered within the context of what else was known, and there was optimism regarding mother’s role in the incident. It was the view of the social work team who undertook the assessment that mother could not have been too drunk at the time as the police let her continue to care for Lucy. The review has found this was not actually the case. The police shared that while mother and child remained together following the incident, it was at a friend’s home who was seen as protective. It was the officer’s view that the mother was in fact too drunk to care for the child. This is an example of assumptions being made and issues downplayed without the full facts being sought and established. There is also the potential for gender having an impact, and it is interesting to consider what the outcome would have been if the perpetrator of the abuse and carer for the child had been male. Mother’s self report about what happened and her denial of being drunk or under the influence of drugs was accepted without confirming with the police officers who were in attendance at the time, despite mother’s history of substance misuse and aggression. 36. Mia was the subject of a child protection plan due to neglect from birth. The risk to her in light of the family’s concerning situation and the experience of her older siblings meant there was a plan in place and recognition of neglect being a significant concern following the baby’s birth. This was positive. While there was a degree of understanding of the root cause of the children’s neglect, which was thought to be because of Mia’s fathers drug use and her mother being unable to cope due her low mood and the overwhelming task of caring for her large family without family support. The use of evidenced based tools and research in this case would have allowed more understanding of the case and provided more clarity amidst the chaos. The children’s social worker reported the difficulty in gaining and then considering the lived experiences of the large number of children in the family, particularly during the COVID-19 pandemic. She worked very hard to get to know each child and to communicate with all of the other professionals involved. 37. At the review event those involved felt that despite the conditions at home, the children were loved and valued by their mother, and that their earlier years had not been neglectful. This made them optimistic that the impact on the children would not be damaging, however there was no assessment of the impact on the children and limits to the understanding sought about their lived experience. The focus of the work now is in respect of their bereavement for their baby sister, but there remains a need to ensure that there is also a focus on the neglect they have suffered in the past and may suffer again in the future. 38. There is currently work going on in South Tees with developing a neglect strategy for adolescent children. This will be beneficial to the older siblings of Mia. It is planned that a strategy for younger children will be developed as the next stage. This will need to include improved awareness and use of the strategy across all partner agencies, in order to improve practice generally. Learning point 6: Final 11 There is a need for transparent and sensitive management of auditing activity in local authorities with improvement plans. There also needs to be a system in place to consider the outcome of actions from audits to ensure they have achieved what was required. 39. The pattern of Lucy’s mother missing appointments, not engaging with professionals and dismissing their concerns continued. This, and the risk associated with mother’s history, was identified during an audit undertaken in May 2020 that suggested that the case needed to have a child protection rather than a child in need focus. A strategy meeting was held following the audit but maintained that Lucy continued to require a child in need plan. It was conceded however that the CinN plan must be ‘really strong’. Those present at the strategy meeting agreed with the decision and no dissent was recorded. Signs of Safety was used during the meeting and the scaling of 5/6 was given, which is an average score - between 0 which means recurrence of similar or worse danger/concerns is certain and 10 which means that sufficient safety has been demonstrated. There is a reliance on scaling to determine if a child is at the right place in the system, but this review has found that scaling can be over optimistic if undertaken in a multi-agency collective setting, particularly if the parents are present. It can also be hard to understand without a clear record and strong narrative around the number agreed. Professional challenge should also be invited and expected. It is noted that when used in social work supervision the scaling was less optimistic and more reflective of what the reality was for Lucy. 40. The social work team that were working with Lucy and her mother were responsible for reviewing the case following the audit. They had a clear view that it was a child in need and not a child protection case, and did not believe there was any evidence that the threshold for child protection had been reached. They also had a view that the thresholds of the auditors were lower than was expected practice in the area, and that they did not understand the levels of concern in the community and the need for keeping thresholds at the level they were. This was despite the external audit team being asked to consider thresholds locally and a view from OFSTED that this was required. 41. Due to their OFSTED rating of ‘inadequate’ Middlesbrough Council’s CSC had the scrutiny and support of a number of outside professionals in order to ensure improvements were made. This was clearly incredibly hard for staff, and this was evident in both the response to the audit in this case and was still evident during the review meeting. To ask the same professionals who had made decisions to review them without any further scrutiny from someone not involved is unlikely to lead to a change in the plan. Particularly when they are resentful of the challenge to their practice. Other case reviews show that it is difficult for a professional to change their mind when they have decided on a course of action, without clear changes in the situation or a significant incident that forces them to reassess their position. Decisions are made with the information available at the time, but they may need to change as more information emerges, and when risks and needs change. Professionals are required to constantly review their own views and to challenge the decisions of others as required. The audit led to a defensive rather than open minded review of the case. 42. It is not easy for those involved to review their own work in this way and to change what they had previously thought. It is also difficult for staff when outside auditors come in and those spoken to felt that they were being criticised by people who had no connection to the area. The audit was put in place as Final 12 an immediate response to the Ofsted inspection, as a 12 week plan before the strategic plan was ready to be rolled out. The initial audit happened while services were adjusting to restrictions and working from home due to COVID 19 and communication platforms were challenging. There is now a fair more transparent and integrated model of audit which includes reflective discussions with the professionals involved. There is also clearer tracking of what happens next after there has been a challenge, re-auditing of plans that were audited as inadequate, and moderation if there is disagreement about an audit rating. 43. There is no evidence that any feedback was given, or requested, by either the audit team or senior managers following the strategy meeting that was held in Lucy’s case. There was also no challenge from any other agency involved in the case. So this opportunity to reconsider where the case was held within the system did not have an impact, other than the acknowledgement that the CIN plan needing to be ‘strong’. There is no explanation regarding what this would involve and there was limited direct involvement with Lucy and her mother in the months that followed, although there is evidence of professionals trying to contact them. Those involved explained that Lucy’s mother could be a challenge to pin down and that it was often hard to speak to or see her. There is always the risk, when a parent is a young care leaver themselves, that professional expectations of them adjust and that this leads to excuses or concessions for missed appointments, negative attitudes towards professionals and difficulties in accepting support. Care leavers have a legacy of being in care which impacts on their relationships with professionals and it can be difficult for those involved to build the relationships and trust required to provide meaningful support and challenge, yet remain focused on the care leaver’s child. Honesty is required when working with care leavers who become parents, about the likelihood that their own history will impact on their parenting, and that they are likely to require on-going involvement with support services. Sadly, care leaver’s children are over-represented in child protection cases and in care proceedings. Professionals must be aware of the need for an understanding of trauma informed care, the impact of adverse childhood experiences, and the need to work differently to ensure that there is the right balance of support for the parent and protection of the child. 44. Following the strategy meeting, child in need meetings were held and those involved continued to be positive about the mother’s care of Lucy. There is little evidence however of much direct contact with either Lucy or her mother at this time to justify the positive picture. This was due to missed appointments but also the challenges of the pandemic. The allocated health visitor and the pathways worker, both of whom who had been seen as important parts of the child in need plan, had no direct contact whatsoever at this time. Staff at the supported accommodation were not undertaking any direct work. There was a plan to involve a family resource worker to provide hands on support with routines and boundaries, but they had no capacity and did not get involved until after Lucy’s accident. Without the involvement of these key professionals, the optimistic view of how Lucy was being cared for during the period of child in need planning is hard to understand. The social worker allocated to Lucy only saw her and her mother once in the two months that followed the audit and strategy meeting, and this was outside the home for a short period of time. She has acknowledged that she was unable to do any planned work due to issues with confidentiality and lack of contact time. Final 13 45. Within two months of the strategy meeting an ambulance was called because Lucy had had fallen 20ft from a bedroom window at her aunt’s house. While a criminal investigation was not pursued, there is a view that a degree of neglect was apparent. It was following the child’s discharge from hospital to her mother’s care, which was agreed at a complex strategy meeting by chaired by a senior CSC manager, that serious concerns about Mother’s care of Lucy, who required additional care due to her injuries, once more became apparent. Care proceedings were swiftly commenced and the Local Authority where granted an Interim Care Order and a Recovery Order. Learning point 7: There is a need for professionals to robustly challenge themselves, each other and parents/carers when it comes to managing cases of neglect. 46. The study ‘Working with Neglected Children and their Families: Linking Interventions with Long-term Outcomes’ (Farmer and Lutman 2012) considers the processes that are likely to adversely affect the longer-term management of families where there are neglect issues. They are: • Becoming de-sensitised to children’s difficulties through habituation • Normalising and minimising abuse and neglect • Downgrading the importance of referrals about abuse or neglect from neighbours or relatives • Over-identification with parents • Developing a fixed view of cases which discounts contrary information • Viewing each incident of neglect or abuse in isolation and not recognising their cumulative impact 47. In both of the cases considered there were indicators of the above in work being undertaken. An example was the school attended by Mia’s eldest siblings, where none of the schools perceived the children to be at risk of neglect. The school reflected that the family were disorganised and at times chaotic, but that they saw no evidence of harm or significant neglect. They told the review that the children’s mother needed help and support, but that this was not out of the ordinary in the community where they live. The oversight of the life experience of Mia’s siblings provided to this review shows that neglect certainly featured and has had a negative impact on their well-being. 48. Curiosity and a willingness to challenge are fundamental professional traits required when working together with other professionals and with families to keep children safe. The need for ‘respectful uncertainty’ is widely known, but not always easy to achieve. Getting the balance right between support and challenge when working with parents can be difficult, it is a complex balance which requires skilled practitioners, reflective practice, effective supervision and professional challenge within and between agencies. The pandemic led to changes to practice that did not help professionals to engage with families or with each other. For example child in need meetings were attempted on Lucy’s case in April, May and June 2020, but they had to be undertaken by telephone. This created a lot of issues, with the health visitor reporting not being able to join, and with various connection and call quality issues. Middlesbrough Council bought a number of WEBEX licences to use for these meetings, but they were prioritised for child protection meetings and social workers coordinating child in need meetings did not have easy access to them. The picture was improving at the time of the completion of the review. Final 14 49. When considering the impact on a child of a number of smaller issues, it is important to compile and consider a chronology. This can help avoid the risk of considering issues in isolation and not understanding the cumulative impact. A chronology, particularly one that includes multi-agency information, shows the full picture and a child’s care over time can be considered. It enables persistent and cumulative harm to be identified. No chronology was evident for Lucy until after her accident and when the local authority decided that they needed to undertake care proceedings. This means that there was no real understanding of how poor her mother’s engagement with professionals had been over time and the number of appointments that had been missed, for example. During the review there remained optimism about how engaged Lucy’s mother had been, despite evidence available to the review that this was not actually the case. Those involved at the time were not aware of the child’s lived experience over the months of the first lockdown as they had minimal contact with her and her mother. The contacts that did happen were for a maximum of 15 minutes and were undertaken outside of the family home. Much of Lucy’s mother’s support was supposed to have been provided by staff at the supported accommodation where she had a tenancy. However due to COVID there was no hands-on support or direct contact. It is now known that Lucy and her mother were spending very little time at the accommodation, instead staying with her sister. The police have a number of examples of her being warned for breaking COVID restrictions. 50. There was also optimism about the willingness of Mia’s mother to work with professionals, despite evidence that she was not always engaged. She swore at the health visitor in a meeting, and was often hostile to professionals. There was only limited engagement with the resource worker who was involved to offer parenting support. Mia’s older siblings were made the subject of child protection plans during mother’s pregnancy with Mia. A pre-birth assessment was completed and a pre-birth conference arranged. By the time of Mia’s birth her mother had asked her father to move out due to drug testing showing on-going significant substance misuse, which was positive and enabled professionals to feel she was listening to advice and willing to make changes for the benefit of her children. Those involved were optimistic that Mother would separate from him permanently. Good work was undertaken with the mother by CGL17 to educate her about substance misuse, to enable her to identifying patterns and recognise her partner’s deceit, in the hope she would be less naive about this. His presence at the family home following the birth was challenged directly with him and with the mother by those involved and information was shared between the professionals involved. This was good practice. 51. Mia’s mother was seen by health professionals as an experienced parent. She breast fed her babies, which was seen as positive and child centred. There was no history of concerns from the previous area where they had lived. When it emerged that appointments for the older children were being missed, including for the six-week check and immunisations for her baby (Mia’s older sibling) this was not immediately identified as of concern. There had also been a change of health visitor within Middlesbrough when the family moved to another part of town not long after arriving in the area. It was not until a strategy meeting was held in February 2020 that health professionals were aware of the neglect concerns about the children. CSC had received four referrals in around three weeks. Firstly from the police regarding one of the older siblings being out in the community unsupervised late at night. 17 CGL provide treatment and support to those who misuse substances in the area. Final 15 Secondly from CGL in regard to mother being pregnant and the father having on-going substance misuse issues. Thirdly from the school of some of the older children stating that they were unkempt, tired and often absent. Lastly from the ambulance service sharing their concerns about the eldest sibling who came to their notice due to issues of anxiety and anger control, their concerns about the home conditions and the child having responsibility for his younger siblings. It was agreed that the children were at risk of significant harm and an ICPC was held, with the older siblings all being made subject to child protection plans for neglect - physical, medical, nutritional, emotional, educational, and lack of supervision and guidance at home. The plan included monitoring of the home and children’s life experience, but was closely followed by the first COVID 19 pandemic lockdown, which had a negative impact on the plan and potentially the children, as their mother exercised her right to keep them at home and the professionals involved had to abide by their agencies rules in respect of home visits due to the pandemic. The social worker described having to view the home and see the children through a downstairs window. 52. There were some concerns about the quality of the child protection plan for Mia and her siblings. The IRO monitoring tool rated the case at a Red, highlighting the urgency of gaining the children’s views and an understanding of their lived experience, as this had not been apparent. The review was told that more recently (as practice has changed and improved within Covic-19 regulations) there has been a lot of work undertaken with the children and that the social worker has developed a good relationship with them. 53. A review child protection conference was held very soon after Mia’s initial conference and there was concern voiced that despite nine months on a plan there had been no real improvements for the children, particularly in regard to their supervision, school attendance, physical appearance and home conditions. Their mother had received some parenting work with a resource worker, but was reported not to engage with what was asked of her and often said that she was confused about what she had been asked to do, or that she did not have time to do it. The chair stated that a legal gateway meeting should be considered if there was no improvement by the next core group. There was no clarity regarding what these improvements were and how positive change would be measured however, and with the absence of an outcome focused plan18 and no evidence that any neglect tools were used, this was going to be difficult. It was shortly after this meeting that Mia died. 54. There were no visits inside Lucy’s home following the outbreak of pandemic and the initial lockdown in the UK until after her accident in July 2020. This appears to be due to it being a temporary supported housing unit with other residents. The 0-19 service delivery (including health visiting) were instructed to have no face to face client contacts until they received appropriate PPE, which took around three weeks. A directive was then made that the only face to face visit should be to new birth contacts, those on a child protection plan or if there was an absolute clinical need, where visits had to be authorised by service manager. This means that Lucy and her mother did not meet the criteria for a face to face visit from the health visitor until the strategy meeting was held on 19th May and it was agreed that the health 18 In a SMART and outcome focused plan the needs of the children should be specific and linked to their growth and developmental milestones and aimed at their preferred future. Actions need to be specific, clear and linked to meeting needs and time specific, linked to a responsible person. Timescales need to be determined to help focus the interventions and progress points. Outcomes need to be stated to outline what life would be like if the interventions were successful and the child’s needs were met consistently over a sustained period of time. Final 16 visitor should visit. However two weeks later the health visitor became unwell and took extended sick leave. 55. Professionals working with Lucy and her mother found that the mother’s engagement deteriorated further during the pandemic. It was easier to avoid professionals or to superficially engage on the telephone or when meeting briefly outside the home. There were attempts from professionals to see Lucy and her mother, but these were not always successful. Despite this, the child in need meetings held on the telephone stated that there had been progress in the child in need planning for Lucy and a generally positive view. There is no evidence that this was actually the case however. Lucy’s mother came across as managing well and this was not adequately questioned by those involved. 56. Following Lucy’s accident there was a complex strategy meeting held which was chaired by a senior manager. It can now be seen that not all of the relevant background information was shared at the meeting, and the same positive feeling about her mother’s care of Lucy was accepted at the meeting. The police and the allocated social worker were unable to attend, which exacerbated this. An agreement was made that Lucy could return to her mother’s care when she was discharged from hospital. No other agency challenged this decision and Lucy returned home. There was good monitoring and information sharing in the days that followed, including home visits from the social worker and health visitor. It quickly emerged that her mother was not meeting her needs at this time and that Lucy was at risk of neglect. Care proceedings were started without delay. 57. In the first weeks of the pandemic the core group meeting following Mia’s siblings being made subject to a CP plan was cancelled, and there is no evidence it was rearranged. There appears to have been a number of attempts by the social worker, health visitor and school nurse to see the children, despite the limitations at the time19. The school nurse did all she could to engage in a meaningful way with one of the older siblings when there were particular concerns about how he was managing. There is also evidence of communication between the professionals regarding who was able to have contact. Families had the right to refuse to send their children to school. There was no government guidance about vulnerable children being required to attend, and limited understanding of who needed to shield. In the case of Mia’s siblings, there was the option of all of the school age children to attend school due to their vulnerabilities. One of the older children refused to do so, saying that it would make her stand out as a child with a social worker. Their mother chose not to send the younger children, and said the whole family were ‘shielding’. The professionals involved thought this was really due to her not having to be organised to get the children to school, bearing in mind her pregnancy and the size of her family. For a family where school attendance had been a long-term issue, the pandemic gave a valid reason for the children to miss school. Most schools took some time to set up virtual learning, and it is not known what home schooling Mia’s siblings had in these months. Those involved at the time reflected that it was unrealistic to think that a family with so many children, in small and inadequate housing that was often described as ‘unsafe’, with additional social problems could actively learn and develop via home schooling. It is known that the school undertook home visits to them and provided lunch, which was good practice. 19 PPE was not available to community health staff until 07/04/20 Final 17 58. The information shared with the review stated that, due to the family shielding, the social worker initially was only able to see the children through the window. This means that the issues that had been identified at the ICPC, which included the poor home conditions, the children dirty and dishevelled and the children’s health needs not consistently being met, could continue without any meaningful oversight from professionals. Shortly afterwards home visits did start again, but just 15 minutes in the home was recommended following a risk assessment. Other concerns also emerged at the time, including the children being out and unsupervised and one of them being hit by a car when out alone on their bike. The impact on the children of their home life was likely to be additionally concerning due to Covid 19. The schools had made sure that the children had appropriate uniform and food when they attended school prior to March 2020, and although there was contact and school dinners provided, this would not have compensated for a day in school when the children were ‘shielding’. Despite the enforced limitations, the social worker and health visitor maintained contact with the family and drew up a safety plan to ensure this was as effective as was possible within the limitations. This reflected a lot of positive work in the town generally from all professionals to ensure that children were seen despite the pandemic. The recording of the work undertaken at the time would have been improved by a clear record of the impact on each child and evidence of an understanding of their lived experience during the lockdown. 59. During the reflective discussion as part of the CSPR process, Mia’s health visitor reflected on the challenges. She stated that there were increasingly high workload demands with CP and CIN families, recruitment issues across the health visiting service and a recent surge in safeguarding cases in Middlesbrough. This was in addition to the demands of COVID. She did not seek safeguarding supervision on this case due to the general pressures and lack of time both to complete supervision forms for all the children and to attend the actual supervision meeting. This requires further exploration by the HDFT to see if it a wider issue and they have agreed to do this. Since the incident HDFT has rolled out 1:1 supervision to all 0-19 practitioners in Middlesbrough over a 3 month period, which is more actively being sought. Group supervision has also been reintroduced. 60. There was also a more general impact from Covid-19 due to professionals catching the virus, self-isolating, or shielding which led to some reduced capacity. This accompanied increased demand due to a local ‘safeguarding surge’. In their second annual report published in May 2021, the national panel described the previous year as ‘an indescribably hard time for children and families’ and ‘a period of unprecedented test and challenge for all those entrusted with safeguarding and protecting children from harm’. There is no doubt that while the incidents that have led to this review were not due to Covid-19, it had an impact on some of the practice undertaken at the time and led to stretched safeguarding systems. Conclusion and recommendations 61. The latest OFSTED report that considered Middlesbrough Children’s Services in 2020 found that assessments were ‘too often poor, leading to over-optimistic decision-making’ and that many ‘fail to understand children’s experiences, lack clear analysis of cumulative harm, and rely on parental self-reporting to consider parents’ capacity to make and sustain change.” Inspectors found child protection plans often took ‘too positive a view of parents’ ability to sustain change’, and that this leaves some Final 18 children in seriously neglectful and harmful situations.’ This review has found that this was the case for Lucy and to a lesser extent Mia and her siblings, despite there also being examples of good individual practice and multi-agency information sharing and communication. A lot of hard work has gone into improvements and a more positive response from OFSTED about progress made, including in regard to the thresholds issue also identified in the review. The learning from this review should be considered as part of this improvement journey. 62. To assist in ensuring that improvements are made that make a difference to the children of Middlesbrough and the wider South Tees area, this review has also made recommendations for the STSCP. Recommendation 1: The STSCP to consider how it can ensure that all professionals in partner agencies are aware of and use the neglect strategy. This should involve a review of the strategy, consideration of how to relaunch it and how to monitor its use. Recommendation 2: The STSCP to request assurance from the Local Authority regarding improvements in the use of the Graded Care Profile and evidence based practice20 in neglect cases, to include consideration of its use by professionals across other relevant partner agencies. Recommendation 3: All plans, be they early help, child in need or child protection, need to provide a clear and detailed description of who is undertaking what work with the family, which takes their role and its limitations into consideration. All members of any team around a child / core group must ensure they provide appropriate challenge if this is not the case. Recommendation 4: The Corporate Parenting Board to be asked to consider how they can develop the concept of being a positive ‘corporate grandparent’ to the children of care leavers. Recommendation 5: The STSCP to consider how it can ensure that the recommendations made in the STORK review, regarding the need to actively involve fathers when providing services to children, are having a positive impact to the children of South Tees. 20 There also needs to be more use of chronologies, genograms and ecograms as part of these improvements. |
NC52444 | Significant harm to a 9-year-old boy over a number of years due to alleged fabricated or induced illness (FII). These concerns became heightened when Child R was placed in foster care where he was seen to flourish, including being fully mobile and eating without medical intervention. Learning includes: agencies, particularly health professionals, may benefit from systems that help recognise FII; when a child is under the care of multiple teams and the diagnosis is unclear, there is a need for a multi-disciplinary team meeting between health professionals; a need for continuing professional curiosity rather than relying on parental response; loss of focus on the harm to the child can occur when concentration on proving FII becomes a distraction; need for a move away from the inability to appropriately challenge parents because of concern about FII; multi-agency representation in strategy discussions is essential so that a full picture of the child's life can be formulated.
| Title: Child safeguarding practice review (CSPR) – Child R 2020. LSCB: Leicestershire and Rutland Safeguarding Children Partnership Author: Margaret Crawford Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Title: Child Safeguarding Practice Review (CSPR) - Child R 2020 Safeguarding Children Partnership: Leicestershire and Rutland Safeguarding Children Partnership Author: Doctor Margaret Crawford 2 Child Safeguarding Practice Review (CSPR) Child R Introduction This Child Safeguarding Practice Review (CSPR) relates to a case of potential Fabricated or Induced Illness (FII) and concerns a young child known as Child R. Most of the agencies or organisations providing services to him or otherwise involved in this case were from Leicestershire. The review also involves a hospital from another county as Child R also spent some time being treated by this hospital. The purpose of a CSPR is to understand what happened and why, so that learning can be identified to support future improvements to safeguard and promote the welfare of children, and this includes the identification of good practice. The overall aim is to learn from what happened to prevent or reduce the risk of similar incidents. It is not undertaken to hold individuals or organisations to account. This CSPR considered any updates to procedures and training that may be required to support practice in relation to FII. The independent report author of this CSPR, Doctor Margaret Crawford, is a Consultant Paediatrician who has taken a special interest in safeguarding children. The Terms of Reference meeting for this CSPR identified several strands of work that would be undertaken in order to better understand what had happened in relation to this case and identify how to improve procedures and processes in the future: • Strand 1: An examination of the Health records of Child R. Interviews with key professionals, as necessary, in order to identify any learning relating to this case in relation to FII and the wider Health agencies’ interaction with Child R and his family. This will include identifying any learning in respect of collation and analysis of Health information in future cases to support timely identification of triggers to consider FII or other safeguarding procedures. • Strand 2: An examination of the role of the Police, Children’s Social Care and Health when FII is identified as a potential factor and how planning processes, such as Strategy Discussions, can explore and plan best practice in gathering evidence and pursuing timely single and joint assessment and investigations. • Strand 3: An audit of cases, by identifying a small number of cases that have been referred to Leicestershire Children’s Social Care (CSC) on the basis of concern regarding FII. The audit focused on: o Evidence of compliance with the updated procedure for FII, introduced in December 2019 o Evidence of good multi-agency information sharing at all points of process applied 3 o Quality of decision making by CSC manager and oversight to process o Action has been taken appropriately to support and protect the child without delay. • Strand 4: All agencies to test the knowledge and confidence of frontline practitioners in responding to cases where FII may be indicated. Summary of the Case Over a number of years, Child R suffered significant harm because of alleged fabrication or exaggeration of illness. Child R presented with a number of medical issues from soon after birth. These required numerous health interventions with increasing complexity, including being subjected to invasive treatment, therapy and surgery. His care involved many specialisms: Gastroenterology, Paediatric Surgery, Paediatric neurology, allergy, Audiology and Ophthalmology. He received input and treatment from Dieticians, Speech and Language Therapists, Physiotherapists, Occupational Therapists and Community Nurses. Child R suffered growth failure due to poor nutrition (that included apparent dependence on artificial forms of feeding, moving from naso-gastric feeding to gastrostomy feeds and for long periods of time, intravenous feeding). He experienced limitations with mobility partly due to lack of nutrition but with no underlying medical cause otherwise. These concerns became heightened when Child R was nearly 9 years old when, because of a multi-agency review of his circumstances, he became subject to legal intervention and was placed in foster care where he was seen to flourish, including being fully mobile and eating normally without further medical intervention. Analysis and Findings The CSPR Panel considered three periods of time: Child R’s birth to Age 2 years 6 months; 2 years 6 months to 5 years old (during this time an initial referral to Social Care was made and a series of Strategy Discussions took place) and 6 to 9 years old, following which the 2nd referral to Children’s Social Care was made. In each of these time periods, the Panel considered reported symptoms and presentations and resulting medical investigations and hospital admissions. Also considered was any parental resistance to advice from health professionals, complaints about health professionals, safeguarding concerns and the voice of Child R. It was acknowledged that fabricated illness is complex and subtle in presentation and may be difficult to identify and presents challenges in planning responses. The findings cover the following learning themes: training, communication (between agencies and between Health professionals, as well as discussion of concerns with carers and experienced practitioners), medical concerns, complaints and schooling: • All agencies, but particularly Health professionals, need support and may benefit from systems that aid the recognition of fabricated illness. The absolute basis of this is that, if any professional is concerned that a 4 presentation may include fabrication, there should be easy access to someone with experience and expertise in planning responses. Within Health, this may be named safeguarding professionals via a senior colleague. • Under new guidelines now in place, when there are alerting signs with no immediate risk to the child’s health (perplexing presentations), the responsible Clinician with appropriate advice may be able to work with the parents/carers to produce a plan that does not lead to continuing over-investigation and possible harm. • When a child is under the care of multiple teams, there is a need for a Multi-Disciplinary Team (MDT) meeting between Health professionals when the diagnosis is unclear. The MDT should aim to triangulate concerns, opinions and especially reasons for second opinions. While it is noted that this should be easier now that remote meetings are common, there is often great difficulty in getting attendance from essential individuals when more than one centre is involved.1 • There needs to be a flow of information between Health organisations to maintain a focus on accumulative concerns relating to FII. • There is a need for continuous professional curiosity and professionals need to check in with each other and not just rely on carers passing on information. With all children with complex needs, there needs to be good communication between the professionals involved with their care, not just relying on parental response. • Recognition and confidence in managing FII requires well-coordinated responses both internally within health but also across any other agencies who may know the child. To support this there should be: o Clear guidance relating to managing FII o A clear pathway to FII expertise for advice for practitioners in any organisation when they are concerned about fabricated illness o Regular updating of FII recognition and response in mandatory training o Training of all professionals involved with children.2 • A naso-gastric tube should be regarded as a medical device and treated as such. Responsibility should be with the Practitioner that prescribed it. • When naso-gastric tube feeding commences, there should be a plan and timeline for returning to normal feeding when there is no clear underlying condition requiring continuation. 1 “Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children RCPCH guidance”, Royal College of Paediatrics and Child Health (RCPCH), March 2021, available at https://childprotection.rcpch.ac.uk/resources/perplexing-presentations-and-fii/ Section 5.3 2 Section 10.1 in relation to Health professionals, “Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children RCPCH guidance”. 5 • When a child is under the care of two different Trusts, and it is known that safeguarding supervision is separate, then there is a case for supervision being common to both organisations. • It is easy to lose focus on the harms occurring to the child when considering FII. Concentration on proving FII can be a distraction from placing the needs and welfare of the child at the centre of professional concern and may hinder conversations with parents and lead to delay making referrals for support and safeguarding. • A Strategy Discussion provides an opportunity for multi-agency information sharing and planning. When a Strategy Discussion is held because of concern about FII, it is important to focus on the harm to the child that is evidenced, rather than identifying or confirming the evidence for FII. • Good multi-agency representation in Strategy Discussions, including Health professionals involved with the child, the GP, Social Care, Education and Police, is essential when considering FII so that a full picture of the child’s life can be formulated. • Consensus about a child’s state of health needs to be reached between all Health professionals involved with the child and family, including GPs, Consultants, private doctors and other significant professionals who have observation about the child.3 This should include Therapists, Nurses and others together with the views of Education and Children’s Social Care if they have already been involved. • A health Chronology is an important part of a complex case where FII may be considered. There should be recognition of these as time consuming and that the professionals doing chronologies need the release of a lot of time to do them. This should be emphasised and supported by organisations.4 • There has been an anxiety about the impact of discussing professional concerns relating to FII with parents in the past which was evident at certain periods of the child’s life. There should be a move away from the inability to appropriately challenge the parents because of concern about FII except where challenging will put the child at immediate risk of harm. This is the approach now recommended by the updated guidance on FII. • It is important that those in Education and Social Care, as well as in Health, have appropriate support and expertise available to support frontline practitioners. This will be particularly important when considering multi-agency referrals and responses. 3 Section 5.3, “Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children RCPCH guidance”. 4 Section 7, “Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children RCPCH guidance”. 6 • When a carefully constructed Clinical Management Plan is met with difficulties, and there is parental refusal to cooperate, FII is a consideration. • When safeguarding issues are being raised by one Health professional, it may be time to have a multi-professional meeting to discuss those concerns with joint safeguarding supervision so that all professionals are aware of the individual concerns. • It should be recognised that GPs are the repository of all health information, including private medical opinions which may have been sought, and interrogation of those records and involvement of GPs may provide information not available in any other forum. • With complaints, when there are safeguarding concerns, good liaison between the Complaints Team and Safeguarding Team can lead to a well thought out response without an unsuitable apology.5 • When a complaint is made about an individual professional in any agency, the cause of that complaint may be that there has been a challenge made to the carer with the response aimed to get a less challenging professional. • Change of professionals is a feature of FII. Recording each complaint, minor or major, if achievable would be helpful in recognising the problem and supporting the diagnosis. • There should be a clear pathway for schools to access health professionals when they have concerns and the carer is resistant to allowing that communication. In this situation, where home schooling was happening, there could still have been communication with the education authorities. Actions related to learning and changes in practice The recently updated Royal College of Paediatrics and Child Health (RCPCH) FII Guidance was published during the course of the CSPR. The overarching themes identified by the CSPR Panel were mapped against the new guidance and it was agreed that any changes to local procedures would reflect both the national guidance and the findings of the CSPR. The updated Leicester, Leicestershire & Rutland (LLR) SCP procedure on “Multi-agency management of Medically Unexplained Symptoms, Perplexing Presentations and Fabricated or Induced Illness (FII)” reflects the national RCPCH guidance in: • emphasising the harms that are occurring to the child rather than the need to confirm evidence for FII, with the welfare of the child being at the centre of any discussion 5 Section 10.3, “Perplexing Presentations (PP) / Fabricated or Induced Illness (FII) in Children RCPCH guidance”. 7 • the need for more open discussion with carers (previously in the national guidance, there was emphasis on not sharing concerns about fabrication with parents) • the need for a consensus about a child’s state of health between all Health professionals involved with the child and family, including GPs, Consultants, Private Doctors and other significant professionals who have observations about the child (including those from other agencies if they have already been involved) • the need for responsibility to be taken by a senior medical practitioner regarding the use of a medical device and a plan to stop its use when the reason for the need is not clear – e.g., use of a naso-gastric tube for feeding • dealing with the issue of complaints, which with perplexing presentation/FII are often frequent and vexatious, and the need to support staff when such complaints are made, recognising the emotional trauma that this can cause • the need for good agency representation at meetings of Health professionals and any multi-agency Strategy Discussion • the need to involve schools in meetings, as appropriate, and the need for a clear flow of information from schools where they have concerns about a child • the need for chronologies when a case reaches the threshold for FII, noting they are extremely time consuming and, in accordance with the new RCPCH guidelines, they are not essential immediately to enable a referral to Social Care. The updated LLR procedure also provides a detailed flowchart to ensure that staff in all agencies, both in the Health sector and other statutory and voluntary agencies, have clear routes to discuss concerns in relation to both perplexing presentations and where there are immediate concerns for child safeguarding from suspicions of FII. Awareness training for relevant staff in all agencies regarding the updated procedure will be directed at a wide range of staff in agencies who both have a potential role in managing cases of FII and perplexing presentations and have staff who may need to have an awareness of this. Conclusions Child R was given excellent medical care with appropriate investigations and management based on the symptoms that were presented. New guidance may aid in earlier action being able to be taken. Changes had already occurred between the first and second referrals to Social Care regarding Child R, with many areas of good practice seen. Between the time of the first referral at nearly 4 years of age and the second referral at age 9 years, there had already been a change of emphasis and procedures that led to good multi-agency management of the situation and the institution of legal proceedings when this became necessary. The case of Child R is extremely complex. As is usual in complicated cases of FII, it has led to a number of findings. These have been managed by an action plan. The issues raised by the findings have been dealt with in the local sub-region by the 8 introduction of the new “Multi-agency management of Medically Unexplained Symptoms, Perplexing Presentations and Fabricated or Induced Illness” procedures. |
NC52694 | Death of a 4-year-old boy in 2022 due to a serious incident whereby he was found face down in a bath. Nicholas had been subject to a pre-birth assessment in a different local authority. Learning includes: consideration needs to be had of a national, uniformed, transfer information policy; and there is a need to develop professional curiosity. Recommendations include: assure of a robust transfer of information policy to be used when a person presents safeguarding concerns from out of area, and when a person with safeguarding concerns moves to another area; assure the partnership around discharge processes and the flow of information from all maternity services; remind and encourage professionals to practice an open-minded awareness of the differences that cultural background can produce; and assure the partnership that professionals from all agencies know when and how to escalate any concerns.
| Title: Local children’s safeguarding practice review: Nicholas: executive summary. LSCB: Salford Safeguarding Children Partnership Author: Allison Sandiford Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Nicholas Final Report 22/12/2022 1 Local Children’s Safeguarding Practice Review Nicholas Executive Summary Presented to the Salford Safeguarding Children Partnership on The 12th of December 2022 Independent Author: Allison Sandiford Nicholas Final Report 22/12/2022 2 Contents 1. Introduction to the Review and Methodology............................................................................................. 3 2. Family Engagement ............................................................................................................................................ 3 3. Parallel Processes ................................................................................................................................................ 4 4. Brief Summary of Events ..................................................................................................................................... 4 5. Nicholas’ Lived Experience of Events ............................................................................................................ 6 6. Consideration and Analysis of Key Practice Episodes .............................................................................. 8 6.1. Key Practice Episode 1 ......................................................................................................... 9 6.2. Key Practice Episode 2 ....................................................................................................... 10 6.3. Key Practice Episode 3 ....................................................................................................... 14 6.4. Key Practice Episode 4 ....................................................................................................... 15 6.5. Key Practice Episode 5 ....................................................................................................... 17 7. Other Considerations ........................................................................................................................................ 18 7.1. Drowning ................................................................................................................................ 18 7.2. The Effects of the Covid pandemic on the support offered to Nicholas ............ 18 8. Good Practice .................................................................................................................................................... 18 9. Improving Systems and Practice ................................................................................................................... 19 9.1. Developments Since the Scoping Period of the Review .......................................... 19 9.2. Conclusion ............................................................................................................................. 20 Appendix 1 - Terms of Reference ......................................................................................................................... 20 Nicholas Final Report 22/12/2022 3 1. Introduction to the Review and Methodology 1.1. This Local Children’s Safeguarding Practice Review was commissioned by the Salford Safeguarding Children Partnership (SSCP) following Rapid Review for National Panel submission. 1.2. The criteria were met as the local authority suspected that a young person (Nicholas) who had died, had been abused or neglected. 1.3. Nicholas aged 4 years, sadly died due to a serious incident whereby he was found faced down in a bath. 1.4. The report has been authored by Allison Sandiford. Allison is an independent safeguarding consultant who gained experience in safeguarding whilst working for a police service. Since 2019 Allison has conducted serious case reviews and safeguarding practice reviews in both children’s and adults safeguarding, and domestic homicide reviews. 1.5. Allison does not have any current links to Salford Safeguarding Children Partnership or any of its partner agencies. 1.6. A multi-agency review panel1 met on the 22nd of June 2022. The panel agreed the scope of the review and the Terms of Reference2. Additional information was requested from the agencies involved to aid the review process. 1.7. The panel met on three further occasions to discuss the case and learning and to monitor the progress of the review. These meetings incorporated two practitioner learning events attended by professionals from the key agencies who had worked with Nicholas3. Contribution from the participants generated positive discussion around both good practice and areas of practice that could be developed and improved; this has formed the basis of this report. 1.8. It was agreed by panel members that the review would follow a question-based learning format in place of traditional recommendations. The questions developed during this Children’s Safeguarding Practice Review process will drive Salford Safeguarding Children Partnership, and its partner agencies, to develop an action plan that will respond directly to the identified learning. 1.9. Panel members had an opportunity to review the final draft of the report and discuss the learning prior to presentation to the Salford Safeguarding Children Partnership. 2. Family Engagement 2.1. Family engagement is an important part of the review process. Discussion with family members about the support offered is hugely beneficial to identifying both good practice, and practice which can be improved upon. 1 The panel consisted of representatives from Northern Care Alliance, Greater Manchester Police, Salford Safeguarding Children Partnership, Integrated Care System, Children’s Social Care (Salford and from the Local Authority where Sarah had previously lived), Adult Social Care, Early Help, North West Ambulance Service. 2 Refer to Appendix 1 3 Adult Social Care, Early Help, Greater Manchester Police, Manchester Foundation Trust, Northern Care Alliance, North West Ambulance Service, Primary Care, Salford Children’s Social Care, Together Housing, Children’s Social Care from the Local Authority where Sarah had previously lived, Salford Safeguarding Children Partnership. Nicholas Final Report 22/12/2022 4 2.2. It has not been possible to speak with family members during the process of this review due to ongoing criminal investigations. The reviewer is happy to offer members of Nicholas’ family the opportunity to meet when appropriate and will update them of the learning the process has identified. 3. Parallel Processes 3.1. At the time of writing this report, Nicholas’ mother (hereafter referred to as Sarah) had been arrested for causing or allowing a child’s death, and a criminal investigation was underway. The investigation had not concluded prior to the review process being completed. The review panel has agreed that the findings of the investigation are not expected to influence the learning identified. 3.2. Ordinarily, a Coroner’s Inquest into a death is opened and then adjourned, pending any criminal trial, which takes precedence. It is the Coroner's prerogative to resume an inquest following a criminal trial. 4. Brief Summary of Events 4.1. Nicholas had been subject to a Pre-Birth Assessment in a different Local Authority. Sarah (aged 21 years at the time) had suffered previous trauma from her own father and had previously been under social care as a child. Sarah was missing midwifery appointments and was smoking and drinking. It was recorded that Sarah had no idea of the potential impact on the baby. 4.2. The Local Authority completed a referral to Early Help and the case was closed but Sarah missed some further ante-natal appointments. As a result, a further safeguarding referral was submitted, and an updated Pre-Birth Assessment was soon recommended. 4.3. The assessment process established that Sarah had moved to Salford4 and therefore a Social Worker contacted Salford Children’s Social Care to share the assessment. For reasons that cannot be confirmed, the assessment was not received by Salford. 4.4. On the 5th of December 2017, Children’s Social Care in Salford received a referral after Sarah had contacted the NHS 111 Service informing them of missed appointments and not being registered with a GP practice. 4.5. On the 22nd of December 2017 Children’s Social Care received a referral from Midwifery services after Sarah had attended an appointment with the community midwife and disclosed that she was low in mood ad had previously attempted suicide on two occasions, had a history of cannabis use, that her father had been abusive when she was a child, and that she was worried as she didn’t know who the baby’s father was. 4.6. Nicholas was allocated a Social Worker five weeks later - the day after his birth - Nicholas had been born in hospital by Emergency section at 35+3 weeks gestation. 4.7. On the 29th of January 2018 Nicholas was subject to a discharge planning meeting in which it was decided that Sarah would meet with the Mental Health team prior to discharge from the perinatal midwives, and Nicholas would be supported under the auspice of Child in Need. 4 Nicholas’ grandmother, Sarah’s mother, already resided in Salford with Sarah’s stepfather and their two children. There is a record of two domestic abuse incidents between Sarah and her mother dating from 2011 when Sarah was aged fifteen. Nicholas Final Report 22/12/2022 5 4.8. Upon discharge Nicholas and Sarah went to stay with a friend of Sarah’s for a while before being placed in temporary homeless accommodation by the Council Housing Services. At this time, Sarah did not have her own tenancy. 4.9. Though the Child in Need process started well, and Sarah engaged with the Social Worker and Health Visitor, in time Sarah was not always available. Subsequently Nicholas was not always seen. 4.10. On the 1st of March 2018, Sarah having gained her own tenancy moved her and Nicholas into their home. 4.11. Around June/July 2018, Nicholas went to stay with a friend of Sarah’s whilst Sarah reportedly attended a funeral abroad. It remains unknown how long Nicholas stayed with the friend but upon it becoming known that he was there, a Social Worker visited him and established that whilst there was evidence of bottles, milk, nappies and clean clothes, Nicholas was co-sleeping with the friend because he had no cot at the address. 4.12. Upon Sarah’s return, safe sleep was discussed during a joint visit from Children’s Social Care and Nicholas’ Health Visitor. During this visit Sarah said that she felt she did not need any further support from the Social Worker, and it was agreed that Nicholas’ Child in Need case would be closed - his support would return to the universal core programme. 4.13. Three days later Nicholas suffered a scalding whilst in the care of his grandmother. The injury was deemed to be accidental, but Nicholas suffered significant burns injury to his abdomen, bilateral thighs, perineum, and genitals. Nicholas stayed in hospital for one week due to infection. Nicholas was taken to an outpatient follow up appointment on the 27th of August 2018 but was not taken to appointments on the 14th and 28th of August 2018. 4.14. On the 12th and 15th of October 2018 Sarah took Nicholas to the Accident and Emergency Unit as he was suffering a cough and runny nose with noisy breathing at night. His scars were seen at this appointment and there were no concerns raised. Staff at the hospital learned that a man who Sarah referred to as her boyfriend, was sometimes staying at Nicholas’ house. 4.15. On the 30th of November 2018 Sarah told her GP that she and a man who she referred to as a boyfriend of five months, were trying for a baby. 4.16. On the 7th of December 2018 Sarah told the Health Visitor that she and Nicholas were going abroad to the country of her birth until the 12th of January 2019. 4.17. Nicholas was not seen again by any professional until the 28th of March 2019 when he was taken for his 12-month vaccinations. Sarah did not report that there had been any medical concerns regarding Nicholas whilst he had been out of the country. 4.18. In May 2019 Sarah reportedly took Nicholas to London whilst she sorted out some legal papers. At the end of the month Nicholas demonstrated his walking skills to his Health Visitor but the Ages and Stages Questionnaire which was completed concluded that his communication, problem solving, and personal social was below expected levels. 4.19. In June 2019 Sarah reported that she was a victim of blackmail. This was dealt with by police from another force as the incident appears to have been related to Sarah’s ex-partner who did not live in Salford. 4.20. In July 2019 the Health Visitor referred Nicholas to Bridge for a home safety assessment by an Early Help Practitioner. Sarah met the practitioner and agreed to a bathmat and cupboard locks Nicholas Final Report 22/12/2022 6 being provided. The home presented clean and tidy and there were no concerns. Sarah told the worker that she was separated from Nicholas’ father who lived abroad but there were no issues. 4.21. In September 2019 during a phone call, Sarah told the Early Help Practitioner that she and Nicholas were going to her birth country again until May 2020. However, Nicholas was presented to his GP on the 14th of November 2019 regarding a keloid scar in his groin area evidencing that they were still in the United Kingdom at this point. 4.22. In April 2020 Sarah contacted the Housing Association to report that she and Nicholas were stuck abroad because of the Covid pandemic lockdown. Neither she nor Nicholas were seen by professionals again until Sarah collected her keys from the Housing Association office on the 15th of September 2021 (it is not known if Nicholas was with his mum on this occasion). 4.23. Nicholas was presented to the Accident and Emergency Unit on the 10th of October 2021 after Nicholas had consumed several vitamin jellies. 4.24. On the 27th of November 2021 Sarah left Nicholas in the care of an ex-partner. When Sarah attended the ex-partners address to collect Nicholas an argument started during which Sarah was pushed. Sarah reported the incident to the police. It is not known what Nicholas saw or heard but he was spoken to by a Police Officer who described him as being in good spirits. 4.25. In January 2022 Nicholas attended ‘settle in’ sessions at nursery. 4.26. On the 21st of February 2022 Sarah visited her GP Practice and reported feeling suicidal to reception. The Practice called 999 and Sarah followed this with a 999 call from herself. When later seen by the Mental Health Liaison Team, Sarah disclosed that she and Nicholas were staying with a friend due to having no heating, electricity, or food. Nicholas was not present during this consultation – he was reportedly staying at his grandmother’s address. 4.27. The following month, Sarah left Nicholas without adult supervision, in the care of relatives aged 15 and 12 years. Sarah went to see a friend in a neighbouring property, with whom she drank alcohol and used illicit substances. Sarah returned the following morning. 4.28. The events that followed are subject to criminal investigation and thus will not be elaborated upon, but Nicholas was later found face down in the bath. Cardiopulmonary Resuscitation and advanced life support was administered to Nicholas by attending health professionals but was not effective. 4.29. Nicholas was unresponsive to treatment and sadly passed away. 5. Nicholas’ Lived Experience of Events 5.1. It is very difficult to gain a true understanding of Nicholas’ lived experience. 5.2. Contact between professionals and Nicholas has been inconsistent as Sarah has not always presented Nicholas to professionals for appointments and assessments. This is partly due to Sarah reportedly taking Nicholas out of the Salford area on occasion, and out the United Kingdom for periods of time on several occasions. Nicholas Final Report 22/12/2022 7 5.3. Nicholas was purportedly out of the United Kingdom from late 2019 until September 2021 when he was aged around 22 months to 3 years 8 months. Language development5 explodes at this age. His vocabulary, understanding and communication will have flourished, but professionals were unable to meet with him, observe his development and/or gain a picture of his lived experience throughout this period. Nicholas was only back in the United Kingdom for five months before he tragically died. 5.4. This review has attempted to reflect upon what life was like for Nicholas. Some of this reflection is contained within the body of the report but it will begin with this overview: As an unborn child, Nicholas was not provided with consistent and regular ante-natal care. He was fully reliant upon his mother who was facing her own challenges and not addressing her own health and care needs - she continued to smoke and drink despite the potential impact on Nicholas. Nicholas was born in hospital by Emergency section at 35+3 weeks gestation due to a premature rupture of membranes. Nicholas wasn’t very well for the first few days of his life and had to spend time away from his mum in the Special Care Baby Unit. When Nicholas left the hospital with his mum, his mum was homeless and was placed, initially in homeless Bed and Breakfast accommodation and then other temporary accommodation by Council Housing Services before securing her own permanent home with a Registered Provider. Because Nicholas’ mum hadn’t been expecting Nicholas to arrive early, she wasn’t fully prepared for him, but Nicholas’ grandfather6 got Nicholas what he needed. When Nicholas was around six weeks old, he and his mum got their own permanent home. Nicholas was still being supported at this time by his Social Worker and he now had a Health Visitor, but he was not always able to meet with them because his mum was not always available and didn’t always respond to texts and messages. When Nicholas was seen by professionals, he was noted to be a happy child. Nicholas and his mum developed a good bond but when Nicholas was five months old, she had to go away for a while, and he was left in the care of his mum’s friend. Besides his mum’s friends, Nicholas had extended family around him in Salford. He had grandparents (grandmother and step-grandfather) and an uncle and aunt who were still children themselves. Nicholas often spent time at his grandparents’ home. Nicholas also had a grandfather who lived close by, but this review has been unable to establish how much contact Nicholas and Sarah had with him. When Nicholas was five months, he was badly burned and had to go to hospital. He had been staying with his grandma and she reported that she had been showering him in the bath, when the cold-water hose came off the shower and hot water scalded his tummy, thighs, and genitals. Nicholas had to stay in the hospital for a week because his burns got infected. Nicholas’ burns required ongoing medical oversight, but Nicholas was not able to go to all the appointments because no one took him. 5 Ages and stages (speechandlanguage.org.uk) 6 The review has been unable to establish whether this was Sarah’s father or stepfather. Nicholas Final Report 22/12/2022 8 Nicholas was closed to the Children’s Social Worker around this time, but he still had a Health Visitor under Universal Services. Though Nicholas didn’t know his dad, there was a man who was now spending time in the house with Nicholas and his mum. Because Nicholas was so young, he was unable to tell anyone what it was like when the man came to stay. Before Nicholas was one year old, he went to stay abroad with his mum for a couple of months. Nicholas was too young to be able to tell anyone back in England what his time away from the United Kingdom was like, or who he met, or who he stayed with. He went to stay abroad again just before he was two. This time Nicholas had to stay abroad for almost two years because of the coronavirus. Whilst he was there, Nicholas missed some health appointments in the United Kingdom including some that were to look at a scar that had developed where he had been scalded. Nicholas also missed a chance to start of nursery. Nicholas and his mum came back to Salford in September 2021. A couple of months later, Nicholas went to see a man who used to be a friend of his mums. His aunt went with him too. When his mum came to pick him up, his mum and the man argued, and the man pushed his mum. Afterwards the police came to see Nicholas and his mum. Nicholas attended some sessions at nursery in January 2022 and was able to play and socialise with children his own age. In February Nicholas’ house got very cold and there wasn’t much food. He and his mum went to stay with his mum’s friend for a while, but his mum wasn’t very happy. Sometimes Nicholas spent time at his grandma’s house whilst his mum stayed with her friend. One night Nicholas was left with relatives who were children themselves whilst his mum went out to see a neighbour. She didn’t return until the following day when she went to bed. The events that followed are subject to a criminal investigation and thus will not be elaborated upon, but Nicholas was later found, face down in bathwater. Nicholas was unresponsive to treatment and sadly passed away. 6. Consideration and Analysis of Key Practice Episodes To enable the review to meet the Terms of Reference, professionals explored the following key practice episodes with the author. Practice episodes are periods of intervention that are deemed to be central to understanding the work undertaken with Nicholas and his family. The episodes do not form a complete history but are thought key from a practice perspective and summarise the significant professional involvements that informed the review. Key Practice Episodes Pre-Birth Assessment Management of Child in Need Professional Management and Response to the Scalding Incident Professional Response to potential Domestic Abuse Nicholas Final Report 22/12/2022 9 Professional Management and Response to Mum’s Suicidal Ideations. Consideration of the key practice episodes highlighted principal issues and the following questions were formulated to guide the development of an action plan which will address the learning: 6.1. Key Practice Episode 1 Pre-Birth Assessment 6.1.1. In November 2017 Sarah was contacted by a Social Worker from the Multi-Agency Safeguarding Hub in the Local Authority where she had previously been living due to concerns regarding missed midwifery appointments. 6.1.2. Sarah informed that she had moved and was now staying between her mother’s address in Salford and a hostel in Eccles. Consequently, following a telephone call with a Salford Children’s Social Worker at the Bridge7, the Multi-Agency Safeguarding Hub Social Worker emailed a Pre-Birth Assessment8 to Salford that they had previously completed. 6.1.3. It has not been possible to locate or confirm whether the Bridge received the email but given that there were concerns for Sarah and unborn Nicholas, best practice would have seen a transfer meeting between the previous Local Authority and Salford. 6.1.4. On the 4th of December 2017 Sarah contacted the NHS 111 Service for advice and reported that she had missed her 20-week scan, was not registered with a GP, and was living in temporary accommodation. As a result, the Ambulance Service sent a Welfare Notice to the Adult Contact Team9 reporting the concerns and Sarah attended hospital. 6.1.5. An Adult’s Social Worker at the Contact Centre spoke to Sarah on the phone and with Sarah’s consent subsequently referred Sarah to Children’s Social Care. 6.1.6. The Bridge screening Social Worker passed the referral for assessment, but a Social Worker was not allocated to Nicholas until the day after Nicholas had been born. Consequently, the opportunity to complete a Pre-Birth Assessment in Salford had passed. 6.1.7. Whilst good practice was demonstrated post Nicholas’ birth by a midwife on the post-natal ward who contacted the hospital that Sarah had initially booked with to obtain their information, without a Pre-Birth Assessment, Salford did not gain a full understanding of Sarah’s lived experience, mental health, unmet needs, or parenting capacity. Instead following Nicholas’ birth, professional focus was on unstable environment and housing issues as detailed by the screening Social Worker at the Bridge who passed the referral for assessment. Question 1 for Salford Safeguarding Children Partnership: How can partner agencies assure Salford Safeguarding Children Partnership of a robust transfer of information policy to be used when a person presents in Salford with safeguarding concerns from out of area, and when a person with safeguarding concerns moves to another area. 7 All reports or enquiries concerning the welfare or safety of a child in Salford go straight to the Bridge Partnership, 8 The presenting concerns identified had included Sarah booking in late at 13 weeks and 5 days gestation, reporting low mood and anxiety, residing temporarily in her friend’s flat (sharing her friend’s daughter’s bedroom), alcohol use during pregnancy, low Body Mass Index, limited finances, history of abuse from her father, not able to confirm baby’s father (two possible fathers), and a limited support network. 9 The adult social care contact team is a single-entry point to streamline social care. Nicholas Final Report 22/12/2022 10 Consideration needs to be had of a national, uniformed, transfer information policy, and this learning should be brought to the attention of the National Child Safeguarding Practice Review Panel. 6.1.8. As an unborn and a new-born Nicholas was totally dependent on others for his care. In the womb Nicholas needed his development to be monitored by health professionals, and Sarah’s physical and emotional health to be checked to ensure that he was protected from the effects of any maternal mental ill health, physical violence, or abuse towards his mother, and maternal substance misuse. 6.1.9. As a new-born Nicholas needed Sarah to respond quickly to his physical and emotional needs, interact with him and observe that he was always safe, warm, and fed. Sarah’s own early experiences may have impacted her ability to do this – the initial Pre-Birth Assessment had already deemed that without support Sarah may be unable to meet Nicholas’ needs. In the absence of professionals in Salford gaining an understanding of Sarah’s parenting abilities, Nicholas was vulnerable. 6.2. Key Practice Episode 2 Management of Child in Need 6.2.1. Nicholas was subject to a discharge planning meeting after his birth at the hospital. This was good practice as it provided an opportunity for Sarah and Nicholas’ information and circumstances to be shared multi-agency. However, it was established by frontline workers attending the learning event that whilst Children’s Social Care, the ward midwife, and the community midwife were present at the meeting, the Health Visitor – the professional who would be a constant in Nicholas’ life from 10-14 days old until school age, was not invited. 6.2.2. This omission was discussed at the learning event, and it was thought that a Health Visitor’s attendance at discharge planning meetings of new-born babies was not being deemed necessary as the midwife would be present. However, it would appear that there is a gap in information sharing and handover discussions when a case transfers from a midwife to a health visitor that in this case was widened with the omission of the Health Visitor being at the discharge planning meeting. Question 2 for Salford Safeguarding Children Partnership: How can Salford Safeguarding Children Partnership be assured around discharge processes and the flow of information from all maternity services that support Salford women? 6.2.3. An action from the discharge planning meeting was for Sarah to attend an appointment with a psychiatrist and records show that Sarah met with a psychiatrist from Pennine Care ante-natal clinic prior to her and Nicholas being discharged from the hospital. 6.2.4. Unfortunately, this review has been unable to locate original documentation regarding this appointment, but professionals have reflected that a multi-agency update from the psychiatrist could have assisted the planning of support that Sarah would need to parent safely and effectively. Nicholas Final Report 22/12/2022 11 6.2.5. This omission of information sharing should be explored by Pennine Care and deliberated to ensure that any safeguarding concerns are being reported. 6.2.6. Also, at the discharge planning meeting, a decision was made to support Nicholas under the auspice of Child in Need and a children and families assessment commenced. 6.2.7. There is evidence of good support being offered to Sarah at this time but overall, whilst Sarah’s immediate issues were addressed, a lack of thorough exploration and curiosity into Sarah’s past experiences resulted in professionals failing to gain any understanding of how Sarah’s history could affect her current and future behaviours or parenting capacity. 6.2.8. It is important to explore and address trauma correctly because many individuals who are living with trauma continue to feel unsafe, anxious and struggle to trust others. Therefore, trauma is often a barrier to an individual feeling safe enough to trust a person who has the potential to help. 6.2.9. Priority work regarding trauma informed practice is set to continue for practitioners in Salford with further training, workshops and events, and the recruitment of Trauma Responsive Practitioners. 6.2.10. Analysis of the Child in Need process for this review has been hindered because there is no official record of the Child in Need meetings, plan and/or actions. 6.2.11. A plan should have been co-produced between professionals and Sarah, and should have ideally included: • the desired outcomes, • who will do what, how and by when to mitigate any risks to Nicholas, • the nature and frequency of professional contact, • the frequency of Child in Need meetings, and • a contingency plan in case actions were delayed, not implemented or there was a change in circumstances. 6.2.12. This plan should then have been shared, in writing, with Sarah and the professionals involved. The effect of no written plan being shared should not be underestimated. Without it neither professionals nor Sarah would have been clear about what needed to be done. And it would not have been possible to accurately measure the impact of the intervention being completed with Sarah and Nicholas. 6.2.13. This review has been unable to confirm the frequency or number of meetings that convened but has been informed that the meetings were undertaken when the Health Visitor and the Social Worker conducted joint visits. They did not include any other professionals who were working with Sarah and Nicholas, and it has now been recognised that housing and the Early Help Practitioner could have been included. 6.2.14. In addition, consideration could have been to include Nicholas’ grandmother in the Child in Need process as she was a person who supported Sarah, and Nicholas spent time at her address in her care. Nicholas Final Report 22/12/2022 12 6.2.15. The review has been reassured that this informal situation could not happen now; meetings can no longer go unrecorded owing to Liquidlogic10 which has been used in Salford since August 2021. 6.2.16. Good support was offered to Sarah with housing issues during the children and families assessment and the Child in Need process. In March 2018 Sarah had secured a tenancy. The home is referred to as clean but sparse. The sparseness could have been an indication of Sarah’s financial problems. Given the known relationship between poverty and neglect it would have been good practice to have undertaken a Graded Care Profile. 6.2.17. Ofsted inspected Salford Children’s Social Care Services soon after Nicholas’ case had been closed in 2018 and found that the local authority’s neglect tool was not being consistently used to good effect by social workers or partner agencies. 6.2.18. Subsequently identifying and addressing the unmet needs of children became a priority for Salford Safeguarding Children Partnership and the current Neglect Strategy was revised. In March 2019 practitioners were updated about the tool in a multi-agency workshop. And the Welfare Rights and Debt Advice Service provided practitioners with awareness training on the relationship between poverty and neglect. 6.2.19. Neither the children and families assessment, or the Child in Need process explored Sarah and Nicholas’ culture - this review has not seen any reference to any professional, who encountered Sarah and Nicholas, striving to understand their culture. Yet, understanding someone's culture can help you better empathise with them and consider whether any changes are needed to support packages to ensure that a service user is not put a disadvantage. 6.2.20. It is not possible for a professional to learn of every culture, but there are generic skills to competence, such as - open-minded awareness of the differences that cultural background can produce. This should be regardless of whether a person is foreign born, or born in the United Kingdom, and should not be influenced by how long a person has lived in the United Kingdom and/or has sought to integrate. Question 3 for Salford Safeguarding Children Partnership: How can partner agencies assure Salford Safeguarding Children Partnership that work is being undertaken to remind and encourage professionals to practice an open-minded awareness of the differences that cultural background can produce. 6.2.21. A better understanding of Sarah’s cultural background may have offered some insight into her engagement with Social Workers and health appointments. For example, did Sarah’s cultural beliefs influence her decision-making process around attending follow up appointments for her mental health. This is significant given that culture can significantly impact various aspects of mental 10 The Liquidlogic Children's Social Care System is a case management solution and supports all aspects of social work with children. It has been specifically developed by and for practitioners to support case management and record-keeping for children in need, looked after children, adoption, and child protection cases, as quickly and simply as possible. Liquidlogic configures workflow and workers cannot move on to the next stage of a process without first completing the previous stage. Consequently, a meeting must always be created, in timescale. Nicholas Final Report 22/12/2022 13 health including the perception of health and illness, treatment seeking behaviours and coping styles. 6.2.22. All professionals must be sensitive to the risk of intercultural misinterpretation in health and social care. 6.2.23. This review has established that information that was shared during the Child in Need intervention, was not always appropriately acted upon. On the 3rd of May 2018 an Early Help Practitioner undertook an unannounced visit, and the door was answered by a male who introduced himself as Nicholas’ uncle. He said that Sarah was ‘working away’, and he was caring for Nicholas. The case worker asked the uncle why he wasn’t in school, and he responded that school was shut. The case worker has reflected that at this point, given that Nicholas would have been just under 13 weeks of age and the uncle, 11 years old at this time, she could have demonstrated further professional curiosity and asked more questions of uncle about how often he cared for Nicholas, for how long, and why. But it was good practice that the worker logged the incident in supervision and that the concerns were then raised with Nicholas’ Social Worker and Health Visitor. 6.2.24. The Social Worker spoke with Sarah the following day (when Sarah cancelled a Child in Need joint visit), but the issue was not addressed - it is possible that the Social Worker was not aware by this time. Following this, Sarah changed her telephone number and did not have any further contact with the Social Worker until the 17th of May 2018. There is nothing to evidence that the uncle caring for Nicholas was discussed on this occasion either. 6.2.25. The final decision to close Child in Need appears to have been made upon Sarah returning to the United Kingdom, when in August 2018, following a meeting between Sarah, the Social Worker and the Health Visitor, Sarah said she no longer felt as if she needed support. Whilst it is acknowledged that in the absence of child protection concerns, if a parent does not want to engage with services, there is little than can be done, no further multi-disciplinary discussion was had regarding closing Nicholas’ case. 6.2.26. The other services involved with Nicholas were the housing association, the GP Practice, Greater Manchester Mental Health Primary Care, and practitioners from Early Help. Early Help were informed by email on the 17th of July 2018 that the family was to be closed to Children’s Social Care and support would revert to Universal Services. The other services were not consulted or informed. Question 4 for Salford Safeguarding Children Partnership: How can Children’s Social Care assure Salford Safeguarding Children Partnership that Child in Need processes are being followed and managed, and how can all partner agencies assure Salford Safeguarding Children Partnership that professionals from all agencies know when and how to escalate any concerns? 6.2.27. All professionals at the learning events for this case demonstrated a good theoretical understanding of professional curiosity. Yet it was not always recognised in practice around Sarah Nicholas Final Report 22/12/2022 14 and Nicholas. Had the professionals involved with Sarah and Nicholas demonstrated more professional curiosity there could have been more information fed into the Child in Need process. 6.2.28. For example, a lack of professional curiosity on the part of the housing officers involved, resulted in no contact being made with the Social Worker to seek more information once they knew a Social Worker was involved. 6.2.29. More professional curiosity to explore Sarah’s finances by all professionals involved, could have ensured that she was being offered effective debt advice and money management advice as part of a multi-agency approach. It may also have encouraged Sarah to disclose other things as part of the conversations. For example, any potential exploitation11 she was being subject to, and/or any substance abuse that was draining finances. 6.2.30. Continuous professional curiosity is an important skill that all professionals must develop. 6.2.31. In his first few months, Nicholas was settling well into a routine. He was presenting as content and calm when seen by professionals but over time his contact with professionals decreased as his mum was not always available to present him for appointments. 6.2.32. Nicholas who had bonded well with Sarah, wasn’t able to be with his mum for a period when he was only 5 months old. He had already lived in four houses since his birth, and he now found himself in the care of a friend of his mums at another house. 6.2.33. It was good that Nicholas was getting to know his extended family but sometimes he was left alone in the care of his uncle which wasn’t safe as his uncle was a child himself. This put Nicholas at risk of injury to inadequate supervision. 6.3. Key Practice Episode 3 Professional Management and Response to the Scalding Incident 6.3.1. In July 2018 Nicholas was brought to the Accident and Emergency Department at North Manchester General Hospital by his grandparents after he had sustained scalds from a hot shower. 6.3.2. The hospital referred Nicholas to Children’s Social Care and Nicholas was transferred to Royal Manchester Children’s Hospital specialist burns unit. 6.3.3. The consultant at the burns unit deemed the injury to be consistent with grandma’s explanation (Grandma’s initial explanation had appeared inconsistent but further exploration explained the irregularities) and to be accidental. 6.3.4. The Royal Manchester Children’s Hospital did not make any referrals because the Consultant discussed his expert opinion with Children’s Social Care, and it was agreed that a section 47 was not necessary. 11 Trafficking was raised as a concern for Sarah at the Discharge Planning Meeting, but this review has been unable to establish how the concern arose and it was not explored in any subsequent assessment. Nicholas Final Report 22/12/2022 15 6.3.5. Practitioners at the learning event were concerned that this decision deviated from the Bruising Protocol for Immobile Babies and Children12 which includes burns and scalds. But consideration of the protocol exposes that it is acceptable not to refer. However, the reason must be documented in detail alongside the names of the professionals taking this decision. 6.3.6. Such practice has recently been supported by government advisors who, although they have not reiterated that scalding should be included, have said that pre-mobile infant bruising should not automatically prompt section 47s13. The Child Safeguarding Practice Review Panel said it did not support policies that required section 47s or other interventions “without an initial appraisal of the circumstances of the presentation”. 6.3.7. Instead, it proposed that there should be: • a review by a health professional with appropriate expertise to assess the nature and presentation of the bruise and any associated injuries, and whether there is any evidence of a medical condition that could have caused or contributed to the bruising, or a plausible explanation for the bruising; and • a multi-agency discussion, always including the health professional who examined the child, to consider any other information on the child and family, including known risks, and to jointly decide whether any further assessment, investigation or action is needed to support the family or protect the child. 6.3.8. The only multi-agency discussion regarding Nicholas was between the consultant and Children’s Social Care. A multi-agency discussion involving other professionals who knew Nicholas and his family was not convened. But given the concerns that were known at this time regarding the problems engaging consistently with Sarah, and the history of Nicholas not being taken to scheduled health appointments, would have been beneficial to assess Nicholas’ situation and on-going support. 6.3.9. Such a meeting would not have been convening to establish ‘blame’ for Nicholas’ injury but for professionals to discuss how best Sarah and the family could be helped to keep Nicholas safe and to care for his injuries. It would have also offered an opportunity to discuss multi-agency whether given the incident, Child in Need should remain open for a further period. 6.3.10. This review has been assured that such meetings are now convening. 6.3.11. Nicholas, at 6/7 months old was unable to verbalise his pain after the scalding injury. Following his discharge from hospital Nicholas was fully dependent upon Sarah and the other adults in his life, to care for his wounds and to present him at appointments for professional scrutiny. Good care of the burns was crucial. The skin would have taken many months to heal completely and left permanent scarring. 6.3.12. The psychological impact of the incident on Nicholas cannot be measured or understood. 6.4. Key Practice Episode 4 Professional Response to potential Domestic Abuse 12 5.2.3 Bruising Protocol for Immobile Babies and Children (proceduresonline.com) 13 Bruising in non-mobile infants (publishing.service.gov.uk) Nicholas Final Report 22/12/2022 16 6.4.1. In November 2017 Council Housing Services became aware during a homelessness assessment that Sarah had been a victim of stalking where she had previously lived. As mentioned, housing was not part of the Child in Need process, and partly as a result, no housing information was shared with other agencies. There was a missed opportunity to share this information when the Social Worker contacted housing by email at the end of January 2018. 6.4.2. Sarah was victim of blackmail in 2019 when she reported that someone was blackmailing her and threatening to post inappropriate photographs on social media. This incident was dealt with by Police from a different force as it was related to Sarah’s ex-partner and his new girlfriend who did not live in Salford. 6.4.3. It is unclear whether this was considered in the context of domestic abuse or exploitation in the context of Sarah’s extensive movements across the United Kingdom and overseas. 6.4.4. The next domestic abuse incident reported was in Salford on the 27th of November 2021. (This was the first reported incident in Salford since Sarah had been a child and two incidents had been reported between her and her mother.) On this occasion Sarah had an altercation with, and alleged that she was pushed by, her ex-partner who appeared to have a caring role in relation to Nicholas. Sarah had called at her ex-partner’s house to collect Nicholas, but he had refused to allow her to take Nicholas home. This crime was assessed as standard risk. 6.4.5. This incident was not shared with Children’s Social Care. Greater Manchester Police have confirmed that the criteria were not met as this was the first reported crime that Nicholas was linked to and was standard risk. Had this been the third incident at standard risk that Nicholas had been linked to, then it would have been referred. 6.4.6. However, expected practice should have seen an Operation Encompass notification being sent to the Health Visitor following this incident which would have provided the opportunity for the Health Visitor to explore the incident with Sarah and Nicholas further. 6.4.7. This review has been assured that the Greater Manchester Police Public Protection Governance Unit are currently developing training programmes to address the referral processes made by Greater Manchester Police to external agencies and the details of this review will be brought to their attention for the omission of the Operation Encompass notification to be addressed. 6.4.8. Later in February 2022 Sarah disclosed during an appointment with a mental health practitioner that she had always been ‘looked after’ by the men she had been in relationships with, and she had wanted for nothing. There is no evidence of these comments being explored in the potential context of domestic abuse, coercive relationships, and exploitation. There was a missed opportunity here to see Sarah alone (she presented with a friend) and explore her understanding of abuse. There was also a missed opportunity to contact the Health Visitor to share this information and the potential to check Nicholas was safe and well. 6.4.9. In the absence of the incidents/disclosures being shared multi-agency, the full picture as penned in this section of the report went unrecognised by the professionals working with Sarah and Nicholas. Nicholas Final Report 22/12/2022 17 6.4.10. Nicholas was too young to tell anyone of any physical or verbal arguments he had seen or heard people have with his mum. He was unable to verbalise if he had been scared or if anyone visiting his mum had been verbally or physically violent towards him. 6.4.11. The males spending time in Nicholas’ home with him, and his mum, remain unknown. Any potential risk they posed was unchecked. 6.5. Key Practice Episode 5 Professional Management and Response to Mum’s Suicidal Ideations 6.5.1. On the 22nd of February 2022 Sarah attended her GP Practice distressed and suicidal. Because the surgery did not have the capacity to review Sarah there and then, the practice contacted 999. 6.5.2. Sarah also called 999 herself. Sarah reported that she could not keep herself safe and wanted to jump off a building. She said that she wasn’t a good mum and couldn’t provide for her child. The clinician asked Sarah who was caring for Nicholas, and she advised that he was with his maternal grandmother. 6.5.3. The circumstances were deemed to be low risk. Sarah had told the clinician that she was not going to take any action, that Nicholas was safe with a relative and that Sarah was being supported by a friend. 6.5.4. The ambulance service sent a Welfare Notice to Adult Social Care reporting that Sarah had been taken to Salford Royal Hospital feeling suicidal regarding financial difficulties. It was acknowledged at the learning event that the ambulance service should also have sent a referral to Children’s Social Care. The Clinician has since reflected that they considered that by raising a safeguarding concern for Sarah, the information would also be shared across to Children’s Social Care. Feedback has now been given explaining that this is not the process and that a separate concern should have been raised for Nicholas in this situation. 6.5.5. The next service to learn of Sarah’s suicidal ideations was the Emergency Department at the hospital. Professionals at the learning event discussed how this was a missed opportunity to further explore who was caring for Nicholas and to make a referral to Children’s Social Care for assessment and support. The review has been informed that this is a process already embedded into training and therefore needs to be reinforced with staff. The review has been unable to establish the rationale as to why this was not done directly from the practitioners involved. 6.5.6. Sarah was then reviewed by the Mental Health Team at the hospital who discharged Sarah back to the care of her GP with a request to prescribe an antidepressant. Professionals at the learning event identified that the Mental Health team could have referred Sarah to Children’s and Adult’s Social Care given that she had disclosed during their consultation, having a child, experience of potentially controlling relationships, and having no heating, money, or food. 6.5.7. An internal three-day review undertaken by Greater Manchester Mental Health Safeguarding team identified the same and consequently held a reflective session with the practitioners involved and a learning event with the whole team in July 2022. The sessions raised the awareness of practitioners to recognise neglect and vulnerability, and safeguarding concerns when there is no immediate risk to either the patient or others. Nicholas Final Report 22/12/2022 18 6.5.8. Upon receipt of the ambulance referral, Children’s Social Care were not notified. Practice should have seen a Social Worker at Adult Social Care, upon receiving the ambulance welfare notice - which noted concerns relating to Sarah’s mental health and outlined that Sarah had a young child, sharing the information relating to the hospital attendance with Children’s Social Care. Question 5 for Salford Safeguarding Children Partnership: How can Adult Social Care assure Salford Safeguarding Children Partnership that practitioners are aware that if an adult referred to Adult Social Care has a child; best practice is to liaise with Children’s Social Care? 6.5.9. Nicholas was four years old when Sarah reported experiencing suicidal ideations. Because his home was cold and there wasn’t much food available, he and his mum went to stay in another house with a friend of his mums. Nicholas’ mum was different to how she usually was. Nicholas could see that she was sad. Nicholas was sometimes taken to his grandma’s house when his mum was very sad. Nicholas couldn’t understand. 7. Other Considerations 7.1. Drowning 7.1.1. There are concerns around the number of recent deaths due to drowning in the Greater Manchester area. Nicholas’ case is different due to his age – professionals expected that a four-year-old child would be able to get out of the bath and alert family if he was distressed. 7.1.2. Work is ongoing in Salford by partners in relation to safeguarding babies and older children and water safety in and out of the home. 7.1.3. The number of incidents must be brought to the attention of the National Children’s Safeguarding Practice Review Panel to assess whether this is a national interest. 7.2. The Effects of the Covid pandemic on the support offered to Nicholas 7.2.1. In November 2019 Nicholas was seen by the GP regarding a keloid scar. The following month, in December 2019 a coronavirus emerged which was swiftly labelled a pandemic. Every country was advised to take urgent action, and major disruption followed. In order to manage the impact of the virus and infection control, several adaptations to working practices had to be made and the United Kingdom Prime Minister announced a national lockdown on the 23rd of March 2020. 7.2.2. A month after the lockdown had begun, Sarah notified the housing association that she and Nicholas were stuck abroad with family and would have to remain there until flights to the United Kingdom resumed. It has not been possible to confirm the exact date that the family flew out of the United Kingdom. 7.2.3. The main effect of the Covid pandemic on Nicholas was that he went unseen by professionals in the United Kingdom for almost two years and during this time his health and education needs went unmet (in the United Kingdom). 8. Good Practice Nicholas Final Report 22/12/2022 19 The agency reports submitted to this review and the discussions around Nicholas, have highlighted examples of good practice14 from professionals involved with her and her family. Including: • There was good practice from the midwife on the post-natal ward who contacted the hospital where Sarah had initially booked to obtain information in relation to Sarah’s antenatal care and did re-refer the case to Social Care. • Northern Care Alliance records indicate regular contact between the Health Visitor and the Social Worker with both committed to keeping track of Sarah’s whereabouts and both engaging in work with Sarah to support her in improving Nicholas’ home circumstances. • The Health Visitor was persistent in her attempts to contact Sarah • Good practice of 111 to inform Adult Social Care of concerns of a possible vulnerable mother in December 2017. • Adult Social Care displayed good practice in December 2017 by consulting with Sarah before closing the case, after ensuring that appropriate services were in place to support her. • Nicholas was not registered at the GP Practice, albeit Sarah was, so it was good practice the surgery had offered to support him with his immunisation schedule despite not being a registered patient. • Early Help Practitioners used all methods of communication to engage with Sarah, these included telephone, text, email, and unannounced visits. Updates were exchanged with the Social worker and Health Visitor. 9. Improving Systems and Practice 9.1. Developments Since the Scoping Period of the Review Agencies have already made some important amendments to practice since the scoping period of this review. Some have been included in the body of this report. Other developments include: 9.1.1. Early Help involvement with Nicholas, crossed over a period of service re-structure. The practitioners allocated at the time had a focus in children aged 0-5 years, were not expected to complete an assessment and were intervention led only. This has now changed, and all Early Help Practitioners follow the new workflow including Early Help assessment for any request made for support. 4 weekly case supervisions are embedded and a clear escalation process in place. Also, at the time of the involvement, there were no clear expectations on ‘child seen’. This has now changed as part of the Early Help service redesign and a clear ‘child seen’ guidance document has been created to support practice. Expectations are clear as to how often a child is seen, how their voice is captured and how this is recorded and discussed in case supervision, assessment, and reviews. Training and support is in place on a weekly basis on how practitioners can capture and record the voice of the child. 9.1.2. Manchester Foundation Trust have since reviewed and updated their own policies on Preventing and Managing Missed Health Appointments for Children and Young People (including unborn babies) and Adults at Risk of Abuse 14 Good practice in this report includes both expected practice and what is done beyond what is expected. Nicholas Final Report 22/12/2022 20 9.2. Conclusion 9.2.1. Sarah’s information was not effectively transferred from the Local Authority where she previously lived, to Salford during the Pre-Birth period. This led to Salford not having a full understanding of Sarah’s parenting capacity and/or the potential risks to Nicholas stemming from Sarah’s past experiences, mental health, and behaviours. Consequently, following Nicholas’ birth, professional focus was on practical support and addressing an unstable environment and housing. 9.2.2. In January 2018 Nicholas was subject of a children and families assessment. There was a missed opportunity during this assessment process to start from Sarah’s beginning and explore Sarah’s and Nicholas’ ethnicity and cultural background. Although not immediately obvious to professionals working with Sarah and Nicholas, this was significant, as a better understanding of Sarah’s cultural background may have offered insight into Sarah’s interpretation of support services, health interventions, abusive behaviours, and parenting. This would have helped professionals to tailor a support plan specific to Nicholas’ needs, with Sarah’s full co-operation. 9.2.3. An overall lack of thorough exploration and professional curiosity into Sarah’s past experiences as a child, and an adult, resulted in professionals failing to gain any understanding of how Sarah’s history could affect her current and future behaviours or parenting capacity. 9.2.4. The Child in Need process was poorly documented but reflection of the process with professionals has evidenced that not all the professionals working around Sarah and Nicholas were involved. Consequently, information was not effectively shared multi-agency. In addition, there is no official record of the Child in Need plan. It was not shared in writing with Sarah, or the professionals involved and without it neither professionals nor Sarah understood what needed to be done or were able to measure the impact of intervention. 9.2.5. Sarah often reported being away from home and consequently due to subsequent cancelled appointments and no access visits, Nicholas was seen less often. This made it increasingly difficult for professionals to gain an understanding of his lived experiences. This was further hindered because throughout the scoping period of this review, his information was not always shared effectively. Notably there was a missed opportunity to discuss Nicholas multi-agency when Nicholas suffered scalding. 9.2.6. When Nicholas was reportedly out of the country, he was totally hidden from professionals in the United Kingdom. Closing his Child in Need case further removed him from professional eyes. 9.2.7. Post Nicholas being closed to Children’s Social Care, Children’s Social Care should have been made aware when, in February 2022, Sarah experienced suicidal ideations. The omission of this communication prevented services being able to fully assess any potential risk to Nicholas at this time and understand how it was for him when his mum was unwell. Appendix 1 - Terms of Reference The panel agreed the following terms of reference: 1. How well did professionals understand the ethnicity and cultural background of the family? Nicholas Final Report 22/12/2022 21 2. What did professionals understand about mother’s lived experience as a child and adult respectively and to what extent did this impact on her ability to parent? (Include alcohol, substances, Domestic Violence) 3. To what extent did professionals understand the Nicholas’ lived experience, the relationships between the family members and significant others (what role did the extended family members play in Nicholas’ life)? 4. How effective was information sharing across borders during the Pre-Birth Assessment period? How did this impact on the offer of support available to the mother when she moved to Salford? 5. How effective was safeguarding practice in Salford? (Focus on Pre-Birth Assessment period, Children and families assessment, Child Protection Processes in relation to the scalding incident in July 2018). 6. To what extent did agencies support the mother to engage with services? Did professionals understand the barriers to engagement at that time? Explore the escalation policies 7. Was Nicholas a hidden child to services given that he was not supported at a statutory threshold? 8. To what extent did the COVID-19 pandemic impact on multi-agency safeguarding practice? |
NC52820 | Death of a 3-month-old infant in March 2022. It is thought Isabels death was an accident linked to an unplanned sleeping environment where drugs and alcohol were present. The mothers extended family were known to services regarding domestic abuse. Learning themes include: responding to the needs of the child, including the unborn child; safeguarding procedures around co-sleeping; considerations of the pre-birth assessment pathway; male figures in the family and fathers engagement with antenatal and post-natal services; recognition of potential indicators of abuse; issues arising from moving to different local authorities; parents previous involvement with adult or childrens services; disguised compliance; response to lack of engagement and Did Not Attends (DNA); interaction of services during the antenatal and perinatal period; and assessment of parental needs including domestic abuse, mental health issues, substance misuse and difficulties with housing. Recommendations for the local safeguarding partnership include: review the antenatal pathway to ensure the referral system identifies concerning families of unborn babies; oversee a review of the local maternity safeguarding hub; ensure all partner agencies have systems to actively consider fathers and other significant males in assessments; review practices about how safe sleeping messages are delivered; oversee an audit of multi-agency practice in relation to domestic abuse at the front door; oversee partner agencies reviews of their supervision practices and ensure managerial oversight of decisions in relation to children and unborn babies where there are safeguarding concerns; and ensure robust liaison between Midwifery services and GPs for pregnant women, including exchanging information about both parents (and partners) during pregnancy.
| Title: Local child safeguarding practice review (LCSPR) Isabel. LSCB: Medway Safeguarding Children Partnership Author: Jane Doherty Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 MEDWAY SAFEGUARDING CHILDREN PARTNERSHIP Local Child Safeguarding Practice Review (LCSPR) Isabel Independent Social Work Consultant Jane Doherty September 2023 2 1 Introduction 1.1 This Child Safeguarding Practice Review was commissioned by Medway Safeguarding Partnership after the death of a 3-month-old baby (known as Isabel in the report) in 2022. The cause of death is unascertained at the time of writing, but she was known to services and was subject to a child protection plan. It is thought (but not confirmed) that Isabel’s death was a tragic accident linked to an unplanned sleeping environment where drugs and alcohol were present. Significant to note, however is that both parents and Isabel tested positive for Covid-19 after the death was discovered. 1.2 The death was notified to the Safeguarding Children Partnership in Medway and a Rapid Review meeting took place a few days later. Members felt that there was learning for the Partnership from the circumstances of this family and recommended a Child Safeguarding Practice Review. They notified the National Panel who agreed with the recommendation. 1.3 At the time of writing, police enquiries and the coroner’s inquest were ongoing. 2 Terms of Reference 2.1 The Terms of Reference were agreed by the panel. Agencies involved with the family were asked to analyse their involvement via a brief written submission. To ensure that the review was proportionate, the period covered is the preceding year i.e., from May 2021 up to the date of the child’s death in March 2022. This covers services provided during the pregnancy and the few months of Isabel’s life. The review period is outside of the main impact of COVID -19, but the panel asked agencies to consider the residual impact of the disruption caused during this time. 2.2 The report is based on the agencies’ submissions and a practitioner event with key staff that had worked with the family and knew them. 2.3 In line with expectations, the family were contacted to contribute to the review. To date, they have not responded but the panel were keen that the door be left open for them to change their minds prior to publication. 2.4 The broad areas included in the Terms of Reference that the panel agreed were the most important to look at were: • What were the key events and relevant points/opportunities for assessment and decision making in relation to the child and family? • How well were the needs of the child, including the developing child in utero responded to and the lived experience of the child once born? 3 • Were there considerations of the pre-birth assessment pathway? What would the response have looked like if concerns around drugs and alcohol use had been considered earlier? • The needs of both parents? What was known about male figures in the family? What did father’s engagement with antenatal and post-natal services look like? • Recognition and assessment of potential indicators of abuse, e.g., the impact of the trilogy of vulnerabilities/risk: (mental health, drugs and alcohol, domestic abuse) • Issues that arose when the family crossed borders and moved to different local authorities • Issues of disguised compliance • The parents’ history including other previous involvement of either parent with adult or children’s services, the police or probation, MARAC (Multi-agency Risk Assessment Conference) for high risk domestic abuse, Housing, GP etc. • How well did policies and procedures assist in safeguarding the unborn or preverbal/ non mobile baby including co-sleeping? • Consideration of local multi agency and single agency policies or procedures • Did actions accord with assessments and decisions made? Were appropriate services offered/provided or relevant enquires made, in light of assessments or presenting factors? Were records systematically reviewed to evaluate and assess risk? • Should the lack of engagement and DNA’s (Did Not Attend) have raised concerns and have been escalated? • During the antenatal and perinatal period particularly, how did services interact with each other when they were concerned about disguised compliance, incomplete information, or failure to engage? • How well were parental needs assessed e.g., domestic abuse, mental health issues, substance misuse and difficulties with housing? Was interaction between services sufficient in identifying information and to support decision making needed? • How was supervision and professional curiosity and possible disguised compliance explored in supervision? How do we support practitioners to work with uncertainty? • Was the application of threshold appropriate given the available information e.g., what was known and knowable in the system? • What recurring issues has this review identified for the service / multi agency? How are these being addressed within the agency? 4 3 Summary of agencies’ contact with the family 3.1 The agencies’ submissions as part of the review process have been co-ordinated into a combined chronology and briefly summarised here. Further information is provided in subsequent sections to add context where relevant. This is not intended to be an exhaustive list of day-to-day contacts but highlights the main interactions and highlights multi-agency activity. 3.2 Mother was known only to universal services prior to Isabel’s birth. Mother had previous relationships where she was a victim of domestic abuse, and this was also a feature in her extended family. During the review period, she was involved with two men, one of whom was the father of the baby. Both men were well known to police and probation services due to violence and aggressive behaviour particularly against women. 3.3 Adult A (the baby’s father) was presented to MARAC1 in Medway twice and assessed as a high-risk offender. He has another child he is prohibited from having any contact with, and a non-molestation order in relation to that child’s mother. 3.4 Mother met Adult B on the internet, and he has a history of assault and battery convictions. Practice Episode: May – June 2021. Mother booked her pregnancy. 3.5 In May 2021 Mother booked her pregnancy in Medway. At the booking appointment, she disclosed significant previous drug and alcohol use (6/7 months previously) but reported that this had stopped by the time of the booking. Screening for domestic abuse took place which Mother denied. She described her relationship with Adult A as ‘on and off’ and it was not clear at this stage what part he would play in the baby’s life. 3.6 Due to the disclosures about potential drug and alcohol misuse, the midwife made a referral to the Medway Maternity Safeguarding Midwifery Hub2. The referral was not accepted as the concerns about drug use were thought to be historical. Alcohol misuse was not included in the referral and the drug use on its own was thought not to warrant inclusion for discussion at the hub. There were no major concerns in relation to the pregnancy at this point and further routine appointments were booked as the pregnancy progressed. 1 Multi Agency Risk Assessment Conference (MARAC) is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, probation, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists. 2 The Safeguarding Midwifery Hub in Medway and Kent is an established multi agency forum where concerns about vulnerable pregnant women are discussed to plan support for them. 5 PRACTICE LEARNING POINTs Poor engagement with and exploration of father’s and other significant males in children’s lives is a familiar theme in multi-agency case reviews. This is explored further in paragraphs 4.32-4.36 The Safeguarding Medway Maternity Safeguarding Hub is an established multi agency forum where concerns about vulnerable pregnant women are discussed to plan support for them. The referral to the hub for this mother was not accepted as the concerns were not thought to warrant it. The information was, however, incomplete as information about previous excessive alcohol use was omitted. The review has highlighted a number of learning points in relation to this forum and more is said about this in paragraphs 4.5 and 4.6. 3.7 During July 2021, Mother DNA’d 2 antenatal appointments. These were rebooked and she did then attend a third one when it was offered. Throughout the pregnancy, lack of contact and DNAs were an ever present feature. Practice Episode: August - October 2021. Domestic abuse incident with extended family 3.8 Mother and Adult A were staying with Mother’s extended family in August 2021. Kent police responded to a domestic incident at this address when an argument occurred between Mother’s stepfather and Adult A as stepfather did not want him staying at the property. A domestic abuse risk assessment was rated as standard but neither Mother nor Adult A were spoken to as they were not at the property when the police arrived. The informant had noted that there was a pregnant female at the home and there was another child present (Mother’s younger sibling). Information about the pregnancy was not passed to the officers dealing with the incident. 6 3.9 Later in the month a further antenatal appointment was missed by Mother and in response, the midwives commenced a DNA checklist to monitor her attendance. Mother was then seen at the beginning of September. 3.10 In September, Mother continued to be inconsistent with her attendance at antenatal appointments. She DNA’d four appointments in this month and attended three. There were no concerns noted at the appointments she did attend. Midwives were persistent in trying to engage her, even suggesting that she book closer to where she was living (Swale). She declined to do so, and the pattern continued in October. Some appointments were missed but then others were attended. 3.11 Mother moved to temporary accommodation in October 2021. 3.12 NB In September a strategy meeting was held by Medway CSC (Children’s Social Care) in relation to Adult A’s other child and a non-molestation order was granted because of Adult A’s aggressive behaviour towards his ex-partner. This activity was not linked to this family at the time because this pregnancy was unknown to social care and the police. PRACTICE LEARNING POINTs Good practice was seen in the midwives’ persistence in offering alternative appointments for Mother and the commencement of a DNA checklist to track her attendance. The review has highlighted some gaps in practice in relation to the DNA checklist, which was incomplete, nor was it clear whether the DNAs should be consecutive or non-consecutive. This is explored further in paragraphs 4.10 – 4.13 Practice Episode: November 2021 – Isabel is born. 3.13 On November 11th Mother DNA’d another ante-natal appointment. The baby’s birth was imminent at this point and so the midwife contacted the safeguarding team for advice. The midwife was advised to contact CSC in Medway to check for previous history, asked to explore concerns other than the DNAs, complete a maternity support form and do a home visit. The safeguarding midwives expressed concerns about possible disguised compliance and DNA’s, hence the number of tasks. The tasks were not completed – possibly due to the proximity to the birth which happened a few days later. 3.14 Isabel was born early (36+4 weeks) in mid-November. Mother gave birth alone (i.e., no birthing partner or family members) but there were no significant concerns noted and Mother and baby were discharged home the following day. Mother was allocated further temporary accommodation, so moved again the day after being 7 discharged. It is unclear how much time she spent there as she also spent time at her parents’ address (the address she was discharged to). The pattern of DNAs continued with midwives and subsequently the health visitor after the baby’s birth. Mother attended just enough appointments to allay professional concern. The family were placed on the health visitor’s targeted support caseload, as additional needs had been identified e.g., the baby was premature, and Mother was still in temporary accommodation. Mother was allocated 28-day care from the midwifery service. 3.15 It is unclear how much time (if any) Mother spent with her family after the birth of the baby, but it seems that at the end of November, she transferred health visiting services from Kent (Swale where her family lived) to Medway. Despite various attempts, mother and baby were not seen by professionals between 24 November and 13 December. On the 13 December they were seen and discharged from midwifery. Again, no concerns were noted but midwives were unaware at that point that the police had responded to a domestic abuse incident on the 9 December. PRACTICE LEARNING POINT It is not completely clear why the tasks advised by the safeguarding midwifery team were not carried out. The consequence of this was that information uploaded to the system was disjointed as both the Maternity Safeguarding Support Form and the DNA checklist were incomplete. A period of sickness in the management group meant that these were not followed up by another manager. A new system is now in place to ensure that cover is available in periods of absence. Designated safeguarding professionals play a vital role in the reliability of the safeguarding system as a whole, and therefore advice given by them should be treated as a priority. This is explored further in 4.14 - 4.17 Practice Episode: December 2021 – Domestic abuse incident leads to CSC assessment. 3.16 On the 9 December, the police received a report that Mother had been assaulted outside her home by Adult B (picked up by MASH (Multi-Agency Safeguarding Hub) in Medway on the 13 December). This was reported as a fight between Adult A and Adult B in and outside of her flat. (Isabel would have been 4 weeks old). The MASH report details Adult A having assaulted Adult B with a knife and he had associated injuries. The immediate safety plan was that Mother and baby went to stay with her parents in Swale. 3.17 On the 10 December, another visit by the midwifery service was DNA’d. A note was left stating the concerns about the lack of contact and that social care would 8 be contacted if there was still no response. Mother responded to this, and mother and baby were seen on the 13th when they were discharged from midwifery. 3.18 On the same day, CSC in Medway responded to the referral from the police regarding the domestic abuse call out on the 9th. Agency checks revealed that mother had previously been a victim of domestic abuse and there were serious concerns about Adult A and Adult B. This was allocated for a Children and Family assessment under s17. 3.19 Mother consented to agency checks and these were completed. There was a decision to refer to MARAC by CSC, but this was not completed. There was no strategy discussion or s47 enquiries as Mother was said to be acting appropriately in going to stay with family. 3.20 The social work assessment started just before Christmas with a home visit to mother and the baby. Mother stated that she was no longer with Adult A, but he was visiting three times per week to have contact with the baby. This was not cross referenced to his other child that he was prohibited from having contact with. 3.21 Throughout December, Mother continued to be avoidant of professionals. PRACTICE LEARNING POINT The response to the initial domestic abuse incident did not take sufficient account of the seriousness of the incident or the coercive control element of the abuse. Mother was seen to act protectively but the decision making would have benefitted from more emphasis on the background and profile of the alleged perpetrators rather than solely on the short term protective action of Mother. Both men involved had significant histories. This is explored further in 4.32-4.37 Practice Episode; January/February 2022 – Further incidents of domestic abuse. 3.22 On the 1 January, Mother called the police after Adult A forced his way into the property and smashed up some of her belongings. The police responded and again Mother and Isabel went to stay with her mother. A domestic abuse risk assessment was completed by the police which was rated as medium. It is not clear what contact there was between the police and CSC but there was no formal strategy discussion. Mother and baby were assessed to be safe, and CSC continued their assessment under s17, while the police attempted to find Adult A to arrest him. 3.23 In the early hours of the 6 February and again on the 7 February Adult A again forcibly entered Mother’s flat via a window. This incident was assessed by police as high risk, but they were unable to find Adult A to arrest him. Mother was assisted in securing the flat and police arranged for panic alarm to be fitted which 9 was completed the same day. 3.24 The allocated Social Worker had contact with Adult A who tried to mislead the social worker and denied having seen Mother. This was untrue. At the same time, Mother was preparing to move into a new property. 3.25 Mother moved again two days later as she had accepted an offer of social housing. The address was close to her previous address. Mother contacted Medway Housing Services twice as it was not considered safe for her to be in Medway due to the risk from Adult A. This was responded to by Housing in the form of advice as they could not contact Mother directly. Their review of CSC’s electronic data system did not corroborate Mother’s information but there was no direct contact between Housing and CSC until the ICPC (Initial Child Protection Conference) in early March. Again, it is not clear how much time she spent at the property or if she was residing mostly at her mother’s address in Swale. 3.26 Medway CSC had reached the end of their assessment. In response to their findings and the domestic abuse incidents, a strategy discussion took place and agreed a single agency s47. Many concerns were shared about Adult A at the meeting e.g., high risk domestic abuse, poor mental health, and drug related issues. It was also shared that Mother’s extended family were also known to services regarding domestic abuse. It was reported that Isabel was ‘not brought’ to many health appointments, including her routine immunisations and screening checks. Housing were not at the strategy meeting so the information about Mother contacting them saying that she felt unsafe was not shared. PRACTICE LEARNING POINT It was good practice to hold a strategy meeting and Initial Child Protection Conference, but this was late in the day and after several very serious domestic abuse incidents. Earlier multi agency collaboration would have revealed the concerns about Mother’s extended family, Adult A, and Adult B at an earlier point. This is discussed in greater detail in paragraphs 4.18 – 4.31. Practice Episode: March 2022 – Initial Child Protection Conference 3.27 In early March, an Initial Child Protection Conference was held. Isabel was made subject to a Child Protection Plan under the category of emotional abuse. The meeting was attended by CSC, police, health visitor, the GP and Housing. Mother was made aware of Adult A’s history at the conference but not Adult B’s. The Chair encouraged Mother in the use of Domestic Violence Disclosure Scheme (Clare’s Law)3 to enable her to keep herself and Isabel safe by understanding partners’ 3 The Domestic Violence Disclosure Scheme (DVDS), also known as “Clare’s Law” enables the police to disclose information to a victim or potential victim of domestic abuse about their partner’s or ex-partner’s previous abusive or violent offending. 10 police histories. 3.28 Adult A was not at the conference, but the Chair spoke to him beforehand. He denied being a risk and wanted to emphasise that he was seeking help. The plan from the ICPC was that Mother and baby would stay with extended family until the house she was moving into was made secure. This did not happen, and Mother moved into the property the same day. This was unknown to professionals at the time, as was the presence of Adult A in the flat. 3.29 Three days after the ICPC, the circumstances in relation to this review unfolded and Isabel died on the 5 March. The cause of death was unascertained at the time of writing, but what is known is that Isabel was sleeping on a mattress with Mother, rather than in a cot. The family all tested positive for Covid-19. Mother had recently moved, and the baby’s cot had not been put together. There was evidence of drug and alcohol use in the flat which is a known risk indicator for Sudden and Unexplained Deaths in Infancy (SUDI). A police investigation into the death was launched straight away. PRACTICE LEARNING POINT Safer sleeping and the risks associated with it were discussed with Mother by the midwifery service, but a learning point has emerged about the importance of checking parents’ understanding of safe sleeping and how practitioners can assess this. This is discussed at paragraphs 4.7- 4.9 4 Findings The identification, referral and assessment of need and risks in pregnancy 4.1 The review has highlighted that Mother required support during her pregnancy but that this was not identified by agencies at the time. Opportunities to fully share information about Mother, her partner, and her circumstances at the initial stages of her pregnancy were missed. This would have been the optimal time for a number of services to form a network around the family and provide some early assessment and support. The following paragraphs seek to explain why this happened and extrapolate the learning for the Partnership. 4.2 It is a familiar scenario for maternity services having to rely on information provided by Mothers at the appointment. Mechanisms in Medway’s NHS Foundation Trust (maternity services) exist to try and triangulate information and identify those who may need extra support, but several factors led to a disjointed approach. 4.3 Mother disclosed at booking that she had used drugs and alcohol historically, but this had stopped by the time of her pregnancy. She reported using 64 units of 11 alcohol4 a week prior to being pregnant and cocaine use 6/7 months prior. This is a significant amount of alcohol - approximately 4 times the recommended weekly allowance. There was no exploration of why she had been drinking at this level or and what had compelled her to stop. Mother gave very little indication of additional needs; she denied any domestic abuse when asked and stated the only service she was involved in was Housing. Mother gave misleading information about the baby’s father as although she named him, she initially said that she did not have any contact with him. 4.4 Information from the GP would have established further concerns for Mother regarding her mental health, but the maternity notification was not responded to. Mother’s excessive drinking, albeit prior to the pregnancy would have been flagged along with concerns about anxiety and depression. The GP had referred Mother to a support service in 2020 to assist with her excessive alcohol use but the referral was closed as Mother did not respond to their invitations. There is work ongoing to try and ensure an exchange of information between maternity services and GP practices and a recommendation is made at 5.8 to try and strengthen practice. Information sharing and the Medway Maternity Safeguarding Hub 4.5 It is positive that the midwife raised a concern by making a referral to the Medway Maternity Safeguarding Hub, but this was made only in relation to Mother’s historical drug use. As such the referral was not accepted for discussion at the hub and was not revisited even after Mother began to miss appointments. It has not been established why the information about alcohol use was omitted from the referral, but it may have been overlooked due to a dual (paper and electronic) recording system. This is significant in this instance as discussion in a wider multi agency forum would have established the concerns about Adult A, mother’s potential drug and alcohol use and, alongside the information from Mother’s GP, this would have warranted a pre-birth assessment. It is not currently standard procedure in midwifery to contact the father’s GP and this represents a gap in current practice. 4.6 Information gleaned as part of this review, has established learning in relation to the Maternity Safeguarding Hub and there are potential improvements to be made. The hub does not currently have specific criterion. In discussion with practitioners about this issue, the reason for this was cited as not wanting to be prescriptive about which women were referred there and there was reluctance to be too strict. In view of this, it seems incongruous that all referrals are screened with some being filtered out. This suggests that there are criterion but they are not widely shared or transparent. The screening is also done internally within midwifery so is potentially based on incomplete information. As noted, in this 4 64 units of alcohol is approximately 4 x times the recommended weekly limit. 12 instance, several factors were unknown, and this led to poor decision making. Had all the information been made available, a prebirth assessment would have been indicated at an early stage in the pregnancy. Recommendations are made at 5.1 and 5.2 about making improvements to Medway Maternity Safeguarding Hub and the antenatal safeguarding pathway. Safe sleeping 4.7 As Mother was not identified as being vulnerable in pregnancy, it is unsurprising that the familiar risks in relation to safe sleeping were also not fully recognised. There is evidence from information provided to the review that midwives discussed safe sleeping with Mother on at least 2 occasions. They were largely in the dark, however about the additional risk factors commonly associated with families who experience SUDI e.g., co-sleeping, drug and alcohol use, poor home conditions, unstable housing situation, smoking and domestic abuse. Neither health visitor was able to see Mother face to face as she did not respond to the invitations, so they were not able to assess the baby’s sleeping arrangements. Although safe sleeping was discussed, the recordings were not clear about how that message was delivered and we also know that Father was not included in those discussions. The recording is important as the ‘tick box’ doesn’t give a sense of parental understanding or whether parents are receptive to what they were being told. 4.8 The report produced by the National Panel 5 published in 2020, emphasised the need for a nuanced approach to educating families about safe sleeping arrangements. The study recognised that for some families whose circumstances were unstable for a variety of reasons, messages about acceptable sleeping arrangements were hard to for them to hear. In this instance, it was difficult for practitioners to assess Mother’s understanding of the information partly because she was avoidant of appointments but also, she was rarely seen at any one of her homes. Mother moved three times during the review period and spent time with her family, therefore optimum opportunities to give practical advice rarely presented themselves. It may be significant that Mother had recently moved and was in the very early stages of unpacking her belongings when the death occurred as the cot had not been assembled. 4.9 Similar issues around safer sleeping are features in other practice reviews in Kent - a neighbouring borough with many joint services. As such, work is currently being undertaken between Kent and Medway Child Death Overview Panel (CDOP) to try and improve this area of practice. 5https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf 13 A recommendation is made at 5.4 about improvements to practice in relation to safe sleeping. Dealing with DNAs in maternity services 4.10 A feature of this review was the number of health appointments Mother missed both prior to and post the baby’s birth. There is a general recognition that poor engagement with antenatal services poses a potential risk to the health and wellbeing of mothers and their babies. Processes are in place i.e., the DNA checklist which is designed to monitor attendance and plan support accordingly. The review has highlighted the chance to strengthen practice in relation to this. 4.11 Poor attendance at appointments was a concern throughout the pregnancy and the DNA checklist was commenced in a timely way. Two contacts were made between the community midwives and Maternity Safeguarding. One was in August, where the midwife was asked to monitor the situation and a later one just prior to the baby’s birth in November. Several appointments were missed in September and October, but it was not until the baby’s birth was imminent that the midwife sought further advice from safeguarding colleagues. This left very little time for any proactive planning and an earlier response to the poor attendance would have been beneficial. This may have created an opportunity to identify Mother’s needs in a timelier manner. 4.12 Mother’s appointment keeping did not follow a particular pattern, though she did respond if midwives said that they were concerned. On at least one occasion, the midwife told Mother that she would need to contact social care if she was unable to reach her and she (Mother) responded swiftly. After seeking advice, the safeguarding midwives expressed concern about possible disguised compliance and advised various tasks to try and gain more information. One of these was to contact social care to check for previous history on both Mother and Adult A. At the practitioner event it was raised that this is sometimes done informally. The tasks were not carried out, possibly due to the proximity to the birth, but this was another missed opportunity to gather valuable information. 4.13 Early learning from the rapid review and confirmed by practitioners in this case highlighted gaps in the current DNA policy. Practitioners felt that there was no clarity about the checklist and whether the DNAs needed to be consecutive or three overall in the pregnancy. As a consequence of learning from review, this has now been modified to the expectation that the checklist commences as soon as there are three DNAs in total, rather than consecutively. DNA’s also need to be considered in the context of other risk variables such as drug and alcohol misuse. There is no recommendation in relation to this learning as the issue has been rectified since the rapid review. 14 Safeguarding Supervision 4.14 Mother often cancelled appointments at the last minute and then rebooked them. When she did attend, there were no obvious concerns and Mother was able to keep professionals at bay. Practitioners who took part in the review, reported that they had been worried about Mother and the number of DNAs, they were put off taking it to formal supervision because of the lack of concerns when they were able to see her. Involvement of the specialist midwives happened at a very late stage. 4.15 The use of safeguarding expertise in an organisation is key to the safeguarding system as a whole and was underutilised in this case. A chance to discuss Mother’s presentation in supervision with a safeguarding advisor would have provided an opportunity to explore avenues to gather information about both parents. This would also have provided clarity about what actions to take and who to contact. For example, supervision may have provided some managerial oversight and ensured that key tasks such as consulting the GP (as per guidance in the DNA checklist) and completing the Maternity Support Form were prioritised. 4.16 There was a similar pattern of DNAs with the health visiting service after Isabel was born and she was never seen by a health visitor. This was partly due to her moving between Medway and Kent, but she also (as previously) made appointments that she did not keep. 4.17 Changes to the supervision arrangements in Medway NHS Foundation Trust are looking to strengthen the supervision offered to designated professionals and practitioners. This coupled with changes to the DNA policy will provoke more curiosity and open more avenues for discussion in circumstances such as these. A recommendation is made at 5.7 about improvements to practice in relation to safeguarding supervision. Multi-agency response to, and assessment of, domestic abuse 4.18 The review has established that insufficient information was known to midwifery about Mother and Adult A. Enough information existed in the system to have warranted a referral to Children’s Social Care in Medway and pre-birth assessment, given Adult A’s previous history. The information provided by Medway NHS Foundation Trust makes the point well that there was a lack of professional curiosity about Mother’s history, her drug and alcohol use, as well as details about Adult A and the part he would potentially play in the baby’s life. 4.19 Isabel would have been 4 weeks old when a fight broke out between Adult A and Adult B at the home address. The police were called and made the referral to MASH in Medway. The informer reported that Mother was physically grabbed by Adult B, and he was shouting at her aggressively. She was carrying the baby when police spoke to her, but she denied that either of them had been involved in the 15 incident and neither of them were hurt. 4.20 The notification was slow to reach MASH due the timings but was then triaged and sent straight to a long-term team for assessment under s17. This was an unusual occurrence in Medway and happened because the referral and assessment service had stopped taking work for a short period of time, due to excessive workloads. Being responsible for the initial response was therefore unfamiliar to this team, who ordinarily would take on a family after the assessment period, when risk had been assessed and an initial plan put in place. Further, the decision to assess under s17 rather than s47, was made at the front door and not re-evaluated by the receiving team. 4.21 The subsequent response was slow to get off the ground, initially with the delay in the police report reaching CSC, but then a visit to the family did not take place until December 17 (8 days after the incident) where no access was gained. Isabel was not seen until three days after this – eleven days after the original incident. Given the history of the two men involved contact should have been made sooner. 4.22 The initial evaluation by CSC was optimistic and possibly based on Mother minimising the concerns and her willingness to go and stay elsewhere. A more robust response would have included a multi-agency strategy meeting with a view to s47 enquiries to assess the risk to Isabel from all three adults present at the incident. Adult A was known as a high-risk domestic abuse offender and Adult B had a very significant past with Probation Services. Mother was vulnerable to violent relationships and known to meet men on the internet. Isabel was a very young baby. The lack of an urgent response may have also reinforced Mother’s view that the incident was not considered to be very serious. It shows a lack of insight into the history and dangerousness of the two men and the nature of domestic abuse where coercive controlling behaviour is a feature of the relationship. 4.23 The grading of risk assessments of individual incidents from the police was inconsistent. Work has been done to try and strengthen their response and information sharing. Incidents in relation to Adult A were graded standard, medium, and high. Kent Police Policy changed in 2020 where there was no longer a requirement to send an automatic referral/Domestic Abuse Notification (DAN) in medium and standard risk domestic abuse incidents. It became policy that only high risk incidents were automatically sent to MASH. This caused issues with risk assessments in MASH and the policy has now changed so that decisions are made on a case by case basis by a select few specialist officers. 4.24 When Mother and Isabel were seen by the social worker, Mother said Adult A was visiting at least three times a week to have contact with Isabel and sometimes sleeping on the sofa. The social worker accepted this, despite knowing that he was not allowed to have contact with his older child. This was also significant 16 information and should have triggered a strategy discussion. Adult A was homeless as this point which was the reason Mother cited for not pursuing a non-molestation order, so it seems implausible that he was only there for part of the week. When Adult A was challenged by the social worker, he denied any contact with Mother which was not true. 4.25 Police responded to three further domestic abuse incidents in January and February and referrals were made to CSC. None of these triggered a strategy meeting to discuss a safety plan or a specialist domestic abuse risk assessment. The reason for this seems to be a perception that Mother had ‘acted appropriately’ by contacting the police. On at least two occasions she had gone to stay at her mother’s house. These were serious incidents which involved Adult A forcing his way into the home, being violent towards Mother and smashing up some of her property. Throughout this period Mother complained on several occasions that Adult A was constantly contacting her and turning up at her house unwanted. 4.26 Whilst Mother was (on some occasions) taking protective action, she was in a very high-risk situation which was unlikely to be resolved without longer term intervention being more focused on Adult A and his behaviour. There was no referral to MARAC and no early attempts to involve an Independent Domestic Violence Advocate (IDVA), though this did later form part of the child protection plan. 4.27 Research6 about controlling and coercive relationships tells us that the risk to women and children increases in certain circumstances. These include during pregnancy and having a child, when ending a relationship, contacting the police and other services and when considering a non-molestation order. Mother was experiencing all of these. Further, the assessment that she was ‘acting appropriately’ did not consider Adult A’s behaviour pattern and his likely need to exert control as she attempted to separate. We also know that perpetrators of domestic abuse often use the pretext of contact with their children to continue the abuse. This is recognised in The Domestic Abuse Act 2021 which acknowledges that separated women are at particularly high risk and so therefore are their children.7 4.28 It was not until the end of the s17 assessment period that a strategy meeting was held which led to s47 enquiries and subsequently to the Initial Child Protection Conference (ICPC). At the strategy meeting police revealed domestic abuse in Mother’s extended family which had previously been considered as a safe haven for her and Isabel. Whilst this was unknown information, Mother and Isabel had stayed there for extended periods. 4.29 The lack of strategy meetings and formal child protection enquiries was not 6 In control: Dangerous Relationships and How They End in Murder Jane Monkton Smith 2021 7 The Domestic Abuse Act 2021 came into effect in 2022. 17 challenged by any agency. Management oversight was frequent but did not alter the trajectory of the case or escalate to child protection at an earlier point. This suggests a training need, some focused practice development and a more strategic approach to domestic abuse which supports frontline practice is needed. 4.30 It is not clear how the incidents and escalating risks were communicated to the health visitor or Housing so that they too could be vigilant about the risks posed and contribute to a safety plan. There is no evidence of network meetings to draw together a more formal plan prior to the ICPC. 4.31 Safeguarding work is extremely challenging and complex. This scenario was complex due to a multi-factorial problem, combined with complete and inaccurate information which increased the likelihood of poor decision making. The cumulative risk was not analysed early enough with the benefits of the right expertise in each individual service to monitor, supervise and review. Recommendations about improvements to multi agency Domestic Abuse work are made at 5.5 and 5.6. Consideration and involvement of fathers/males in multi-agency work 4.32 Involvement of fathers and significant males in assessments is a familiar theme in multi-agency reviews. Maternity services involved with Mother did not show sufficient professional curiosity about who the father of the baby was, nor did they explore with Mother what role the baby’s father would play in their lives. 4.33 Whilst the social work assessment and the child protection plan acknowledged the risks posed by Adult A, the emphasis on keeping Isabel safe was weighted towards Mother and her extended family. The assessment lacked an analysis of Mother’s vulnerabilities and how domestic abuse in her extended family may have shaped her views about relationships. The plan would have benefitted from being more specific about what contribution (or not) Adult A could make towards keeping Isabel safe e.g., co-operating with the police, ensuring that he did not contact Mother, and addressing his violent behaviour. These things are implicit but not explicit. Tasks for fathers and significant males in children’s lives should be prioritised within multi agency plans and assessments should be explicit about the source of the risk, especially where they pose a major risk as was the case here. 4.34 Insufficient weight was attached to the significance of Adult A’s history and his persistent violent behaviour towards Mother. Risks escalated without robust response and there was a lack of formal assessment of him as a father, despite there being a full history to draw on. Further, information about Adult B was not shared at the ICPC and the risks that he posed were not considered, even though Mother had said that he was her current partner. 4.35 Research tells us that the focus of multi-agency engagement in cases where domestic abuse is an issue is often the mother. This is problematic as they are 18 often left with responsibility for controlling the abusers’ behaviours which they are unable to do. It is important to avoid the pattern of too readily accepting explanations from families e.g., where parents claim to have separated and thereby assuming mothers and children’s safety. The emphasis needs to shift to a more inclusive framework that attempts to address the risk from perpetrators by providing a range of interventions to both the abusing and non-abusing parents. 4.36 Adult A also told the Chair of the ICPC about his attention deficit hyperactivity disorder (ADHD). ADHD is a static neurological condition, the core symptoms of which are short attention span, excessive activity, anxiety and impulsiveness which can be cause for concern if not managed. Historically, Adult A had sought help with this; some provision in the plan to support his intentions to address it may have also been useful. A recommendation is made at 5.3 about improvements to multi agency working with significant males in families. 5 Recommendations 5.1 The Medway Safeguarding Children Partnership to request a review of improved arrangements for the antenatal pathway and satisfy itself that the referral system is working in a way that. • Identifies the most concerning families of unborn babies. • Refers them to relevant services in a timely way. • All information is accessible and recorded in one place to ensure consistency of information sharing. 5.2 In line with the above, Medway Safeguarding Partnership should oversee a review of Medway Maternity Safeguarding Hub to establish clear terms of reference, criterion, and governance. 5.3 The Medway Safeguarding Children Partnership should reassure itself that all partner agencies have robust systems in place to ensure that fathers and other significant males are actively considered in assessments and ongoing work with families. 5.4 The Medway Safeguarding Children Partnership and Kent and Medway Child Death Overview Panel (CDOP) to oversee a review of current practices about how safe sleeping messages are delivered and develop a strategy to promote and raise public and practitioner awareness of the need to deliver safe sleeping advice. 5.5 Medway Safeguarding Children Partnership to oversee an audit of multi-agency 19 practice in relation to domestic abuse at the front door. The audit should focus on threshold, multi-agency information sharing, involvement and assessment of perpetrators, decision making, consent, use of specialist services and outcomes. 5.6 Medway Safeguarding Children Partnership to develop (or review if one exists), a multi agency strategy detailing a robust response to families where domestic abuse and coercive control are present. The strategy needs to be overarching and provide a range of multi-agency interventions to children affected by domestic abuse, as well as the abusing and non-abusing parents. 5.7 Medway Safeguarding Children’s Partnership should oversee partner agencies’ reviews of their existing supervision practices and seek assurances that agencies have robust managerial oversight of actions, decisions, and plans in relation to children and unborn babies where there are safeguarding concerns. This should include the exploration of a range of supervision practices such as external supervision and group supervision. 5.8 Medway Foundation Trust and Kent and Medway Integrated Care Board should continue their work on ensuring robust liaison between Midwifery services and GPs for pregnant women. This should include reviewing and modifying current systems to ensure that there is an exchange of information (I.e., two-way communication) about both parents (and partners) during pregnancy. Jane Doherty Independent Social Work Consultant July 2023 |
NC049025 | Death of a 2-year-4-month-old child (Child P) and a 7-month-old child (Child H) at home in unrelated incidents, with no specific cause of death identified. Child H was co-sleeping with parents when the death occurred. Child P was found not breathing in the cot. Agencies had been involved with their families because of concerns about neglect and welfare of the children. Findings include: assessments undertaken were inadequate and adult focussed; failure to incorporate males in assessments; lack of professional curiosity and an over optimistic view of parental ability to effect change; effects of substance misuse was overlooked; poor information sharing. The thematic review was carried out applying the Significant Incident Learning Process. Recommendations include: requiring the preparation and consideration of an up-to-date genogram for all interagency meetings concerning a child's welfare; to carry out an audit of cases to form a judgement on the impact of the Neglect Strategy; to review arrangements for the timely completion of serious case reviews; and to ensure more effective consideration of mental health issue within assessments of the needs of children.
| Title: Overview report: serious case review: significant incident learning process: Child P (age at death 2 years 4 months) and Child H (age at death 7 months). LSCB: Dudley Safeguarding Children Board Author: David Spicer and Donna Ohdedar Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 OVERVIEW REPORT SERIOUS CASE REVIEW SIGNIFICANT INCIDENT LEARNING PROCESS Child P (age at death 2 years 4 months) and Child H (age at death 7 months) Report Authors: David Spicer, LLB, Barrister and Donna Ohdedar Presented to Dudley Safeguarding Children Board: February 2017 Final Report: August 2017 2 Contents Section Page 1 Introduction 3 2 Process 3 2.1 Family Involvement 4 3 The Facts 4 3.1 Child H 4 3.10 Child P 5 4 Key Episodes: Child H 6 4.1 Antenatal Period (2014) 6 4.4 Referral leading to Children Social Care Involvement (winter 2014 to spring 2015) 7 4.9 Child H’s death (spring 2015) 7 5 Key Episodes: Child P 8 5.1 Child P’s Early Babyhood 8 5.5 Escalating Concerns leading to an Assessment (the 4th to 7th months of Child P’s life) 8 5.10 Child in Need Plan (Child P aged 9 months up to 1 year) 8 5.15 Intervention Following Child P’s Second Seizure (Child P aged 16 to 24 months) 9 5.19 Threats to Kidnap 9 5.24 Child P’s Death (April 2015) 10 6 Analysis by Themes 10 6.1 Assessments 10 6.11 Family History 11 6.24 Complexity 12 6.36 Fathers and Males 13 6.53 Information from Relatives, Neighbours and the Community 15 6.86 Common Assessment Framework 18 6.94 Neglect 19 6.117 Neglect Strategy 21 6.119 What is the current position on neglect strategy? 21 6.125 Previous Serious Case Review 22 6.135 Sudden Infant Death Syndrome 24 6.153 Cannabis Use 26 6.160 Domestic Abuse 26 6.167 Mental Ill Health and Disabilities 27 6.188 Non-engagement 30 7 The Safeguarding Response 31 7.1 Barriers 31 7.4 Communication Between GP and Health Visitors 31 8 Quality of Decision Making and Plans 32 9 Supervision 32 10 Challenge and Escalation 34 11 Holiday Periods 35 12 Information Sharing 35 13 Good Practice 38 14 Improvements Already Implemented 38 15 Conclusions and Lessons Learned 39 16 Recommendations 41 Appendix A Terms of Reference 43 Appendix B Single Agency Recommendations 47 3 Introduction 1.1. In Spring 2015, two young children died in their homes in Dudley. They were unrelated and unconnected. In both cases no specific cause of death was identified. 1.2. Agencies had been involved with their families because of concerns about neglect of the welfare of the children. The then Chair of Dudley Safeguarding Children Board decided that the criteria for carrying out Serious Case Reviews under statutory guidance1 were not met but, in accordance with the Board’s Learning and Development Framework, a Thematic Review considering the background of both cases should be carried out applying the Significant Incident Learning Process (SILP) to ascertain whether there were lessons to be learned. 1.3. It was understood by staff commissioning the review that the decision not to carry out Serious Case Reviews was supported by the National Panel of Independent Experts on Serious Case Reviews and the Thematic Review was scoped on that basis at a meeting held on 1st October 2015. 1.4. OFSTED undertook an inspection of Children’s Services in January 2016. The effect of the inspection was that it became extremely difficult for the reviewers to obtain vital information from staff. When the draft overview report was due to be submitted to the Serious Case Review Sub-group on 7th April 2016 the reviewers were presenting a report which still contained unanswered questions. It transpired that on that day correspondence between the board and the National Panel suggested only Child H’s case had been notified to the National Panel of Independent Experts and the decision not to carry out a Serious Case Review by the then Independent Chair was challenged. However, the response received had incorrectly assumed the Board had made a decision in favour of carrying out a serious case review. 1.5. On 11th May 2016 the newly appointed Independent Chair of Dudley Safeguarding Children Board reviewed these decisions and decided both cases met the criteria for a Serious Case Review. The decision to undertake further work on the Thematic Serious Case Review was made. Due to staff turnover and internal capacity issues, the ‘phase 2’ work was not formally commissioned until 8th July 2016. For a similar reason, information vital to completion of the review was 19 weeks overdue. The draft Overview Report was submitted to the Board on 13th February 2017. Following further correspondence, the report was finalised in August 2017. 1.6. The Thematic Review looked beyond individual incidents or individuals and focussed on identifying, examining, and recording patterns or themes within the cases that are likely to apply in other circumstances. 2. Process The thematic review was carried out applying the Significant Incident Learning Process. This involves agencies producing timelines and analytical reports of their involvement and encourages learning to be identified by the staff involved in the cases and so far as possible aims to involve members of the families affected by the incidents. The Terms of Reference for the review are set out in Appendix A. Staff involved and the report writers were brought together at a Learning Event to discuss the reports, issues and themes emerging, focusing on Key Episodes identified from the reports. A Recall Day followed to discuss a first draft of the Overview Report. Staff from some agencies 1 Working Together 2015 Chapter 4 4 including Children Social Care were unable to attend the Recall Event. Arrangements were made for a meeting to take place separately with the writer of the Children Social Care Reports. During phase 2, a further professionals meeting was held in September 2016 to look at specific research questions following agencies producing and sharing Agency Questionnaires. One Agency Questionnaire was not submitted and a draft overview report was prepared highlighting the gaps in the review. It was agreed that the information was needed and that the report should not be signed off until a thorough review had been conducted. The Reports provided by agencies are thorough and of a high standard. The Learning and Recall Events reflected careful consideration and a determination to learn. The recommendations made in the reports for their agencies if implemented are calculated to bring about change. These recommendations are set out in Appendix B to this report. The Significant Incident Learning Process was led and the meetings were chaired by Ms Donna Ohdedar. David Spicer and Donna Ohdedar co-authored the Overview Report. We both have the qualifications, experience, suitability and independence to undertake reviews required by statutory guidance. 2.1 Family Involvement 2.1.1. Attempts were made to involve members of the families to contribute to the process but they declined to do so. The mother of Child H asked to be informed in due course about the conclusions and recommendations. 2.1.2. Over the telephone Child H’s mother also reported that Child H “had never been the same” since he had an admission to hospital with bronchial problems in 2015. This was discussed at the Recall Event and it was confirmed that there was no record of any such concerns having been brought to the attention of any health or other professional. 2.1.3. It was noted however that the hospital discharge letter did not suggest any follow up with the GP. This led to a discussion about advice given to parents when children are discharged from hospital and whether there should be a leaflet advising them in what circumstances to make appointments, particularly during the winter months. 2.1.4. The author of the Dudley Group NHS Foundation Trust Report agreed to look at the standard arrangements and consider whether there should be any changes to arrangements made to information and advice given to parents on the discharge of their children from hospital. 3. The Facts Child H 3.1 There is very little recorded about Child H prior to the death, other than that the child slept in a bouncy chair. It later transpired that Child H was co-sleeping with parents. Recording of home visits suggests there was evidence of suitable age related toys were available for the children in the household and also evidence of warmth and affection in the interaction between adults and children within the family. 3.2 In Spring 2015, a 999 call was received by the ambulance service concerning a seven-month-old child, Child H, who was said not to be breathing. 5 3.3 The female caller originally stated that the baby had woken up in the cot. However, a man could be heard in the background who shouted “tell the truth” and the caller then said that Child H had been in bed with them and they had woken up to find Child H not breathing with blood coming from the nostril. 3.4 Upon arrival at the Accident and Emergency Department it was confirmed that he had died. 3.5 Home conditions were found to be cluttered, with sparsely furnished bedrooms and evidence of use of dried herbal cannabis in the adult bedroom. In the rear bedroom, the door was damaged by four dents. 3.6 A post mortem examination failed to identify a cause of death and the inquest recorded an open verdict. 3.7 At the time of death, Child H lived with mother, half-sibling, the mother’s partner, who was the father of Child H, and an adult relative of the partner. On the night of the incident Child H’s half-sibling was staying with the father. 3.8 It appears that Child H had a cot in the parents’ bedroom in which there were stored nappies and clothing. The paternal relative was sleeping in the spare bedroom using the bed intended for Child H’s half-sibling. The father had arranged pillows and bedding around Child H in the parents’ bed. 3.9 After the death of Child H, child protection enquires were carried out in relation to Child H’s half-sibling who was made subject to a child protection plan. This child continues to reside with Child Hs’ mother, although there have been continued missed appointments and lack of engagement with services by mother. At the Recall Event, some practitioners were concerned that the plan had not been actioned appropriately since July 2015. Child P 3.10 Child P was described as a happy little child who had age appropriate toys in the home and liked playing alone or with siblings. As a baby, Child P was changed from formula milk to cow’s milk, although not weaned. Workers were concerned that Child P was not eating any solid food and was seen infrequently by professionals, who were often told Child P was having a nap. On home visits, Child P was observed to be sleeping in a pushchair appropriately dressed. 3.11 In Spring 2015, a 999 call was received by the ambulance service. The male caller was very distressed and stated that 2-year-old Child P was not breathing. He passed the phone to a female who confirmed that the child had been taken out of the cot and laid on the bedroom floor. 3.12 Basic life support was carried out by the paramedics on the way to the hospital where it was confirmed that Child P had died. 3.13 A post mortem examination was not able to establish the cause of Child P’s death, and the inquest recorded an open verdict. 3.14 At the time of death Child P lived with mother, two half siblings and the mother’s partner who was not the father of any of the children. 6 3.15 The home conditions were reported to be very poor, unhygienic and potentially hazardous to young children. 3.16 This review received concerning information regarding the safeguarding response to Child P’s death and the circumstances of the surviving children, who now reside with their mother. Evidence since the death of Child P shows that the concerning situation was continuing, with further house moves, another male in the family’s life and continued lack of engagement with professionals. There was no indication that possible sexual exploitation had been addressed. The police were concerned about Child P’s mother having an ‘unfitting’ relationship with a child who had been identified as at high risk of child sexual exploitation. 3.17 In the cases of both Child H and Child P it was impossible to conclude that from the circumstances known to agencies the specific circumstances of their deaths could have been predicted. 3.18 However, within the two households the concerns, priorities and capabilities of the adults were affected by their own circumstances. This resulted in the conditions that increased the risk of serious incidents or deaths of children not being recognised and acted upon by the adults responsible for their care. 3.19 Both households attracted the concern of agencies because of neglect. Improving the quality of life, health and development of children living in circumstances of neglect is important whether or not there is a risk of death or other serious incidents. 3.20 The Children Social Care Report correctly asserts: “Although, Child P’s death is not attributed to any action by the Local Authority, (or any other agency or professional) there were a number of opportunities for agencies to take appropriate and timely action to safeguard Child P (and the two siblings).” 3.21 And: “Whilst we cannot say whether Child H’s death was or was not preventable we can say that a robust assessment would have provided a better picture of the children’s developmental needs and parents’ capacity to meet them. This in turn would have provided a solid evidence base for decision making and planning.” 4. Key Episodes: Child H The review highlighted the following as the key episodes in Child H’s case during the scoping period: 4.1 Antenatal Period 4.2 Antenatal care was considered routine, one feature being that Child H’s mother received smoking cessation support. Whilst the GP records show Child H’s mother took medication for depression during this period this information was not shared with the Health Visitor. When asked by the Health Visitor, Child H’s mother gave no information suggesting she suffered from mental ill-health. She also failed to provide urine samples for routine tests. This was not proactively addressed and is not unusual. Routine testing would not reveal substance misuse unless the samples were sent elsewhere for analysis, although some 7 mothers may think it would. Health Visitors described Child H’s father as uncommunicative, and that he had a “concerning medical history.” 4.3 This is a key episode because it raises information sharing issues and provides a context for the referral which led to Children Social Care becoming involved. 4.4 Referral leading to Children’s Social Care Involvement 4.5 Concerns were raised with Children Social Care by the owner of the property in which the family lived in Winter 2014. She reported poor home conditions, adult cannabis use and poor child care and described the property as “untidy” with no beds, and only 1 mattress. Two social work visits followed. The first confirmed the concerns. The second identified that the cluttered home conditions had improved. The mother mentioned her depression. Children and Young Persons Assessments were completed, although these produced identical assessments for each child. 4.6 Child H’s mother reported that due to breathing related concerns, she took Child H to a doctor’s surgery. She told police this was because Child H was becoming breathless during feeds. She stated being told that Child H had bronchitis, a chest infection and conjunctivitis. 4.7 Children Social Care involvement ended in early February 2015 when the case was closed with an expectation that an assessment under the Common Assessment Framework would be carried out. There was lack of formality and planning for this process and it did not take place. Some agencies believed it was to be undertaken by the Health Visitor and reports suggest it was proposed to involve the Children’s Centre. There is no evidence of a “step-down” process being followed or of a lead professional taking this forward. 4.8 This is a key episode because it shows the level of agency activity in the period prior to Child H’s death. The review considered whether there were opportunities within this period to recognise increased risk around Child H or to provide additional services to the family. 4.9 Child H’s death 4.10 When Child H was found not to be breathing, parents called an ambulance. Upon arrival at the Accident and Emergency Department it was confirmed that Child H had died. 4.11 The Ambulance Service notified the Police and Children Social Care. The two agencies visited the family home and recorded in some detail the appearance of the property. In the Children Social Care Report, the team manager’s opinion was recorded that the home conditions were significantly worse. Child H’s half sibling, had been sharing a bed with the parents. The paternal uncle was sleeping in the sibling’s bed. Child H had been sleeping in a bouncy chair. There was evidence of cannabis use. 4.12 This is a key episode because the agencies’ responses to Child H’s death and the safeguarding measures taken were considered by this review. 8 5 Key Episodes: Child P The review highlighted the following as the key episodes in Child P’s case during the scoping period: 5.1 Child P’s Early Babyhood 5.2 Before Child P’s birth, Children Social Care had been involved with the family due to two domestic abuse incidents and concerns about non-attendance for appointments. When Child P was only a few months’ old, the Emergency Duty Team received information that an external family member had appeared in court in relation to sex offences. Child P’s parents assured social workers the individual was not having contact with any of the children. 5.3 Also during this period, the Health Visitor saw two men leaving the family home. After this, the Health Visitor made 2 unsuccessful visits and requested a joint visit with the social worker. Children Social Care responded that they were unable to become involved on the basis that they understood the Health Visitor’s concerns to be primarily around the family’s failure to register with a GP or to have immunisations, neither of which are compulsory. 5.4 This is a key episode because it shows the information that was known to services in the early part of Child P’s life and provides a context for the next period in which concerns escalated. 5.5 Escalating Concerns leading to an assessment 5.6 When the children were observed during a hospital appointment at the start of this period, this prompted an enquiry from the hospital to Children Social Care as to whether Child P’s older sibling was subject to a Child Protection Plan. The children were observed to be “grubby” and an “uncle” was with them. 5.7 Within a month of this, the Health Visitor referred the case to Children Social Care. She had seen unknown males at the house. This led to the case being allocated for initial assessment. A Social Worker visited during each of the next two months. A decision was made by Children Social Care that there were no concerns and thus no further role for the service. 5.8 Over the next two months two anonymous referrals were made to Children Social Care about the children’s welfare. Two Social Worker visits followed and a Child in Need Plan was recommended. 5.9 This is a key episode because the initial assessment conducted of the family circumstances was the first in Child P’s lifetime and at the time it concluded there was no role for Children Social Care. It is significant that immediately after this, two anonymous referrals were made to Children Social Care. 5.10 Child in Need Plan 5.11 At the beginning of the Child in Need Plan period Child P was admitted to hospital due to vomiting. The consultant queried the mother’s understanding in terms of how to feed Child P appropriately. The first Child in Need meeting followed quickly after this admission. During this meeting, Child P’s mother was observed to be defensive, and not accepting of professional concerns. 9 5.12 6 weeks later the Children’s Centre Worker queried possible lack of attachment between Child P and mother. However, at this time the next Child in Need meeting was cancelled due to health professionals being unable to attend. 5.13 A few days later consideration was being given to closing Child P’s case as the mother’s partner had been sentenced for kidnapping. On the same day, the Midwife reported Child P’s younger sibling had been born and queried whether the mother and baby could return home. The Social Worker responded that there were no safeguarding concerns. The case was subsequently closed to Children Social Care. 5.14 This is a key episode as it shows the fast progression from Child P being treated as a Child in Need to professional opinion being that there were no safeguarding concerns and the case being closed, which seemed to be driven by mother’s partner being sentenced to imprisonment. 5.15 Intervention Following Child P’s Second Seizure 5.16 When 16 months old Child P was taken by ambulance to hospital having had a seizure. The mother discharged Child P against medical advice because the siblings had been left at home with a male she did not know very well. The ambulance staff had been concerned about the conditions they observed in the family home. Also at this time information was received by Children Social Care regarding the unsuitability of another mother who was caring for Child P’s two siblings. A social work visit revealed the house smelt strongly of urine but had been cleaned up by two maternal family members. 5.17 A month later an anonymous contact reported that Child P’s mother had been witnessed slapping and dragging an older sibling along the road. Then a month after that two separate reports of concern about the children’s welfare were received from sources close to the family. Two Children in Need meetings were held and a third cancelled as the mother refused to attend. The mother was engaging with the Children’s Centre, Health and Housing and this led to the case being closed. 5.18 This is a key episode because the chronology shows an escalation of concerning evidence and two meetings having taken place at which there was an opportunity to stand back and consider the case/the evidence but the case was closed. 5.19 Threats to Kidnap 5.20 Threats were made to kidnap the children. It was initially thought the threats were made by their mother’s current and previous partner. Police requested a child protection conference as the appropriate course of action. However, in Children Social Care, the team manager recommended instead that a home visit should take place. The mother refused to disclose key information, suggesting it may have been other members of the family who made the threats and suggested she was safe as she had moved address. However, the new address was only 2 minutes’ drive from the old address. 5.21 In February 2015, a neighbour reported numerous visitors to the family home and that the children had been heard crying at all times of the day and night. An unannounced visit revealed “no concerns” for the children. However, recording made subsequently described the social worker discussing with the mother having observed Child P’s younger sibling “in the dog bowl”, Child P’s hand down the toilet and that the mother 10 had been harbouring a male wanted by the police. There was no evidence within recording that this was considered further. 5.22 During mid-April, the decision was made within Children Social Care to close the case. 5.23 This is a key episode because there is evidence that police recognised that the risk was escalating to the extent that the case should be considered as a child protection case but Children Social Care disagreed. 5.24 Child P’s Death 5.25 Two days after the case was closed a man called an ambulance in respect of Child P who was reported to have been found dead in a cot. 6 Analysis by Themes 6.1 Assessments 6.2 In the two cases, a number of “Initial Assessments” were carried out by Social Workers and there were other circumstances that should have generated an assessment. 6.3 In Child H’s case, the assessment completed for each of the children was identical, mainly making reference to Child H’s half-sibling only or “the children”. Also, it was adult focussed. Observations were recorded and although it is clear that the Health Visitor was spoken to there is nothing recorded regarding immunisations, attendance at appointments or whether Child H was meeting milestones. Furthermore, Child H’s assessment provided a snapshot of the concerns and focussed specifically on the referral reports about the state of the property. “Family and Environmental factors” was the most detailed part of the assessment and was “cut and pasted” from recordings of the two visits to the family. 6.4 There were two occasions in which Child P was treated as a Child in Need when formal assessments should have informed plans. 6.5 The concept of the “Cumulative error” appears to have had a role in the shortcomings in these assessments. Each single factor in the chronology compounded the last so that the risk was multiplied, heightening the risk of severe harm. 6.6 The Children Social Care Report reflected that “there is a need for social workers and managers to go back to the basic principles of child protection work.” 6.7 Research has emphasised2 that assessments must be on a ‘child by child’ basis and must include a formal assessment of the parents’ capacity to change. To understand the failure to provide safe, adequate and consistent standards of care requires interviews, observation, standardised measures, use of previous reports, and information from multiple informants. There is no recorded evidence that this approach was taken in either case. 6.8 In both cases the ability of parents to understand, and respond to, professional concerns was overestimated. 2 Social work assessment of children in need: what do we know? Messages from research Turney, Platt, Selwyn and Farmer, School for Policy Studies, University of Bristol; DFE Research Brief (March 2011)) 11 6.9 There is no evidence that published materials3 were considered or informed the assessment processes carried out or that if the staff had received training that the training informed practice or management of the cases. 6.10 Assessments were not timely and did not consider all that was known about the child and family; they were not informed by the child (age appropriately) and all those involved in the child and family’s life. An analysis was lacking which made sense of what all the information gathered meant for the children in each case, identifying their needs and what needed to change or remain the same to improve their outcomes. As well as not being completed and authorised within an appropriate timescale, some assessments were insufficiently robust in that they failed to provide an evidence base for decision making that ensured the child’s welfare was the focus. 6.11 Family History 6.12 The importance of understanding the family history has been reinforced by various publications of lessons from review processes and tools designed to assist with the process of assessment.4 6.13 Adults related to and involved with the children had histories of serious and persistent criminal activity involving drug abuse and violence but the impact of this on family functioning and prospects for the children was not included in assessments. Issues relating to the disclosure of police information and that held by the Probation Service are covered elsewhere in this report. Also, Child H’s parents told the Pathologist that Child H’s father’s family “were known to Children Services previously.” There is no evidence that this history was considered. 6.14 As a child, Child P’s mother had been looked after by the local authority, but there is no evidence that her history or records were accessed and considered and this fact was not known or shared with the Health Visitor at any point. The Health Visitor became aware of it even though it was not documented in the main body of the record. Records show Child P’s mother had a relationship with Child P’s father as a child, but no ages were stated. It is not clear what is meant by this statement and this notification is not analysed in the main body of the records. 6.15 There is no evidence of the analysis of the lack of consistency in the lives of Child P and the siblings due to the numerous house moves and numbers of males being present short or long term in their lives. 6.16 The Police Report includes information held about the background of Child P’s mother in relation to a background of committing violent offences, criminal damage and theft and regarding her diagnosis of attention deficit hyperactivity disorder. She had lived with her mother and step-father whose relationship was turbulent, characterised by several incidents of aggression and assaults, the first of which took place in her teenage years. She had lived in a Children’s Home. In addition, there had been 73 recorded incidents involving the mother at various addresses during the scoping period, with numerous other logs and intelligence reports. 3 For example: DCSF Research Report RR023 (2009), OFSTED ‘In the Child’s Time: Professional responses to Neglect’ March 2014, DFE ‘Assessing Parental Capacity to Change When Children Are on the Edge of Care’ June 2014 4 For example: Analysing child deaths and serious injury through abuse and neglect: what can we learn? a biennial analysis of serious case reviews (DCSF Research Report RR023 (2009)), Reder and Duncan in Lost Innocents: A Follow-up Study of Fatal Child Abuse (Routledge. (1999)) 12 6.17 There is no evidence that any of this family background was considered in any assessment process undertaken. 6.18 There was no evidence within the GP records that any formal assessment of either family was undertaken. Furthermore, there is no evidence in health records to indicate whether or not primary health care professionals were contacted to contribute to assessments. 6.19 Although it became clear after the deaths of the children that both families were previously known to Children Social Care this was not evident within the GP records. There is no documented account of any telephone calls from Children Social Care to gather any information from the GP practice. Also, there are no Child in Need plans or references to referrals within the notes. 6.20 In the GP’s records, there was significant information regarding the mental ill-health and disabilities and difficulties in functioning of both mothers and drug use and the men involved. 6.21 Mental Health issues are covered specifically in other sections of this report. 6.22 The weaknesses identified in these cases are indicative of poor standards of practice within Children Social Care in general, as reflected in the Children Social Care Report recommendations regarding various forms of refresher training. However, the findings are more far reaching across other agencies. 6.23 The Children Social Care department does appear at this time to have lacked an awareness of the personal responsibility that social care workers have for their own professional development and for ensuring that they are equipped with the knowledge and skills to carry out their duties. 6.24 Complexity 6.25 Cases involving child neglect are complex. In these cases, a combination of concerning circumstances brought together neglect of health, poor home circumstances and arrangements for care, domestic abuse, lack of cognitive ability, skills and motivation, drug misuse, mental ill-health, and deceitful, manipulative and collusive adults which added to the complexity. 6.26 The agency report writers found and reflected in their reports and in the discussions at the Learning Events that the complexities were not recognised and that the processes did not operate to bring together the information and knowledge held by individual practitioners – the familiar weakness of failing to understand the bigger picture. 6.27 Complexity of cases will only be understood and plans and services effective if information sharing, response to concerns, assessments and interagency processes operate to identify the relevant issues and analyse and evaluate the information with a focus on the impact on the children. 6.28 Child P’s case was the more complex of the two. The length of time over which concerns persisted and the opportunities to understand the reasons for concern and respond were greater. 13 6.29 A further question from the terms of reference concerned evidence of use of a genogram to understand the complexity of the families. 6.30 There was no evidence of any agency preparing a genogram in either case individually or as part of interagency processes. 6.31 For the purposes of the review genograms were prepared setting out the relationships of people close to both the children who had died. 6.32 In both cases a genogram was important to understand the relationships between adults involved in the lives of the children. 6.33 During the review of Child P’s circumstances, the genogram clarified the number of men involved and uncertainty and deception that had occurred about who were the fathers of each child and the roles and impact of members of the very extended family. 6.34 The Health Visiting and National Probation Services have recommended their future use. 6.35 In discussion, the author of the Children Social Care Reports stated that it was now understood that the Information Technology systems within Children Social Care can easily generate a genogram in a case. There is now an expectation that a genogram will be compiled and updated in every open case. This recommendation could be improved by an audit after 6 months within Dudley Children Social Care Services to ascertain whether the expectation that a genogram should be prepared and updated has been met and a report on the conclusions made to Dudley Safeguarding Children’s Board. Recommendation 1. Comments regarding genograms are equally applicable to other agencies involved in safeguarding children. 6.36 Fathers and Males 6.37 A large number of high profile child abuse reviews beginning in the 1980’s refers to the lack of engagement with fathers and other males and the fact that in the main, assessments and planning focus on a mother’s parenting capacity and place the onus of changing the situation on the mother - even when it is the father/partner whose behaviour has caused or contributed to the concerns. 6.38 The Overview Reports published in 2013 concerning the deaths of Daniel Pelka5, Keanu Williams6 and Hamzah Khan7 all addressed the “invisibility” of males in the assessment and planning process and the importance of having the “whole picture”. 6.39 Assessments in Child H’ and Child P’s cases failed to recognise the importance of understanding the background, influence and impact of the men in the mothers’ lives, rendering them flawed. At the Learning Event, it was suggested that this was a cultural norm across agencies in Dudley at that time. 6.40 Within GP records there was no reference to fathers or mother’s partners within the children’s notes in either of the cases. Child P’s mother had 9 known partners in 4 years and had 3 children by 3 different partners in 3 years including the fathers of 2 of the children being closely related. 5 Coventry Local Safeguarding Children Board (2013). 6 Birmingham Safeguarding Children Board (2013). 7 Bradford Safeguarding Children Board (2013). 14 6.41 There were also in health visiting records references to home visits when unknown males were in attendance at the property but no evidence of this being discussed. The potential for sexual exploitation of mother and the impact on the children was not analysed. 6.42 The Police held extensive histories regarding 5 men with close associations with Child P’s mother. 6.43 The mother’s partner at the time of Child P’s death had a lengthy history of involvement with Police from 2001 onwards. He had 19 convictions from 30 offences and 2 cautions, which relate to assaults, public disorder, theft, drugs and offences relating to court/police/prison. 6.44 At the time of Child P’s death, this man was living with the mother and her children, having recently been released from prison after a short sentence for theft. 6.45 During a police inquiry Child P’s mother asserted that she was safe because she had a “new partner everyone is afraid of”. 6.46 The Police had information about drug use by Child H’s mother’s partner and a close relative living with them. However, no link was made between Child H’s mother and the information about these males. This was also an issue for information held by GPs involved in the case. The GP Communication Policy is “work in progress”. An Information Sharing Agreement is being established with every GP practice. Clearly this would only have helped in Child H’s case if the adults had been linked with Child H. 6.47 At the Recall Event, it was clear that apart from the Police, the background of these men was largely unknown and did not inform assessments or the work involved in the cases. The Police Report accepts that there was a significant under-recording of child protection concerns which resulted in limited information sharing with partner agencies. Action has been taken by West Midlands Police to ensure children’s welfare is a priority whatever the area of activity undertaken by the police. 6.48 There was no attempt by Children Social Care to access information about the men during assessments and interagency processes. This gap led to links with important networks being missed, such as police offender managers, substance misuse services or adult social care. 6.49 It was also important for staff visiting the households to be aware of risks to their own safety. 6.50 At the Recall Event, it was acknowledged that there was insufficient curiosity about these men and their relationships to the children. 6.51 In health agencies discussions have led to work being done to review process prompts to inquire “about consanguinity” at pregnancy booking appointments and to address lack of enquiry by GPs. 6.52 Improvements that have taken place in Children Social Care in assessment processes should address the issue. The interest in men, their backgrounds and impact on children’s lives was a more general issue of culture at the time and forms part of the Back to Basics work discussed in Section 7. 15 6.53 Information from Relatives, Neighbours and the Community 6.54 Assessments in both cases failed to identify why the households were chaotic or why on occasions conditions improved. Without this understanding plans were likely to be ineffective. 6.55 Close relatives of Child P contacted Children Social Care with serious concerns about the children and wished not to be identified. It was suspected by a Social Worker that these may have been the same relatives that cleaned up the household. They were assumed to be a resource available to mitigate the weaknesses of the mother. 6.56 Other Serious Case Reviews involving chronic neglect and serious incidents of maltreatment have warned against placing reliance on close relatives without speaking to them alone and thoroughly assessing their ability or willingness to be relied upon to mitigate the neglect or to blow the whistle in the event that circumstances deteriorate. 6.57 Assessing the potential should include researching their family and medical histories. Relatives involved in Serious Case Reviews have stressed how difficult they find it to report on their daughter or granddaughter or to express reservations at interagency meetings when the mother is present. Frequently no-one had spoken to them alone about these issues.8 6.58 There is no evidence that in Child P’s case assumptions about the contribution actual or potential of close relatives tested. At the Recall Event, it was emphasised that in fact one relative had 2 carer jobs. 6.59 In November 2012, the Emergency Duty Team received information that an extended family member had appeared in Court in relation to sex offences. Between December 2012 and January 2013 three letters were sent to the mother inviting her to the Children Social Care office to discuss this. She did not respond or attend any of the appointments. (We refer in paragraph 6.175 to the information given at the Learning Event that the mother has great difficulty reading.) 6.60 Three months later the Team Manager decided that a home visit should be undertaken. The mother and an adult man present said that the extended family member had no contact with the children and the charges had been dropped. The Social Worker recorded that no concerns were identified. She felt that both had been open and honest with her. No further action was required and the case file was closed. No action was taken to check the accuracy of the responses. 6.61 In the event, the adults had misrepresented their relationship and the identity of the extended family member. The charges had not been dropped and the male relative was subsequently convicted and imprisoned. No assessment took place on the risks to the subject children or others in the community. 6.62 The Children Social Care Reports robustly acknowledge the weakness throughout in assessment and enquiry processes which raise questions about the practice in other cases. 6.63 We agree with the recommendations in the Children Social Care Report intended to address these weaknesses in basic practice. 8 See for example Executive Summary of Overview Report of SCR Concerning Children M1 and M2. Bridgend LSCB. 2010. 16 6.64 In Child H’s case, a member of the community contacted Children Social Care about conditions in the property led to inter-agency consideration of neglect. A visit by the Social Worker found that conditions had apparently improved in the two weeks it took the member of the community to make contact with Children Social Care. However, no further contact was made with the member of the community to check out the assumptions that were made following this visit or to ascertain whether there was any additional information. 6.65 The Children Social Care Report comments that: “The response from Children Services was timely a home visit took place within 24 hours of the referral. However, the intervention was ineffective as the failure to undertake a robust assessment resulted in what in the author’s view was a poor outcome for the children.” “It is likely in light of what the mother reported during the first assessment visit that if the member of the community had referred the concerns when the visit was made to the property two weeks prior, that a Child Protection Enquiry would have been initiated.” 6.66 During the Social Worker’s visit the mother and her partner were angry stating that they believed a named relative had made the referral as he had threatened to do so. However, there was no enquiry into what might have influenced the relative to threaten this action. 6.67 We discuss the inadequacy of assessments in Section 6.1. 6.68 In Child P’s case relatives contacted Children Social Care with concerns about the children and state of the premises but wished to remain anonymous. On several occasions Children Social Care received information anonymously from individuals in the community expressing serious anxiety about the welfare of the children. Sometimes it was suspected or known who was likely to be the referrer. They concerned serious allegations and were clearly from individuals with knowledge of the circumstances and activities in the property. 6.69 These concerns were not pursued with any rigor and elementary steps to enquire were not undertaken. When the identity of the referrer was known no feed-back or checking of factual issues or conclusions following assessments took place. Although the reasons for this are not recorded, the impression is given that because they were anonymous or from a family member or likely to be from neighbours, the accuracy was in doubt and they were more likely to be malicious. 6.70 Evidence and experience suggests that this is not likely to be the case. While some malicious complaints may be made when there are already concerns about the welfare of children such contacts are more likely to understate concerns and express them sufficiently to generate some action. They may make tentative contact or report minor issues, to generate inquiry when actually, more serious issues are occurring.9 6.71 In any event, the motive for making and the source of a referral should not impact on the thoroughness of the inquiries. 6.72 The importance of considering the relevant information known to the community has been increasingly emphasized following high-profile reviews and research dating back to 2003.10 Reports of Serious Case Reviews, Domestic Homicide Reviews, Child Practice Reviews 9 Proceedings of a Symposium on risk assessment in child protective services National Centre of Child Abuse and Neglect Cicchelli (1991) 10 Report of the Climbié Inquiry (2003); Executive Summary of Overview Report of Serious Case Review of Concerning Children M1 and M2: Bridgend Local Safeguarding Children Board (2010); Overview Report of Serious Case Review: Hamza Khan; Bradford Safeguarding Children Board (2013); Overview Report of Serious Case Review: Daniel Pelka; Coventry Safeguarding Children Board (2013); Overview 17 and research confirm that even when neighbours or other members of the community do contact child protection agencies often the information they share is given a low status and the importance is downgraded.11 6.73 In 2012 a substantial research study into social care provision for children, provided “a rare insight into the experiences of neglected children” over a period of five years, examining the responsiveness of parents and children to social care support and their progress. The researchers commented that: “It was noticeable that referrals from neighbours and relatives were often discounted or ignored.”12 6.74 Working Together to Safeguard Children 2013, which was current at the time these cases attracted concern, repeated guidance13 in previous versions which is reproduced in Working Together 2015: 19. Anyone who has concerns about a child’s welfare should make a referral to local authority children’s social care. For example, referrals may come from: children themselves, teachers, a GP, the police, health visitors, family members and members of the public. 21. Feedback should be given by local authority children’s social care to the referrer on the decisions taken. Where appropriate, this feedback should include the reasons why a case may not meet the statutory threshold to be considered by local authority children’s social care for assessment and suggestions for other sources of more suitable support. 6.75 Earlier versions of Working Together to Safeguard Children spelt out that: “In the case of public referrals, this should be done in a manner consistent with respecting the confidentiality of the child.” 6.76 Statutory regulations and guidance prohibit some decisions concerning Children Looked After by the local authority being taken without considering relationships with adults who are not members of the household but likely to have regular contact with the child and the nature of the neighborhood in which the home is situated and resources available in the community to support the child and parent.14 6.77 At the Learning Event, a Team Manager was very clear that she would not expect social workers to contact neighbours during enquiries or assessments or to go back to them following a “referral”. This appeared to be a widely held approach to practice. 6.78 It is important that when enquiries and assessments are being carried out there is careful identification of what needs to be known and how to source of that information. Where that source might be a neighbour or other member of the community rather than a professional Report of Serious Case Review: Child T (Poppy Widdowson) North East Lincolnshire Local Safeguarding Children Board (2017); What research tells us: Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln (2010); 11 Effective Working with neglected Children and Their Families – Linking Interventions to Longterm Outcomes: Elaine Farmer and Eleanor Lutman (2012; Jessica Kingsley) Farmer and Owen 1995; Munro 1996; 1999) 12 Case management and outcomes for neglected children returned to their parents: a five-year follow-up study: Elaine Farmer and Eleanor Lutman, School for Policy Studies, University of Bristol; Research Brief DCSF (2010) 13 Working Together to Safeguard Children 2013 Chapter 1: Assessing need and providing help: Paras 19 and 21; HM Gov.(2013) 14 See for example: Provision for different types of placement - decisions to place a child subject to care order with a parent: para 18 and Schedule 3 Part 4. The Care Planning, Placement and Case Review (England) Regulations 2010. 18 it is inappropriate to practice on the basis that they will never be approached by any professionals. 6.79 This is therefore an area that has attracted careful consideration by the Board of guidance, procedures and training arrangements to ensure that the legal obligations and principles concerned with carrying out enquiries and reaching sound judgments are met. 6.80 It Is recognised by Dudley Safeguarding Children Board partners that for any agency only to have regard to such information only when by chance those with the information report it, is inappropriate, and that on occasions it might be necessary to proactively approach possible sources of information held by relatives or members of the community. 6.81 This is a skilled area of practice that requires care in its application, taking account the implications and likely impact on children, families and professionals and the form and extent of such enquiries must be considered on a case by case basis, considering principles of confidentiality, data protection and proportionality. 6.82 In Dudley, a Multi-Agency Safeguarding Hub has been established and the approach to these issues in individual cases referred into the Hub can be discussed and agreed. The appropriate practice can also be addressed within supervision. 6.83 Clearly, where members of the community or relatives hold information that should reasonably be reported to agencies, it is preferable that they recognise that they have a responsibility and make such a report. 6.84 An emphasis of the recently published Government Advice on Child Sexual Exploitation has encouraged making links with communities so that those who do not necessarily “work with children” also make a contribution to tackling child sexual exploitation.15 6.85 Considerable work has been done in Dudley to address communication with the public and encourage members of the community to take an active interest in safeguarding. 6.86 Common Assessment Framework 6.87 Professionals across all agencies during discussion agreed that during the scoping period and still at the time the practitioner events took place in 2016 there was a lack of robust understanding and elements of confusion regarding the Common Assessment Framework. It is understood that work undertaken by Early Help will help to resolve this. 6.88 Children Social Care closed Child H’s case expecting that a Common Assessment Framework involving the Children’s Centre would be carried out. The dynamic between one agency recommending that another undertakes a Common Assessment Framework was discussed at some length as part of this review. This revealed that the lack of a robust process around Common Assessment Frameworks was an issue for this review. 6.89 A Common Assessment Framework had been recommended in January 2015 but this had not been progressed by the time Child H died. There is no evidence in the GP records that a Common Assessment Framework was due to be undertaken which would suggest that the GP had not been contacted for any information. 15 Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation; Department for Education (February 2017) 19 6.90 There was no evidence of a step-down process being followed, nor of a lead professional taking forward the Common Assessment Framework process. 6.91 At the Recall Event, a discussion took place about the Common Assessment Framework (replaced with Early Help Assessment) arrangements which were said to be insufficiently robust with a lack of clarity about who is to be involved, who is the lead professional to drive it forward and what are the expected timescales. There is poor administrative support. A central team with responsibility to monitor these assessments did not receive information about all those carried out. 6.92 An audit of Common Assessment Frameworks was carried out 18 months prior to the Learning Event but inquiries about this indicated that the work had not progressed as the Quality Assurance officer had since left the authority. An audit has since been carried out relating to Early Help Assessments. It is hoped that the development of Early Help services and support will ensure and secure significant improvements. 6.93 A single agency report recommendation suggested “For all practitioners to assess home conditions using a recommended tool to be utilised across all agencies.” We have been informed that training on the Graded Care Profile has taken place, was well attended and at the time of publication has been implemented across the partner agencies in Dudley. 6.94 Neglect 6.95 In both cases concerns arose because of chaotic and poor conditions within the homes and neglect of the children’s welfare. The recognition of the need to address neglect was reflected in the approach taken to both cases and the work undertaken. 6.96 Working with neglect and achieving significant improvements is difficult. The concerns in Child P’s case were chronic and in both cases the involvement of agencies brought about only short-term improvements with no change in the underlying circumstances. The circumstances of the deaths of the two children could not have been predicted but the likelihood of serious incidents occurring is greater in neglectful households. 6.97 The adverse consequences of neglect are well understood and there has been a significant body of research and guidance published. This learning has informed the process of the review and the identification of themes. 6.98 In Child P’s case decisions were made to close the case without consideration as to whether the risks to the children had been minimised and whether it was safe to do so. One hypothesis raised by current Children Social Care staff was that workers over identified with Child P’s mother, and continued to view the mother as a Looked After Child. Child H’s case was also closed prematurely. 6.99 Plans in the two cases failed to require workers to maintain a focus on the child and their needs throughout assessments and interventions. The children were not given a voice, and there was no evidence that their behaviour and interactions with others was observed. Such a focus would have improved understanding of the impact of neglectful care on their lives and potential and it would have provided a benchmark for measuring progress. The consensus of practitioners across agencies was that this weakness reflected a culture that prevailed across agencies at that time. 6.100 The reports confirmed that although there were occasions on which physical descriptions of the children were made by practitioners there was little comment on the 20 children’s presentations, their interaction or demeanour, which may have contributed to an understanding of what life was like for them or how adults were interacting with them. 6.101 There was little analysis of what was observed or the impact of actions undertaken in response. Essentially, the voice of the child in both cases was either not heard or, if/where it was heard, it was given insufficient weight. 6.102 In Child P’s case, there was no analysis of the impact of the mother’s relationships on the children nor any analysis regarding the males with responsibility for parenting. 6.103 Child P’s mother disclosed that her current partner had been sentenced to imprisonment for 2 years. There is no indication that this prompted any consideration of what the impact would be for the children in the household. 6.104 During supervision meetings with Social Workers and their managers when decisions were made to close a case, there was no reflection or consideration of the impact on each child or clarity about how risks had been minimised. Assessments did not focus on individual children. 6.105 The Police Report concerning Child P comments that contact with the mother by police officers lacked a child-focussed approach and consideration of the effect that individuals or the circumstances of incidents may have had on the children. 6.106 Following an inspection by Her Majesty’s Inspectorate of Constabularies which highlighted a lack of awareness by officers regarding the importance of considering “the voice of the child”, action was taken by the force. Officers were provided with training in respect of their role in the safeguarding of children and there have been numerous training packages and force initiatives recently to increase the knowledge of West Midlands Police staff around child protection issues. Encouragingly, it was reported at the Recall Event that there has been training arranged specifically for staff working within the Intelligence Department to emphasise that they “must think children”. 6.107 The interagency processes, which in the case of Child P included Child in Need meetings, failed to focus specifically on the impact on the children and what was necessary within appropriate timescales to impact on the adverse consequences. 6.108 Discussions at the Learning Events confirmed that despite the considerable activity and obvious concern among professionals there was little evidence of focus on the experiences of life and the impact of their environment for the individual children or of what life was like for the children 24 hours a day, seven days a week and the likely impact of the neglect upon them in the short and long term. 6.109 Discussion with the author of the Children Social Care Reports suggested that the documentation in place to support practice and provide triggers to ensure relevant issues receive attention is adequate and does require consideration of individual children. However, unless there is a clear understanding about the purpose and importance of those triggers the documentation will become an administrative requirement rather than an aid to ensure good practice. 6.110 The Children Social Care Reports address poor case recording and the need for refresher training for social workers on Child Development. 6.111 Many of the common weaknesses in working with neglect that have been highlighted by research were evident i.e. failure to gather information about the family’s past history, 21 their relationships and functioning, viewing each concern in isolation, not maintaining up to date chronologies, and the “rule of optimism” each played a role. 6.112 An Ofsted thematic report of evaluations of reviews published in 2011 found that practitioners underestimated the fragility of babies16 and emphasised the need to reflect that vulnerability to very serious harm through inter- and intra-agency processes and communication. 6.113 In March 2014 Ofsted published “In the child’s time: professional responses to neglect”. One of its key recommendations was that Local Safeguarding Children Boards should ensure that the training provided for front-line practitioners and managers enables access to contemporary research and best practice in working with neglect. 6.114 This is reinforced by the requirement in Working Together to Safeguarding Children 201517 that Social workers and managers should always reflect the latest research on the impact of neglect and abuse and relevant findings from serious case reviews when analysing the level of need and risk faced by the child. This should be reflected in the case recording. 6.115 Whilst Dudley Safeguarding Children Board did disseminate the OFSTED recommendations, there was no evidence of a clear steer on the actions required to ensure improvement in practice and then to test the impact of this. There is no evidence that the body of knowledge regarding the impact of neglect or the practice and management skills required were considered or applied in either of these cases. 6.116 Information Technology resources make it easier now than at any time to ensure that practice is underpinned by consideration of research and Serious Case Review findings. In 2015 the University of Huddersfield established a Web-Based Register of all completed and ongoing child protection research in the UK.18 The NSPCC Library has copies of all Serious Case Review Reports published and will also undertake literature searches. Local Safeguarding Children Boards must now make readily accessible on their websites Reports of Serious Case Reviews for a minimum of least 12 months.19 6.117 Neglect Strategy 6.118 Clearly the absence of an overarching plan or Neglect Strategy within the scoping period is significant in these cases. It would appear from records that the Dudley Safeguarding Children Board was aware there was a gap across the staff groups of the understanding of indicators for neglect and the impact of long term neglect. There was also work within individual agencies to improve understanding of neglect and the response to it, but this was not driven or monitored by the Board. 6.119 What is the current position on neglect strategy? 6.120 The Board approved a Neglect Strategy in July 2016, the implementation and governance of which is being overseen by the Children and Young People’s Alliance. 16 Ages of Concern: learning lessons from serious case reviews 2011: A thematic report of Ofsted’s evaluation of serious case reviews carried out in England from 1 April 2007 to 31 March 2011. 17 Working together to safeguard children A guide to inter-agency working to safeguard and promote the welfare of children; Chapter 1: Research and SCR findings. HM Government (March 2015) 18 http://www.hud.ac.uk/hhs/research/ukrcpr/ 19 Working together to safeguard children A guide to inter-agency working to safeguard and promote the welfare of children; Chapter 4 Serious Case Review Checklist. HM Government ((March 2015) 22 6.121 The new threshold framework was rolled out to practitioners from May 2016. This included information about the Multi-Agency Safeguarding Hub and Single Point of Access which is hoped will improve responses. The Safeguarding Children Board is also receiving data regarding the impact of these new service developments. 6.122 The Board received two audit reports carried out by staff independent of the partnership during 2016 and continues to receive routine performance data regarding contact and referrals to the Multi-Agency Safeguarding Hub. OFSTED monitoring is in place and scrutinises the Multi-Agency Safeguarding Hub as well as other Children Social Care systems and processes. 6.123 Board members collectively and individually will be responsible and accountable for ensuring that this work progresses and that appropriate arrangements are in place to ensure that there is a significant impact on practice. 6.124 The lack of a strategy for neglect and response to recommendations made in previous serious case reviews and national reports and guidance suggest it is likely that weaknesses identified in this review will have been apparent in the approach to other cases. While it is probably impractical and unrealistic to expect that every case involving neglect is reviewed, the Board should take some action to ascertain whether there is a need to take significant action to review individual past cases. Recommendation 2 The Board has identified neglect in its business plan as a themed area on which to focus and will monitor the implementation of the strategy and periodically undertake case file audits to test the impact. 6.125 Previous Serious Case Review 6.126 Two years before the deaths of Child P and Child H, Dudley Safeguarding Children Board and Sandwell Safeguarding Children Board jointly published the Executive Summary of a Serious Case Review carried out by the two Boards concerning the death of Child C. She was an 18-month-old girl who died at home in Sandwell and despite extensive forensic testing, it was not possible to establish the cause of death. 6.127 The key Issues identified in the report arising from the case were: Protocols and Practice in Managing Neglect: essential that practitioners use assessments of risk to develop plans that include clear and measurable targets for improvement. Role of Partners: no evidence that mother’s partner’s role in respect of the children was researched or understood by those practitioners. SSCB and DSCB need to satisfy themselves that existing guidance is sufficiently robust in this area and that all practitioners recognise the imperative of engaging male partners in the assessment process. Disguised Compliance: despite occasional optimism that Mother was showing signs of improved co-operation and engagement, there was no discernible improvement even in the face of considerable input and activities by professionals. Families Who Avoid Professionals: Such situations need to be robustly assessed and given sufficient weight in the findings of assessments. Voice of the Child: opportunities to hear the ‘voice of the child’ were missed and resulted in incomplete assessments. 6.128 The report emphasised the need for improved communication between agencies, thresholds and timing of intervention, implementation of agreed protocols for escalating 23 unresolved concerns about children and the importance of frontline staff being adequately trained in safeguarding children issues. 6.129 The recommendations accepted by Dudley Safeguarding Children Board included: Recommendation 1: That DSCB and SSCB take urgent steps to satisfy themselves that: procedural guidance in the area of neglect is robust and reflects latest research; and the training programme to support that guidance is reaching all relevant personnel. Recommendation 3: That SSCB and DSCB: Review their procedural and practice guidance to ensure that it robustly promotes the participation and engagement of fathers and other male partners in any assessment process; and Review their multi-agency training programme to ensure that this issue is adequately promoted. Recommendation 4: That DSCB and SSCB undertake a review of existing guidance in respect of disguised compliance by parents/carers, to ensure it reflects current research. This review should also include an audit of current practice to establish practitioners understanding and compliance with the guidance, and the training that underpins this practice. Recommendation 5: That DSCB and SSCB review existing guidance to ensure that assessments of families who persistently avoid contact with professionals give appropriate weight to that non-compliance. Evidence that guidance is widely known and understood by practitioners should also form part of this Review. Recommendation 7: That DSCB and SSCB commission or undertake quality assurance measures to satisfy themselves that: Existing training programmes adequately emphasise the importance of canvassing the views and feelings of all children, and taking account of that information in safeguarding assessments; and Practitioners across all partner agencies have accessed relevant training in this area and can demonstrate their awareness of its significance. The report stressed that: “All of these issues have been identified in previous Serious Case Reviews, both locally and nationally, and the challenge is for the two LSCBs concerned to ensure that they become embedded in local practice.” 24 6.130 It is very disappointing and of serious concern that the issues arising and weaknesses identified from the review of the deaths of Child P and Child H are so similar to those identified in the Serious Case Review concerning Child C. 6.131 Some staff who attended the Learning Events were aware of and referred to the Child C Serious Case Review but no-one attending was able to identify any steps taken to implement the recommendations. 6.132 However, this review has established that there were clear arrangements for implementing and monitoring the implementation of the Serious Case Review recommendations at the time. There was evidence of monitoring of the implementation of action plans by the Serious Case Review Sub-Group and members of the Safeguarding Children Board. There is also a suggestion that the then Independent Chair of the Board met senior officers to ensure evidence would be provided to demonstrate actions taken for their implementation. 6.133 However, there is no evidence that the lessons from that Serious Case Review and any actions taken to implement the recommendations had any impact on the practice in relation to the neglect of Child P and Child H. 6.134 All partner agencies have individual and collective responsibility and accountability for ensuring that the implementation of recommendations is carried out effectively and that national findings and recommendations are considered and implemented and have the intended impact to improve practice Recommendation 3. 6.135 Sudden Infant Death Syndrome 6.136 Much has been learnt about why some very young children die suddenly.20 Babies living in households where drugs are taken, sleeping on their fronts, in very warm rooms, experiencing passive smoking or in beds with adults are accepted as being at increased risk of sudden deaths. 6.137 The Post Mortem Report for Child H highlighted that there were risk factors of “cot death” present – “baby born prematurely, parents smoking and smoking of cannabis and co-sleeping”. 6.138 Standard operating procedures for Midwives and Health Visitor’s require mothers and fathers to be advised about these risks. Were adequate warnings and advice given by the health staff? 6.139 The written material left with the parents clearly identifies the risks. The records indicate that this was reinforced by health staff in discussions with the mother and the other adults in the household. They stated that smoking took place outside the house. The mother was offered but refused smoking cessation services. The mother was given a thermometer and advised on appropriate room temperatures. 6.140 It is clear that not only were warnings given but they were understood. 6.141 When the mother called emergency services when she found that Child H was not breathing she lied about the circumstances and initially claimed Child H was found in his 20 See for example a report on Birmingham cases Investigating Unexpected Child Deaths: An Audit of the New Joint Agency Approach; Garstang, Debelle, and Auket: Child Abuse Review volume 24, issue 5 (2015) pp 378-384. 25 cot before being prompted by the male present to “tell the truth”, that is that Child H had been sleeping in bed with the adults. 6.142 There is evidence within the post mortem report which suggests it is also possible that the adults misled staff about the extent to which smoking took place in the household. There was small amount of cannabis shown in Child H’s blood which may have arisen from passive smoking. 6.143 If it had been apparent that a parent had slept with Child H under the influence of alcohol or drugs they may well have been prosecuted.21 6.144 In December 2014, the National Institute for Health and Care Excellence (NICE) updated national guidance to clarify the association between co-sleeping and Sudden Infant Death Syndrome. 6.145 Unfortunately, the guidance and the press release issued by NICE on 3 December 2014 – “Empowering families to make informed choices on co-sleeping with babies” - lacks the directness required concerning such a serious risk. It permits parents to weigh up the possible risks and benefits and decide on sleeping arrangements that best fit their family.” 6.146 Parents are therefore to be told they can make an informed decision to expose their infants to increased risk of a premature and unnecessary death. 6.147 This is not helpful for community health professionals attempting to impress upon households such as those in which Child H lived the importance of avoiding behaviours that increase risks. 6.148 In a survey involving 600 parents 46% said they lied to their GP or Midwife or Health Visitor about whether they “co-slept” with their babies.22 Recommendation 4 6.149 At the Recall Event, there was discussion about whether there should be more and stronger advice given locally to parents when a baby is discharged following birth and thereafter. Practitioners discussed whether a leaflet could be provided specifically on these issues. Also, the importance was noted of recording not only that advice was given but that so far as possible that the reasons underpinning the advice were understood where applicable. 6.150 Factors such as depression, mental ill health and learning disabilities may influence the practice and suggest a need for repetition and emphasis. Amendments made recently to ‘The Red Book’ which is left with parents at their home contain a requirement that Health Visitors undertake a safe sleep assessment. This was not a requirement during the scoping period for Child H, although formed part of best practice. In Child H’s case, the family’s change of GP resulted in a new Health Visitor assuming the previous one had undertaken this assessment. We welcome that agency’s recommendation to audit whether the red book’s new requirement is being implemented robustly. 6.151 There was general agreement that professionals can only give advice and monitor the circumstances. The responsibility is that of the parents. Both written and verbal indications from staff involved in Child H’s case suggest there was no evidence available to staff to 21 Children and Young Persons Act 1933 s1(2)(b) 22 Reported in Sunday Times 13 March 2016 26 suggest that the adults would have deliberately disregarded the advice they had been given. 6.152 Cannabis Use 6.153 The adults close to Child H and to Child P used cannabis. 6.154 There appears to be a weak association between drug use generally and Sudden Infant Death Syndrome particularly in the context of co-sleeping, but very little specifically relating to cannabis.23 24 6.155 But what might be the impact on the welfare of children in a household in which drugs are routinely misused, where dealing might also take place, particularly in the context of concerns about the neglect of the children? 6.156 Research is clear that parenting capabilities may potentially be affected25 The Clinical Commissioning Group Report comments that: “Substance misuse can have an impact on parental capabilities and whilst it is not clear from the records if the adult’s substance misuse was problematic, it should still have raised concerns when seen in conjunction with the other parental issues, namely domestic abuse, mental health issues and poor home conditions. Again, however, this was not evident within the parental GP records. There is also no evidence of any involvement with substance misuse services in any of the adult’s records.” 6.157 At the Learning and Recall Events, Health Visitors for Child P confirmed that they had no evidence or knowledge of drug use and had not been informed about the misuse. Police held extensive intelligence concerning drug misuse and if the network had been more curious about family life this information may have been unlocked. It is hoped the recommendation made within a serious case review in Dudley regarding Health Visitors reviewing medical notes should change this approach in future. 6.158 Where drug use is a feature of the family environment as a minimum there is likely to be a lack of routines and a focus on drug acquisition. The interests and welfare of children are likely to be a low priority. Practitioner discussions suggested that local practice at the time was to rely heavily on involving family support workers. Recommendation 5 6.159 Domestic Abuse 6.160 Any child/young person who lives in a home where domestic abuse is taking place is personally at a higher risk of direct abuse. Some estimates suggest that between 45 and 70% of children exposed to domestic violence are also subject to physical abuse. The social, emotional and psychological impact of violence upon women can seriously affect their parenting capacity. Research has consistently shown that a high proportion of children living with domestic violence are themselves being abused, either physically or sexually, by the same perpetrator.26 23 Maternal cannabis use in the sudden death syndrome. Scragg, Mitchell, Ford, Thompson, Taylor, and Stewart published online: 2 Jan 2007 DOI: 10.1111/j.1651-2227.2001.tb00256.x 24 Maternal and Paternal Recreational Drug Use and Sudden Infant Death Syndrome. Klonoff-Cohen and Lam-Kruglick. Arch Pediatr Adolesc Med. 2001;155(7):765-770. doi:10.1001/archpedi.155.7.765. 25 Cannabis and Mental Health; Royal College of Psychiatrists (June 2014) http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/cannabis.aspx 26 Walby and Allen (2004) Mullender et al (2003, 2005) 27 6.161 Studies indicate that child witnesses to domestic violence are, on average, more aggressive and fearful and more often suffer from severe anxiety, depression and other trauma-related symptoms. They live with constant anxiety and may be at a higher risk of alcohol or drug abuse, experience cognitive problems or stress-related ailments and have difficulties in school.27 6.162 Recent national developments include the publication in January 2016 of a report concerning nineteen children killed over a decade by known domestic abusers allowed contact with the children by courts.28 In December 2015 the Home Office issued statutory guidance concerning the implementation of section 75 Serious Crime Act 2015 which created a new offence of controlling or coercive behaviour in intimate or familial relationships. 6.163 The Police Report highlights that in 2012, within the 49 recorded incident logs which involved the mother there were numerous incidents of domestic abuse. Within the response to the concerns, including whether appropriate notifications were made, in Child P’s case the consideration of the impact of Domestic Abuse was not effective. 6.164 In Child H’s case, there were no reports of domestic abuse but damage to doors in the house was not explained and, after Child H’s death, neighbours said they heard arguing and noise. Midwives and Health Visitors routinely ask asked questions about domestic abuse. Child H’’s mother did not disclose abuse. 6.165 At the Recall Event, it was suggested that these issues and how far to pursue them are matters of professional judgement and professional curiosity but are not the focus of work. At the Professionals’ Meeting, there was a consensus that the culture in Dudley at the time lacked professional curiosity generally. Also, even when identified, it was thought staff may be uncertain how to address Domestic Abuse. Recommendation 6 6.166 Mental Ill Health & Disabilities 6.167 Mental ill-health in adults was feature of both cases and concerned the mothers and the men close to them. 6.168 Child H’s mother was asked about her mental health by the Health Visitor as part of the post-birth assessment 3 weeks after Child H was born. She gave no information suggesting that she suffered from mental ill-health, despite having been prescribed medication for depression which despite an increasing dose she felt had been ineffective. 6.169 Child H’s mother disclosed to the GP that she was prescribed antidepressants since Child H’s half-sibling was a baby but this information had not been shared with the Health Visitor. 6.170 Likewise, key information was held in GP records of Child P’s mother concerning mental health issues, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder and domestic abuse. The complexity around sharing such information is acknowledged. However, barriers were not overcome and this information was not accessed by other professionals or considered within assessments or in deciding on appropriate services or evaluating their impact. 27 Silvern et al (1995) (1998) 28 Nineteen Child Homicides; Women’s Aid 20 January 2016 28 6.171 At Children in Need meetings, Attention Deficit Hyperactivity Disorder was discussed and Child P’s mother was encouraged to go back to the GP. Again, there was no communication with the GP who was unaware of the status of the case. Adults with Attention Deficit Hyperactivity Disorder are more likely to experience more interpersonal and relationship difficulties. Break-ups are more common. The risk of drug and substance abuse is significantly increased in adults who have not been receiving medication.29 6.172 Child P’s mother’s diagnosis of Oppositional Defiant Disorder was also significant in that symptoms include negative and disruptive behaviour, often to people in authority. There are persistent references in the records to Child P’s mother refusing to engage with services, missing appointments and declarations that she “did not have to” do whatever she was advised. 6.173 There was a lack of support for a mother with Oppositional Defiant Disorder and Attention Deficit Hyperactivity Disorder which would be likely to result in her struggling with concentration and organisation. There is no evidence that she was advised to consult with mental health services, nor was engagement with Adult Social Care services explored as a possibility. There is no recording suggesting workers knew how her conditions were managed, let alone assessing the impact of this on her parenting capacity. 6.174 Knowing this background would clearly have affected the practice and communication with Child P’s mother and should have been considered within any assessment carried out, in particular when trying to understand why she did not take advice or agree to access supportive resources. The Housing Officer, who had successfully secured greater engagement, was not involved by the professional network to share strategies for working with Child P’s mother. This was a missed opportunity. 6.175 At the Learning Event, it was confirmed that in addition Child P’s mother was either unable to or has great difficulty with reading and writing. 6.176 These issues had the potential to impact on the ability to parent and how best to communicate with Child P’s mother. However, practitioners noted an absence of any assessment of these impacts. This was considered to be cultural in terms of the lack of professional curiosity that was the norm in Dudley at the time accompanied by the shortcomings in assessments which were a feature of practice then. Reviews of medical notes during pregnancy was the subject of a recommendation in a serious case review undertaken in Dudley in 2015. It is hoped a positive impact is being derived from this. 6.177 There is no evidence that either of the mothers received added support for their mental health issues whilst pregnant. Women who have suffered from mental health issues or received treatment from mental health services in the past should receive specialist advice as they have a high risk of becoming unwell after childbirth (RCPSYCH 2012).30 There is also very little information available within the GP records regarding psychiatric input during the pregnancies or any evidence of a discussion between the midwives and GP’s involved around their mental health and wellbeing. 6.178 At the Recall Event, it was emphasised that perinatal mental health is different from that within the general population and is a specialist area of practice. The point was made also that with the provision of adult services the patient or client have to want to engage and that without co-operation mental health is difficult to assess. 29 Harpin: The effect of ADHD on the life of an individual, their family, and community from preschool to adult life: Arch Dis Child 2005;90:i2-i7 doi:10.1136/adc.2004.059006 30 RC Psych (2012) Mental health in pregnancy: http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/mentalhealthinpregnancy.aspx 29 6.179 There is no evidence that Child H’s GP was contacted in relation to the mother stating she had post-natal depression. Furthermore, no efforts were made to ascertain whether mother or father were known to mental health services as part of the assessment process. 6.180 In Child P’s case, initially maternal mental health issues were raised following one of Child P’s sibling’s birth. Child P’s mother stated she was low in mood and felt paranoid due to her partner at the time using hard and soft drugs. The Health Visitor ensured that mother had a GP appointment but there is no follow up documented in the records. Maternal mental health does not appear to be referred to again in the children’s records therefore presuming that no further concerns were identified. 6.181 The Clinical Commissioning Group Report emphasises the need to access all available records for relevant information about health and to check and if necessary contradict assertions or claims made by adults. It is now clear that the fact that Child H’s father stated that he was schizophrenic and used cannabis to self-medicate could not be verified from the GP records. However, further checks were never made. This is likely to be attributable to the fact that Child H’s mother was not linked to her partner as a couple or as living with a relative, all being in the same household with a young baby. 6.182 There is growing evidence that people with serious mental illness are more likely to use cannabis. Also, evidence shows that those who use cannabis particularly at a younger age, have a higher than average risk of developing a psychotic illness.31 6.183 At the Learning Event, it was emphasised that provision of perinatal mental health is not addressed in the national contract for health services. Locally steps are being taken to develop a Perinatal Mental Health Service through a Dudley Group of professionals a business case has been put together. Lower level cases are dealt with by Primary Care and acute vulnerable women by services commissioned by NHS England. However, a substantial cohort of women (it was estimated about 300 per annum) fall between these 2 levels. Discussions at present concern the need to develop the service and capture the “mid-section” of cases. Recommendation 7 6.184 A further development arises from the need for adult and children’s safeguarding services to be co-ordinated. Dudley Safeguarding Children Board and Dudley Safeguarding Adults Board have introduced twice yearly joint Board meetings to address issues which overlap both Boards in order to ensure a more joined up approach. It is expected that the mental health of adults and child welfare will be considered at these joint meetings. 6.185 Accessing information about the mental health backgrounds of adults caring for children should improve if the arrangements to address weaknesses in assessments are addressed as discussed above. 6.186 The Board will no doubt be interested in understanding how the government’s five-year strategy to help new and expectant mothers 32 is assisting with improving provision in Dudley Recommendation 4 31 Cannabis and Mental Health; Royal College of Psychiatrists (June 2014) http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/cannabis.aspx 32 Times 11 January 2016 p12. 30 6.187 Non-engagement 6.188 In both cases, professionals in health services were concerned about the mothers’ engagement with their services. Appointments were missed and health checks for the children and immunisations not arranged. In Child P’s case, there were long periods during which the children were not registered with a GP. 6.189 The Children Social Care response to these concerns was to assert a parent could choose not to register with a GP or have children immunised, which is clearly correct in law. However, a pertinent question during assessment would be whether the approach by the parent reflects a carefully reached decision, alongside the network attempting to make other arrangements to ensure surveillance of health needs. In this case lack of attention, ability or motivation to make appropriate arrangements may have been the drivers. 6.190 The Housing Report sets out the persistent attempts that the housing worker together with the Health Visitor made to impact on the poor standards. The Report notes that the mother only appreciated interventions that involved doing something for her. Examples of this included arranging house moves, sorting out arrangements to deal with chronic debts and loss of benefits. While suggestions that she make changes, or take action herself led to her avoiding contact or becoming aggressive, to the extent that staff became nervous of visiting alone. This report includes the only reference to the mother receiving a Disability Living Allowance and a Personal Independence Payment. The reason why she qualified for payments or what impact it would have on her cognitive abilities or functioning was not considered within any assessment. 6.191 The Housing Worker and Health Visitor were keen to take part in interagency processes and were disappointed when these ceased. Upon case closure no reason was given by Children Social Care when there could be no confidence in the issues that had given rise to concern having been addressed. 6.192 Discussions at the Recall Event concerned what impact the attitude of a parent can have on the services that are offered. 6.193 Child P’s mother was manipulative - engaging with some services and not with others. She was reluctant to get help for Attention Deficit Hyperactivity Disorder. The Health Visitor advised referral to her GP but could not make the referral without her co-operation. She could not be forced to seek advice. Disability living allowance benefits were stopped because she failed to complete forms or attend for assessment. The likely impact of Oppositional Defiant Disorder on the attempts made to persuade her to engage with services was not part of the assessment. 6.194 The parents of Child H while appearing to understand advice failed to act on it. 6.195 Previous Serious Case Reviews locally and nationally have consistently identified that families who persistently avoid contact with professionals, or who prevent their children having such contact, may present a serious risk to the children’s safety and welfare. 6.196 It is encouraging to note the Board approved guidance on this topic following a serious case review in 2013 and audits of understanding and awareness were undertaken. 6.197 The Ofsted publication “In the child’s time: professional responses to neglect”, (March 2014) recommended that local authorities should: 31 “ensure that social workers have specialist training and supervision to enable them to exercise professional authority and challenge parents who fail to engage with services, particularly when their children are subject to child protection plans; this process should be subject to robust, regular management oversight and practice audit.” 6.198 The Children Social Care Reports include recommendations that staff in the department should receive an intensive programme of training to raise the standard of practice. Recommendation 8 6.199 The mother of Child H failed to provide a urine sample during either of her pregnancies. It was not possible to insist that she did so. It is not clear whether the reason for not providing a urine specimen was discussed with Child H’s mother by the Midwife. It was not seen as particularly significant by the Midwife. 6.200 Testing is not concerned with identifying substance misuse, although some mothers think this. Unless sent elsewhere for analysis the samples would not show up substance misuse. 6.201 It is not unusual for pregnant women not to provide regular urine samples. In a busy clinic, the Midwife might not query this and might inadvertently overlook a possible safeguarding concern. It was confirmed that there is no recommendation made by NICE in relation to this issue. 6.202 Discussion included whether there should be a system whereby after a number of missed samples the issue is addressed more proactively. It was felt that there are learning points for staff concerning the relevance of urine testing and an increased awareness of reasons why a urine specimen may not be provided. 7 The Safeguarding Response 7.1 Barriers 7.2 The barriers to providing an adequate safeguarding response included a lack of professional curiosity at critical points. Also, assessments which were adult focussed and did not consider what life was like for the children or their individual needs were a barrier within Children Social Care. Although the historical information was included (some more than others), this was not then used to inform the analysis and a professional judgement that was child focussed and addressed the risks for the children or the concerns apparent from the referral. 7.3 This was accompanied by a lack of forensic approach and management oversight. At the point when the case was referred to Children Social Care, there was no evidence of management oversight considering why the assessment was required. 7.4 Communication Between GP and Health Visitors 7.5 Health Visitors could not be relied upon to be familiar with the GP records during the scoping period. However, Social Workers assumed that all health information would be accessed and disclosed by the Health Visitor. 32 7.6 This is a serious issue and is well documented33. In discussion, the Children Social Care Report author commented that she had “audited hundreds of cases” and that “GPs were not contacted routinely.” The GP had not been made aware that Child P had died or the processes taking place and was seeing other family members. 7.7 There is evidence of the development a GP Communication Policy and an Information Sharing Agreement with each GP Practice. This will enable information to be shared daily regarding changes of status of children in certain categories. GPs will also be able to use a form to refer children to safeguarding leads. The Board will want to be assured of the impact these developments are having. 8.0 Quality of Decision Making and Plans 8.1 A pre-condition for an effective plan is a thorough assessment and this was lacking in the two cases. Also, the inadequacy of interagency processes is highlighted within this report. Given that these two elements were present it follows that plans were likely to be flawed. There were no interagency plans formulated to address effectively the risks to and needs of the children in these cases. 8.2 In addition, plans were made by Children Social Care without the benefit of contributions from all relevant professionals or with opportunities to question or challenge their effectiveness. There was a lack of clarity regarding benchmarks of “what the protected child will look like”. There were no contingency plans to address circumstances if even vague objectives were not met. The opinion of practitioners who contributed to the review was that these were not isolated cases and that these were the standards in operation locally at that time. 8.3 The plans failed to set out clearly what was required, by whom and when. The standards expected were not precise or measurable. There was no reflection of why standards in the households fluctuated so dramatically. It is hoped that the action by Dudley Safeguarding Children Board to develop a strategy and training programme to address neglect would impact positively on these issues. 8.4 The approach to and content of plans has been addressed by government in regulations and guidance and has attracted judicial comment and criticism in reviews and inquiries. The “how, who, what and when”34 and why were left unclear. Contingencies for withdrawing support or taking further action were not indicated.35 36 These are particularly important in cases of child neglect where often there is no single event that ‘triggers’ matters escalating. Realistic timescales were missing to ensure the children were not subjected to long-term neglect. 9 Supervision 9.1 Good management impacts significantly on outcomes for children in any case. However, OFSTED and others highlight the need for it more specifically in neglect cases to avoid drift and delay. 33 The Victoria Climbié Inquiry Report. Paras. 12.26 and 12.29 TSO (2003) 34 Richards J in R(AB & SB) v Nottingham CC (2001) 35 The Protection of Children in England: A Progress Report in 2009, Lord Laming 36 In the child’s time: professional responses to neglect, March 2014, OFSTED 33 9.2 In Child H’s case, there was no evidence of supervision on the case file in Children Social Care. This is of additional concern as Child H’ was a case in which neglect was suspected.37 9.3 In Child P’s case, oversight was not robust, with team managers failing to provide challenge to workers and establish clear contingencies. Decision making, including within supervision, was adult focused. There was virtually no reference to the children or whether specific issues have been addressed, no rationale provided for decision making so the author did not get a sense of what life was really like for the children. 9.4 The Children Social Care Report author identified the lack of an up to date chronology and robust supervision as a key omission at various critical points. It was felt these two elements could have pulled all the concerns highlighted above together, possibly leading to a Core Assessment being undertaken. A contingency plan could have been developed that if Child P’s mother did not engage within a specified period of time that consideration would be given to initiating a Strategy Discussion with Police and Health to consider a Child Protection Enquiry and Initial Child Protection Conference. 9.5 The Children Social Care Report states that this was not unusual practice in Dudley at that time. The author had audited many cases where management oversight is either not present or is limited at the commencement of the Children Services involvement. Team managers failed to ensure that their management footprint is evidenced on the case file from the point of allocation until the case is closed including regular supervision, providing a rationale for decision making and giving direction. 9.6 We are pleased to note that there are 3 separate recommendations regarding supervision in the Children Social Care Report. 9.7 Research, guidance and serious case reviews suggest all open cases must have an up to date supervision recorded on the case file. The Victoria Climbié Report published in 2003 recommended that Directors of social services must ensure that the work of staff working directly with children is regularly supervised. It also recommended that Directors of social services must ensure that senior managers inspect, at least once every three months, a random selection of case files and supervision notes. The accreditation arrangements for Knowledge and Skills: Practice Leaders and Practice Supervisors will no doubt have an impact, but this issue is not only relevant for social services staff and managers. 9.8 Earlier statutory guidance emphasized the need for effective support and supervision38 for all agencies. This was required to include scrutinising and evaluating the work carried out, assessing the strengths and weaknesses of the practitioner and providing coaching development and pastoral support. 9.9 The Children’s Centre Report indicates that the service has adopted a practice of ensuring “2nd pair of eyes” and focuses on robust evidence to support judgments. 9.10 The Police have monthly reviews of their cases carried out by a supervisor alert to children’s interests. 9.11 Housing have senior staff who hold monthly meetings with supervisees, shadow them on visits and ensure robust handover of case responsibility. However, it is significant that 37 (Farmer et al Case Management and Outcomes for Neglected Children returned to their Parents: A Five-Year Follow-up Study 2010.) 38 Working Together to Safeguard Children DSCF (2010) paras 4.58 to 4.55 34 the officer involved at the time was supervised by 5 different managers during the scoping period, which affected the level of confidence of that officer to challenge, both the mother personally but across the network. 9.12 Health Visitors have Team Leaders with specialist training with enhanced skills in particular areas and checks on practice in a way that is expected to avoid a tick box approach. In Child P’s case, however, the Health Visitor felt with hindsight she may have been more challenging of Child P’s mother and felt the fact that she did not have a team leader at the time may have contributed to this. 9.13 More generally, faced with manipulative and uncooperative mothers most workers will benefit from supportive and pro-active supervision. At the Recall Event, it was clear that not all staff within health organisations receive supervision. 9.14 It is important that Dudley Safeguarding Children Board is aware of the arrangements in each agency. We invite the Board to seek assurance on these arrangements to support the other workstreams within its improvement framework. 10 Challenge and Escalation 10.1 Safeguarding Children Board partners individually and collectively have a responsibility for the healthy functioning of the child welfare system. This accountability can only be effective if there is a willingness to raise and comment on issues of concern relating to the functioning and approach of partner agencies and a willingness to listen and take seriously concerns when they are raised by other agencies. This review has examined why the weaknesses identified and the concerns expressed about approaches within Children Social Care had not been raised and addressed by partner agencies within the Dudley Safeguarding Children Board. There is evidence to suggest partners did not feel that constructive challenge was welcomed or effective. 10.2 During the scoping period, the Board lacked support in the form of a business infrastructure, and this affected how well its members understood their roles and accountabilities. It was recognised and commented upon by partner agencies that there have been significant changes in management, leadership and governance arrangements within Dudley Safeguarding Children Board and this has led to a more positive and responsive environment. 10.3 All members of the Board have responsibility and accountability which include ensuring recommendations from serious case reviews are effectively and promptly implemented. Lay Members are full members of the Board and with Lead Members for Children’s Services have particular roles to play in challenging professional practice and agencies. During the scoping period, no induction document was in place to guide and support members as to how their role works in practice. There are now robust induction and peer support processes in place for all members of the Board. The Board may wish to consider on an on-going basis how these developments have impacted on and improved the culture of challenge within the Board and make it less likely, for example, that urgent recommendations from serious case reviews are not effectively implemented, despite processes being in place. Recommendation 9 10.4 There is now clear evidence of the Board having clear and robust arrangements for implementing and monitoring implementation of Serious Case Review recommendations, and monitoring of the implementation of Action Plans by the Serious Case Review Sub-Group and members of the Board. 35 11 Holiday Periods 11.1 When Child H’s Health Visitor made a referral to Children Social Care, it appears likely that the holiday period contributed to the delay in the safeguarding response. The agency report author concluded the likelihood that supervision would have taken place over the Christmas and New Year break was small. 11.2 The Report reflects careful analysis of contacts and progressions to referral and assessment. Between the 22 and 23 December prior to the Christmas break the teams would have been extremely busy. Although there is no evidence that this had an impact on the timeliness of response, the proximity of the holiday period contributed to what appeared to be haste to close the case and in failing to keep the children at the centre of the assessment. 11.3 The services available out of hours and the impact on decision making in the period approaching and during weekends and statutory holidays has been an issue of concern repeatedly identified in Serious Case Reviews and inquiries.39 The chief executive of each local authority with social services responsibilities is required to ensure that specialist services are available to respond to the needs of children and families 24 hours a day, seven days a week, as opposed to out-of-office-hours teams.40 11.4 Managers have a responsibility to ensure that an effective service is delivered and staff have a personal responsibility arising from contracts of employment and professional codes to alert managers to any circumstances that indicate that the service will not be delivered effectively. 11.5 At the Recall Events, the discussion included reference to a “bulletin” that had been sent out recently about when offices were closed and the alternative contact numbers. This issue does not only concern social care services. Across agencies there was a consensus that personal annual leave should be raised and agreed with supervisors with proper arrangements for cover and handover. 12 Information Sharing 12.1 The Police Report identified failures by officers to make referrals and share information about domestic abuse incidents. In Child H’s case, known males were not linked with the mother. In Child P’s case, there were three separate police intelligence logs submitted during November 2014 which related to the mother’s previous address and information that she was suspected to be growing cannabis. More similar intelligence was logged after she moved to a different address. There is no record that Children Social Care or other agencies were aware of this intelligence. 12.2 Awareness-raising about the significance for child welfare of domestic abuse and misuse of drugs has underpinned the West Midlands Police’s action to robustly address this issue. All staff within the Intelligence Department have received training on their responsibility to identify child welfare concerns and the need to ensure that appropriate referrals have been made. 12.3 The GP practices were unaware of the previous history, referrals and concerns around neglect until after the deaths of both children. They would have been unable to take these into consideration during any consultation. There is also no evidence of discussion 39 See for example the Executive Summary of the Overview Report of the SCR carried out by Bridgend SCR concerning Child O (2012) 40 The Cllmbie Inquiry, 2003 36 or communication between the Health Visitor and the GP in either case. From reviewing the GP records, it is not apparent that there had been concerns for both families. There is also no evidence that the GPs had been contacted when referrals had been made for both children to Children Social Care. 12.4 The Clinical Commissioning Group Report notes that the GP as a member of the Primary Care Team will often have information that would be beneficial to any information gathering process. 12.5 From completed chronologies in the case, prior to the scoping period for the review, it was clear that Child P had been known to Children Social Care since soon after birth in relation to two domestic abuse incidents. The Report highlights as good practice that the GP practice had recorded these in the notes and in the problem summary which meant that any clinician reviewing the case would be aware of them. 12.6 At the Recall Event, it was emphasised that the GP responsible was not aware that Child P had died when seeing other family members. The case was transferred to a new health visitor in October 2014 due to a change of GP. There is no documented evidence that there was a verbal handover with the new Health Visitor. 12.7 There was, however, good information exchange between the Housing worker and Health Visitor in Child P’s case. 12.8 The other reports give examples of weaknesses in sharing information; delay in feedback between Health Visitors and Social Workers; no information regarding past history or home conditions was shared with the Children Centre; not making colleagues aware of house moves; failure to share information from Child P’s mother who stated that the father of one of the children had been charged with causing Actual Bodily Harm, kidnap and witness intimidation and was serving a prison sentence. 12.9 There were indications of uncertainties and confusion about information sharing and incorrect assumptions about the barriers to sharing information that led to an inappropriate culture developing - a persistent theme that has led to repeated national guidance on the issue. From discussions at the Learning Event it appears that staff are uncertain about when information can be shared unless there are clear child protection concerns. 12.10 In Child P’s case, a Social Worker reported that Police had refused to disclose information about adults as these were “Child in Need enquires, not Child Protection”. This is a serious issue. Despite a well-established acceptance of the importance of good communication, weaknesses have persisted.41 12.11 Working Together 2015 continues to emphasise that: “Serious Case Reviews (SCRs) have shown how poor information sharing has contributed to the deaths or serious injuries of children.” 12.12 National guidance intended to improve practice has regularly been issued, the latest in March 2015.42 41 The Victoria Climbié Inquiry Report. TSO (2003) 42 Sharing Information: Advice for practitioners providing safeguarding services to children, young people, parents and carers, HM Government (2015). 37 12.13 The approach adopted suggests that a Child in Need case is treated as requiring a less rigorous application of process than a Child in Need of Protection. Within health organisations it was suggested that Child in Need is treated as less serious. The Named Nurse does not review Child in Need cases whereas if Child Protection is involved she does. 12.14 A Child in Need includes one is who is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, even a reasonable standard of health or development or whose health or development is likely to be significantly impaired, or further impaired, without the provision of services. 43 12.15 If the services are not provided or are ineffective the child will be likely to suffer significant harm. A proper assessment requires accessing all the information relevant to forming a judgement.44 Agencies to whom Section 11 Children Act 2004 applies have a statutory duty to discharge their functions with regard to the need to safeguard and promote the welfare of children. This includes partner agencies and those commissioned by those agencies. These agencies are unable to carry out this statutory duty without access to the relevant information. The duty includes sharing and acquiring and considering the necessary information to form appropriate judgments about how to exercise their functions to safeguard promote the welfare of children – not only to contribute to child protection processes. 12.16 The Dudley Group NHS Foundation Trust Report expressed concern having made referrals to Children Social Care that consistent feedback on action and decisions made was not received. Arrangements have been made to disseminate information about the Single Point of Access which it is hoped will improve the approach and consistency to sharing information and responding to referrals. Dudley Safeguarding Children Board has arrangements in place to review the effectiveness of the Single Point of Access. 12.17 If the approach to sharing information is not sound, it is likely to have an impact on inter-agency processes. For example, Child in Need meetings took place without any input from health practitioners as the social worker was reported to have stated she was unaware of who the Health Visitor was. 12.18 At the Recall Events, there was considerable anxiety about the approach to interagency working and processes with criticism of Children Social Care for the lack of explanation for cancelling Child in Need meetings and closing cases without expressed reasons or consultation. 12.19 It was also suggested that minutes of Children in Need meetings are not consistently received. We anticipate the Board will wish to satisfy itself that inter-agency processes take place effectively. Administrative support for inter-agency processes should be ensured and an audit regarding promptness of circulation and adequacy of minutes would inform where any gaps lie. 12.20 Discussion of the issues generated a healthy determination that “In future I would escalate it higher.” One agency sought to recommend that “Children Social Care to liaise with all agencies involved prior to closing any case e.g.: Child in Need.” 43 s17(10) Children Act 1989. 44 Lord Laming in The Protection of Children in England: A Progress Report (2009) 38 12.21 In Child P’s case, the Police asked for a Child Protection Conference to be convened but Children Social Care refused to do so. It does not appear that other agencies were consulted. The issue was raised with senior staff but the decision was not changed. It was considered by current Children Social Care staff that the mindset at that time was that this case concerned medical neglect, the mother had cooperated, Health Visitors were making visits and the Police were aware of the family. The case, it was suggested was only “seen at surface level”. 12.22 This raises the issue of where the responsibility should lie for deciding whether an inter-agency process takes place and how appropriate it is when a partner agency feels strongly that a conference should take place not to convene the meeting. A benefit of a conference is that it involves experienced child protection professionals uninvolved in the case who are more likely to identify weaknesses in the approach.45 13 Good Practice 13.1 There were elements of practice which made a difference in these cases and there is equal learning to be derived from these as from shortcomings in practice. The network as a whole was able to reflect on the persistence of the Housing Officer who worked with Child P’s mother. 13.2 Good inter-agency working was apparent between Child P’s Health Visitor and the wider network in her approach to referring the case and then following up. She attended GP practice meetings to share information and exercised curiosity when she watched a male leaving the property and alerted Children Social Care. 13.3 There was good co-working between the Housing Officer and the Health Visitor. Also, the Children’s Centre offered joint visits, showing good inter-agency working. 14 Improvements Already Implemented 14.1 There have been a lot of developments since the scoping period for two reasons. The first is that this review has taken longer than it should have to complete. However, the second is more positive and it is that Dudley is on a journey of improvement. This journey was under way at the time of the OFSTED inspection. 14.2 The developments of most relevance to this review have been mentioned within this report. These are the introduction of the Multi Agency Safeguarding Hub and the Single Point of Access. These are still early in implementation and there is some way to go. The work around communication with GPs will, it is hoped, also secure improvement. The Unborn Baby Network is also an encouraging development, providing an opportunity for multi-agency discussion of certain cases. 14.3 The Back to Basics Training module, offered to Social Workers is a significant development which, it is hoped will make a difference. We take a similar optimistic view regarding the Resolving Professional Differences Protocol, which we hope will be instrumental in changing the culture in Dudley, if arrangements are made for it to reach all levels, including the front line. Building confidence is in operation and will only be successful if accompanied by appropriate oversight and support. 45See for example the Executive Summary of the Overview Report of the Serious Case Review of the Circumstances Concerning KaB (dob 13.12.1994) and KiB (dob 10.03.2012) who both died in a house fire on 18.09.12. South East Wales Safeguarding children Board January 2015 39 14.4 Workforce changes to enhance leadership and capacity, the re-launch of the Resolution Policy and the Graded Care Profile are all worthy of note. It is expected that the impact of the work of the Improvement Board will be significant. 15 Conclusions and Lessons Learned 15.1 In both cases it was impossible to conclude that from the circumstances known to agencies the specific circumstances of the deaths could have been predicted. The cases have facilitated a thematic review which is intended to assist the board identify areas which may arise or have arisen in other similar situations. 15.2 The assessments that were undertaken in relation to both cases under review were inadequate for a variety of reasons. The number of “initial assessments” was striking, as was the lack of assessments in circumstances which required one to be carried out. In both cases assessments were adult focussed. In Child H’s case, the assessment seemed to take a snapshot of concerns. This review has highlighted where robust assessments, analysis, planning and review were found to be lacking. This was confirmed by an OFSTED inspection in January 2016. In Child P’s case, each development in the case compounded the last so that the risk was multiplied. Workers over identified with Child P’s mother, who continued to be seen as a Looked After Child. 15.3 It appeared that practice was incident led in both cases with a lack of overview with the result that the level of risk was not recognised. In both cases assessments failed to take account of the family history, and there was no evidence of information being gathered in one place for reflection and debate. There was no evidence of use of a genogram in any agency. These deficiencies were described as being “the norm” in Dudley. It is encouraging that these areas form part of the “Back to Basics” work undertaken with Social Workers. 15.4 The complexity of factors contributing to the risk to Child H and to Child P was not always fully appreciated, and this no doubt results from deficiencies in practice highlighted above. Poor information sharing, response to concerns, assessments and interagency processes prevented the complexity from being recognised and responded to. The review reveals not a situation in which specific instances of underperformance from any single agency are to be highlighted but a fundamental systemic failure. 15.5 A striking feature of the cases was the failure to incorporate males in assessments. This had an enormous impact on professionals’ ability to understand what life was like for the children in these two cases. Described as culture and practice at that time, this factor was identified by OFSTED and is now the subject of improvement work. 15.6 Professional curiosity was lacking on many occasions, resulting in information from the community and relatives not being incorporated into assessments and brought within the professional networks. Child P’s relatives were considered to be a protective factor without sufficient assessment and an over optimistic view of parental ability to effect change prevailed. The workers’ over identification with the mother and failure to maintain child focus contributed to this optimism. 15.7 The issue of substance misuse was largely overlooked and this was no doubt made more difficult by parental non-engagement in both cases as well as some agencies failing to make the connection between the adults and the children who were residing together. But where the issue was recognised it was not treated with sufficient seriousness. 40 15.8 Similar comments apply to the issue of domestic abuse. It was not recognised in Child H’s case until after death. There was no effective consideration of the impact of this on Child P and the siblings. It seemed to raise insufficient levels of concern even when evidence was brought to the attention of the professional network. 15.9 Poor information sharing played a role with a lack of awareness among agencies which never gained an understanding of the importance of mental ill-health and disabilities for these two mothers. Missed appointments were not considered in the context of these issues, with a professional mindset that lacked the curiosity to gather information and assess this important element. Such an assessment may have helped professionals find ways to engage better with both mothers and support them better to effect improvements. 15.10 Parental non-engagement with professionals had the effect of blocking interventions, particularly in Child P’s case. Management oversight was lacking at this time across some agencies and this did not help practitioners overcome this barrier. Poor communication between Health Visitors and GPs presented a similar barrier, with Social Workers acting on an incorrect assumption that all health information will be accessed by Health Visitors. 15.11 When the Housing Officer in Child P’s case considered challenging the lack of progress being made, perceptions of power and status prevented this. With management oversight lacking, there was not the support to carry this through. Safeguarding is everyone’s responsibility, and lack of follow up from agencies who felt strongly about the situation contributed to the safeguarding response being inadequate. 15.12 The Police failed to understand impact on children of domestic abuse and drug misuse and so did not make referrals. The GP had no knowledge of many of the concerns; the home conditions in Child P’s case were not known to the Children’s Centre and there was significant delay in feedback between Social Workers and Health Visitors. There were indications of uncertainties about the barriers to sharing information, with an inappropriate and overly restrictive culture developing. It is hoped that improved awareness of the Single Point of Access will improve the approach and consistency to sharing information and responding to referrals. 15.13 We were asked to consider systemic issues and explore the reasons why there were these shortcomings. This led us to explore whether the Safeguarding Children Board was undertaking work in respect of the role of partners, disguised compliance, families who avoid professionals and the voice of the child during the scoping period. It was also important for us to examine why learning activity flagged for the Board two years before had little or no impact on practice in these two cases. 15.14 All of these questions, and also repeated attempts to understand how the Safeguarding Children Board was approaching neglect at the time were finally responded to fully, albeit after queries being raised as to the relevance of our questions. It now appears that the reason for the delay was simply a lack of capacity in house to complete the work. This has been a striking feature of this review and is the reason for the enormous amount of delay in bringing it to a conclusion. We have learned that some of this work was being undertaken at Board level, but it was not having the desired impact on practice on the ground. Reasons for the loss of organisational memory may well have included the enormous amount of staff turnover in Dudley at the time. 15.15 There is no doubt that achieving sustained improvement in neglect cases is difficult, as these cases demonstrate. However, if the voice of the child is not at the centre of 41 assessments, as was the case here, it is impossible for intervention to focus on their needs. In Dudley this has been recognised, and the Early Help Strategy, the Neglect Strategy, the threshold framework, the Multi Agency Safeguarding Hub and the Single Point of Access are all designed to effect improvement. 15.16 In undertaking this review, we have been fortunate to experience openness and transparency from practitioners involved at the time and from agency report authors, who have been committed to helping us to understand why events unfolded as they did. We acknowledge that this has been difficult due to turnover of staff and we extend our thanks to those who have assisted. 15.17 We hope this report will act as a reminder regarding accountability, for those who have a key role in ensuring arrangements are in place for safeguarding children. Safeguarding Children Board members, Chief Officers, the Lead Member for Children’s Services and the Lay Members on the board play a role in ensuring national guidance and serious case review recommendations are implemented. This review’s conclusions and recommendations should be brought to their attention. 15.18 Pockets of good safeguarding practice were identified, with individuals demonstrating tenacity and persistently offering opportunities for these families to engage and benefit from the support of agencies. It was clear that the Housing Officer, the Health Visitors and the Children’s Centre were working collaboratively in Child P’s case and this was noted during the review. 16 Recommendations Recommendation 1 Dudley Safeguarding Children Board should consider requiring the preparation and consideration of an up to date genogram to be a requirement at all interagency meetings concerning a child’s welfare. Recommendation 2 Dudley Safeguarding Children Board should arrange for an audit to be carried out of a sufficient number of cases to form a judgment on the impact of the Neglect Strategy. Recommendation 3 Dudley Safeguarding Children Board should urgently carry out a review of the arrangements for timely completion of serious case reviews and for ensuring effective implementation of the recommendations of Serious Case Reviews and other learning review processes and the monitoring by the Board of the impact of implementation on practice. Recommendation 4 Dudley Safeguarding Children Board should recommend to NICE that it reviews the guidance on co-sleeping to emphasise that adults should not co-sleep with their infants Recommendation 5 Dudley Safeguarding Children Board should consider the priority given to the issue of substance misuse within improvement work including for the Neglect Strategy and associated training. 42 Recommendation 6 Dudley Safeguarding Children Board should consider whether the current guidance, procedures and training sufficiently address the need for curiosity regarding domestic abuse and the practice to address risks to children. Recommendation 7 Dudley Safeguarding Children Board should arrange for a report to be prepared on the arrangements being made; (i) to ensure more effective consideration of mental health issues within assessments of the needs of children, (ii) for addressing mental health needs of adults caring for children and (iii) the impact of the five-year funding strategy to help new and expectant mothers and their mental health needs. Recommendation 8 All partner agencies should report to Dudley Safeguarding Children Board on the arrangements that they have in place to ensure that staff are enabled to exercise professional authority and challenge parents who fail to engage with services. Recommendation 9 Dudley Safeguarding Children Board should keep under review whether the culture and environment encourages and supports raising concerns about the exercise of Board functions, and whether all those with roles in calling the Board to account have an understanding of the duty upon them. Donna Ohdedar August 2017 David Spicer, LLB, Barrister 43 DUDLEY SAFEGUARDING CHILDREN BOARD THEMATIC SIGNIFICANT INCIDENT LEARNING PROCESS Appendix A Terms of Reference CASES INVOLVED Child P (age at death 2 years 4 months) and Child H (age at death 7 months) 44 SCOPE The review will focus on a general theme of young children that have died in neglectful circumstances although the cause of death was found to be non-ascertainable. The review will focus on the learning that arises from an analysis of two separate cases. Where an agency had involvement in both cases, there will be two timelines of significant events, but one questionnaire which answers the TOR, and uses the two cases to illustrate the analysis of practice. Time period on which agency reports shall focus: Child P: 16 October 2012 to 16 April 2015 Child H: 1 January 2014 to 10 April 2015 LEARNING AND IMPROVEMENT FRAMEWORK Dudley Safeguarding Children Board has a learning and improvement framework which is used to guide the way in which reviews will be conducted in Dudley. The guiding principles below are central to the approach taken in Dudley. Serious Case Reviews and other case reviews should be conducted in a way in which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. (Working Together to Safeguard Children Chapter 4 para 11, March 2015) AGENCIES INVOLVED Child P Child H 1. Dudley Metropolitan Borough Council Children Social Care. 2. Halesowen Children’s Centres. 3. West Midlands Police Force. 4. Dudley Clinical Commissioning Group (General Practice). 5. Dudley Group NHS Foundation 1. Dudley Metropolitan Borough Council Children Social Care 2. Halesowen Children’s Centres 3. West Midlands Police Force 4. Dudley Clinical Commissioning Group (General Practice) 5. Dudley Group NHS Foundation 45 Trust. 6. Black Country Partnership Foundation NHS Trust (Health Visiting). 7. National Probation Service. 8. Staffordshire and West Midlands 9. Community Rehabilitation Company. 10. Bromford Housing Association. 11. West Midlands Ambulance Service NHS Foundation Trust. Trust 6. Black Country Partnership NHS Foundation Trust (Health Visiting) 7. Blowers Green Nursery 8. The Wordsley School Where an agency is considering both cases, they will provide an analysis of practice, using examples from each case to illustrate the analysis made. ORIGINAL TERMS OF REFERENCE 1. How well did practitioners recognise and understand the complexity of factors contributing to the risk to the children including neglect from parental behaviours such as substance misuse, domestic abuse? 2. What were the barriers to providing an adequate safeguarding response? 3. Were the voices of the children heard, (including an understanding of the children’s lived experiences)? 4. How were the family histories incorporated into assessments? 5. To what extent did practitioners “Think Fathers”? 6. How did practitioners approach challenge and/or escalation and what was their level of knowledge around the processes for these? 7. What was the quality of information sharing including the making of referrals? 8. Analysis of the quality of decision making. Was there evidence of use of genogram or an understanding of the complexities of the families? 9. Were the responses to families timely and were the interventions effective? 10. What views do family members have on what might have made a difference? FURTHER AREAS TO BE CONSIDERED ADDED DURING THE REVIEW Reflecting on the integrated chronology and the key practice episodes identified: 1. How did agencies assess and support a mother with Attention Deficit Hyperactivity Disorder? 2. Describe Child P’s contact with services and address “why” things happened e.g. the professional mind set and working culture or environment at the time. 46 3. What revised recommendations can be formulated to address the issues that will have greatest impact on reducing the likelihood of similar failure in the system? 47 DUDLEY SAFEGUARDING CHILDREN BOARD THEMATIC SIGNIFICANT INCIDENT LEARNING PROCESS Appendix B Agency Recommendations CASES INVOLVED Child P (age at death 2 years 4 months) and Child H (age at death 7 months) 48 Black Country Partnership NHS Foundation Trust Escalation process to be embedded in Health Visiting and School Health Services For evidence of voice of the child to be documented in all child records For professionals to be curious and challenge unknown people within the home during visits and record the information. Practitioners to ensure analysis of contacts is evident in the child record, professional curiosity is executed and challenge is applied where needed. Genogram’s to be included for all cases as standard information above universal services and to be reviewed when new information is identified. All information is reviewed and pertinent information is recorded in the main body of the record. E.g.: DA notification received stating mother is a LAC child- this information is required in the main record. For practitioners to assess home conditions using a recommended tool to be utilised across all agencies. Any clinic attendance request to parents by practitioners must be followed up to ensure this was undertaken Verbal handover to be given by current practitioners to new practitioners if a child is above universal services. Supervision to be in place for all practitioners on all cases above universal services. To ensure attendance at all child protection core groups and case conferences To ensure a care-plan is in every child’s record and is updated following every contact with the child/family. Dudley Clinical Commissioning Group Children who miss appointments should be followed up That GP’s are aware of the impact of parental behaviours such as domestic abuse, substance misuse and mental health on the wellbeing of children. 49 Communication between GP’s and HV’s is improved in relation to vulnerable children Dudley Metropolitan Borough Council Children Social Care Management Oversight is robust in closing cases. Assessments include all adults in the household. All assessments include appropriate lateral checks. The voice or lived experience of the child is evident in all assessments. Training on improved understanding about males in the household. Refresh training on working with parents. In line with CSIB Improvement Plan – Supervision. Improvement Plan. Continuity of Service over holiday periods. Children’s services to consider a process to feedback following a referral as per Working Together 2015. Dudley Group NHS Foundation Trust Learning from these cases to be incorporated into midwifery in-house training days and be communicated in departmental meetings Lack of urine specimens for routine testing to be addressed by specific discussion with the pregnant woman and reasons for this documented. Staff need to consider the significance of the role that fathers play in families. Staff need to consider the significance of parental issues e.g. mental health and domestic abuse on their ability to parent their children and incorporate into the documented assessment. West Midlands Police Force 50 Offender Management training need identified regarding recognising and recording CA matters. West Midlands Ambulance Service NHS Foundation Trust None Bromford Housing Association None Halesowen Children’s Centres Processes for Family Support including paperwork, engagement and supervision should be robust Step down and step up processes are robust between specialist and early help Strategies are in place for managing risks during remodelling Access to CCM for Managers of Family Support Services so previous history of children is established. National Probation Service Consideration to be given to initiation of no contact conditions with co-accused whilst in HMP Genogram to be completed and information fully incorporated into oasys where possible All children to be cited in oasys – the two children living in Wolverhampton were missing from the original assessment Staffordshire and West Midlands Community Rehabilitation Company All Probation Practitioners to ensure they undertake a prompt home visit for safeguarding purposes in line with IC 01/2013 – Staff Responsibilities in Respect of protecting children from harm. 51 PSO1 to undertake an OASys refresher course. All relevant Agencies to share relevant convictions and allegations at the earliest opportunity to safeguard children in a timely manner. All Sandwell Probation Practitioners to improve their ORA Adult Custody Licence Practice All Sandwell and Dudley Probation Practitioners to ensure they record safeguarding decisions and discussions in Service User case records. |
NC50858 | Serious injuries to an adolescent girl in supportive accommodation by her partner in September 2016. N was known to Children's Social Care since 2008; had been in local authority foster care and residential placements because mother stated she was unable to cope with her behaviour. History of self harm, criminal offences, going missing and possible risk of child sexual exploitation. In September 2015, N became subject of a Care Order just before her 16th birthday. N became pregnant and unborn child made subject to a Child Protection Plan. In February 2016, her son A was born. Father initially believed to be M1 but subsequent DNA testing clarified that M2 was the father. N had been in a relationship with M1 since 2014; history of domestic violence and a violent assault on N in August 2016 when she was pregnant. In September 2016, M1 broke into N's supported living accommodation and stabbed her five times; she received life changing injuries and M1 was arrested, charged and convicted. Ethnicity or nationality not stated. Key themes for learning includes: dealing with domestic abuse in teenage children; dealing with 'missing' episodes with Looked After Children; multi-agency working and working with a group of children who are engaging in abusive behaviour to one another; transition and accommodation issues for Children Looked After; approaches to children who are part of 'intergenerational' need and/or abuse. Recommendations to Safeguarding Children Board include: review of the way in which children who are involved in domestically abusive relationships are assessed in terms of risk of harm.
| Title: Serious case review: Child N. LSCB: Dudley Safeguarding Children Board Author: Steve Ashley and Mick Brims Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Dudley Safeguarding Children Board Serious Case Review Child N Author: Steve Ashley Lead Reviewer: Mick Brims 2 SECTION ONE – INTRODUCTION 4 1.1 What this review is about 4 1.2 Why this review was conducted 4 1.3 How this review was conducted 5 1.3.1 The Review Panel 5 1.3.2 The Terms of Reference 5 1.4 Methodology 6 1.4.1 Chronologies and Management Reports 6 1.4.2 Learning Event 6 1.4.3 Family Engagement 7 1.4.4 Parallel investigations 7 1.5 How this report has been structured 7 SECTION TWO – THE STORY OF N 8 2.1 Introduction 8 2.2 The background 8 2.4 The facts of this case 9 2.4.1 Phase one – N’s journey from September 2014 to February 2016 9 2.4.2 Phase two – March 2016 to September 2016 12 SECTION THREE – ANALYSIS OF SIGNIFICANT ISSUES 15 3.1 Introduction 15 3.2 Significant Issues 15 3.2.1 Significant issue one 15 3.2.2 Significant issue two 19 3.2.3 Significant issue three 21 3.2.4 Significant issue four 23 3.2.4 Significant issue five 24 3.2.5 Significant issue six 26 3.2.5 Significant issue seven 27 SECTION FOUR – KEY THEMES 28 4.1 The application of child protection processes 28 4.2 Dealing with domestic abuse in teenage children 28 4.3 Dealing with ‘missing’ episodes with Looked After Children 29 4.4 Multi-agency working and working with a group of children who are engaging in abusive behaviour to one another 29 3 4.5 Transition issues for Children Looked After 29 4.6 Accommodation issues for Children Looked After in transition to adulthood 30 SECTION FIVE – KEY FINDINGS 30 SECTION SIX – RECOMMENDATIONS 31 6.1 Recommendation one 31 6.2 Recommendation two 31 6.3 Recommendation three 31 6.4 Recommendation four 31 6.5 Recommendation five 31 6.6 Recommendation six 31 4 Section One – Introduction 1.1 What this review is about This serious case review concerns a young person known, for the purposes of this review, as N. Dudley Safeguarding Children Board (DSCB) agreed this case met the criteria laid down in Working Together 2015 for a serious case review to be conducted. The brief circumstances of this case are as follows; N had been known to Dudley Children’s Social Care (DCSC) since 2008 and had spent several periods in local authority foster care and residential placements under section 20, Children Act, 1989. This was because her mother repeatedly stated she was unable to cope with her behaviour. In April 2015, following extended periods of going missing and possible CSE risks, N became subject of care proceedings. N became the subject of a Care Order1 in September 2015, immediately before her 16th birthday. N became pregnant and her unborn child was made subject to a Child Protection Plan in October 2015. In February 2016, N gave birth to a son (known in this review as A) and in August 2016, the court ratified a decision to pursue the adoption process for that child. The father of the child was initially believed to be a male known for the purposes of this review as M1. Subsequent DNA testing clarified that another male, known for the purpose of this review as M2, was in fact the father of A. N had been in a turbulent relationship with M1 since 2014. That relationship had involved domestic violence and the couple had separated and reunited several times. At these points, N had formed other relationships. In the early summer of 2016 the relationship with M1 had resumed but this relationship again broke down after M1 violently assaulted N on 2 August 2016. At this point, N was pregnant. In September 2016, M1 broke in to N’s supported living accommodation and waited for her to return home. On her arrival an argument ensued and M1 stabbed N 5 times. N received life changing injuries from this attack. M1 was arrested, charged and was convicted. M1 received a 10-year restraining order and four years detention for an offence of section18 Wounding, contrary to the Offences against the Person Act 1861. 1.2 Why this review was conducted The Independent Chair of the DSCB agreed with a recommendation of the Serious Case Review sub-group that this case should be the subject of a serious case review; under the requirements of the Local Safeguarding Boards Regulations 2006, section 5(1) (e) and (2). The statutory basis for conducting a serious case review (SCR) and the role and function of a Local Safeguarding Children Board is set out in law by: The Local Safeguarding Children Board Regulations 2006, Statutory Instrument 2006/90. Regulation 5 requires the Local Safeguarding Children Board (LSCB) to undertake a review where – 1 Care order - A Care Order can be made in Care Proceedings brought under section 31 of the Children Act 1989 if the Threshold Criteria are met. 5 (a) abuse or neglect of a child is known or suspected; and (b) either – (I) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Guidance for Local Safeguarding Children Boards (LSCBs) conducting a serious case review (SCR) is contained in Chapter 4 of Working Together 2015. This version of Working Together was used when deciding upon the serious case review process, as it was the most current at the time decisions were taken around the review process (published in March 2015). The purpose of this serious case review is to establish the role of services and their effectiveness in the care of N, whether information was fully shared by the professionals involved and child protection procedures were appropriately followed. This process ensures that any deficiencies in services can be identified and lessons learned, to minimise the risk to other children or young people. 1.3 How this review was conducted 1.3.1 The Review Panel The author of this report was Stephen Ashley who has extensive experience in the compilation of high-level reports into child protection issues, having been a senior police officer for thirty years and worked for Her Majesty’s Inspectorate of Constabulary. He has conducted several serious case reviews and is the independent chair of two safeguarding children boards. The lead reviewer was Mick Brims who is a qualified social worker and has extensive experience in children’s social care in several local authority areas. The author and lead reviewer are independent of Dudley Safeguarding Children Board in accordance with Working Together 2015 chapter 4 (10). In addition, a review panel was established. Meetings were held at regular intervals and the panel was consulted about the progress of the review and provided further information where appropriate. The panel included a senior manager from each of the key agencies. The Dudley Safeguarding Children Board (DSCB) business unit supported the panel. 1.3.2 The Terms of Reference This SCR has been conducted using a methodology adapted to suit the circumstances of this review and is described in more detail in the next section. The methodology established how well systems have worked, and where they can be improved. It is not a criminal or disciplinary review designed to attach blame to individuals. This review looks at the period of N’s life from September 2014 until the point of her injury. However, where appropriate, reference is made to the earlier periods of her life. This period was selected following a Serious Case Review Panel meeting and is of a sufficient range to include all key episodes of engagement that N had with agencies in Dudley. Whilst this period was the basis for the review, contextual and relevant information falling outside of this period was also included. 6 The review was conducted in a way which: • Recognised the complex circumstances in which professionals work together to safeguard children; • sought to understand precisely who did what, and the underlying reasons that led individuals and organisations to act as they did; • sought to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight; • was transparent in the way data is collected and analysed; • made use of relevant research and case evidence to inform the findings. Agencies that are involved in child safeguarding are required to follow the statutory guidance laid down by government. The guidance is called Working Together. It contains all the processes that agencies are required to follow. Working Together has been through several iterations. This review benchmarks against the statutory guidance contained in Working Together 20152. This is the version that professionals would be working to during the timeframe of this case. The author took full cognisance of the third annual report of the national panel of independent experts on serious case reviews that was published in November 2016. 1.4 Methodology The methodology agreed by the Dudley Safeguarding Children Board (DSCB) review panel is based on a model consistent with the requirements of Working Together 2015. It ensures that: • A proportionate approach is taken to the SCR; • it is independently led; • professionals who were directly involved with the case are fully engaged with the review process; • families are invited to contribute. 1.4.1 Chronologies and Management Reports Agencies were asked to compile a report detailing their contacts with the individual involved in this case, resulting in a combined chronology of events. In addition, each agency was asked to highlight areas of concern and good practice. Where appropriate, an action plan, detailing those areas for improvement, and the work being undertaken to address those issues, was included. All the agencies that were asked for a report provided the information requested. In cases where further clarification was required agencies responded in an open and honest way. In some cases, where contact with the subjects was minimal, agencies were only asked to provide a chronology. In addition, interviews with front line staff and managers took place. 1.4.2 Learning Event The learning event with front line practitioners is an essential part of the process. In the learning event front line staff and managers that had had contact with N were brought together 2 Working Together March 2015 - https://www.gov.uk/government/.../working-together-to-safeguard-children--2 7 for discussions around themes that had been identified from the chronologies and reports. This engagement provided a view of their engagement with N that enriched the information provided by agencies and ensured that all the relevant facts were recorded. It was the most effective way of triangulating the evidence and ensuring that an accurate picture of N and the traumatic events is provided. This review seeks to determine why events occurred and not just record the facts of what happened. The front-line view is essential in achieving this. Whilst the details of discussions that took place were recorded, the comments made by the staff involved were non-attributable and their comments are not quoted directly in this report. For many front-line practitioners, this was the first opportunity for them to discuss with other professionals their engagement with N; it was pivotal to the learning from these events. 1.4.3 Family Engagement The period over which this review was conducted was parallel with criminal investigations and consequently no family members were interviewed. 1.4.4 Parallel investigations Throughout the period covering the review there have been several police investigations concluding with the stabbing of N. This investigation resulted in the conviction of M1. 1.5 How this report has been structured Following the introduction, section two provides the story of what happened to N. There is a description of N and her life and then the detail of what happened to N over the timeframe agreed within the terms of reference. It provides a synopsis, and tries to paint a picture, of the N’s world and the circumstances in which she lived during this period. Where an event or issue has proved to be significant, it is highlighted and any pertinent questions are raised at that point. These areas of significance are analysed in greater depth in section three. Section three analyses the significant issues exposed in section two and explains WHAT happened and WHY. From this analysis, the key themes are discussed in section four. Section five contains the key findings. The recommendations in section six have been developed from these findings taking account of the work carried out by agencies since these events occurred. This report has been written so that it can be read by the public without redaction. As a result, the names of the main subjects are not used and there are no dates that might readily identify N. In this report, the following initials represent the main subjects: N – the subject of the review MN –mother of N A – child of N and M2 S1 – sister of N M1 - boyfriend of N and offender M2 – boyfriend of N and father of A M3 – boyfriend of N 8 Section Two – The Story of N 2.1 Introduction This section sets out the facts in this case. It begins with the background of N and her closest associates. This provides an insight to the type of child N was at this time and those she associated with. 2.2 The background N is a woman who has had contact with DCSC and other key agencies in Dudley for most of her life. Her early life could be considered as chaotic. N attempted to deliberately harm herself aged 4 years old. There had been a further 4 self-harm incidents reported between that time and 2014. N first reported an incident of domestic violence in May 2012. N had been arrested for criminal offences including 24 charges of criminal damage and 2 assaults prior to September 2014. By September 2014, there had already been 13 reports of N going missing, but conversations with front line practitioners indicate that it was many more times than this. N’s mother (MN) reported to DCSC on a number of occasions over time that she was unable to cope with N and DCSC would become involved with the family. At one point, N had allegedly threatened her mother with a knife. In September 2015, N became subject to a Care Order and became a Child Looked After3 (CLA). Prior to this, in mid-January 2015 N had been placed with experienced foster carers who specialised in looking after adolescents. At that point she was in a relationship with M1. The placement came to an end within a month because N was continually allowing M1 and other males in to the house through her bedroom window. Over the next 2 years at least two other males – M2 and M3 - also feature as her partners. M2 is the father of A, N’s child who later came into care of the local authority. It is unclear exactly when these relationships commenced and finished, however there is a suggestion that N was in a relationship with each of these males over time, both separately and simultaneously. These relationships often included incidents of domestic abuse and N was continued to be regularly classified as ‘missing from care’. N gave birth to a son, N, in January 2016. The father of this child was believed at one time to be M1, although it was later established in A’s care proceedings (by means of paternity testing) that his father was M2. In March 2016, N, A and M2 moved to a residential placement for the purposes of a parenting assessment as part of A’s care proceedings. In April 2016, M2 was asked to leave the residential parenting placement after a domestic abuse incident with N. In June 2016, N decided to leave the residential parenting placement and A went into foster care. In August 2016, A was placed for adoption. In July 2016, N was again pregnant, but it has not been established who is the father of that child. The offender in this case was M1. M1 had also had a turbulent and troubled childhood. Whilst there can be no excuse for the violence perpetrated against N and others, it is worth providing some information regarding his background. M1has had little or no contact with his father and contact with mother has been characterised by ambivalence and rejection. At the age of 4 3 Child Looked After - A child who is being looked after by their local authority is known as a child in care. They might be living: with foster parents. at home with their parents under the supervision of social services. in residential children's homes. 9 years M1 found his step father dead, having taken an overdose of drugs. At aged 7, M1 was made the subject of a section 31 Care Order to Dudley Metropolitan Borough Council, on grounds of neglect. M1 had at least 8 different foster placements and was placed in 3 residential units. M1’s secondary education took place at a school reserved for young people with statements of special educational needs relating to emotional and behavioural issues. M1 had a criminal record that began on 3 December 2014. Most of the offences he has been arrested for are criminal damage and theft. The non-violent nature of his criminal antecedents escalated in severity on 2 August 2016 when he became involved in the assault on M2. This was followed by further violent offences. M1 received a 12 month Youth Rehabilitation Order for an offence of being in possession of an Imitation Firearm on 4 August 2015. M1 had a history of missing episodes. All of the young people involved in this case were Children Looked After (CLA) and subject to statutory guidance relating to the way in which they are accommodated and supported. 2.4 The facts of this case 2.4.1 Phase one – N’s journey from September 2014 to February 2016 When N’s mother reported her missing in September 2014 she also told the police she had been self-harming. The police reports reflect that she had returned home and that she was reporting self-harming to get engagement from DCSC. No further action was taken. A month later N reported she had been raped. The circumstances described to the police were that she had been with M1, but they had argued, and she then met some boys; one of whom raped her whilst his friends watched. The police began enquiries but N then admitted it was a false allegation; she said she had made it up to get moved away from her mother. At the beginning of 2015, N was again reported missing and was subsequently located in North Wales with M1. Significant Issue One N was a looked after child. CLA processes should have incorporated consistent overview of the holistic range of N’s needs (including mental health, personal safety needs and domestic abuse support) - outside of crisis events. Pathway Plans should have consistently considered the wider range of N’s needs in achieving positive transition to adulthood. Significant Issue Two N had a troubled childhood, including documented issues with her mental health. It would be expected that N would be referred for support to CAMHS and other adolescent support services. 10 Several other missing person reports are made about N over the next month and in February 2015 the police made a referral4 to DCSC and a strategy discussion5 was held. This followed the West Midlands Police missing person strategy. The meeting agreed that a section 47 investigation6 should take place. It is unclear what action took place as a result of this investigation. There was an agreement that N would move to Wrexham to go to college and stay with her father. N remained with her father a few days before this arrangement ended and instead N was placed in residential accommodation in Staffordshire that she had resided in previously. Over the next month N was missing virtually every day. There were numerous missing reports and logs of checks made across a range of addresses. In the majority of cases, it seems N was with M1 who had been relocated to Manchester, however he was also regularly reported as missing. On 19 March 2015, N disclosed a serious incident by M1 the previous month. The police recorded the incident and began an investigation. The report had been made in the late evening by staff at her care home. Police contacted the DCSC Emergency Duty Team (EDT) and liaised with them. N did not want to be spoken to that night and, as there were no forensic issues, an appointment was booked for her to attend the police station the following day. N went the next day with a staff member from the care home and was ABE7 interviewed. The detective constable called the DCSC duty social worker to update N’s social worker with the result of the interview. N withdrew the allegation saying she had now resumed her relationship with M1. There is no evidence, in the information provided, as to whether a section 47 investigation commenced following this allegation or whether appropriate support (whether Victim Support, Respect Yourself or CAMHS) was offered to N at this time. The detective in the case stated that it had been agreed DCSC would arrange for any further support. Considering events over the following month, it may be that DCSC’s immediate focus was on securing placement stability for N. On 24 March 2015, police utilised Powers of Police Protection (often referred to (erroneously) as a ‘Police Protection Order’ (PPO),)8 to place N in to a place of safety. At this point, N had been placed in residential accommodation in Dudley. Staff at that accommodation stated she could no longer be protected and would break windows to allow males in to the premises and despite their efforts, repeatedly went missing. Information suggests that police used powers of police protection as they felt the current placement was not suitable for N. After the Police Powers of Protection were utilised, N was moved to a rural placement in Somerset. On 3 April 2015, N was arrested and later convicted for assault on a police constable after being located after a missing episode. N was taken to hospital whilst in custody and attempted to escape, causing damage. The carers who were sent to bring N back to the West Midlands reported that she had absconded from them. It was believed that N was in Manchester looking for M1. Once located, it was agreed that N could remain at her sister’s home for a brief period and strategy meetings would be held the following week. 4 Referral - The referring of concerns to local authority children's social care services, where the referrer believes or suspects that a child may be a Child in Need or that a child may be suffering, or is likely to suffer, Significant Harm. 5 Strategy meeting - A Strategy Meeting (sometimes referred to as a Strategy Discussion) is normally held following an Assessment which indicates that a child has suffered or is likely to suffer Significant Harm. The purpose of a Strategy Meeting is to determine whether there are grounds for a Section 47 Enquiry 6 Section 47 investigation - Under Section 47 of the Children Act 1989, if a child is taken into Police Protection is the subject of an Emergency Protection Order or there are reasonable grounds to suspect that a child is suffering or is likely to suffer Significant Harm a Section 47 Enquiry is initiated. 7 ABE interview - Achieving Best Evidence in Criminal Proceedings: Guidance for Vulnerable or Intimidated Witnesses, Including Children. The Crown Prosecution Service, 2001. 8 Police Protection Order - In England and Wales, Police child protection powers concern the powers of the individual local Police forces to intervene to safeguard children. ... Under this law, the police have the power to remove children to a safe location for up to 72 hours to protect them from "significant harm". 11 On 24 April 2015, Police Powers of Protection were again utilised again for N. Information provided suggests that this decision was taken due to concerns about N’s being frequently reported as missing, but also due to her staying in accommodation with a 52-year-old male in Manchester, who was known to be under police investigation for a sexual offence. Information provided suggests that authorisation was received from DCSC senior managers for N to immediately enter a secure placement for 72 hours to ensure her safety, in line with section 25 Children Act 1989. It is noted however that despite the gravity of this decision, N’s casefile does not contain a detailed record of the rationale taken by DCSC senior management in authorising this 72-hour period of secure accommodation for N. On 27 April 2015, following a strategy discussion between Police and DCSC, agreement was reached that DCSC would apply to the Family Court for a Secure Accommodation Order9 and an Interim Care Order. These court applications were refused on 28 April 2015, however care proceedings continued. N moved to the care of her adult sister, S1. N was referred to CAMHS and support services. A CLA review was conducted. Over the next 2 months N went missing on several occasions and was convicted of breaching bail conditions and assaulting her mother. At this point, N was pregnant and the father was believed to be M1. N had been referred to CAMHS but failed to attend appointments and in August 2015, the care proceedings concluded with N being made subject to a Care Order. This judgment was against the care plan proffered by DCSC, who sought to support N on an ongoing basis under section 20 Children Act 1989 rather than via an order under section 31, Children Act 1989. As N was pregnant she was also receiving ante-natal care from midwives and support from the Family Nurse Partnership. In October 2015, an Initial Child Protection Conference took place in respect of N’s unborn child A. It was agreed the unborn baby would be placed on a Child Protection Plan. At this point, N had begun a relationship with M2 and was housed in a hostel under section 20. N was continually being reported as missing and graded as being at high risk. In November 2015, N twice reported incidents of domestic abuse by M2. In the first incident, he broke her phone and in the second he threatened to kill her with a knife. N later stated she was not willing to cooperate with the police and withdrew her statement and allegation. 9 Secure Accommodation Order – Section 25 Children Act 1989. These orders permit a local authority to place a child in secure accommodation. The court can make a secure accommodation order where a young person has a history of running away, is likely to run away from any other kind of accommodation and if they do so is likely to suffer significant harm. Significant Issue Three N and M1 went missing on a continual basis and considerable resources were put in place to locate them. N was graded at high risk from CSE and at high risk when she went missing. Agencies should have a plan for regular and high risk missing persons. 12 In February 2016, N gave birth to her child, A, who was subject to a child protection plan. A was made subject to an Interim Care Order and both mother and baby were moved to foster care in Birmingham. At this point it seemed that the chaotic life style N had been involved in over the previous 2 years with regards to missing episodes, frequent placement changes and youth offending may be coming to an end. 2.4.2 Phase two – March 2016 to September 2016 In March 2016, N and M2 moved to a residential unit out of borough with A. In April 2016 M2 was asked to leave the residential unit following an incident where he head-butted N. N was assessed by the police as being at high risk of domestic abuse. N stated she was in low mood and wanted to leave but was persuaded by staff to stay. N also made further disclosures of domestic abuse from M2, including that she had been assaulted by M2 over a period of weeks, in which on one occasion, he had placed his hands around her throat and choked her. She also stated on another occasion that he had pushed her onto the bed and cut her calf with a small knife. On 28 April 2016, N was referred to the Respect Yourself team. The team provided one to one sessions and home visits as part of a support programme for persons involved in domestically abusive relationships. On a number of occasions, these sessions included other professionals. The Intensive Family Support Worker/Independent Domestic Violence Advocate allocated to N remained engaged with her up until the significant event in September 2016. In June 2016, N went missing and was found with M2 at his grandmother’s house in the West Midlands. In July, it appears there was a further domestic incident between N and M2. In June 2016, N was again subject of a CLA review by DCSC and it was agreed to find her supported accommodation. It also seems that N had renewed her relationship with M1. On 2 August 2016, police received a report that N had been assaulted by M1 at her sister’s flat. M1 was reported to have dragged N around the flat by her hair and caused criminal damage. N was taken to hospital and M1 was arrested. A DASH10 assessment was completed which graded N as ‘high risk’. N received significant injuries as a result of the 10 DASH - Domestic Abuse, Stalking and Harassment and Honour Based Violence (DASH, 2009) Risk Identification and Assessment and Management Model Significant Issue Four N was graded as at high risk of CSE, was continually missing and committing criminal offences. N had contact with several agencies including children’s social care, the police, health and housing. N was later at risk of and suffered serious incidents of domestic violence; including life-changing injuries. Many of the children N was associated with also had the support of a number of safeguarding agencies. There should be clearly documented evidence of multi-agency working, the use of statutory child protection procedures, consultation between professionals working with all linked children and effective use of supervision to keep the child’s needs in mind. . 13 assault by M1, including internal bruising to her ribs, grazing to her arm, scratches and a loose tooth. The Domestic Abuse, Stalking, Harassment and Honour based Violence (DASH) risk assessment makes the following observations: • “Incident has resulted in injury, internal bruising to ribs, grazing to left arm and scratches, scratches to back and soreness to head. Loose tooth in bottom set right hand side. • Victim is frightened of what he is capable of as felt in fear of life today when he was strangling her. • Afraid he will either kill her or seriously injure her. • Tries to stop her seeing her friends. • Separated 18 months ago. • Offender constantly texts and follows her. • Had a baby boy 6 months ago who is currently in care [A]. • Abuse is happening more often even though they split up 18 months ago. • Abuse getting more violent. • Offender is very jealous. • Offender has threatened to kill the victim. • Attempted to strangle the victim today. • Offender has had problems with drugs, alcohol and mental health in the last year according to the victim. • Victim states that he previously self-harmed and also tried to hang himself. • Victim believes he has had contact with police due to sexual offences and also other violence matters.” This information would have been of use to a number of partners and the use of the DASH risk assessment should be shared so that agencies have a full picture of a young person’s circumstances. Funding was agreed to place N in a Churches and Housing Association of Dudley and District (CHADD)11 (On Route) placement. Funding for CHADD On Route was agreed until N was 18 years old and a referral made to Dudley Adult Social Care for transitional arrangements to be put in place. N remained in her accommodation but there were concerns raised that she was allowing male visitors in to the premises. One of those males was M3. A MARAC12 meeting was held on 11 CHADD provides a safety net of supported homes and community-based services for people in Dudley who may be experiencing crisis or challenging transitions, homelessness, domestic abuse or may need support with independent living. – it is a local, voluntary sector organisation fulfilling a charitable and social mission, exclusively in the metropolitan borough of Dudley. 12 MARAC –multi-agency risk assessment conference, is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, probation, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists Significant Issue Five N suffered numerous episodes of domestic abuse and two of her boyfriends were identified as domestic violence perpetrators. There are clear processes, including the MARAC process, that would be expected to put plans in place to protect N. 14 25 August 2016. There were considerable concerns raised around both M2 and M1. MARAC minutes indicate feedback from some agencies that N was still in fear of M2, who was in prison, but had sought to contact N from there. Information in the DASH risk assessment suggests that N was also scared of what M1 was capable of, highlighting stalking behaviour (constant texting and following N) as part of her concerns. It is unclear from the information provided to reviewers what, if any, protection was put in place to protect N from M1 or M2. M1 was later charged and remanded in custody by the police. The following day he was released on bail by magistrates. On 12 September 2016 M1 was found guilty of various offences (including Battery) relating to this domestic abuse incident against N. MARAC minutes on 25 August 2016 also indicate that N had been referred by Black Country Women’s Aid to the IDVA service due to fears of violence from M2 and possible post-natal depression. The reviewers are of the view that this feedback to MARAC actually reflects the original referral made to the IDVA service in April 2016, after the incident where M2 headbutted N in the residential placement and that support was ongoing when MARAC convened in August 2016. Information provided suggests that due to N’s age, an Intensive Family Support Worker/IDVA from Respect Yourself was provided for N in April 2016 and it appears that engagement was ongoing from that point forward between Respect Yourself and N around domestic abuse support. At the end of August 2016, N stated she would like her own property because she still felt like she was in care and needed to move on. N was engaging with the IDVA but stated she was worried that M1 knew her address. On 11 September 2016 M1 was arrested for an offence of threatening M3 with a hammer and charged with several offences including several public order offences, possession of an offensive weapon, criminal damage and breach of a youth rehabilitation order. M1 was again remanded in custody by the police to appear before magistrates the following day. On 12 September 2016 M1 appeared in court and was found guilty of a range of violent offences relating to the domestic abuse incident with N on 2 August 2016 and the instance of threatening the M3 with a hammer on 11 September 2016. M1 was released by the court pending a sentencing hearing. On 14 September 2016 M1 went to the accommodation N was residing in and, following an argument, stabbed her 5 times. N received life changing injuries. Statements made by M1 later provided some detail to the relationships between N, M1, M2 and M3. The three young people had known each other for a number of years and N was in relationships with each of them during that time. M1 stated that when he resumed his relationship with N in August 2016 she had told him that his child, A, had died at birth and been buried. N told him that M3 had desecrated the grave and this had caused him to lose his temper and seek out M3 to cause him harm. This information contrasts with the established facts of A’s circumstances (that he was in fact the child of N and M2 and that he was alive and in foster care at the time that N was stabbed). There is clearly no excuse for the behaviour of M1 or M2 with regards to the assaults they perpetrated on N. It is acknowledged however that these were clearly complex and difficult relationships between young people with challenging pasts, who were moving in to adulthood. 15 Section Three – Analysis of Significant Issues 3.1 Introduction This section looks at the issues highlight in section 2 and provides an analysis of each of those areas. 3.2 Significant Issues 3.2.1 Significant issue one N was a looked after child. CLA processes should have incorporated consistent overview of the holistic range of N’s needs (including mental health, personal safety needs and domestic abuse support) - outside of crisis events. Pathway Plans should have consistently considered the wider range of N’s needs in achieving positive transition to adulthood. Work to safeguard children who are ‘looked after’ and plan for their welfare and pathway into adulthood are documented in two key processes. Children Looked After (CLA) reviews and Pathway plans. This section contains an analysis of the work that was conducted using these processes. Reviewers have examined the four CLA reviews that took place between October 2015 and June 2016 and have noted the following key points: Children Looked After Review – October 2015 • The review does not reference that N was made subject to a Care Order a month earlier in September 2015, after proceedings commenced on 28 April 2015. The review does not reflect on the outcome of the care proceedings or the potential impact of this upon N. Significant Issue Six The transition process from childhood to adulthood is a difficult period and this is more significant for children who are Looked After. There should be clear support processes for Children Looked After as they move through this transition, which is underpinned by consistent planning and review to ensure that positive outcomes are clearly outlined and achieved wherever possible. Significant Issue Seven Child N came from a family that had been subject to significant involvement from safeguarding agencies over many years. Clear processes are required to swiftly identify children who are or could become part of inter-generational involvement with safeguarding services and what support can be offered to ‘break the cycle’ of involvement. 16 • This review contains input from N, although the minutes are brief and erroneously references the pre-birth Initial Child Protection Conference (ICPC - held subsequently in November 2015) as a forum to decide on the future care arrangements of the unborn A rather than the appropriate forum to decide whether the unborn child was at risk of significant harm (planning for any legal action takes place outside of the ICPC process). The minutes do not contain evidence of exploration or challenge around key issues such as mental health, domestic abuse and relationships with other boys/father of unborn child. • The review does not reference any of the key incidents later recorded in the combined chronologies. For example, incidents such as M1 being upset (via Facebook research) in August 2015 that N may have been involved with someone else; that N had recently missed a CAMHS review in late August 2015 (significant given N’s history of concern with regards to mental health and traumatic experiences of domestic violence she had experienced to that point in time); that she had breached her Youth Referral Order in late September 2015, leading to a plan for N to move to ‘Higher Level’ care. • The review also contains limited reference to key issues of concern regarding N being connected to both M2 and M1. At the learning event, it was noted by professionals that for some time, concern had been held regarding N having been involved at different points with both boys (along with a third male child, M3). However, there is no real mention of N’s relationships with these boys – all of whom had a history of being Children Looked After themselves - despite domestic abuse concerns and previous potential pregnancies prior to N being pregnant with A in October 2015. Children Looked After Review- February 2016 • The CLA Review in February 2016 occurs when the birth of baby A is imminent. Understandably, there is considerable focus on arrangements and support for N and soon to be baby A, given the concerns identified around parenting capacity and the need to locate a mother and baby residential placement. It is also noted that the allocated social worker had experienced a period of illness in the lead up to this CLA Review. However, whilst these practical support issues are taken into account, there is only mention of ‘concerns’ regarding N’s relationship with her boyfriend (who is not identified). Similarly, there is no evidence of attempts to gain information or an update from N or the allocated social worker as to what level of concern existed around domestic abuse or what strategies may be being employed to try and engage with N (and potential child perpetrators) around this issue, which would be significant given that N was soon to become a parent. • There is a review of a plan from the previous CLA Review in February. However, this plan, which was then reviewed, does not include information as to when listed actions should have been completed or how outcomes from these actions would be measured. Children Looked After Review- April 2016 • In the April 2016 CLA Review - which occurred just two days after the incident where M2 allegedly head-butted N in the residential mother and baby placement - the chair acknowledged that professionals present expressed sympathy for N as a domestic abuse victim, however there is no reference in the meeting discussion as to how N would be supported around domestic abuse (from any party or whether liaison should occur with other social workers around the perpetrator. 17 • The review is a detailed document that spends considerable time working with N and professionals present to stabilise her current mother and baby placement. The document also references concerns that N was experiencing low mood and refusing/unwilling to eat, there is a reference made to her being advised to see her GP for support and for the health visitor to see N regarding possible post-natal depression. It is of interest however that N notes in the CLA Review minutes that she had not eaten and felt low in mood “since the incident with [M2]”, suggesting that the domestic abuse itself may have been a possible cause of these issues. • Despite a referral having been made in early 2015 to CAMHS, when care proceedings commenced, and a previous CLA review making mention of CAMHS involvement with N – there is no reflection of work that may have been conducted or whether CAMHS would be contacted as a result of current circumstances to provide input and support for N. Despite the documented history of alleged domestic violence from both M1 and M2, it is unclear how the CLA reviewing process sought to support N around understanding this abuse and empowering her to remain safe to this point. It is unclear whether any actions were explored with professionals responsible for working with the abuser/s. Children Looked After Review- June 2016 The minutes of this CLA Review have now been sighted by reviewers. Some key areas noted from this document include – • Considerable, good quality information was included in terms of input from N regarding her wishes and feelings and the wishes and feelings of her family in this CLA Review; • CAMHS were invited to attend this review but were unable to attend. The social work team had contacted CAMHS on 25 May 2016 to explore whether further support could be offered, with the allocated social worker to facilitate N attending a CAMHS appointment in the next two weeks. Information obtained from CAMHS for the CLA Review indicated that N had been known to that organisation at different times since she was 13 years of age and that a further CAMHS appointment was scheduled for 24 June 2016. CAMHS also undertook to oversee the process of linking N in with Adult Mental Health Services as part of transition planning as she approached 18 years of age. • Information was considered at this CLA Review as to the work of the Respect Yourself Intensive Family Support/IDVA worker, who had been completing one-to-one sessions with N until a space on an upcoming ‘Freedom Program’ (empowerment and support for women who have survived domestic abuse) was available. N was reported to have engaged well with Respect Yourself around domestic abuse. • Other aspects of N’s needs were considered, such as her education needs and follow-up from the previous CLA Review indicated that N had seen her GP around feelings of low mood and had been diagnosed with mild depression and prescribed medication for this. • As with other CLA Reviews, this meeting occurred near a significant event in N’s life, in this case, N had taken the decision on 12 June 2016 (approximately 2 weeks earlier) to end her involvement with the residential parenting assessment around her retaining care of A going forward. A had subsequently gone into foster care. The CLA Review 18 sought to make parallel plans for N, who had indicated regret at this decision and would be seeking a further period of parenting assessment. N was residing with her mother on a temporary basis and the social work team had recently made a referral to CHADD ON Route for supported accommodation for N should any further assessment period with A not be granted or not be successful. • This CLA Review also makes some limited reference to concerns about N being back in Dudley borough and the risks this might pose in terms of becoming involved or having contact with past associates. The need to engage with support was also emphasised to give N the best opportunity to have A returned to her care. There is no evidence in any of the CLA Reviews sighted as to whether information had been obtained by the allocated social worker or Independent Reviewing Officers (IROs) from other allocated social workers or professionals working with the partner of N at the time. Whilst this may have occurred, this is not evidenced in CLA Review minutes. M1 for example is known to have had ongoing absconding issues and had unfortunately been involved in several youth offending incidents (some of which were with N in 2015). It is possible that when considering the needs of N in the reviewing process this context may have been useful in considering risk to both N and - where applicable - her child. The challenges of working with a young mother who is also a Child Looked After are evident in these CLA Review documents. It is apparent that the Independent Reviewing Officer/s had to spend considerable time considering and addressing arrangements and risks with regards to the care of A, which may have reduced the time available and ability to engage with N around her own needs and vulnerabilities, in the face of the pressing demands of working to safeguard an unborn/new-born infant in her mother’s care. Pathway Plans Pathway Plans are intended to be living documents to assist 16+ children on the path to independence. Guidance suggests that these should comprise of an assessment of need and how any needs identified as the child moves forward into adulthood will be supported. The 2 pathway plans analysed do not suggest an evidence-based approach to providing N with the right support. Pathway Plan – October 2015 The first plan reviewed, commencing in October 2015, contains an update from a previous plan, which notes that support such as CAMHS, Youth Offending Service, Pace Education and Respect Yourself has been implemented and work carried out to address issues such as attachment problems between N and her mother (including family therapy), educational support and ‘keep safe’ concerns. It also addresses N's offending behaviour at the time and describes plans to try and get her back into education. However, the document is essentially left blank thereafter, with key areas around what evidence supports the proposed plan, the input of the child and mother around the plan and whether key CLA processes had been followed missing or not being completed. There is limited evidence of an assessment of needs informing future planning. It is notable that the referrals and associated work with N from these agencies are not then referenced in the October 2015 CLA Review. Finally, this Pathway Plan does not contain a clear statement as to what the plan for permanence is for N and what actions are required to implement this. 19 Pathway Plan – June 2016 The second plan, commencing June 2016 does contain a clear statement around what the Pathway Plan is – namely to support N into semi-independent living whilst enabling her to provide care for child A. It also outlines several actions required to make this occur, although this is not presented in a SMART format and it is unclear when these actions should be undertaken and by whom; the reviewers understand that the actual Pathway Plan actions are typically located in a separate document on Dudley’s IT system and may exist in this format. The actions in this Pathway Plan do not relate to support around domestic abuse, healthy relationships, CAMHS support - in fact the actions outlined relate exclusively to N in terms of her care of A and transition to new supported accommodation with him; despite the fact that by June 2016 there had been a recent history of concern around domestic abuse from M2 and recent contact with CAMHS to provide N with support. It is acknowledged that action around these issues may cross over somewhat with the purview of the CLA Reviewing process, however Pathway Plans seek to address key outcomes such as healthy relationships for children, career success and being healthy amongst other issues, all of which are related to good mental health, basic safety and the ability to maintain healthy, boundaried relationships. Actions were completed around some of these issues in the previous Pathway Plan, however do not seem to have been considered again when the June 2016 Pathway Plan was devised. This Pathway Plan does contain more detailed information in other sections such as the views of the mother/child this time and more detailed analysis of the accommodation and N’s financial circumstances. Information provided does note that N’s case was considered at Dudley’s Access to Resources Panel in August 2016, where funding was provided for accommodation at CHADD On Route and that a referral would be made to Adult Services for transitional support. Overall, based on the Pathway Plan document provided, the focus of the Plan whilst aspiring towards semi-independent living with A seems to focus more on current accommodation needs and does not appear to be informed by a Pathway Plan Needs Assessment; information suggests that this Needs Assessment was commenced on 10 June 2016 but was incomplete. In contrast, a much more detailed Pathway Plan on file dated 30 August 2016 provides a much more in-depth look at N’s circumstances. This document directly considered key issues such as mental health and domestic abuse as part of the pathway plan going forward and highlighted current support in place at that time (CAMHS, Respect Yourself IDVA and the impending Freedom Program). This document seems to have planning steps for N within it that are based on an assessment of N’s needs. Therefore, as with other aspects of work done with N, Pathway Planning at times has focused on presenting issues and work around N as the parent of A without necessarily fully supporting N’s personal needs as part of reaching positive permanence outcomes around relationships, mental health and safety from violence. Elements of these varying needs have been addressed at different times, but do not always appear to have considered on a consistent basis. 3.2.2 Significant issue two N had a troubled childhood, including documented issues with her mental health. It would be expected that N would be referred for support to CAMHS and other adolescent support services. 20 Child and Adolescent Mental Health Service (CAMHS) Information provided suggests that CAMHS had been engaged with N since she was 13 years old, although this information comes from various sources and it is not always clear when CAMHS periods commenced and ended. CAMHS had engaged with N periodically and continued to try and maintain their involvement even when she made it clear she did not want to engage. At times, work with CAMHS ceased because of non-attendance at appointments. There is mention in case files of N being referred to CAMHS in April 2015 after care proceedings commenced. The Pathway Plan in October 2015 notes that ‘attachment work’ was undertaken and completed by CAMHS and the Youth Offending Service together, including CAMHS offering family group therapy to N and MN (mother), which was also completed. On 25 May 2016, the social worker contacted CAMHS to ascertain whether there was any further support that could be offered via CAMHS, as N had spoken of wanting to get back in touch with her CAMHS worker. The social worker agreed to contact N to facilitate re-engagement – it appears that N was still open to CAMHS at this time, thus if N was not willing to engage with CAMHS within the following two weeks, she would need to be discharged from the service. Supervision records on 17 June 2016 note that N had requested a referral to CAMHS again – it is noted that this is a few days after N had decided to end the mother and baby parenting placement with A and DCSC were also seeking to support N through upcoming legal processes, including possible adoption. At the CLA Review on 28 June 2016, information from CAMHS suggested that a successful appointment had taken place on 24 June 2016. Whilst CAMHS were not in attendance at this review, consideration was given to CAMHS overseeing N’s transition to Adult Mental Health Services. However, information provided by CAMHS to DCSC indicates that this involvement was around accessing the ADHD Clinic and that involvement ceased in August 2016 due to ‘non-engagement’. It is noted that information about N’s involvement with CAMHS suggests that she was diagnosed with ADHD and prescribed medication prior to N becoming pregnant with A, at which point the medication ceased. The request for further ADHD work by CAMHS may have come from the MARAC meeting on 25 August 2016, where this is listed as an action going forward. It could be extremely difficult to convince N to attend services consistently. There is evidence that N was offered appointments with CAMHS but that she failed to attend. It is recognised both locally and nationally that CAMHS resources are stretched; despite this, CAMHS continued to try and engage with N on several occasions. It is not clear that CAMHS, or other services (e.g. Domestic abuse support services), were consistently kept in mind when reviewing N’s CLA circumstances. It is also unclear if these services were fully considered in pathway planning going forward; until much closer to N’s transition from a Child Looked After to a Care Leaver. Other Services N also received support through CHADD On Route after being referred and placed in CHADD supported accommodation when N decided not to continue with the mother and baby placement with A. N was also supported by Respect Yourself and the IDVA service (see below). 21 Whilst there is no evidence that the support provided to N had a positive effect, considerable effort was made to support her; including attempts to link her to the Connexions team and the FAST team which she failed to respond to. Whilst there is evidence of considerable multi-agency work taking place over time, there is a lack of coordination in planning for N. Whilst the CLA processes outlined above did at times consider the various issues N was facing, this was not always done holistically and on a consistent basis. CLA Reviews or Pathway Planning was often, understandably, concerned with serious presenting issues such as: the lack of mother and baby placements; N threatening to leave a mother and baby placement; N having just decided to leave the mother and baby placement and being in crisis. 3.2.3 Significant issue three N and M1 went missing on a continual basis and considerable resources were put in place to locate them. N was graded at high risk from CSE and at high risk when she went missing. Agencies should have a plan for regular and high risk missing persons. It is impossible to calculate the number of times N was ‘missing’. At some points in her life she was missing virtually every day. The police and children’s social care always responded to missing reports and used considerable resources over this period looking for N and then returning her to accommodation. Professionals have expressed frustration at dealing with N and her missing episodes. At various points professionals used all of the tools they believed were available to them. The police used their protection powers and children’s social care placed N in accommodation out of the area in an attempt to break the cycle of missing episodes. They used section 25 powers to place N in secure accommodation for 72 hours and applied to the court for a Secure Accommodation Order. Family members were used to accommodate N and she was placed in the full range of accommodation options open to DCSC. None of these options worked for any length of time. It is understandable that professionals became frustrated and seemed to run out of ideas. There are areas that agencies can improve on and in fact have already made changes to improve missing from home processes. In particular, the following points highlight areas where the response could have been improved: • Agencies lacked a coordinated response and often took individual action rather than considering a multi-agency response. One example was the police use, in March 2015, of Powers of Police Protection. At this point, N was in residential accommodation in Dudley but was regularly missing so police used these powers to place her in a ‘place of safety’. As a result, N was moved to new accommodation in Somerset. It is understandable that the police became frustrated and took the action they did, but there seems to have been little consideration of how this fitted in to a longer-term plan and does not appear to have been a co-ordinated response. • There was no documented plan regarding N’s missing episodes. It seems that each episode was dealt with in isolation. On some occasions (as documented in the previous point) frustration would result in single agency action. The failure by agencies to understand the relationships between N and her friends (particularly M1) resulted in action that was almost certain to be ineffective. For example, at one point M1 was moved to the north of England. N went missing on numerous occasions to meet up 22 with him. N often went missing with other Children Looked After and in fact her patterns of behaviour were predictable. The failure to bring all the information and intelligence about N and her associates together resulted in inappropriate responses that were unlikely to succeed. • The multi-agency forum in place at this time to review missing persons cases reviewed N on one occasion but there is no record of the decisions taken. An effective multi-agency panel is essential to produce meaningful plans and ensure that one agencies actions do not contradict the work of another. This matter has now been addressed. • Arrangements for accommodation were put in place reactively rather than pro-actively. Where was the voice of the child? N was often in placements away from her peer group and there is nothing to suggest that she was ever asked for a view on where she should be placed. In December 2017 Dudley Metropolitan Council published new guidance for agencies13. The guidance addresses a number of the issues raised in this report. The guidance lays out the processes to be followed and contains detail in each of the following areas: • Why children go missing; • risks of going missing; • ‘Missing’ and ‘Absent’ definitions; • reporting to the police and police response; • thresholds for strategy meetings; • location and ‘Return of Child Return Interview’; • ‘Out of borough’ placements; • children missing from care. The guidance also introduces and describes the role of the Adolescent Response Team (ART) in dealing with children who go missing. This team review all missing episodes on a daily basis. In terms of improved management oversight, a Child Missing Operational Group (CMOG) chaired by a senior manager from DCSC meets every 3 weeks to review those children identified as high risk, to ensure appropriate referrals have been made and to consider patterns and trends in missing behaviour. Clear pathways have been established to ensure front line professionals have clarity around roles and responsibilities. The pathways can be found at the following link: http://www.proceduresonline.com/dudley 13 “Children Missing from Home and Care” – Dudley Metropolitan Council http://www.proceduresonline.com/dudley/childcare/user_controlled_lcms_area/uploaded_files/MISSING%20FROM%20CARE%20PROCEDURES.pdf 23 3.2.4 Significant issue four N was graded as at high risk of CSE, was continually missing and committing criminal offences. N had contact with several agencies including children’s social care, the police, health and housing. N was later at risk of and suffered serious incidents of domestic violence; including life-changing injuries. Many of the children N was associated with also had the support of a number of safeguarding agencies. There should be clearly documented evidence of multi-agency working, the use of statutory child protection procedures, consultation between professionals working with all linked children and effective use of supervision to keep the child’s needs in mind. N was initially graded as at high risk of CSE, was continually missing and committing criminal offences. N had contact with a number of agencies including children’s social care, the police, health and housing. There should be clearly documented evidence of multi-agency working and the use of statutory child protection procedures. The issue of CLA Reviews and Pathway Plans is dealt with at section 3.2.1. It is not clear in the files presented to the review, where any multi-agency collaboration took place in the months leading up to the stabbing of N with the exception of the MARAC meeting in August 2016. It remains unclear as to whether section 47 investigations were commenced after some key violent incidents. At the learning event, the network present were clear that the social worker for N, M2, M3 and M1 all met to systemically look at the interactions of these four children, yet the documents provided do not reference or evidence this and review of CSC records does not contain evidence of documented multi-agency discussions across professionals working with the various CLA children referenced in this review document. This appears to highlight a weakness in recording and supervision. Furthermore, N’s case highlights the importance of professionals actively looking beyond the ‘silo’ approach of working with one child/family without considering how to work closely with professionals working with linked children or families. As noted elsewhere in this document, N, M2, M1 and M3 were all CLA children and thus each had their own range of professionals working with them. They were inherently vulnerable and some of these children appeared to be engaging in violent behaviour against N. Whilst there is evidence of A and N’s social worker having some contact, and professionals at the learning event spoke of meeting as a group to consider all 4 children together; evidence of this collaboration across children’s services has not been located. Multi-agency meetings (e.g. CLA Reviews) have occurred, however as noted above, there are areas where the needs of N may not have been consistently followed through over time (see 3.2.4). In terms of CSE, there is acknowledgement that N is at high risk of CSE, but no action plans have been presented detailing how agencies will protect N. As documented throughout this report there were a number of occasions when referrals could have been made and section 47 investigations instigated. Whilst N was CLA and so was subject to supervision by DCSC the lack of recorded adherence to child protection guidance remains a cause for concern. Social Worker’s files show poor levels of recording with brief notes kept that do not always provide case context. Supervision for frontline social workers, as reflected in DCSC records, whilst at times frequent, was often of poor quality. Many supervision records were brief, task-oriented and often did not record reflective thinking about N’s circumstances and overall vulnerabilities or provide clear consideration of risks at different points. Reflective supervision 24 may have enhanced the prospect of considering N within an enmeshed group of CLA children and how these children as a group needed to be supported; on the evidence provided these children had been involved in domestically abusive relationships over a considerable length of time, combined with risk-taking behaviour such as frequent missing episodes, often involving travel over considerable distances. Reflective supervision may also have assisted frontline staff in keeping issues such as mental health and domestic abuse in mind at different junctures whilst also responding to the challenging, intensive crisis events that did arise over time in N’s life. It is noted that DCSC will shortly be moving to a new electronic recording system. This will provide considerable support to frontline staff in evidencing the work they are carrying out with children and families. 3.2.4 Significant issue five N suffered numerous episodes of domestic abuse and two of her boyfriends were identified as domestic violence perpetrators. There are clear processes, including the MARAC process, that would be expected to put in plans to protect N. Multi-agency Risk Assessment Conference This report details several domestic violence incidents that N was subjected to. This included at least two serious assaults by two perpetrators. At least two DASH risk assessments were completed in respect of N and in both she was classed as being at high risk. As noted elsewhere, the domestic abuse that N suffered in 2016 were both serious incidents. On 4 April 2016, M2 attempted to head-butt N in a mother and baby residential placement and was subsequently removed from the placement. No evidence of a section 47 investigation following this event has been identified. Information shared by the police indicates that on 5 April 2016 “…West Mercia added the victim to their MARAC agenda and are managing safeguarding”. The reviewers have not received any information indicating N’s case was ever presented to MARAC thereafter or that a multi-agency safeguarding plan was put in place to protect N. On 2 August 2016, M1violently assaulted N. The MARAC referral document suggests that this included - " M1 grabbing N’s mobile telephone and throwing it on the floor causing it to smash. N was upset because she had photos of her child on there that is in care. M1 then grabbed her around the throat with both hands and tried to strangle her. N believed he was going to kill her. She describes him as being very angry. She tried to push him off her. He then punched her on her head and kneed her on the leg. N shouted for her sister to call the Police. S1 entered the bedroom and told them both to calm down. N called the Police using S1’s mobile telephone and tried to stop M1 leaving before the Police arrived. She grabbed the front door key which he wanted. He then assaulted N again by throwing her to the floor. He then grabbed the key and jumped out of the window and walked off. N wanted the key back and followed M1. They were arguing, and he assaulted her again by punching her twice on her face causing her to fall to the floor." It is entirely possible that N could have been seriously injured in this incident. DCSC records contains a MARAC invitation letter dated 18 August 2016, noting that the case was to be heard at MARAC on 25 August 2016. Information provided suggests that no section 47 investigation commenced following this incident. Minutes of the MARAC Meeting on 25 August 2016 note that CHADD On Route (housing provider) felt that they were not worried about the current offender (M1) but were concerned 25 about M2 (N’s previous partner) as he had contacted N from prison. The MARAC were also aware that M1 had 'Eight convictions, noted whilst in 2015 he was in public brandishing an imitation firearm. Violence, suicide and self-harm markers.' N was engaged with the Respect Yourself team; MARAC minutes indicate that - 'Referral received from West Mercia Women’s Aid after scoring 16 on DASH. Suffering from postnatal depression, afraid of A’s father, M2. Due to her age, she is being supported by Respect Yourself.' It is the view of the reviewers that this information refers to Respect Yourself/IDVA becoming involved with N after the headbutting assault by M2 on 4 April 2016, not in immediate response to the assault by M1 on 2 August 2016. Thus, whilst N had not been discussed at MARAC in April 2016, support around domestic abuse had been in place since that time via Respect Yourself. The only MARAC actions in August 2016 were for CHADD On Route to provide an update which was completed (part of which is in the information above) and for N to be linked back in with CAMHS regarding an ADHD assessment. There are no references to any pro-active protective work, for instance consideration as to whether injunctions could or should be sought or other direct actions to address potential domestic abuse from M1 (or M2). It is likely that the CLA status of M1 and M2 were known to MARAC, however no actions were outlined with regards to DCSC and the wider safeguarding network to come together operationally to consider domestic abuse risks across this group of children and how these might be mitigated. Given the severity of the assault and that N may have been the victim of two significant domestic abuse incidents from two different child perpetrators within 6 months, the MARAC actions could have been more specific in generating swift multi-agency consideration and response to mitigate domestic abuse risks. If this was an adult male offender to an adult victim, would the response have been different? There is mention in information provided of N being referred to, and receiving, support from CHADD On Route – her accommodation provider - in the weeks prior to the stabbing incident. At the learning event, it was stated that CHADD and the Youth Offending Service had both sought to work with N around domestic abuse issues, but the exact nature of that work has not been provided. Respect Yourself and the Independent Domestic Violence Advocate Information provided suggests that early parts of N’s relationship with M1 were also violent. For example, it is noted in March 2015 that N had been moved out of Dudley in order to safeguard her from the ‘volatile’ relationship with M1 – this is some 18 months prior to the stabbing incident in September 2016. As noted earlier in this review document, prior to March 2015, N had made and retracted serious criminal allegations against M1. A supervision record on 9 March 2016 notes that that the relationship between N and M2 is “volatile”, yet at this time there is no evidence of domestic abuse support or planning around this relationship, despite N and M2 being about to enter the intensive environment of a ‘parents and baby’ residential assessment setting. It is important to note the multiple descriptions of abusive relationships as “volatile”. This speaks to a possible minimisation of the abusive incidents within these relationships and may reflect the need to re-frame how domestically abusive relationships between children are viewed by safeguarding professionals. As noted elsewhere in this document, following the headbutting assault and disclosures of additional abuse perpetrated by M2 against N in April 2016, Black Country Women’s Aid referred N to Respect Yourself on account of her age (under 18 years) for support around 26 domestic abuse. An Intensive Family Support Worker/Independent Domestic Violence Advocate was appointed to work with N after the referral to Respect Yourself on 28 April 2016. Feedback at the CLA Review on 28 June 2016 suggested that N continued to engage with Respect Yourself and that one-to-one sessions would continue until a space on the next available Freedom Program could be obtained. File information suggests that there was contact between DCSC and Respect Yourself over time to see how N was engaging with domestic abuse support. A brief update on 2 September 2016 suggested that N continued to work with Respect Yourself and by 6 September 2016 a Freedom Program place had been identified. What remains unclear from file information is what immediate protective measures were put in place following the assault on 2 August 2016 at N’s flat by M1. The police chronology notes that N scored 14 (high) on a DASH risk assessment, stating that she was afraid of what M1 might do and that he continued to constantly text her and was following her. It is unclear what measures may have been taken to strengthen security at the CHADD On Route placement, or what advice given, or safety planning considered with N if M1 were to present to the flat again. A CLA visit to N at her accommodation on 6 September 2016 does not document discussions around immediate domestic abuse safety measures or considerations. This is relevant given that there is a history in 2015 of N reporting domestic abuse allegations about M1, thus there could be a possibility of further incidents of violence from M1. Reviewing the incidents thereafter (with the benefit of hindsight), it appears that M1 was in an escalating pattern of violence. Following his arrest after assaulting N, he was then arrested after seeking to assault the child M3 with a hammer on 12 September 2016, just two days before he then stabbed N at her accommodation. There needs to be review and improvement of the way domestic abuse is dealt with by individual agencies and multi-agency forums in Dudley when dealing with children and young people. 3.2.5 Significant issue six The transition process from childhood to adulthood is a difficult period and this is more significant for children who are Looked After. There should be clear support processes for Children Looked After as they move through this transition, which are underpinned by consistent planning and review to ensure that positive outcomes are clearly outlined and achieved wherever possible. This issue has been largely dealt with in section 3.2.1. The transition period between 16 years and 18 years is particularly difficult for Children Looked After. CLA reviews and Pathway Plans hold the key to this transition. It is also noted that N regularly presented at panels likely to be chaired by senior managers, such as the ‘Access to Resources Panel’. This panel was often concerned with understanding N’s accommodation needs and associated risks and authorising placement options for her. Due to N moving amongst various placements, initially due to ongoing missing behaviour in 2015 and latterly due to the need to find specialist mother and baby provisions, her case was considered on a number of occasions. Similarly, in 2015, N was open to the ’Missing’ Panel, although in 2016 this behaviour appeared to abate considerably. As noted elsewhere, DCSC has implemented new procedures around missing children. Information provided suggests that this panel did not consistently seek to understand or address wider issues such as mental health, domestic abuse or the concerns raised by the 27 interactions of this group of children. It may be that this was simply not the function of the Access to Resources Panel, although on occasions these needs were considered, such as the Access to Resources Panel on 9 August 2016, which directed that Adult Mental Health Services should be invited to attend the next CLA Review for transition planning and to ensure that N was provided with all relevant information and support around the upcoming adoption of her son A. As noted in concerns regarding supervision, it was not possible to identify a thread of ongoing management and review of the needs of N given the level of risk she was exposed to within her personal circumstances. It may be that in addition to structures put in place around missing children that DCSC considers how it retains oversight of children in other high risk situations. The front-line practitioners interviewed in this review showed no lack of care or compassion but did exhibit considerable frustration about the options open to them when dealing with N. It should not be under estimated how difficult it was for professionals to protect N. N had had a troubled childhood as had her mother and sister and it is true to say that N was part of a family that had suffered inter-generational abuse and need for care services. N engaged in relationships which were high risk, with other children who had been in the care system most of their lives. There is no doubt that N did not understand the risk she was facing and clearly did not feel that agencies were likely to offer the type of support she felt she needed – at times it may have felt to N that these relationships were meeting her needs. N had known her associates in this report for many years and there are school records of N, M1 and M2 running away from school when they were 14 years old. When offered help and support, N declined services or failed to keep appointments. N stayed in different types of accommodation, in numerous locations and huge resources were expended attempting to keep her safe. It is important to acknowledge that taking into account all of these factors, N, as a 16 or 17-year-old child, may have exercised her ability at times to choose whether to engage or not engage with services at different times and that it may not always be possible to ensure that young people will choose to take up support offered. However, whilst this review concludes that it was extremely difficult to keep N safe through this transition period, consistency in application of child protection procedures when risks arise and consistency in CLA Reviewing and Pathway Planning to maintain an holistic overview of children’s needs are crucial in working towards a safer and less troubled transition to adulthood. 3.2.5 Significant issue seven N came from a family that had been subject to significant involvement from safeguarding agencies over many years. Clear processes are required to swiftly identify children who are or could become part of inter-generational involvement with safeguarding services and what support can be offered to ‘break the cycle’ of involvement. Information was clearly provided at the learning event that N’s elder sister, had been known to Children’s Services and was herself a Child Looked After and presented with similar vulnerabilities and behavioural issues. Information gathered at the learning event also suggested that N’s mother, was a Child Looked After. File information suggested that a chronology had been compiled of the family history over the last 30+ years, which was good practice. 28 Sadly, N’s own child, A was taken into Local Authority care on a permanent basis, meaning that child A may now be the third generation of this family that has at some period been a Child Looked After. A clear focus at the learning event for the professionals present was around the offer available in Dudley for children and mothers who had been in care and themselves and/or who may be vulnerable to their own children entering the care system. Professionals felt that consideration should be given to projects that have been considered in other authorities that work to ‘break the inter-generational cycle’, such as the ‘Pause Project’ or other examples where mothers who have had children taken into care receive significant support and input to equip them to avoid this outcome for future children. It is noted that N became pregnant again later in 2017. This type of support may therefore still be very relevant to N, as well as other mothers in Dudley. Section Four – Key Themes 4.1 The application of child protection processes This review has established that whilst many child protection processes were followed there were key times when referrals were not made and strategy meetings and section 47 investigations did not take place or were not properly recorded. CLA reviews and Pathway Plans did take place and there was a level of SMART planning within reviews. However, some of these reviews did not consistently consider N’s needs holistically and at times – possibly out of necessity – have focused on crisis events. CLA Reviews and Pathway Plans need to ensure that all aspects of a child’s needs are considered despite current events and are kept in mind when planning for transition phases. Recording by social workers on DCSC systems was generally very brief and whilst supervision often occurred quite frequently, it was difficult to obtain a clear outline of planned case direction due to the brevity and often task-focused nature of supervision records. Reflective supervision may also have led to a greater focus on the wider needs of N outside of the crisis situations that arose. 4.2 Dealing with domestic abuse in teenage children N was subject to a number of incidents of domestic abuse, including a number of historic allegations in 2015, some of which were later retracted. Prior to being stabbed in September 2016 she had been seriously assaulted by two different perpetrators in 2016 alone. Two DASH risk assessments were completed for N and her cases were referred through the MARAC. It is unclear what plans were put in place to protect and support N as a victim and what preventative measures were in place to ensure that two known and identified perpetrators could not harm her again. One of those perpetrators (M1) went on to stab N causing life changing injuries just 2 weeks after a MARAC meeting had discussed the case. Despite meeting to consider these risks, it must be concluded that the MARAC failed to implement effective plans to protect N. The DASH risk assessment should be shared between partners to ensure that agencies have a full picture of a young person’s life and fears. 29 4.3 Dealing with ‘missing’ episodes with Looked After Children This case involves a child who went missing on a huge number of occasions. Whilst missing reports were taken seriously by agencies and the police and children’s social care took some reactive steps, there was a failure to work together. Agencies did not consider the whole picture concerning N and her associates. There was a lack of multi-agency planning and little managerial oversight. Whilst individual professionals took action and did what they could, the collective effort by agencies to deal with N’s missing episodes was insufficient. New guidance introduced in December 2017 is clear and addresses many of the issues raised in this review. 4.4 Multi-agency working and working with a group of children who are engaging in abusive behaviour to one another There are a number of examples of agencies working together when dealing with N, such as liaison between CAMHS, DCSC, YOS, Connexions, Respect Yourself/IDVA and other agencies. However, given the high risks N faced and the issues that a number of agencies identified around the high-risk nature of her behaviour and the behaviour of those around her, there is not sufficient evidence of multi-agency information sharing or multi-agency action plans to address the risks faced by N. This review concludes that individual’s actions were not sufficient to protect N and despite CLA Review planning around some of N’s needs, there was no overall multi-agency plan to address the risks posed by the children highlighted in this document individually and as an enmeshed group. Work with N lacked grip, leadership and long term multi-agency planning. Another key issue in this case is the ability to consider N not only individually but as part of a group of enmeshed children who appear to have moved towards negative, abusive behaviour towards one another over time. It is crucial in multi-agency safeguarding partnerships that active consideration is given to bringing together professionals who are working across children in groups such as that encountered in N’s case. Whether under the guise of a strategy meeting or a professionals meeting, this will allow the safeguarding network to share information about risk and need and develop plans that will work to enhance safety across all children involved. As noted above, professionals at the learning event feel that this did occur to some extent, although records of this could not be located. Ensuring that safeguarding professionals work outside of ‘silos’ is crucial to ensuring that the most effective support and intervention can be identified and implemented to keep children safe. 4.5 Transition issues for Children Looked After The transition in to adulthood is difficult for all young people. These issues are more acute for Children Looked After. They have, by definition, suffered a difficult childhood and face issues around accommodation and support that others do not. CLA Reviews and Pathway Plans are an essential element in preparing Children Looked After for this transition. Whilst they were conducted regularly, they were not always consistent in reviewing the whole spectrum of N’s needs, to provide effective support and challenge. It is noted that an Independent Reviewing Officer on one occasion challenged the social work team about why they were unable to find a mother and baby placement for N and A. Whilst this is an example of positive challenge, there is no evidence of similar challenge being exerted as 30 to why safeguarding procedures were not followed after incidences of violence or whether appropriate safety measures were taken following these violent assaults. Similarly, Pathway Planning may have benefited from consistent consideration of needs such as mental health and healthy relationships alongside pressing accommodation priorities and other types of support that arose around N in this complex case. 4.6 Accommodation issues for Children Looked After in transition to adulthood N was offered a variety of accommodation through this period. In fact, she stayed in: supported accommodation; with specialist foster carers; in specialist residential assessment accommodation; and with her sister. The accommodation she was offered was both local and further afield. On one occasion she was placed in secure accommodation. Despite the efforts to find suitable accommodation N was at times disruptive or went missing. CLA Reviews could have considered a longer-term solution for N earlier, however the landscape around accommodation changed considerably with the impending arrival of A, then followed by the need for further accommodation following N deciding not to continue the residential parenting process. The review accepts that finding suitable accommodation that N would have remained in was an extremely difficult task, whilst the changing accommodation needs of N in 2016 to some degree made it difficult to plan for longer-term accommodation until after the residential parenting process ended in June 2016. 4.7 Approaches to children who are part of ‘inter-generational’ need and/or abuse One of the sad facts of this case is that N was a Child Looked After as were her mother and sister. N’s first child has been adopted. This is not a problem that is suffered by one Child Looked After or is only apparent in Dudley. It is a national problem and the evidence of the outcomes in adulthood for Children Looked After reflects that. Consideration needs to be given to the current offer available in Dudley for children and mothers who had been in care themselves and who may be vulnerable to their own children entering the care system. There are projects that have been successful elsewhere that Dudley may consider examining (for instance the ‘Pause Project’) where mothers who have had children taken into care receive significant support and input to equip them to avoid this outcome for future children. Section Five – Key Findings N and her associates (including those who assaulted her) were Children Looked After. N was a troubled child who suffered from mental health issues and had been subjected to domestic abuse from two different perpetrators. Attempts to support her and find suitable accommodation, prior to the birth of A, often failed because N refused to cooperate and actively sought to distance herself from those seeking to help her. Following A’s birth, N’s accommodation situation was slightly more stable, although her life was adversely affected on several occasions by violent instances of domestic abuse, culminating in the life-changing injuries sustained on 14 September 2016. Agencies in Dudley were aware that N was at high risk of suffering from further domestic violence but did not put in place sufficient protective measures, or apply sufficiently robust 31 child protection measures, to prevent the serious assault at the hands of a M1; a previous perpetrator of violence against her. Section Six – Recommendations 6.1 Recommendation one Dudley Safeguarding Children Board should consider a review of the effectiveness of the new guidance on missing persons published in December 2017. This review should be completed by November 2018. 6.2 Recommendation two Dudley Safeguarding Children Board should consider requesting evidence of how DCSC senior management retains effective oversight of children identified at being at high risk of harm, whether by virtue of domestic violence or other risk factors and seek assurance regarding the supervision of cases. Agencies should consider the role of the MASH in these circumstances. 6.3 Recommendation three Dudley Safeguarding Children Board should consider holding a learning event for front line professionals, to review and discuss the learning from this and other recent cases. The event should focus on statutory child protection procedures, leadership, reflective supervision and effective working with enmeshed groups of children who may be involved in violent or other negative behaviours. 6.4 Recommendation four Dudley Safeguarding Children Board should consider a review of the way in which children who are involved in domestically abusive relationships are assessed in terms of risk of harm. They should also review the provision of support and effective action planning that takes place through the MARAC process for young people. This review should be conducted by September 2018. Consideration should be given to ensuring DASH risk assessments are appropriately shared by agencies. 6.5 Recommendation five Dudley Safeguarding Children Board should consider the current quality of CLA Reviews and Pathway Plans, whether sufficiently robust challenge is received from Independent Reviewing Officers to safeguard the interests of Children Looked After and consider whether current systems are effective in protecting Children Looked After whilst providing meaningful plans to ensure their safe transition to adulthood. 6.6 Recommendation six Dudley Safeguarding Children Board should work with key partners to examine the level of support for children and mothers who have become part of inter-generational cycles of children coming into local authority care. Consideration should be given to projects that might help support children and mothers in these circumstances. 32 |
NC048214 | Death of a 23-month old child in May 2014 due to non-accidental injuries. Child BB was taken to hospital in a state of extreme physical collapse, with bruises and burn marks, and died the following day. Criminal charges were brought against the mother and her partner in March 2015, but the partner committed suicide before the trial. Mother was found not guilty. Child BB and the mother were only known to universal services and none of the agencies were aware of any concerns about the child's wellbeing, nor were they aware that the mother was in a recent relationship with a man whom she met through an online dating site, with a history of domestic violence and allegations of ill-treatment of children in another local authority area. Key findings: concerns regarding inter-agency communications between police, probation services and children's services about incidents and call-outs in relation to domestic violence in the other local authority area; safety messages on dating websites focus on the users' personal safety but not on potential risks after a relationship is established. Recommendations include: police, probation service and children's services to review processes for liaison about incidents and call-outs in relation to domestic violence; national consideration be given to how mothers can be alerted to the need for caution when engaging in new relationships with previously unknown men, potentially with an emphasis on relationships made through internet dating sites and social media.
| Title: Overview report of the serious case review relating to Child BB. LSCB: Surrey Safeguarding Children Board Author: Arthur Wing Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Overview Report of the SERIOUS CASE REVIEW relating to Child BB Arthur Wing March 2017 1 of 26 CONTENTS Page 1. Introduction 2 2. Arrangements for the Serious Case Review 3 3. Methodology 5 4. Summary Chronology 6 5. The Family 8 6. The Agencies who contributed to the Review 11 7. The Findings 15 8. Key Issues 20 9. Conclusions and Lessons identified by Agencies 22 10. Recommendations 24 Appendix 1 The Serious Case Review Group 25 Appendix 2 Terms of Reference of the Serious Case Review 26 2 of 26 1. INTRODUCTION 1.1. In late May 2014, the child BB was taken to hospital in a state of extreme physical collapse. It was noted that BB had a large bruise to the side of the head and other bruise and burn marks. BB was transferred to a hospital with a paediatric intensive care unit later that day and died there the next day. 1.2. There is a legal requirement, as defined in Statutory Guidance, Working Together to Safeguard Children 20131, to undertake a serious case review when abuse or neglect of a child is known or suspected and either a child has died, or a child has been seriously injured and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.3. This matter was referred to the Local Safeguarding Children Board in Surrey where child BB had been living. In June 2014, the Strategic Case Review Group (SCRG) of the Surrey Safeguarding Children Board (SSCB) met to consider whether the criteria for a Serious Case Review were met. It noted that BB had only been known to universal services and that there had been limited contact with BB and family. Having considered the circumstances and taken the advice of the National Panel of Independent Experts on Serious Case Reviews, the Chair of the SSCB determined, in August 2014, that it would carry out a review. It was noted that the National Panel had advised that the review should be proportionate. 1.4. The purpose of a Serious Case Review, as set out in the Statutory Guidance, Working Together 2013, is to identify improvements which are needed and to consolidate good practice in order to prevent similar deaths or serious injury. 1 Working Together to Safeguard Children, HMSO, 2013, since superseded by Working Together to Safeguard Children, HMSO, 2015 3 of 26 2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 2.1. The SSCB decided that its Strategic Case Review Group would be the reference group for this review. It was chaired by Alex Walters, the Independent Chair of the Board at the time. Its function was to manage and oversee the conduct of the review. The membership of the SCRG is set out at Appendix 1. The Board appointed an independent reviewer, Arthur Wing, to lead the review and to write this overview report. He was assisted by Amanda Quincey, SSCB Partnership Support Manager. 2.2. Internal management reviews (IMRs) were submitted in November 2014. In total, six IMRs were requested from the following agencies which had had contact with child BB and the family: Health Care Provider of hospital services Health Care Provider of mental health services and community alcohol and drug services Health Care Provider of community services providing health visiting, school nursing, and speech and language therapy services Surrey Police Bedfordshire Police (IMR subsequently updated) Bedfordshire Probation Trust. The IMR was provided by the National Probation Service – Bedfordshire as Bedfordshire Probation Service ceased to exist in 2014. 2.3. In addition, written information was provided by agencies with less significant or less recent information: Local Clinical Commissioning Group (Surrey general practitioners) Surrey County Council Schools and Learning Health Care Provider of Paediatric Intensive Care Unit Local Housing Department Luton Safeguarding Children Board on behalf of Luton, Bedford Borough and Central Bedfordshire Children’s Services Metropolitan Police The report of the Consultant Paediatric Pathologist who examined BB was also considered. 2.4. This report was written in anticipation that it will be published. Consequently, the information in the report is limited so as to: a) take reasonable precautions not to disclose the identity of the child or family b) protect the right to an appropriate degree of privacy of family members The health services involved and the local borough council are anonymised in order to avoid revealing in which part of the county the family live. 2.5. Terms of Reference for this SCR are at Appendix 2. The child BB was the main subject of the review and its principal focus was from June 2012 (when BB was born) 4 of 26 until June 2014. All agencies were, however, asked to provide a summary of all significant events and relevant family history outside the specific timescale where this would inform the overall analysis. 2.6. All internal management reviews addressed the terms of reference. All the authors of the internal reviews were independent of the case and its management, and all bar one conducted interviews with staff involved with child BB and the family. Seven members of staff were interviewed in total. 2.7. Following consideration of the combined chronology of events and the internal reviews, the independent reviewer met with BB’s father. He provided helpful information as well as his perspective on what had happened. It is recognised that this hasn’t all been corroborated. 2.8. It was not possible to interview either BB’s mother or the mother’s partner or the maternal grandparents at this stage as criminal proceedings were continuing. 2.9. In February 2015, after the first draft of this report had been compiled, the independent reviewer met with the Strategic Case Review Group. It was agreed that a report would be requested from Luton, Bedford Borough and Central Bedfordshire Children’s Services Departments. Luton Safeguarding Children Board agreed to coordinate their responses. This report was received in May 2015 and a second draft of the Interim Overview Report was considered by the Strategic Case Review Group in June 2015. The Group commented on the findings and recommendations and agreed that the Interim Report should be considered by the Surrey Safeguarding Children Board in July 2015. 2.10. Following this meeting, the Interim Report was circulated to the agencies confirmed to enable them to check its accuracy. Minor changes were then made. It was decided that the Report should not be published as there were ongoing criminal proceedings. Key aspects of the learning from the Review were however published in November 2015. 2.11. BB’s mother and her partner were sent for trial at Crown Court charged with two offences: causing or allowing the death of a child and causing or allowing a child to suffer serious physical harm. Shortly before the original date for the trial, the mother’s partner committed suicide. BB’s mother was tried and found Not Guilty of both charges. 2.12. The Interim Report was then shared with both BB’s mother and BB’s father. Their comments have been taken into account in the preparation of this, final, version of the report. 2.13. The completion of the report was initially delayed pending the possible holding of an inquest. In early 2017, it was determined that an inquest would not be held. The Overview Report was considered and accepted by the Surrey Safeguarding Children Board. 5 of 26 3. METHODOLOGY 3.1 The review process has been conducted in line with the agreed Terms of Reference and has taken account of the principles set out in Working Together 2013. It has aimed to contribute to learning and improvement through consolidating good practice and identifying where practice can be improved and to recognise the complexity of safeguarding children and to seek to understand not only what happened but why individuals and organisations acted as they did. 3.2 The principles as set out in Working Together are: There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice. The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed. Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process. Final reports of SCRs must be published, including the LSCB’s response to the review findings, in order to achieve transparency. The impact of SCRs and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children must also be described in LSCB annual reports and will inform inspections. 6 of 26 4. SUMMARY CHRONOLOGY 4.1. BB was born in June 2012, weighing 3.044 kg, which is in the 25th percentile. It was a normal birth at the local hospital. No concerns were noted and mother and baby were discharged home the following day. 4.2. There were routine visits by the health visiting service and it was noted that BB gained weight during the next two weeks. BB was subsequently taken to the clinic for immunisations. 4.3. In the summer of 2013, BB’s mother moved home and for a while the health visitors weren’t aware of her address. Contact was resumed in February 2014. In March 2014, BB was taken to the local Paediatric Accident and Emergency Department, suffering from viral gastroenteritis. In May 2014, it is recorded that BB was seen by the GP. BB presented with polyuria and polydipsia (excessive drinking and urination). The records state that BB was well throughout and happy and very active. BB’s mother was asked to bring in a urine sample but did not do so. This was less than two weeks before BB died. 4.4. BB was brought to the local hospital’s Paediatric Accident and Emergency Department in late May 2014. This is recorded as being at 2.52pm and by mother. BB was noted to be in a state of extreme physical collapse and with bruises, scratches and burn marks. The possibility of non-accidental injury was raised as a concern. Appropriate procedures were followed and a strategy meeting was held. Following examination and a CT scan, BB was transferred to the hospital with a Paediatric Intensive Care Unit, about twenty miles away. On arrival at this Unit, it was noted that BB was very unwell and in a critical condition. Although given full support to vital systems, BB died the following afternoon. 4.5. It was noted that BB’s mother was joined at the local hospital by her partner and her grandmother and then at the second hospital by BB’s father. 4.6. The history given to the review by BB’s mother was that she had put BB to bed and gone out to work in the early hours of the morning, leaving BB asleep and her partner to care for her. She had returned at about 10.30am. Her partner told her that BB had woken early but was asleep again. She went to bed herself and was later woken by her partner who said that BB was still sleeping. She found BB limp and not responsive and so took BB to hospital. She stated that she changed BB before leaving for the hospital. It is recorded that when she was asked why she didn’t call an ambulance she gave no explanation. She has subsequently explained that she lived near the hospital and had previous experience that it was quicker to get there by car. 4.7. When asked at the hospital about the other marks on the BB’s body, BB’s mother said that what appeared to be burn marks on the trunk had been caused by a hairdryer. This happened when BB was sat on her lap while she dried BB’s hair. Her partner told the staff in the first Paediatric Accident and Emergency Department that the bruise on BB’s forehead was caused by the shower head falling while he was bathing BB a couple of days earlier. The Ambulance Network staff who conveyed BB 7 of 26 between the two hospitals said they had been told that the bump to the head had happened two days earlier in a fall in the garden. BB’s mother has said to the author that these accounts were not accurate but that she did not know how or when the injuries were caused. 4.8. It is noted that the pathologist considered that it was unlikely that the burns had been caused accidentally, that the severity of the head injury was in excess of that which might be due to a shower head falling on the child and that the extent of the injury would be incompatible with other than a very short survival following infliction. 8 of 26 5. THE FAMILY 5.1 BB’s Mother 5.1.1 BB’s mother was 24 years old when BB died. She had been brought up locally and received a normal secondary education. It is understood that she had some contact with the Child and Adolescent Mental Health Service which was linked to her having witnessed domestic violence as a child as well as having been the victim of some parental violence. It is recorded that she suffered from depression and self-harming. 5.1.2 She was referred to the local Community Mental Health Team in 2009 as she was experiencing depression and mood swings and had taken an overdose. She was assessed, asked to consider taking anti-depressant medication and referred for psychotherapy. She did not attend for a follow-up appointment or for a psychotherapy appointment. 5.1.3 BB’s mother attended for ante-natal appointments at which her history of depression was discussed. This was then picked up by health visitors during their post-natal visits. In view of her history of depression, a specific mood assessment was carried out on July 2012 and no concerns were identified or raised by BB’s mother. 5.1.4 In June 2013, BB’s mother, who had been living in privately rented property, moved to another part of Surrey. The move meant that she was living nearer her parents. 5.1.5 BB’s mother was in work and regularly used her parents to care for BB. It was, for example, recorded by the health visitor that in February 2014 she was on a course and her step-father was looking after BB. It is also recorded that at the time of BB’s death she was working as an airport security guard. 5.1.6 BB’s mother has stated that she was not aware that her new partner (Mr Y) had a history of domestic violence or allegations of assaults on children. He appeared to be good with BB and she considered that he seemed used to helping with young children which was consistent with the partial history he had given her. 5.2 BB’s Father 5.2.1 BB’s father was 33 years old when BB died. He lives in London. 5.2.2 He explained that he had met BB’s mother through an internet dating site – “PlentyofFish”. 5.2.3 He explained that the two of them had never lived together but that he remained in contact with her because of BB. He stayed with her for the first few days after BB’s birth and then travelled back and forth regularly during the first month. In order to be sure that he was BB’s father, they arranged their own DNA test. 5.2.4 There was no arrangement for him to pay maintenance but he contributed when he was working. There was also no formal agreement about his contact with BB. It developed into an arrangement whereby he would see BB for the day every other week. He would take BB out locally and then sometimes to visit his family and, latterly, to his current girlfriend’s. 9 of 26 5.2.5 He had last had contact with BB on 17 May 2014, the day of the FA Cup Final. He did not have any concerns about BB that day; he thought BB was happy although he did comment that BB had eaten more than usual. 5.2.6 He was alerted to BB’s admission to hospital as BB’s mother had called his sister. He travelled to the hospital and was in transit when diverted to the specialist hospital. 5.2.7 He had not been aware of any injuries to BB. He was not aware of any concerns about BB having been shared with statutory or voluntary agencies. He commented that BB’s mother had always taken BB to the doctor’s promptly when unwell which made the report that BB had suffered injuries in the days before her death and yet wasn’t taken to the doctor’s or the hospital unexpected. 5.2.8 He had been aware that there was a man in BB’s mother’s life as he had seen a photo of him kissing BB, something which had concerned him and that he had taken up with BB’s mother. He said that he did not know how they met or anything about him. He did, though, say that, a short while before BB’s death, BB’s mother had told him that in future he should communicate with her by email and not phone or text. 5.3 BB’s Grandparents 5.3.1 BB’s mother’s parents lived nearby. It is understood that they were actually BB’s mother’s mother and her step-father, although he had been part of her life from the time she was a baby. It is understood that she was working but that he didn’t following an injury at work. It is known that when BB’s mother was at work or on a course he provided some care for BB but the details of this aren’t known. 5.4 BB’s Mother’s Partner (Mr Y) 5.4.1 Mr Y was 35 years old when BB died. It is understood that he and BB’s mother met through an internet dating site in early 2014 and that by the time that BB died he was living with her. Following his arrest, he was prevented from having contact with her through his, and her, bail conditions. 5.4.2 It is understood that he had two sons, one born in 2003 and the other (with the victim of the offence referred to in paragraph 5.4.3 below) born in 2009. 5.4.3 He was previously living in Bedfordshire, where he was known to various statutory services. He had a history of domestic violence and had served a prison sentence for assault (on a stranger) in 2006. For his 3rd conviction for domestic violence, the common assault of his girlfriend, he was placed on a Community Order for 2 years with requirements of supervision and attendance at a domestic violence programme. 5.4.4 He did not complete the domestic violence programme and it was replaced with an unpaid work requirement. He completed this and his supervision requirement in 2013. As he was under supervision, there are probation records available about this time (see paragraph 6.11 below) as well as police and children’s services records (see paragraphs 6.10 and 6.7). 5.4.5 From these records it is clear that he had a number of relationships with women who had children and that there had been a number of incidents when police or children’s 10 of 26 services had been alerted to concerns about these children (described in paragraph 6.10). 5.4.6 There are known to have been two further agency contacts with Mr Y in Bedfordshire in 2014. In the first, Bedfordshire Police were called to a domestic violence incident in Luton on 5 April 2014 in which a woman said he was still harassing her and that their relationship had ended a month previously. 5.4.7 In the second, on 26 April 2014, he was arrested by the Metropolitan Police, in Bedfordshire, in relation to the sending of a malicious communication to his cousin’s then girlfriend on 26 March 2014. He was prosecuted for this and, on 18 February 2015, a Restraining Order was made and he was sentenced to a Community Order with an Unpaid Work Requirement. 11 of 26 6 THE AGENCIES WHO CONTRIBUTED INFORMATION TO THIS REVIEW 6.1 Health Care Provider of hospital services in Surrey 6.1.1 The hospital had contact with BB and mother at the time of BB’s birth in 2012. This included BB’s mother’s disclosure of her earlier episode of depression. The midwife discussed this with her and, with the mother’s agreement, made a referral to the Health Visiting Service. 6.1.2 There was a further contact on 19 March 2014, when BB was referred by a G.P. at a local Walk In Centre to the Paediatric Accident and Emergency Department, suffering from viral gastroenteritis. The record of this presentation shows that a holistic assessment of BB’s presentation, birth, past and present medical history was considered. It was noted that BB was living with mother, who was receiving support from her family. It is reported that no details of BB’s father or any male partner are recorded but that it is noted that BB’s parents were no longer in a relationship. 6.1.3 The next contact was at the end of May 2014, when BB was brought to the Paediatric Accident and Emergency Department by BB’s mother. During examination, multiple bruise and burn marks were noted and the possibility of non-accidental injury was raised as a concern. Efforts were made to stabilise BB’s condition and following a CT Scan, BB was transferred to the appropriate hospital providing a Paediatric Intensive Care Unit. In parallel, actions were taken in relation to safeguarding. Children’s Services were contacted and a strategy meeting was held later that day. 6.2 Health Care Provider of mental health services in Surrey 6.2.1 This provider reported on its contact with BB’s mother in 2009, as described in paragraph 5.1.2 above. 6.3 Health Care Provider of community services providing health visiting, school nursing, and speech and language therapy services in Surrey 6.3.1 This provider gave comprehensive details of the contacts that health visitors had had with BB and mother. Following assessment, no safeguarding concerns were identified and the family was placed in the core, or universal, service. There is no information that suggests that this wasn’t an appropriate decision. 6.3.2 As has been noted in paragraph 5.1.3 above, a mood assessment was carried out in the light of BB’s mother’s disclosure of her history of depression. She expressed no mental or emotional health issues at that time and it was also noted that the attachment observed between mother and child was good and that she was able to meet all her child’s needs and had good support from her partner (BB’s father) and her family. 6.3.3 Records indicate that BB was taken to appropriate clinics in early 2013 but was not taken to an optional one year developmental screening. In September 2013, the health visiting service received a report that BB had been taken to a Walk In Centre with constipation. This indicated that the family had moved and the health visitor made considerable efforts to confirm this in order to transfer them to the local team. Ultimately these efforts were successful and telephone contact with BB’s mother was 12 of 26 made in February 2014. When asked by the health visitor, BB’s mother said she had no concerns about BB’s general health. 6.4 Surrey General Practitioners 6.4.1 A review of records shows that BB was registered with a G.P. There were no recorded non-attendances and BB was repeatedly referred to as a “happy, well and active child”. 6.4.2 The records refer to the attendance at the Paediatric Accident and Emergency Department on 19 March 2014 referred to in paragraphs 4.3 and 6.1.2 above and to the attendance in mid-May 2014, referred to paragraph 4.3 above. On this latter occasion, BB presented with polydipsia and polyuria (excessive drinking and urination). The records state that BB was well throughout and happy and very active. There is no record of an examination. BB’s mother was asked to bring in a urine sample but had not done so by the time BB died. 6.5 Surrey County Council Schools and Learning 6.5.1 This service confirmed details of BB’s mother’s education. There is also reference to BB in an Early Years database but without any additional information. 6.6 Health Care Provider of Paediatric Intensive Care Unit 6.6.1 This hospital only had contact when BB was admitted and died at the end of May 2014. Its report gives details of BB’s presentation on admission, the assessments carried out and the treatment given. 6.6.2 The history taken has been summarised in paragraphs 4.6 and 4.7 above. 6.6.3 Staff at the hospital were aware of the safeguarding concerns and recorded them on the relevant form. 6.7 Luton Safeguarding Children’s Board - on behalf of Luton, Bedford Borough and Central Bedfordshire Safeguarding Children Boards 6.7.1 This report established that none of the three Bedfordshire Children’s Services had any contact with Mr Y at the time he is likely to have met BB’s mother nor at the time of BB’s death. They were not therefore in a position to alert Surrey agencies to his presence. Their reports indicate that although Mr Y had been named in connection with a number of allegations, as described in paragraph 6.10 below, they had not had any direct contact with him at those times. 6.8 Local Housing Department 6.8.1 The local housing department had had minimal contact with BB’s mother. She contacted them when she was pregnant. She was living with her parents at the time and subsequently found her own accommodation. 13 of 26 6.9 Surrey Police 6.9.1 Surrey Police have reviewed their records. They had no contact with the family prior to BB’s final admission to hospital. 6.10 Bedfordshire Police 6.10.1 BB’s mother’s partner, Mr Y, was well known to Bedfordshire Police as described in paragraph 5.4 above. 6.10.2 Following the making of his Community Order on 11 August 2011, a number of incidents were recorded. It is noted that the victim of the common assault that led to this order had been the subject of a number of domestic related incidents and obtained a non-molestation order against Mr Y in January 2012. There was a report a short time later that he was attempting to gain entry to her house. When police attended, she stated that nothing had happened. 6.10.3 In May 2012, August 2012 and October 2012, there were incidents relating to a family in Bedford. The police investigated allegations of assaults on children in May and October 2012 and an alleged incident of domestic violence in August 2012. The children were aged twelve and four respectively. The allegations implicated Mr Y but, in the case of the assaults, the child’s mother or the child gave a different explanation and in the case of the domestic violence incident, no-one in the home made a complaint when the police attended. The first two incidents were reported to the local children’s services while the third incident had been referred to the police by them. On each occasion, no further police action was taken. 6.10.4 In April 2013, the police investigated an allegation of an assault on a six year old child in Luton. Mr Y was interviewed but the child’s mother corroborated his account of what had happened. The local children’s services were made aware of the incidents and no further police action was taken. 6.10.5 It is recognised that in themselves these incidents and alleged assaults were not the most serious. Two of the complaints had also come from the mothers’ ex-partners. A common feature of these incidents was however that, while the relevant children’s services were informed about them, the probation service wasn’t even though Mr Y was under supervision for assault in a domestic situation. This was unfortunate as, if these links had been made, then the pattern of incidents could have been identified and consideration given to how Mr Y’s behaviour could be addressed. 6.10.6 In April 2014, the Bedfordshire Police received a report from a woman living in Luton that Mr Y had been sending her threatening messages following their separation a month previously. She was visited but it was concluded that no offence had been committed. The Bedfordshire Police IMR writer considers that this incident could have been further investigated and reviewed. 6.10.7 Mr Y was also stopped or questioned by the police about three other matters. Of most significance was that in May 2013, he was questioned about an alleged sexual assault on a female. Forensic examinations and identification procedures did not identify Mr Y and, following evidence that the victim might have made the story up, 14 of 26 no further action was taken. The Probation Service record does not refer to this incident. 6.11 Bedfordshire Probation Trust 6.11.1 As stated in paragraph 5.4.3 above, for his third conviction for domestic violence, the common assault of his girlfriend, in August 2011, Mr Y was placed on a Community Order for 2 years with requirements of supervision and attendance at a domestic violence programme. This order was managed by the then Bedfordshire Probation Trust. He was assessed as posing a Medium Risk of Serious Harm2 to a known adult (his previous partner), his two children when in contact, future intimate partners (plus their children) and the public (he had a previous conviction for assaulting a stranger). 6.11.2 He only attended the domestic violence programme a few times and was taken back to court in May 2012 for failing to comply with the court order. He showed little motivation and was re-assessed as being unsuitable for the programme. An Unpaid Work Requirement was made instead. He was again taken to court in June 2012 for failing to comply with the requirements to attend for supervision and unpaid work. Following adjournments, he was ordered to carry out additional hours of Unpaid Work. He completed his order in November 2013. 6.11.3 The probation review noted that there had only been one check with the police to see if there had been any call-outs to his original victim’s home – there had been none. 6.11.4 In November 2012, it is recorded that Mr Y wanted to resume contact with his son. His son’s mother had been the victim of the offence for which he was under supervision. It would seem that he was successful as he subsequently reported having contact with his son, although later, in May 2013, he reported that his son’s mother had stopped his contact. 6.11.5 In March 2012 and April 2013 he told his probation officer that he was in new relationships with women who had children. He provided little information about them. On the latter occasion, he said that there had been an accusation against him of assaulting her child but that no action had been taken. This was not followed up by the probation officer. The reports to this review indicate that this was the incident described in 6.10.4 above. 6.12 Metropolitan Police 6.12.1 In April 2014, the Metropolitan Police arrested Mr Y. He was interviewed in Bedfordshire and the investigating officer was unaware that he was in a relationship with anyone in Surrey. He was charged with the sending of a malicious communication to his cousin’s then girlfriend on 26 March 2014 and convicted of this as detailed in paragraph 5.4.7 above. 2 The definition of medium risk is “that there are identifiable indicators of risk of serious harm. The offender has the potential to cause serious harm but is unlikely to do so unless there is a change in circumstances for example failure to take medication, loss of accommodation, relationship breakdown, drug or alcohol misuse”. 15 of 26 7 FINDINGS 7.1 The Terms of Reference laid out a series of critical questions, which are addressed below: 1. Did agencies communicate effectively and work together to safeguard and promote the child’s welfare? No concerns were raised about BB’s safety or welfare prior to the final admission to hospital at the end of May 2014. The review from the Health Care Provider of the Paediatric Intensive Care Unit has identified a number of improvements that could be made in relation to communication and the recording of it. This information is critical both to the medical processes and to the assessment of how the injuries occurred, e.g. how, where, when. On this occasion, there were two recorded explanations of the bruising to the child’s forehead – from a shower head and, alternatively, in the garden. In addition, there needs to be an expectation of a record of who was with the child in hospital in these circumstances, and when, and also of any phone calls made. Although there is no suggestion that in this case, everything wasn’t managed well, it can be helpful to have more details about these matters, including any disagreements between relatives about the cause of the injuries. That provider has made a recommendation for action by that Trust (see paragraph 9.2.2). 2. Was the level and extent of agency engagement and intervention with the family appropriate? In view of the difficulties that Health Services had in contacting the mother, were assessments undertaken in a timely manner, was the quality adequate and did they include fathers, extended family and all historical information? BB was appropriately placed in the “Universal” health visiting service. There was a period when BB’s mother had moved and they were out of contact with services. They would seem to have moved between the end of May 2013 and September 2013. During this period, BB was not taken for a one year developmental assessment, although this is described as optional. The first knowledge of the move was when BB was taken to a Walk In Centre near the family’s new address in September 2013. The health visitor attempted to contact BB’s mother to establish if she had moved and the records should be transferred to the local health visiting team. In February 2014, the Health Visitor made contact with the GP’s surgery and found they still had the old address. The efforts to contact BB’s mother were successful and she was contacted by phone. In February 2014, she registered BB at a G.P.’s surgery near her new address. 16 of 26 Although the efforts made to contact BB’s mother were commendable it would have been good practice to have carried out a home visit rather than assessing the situation over the phone. 3. Was any information known by any agency about parental mental health issues, domestic abuse, substance misuse or parental antisocial behaviours or concerns re neglect? If so was appropriate consideration given to how these impacted on parenting capacity and were appropriate referrals made? BB’s mother had disclosed her history of depression to her midwife. This was then passed on to the health visiting team. The review of the midwifery involvement comments that there was some limited consideration of whether this should lead to a referral to a specialist provider. The history of depression was notified to the health visiting service although this referral could have been recorded more clearly. The history of depression was then considered by the health visitor who conducted a mood assessment. 4. What information was known by agencies about the wider family in particular BB’s father, mother’s partner - Mr Y, maternal grandparents and maternal great grandparents who were all involved in BB’s care? No significant information was held on BB’s record about any of these adults. There was a minimum of information recorded about BB’s father at the time of BB’s birth. There was no record of BB’s mother being asked why she had moved. It was though noted by the health visiting service that BB’s grandfather was looking after BB while mother was on a course. No Surrey agencies held any information about Mr Y nor did any of the agencies dealing with BB know of his relationship with the family prior to the final hospital admission. Information about him was held by agencies in Bedfordshire - Children’s Services, Police and Probation, although they did not know that he had moved to Surrey or that he was in a relationship with BB’s mother. 5. Did Bedfordshire Probation Service know that Mr Y was living in Surrey and in a relationship which enabled contact with Children? Bedfordshire Probation Trust had no knowledge that Mr Y was living in Surrey or that he was in a relationship with BB’s mother. Their last contact with him, apart from a phone call from him to an administrator on 4 December 2013, was on 16 October 2013. From BB’s mothers account, she only met Mr Y after his contact with the probation service had ended. 17 of 26 6. Was there sufficient consideration of the vulnerability of this family in relation to their housing situation and the impact on their parenting capacity and what support was provided? Although BB’s mother contacted the local housing department when pregnant, she then found her own accommodation. There was no suggestion that she was vulnerable in housing terms. 7. Were the children’s views and wishes sought and taken account of in assessments and planning? Did this include the presentation of these young non-verbal children being fully considered? The agency reports state that BB’s non-verbal communications were considered appropriately when BB was examined at different times. 8. Were any safeguarding issues in respect of BB identified and acted on appropriately and in a timely way by all agencies? The review by the provider of hospital services in Surrey confirms that safeguarding issues were taken into account when BB presented at the Paediatric Accident and Emergency Department. They were then taken very specifically into account when BB was admitted to the Paediatric Intensive Care Unit and assessed and treated there. 9. Were missed appointments and failure to engage considered as indicators of neglect? BB’s mother did not miss any specific health or other appointments. The efforts to re-engage with her were to establish where she lived and there had been no suggestion of neglect. 10. Was race, religion, language, culture, ethnicity or disability a factor in this case and was it considered fully and acted on if required? How was the uniqueness of this particular family recognised? The ethnicity of BB’s parents was recorded at birth. That BB’s mother was white and BB’s father was black does not appear to have ever been an issue within the family or with agencies. BB’s father has confirmed that this was the case. Mr Y is also black and there is no information as to whether this has any significance. 11. Were there any organisational or resource factors which may have impacted on practice in this case? None have been identified that impacted significantly on the case. 12. Were appropriate management/clinical oversight (supervision) arrangements in place for professionals making judgments in this case? Appropriate management, clinical and supervision arrangements were in place in the various agencies. 18 of 26 It is noted that BB’s first health visitor was a student health visitor. She was sufficiently experienced for the tasks she performed and her work was overseen and supervised appropriately. The Bedfordshire Probation Trust review identifies that it would have been helpful if a manager had reviewed the assessments of Mr Y in order to provide a fresh perspective and also if a manager had been consulted in relation to a large number of absences which were authorised as being for acceptable reasons. Bedfordshire Police have acknowledged that two of the decisions to take no action were open to question and management oversight of them might have been beneficial. 7.2 Summary of Findings in relation to work in Surrey 7.2.1 BB’s mother received an appropriate level of midwifery service. She admitted to a history of depression and this was then shared with the health visiting service, who carried out a mood assessment. BB was dealt with by health visitors within the “Universal Service” which was appropriate given the information known. The family lived in privately rented accommodation and, according to all the reports, made only routine contacts with the various statutory agencies. 7.2.2 BB’s father has said that, BB’s mother would, if anything, seek medical help more quickly than was really necessary. The break in contact with services when she moved was disappointing but there is no evidence that this was for any concerning or neglectful reason. 7.2.3 The agencies did not make detailed records about the family and extended family. Although this would have been helpful to this review there is no evidence to suggest that it should have been a priority at the time. 7.2.4 There was also no information about BB’s mother’s new partner. Even if this could have been obtained at the Walk In Clinic or hospital in April 2014, this would not have led to any background checks on him unless BB’s mother raised any concerns or something untoward was observed. 7.3 Summary of findings in relation to work in Bedfordshire 7.3.1 Several agencies in Bedfordshire were aware of Mr Y and his behaviour. None, however, were aware of his relationship with BB’s mother and so none were in a position to alert her to his previous behaviour or to alert their Surrey counterparts. 7.3.2 Two of the three Children’s Services in Bedfordshire had dealings with, or received referrals about, families with which Mr Y had been in relationships following allegations made about his behaviour between May 2012 and April 2013. It would appear that there was, though, no direct contact with him. 7.3.3 The Bedfordshire Probation Trust managed Mr Y between 2011 and 2013. Its review comments on a number of aspects of his management. These include the way in which his case was reviewed by his probation officer, the decisions about authorising some of his absences as acceptable and that there should have been 19 of 26 action to check on his behaviour with the police and to liaise with children’s services about his new relationships where children were involved. It is noted that he did not provide detailed information about them and that he had a tendency to talk enthusiastically about a new relationship only to say afterwards that it was over. The Probation review also commented that a data cleansing exercise had meant that some records that could have been useful were no longer available. 7.3.5 The Bedfordshire Police review commented on the three allegations of ill treatment directly towards children. In two of them the allegation was made by the child’s father and was that Mr Y had caused the injuries while staying at the child’s address. On both occasions the mother explained the injuries, clearing him of any blame. Following another incident, the order of questioning was such that it could have assisted Mr Y in clearing himself. 7.3.6 While the police officers made referrals to children’s services, they did not liaise with the probation service. They should have noted that Mr Y was on a Community Order and done so, particularly in view of the nature of the allegations. Doing so, and considering his record in more detail, would have enabled them to make a more informed risk assessment and decision in relation to the various incidents. 7.3.7 While it is recognised that each of the recorded incidents in Bedfordshire was relatively minor, the pattern of frequent alleged incidents of domestic violence and assaults on children is a matter of concern even if no complaint was made or the various incidents explained away. 20 of 26 8. KEY ISSUES 8.1 The Police Investigation 8.1.1 Following the conclusion of the police investigation into BB’s death, in March 2015 BB’s mother and her partner, Mr Y, were charged with Causing or Allowing the Death of a Child and Causing or Allowing the Serious Physical Harm to a Child. In July 2015, shortly before the date of the trial, Mr Y committed suicide. The trial was postponed until January 2016. It resulted in BB’s mother being found Not Guilty. In March 2017, it was determined that an inquest would not be held. There is therefore no finding as to how BB might have suffered the fatal injuries. 8.2 Could BB have been protected more? 8.2.1 What is clear from the information available to this review, is that, when the various statutory agencies were working with BB and BB’s mother, they did so appropriately and that BB appeared to be well cared for and no concern was raised. Any weaknesses identified in agency practices through the majority of BB’s life were therefore not significant in terms of BB’s protection and welfare. 8.2.2 BB’s father has said that he did not notice any injuries when he was looking after BB on 17 May 2014 and there is no record of any being noticed in March 2014 or 19 May 2014 at the Walk In Clinic and hospital and at the G.P.’s Surgery respectively. It is also understood that BB’s maternal grandparents didn’t see any injuries when caring for BB on or about 20 May 2014. It therefore seems that the injuries were not evident at the time of the visit to the G.P.’s Surgery on 19 May 2014. 8.2.3 BB’s mother has said that she was not aware of My Y’s background and previous behaviour with women and children. She had no mutual friends as he came from a different area. At the time, she had no reason to suspect that he was a risk to her daughter. She would say that he was a persuasive and manipulative character. 8.3 Could Mr Y have been managed better and thus kept away from BB? 8.3.1 It is clear that there were weaknesses in the way Mr Y was managed in Bedfordshire. Better communication between the various agencies could have led to a more comprehensive understanding of his behaviour patterns. Although this might have led the police investigating the various incidents to take a more robust approach to his questioning, without different evidence he would have been unlikely to have been charged and convicted. Closer inter-agency work would however have made it clear to him that the relevant agencies were working together. This might have exposed the inconsistencies in what he was telling his probation officer and what the police and children’s services knew and could have led to tighter and firmer management by the probation service while he was under supervision. 8.3.2 BB’s mother met both BB’s father and Mr Y through internet dating sites. She has said that she was not aware of his history of domestic violence or of the allegations about injuries to children in Bedfordshire. It is recognised that such encounters can be risky and that those using such websites may not be honest about their identities 21 of 26 and backgrounds. The safety messages on such websites are about users’ personal safety and not about the potential risks once they have begun to establish a relationship. At that stage, it is possible for a woman to use the provisions of “Claire’s Law” to make an application to check whether a man with whom she is entering into a relationship has a history of domestic violence. Doing so does, however, require the woman to first of all consider that there could be such a risk. 8.3.3 While it cannot be said that Mr Y was responsible for BB’s injuries, it is clear that his record, both of convictions and of police call-outs, was such that had the relevant agencies known he was spending time with BB, they would have wished to carry out a risk assessment. For this to have happened they would have had to have had some concerns about Mr Y as there is no expectation that health agencies should carry out such checks routinely. Had they had concerns they would have been likely to check with the Surrey Police and Probation Services. It would only have been if they had known about a Bedfordshire address that they might have checked with Bedfordshire Police and Probation Services and the different Children’s Services in Bedfordshire. By the time Mr Y became involved in BB’s care, he was no longer under the supervision of the probation service; had he been, then he might have told his probation officer about his new relationship and contact with the Surrey agencies could have been made. 8.4 The management of BB after admission to hospital in late May 2014 8.4.1 Some improvements in the transmission and, particularly, the recording of information have been suggested in order to give more certainty to Safeguarding processes. 22 of 26 9. CONCLUSIONS AND LESSONS IDENTIFIED BY AGENCIES 9.1 Conclusions 9.1.1 It is clear from the agency reviews and the interviews conducted with staff involved, that none of the agencies in contact with BB and mother were aware of any concerns about BB’s wellbeing nor were they aware that BB’s mother was in a relationship with a man with a history of domestic violence and allegations of ill-treatment of children. 9.1.2 There were therefore no actions that those agencies could have taken to protect BB. 9.1.3 Although they were not aware of his relationship with BB’s mother, the agencies dealing with Mr Y in Bedfordshire should have liaised more effectively. 9.1.4 It is understood that Mr Y and BB’s mother met through a dating website. This case illustrates the risks in making relationships with relatively unknown people, about whom little background information is available. 9.2 Actions by Agencies 9.2.1 The provider of local hospital and midwifery services has recommended: Improving the recording of actions taken and referrals made where vulnerability or risk is identified in the ante-natal period; Considering including in safeguarding supervision/midwifery supervision all cases where there is a maternal history of mental illness; Considering the creation of separate health records for the unborn to include all significant maternal vulnerability and risk issues. 9.2.2 The provider of the Paediatric Intensive Care Unit has identified: The need to ensure that communication between referring hospital staff and the PICU or specialist teams is recorded in advance of the child’s arrival or retrospectively as soon as the child arrives. 9.2.3 The Bedfordshire Police have advised that: New processes will mean that all domestic related incidents will automatically be referred to the Domestic Abuse Investigation Unit, which will review the risk assessments, the history of the individuals concerned and the action taken during the initial response stage and will make referrals to partner agencies and contact the victim. 9.2.4 The National Probation Service, Bedfordshire Local Delivery Unit has, following its review of work carried out by the old Bedfordshire Probation Trust, recommended that: Procedures should be reviewed to ensure relevant information is retained from closed cases; Action should be taken to improve the practice of the responsible probation officer in relation to domestic abuse and other practice issues. 23 of 26 10. RECOMMENDATIONS The following recommendations are made: 1. The actions planned by agencies, as listed in paragraph 9.2 are welcomed and it is recommended that they are endorsed by the Surrey Safeguarding Children’s Board. 2. The Review has noted the concerns expressed in the reviews of the work of Bedfordshire Police and Bedfordshire Probation Trust about the deficiencies in their liaison. It recommends that the report of this Serious Case Review be provided to them and the three Safeguarding Children Boards and that Bedfordshire Police, the National Probation Service – Bedfordshire and BeNCH Community Rehabilitation Company be invited to review these processes together. This review could helpfully include the three Bedfordshire Children’s Services and might be led or coordinated by the three local Safeguarding Children Boards. 3. Having identified concerns about liaison in Bedfordshire, it is also recommended that the Surrey Police, the National Probation Service – Surrey, the Kent, Surrey and Sussex Community Rehabilitation Company and the Surrey County Council Children’s Services review their processes for liaison about incidents and call-outs in relation to domestic violence. Consideration should also be given to how any requests from health and social care agencies for information about offenders are handled so that contact with the police and probation services in other areas is also checked as far as is possible. 4. BB’s mother met her partner, Mr Y, through an internet dating site and has said that she was unaware of his behaviour in his previous relationships. It is recommended that consideration be given to how mothers can be alerted to the need for caution when engaging in new relationships with previously unknown men, potentially with an emphasis on relationships made through internet dating sites and social media. This is a concern that crosses boundaries and it is recommended that it be referred for national consideration and action. Arthur Wing March 2017 Independent Reviewer/Author . 24 of 26 Appendix 1 Composition of the Serious Case Review Group Alex Walters SSCB and SCR Panel Independent Chair Designated Nurse for Child Protection Surrey Clinical Commissioning Group Director of Quality and Executive Nurse Surrey Clinical Commissioning Group Deputy Director Children, Schools & Families, Surrey County Council Head of Safeguarding Surrey County Council Assistant Director Schools & Learning, Surrey County Council Assistant Director National Probation Service – Surrey Director Kent, Surrey and Sussex Community Rehabilitation Company Detective Superintendent Surrey Police Head of Youth Support Services Surrey County Council In attendance Case Review Administrator Surrey Safeguarding Children Board Partnership Support Manager Surrey Safeguarding Children Board Arthur Wing Independent Reviewer 25 of 26 Appendix 2 Terms of Reference of the SCR 1. Did agencies communicate effectively and work together to safeguard and promote the child’s welfare? 2. Was the level and extent of agency engagement and intervention with the family appropriate? In view of the difficulties that Health Services had in contacting the mother. Were assessments undertaken in a timely manner, was the quality adequate and did they include fathers, extended family and all historical information? 3. Was any information known by any agency about parental mental health issues, domestic abuse, substance misuse or parental antisocial behaviours or concerns re neglect? If so was appropriate consideration given to how these impacted on parenting capacity and were appropriate referrals made? 4. What information was known by agencies about the wider family in particular BB’s father, mother’s partner, maternal grandparents and maternal great grandparents? Who were all involved in BB’s care? 5. Did Bedfordshire Probation services know that BB’s mother’s partner was living in Surrey and in a relationship which enabled contact with Children? 6. Was there sufficient consideration of the vulnerability of this family in relation to their housing situation and the impact on their parenting capacity and what support was provided? 7. Were the children’s views and wishes sought and taken account of in assessments and planning? Did this include the presentation of these young non-verbal children being fully considered? 8. Were any safeguarding issues in respect of BB identified and acted on appropriately and in a timely way by all agencies? 9. Were missed appointments and failure to engage considered as indicators of neglect? 10. Was race, religion, language, culture, ethnicity or disability a factor in this case and was it considered fully and acted on if required? How was the uniqueness of this particular family recognised? 11. Were there any organisational or resource factors which may have impacted on practice in this case? 12. Were appropriate management/clinical oversight (supervision) arrangements in place for professionals making judgments in this case? 15 September 2014 |
NC52270 | Ingestion of a potentially fatal amount of methadone by a 20-month-old boy in the autumn of 2018. Both parents were arrested on suspicion of child neglect. Liam is the youngest of three children to the same mother and father. Prior to Liam's birth parents had only been known to universal services and substance misuse services, as both parents were known to have misused heroin. Liam was in the care of the local authority, placed with his mother. Enquiries subsequently revealed that Liam's father had been staying at the family home, without the local authority's agreement, and that, despite suspecting that Liam had consumed methadone, parents had delayed seeking medical help for him. Ethnicity or nationality not stated. Learning includes: ensure that assessments collect and synthesise information from a range of sources; improve the quality of analysis of known risks; the importance of being tenacious about engaging fathers and understanding their role in the family; the challenges of working with families where children are placed with parents as an outcome of care proceedings; improve safeguarding of children living with parents when care proceedings have ended. Recommendations include: revise existing multi-agency safeguarding procedures, protocols and guidance in respect of parents who misuse substances; improve levels of basic awareness of substance misuse, specific safeguarding issues and how to obtain specialist advice; undertake a multi-agency audit of cases where children are living in households where adults are known to misuse drugs or who are now being treated with opioid substitute therapy.
| Title: Serious case review: Liam. LSCB: Wirral Safeguarding Children Partnership Author: Wirral Safeguarding Children Partnership Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review ______________________________________________ LIAM This report will be published in line with statutory guidance. In order to preserve the anonymity of the children in this family, Wirral Safeguarding Partnership has taken steps to disguise the children’s identities and circumstances. It has: • represented the children by names chosen at random and which do not necessarily reflect the children’s true gender; • used initials for key family members, indicating their relationship with the child; • avoided the use of exact dates; and, • removed details about local services which could lead to the recognition of the children and family. 1 Wirral Safeguarding Children Partnership February 2020 1. Background to Review 1.1 Liam was admitted to hospital in the autumn of 2018, having ingested a potentially fatal amount of methadone. Liam was 20 months old and had been in the care of the local authority, placed with his mother (ML). 1.2 Enquiries subsequently revealed that Liam’s father (FL) had been staying at the family home, without the local authority’s agreement. It was also reported that, despite suspecting that Liam had consumed methadone, parents had delayed seeking medical help for him. Both parents were later arrested on suspicion of child neglect. 1.3 This was the second time that Liam had come to the attention of services following an incident. While still in the hospital where he was born, Liam was found to have suffered two skull fractures, with no explanation as to how they could have occurred. Medical evaluation was that such injuries were likely to have been caused by non-birth trauma. Care proceedings were initiated by the local authority. During the course of those proceedings, ML revealed that she had dropped Liam. 1.4 Within a month of the second event, Wirral Safeguarding Children Board (WSCB) undertook a rapid review of information readily available to agencies and organisations. In accordance with the still current requirements of Working Together to Safeguard Children 2015, WSCB concluded that the criteria had been met for a serious case review. This decision was endorsed by the national Child Safeguarding Practice Review Panel. 1.5 The purpose of the Serious Case Review is to establish what lessons can be learned from the case about the way that organisations worked together to promote Liam’s welfare and to keep him safe, especially given that he was the subject of a care order at the time of incident. 1.6 WSCB decided to take a hybrid systems approach to the review which would ensure that practitioners and first line managers were able to participate. Current police investigations have precluded parents being offered the opportunity to participate in the review process. 1.7 A Serious Case Review Panel (SCRP) of senior managers from agencies involved with the family was appointed to oversee the conduct of the review. The review was facilitated by an independent reviewer. 1.8 Throughout the course of the review, the SCRP reviewed and revised key lines of enquiry. The final key lines of enquiry are: 2 Wirral Safeguarding Children Partnership February 2020 i. Prior to the period under review, what relevant knowledge did agencies, organisations or individual professionals have about parents or children in the family? What services were being provided for family members when Liam was born? ii. How effective was the response of services to original incident? iii. How effective were care proceedings in terms of promoting the children’s welfare and keeping them safe? iv. How did the making of care orders with children placed at home affect assessment of risk; care planning; service provision; and, management oversight and review? v. Given that parental drugs misuse was a key feature of this case, how well did professionals understand the nature of parents’ legal and illegal drugs use and their implications for the care of the children? How effective were safeguarding measures? vi. How effective was professional communication and joint working during the period of the review? vii. How well were the lived experiences of the children known and how did this affect professional practice? viii. When ML disclosed causing the injuries to Liam; how was the original incident at hospital reviewed and what action was taken? ix. To what extent did learning from the multi-agency case review Child 8 (2017) affect the work of practitioners, the nature of services offered to this family and/ or management oversight? 1.9 A combined chronology of significant events was completed. Five key agencies or services were asked to complete learning summaries. A learning review for practitioners and managers was held in September 2019. Members of the SCRP also attended that event. This was well attended with good representation from relevant services. Participants demonstrated ability to reflect on their own service’s contribution to practice and to make respectful enquiries of others. They were analytical in their approach to learning both as individuals and as a group. Notes of the meeting were later provided by the Safeguarding Partnership Administrator. 1.10 A complicating feature of this review has been the absence of some key practitioners and managers as a consequence of staff turnover, particularly within the local authority. The serious case review would have benefitted had learning summaries been requested of all agencies which contributed to the learning event. 3 Wirral Safeguarding Children Partnership February 2020 2. Key Lines of Enquiry 2.1 Prior to the period under review, what relevant knowledge did agencies, organisations or individual professionals have about parents or children in the family? What services were being provided for family members when Liam was born? 2.2 Liam is ML’s third child. The father of all three children is FL. Prior to Liam’s birth, with the exception of substance misuse services, family members had been mainly known to agencies providing universal services. During ML’s pregnancy and after Liam was born, professionals understood that ML and FL had ended their relationship. Agency records suggest that the couple had separated and reunited on more than one occasion during the course of their relationship. 2.3 Both parents were known to have misused heroin. They had both undergone residential rehabilitation in the past for heroin misuse and both had had opioid substitute therapy. When Liam was born, ML had been on an opioid substitute programme for a number of years. ML told midwives that she felt well-supported by the local substance misuse service. The substance misuse service had adopted a ‘Think Family’ approach to her care. 2.4 FL was said by ML and other family members to have significant health and mobility problems. His living arrangements were not known to professionals at the point that Liam was born. The nature and frequency of the children’s contact with their father was unclear. 2.5 Liam’s health visitor had worked with the family since Liam’s older brother, George, was six weeks old. FL was never seen during this time and ML had said that they were no longer in a relationship. FL’s details were, therefore, not recorded on the health visitor file. The relevant agency learning summary indicates that this was normal recording practice at that time. Since a recent CQC inspection, however, changes are to be made to include information about absent fathers. 2.6 Police and CSC held information about FL’s history of domestic violence in a previous relationship which included an incident in which two of his children were directly harmed. Within CSC, however, no link had been made between the children of FL’s first family and Liam and his brothers. Practitioners were, therefore, unaware of this connection. 2.7 Police records also revealed that, as a young person, FL was a suspect in a violent incident which resulted in the death of another individual. FL later reported to substance misuse services that he suffered post-traumatic stress as a consequence of his involvement in this event. 2.8 ML’s family did not live locally and her mother and stepfather spent most of the year abroad. While ML was pregnant with her first child, Alexander, she had recently been discharged from residential detoxification and rehabilitation. Midwives were concerned that she had separated from FL, was low in mood and was socially isolated. The midwife 4 Wirral Safeguarding Children Partnership February 2020 requested an assessment by CSC. She noted that FL had relapsed and that ML might also be at high risk of relapse. The midwife also referred to ML’s ‘ability to be misleading of professionals’. ML, however, told CSC that she was adequately supported by her worker from her housing project and no assessment was undertaken. 2.9 It is not clear whether ML was having opioid substitute therapy when she was pregnant with Alexander. Records suggest, however, that therapy was established when George was born twenty months later. There was no indication that ML’s care of the older children had been negatively affected by methadone therapy or substance misuse. 2.10 The overall professional impression of ML appears to have been of a mother who was somewhat socially isolated but who was generally capable: ‘she presented very well.’ 2.11 How effective was the response of services to original incident? 2.12 When he was born, Liam was monitored for symptoms of Neonatal Abstinence Syndrome. The hospital had previously checked whether there were safeguarding concerns in respect of the infant but there were none. ML was given methadone in accordance with her prescription. Hospital staff tried to support ML, both to provide close physical care as advised for babies with withdrawal symptoms while, at the same, helping her to avoid the potential dangers of co-sleeping. 2.13 When Liam was found to have swellings on his head, a CT scan revealed fractures of the skull with underlying bleeding. Appropriate medical enquiries were undertaken and care provided. It was noted that no issues had been raised about Liam’s development in the ante-natal period and there was no history of injury to Liam during delivery. No other bruises or injuries were noted. No accidental explanation for Liam’s injuries was provided. ML denied having dropped the baby. 2.14 In those circumstances, the question of non-accidental injury arose and child protection procedures were initiated. At that point, Liam was in an effective place of safety with the consent of ML. Arrangements were made to supervise ML’s contact with Liam while he was in hospital. The other two children were already with paternal grandparents. Paternal grandparents agreed that ML could live with them and that they would supervise ML’s contact with her children. It appears that ML was also agreeable to this. 2.15 There is no record of professional discussion with FL during this period. There is no record either of his having, or seeking, contact with Liam or with the older children. 2.16 Within the hospital, formal enquiries were undertaken in respect of members of staff who had cared for Liam. 2.17 At this point, the local authority considered the children’s living arrangements to have been made by family agreement. This issue was discussed in depth at the learning event. Practitioners who had been involved at the time emphasised the levels of uncertainty 5 Wirral Safeguarding Children Partnership February 2020 which prevailed and recalled general concern not to wrongly attribute culpability for Liam’s injuries. Although there was a possibility that Liam had been deliberately harmed by ML or by a member of staff; in reality, practitioners suspected that ML had hurt Liam accidentally but did not want to say so. At the same time, ML’s ‘very convincing’ denial that she had harmed Liam in any way created further doubt and uncertainty. 2.18 It is acknowledged that this context could have influenced decisions about arrangements for the children. The local authority was, however, of the view that it would have intervened had ML insisted on the children living at home with her. In those circumstances, the local authority should have considered looking after the children. 2.19 A second opinion in respect of Liam’s injuries was obtained from a large city children’s hospital. Medical enquiries were completed within a week reflecting ‘a clinical consensus view of eight other consultant paediatricians from the department, with experience of safeguarding’. This report concluded that ‘trauma was the most likely cause of these fractures. In the absence of a history of accidental trauma…non-accidental injury cannot be excluded’. 2.20 A week later, before Liam was discharged from hospital, Liam and his brothers were made the subjects of interim care orders. 2.21 Around this time, ML had told her key worker in the substance misuse team (DW1) that she had taken heroin on one occasion since her discharge from hospital: her prescription for methadone had been increased as a result. 2.22 How effective were care proceedings in terms of promoting the children’s welfare and keeping them safe? 2.23 At the point that care proceedings began all parties had agreed that this was a ‘single issue’ case’ focussing on determining the cause of Liam’s injuries; who caused them; and, whether this had been accidental or otherwise. When it became clear, however, that a hair-strand test was to be ordered to provide a picture of ML’s drugs use over the previous 6 months, ML revealed that she had been using heroin daily while she was pregnant. At that stage, however; it was acknowledged that concerns about ML’s drugs use, and her lack of honesty about it, would not, of themselves, have given rise to care proceedings. The court’s focus would continue to be on Liam’s injuries. 2.24 It was noted, from the first hearing, that FL did not intend to take part in the proceedings. 2.25 Shortly afterwards, ML told DW1 she had ‘admitted’ to the court that she had used heroin use in pregnancy. ML said that she had been able to evade urine testing reviews during that time by attributing opioid positive results to co-codomol. ML told DW1 that she was in debt as the result of funding her drugs use. Significantly, ML also said that she had stored surplus methadone while she was pregnant and taken this into hospital to reduce heroin withdrawal symptoms. Following those disclosures, ML was transferred by the 6 Wirral Safeguarding Children Partnership February 2020 substance misuse team to supervised consumption of methadone. The substance misuse team reported having informed CSC of the details of this discussion. 2.26 Practitioners at the learning event considered the significance of the likely impact of ML consuming non-prescribed methadone, in addition to the dosage dispensed by staff. It was suggested that ML would have been drowsier than she would otherwise have been and so, it could have had an impact on her ability to care for Liam. 2.27 This information was not, however, generally known to practitioners and managers prior to the learning event. Following the initial court hearing, the fact of ML’s heroin use in pregnancy is reflected in a number of records. ML also provided details in a statement to court. The SCR, however, has been unable to find evidence that ML’s self-medication on the ward was known to the court. 2.28 The local authority’s assessment does not refer to ML using methadone she had taken on to the ward. Rather, it refers to later communication with DW1 as recorded by CSC. That indicates that drugs testing, on the day after Liam was found to have been injured, proved negative for illicit substances. This was a completely different matter and clearly has a more reassuring quality. 2.29 During the week following the court hearing, Liam was discharged to his paternal uncle and aunt’s care. ML remained in grandparents’ home along with the older children. 2.30 The notes of hospital discharge meeting refer to paternal grandparents supervising ML’s and FL’s contact with the children. They describe CSC as being ‘happy’ with arrangements for Liam’s contact with his father, although it is not clear what those were. All three children were now living within FL’s ‘very large family’. At the same time, FL continued to avoid both social workers and the Children’s Guardian. 2.31 Neither connected carers’ assessment refers in detail to FL. Although he is described as having been the most ‘challenging’ of his siblings, as far as their parents were concerned; there is no reference to his history of drugs use or to his living arrangements. It was agreed in principle that FL’s brother could facilitate contact between Liam and FL. Paternal grandmother indicated that there was currently no contact between FL and the older two children, due to his chronic ill health. She also reported having no contact with FL’s other children as their mother ‘had made this difficult’. There is no evidence of cross-reference between the children’s records at that point. 2.32 At the learning event, the Children’s Guardian described the relationship between ML and paternal grandmother as somewhat tense. He gained the impression that grandmother favoured FL and tended to blame ML for the family’s problems. This is not, however, reflected in the assessment undertaken by the local authority which refers to a positive relationship between ML and paternal grandmother. 7 Wirral Safeguarding Children Partnership February 2020 2.33 Twelve weeks into care proceedings, ML told professionals that she had accidentally dropped Liam while they were in hospital. This should have led to a multi-agency strategy meeting, but none was held. The police were, therefore, unaware that there was new information about how Liam had come to be injured and so, were unable to review their earlier position in relation to criminal investigation. A strategy meeting might also have identified that no account had been taken of ML’s earlier disclosure that she had been self-medicating with illicit methadone while in hospital. 2.34 It was also revealed that, earlier that day, ML had told DW1 that she had recently been using heroin. 2.35 The following day, the local authority’s parenting assessment of ML was submitted to the court. This had been completed before ML said that she had accidentally dropped Liam. A short statement about ML’s disclosure was appended. The CSC learning summary acknowledges that, an extension for submission of the parenting should have been sought in the light of this new information as it ‘fundamentally changed the assessment of mother’s capacity to parent’. 2.36 At a court hearing the following month, parties discussed ML having dropped Liam and having recently taken heroin. It was agreed that care proceedings would continue due to ‘ML’s failure to seek immediate medical attention for Liam, the concealment of the accident, coupled with a longstanding history of substance misuse’. No evidence has been provided that there was any discussion as to whether there were avoidable factors on ML’s part which could have contributed Liam’s fall. 2.37 It appears that CSC and the Children’s Guardian accepted that Liam’s injuries were the result of an accident for which no blame could be ascribed. The court commissioned medical opinion did not contradict ML’s account of the time that the injury occurred or that the event as she had described had the potential to cause Liam’s skull fractures. Without analysing other risk factors, the paediatric report concluded that the injuries were accidental. Supervision arrangements were lifted and it was agreed that the children could return to ML’s care prior to the final hearing. 2.38 No evidence has been provided of consultation with the Independent Reviewing Officer or with partner agencies in respect of the decision to return the children to their mother’s care, although these are required by Wirral Children’s Specialist Services Procedures Manual when reunification of looked after children with their parents is being considered. 2.39 The CSC learning summary indicates that there is little information on file in respect of the analysis and decision to return the children to their mother’s care. It notes that the reunification was ‘not informed by, or supported by’, the NSPCC framework for reunification . As a consequence, the approach taken was ‘overly optimistic’ and the reunification was ‘not based on sound assessment and analysis.’ 8 Wirral Safeguarding Children Partnership February 2020 2.40 It is significant, however, that, according to the CSC learning summary, there is no record of formal supervision being provided to the allocated social worker from the start of care proceedings until after the children had returned home. Absence of supervision and management oversight would clearly be serious impediments to good risk analysis and case planning. 2.41 A week after assuming the care of all three children, ML told DW1 that she had taken ‘2 bags of heroin’. Her treatment was adjusted and CSC were informed. There is no evidence that this disclosure had any significant impact on care planning. 2.42 Two weeks later, FL attended the substance misuse service for an initial assessment, as he had relapsed on heroin. He said that he lived with his mother and had no contact with his children. He made no reference to ML. Although FL had previously been known to the substance misuse service; he had not been an active service user at the point when the current service was commissioned. This meant that his historical records were not taken forward when service provision transferred. As a result, the service was unaware of the link to ML and the children. FL was offered opioid substitute therapy, under a supervised consumption regime. 2.43 Four days later, at the final court hearing, it was acknowledged that ML had relapsed but that she was seeking appropriate support. Care orders were made by agreement: the children’s placement with their mother continued. 2.44 As he had previously declared; FL had been wholly absent from care proceedings. He had stated at an early stage that, if the children could not remain with their mother; he did not want to be considered as an alternative carer. As a consequence, he was not the subject of a parenting assessment. Despite being the father of ML’s three children, there was little consideration of the role that he played in ML’s life. The matter of his current and envisaged contact with the children did not form part of the final analysis of risk. Details of FL’s previous family and criminal convictions appear to have been unknown to practitioners working with ML and her children. This suggests that standard agency checks, including with police records, were not undertaken. 2.45 During the course of care proceedings, there were two looked after child reviews. A learning summary has been provided by the local authority Safeguarding Unit. This summary describes the recommendations of the first review as ‘very passive’ and ‘limited in value’. The full report of the looked after review was not found due to a technical issue about workflow within the local authority electronic record. 2.46 Between the first and the second review, there was a change of IRO. At the second review meeting, ML talked about having dropped the baby while they were in hospital. Although this disclosure created a watershed in case planning; the Safeguarding Unit learning summary describes the notes of the meeting as being of poor quality; brief; and lacking reflection or challenge. Only two recommendations ‘of little value’ were made. 9 Wirral Safeguarding Children Partnership February 2020 2.47 Shortly before the children returned home, the social worker spoke to the IRO about events in court and confirmed what was to happen. The IRO record, however, provides ‘no commentary or analysis in respect of the care plan or discussion with the social worker’. At that point, the allocated IRO changed for the third time. 2.48 There is little evidence of effective multi-agency working during care proceedings. This matter is considered in more detail later in this report. 2.49 How did the making of care orders with children placed at home affect assessment of risk; care planning; service provision; and, management oversight and review? 2.50 When care orders were granted, Liam was less than 6 months old and there were two other young children in the household. It was known that Liam had suffered a serious injury and that his mother had delayed seeking treatment for him, exposing him to further risk of harm as well as to the possibility of unnecessary additional medical investigations. ML’s explanation was that she had been afraid to say what had happened, ‘due to her drugs use’. ML was now understood to have relapsed on heroin for which she was seeking support. 2.51 Uncertainty about FL’s role in the children’s lives continued. While not recognised during care proceedings, practitioners working with the children appear to have been generally aware that they were having contact with FL, although the nature and frequency of that contact was not clear. There is more than one reference to the contact taking place at paternal grandparents’ home, where FL had told the substance misuse service he was living. There was a general belief that there was no current relationship between ML and FL. 2.52 It might have been anticipated that care plans would have focused on continuing to assess the impact of ML’s drugs use on her capacity to care safely for the children; multi-agency arrangements to increase the opportunities to scrutinise compliance with expectations; and, efforts to establish and assess the implications of FL’s involvement in the children’s lives. 2.53 In the event, however, rather than being seen as the beginning of new phase of work with the family; the granting of care orders appears to have been considered as an end in itself. The care plans presented to court describe the new situation as ‘permanence plans until such a time as the court discharges the care order or until the children reach the age of 18’. The local authority did not recognise the change of legal status as offering an opportunity to review previous history and to set a clear, targeted plan for the future. Instead, the local authority anticipated that the benefits of shared parental responsibility would be to ensure ‘a high level of monitoring’ and the capacity ‘to take protective action if the children were deemed at risk’. During care proceedings, the local authority had specifically ruled out any further assessments ‘as not being within the children’s timescales’. 10 Wirral Safeguarding Children Partnership February 2020 2.54 As a result of this somewhat passive approach, therefore, significant gaps which had already developed were not identified and managed. Instead, the local authority acknowledges that care planning became ‘somewhat chaotic’, ‘directionless’ and ‘inadequate’. In particular, care plans ‘did not provide a road map for all agencies to understand what they were doing and what the objectives they were working towards’1. 2.55 No evidence has been provided that professionals working with the family had been party to developing a shared care plan or that a placement plan was completed. As a result, there was no clear articulation and shared undertanding of what was expected of ML; of the local authority; of partner agencies; and, of other family members. Proposals within the court care plan to have 4-weekly care planning meetings were not realised. 2.56 Within a week of care orders being made, FL attended substance misuse services. Blood tests were positive for illicit methadone and opiates. FL said that he had been using heroin regularly for the previous four years. His drugs use was ‘funded by benefits and friends’. FL reported also having depression, which he said was being treated by his GP. 2.57 The following day, the pharmacy contacted the substance misuse service to say that ML had not been consuming all of the methadone that had been prescribed. The service had not yet made the connection between FL and ML. 2.58 Less than a week later, CSC received an anonymous referral reporting concerns about ‘children out late and unsupervised at night; mum and dad’s drug use; and, drug users calling at the property’. CSC concluded that there was no evidence to support allegations: it was suspected that the allegations were malicious. There was no apparent enquiry about the significance of the reference to ‘dad’s drug use’. 2.59 A month after the care orders were granted, ML told the health visitor that she was to be evicted. ML said that this was due to damage to the property but she denied that she was responsible for it. ML said that she was receiving support from the relevant services. 2.60 Within CSC, a family support worker services were allocated for ‘direct work’ but it is not clear what this entailed. No summary has been provided to the review. The local authority did not identify a family support worker or manager to attend the practitioner learning event. 2.61 When Liam was seven months old, ML attended the first two sessions of the parenting course provided by the substance misuse service. She was still using heroin and drugs use was having an impact on her lung function. ML told DW1 that she only used heroin when she did not have the children with her. ML said that she had only had a small amount of contact with CSC and that her social worker was absent due to illness. 1 Safeguarding Unit learning summary 11 Wirral Safeguarding Children Partnership February 2020 2.62 Throughout this time, FL was receiving methadone on prescription but he was not initially compliant with collection arrangements and did not attend planned sessions with his recovery co-ordinator. When he began to attend as required, he tested positive for methadone and opioids. 2.63 During the autumn, ML secured a new tenancy. 2.64 Within CSC, casework responsibility was reallocated to a newly qualified social worker in her Assessed and Supported Year in Employment (ASYE). The CSC chronology provided for the review, suggests that, because of its complexity, this case was not appropriate for an ASYE to hold. In the learning event, however, it was acknowledged that with a third of children’s social workers being ASYE; ideal allocation was not always possible. In recognition of their lack of experience and expertise, however, ASYEs are expected to have fortnightly reflective casework supervision. In this case, no record was found of social work supervision for almost 12 months after the care orders were granted, including eight months after casework responsibility transferred an ASYE. 2.65 Throughout this time, the absence of regular case management meetings meant that agencies were working separately, rather than collaboratively, with ML and the children. This increased the likelihood that the significance of information known to agencies would be overlooked. For example, on three separate occasions in three months; Liam was seen to have either a fading bruise or a cut to his head which, each time, ML explained as having resulted from a fall against a glass TV cabinet. It is acknowledged that children learning to walk are prone to falling. In the circumstances of the case, however, the detail and significance of these incidents should have been more fully explored. Consideration should have been given as to whether a child protection medical was required. 2.66 At the beginning of the New Year, when Liam was coming up to his first birthday; ML was continuing to struggle to abstain and she indicated that she would like to attend residential detoxification and rehabilitation. The substance misuse team could only provide funding for the adult component of a placement. DW1, therefore, negotiated with CSC to provide funding for a specialist family rehabilitation placement. 2.67 The following month, ML and the children moved out of area to the rehabilitation facility for 12 weeks. The health visitor, however, was not informed that ML had left the area with the children. 2.68 At the end of the 12 week period, ML was drug-free. She was keen to return home as soon as possible: an abstinence based aftercare plan was designed to support her. This would be a new phase of recovery and would include access to peer-to-peer support. CSC agreed to support the necessary child care arrangements. CSC records state that if ‘all continued to go well until the end of the year’; discharge of care orders would be considered. 12 Wirral Safeguarding Children Partnership February 2020 2.69 On the family’s return home, Liam started nursery. Alexander and George re-enrolled at the school they had previously attended. The school found that they adapted to this change back without difficulty. 2.70 From the New Year until this point, FL’s engagement with the substance misuse service had been poor: he had not attended planned medicals. Around this time, ML told her recovery worker that FL was also a service user and that he wanted residential rehabilitation. ML said that she had also told her social worker this. It appears that it was at the point that the connection between parents had been made as, around this time, DW1 was allocated as FL’s key worker. 2.71 Shortly afterwards, ML said that she had decided to work with a different abstinence-based provider to support her recovery. 2.72 During the summer, FL reported to the drugs service that he had not used illicit drugs for six weeks. A mouth swab test showed positive for methadone only. The drugs service record indicates that FL was now having regular contact with the children and that the relationship between parents was said to be positive. 2.73 In the same month, ML and FL planned to go on holiday with the children, visiting ML’s mother and stepfather. ML initially spoke to CSC about the planned holiday, but it is not clear what was understood about the travel plans and where the children would be staying. No record of agreement to travel arrangements has been provided by CSC to the SCR. 2.74 ML later telephoned DW1. She confirmed that she and FL would be on holiday together. ML and the children would, however, be staying with maternal grandmother while FL would be staying in another hotel with relatives. Arrangements were made for FL’s medication. These took into account that children would be in the travel party although FL would not have direct responsibility for them. 2.75 These events suggest that there was a material change in family circumstances which warranted further evaluation. 2.76 Around the start of the next school term, a looked after child review was held. This was the 5th review which had taken place since care orders had been granted. The Safeguarding Unit learning review notes that IRO activity had increased over the previous ten months. There had been a further change of IRO. 2.77 At the point of the latest review, the children’s placement was noted to be ‘going well’. Recommendations were generally designed to support progress, although gaps in health information were identified as continuing a problem. It is not clear what these gaps were but it is suggested that they had endured for some time without resolution. FL’s absence from the review process was noted, although it was recorded that he was now having ‘unrestricted contact’ with the children. No plan to engage him was identified, however, 13 Wirral Safeguarding Children Partnership February 2020 and no actions were recommended to assess the suitability of this contact or to formalise arrangements. It was proposed that the care plan would be discharged if ML could demonstrate sustained change over the following 12 months. 2.78 In considering the effectiveness of the IRO role in this case, the local authority Safeguarding Unit concludes that there was an over-reliance on ML’s perceived openness while ‘the fact that she had denied dropping the baby and later admitted to it, would seem to have diminished in importance’. The learning summary refers to a ‘silo mentality as opposed to true partnership working’. At the learning review, partner agencies were surprised to learn that 4-weekly planning meetings had been agreed in court and it was acknowledged by the local authority that regular planning meetings for looked after children were not common practice. 2.79 The Safeguarding Unit learning summary also notes that, throughout case planning, insufficient attention was given to building ML’s resilience. As with the practitioners in the case, the IRO service was ‘overly optimistic’ about the family’s progress and about their ‘levels of cooperation and truthfulness’. 2.80 A week after this looked after child review; Liam was taken by ambulance to hospital following a 999 call from house. Ambulance staff found him to be unresponsive, grey and not breathing on his own. On admission to hospital, Liam was very close to death. 2.81 Child protection procedures were put into effect. Alexander and George were taken from school to a place of safety. The police began an investigation and both parents were arrested. At the time of writing, the police investigation remains live and so, no details of parents’ accounts are provided. 2.82 Given that parental drugs misuse was a key feature of this case, how well did professionals understand the nature of parents’ legal and illegal drugs use and their implications for the care of the children? How effective were safeguarding measures? 2.83 Elements of this line of enquiry have been addressed in earlier sections of this report. 2.84 As is already evident, the substance misuse team was very active during the period of the review. The relevant learning summary indicates that the recovery plan that was developed with ML would ordinarily be viewed as an example of good practice in addressing opiate addiction. 2.85 There is evidence that ML’s methadone prescription was reviewed in accordance both with her assessed need and in the context of any disclosed illicit drugs use. CSC was provided with up-to-date information. When ML made clear that she was committed to becoming drugs-free; the service was instrumental in helping to secure funding in CSC for a rehabilitation placement that would allow the children go with ML. In-patient detoxification and residential rehabilitation is regarded as an intensive intervention that maximises the chances of successful recovery. 14 Wirral Safeguarding Children Partnership February 2020 2.86 At the end of the 12 week period, ML was drug-free. From the perspective of the substance misuse service, therefore, ‘the objectives of the structured drug treatment appeared to have been reached’. The service also advocated on behalf of ML and sought child care support from CSC. 2.87 From a child protection perspective, however, there should have been a much more effective multi-agency approach to recognising and responding to the risks of parental drugs misuse. 2.88 For the greater part of this review period, parents were understood to be estranged. ML was known to be the children’s primary carer. During this time, the pattern of ML’s known drugs use varied, but no comprehensive assessment was ever completed of its impact on her care of the children. 2.89 At the same time, it was generally understood by professionals that the children were having some contact with their father although this had never been formally assessed or agreed. FL’s inconsistent engagement with the substance misuse service, however, meant that there was only a partial understanding of his drugs use. 2.90 Finally, there was no clear understanding of the parents’ relationship. Despite their going on holiday together with the children, no evidence has been provided of significant enquiry as to whether they had reunited. As a consequence, no assessment was proposed of the couple as a parenting partnership. There was no formal evaluation of the impact that of each individual’s drugs’ use on the drugs’ use of the other or of implications of that interaction for the children. 2.91 As the substance misuse learning summary indicates: ‘It is reasonable to believe that FL spent more time at ML’s house than the service or children’s social care were aware of at the time. Because the service wasn’t aware of FL’s methadone being in the children’s home environment, the risk could not be adequately or safety managed’. In addition, it had been understood that due to the combined work by the service and by CSC, ‘the case wasn’t viewed as high risk’. ML was considered to be ‘a protective factor’ after leaving rehabilitation. As the learning summary acknowledges, however; ‘this assumption was incorrect’. 2.92 Beyond discussion about this particular family, the practitioner learning event revealed that most practitioners had significant gaps in their knowledge about both the potential effects of opioid use on parents’ capacity to provide care for their children and how their impact would be measured in any individual case. 2.93 There were also clear misunderstandings of the purpose and effectiveness of routine drugs testing as an indicator of illicit drugs use. This was significant as non-specialist practitioners were overly reassured by negative results. 15 Wirral Safeguarding Children Partnership February 2020 2.94 How effective was professional communication and joint working during the period of the review? 2.95 Throughout the review period, there are examples individual practitioners working well with family members and in accordance with the expectations of their agencies and organisations. A number were discussed at the learning event and are acknowledged in agency learning summaries. There are also examples of good communication, particularly between health disciplines. Where barriers were encountered, there are also examples of tenacity and escalation. The contribution of DW1 both in terms of professional practice and input to review’s learning event is particularly acknowledged. 2.96 Immediately following Liam’s initial injuries, communication between professionals was good. Communication between the hospital, the local authority out-of-hours service and the police was timely and safety plans were implemented. At the earliest opportunity, the allocated social worker and DW1 made a joint visit. The health visitor spoke to ward staff for an update in respect of Liam. A strategy meeting was held in hospital which facilitated the attendance of staff involved with Liam’s care. CSC attended with a local authority solicitor to expedite care proceedings if required. 2.97 When care proceedings were current, however, there were few formal opportunities for information-sharing and case planning. Participants at the learning review described this as unsatisfactory but reported that it was consistent with their experience and preconceptions. There was an assumption that, in proceedings, the local authority and lawyers effectively ‘own the case’ and, as a result, there is little expectation of a multi-agency approach. 2.98 Concerns were expressed that this had potential disadvantages in day-to-day casework with families. In addition, questions arose as to whether, in the absence of jointly approved notes of meetings and discussions, there was an increased possibility of professionals’ views being misrepresented or inaccurately interpreted. Two examples of such instances were identified in this case. The implications of not holding a multi-agency strategy meeting when ML said that she had dropped Liam have already been outlined. 2.99 Then, when the children returned to ML’s care, practitioners were unclear both about the local authority’s rationale for their return and about what it signified in terms of risks and safeguards. There was no clear understanding of the implications of ‘shared parental responsibility’ and what this might look like in practice. As already noted, this was exacerbated by the lack of a care plan and placement plan for which they had shared responsibility. 2.100 Throughout the time that the children were subjects of care orders, both 0-19 service and the substance misuse service experienced considerable delays in calls being returned by CSC and information was rarely shared with them in a timely manner. The quality of looked after child reviews, while improving over the period of the SCR, was generally poor. 16 Wirral Safeguarding Children Partnership February 2020 2.101 Although the children’s school was represented at the learning event, only minimal information was provided for the joint chronology and they were not asked to provide a learning summary. There are few references to the school in the documents which have been provided to the SCR and no evidence has been provided that the children had personal education plans. This represents a gap in the SCR process but also suggests shortcomings in a multi-agency approach. 2.102 The initial incident considered by this review was characterised by ML’s concealing both her illicit drugs use and the circumstances in which Liam was injured. During the review period, however, ML came to be seen as ‘open and honest with regards to her drugs use’2. Professionals did not recognise that, in reality; ML, FL and, to a lesser extent, members of FL’s extended family had all concealed, or failed to divulge, information that was significant to the children’s wellbeing and safety. While better formal arrangements for information-sharing, planning and joint working, therefore, would not necessarily have led to a better outcome; it would have made good safeguarding practice more likely. 2.103 How well were the lived experiences of the children known and how did this affect professional practice? 2.104 The information which has been provided to the review suggests that professionals did not have a very clear understanding of the lived experiences of the children. Participants at the learning event talked about how well ML presented at all times. She has been described as ‘middle class’. There is no reference to any professional concerns about home conditions, despite ML being evicted at one stage du, by her own report, to damage to the property. The family moved twice during the review period, not including the temporary move out of area. There was a single referral to CSC during the review period which referred to illegal drugs use and to poor supervision of the children: this was understood to be malicious. 2.105 The children appear to have had generally good health, although Liam had eczema which required medical management. He appears to have made a good recovery from head injuries. Liam and one of his brothers had planned minor surgery. The relationship between ML and the children was good and, according to the IRO, the children appeared to be happy around her. The health visitor described ‘excellent attachment’ between Liam and ML: she was warm and responsive towards him. 2.106 Around 12 months old, Liam was not yet achieving some personal/ social developmental milestones. Liam and George were, at different times, referred to Speech and Language Therapy. 2.107 While the children were with ML outside of area, no significant concerns were identified about ML’s care although it was noted by the health visitor that ‘supervision of the children 2 CSC learning summary 17 Wirral Safeguarding Children Partnership February 2020 has occasionally been an issue as it a busy place … where they are staying’. It was reported that there had been ‘a serious incident’ at school when Alexander described an assault by a fellow pupil. No further details are provided but CSC record indicates that practice was as expected and that a safety plan was put in place. 2.108 At the learning event, practitioners referred to ML struggling to manage the children’s behaviours. A family support worker was involved but, as noted earlier, it is not entirely clear what her role was: no record of her observations has been provided to the review. 2.109 The CSC learning summary notes that there is little evidence of direct work with the children and visits did not explore their lived experience. Information which was relied on came from other agencies rather than directly from the children. Significantly, Alexander’s ‘comments regarding his father being in the home were not picked up on and actively explored by the social worker and family support worker’. 2.110 When ML disclosed causing the injuries to Liam; how was the original incident at hospital reviewed and what action was taken? 2.111 Following the original incident, the hospital undertook a root cause analysis (RCA). This allowed the hospital to identify any critical problems or issues. According to the hospital learning summary, key safety and practice issues were noted. It concluded that ‘while they may not have contributed to the actual incident’, others could learn from the findings. 2.112 The changes which have taken place include employing a specialist drugs and alcohol midwife who will develop detailed plans for mothers using drugs, whether or not there are safeguarding concerns. It is anticipated that this approach will help develop a trusting relationship with mothers and will contribute to a better response around any potential incidents. This has also been supported by learning for ward staff and increased vigilance in respect of co-sleeping. 2.113 At the time the RCA was conducted, however, it was not known that ML had dropped the baby although the hospital had been informed of ML’s reported heroin use in pregnancy. As already indicated, it is not clear whether ML’s information about ML’s illicit methadone use on the ward had also been provided. In terms of the hospital’s learning, mother’s concealed drugs use is significant particularly in the context of her later admission that she had dropped the baby. 2.114 To what extent did learning from the multi-agency case review Child 8 (2017) affect the work of practitioners, the nature of services offered to this family and/ or management oversight? 2.115 There is no indication from the record that this was influential on practitioners’ work with Liam and family members. The CSC learning summary notes that there was ‘again evidence of disguised compliance and a lack of assessing parental capacity to change. No evidence based risk assessment tools appear to have been used.’ The 0-19 learning 18 Wirral Safeguarding Children Partnership February 2020 summary indicates that the review had been shared with staff across the workplace. The report states that staff have ‘a clear understanding of disguised compliance’ which is emphasised in agency and LSCB safeguarding training. 19 Wirral Safeguarding Children Partnership February 2020 3. Lessons learned 3.1 The principal lessons and recommendations will be focused on two specific practice issues which arise from this case. They are: • safeguarding children where parental drugs use is a feature of family life, particularly where individuals are receiving opioid substitute therapy; and, • the particular challenges of working with families where children are placed with parents as an outcome of care proceedings. 3.2 At the same time, there are a number of issues raised by basic safeguarding practice in this case which have more general application. These include: ensuring that assessments collect and synthesise information from a range of sources; improving the quality of analysis of known risks; and, helping practitioners identify the most appropriate means of measuring how these risks are being managed in the children’s everyday lives. Most significantly, this case illustrates the importance of being tenacious about engaging fathers and understanding their role in the family. 3.3 It is acknowledged that, when Liam was born, the local authority children’s services and the Local Safeguarding Children Board had been recently judged as inadequate by Ofsted. As in this review, inspectors found that good practice standards were not being communicated to practitioners through managerial oversight or supervision and that IRO challenge was ineffective and did not lead to positive change for children. Inspectors concluded that, as a result, a culture of over-optimism often went unchallenged. 3.4 The Ofsted report also made reference to the impact that poor case recording; insufficiently focused assessment and plans; case complexity; and, high staff turnover had on practice and on outcomes for children. These were also features of local authority work with this family. 3.5 Over the course of the following 18 months, Ofsted made eight further visits during which progress in making improvements was evaluated across discrete elements of social work and service provision. Improvements were noted in purposeful visiting and direct engagement with children. Similarly, improvements were noted in management oversight; elements of assessment; the quality of support plans; and, in effective record keeping. Additional resource had been added to the IRO service which was found to be more challenging. 3.6 In 2019, a second full inspection by Ofsted found that leaders were making a good impact on social work with children and families and that there had been improvement in areas previously identified as inadequate. Not all areas of practice were found to have improved at the same pace but it was acknowledged that the local authority had plans in place to address outstanding as part of ongoing service improvement. 20 Wirral Safeguarding Children Partnership February 2020 3.7 The Safeguarding Partnership will, however, want to be assured that safeguarding improvements identified by Ofsted in children’s social care have been consolidated since the inspection and that they are reflected in improved multi-agency practice. In terms of recommendations, however, it is anticipated that, where possible, necessary actions will be incorporated into existing or proposed practice improvement plans and learning schedules, both single- and multi-agency. 3.8 Safeguarding children where problematic parental drugs use is a feature of family life, particularly where opioid substitute therapy is prescribed 3.9 The NSPCC provides a summary of risk factors and learning for improved practice around parents with substance misuse problems. The learning in respect of Child 8 undertaken by Wirral LSCB in 2017 is consistent with this summary report. This review does not propose to repeat that learning, although there are common features in both. In particular, there were findings in respect of ‘disguised compliance’ and the need to ensure holistic assessments addressing parents’ capacity to change. These findings are highly relevant to this case. 3.10 Where parents are being treated with opioid substitute therapy 3.11 In 2014, Adfam published Medication in Drug Treatment: Tackling the risks to children. This report acknowledged that since the publication of Hidden Harm in 2003, the needs of the children of problem drug users have received much greater attention in policy and practice, including a greater emphasis on child protection in clinical guidelines. Opioid substitute therapy is considered to be an effective treatment which reduces harm across a number of measures. 3.12 Opioid substitute therapy can be a protective factor for children as it can allow parents to improve their finances; to stabilise relationships; and, to be more available for their children. Opioid substitute therapy is described as having ‘a rightful place of medication in a recovery-orientate treatment system’. At the same time, accidental ingestion of methadone is a specific risk for children living in the household. 3.13 Readily available data 3.14 In Medication in Drug Treatment, One Year On, Adfam expanded upon the findings and recommendations of its previous report. New data revealed that, between 2003 and 2013, at least 110 persons aged 0-18 died from opioid substitute drugs in the UK. In England and Wales, of the 72 methadone related deaths involving children and young people, 18 years old and under. Only 6 of those deaths resulted in a SCR. During that same period, hospital admissions statistics in England indicated that at least 310 children under 18 were admitted to hospital with methadone poisoning: a further 18 were admitted in 2013-14. Given identified gaps in the data, however, this was believed to be an underestimation of the true figure. 21 Wirral Safeguarding Children Partnership February 2020 3.15 New data also suggests that the majority of children ingesting opioid substitute drugs are adolescents; not very young children as had been previously reported. Although the details of how these young people were able to access the medication and the circumstances in which they ingested was not known, the data from Scotland might suggest that some of those adolescents were drug users or had taken the drug as a suicide attempt. Those hypotheses could not be confirmed against the data available. 3.16 The SCRP discussed the potential implications for safeguarding practice where substance misuse, particularly drugs use, is a feature of family life. Panel members, from their experience of attending the learning event, raised a number of questions about local professional culture and practice. Members questioned whether there might be some reluctance on the part of practitioners to ask potentially intrusive questions of drugs users especially when that use was thought to be ‘managed’ and there were no obvious signs of child neglect. In addition, they gained the impression that, when the substance misuse team became involved with a family; there was tendency for others to see the team as holding both the requirement to understand the details of risk and the responsibility to challenge it. Taken together, these factors would produce a fundamentally flawed safeguarding environment. 3.17 The SCRP is keen, therefore, to ensure that professionals from all agencies are sighted on the inherent safety and safeguarding risks to children in households where parents are misusing drugs; particularly, but not exclusively, when parents are receiving opioid substitute therapy or treatment. 3.18 In September 2018, Adfam published Opioid Substitute Treatment (OST) and risks to children: Good Practice Guide. Adfam acknowledges that their guide is aspirational. While they propose this as the standard to which all those involved should be aiming for, the organisation recognises that agencies are under pressure and may not have the resources needed to comply fully. It is recommended for the purposes of this SCR, however, that this guide should inform any proposed changes to local guidance. 3.19 In December 2018, HM Government published a guide for local authorities; ‘Safeguarding and promoting the welfare of children affected by parental alcohol and drugs use’. That guide suggests what alcohol and drug treatment services can do to help prevent harmful consequences for both parents and children. In addition, it recommends that there should be a local joint protocol between substance misuse and children and family services in order to safeguard affected children; to promote effective communication between adult-focused and child-focused services; and, to set out good working practice for the services involved. 3.20 The substance misuse service learning summary acknowledges that recommendation and indicates its intention to support such an initiative whose consolidation, it states, ‘would form part of the CQC improvement plan following its local inspection of health services for children looked after and safeguarding (2019)’. 22 Wirral Safeguarding Children Partnership February 2020 3.21 The particular challenges of working with families where children are placed with parents as an outcome of care proceedings. 3.22 There are two separate but related central issues. The first issue is professional practice when children are placed with parents following care proceedings. The lessons in respect of this first issue can be implemented locally in the expectation of positive change. The second issue is more complex and includes questions about the extent to which decisions to place children with parents at the end of proceedings are necessarily a response to the child’s need or whether they are disproportionately affected by cultural assumptions and practice. 3.23 Improving safeguarding of children living with parents when care proceedings have ended 3.24 The main lesson from this case review is that where the intention is for a child to live with a parent at the end of care proceedings, the child must be able to benefit from co-ordinated multi-agency support and protection. To that end, there needs to be an increased awareness across the Partnership that, when children remain with parents at the end of care proceedings; this is not necessarily an endorsement of the quality of care that parents are providing. There are highly likely to be continuing child protection concerns. 3.25 This means that, while there are statutory requirements in respect of children who are looked after; such arrangements may be insufficient for children where there are continuing child protection risks. This finding has implications not just for CSC social work teams but also for IROs and local authority partner agencies who are expected to contribute to keeping children safe. 3.26 Clarifying the purpose and aims of placement with parents following care proceedings 3.27 For children who are placed with parents, it is particularly important to question whether such placements are, in themselves, permanence plans as they were described in this case. The Children Act 1989 guidance and regulations (2015) states that for many children, permanence will be achieved through a successful return to their birth family, ‘where it has been possible to address the factors in family life which led to the child becoming looked-after’. For children placed with parents following care proceedings, these issues are, almost by definition, unlikely to have been resolved. The question is, therefore, whether such placements might be more usefully regarded as a stepping stone to living permanently with parents without a legal relationship with the local authority. 3.28 This approach would require a more focused approach to care planning in the immediate post-order period, clarifying what changes need to be made and sustained. Timescales could be set for appropriate discharge of the care order and identifying a suitable contingency if this cannot be achieved safely. The expectations for children who are placed with parents cannot be less than for children who are placed away from their 23 Wirral Safeguarding Children Partnership February 2020 parents or who have never been the subjects of care orders. The contingency plan for children placed with parents might be for the children to live elsewhere rather than, as might happen by default, to live indefinitely under the auspices of a care order with no prospect of adequate change. 3.29 Reviewing and implementing revised placement with parents procedures 3.30 Wirral Children's Specialist Services Procedures Manual contains comprehensive procedures in respect of placing children with parents. These appear to be consistent with statutory guidance. No evidence has been provided, however, that the procedures were implemented in this case or, indeed, that there was a clear expectation that they would be. At the same time, it is not wholly evident that the procedures as they stand address the particular vulnerabilities illustrated by, but not restricted to, this case. 3.31 Without adequate guidance for practitioners and managers and scrutiny of its implementation, the shortcomings identified in this case are likely to be replicated in future. 3.32 To what extent are the issues in respect of placement with parents from court common to other local authorities? 3.33 The data indicates that there are regional disparities in applications for care orders and their outcomes3. Among those disparities; it has been recognised that, in the NW of England, children are more likely to be made the subjects of care orders when proceedings end and that placements with parents are disproportionately represented as a care option when compared to all other regions of the country. 3.34 At the end of March 20184, of children who were recorded as being the subjects of care orders (CO) or interim care orders (ICO); in England overall, 8.5% lived with parents while, in the NW, 15.6% were placed with parents. In Wirral, on the same date, 11% of children subjects of CO or ICO were placed with parents. 3.35 It was in recognition of the regional discrepancy in respect of placements with parents that the North West Association of the Directors of Children’s Services worked with CAFCASS and Sefton Council to coordinate an audit of commissioned, in 2017, an audit of 62 cases, across 18 authorities in NW England, where children had been placed with parents. Copies of the report were made available to all LSCBs in the region5. Authors identified that, following care orders, the children’s circumstances had improved in 60% of cases, but in a substantial minority of cases; the situation was said as ‘tentative with evidence of recent 3 See: Care Demand and Regional Variability in England: 2010/11 and 2016/17, a report by the Centre for Child and Family Research and Lancaster University (2018). 4 https://www.gov.uk/government/collections/statistics-looked-after-children 5 Hodgson, Hayes and Bunker (2017): Placement at home with parents – North West Audit Summary Report. Sefton MBC, CAFCASS and ADCS 24 Wirral Safeguarding Children Partnership February 2020 slippage’. In three cases, children had already been removed. Although only a small scale survey, the audit tends to confirm that placement at home does not, of itself, lead to children living stable lives with their families. 3.36 The SCRP understands that there is generally an increased awareness across the region that the NW is an outlier when compared with other authorities. It has also been reported there is a present willingness on the part of local authorities, CAFCASS and the judiciary to consider how the local culture has developed and to examine its merits. In October 2018, the then Chair of Wirral Safeguarding Children Board wrote to the President of the Family Division of the High Court highlighting the issue from Wirral’s perspective. 3.37 It is suggested, therefore, that there could be significant benefit in conducting a systematic analysis of decision making by professionals and outcomes for children across the wider area. This could certainly not be achieved, however, using the resources of a single local authority or Safeguarding Partnership. This has implications for any related recommendations. 25 Wirral Safeguarding Children Partnership February 2020 4. Recommendations 4.1 Safeguarding children where problematic parental drugs use is a feature of family life 4.2 The learning event for practitioners and managers revealed the low levels of knowledge among non-specialist practitioners about drugs misuse and its impact on parents’ capacity to keep their children safe. At the same time, concerns were expressed that substance misuse practitioners were not sufficiently included in multi-agency assessment, planning and working. There was no evidence either that practice was influenced by learning from the previous case review conducted in similar circumstances. These factors contributed to ineffective risk assessment and risk management in this case. 4.3 Wirral Safeguarding Children Partnership has recently updated its website to provide guidance to professionals about substance misuse and the potential safeguarding risks that children can be exposed to due to their parents’ addiction. The information is up-to-date and includes links to the local substance misuse service. Improvements have also been made to enable young people, parents and carers to more easily find relevant information. Links have also been made to the Safeguarding Partnership multi-agency training programme. The Partnership intends to work with the local service provider to improve available information about methadone treatment in the community. 4.4 The SCRP, however, recognised that multi-agency information and training is not a substitute for the responsibility that each agency has to ensure that practitioners and managers have appropriate levels of knowledge about the impact of substance misuse on children and, as importantly, know how to seek information from experts where there are gaps. 4.5 The first 3 recommendations relate to safeguarding children whose parents misuse substances. It is anticipated that they will be enacted sequentially, as they should, in turn, improve the availability of basic information; encourage better joint working; and, measure the extent to which learning has been embedded in practice. 4.6 Recommendation 1: The revision of existing multi-agency safeguarding procedures, protocols and guidance in respect of parents who misuse substances. 4.7 It is recommended that the Partnership: i. oversees the development of a joint working protocol between substance misuse and children’s services; ii. works cooperatively to develop with substance misuse services to complete its revision of practice guidance in respect of children whose parents misuse substances, ensuring that this specifically addresses safeguarding children in households where an adult is being treated with opioid substitute therapy; and, iii. ensures that, as existing generic safeguarding procedures are reviewed, there is an assessment of the impact of changes on children whose parents misuse substances. 26 Wirral Safeguarding Children Partnership February 2020 4.8 Recommendation 2: Improving levels of basic awareness of substance misuse, specific safeguarding issues and how to obtain specialist advice 4.9 The Safeguarding Children Partnership should require agencies to provide evidence that relevant practitioners and managers : i. have sufficient levels of knowledge about the potential negative impact on children of parental substance misuse, proportionate to their role; ii. know how to access specialist knowledge; and, iii. are able to respond appropriately to concerns about a child’s welfare. 4.10 Where agencies are not able to provide this assurance; they should provide details of the steps that they intend taking to improve awareness and practice knowledge. 4.11 Recommendation 3: Measuring the impact of change on practice 4.12 It is recommended that, within 12 months of roll out of updated guidance, the Partnership undertake a multi-agency audit of cases where children are living in households where adults are known to misuse drugs or who are now being treated with opioid substitute therapy. 4.13 The particular challenges of working with families where children are placed with parents as an outcome of care proceedings 4.14 In December 2018, on its final monitoring visit, Ofsted found that, in the previous 12 months, the local authority had successfully discharged the care orders of more than 30 children who had been placed with parents, with the potential for a similar number to follow. During that visit, inspectors also ‘saw examples of strong, clear placement, with parents’ agreements and good support work to ensure that children were safe, and that their needs were met’. This suggests that there has been a significant effort within the local authority to combat drift for children placed with parents resulting in successful resolution for a good number of families. 4.15 The key issues raised by this review remain, however, in respect of the specific safeguarding /child protection needs of children immediately after being placed with parents. The following two recommendations address these matters. As before, it is anticipated that these will be implemented consecutively. 4.16 Recommendation 4: Revising procedures and practice guidance in respect of children placed with parents. 4.17 The Safeguarding Children Partnership should ask the local authority to revise its Placement with Parents protocol to take account of the learning from this review. The local authority should also outline for the Safeguarding Children Partnership, a strategy for engaging with partners in respect of any proposed changes to multi-agency working and how they will be 27 Wirral Safeguarding Children Partnership February 2020 implemented. The local authority should highlight any anticipated implications for multi-agency training. 4.18 This review has identified the particular vulnerability of children placed from care proceedings with parents as they may be less likely to be seen as being in need of protection than other children who are at risk of, or who have suffered, significant harm. The SCRP recognises the challenges in changing professional assumptions and expectations of multi-agency practice with children in those circumstances. It has suggested, therefore, that there should be an imaginative approach to disseminating and promoting learning for practitioners and managers. 4.19 Recommendation 5: Increasing the likelihood that practice will improve 4.20 The Safeguarding Children Partnership should ask relevant partners, following the revision of procedures as proposed; to develop a plan of learning sessions, workshops and/or other means to support practitioners and managers to understand ‘what good looks like’ in this area and how it can be best achieved. 4.21 Recommendation 6: Engaging with others to analyse and evaluate the use, in the NW of England, of placement with parents following care proceedings. 4.22 The Safeguarding Children Partnership should seek opportunities to initiate, collaborate or build on local research in the NW of England to understand the extent of placements with parents following care proceedings and review the reasons for the NW being an outlier. 4.23 Issues raised in this case about basic safeguarding practice 4.24 Key agencies provided learning summaries for this review. These identified lessons learned and made recommendations for change. It was not always clear, however, how these recommendations would be translated into action. At the same time, the learning event and the analysis contained in this report have identified additional potential learning for those agencies as well as for organisations from which summaries were not requested. 4.25 Recommendation 7: Translating single-agency learning into action 4.26 The Safeguarding Children Partnership should require all agencies and organisations which contributed to the SCR to review and, where appropriate, to revise their learning and recommendations for change. In particular, all agencies and organisations should consider their response to ‘hidden males’. Agencies and organisations should provide evidence that they have clear plans identifying the actions that they intend to take. 28 Wirral Safeguarding Children Partnership February 2020 4.27 Recommendation 8: Confirming single-agency learning 4.28 The Safeguarding Children Partnership should reserve the option of requesting evidence that single agency action plans have been effectively completed. The Partnership should determine the mechanism by which this can be most constructively achieved. IC/25.10.19 |
NC047353 | The sexual exploitation of young people in Peterborough over the period 2010-2016. Focuses on learning from Operation Erle, a multi-agency investigation which resulted in ten male defendants being found guilty of 59 offences against 15 girls. Issues identified include: lack of robust response to disclosures of sexual activity at a young age; lack of robust response to the assessment and safety planning of missing episodes; difficulties in transitions between children's and adult's services and a tendency to see young people as adults capable of choosing to be in abusive relationships. Identifies examples of good practice, including: close co-ordination and joint working between children's social care and the police; the appointment of a named child sexual exploitation lead in every secondary school and introduction of an under 18 assessment by the contraception and sexual health service which identifies potential indicators of child sexual exploitation. Learning includes: the need to produce and share victim contact strategies with all members of a joint enquiry; the importance of considering the needs of the family as a whole and the need for young people to talk to an independent person when returning home after a missing from home episode. Recommendations include: local safeguarding children board (LSCB) to undertake an audit of provision of child sexual exploitation interventions within educational establishments; all agencies should ensure that the voice of the child is central to all child sexual exploitation work and the safeguarding board to use multi-agency data to map and evaluate high risk areas for child sexual exploitation to inform early identification of perpetrators and victims.
| Title: An overview of the multi-agency response to child sexual exploitation in Peterborough. LSCB: Peterborough Safeguarding Children Board Author: Ceryl Teleri Davies Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Prepared by:- Ceryl Teleri Davies Independent Author June 2016 AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 2 Contents Forward: Independent Chair, Peterborough Safeguarding Children Board ...................... 3 1. Introduction & Background ..................................................................................................... 4 2. Independent Author ................................................................................................................... 5 3. The Context of Child Sexual Exploitation in the UK ......................................................... 5 3.1. UK Perspective ................................................................................................................... 5 3.2. The Context and Experiences in Peterborough ......................................................... 7 3.3. Multi-agency Operation .................................................................................................... 8 3.4. The Nature & Extent of Child Sexual Exploitation in the Area:.............................. 9 4. What Worked Well: Partnership working in Peterborough ........................................... 10 5. What was Learnt & Evaluated? ............................................................................................ 24 6. Future Developments .............................................................................................................. 26 7. Conclusion ................................................................................................................................. 28 8. Recommendations: ................................................................................................................. 29 9. References ................................................................................................................................. 31 AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 3 Forward This overview report has been compiled, by taking account of the known child sexual exploitation in Peterborough, during the period 2010-2016. The report is focussed on the learning from Operation Erle which was the operational name of a multi-agency partnership investigation into child sexual exploitation in the City which spanned 2013 to 2015. Although this report is based upon the experiences of those young people who were victims and witnesses under Operation Erle, it is extremely important to note that the experiences of these children and young people, whilst fundamentally important in their own right, are accepted by the partnership within Peterborough as being indicative of the experience of a wider group of young people who were also victims of child sexual exploitation at the time, and those who continue to be at risk today. The joint investigation, Operation Erle, has received national praise for Cambridgeshire Constabulary, Peterborough Children’s Social Care, the Peterborough Safeguarding Children Board and its partners for how they tackled child sexual exploitation and continue to tackle the issue within the city. However, this must not for one moment diminish the suffering of all of the victims involved and they must be at the centre of any learning to try to prevent similar situations arising in the future. This must be the overarching aim of the publication of this document: to promote the safeguarding of children and young people from child sexual exploitation, locally and nationally. I would like to extend my thanks to those agencies who have contributed to the process of collating this document, the openness of their responses and their dedication to make improvements. The learning from this review must though be dedicated to the brave victims of child sexual exploitation and the frontline staff who went above and beyond to support them in their recovery. Dr Russell Wate QPM Independent Chair Peterborough Safeguarding Children BoardAN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 4 1. Introduction & Background 1.1. The aim of this report is to evaluate the overall learning regarding the multi-agency practice of addressing child sexual exploitation in the city of Peterborough and its surrounding area. The report will focus on both strategic and operational learning drawn from the reflective experiences of a spectrum of agencies. The focus is on reflecting and analysing the key themes to inform future learning, service delivery and developments. However, the multi-agency experiences of addressing child sexual exploitation in Peterborough may also assist other areas in tackling this issue. The key reflection on practice will focus on the period from 2010 to early 2016. 1.2. This review has been undertaken in line with the key concepts outlined within Working Together (2015), primarily: Reflecting and analysing the multi-agency lessons to be learnt; Reflecting upon the lessons to be learnt in a constructive manner to inform future learning and developments; Evaluating the outcome and impact of this learning on multi-agency strategic and operational developments. Therefore, using the root cause learning in a constructive and reflective manner. 1.3. The Peterborough Local Safeguarding Children Board (PSCB) and several key agencies have contributed to this review, primarily via the desktop review of key documentations. These documents have been appraised to inform the context and learning, in particular a summary of the multi-agency debrief of Operation Erle (the child sexual exploitation inquiry in Peterborough: see section 3.3.2) and the report of the independently facilitated action learning child sexual exploitation workshop held in September 2015. 1.4. The journey of addressing child sexual exploitation has been proactively facilitated on a multi-agency platform, demonstrating complex issues and ‘rich’ learning. There is evidence that this learning has been reflected upon from a multi-agency perspective in the aim of making child sexual exploitation visible now and to the future. AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 5 1.5. In summary, the purpose of this report is to provide an overview of:- The context of child sexual exploitation in Peterborough; Assess how child sexual exploitation was addressed on a multi-agency basis; Evaluate the overall learning; Reflect on the outcomes achieved; Consider potential future learning and developments. 1.6. Therefore, the intention is not to unpick the details of specific cases, but rather to evaluate the overall learning in a constructive and reflective manner. 2. Independent Author 2.1. The author is a qualified Solicitor and Social Worker, with a Master’s degree in both work areas, a postgraduate diploma in Community and Criminal Justice, and qualifications in Mental Health. She has extensive practice-based experience across social care, criminal justice and mental health services, including work on a multi-agency basis to support children, young people and vulnerable adults at practitioner, middle and senior management level. In addition, she is research active and has undertaken several reviews, including SCRs & DHRs. Ceryl Teleri Davies is not employed by any of the Peterborough Safeguarding Board Agencies. 3. The Context of Child Sexual Exploitation in the UK 3.1. UK Perspective 3.1.1. The Jay report (2014) and the Casey report (2015) acknowledged the presenting challenges posed by child sexual exploitation. Recent national high profile court cases reported in the media have assisted in raising awareness of child sexual exploitation, whilst several serious case reviews (SCRs) have highlighted lessons to be learnt by the three key agencies; specifically, Peterborough Children’s Social Care, Cambridgeshire Constabulary and Health services covering the Peterborough area. Despite evolving knowledge and AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 6 practice experiences, lessons need to be learnt on how best to respond to the multitude of complexities when addressing child sexual exploitation. However, this is not a phenomenon or a challenge uniquely faced by Peterborough, but rather a national concern requiring continuous review and analysis. On a national basis, the distance travelled in addressing child sexual exploitation has been rapid, from the development of National Guidance (2006), a plethora of research reports and Government Action Plans (2011). During this timeframe, there have been several serious case reviews across England, resulting in increasing media attention of its impact on the victims/survivors. However, at the beginning of the period covered by this review there was a general lack of awareness of the signs and symptoms of child sexual exploitation, which resulted in low level identification and a lack of drive towards proactive intervention. 3.1.2. Child sexual exploitation is a form of child abuse/harm often hidden and indeed misunderstood (Thomas, 2015). Child sexual exploitation is defined as: Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’(e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. Child sexual exploitation can occur through the use of technology without the child’s immediate recognition; for example being persuaded to post sexual images on the Internet/mobile phones without immediate payment or gain. In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person’s limited availability of choice resulting from their social/economic and/or emotional vulnerability. (DCSFa, 2009, p.9). AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 7 3.1.3. Child sexual exploitation can take several forms, for example, inappropriate relationships involving one perpetrator holding disproportionate power and control over a young person, peer exploitation involving sexual coercion and organised/networked exploitation and trafficking (Barnados, 2011). 3.2. The Context and Experiences in Peterborough 3.2.1. Peterborough is a diverse city experiencing a rapid growth in population and a higher than average younger population. It is a cathedral city with a mixture of both affluent and deprived areas. Therefore, the dynamics of a younger population, growing ethnic diversity and pockets of deprivation bring increased pressures on public services. 3.2.2. During the course of this review there have been several high profile child sexual exploitation criminal cases/trials in Peterborough, which have resulted in significant periods of imprisonment for the perpetrators. This was during a national climate of a void in systematic multi-agency working to identify and address child sexual exploitation. The initial picture in Peterborough does not diverge from the national picture. However, proactive reflections have been gathered on a multi-agency basis through the Peterborough Safeguarding Children Board and via a facilitated action learning session. 3.2.3. The following factors were identified as influencing the historical context of child sexual exploitation in Peterborough (pre 2012):- Box 1: Historical Context The general lack of awareness of CSE; The lack of confidence, knowledge and understanding of practitioners and managers to grasp that several factors may be the root cause, signs and symptoms of CSE; The lack of robust response to disclosures of sexual activity at a young age; Lack of robust multi-agency response to safety planning and disclosures of harm. The high level of deprivation and access to illegal substances within particular areas of Peterborough. AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 8 The culture of conceptualising young people as ‘young adults’ capable and with the freedom to make ‘unwise decisions’ and the notion that they were choosing to have abusive relationships. Therefore, the lack of visibility of conceptualising young people as victims of CSE with complex needs. The lack of robust response to the assessment and safety planning of missing episodes. The lack of robust information sharing of concerns to assist agencies to establish a comprehensive picture of all the emerging concern around CSE. Difficulties in the transition process between Children’s and Adult’s Services. 3.3. Multi-agency Operation 3.3.1. The brief descriptive summary provides details of the multi-agency operation which established a clear but different remit for addressing child sexual exploitation:- Operation Erle: 3.3.2. This operation commenced in January 2013 as a joint operation between Cambridgeshire Constabulary and Peterborough Children’s Social Care in response to an aspiration to proactively identify child sexual exploitation in Peterborough. At this time, the benefit of very close working relationships including many opportunities for joint working could not be underestimated. This operation was victim focused and involved the engagement of over 110 young people as potential victims or witnesses. It also involved the arrest of nearly 40 individuals. In total, this operation consisted of 5 separate criminal trials, resulting in 10 male defendants being found guilty of 59 offences against 15 young women. The punishment for these male defendants amounted to custodial sentences totalling 114 years and nine months. The final trial was held in May 2015. 3.3.3. Operation Erle has received national recognition as a model of good practice for identifying and investigating child sexual exploitation. AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 9 3.4. The Nature & Extent of Child Sexual Exploitation in the Area: 3.4.1. Estimating the extent of child sexual exploitation nationally is difficult given the low awareness of the indicators of this form of abuse (DCSFa, 2009). However, knowledge and practice is evolving with continuous developments in the process of evaluating prevalence data to gain a sense of the nature and extent of child sexual exploitation in Peterborough and its surrounding area. The learning from Operational Erle identified that several of the victims of child sexual exploitation had experienced difficult home circumstances. These difficulties included neglectful parents, witnessing domestic violence and abuse and substance misuse. Box 2 outlines the emerging themes identified to assist in preventing this form of abuse. The data was gathered as part of the work conducted by Operation Makesafe, which was utilised to inform the victimology assessment. Box 2: 86% of victims are female and 14% are male. Two thirds of victims are aged 12-14 with 14 years being the most frequently occurring age. 68% of Peterborough victims were White British (this is line with census 2011 ethnicity), 22% ‘Any Other White’ (twice the 2011 ethnicity rate) and 4.5% Asian Pakistani (6.6% for all Asian ethnicities) Half of all victims came from Peterborough. The high levels in Peterborough are likely to be due to the publicity around the Operation Erle trials, and the increased awareness of professionals in the city as a result of these The vulnerability of victims was further perpetuated due to the barriers to accessing support, the continual contact with the perpetrator in the form of manipulation, coercion and grooming and the impact of these abusive relationships based on unequal power and control. The impact of the child sexual exploitation on the victim’s health and wellbeing need to be assessed, reviewed and managed to ensure that the appropriate AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 10 support is offered at the right level to manage, support and reduce the risk, whilst promoting protective factors. (Source: Cambridgeshire Constabulary, child sexual exploitation Victimology analysis, 2015: data for Peterborough). 4. What Worked Well: Partnership Working in Peterborough 4.1. As knowledge, experience and practice has developed on a strategic and operational level, the understanding and reflection on ‘what has worked well’ has been gathered on a multi-agency basis. The initial position of proactively addressing child sexual exploitation in Peterborough is evidenced from the strategic authority and degree of ownership of Operational Erle. This degree of ownership subsequently translated into practice through the development of a bespoke investigation team and the practice of identifying witness, victims and perpetrators. The overarching principle of achieving good evidence further shaped the nature and person centred approach adopted when supporting victims. The very close co-ordination and joint working between Cambridgeshire Constabulary and Children’s Social Care assisted in facilitating this process by helping to remove barriers regarding different professional roles and responsibilities. During this time, working within a framework of joint working facilitated positive and consistent support for victims to build and sustain relationships in a patient rather than time limited manner. Also, effective joint working ensured equal access to all key information in a timely manner, for example, as facilitated via joint briefings. As part of Operational Erle, safeguarding was seen as a ‘golden thread’ through the silver and gold strategies. Gold, silver or bronze command structures are used in response to emergency or major incidents to establish a hierarchical framework for their command and control. Gold focuses on strategic, silver on tactical and bronze on operational. The executive steering group instigated a Consequence Management Group of senior partnership and community representatives. This was extremely useful in managing community reaction and implementing preventative and educational responses to lessons learnt during the inquiry. AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 11 4.2. Undoubtedly, there has been significant progress in understanding and analysing active and potential cases of child sexual exploitation by Cambridgeshire Constabulary, Children’s Social Care, Health, Education and several agencies across the voluntary sector. This progress has primarily been achieved through the relentless commitment of a spectrum of dedicated professional staff. As a result, the importance of good practice has further embedded as part of subsequent models of working, for example, within Cambridgeshire Constabulary, the Missing Person Investigation Unit is now co-located with the Child Sexual Exploitation Investigation Team. This model of working assists in ensuring a comprehensive flow of information in a proactive rather than reactive manner. 4.3. Outlined below are the reflections of several agencies on their progress to address child sexual exploitation from their own perspective. a) Education Schools are now far more aware of the signs and possible indicators for child sexual exploitation. There is a named child sexual exploitation lead in every secondary school, with direct links to the Peterborough Safeguarding Children’s Board’s Sexual Exploitation Coordinator. All basic safeguarding awareness sessions, both for staff and governors, are inclusive of information relating to child sexual exploitation, and there are clear mechanisms in place for sharing information with statutory agencies. Schools are encouraged to build work around healthy and safer relationships into their curriculum. However, along with the constant strive to improve education around personal safety and child sexual exploitation there are still stumbling blocks, mainly in terms of the lack of statutory status for some subjects. However, further audits will assist us to assess the current landscape in detail and in planning work to the future. b) CAFCASS Child sexual exploitation forms one element of CAFCASS’ Exploitation Strategy, along with radicalisation and trafficking. The overarching aim of the strategy is to provide staff with the knowledge and skills required to assess and support children and families affected by these matters in line with CAFCASS’ AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 12 functions and duties. At the core of the strategy is a network of ambassadors (at service area level) and champions (at team level) who receive up-to-date knowledge and cascade this down to colleagues. Management time is dedicated to creating and implementing the strategy, further elements of which include: presentations by experts in these fields; updated training; internal research; the collation of learning generated by colleagues in partner agencies and by Peterborough Safeguarding Children Board and so forth. The CAFCASS team that provides services in the Peterborough area has shared its national and local exploitation plans with the Peterborough Safeguarding Children Board and has both a local exploitation ambassador and champion. c) Cambridgeshire Constabulary The partnership in Peterborough is committed to supporting identified (and potential) victims of child sexual exploitation, whilst disrupting precursor contact and behaviour that may lead to child sexual exploitation, and bringing those offenders of child sexual exploitation to justice. The Partnership has a number of operational and strategic meetings to ensure all agencies are joined up in the response to tackling child sexual exploitation. Development of processes over the last few years has seen improved information sharing, awareness training and partnership response to tackling child sexual exploitation. These processes remain under continuous review for improvements to be made and continued evolvement of our approach to this complex and ever changing crime type. Child sexual exploitation forms one of the key priorities for Cambridgeshire Constabulary, with a dedicated team having been established over the past few years to deal with this type of crime. Highly trained and skilled officers respond to all identified potential victims of child sexual exploitation to support them from the outset and reduce the likelihood of them being exploited. Operation Makesafe has been developed within Cambridgeshire Constabulary to ensure joined up information sharing, identifying those most at risk of child sexual exploitation and hotspot areas for child sexual exploitation perpetrators to move in. This informs proactive activity from all partner agencies to try and prevent child sexual exploitation taking place, whilst having the ability to target those suspected of child sexual exploitation to ultimately bring them to justice. AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 13 Identifying missing from home episodes are linked to child sexual exploitation, Cambridgeshire Constabulary has taken steps to increase its scrutiny of all reports of people reported missing. The Constabulary now classify all unaccounted for children as missing, ceasing to use the category of absent (previously used in instances of truancy etc.) thereby ensuring a consistent and thorough level of investigation. A Missing Person Investigation Unit has been created to work alongside the Child Sexual Exploitation Investigation Team. This Unit investigates all reports of people having gone missing and are skilled in identifying where children have gone missing and the potential links this may have to child sexual exploitation. In addition to these teams, all officers and staff across Cambridgeshire Constabulary have been provided with in depth training to enhance their awareness of child sexual exploitation and ensure a positive response in every identified case. Recognising the changing dynamics to Child Sexual Exploitation and the significant impact social media and the World Wide Web has in relation to this, a dedicated “on-line” investigation strand has been developed. This is based within the Child Sexual Exploitation Investigation Team and means faster time information sharing, response and opportunities to tackle child sexual exploitation. The whole Child Sexual Exploitation and Missing Person Investigation Unit are based in the same location as partner agencies within the Multi-agency Safeguarding Hub, placing all the needs of child sexual exploitation victims within a well-established partnership arena to provide the best response and support possible to victims of child sexual exploitation. All of the current processes within Cambridgeshire Constabulary regarding the provision for child sexual exploitation have been subject to an independent peer review by the College of Policing. The findings of this review were positive and identified some of the practices undertaken by Cambridgeshire Constabulary and the wider partnership working as leading the way nationally for best practice. AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 14 d) Children’s Social Care At the time that the young people who became victims or witnesses under Operation Erle were first being targeted by men seeking to sexually exploit them, the response of agencies in Peterborough, including Children’s Social Care, was in many ways similar to the response in other parts of the country. There were examples of positive individual work with young people, and a variety of approaches were used to try to reduce the risk of harm they were facing. These interventions, however, tended to lack focus and did not name the central issue of the organised exploitation of vulnerable young people by groups of men. This meant that the specific risks to young people were not fully identified, making it more difficult to develop plans that would offer them sufficient protection at the earliest opportunity. The unfolding of the harm that these young people had suffered, as well as the greater understanding of child sexual exploitation prompted by the national picture, led Children’s Social Care on a rapid journey of developing practice and implementing new systems and processes to tackle child sexual exploitation in Peterborough, in partnership with other agencies. This rapid change of approach across Children’s Social Care and Cambridgeshire Constabulary resulted in the success of Operation Erle and other legal action to safeguard the young people in the short-term. A shared commitment to continuing to develop best practice approaches to protecting vulnerable young people from this type of organised exploitation has now resulted in the development of a much broader Council and partnership wide child sexual exploitation prevention and management strategy, which recognises the importance of whole families and the wider community in successfully tackling child sexual exploitation. Within the Council, this cross cutting approach is made much easier by the creation of a People and Communities Directorate in March 2015 that has responsibility for all Adult, Children and Community Services, and is able to ensure that synergies and the impact of individual policies are always considered through the lens of improving safeguarding for families and children. AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 15 Protocols on child sexual exploitation and children who go missing from home or care have been rewritten to reflect learning and to ensure that safety plans for children and young people are reviewed regularly to ensure their effectiveness. Changes also include the ongoing monitoring of potential child sexual exploitation activity and the needs of individual young people through a specific Peterborough multi-agency group; and the continuing understanding of the link between children missing from education, home or care and possible child sexual exploitation; issues that are now all considered alongside intelligence from Cambridgeshire Constabulary. Any young person who goes missing is now provided with an independent Return Interview, either through Barnados for children who have gone missing from home or by National Youth Advocacy Service for children in care. This means that in both cases, young people can talk to independent and trained staff about any issues that may be worrying them. The information from those interviews is considered both on an individual child basis and also to assist in intelligence gathering at the multi-agency meetings. A risk assessment is undertaken with all young people open to Children’s Social Care – including those who are in care. These assessments are regularly reviewed and enable protective plans to be put in place where any risks are identified. Child sexual exploitation is explicitly considered as a possible factor in any concerning activity or behaviour; and protective plans explicitly address any risk from child sexual exploitation. Most importantly, the Service has renewed its commitment to the importance of listening properly to what children and young people are telling us, and then taking timely and appropriate action to safeguard and support them. e) Health The Integrated Contraception and Sexual Health Service (iCaSH) has developed a focus on professional curiosity around the potential indicators of risk, harm and abuse of pregnancy at a young age. This service now has a detailed under 18 assessment template which has alerts to areas such as child sexual exploitation, which has been developed in response to the indicators of risk of harm of child sexual exploitation. Also, multi-agency audits focused on AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 16 child sexual exploitation have been undertaken to identify future learning and developments required. Peterborough and Stamford Hospitals NHS Foundation Trust (PSHFT) has undergone a significant transformation in the last 4 years, in terms of the capacity of staff to recognise the signs of abuse and exploitation and to work with other agencies to protect children and young people. Child sexual exploitation has been a dominant theme in our training packages for staff, and additional focused training has been delivered to high risk areas such as sexual health, paediatrics, maternity and the emergency department. Staff can now identify the presentations of exploitation without an allegation being made. For example, staff on Amazon children’s ward will work with Child and Adolescent Mental Health Services (CAMHS) staff to identify behaviours and risk factors for child sexual exploitation in all presentations of overdose and self-harm. A culture of professional curiosity has been strengthened. The Trust has identified a child sexual exploitation champion, with regional participation in the Local Safeguarding Children Board child sexual exploitation multi-agency working group and joint action plan. The Trust has actively participated in education programs and dissemination of literature to children and young people using the Trust’s services. Staff in PSHFT are now highly aware of the presence of criminal child sexual exploitation in Peterborough, and know how to identify the problem and then work with other agencies. The Designated Professionals from the Cambridgeshire and Peterborough Clinical Commissioning Group have sought to support and lead the health economy in regards the issue of child sexual exploitation across both Cambridgeshire and Peterborough. This has enabled the embedding of knowledge and practice around sexual exploitation in all the services we commission. Substantial reporting is received from Health Care Providers around their safeguarding activity and this includes reporting around cases of child sexual exploitation. It also forms part of the teaching packages that Providers deliver to all staff. The strengthening of transition planning for children who receive health care services and are continuing on into adult service is also AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 17 underway in accordance with the new NICE guidance. The Designated Doctor was part of the local safeguarding children board multi-agency working group that developed a resource pack around child sexual exploitation for all professionals and for parents. This has been well utilised and embedded across the health economy and beyond. Within Primary Care the issue of child sexual exploitation has also been addressed. Training has been given to Primary Care through both the briefing that is sent to all practices, the Level 3 Safeguarding training for Primary Care and the Safeguarding Leads conference. Child Sexual Exploitation is part of the Safeguarding Resource Pack provided for Primary Care staff to access, and includes direction to the Peterborough Safeguarding Children Board Resource Pack. Recently an NHS England leaflet on child sexual exploitation was sent to all General Practitioners (GP) practices to assist them in knowing the signs and symptoms of child sexual exploitation. In partnership with Cambridgeshire Constabulary, when live operations are under way in specific areas of the county, a visit is made by the Senior Investigating Officer to the GP practices in the area to raise awareness with them of the concerns for children in their area. f) NSPCC The National Society for the Prevention of Cruelty to Children (NSPCC) has a dedicated Service Centre in Peterborough delivering to children, young people and families through two teams of social workers. At the outset of Operation Erle resources within the centre were redirected to deliver within the child sexual exploitation agenda, drawing on a national body of evidence and model of intervention focusing on prevention where child sexual exploitation is a risk, protection where child sexual exploitation is ongoing, and recovery through delivery of therapeutic service. In addition, centre managers have supported strategic planning, and a range of training and awareness raising sessions for professionals have been delivered. A dedicated child sexual exploitation focused intervention continues to be delivered from the Service Centre, with group work provided in secondary schools, including where children have special educational needs, aimed at diverting young people at risk of sexual exploitation away from those risks. The AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 18 majority of ongoing service delivery is directed at young people where sexual exploitation is still happening or where post abuse therapeutic work is required – with some post abuse interventions provided for many months. The Peterborough NSPCC team has a strong focus on participation work with young people, and through this work have provided the voice of young people about their experiences to aid professional learning in the city. Looking to the future, the Peterborough NSPCC team are planning to support the roll out of our preventative group work into school and community settings, for others to co-deliver if a need arises. One of the benefits of this service provision by the NSPCC is that work is not restricted by city or county boundaries, and this has allowed specific support and interventions to be provided where young people have featured in the Operation Erle investigation, but are not children from Peterborough. 4.4. As an outcome, as a partnership the Peterborough Safeguarding Children Board produced several key documents to provide context, direction and purpose to the development of their work as outlined in Box 3. Box 3: Work completed and developments within agencies in response to the Historical context (See: Box 1). Child Sexual Exploitation Strategy and Action Plan: The progress and completion of this comprehensive work plan is regularly monitored and reviewed by the multi-agency strategic child sexual exploitation group. Not only does this provide a forum to discuss child sexual exploitation and the work plan, but ensure that the impact and outcome of the work plan is evaluated on a continuous process. There have been key developments implemented on a multi-agency basis, which clearly highlights the resources, multi-agency approach and progressive nature of the comprehensive action plan implemented to address child sexual exploitation in Peterborough and indeed across Cambridgeshire. The flow of practice changes illustrated below demonstrates the development and impact of change at each level of practice, from referral, assessment, intervention to measuring the impact of AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 19 interventions. This is framed within the developments of quality assurance systems and a comprehensive training programme, which are all supported by a new Co-ordinator role. The following points illustrate the flow of these comprehensive developments. Sexual Exploitation Co-ordinator Role: The Peterborough Safeguarding Children Board created the post of a part-time Sexual Exploitation Co–coordinator to map multi-agency connections, ensure risk assessment is robust and interventions are available and suitable, develop multi-agency policies and procedures and ensure these are embedded across partners, raise awareness and drive continuous improvement. A Multi-agency Child Sexual Exploitation Referral Tool: In January 2013 in the early stages of Operation Erle, a numerical scoring tool was introduced for across agencies. During September 2014 the National Working Group (www.nwgnetwork.org) produced a vulnerability checklist, which was adopted in Peterborough and Cambridgeshire. The referral route remained the same: directly into the Multi-Agency Safeguarding Hub (MASH) and the new ‘tool’ relied much more upon professional judgement. In April 2015 the pathway was amended to align with all other child protection concerns and as a result, the checklist was added to the existing child protection referral form. This shift recognised child sexual exploitation as a mainstream child protection issue as a result of fundamental shifts in policy, practice and service delivery in line with good practice guidance (Barnados, 2011). A decision was made to implement a bespoke risk assessment tool alongside the referral tool. As a result, a Risk Management Tool was devised by a multi-agency group and launched in August 2015. Therefore, evidence from national forums, the criminal trials have proactively informed the development of a tool focused on promoting professional curiosity, vulnerabilities and risk indicators. In addition, there is a free narrative section for professionals to details their concerns. To measure the quality, proportionality of threshold and impact of the use of this tool, quality assurance measures were implemented and monitored by the Peterborough Safeguarding Children Board. The continuous and reflective manner of addressing child sexual exploitation is further evidenced by the decision of assessing child AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 20 sexual exploitation as part of identifying sexual abuse concern rather than seeing it a standalone concern. Not only does this assist with key processes, for example, data gathering, it also embeds the culture of evaluating child sexual exploitation as a ‘golden thread’ running through all sexual abuse work with children and young people. It is also clear that the multi-agency commitment and drive has continuously placed child sexual exploitation as a key priority for development, review and embedding as part of ‘everyday’ professional practice. Interventions/Chelsea’s Choice: In June 2013 the Peterborough Safeguarding Children Board commissioned the drama Chelsea’s Choice (delivered by Alter Ego Creative Solutions www.alteregocreativesolutions.co.uk/chelseas-choice) which was delivered to nearly all of the secondary schools in Peterborough. In excess of 3,000 Years 8 and 9 students saw the drama, which has been followed up by Cambridgeshire Constabulary Safer Schools Officers via the roll out the “Exploited” CEOP programme. The “Exploited” film and resource pack aims to support and educate young people on how to stay safe from abuse and exploitation. The Peterborough Safeguarding Children Board sought evidence of the impact of Chelsea’s Choice and as a result a questionnaire was sent to all secondary schools in April 2014. As a result, 515 responses were received across all schools, which is an excellent return rate. This consultation evidenced that the majority of young people (72%) replied that their ‘sympathetic adult’ for sharing safeguarding concerns with would be a teacher. As a result, since January 2015 all Secondary Schools in Peterborough have appointed a Child Sexual Exploitation Lead, which are supported by the Sexual Exploitation Co-ordinator via a termly focus group. From a critical and reflective viewpoint, this development evidences:- a) The aim towards prevention and early intervention. b) The comprehensive reflection of further measuring the impact of intervention to gather evidence to inform ‘what works’. Not only does this ensure that interventions are designed at the right level, but considers amendments/revision in a fluid manner. c) The drive to gather evidence to further inform practice developments. AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 21 d) Illustrates the emerging culture of incorporating young voices in practice developments about sensitive issues that impact on their ‘everyday’ lives. Participants were asked to comment on their understanding of child sexual exploitation, which provided the opportunity for them to define this concept and for any misconceptions to be identified and addressed as part of any further prevention/intervention work. e) That key findings from the questionnaire are implemented and barriers removed to further encourage young people to access their ‘sympathetic adult’ of choice. f) The support and guidance provided by the Sexual Exploitation Co-ordinator in this specialised role via the facilitation of focus groups to develop knowledge, skills and share good practice. Information Packs: The Peterborough Safeguarding Children Board Strategic Learning & Development Group identified the requirement for agencies to be fully aware of the signs and symptoms of child sexual exploitation. As a result a multi-agency task and finish group developed a child sexual exploitation resource and training pack. The pack is free of charge to all agencies and includes leaflets, posters, details on signs and symptoms and a 2 hour child sexual exploitation briefing which can be shared as part of agencies training or team meetings. The leaflets for young people and parents/carers were co-produced with a group of secondary school students to ensure that their critical eye and voice was constructively used to develop ‘user friendly’ materials. The leaflets are currently available in English, Polish, Russian, Latvian, Lithuanian, Portuguese, Slovak and Urdu. Multi-agency Training: The Peterborough Safeguarding Children Board has developed and delivered a multi-agency child sexual exploitation training package. To date the course has been oversubscribed each time it has run and additional sessions have been arranged to meet the demand. Therefore, there is a good degree of professional time allocated to prioritise attendance at this training. Level 1 training is developed and delivered by the Sexual Exploitation Co-coordinator with training materials developed in AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 22 conjunction with the Joint Child Sexual Exploitation and Missing Strategic Sub-group. A review of the training delivered over the past 12 months illustrates the comprehensive nature of the training (e.g. from sexually harmful behaviour to child sexual exploitation and learning disabilities) and the range of agencies accessed (e.g. from the Citizen’s Advice Bureau (CAB) to CAFCASS). The Peterborough Safeguarding Children Board has also been a key contributor to the “Say Something If You See Something” campaign which has been delivered to hotels, multi-agency partners, Elected Members and other Local Authorities. The Peterborough Safeguarding Children Board has also delivered awareness training to over 480 approved drivers (including taxi drivers) and voluntary drivers, which is part of the annual updated training. Targeted awareness raising activity across the night-time economy workforce (taxi drivers, bouncers, takeaway food outlets, hotel receptionists and off-license staff) has also been delivered to ensure the visibility of child sexual exploitation. Not only does this ensure that training and awareness raising is offered to the wider community, but is also aligned to key messages from research (ESRC, 2015). Also, the National Working Group suggests that this is a sector that should receive training due to their role and contact with the public during the evening to assist them in identifying the signs and symptoms of abuse and exploitation. ‘Ambassadors’ and ‘Champions’: The Peterborough Safeguarding Children Board is currently running a pilot with two local primary schools to train a group of pupils as “Safeguarding Internet Safety Ambassadors”. The pupils will be trained on inter net safety and then be champions within the school setting by assisting and skilling up other pupils on how to stay safe online, including running assemblies and contributing to lessons on internet safety. Again, this is key evidence of collaborative work across the local community and the inclusion of younger voices in sensitive matters that impact on their live. Offering young people the space to share their views encourages their engagement and participation. There is evidence of continual processes of raising awareness of child sexual exploitation throughout the local communities., for example the Muslim community AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 23 have been proactively involved as several briefing events have been facilitated in Mosques and Madrasah’s in Peterborough. Measuring Performance and Quality Assurance: Key developments have focused on developing new data sets to primarily monitor the demographic information of young people who are the subject of a child sexual exploitation referral. Multi-agency audits have also been undertaken to monitor the themes and messages from practice to inform future developments. The opportunity has also been taken to use audits to identify good practice and acknowledge how practitioners established relationships and addressed challenges. The good practice identified is focused on the final stage of this quality assurance process; focused on offering a debrief for young people on the findings of the audit of their case file. Not only does this ‘close’ the cycle of this quality assurance work, it also again includes the young person’s voice in a collaborative, co-production and partnership manner. This form of quality assurance practice assists in ensuring that learning is robust, meaningful and in keeping with effective participation guidance when engaging with young people. During April and May 2015, Peterborough was inspected by Ofsted, who judged that joint working between Cambridgeshire Constabulary and Children’s Social Care was effective, in particular in ensuring a victim led approach, raising the awareness of child sexual exploitation whilst ensuring the safety of young people in Peterborough. It appears that significant efforts have been undertaken to drive forward organisational cultures focused on identifying and addressing child sexual exploitation. Operation Makesafe: This operation has two key objectives as outlined below:- 1. Target suspected offenders /locations and also identify the most vulnerable victims to ensure targeted support is provided. 2. Facilitate the increased awareness raising of child sexual exploitation to highlight the signs and symptoms of child sexual exploitation to stimulate early identification of these risk factors. AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 24 Operation Makesafe is led by a Detective Inspector who is based within the Child Sexual Exploitation and Missing Investigation Unit. The Cambridgeshire Constabulary Central Intelligence Bureau are currently building dynamic intelligence pictures of child sexual exploitation across the Constabulary. This will be used to drive operational activity. The intelligence pictures will concentrate on suspected perpetrators, potential victims and locations or ‘hotspots’. The Detective Inspector will make a policy decision in respect of whether to adopt a potential victim or potential perpetrator on a case by case basis. 5. What was learnt & evaluated? 5.1. Undoubtedly, Operation Erle was managed via a robust ethos of multi-agency working, reflection and good practice. It is evident that a reflective approach was adopted to evaluate the key learning to establish robust service development. Summarised below are the key learning points identified:- The requirement for robust information sharing, but also a focus on multi agency analysis of presenting information to evaluate and map victims, perpetrators, ‘hotspots’ and common themes across cases. It became apparent over time that schools were essential in supporting victims and a source of intelligence and evidence. Schools and other educational settings hold a wealth of information which is incredibly valuable in establishing a picture of a young person’s everyday life, including their concerns and vulnerabilities. However it should be considered that during the time of this review, Sex and Relationship Education with a focus on child sexual exploitation was inconsistent across all UK schools. Therefore, the lack of understanding of the signs and symptoms of child sexual exploitation may have reduced the urgency to fully investigate and escalate concerns. In response, several focus groups have been held with young people, which have also been included as part of the child sexual exploitation consultation events. This increased emphasis locally has improved information sharing between education and other agencies. All young people who were part of the Operation Erle enquiry, irrespective of disclosures were automatically subject to a s47 joint enquiry procedure unless AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 25 exceptional circumstances were evidenced. This ensured that the complexities of the impact of child sexual exploitation on young people were properly considered in a multi-agency information sharing context. However, this adversely affected Local Authority performance indicators regarding quantity and timeliness of joint enquiries. Despite this adverse effect, this shift in focus was necessary and beneficial to ensure that the complexities of each case were thoroughly considered and the appropriate relationships fostered. The need to produce and share victim contact strategies with all members of a joint enquiry. These strategies should include, contingency planning following a cold call of a potential victim; social media strategy; and suicide strategy. The importance of considering the needs of the family as a whole during the investigation that is, adopting a ‘think family’ approach (DCSFb, 2009). Also, the importance of considering the range of intersectional needs across the family unit is crucial. In particular, consideration needs to be given to messages from research and practice of the increased risk within specific ethnic minority groups of honour based violence and bringing perceived shame on the family. This relates both to a victim’s family and that of any perpetrators. A common feature across several of the cases was the prevalence of missing from home episodes. It has been acknowledged that young people need to talk to an independent person when returning home following a missing episode. A dedicated Missing Case Worker is now commissioned from Barnados to undertake this task for young people missing from home and National Youth Advocacy Service (NYAS) for young people in care, providing consistency and data oversight from these episodes. As a response a joint protocol was established between Cambridgeshire Constabulary and Children’s Social Care, which is updated on an ongoing basis. A key requirement identified was the need to establish robust safeguarding contingency planning across each element of the investigation, for example, suicide prevention strategies. The need was identified to have robust recording to assist with achieving best evidence and placing safeguarding as a golden thread to all aspects of the AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 26 enquiry for example, the need to ensure that significant unsolicited comments made by family members during searches are recorded evidentially. 6. Future developments 6.1. The pace of change and development in Peterborough has gathered momentum as the criminal trials have progressed and the general national understanding of child sexual exploitation advanced. The focus of future work needs to be based on messages from research, practice and lessons learnt both locally and nationally. Overall, the key focus should be on maintaining the positive commitment, interest, momentum and continuous development achieved during this challenging period. Consideration needs to be given to the following developments as identified following the multi-agency action learning workshop:- The requirement to continue to work together and develop practice in a multi-agency manner. The continual development of comprehensive training and learning across key agencies working with children and young people via a robust training plan. The child sexual exploitation strategy to cover each stage of child sexual exploitation, from prevention, pre-court to post court interventions. Also, the strategy needs to highlight the media engagement and monitoring process. The identified issues with the previous management of missing from home episodes requires further attention, in particular the timeliness of reporting these incidents, lack of consistency in recording information and the completion of risk assessments. The reinforcement of appropriate assessment routes to ensure that young people at risk of or suffering child sexual exploitation are able to access support and services in a timely manner. There is a need to formalise all forms of inter and multi-agency information sharing by developing robust governance arrangements. This governance arrangement to outline the roles and responsibilities of intermediaries and translators during the prevention, pre and post court stages. AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 27 The aim to strengthen links between Education providers, Children’s Social Care and Cambridgeshire Constabulary around evaluating missing episodes from home and evaluate behaviour around patterns of returning home late and truancy from school. Monitoring patterns of behaviour across schools and colleges on a multi-agency basis to identify any trends and learning in a timely manner. This is now being taken forward in the Operational Group Meeting, led by the Strategic Lead for child sexual exploitation and missing within Children’s Social Care. This group involves all multi-agency partners. As a result of identified trends, include specific consideration of issues in relation to child sexual exploitation within general transition planning for young people reaching adulthood to ensure robust planning and communication. Continual development and training around professional curiosity, challenge and listening to the voices of young people, in particular when addressing sensitive issues, needs consideration. However, the continual nature of this work needs to acknowledge the challenging aspect of working with families collaboratively, whilst also evaluating particular risk and vulnerability factors around child sexual exploitation. This continual professional curiosity needs to be formed on a foundation of an open and trusting relationship between key professionals and the family as a whole. As highlighted in Recommendation 8.1 there needs to be a focus on preventative education in schools and beyond. As a future development, this focus should include parents and carers. Also, the use of new media technologies, including social media should be considered as a platform for children and young people and their parents or carers to raise and discuss issues. Not only will this ensure that wider communication strategies are fostered to share concerns, it will also work to foster an environment for discussion without the need for direct human contact. As discussed, the normative structure through children and families services cannot necessarily prescriptively be adopted in these types of cases. There needs to be a continuous flexible approach to the service provision pathways, to include planning across children and adult services but also taking into AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 28 account legislative restrictions and access to appropriate expertise and resources. 6.2. To summarise, as the pattern and knowledge of child sexual exploitation evolves the Peterborough Safeguarding Children Board partnership should remain open to new patterns of concerning and harmful behaviour. 7. Conclusion 7.1. Despite the challenges faced, key milestones have been achieved to ensure that the voices of children and young people are incorporated to inform multi-agency practice developments. Recent developments reflect that when concerns of child sexual exploitation have been identified, the multi-agency response has been proactive, comprehensive and reflective. This is not a simple task to achieve and the multi-agency drive of partnership working across Peterborough should not be underestimated. This has been driven and achieved under the watchful eye of the media and during a period of several investigations and criminal trials. Furthermore, continuing to listen to the voices of children and young people will assist the Peterborough Safeguarding Children Board in moving forward with their child sexual exploitation action plan, to build community confidence that appropriate safeguards are implemented. 7.2. To summarise, the evidence suggests that the partnership working together under the Peterborough Safeguarding Children Board in Peterborough have resisted the potential for agency inertia and the dismissal of child sexual exploitation as a problem within the city. As highlighted, there have been continuous developments to address this issue in a proactive rather than reactive manner. It appears that the focus of the strategy and action plan adopts a robust dual approach to prevent child sexual exploitation by protecting children and young people and prosecuting perpetrators (Pearce, 2014). Therefore, the responsibility for child sexual exploitation has clearly developed as a core business for the Peterborough Safeguarding Children Board. 7.3. In accordance with key national guidance (DCSFa, 2009) there is a sense that the Peterborough Safeguarding Children Board has effectively monitored how key agencies have continually assessed how young people are being groomed AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 29 for sexual exploitation and reflectively considered the routes into child sexual exploitation in their area. In response to the messages from practice and the criminal trials, the Peterborough Safeguarding Children Board have worked to amend their prevention and interventional approaches to take account of evolving knowledge of the patterns of child sexual exploitation. 8. Recommendations: 8.1. The Peterborough Safeguarding Children Board should undertake an audit of the current provision within educational establishments to establish the current programme of interventions and its effectiveness. The audit should include the following: Risk taking behaviour Myths Role of Social Media Spectrum of abuse and violence Use of coercion Signs of abuse and exploitation Appropriate behaviour in respectful and consensual relationships Legal context (Consent, Sexting etc.) 8.2. Relevant agencies to provide assurance to the Peterborough Safeguarding Children Board that they review their ‘missing from home’ procedures to ensure:- a) multi-agency information sharing, b) appropriate recording, c) timely discussion with young people and their families, d) consideration of previous episodes of missing from home, e) clear expectation for strategy meetings, AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 30 f) completion of return to home interviews, g) clear evidence of management oversight, h) robust data capture to identify any trends. 8.3. All agencies to ensure that the voice of children and young people is incorporated as a central aspect in all child sexual exploitation work. 8.4. The Peterborough Safeguarding Children Board should assure itself that a ‘whole family’ approach (DCSFb, 2009) is adopted by all agencies when working to identify and address child sexual exploitation to ensure holistic engagement, support and protection. This approach to be driven forward by changes in policies and practitioner training. In addition, case file audits to be completed to evaluate and measure this change in practice. 8.5. The Peterborough Safeguarding Children Board should ensure that if a large scale investigation arises, the needs of the specific young people or adults involved are considered at the earliest possible point, and identify the most helpful response from all agencies involved, including addressing their long term emotional health and wellbeing needs. 8.6. The Peterborough Safeguarding Children Board should assure itself that transition planning takes place across all agencies with young people reaching transition age who have experienced child sexual exploitation. Flexibility is key in responding to individual needs, for example, it should be recognised that not all such young people may be open to Children’s Social Care or willing to accept services from them. Some young people will require a very specialist transition plan, and this will need to take into account legislative restrictions and access to appropriate expertise and resources. The voice of the young person should be central to all planning AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 31 across agencies. This will require joined up working with Safeguarding Adults Boards (SABs). 8.7. The Peterborough Safeguarding Children Board to use multi-agency data to map and evaluate high-risk areas for child sexual exploitation to inform the early identification of perpetrators and victims. 9. References Barnardos (2011). Puppet on a string: The urgent need to cut children free from sexual exploitation. [Online] Available from: www.barnardos.org.uk/ctf_puppetonastring_report_final.pdf Burton, S. & Kitzinger, J. (1998) Young People’s Attitudes Towards Violence, Sex and Relationships: A Survey and Focus Group Study. [Online] Available from: www.vawpreventionscotland.org.uk Burman, M. & Cartmel, F. (2005) Young People’s Attitude towards Gendered Violence, Edinburgh: NHS Scotland. [Online] Available from: www.equation.org.uk/.../Young-Peoples-Attitudes-Towards-Gendered-Violence Casey, L. (2015) Report of Inspection of Rotherham Metropolitan Borough Council. [Online] Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/401119/46966_Rotherham_Report_PRINT.pdf Department for Children, Schools and Families (2009a) Safeguarding Children and Young People from Sexual Exploitation: Supplementary guidance to working Together to Safeguarding Children. The Stationery Office, Nottingham Department for Children, Schools and Families (2009b) Think Family Toolkit Improving support for families at risk Strategic overview. [Online] Available from: http://webarchive.nationalarchives.gov.uk/20130401151715/http://www.education.gov.uk/publications/eOrderingDownload/Think-Family.pdf AN OVERVIEW OF THE MULTI-AGENCY RESPONSE TO CHILD SEXUAL EXPLOITATION IN PETERBOROUGH Ceryl Teleri Davies 32 ESRC (2015) Taxi drivers and bouncers could help tackle child sex abuse [Online] Available from: http://www.esrc.ac.uk/news-events-and-publications/news/news-items/taxi-drivers-and-bouncers-could-help-tackle-child-sex-abuse/ HM Government (2015) Working Together to Safeguard Children [Online} Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_Children.pdf Jay, A. (2014) Independent Inquiry into Child Sexual Exploitation in Rotherham. [Online] Available from: file:///C:/Users/ceryl/Downloads/Independent_inquiry_CSE_in_Rotherham%20(1).pdf Kelly, L. (1988) Surviving Sexual Violence. Oxford: Basil Blackwell Ltd. Pearce, J. (2014) ‘What’s Going On’ to Safeguard Children and Young People from Child Sexual Exploitation: A Review of Local Safeguarding Children Boards’ Work to Protect Children from Sexual Exploitation. Child Abuse Review 23 pp.159-170. Thomas, R. (2015) ‘A good understanding of child sexual exploitation is essential to ensure early identification’. British Journal of School Nursing 10 (5) pp.250-51. |
NC043932 | Death of a 7-week-old baby girl in April 2012 from a serious head injury. Post mortem revealed additional substantial injuries thought to be at least 10 days old. Father was sentenced to 8 years imprisonment for causing or allowing the death of a child; mother was acquitted of the same charge. Emma was subject to a Child in Need plan following a pre-birth assessment. Father was diagnosed with significant learning difficulties as a child and his family were well known to children's services. He had a significant history of domestic abuse involving: being reported as the perpetrator in more than 10 incidents; being convicted of assault against an ex-partner; and being charged but not prosecuted for Section 47 assault of the 2-year-old daughter of an ex-partner. Mother was understood to possibly have learning difficulties and was in contact with services regarding violent behaviour and anger management. Issues identified include: implications of learning difficulties on how parents receive information and their parenting capacity; and lack of professional curiosity in regards to father's history. Frames key findings using the systems model developed by the Social Care Institute for Excellence (SCIE). Makes recommendations covering: health services, Barnardo's Young Families service, children's services and the commissioning of adult services.
| Title: Serious case review: ‘Emma’: the overview report LSCB: Wakefield and District Safeguarding Children Board Author: Peter Maddocks Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review ‘Emma’ The Overview Report December 2013 2 Index 1 Introduction and context of the Serious Case Review 4 1.1 Rationale for conducting a Serious Case Review 5 1.2 Reasons for the Serious Case Review and Terms of Reference 5 1.3 The methodology of the Serious Case Review 6 1.4 The scope of the Serious Case Review 7 1.5 The Terms of Reference as described in statutory guidance in 2010 9 1.6 Particular issues identified for further investigation by the Individual Management Reviews: the key lines of analytical enquiry 9 1.7 The Terms of Reference for the Health Overview Report 12 1.8 The Terms of Reference for the Overview Report 13 1.9 Membership of the Serious Case Review Panel and access to expert advice 13 1.10 Independent author of the Overview Report and Independent Chair of the Serious Case Review Panel 14 1.11 Parental and family contribution to the Serious Case Review 14 1.12 Timescale for completing the Serious Case Review 16 1.13 Status and ownership of the Overview Report 16 1.14 Previous Serious Case Reviews 17 1.15 Synopsis and conclusions of the Serious Case Review Panel 18 1.16 The family and other significant people 34 1.17 Cultural, ethnic, linguistic and religious identity of the family and their community 34 2 Narrative account of agency involvement 35 3 Synopsis of the learning and analysis from the Individual Management reviews 46 3.1 Summary 46 3.2 Significant themes for learning that emerge from the Individual Management Reviews 47 3.3 Good practice identified by the review 48 3.4 Learning difficulty 49 3.5 Violence and control 55 3.6 The limited information about Emma’s father in agency records 59 3.7 The Child in Need Plan 60 4 Analysis of key themes for learning from the case and recommendations 65 4.1 Innate human biases (cognitive and emotional influences): 68 3 repeated exposure of professionals to intractable and long term problems such as domestic violence contributed to a normalisation and de-sensitisation in the response and understanding the significance of deviant or risky parental behaviour that included evidence of historic and current domestic abuse 4.2 Difficulties in achieving a balance between keeping a mind open to new information and making judgments and decisions in a timely fashion for children such as Emma 69 4.3 Responses to incidents; inadequate checking of history and the collation of emerging information created the conditions where individual incidents were viewed in isolation and inhibited the identification and clarification of patterns from different sources; the influence of mind-set 70 4.4 Tools; the tools and assessment process for multi agency collating, sharing and analysing information were not sufficiently developed and embedded and provided no resolution to issues such as whether either parent had a learning difficulty or disability 73 4.5 Management systems; the commissioning and contracting arrangements placed a limit on how aspects of the work was completed 75 4.6 The implementation of new systems including electronic recording arrangements contributed to communication difficulties 75 4.7 The workload and organisational capacity had an impact on how several professionals processed information and worked with Emma’s family 76 5 Recommendations 79 6 Appendix 82 4 1 Introduction and context of the review 1. Seven week old Emma was admitted to hospital via ambulance in April 20121. The ambulance had been called by Emma’s father because she was gasping for breath. On arrival at the home address, paramedics noted that Emma was pale, limp and showed little sign of life. She was ventilated and transported to hospital accompanied by her parents. 2. On arrival at the hospital, doctors continued to ventilate Emma and noted bruising on the right side of her cheek and an external injury on the right forehead. These injuries were considered to be non-accidental. Due to these concerns a skeletal survey was undertaken. This identified fractures to the skull, ribs and a limb, a retinal haemorrhage and wide spread brain injury. Medical opinion strongly suggested non-accidental injury possibly from shaking. Some of the injuries were estimated to be at least ten days old. 3. Due to the severity of her injuries, medical treatment was withdrawn and Emma died. A forensic post mortem was conducted at a regional children’s hospital. The cause of death was given as a head injury pending further investigations. 4. Both parents were first charged with a S18 wounding. Following Emma’s death, both parents were then charged with her murder. Emma’s father was remanded to custody. Emma’s mother was also remanded to custody but was subsequently released on bail. 5. There were protracted legal proceedings that saw both parents eventually charged with causing or allowing the death of Emma when the case went to trial. Emma’s father was convicted and was sentenced to eight years imprisonment. Emma’s mother was acquitted of the charge. The Serious Case Review process could not be concluded until these proceedings had ended. 6. The initial Serious Case Review panel met on 10th May 2012 to consider if this case met the criteria for conducting a Serious Case Review. The panel subsequently recommended to the independent chair of the Wakefield and District Safeguarding Children Board (WDSCB) that the criteria for conducting a Serious Case Review in national guidance were met and therefore should be undertaken. The chair made the decision to commission a Serious Case Review on 11th May 2012. Work began in May 2012 on compiling a chronology of the involvement of different services for the review. 7. Both parents are white British and speak English as their only language. The Serious Case Review Panel identified that both parents have some degree of learning difficulty. They are believed to have begun their relationship in March 2011. Mother was aged 19 years and father was aged 28 years old when Emma died. Emma was their first child together. Father has previous convictions for violence, theft and criminal damage; of particular significance to the review is a history of domestic abuse incidents that 1 Emma is not the real name. 5 included a prosecution several years previously and child protection reports relating to violence committed against two ex-partners and allegations regarding the respective partners’ children. Those incidents occurred outside Wakefield. This information was not known to the health and social care services working with Emma’s family before she died. 8. A child in need plan was in place at Emma’s birth as a result of an assessed need for support in relation to parenting and this was reviewed once at the family home on 8th March 2012. The Child in Need plan included a social worker, a Wakefield-based voluntary sector organisation providing support in relation to domestic abuse and anger management (Vol 1), Barnardos (Vol 2) service and a midwife (followed by health visitor after Emma’s birth). A second meeting had been postponed in the week before Emma died due to severe weather disruption and had been re-arranged for a week later. 9. The GP and the health visitor had both seen Emma within 48 hours of her being admitted to hospital with the head injury. Although the health visitor had referred Emma to the GP because of some weight loss no injuries were observed by either the health visitor or the GP. 10. Failure to detect fractured ribs, sustained days before death should not be a cause for criticism. Such fractures are rarely detected acutely in babies. They do not seem to cause persisting distress and are not usually detected by carers, members of the extended family or professionals. They are almost always an incidental finding when a child presents for another reason. This is why they are specifically sought, with routine chest x-rays, as part of child protection assessments on infants and why further x-rays are taken two weeks after initial x rays as even quite new fractures may not be detected clinically or on a first x-ray. 1.1 Rationale for conducting a Serious Case Review 11. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with procedures set out in chapter 8 of Working Together to Safeguard Children (2010). 12. The LSCB should always undertake a Serious Case Review when a child dies and abuse or neglect is either known or is suspected to be a factor in their death. 1.2 Reasons for the review and terms of reference 13. The reason for undertaking this review is that Emma had substantial injuries, some of which were considered to be at least ten days old. Medical opinion strongly suggested a non-accidental injury possibly from shaking. The post-mortem identified the cause of death as a head injury. Given the nature of Emma’s death, the panel 6 considered that this case met the following criteria for a Serious Case Review, as stated in Chapter 8(9) of Working Together to Safeguard Children2. 14. The Serious Case Review panel at their first meeting on the 10th May 2012 agreed the scope and overall terms of reference for the review and established a timeline for the completion of work. The panel discussed the chronology and first drafts of narrative information from the authors of the individual management reviews (IMR) at the meeting of the panel in July 2012. The scope and terms of reference of the review was routinely discussed and updated at panel meetings to take account of new or emerging information and reflection. 15. The overall purpose of the review is to establish how lessons can be learned from the case through a detailed examination of events, decision-making and action. In identifying what those lessons are, to improve inter-agency working and to better safeguard and promote the welfare of children in Wakefield. 1.3 The methodology of the Serious Case Review 16. This Serious Case Review was completed using the methodology and requirements set out in the government national guidance (Working Together to Safeguard Children 2010) that applied at the time of the review being commissioned and completed. That guidance has been extensively revised and was reissued in April 2013. The revised guidance has given responsibility for the development of learning and improvement frameworks to LSCBs and greater discretion about how any future Serious Case Reviews should be conducted and includes the use of systems based learning methodology that had been advocated by Professor Munro. The WDSCB are working on how future Serious Case Reviews in Wakefield can be developed in order to provide a more productive window into the local systems for safeguarding and protecting children3. 17. The analysis in the final chapter of this report uses some of the framework developed by SCIE (Social Care Institute for Excellence) to present key learning within the context of local systems. This approach also takes account of recent work that suggests that an approach of developing over prescriptive and SMART4 recommendations have limited impact and value in complex multi system work such as safeguarding children5. The final chapter of the review for example explores the 2 The revised version of Working Together to Safeguard Children published in April 2013 has moved the guidance to chapter four. 3 Analysis of clinical incidents; providing a window on the system not a search for root causes. CA Vincent; Quality and Safety in Health Care, 2004; The article argues that incident reports by themselves tell comparatively little about causes and prevention, a fact which has long been understood in aviation for example and is the basis of developing a systems learning approach to Serious Case Reviews in England. 4 Specific, Measurable, Achievable, Result-oriented/realistic and Timely/Time-bound 5 A study of recommendations arising from Serious Case Reviews 2009-2010, Brandon, M et al, Department of Education, September 2011 The study calls for a curbing of ‘self perpetuating and proliferation’ of recommendations. Current debate about how the learning from Serious Case Reviews can be most effectively 7 influence of family and professional interactions on how some aspects of information was processed, the responses to incidents and the tools used by professionals. 18. Systems methodology collects information directly from the people involved with the family. This is not a systems review but the panel have worked to place the evidence that has been analysed into a framework that begins to explore how the local systems both promote and in some circumstances inhibit professional practice and decision making. A systems based review would provide greater opportunity for the practitioners to be central to the process of the review in terms of collating information and helping develop the analysis and understanding about why the case developed in the way that it did. 19. A Serious Case Review panel was convened of senior and specialist agency representatives to oversee the conduct of the review. The panel was chaired by an independent and experienced person. An experienced and independent person has provided this overview report. Further information about their respective experience is provided in section 1.10. 20. The panel agreed case specific terms of reference that provided the key lines of enquiry for the review and were additional to the terms of reference described in national guidance. The panel established the identity of services in contact with the family during the time frame agreed for the review. For services that had significant involvement they were required to provide an independent management review (and are listed in paragraph 25). These reports were completed by suitably experienced people who had no direct involvement or responsibility for the services provided to the children and their parents. 21. An overview report of the health agencies was provided by the Head of Safeguarding for the NHS Wakefield District Trust in accordance with guidance. 1.4 The scope of the Serious Case Review 22. The period of the review is from the beginning of mother’s known pregnancy with Emma to the death of Emma in April 2012. All information known to a service providing an IMR was reviewed. Any information regarding involvement prior to the period of the detailed chronology and analysis was summarised in the IMR. 23. All agency chronologies include detailed information about when the children were seen, spoken to or observations made about them. 24. Agencies that identified significant background histories on family members pre-dating the scope of the review have provided a brief summary account of that significant history. achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans 8 25. Reviews of all records and materials that have been examined include; • Electronic records • Paper records and files 26. Individual management reviews were completed using the template provided by the Wakefield and District Local Safeguarding Children Board (WDSCB), and were quality assured and approved by the most senior officer of the reviewing agency. 27. The following agencies have provided an individual management review that was completed in accordance with Working Together to Safeguard Children (2010), Chapter 8 and the associated WDSCB guidance and relevant procedures. a) Barnardos (manage the Vol 2 service that provides a referral based and targeted support for young parents) b) West Yorkshire Police c) Health services that include: � The Mid Yorkshire Hospitals NHS Trust (provided hospital including hospital emergency department treatment, midwifery, health visiting services) � NHS Wakefield District (commission district health services and commissioned the GP IMR6) d) Wakefield Safeguarding and Family Support Services are the statutory specialist social care services provided by the local authority e) Wakefield Early Years Children’s Services (children’s centre service) f) Wakefield Adult Services (in regard to the referral and assessment by the Community Team for Learning Disability 28. Information was also received from the South West Yorkshire Partnership Foundation Trust7, Wakefield Family Services - Schools and Lifelong Learning Services, Connexions, a supported housing service (a not for profit company who provide tenancies for vulnerable adults on a temporary basis for up to two years) and a local 6 Emma’s parents were for most of the time that is examined registered with separate GP practices and up to 12 different GPs had contact. 7 This is a specialist NHS foundation trust that provides community, mental health and learning disability services to the people of Barnsley, Calderdale, Kirklees and Wakefield. Mother was referred for CAMHS support to help with stress, bad temper and bullying when she was 11 years old. 9 Wakefield based voluntary organisation that help people affected by domestic violence to change their behaviour (Vol 1). 1.5 The terms of reference as described in national guidance in 2010 • Keep under consideration if further information becomes available as work is undertaken that indicates other agencies should carry out individual management reviews. • To establish a factual chronology of the action taken by each agency; • Assess whether decisions and action taken in the case comply with the policy and procedures of the Wakefield Safeguarding Children Board; • To determine whether appropriate services were provided in relation to the decisions and actions in the case; • To recommend appropriate inter-agency action in light of the findings; • To assess whether other action is needed in any agency; • To examine inter-agency working and service provision for the children; • To establish whether interagency and single agency policies adequately supported the management of this case; • Consider how and what contribution is sought from the family members; • To develop a clear multi agency action plan from the overview report. 1.6 Particular issues identified for further investigation by the individual management reviews8: the key lines of analytical enquiry 29. In addition to analysing individual and organisational practice, the individual management reviews should focus on: A. Learning Difficulty • The Serious Case Review Panel considers that the difference between learning difficulty and learning disability may not be well understood. Individual Management Reviews should clarify professional understanding of learning difficulty and the impact it may have on parenting capacity. 8 These are the detailed issues that are analysed by the IMRs and in the detailed analysis in chapter five of this report. 10 • The Serious Case Review Panel identified concerns within different agencies that Emma’s mother may have had a degree of learning difficulty. Individual Management Reviews should identify: the extent to which professionals were concerned about Emma’s mother’s learning capacity; the evidence on which concerns about learning difficulty were based; and how evidence of learning difficulty was acted upon (i.e. taken into account when providing services, referral for additional support)? • The Serious Case Review Panel found that Emma’s father had a learning difficulty. Individual Management Reviews should identify: if this information was known to professionals working with the family; if professionals had any concerns about Emma’s father’s learning capacity; the evidence on which concerns about learning difficulty were based; and how evidence of learning difficulty was acted upon (i.e. taken into account when providing services, referral for additional support)? B. Violence and Control • The Serious Case Review Panel identified domestic incidents where Emma’s father was alleged to have assaulted Emma’s mother. Individual Management Reviews should identify: how allegations of domestic abuse were acted upon and followed up, particularly in the context of the risk to Emma; and any missed opportunities to refer the family on to a different agency or source of support, such as a Multi-agency Risk Assessment Conference or other intervention. Could more have been done to support Emma’s mother to disclose information about violence within the home? • The Serious Case Review Panel found evidence that Emma’s father was violent, controlling towards Emma’s mother and had sought assistance with anger management. To what extent were professionals aware of Emma’s father’s violent and controlling behaviour and/or his propensity to be violent? If they were, was this information shared with other agencies and what were the expectations associated with sharing this information? C. The Serious Case Review Panel found limited information about Emma’s father in agency records. • Were professionals sufficiently curious about Emma’s father and his role within the family? • Did Emma’s father receive information/advice about appropriate handling of the child? D. Child in Need Plan • Emma was subject to a Child in Need Plan following a pre-birth assessment. Was this Plan sufficiently robust, with clear actions, responsibilities and contingencies if the Plan was not followed? Were professionals clear about their role and the role 11 of other professionals? Did the family appear to understand the Child in Need Plan and what was expected of them? Was the plan adhered to? How was it monitored? • The Serious Case Review Panel has identified that Emma’s paternal grandmother had a role within the Child in Need Plan. What was the nature of this role and why was it considered to be necessary? Was it appropriate? Were professionals clear about this role? Was the nature of this role sufficiently communicated to Emma’s family? • Were the support needs and parenting capacity of Emma’s parents adequately considered by professionals and are there any lessons to be learned? E. Were practitioners aware of and sensitive to Emma’s needs in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? Were there any indications or cues from this child that may have indicated that the child was being mistreated? F. The Serious Case Review panel has been advised that the police held information that would have been relevant to professionals working across agencies. All Individual Management Reviews will need to examine whether information held by their agency in relation to Emma’s parents was used effectively in terms of assessing risk to the child. G. Learning lessons about Professional Practice • Did professionals work with this family in line with expected professional standards? • Was there sufficient management oversight or supervision of front-line staff involved with this family? Individual Management Review Authors should take account of what level of supervision was available to practitioners and whether management oversight or supervision met the perceived needs of the practitioner. • What good practice, for other agencies as well as your own, and lessons can be learned from an analysis and evaluation of professional intervention with Emma and the family? • Where learning is identified for your agency, has this also been identified in previous Serious Case Reviews? If so, what recommendations were made and what action was taken previously? The Individual Management Review should identify why the issue has arisen again in this Serious Case Review. • To what extent did any organisational issues impact on the way in which your agency worked with Emma and her family? This could include issues related to staffing, workloads, agency structure and staff training as well as any other issues identified by the Individual Management Review author and the staff who were 12 involved with the case. The Individual Management Review should where possible also express the views of the professionals involved in the case. 1.7 The terms of reference for the health overview report 30. The Health Overview Report should provide an overview of the information and analysis provided by all health services for the Serious Case Review. In particular it should address the following: • Comment on the quality of information and analysis and identify significant themes and areas for learning • Comment on any specialist referrals or assessments undertaken and the extent to which these contributed to appropriate decision making • Provide comment on the extent to which evidence about neglect was identified and acted upon by various health services • Comment on the extent to which the reports provided by health services have identified appropriate learning and have provided sufficiently informed analysis • Give particular regard to any implications for the likely reform of health arrangements in Wakefield identified through the review regarding the capacity of primary health professionals to identify and follow up of children not presented for routine health advice or treatment • The quality of action already taken in response to the Serious Case Review and the recommendations and action proposed by the health IMR reports • Identify any further themes to be explored within the overview report • Make any recommendations necessary to ensure appropriate implementation of learning across the health service in Wakefield 1.8 The terms of reference for the overview report 31. Provide a multi-agency overview report in accordance with the national guidance in Working Together to Safeguard Children. 32. In addition to the requirements of Working Together to Safeguard Children (2010) and taking into account the specific issues identified above, the overview report author should: • Comment on whether the individual management reviews have addressed the terms of reference and all relevant issues; • Examine the inter agency working and communication between all involved agencies; 13 • Determine whether services which were provided, actions taken and decisions made were in accordance with current policies, procedures and government guidance; • Consider, using the benefit of hindsight, whether different decisions or actions may have led to a different course of events; • Provide an executive summary on behalf of the WDSCB. 1.9 Membership of the case review panel and access to expert advice 33. An independent person was appointed to chair the case review panel from the outset. Section 1.9 includes information about her experience and knowledge. 34. The case review panel that oversaw this review comprised the following people and organisations; Position Organisation Service Manager Safeguarding and Family Support Assistant Director Barnardo's Yorkshire Assistant Director, Patient Experience The Mid Yorkshire Hospitals NHS Trust Service Manager Wakefield Schools Inclusion Service Named Nurse South West Yorkshire Partnership Foundation NHS Trust (SWYPFT) Serious Case Review Co-ordinator, WDSCB Head of Safeguarding NHS Wakefield District and the health overview author Superintendent West Yorkshire Police Service Lay Member WDSCB 35. The independent author of the overview report attended every meeting of the panel after he was appointed in July 2012. 36. The panel had access to legal advice from a solicitor in the council’s legal service. 37. Written minutes of the panel meeting discussions and decisions were recorded by a member of the WDSCB staff team. 1.10 Independent author of the overview report and independent chair of the Serious Case Review panel 38. Edwina Harrison was appointed as the independent chair of the Serious Case Review panel. Edwina is a qualified social worker and has an MA in management and leadership. 14 She has many years of experience of children’s social care services in the statutory and voluntary sector. Her experience of Serious Case Reviews is as an author as well as independent chair. Edwina is a director of the National Association of Independent Chairs (LSCBs). 39. Peter Maddocks was commissioned in July 2012 as the independent author for this overview report. He has over thirty-five years of experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the Health and Care Professions Council. He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several LSCBs in England and Wales. 1.11 Parental and family contribution to the Serious Case Review 40. Emma’s mother and father were made aware of this Serious Case Review at the outset. In view of the parallel separate investigation by the police and the coroner, the Serious Case Review panel had to ensure that all contact with the family was the subject of appropriate consultation and advice. The panel used the national guidance agreed between chief police officers, the Crown Prosecution Service and the Directors of Children’s Services in England9. 41. The paternal grandmother and maternal grandfather responded to the invitation to meet with a representative of the review panel. The independent author of this overview report and the panel advisor met with them. They were also invited to meet again with the author and panel advisor prior to finalising the report and after the criminal proceedings had been concluded. The maternal grandfather together with Emma’s mother and another relative took up that opportunity. The following four paragraphs summarise key points raised during those discussions for the Serious Case Review and from their point of view. 42. The paternal grandmother was aware that both of Emma’s parents had a capacity to lose their temper with each other. Although the paternal grandmother had advised Emma’s mother that she would need to calm her anger when Emma was born the paternal grandmother did not have sufficient cause for concern to speak with any of the professionals working with Emma’s parents about this. Emma’s paternal grandmother acknowledged that Emma’s father had a temper and also referred to his difficulties with drugs. Emma’s paternal grandmother described Emma’s father as wanting to become a father to his own child. The paternal grandmother did not refer Emma’s father’s convictions. 9 A Guide for the Police and the Crown Prosecution Service and Local Safeguarding Children Boards to assist with liaison and the exchange of information when there are simultaneous chapter 8 Serious Case Reviews and criminal proceedings; April 2011 15 43. The paternal grandmother was aware that Emma’s mother had difficulty adjusting and preparing for the pregnancy but felt that her son’s willingness to be involved in the care of Emma was going to be helpful. The paternal grandmother had found it difficult to get to know Emma’s mother although both parents had visited her home. Emma’s paternal grandmother was not clear about why Safeguarding and Family Support Services were involved with Emma’s parents. Emma’s paternal grandmother said that she had not been aware that there had been a plan for her to live with Emma’s parents after Emma left hospital after her birth and she never had stayed with Emma and her parents. 44. Emma’s maternal grandfather (maternal grandfather) was aware of violence between Emma’s parents. His concerns centred on Emma’s father. He had had been involved on more than one occasion in confronting Emma’s father; on one of those occasions he had been telephoned by Emma’s mother for help just after Christmas 2011. He had gone to the house and had been involved in a physical and verbal confrontation with Emma’s father after which he took Emma’s mother to the police station with the intention of supporting her in making a formal complaint about the domestic abuse. He confirmed that Emma’s mother was spoken to in private by police officers and although the police asked if either of them wanted to make a formal criminal complaint Emma’s mother had declined the opportunity; Emma’s maternal grandfather felt unable to do anything further in the circumstances. 45. After the criminal proceedings had been completed they explained that they had concerns that if a formal complaint had been made to the police this would have led to further violence and repercussions for Emma’s mother. This matter is dealt with in detail later in the report. 46. Emma’s maternal grandfather did not seem aware that domestic abuse was something he could report to anybody else apart from the police although he had mentioned concerns about Emma’s father to at least one other professional. He felt that none of the services would take any significant action. 47. Emma’s maternal grandfather felt that some of the professionals working with Emma’s mother had more experience than others; he said that he felt more confident about the more experienced practitioners but was surprised that they were not always the lead professional for a service; for example he thought that the more experienced social worker appeared to take a less active role in the case. Emma’s maternal grandfather was particularly upset and disappointed in how the case had been managed by Safeguarding and Family Support Services although did not describe any specific incident or occasion when particular opportunities had been missed by any service. 48. The maternal grandfather was concerned that the previous history of Emma’s father had not been known to the family or to the professionals who had been working with Emma and her parents. The family felt strongly that there should be mechanisms for women to be alerted to a history of violence and convictions. 16 49. The extended family were critical of the questioning they had during the criminal proceedings about their knowledge of injuries to Emma. They felt that if professionals were unable to identify injuries without x-rays it was unrealistic to expect relatives to be able to do this. 1.12 Time scale for completing the Serious Case Review 50. The case review panel met on twelve occasions between July 2012 and May 2013. The initial chronology of services involvement was largely completed by July 2012. The first draft of the narrative agency reviews were also completed in July 2012 although not all final drafts including agency analysis were finalised until February 2013. The delay in being able to secure access to relevant health records was a significant barrier to completing a comprehensive narrative and analysis more quickly. The first draft of the Health Overview Report was completed in October 2012. The final report was presented to an extraordinary meeting of the WDSCB in March 2013. 1.13 Status and ownership of the overview report 51. The overview report is the property of the Wakefield and District Safeguarding Children Board (WDSCB) as the commissioning local safeguarding children board. Since June 2010, all overview reports provided to LSCBs in England are expected to be published unless there are exceptional circumstances. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Emma and her family. 52. The Overview Report is primarily written with the intention of addressing professionals involved with the design, oversight or delivery of multi-agency safeguarding services although it should also provide accountability and information to other interested parties. The Executive Summary provides a shorter account of the key findings from the review. 53. Both of the reports have to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible depth and range of learning required from a Serious Case Review. 54. The purpose of this review is not to try and second guess the judgements and decisions that various people and organisations made at the time of the events examined by the review. Hindsight can severely distort the clarity of information that was available and underplay the impact of time pressures, and the other influences and dilemmas that confront people dealing with a complex interplay of different factors. 55. In reading this overview report, it is important to remain clear about the purpose of the overall review and of this overview report in particular. The review examines with the benefit of hindsight and with other analysis, if it is possible to identify whether alternative judgments and decisions could or should have been taken, and whether different outcomes might have been achieved for Emma. This is summarised in section 17 1.16. The review does not investigate the circumstances of Emma’s death. That is a matter for the coroner and for the judicial system to investigate. 56. The review aims to be very challenging of all services for the purpose of building on the considerable knowledge and expertise that has developed in relation to the safeguarding of children in the UK. 57. The WDSCB will determine how and what further information is provided to the family at the conclusion of the review and submission to the Department of Education. 1.14 Previous Serious Case Reviews 58. The WDSCB in Wakefield has published executive summaries of four Serious Case Reviews undertaken between 2006 and 201010. 59. Reference is made to these previous Serious Case Reviews by several IMR authors and is also referenced where relevant in this overview report. The purpose of this is to highlight where similar issues or themes have been identified in previous reviews. This ensures that action already recommended is not unnecessarily repeated. Themes include domestic abuse, the resistance of some families to professional help and support and the important role of primary health professionals such as health visitors, midwives and GPs in collating information and recognising safeguarding concerns. All of these professionals are working with a large number of patients and have to navigate different information systems and are also subject to significant changes to commissioning and organisational arrangements. GPs in particular are the recipients of a great deal of different information from other health professionals that are stored in the individual patient record that can be extensive and complex. The events examined by the review coincided with the implementation of a revised electronic information system; this caused additional complexity for example in how information between different primary health professionals was shared and accessed. 60. All children’s services in England are subject to inspections. There are also inspections of other services such as health and the police. The panel has considered evidence from those inspections and other sources to inform the analysis and judgments in this case and to maintain a balance between identifying systemic issues or influences that can assist in the continued development of local safeguarding arrangements rather than becoming too preoccupied with case specific issues or hindsight bias. The inspections that are most relevant to the work of this panel relate to the annual assessment of the local authority that includes consideration of strategic partnerships between services and the focused assessment by Ofsted of the safeguarding arrangements. 10 These reviews were completed prior to the changes to the statutory guidance relating to publication of overview reports after the coalition government’s notice issued on the 10th June 2010 under section 16(2) of the Children Act 2004 which amended the previous national guidance in Working Together to Safeguard Children. 18 61. Chapters three and four of this review describe in greater detail the specific lessons to emerge from a detailed analysis of this Serious Case Review and include comments on how learning from previous reviews has been used. 1.15 Synopsis and conclusions of the review panel 62. Although Emma and her parents were known for a relatively short time, there was a high level of contact by several different services before and after Emma’s birth. This reflected the priority given by health and social care professionals in supporting Emma and her mother in particular who was recognised to have some additional needs. 63. Emma had not been identified as a child in need of protection although some professionals were concerned about the parents’ relationship and one health professional had felt that Emma’s case should have been discussed at a child protection conference and had raised this with Safeguarding and Family Support Services. However, this was not escalated through any formal processes in health or social care services. At the time, Safeguarding and Family Support Services was satisfied that the case could be appropriately managed as a Child in Need case. 64. With the benefit of hindsight, it is clear that in spite of the high level of contact with the family and the well intentioned and generally sensitive approach to Emma’s parents, there was important information about both of Emma’s parents that was either unknown or was only partially explored. 65. This related to evidence of historical violence, knowledge about the learning difficulties identified in both parent’s childhood and the sharing of information about domestic abuse and medical treatment. Both parents were reluctant to acknowledge problems and presented themselves as being motivated and capable of caring for Emma with contact from relevant services. 66. Emma died as a result of a physical injury for which her father was convicted. It is now known that there is a significant history of violence and anger in the individual history of both of her parents that was not largely known and therefore understood by the professionals in contact with Emma. The review analyses the multiple factors that contributed to how information and Emma’s case was generally managed and this is set out in the following sections of the report. 67. The only guarantee that Emma would not have been harmed would have been if she had been removed from the care of her parents; no professional in contact with the family had judged this necessary at the time although there was consensus about maintaining the high level of contact with the family which had continued up to her death. 68. If any professional had thought it necessary to remove Emma from her parents care it would have required the authorisation of a court for anything beyond using the emergency powers conferred on the police that are only intended for dealing with 19 immediate threat to the safety and wellbeing of a child; those circumstances did not apply in this case. 69. The police never had any contact with Emma. There was one brief episode in late December 2011 when the maternal grandfather took Emma’s mother to the police station following a confrontation with Emma’s father although none of the family made a direct and explicit complaint about violence. 70. A court would have required evidence in regard to the attitude, behaviour and care of both parents towards Emma. During her short life there was a high level of contact by health and social care staff with Emma and her parents’. Nobody identified any evidence of physical harm or injury to Emma and in general had observed parents who appeared to provide appropriate attention and care although recognised that they lacked experience and therefore needed the regular support of health and social care professionals in developing routines such as feeding and regulating the extremes of temperature for Emma for example from being too swaddled. The parents appeared to accept such advice from primary health professionals and this included taking Emma to be examined by the GP just prior to her death. 71. Services such as Safeguarding and Family Support Services were working with other families who at the time presented with a much more explicit level of risk and concern than Emma’s parents who were primarily seen as needing, and were apparently accepting, the contact and support from several different services. 72. The focus of the support was primarily upon Emma’s mother and although there was considerable contact with Emma’s father, his needs and history remained largely invisible for the purpose of formal assessment and planning. Some of this was because the remit of some services was to only work with a teenage parent and Emma’s father was 28. 73. There were gaps in how information that was held by different services was made available to the pre-birth assessment. There were issues for example in how the GP and other health and social care professionals communicated with each other; there were gaps between the midwifery and health visiting services, between hospital and other services, between adult and children’s services, between the police and Safeguarding and Family Support Services as well as between health and Safeguarding and Family Support Services. Signs and indicators of concern in regard to evidence of domestic abuse or abuse and the risk of harm were not sufficiently recognised or acted upon; this reflected a lack of willingness to report violence from within the family as well as no professional observing violence and disagreement over evidence such as bruising on Emma’s mother. 74. Important historical information that was known to some services such as the GP practice was not shared directly (although was shared via a third party who had alerted the GP to the significance of the information) with the social workers undertaking a pre-birth assessment and the social workers did not seek information from GP before or after the third party referral. The GP practices were not aware that a pre-birth 20 assessment was being undertaken. When information was shared by a third party from a non-statutory service it does not appear to have been recognised as potentially significant. 75. The GP practice along with the other health and social care services had a higher than usual contact with Emma’s mother before and after the birth. This contact was not with one individual GP; in line with other GP practices appointments could be made with different GPs. Until Emma’s father registered with the GP practice where Emma’s mother was already a patient, there was no knowledge in the separate GP practices about the relationship between Emma’s parents. 76. There was a degree of difference between professionals regarding aspects of mother’s cognitive functioning and the evidence of verbal and physical violence between the parents which were not satisfactorily resolved and were never properly discussed in a multi-agency meeting. This increased the potential for misunderstanding when information was relayed by third parties and through electronic and telephone messages. 77. The police, a local hospital as well as Safeguarding and Family Support Services did not pass on all relevant information for example when Emma’s mother had been subject of domestic abuse. There were also gaps in how plans were agreed and communicated both between the professionals and with the family. For example, Emma was discharged from hospital on the understanding provided by Safeguarding and Family Support Services that Emma’s paternal grandmother would be living with Emma and her parents; in the words of the health overview report (Health Overview Report) this was ‘lost in the transfer from hospital to home’ because the paternal grandmother never stayed with the family. 78. Although Emma’s mother was not formally assessed as having a learning disability it was apparent to some of the people working with her in 2011 and 2012 that she had difficulties in processing information and there were queries about aspects of her cognitive functioning. A referral was made to the Community Team for Learning Disability although the purpose of the work was the subject of misunderstanding and partial communication. An assessment of mother’s cognitive functioning had not been completed before Emma died. 79. None of the services were aware that Emma’s mother had been supported by the learning support service when she was at school; she was not asked and did not tell anybody about this aspect of her childhood history. Various childhood assessments had established that she had difficulties with auditory memory and sequential memory tasks which had an impact on her verbal understanding. There was indication of specific learning disability such as dyslexia. The problems with processing information were identified by Vol 2, the Parents with Prospects11 (PwP) course tutors and Vol 1. 11 Parents with Prospects is the name of the accredited parenting training programme provided nationally working to support parents and their children from birth to three years old in a range of places qualified to provide it that can include for example local colleges and children’s centres. The programme can lead to a 21 80. The only domestic incident recorded on the police systems between Emma’s mother and father was in late December 2011 when mother, along with Emma’s paternal grandfather, had gone to the police in Wakefield with the intention of reporting a physical assault by Emma’s father. None of the other incidents of violence between Emma’s parents in Wakefield were reported to the police. 81. Emma’s father’s history of convictions for violence, theft and criminal damage was not revealed as part of the pre-birth assessment. He had been reported as the perpetrator in ten domestic abuse incidents involving former partners that occurred outside of the time scale of the Serious Case Review and outside the Wakefield district. The incidents of domestic abuse as well as allegations of child abuse had been the subject of enquiries. In 2002 he had been charged with the Section 47 assault of a two year old female child. The victim was the daughter of the partner that he was in a relationship with at the time. There was no prosecution. 82. Emma’s father subsequently began a relationship with another partner who also lived outside the Wakefield area and who already had a child. It is well documented in that other local authority area that father had subjected that partner to repeated domestic abuse that had escalated in severity and had continued for a number of years until that relationship ended in 2010. The domestic abuse in that relationship had been referred to the MARAC12 in that other area in early 2007, after Emma’s father had subjected his ex-partner to a serious and sustained violent assault in which the ex-partner had suffered broken ribs. Emma’s father was convicted of a Section 47 Assault at Crown Court in 2007 as a result of that assault. 83. Due to the seriousness of the domestic abuse and the fact that there was a young child in the relationship, child protection referrals had been made to the local children’s services (not in Wakefield) after every incident of domestic abuse. In 2008 Emma’s father had been convicted and sentenced to 12 months imprisonment suspended for two years and a supervision requirement for six months. The final reported crime of battery and domestic abuse incident between father and his ex-partner was in early 2010. 84. This information about historic domestic abuse was not known to Safeguarding and Family Support Services in Wakefield before Emma died. Emma was never assessed as a child in need of protection and there were never any concerns about physical or other abuse of Emma. Formal safeguarding enquiries were therefore never invoked in foundation learning qualification in parenting, designed specifically for young dads, mums, partners as well as step parents. The training resources encourage discussion, help build confidence in relationships and encourage parents to develop their communication and family skills. The material is relevant to the diverse lifestyles of families and reflects the challenges parents face and especially for young and new parents such as Emma’s. 12 Multi-Agency Risk Assessment Conferences (MARACs): The MARAC is a victim-focused meeting, where information is shared on the highest risk cases of domestic abuse between criminal justice, health, child protection, housing practitioners, as well as other specialists from the statutory and voluntary sectors. A safety plan for each victim is then usually created. 22 Wakefield. The decision to complete a pre-birth assessment did require Safeguarding and Family Support Services to make enquiries of services, including the police, about what they knew about the family. 85. Safeguarding and Family Support Services believed that all relevant enquiries in relation to the pre-birth assessment had been completed although the Serious Case Review has identified that these were not as complete as had been believed at the time. For example, historical records were not accessed due to names being spelt differently. 86. Although there is a record in Safeguarding and Family Support Services of a check being made with the police there is no corresponding record in the police service. The Safeguarding and Family Support Services record is inadequate in as far as it does not identify who made the check from Safeguarding and Family Support Services or record the identity and location of the police contact. Requesting access to police information requires Safeguarding and Family Support Services to provide reasons for such access and there should be clarity in the record of the enquiry with the police about what data is being searched. 87. The discrepancy has been the subject of detailed inquiry in both services and to careful analysis by the review panel. In spite of this work it has proved impossible to fully reconcile the circumstances of the difference in recording within the two services and the reason for important information not being available and therefore not satisfactorily reflected in the pre-birth assessment. 88. Both of the social workers have been consistent in their firm recollection that a phone call was made to the police although neither can identify who had actually made the call. 89. The police check of relevant databases has not shown any evidence of those systems being accessed as an enquiry and check. 90. The Team Manager in Safeguarding and Family Support Services had been told that all relevant checks were completed by the social workers. The circumstances in which such important checks were not completed and recorded as thoroughly as they should be are examined later in this report. The Police and Safeguarding and Family Support Service have worked together to develop a new system for police checks involving an improved audit trail. 91. A combination of factors including heavy workload, a temporary office re-location to a venue in a more remote part of the district away from the community in which the team worked and a significant distance away from line-managers and colleagues, co-working arrangements that did not always define clearly enough responsibility for specific tasks including recording and having an unduly positive and insufficiently sceptical impression of parenting behaviour and motivation all had an influence on how the case was managed. 23 92. Serious Case Reviews frequently identify how events are influenced by men who were invisible to services. In this case there is significant information about Emma’s father that remained hidden from the assessment in particular. 93. The cognitive influence on professional judgment and decision making such as never seeing Emma’s father as a potential source of threat because of the positive way he interacted with social workers in particular is explored in later sections of the report. 94. Initially the focus had been on Emma’s mother’s anger problems and father was seen to be a counterbalance to some of mother’s difficulties. Although Emma’s father was seen on a regular basis by different professionals, the extent and significance of his history remained invisible and when there was a reference to violence it did not attract attention or inference. 95. In a district and culture where men are more often less visible and involved in the day to day care of children, there was an implied and positive inference that Emma’s father was more engaged and interested in Emma’s care and welfare compared to other men in many other families. 96. There is, particularly with the benefit of hindsight, some indication that he was increasingly coercive in his relationship with Emma’s mother and is consistent with the pattern of his previous relationships. The evidence of coercion was most clearly identified by professionals from a non-statutory service and who in relative terms had less training and by implication less professional standing or status in comparison to others. 97. Emma’s mother was both a victim of violence as well as being capable of losing control of her own emotions and this added to the complexity of providing effective help and support for Emma’s mother and for her baby. The grandparents had been aware of the violence in the relationship although each tended to feel that their own child was more the victim than the perpetrator. 98. The evidence of injuries to Emma’s mother, the reports of concerns and her assertion that any bruising was a result of her colliding with doors were heard and recorded but did not provoke more sceptical or curious responses. There was also disagreement between professionals about whether there were bruises or not. On one of the occasions there had been a visit made by a qualified social worker who did not see any bruising. 99. Disclosures about the evidence of injuries were not always communicated and recorded clearly enough; an example occurred between the health visitor and social worker in April 2012. Another was the treatment at hospital for a hand injury that was not referred on. 100. There was an opportunity in late December 2011 for a safeguarding referral to have been made by the police to Safeguarding and Family Support Services when Emma’s maternal grandfather had taken Emma’s mother to the local police station to 24 complain about the assault by Emma’s father that grandfather had stopped. It did not happen because although there was a clear record on the DASH risk assessment about the pregnancy and about prior history of violence the officer responsible for signing off the incident did not check the full documentation thoroughly enough and relied on a shorter summary of the incident that did not identify that Emma’s mother was pregnant. 101. It was recorded on the shorter summary log of the incident that Emma’s mother ‘did not have children yet’; this was rather than making a more explicit statement that she was in fact pregnant and also making clear that the pregnancy was at an advanced stage and therefore any assault represented risk to the mother as well as to the baby she was carrying. The signing off did not challenge how the incident had been handled and recorded in terms of whether there was evidence of violence that deserved investigation as a crime. 102. The reliance on Emma’s mother or her maternal grandfather telling the police that a violent argument had occurred did not have to exclude the police from deciding whether the incident required further enquiry by that service or consulting other agencies such as Safeguarding and Family Support Services. The police were hampered by the lack of information apparently provided. 103. People in other services could also have made safeguarding referrals at other times to Safeguarding and Family Support Services but did not. Concerns were raised especially in February 2012 in regard to how the Emma was being categorised as a child in need in contrast to seeing her as a child who potentially required protection although the concerns were not formalised either as a referral or through other formal escalation procedures. Some of this may have reflected a lack of professional confidence as much as relying on Safeguarding and Family Support Services having all the relevant information required to make an informed and balanced judgment. 104. Several services had information at different times that could have prompted further and better informed enquiries being made that included the GP practice, the specialist midwifery service, Vol 2, the police as well as Safeguarding and Family Support Services. It is now known that the GP records held information about father’s history of violence. The GP made a referral to the Vol 1 with the apparent purpose of helping father with his anger management. 105. Although Vol 1 recognised that this had potential implications in relation to Emma and discussed this with the GP and with Safeguarding and Family Support Services, the GP practice did not share information with Safeguarding and Family Support Services or make a referral. The GP records also contained information about Emma’s mother having been the victim of harassment in regard to a previous partner which was not known by other services. 106. It is highly probable that if all the information known about Emma’s father had been more fully considered, using the local safeguarding processes, he would not have been allowed to have cared for Emma without a very high level of formal supervision and under limited circumstances; the paternal grandmother had expressed surprise that 25 there had not been more apparent supervision and this no doubt reflected the fact that she knew the history although had not realised that Safeguarding and Family Support Services were not in possession of the same level of information. 107. Regrettably, rather than being seen as a potential source of risk because of his historical behaviour, Emma’s father was regarded as a source of day to day care for his daughter and it was felt at the time that he compensated for some of the more apparent difficulties that Emma’s mother has. This was the view of the paternal grandmother who also saw how much her son wanted to be a father. He took responsibility for many of the household tasks and was observed handling and caring for Emma appropriately. 108. Emma’s father had talked with the GP about his anger problems and had initially agreed to participate in local services designed to help change violent behaviour. He seemed responsive to advice from people such as the midwife and health visitor, although there were other occasions when he was seen to be controlling and more reluctant to have contact particularly from health and early year’s workers. 109. The GP practice was not aware that Emma’s father had not engaged with the anger management service until the SCR collated information across the different services. Emma’s father had left the practice and his records were transferred out. 110. There would have been better opportunity to have protected Emma if the risks from both parents had been more clearly identified and had triggered local safeguarding procedures and had been addressed through a child protection plan from the time of her birth. The benefit of hindsight indicates that this is what should have happened. 111. It is an acknowledgement that the lack of knowledge in particular about the history of both parents and their difficulties with violence was a significant influence in how they were both assessed. The pre-birth assessment did not secure this information. There were other factors in addition to the history of anger and violence that that can now be seen as deserving of consideration. 112. From the first contact in regard to Emma in July 2011 when her mother was booked in for ante-natal care for her pregnancy there was recognition that additional support would be required. The sources of vulnerability identified at the initial booking had included the short length of time that the parents had known each other; the fact that mother was 18 years old and father was 28 years old; there were already arguments between the couple. 113. There was far more limited information sought or recorded about father although it was known that he had problems with his anger and he acknowledged that he had attended anger management sessions although no specific information was sought in regard to this. 114. Emma’s father had been diagnosed with significant learning difficulties as a child. There had also been considerable historical involvement by Safeguarding and Family Support Services with his family. This was in addition to the involvement of 26 criminal justice services and of a neighbouring Safeguarding and Family Support Services in regard to father’s alleged physical abuse of previous partners and their children. Reasons for the limited focus on Emma’s father at the outset included the structure of the forms that were used for recording details of a new pregnancy; these have already been changed and midwives are now required to collect more detailed information about fathers at the point of booking a pregnancy that includes relevant history. Inevitably, this information relies substantially on the information that is disclosed by the parent (s). 115. Other factors that contributed to insufficient attention on father and his background at the outset were that the contract for the Vol 2 service was focussed on young people aged 18 or younger. Mother was regarded as the ‘client’ of the service and father remained peripheral and did not qualify for help or advice from the service because of his age. This has already been addressed in a review of the contract and working arrangements in 2010 following a previous SCR in regard to Child D. 116. Although a decision was made by Vol 2 to use the Common Assessment Framework as a means for coordinating information and support when they became involved, this was never adequately completed or used to inform the work of the other services at a later stage. This reflected a range of factors that included confusion arising from the piloting of new arrangements, the heavy workload across the different services, some lack of clarity in regard to specific specialist roles and insufficient co-ordination of information and action between the different people who became involved. All of this was occurring during a time of considerable organisational change for several services. 117. There was also a high reliance on telephone conversations and messages to relay important information that was not routinely followed up in writing or using a written referral to record a concern with Safeguarding and Family Support Services. Some services such as the GP never apparently initiated any contact with the other community health services or Safeguarding and Family Support Services in regard to either parent although made a referral to the Vol 1 in regard to Emma’s father and his anger issues. 118. The case was allocated to one of the specialist midwives who was collocated with and worked closely with Vol 2, a specialist commissioned service, which provides targeted support to young teenage parents designed to help them to become involved in education, employment and training as well as caring for their baby. 119. The involvement of these services meant that a specialist midwife, a Connexions personal assistant (CPA1) and two family support workers (FSW1 and FSW2) were providing intensive and regular contact during the early stages of the pregnancy and the case was allocated to a worker in the Vol 2 service from August 2011. 120. It had been noticed early on that mother appeared reluctant to accept help. This behaviour is not particularly unusual. A critical part of the role and skill of health and social care professionals is to try and develop a relationship with young adults who may feel frightened of professional involvement and may have had a poor experience such as 27 difficulties in education. There was some discussion at an early stage as to whether mother might have a learning difficulty although others also felt that it might be a reflection of just being shy and lacking confidence. 121. In early October 2011 there was an initial meeting involving Vol 2 and Emma’s parents. At that first meeting FSW2 had explained the purpose of the Common Assessment Framework. Mother had needed some persuading to agree to a meeting. This initial discussion focussed upon Emma’s mother and her difficulties with anger and her feelings of depression. Although Emma’s father mentioned that he had a criminal record for violence and that he ‘thought’ he had two children this information was only recorded but not followed up (because he was not seen as the focus of the work). This would otherwise have been the first opportunity to have secured clearer information although there were other subsequent occasions involving other professionals when this information was also missed. 122. The Common Assessment Framework that was subsequently developed had focussed on Emma’s mother. The plan described a list of actions that included securing the appropriate benefit income; this proved to be complicated by the fact that mother moved frequently between Emma’s father’s flat and the maternal grandfather’s home. This occurred largely as a result of the arguments the couple regularly had although this was not understood at the time. 123. The Common Assessment Framework plan also included seeking treatment and support for mother’s depression and encouraging her participation on anger management work with a voluntary organisation in Wakefield. Arrangements were also made for mother to participate in a ten week course at the local college called Parents with Prospects (PWP). 124. The Common Assessment Framework was not shared either with the parents or with any of the other services or professionals at any stage. A similar lack of sharing a plan occurred in regard to the Child in Need plan that was subsequently developed in early 2012. Separate to the Common Assessment Framework process, the GP had made a referral to Vol 1 in regard to Emma’s father’s anger management. 125. It seems the referral was at the request of Emma’s father who knew that his partner (Emma’s mother) was pregnant. Emma’s father had already declined to participate in the anger management work; he cited not having financial support to attend the sessions but during other discussions with professionals he also made clear that he saw no point in participating in such sessions and on at least two occasions made it clear that he had already undertaken work in relation to his anger management. This was never followed up either in ascertaining why he had been referred or what outcomes had been achieved. 126. The concerns about mother’s ability to process information were a reoccurring issue for the Vol 2 practitioners. Examples included a discussion with CPA1 about how mother planned to leave Emma with the maternal grandparents when she and Emma’s father were having arguments. She also talked about sending mobile phone texts to 28 Emma to check she was alright because she had been learning about the importance of bonding with her baby. On another occasion in college she had talked about the difficulties she had in understanding what people were saying to her and she needed to have it ‘broken down’. She was also observed to defer frequently to Emma’s father and to members of the extended family during discussions. 127. As these concerns about mother’s level of understanding were being noted particularly by CPA1, the first evidence about domestic abuse emerged. Mother had disclosed that the arguments she had with Emma’s father were frequent and that it could involve father hitting cupboards. Emma’s mother was also observed on more than one occasion to have bruising; this was noticed in college as well as by the FSW and CPA1. On every occasion mother denied that the injuries were a result of a physical assault and claimed consistently those had been caused by a collision with an object such as a cupboard door. It is notable that there was disagreement on some of these occasions between Vol 2 and Safeguarding and Family Support Services in particular as to whether there was any evidence of a bruise. 128. In November 2011 CPA1 sought advice from the community team for learning disabilities in regard to how she could develop a better understanding about whether mother had a learning difficulty. She was told that she had to make a formal referral through Safeguarding and Family Support Services. She completed this referral and sent it to Social Care Direct where it was mistakenly filed by an administrator as an opened case note on the Care Director electronic records system and was therefore not sent to the Community Team for Learning Disability as a referral until it was followed up in mid-January 2012 by CPA1 asking what had happened. The reason for the misfiling was that Emma’s mother was correctly identified as being an ‘open case’ for Safeguarding and Family Support Services and therefore did not recognise that the referral was specifically for adult’s services. It was filed with Safeguarding and Family Support Services records. Nobody spotted this error. 129. The referral to the Community Team for Learning Disability asked for an assessment of learning difficulty, an assessment of what services could be provided and a consideration of an independent advocate. The purpose of the referral was to have further help from the specialist adult’s service in developing a better understanding about how Emma’s mother was processing information and advice. 130. This was not clearly understood by the Community Team for Learning Disability service who managed the referral as a request for community care services against the framework and criteria set out in relevant national and local guidance and standards in regard to fair access to services against benchmarks or thresholds of learning difficulty. 131. There was continuing divided opinion between Safeguarding and Family Support Services and other professionals as to whether there was evidence of any cognitive difficulty and therefore justifying the need for an assessment by Community Team for Learning Disability. Safeguarding and Family Support Services was more persuaded that Emma’s mother lacked confidence and had been the main point of contact for the Community Team for Learning Disability social worker. Community Team for Learning 29 Disability were therefore influenced by the ambivalence of the social worker in Safeguarding and Family Support Services in regard to learning difficulty in contrast to CPA1 who had originally made the referral. 132. The first referral made to Safeguarding and Family Support Services in early November 2011 was from the supported living service that was working with Emma’s father. The referral stated that neighbours had heard regular arguments between Emma’s parents and the latest argument had included overhearing father saying he would not go back to prison; this had been understood as suggesting he had already been convicted for a previous violent assault. 133. This incident was not reported to the police by either the supported living service or by Safeguarding and Family Support Services after they received the referral. It should have been. Although the case was allocated within timescales the first record of enquiries by Safeguarding and Family Support Services in regard to the information provided by the supported living service was a telephone call to Vol 2 almost two weeks later to find out what information that service could provide. At that stage, a delay may have been attributable to the fact that Emma was not due to be born imminently and there were other cases taking more urgent priority due to the workload in the service. 134. A decision was made that a pre-birth assessment would begin within ‘the next couple of weeks’. This was interpreted by the Vol 2 as meaning that a statutory assessment was being started by Safeguarding and Family Support Services and therefore the Common Assessment Framework was closed. This was in line with the understood practice arrangements that had been developed. It signified that Vol 2 would no longer be the lead agency given the involvement of Safeguarding and Family Support Services. 135. From late November 2011 Vol 2 had remained involved but believed that the lead professionals for co-ordinating work with Emma’s parents were Safeguarding and Family Support Services. In Safeguarding and Family Support Services, although a decision was taken to complete a pre-birth assessment this was not governed by any explicit national standards although there is a local framework that requires multi-agency contribution and for the assessment to be written. Two social workers were appointed to undertake the assessment although it did not begin until February 2012 and had not been written up by the time Emma was born; seven visits had been made and the IMR author confirms that there were detailed handwritten notes. 136. The significance of the assessment not being written is that although a considerable amount of information had been collected, it had not been subjected to a sufficient level of analysis and reflection by the two social workers in consultation with other professionals or in their regular supervision with the Team Manager. 137. It is possible that if a written assessment had been completed by the social workers and had been shared with the other services working with Emma it might have highlighted the gaps and inconsistencies for them to address and would have also been subject to a check by their Team Manager who is very experienced. 30 138. Instead there was a high reliance on discussion in formal supervision as well as other more ad hoc conversation just within Safeguarding and Family Support Services. A number of issues are identified in regard to how the assessment was handled and are analysed in further detail later. 139. The pre-birth assessment had been an opportunity for routine checks with the police (as well as with other services) to discover what information they had about either parent. The pre-birth assessment should have sought contributions from other services. This was not done. There is evidence that Vol 2 and the specialist midwife queried the assessment process on more than one occasion. These were generally met with assertions that the assessment would be completed over the ‘next couple of weeks’ and that it was looking positive. This prompted the CPA1 in particular to try to escalate her concerns. 140. The process has now been thoroughly reviewed and in respect of pre-birth assessments the Safeguarding and Family Support Service and Mid-Yorkshire Hospitals NHS Trust now work together more closely. Pre-birth assessments are complete jointly between the social worker and the midwife using an agreed written protocol and joint audit activity takes place to enable quality to be assessed. 141. Vol 2 and the specialist midwife wanted to have Emma escalated to a level of formal child protection rather than as a Child in Need in February 2012. Safeguarding and Family Support Services were not persuaded that Emma was a child at risk of significant harm on the basis of the information they had accumulated at that time. The safeguarding procedures would have been invoked by that service if the information about Emma’s father’s history of violence to previous children had been sought. 142. When Emma’s mother was still in labour the hospital were aware of Safeguarding and Family Support Services involvement and sought clarification about the birth plan and the hospital discharge arrangements. No formal written plan was in place although they were informed that arrangements had been made for the paternal grandmother to move into Emma’s household to provide support; reference has already been made to paternal grandmother stating that she had no knowledge about this arrangement although there is evidence of discussions having taken place that involved Emma’s paternal grandmother. 143. After Emma was discharged from hospital there was a high level of visiting by the different services. On the majority of these contacts it was Emma’s father who was providing the care to Emma. For some practitioners such as the children’s centre there was a concern that father was very overbearing. 144. Two days before Emma died the health visitor had made a routine home visit and found that Emma had lost weight. The health visitor wanted Emma to be medically examined and her first choice was for Emma to be seen by the hospital paediatric service. This was a referral she could make direct to the hospital. Emma’s parents were given the option of taking their daughter to the GP as an alternative and reflected 31 sensitive practice given there were no pressing concerns about the immediate safety of Emma. The parents found this arrangement more convenient given their lack of personal transport. 145. The health visitor was unable to speak to the GP but made an entry on SystmOne13. Emma was examined by the GP later that day who regarded the examination as routine and found nothing of concern in the absence of any prior discussion with the health visitor; the health visitor’s recording which was the last entry on the patient record and should have been visible but was not read by the GP, and who therefore remained unaware of the health visitor’s interest in making the appointment for Emma to be seen by a doctor. 146. It is not clear from the reports provided to the SCR panel why the GP did not see and therefore read the record made by the health visitor. However, discussion between the Health Overview Report overview author and the named GP14 has provided a better insight in regard to the use of filters that can be set by users of the electronic records system. For example, the GP can set a filter that limits the notes being shown on their computer screen to just showing clinical records and excluding other information for example from third party entries such as a health visitor. 147. Although it is understandable that a busy professional such as a GP who has limited consultation time with a patient will want to streamline the information they are having to access during a consultation it clearly has implications for how the information is used by all health professionals. 148. This is an example of where in spite of investment in new systems designed to enhance communication within complex and dispersed clinical and organisational settings, human interaction with those systems can be inconsistent for busy health professionals. Significant work has been taken forward to understand the underpinning systems and processes of information sharing between hospital and primary care. The Mid Yorkshire Hospitals NHS Trust has held a number of workshops with hospital and community staff to develop solutions to these problems. This work is still in progress and now forms part of the IT Strategy for the Trust. 149. For the purpose of clarity, even if the GP had read the health visitor’s note, the panel do not believe that the outcome of the examination by the GP would have been different given the injuries that Emma had suffered were largely detected by x-ray. The 13 SystmOne, is an electronic patient records system being implemented in some areas within the NHS. The introduction of the system is intended to improve information sharing and provide greater clarity about which services are being provided to a family and helps improve the interface between adult and children’s services protecting children or vulnerable adults. 14 Named Doctors and Named GP's are paediatricians and GP's who have additional roles and responsibility for child protection. They provide advice and expertise to fellow professionals either within their organisation or within their region. They have a key role in promoting good professional practice within their organisation or within their region 32 focus of the consultation was Emma’s slight weight loss and she was brought to the surgery by both of her parents. 150. When the health visitor subsequently spoke with the GP after he had seen Emma, the GP had a clearer understanding about why the health visitor had asked for the examination. Although the GP would have been made aware that Emma was subject of a Child in Need plan, it does not suggest there would have been a different outcome from a physical examination of Emma. 151. During that last visit by the health visitor the maternal grandfather had also told the health visitor that he had to intervene in an argument between Emma’s parents when her father was dragging Emma’s mother by her hair. Although the health visitor telephoned Safeguarding and Family Support Services after her visit the phone call was not included in the Safeguarding and Family Support Services records. It remains unclear whether the information about the physical assault on Emma’s mother was passed on to Safeguarding and Family Support Services. 152. The various contributory factors identified by the review influenced how Emma’s case was managed. The communication of information was not handled with enough clarity of purpose or attention to detail. The practice of allocating co-workers by Vol 2 and by Safeguarding and Family Support Services contributed an additional layer of complexity for both the family in the number of professionals in contact with them as well as managing information between the different workers. It is a possibility that the heavy workloads and co-working was a contributor to the social workers assuming that a check with the police had been completed. 153. Not enough attention and significance was given to what members of the maternal extended family were saying especially about their concerns regarding Emma’s father. The initial referral was not followed up for several days and there were delays in responding to some messages. When the raising of concerns failed to deliver an expected outcome there was reluctance to escalate matters further. Some of this reflected the different professional status for example between the CPA1 and SW1 and SW2. There were also problems arising from the piloting of the Common Assessment Framework system as an initial assessment in the Vol 2 service. The co-location of the specialist midwife meant that she did not have access to her professional intranet communication network and records. 154. Assumptions were also made that key people such as Safeguarding and Family Support Services were in full possession of all the relevant information and were therefore able to make appropriately informed judgments. 155. The health overview report (Health Overview Report) highlights that although individual health practitioners from the GP to specialist staff such as the midwife displayed positive care and attention to the support needs of her mother in particular there were gaps in critical communication within the health community as well as with other services such as Safeguarding and Family Support Services. 33 156. The early recognition that Emma was a pregnancy requiring higher levels of support were notified as usual after booking to the health visiting service who did triage the case as a priority. However Emma’s mother did not receive an antenatal visit. The practice at that time was that on receipt of the booking form with the Perinatal Mental Health Pathway the case should be triaged and placed into a file. Subsequently another person would place it in the allocations file two months prior to delivery to prompt an antenatal visit for “priority” cases only. Immediate action has been taken and the process of receipt and allocation of the information from the midwifery service has been reviewed and a better, uniform approach developed across all health visiting teams within the Wakefield district. Once Emma had been allocated after birth the health visitor very quickly gave priority to Emma and her mother from the first visit. 157. Similarly, GP information about Emma’s father having anger problems was not sufficiently recognised as a potential source of concern when the pregnancy began. However, Emma’s father was registered with a different GP several miles away and therefore there was even less opportunity to link his history with the information about a pregnant girlfriend unless he either volunteered information or had been asked. The GP was not aware of the pre-birth assessment and was never asked for information. 158. Although the midwifery service did know that Safeguarding and Family Support Services were conducting a pre-birth assessment and managing Emma as a child in need no request was made to participate in the assessment or to seek a copy of the Child in Need plan. There was in the words of one of the IMR author’s a general absence of curiosity. It is significant that all of the health services together with the other agencies working with Emma were operating with high levels of workload. Further information and analysis is provided in this report. 159. Other factors identified by the review that had an influence included the overall work capacity of individuals and services; a degree of normalisation in regard to how relationship problems were viewed; professionals being asked to undertake work without understanding the purpose. 160. The assessment that did not reflect multi agency contribution is an important example but there were also problems for example in the request that was made for Emma to be examined when the health visitor assessed that she had lost weight. Another factor was the dilemma and difficulty that confronted professionals wanting to get a foothold with two adults who were not easy to engage or open to contact but who also appeared to be accepting of help. 161. There was limited understanding displayed about the nature of violent and coercive relationships. Reliance by any service on the victim to make open and consistent disclosures is fundamentally flawed and displays a lack of understanding about the psychological and other pressures that operate in such relationships especially during pregnancy and following birth. This has implications for how crime is recorded and investigated as well as for the type of enquiry and assessment by health and social care professionals. 34 162. Many of the services reported very heavy workloads at the time of their involvement with Emma and her family. Examples are the Safeguarding and Family Support Services Team Manager having responsibility for supervising ten social workers who between them had over 280 cases that by definition represent high thresholds of need or risk and complexity or they would not have been allocated. The specialist midwife had a personal case load in excess of what had been anticipated when the post was created and was personally working with 26 very vulnerable young women of whom 18 were safeguarding concerns; significantly, Emma’s mother was not one of those 18. 163. The health visiting service was operating at above average caseload levels and at the time Emma died had one vacancy and a team member on leave out of a complement of 5.9 professional staff working with over 1800 children. 164. This information about resource allocation is not intended to indicate that it is an excuse for what occurred in this case. It is however important to understand the realities and circumstances within which professionals worked with Emma. 165. For example, Safeguarding and Family Support Services and the health visitor were undertaking a higher number of visits to Emma but the quality of their follow up, recording of information and their opportunity for proper reflection are aspects of this case that require a better understanding than simply regarding it as a problem about the performance of any individual. 166. The police also comment about the very high workload in the police safeguarding unit that was a contributory factor in the way in which the report of the domestic abuse in December was recorded and checked. 1.16 The family and other significant people 167. At the time of Emma’s death she was living with both of her parents at their home. The grandparents live locally and were in regular contact. They participated in some meetings with professionals. Considerable reliance was given to their involvement in being able to mitigate some of the vulnerability. 168. Emma’s father was diagnosed as a child with a significant level of learning difficulty which if it had been known about deserved examination within a parenting assessment. 1.17 Cultural, ethnic, linguistic and religious identity of the family and their community 169. Emma’s parents are white British. They speak English as their only language. They were both unemployed. There is no known affiliation with a particular religion. 170. The large majority of the population in Wakefield is white British (96.7 per cent), which is significantly higher than the national figure of 87 per cent. There is, however, a significant Pakistani community in Wakefield East. 35 171. Wakefield ranks as the 66th most deprived local authority in England out of 354 based on the average Index of Multiple Deprivation scores, with particular issues around household income and employment. According to the October 2010 school census, just over 17 per cent of statutory school aged pupils are enrolled for free school meals. The area in which Emma’s family lived is amongst the most disadvantaged areas in the district. There are higher levels of unemployment and ill health. Diet and life styles are poorer. 2 Narrative account of agency involvement 172. This chapter provides a narrative of professional contact with Emma and her family which has been summarised in chapter one. Although the focus of the Serious Case Review is upon the involvement of different services from when it was known that mother was pregnant with Emma up to her death there is relevant prior history that is summarised in the IMRs. 173. This chapter provides an account of the most significant events and decisions from the different services involved with Emma and her family. The analysis of that involvement is provided in chapter four of this report against the key lines of enquiry. 174. The parents made an application for housing on 28th June 2011 after becoming homeless due to the maternal grandparents asking them to leave their home. They secured a tenancy on the 4th July 2011. As part of that tenancy agreement they were required to come to the supported living service once a week to discuss with their case worker how the service could assist them with moving onto a secure and longer term tenancy as well as providing help with training and work. 175. On the 1st July 2011 mother attended for an antenatal booking with the community midwife at approximately seven weeks of her pregnancy. A routine booking and a pre Common Assessment Framework assessment was undertaken and the community midwife identified low BMI (body mass index; low BMI is associated with adverse outcomes such as low birth weight); the midwife provided information about diet and noted ‘the possibility of learning difficulties’. 176. The community midwife made a referral to the specialist midwife who met with Emma’s mother on the 18th July 2011; she was provided with leaflets and the suggestion was made about agreeing to the midwife making a referral to the Vol 2 service. This referral was made the following day. 177. Unknown to the midwife, Emma’s mother had received treatment at The Mid-Yorkshire Hospitals NHS Trust emergency department on 14th July at 18.34hrs with abdominal pain. She was sent home and follow up was arranged for the early pregnancy assessment unit. Later on the same evening Emma’s mother had gone to a different hospital outside the Wakefield district at 22.57hrs when she was admitted to a ward with symptoms associated with the pregnancy. She was discharged on the 15th July at 03.00hrs. 36 178. A letter was received at the GP practice on the 20th July regarding the hospital emergency department attendance out of district. Although there is no record that Emma’s mother stated that the visit to either emergency department had followed any physical violence or that she was specifically asked whether she had been assaulted, it remains a possibility that the visits to the hospitals had followed a violent argument. Further information is analysed in later sections. 179. The referral to Vol 2 on the 19th July 2011 stated that Emma’s mother was 18 years old and about nine weeks pregnant. Emma’s father was named on the referral as Emma’s mother’s partner but was not referred in his own right; this would become significant for the ways services were provided and allowed father to remain of secondary interest. The reasons for the referral were that Emma’s mother and father’s relationship was relatively new and they were arguing daily. The analysis provided in later sections of this report reflects on the extent to which mother remained the focus of contact. 180. The referral noted that Emma’s father had said that Emma’s mother could get very aggressive and ‘lash out’ or ‘throw things’ and that Emma’s mother had acknowledged she had issues with anger that she would like support with before the baby arrived. Emma’s father had also acknowledged that he had issues with anger in the past for which he had attended anger management sessions. Emma’s mother’s expectations of the referral were recorded as support with her relationship and parenting. The specialist midwife noted on the referral that she had spoken to Emma’s parents about completing a Common Assessment Framework when she returned from annual leave. 181. The specialist midwife subsequently discussed during supervision with the safeguarding midwife, the disclosure of anger management issues and of arguments between Emma’s parents but did not open a Common Assessment Framework which would have been the expected practice and would have provided the initial opportunity for coordinating an early assessment involving other services. 182. Vol 2 undertook an assessment using the Common Assessment Framework which was completed on the 31st August 2011. The assessment was in the name of the unborn baby but focussed mainly on mother’s needs and abilities. At the point of that assessment Vol 2 thought that there appeared to be a lot of strengths for mother including her strong family support; she was beginning a college course in September 2011; she appeared to have good self-care skills; she appeared to have an understanding of the responsibilities and demands of parenting and she was apparently keen to access support. 183. The main risks identified were that Emma’s mother had nowhere settled to live; she was living between her parents’ home and the flat that Emma’s father had; she would be a first time parent; she had difficulties with her anger control (on one occasion she had thrown a cup of hot coffee at Emma’s father) and she was not in receiving any money of her own. During the assessment process Emma’s mother had said that ‘family 37 services’ had been involved with Emma’s paternal uncle but she did not know the reason for that involvement. 184. The recommendations of the assessment were to put a multi-agency Common Assessment Framework plan in place; to involve Emma’s father in the support; to work with them to be better prepared for parenting; to access support around anger management and be in a better financial position (by accessing all benefits that they were entitled to receive as parents as well as access to training for employment) 185. Following the assessment, arrangements were made to give Emma’s mother a lift to her first appointment at the Vol 1 for support with her anger management. She was not at home when a worker went to pick her up. She subsequently said she would attend the next appointment in September 2011. It is significant that when Emma’s mother did attend at Vol 1 in October 2011 she declined to give her consent to information being shared with other services such as social workers and primary health care workers. This issue is explored further in later chapters; although it is required practice to seek the agreement of parents in regard to sharing sensitive and confidential information with third parties, the legislation and codes of professional practice are explicit about a higher duty to discuss information when there are concerns about the safety or wellbeing of children (or vulnerable adults). 186. A family support worker was allocated to work with Emma’s mother on the 13th September 2011 and she updated the Common Assessment Framework with Emma’s mother on the 22nd September. Emma’s mother disclosed that members of her close family had received support because of their anger issues which consisted of shouting when angry but neither she nor her brother had witnessed or experienced any physical violence as children. She appeared to have an understanding of her own anger issues identifying that it mostly happened when she was with Emma’s father and acknowledged that she could ‘hit or throw drinks’. She said that Emma’s father would hit doors when he got angry but that he had not hit her and that he would also like to be helped to address his anger. 187. Emma’s mother appeared to understand the risks that this behaviour could pose to her baby when it was born and stated that this was why she wanted to accept support. She had not yet attended an appointment at Vol 1 but had attended one session of the teenage ante-natal group at the children’s centre. At this stage mother said that she did not find Emma’s father’s family supportive and would not want them to attend a Common Assessment Framework meeting. 188. On the 4th October 2011 Emma’s mother went to the emergency department at The Mid-Yorkshire Hospitals NHS Trust to receive treatment for swollen fingers on her right hand that she had sustained when she had punched a wall three days previously. She told a nurse that she had problems with her partner who becomes violent when he is drunk. She told the nurse that she had moved to her mother’s home to be safe. An X-ray was taken that showed no fractures. The doctor who examined mother was a locum (and therefore was not available for a discussion with the IMR author). There is no recorded evidence that the disclosure of domestic abuse was discussed. The GP practice 38 was notified about this visit to the emergency department. Coincidentally Emma’s mother was also in contact with the midwife to cancel the planned Common Assessment Framework meeting. 189. There were attempts to engage both of Emma’s parents in the Common Assessment Framework process in early October 2011; however Emma’s mother declined further involvement on the day and whilst a further Common Assessment Framework meeting was arranged by specialist midwife and Vol 2 for 16th November 2011 Emma’s mother continued to resist involvement in the Common Assessment Framework. 190. The first Common Assessment Framework meeting was on the 6th October 2011 that was attended by Emma’s parents and the maternal grandparent. Emma’s mother had tried to cancel the meeting and when asked why, she initially said she didn’t know, and then had said that her family didn’t think she needed support but that she was persuaded to go ahead with it. At the meeting Emma’s father stated again said that he didn’t think they needed support but when the concerns around mother’s anger issues posing a risk to a baby were explained they all agreed to the process. 191. At this meeting Emma’s father disclosed that he had a criminal record for violence and also thought he might already have two children that he did not have contact with. He talked about being anxious about having this baby taken away from them. Emma’s mother discussed having been bullied in the past and feeling depressed and crying a lot of the time. A plan was agreed to provide support to mother. This involved mother talking to her GP about sources of help with her depression; she would also attend appointments at the Vol 1; she would attend ante-natal classes with Emma’s father and maternal grandfather to prepare them for parenthood; sort out her benefit entitlement. Analysis is provided in later sections about the lack of follow up to the information about father’s criminal record or previous children. 192. In October 2011 Emma’s mother was accepted onto the Parents with Prospects (PwP) course (a Level 1 accredited course with a focus on developing parenting and life skills) run by Vol 2; she started attending on the 11th October 2011. Her college tutor had identified that because of her learning needs she was struggling with a Level 1 health and social care course and felt that the content of PwP would be more appropriate for her. 193. During this time Emma’s mother was supposed to be attending appointments at Vol 1 (although was not engaging with that service), attending PwP, and accessing counselling for her depression at the GP surgery. The PwP tutors were becoming aware that Emma’s mother was struggling to understand the course content. 194. On the 20th October 2011 Emma’s mother shared with one of the PwP tutors that she often found it difficult to understand the meaning of what people were saying and was struggling to apply the learning from PwP into her life. She said that Emma’s father often had to explain to her what the midwife had said and that generally she needed things ‘broken down’ in order to understand them. This was a source of 39 frustration that made her angry and could lead her to argue with Emma’s father or her family. She went on to say that what she was learning at Vol 1 was also motivating her to keep attending. 195. On the 21st October 2011 Emma’s mother told a member of staff that her plan to keep her baby safe when she and Emma’s father argued was to leave the baby with her mum or dad. When she was reminded about the work she had done at PwP about the importance of bonding and about the need to be close to her baby mother stated she would text to see if the baby was ‘ok’ but upon further discussion she appeared to understand the need to have a safe place for her baby and said she would approach her dad to see if she could stay there. 196. At the beginning of November 2011 the GP had referred Emma’s father to the Vol 1 to provide support on anger management. The letter of referral describes Emma’s father as having a long history of anger and violence resulting in several prison sentences possible exacerbated by his use of cannabis. He is described as having a poor relationship with Emma’s mother and that father ‘recognises he needs to do something about his anger if he is to be a good enough parent’. 197. On 7th November 2011 the supported living service received a written complaint from other tenants alleging that Emma’s father may be physically abusing mother. On 8th November 2011 the manager telephoned Social Care Direct to pass on this information and spoke to a social worker. Emma’s mother was five/six months pregnant at the time and the supported living service was concerned about the domestic abuse displayed by Emma’s father. Safeguarding and Family Support Services was told that father had a history of violent behaviour and that their neighbours had reported concerns to the supported living service. At the time, parents seemed to have separated although this was not clear. On 9th November 2011 the manager followed up the telephone contact in writing by email the details of what had been discussed on the telephone. 198. On the 9th November 2011 Emma’s mother had a ‘very confusing conversation’ with a worker at PwP where she stated that she had bruises on her neck and back and that Emma’s father had done it. However, she then subsequently went on to say she hadn’t seen any bruises, couldn’t feel the bruises and that Emma’s father had not been responsible. 199. The worker asked to look and couldn’t see any bruising. Emma’s mother stated she didn’t know why she thought she had bruises but maybe she had bumped her head. She appeared relaxed and in good spirits during the conversation and when asked did not seem to recognise the inconsistencies in what she was saying. She said that she sometimes felt scared of Emma’s father and linked this to her experience of adult relationships when she was younger. She also said that her own father had said, ‘if (Emma’s) father is capable of doing this when he’s sober, imagine what he could do if he was drunk’. When the worker had tried to clarify this, Emma’s mother reiterated that Emma’s father had not done anything. The worker felt unable to establish what had actually happened and that there was no evidence of physical harm. 40 200. The referral that had been made to Safeguarding and Family Support Services was transferred to ACPT1 on 11th November 2011 and the case was allocated for a pre-birth assessment. On 17th November 2011 the housing manager received a telephone call from a social worker who had been allocated to the referral and they discussed the complaint. On 18th November the housing manager emailed the written complaint and confirmation of what was discussed on the telephone to the social worker. Because of the delay in the follow up the opportunity to check for signs of injury on Emma’s mother had been lost. 201. On the 14th November 2011 the Vol 1 made their first phone call to Safeguarding and Family Support Services following an initial telephone call to the GP about the potential child protection issues and seeking permission from the GP practice to make a third party disclosure to Safeguarding and Family Support Services. According to Vol 1 they informed the social worker about the information they had received from the GP regarding Emma’s father and passed on the details of the GP practice with the expectation that Safeguarding and Family Support Services would make further inquiries. There is no record of the phone conversation in Safeguarding and Family Support Services recording and no evidence that a follow up was made with the GP either. Further analysis is provided in later sections including the role of the GP practice in sharing information and making referrals to Safeguarding and Family Support Services. 202. At the Common Assessment Framework meeting on the 16th November 2011 it was agreed to continue to support mother around housing and benefits; to access support around her anger and depression; to attend ante-natal classes and PwP and arrange for her to participate in a healthy eating course; to make a referral to the Community Team for Learning Disability for an assessment of Emma’s mother’s understanding. 203. On the 22nd November 2011 Vol 2 were informed that Safeguarding and Family Support Services would be undertaking a pre-birth assessment following a referral by the supported living service in respect of domestic abuse perpetrated by father. Details of Vol 2’s involvement with Emma’s parents and the concerns around their relationship, their issues with anger and Emma’s mother’s ability to understand were shared with the social worker. 204. On the 23rd November 2011 Emma’s mother attended Vol 1 and disclosed a significant level of coercive behaviour from Emma’s father; this included threatening to make her homeless, lack of income and an impact on Emma’s mother’s emotional wellbeing from threats that Emma’s father intended to reconcile with his previous partner and return to live with her. This information was shared by Vol 1 during a telephone discussion with SW2 on the same day. The conversation also included reference to concerns about mother’s possible learning difficulties. 205. On the 24th November 2011 mother confided with other students whilst at PwP that Emma’s father was likely to be violent to her later that day but stopped talking 41 when she realised the tutors could hear what she was saying. She went on to say that Emma’s father was upset because his granddad had died but when she was asked what she thought might happen she said she didn’t know. This information was shared with the social worker on 28th November 2011. 206. In November 2011 Emma’s father was referred to the Vol 1 by his GP for help with his anger management. The Vol 1 made contact with him however he was only prepared to attend if Vol 1 paid his bus fares. As Vol 1 did not have access to funds this was not possible and he did not engage with the service. 207. On the 8th December 2011 the specialist midwife was made aware by a phone call from the FSW at Vol 2 of the domestic abuse incident (8th November 2011) and the subsequent referral made by housing to Safeguarding and Family Support Services and was told about the pre-birth assessment by Safeguarding and Family Support Services; she commenced an Integrated Care Pathway (ICP) document for the unborn baby15. The specialist midwife recorded in the Safeguarding Integrated Care Pathway her attempts to speak to the allocated social worker. 208. The Common Assessment Framework was closed on the 8th December 2011 as the case had now been accepted as a referral for Safeguarding and Family Support Services involvement although Vol 2 continued their contact with Emma’s mother. 209. On the 9th December 2011 the Vol 2 service made a referral to the adult Community Team for Learning Disability service requesting a learning disability/capacity assessment of mother and asking for the provision of an independent advocate. This was re-referred on 18th January 2012 after there had been no response (further information is provided later about the misfiling of the referral). Emma’s mother was assessed in February 2012 by the Community Team for Learning Disability but was not considered to meet criteria for Community Team for Learning Disability service as she has most skills to enable her to live independently. A referral was made to a specialist centre16 by the social worker in ACPT1. 210. On the 13th December 2011, a Vol 2 worker visited Emma’s mother and observed bruising around her right eye. Emma’s mother stated that she had walked into a door but appeared anxious so the worker did not ask any further questions in front of Emma’s father. The information was shared with the social worker on the 14th 15 This is a health based clinical pathway rather than describing a multiagency or LSCB protocol. Clinical pathways, also known as care pathways, critical pathways, integrated care pathways, or care maps, are one of the main tools used to manage the quality in healthcare concerning the standardization of care processes. It has been proven that their implementation reduces the variability in clinical practice and improves outcomes. Clinical pathways promote organized and efficient patient care based on the evidence based practice and in this case are evidence that mother’s circumstances required clear coordination between specialist, hospital and community based services. 16 A new centre located at a local hospital providing specialist services for people with learning difficulties. The accommodation includes both day care and short stay units that offer a wide range of facilities for assessment, treatment and special therapies. 42 December 2011. Emma’s mother was also asked about the bruising again at PwP; she reiterated that she had walked into a door. 211. On the 27th December 2011 Emma’s parents had a verbal argument at their home address regarding Emma’s father wanting to visit mother’s father (PGF) who had arrived at their property and removed Emma’s mother after hearing them shouting. Emma’s mother and PGF had gone to the police station as the PGF believed that Emma’s mother had been assaulted. Whilst at the police station, Emma’s father had arrived and remonstrated with the maternal grandfather. No complaints were made by any of the parties. Mother denied that she had been assaulted; it was noted by the police that she was 26 weeks pregnant at the time. A DASH risk assessment was completed17; the result was ‘standard risk’. A letter and Information pack were sent to Emma’s mother. 212. Emma’s father was taken to his mother’s address. Analysis is provided in later sections about why the police did not complete a domestic abuse notification or a child protection referral to Safeguarding and Family Support Services. 213. The children’s centre contacted the family in January 2012 because the Vol 2 had registered them as new parents on the EStart electronic system. When a new family are registered on the system the children’s centre undertakes an initial welcome visit. This is routine and does not reflect a cause for concern for the contact to be made with the family. 214. On the 12th January 2012 a family play and learning worker and a student called at the family home to introduce the children’s centre and its services and to invite mother to a Vol 2 event. On returning to the children’s centre the worker spoke to the children’s centre manager and expressed her concerns about the apparent dominance of Emma’s father. The manager recommended that the worker should contact Vol 2 and share her concerns with them. The worker telephoned Vol 2 and although she could not speak with the worker who was in contact with mother, she was assured that her concerns would be passed onto the mother’s worker in Vol 2. No written information was provided. 215. On the 1st February 2012 two workers from Vol 2 visited the parents and agreed a support plan around support with benefits, housing repairs and for mother to attend a cookery course. Following this visit one of the workers shared their concerns with the social worker that Emma’s father did most of the talking during their visit and was behaving in a controlling way towards mother. 17 The introduction of the Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management Model from March 2009 meant that for the first time all police services and a large number of partner agencies across the UK are using a common checklist for identifying and assessing risk with the aim of saving lives. ACPO (association of chief police officers) Council accredited the DASH (2009) model to be implemented across all police services in the UK from March 2009. 43 216. On the 2nd February 2012 Vol 1 emailed information to Safeguarding and Family Support Services about the original referral from the GP in November 2011 describing the history of violence and reference to several prison terms in relation to Emma’s father that had been included by the GP. The email also confirmed that Emma’s father had never attended Vol 1 because they were unable to fund his bus fare. It was the following day that Safeguarding and Family Support Services recorded making a telephone inquiry with the police Public Protection Unit (PPU) regarding Emma’s father; there is no corresponding record by the police of a telephone call or other enquiry being made. 217. On the 8th February 2012 the specialist midwife spoke with the social worker who reported that the pre-birth assessment was progressing positively. Both the specialist midwife and the Vol 2 worker discussed their concerns in a telephone conversation; however they were both told that the social worker had no concerns; they were informed that there was one further session with the parents to complete the assessment when a decision would then be made. The specialist midwife requested it be managed at child protection plan level and the social worker indicated it would be at least a child in need decision18. The specialist midwife recorded that there were currently no concerns by the social worker regarding the parents taking their baby home following the birth although that could change. Later analysis explores that this was one of the opportunities for an escalation of concern. 218. Further phone calls by Vol 2 following up the initial call to Safeguarding and Family Support Services on the 1st February 2012 were made on the 8th February 2012 and again on the 15th February 2012. This last phone call was to reiterate their request for a multi-agency meeting and plan and to also express the service’s opinion that the severity of their concerns around mother’s ability to understand and the risks in Emma’s father and mother’s relationship were not apparently being acknowledged by the social workers. 219. Several further phone calls were made by the specialist midwife and FSW at Vol 2 until the 22nd February 2012 when the social worker spoke by telephone to Vol 2 and after discussion agreed to talk to her manager about arranging a multi-agency meeting. After a further phone call from Vol 2 on the 29th February 2012 the social worker said there would be a Child in Need meeting the following week. 220. On the 25th February 2012 mother was admitted to hospital having begun her labour. The labour ward midwife caring for mother attempted to contact Safeguarding 18 This distinction refers to the different sections described in the Children Act 1989 and summarised in the appendix to this report. Children in need are defined in law (S17) as children who are aged under 18 and need local authority services to achieve or maintain a reasonable standard of health or development, need local authority services to prevent significant or further harm to health or development or are disabled. S47 describes specific enquiries and duties in regard to children at risk from or suffering significant harm. 44 and Family Support Services at 12.45 hours to inform them that mother was in labour and to seek clarification on the situation with regard to safeguarding the baby after delivery as there was no evidence of a birth plan or instructions from Safeguarding and Family Support Services in the records. The phone was not answered although a further call was apparently made later. The labour ward midwife recorded that she had spoken to Safeguarding and Family Support Services and the social worker had confirmed that mother and father were ‘OK’ to take the baby home as long as the grandmother stayed with them as agreed. Reference has already been made to the paternal grandmother stating that she had not been aware of this arrangement despite evidence of discussions with Safeguarding and Family Support Services and further analysis is provided in later sections of the report. 221. Eleven sessions had been undertaken by the two allocated children’s social workers prior to birth to develop the pre-birth assessment and a child in need plan. According to case recording made by the social workers as part of assessment, a request was made to the police about information on both parents. The case recording states that the police advised Safeguarding and Family Support Services on the 3rd February 2012 that there were no relevant offences regarding either parent. The police have no record of any contact from Safeguarding and Family Support Services or providing any information. 222. The records in Safeguarding and Family Support Services do not record who made the contact from Safeguarding and Family Support Services or who they spoke to. It is now known that in addition to the incident in December 2011 father had several incidents of domestic abuse with previous partners; one previous allegation in 2002 concerned him allegedly punching the two year old daughter of a previous girlfriend and there were allegations of sexual abuse. Emma’s father had been charged but the case had then withdrawn before it went before a court. Further analysis is provided in later sections of this report. 223. The first home visit after Emma’s birth by Safeguarding and Family Support Services was with the specialist midwife on the 27th February 2012. The specialist midwife on examining Emma found her clothing to feel damp and that there were five blankets on Emma. Father told the midwife that grandmother had encouraged them to keep Emma warm. The specialist midwife discussed sudden infant death syndrome (SIDs) and demonstrated how to position Emma in her cot as well as discussing the making up of formula feeds19. Mother indicated she felt confident with Emma’s care. 224. At the child in need meeting on the 8th March 2012 mother was observed to have a bruise on her head; this was the second occasion a bruise had been recorded. 19 SIDs is also referred to as cot death; approximately 300 babies die suddenly and unexpectedly in the UK each year. Most of these deaths occur during the first three months after birth; babies who are premature and are a smaller birth weight and male are most at risk. The cause of such deaths is unknown although others can reduce the risk of SIDS by not smoking while pregnant or after the baby is born, and always placing the baby on their back when they sleep. Other measures included not letting the baby get too hot and for parents not to sleep with their baby on beds or sofas; hence the advice and demonstration provided. 45 She said that she had bumped into a cupboard. The meeting was attended by SW 1 and SW 2, both Emma’s parents and the Vol 2 worker. Apologies had been received from the specialist midwife and health visitor. Emma’s paternal grandmother and Emma’s maternal grandfather were also unable to attend the meeting. 225. On the 14th March 2012 the specialist midwife asked Vol 2 staff to speak in private to mother when they got a chance about a bruise she had seen on her head during a visit that day; this was the third bruise that had been observed. Mother had told the midwife that she had bumped into a cupboard. 226. On the 28th March 2012 a worker from Vol 1 rang FSW2 to say that when Emma’s mother had attended a session that day she had a black eye that she was unable or unwilling to explain; this was the fourth incident of bruising. FSW2 had not noticed this on a visit the day before but the room was dark because the curtains had been closed. The FSW was told that Emma’s father had been referred to Vol 1 for support (although had not attended) and that he had a history of perpetrating domestic abuse in his previous relationships. Emma’s mother agreed to encourage him to attend; this was not realistic. The Vol 1 worker told FSW2 that she would contact Safeguarding and Family Support Services about the bruise; this was done. 227. The social worker made a home visit on the 30th March 2012 to discuss the report of mother having evidence of being bruised; this was met with denials that she had been subject of domestic abuse; further analysis and comment is provided in later sections about how the evidence of domestic abuse was managed. 228. A Child in Need review meeting was to have taken place on 4th April 2012 but this was postponed due to heavy snow. 229. On the morning of the 10th April 2012 Emma was seen at home by the health visitor with her mother and the maternal grandfather; Emma’s father was reported to have been upstairs but was not seen. Emma’s mother stated they had tried to feed Emma every three hours but that Emma had vomited after her feed. The feeding and management of reflux was discussed by the health visitor. Feeding was observed with good swallowing reflex and tone. The health visitor noted that Emma had a ‘weak cry’ and advised that a paediatrician or GP should see Emma. The health visitor arranged an appointment with the GP to review Emma’s weight loss and reflux and to provide an opinion or diagnosis. During this visit the maternal grandfather had mentioned that he had stopped father dragging Emma’s mother up the stairs in the home. 230. The GP saw mother and Emma on the 10th April 2012. The health visitor had tried to contact the GP practice by phone but was not able to speak to the GP before they saw Emma. The health visitor made an entry on the electronic patient record although this was not seen by the GP who therefore regarded the consultation as routine and at the request of the parents. The GP had no concerns about Emma from the examination although advised Emma’s mother to seek an earlier review if the symptoms (of falling weight) or any new concerns emerged. Further analysis and 46 comment is provided in later sections about the clarity of communication with the health visitor and the reliance of the GP on mother seeking appropriate advice. 3 Synopsis of the learning and analysis from the individual management reviews. 3.1 Summary 231. This part of the report is an opportunity to try and to understand what people knew and how they were making their judgments at the time. The key lines of enquiry provided a framework for structuring particularly important areas for learning and development to come from the review. 232. Writing an IMR is a significant piece of work. The majority of authors provided their IMRs within timescales and have undertaken redrafting following discussion at the panel. The panel undertook a detailed critical reading of each IMR. 233. For some of the authors, they were simultaneously working on IMRs for other Serious Case Reviews. All of the authors were also undertaking their usual range of professional roles and responsibilities. 234. All of the services contributing to the Serious Case Review have ensured that the quality of information provided to the panel has supported appropriate learning. When senior managers became aware of problems regarding the quality of some agency reports, action was taken to address this and to ensure that the panel had sufficient quality of information and analysis. 235. The review has revealed particular issues in regard to the ethical and professional concerns that face professionals in possession of sensitive and confidential information. This has had an influence for example in how information sharing was managed by one of the GP practices during their routine contact with Emma and her parents and during the Serious Case Review itself. That GP declined to provide detailed information for the Serious Case Review until very late into the review despite rigorous efforts to obtain the information by health representatives to the Serious Case review Panel. 236. The conduct of a Serious Case Review is an opportunity to examine in detail the systems and professional practice and is also a litmus test for the capacity of the individual organisations to understand both the quality and the quantity of the services for which they are responsible. 237. The skills required to undertake an effective IMR are the skills that a good manager should want to develop and have the capacity to deploy in their day to day role; the work involves collating relevant information, understanding what the experience of children and families are when they come into contact with their service, be confident that staff have appropriate skills and experience and are making balanced and informed judgements and be able to analyse how to improve practice and service further. In the most simple of terms the objective should be on encouraging and 47 ensuring that people are making the right judgments that lead to the right action and making it more difficult to make poor judgments and to take the wrong action. 238. Serious case reviews are essentially about trying to understand how events looked to key people at the time and understanding what frameworks and information were being used to help them make their judgments. Hindsight always identifies the other options that may have been available; the effective learning comes through understanding why things happen. 3.2 Significant themes for learning that emerge from examining the IMRs 239. The agency reviews identify themes that apply to all services working with children and that have implications for policy development and staff training. In the summary of the review’s finding provided in chapter one there is acknowledgement that some of the issues to come out of this review are reflected in the findings of national evaluation and research. Important messages for learning from this review include: • Effective safeguarding is only achieved if all professionals understand the importance of recognising signs and symptoms of abuse that can harm children before and after birth and understand their responsibilities to share such information with the relevant services; • Historical information is essential to understanding the significance of current events and identifying long term patterns of concern; evidence about childhood abuse, history of violence and use of drugs, and learning difficulty was not established and led to minimisation; • Coercive relationships combined with poor self-esteem and emotional vulnerability combined with unemployment and fear of homelessness will all present significant barriers for women to disclose information about domestic abuse; threats of physical violence were also a factor in this case; • Cognitive functioning may not reflect frameworks of diagnosis or thresholds of priority for service; father’s significant learning difficulties were not recognised by any of the agencies and the queries in regard to mother were not analysed or resolved within any meaningful structure of assessment; • The different professional status in multi-agency working can be a threat to effective communication; CPA1 had a consistent level of concern about domestic abuse and mother’s cognitive functioning; her concerns were not regarded with sufficient attention; • Busy services and high caseloads that comprise significant levels of social problems can lead to professionals becoming more tolerant of issues such as violent arguments; using cultural relativism to tolerate inappropriate behaviour; 48 • Other cases that are displaying more explicit and unambiguous concerns can distract and demand more urgent attention; in this case the writing up and analysis of the pre-birth assessment was apparently deferred although visits and contact with Emma’s parents were taking place; • Supervisors and line managers need the capacity to provide the quality of critical challenge, oversight and reflection; none of the services were able to provide an effective response to the domestic violence and seeing the underlying themes and patterns; • Telephone and face to face conversations are not a substitute for making formalised referrals of concerns to relevant services; • Effective multi agency working requires clear professional leadership and the full participation of relevant people; • Critical professional activity such as assessment requires appropriate frameworks to guide multi agency contributions and analysis and planning; • The education records of young parents can be an important source of information relevant to assessing adult needs and capacity. 240. The remainder of this chapter summarises key evidence relating to the terms of reference established for the IMRs. 3.3 Good practice identified through the review 241. To support the learning from the review the panel looked for examples of good practice. To constitute good practice, the panel looked for action or decision making that went beyond compliance with local and national policy, procedures and guidance. 242. Examples of good practice identified by the review include; • There was a much more frequent level of contact with Emma’s mother by health and social care services than was required by local and national standards and expectations; • The early identification that Emma’s mother would require additional support when the first ante natal booking was taken and a referral was made to the specialist midwife and Vol 2 service; • There was a good level of communication between the college tutors and the Vol 2 service in regard to mother’s cognitive problems and evidence of domestic violence; • The referral by the CPA1 to Community Team for Learning Disability showed a commitment to exploring Emma’s mother’s level of understanding and she showed persistence in following up the lost referral; 49 • The health visitor ensured that Emma was seen on a very frequent basis and the focus on her physical development ensured a prompt referral on two occasions in regard to Emma’s weight; • When the health visitor was unable to speak to the GP about her concerns on the 10th April she ensured that information was entered on to the SystmOne that would have allowed an opportunity for the GP to access it before or during the consultation; • The GP practice sent SMS (short message service) text reminders to Emma’s mother about medical appointments. 243. The remaining sections of this chapter summarise the most significant learning from the IMRs against each of the case specific terms of key lines of enquiry. 3.4 Learning Difficulty The Serious Case Review Panel considers that the difference between learning difficulty and learning disability may not be well understood. Individual Management Reviews should clarify professional understanding of learning difficulty and the impact it may have on parenting capacity. 244. Learning disability is the term used by the government and is utilised throughout all government produced documents. Learning difficulty is the term preferred by the self-advocacy movement such as People First and is the term used by many local services to people with learning difficulties. 245. The two terms are often used interchangeably but it can be confusing as ‘learning difficulty’ is also a more general term used within education as well as by other services. However people who have a specific educational difficulty do not generally fit into the definitions given below. 246. Learning difficulty is a term used to describe any one of a number of barriers to learning that a child may experience. It is a broad term that covers a wide range of needs and problems, including dyslexia and behavioural problems, and the full range of ability. Most people with a learning disability have only a mild disability that simply means they need more help than most to learn new skills. 247. A learning difficulty is a permanent condition. People with learning difficulties grow and develop as individuals, but at a slower pace. Some people with learning difficulties may also have physical disabilities or other medical conditions, but many do not. Valuing People20 states that a learning disability includes the presence of: 20 This was the first White Paper on learning disability for thirty years published in 2001 and set out an ambitious and challenging programme of action for improving services 50 • A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with; • A reduced ability to cope independently (impaired social functioning); • And which started before adulthood, with a lasting effect on development. 248. This definition encompasses people with a broad range of disabilities. The presence of a low intelligence quotient, for example an IQ below 70, is not of itself a sufficient reason for deciding whether an individual should be provided with additional health and social care support. An assessment of social functioning and communication skills should also be taken into account when determining need. (DOH.2001 pp14-15) 249. A learning difficulty/disability is said to exist then if: • The person has an intellectual disability developed before the age of 18; • The person has reduced ability to understand new or complex information; • The person has reduced ability to cope independently; • The person has difficulty or is unable to learn new skills; • The person has been assessed to have an I.Q. of less than 70. 250. Clarity about the nature of learning disability or a learning difficulty has implications for both informing a professional’s understanding about how parents are receiving information and advice as well as having implications for how different services use such definitions to apply threshold judgments in terms of access to services. This was an issue in this case for example in regard to the referral to the Adults Community Team for Learning Disability service. 251. It is significant that most of the references to learning difficulty are in respect of the mother and does not include father. This reflects the degree to which father was not as central to the assessment that did take place; this is a factor commonly identified in reviews such as this one. In this case, Emma’s father was seen to be dominating of Emma’s mother and he was apparently influential in both parents being less engaged with the people offering help and support. 252. Emma’s father was the subject of a statement of educational need (SEN) when he was at school; this identified borderline severe learning difficulties and he received additional support for much of the time he was in education including at a specialist school. 253. Emma’s mother was never the subject of SEN assessment whilst at school although she did have support in regard to her anger management. It was noted that whilst she 51 was still at primary school that she took a long time to respond to most words and sentences; this led to assessment for any hearing impairment. No impairment was diagnosed. 254. A referral was made to the Community Team for Learning Disability when it was becoming apparent that Emma’s mother was having some particular difficulty in applying the learning from her parenting sessions. The initial referral was filed as a case episode that meant it was not processed as a referral for action and it was in February 2012 that an assessment was undertaken by the service. 255. The assessment did not involve any discussion between the assessing social worker with CPA1 who had made the referral. The response by the service appeared to focus on whether mother had a learning disability that qualified her for support from the service rather than assessing any needs or difficulties she might have in processing information. 256. The assessment was conducted against the criteria and framework of the Community Care Act which was different to the type of assessment that was sought. The Community Team for Learning Disability social worker was assessing under NHS and Community Care Act 1990 which is the normal practice for the service. She advised Safeguarding and Family Support Services that an assessment of cognitive abilities was not within her area of responsibilities and ensured that a referral went to the local specialist service. As a result of this Serious Case Review the Safeguarding and Family Support Service and Adults Services are now working together in relation to assessments of parents who are felt to have learning difficulty or learning disability. 257. It is not known what information the GP had in regard to either parent’s learning difficulties. No consultation was made by the other services with the GP. The Serious Case Review Panel identified concerns within different agencies that Emma’s mother may have had a degree of learning difficulty. Individual Management Reviews should identify: the extent to which professionals were concerned about Emma’s mother’s learning capacity; the evidence on which concerns about learning difficulty were based; and how evidence of learning difficulty was acted upon (i.e. taken into account when providing services, referral for additional support)? 258. Emma’s mother completed her statutory schooling in 2009. Although a significant amount of information was lost in a school fire there were records held by the education service in regard to the difficulties that Emma’s mother had. She received support from specialist services who identified that mother had some problems in processing information. This information was not known to any of the people who were working with Emma’s mother in 2011 and 2012. 259. When Emma’s mother booked, the midwife (RM1) presumed she had learning difficulties on the basis of her own informal assessment, noting that she often looked to others to answer questions for her. This was one of the three factors she highlighted in her pre Common Assessment Framework assessment and was included in her referral to the 52 specialist midwife. She did not initiate a formal assessment of Emma’s mother’s learning ability through the local pathway protocol or file a Common Assessment Framework herself believing that this would be the responsibility of the specialist midwife. 260. The specialist midwife did not initially feel that Emma’s mother had a learning difficulty that would affect her ability to care for Emma. However she did record possible maternal learning difficulty in the Integrated Safeguarding Pathway (ICP) and highlighted concerns about mother’s understanding and about mother and fathers parenting ability when speaking on the phone to SW1 shortly before Emma was born. She also discussed the possibility of mother having learning difficulties with the health visitor after Emma was born. She never thought father had a learning difficulty nor had access to any information about this. 261. The concerns about parenting ability and possible maternal learning difficulty were among the reasons the specialist midwife referred to Vol 2 for additional support. She also planned with Vol 2 that a Common Assessment Framework would be completed and towards the end of pregnancy listed this among her concerns when asking SW1 to manage the case at an escalated child protection level. 262. The health visitor felt she was unable to assess any learning difficulty in mother and had queried if she was just shy. This view was apparently shared by the social worker in the Safeguarding and Family Support Service and subsequently by the social worker in adult’s services. The health visitor allocated Emma and her family to the Complex Programme as a result of multiple concerns and had planned to assess the parenting although this work was not complete when Emma was injured and died. 263. During the course of Vol 2 involvement with Emma’s mother, CPA1 developed significant concerns relating to her capacity to learn and submitted the referral to Community Team for Learning Disability at the beginning of November 2011. This followed a discussion with the Community Team for Learning Disability duty worker who recommended this course of action. CPA1 had also informed the social worker in the Safeguarding and Family Support Service that Emma’s mother did not seem to understand the pre-birth assessment. 264. It was the CPA1 who raised the referral to the Community Team for Learning Disability by sending it through to Safeguarding and Family Support Services on the 9th December 2011. The referral stated clearly the purpose of the referral. It requested an assessment to be undertaken of Emma’s mother’s needs so that support could be provided that would give her the best chance of parenting her child. 265. The referral added two distinct requests, for the team to provide an advocate for Emma’s mother to support her through the pre-birth assessment and for an assessment to be made to ensure she can understand legal proceedings which may follow. The referral included details summarising the involvement that the service had to date along with detailed examples that might illustrate the concern, including details about the “confusing” conversation she had held with Emma’s mother. 53 266. According to the IMR regarding the Community Team for Learning Disability service the original referral was placed on Emma’s file as an open activity case note for Safeguarding and Family Support Services. It was only sent through as a referral on the 18th January 2012 by the CPA1. It is probably significant that the adults IMR states that the primary purpose of the referral was for an assessment of eligibility for support; this certainly was the principal focus of the assessment by the social worker allocated to undertake the Community Team for Learning Disability assessment. 267. The adult’s IMR acknowledges that the assessment was too preoccupied with whether Emma’s mother had a learning difficulty that would qualify her for access to support and services. It did not give attention to specific issues such as the pregnancy and impending parenthood and inquire as to the capacity and implications for Emma’s mother. This probably reflected a misplaced assumption that this was entirely the responsibility of Safeguarding and Family Support Services rather than being seen as a ‘corporate’ responsibility. 268. CPA1 was aware from her conversations with the college that Emma’s mother had been receiving additional support through the Flex Team (a team for students with learning difficulties). CPA 1 had undertaken conversations with Emma’s mother where in her assessment she appeared to have been unable to absorb any understanding from the learning being undertaken at the PWP group. During a particular conversation with Emma’s mother she appeared to indicate she may have been suggesting that she would text to see if the baby was ok and appeared to have no understanding about the importance of bonding which she had just learned about on the PWP course. 269. CPA1 was concerned by conversations she had with Emma’s mother where she seemed unable to recognise or understand the contradictions in what she was saying for example in relation to the suitability of living with her parents when the baby arrives, whilst providing obvious information to the contrary. 270. CPA1 was aware that Safeguarding and Family Support Services was undertaking a pre-birth assessment but when CPA1 discussed this with her, Emma’s mother did not appear to have any level of understanding of what this entailed. Following this referral there remained concerns, an example being that Emma’s mother did not appear to have an understanding about where she could for example buy baby formula milk. 271. Following the re-submission of the referral in February the Community Team for Learning Disability social worker reported back that they would not be able to undertake an assessment because mother was due to give birth in two weeks’ time; the original referral had been sent almost three months previously. 272. According to the adult services IMR, once the referral had been sent through correctly in January the case was allocated on the 23rd February 2012. The IMR does not state whether this is a usual timescale for allocating a referral. The one home visit made by Community Team for Learning Disability was made on the 15th March 2012. This was a joint visit with SW1 from Safeguarding and Family Support Services. 54 273. The respective IMR states that the Community Team for Learning Disability does not undertake assessments of cognitive functioning and that Emma’s mother did not meet criteria for the service. According to the IMR she presented initially as being quite shy. However her confidence grew in the interview and told SW2 that she thought most of the questions asked were things that everyone should know. SW2 in interview was very clear in interview that mother gave appropriate answers to her questions and showed no evidence at all about not being able to understand information or manage her day to day life. The Community Team for Learning Disability social worker had previously spoken with the housing support worker who stated that she did not believe that mother had a learning disability. 274. The IMR does not provide any further insight into how the judgment about not qualifying for service in the absence of an assessment of cognitive functioning was reached. The social worker informed CPA1 that she had made a referral to the local specialist service for an assessment of her cognitive functioning; the CAP1 recorded this as a psychological assessment. Although the adults services IMR states that the Community Team for Learning Disability social worker followed the referral up with the local specialist service there is no specific information about what this involved or outcome. The Community Team for Learning Disability social worker had put referral in to a specialist centre and arranged for it to be discussed at the allocation meeting within two days. The social worker also spoke to the psychologist who was allocated the case. These conversations are recorded on the case file although do not appear to have been communicated to the CPA1 who had initiated the original referral. The Serious Case Review Panel found that Emma’s father had a learning difficulty. Individual Management Reviews should identify: if this information was known to professionals working with the family; if professionals had any concerns about Emma’s father’s learning capacity; the evidence on which concerns about learning difficulty were based; and how evidence of learning difficulty was acted upon (i.e. taken into account when providing services, referral for additional support)? 275. The police had father in police custody on ‘numerous times’ over a period of several years; this contact was not known to other services working with the parents until 2012 and after Emma had died. According to the IMR the police knew that father had learning difficulties although the severity is not recorded and was generally limited to knowing that father had ‘trouble with reading and writing’. 276. The other service that had information about Emma’s father (and her mother’s) learning difficulty was the education service. This information is not routinely sought although this case has demonstrated the potential value in helping establish whether parents have an identifiable learning or communication difficulty. The records collated by health services during childhood are subject of record keeping policies that require their destruction after 25 years. 277. Although several professionals began to consider whether mother had a learning difficulty that is described in greater detail in the next section, none of the professionals ever considered whether father had a learning difficulty or disability. This is in spite of father 55 having a support worker and living in a supported housing scheme. An important contributory factor in Emma’s father not being regarded as having a learning difficulty was that he had good verbal skills and was much more confident in conversations. This was observed when father was at school and assessed as having significant learning difficulties. 278. The concerns in regard to father related to anger control, the evidence of him controlling mother and a concern about whether he was physically abusing her. 279. Emma’s father told the health visitor that he had “difficulty reading long words” at her first visit but this was the only reference to him having learning difficulty in The Mid-Yorkshire Hospitals NHS Trust records during the period under review. The details of his special educational needs statement in the child health files would be subject to a policy of destroying historical records. 280. There is no evidence on file that the staff at Vol 2 were aware that Emma’s father had a learning difficulty and this was confirmed by all the staff that had direct involvement with Emma’s mother at interview as well as their Supervisor and the Service Manager. 281. The Community Team for Learning Disability IMR confirms that they did not know about Emma’s father’s learning disability and acknowledge that they did not seek any information either about him from the Safeguarding and Family Support Services social worker or from father direct. Community Team for Learning Disability were aware that he was living in supported accommodation and imply that they understand that he had the tenancy and was therefore the focus of that support. The Community Team for Learning Disability did not know about the cognitive functioning difficulties identified when Emma’s mother was attending school; they were instrumental in making a referral to the specialist centre although this assessment had not been completed when Emma died. 3.5 Violence and Control The Serious Case Review Panel identified domestic incidents where Emma’s father was alleged to have assaulted Emma’s mother. Individual Management Reviews should identify: how allegations of domestic abuse were acted upon and followed up, particularly in the context of the risk to Emma; and any missed opportunities to refer the family on to a different agency or source of support, such as a Multi-agency Risk Assessment Conference or other intervention. Could more have been done to support Emma’s mother to disclose information about violence within the home? 282. There were four visits to hospital emergency departments while Emma’s mother was pregnant. On one of those occasions she acknowledged that she had injured her hand during an argument with Emma’s father. This information was not shared outside the emergency department. The GP was informed of the other visits to the emergency department in Wakefield and out of district; although Emma’s mother did not disclose any information about domestic abuse the GP practice was made aware of the history of violence and harassment. 56 283. Although there were several reports of Emma’s mother having physical injuries such as bruises there were just two formal allegations of domestic abuse that were recorded and were made by third parties (neighbours) rather than from mother or another family member. The maternal grandfather made three statements or reports about domestic abuse although these were not formally recorded as domestic abuse 284. The first referral to the Safeguarding and Family Support Service was made by the Supported Living Service on 8th November 2011. The information given to Safeguarding and Family Support Services included information about Emma’s father’s previous history of domestic abuse and that he had served a prison sentence as result. This information was not discussed with the police or with probation. A decision was taken to not undertake an initial assessment but rather complete a pre-birth assessment because of the risk to the unborn Emma. The basis of the decision was that a detailed assessment was required over and above an initial assessment which was therefore not completed. The case was allocated to the social worker on 17th November 2011. 285. The social worker discussed the referral with supported living services on the 18th November 2011; the conversation appeared to focus on Emma’s father’s history of being homeless, his mental health and that he had self-harmed. The focus does not appear to have been upon the allegation of domestic abuse. 286. The implications of the decision were that none of the preliminary enquiries were undertaken at the outset; this for example meant that the specialist midwife was not consulted by the social worker (although did learn of the referral and made contact). Most critically, no discussion took place with the police. This would have provided an opportunity to investigate the allegation and that could have led to a disclosure to Safeguarding and Family Support Services of the previous history of violence in a neighbouring area. 287. The pre-birth assessment included a session that explored domestic abuse by asking questions from the parents and family. Significant misdirection appears to have occurred when Emma’s father said that his prison sentence was for breach of an order and only referring to being drunk and disorderly and public order. Checks were not made with probation to verify the information or to check the anger management work that Emma’s father claimed he had done and who felt did not need to do any further work in site of the evidence of continuing issues. 288. On the 1st February the maternal grandfather told the social worker about an incident of domestic abuse in December 2011; it is not clear if this was the same incident that the police had been informed about. The maternal grandfather described Emma’s mother phoning him screaming that Emma’s father was grabbing her and he said that believed there were other incidents when she had been grabbed and bruised. 289. It was two days after this conversation that the social worker has recorded that they had contacted the police asking for any information about relevant offences. The police have no record of this contact and the Safeguarding and Family Support Services records do not provide details about who their police contact had been. The social worker’s recording 57 stated that no offences were disclosed and this was reported to the Team Manager who therefore believed that all the relevant checks had been completed. 290. These types of enquiry by Safeguarding and Family Support Services to the police are routine and the expected practice would be for the police to provide any relevant information over the telephone after having confirmation that it was in relation to s47 enquiries (in which case there would be a strategy discussion) and information would be provided or if the case was being managed as a child in need there would been a formal request for information under the relevant protocols. Emma was being managed as a child in need although the detail of the assessment and plan was not shared with other services. 291. On the one occasion in December 2011 when the police were told about an allegation of domestic abuse, the DASH assessment was completed. This recorded the fact that Emma’s father had a prior ‘domestic history with other partners’ but did not include information about any of the alleged child abuse. The DASH did record the fact that mother was 26 weeks pregnant. No statements were taken after Emma’s mother declined to make a formal complaint. A routine letter was sent out to mother with an information pack about advice that was available. Further comment is provided in later analysis in this report. 292. The police service policy requires a formal child protection referral to be made if the victim is pregnant. The referral was not made; although the officer completing the assessment knew mother was pregnant and correctly recorded this information on the DASH risk assessment the shorter summary of the incident upon which the authorising officer relied upon for signing off the incident stated that there were ‘no children as yet’. 293. Although the statement is true and accurate, it meant that the officer reviewing the documentation and assessment was not aware of the pregnancy. The IMR describes how the volume of work within the safeguarding unit at the time was high and therefore there was an increased reliance on written information providing sufficient detail to make decisions on summaries such as the information in the occurrence entry log (OEL). 294. The two incidents in November and December 2011 provided the clearest opportunity for information about domestic abuse to have been properly accessed and shared and would almost certainly have resulted in a multi-agency discussion and enquiry under the WDSCB framework. 295. The booking midwife RM1 did not suspect or know of any domestic abuse but the IMR author comments that she should have considered it when seeing the mother behaving differently at her second contact when Emma’s father and his mother were not present. This was an opportunity to raise the question of domestic abuse. 296. The specialist midwife became aware of mother having anger management issues at the end of her first contact when paternal grandmother urged her to disclose this and this was a factor in her deciding to add Emma’s mother to her case load, involve Vol 2 and to propose a Common Assessment Framework. The specialist midwife learnt from FSW2 on the 8th December 2011 that a referral had been made to Safeguarding and Family Support Services following a “domestic violence incident”. She included this information in the 58 integrated safeguarding record that she opened on the 6th January 2012. This could have been an opportunity to escalate by making a referral on the basis of her safeguarding concerns. 297. The health visitor was not aware of domestic abuse issues until informed of this by the specialist midwife after she had made initial contact with family. 298. There are at least four references to bruising being observed on mother by professionals other than the social workers. Neither of the social workers observed the bruising; on one occasion there was a difference of view about whether Emma’s mother’s complexion rather than a bruise was visible. The result was that several professionals had more concern about possible domestic abuse than was shared by the social workers. The Serious Case Review Panel found evidence that Emma’s father was violent, controlling towards Emma’s mother and had sought assistance with anger management. To what extent were professionals aware of Emma’s father’s violent and controlling behaviour and/or his propensity to be violent? If they were, was this information shared with other agencies and what were the expectations associated with sharing this information? 299. At the initial postnatal visit the health visitor commented that Emma’s father attended to all of Emma’s needs and that her mother was not observed to handle her baby. Her instinct had suggested this might be controlling behaviour but she felt that establishing a relationship and ensuring access was more important than pursuing this at that stage. These types of dilemma are not unusual for all professionals although what should have happened in this case is for advice to have been sought after the visit. If there had been a clearer structure to the pre-birth assessment and plan this might have also encouraged a more appropriate discussion and reflection with Safeguarding and Family Support Services. 300. On the 16th March 2012 she was informed in a phone call with SW2 that both parents were attending anger management sessions. She had once seen a “flash of anger in his eyes” when she was discussing care of the baby, but otherwise she personally saw no evidence of domestic abuse. The IMR comments that she could perhaps have liaised with the Multi Agency Risk Assessment Conference (MARAC) to see if more information was available especially when she learnt more about background. 301. During her visit on 10th April 2012 the health visitor saw mother and maternal grandfather and was told that Emma’s father was upstairs and that Emma’s maternal grandfather had no time for him and that he had seen him “dragging” mother upstairs the previous week. The IMR comments that this could have been an opportunity to escalate with a safeguarding referral to social care or to liaise with MARAC. A telephone message was left with Safeguarding and Family Support Services although there is no reference to the information provided by the maternal grandfather. 302. The Vol 2 IMR describes how their staff became suspicious about the possibility of ‘further violence’ and in their referral to the Community Team for Learning Disability described Emma’s mother as being in a violent relationship. Bruising had been observed on three occasions to mother although on each occasion attributed the injuries to accidents 59 rather than any assault. There are references in the records to Emma’s father’s behaviour appearing to make Emma’s mother nervous and watchful. For example, during a visit to the home on the 13th December 2011 Emma’s father ‘walked through the room for no apparent reason’; the conversation at the time was about the injury to Emma’s mother’s face. 303. On another occasion Emma’s father is described as doing all the talking for Emma’s mother and the staff at the children’s centre found him to be ‘overpowering’. 304. On one occasion a worker asked why Emma’s mother was so quiet when Emma’s father was present; she replied that she found talking in front of people to be embarrassing. It is not clear that this was ever explored further by professionals working with her or in any future conversation with her. 305. In spite of the injuries and concerns about Emma’s father’s influence on Emma’s mother, these do not escalate beyond a sense of what one IMR describes as ‘niggles’. 3.6 The limited information about Emma’s father in agency records Were professionals sufficiently curious about Emma’s father and his role within the family? 306. Although the social workers believed that they had made sufficient enquiries of other services to acquire appropriate information about father there were significant limitations to what was actually achieved. If a request for information had been made, it was not done in accordance with the well-established protocols. When a domestic abuse incident occurred in Wakefield requiring a police response, information was not forwarded either through the domestic abuse or child safeguarding protocols in regard to the unborn Emma. 307. Limited information about Emma’s father was gathered by RM1 as this was not required as part of the pregnancy booking process. She was not aware of father’s learning difficulty. Since then the booking form has been redesigned to require more information about fathers. The Health Overview Report explains the information pathways that had been put in place following an earlier SCR to ensure that fathers were considered although the electronic recording system was not in place; the Health Overview Report provides historical context in regard to the liquidation of a key supplier of information recording systems. 308. The Vol 2 ’were not sufficiently curious’ about Emma’s father according to the IMR authors. This could be applied to other services that were in contact with the family after mother’s pregnancy was confirmed and the Common Assessment Framework and subsequent support was arranged. 309. The adult IMR confirms that no information was known about Emma’s father’s history. The social worker had been given limited background information about a previous domestic abuse issue by the referrer but was not given any detail and made no contact with CPA1. SW2 was aware that Emma’s father was in accommodation with support so should 60 have known that he had some support needs. SW2 did not ask the nature of these support needs, although he was present during the home visit on the 15th March 2012. SW2 took the view that she had been asked by other professionals to do a specific piece of work and accepted this on face value. SW2 said that she did not consult the relationships screen on Care Director (the electronic records system) which would have allowed her to access case notes on unborn Emma or her father. The IMR comments that this displays a lack of curiosity. The gaps in information about Emma’s father means that if such a check had been completed it is unlikely that this social worker would have been able to be much better informed. Did Emma’s father receive information/advice about appropriate handling of the child? 310. Emma’s father was present at booking and was subsequently seen by both the specialist midwife and health visitor, both of who felt that he was given as much information as mother with regard to child care issues. Specifically he was given information about handling a baby, temperature control, cot death prevention, feeding advice, advice about not shaking babies. The health visitor continued to make a high level of visits. 3.7 Child in Need Plan Emma was subject to a Child in Need Plan following a pre-birth assessment. Was this Plan sufficiently robust, with clear actions, responsibilities and contingencies if the Plan was not followed? Were professionals clear about their role and the role of other professionals? Did the family appear to understand the Child in Need Plan and what was expected of them? Was the plan adhered to? How was it monitored? 311. Although the referrals that were made to services such as Community Team for Learning Disability and Safeguarding and Family Support Services are generally described as containing a good level of information, the overall approach between the services relied heavily on conversations by telephone, in occasional meetings and individual supervision sessions. 312. The child in need plan was not circulated outside of Safeguarding and Family Support Services. Whilst there are references to possible child in need meetings within the Mid-Yorkshire Hospitals NHS Trust records there is no evidence in their records of them being informed that a child in need meeting ever took place or that a Child in Need plan was ever produced. No member of staff ever attended or contributed to a meeting or saw a written plan. 313. Consequently no Mid-Yorkshire Hospitals NHS Trust employee was aware of its contents. The Health Overview Report comments that the health visiting and midwifery professionals would have known that a Child in Need plan was being developed and that they could have been more assertive and proactive in following up the absence of information. The final chapter of this report provides further reflection about the context and circumstances for the different professionals and how it could influence aspects of behaviour and decision making. 61 314. The Vol 2 service had an ‘implicit understanding’ that their role was to ‘continue to support mother’. There were no explicit conversations about how information was to be coordinated or the various indicators of concern were to be monitored. 315. The child in need meeting on the 24th February 2012 involved only the two social workers, the Community Team for Learning Disability and family. The purpose of the meeting was to discuss the outcome of the pre-birth assessment. Although the plan set out expectations that the parents would ‘engage’ with support that would include father participating in the safe @ home21 men’s group and that concerns were to be reported by the family, the content of the on-going assessment and work with services such as Vol 2 ‘could have been more clearly outlined’. 316. The second meeting that was planned for the beginning of April was cancelled due to severe weather although the health visitor did a home visit on that day. The adult’s IMR makes clear that they were unaware of the Child in Need plan. 317. The Health Overview Report comments on how high workloads have a clear link with the inflation of thresholds for follow up and more intensive intervention and the implications for specialist practitioners. This is explored further in the final chapter of this report. The Serious Case Review Panel has identified that Emma’s paternal grandmother had a role within the Child in Need Plan. What was the nature of this role and why was it considered to be necessary? Was it appropriate? Were professionals clear about this role? Was the nature of this role sufficiently communicated to Emma’s family? 318. The role of the grandparents was not clear over and above the expectation that Safeguarding and Family Support Services had that the paternal grandparent would provide support when Emma and her mother were discharged from hospital following the birth. Discussion in the meetings did not clarify the role of the maternal and paternal grandparents. 319. The Community Team for Learning Disability social worker was made aware by Safeguarding and Family Support Services that the paternal grandmother planned to move into Emma’s home after her birth to provide support. The respective IMR acknowledges that no inquiries were made in regard to the reasons for the support and in the absence of any information about father or his background it was none the less seen to be a positive source of support for Emma. This reflects a common assumption that extended families will be a source of positive support and influence. 21 A specialist ‘one stop service’ offering advice, support and information to those affected by domestic abuse in the Wakefield district. 62 Were the support needs and parenting capacity of Emma’s parents adequately considered by professionals and are there any lessons to be learned? 320. It was recognised that Emma’s parents had additional support needs and steps were initiated to address these. At the initial booking RM1 expressed concern and involved the specialist midwife. The specialist midwife at first contact learnt about anger issues and referred to Vol 2 and agreed a Common Assessment Framework should be filed. Also as delivery approached the specialist midwife liaised with Safeguarding and Family Support Services to highlight her concerns in consultation with Vol 2. 321. However, the IMR authors acknowledge that there was a lull in activity in the middle of pregnancy particularly in relation to making progress with the Common Assessment Framework. This should have been managed on a tighter timescale and when the parents withdrew a referral to social services would have been appropriate. The parents were apparently both involved in anger management support but their engagement was never adequately achieved. 322. Although Emma’s father said that he would have participated if bus fares had been paid the reluctance of both parents to participate meaningfully in the Common Assessment Framework reflected an unwillingness to be involved; it is generally thought that Emma’s father was very influential in controlling Emma’s mother’s responses. 323. Much of the direct family work was placed with the Vol 2 service although The Mid-Yorkshire Hospitals NHS Trust had a responsibility to ensure this was proceeding satisfactorily. The IMR from Vol 2 comments that the ownership of the Common Assessment Framework process needs to be made explicit. For example, in this case RM 1 should have completed the pre-assessment form to show who was going to be responsible for it and the specialist midwife should have either taken responsibility for filing it or at least ensured that it was progressed in a satisfactory manner. 324. The adult service IMR comments on several aspects of learning to have emerged from examination of their involvement. In particular the IMR refers to the importance of understanding the requirements of the relevant legislation that includes the Mental Capacity Act 2005 and ensuring that assessment practice takes account of the particular circumstances of an adult. In this case there was insufficient understanding about the implications of the pregnancy and parenthood to be incorporated into the enquiries by Community Team for Learning Disability. 325. The focus of the adult assessment was on a narrow aspect of whether mother individually qualified for access to any services; the IMR author makes reference to the fact that access to services will require a high level of urgent need. The IMR acknowledges that no assessment of mother’s (or father’s) cognitive functioning had been undertaken. There had been discussions with a housing support worker and the one home visit that involved it appears the use of an everyday tasks questionnaire did not reveal any concerns for either social worker about mother’s level of understanding. 63 326. In the absence of any detail or comment about the tool that was used by the Community Team for Learning Disability social worker and the extent to which it could have probed how mother was processing information is not clarified. There was no discussion with CPA1 who had raised the original referral. 327. The referral by the GP to Vol 1 in regard to Emma’s father’s anger problems was a response to providing support to Emma’s parents. However it was in isolation from talking with any other professionals either within the health service or with other services such as Safeguarding and Family Support Services. As highlighted previously the GP was not consulted by other services other than Vol 1 who discussed the safeguarding implication of the referral to their anger management service. 328. The locum doctor and triage nurse who dealt with Emma’s mother and her injured fingers in the hospital emergency department in October 2011 did not apparently recognise that she was the victim of domestic abuse. The triage nurse was unaware of local services and arrangements such as the Safe @ Home integrated domestic abuse service or other relevant local groups offering advice, support and information to those affected by domestic abuse in the Wakefield district. The Mid-Yorkshire Hospitals NHS Trust has now taken action to improve the awareness of staff in relation to domestic abuse. An independent person was asked to review the content of the existing domestic abuse training in the trust and as a result of this work the delivery of this training has been strengthened considerably for example all Emergency Department staff now receive training on domestic abuse along with nursing and medical staff and this has been supported by a new campaign involving posters, screensavers etc. that are visible to all staff. Were practitioners aware of and sensitive to Emma’s needs in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? Were there any indications or cues from this child that may have indicated that the child was being mistreated? 329. Although the involvement of the specialist midwife and the organisation of the Common Assessment Framework and referral to the Vol 2 service were all indicative of the early recognition that Emma’s parents had additional needs, when it came to the birth of Emma and the involvement of the health visitor there was not an adequate plan in place. The completion of the Integrated Care Pathway (ICP) had not provided an opportunity to provide prior notice to the health visitor of a birth to a vulnerable family. The health visitor allocated to Emma had no prior information. 330. The health visitor who made the referral to the GP on the 10th April 2012 mentioned that Emma had a cry that was “not usual” at her initial visit but this was too nonspecific to require any action. However, when the health visitor noted the weight loss, on the background of the other concerns she correctly recognised the need for a further assessment which is when she made her referral via the GP. She would have preferred a paediatric referral but as parents had problems getting to the hospital she referred to the 64 GP instead. Unable to speak to GP she had put her concerns on SystmOne22. The GP did not know about the health visitor’s concerns placed on the electronic patient record until he spoke to her the next day after seeing Emma. 331. The IMR says that she had appropriately identified the possibility of safeguarding issues and should have either insisted on a paediatric referral or been explicit in her referral to GP indicating that she wanted the child admitted. After speaking to the GP there was also another opportunity to refer to social care with her safeguarding concerns. 332. The GP practice had important information about the harassment that Emma’s mother had experienced and was also aware of father’s extensive history of violence that had resulted in more than one term of imprisonment. Although the referral to the Vol 1 had resulted in that service contacting the GP practice to highlight the implications for child protection, no referral or other contact was made by the GP practice with Safeguarding and Family Support Services or any other health practitioners who were in contact with Emma’s mother in relation to the pregnancy. 333. The visit by Emma’s mother to the Mid-Yorkshire Hospitals NHS Trust in October 2011 for the injury to her fingers was reported to the GP but did not include information that it had occurred during an argument with Emma’s father; the information was not shared with any other service. This was a significant gap in sharing information. 334. The Health Overview Report comments that the absence of involvement by health practitioners in the Child in Need plan and the apparent lack of appreciation that Emma’s mother had stress and anger issues presented to the GP during pregnancy had implications for her emotional and practical capacity as a parent demonstrates a degree of insensitivity to needs. 335. The adult service IMR acknowledges the lack of curiosity on the part of the Community Team for Learning Disability social worker who undertook the home visit. There is no substantial comment about the extent of knowledge and responsibility that the service expects of its staff in collating information about potential neglect. The IMR confirms that Emma’s parents and grandparent presented a very positive picture during the home visit. The Serious Case Review panel has been advised that the police held information that would have been relevant to professionals working across agencies. All Individual Management Reviews will need to examine whether information held by their agency in relation to Emma’s parents was used effectively in terms of assessing risk to the child. 336. The police had significant information about Emma’s father in regard to the domestic abuse in previous relationships and physical injury of a child. In 2002 a two year 22 SystmOne, is an electronic patient records system being implemented within the NHS. The introduction of the system is intended to improve information sharing and provide greater clarity about which services are being provided to a family and helps improve the interface between adult and children’s services protecting children or vulnerable adults. 65 old child was injured and this was the subject of police investigation and enquiries through the child protection procedures of a neighbouring authority. 337. Emma’s father subsequently began a relationship with another partner who also had a child. That relationship lasted for several years during which time it is known that he subjected the partner to domestic abuse that escalated over time. The ex-partner suffered a particularly violent assault during which her ribs were broken. Emma’s father was convicted and received a prison sentence that was suspended. Child protection procedures were again invoked in regard to the child. 338. The police were told about an incident of domestic abuse between father and mother at the end of December 2011. Although there was a DASH assessment that recorded the history of domestic abuse with previous partners it did not include reference to the allegations of child abuse. The incident was not reported to Safeguarding and Family Support Services by the police safeguarding unit. No statements were taken when Emma’s mother declined to make a complaint. 339. The earlier incident at the beginning of November 2011 that was reported to Safeguarding and Family Support Services by the housing provider was not reported to the police; this was in spite of information that indicated that Emma’s father had physically assaulted Emma’s mother. 340. The Health Overview Report comments on the lack of detailed analysis about risk assessment available from health reports and information. Although the specialist midwife made a number of attempts to raise issues about Emma’s mother in the latter months before the birth she did not formally escalate any concerns about any risks to Emma to others. The GP had information about Emma’s mother suffering harassment from a previous partner and also had information about Emma’s father and his history of violence including imprisonment. Although referrals were made to a specialist service to help both parents with anger there was no referral to Safeguarding and Family Support Services. 341. The specialist voluntary organisation was concerned about the implications of Emma’s father’s history and contacted the GP about this; the GP did not make any referrals or share information with any other service. The specialist service did make two contacts with Safeguarding and Family Support Services; once by phone in 2011 and again in a follow up email in February 2012. Although the information referred to the GP having information about a history of violence, they did not make a formal referral or follow up concerns in writing. 4 Analysis of key themes for learning from the case and recommendations 342. This report began with an acknowledgment of the imminent changes that are to take place over the forthcoming months in the conduct of Serious Case Reviews locally and across England. These changes are driven by the recognition that any meaningful analysis of the complex human and professional interactions and processes for decision making that characterise multi-agency work with vulnerable families has to understand why things 66 happen and the extent to which local systems help or hinder effective work within ‘the tunnel’23. 343. There is a risk when undertaking a Serious Case Review that has examined the involvement of several different services, for it to then result in a range of recommendations that overwhelm rather than promote the further positive development of services and practice. A review can also become misdirected in trying to fix a set of issues that relate to a specific case or particular historical circumstances that are out of the ordinary or have already been resolved. The overview author also has to take account of the number of recommendations and action plans that are the outcomes of the IMRs and the health overview report. 344. From the start of this review the panel have been determined to be very challenging in order to bring out as much learning as possible. It is for this reason that a great deal of detail has been reflected upon within many of the individual agency reviews, the health overview report and within the content of the previous chapters to this overview report. The IMRs and the Health Overview Report have generated over 19 recommendations as a result of this specific review and are also working on action plans following previous Serious Case Reviews. 345. The review panel acknowledge the contribution made to the learning from this review by the many people who participated in the interviews and discussions with the agency IMR authors. The panel also acknowledge the considerable work undertaken by the authors of the agency IMRs and of the Health Overview Report. These are complex and significant processes taken on by people already with a wide and extensive range of responsibilities in their usual professional role. 346. There is a temptation in thinking that reports such as this will resolve the areas for learning and development identified through the review. It is not the reports that achieve this but rather the dedicated and purposeful work of the managers, specialist advisors and practitioners in the different services and of the WDSCB who will oversee the learning from the review. It is their work with some of the most vulnerable children and young people that can make a difference in continuing to achieve ever better outcomes for children. 347. This report and all the others that are provided through a Serious Case Review should acknowledge the complexity facing people working in these services. The benefit of the hindsight offered through a review should not over simplify or devalue the skills and knowledge that the combined workforce of criminal justice, education, health and social care professionals has developed and that they deploy on a daily basis. 23 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight and a far more detailed compilation of information. 67 348. In this final chapter of the report, the focus is upon the key points of learning to come out of this particular review. Members of the maternal family have expressed their hope that there is effective learning and that it is implemented from the review. The process of undertaking the review has already generated learning across several services and therefore it is of doubtful quality to take an unduly forensic approach of dealing with every detailed aspect; such an approach leads to over complicated and ultimately less effective action plans and strategies. The fact that this overview report is a public document also means that the full content is available for relevant training and development to promote continued learning. 349. A few well-chosen critical reflections are more likely to be effective than trying to address every micro detail, especially at a time when all organisations are also managing significant change in response to the national and local challenges. This final chapter’s purpose is to be proportionate in identifying those most important areas for learning that result from this particular Serious Case Review. 350. There is nothing to prevent any organisations or individuals from identifying additional action as a result of their own management review or the overarching themes highlighted by either the health overview report or in this overview report. 351. The key findings in this chapter are framed using a systems based typology developed by Social Care Institute for Excellence. Although this Serious Case Review has not used systems learning to collate evidence there is value in using the following framework to identify some of the underlying patterns that appear to be significant for local practice whilst accepting there are some limitations and mismatch between how the evidence has been collated and this form of presenting the key findings. a) Innate human biases (cognitive24 and emotional) b) Family and professional interactions c) Responses to incidents d) Longer term work with vulnerable children and families e) Tools f) Management systems 352. The remainder of this report aims to use this particular case, to reflect on what it appears to reveal about gaps and areas for further development in the local safeguarding system and use it as far as possible as a window into those local systems. 353. In providing the reflections and challenges to the WDSCB there is an expectation that the Board will want to provide a response to each of the key findings as well as to the recommendations and action plans that are described in the IMRs. As far as the key finding described in the remainder of this chapter it is anticipated that the Board will take the following action. 24 This describes the functions of knowing, perception and intuition 68 a) Does the Board accept the finding? b) How is the Board to take this forward? If not, please explain why. c) Who is best placed to do this? d) What are the timescales for response? e) How and when will it be reported? 354. The WDSCB will determine how this information is managed and communicated to relevant stakeholders. The reason for structuring this final and important part of the report in this way is that it gives responsibility and empowerment to the people who know their community and services to develop appropriate responses rather than have action imposed. 355. The remainder of the report summarises key influences in relation to the key practice or episodes. 4.1 Innate human biases (cognitive and emotional influences): repeated exposure of professionals to intractable and long term problems such as domestic violence contributed to a normalisation and de-sensitisation in the response and understanding the significance of deviant or risky parental behaviour that included evidence of historic and current domestic abuse 356. Emma’s family were not regarded as the most vulnerable family known to the various services that were all under significant workload pressures. The fact that the pre-birth assessment had not been written up and analysed probably reflects that other cases were taking a higher priority in Safeguarding and Family Support Services. 357. Services that are regularly dealing with domestic abuse did not recognise information as significant. Examples included the disclosure by Emma’s father about a record of imprisonment and reference to violence during the first Common Assessment Framework meeting. Safeguarding and Family Support Services was provided with information about concerns regarding Emma’s father’s history and behaviour. 358. The response by the police when the maternal grandfather took Emma’s mother to the police station and the reliance on mother making a complaint rather than taking a more proactive stance to the evidence of domestic abuse indicates a degree of normalised behaviour reflected by all of the services in this particular case; none were able to overcome the reluctance of Emma’s parents to take opportunities to address the violence in their relationship. 359. The only professional referral of domestic abuse (in contrast to the telephone discussions and messages between professionals) was in early November 2011 from the supported living service to Safeguarding and Family Support Services. It is not clear why the police had not been called when the argument was occurring although it may reflect a reticence to have contact with police from a community that feels it to be living on the margins by virtue of their lifestyle and circumstances. 360. A Multi-Agency Safeguarding Hub (MASH) will be operational at the new Wakefield District Police Headquarters by the end of January 2014. The Wakefield MASH will involve 69 statutory and other services in co-ordinating reports and information and making joint analysis in relation to children where concerns about safety and vulnerability are being identified. In the meantime social workers undertaking S47 Enquiries and police officers are already co-located at a local police station and this has led to closer working and improved information sharing. The MASH will include representatives from the Safeguarding and Family Support Service, West Yorkshire police and health agencies. 361. At no stage during the time period under review was there a sufficiently structured meeting that involved the different services to collate the information that was held by different people and services; the pre-birth assessment was a framework for doing this but did not involve other services and the two Child in Need meetings did not involve all relevant people involved with Emma and her family. 362. Evidence of domestic abuse did not attract sufficient sceptism. Although Emma’s father had considerable contact with several different professionals, some of whom had significant information about his history, this remained effectively invisible for the purpose of any formal assessment and analysis of information. 363. Vol 1 made two contacts with Safeguarding and Family Support Services as well as one telephone call to the GP to raise their concern about the information regarding Emma’s father. The telephone call to Safeguarding and Family Support Services in November 2011 and the email in early February 2012 clearly expected that further discussion would take place between Safeguarding and Family Support Services and the GP. It did not happen. 364. Vol 2 had become concerned; this reflected a greater level of contact even when they believed the case had effectively been taken over by Safeguarding and Family Support Services to undertake the pre-birth assessment. 365. The maternal grandfather commented about his lack of confidence in services taking sufficient notice and action in response to domestic abuse. 366. The Health Overview Report acknowledges the learning that has been identified in previous Serious Case Reviews in regard to exploring the possibility of domestic abuse with pregnant women and refers to ‘Asking the question’. Recommendations in regard to Abigail (WDLSCB 2012) are addressing this. 4.2 Difficulties in achieving a balance between keeping a mind open to new information and making judgments and decisions in a timely fashion for children such as Emma 367. The Safeguarding and Family Support Services author refers to the dangers and influence of cognitive fixation that prevents people from giving proper inference to new or contradictory information that does not fit with a prevailing mind-set. In this case there was a mind-set from very early on that inferred that Emma’s mother had the greater level of difficulties and that Emma’s father was going to be a committed father who could compensate for some of the areas of difficulty. 70 368. Although this view of father was being challenged by the Vol 2 by the beginning of 2012 it was apparent that Safeguarding and Family Support Services did not see Emma as a child requiring protection but rather a family needing and accepting help and support. This may have been an unconscious influence on how important tasks such as making the enquiries of other services such as the police were dealt with. 369. They were not expecting to receive information that would challenge a pre-existing view based on their own observations of Emma’s parents who wanted to present a positive front to statutory services that would have been able to remove Emma if they had concerns. 370. Emma’s father expressed his motivation to be a good parent to Emma. He talked with the GP about his anger difficulties and he attended sessions with different professionals. He had the support of his family. The degree to which either of Emma’s parents had the capacity to overcome their difficulties was the subject of much optimistic hope and intention and not enough attention to the barriers and contra indicators. 4.3 Responses to incidents; inadequate checking of history and the collation of emerging information created the conditions where individual incidents were viewed in isolation and inhibited the identification and clarification of patterns from different sources; the influence of mind-set. 371. There will be surprise as well as concern about how the very significant history in regard to Emma’s father did not become known more clearly prior to Emma’s tragic death. Safeguarding and Family Support Services were told on two separate occasions by Vol 1 that they had been given information by the GP that Emma’s father had a history of violence and had served several terms of imprisonment. The referral in early November 2011 from supported housing had also included reference to the overheard comments by Emma’s father that he would not go back to prison. 372. It is quite possible that the nature of the discussion between the two social workers was such that neither checked that it was the other who had actually made the phone call and because they had only seen him providing attentive care to Emma they did not have a prior anticipation that he was a source of risk to Emma. 373. It remains somewhat problematic trying to understand why having been told in unequivocal terms by Vol 1 that Emma’s father had a record of violence and had been in prison that a further verification was not made. The fact that both social workers and their manager felt overwhelmed by their workload is a contributory factor that impeded their opportunity for meaningful reflection and challenge. 374. This impaired capacity was probably a contributory factor to explain why a further check was not made with the GP or with the probation service. There would have been a further opportunity for a check if the GP practice had made a referral to Safeguarding and Family Support Services with first-hand information. 71 375. The rule of optimism25 has been recognised as a significant cognitive influence in how professionals receive and process information. The significance is that it leads to minimising information that represents a source of risk by concentrating on information that supports a positive framing of parental capacity for example. 376. In this case the mind-set that had developed was that it was mother who had difficulties with her anger and household management but that Emma’s father was presenting himself as being motivated and more than prepared and capable to take responsibility for Emma and her mother; he was regarded as an important source of resilience to counteract the deficits that had been identified. 377. Too many of these judgements had relied on observing the parents behaviour for relatively short periods of time without closer attention to collating historical information and involving all relevant people in helping with collation and analysis of information. Background information is always important to consider alongside direct observation. 378. Some professionals faced particular problems in how stored information was available to inform their judgement. For example, the complexity of data systems in health services often means that several different sources of information have to be accessed to ensure sufficient information is revealed. The storage of patient information in GP practices does not routinely identify for example relationship links between men with a violent history such as Emma’s father with a pregnant woman. 379. This is exacerbated when different GPs see a patient and therefore are not in a position to have a personal overview of information although with the number of patient consultations undertaken by a GP there will always be a high reliance on what is stored in the patient record. In Emma’s case, although there was information about his violent history and imprisonment this was not known or looked at in detail until after Emma had died. 380. There are also complex and difficult ethical and legal dilemmas that confront professionals such as doctors in determining when they should share patient information. The GP practice often has information that can be a crucial part of a multi-agency jigsaw of data and intelligence about a child and their family. In this case there were specific opportunities when the GP practice could have made a referral about Emma’s father and the GP practice also had important information about the vulnerability and needs in regard 25 In 1983, Dingwall, Eekelaar Dingwall and Murray, (The Protection of Children: State Intervention and Family Life, Blackwell, Oxford) investigated professional decision making in an English child protection system. They developed the 'rule of optimism' to explain how health and social workers were screening or filtering out many of the cases with which they were involved. These researchers asserted that under the 'rule of optimism' workers applied a heuristic or routine method of practice which was used to reduce, minimise, or remove the concerns for the child's welfare or safety. This was done via the workers applying overly positive interpretations to the cases that they were assessing. The same research suggested that the 'rule of optimism' was only discounted when parents refused to cooperate with workers and rejected help (a 'failure to cooperate'), or when there was a 'failure of containment' where a number of workers became involved with the case and the pressure for protective action became too great. Child death inquiries and Serious Case Reviews have continued to comment on the phenomenon and Lord Laming has also referred to the same rule of optimism. 72 to Emma’s mother. Not all of this information was known to any single GP and the fact that more than one GP practice had contact with Emma’s parents was a further hindrance to seeing a complete picture about Emma’s circumstances. 381. Another cognitive influence was the work circumstances that several of the professionals were experiencing; the ability to stand back and reflect on the contradictions and inconsistencies in regard to information and observation are more limited when people feel under pressure to process information quickly and make judgements based on that fast processing. Daniel Kahneman describes how human brain function is dominated by fast and intuitive functioning that primarily relies on personal experiences and immediate information where as more analytical processing is far more difficult to achieve without conscious discipline26. 382. The significance of understanding the impact of such cognitive influences on the behaviour and processing of information by professionals has to be recognised in developing the conditions that make right judgments more probable. In this case the simple description of how key aspects of information were processed leads to a linear conclusion that people made misguided decisions. But trying to understand why the decisions do not stand up to hindsight examination requires a more challenging and rigorous response. 383. The referral to adult’s services did not result in any checks of historical information; both Safeguarding and Family Support Services and the Community Team for Learning Disability remained unaware of the history of learning difficulty for both of Emma’s parents. 384. There were disclosures of his violence during early discussions but because mother was the focus of professional involvement and he was not seen as a person meeting the criteria for support from the service (he was not a young parent whereas Emma’s mother was) and there was no follow up. 385. The review has highlighted that conditions such as workload and information management contributed to an over reliance on how Emma’s parents behaved with professionals. There were also further missed opportunities in later meetings when for 26 Thinking, fast and Slow; Daniel Kahneman, (New York: Farrar, Straus and Giroux, 2011. The title of the book refers to what Kahneman, adapting a device that other researchers originally proposed, calls the “two systems” of the human mind. System 1, or fast thinking, operates automatically and quickly with little or no effort and no sense of voluntary control. Most System 1 skills such as detecting the relative distances of objects, orienting to a sudden sound, or detecting hostility in a voice are innate and are found in other animals. Some fast and automatic System 1 skills can be acquired through prolonged practice, such as reading and understanding nuances of social situations. Experts in a field can even use System 1 to quickly, effortlessly, and accurately retrieve stored experience to make complex judgments such as undertaking what might be regarded as a routine assessment. A chess master quickly finding strong moves when he recognises a defensive weakness are examples of acquired System 1 thinking. System 2, or slow thinking, allocates attention to the mental activities that demand effort, such as complex computations and conscious, reasoned choices about what to think and what to do. System 2 requires most of us to “pay attention” to do things such as drive on an unfamiliar road during a snowstorm, calculate the product of 17x24 or understand a complex logical argument. 73 example Emma’s father was ambivalent to participate in anger management sessions because he had already done this in the past. 386. The lack of reporting to the police about incidents in November 2011, February and April 2012 left the police outside of the circle of information sharing for the for pre-birth assessment and Child in Need plan. Safeguarding and Family Support Services were not aware of the contact that Emma’s mother and maternal grandfather had with the police in December 2011 because a safeguarding referral had not been made to Safeguarding and Family Support Services; the circumstances and the reasons have been described previously. 387. The IMR from Safeguarding and Family Support Services has acknowledged there was information that was not sought in relation to this case. There were other checks in addition to the police that were not completed adequately. The consequence was that the information being passed through particularly from Vol 2 was never given the inference it deserved if the historical information had been secured. 388. This resulted in over reliance on what the social workers observed during their seven visits of meeting with Emma’s parents and during which father in particular made sure that Emma was seen to be well cared for. 4.4 Tools; the tools and assessment process for multi-agency collating, sharing and analysing information were not sufficiently developed and embedded and provided no resolution to issues such as whether either parent had a learning difficulty or disability 389. The effective sharing and analysis of information within a framework of theoretically robust and child focused assessment is a perennial challenge for multi professional teams and practitioners and has been described and discussed in national research, inspections of children’s services as well as being a regular feature in Serious Case Reviews. 390. The assessment of neglect and the quality of emotional care of very young children is especially problematic if the information and professional systems do not have the capacity to reflect upon the accumulated evidence of direct observation and professional reporting. It is being able to identify and understand the underlying patterns to behaviour and interaction rather than relying on single defining events (such as a physical injury for example) that are important to safeguarding children. 391. National efforts to achieve improved consistency have largely resulted in processes becoming ever more bureaucratised and process driven through computer based electronic recording frameworks. This has left professionals completing processes that have little apparent benefit for improving the clarity and insights regarding complex behaviours and family circumstances and their interplay. The tools focus on describing events or behaviour and offer limited opportunity to record professional reflection, hypothesis or analysis. 392. In this case there were issues identified by some professionals regarding the cognitive functioning of Emma’s mother. These were never adequately explored or resolved. Historical checks with education services is not a local or national requirement and is not a usual or required practice; in regard to Emma’s father and mother there was 74 important and relevant information within the education service in regard to childhood learning difficulties that could have helped inform the pre-birth assessment. 393. The current systems work with the greatest effectiveness when a tangible event or incident is being reported or recorded and this has encouraged a degree of reliance on the single record or event needing to provide a compelling and clear reason for a reaction especially from specialist higher tier services that are working with the most vulnerable of children. Most of the IMRs reported that the attention of professionals was being diverted to other more pressing cases at the time. 394. There was very little information sought about the parents’ personal and family histories27. The current assessment framework almost invites such an approach. The national frameworks for assessment are likely to be changed as a result of the national consultation referred to at the start of this report and will place a greater emphasis on local areas developing their own arrangements28. 395. Too much practice reflected through this case for Safeguarding and Family Support Services is a one dimensional and static approach to viewing the needs and circumstances of children and a preoccupation on physical conditions rather than the emotional needs and circumstances of children for example. The completion of the assessment appeared to be regarded as an administrative task rather than being an important exercise of professional skill and judgment that involved other people in the completion and subsequent planning of action. The fact that the assessment had not been written up by the time of Emma’s birth is also perhaps indicative that other assessments were regarded as more urgent at the time because Emma was not viewed as being a baby at risk compared to other children requiring professional attention at the time. 396. Another dimension revealed in this review and which is reflected in national studies29 concerns the extent to which questions about what a child means to a parent and what the parent means to that child in respect of their emotional care and security are not routinely explored. The same report offers reflection on the important relationship between having a good understanding about all aspects of maltreatment and its relationship with the development of children. 27 Reder and Duncan found similar issues in their review of Serious Case Reviews in 1999; Lost Innocents: A Follow-up of Fatal Child Abuse. It has become apparent in this review. 28 The national consultation guidance proposes the abolition of national frameworks and standards and instead will emphasise that local areas are clear about legal requirements, secure effective and co-ordinated cross agency working and increased responsibility for monitoring and challenge through local accountability arrangements. 29 Brandon, Sidebotham, Ellis, Bailey and Belderson. Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of Serious Case Reviews Department for Education May 2011 75 4.5 Management systems; the commissioning and contracting arrangements placed a limit on how aspects of the work was completed 397. This Serious Case Review has revealed that the commissioning arrangements for services can create unintended consequences. The creation of the specialist midwife role has been recognised as good practice in recent inspections of local services. The co-location of the midwife with the Vol 2 service is an example of good collaboration. 398. It is known that the police and Safeguarding and Family Support Services have created a Joint Investigation Team (JIT) and plans are well advanced for establishing a Multi-Agency Safeguarding Hub (MASH) to create the conditions for more effective management of domestic abuse referrals; this was planned before the completion of this review although is seen to be an important measure of implementing the learning from Emma’s case. 399. The terms of the contract agreed for the provision of the Vol 2 service meant that Emma’s father could not receive a service from that team of workers. It is acknowledged that this had some influence on how the case was initially handled and the disclosures of information. 400. The case has also raised issues in regard to the clarity of understanding between specialist adults services and professionals seeking their advice and help in regard to the functioning of adults caring for children. Health professionals have used the learning difficulty protocol on several occasions but it is obviously not fully implemented as health did not use it in the case and the initial adult services IMR author was not aware of its existence despite it being a joint protocol. The issue will continue to be problematic unless resolved across agencies 4.6 The implementation of new systems including electronic recording arrangements contributed to communication difficulties 401. More than one of the IMRs provided for the review have described how the implementation of new working arrangements had an influence on how information was shared and managed between different people and service locations. For example, the co-location of the specialist midwife removed her from the professional intranet and other communication tools. This created barriers for effective communication and left her professionally isolated from her peers. 402. The challenge of creating conditions in which busy professionals are enabled to share information efficiently and have the ability to identify emerging patterns is a regular feature in reviews and inspections of services. 403. In this case, the introduction of co-located professionals had unintended consequences in compromising their access to information systems; there misunderstandings and differing assumptions about aspects of working arrangements when Safeguarding and Family Support Services became involved and managing the transition from a Common Assessment Framework to higher level of support. 76 404. Organisations that have staff sharing information systems across different service locations will have considerable challenges in managing the logistics associated with implementing new systems and achieving consistent use of the systems. For example, in this case, information contained in some of the SystmOne health system was not used in the same way by different health professionals. 405. For example, when the health visitor agreed with Emma’s parents that Emma would be seen by the GP just prior to her death, the health visitor placed a note on the electronic patient system that was intended to alert the GP to the fact that Emma was the subject of a Child in Need plan. The GP did not read that entry. 406. The review has identified that the use of filters to help busy professionals access and use extensive patient information records might be a factor in why the health visitor note was unread in this case. It has to be remembered that in this case, the health visitor did not have enough information to be concerned about Emma’s immediate safety and wellbeing; if she had been it is very likely that the health visitor would have ensured a conversation with the GP was had before the examination. 407. This is not to suggest that if the GP had seen the note the outcomes would have been different for Emma but it does highlight that when the health visitor was unable to speak by phone she had assumed that there would be her background information for the GP to consider alongside the fact that it was the health visitor who had advised the consultation with the GP rather than Emma’s parents having taken the initiative themselves. 408. It became apparent through the review that there are variations in how different work locations such as GP practices place patient related information such as copies of referrals to other services into the recording system. 409. The workload and organisational capacity had an impact on how several professionals processed information and worked with Emma’s family 410. The majority of IMRs reported that individual practitioners or services were working with higher levels of need than other comparable services or had been anticipated in the original service specifications for commissioning services. 411. Some of the practitioners and managers reported how they felt overwhelmed by events occurring at the time; for example some services were experiencing reorganisation; several individual practitioners were clearly working with a personally very demanding workload that involved working far in excess of their core hours. 412. Senior managers and strategic bodies are involved in the delivery of complex services against a background of significant constraint or reduction in the resources that are available. The type of activity that is carried out by these services and the professionals involved in this case do not lend themselves to the application of a set of practical heuristics and objective formulae. 413. For example, a workload that feels manageable can change quickly as a result of an unexpected crisis involving a child at risk. The nature of the work requires an ability to 77 process a significant range of complex information. People are less likely to show the level of curiosity, analysis and reflection required when they are also required to deploy considerable pragmatism to how they prioritise a range of competing tasks and demands. Emma was one child among several who required the attention of different individual professionals already under considerable stress and pressure. 414. By definition, the range of work and the responsibility that individuals carry is very difficult to quantify either in respect of the level of demand or the range and complexity of the task. Those people at the public front of the service in direct contact with families had to apply a degree of pragmatic thinking and action. 415. When individuals began to feel higher levels of concern about Emma it proved difficult to achieve an escalation on the part of other professionals and organisations. This applied in regard to the communication between Vol 2 and Safeguarding and Family Support Services as well as the information sharing between the health visitor and the GP. The review has described and analysed the various factors that influenced communication. 416. This phenomenon of people being unable to recognise new and significant information and analyse the significance has been identified in research and Serious Case Reviews. Although this implies that it is more an issue for cognitive and other functioning, the capacity of individual professionals to think critically and to reflect upon information will be affected by the conditions within which they work. The organisational context for effective safeguarding work was highlighted by the Munro Review. 417. It is notable that all the IMRs have reported that supervision arrangements complied with the organisational standards and requirements. In effect this meant that people had supervision at the required intervals and had access to advice and guidance. 418. Examination of Emma’s story has revealed that some fundamental aspects of practice were not dealt with adequately and with sufficient attention to detail. Some of this might reflect pragmatic cutting of corners in a case that at the time was not seen as the most problematic or dangerous for a child’s safety and wellbeing. 419. For example the quality of recording activity such as checks with other agencies and ensuring that assessments are written up and plans involved other services more fully. The approach taken to sharing information by all of the professionals who were all very busy relied on relatively informal methods rather than for example opening a Common Assessment Framework or making a written referral of concern. 420. With the benefit of hindsight, if there had been a better capacity to provide challenge and reflection as well as checking that work such as the pre-birth assessment was being completed appropriately and on time, it is quite possible that the gaps and inconsistencies that were missed particularly in Safeguarding and Family Support Services would have been recognised. 421. In Safeguarding and Family Support Services the Team Manager was supervising ten social workers who between them had 280 cases. The statutory role of a children’s service 78 inevitably means that all the cases will reflect a high level of need and risk. Regarding one case as being more risky than another creates the conditions within which the hidden or latent risk continues to go unrecognised. 422. There were additional barriers for practitioners being able to access relevant archived records that were held in paper files. For some services such as health, there are cost implications that arise for example if health practitioners seek historical information. 4.7 Issues for national policy 423. The only statutory requirement of all GPs under the remit of the Primary Care Trust is that they must “give regard to the local safeguarding policy”. The arrangements in Wakefield exceed this statutory requirement in that local contracts with GP practices insert an explicit requirement to comply with the local safeguarding policies and procedures. This includes specifying the arrangements for a Serious Case Review such as this. 424. The difficulties encountered during this review to secure the full disclosure of information by the GP practice has been a significant impediment for the panel and added to the overall workload for the panel and are in contrast to the experience in other reviews and with other GP practices. An appendix to this overview report sets out the advice and guidance in place at the time of the Serious Case Review taking place. 425. The national guidance in regard to the conduct of Serious Case Reviews was the subject of a government consultation that was closing as this review was being completed. The panel have noted that the proposals made by government in regard to learning and improvement will remove any national guidance to assist local safeguarding children boards on such matters. 426. Guidance was sought from the General Medical Council (GMC) and the Medical Protection Society (MPS) in regard to the professional responsibilities of doctors providing treatment for women known to be pregnant. The GMC reinforces that in the first instance doctors should provide what support they can including the provision of advice and information that encourages the woman to seek help. 427. The GMC also acknowledges the public interest justification in dealing with cases where there are concerns about the safety of the baby. The GMC and the MPS both recognise the absence of legal identity and right to protection for an unborn baby. The GMC reflects on the need to balance the potential harm that could arise from not sharing information about a pregnant woman and the potential for harm to her baby against the duty of confidentiality to the patient. 428. The MPS also encourages doctors to take action and share any concerns about a pregnant woman in regard to the safety of her baby. The MPS and the GMC both emphasise the importance of seeking advice from lead or specialist practitioners and to comply with any local guidance and protocols. 79 5. Recommendations The Mid Yorkshire NHS Trust 1. Following review of training in relation to Domestic Abuse the Assistant Director of Patient Experience and Improvement will ensure the content and quality of the training meets the specific needs of the Health Visiting, Midwifery and Emergency Department professionals 2. Health visitors are informed of all antenatal bookings but there needs to be a more reliable and effective system of allocation of cases to individual health visitors than is currently in place. An effective pathway will be developed by the Division of Integrated Care with: • clear time scales (related to stage of pregnancy), • defined individual responsibilities (i.e. who receives referral, who allocates, who visits) • compliance checks to ensure all women are allocated and visited as planned • escalation plans (i.e. what to do if women remain unallocated or unvisited within defined timescales) The proposed standard is “All first time mothers should receive at least one face to face antenatal contact with a health visitor in the third trimester.” Current performance will be audited against this standard by April 2013 and a further audit to assess progress will be undertaken in October 2013. (Target 75% compliance by October 2013) 3. Review the provision of midwifery support to the pregnant teenager. Currently there is only one part time Specialist midwife providing tailored support to a proportion of these clients in one half of the Trusts catchment area. Alongside this and on both sides of the district there is an increasing development of the Family Nurse Partnership (FNP). There is significant overlap of the responsibilities of each role and the services they offer. This introduces a risk of both duplication of, and gaps in, provision. Consequently there needs to be a review of the model of provision of these services leading to a strategic decision about the best way forward 4. All staff to whom a pregnant woman might disclose domestic abuse need to be aware that LSCB safeguarding procedures require them to follow Local Safeguarding policies. 5. The Mid-Yorkshire Hospitals NHS Trust will ensure that all level 3 practitioners who become aware that a child is subject to a Common Assessment Framework, Child in Need plan, Child Protection Plan or is Looked After, will communicate this to other The Mid-Yorkshire Hospitals NHS Trust professionals involved in the care of the child (e.g. HV, Midwife, AHP). This recommendation should also consider how this could include information sharing with GPs. 80 6. When considering the communication between health visitors and GPs (Abigail SCR 2012) The Mid-Yorkshire Hospitals NHS Trust will consider the communication structures to enable the SPM to communicate with GPs. Barnardo’s Young Families 7. Barnardo’s Young Families staffing structure should be reviewed to ensure: • that when more than one line manager is involved in a case there is an appropriate communication strategy and clear lines of responsibility for escalating concerns • the staffing structure reflects the level of knowledge, skills and experience required at management and supervisory levels of Safeguarding 8. Barnardo’s Young Families should review the use of Common Assessment Framework and clarify the assessment process to ensure that all staff understand their roles, specifically if identified as lead professional, and are able to engage significant adults and other agencies in the process. 9. Barnardo’s Young Families reviews the Safeguarding Policy to ensure all staff understand their responsibilities in escalating concerns and that line managers intervene at the appropriate level with written communication 10. Barnardo’s Young Families to consider how domestic abuse knowledge is shared in the Service in order to embed good practice and ensure the staff team are all able to respond appropriately to indicators of domestic violence Safeguarding and Family Support Services 11. There should be a review of information sharing systems between the Safeguarding and Family Support Service and the Police in relation to Police checks on S.17 cases, under the Children Act 1989, to ensure a streamlined and timely route for such information sharing 12. The Service Director will consider the configuration of the Social Work Teams and the need for any redesign of the local operational child and family social work system to ensure configuration is the most effective to meet the needs of children and families. 13. As part of the development of practice standards for Social Work, relevant sections should outline: • The timeliness and accuracy of recording, including the recording of multi-agency views in pre-birth assessments and the distribution of assessments and Child in Need plans • A formal recording mechanism in relation to Social Workers recording the name and designation of the Police Officer who completed a police Check, including the 81 reasons and whether any parental or young person’s consent has been given or overridden, with reasons as to why • The quality of management assessment, oversight and supervision 14. The Service Director should ensure that a sample of pre-birth assessments is undertaken in relation to the quality of referral taking, evidence of multi-agency assessment, analysis, planning and review 15. The Service Director should implement training or developmental learning in relation to reflective practice, professional curiosity and methods to engage families Wakefield MDC – Adults Operations and Strategy and Commissioning 16. Staff working with young people over the age of 16, including people with a learning disability or learning difficulty should be trained to understand the principles of the Mental Capacity Act, 2005. 17. A clear protocol for practitioners in Community Teams for Learning Disabilities to deal with cases where there are parenting issues, specifically if there is an unborn child. 18. Ensuring holistic assessments take place when a parenting issue is identified of both the unborn child and parents, establishing role clarity and effective communication. 19. Effective recording required when practitioners make a decision on eligibility, using appropriate assessment and documentation, if the referral is allocated to the team 6. APPENDIX Procedures and guidance relevant to this Serious Case Review Legislation The Children Act 1989 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act30 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need. Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm. These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a Baby Has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998. Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm. The Children Act 2004 Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate. The arrangements are to be made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes. This section is the legislative basis for children’s trusts arrangements. 30 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act31 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Safeguarding Procedures The Wakefield Safeguarding Children Procedures The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this Serious Case Review. National guidance32 Working Together to Safeguard Children (2010) The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable. Framework for the Assessment of Children in Need and their Families 2001 The guidance in respect of the Framework for the Assessment of Children in Need and their Families is issued under section 7 of the Local Authority Social Services Act 1970 and is therefore mandatory. 31 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. 32 The election of a coalition government in May 2010 may result in changes to guidance and policy developed by the previous government. The framework sets out the framework for ensuring a timely response and effective provision of services to children in need. It makes clear the importance of achieving improved outcomes for children through effective collaboration between practitioners and agencies. The framework sets out clear timescales for key activities. This includes making decisions on referrals within one working day, completing initial assessments within seven working days and core assessments within 35 working days. As part of an initial assessment children should be seen and spoken with to ensure their feelings and wishes contribute to understanding how they are affected. If concerns regarding significant harm are identified they must be subject of a strategy discussion to co-ordinate information and plan enquiries. Child protection procedures must be followed. Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should be a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention is required to secure the well – being of the child. Such intervention should be described in clear plans that include the services being provided, the people responsible for specific action and describe a process for review. Common Assessment Framework (Common Assessment Framework) The Common Assessment Framework is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The Common Assessment Framework is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The Common Assessment Framework promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The Common Assessment Framework also aims to improve integrated working by promoting coordinated service provisions. All areas were expected to implement the Common Assessment Framework, along with the lead professional role and information sharing, between April 2006 and March 2008. |
NC52847 | Concerns a 12-year-old boy who was made the subject of an Emergency Protection Order in 2021. Elliot attempted suicide in his respite care placement and was admitted to hospital, where he communicated extreme distress through self-harm and violent behaviour towards staff. Learning considers: understanding of Mental Health Act assessment processes; child and adolescent mental health services (CAMHS) support to the paediatric ward; hospital as a place of safety; childrens social care (CSC) support and placement provision; planning and escalation procedures; and service re-design and planning around managing children and young people with complex needs. Recommendations include: local NHS foundation trusts should clearly outline the process for a child to be referred for a Mental Health Act assessment, criteria for inpatient CAMHS admission and the routes for professional challenge when there is a disagreement; a joint Health and Social Care Escalation Policy should be developed to ensure that when there is a risk of a child remaining on a general paediatric ward inappropriately, there are clear processes to alert senior leaders; the local Mental Health NHS Foundation Trust should review out of hours psychiatry provision for children; the local Hospitals NHS Foundation Trust should consider developing a safe place where children who have been admitted can be assessed and cared for; CSC should explore the provision of suitable registered residential therapeutic placements; staff should develop skills to reflect on how children communicate through their behaviour, interaction and physical presentation, and how this can be used to plan their care; and the development of a joint health and social care escalation policy, ensuring the focus remains on the child.
| Title: Local child safeguarding practice review: ‘Elliot’. LSCB: Wigan Safeguarding Children’s Partnership Author: N. Osborne and L. Cunniffe Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Wigan Safeguarding Children Partnership Local Child Safeguarding Practice Review ‘Elliot’ Reviewers: June 22 N Osborne and L Cunniffe May 23 report condensed by S Whitelaw 2 CONTENTS Page INTRODUCTION 2 • Safeguarding History 3 • Elliot’s Admission to Hospital and Care Management 3 • High Court Judgement 4 WSCP RAPID REVIEW PROCESS AND IDENTIFIED LEARNING 5 • Rapid Review Process 5 • Identified Learning 6 • Good Practice 7 METHODOLOGY 7 • Methodology 7 • Parallel Proceedings 8 • Practitioner Learning Event 8 INTRODUCING ELLIOT 9 • Elliot’s Involvement and Contribution 9 • Family Involvement and Contribution 10 TERMS OF REFERENCE AND KEY LINES OF ENQUIRY 10 • Terms of Reference 10 • Key Lines of Enquiry 10 SUMMARY OF KEY EVENTS 11 KEY LINES OF ENQUIRY (KLOE) 14 KLOE 1 14 KLOE 2 18 KLOE 3 26 KLOE 4 32 KLOE 5 36 KLOE 6 41 KLOE 7 45 OVERVIEW REVIEWER RECOMMENDATIONS 49 REFERENCES 53 APPENDIX 1 - LOCAL CHILD SAFEGUARDING PRACTICE REVIEW PANEL MEMBERS 54 3 INTRODUCTION 1. This Local Child Safeguarding Practice Review (LCSPR) centres around a 12-year-old child who came into Local Authority care in an unplanned way after being made the subject of an Emergency Protection Order. This child will be referred to as ‘Elliot’ in this report. 2. Prior to coming into the care of the Local Authority Elliot lived with his Father and sibling at home. He also has three other siblings who lived with their Mother. Elliot had regular contact with his Mother and all his siblings as they lived close by. 3. Elliot was placed in a respite care placement as a short-term measure until an appropriate placement could be found. Two days later Elliot attempted to self-ligature at his placement and was taken to Accident and Emergency (A&E) where he was admitted to hospital onto a general paediatric ward. 4. Whilst in hospital Elliot exhibited extreme emotional distress which required management in the form of physical and chemical restraint1. A Court order was issued authorising the Wigan National Health Service (NHS) organisations involved in providing his care and Wigan Children’s Social Care staff to deprive Elliot of his liberty. 5. At a later High Court hearing the Judge declined to further authorise the deprivation of Elliot’s liberty and he was satisfied that the current arrangements for Elliot constituted a breach of his human rights under Article 5 ‘Right to liberty and security’ of the Human Rights Act (1998). 6. Wigan Council Children’s Social Care subsequently identified a suitable placement within the community and Elliot was discharged from hospital after an eleven-day admission. 7. Wigan Safeguarding Children Partnership agreed that the threshold was met for a Local Child Safeguarding Practice Review (LCSPR). This report will outline Elliot’s lived experiences and the identified learning from this LCSPR. 8. LCSPR Panel Members agreed that the terms of reference should start on the day Elliot became the subject of an emergency protection order, care proceedings were issued, 1 Chemical restraint is the use of prescribed medication which is administered by health professions for the purpose of quickly controlling or subduing disturbed or aggressive behaviour (page 42, https://www.gov.uk/government/publications/reducing-the-need-for-restraint-and-restrictive-intervention ) 4 and he was placed in a residential care placement (Day 1); and should end when he was discharged from hospital (Day 14). Safeguarding History 9. Elliot first became known to the Local Authority in 2011, Elliot and his siblings were made the subject of Child Protection Plans under the category of emotional abuse. 10. Between 2011 - 2015 Elliot spent periods as the subject of a Child Protection Plan and as a Child in Need. 11. In mid-2015, Elliot became a Looked After Child and was placed with foster carers. He was returned to his Father’s care in 2016. 12. In 2021, Elliot was placed on a Child Protection Plan under the category of neglect. 13. An Emergency Protection Order was made in mid-2021, care proceedings were also issued on this date. Elliot was placed in a respite care placement as a short-term measure until an appropriate placement could be found. 14. Two days later Elliot attempted to self-ligature at his placement and was taken to Accident and Emergency (A&E) where he was admitted to hospital. Elliot’s Admission to Hospital and Care Management 15. Elliot had a diagnosis of attention deficit hyperactivity disorder (ADHD), epilepsy and medical staff were querying a possible autistic spectrum disorder. On admission to A&E an initial mental health assessment determined that his presenting acute emotional and behavioural difficulties were as a result of trauma and abuse. 16. From the time he was placed at the respite care placement and throughout his time in hospital Elliot communicated his extreme distress through self-harming behaviour and displaying violent behaviour to those who were caring for him. 17. Staff were unable to calm Elliot’s distress and contain his subsequent behaviour which resulted in the Local Authority applying for Deprivation of Liberty to authorise management by means of chemical restraint, physical restraint and a 6:1 staffing ratio to support Elliot. 18. Staff caring for Elliot were emotionally and physically injured whilst physically and chemically restraining him. Clinical staff felt they were working outside their usual scope 5 of practice, particularly in relation to the administration of sedatives and anti-psychotic drugs. 19. Following admission to hospital Elliot was detained under Section 5 (2) of the Mental Health Act (1983) to allow him to be assessed. He subsequently had a Mental Health Act assessment which determined that he did not meet the relevant criteria for further detention under Section 2 or Section 3 of the Mental Health Act. The Local Authority urgently tried to source a suitable therapeutic placement which was unavailable meaning Elliot remained on the ward despite this not being an appropriate place for him to be when not requiring medical treatment. 20. WWL general paediatric ward was closed to new admissions and beds were closed due to the risks presented to staff and towards other children on the ward due to the way Elliot communicated his extreme distress. Planned elective surgery lists for children were also cancelled. 21. Elliot’s admission to hospital and presenting extreme distress was escalated to senior leaders both internally in the hospital and externally to multi-agency partners. Multiple Daily Planning Meetings were held to coordinate a multi-agency approach to meet Elliot’s needs. High Court Judgement 22. There was a High Court hearing on Day 13 in relation to Elliot. The pertinent points from this High Court Judgement in relation this LCSPR are as follows: a. The Judge stated that Elliot was inappropriately placed on a clinical ward. b. A Deprivation of Liberty application had been previously issued however at this hearing the Judge declined to authorise the continued Deprivation of Liberty of Elliot. c. The Judge outlined that he was satisfied that the current arrangements for Elliot constituted a breach of his human rights under Article 5. d. The acute lack of resources for vulnerable children in Elliot’s situation has impacted severely on many other children and families. e. The adverse impact of the lack of appropriate provision and its impact on the health and welfare of children and families who are not involved with the court system. f. That professionals involved had tried to do their best “Finally, I wish to make clear that nothing that I have said in this judgment constitutes a criticism of the doctors, nurses, social workers, police, and other professionals who have been required to engage with <Elliot>. They have, I am satisfied on the evidence before the court, tried to do their best in a situation 6 in which they should never have been placed. All those involved have done their level best in a situation that has bordered on the unmanageable.” Wigan BC v Y (Refusal to Authorise Deprivation of Liberty) [2021] EWHC 1982 (Fam) (14 July 2021) 23. The Judge outlined his intention to direct that a copy of their judgment is provided to the Children's Commissioner for England; to Lord Wolfson of Tredegar QC, Parliamentary Under Secretary of State for Justice; to the Rt Hon Gavin Williamson CBE MP, Secretary of State for Education; to Josh MacAllister, Chair of the Review of Children's Social Care; to Vicky Ford MP, Minister for Children; to Isabelle Trowler, the Chief Social Worker; and to Ofsted. 24. As a result of the above Court judgement CSC were directed to identify a suitable placement to discharge Elliot to by Day 14. CSC identified a property which was adapted to make safe for Elliot and a wraparound support package of care was commissioned. 25. A referral was made by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust (WWL) to the Wigan Safeguarding Children Partnership (WSCP) for consideration of a Rapid Review. WWL Safeguarding Team felt that the High Court ruling demonstrated that Elliot had suffered significant harm and would therefore meet the Working Together (2018) criteria for a Rapid Review. WSCP RAPID REVIEW PROCESS AND IDENTIFIED LEARNING Rapid Review Process 26. A Rapid Review meeting held by WSCP considered whether the case met the criteria for a LCSPR as outlined in Working Together (2018). 27. The Rapid Review Panel concluded that it was a matter of fact that Elliot had had his human rights breached as established via the High Court ruling and that the criteria was met to proceed to a LCSPR. 28. The Rapid Review Panel noted that some of the learning identified in this case was already being addressed in other ongoing LCSPRs being conducted by WSCP. This included: • Disproportionate professional optimism, and lack of challenge to drift and delay in permanency for children. Specifically with children subject to repeated Child Protection planning and repeat referrals to Children’s Social Care. • Attendance at core group meetings and contributions to plans was variable. 7 • Pre-proceedings were not effective or mobilised swiftly which probably meant the parent believed there were no consequences. • Lack of suitable therapeutic beds and general placement sufficiency. 29. In line with National Child Safeguarding Practice Review Panel guidance, as the above themes are being addressed in other LCSPRs, this review will focus on the new learning. Identified Learning 30. The Key Lines of Enquiry (KLOE) for this LCSPR will focus on the new learning identified by the Rapid Review Panel following Elliot’s admission to hospital. A full report of the learning identified at Rapid Review was provided to the National Child Safeguarding Practice Review Panel and has been summarised below: • Understanding of Mental Health Act Assessment Processes There appeared to be different levels of understanding regarding the Mental Health Act Assessment. This led to multi-agency disagreements regarding the outcome and quality of the assessment. This resulted in drift and delay without a clear pathway for escalation. • Child and Adolescent Mental Health Services (CAMHS) support to the Paediatric Ward CAMHS support on the ward was described as intermittent whilst mental health assessments were ongoing which put additional pressure on clinical staff, with unclear advice regarding the use of anti-psychotic drugs. GMMH explained that in reach support is not currently commissioned. The out of hours Psychiatry support was not clear and was provided by a different NHS Trust than the in hours support. • Hospital as a ‘Place of Safety’ Elliot remained in hospital inappropriately after he was assessed as not requiring an inpatient CAMHS bed due to a lack of appropriate placement alternatives. Hospital staff were injured during this time, and felt they were working outside of their usual scope of practice. More specialist training is needed for staff on the acute general paediatric ward on de-escalation, safe restraint and trauma informed practice. • Children’s Social Care (CSC) Support and Placement Provision CSC did not have an agile, responsive resource of suitably skilled staff to support children like Elliot, which meant that WWL had to care for Elliot for a prolonged period of time even though it was not an ideal environment to meet his needs.8 There is a lack of national and local joined up strategy for CSC and health to manage the placement provider market, and this remains underdeveloped to address the needs of children like Elliot. • Planning and Escalation Procedures It appears that at times planning and escalation procedures lost focus on Elliot’s immediate situation. The focus was lost from Elliot to wider system issues that could never be resolved in the daily planning meetings which included senior and executive leaders. • Service re-design and planning around managing children and young people with complex needs Attempts had been made within the Borough to work in an integrated way to address the emerging gaps in the system for children who presented with similar needs to Elliot; however, this had not progressed quickly enough. Good Practice 31. The Rapid Review Panel did note some good practice which has been outlined below: • Children and Family Court Advisory and Support Service (CAFCASS) noted in their response that they saw excellent engagement and communication across all agencies. • The risks were well understood by all agencies and escalated accordingly. • All frontline professionals did their very best for Elliot (as noted by the Judge and outlined in paragraph 20f above). 32. The Rapid Review proposed that the learning outlined above should be explored through a short LCSPR which is limited to a timeframe of Elliot being removed from his home and his subsequent hospital admission until he was discharged. WSCP notified the National Child Safeguarding Practice Review Panel of this intention and they confirmed they agreed with this plan. METHODOLOGY 33. This LCSPR which will be limited to the scope of the issues identified in the Rapid Review. A root cause analysis approach will be used in relation to some aspects (e.g., around pathways of decision making) but will be blended with the Welsh model to include family and practitioner involvement. 34. The Child Safeguarding Practice Review Panel considered this case and agreed with the proposed methodology and noted they had received correspondence from the National Network of Designated Health Professionals (NNDHPs) regarding this case along with the High Court Judgement. 9 35. Given the short timeframe for the Terms of Reference for this LCSPR, WSCP Executive Leaders decided that the Assistant Director for Safeguarding Children at NHS Wigan Borough Clinical Commissioning Group (WBCCG), supported by their Deputy should undertake this LCSPR. 36. It was felt that the Reviewer for this LCSPR should be independent of NHS Providers whilst having an expert knowledge of the health system, and how this interconnects with the wider system, for children who present with needs like Elliot. 37. The WSCP Rapid review took place on 5th August 2021, however due to the extreme pressures in the health system due to the Covid-19 pandemic the LCSPR did not commence until February 2022. 38. The lead reviewer left the organisation in June 2022 and had completed the draft report. The Case Review panel requested amendments were made. These amendments were undertaken but there were some issues with the assurance and sign off processes which has caused delay in finalising. WSCP worked with the National Panel to ensure that the final report was an open and accurate reflection of the presenting issues and was suitable for publication. The Case Review Panel and the Executive Panel approved the finalised report in February 2023. Parallel Proceedings 39. Parallel proceedings have been considered to avoid potential conflict of interest. Greater Manchester Police confirmed to the LCSPR Panel that there are no criminal proceedings in relation to Elliot or his family and NHS Provider organisations were not conducting any Serious Incident Investigations under the NHS Serious Incident (SI) Framework. Practitioner Learning Event 40. A learning event was held for practitioners from all agencies who had provided care for Elliot and had been involved in care planning discussions. Participants were asked to: • Describe Elliot • Tell us what his personality was like • Reflect on what they thought Elliot would say about his experience • Consider each Key Line of Enquiry and discuss o Elliot’s Experience o Operational difficulties faced by staff working with Elliot o Strategic Barriers o Good Practice o What is the learning? 41. The information shared within the Learning Event has been incorporated throughout this LCSPR report. 10 INTRODUCING ELLIOT 42. Elliot is a white British 12-year-old boy who lived with his Father and siblings prior to the time period being considered within this review. He attended a school for children with additional needs and his attendance had been 39.4% prior to him coming into the care of the Local Authority. 43. Elliot has a diagnosis of ADHD which he was not taking medication for at Father’s request. He also has epilepsy and some practitioners working with him thought he may have a possible Autistic Spectrum Disorder. He had an Education and Health Care (EHC) Plan in place. 44. Elliot’s Father described him as an energetic and passionate boy who loved his dog. He enjoyed playing the drums and his keyboard and loved singing and watching musicals. 45. His Mother described him as full of energy and liked watching musicals. He loves his siblings and there is the usual sibling rivalry when they come together. 46. At the WSCP Rapid Review the following description was given of Elliot “He is known to be a fun and loving young man with a good sense of humour. His stature is very tall, and he enjoys physical interaction. He enjoys long walks and being outside and exercising.” Elliot’s Involvement and Contribution 47. The LCSPR Panel Members explored with Elliot’s Social Worker how we could best involve him in the review and fully capture his voice and lived experience. It was felt by those who knew him best that to discuss this period in his life would be too emotionally painful. Elliot appears to remain traumatised following his experiences at the centre of this review. Therefore, it was agreed not to approach Elliot directly, but the Key Lines of Enquiry should robustly capture his voice and experiences. 48. In the forensic psychologist’s report completed following Elliot’s discharge from hospital Elliot is described as having a diagnosis of ADHD (Severe), learning disability or intellectual disability, autism and a complex trauma based presentation. 49. In the absence of Elliot’s actual voice, the Reviewers have attempted to capture this by detailed discussion with his family and frontline practitioners who were involved in his care. 11 Family Involvement and Contribution 50. Elliot’s parents were approached to contribute to the LCSPR. Separate home visits to his Mother and Father were undertaken by the Reviewer along with a Service Manager from Children’s Social Care. 51. Elliot’s Father described him as a “pleasant, beautiful child who had his frustrations.” He talked at length about his experiences and his feelings following Elliot’s removal from his home. He was aware of his hospital admission but felt frustrated that he was unable to see Elliot. 52. His Mother described not being aware that Elliot had been admitted to hospital and was not contacted by any agencies at the time. She was subsequently made aware and described that Elliot’s father does not always share information with her. 53. Reflections and perspectives from both parents have been included throughout the relevant sections of this LCSPR report and will be shared with the parents before final approval and publication. TERMS OF REFERENCE AND KEY LINES OF ENQUIRY Terms of Reference 54. LCSPR Panel Members agreed that the terms of reference should start on the day when Elliot became subject of an emergency protection order, care proceedings were issued, and he was placed in a residential care placement (Day 1) and end when he was discharged from hospital (Day 14). Key Lines of Enquiry 55. The LCSPR Panel Members agreed seven Key Lines of Enquiry (KLOE) as outlined below: KLOE 1 To consider if multi-agency disagreements about the outcome and quality of the mental health assessments led to drift and delay and whether there is a clear pathway for escalation in these circumstances. KLOE 2 To explore how Elliot's presentation was managed and his care needs met effectively; particularly focusing on effective use of mental health services expertise to support the Acute Paediatric environment including the use of antipsychotic drugs. KLOE 3 Establish how hospital provision was used in relation to Elliot, what alternatives were available and how WWL’s general paediatric provision is equipped to manage and respond to presenting need. 12 KLOE 4 To consider the impact on Elliot and other services of Children’s Social Care (CSC) not having an agile, responsive resource of suitably skilled staff to support Elliot and explore what resources are needed. KLOE 5 To explore the planning and escalation procedures, the involvement of senior leaders and how effective these were in responding to Elliot’s immediate needs. Was there sufficient focus on Elliot as well as consideration of implications for the wider system? KLOE 6 To establish what work has been undertaken by Children’s Social Care to manage the lack of suitable therapeutic placements for children like Elliot, including joint working with Partners. KLOE 7 To develop an understanding of Elliot’s lived experience and what efforts were made to capture Elliot’s voice. SUMMARY OF KEY EVENTS 56. This section will give an overview of the key events which took place within the agreed timeframe for the terms of reference which is Day 1 when Elliot became subject of an emergency protection order, care proceedings were issued, and he was placed in a residential care placement to Day 14 when he was discharged from hospital. 57. The following table outlines the timeline of key events which has been summarised from a 60-page chronology compiled by all agencies into the LCSPR process: Date Key Events Day 1 (Thursday) • Urgent Court Hearing - Emergency Protection Order granted. Day 2 (Friday) • Elliot is taken to a residential placement which is a respite home for children with complex needs. • Child Protection Medical completed at WWL. Day 3 (Saturday) • Emergency 999 call received by NWAS as Elliot has attempted to self-ligature. • Elliot was taken to WWL A&E at 23:37hrs, he arrived in restraint to protect Elliot and staff. Day 4 (Sunday) • Elliot was admitted to the general paediatric ward at around 04:00hrs (around 4.5hrs after first arriving at A&E) as he required a period of observation following sedation. • Mental Health Liaison Team (MHLT) discussion with Ward Manager and a mutual decision made to delay Mental Health Assessment until Day 5 due to Elliot’s level of distress. 13 Day 5 (Monday) • Medical staff explored options for Rapid Tranquilisation medication with mental health colleagues. Pharmacy colleagues sourced a Rapid Tranquilisation Protocol from Alder Hey which was followed. • Three Urgent Planning Meetings held throughout the day. It was agreed that a court order should be sought. An Independent Care Provider would be contacted to provide 4:1 staff ratio to Elliot. • A request for an urgent mental health assessment was made. A mental health assessment was completed at 14:17hrs. The outcome of the mental health assessment was that Elliot’s presentation was not the result of a mental health 14 condition but was due to significant distress in his life and particularly over the past few days. • Section 5 (2) of the Mental Health Act Implemented following 2nd meeting. Day 6 (Tuesday) • Daily Planning Meetings held at 09:00hrs, 12:00hrs and 15:30hrs. • A decision was later made to reduce to ten beds and two High Dependency Unit beds, this is a reduction of seven acute medical beds. Paediatric surgery lists had to be cancelled. • Independent Care Provider sourced with four carers being provided alongside a hospital nurse who will support airway management and clinical observations – resulting in a 5:1 staff ratio to support Elliot. • Elliot remains subject of Section 5 (2) of the Mental Health Act. • Court order issued in the afternoon authorising the continued deprivation of Elliot’s liberty on the hospital ward until 16:00hrs on Day 8. Day 7 (Wednesday) • Daily Planning Meetings were held at 09:00hrs and 15:00hrs. • Escalation to WBCCG, CQC, NHS England and GMHSCP • At the 15:00hrs meeting concerns were raised from WWL regarding the quality of the Mental Health Act assessment. There were differences of opinion regarding the outcome and WWL and CSC were requesting a second opinion. • CSC agree to increase the number of care support workers to five alongside a hospital nurse who will support airway management and clinical observations – resulting in a 6:1 staff ratio to support Elliot. • Mental Health Act assessment was completed with three registered practitioners in line with the Mental Health Act legislation. They concluded that Elliot did not meet the criteria under the Mental Health Act, and it was not in his best interests to further detain him. • Court order remains in place authorising the continued deprivation of Elliot’s liberty on the hospital ward until 16:00hrs on Day 8 Day 8 (Thursday) • Continued 6:1 staff ratio to support Elliot. • Daily Planning Meetings held at 09:00hrs and 12:00hrs, chaired by the CSC Practice Director. • WWL escalate concerns to Greater Manchester Gold Command regarding the impact on the Ward. • Elliot’s Children’s Guardian requested a second opinion in respect of the Mental Health Act assessment from the previous day, specifically regarding the medications required to manage Elliot’s anxiety. • Court hearing Interim Care Order (ICO) granted alongside an authorisation for the continued deprivation of Elliot’s liberty on the hospital ward until 16:00hrs on Day 13 when this will be reviewed in Court. The NHS can legally chemically and physical restrain, and the Local Authority can physically restrain. Day 9 (Friday) • Continued 6:1 staff ratio to support Elliot. • Between 01:24hrs and 05:00hrs Elliot continued to demonstrate verbal and physical aggression towards staff. Care staff found it difficult to settle him. Father contacted the Ward twice during this time to ask how Elliot was. • Elliot absconded from the Ward in the afternoon and required periods of regular restraint and safe holding. • Daily Planning Meetings held at 09:00hrs and 12:00hrs, chaired by the CSC Practice Director. • In the daily planning meetings (which were attended by executive leaders from various agencies) there were extended discussion regarding the quality of the Mental Health Act assessment and whether this could or should be repeated. Day 10 (Saturday) • Staff ratio to support Elliot remained at 6:1, however, the package of care is increased to include two Registered Mental Health Nurses and four carers. However only one Registered Mental Health Nurse arrived for the night shift. 15 • One episode of Elliot absconding from the Ward at 21:20hrs-21:50hrs. Elliot was sedated whilst receiving physical restraint. • There was no daily planning meeting on Day 10 as it was the weekend. Day 11 (Sunday) • Staff ratio to support Elliot remained at 6:1, including two Registered Mental Health Nurses and four carers. • There was no daily planning meeting on Day 11 as it was the weekend and no system escalations. Day 12 (Monday) • Staff ratio to support Elliot remained at 6:1, including two Registered Mental Health Nurses and four carers. • Consultant Psychiatrist has made changes to the medication prescribed which means the Alder Hey Rapid Tranquilisation Policy will no longer be needed. • Daily Planning Meetings held at 09:00hrs and 15:30hrs. • WBCCG Designated Nurse escalated further concerns to GMHSCP regarding the level of restrictive practices. • A decision is made that Mental Health Act assessment should not be repeated unless there are changes to Elliot’s presentation Day 13 (Tuesday) • Staff ratio to support Elliot remained at 6:1, including two Registered Mental Health Nurses and four carers. • Order made in the High Court, Family Division. In this hearing the Judge declined to authorise the continued deprivation of liberty of Elliot. The Judge outlined that he was satisfied that the current arrangements for Elliot constitute a breach of his Article 5 rights. Day 14 (Wednesday) • Staff ratio on the Ward to support Elliot remained at 6:1, including two Registered Mental Health Nurses and four carers. • CSC sourced a temporary placement for Elliot with a 3:1 staff ratio with mental health trained staff. Discharge Planning Meeting held with key agencies and workers to ensure a robust plan of support was in place to reduce risks in the community. • Court order updated regarding authorised restrictive practices. • Elliot discharge to placement at 18:45hrs 16 KEY LINES OF ENQUIRY (KLOE) KLOE 1: What happened? 58. Elliot was admitted to A&E at 23:37hrs on Day 3 accompanied by two carers. He was brought to A&E following an emergency 999 call received by NWAS as Elliot had attempted to self-ligature. A high level of restraint was needed to protect Elliot and the staff. 59. There were prolonged discussions between medical staff who were unclear about appropriate use of chemical sedation in this circumstance. The A&E Doctor (Registrar) discussed sedation with an Anaesthetic Consultant who advised not to sedate due to the potential of airway complications. Nurses also highlighted concerns regarding Elliot requiring sedation. 60. MHLT first reviewed Elliot at 00:20hrs (Day 4), 43 minutes after Elliot was admitted. The MHLT challenged the clinical staff’s reluctance to prescribe sedation to Elliot. This was discussed with the on-call Psychiatrist who agreed to prescribe sedation. The MHLT then advised WWL staff that they were unable to complete a mental health assessment due to Elliot’s level of sedation. They did however advise that the staff ratio should be increased from 2:1 to 4:1 to support Elliot. 61. Later that day (Day 4) the MHLT had a discussion with the ward Manager and a mutual decision was made to delay mental health assessment until Day 5 due to Elliot’s level of distress. 62. On Day 5 the MHLT advised WWL staff how they could de-escalate and calm Elliot. They completed a mental health assessment at 14:17hrs which suggested that presenting behaviours were likely to be due to Elliot being unable to self-soothe. 63. Following the 2nd Daily Planning Meeting a request for an urgent Mental Health Act (MHA) assessment was made as professionals from WWL and Wigan Council CSC disagreed with the outcome of the mental health assessment. Following this meeting To consider if multi-agency disagreements about the outcome and quality of the mental health assessments led to drift and delay and whether there is a clear pathway for escalation in these circumstances. 17 Section 5 (2) of the MHA was implemented which allowed professionals 72-hours to undertake a full MHA assessment. 64. On Day 6 concerns continued to be raised at the Daily Planning Meetings regarding Elliot not yet having had a MHA assessment. Mental health colleagues held an urgent meeting to discuss next steps and consulted with inpatient CAMHS colleagues for advice. A MHA assessment was arranged but this had not taken place. 65. On Day 7 a MHA assessment was completed at 13:00hrs with three registered practitioners in line with the MHA legislation. Elliot became extremely agitated, and the Police were called to assist the ward in management of his behaviours. The assessment concluded that Elliot did not meet the criteria under the MHA, and it was not in his best interests to further detain him. He was assessed as not requiring a CAMHS inpatient Tier 4 admission as it was felt that a mental health setting would be highly likely to exacerbate Elliot’s presentation. Therefore, the Section 5 (2) was rescinded. They made some changes to his prescribed medication to assist with agitation. 66. At the Daily Planning Meeting held at 15:00hrs concerns were raised from WWL regarding the quality of the MHA assessment. WWL staff felt that the MHA assessors had not spent time with Elliot and had based their opinions on a review of health records. WWL and CSC requested a second opinion and wanted the MHA assessment to be repeated. 67. On Day 8 the Children’s Guardian for Elliot requested a second opinion in respect of the MHA assessment from the previous day, specifically regarding the medications required to manage Elliot’s anxiety. 68. On Day 9 in the Daily Planning Meetings (which were attended by executive leaders from various agencies) there were extended discussion regarding the quality of the MHA assessment and whether this could or should be repeated. It was highlighted by some participants in the meetings that MHA assessments cannot be repeated unless there are significant changes in a person’s presentation. It was agreed at this point that the MHA assessment would be repeated, and discussions would take place to explore how and when this could take place. 69. On Day 12 at the Daily Planning Meeting participants were informed the MHA assessment documentation was reviewed from a quality perspective and deemed appropriate. A discussion had taken place between senior leaders within CSC and health, and despite a previous agreement that the MHA assessment would be repeated, GMMH believed that a repeat assessment was not clinically indicated and did not happen. This therefore this meant that professionals needed to focus on sourcing an appropriate placement to enable a safe 18 discharge for Elliot into the community. 70. On Day 13 a written report was shared with the ward regarding the MHA assessment that had taken place on Day 7. There was a High Court hearing in which the Judge declined to authorise the continued deprivation of liberty of Elliot. This meant that Elliot needed to be discharged the following day to a suitable placement. KLOE 1 Findings 71. The findings of KLOE 1 are that there was drift and delay in the care planning for Elliot due to other agencies challenging the outcome and quality of mental health assessments. 72. As a result of the WWL staff and CSC staff being unwilling to accept the outcome of the Mental Health Act assessment, mental health staff felt there was a lack of respect for their professional opinion. They also felt that other agencies view an inpatient CAMHS admission as a place of safety and the solution for all children who present like Elliot. Mental health professionals were also highlighting the potential impact of a hospital admission on a child with autism and or a learning disability. They felt a long hospital admission for a child like Elliot would be traumatic. 73. This dynamic was further complicated by the Daily Planning Meetings including a range of professionals from frontline practitioners to executive senior leaders. This led to protected discussions about the right way to proceed. 74. It is clear from the information provided to the LCSPR that there is confusion regarding the steps in the process for a child to be referred and assessed under the Mental Health Act. The Reviewers concluded that whilst challenge should be encouraged it is imperative that this is done with professional respect. 75. Ultimately it was apparent that there is a lack of understanding regarding the MHA assessment criteria, when an inpatient CAMHS admission is in the best interests of the child, and how and when to appropriately challenge decision making by those services outside mental health. 19 KLOE 1 RECOMMENDATIONS: Recommendation 1: Greater Manchester Mental Health NHS Foundation Trust and Pennine Care NHS Foundation Trust need to clearly outline the process for a child to be referred for a Mental Health Act assessment, criteria for inpatient CAMHS admission and the routes for professional challenge when there is a disagreement. This document should be accessible to all agencies. Recommendation 2: A joint Health and Social Care Escalation Policy should be developed to ensure that when there is a risk of a child remaining on a general paediatric ward inappropriately and we are unable to achieve a safe discharge there are clear processes to alert senior leaders to take action. 20 KLOE 2 What happened prior to admission to hospital (Days 1-3) 76. On Day 2 Elliot was taken to a residential placement which is a short-term respite home for children with complex needs. Elliot stated that he did not want to live with his Father. 77. On Day 3 the residential placement made an emergency 999 call to North West Ambulance Service (NWAS) as Elliot had attempted to self-ligature. Police, NWAS and the Fire Service attended the care home, and six members of the Fire Service were required to physically restrain Elliot. Elliot was taken to WWL A&E at 23:37hrs along with two carers. On arrival at A&E care home staff expressed concerns to WWL staff that the placement was not right for Elliot as they usually provide care for children who have complex disabilities, and their families require respite. What happened in A&E (Day 3-4) 78. Once at A&E Elliot was distressed and needed a high level of restraint. 79. There were prolonged discussions between medical staff who were unclear about appropriate use of chemical sedation in this circumstance as Elliot was only 12 years old. The hospital records reflect that clinical staff were concerned about sedating Elliot due to potential airway complications. A&E medical staff consulted with colleagues in the Intensive Care Unit (ICU) and Anaesthetics. 80. The Police were requesting to leave the A&E Department as they were out of their policy timeframes for restraint and concerned about breaching Elliot’s human rights. The Police were also concerned about needing four officers to restrain Elliot for long periods. Police officers were also querying why sedation had not been given. The nursing staff felt that it was unsafe for the Police to leave and outlined why sedation had not been given. Police and nursing staff continued to work together and follow their restraint policies to keep Elliot as safe and comfortable as possible. To explore how Elliot's presentation was managed and his care needs met effectively; particularly focusing on effective use of mental health services expertise to support the Acute Paediatric environment including the use of antipsychotic drugs. 21 81. Initially Elliot was deemed as not requiring admission to the General Paediatric ward as “he had no medical needs”. However, the Mental Health Liaison Team (MHLT) attended at 00:20hrs and challenged clinicians’ reluctance to prescribe sedation. Sedation was discussed by the MHLT with the on-call psychiatrist due to Elliot’s “high levels of distress and aggression” who agreed to prescribe sedation. 82. Elliot was given intramuscular sedation at 01:23hrs and the Police left A&E shortly after as Elliot was calm. MHLT advised WWL staff that they were unable to complete a mental health assessment due to Elliot’s level of sedation. 83. At around 03:30hrs records reflect that Elliot was no longer in restraint or attempting to leave the room. Elliot had 2:1 staff ratio of Care Home Staff and MHLT recommended to CSC that this should be increased to a 4:1 ratio to support Elliot. What happened during Elliot’s stay on the General Paediatric ward Day 4 84. Elliot was admitted to the General Paediatric ward at around 04:00hrs (around 4.5hrs after first arriving at A&E) on Day 4 as he required a period of observation following sedation. CSC informed Elliot’s Father in the early hours that he had been admitted to hospital. 85. At 08:43hrs the ward Manager contacted the Residential Placement Manager to discuss safety planning and the residential placement agreed to continue to provide a 2:1 staff ratio until next day (Day 5) when a Discharge Planning Meeting had been arranged. 86. The MHLT arrived on the ward and had a discussion with the Ward Manager. A mutual decision was made to delay the Mental Health Assessment until Day 5 due to Elliot’s level of distress. 87. In the afternoon Elliot absconded from the ward followed by his two carers. The Police were called, and Elliot was located across the road from the hospital and brought back to the ward by Police. Upon arrival back to the ward Elliot climbed under his hospital bed and attempted to injure his arm in the bed mechanism. This resulted in him being restrained by the Police and the bed frame was removed from the room. This led to Elliot having only a mattress placed on the floor of his room for his own safety. 22 Elliot’s Presentation Day 5-14 88. Between Day 5 and Day 14 when Elliot was discharged, he presented as a child in extreme emotional distress. He communicated this distress in a number of ways including self-harm, screaming, attempting to leave the ward, verbally and physically assaulting staff, and damaging fixtures and fittings of the ward. 89. There were several escalations in Elliot’s distress each day with no evident triggers which often resulted in medical staff, nursing staff, support staff and security officers needing to restrain him. The Alder Hey Rapid Tranquilisation Policy was utilised in order to help calm Elliot. Police Assistance to the Ward 90. The Police were called to assist in the management and restraint of Elliot via emergency 999 call from WWL on nine occasions. On some of these occasions (Days 3-7) between two and six Police officers were required to remain on site for prolonged periods of time including overnight. On Day 5 the highest number of Police officers were dispatched to the ward and needed to use a high level of restraint to keep Elliot safe. Staff Ratio to Support Elliot during his Admission 91. On admission to the ward (Day 4) Elliot had a 2:1 staff ratio (Care Home Staff). The MHLT recommended to CSC that this should be increased to 4:1 staff ratio. 92. On Day 5 it was agreed at the Daily Planning Meeting that an Independent Care Provider would be commissioned by CSC to provide 4:1 staff ratio to support Elliot. Professionals agreed that at least one of the four carers should be a Registered Mental Health Nurse (RMN). This was implemented on Day 6 with four carers being provided alongside a WWL hospital nurse who would support airway management and clinical observations – resulting in an overall 5:1 staff ratio to support Elliot. This change supported WWL staff to be able to more safely care for Elliot. 93. On Day 7 CSC agree to increase the number of care staff to five alongside a WWL hospital nurse who would support airway management and clinical observations – resulting in an overall 6:1 staff ratio to support Elliot. This staffing ratio continued until Elliot’s discharge, however on Day 10 the package of care was increased to include two Registered Mental Health Nurses as part of the five carers. Physical and Chemical Restraint 94. Paragraphs 81-86 clearly outline that Elliot arrived in A&E already in physical restraint put in place by the Police and there were discussions between clinical staff regarding the need for chemical sedation soon after his arrival in A&E. 95. During Elliot’s admission he required physical and chemical restraint every day 23 on multiple occasions with Rapid Tranquilisation being utilised several times. Elliot required daily administration of both intramuscular sedatives and/or intramuscular antipsychotic drugs. 96. Medical staff explored the possibility of introducing oral medication to replace the intramuscular injections, but it was felt that these would take too long to take effect and Elliot often refused to take or covertly discarded oral medication. 97. On Day 9 WWL medical staff liaised with CAMHS and was advised by a Registrar to consider giving oral medication covertly. The WWL Legal Team advised there was no provision to do this within the agreed Court order. On Day 11 he asked if he could have this in tablet form. Medical staff agreed and Elliot was given the medication orally. This resulted in his level of distress reducing. 98. On Day 12 there were discussions between the Paediatric and Psychiatric Medical Teams due to disagreements about prescribed medication. The Psychiatric Team was uncomfortable with prescribing routine medications for a 12-year-old child who did not have a formal mental health diagnosis. Following this conversation, the Consultant Psychiatrist made changes to the medication prescribed which meant that the Alder Hey Rapid Tranquilisation Policy would no longer be needed. 99. In a statement to the High Court Elliot’s Paediatric Consultant explained that on one occasion they had administered the maximum amount of daily sedative to Elliot that would be safe and in his best interests. They went on to outline that despite the high 6:1 staff ratio chemical restraint was still required several times a day. This statement is supported by the documentation submitted to the LCSPR and the reflections from clinical staff in the LCSPR Learning Event. Staff expressed that when Elliot’s levels of agitation and distress increased staff struggled to calm, de-escalate, and physically restrain him. 100. The continued inability to contain Elliot during physical and chemical restraint led to an increase in the care staff ratio. The WWL Security Team also arranged additional security officers for the weekend shifts in order to support the ward. 101. Some of the difficulties experienced in the physical restraining of Elliot were due to care staff sometimes being provided by different organisations who worked to different policies. This meant they used different methods of physical restraint and for differing maximum lengths of time. 102. Hospital records outlined that Elliot appeared to be having vacant episodes during physical restraint which medical staff felt were being triggered by the circumstances and environment rather than a medical reason. During these episodes staff experienced difficulties obtaining physical observations due to Elliot’s distress. This made it difficult for staff to ensure his safety. 24 103. There were frequent discussions evident in the information provided to the LCSPR that Paediatric Consultants felt uncomfortable and inexperienced in the prescribing and administration of sedatives and antipsychotic medication. WWL did not have a policy or protocol to support this and arrangements for psychiatric support in relation to this was unclear, particularly out of hours. 104. Generally, the out of hours Psychiatrist on call was not a Paediatric Psychiatrist. The out of hours provision was delivered by a different NHS Mental Health Trust to the in hours provision. This led to delays in medical staff being able to access specialist advice needed to administer Rapid Tranquilisation. However, there were examples of occasions when support was more easily accessed. For example, on Day 10 the Paediatric Consultant rang the on-call Psychiatrist as per the Alder Hey Rapid Tranquilisation Policy and was able to obtain advice regarding suitable dosage for Elliot. Legal Framework 105. On Day 5 Section 5 (2) of the Mental Health Act was implemented in relation to Elliot with a view to undertaking a full Mental Health Act assessment within 72 hours. 106. On Day 6 a Court order was issued in the afternoon authorising the continued Deprivation of Elliot’s Liberty on the hospital ward until 16:00hrs on Day 8. 107. A Mental Health Act assessment was completed with three registered practitioners in line with the Mental Health Act legislation on Day 7. They concluded that Elliot did not meet the criteria under the Mental Health Act, and it was not in his best interests to continue to detain him. It was felt that a mental health setting would be highly likely to further exacerbate his presentation, therefore the Section 5 (2) was rescinded. 108. On Day 8 an Interim Care Order (ICO) was granted alongside an authorisation for the continued Deprivation of Elliot’s Liberty on the hospital ward until 16:00hrs until Day 13 when this would be reviewed in Court. This authorised the NHS to legally chemically and physical restrain Elliot, and the Local Authority to physically restrain. 109. On Day 13 an order was made in the High Court, Family Division. In this hearing the Judge declined to authorise the continued Deprivation of Liberty of Elliot. The Judge outlined that he was satisfied that the current arrangements for Elliot constituted a breach of his human rights under Article 5. 25 KLOE 2 Findings Management of Elliot’s Presentation and Care Needs 110. Despite the best efforts of all staff Elliot’s presentation was extremely difficult to manage and this resulted in his care needs not being met effectively. This led to an increase in Elliot’s distress. 111. In paragraph 59 of the High Court ruling the Judge commented that “All the evidence in this case points to the current placement being manifestly harmful to <Elliot>”. However, later in the published judgement the Judge states “Finally, I wish to make clear that nothing that I have said in this judgment constitutes a criticism of the doctors, nurses, social workers, police, and other professionals who have been required to engage with <Elliot>. They have, I am satisfied on the evidence before the court, tried to do their best in a situation in which they should never have been placed. All those involved have done their level best in a situation that has bordered on the unmanageable.” Support from Mental Health Services to the Acute Paediatric Team 112. It was clear from the information provided to the LCSPR that WWL medical staff felt they were working outside of their usual scope of practice, and at times felt unsafe and unsupported by mental health services. 113. Out of hours Psychiatry support was provided by a different NHS Provider to the main in hours support for the ward. This was confusing for clinical staff and did cause delays in WWL accessing out of hours Psychiatry advice and support. 114. This gap appears to have been created during the April 2021 transfer of services from one mental health NHS provider to another. It seems that the comprehensive NHS due diligence process for this transfer may not have adequately considered the out of hours CAMHS arrangements. 115. It was clear from discussions with staff at the Learning Event that the relationships between WWL and CAMHS staff was at times strained. However, there is evidence that ward staff and the MHLT did work together to explore how they could de-escalate and calm Elliot. Physical and Chemical Restraint 116. Staff attending the LCSPR Learning Event told the Reviewers that Elliot had expressed to staff that he was scared of injections and did not like the feeling the medication gave him. Nursing staff explained that the intramuscular medication, particularly Haloperidol, is likely to feel uncomfortable. 117. Staff also described that prescribing advice for antipsychotic drugs was being provided virtually and there was little face to face support from Psychiatrists. WWL medical staff were using the Alder Hey Rapid Tranquilisation Protocol as they had no internal policy, procedures, or guidance in respect of this. 26 118. There was a Court order in place which authorised NHS staff to chemically restrain Elliot and use Rapid Tranquilisation in his best interests. In the High Court Ruling on Day 13, the Judge stated in paragraph 56 that whilst this had been authorised by the Court, he felt that the “current regime of chemical restraint cleaves closer to that of constant sedation”. His honour went on to comment that “This is not the result of malice or negligence but simply of an increasingly desperate attempt to contain <Elliot> in a situation that is not designed, in any way, for that purpose.” 119. Overall, it was clear to the Reviewers that all staff quickly recognised that they were unable to effectively meet all of Elliot’s presenting care needs. As a result, this was escalated internally in a timely manner and there were efforts to obtain the appropriate advice and expertise to inform Elliot’s care plan. KLOE 2 RECOMMENDATIONS: Recommendation 3: Commissioners need to work with Greater Manchester Mental Health NHS Foundation Trust to review the current out of hours Psychiatry provision for children and ensure that arrangements are fit for purpose and clear to other NHS providers who use this service. Recommendation 4: Work needs to be completed to facilitate the coming together of clinical staff at Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation (WWL) Trust and Greater Manchester Mental Health NHS Foundation Trust (GMMH). This will need to fully explore perspectives, roles, and responsibilities with a view to improving working relationships and developing clear joint protocols for working together. WWL must also develop an agreed, easily accessible Rapid Tranquilisation Policy for use within Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust. 27 KLOE 3: Use of Hospital Provision 120. When Elliot was admitted to A&E medical staff determined he had no medical needs and therefore did not require admission to the general paediatric ward. 121. Elliot subsequently required sedation to manage his level of emotional distress and self- harming behaviour. As a result of this sedation, he was admitted facilitate a period of observation. observation following sedation. 122. Elliot was presented to A&E on Day 3 and admitted to the general paediatric ward on Day 4. He had a mental health assessment by the MHLT Team on Day 5 and subsequently a Mental Health Act assessment on Day 7. The Mental Health Act assessment determined that Elliot did not meet the criteria for further detention under Section 2 or Section 3 and the Section 5 (2) was therefore rescinded. 123. Following the outcome of the Mental Health Act assessment on Day 7 Elliot did not require continued admission to a general paediatric ward. Therefore, Elliot remained on the ward for further 6 days because a safe discharge could not be achieved due to lack of an appropriate placement being sourced by CSC. Hospital Environment and Staffing 124. The general paediatric ward is situated on the fourth floor of the district general hospital. The ward has capacity for 34 paediatric beds for children and young people aged 0-16 years. The ward has twelve individual cubicles and four bays each with up to five beds, and two High Dependency beds. The ward offers a wide range of services and cares for children with a range of conditions and illnesses. 125. For the safety of the patients, access to and from the ward is via an intercom system located on the wall on each side of the entrance doors. Only ward staff can provide access. Pressing the buzzer will identify that access is needed and visitors are asked for identification and who they are visiting. 126. The ward is staffed by registered paediatric nurses and support staff. At the learning event WWL staff described feeling that they were not trained to care for children who Establish how hospital provision was used in relation to Elliot, what alternatives were available and how WWL’s general paediatric provision is equipped to manage and respond to presenting need. 28 presented like Elliot. Staff said that they are not experienced in managing challenging behaviour, de-escalation of children in extreme emotional distress and the level of physical restraint that Elliot needed. 127. As outlined in KLOE 2 above medical staff also felt that they were working outside of their scope of practice Elliot’s Room 128. Elliot’s room on the ward needed to be made increasingly sparse in an attempt to keep Elliot safe. The High Court Judgement gave an overview of the condition Elliot was experiencing in Paragraph 26 “The door to the shower in which he washes himself has been removed, and therefore <Elliot> has no privacy at all when showering or dealing with other aspects of his hygiene. He is at present sleeping on a mat on the floor and he is unable to have a pillow, or a sheet due to the risk of self-harm and suicide.” Additional Resources and Impact 129. In order for Elliot to remain on the general paediatric ward the following list of measures were required: • Elliot was subject to chemical restraint, physical restraint and 6:1 staffing to attempt to control his behaviour. • Police were called to the ward to assist in the management and restraint of Elliot via emergency 999 call from WWL on nine occasions. • WWL Security Team increased the number of staff on duty to support the ward. • Capacity and activity needed to be reduced in the department to safely care for Elliot and the other patients. Alternative Provisions Available 130. At the Daily Planning Meetings CSC explained that they were exploring placements available nationally that could meet Elliot’s needs. They continued to highlight that there was a chronic shortage of therapeutic placements across the country, and they were at the mercy of private providers who were more inclined to accept children with less complex needs. They advised they were exploring secure placements and non- regulated placements. 131. CSC also explored the possibility of obtaining a secure placement for Elliot but again highlighted that there were a handful of vacant beds with a long waiting list. The CSC Placement Team advised the Daily Planning Meeting that there was only one secure bed in England, with 47 applications being considered. The 29 level of staff ratio Elliot required, and his young age further challenged the CSC Placement Team in finding a willing placement provider. 132. At the Daily Planning Meetings other agencies voiced that CSC should establish an ‘in house’ placement for Elliot. CSC were reluctant to pursue this option as this would be ‘unregulated’ and therefore an illegal placement. 133. Despite CSC’s reluctance to establish an unregulated placement and because there was a lack of regulated therapeutic placements available to commission CSC were making arrangements to commission an unregulated placement. 134. CSC identified a property and arranged for the necessary work to be undertaken to make it a suitable and safe environment within which Elliot could be cared for. They arranged for commissioned providers to continue to provide a wrap around package of support on a 2:1 staff ratio. The commissioning of a safe package of care took many days to arrange due to its complexity. Elliot’s Discharge from the Ward 135. Elliot was discharged from the ward on Day 14 into a property sourced and staff by Wigan Council CSC. This was arranged following the High Court Ruling on Day 13 when the Judge declined to further authorise the Deprivation of Elliot’s Liberty. 136. CSC arranged for commissioned providers to continue to provide a wrap around package of support on a 2:1 staff ratio. Elliot was therefore discharged into the care of the Local Authority on Day 14. KLOE 3 Findings Use of Hospital Provision 137. WWL is commissioned to admit children to hospital who require an assessment of their mental health. Once a mental health assessment has been completed the child should be safely discharged to the most appropriate place such as their home, an appropriate placement or when the Mental Health Act criteria is met, transferred to an NHS inpatient CAMHS provision. 138. The challenges begin when a child has had a Mental Health Act assessment and is not assessed as meeting the Mental Health Act criteria and therefore is not eligible for an inpatient CAMHS admission. In Elliot’s case he was assessed as not requiring a CAMHS admission on Day 7 however it was clear that he continued to present as a risk to himself. 139. Therefore, Elliot’s safe discharge was delayed by seven days due to the lack of an appropriate placement which could meet his needs, and the time that it takes to commission a safe complex package of care. This resulted in Elliot being 30 Deprived of his Liberty and enduring extremely restrictive practices to be kept safe on the ward. This included him being sedated most of the time as articulated by the Judge. 140. Nationally, Children’s Social Care are dealing with a chronic shortage of appropriately registered therapeutic placements for children like Elliot. This leads to long periods of time when children are ‘medically fit’ for discharge but an appropriate safe place for the child to be discharged to cannot be sourced. 141. This is particularly highlighted within the briefing paper published by the Children’s Commissioner in November 2020 entitled ‘The children who no-one knows what to do with’. On page one of this briefing paper the Children’s Commissioner outlines that “Again and again the courts have castigated the Government for a failure to plan and provide for these most desperately vulnerable children” and goes on to assert that thousands of children with complex needs fall through these gaps in the system each year. 142. This assertion by the Children’s Commissioner is supported by paragraph 2 of the High Court Judgement regarding Elliot. The Judge commented “In what will be a scenario now depressingly familiar to those in the habit of reading on BAILII judgments given by High Court judges and Deputy High Court judges in cases of this nature, and within the context of acute emotional and behavioural difficulties consequent on past abuse, <Elliot> has been assessed as not meeting the relevant criteria for detention under ss.2 or 3 of the Mental Health Act 1983 as he is not considered to be suffering from a mental disorder. At the same time, the therapeutic treatment within a restrictive clinical environment for acute behavioural and emotional issues arising from past trauma that he does urgently require is simply unavailable”. 143. As a result, nationally general paediatric wards are increasingly being used as a ‘Place of Safety’. Paragraph 55 of the High Court Ruling outlined that the challenges faced by WWL in caring for Elliot “…have their roots in the fact that a paediatric hospital ward is simply not equipped to undertake the task that circumstance, and an acute lack of appropriate resources, has assigned to it”. How equipped is general paediatric provision to manage and respond to presenting need? 144. As outlined above some staff from the general paediatric ward at the learning event described feeling ill equipped and uncomfortable in caring for children who present with needs such as Elliot. There appeared to be a culture of ‘these children’ should not be on our ward and when there is an emotionally distressed child on the ward it is more difficult to care for physically ill children. Some staff feel they are not trained to nurse children with mental health needs and seemed to clearly separate physical and mental health needs as being very different. 31 145. The main issues of concern included a lack of training in mental health, managing challenging behaviour, de-escalation skills, and more enhanced levels of physical restraint. 146. The Reviewers concluded that in response to the changing presentation and complexities of children requiring admission to general paediatric wards, NHS Providers need to evolve existing provision. This could include reviewing skill mix of the ward team to include employing Registered Mental Health nurses as part of the ward’s establishment. Reconfiguring the skills of the team would facilitate the needs of children and young people being fully met and reduce risks created by lack of training and experience. 147. The view of the Reviewers is supported by a joint statement issued by the Royal College of Psychiatrists with the Royal College of Emergency Medicine and the Royal College of Paediatrics and Child Health on 21st December 2021. 148. The position statement entitled “Meeting the mental health needs of children and young people in acute hospitals: these patients are all our patients” highlights that the number of children presenting with to A&E with “complex psychosocial crises” is significantly increasing. It acknowledges that CAMHS is struggling to manage “unprecedented demand” especially following the Covid-19 pandemic with more children being admitted to general paediatric wards “…simply because it is the safest place for them at that moment in time”. 149. The statement clearly outlines that “Regardless of where children and young people present to care or what their specific health needs are, we must work together to ensure they receive the highest quality care, from qualified clinicians, as quickly as possible.” They go on to say, “These patients are all our patients, and we must work together to ensure they receive the right treatment, in the right place, at the right time.” What Alternative Provision was Available? 150. As outlined above Wigan Council CSC were attempting to source a therapeutic placement for Elliot in the private provider market. They also considered the possibility of a secure placement; a child can only be placed in a secure placement if supported by a Court Order under Section 25 of the Children Act (1989). In the view of the Reviewers the only realistic alternative available to CSC was to establish an ‘in house’ unregulated placement which ultimately, they were directed to do by the High Court. CSC maintain that this was their least preferred option and were trying to secure a regulated therapeutic placement whilst commissioning an unregulated placement as a last resort. 151. In ‘The children who no-one knows what to do with’ the Children’s Commissioner 32 points out that Local Authorities have a statutory responsibility to take steps, as reasonably practicable, that ensure children in care are provided with accommodation that “(a) is within the authority's area; and (b) meets the needs of those children” (Children Act 1989). 152. She states that Local Authorities need to work together to better to improve provision, making best use of their buying power to better shape the market. She suggests this can be achieved through the “greater use of regional commissioning and frameworks” (page 11). KLOE 3 RECOMMENDATIONS: Recommendation 5: Wrightington, Wigan and Leigh Teaching Hospital NHS Foundation Trust should: • Consider the skill mix of staff on the general paediatric ward, this could include employing Registered Mental Health Nurses as part of the ward establishment. • Consider developing a ‘Safe Place’ within WWL where children who have been admitted can be assessed and cared for in an appropriate safer environment (e.g., ligature risk free). • Complete a Training Needs Analysis of the training requirements of existing staff in relation to safer clinical holding and restraint techniques, de-escalation skills, mental health needs of children and young people etc. • Work with staff to encourage parity of esteem between physical and mental health and develop confidence when providing care to children who present with mental health needs. Recommendation 6: Children’s Social Care should work in partnership with other Local Authorities and health colleagues to explore the provision and/or the joint commissioning of suitable registered residential therapeutic placements. Children like Elliot need to be cared for in a suitable and safe setting that meets their needs and prevents them remaining in hospital unnecessarily. 33 KLOE 4: 153. The impact on Elliot and other services due to CSC not having an agile, responsive resource of suitably skilled staff to support Elliot has already been identified as part of the discussion in KLOE 2 and KLOE 3. 154. This included reference to: • Elliot’s room being made increasingly sparse in an attempt to keep Elliot safe • The need for additional resources to be put in place for Elliot to remain on a general paediatric ward 155. In KLOE 2 the Reviewers identified that there were difficulties experienced in the physical restraining of Elliot due to care staff being provided by different organisations who worked to different policies. This meant they used different methods of physical restraint and for differing maximum lengths of time. 156. These issues were discussed in the High Court Judgement. WWL informed the Court that their staff on the ward did not have the training or expertise to manage the challenging behaviour that was exhibited by Elliot. Specifically, regarding the deployment of physical restraint techniques to the level Elliot required. For this reason, Wigan Council CSC and Wigan CCG agreed to provide trained staff to undertake these tasks and provide the majority of the staffing ratio to support Elliot. In the High Court Ruling (Paragraph 14) WWL described that there had been difficulties with both the attendance of and the qualifications of the staff provided by the Wigan Council and Wigan CCG. This has resulted in the Trust having to make frequent calls to the duty social worker in relation to the care provision for Elliot. 157. As established in the previous KLOEs above in an attempt to coordinate a multi-agency care plan for Elliot and manage the escalating risk Daily Planning Meetings were held. As these were held up to three times a day this presented a significant demand on time for all professionals. To consider the impact on Elliot and other services of Children’s Social Care (CSC) not having an agile, responsive resource of suitably skilled staff to support Elliot and explore what resources are needed. 34 KLOE 4 Findings Impact on Elliot 158. It has been established by the Reviewers in the above KLOEs that Elliot’s safe discharge was delayed by seven days due to the lack of an appropriate placement which could meet his needs. This resulted in Elliot being subject to extremely restrictive practices, including daily physical and chemical restraint. is behaviour most likely escalated due to the level of restrictive practices being deployed in an attempt to keep Elliot safe. His human rights were breached and whilst his admission was intended to provide sedation and observation following sedation and due to the breakdown of his social placement , ultimately it contributed to his trauma. 159. Participants at the Learning Event described Elliot as feeling scared and frightened when the Police came to the ward. He told staff he felt he was in prison. 160. WWL nursing and medical staff were clear that Elliot hated injections and often begged not to be injected. 161. When participants were asked what they thought Elliot would say about his stay in hospital one nurse commented “I think he would say he had been violated. He spoke in adult terms about his restraint, accusing staff of abusing him. One trigger was anyone going near his suitcase”. 162. Another Learning Event participant from WWL reflected that much of the workforce looking after him was female and “He did not have a very favourable opinion of them. As a service we (WWL) felt powerless”. Other participants observed that he did bond with some female Nurses. 163. Some staff were concerned about the restrictions needed in his room to keep him safe. In relation to Elliot’s Room one participant said “The room was stripped bare – but the only way to keep him safe. A blanket was only put on him once he was asleep. The bathroom was also stripped. He had no privacy/dignity – no lock on the door of the bathroom. He only slept in his room. Outside these times he had the play area, sensory room, and the rest of the ward. A child’s bedroom should be their own place where they feel safe”. 164. Elliot only had one visit from his two schoolteachers during his stay in hospital. His Father and sibling attended the ward to drop off clean clothes and snacks for Elliot but did not see him. Learning Event participants described that the one thing Elliot was clear in articulating was that he didn’t want to see his Father. When one of the Reviewers spoke with his Father as part of the LCSPR process he was clear that he desperately wanted to see Elliot. His perception was that he was not allowed to attend the ward due to Covid-19 pandemic restrictions on 35 hospital visiting. Impact on Health Services WWL had to reduce activity to be able to safely care for Elliot and the other children which had a detrimental impact on other children and families who needed care. 165. Although Wigan CSC and Wigan CCG did commission additional care staff to support Elliot’s specialist care whilst in the ward, this took some time to arrange, and it was problematic and needed to be refined as original agency staff were not meeting his needs. This placed WWL staff in the difficult situation of having to provide care that they did not feel suitably equipped to deliver. 166. As a result of CSC being unable to source a suitable placement for Elliot, relationships became strained between health and social care staff with each agency becoming increasingly frustrated. 167. The Court ordered that Elliot had to be discharged by 5pm on Day 14 as the Judge refused to further authorise his Deprivation of Liberty. CSC identified a property and wrap around staff to enable this Court directed discharge to take place. This led to health staff feeling that CSC had not done everything within their power in the preceding days.. CSC had been commissioning an unregulated placement as a last resort, and were trying to source a regulated therapeutic placement as a preferred option but it is clear that other agencies were unaware of this and assume that the unregulated placement was arranged within a day, which is not the case. This impacted on trust and partnership working between agencies Impact on Police 168. There was a significant impact on their resources with nine calls to 999 and significant numbers of Police officers attending the ward. They were clearly highlighting the potential of breaching Elliot’s human rights right at the beginning when they were called to accompany Elliot to A&E. What is Needed? 169. At the Learning Event representatives from all agencies explored what they felt the learning was and what is needed to prevent a similar situation should a child presenting like Elliot be admitted to a general paediatric ward today. 170. Reflections included the need for: • Wigan Council to commission an emergency placement provision in the Borough, staffed by people appropriately trained in trauma informed practice and building nurturing relationships, de-escalation skills, least restrictive practices, and physical restraint techniques. This emergency placement provision should be ‘on call’ and with the ability to mobilise in a 36 short timeframe. • An ‘in reach’ wrap around service which can support children at home, in A&E, on a ward, in transition and to their placement in the community. This service needs to be 24 hour, 7 days a week, with more staff and direction over the weekend. 171. The Reviewers were made aware that CSC and Wigan Borough Clinical Commissioning Group have already initiated work in partnership with the Greater Manchester Health and Social Care Partnership to identify funding and develop provision. CSC and WBCCG are currently developing a business case to commission a ‘Parachute Team’ who would provide ‘in reach and wrap around support as well as exploring an emergency placement provision in the Borough. 172. Multi agency planning meetings need to focus on providing detail about how long it takes to commission a complex placement and an expected date of admission so that agencies have a clear understanding of the length of time that someone will need to remain in the hospital. KLOE 4 RECOMMENDATION: Recommendation 7: Wigan Children’s Social Care and NHS Wigan Borough Clinical Commissioning Group to continue the work initiated to develop a ‘Parachute team’ and residential provision in the Borough. This should include the development of standardised requirements for supporting staff including appropriate training (de-escalation skills, safe restraint, and clinical holding), trauma informed practice, clear standardised policies which outline a consistent approach to restraint. 37 KLOE 5: What Happened 173. Elliot was admitted to A&E on Day 3 (Saturday) at 23:37hrs. He was admitted to the general paediatric ward in the early hours of Day 4, 4.5 hours after first arriving at hospital. Day 5 - Monday 174. The first formal escalation of the situation was made internally in WWL by the Ward Manager on Day 5 (Monday) at 09:00hrs to the Child Health Senior Leadership Team at WWL. 175. Three Urgent Planning Meetings were held throughout Day 5 which included ward management, health providers and commissioners, CAMHS staff and CSC. Prior to the 2nd meeting ward staff escalated the situation to WWL Head of Safeguarding and WWL Legal Department who attended the 2nd Urgent Planning Meeting. Day 6 - Tuesday 176. On Day 6 there were three Daily Planning Meetings held at 09:00hrs, 12:00hrs and 15:30hrs. At one of the meetings, it was decided that an email would be sent from WWL Deputy Director of Operations to senior leaders at WWL, GMMH, WBCCG and CSC outlining concerns about the dangers to staff and other patients on the ward in the light of the issues with support staff provided by CSC and the possible need to close the ward. 177. An emergency CAMHS meeting held to discuss next steps. Galaxy House (Tier 4 inpatient Mental Health Unit) approached to explore if they can assist. Galaxy House explained that they do not accept emergency admissions and they have no beds available. Day 7 - Wednesday 178. Daily Planning Meetings were held at 09:00hrs and 15:00hrs. 179. The WWL Named Nurse for Safeguarding Children escalated the situation to the WBCCG Designated Nurse for Safeguarding Children. The Designated Nurse at WBCCG subsequently escalated concerns to Executive Leaders and relevant commissioners at To explore the planning and escalation procedures, the involvement of senior leaders and how effective these were in responding to Elliot’s immediate needs. Was there sufficient focus on Elliot as well as consideration of implications for the wider system? 38 WBCCG and the Head of Nursing at Greater Manchester Health and Social Care Partnership. 180. WWL Chief Operating Officer advised in one of the meetings that she had escalated the case to the Care Quality Commission (CQC) as they were on site at the hospital. 181. At the 15:00hrs meeting concerns were raised from WWL regarding the quality of the Mental Health Act assessment. There were differences of opinion regarding the outcome and WWL and CSC were requesting a second opinion. Day 8 - Thursday 182. Daily Planning Meetings held at 09:00hrs and 12:00hrs, chaired by the CSC Practice Director. 183. WWL escalated concerns to Greater Manchester Gold Command regarding the impact on the ward. Day 9 - Friday 184. Daily Planning Meetings held at 09:00hrs and 12:00hrs, chaired by the CSC Practice Director. 185. In the daily planning meetings (which were attended by executive leaders from various agencies) there were extended discussions regarding the quality of the Mental Health Act assessment and whether this could or should be repeated. Day 10 – Saturday 186. There was no daily planning meeting on Day 10 as it was the weekend. 187. WWL escalated concerns to CSC Manager and WWL Head of Safeguarding that one of the Mental Health Nurses caring for Elliot stated they were unable to maintain Elliot’s safety and required additional support. Day 11 – Sunday 188. There was no daily planning meeting on Day 11 as it was the weekend and no system escalations. Day 12 - Monday 189. Daily Planning Meetings held at 09:00hrs and 15:30hrs. 190. WBCCG Designated Nurse escalated further concerns to GMHSCP regarding the level of restrictive practices. 39 Day 13 and Day 14 (Monday and Tuesday) 191. On day 13 and Day 14 discussions took place between relevant frontline professionals to develop a robust discharge plan. KLOE 5 Findings Planning and Escalation Procedures 192. The first escalation of this case was made internally by WWL ward staff to the Senior Child Health Leadership Team. Elliot was admitted to A&E in the last hour of Day 3 (which was a Saturday) and admitted to the ward in the early hours of Day 4 (which was a Sunday). This explains why the situation was not escalated to senior leaders within WWL prior to Day 5. 193. The situation was not escalated to the WWL Safeguarding Team or the WWL Legal Team until Day 5 (Monday) following which the WWL Named Nurse for Safeguarding Children escalated to the WBCCG Designated Nurse for Safeguarding Children. This then led to subsequent escalations of concerns to Executive Leaders and relevant commissioners at WBCCG and the Head of Nursing at GMHSCP and NHSE. This appears to have been a timely escalation. 194. The Reviewers have identified that despite there being no formal joint multi-agency escalation process in place, once the case was escalated all agencies were responsive and understood the risks. 195. All agencies participated in the escalation and concerns were raised beyond local organisations, for example to NHS England and Greater Manchester Health and Social Care Partnership. Daily Planning Meetings were held up to three times a day, participants included front line practitioners up to the most senior leaders within the system. Daily Planning Meetings 196. The Reviewers concluded that following escalation from Day 7 there was good attendance at the Daily Planning Meetings. Although the range of seniority of those attending sometimes led to insufficient focus on Elliot due to of implications for the wider system being considered and debated. 40 197. Elliot, his presentation, and his voice were a significant focus of the Daily Planning Meetings. It was clear from the records that participants were very much focused on the lived experience of Elliot in these challenging circumstances. Despite professionals capturing the voice of Elliot this did not lead to any tangible improvement in Elliot’s experience because ultimately he was being cared for in an inappropriate setting and staff had to keep him safe in an environment that was not suitable to support his emotional distress. 198. Those involved knew that the situation was not appropriate and that the level of restrictive practices was at risk of breaching Elliot’s human rights. Participants in the Learning Event described knowing it was not right but feeling completely powerless to do anything different to keep Elliot safe. 199. Participants at the Learning Event were also asked to reflect on the Daily Planning Meetings and the following themes were identified in relation to: Power imbalance and operational v strategic 200. Due to frontline practitioners and executive leaders attending the meetings, some frontline staff sometimes felt intimidated and unable to challenge. Discussion in the meetings often included operational care delivery issues such as the staff rota, as well as strategic considerations about the risk being held in the wider system such as closing beds and cancellation of elective surgery lists. Other staff reported that they felt supported by their managers and able to participate. Professional challenge and professional respect 201. At times discussions became emotive and strained as participants sometimes felt frustrated. There were some key issues which were highly debated such as whether the Mental Health Act assessment had been completed to an appropriate quality standard and the lack of placements available for CSC to commission. Mental health professionals felt their expertise and clinical decisions were challenged and they were not professionally respected by ward staff and CSC. Consistency 202. There was a lack of consistent structure and approach to the Daily Planning Meetings. This was likely due to the inconsistency of people attending leading to a repetition of information being shared. Meeting invitations were often forwarded on to numerous other colleagues. As the meetings were held virtually via Microsoft Teams this often meant there was no limit to the number of participants. 203. Overall, the level of escalation and response was appropriate once senior leaders were aware of the situation. 41 204. There needs to be a clear route for full discussion of operational and care planning considerations alongside the formal escalation pathway and consideration of implications for the wider system. KLOE 5 RECOMMENDATIONS Recommendation 8: A joint health and social care escalation policy needs to be developed which: • Is responsive and proactive to present drift and delay. • Outlines roles and responsibilities for all agencies including who will take the lead. • Provides a clear structure for points of discussion at the escalation meetings. • Ensures the focus remains on the child. • Considers legal frameworks and ensures that all restrictive practices are the least restrictive and proportionate. • Directs that operational care planning discussion should take place separately to senior leaders/strategic meetings. • Directs organisations to nominate a consistent contributor to attend the meetings with the right level of seniority/ability to decision make. • Encourages integrated working and articulates how collective risk is shared. 42 KLOE 6: Work Already Undertaken 205. Wigan Children’s Social Care informed the LCSPR Reviewers that they have developed a strategic plan which includes the commitment to progress an overall sufficiency plan with providers to ensure there are a variety of homes and therapeutic support available. They are also working closely with other Local Authorities within Greater Manchester and across the North West to collaborate on a larger geographical footprint and ensure that their plans anticipate future needs. 206. In 2020 Wigan health and CSC leaders recognised that the Borough had an increasing number of children and young people being admitted to hospital with complex health and social care needs. These children often did not meet the criteria for detention under the Mental Health Act and due to the lack of suitable placements agencies were unable to achieve a safe discharge. Healthier Wigan Partnership Complex Children and Young People Workshop 207. In response to this emerging need in December 2020 a Healthier Wigan Partnership workshop was arranged to focus on complex children and young people. Over 30 professionals from various organisations came together including NHS Wigan Borough CCG, WWL, NHS mental health providers, Wigan Council, GM Rapid Response Team, GP leads, Advancing Quality Alliance (AQuA), school leaders and looked after children leads. 208. The objective of workshop was to look at how they could work effectively together as a system to support the most vulnerable children and young people whose individual health and social care needs could be difficult to meet through the existing services, as a result of their unique and complex circumstances. 209. The workshop gave an overview of the Wigan Deal 2030, the NHS Long Term Plan – Children and Young People’s Urgent and Emergency Mental Health, and the GM Crisis Care Pathway. A story was presented to participants told through the eyes of a child in a trauma informed way. To establish what work has been undertaken by Children’s Social Care to manage the lack of suitable therapeutic placements for children like Elliot, including joint working with Partners. 43 210. Learning from recent case examples was presented around the following themes: • Inpatient CAMHS criteria and children who do not fit this • Care Placements and Looked After Children • Commissioning Arrangements • Parity of Esteem • Workforce Development and Training • Communication and Information Sharing • Planning and Risk Assessment • Escalation Pathways • Messages from “The children who no one knows what to do with” (Children’s Commissioner, November 2020) 211. A comprehensive multi-agency action plan was developed including creating a Wigan System Toolkit to standardise the system approach to escalation of children with complex health and social care needs, data analysis to identify trends, the creation of a risk register, and workforce development to encourage parity of esteem. The action plan was overseen by the Wigan Mental Health Programme Board. Regular updates were provided to WSCP Partners Improving Practice Subgroup and the WSCP Executive Meetings. KLOE 6 FINDINGS 212. Health and CSC had clearly recognised that children presenting in extreme emotional distress due to trauma, and therefore not meeting the criteria for inpatient CAMHS admission, was increasing. Appropriate steps had been taken to bring together key partners across the system to explore the reasons for this and develop a coordinated plan to begin to address this. 213. The Reviewers concluded that whilst the right actions were being taken, pace in implementing them was not fast enough. It is likely that the Covid-19 pandemic slowed the pace of progress as health and CSC staff did not have the capacity to progress the work although they did continue to meet. 214. To some degree this work did have a positive impact on the way in which Elliot’s admission was managed. Elements of the toolkit that being developed were utilised such as escalation to senior leaders, the use of Daily Planning Meetings, and the consideration of legal frameworks and restrictive practices. CSC mobilised quickly to identify and provide care support staff to the ward and all relevant agencies participated in the Daily Planning Meetings. 44 215. In KLOE 7 we will explore how staff developed an understanding of Elliot’s lived experience and what efforts were made to capture Elliot’s voice. The toolkit in development included the need to focus on the child’s lived experience. Actions Taken Since the High Court Ruling GMHSCP Children and Young People Mental Health Severe Incident System Panel 216. The day after the High Court Ruling in relation to Elliot, Greater Manchester Health and Social Care Partnership (GMHSCP) held an emergency Children and Young People Mental Health Severe Incident (SI) System Panel, which was chaired by Professor Sandeep Ranote, GM Medical Executive Lead for Mental Health. 217. The Panel was convened due to GMHSCP seeing a significant rise in mental health and social care demand across the ten localities and the issues escalated to GMHSCP specifically related to Elliot. 218. There was system-wide senior level representation from the GMHSCP, GM commissioning, NHS mental health Providers, CSC including the Directors of Children’s Services, safeguarding, nursing and quality, NHS England, and GM Paediatrics. 219. Ten example cases of children and young people with high complexity, acuity and risk who had been escalated to GMHSCP over a four-week period were presented for discussion. A system discussion of themes was facilitated by the Chair to support further recommendations with a focus of this panel to be on immediate solutions to mitigate identified risks. 220. The Panel made several recommendations, and an action plan was developed to be monitored and reviewed at the GM CYP Crisis Care Board. Health Wigan Partnership Activation Board 221. At the end of July 2021, the Healthier Wigan Partnership held an Activation Board in relation to this High Court Ruling regarding Elliot and to further explore children and young people with complex health and social care needs. 222. The following actions were agreed: • Consider developing a joint mental health and social care alternative crisis care placement in Wigan, expanding on the GM offer which is being developed. • Rapid development and implementation of an GM Integrated Care System Joint Social Care and Mental Health Escalation Policy for children and young people in Wigan. 45 • Delivery of trauma informed training for staff at WWL. • Open five paediatric beds on the general paediatric ward to manage demand. • Option to be explored to have community CAMHS staff on the ward. • Training for ward staff on understanding of mental health, emotional and behavioural issues in children and young people. 223. A small task and finish group of key people from each organisation was convened to quickly progress these actions, which were monitored via the Wigan Mental Health Programme Board and the Wigan Urgent Emergency Care Board. 224. Subsequently health and CSC leaders in Wigan are currently developing a business case to fund a ‘Parachute Team’ and residential therapeutic placement in the Borough. Parachute Practitioners aim to provide short term, young person centred, trauma informed, de-escalation support for young people aged 11-18 integrating with key existing professionals and existing and emerging health and social care pathways, supporting young people and professionals as they navigate and agree a response to their wider requirements. Concluding Comments 225. The Reviewers concluded that prior to Elliot’s admission health and CSC leaders had recognised the issues highlighted by Elliot’s Case and had attempted to work together to address them. As stated above this work in Wigan was good but did not progress at the required pace. The Reviewers are also of the opinion that this issue required a whole system approach beyond the Wigan Borough. 226. At a GM and Wigan Borough level the system mobilised quickly to respond to the highlighted risks and gaps in the system following the High Court ruling in relation to Elliot. The action plans developed as a result are more likely to be successful as this complex issue requires a wider system response. It is evident that the action plans continue to progress at the time of writing this report. It is vital that this work is completed at the earliest opportunity and that WSCP are assured that the actions implemented lead to improved outcomes and a better experience for children like Elliot. KLOE 6 RECOMMENDATIONS Recommendation 9: The joint work that has been initiated between health and social care to explore a ‘Parachute Team’ and associated residential placement needs to be completed. Once implemented evidence should be provided to Wigan Safeguarding Children Partnership which gives assurance that this work has positive outcomes for children like Elliot. 46 KLOE 7 227. Throughout the recordings from all agencies reviewed for the LCSPR it was evident that professionals have attempted to develop an understanding of Elliot’s lived experience. All agencies could evidence that they had captured Elliot’s voice within their records and this included recording his words verbatim around various aspects of his care. 228. The Daily Planning Meetings were minuted and included lengthy discussion regarding the impact the situation was having on Elliot. Participants clearly attempted to view the situation through Elliot’s eyes. Staff working directly with Elliot who attended the Daily planning Meetings shared with participants examples of Elliot’s views and feelings on what was happening to him. 229. Whilst Elliot’s behaviour was aggressive and difficult to manage, viewed his behaviour through the lens of trauma informed practice. Staff clearly understood that Elliot was communicating his level of distress and anxiety through his behaviour. Reflections and Learning from Agencies 230. Elliot’s allocated Social Worker visited Elliot on the ward on several occasions. The Social Worker felt that they were developing a very positive relationship which has continued to develop since his discharge from hospital. Elliot’s voice was captured but it was recognised that given his heightened state that this was not fully explored and at times it was difficult to engage with him. 231. His Social Worker arranged for his two school teachers to visit him on the ward to facilitate contact with some familiar people who knew him. Ward staff reflected that Elliot had “taken great joy” in this visit. CSC felt that on reflection that they could have explored the benefits of engaging Elliot’s family. This might have included visits or telephone calls to give him a sense familiarity. His family may have been able to help capture his voice and inform more care planning and interventions. 232. It is evident from the records that Elliot’s Father and sibling consistently contacted the ward to request to see Elliot or to enquire about how he was. They attended the ward to drop clean clothes and snacks for Elliot. Elliot had been vocal to staff about not wanting to see his Father. To develop an understanding of Elliot’s lived experience and what efforts were made to capture Elliot’s voice. 47 233. When one of the Reviewers met with Elliot’s Father, he stated that Elliot was “Scared to death of Covid and didn’t want to be in the hospital as he was worried about people dying”. His Father felt that these worries contributed to his agitated state. He described Elliot as having a lot of energy and being “cooped up” in hospital without the freedom to run around would explain his behaviour. Elliot’s Father said he was updated regularly by the hospital and CSC via phone calls but would have preferred home visits. He described being very rude to staff on the phone but felt that in person he was better able to control his emotions and relate to professionals. 234. When meeting with Elliot’s Mother she was unsure of the reason for his hospital admission, although her eldest child had a good recollection of what happened. His Mother described not being updated at the time of Elliot’s admission, but she was made aware at a later stage. CSC have acknowledged that on reflection they should have ensured that Elliot’s Mother was as well informed as his Father. 235. It is clear from the WWL health records that several attempts were made to work jointly with CSC, care home staff and through liaison with Elliot’s Father to identify ways to effectively support Elliot when staff were unable or not best placed to. 236. Ward staff used the ‘likes and dislikes’ framework to understand his routine and how best to support his needs. A copy of this was shared with participants on the Learning Event. Elliot was often included within discussions with doctors and nursing staff regarding his care such as being asked his wishes to share at Daily Planning Meetings. The ward also obtained copies of existing documentation such as his EHCP and Child Protection Plan to best understand him and listen to his voice. 237. CAMHS visited Elliot on the ward and attempted to engage and interact with him. CAMHs and Liaison staff described attempting to maintain a consistent practitioner in order to help build a relationship and encourage engagement. KLOE 7 Findings 238. Attempts were made to capture and incorporate Elliot’s voice into care planning. However, whilst his voice and feelings were recorded, and reasonable adjustments were made when possible staff felt unable to meet his all of expressed needs whilst keeping him safe because the environment was not conducive to attending to his emotional distress. Capturing his lived experience and wishes did not lead to significant change or improved outcomes for him. From Elliot’s perspective, even when he told staff what he wanted it must have felt to him as if he was ignored. 48 239. His behaviour is representative of a child feeling scared and in despair. Elliot’s Diagnosis of ADHD and his possible autism adds additional complexities to how he processed and understood what was happening to him and why. On Day 5 a Mental Health assessment outlined that this admission into hospital would be new, unknown, and very frightening to Elliot and would exacerbate the difficult traits that may be associated with ADHD and autism. Many of Elliot’s soothing mechanisms involved being outside, however, due to his high risk of absconding this could not be safety facilitated. Ward staff felt that the subsequent MHA assessment did not adequately involve Elliot, however his escalating presentation made it extremely difficult for staff to develop trusting relationships. 240. Staff tried hard to engage Elliot and make him feel safe, examples of this would include buying him a Nintendo Switch and bringing him treats 241. The National Child Safeguarding Practice Review Panel Annual Report 2020 (page 27) highlighted that ‘Understanding what the child’s daily life is like’ is vital in good safeguarding practice. Understanding what a child sees, hears, thinks, and experiences on a daily basis, and the way this impacts on their development and welfare, is central to protective safeguarding work. 242. Key learning from case reviews has highlighted the importance of practitioners building trusting and respectful relationships with the children, which go beyond listening to and recording the child’s views, to critically reflecting on what the child is trying to communicate through their behaviour, interaction with others and physical presentation. 243. In this case staff went beyond just recording and documenting Elliot’s wishes and feelings. They did recognise that Elliot’s challenging behaviour was a reflection of his extreme emotional distress. KLOE 7 RECOMMENDATIONS Recommendation 10: Partners should undertake workforce development activities to support staff to develop skills to critically reflect on how children communicate through their behaviour, interaction with others and their physical presentation; and how this can be used to plan their care. This should be supported by practice tools which assist staff to advocate for the child and focus on their voice translating to their care planning. 49 OVERVIEW OF RECOMMENDATIONS The recommendations are different in both reports. Feedback from panel members is that the second set of recommendations are not accurate and not based on the analysis of the first review. Organisations have based their working action plans on the first recommendations not the second so I propose we leave the first recommendations below in the report KLOE and Number Recommendation Theme KLOE 1 Recommendation 1 Greater Manchester Mental Health NHS Foundation Trust and Pennine Care NHS Foundation Trust need to clearly outline the process for a child to be referred for a Mental Health Act assessment, criteria for inpatient CAMHS admission and the routes for professional challenge when there is a disagreement. This document should be accessible to all agencies. Mental Health Processes Recommendation 2 A joint Health and Social Care Escalation Policy should be developed to ensure that when there is a risk of a child remaining on a general paediatric ward inappropriately and we are unable to achieve a safe discharge there are clear processes to alert senior leaders to take action. Escalation KLOE 2 Recommendation 3 Commissioners need to work with Greater Manchester Mental Health NHS Foundation Trust to review the current out of hours Psychiatry provision for children and ensure that arrangements are fit for purpose and clear to other NHS providers who use this service. Commissioning 50 Recommendation 4 Work needs to be completed to facilitate the coming together of clinical staff at Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation (WWL) Trust and Greater Manchester Mental Health NHS Foundation Trust (GMMH). This will need to fully explore perspectives, roles, and responsibilities with a view to improving working relationships and developing clear joint protocols for working together. WWL must also develop an agreed, easily accessible Rapid Tranquilisation Policy for use within Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust. Professional Relationships Policy and Procedures 51 KLOE 3 Recommendation 5 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust should: • Consider the skill mix of staff on the general paediatric ward, this could include employing Registered Mental Health Nurses as part of the ward establishment. • Consider developing a ‘Safe Place’ within WWL where children who have been admitted can be assessed and cared for in an appropriate safer environment (e.g., ligature risk free). • Complete a Training Needs Analysis of the training requirements of existing staff in relation to safer clinical holding and restraint techniques, de-escalation skills, mental health needs of children and young people etc. • Work with staff to encourage parity of esteem between physical and mental health and develop confidence when providing care to children who present with mental health needs. Workforce Development Parity of Esteem Safe Environment Recommendation 6 Wigan Children’s Social Care should work in partnership with other Local Authorities and health colleagues to explore the provision and/or the joint commissioning of suitable registered residential therapeutic placements. Children like Elliot need to be cared for in a suitable and safe setting that meets their needs and prevents them remaining in hospital unnecessarily. CSC Placement Commissioning KLOE 4 Recommendation 7 Wigan Children’s Social Care and NHS Wigan Borough Clinical Commissioning Group to continue the work initiated to develop a ‘Parachute team’ and residential provision in the Borough. This should include the development of standardised requirements for supporting staff including appropriate training (de-escalation skills, safe restraint, and clinical holding), trauma informed practice, clear standardised policies which outline a consistent approach to restraint. Commissioning Workforce Development 52 KLOE 5 Recommendation 8 A joint health and social care escalation policy needs to be developed which: • Is responsive and proactive to present drift and delay. • Outlines roles and responsibilities for all agencies including who will take the lead. • Provides a clear structure for points of discussion at the escalation meetings. • Ensures the focus remains on the child. • Considers legal frameworks and ensures that all restrictive practices are the least restrictive and proportionate. • Directs that operational care planning discussion should take place separately to senior leaders/strategic meetings. • Directs organisations to nominate a consistent contributor to attend the meetings with the right level of seniority/ability to decision make. • Encourages integrated working and articulates how collective risk is shared. Escalation KLOE 6 Recommendation 9 The joint work that has been initiated between health and social care to explore a ‘Parachute Team’ and associated residential placement needs to be completed. Once implemented evidence should be provided to Wigan Safeguarding Children Partnership which gives assurance that this work has positive outcomes for children like Elliot. Commissioning Placement Sufficiency KLOE 7 Recommendation 10 Partners should undertake workforce development activities to support staff to develop skills to critically reflect on how children communicate through their behaviour, interaction with others and their physical presentation; and how this can be used to plan their care. This should be supported by practice tools which assist staff to advocate for the child and focus on their voice translating to their care planning. Workforce Development REFERENCES Human Rights Act (1998) https://www.legislation.gov.uk/ukpga/1998/42/contents [Accessed 30.03.2022] Wigan BC v Y (Refusal to Authorise Deprivation of Liberty) [2021] EWHC 1982 (Fam) (14 July 2021) https://www.judiciary.uk/wp-content/uploads/2021/07/Wigan-BC-v-Y-Refusal-to- Authorise-Deprivation-of-Liberty-judgment.pdf [Accessed 30.03.2022] APPENDIX 1: LOCAL CHILD SAFEGUARDING PRACTICE REVIEW PANEL MEMBERS The Local Child Safeguarding Practice Review (LCSPR) Panel was comprised of: Reviewer Assistant Director Safeguarding Children/ Designated Nurse for Safeguarding Children & Looked After Children NHS Wigan Borough Clinical Commissioning Group (WBCCG) Supporting Reviewer Deputy Designated Nurse for Safeguarding Children & Looked After Children WBCCG Assistant Director of Commissioning and Transformation WBCCG Commissioning and Transformation Manager – CYP, Mental Health and Learning Disability WBCCG Business Manager Wigan Safeguarding Children Partnership (WSCP) Learning and Improvement Officer WSCP Specialist Nurse for Safeguarding Children Wrightington, Wigan, and Leigh Teaching Hospitals NHS Foundation Trust (WWL) Head of Safeguarding WWL Named Nurse for Safeguarding Children WWL Head of Nursing & AHP for Surgery and Child Health, WWLFT WWL Named Nurse for Safeguarding Children Greater Manchester Mental Health NHS Foundation Trust (GMMH) Service Lead, Children’s Social Care Wigan Council Legal Wigan Council Detective Constable, Public Protection & Serious Crime Division, Investigation & Safeguarding Review Unit Greater Manchester Police Registered Manager Leaf Complex Care |
NC050511 | Alleged rape of a 16-year-old boy in May 2020. Child K disclosed that he had been assaulted by another looked after child whilst in semi-independent accommodation. Learning includes: decision-making when identifying placements for young people with autism and additional vulnerabilities should be needs led; key partners should have confidence that placements for young people with complex needs have the capacity and expertise to meet assessed needs, and that specialist services are spot purchased if necessary; effective collaboration, as directed by the Transforming Care Programme, will prevent inappropriate hospital admissions; a multi-agency discharge plan for young people admitted to a mental health in-patient unit is essential in preventing further hospital admission; professionals require appropriate knowledge, skills, and competence, to effectively support young people with autism and for a clear understanding of needs and vulnerabilities; professionals should have a shared understanding of the impact of autism on the behaviour, wellbeing and mental health of young people and work collaboratively to understand what the young person may be attempting to communicate by their behaviour; multi-agency assessments of young people with autism should inform a consistent approach to care; when young people with autism are home-schooled, effective oversight is required to ensure that education and health care needs are met; when professionals are concerned about the provision of care, a formal escalation policy is important in highlighting unmet needs and practice shortcomings. Recommendations are embedded in the learning.
| Title: Multi-agency child safeguarding practice review: Child K: final report. LSCB: Milton Keynes Together Safeguarding Partnership Author: C. Connor Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Milton Keynes Multi-Agency Child Safeguarding Practice Review Child K Final Report Author Dr C Connor Publication Date: 28 February 2022 2 Contents Page Introduction 3 Process 3 The Family and Background information 4 Agency Involvement 5 Analysis 8 Good Practice 21 Conclusion 21 Learning Points 22 Question for the MK Together Partnership 23 3 1. Introduction 1.1 In April 2021 the MK Together Partnership commissioned a multi-agency Child Safeguarding Practice Review1 in respect of K, a 16-year-old looked after child with a diagnosis of autism spectrum disorder (ASD). K alleged that he had been raped by another resident whilst placed in semi-independent accommodation. The alleged perpetrator was a looked after child at the same placement and police investigations into the allegation are ongoing. 1.2 It was recognised that there was potential learning from this case in the way that agencies work together to safeguard children in Milton Keynes. The national CSPR Panel was informed of the review. 1.3 ASD2 is the medical name for autism however autistic spectrum condition (ASC) is also used instead of ASD to highlight the broad spectrum of autism and avoids the label of having a ‘disorder.’ Autism affects how people communicate and interact with the world; with the right level of help and support people with autism can lead fulfilling lives. This review will use the term autistic spectrum condition. 2. Process 2.1 This report has been written with the intention that it will be published, and only contains information about K and the family that is required to identify the learning from this case. 2.2 The review considered agency chronologies, relevant records, and assessments. The independent author met individually3 with key professionals. A learning event was attended by practitioners and opportunities for multi-agency practice improvement were identified. All who participated in the review had an opportunity to comment on the draft report and information shared informed the learning and recommendations. 2.3 The review timeline included multi-agency practice from December 2019 (one month before K’s discharge from an inpatient mental health unit) until May 2020 when the allegation was made. Relevant information beyond this timescale also contributed to practice learning. 2.4 K, his Mother and Stepfather were invited to participate in this review, K’s views were obtained by the social worker and there was no response from other family members. Comments attributed to Mother and Stepfather within this report have been obtained from agency records. 1 Child Safeguarding Practice Reviews (CSPRs) replaced SCRs; CSPRs should be considered for serious child safeguarding cases where: abuse or neglect of a child is known or suspected, and a child has died or been seriously harmed. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 2 https://www.nhs.uk/conditions/autism/what-is-autism/ Autism is not a mental health problem although it can affect a person’s mental health Autism and Mental Health | Signs & Symptoms of Autism | YoungMinds 3 Via Microsoft Teams 4 3. The Family and background information 3.1 K was diagnosed as autistic at 9 years of age and was home schooled between ten - fifteen years. Agencies had limited involvement with the family at this time. Records indicate that college made a referral to children’s social care (CSC) when K was sixteen years old, due to challenges with social interactions, maintaining appropriate boundaries with peers, and it was reported that he was vulnerable to bullying. K’s mother did not engage with children and families practice (CFP) and considered that the behaviour was due to K’s autism and could be managed within the home4. 3.2 Following several incidents5 college assessed that the risk to K and his peers was too great, and the placement broke down. It was recorded that K did not understand why the college placement had ended and not attending college was a trigger for an escalation of self-harming behaviour which included attempts to take his own life and threats to harm others. 3.3 K presented at Milton Keynes University Hospital Foundation Trust accident and emergency (A&E) department on three occasions within a two-month period. K’s mother and stepfather became unwilling for him to return home due to the potential risk to younger siblings following increased violence at home and K’s obsession with knives. K’s mother also expressed concerns that she was unable to keep him safe. 3.4 A Local Emergency Area Protocol (LEAP) meeting was chaired by the CCG Commissioner and Transforming Care lead at Milton Keynes6. Northamptonshire CCG was the responsible commissioner at the time as K’s GP was in that area. The Northamptonshire HSE Case Manager and Transforming Care Lead were informed that that the LEAP meeting had taken place. Professionals agreed that the risk was too high for K to remain in the community and there was a need to manage behaviours which may be a result of his autism. It was recommended that K should be admitted to a mental health in-patient unit for a short period of assessment. The focus of the assessment was to clarify if K had an underlying mental health need and to identify a clear plan for support in the community on discharge7. 3.5 As an in-patient K continued to struggle with social interactions and it was recorded that he was vulnerable and bullied by peers. K told medical staff that his educational life was ruined after suspension from college and there was no 4 Information from the minutes of a Local Area Emergency Protocol (LEAP) meeting 5 Involving knives and challenging communication/physical interactions with peers 6 When admission is being sought in an urgent and unplanned way, a LEAP meeting must be undertaken to avoid unnecessary admissions: ‘The aim of the Local Area Emergency Protocol is to provide the commissioner with a set of prompts and questions both to prevent people with learning disabilities being admitted unnecessarily into inpatient learning disability and mental health hospital beds and, where there is a clearly supported clinical indication for admission to ensure that there is clarity about the intended outcomes and timescales’. Care and Treatment Reviews (CTRs): Policy and Guidance, NHS England, 2017 p 102 https://www.england.nhs.uk/wp-content/uploads/2017/03/ctr-policy-v2.pdf 7 Minutes of the LEAP meeting noted that: ‘All [professionals] were clear that a period of admission for assessment is what was needed with a clear plan to support in the community. 5 point to life. Following a verbal and physical assault by another patient K was transferred to a different mental health unit for his own safety. 4. Agency involvement December 2019 - May 2020 4.1 The following key services were involved with K: Milton Keynes Children’s Social Care (CSC) Thames Valley Police (TVP) Milton Keynes Virtual School Central and North West London (CNWL) Foundation Trust, Child and Adolescent Mental Health Services (MK CAMHS) Milton Keynes University Hospital Foundation Trust (MK UHFT) Essex Partnership University Foundation Trust EUPT Northamptonshire Child and Adolescent Mental Health Services (N CAMHS) Milton Keynes Clinical Commissioning Group (MK CCG) Northamptonshire Clinical Commissioning Group (N CCG) St Christopher’s (provider of semi-independent accommodation) Milton Keynes Christian Foundation (education/training provider) Chronology of key activity 4.2 December 2019 Following admission to the in-patient unit K received support with anxiety and a high level of observation for his own safety, there were ongoing concerns about K’s interaction with peers. K’s mother and stepfather were unwilling for him to return home due to their concerns about increased aggression, unpredictability of his behaviour, and risk to younger siblings. CSC explored the options for K to remain within the family and a family group conference took place8. Discharge from the in-patient unit was delayed and it was recorded that this was due to the challenge of identifying an appropriate placement9. 4.3 January 2020 K’s social worker sought advice from the MK CCG commissioner regarding community support and specialist autism provision. The Northamptonshire transforming care lead was informed of the need for support. K became a looked after child (s.20 Children Act 1989) and CSC submitted a placement request to local authority commissioners for a 16+ provider and independent fostering agency (IFA). St Christopher’s was one of two 16+ providers identified and confirmed that they were able to provide appropriate support to K. Medical professionals and K’s mother expressed concerns about whether the placement would meet his needs. 8 The purpose of the family group conference was to bring together family members to explore, how K might be supported to return to the care of his mother, or an extended family member, and how the family might support one another to meet K’s needs. 9 It is important to note that 24 hours following receipt of a referral from CSC, local authority commissioners identified placement options. 6 K moved into St Christopher’s and the Christian Foundation was identified as the education/training provision. There was a change in GP and transfer of care to a GP practice based in Milton Keynes. N CAMHS agreed to provide 7 days post-discharge follow up10, as the transfer of care to MK CAMHS had not progressed. A referral from N CAMHS requesting post in-patient discharge follow up was refused by MK CAMHS citing no evidence of moderate to severe mental health disorder. 4.4 February 2020 The mental health in-patient unit sent a discharge letter to the GP with details of the care and treatment provided to K and an outline of his ongoing needs and vulnerabilities11. The police responded to incidents when K alleged that he was threatened and physically abused by peers in the community. An initial looked after child review was held. CSC records indicated that K was happy in placement and engaging with the Christian Foundation. 4.5 March 2020 K advised professionals at Christian Foundation that he did not feel safe in Milton Keynes and CSC were informed about concerns regarding K’s presentation. N CAMHS care coordinator liaised with support workers at St Christopher’s and K’s social worker regarding concerns about a deterioration in K’s mental health. The police responded to further incidents; K was described as vulnerable to ongoing abuse and threats by peers and there were concerns that he may take his own life. A female resident at St Christopher’s contacted the police stating that K had a knife, was threatening to self-harm and she was injured12. K was moved to a different house within St Christopher’s following this incident and ongoing concerns for his wellbeing and challenges in making female relationships were noted. GP records indicate that the Police contacted MK CAMHS for information and were advised there was no identified role for mental health services. 10 The case worker was advised to focus on practical support rather than therapeutic intervention due to the proposed transfer. 11 The discharge letter included behavioural and social difficulties, past behaviour, and risks, including knives and ligature use, impulsivity self-harm, threat to others and description of inappropriately coercing and touching another patient at the inpatient unit and vulnerability of him from others. 12 The female resident did not pursue a complaint when subsequently contacted by the police. 7 K presented at MK UHFT A&E department13 on two successive days and was seen by the MK Liaison and Intensive Support Team (LIST-CAMHS Crisis Team). The MK Children & Young People Commissioner was notified of K’s presentation by CAMHS LIST through the Transforming Care referral process. K remained in hospital and health professionals liaised with the social worker regarding his social care needs. A LEAP meeting was held, and a safety plan agreed between professionals. St Christopher’s requested additional funding from CSC to provide 1-1 support for K. A keyworker from Compass (community substance misuse service) was allocated. K was presented by CSC at an adult transitions meeting. The transfer of care was agreed from N CAMHS to a Locum Consultant Psychiatrist at MK CAMHS. 4.6 April 2020 Following an initial review, the Locum Consultant Psychiatrist planned to see K every 6-8 weeks. It was recorded that K experienced periods of stability and deterioration was due to social factors rather than mental health relapses. Staff at St Christopher’s contacted the police as K refused to follow Covid-19 lockdown rules. Police responded to a further call from support staff at St Christopher’s who expressed concern for K’s welfare, a safety plan was agreed, and a child protection report was shared with CSC. K told his social worker that he wanted independence and said that he did not want to move placement and was not happy with the education provision. St Christopher’s requested additional funding from CSC to enable the provision of 2-1 support for K. A meeting to discuss the Interim Personal Education Plan was held at the Christian Foundation. A looked after child review took place and the support plan noted that a medication review was required, and psychological support was to be considered. Minutes of the review include the views of K’s mother, that St Christopher’s was not a suitable provision for K’s high level of need. 4.7 May 2020 K presented at MK UHFT A&E following an alleged overdose, K declined CAMHS, and no suicidal ideation was noted, K was discharged following observations. Support staff at St Christopher’s made a report to CSC emergency duty team that K had self-harmed. 13 K had self-harmed presented with heightened anxiety around a recent incident within the placement 8 K’s mother contacted the police regarding malicious postings on social media and expressed concern for K’s wellbeing14. Staff at St Christopher’s reported K missing from home to the police on successive days and said that he was vulnerable due to his mental health condition. K returned to the placement on both occasions. K was discussed at a multi-agency complex needs forum, MK CAMHS raised concern that K’s presentation was impacted by his autism. MK CCG Commissioner sent an email to the CAMHS Locum Consultant Psychiatrist regarding the need for an urgent multi-agency behavioural/supportive approach to care to avoid an inappropriate hospital admission. St Christopher’s made a third request for additional funding from CSC, to enable the provision of 2-1 support for K. A strategy meeting was held to discuss the increased number of reports that K was missing from home and escalation of self-harming behaviour. The record indicates that professionals acknowledged that St Christopher’s was not an appropriate placement for K. It was noted that police had responded eight times in a two-month period to incidents and concerns regarding K. K attended MK UHFT A&E following an assault by a peer and information was shared with the LAC nurse, social worker, and school nurses. The CMET (Youth Risk Group) was contacted due to the identified risk of exploitation due to K’s vulnerability. The MK CAMHS locum consultant psychiatrist requested the MK CAMHS manager to urgently allocate a care coordinator to provide supportive therapy to K. A crisis plan was circulated to key agencies to cover situations of distress, overdose, and self-harm. K attended MK UHFT A&E following attempted asphyxiation in response to a girl saying she wants to be a friend and not K’s girlfriend, this was assessed as self-harm not suicidal ideation. K alleged that he had been raped by another resident at St Christopher’s. 5. Analysis 5.1 Guided by the Terms of Reference for this Review and following analysis of the available information, key themes and potential opportunities for multi-agency practice improvement when working with young people who have complex needs were identified as: 1. Decision-making process and assessment of strengths, needs and vulnerabilities when placing young people in semi-independent15 living. 14 K’s mother later advised the matter had been resolved and the posts removed so police involvement was no longer needed. 15 Accommodation with support for young people to assist in the development of skills to enable them to transition to independent living. 9 2. Provision of support and intervention following discharge from hospital into the community. 3. Professional understanding of autism, appreciation of K’s lived experience and response to presenting behaviour. 4. Escalation of concerns by professionals. 5.2 Multi-agency practice is discussed below, and key learning points identified. Some information is relevant to more than one theme and care has been taken to avoid repetition. 1. Decision-making process and assessment of strengths, needs and vulnerabilities when placing young people in semi-independent living 5.3 Professionals had different views about the needs and vulnerabilities of K and his capacity to function effectively with limited support. This was reflected in the decision to place K in semi-independent accommodation. There was a lack of communication between practitioners and agencies and the different views were not effectively communicated or resolved. 5.4 K became a looked after child when his Mother and Stepfather were unwilling for him to return home following discharge from the mental health unit as they considered that the risk to the younger siblings was too great. This view was supported in the discharge summary letter to the GP which noted: ‘K’s behaviour is at times aggressive, and although may be brief and followed by regret, posed a risk of serious injury to family members and K themselves’. In contrast, the initial view of CSC professionals was that it was appropriate for K to remain within the family, however efforts to explore16 family relationships that may enable this were unsuccessful. It became apparent that K would not be able to return home and CSC subsequently made a referral to the Local Authority commissioning team for 16+ semi-independent living providers and an Independent Fostering Agency (IFA), the referral did not request a specialist autism placement. 5.5 Efforts of professionals to explore options for keeping K within the family, and lack of effective communication regarding K’s needs delayed the discharge process which had a negative impact on K. There were concerns that he would self-discharge and become homeless. Health records detail K’s needs and vulnerabilities at this time and a clear purpose of the hospital admission was to identify K’s needs for support following discharge into the community. Information provided to this review indicates that multi-agency discussions and meetings at the end of the hospital admission were focussed on identifying a resource to accommodate K rather than understanding the support required to reduce his known vulnerabilities and meet his complex needs. 5.6 The local authority commissioning team submitted two 16+ providers and an IFA17 to CSC for consideration. St. Christopher Homes provided assurance to CSC that they could meet the needs of K and it was decided that he would be 16 A family group conference to explore a placement with extended family members was unsuccessful. 17 Following discussions between CSC and the IFA the offer was withdrawn as the placement was short term. 10 placed at St Christopher’s, a semi-independent living service for young people 16+. This decision contradicts the record of a Care Plan Review (CPR) meeting, four weeks before K was discharged which noted that K would not be considered for supported housing due to the high levels of social risk. 5.7 At the learning event support staff from St Christopher’s stated that the initial referral did not contain a lot of detail and: “K’s challenging behaviours became apparent during the first couple of weeks.” Support staff informed the review that following a risk assessment shortly after K moved into St Christopher’s CSC were advised via email that the placement was unable to meet K’s needs. This information was not followed up by St Christopher’s or CSC staff and it was not effectively addressed in LAC reviews. Consequently, the needs of K remained unmet and contributed to a deterioration in his presenting behaviour and increased anxiety. At the learning event there was consensus among professionals that semi-independent living was not appropriate for K as this did not provide the level of care required to meet his needs or support him with specific vulnerabilities relating to his autism. 5.8 The local authority commissioning team advised that they followed the legal requirements to source the placement for K and were not involved in decision making regarding the suitability of the placement, as this was the responsibility of CSC and the provider. At the Learning Event, managers from the CCG and CSC stated that it would be helpful to have a more joined up approach with the local authority commissioning teams, specifically, when working to place a young person with complex needs, to ensure that knowledge about a young person’s vulnerabilities and needs are shared effectively. 5.9 The local authority commissioner confirmed that: “In exceptional circumstances, when commissioned services do not have sufficient capacity or are considered unsuitable to meet the needs of the young person, the Local Authority Community Resource team may also Spot Purchase provision.” It is unclear why CSC did not request that a specialist placement was sourced, this was a missed opportunity that had a significant negative impact on K and his experience following discharge from hospital. 5.10 It was a significant omission that the referral to local authority commissioners did not specify the need for a specialist autism placement18. When requesting placements for children and young people with complex needs it would seem appropriate that there is an opportunity for professionals to discuss specific requirements in addition to submitting an electronic referral form. Increased communication and collaboration between the CCG, CSC, and the Local Authority commissioning teams, is likely to improve the process of providing young people in care, who have similar requirements to K, with appropriate placement opportunities to meet their complex needs. 18 The Local Authority commissioning team advised that ‘despite the market shortage of specialist residential ASD, MKC does manage to locate placements when requested by CSC (although the search would take more time and the provider may not necessarily be in the Milton Keynes area).’ 11 5.11 There was consensus among professionals involved in this review that there is a gap in Milton Keynes of suitable placements for children and young people with autism, particularly 16+. It was acknowledged that lack of funding and resources are significant factors which have a negative impact on the placement options for young people with complex needs. This is a national issue, as highlighted by the Report of the UK Children’s Commissioner, Unregulated (2020)19 which documents concerns about children in care living in unregulated placements. 5.12 The report notes: ‘It is true that some 16- and 17-year-olds may be ready to begin to make steps towards independence. However, as our research suggests, our assumption should be that most are not, and are being forced into semi-independent living, unregulated provision when it is not in their best interests, simply because there is no other option available – including children with complex needs and multiple vulnerabilities’. There was no indication that the possibility of sourcing a specialist placement was considered, prior to K moving into St Christopher’s, and whilst information provided to this review suggests that staff did their best to support K, this was not adequate given his vulnerabilities and needs. 5.13 This review has found that there was no communication between St Christopher’s and CSC when K moved houses within the unit. It is a concern that the social worker and IRO for both K and the alleged perpetrator were not aware of the needs and vulnerabilities of other young people within the placement prior to the allegation of rape which triggered this review. This was a missed opportunity to identify appropriate intervention and support, to safeguard both young people. 5.14 A key purpose of the hospital admission was to identify K’s support needs within the community. The assessment of health professionals at the mental health unit did not inform decision-making regarding K’s placement following discharge. There was a lot of knowledge about K’s needs however this was not shared effectively. Decisions were resource-led not needs-led and resulted in K being placed in an inappropriate semi-independent provision. Learning points 1 It is important that young people with complex needs, their family and key professionals, have a meaningful opportunity to contribute to a holistic multi agency assessment, to identify strengths, vulnerabilities, and clarify support required, prior to the identification of a potential residential placement. 2 Decision-making when identifying placements for young people with autism and additional vulnerabilities should be needs led, this will be 19 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2020/09/cco-unregulated-children-in-care-living-in-semi-independent-accommodation.pdf 12 supported by improved communications between CSC and the Local Authority commissioning teams when making a placement request, to increase understanding about specific requirements and available resources. 3 It is essential that key partners have confidence that placements for young people with complex needs have the capacity and expertise to meet assessed needs, and specialist services are spot purchased if necessary. 2. Provision of support and intervention following discharge from hospital into the community 5.15 K was entitled to receive robust wrap around intensive support via the Transforming Care Programme which aims to improve the lives of children, young people, and adults with a learning disability and/or autism who display behaviours that challenge, including those with a mental health condition (NHS England 2017)20. There were a series of factors which impacted on the capacity of agencies and key professionals to respond in a timely way and work proactively to provide the appropriate level of support to K. These included: poor information sharing and professionals not being aware that K was in their area, omission to involve all key practitioners at the in-patient Care and Education Treatment Review (CETR), and challenges in the transfer of care between N CAMHS and MK CAMHS. 5.16 The multi-agency support and intervention provided to K following discharge from hospital lacked coordination and was inadequate to address his needs and vulnerabilities. The chronology provided by N CAMHS noted that: ‘…everything was fixated on finding a placement rather than overall support and care for crisis, his ASD, education etc. There was no holistic plan for discharge’. Limited information sharing between agencies and inconsistent understanding among professionals of K’s needs and vulnerabilities impacted on the development of effective multi-agency care planning. 5.17 The response to recommendations within the LEAP meeting (see paragraph 3.4) held prior to admission was not robust and key professionals were not involved in planning for K’s discharge21. The discharge plan lacked clarity, was inadequate to address K’s complex needs and vulnerabilities, and K was not effectively supported to manage his anxieties and impulsive behaviours. Consequently, practitioners and agencies spent a significant amount of time and resources responding to crisis as K’s needs remained unmet and his self-harming and challenging behaviour within the community increased. 20 model-service-spec-2017.pdf (england.nhs.uk) 21 K’s social worker was not in work when K was discharged and had limited involvement with the discharge plan. MK CAMHS were not involved in any care planning meetings. 13 5.18 There were missed opportunities to hold a timely Care Education and Treatment Review22 (CETR). The foreword to the CETR policy and guidance (2017) notes that: ‘People with learning disabilities, autism or both have a right to CTRs if they are in hospital for a mental health problem or behaviour that challenges services. And if they are at risk of going into one’. The aim of the CTR is to bring a person-centred and individualised approach to ensuring that the care and treatment and differing support needs of the person and their families are met, and that barriers to progress are challenged and overcome. 5.19 The provision of appropriate early intervention and support to meet the needs of children and young people is essential, particularly for those with complex needs. In the absence of appropriate early help K experienced a crisis which resulted in an admission to an assessment and treatment unit. Professionals involved in the Review stated that given the history of K’s presentation at home and college it would have been appropriate for a multi-agency coordinated approach and a Transforming Care referral for a community CETR to have been considered earlier. There was a view among professionals at the Learning Event that had these meetings taken place it is possible that admission to hospital may have been prevented. 5.20 Records indicate that a CETR was held whilst K was an in-patient however the impact of this on the care and support provided to K was unclear. Practitioners stated that one of the challenges to holding a CETR was that agencies with responsibility for health and social care were in different areas. However, it should be expected practice to facilitate a CETR for all young people who would benefit, and the location of key agencies should not be an issue. 5.21 When K’s behaviour escalated in the community following discharge from the in-patient unit the Transforming Care Lead for Milton Keynes was proactive in challenging services to provide intensive support to meet K’s needs and facilitated a CETR with the purpose of preventing a further hospital admission for K. 5.22 Effective multi-agency cooperation and collaboration is essential when working to support children with complex needs. This is highlighted in the Code and Toolkit guide for commissioners which notes: ‘Multi-agency CETRs are driven by the NHS but the involvement of local authorities and education services in the CETR process and its outcomes is integral to improving care, education and treatment for children and young people with learning disabilities, autism or both and their families’.23 22 CETRs were developed as part of NHS England’s commitment to improving the care of people with learning disabilities, autism, or both in England with the aim of reducing admissions and unnecessarily lengthy stays in hospitals and reducing health inequalities. NHS England » Care, Education and Treatment Reviews (CETRs) 23 (p6) https://www.england.nhs.uk/wp-content/uploads/2017/03/children-young-people-cetr-code-toolkit.pdf 14 5.23 Information within the chronologies provided by N CAMHS and MK CAMHS identified challenges to the referral process between services, and lack of clarity and different expectations amongst professionals about the role and responsibility of each service when K moved from hospital to the community. In addition, practitioners at the learning event noted a discrepancy in thresholds, and lack of understanding about the role of CAMHS when working with autistic young people. 5.24 K had three sessions with N CAMHS post discharge and following transfer to MK CAMHS was reviewed by a consultant psychiatrist every six weeks. A crisis plan was developed and arrangements to provide therapeutic support from MK CAMHS were made immediately before K alleged that he had been raped in placement. There was an expectation by some practitioners that CAMHS would provide therapeutic intervention for K. 5.25 St Christopher’s staff advised that significant efforts were made to support K and understand his needs. However, it appears that there was a lack of resource, knowledge, and experience to meet K’s needs and prevent the escalation of K’s behaviour. K was heavily influenced by peers within the placement and community to drink and smoke cannabis. St Christopher’s requested additional funding from CSC on three occasions to enable the provision of increased support. There was a lack of clarity about how the additional support would impact on the care provided to K and funding was not provided. It appears that agencies were working in isolation to support K, the adequacy of this support was not effectively monitored, and the responsibility and accountability of agencies was unclear. Intervention was unplanned and reactive, often in response to a crisis. This was supported by staff from St Christopher’s who stated: ‘K needed more support, and he wasn’t engaging. All the staff at the placement are trained, but K’s needs were so complex, and he needed such a large support package, the placement needed the professionals to be on board and they didn’t have them’. 5.26 Chronologies provided by MK CSC and the Virtual School noted that K’s needs were not fully known or assessed. It was an omission that there was a lack of focussed support to assist K to engage in education following discharge. This is significant as there was evidence to suggest that loss of a college place was linked to the initial deterioration in K’s wellbeing prior to the hospital admission. Agency records indicate that education was closely linked to K’s sense of self-esteem and hope for the future. K’s attendance at education whilst in placement was sporadic and it was the view of professionals that he was distracted due to influences in the community and placement. There were further challenges as K was not suited to online learning which was in place during lockdown. There was a lack of exploration by professionals to understand why K was not engaging in education and what may help him to do so. 5.27 It is important to note the challenges experienced by services during this time due to Covid-19. K should have been visited in person by a social worker weekly during lockdown due to his vulnerabilities. However, statutory visits took place 15 virtually for six months24 and the social worker advised that it was difficult to understand what was happening for K who would pace and avoid eye contact. K talked during virtual visits about feeling scared and wanting education, there was no indication that his views were robustly explored and responded to within the statutory LAC review process. 5.28 At the learning event professionals stated: ‘K struggled with lockdown restrictions, not going out, not seeing family. The reduced interaction with adults really negatively affected him and he didn’t really understand lockdown’. There was no multi-agency assessment to clarify K’s understanding of lockdown and identify what support may be provided to mitigate the constraints and challenges presented. It is possible that increased rules and restrictions contributed to K experiencing fear and increased anxiety. The significant and negative impact of coronavirus on autistic people and their families is highlighted in a report by the National Autistic Society ‘Left Stranded’ (2020)25. 5.29 Whilst Covid-19 presented significant challenges for agencies, it was an omission that K was not reallocated to a social worker able to visit K in person. Face to face meetings with a social worker may have supported K to understand the Covid-19 lockdown restrictions and provided an opportunity to fully explore the deterioration in his behaviour. K was a looked after child and the local authority did not fulfil its responsibility as corporate parent. There were gaps in the provision of support, and intervention fell short of what K should have received as outlined in the MK pledge to looked after children26. 5.30 The concerns which resulted in K being admitted to an in-patient mental health unit27 were not effectively addressed and increased during the period considered by this review. K’s needs were unmet and his presentation to emergency services at times of crisis increased. Whilst professionals were aware of K’s needs and vulnerabilities multi-agency support lacked coordination and did not prevent K from experiencing ongoing distress and crisis. 5.31 The absence of a coherent discharge plan and robust care plan had a significant impact on the provision of effective multi-agency support and intervention to meet the needs of K. Lack of clarity about professional roles and responsibilities, different understanding of K’s needs, inappropriate placement and limited collaboration between agencies were contributory factors which impacted on the provision of support and contributed to K experiencing ongoing vulnerabilities and unmet needs. 24 Between March and August 2020 25 https://s4.chorus-mk.thirdlight.com/file/1573224908/63117952292/width=-1/height=-1/format=-1/fit=scale/t=444295/e=never/k=da5c189a/LeftStranded%20Report.pdf 26 https://www.milton-keynes.gov.uk/children-young-people-families/kic-mk-home 27 Aggressive, impulsive, and risk-taking behaviour, handling of knives, threatening others lack of routine/education, poor relationships with peers, being easily led/manipulated/exploited by others, inability to manage emotions/behaviour. 16 5.32 From information provided to this review there is little evidence that K received adequate practical and therapeutic support from agencies to assist with the difficulties he experienced. It was a challenge for professionals within CSC, who had limited prior knowledge of K, to gain a full appreciation of his needs and vulnerabilities in the timeframe required. Omission to hold a CETR and ineffective discharge planning limited the effectiveness of multi-agency partnerships and opportunities to develop constructive relationships with key family members were missed. Learning points 4. Effective collaboration of all key partner agencies, as directed by the Transforming Care Programme, will support the prevention of inappropriate hospital admissions, and enable young people with complex needs to live to their full potential. 5. It is essential that there is a holistic multi-agency discharge plan for young people admitted to a mental health in-patient unit, to clarify the support required to prevent a further hospital admission. 6. When statutory visits to young people in care who have complex needs and vulnerabilities are face-to-face, the opportunity for professionals to fully understand and appreciate ongoing risks and vulnerabilities will increase. 3. Professional understanding of autism, appreciation of K’s lived experience and response to presenting behaviour 5.33 There was inconsistency in the understanding of professionals from different agencies about the impact of autism on the behaviour of K and his mental health, which was not resolved during the time considered by this review. 5.34 For many years, the family managed K’s behaviours within the home and there was limited involvement of external agencies. K’s Mother declined the involvement of CSC following a referral by college and advised that K’s behaviour was due to his autism and was being managed within the home. When K turned sixteen the family was no longer able to manage his presenting behaviours or safeguard the younger siblings. At this time K had extensive vulnerabilities and needs which were not holistically assessed. 5.35 There was a fundamental discrepancy in the way in which professionals perceived and understood the impact of autism on K’s presentation and emotional wellbeing. There was a lack of information sharing between agencies and professionals had different views about the level and nature of support required to meet K’s needs, as illustrated by the following examples: a) Medical records from the in-patient unit noted that: ‘The team is of the view that if K was to return home the impact of his behaviour (intentional or unintentional) on younger siblings would place them at risk of developing mental health issues themselves and should therefore be considered a 17 safeguarding risk’. Around the same time CSC was exploring options, which included a Family Group Conference (FGC) to identify the support needed to enable K to return home or live with other family members. It is unclear whether the view of the in-patient team was communicated to CSC professionals. b) Health professionals focussed on K’s behaviours in the context of his autism. The discharge summary provided to the GP concluded that a: ‘Combination of ASD and anxiety [were] responsible for many of the issues’. Professionals from other agencies, including CSC and staff in placement, were more concerned about what was described as K’s ‘mental health needs’ and there seemed to be a reliance on CAMHS to provide a therapeutic intervention. c) At the learning event professionals shared the view that K’s behaviour escalated as he sought attention and affection from his family and peers. The influence of family and peer relationships on the wellbeing and presentation of K was not fully explored. Professionals spoke about attachment issues and possible unresolved trauma28 however these were not effectively assessed or addressed. It was acknowledged that the escalating behaviour of K may have been a response to unmet needs and there was a lack of understanding or exploration about whether the behaviour was designed to elicit care and protection. 5.36 The 2020 summary report of the Child Safeguarding Practice Review Panel29 identified ‘understanding the child’s daily life’ as a key practice theme for learning and noted: ‘It is important for practitioners to build a trustful and respectful relationship with the child and critically reflect on what the child is trying to communicate through their behaviour, interaction with others and physical presentation. Practitioners should be aware that challenging or help-seeking behaviour may reflect harm and distress’. 5.37 Absence of a shared understanding of K’s needs and vulnerabilities contributed to a disjointed approach by agencies regarding the provision of support. At the learning event professionals stated K’s behaviour was not seen in the context of his autism and the perception that his escalating presentation indicated a deterioration of his mental health may have contributed to the initial hospital admission. A report by the National Autistic Society and the All-Party Parliamentary Group on Autism30 highlighted inequalities for autistic people in the provision of support for physical and mental health, and the need for early intervention and support to prevent inappropriate hospital admissions. 28 During a family argument K found out that he had a stepfamily and professionals expressed concern that this was not verbalised or processed 29 file:///C:/Users/cathc/Documents/MK%20CSPR/child-safeguarding-practice-review-panel-annual-report-2020-summary.pdf 30 nas_appga_report.pdf (thirdlight.com) 18 5.38 Efforts by CSC to have a FGC with a view to maintaining K within the family, impacted negatively on the working relationship with the social worker. When K was placed in semi-independent living it was recorded that Mother and Stepfather were very angry and felt that K had been failed by professionals and agencies. 5.39 Professionals had a very different understanding of K’s wellbeing, behaviour and associated risks, which was informed by his presentation which fluctuated rapidly. This was demonstrated in an email response from the MK CAMHS Psychiatrist in response to an urgent request to increase multi-agency support to prevent a further hospital admission. The Psychiatrist met with K following an incident and reported that K was in good spirits and stated, “I was just a bit upset at the time...it could have been avoided if I just talked to someone but wasn’t sure who I could talk to”. In addition, records from CSC provided a positive reflection about K’s progress and the stability of the placement, however shortly afterwards health records indicated that K had presented to A&E following self-harm and concerns of support staff about taking his own life. 5.40 Information was not always shared with professionals who responded to incidents. At the learning event a Police Officer described responding to a call from staff at St Christopher’s regarding a 17-year-old with a knife who was agitated and threatening to hurt himself. Information about K’s autism, and complex needs was not shared. Whilst K was calm when the officer arrived, this information would have assisted the officer to be better prepared to respond to the presenting behaviours and ensure that any intervention was proportionate and appropriate. 5.41 Lack of a shared multi-agency understanding of K’s vulnerabilities and the impact of autism on his behaviour contributed to practitioners and agencies providing a reactive response to incidents. Support and intervention focussed on containing behaviour rather than assisting K to improve his capacity to control his own behaviour and emotions. In addition, there was a lack of clarity amongst practitioners regarding the roles and responsibilities of other agencies. At the learning event a professional from CSC stated: “There’s a lack of understanding of autism and related needs. There’s a lot of discussion about risk and management but a lack of joined up working”. 5.42 Throughout the period considered by this review the Police were involved in a significant number of incidents involving K. At times officers were contacted by staff at St Christopher’s in response to challenging behaviour which was considered threatening to staff, K, or others. Records indicate that the Police were, on occasion, used to control and de-escalate the behaviours of K which were due to his autism. This was not an appropriate use of Police resources, however it was evident that staff at St Christopher’s did not have the capacity or experience to de-escalate K’s behaviour and presentation. 19 5.43 The report of the UK Children’s Commissioner into unregulated placements31 noted that: ‘contacting police can be the default response to unwelcome behaviour in unregulated accommodation, instead of situations being dealt with by the settings alone. This can land young people with criminal records for low-level incidents and contribute to negative relationships between themselves, police and the staff around them’. 5.44 K attended the A&E unit at MK UHFT three times on the same day. On one occasion it was recorded that he was cared for on social grounds and not discharged until contact had been made with a social worker due to concerns about unmet social care needs and suitability of placement. Colleagues in health provided challenge to partner agencies regarding the discharge of K to a more suitable place. 5.45 At the learning event autism training was noted to be a significant priority for agencies32, it was acknowledged that some practitioners lacked knowledge and understanding regarding autism which impacted on their confidence and skills to provide appropriate support. Practitioners acknowledged that: “It would be helpful for everyone to come together to discuss needs and requirements and find a suitable resolution when working with young people who have complex needs”. 5.46 Whilst the voice of K was recorded within agency reports, there was no evidence that his views were explored or influenced decisions about his care. There was a pattern of K being moved when his behaviour could have been an indication of heightened distress. He was transferred from one in-patient unit to another and moved house while at St Christopher’s. It is a concern that K told professionals that he had been moved because of his behaviour which may indicate that K felt blamed and punished for behaviours which he was struggling to manage and contain. 5.47 There was a gap in professional knowledge and understanding of K’s needs due in part to the limited involvement of agencies before he was 16 years old. Whilst outside the timeline considered by this review, there is potential learning to ensure the education and health care needs of autistic children and young people who are home schooled are met. 5.48 There was limited understanding among professionals about the impact of autism on K’s behaviour. Lack of collaborative and effective multi-agency cooperation impacted on the ability of professionals to work in partnership with the family, and the needs of K were not fully understood and remained unmet during the period considered by this review. 31 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2020/09/cco-unregulated-children-in-care-living-in-semi-independent-accommodation.pdf p23 32 Autism is to form part of the 2022 vulnerability-training programme for TVP 20 Learning Point 7. Professionals require appropriate knowledge, skills, and competence, to provide effective support to young people with autism and to develop a clear understanding of needs and vulnerabilities. 8. It is important that professionals have a shared understanding of the impact of autism on the behaviour, wellbeing and mental health of a young person and work collaboratively to understand what the young person may be attempting to communicate by their behaviour to develop a consistent multi-agency response. 9. It is important that multi-agency assessments of young people with autism support the development of a shared understanding amongst professionals of the key strengths, vulnerabilities, needs and risks which should inform a consistent approach to the provision of care and support. 10. When young people with autism are home-schooled, effective oversight is required to ensure that education and health care needs are met, and effective support is provided to enable the child to reach their full potential. 4. Escalation of concerns by professionals 5.49 It was evident from information shared by professionals at the learning event and within agency chronologies, that concerns regarding the provision of intervention and support to K were escalated within and between agencies during the period considered by this review. Examples of professionals sharing concerns include: • N CAMHS care coordinator escalated concerns to managers in N CAMHS regarding the declined referral by MK CAMHS. • MK LAC nurse liaised with MK GP and raised concerns about the declined referral by MK CAMHS. • MK Transforming Care Lead raised concerns with N Transforming Care Lead about the absence of multi-agency support and intervention in the care of K and risk of a further inappropriate hospital admission. • K’s social worker reported concerns about K’s unmet needs and ongoing risks to their manager. • St Christopher’s informed CSC that they did not have the capacity to meet K’s needs and were unable to contain his behaviours shortly after he moved in. • The IRO for K consistently informed senior managers that St Christopher’s was not an appropriate placement for K. • K’s Mother and Stepfather were angry that the placement identified for K was not adequate to meet his complex needs or keep him safe. 5.50 Whilst professionals and K’s Mother and Stepfather expressed their concerns, there was little impact on the provision of support to K during the timeframe 21 considered by this review. Formal procedures were not implemented, and informal escalation of concerns were ineffective. Learning Point 11. When professionals have concerns about the provision of care and support to a young person with complex needs it is important that the formal escalation policy is implemented to highlight unmet needs and practice shortcomings, effect change and prevent drift. 6 Good Practice/ improvement • The MK CCG commissioner worked proactively to inform N CCG commissioner about K and facilitated a timely LEAP in response to K’s escalating behaviour when this was not her responsibility. • Medical staff at MK UHFT liaised with K’s social worker regarding his social care needs prior to discharging him from hospital. • MK LIST CAMHS referred K to MK CCG transforming care lead for multi-agency triage. This is good practice as when K was in crisis the responsible CCG commissioner was notified in a timely way and able to act and prevent an inappropriate admission. • The police provided a consistent response to K and worked with partners to address K’s immediate need for support at times of crisis. • The police provided a comprehensive analysis of single agency practice and identified opportunities for learning and improvement that have been addressed. 7. Conclusion 7.1 It was evident that professionals worked to establish a relationship with K and meet his needs with the resources and knowledge they had. In addition, it must be noted that the restrictions of lockdown due to Covid-19 had a significant impact on K and all professionals who worked to support him during the period considered by this review. 7.2 K did not receive appropriate multi-agency help and support to address his needs and vulnerabilities, and it is possible that his escalating behaviour was a response to distress due to unmet needs. This review has benefited from the frank reflection of professionals, many of whom worked hard to support K in very challenging circumstances. The review has highlighted specific shortcomings in multi-agency practice and an urgent need for autism training for key practitioners. High quality robust training will increase the competency of the workforce and have a positive impact on the support provided to vulnerable young people. 7.3 This review has highlighted the experience of K, a looked after young person with autism whilst living at a semi-independent placement that was inappropriate and unable to meet his needs. It is recognised that there are serious funding and resource issues which require complex solutions and the shortage of residential provision for young people with autism aged 16+ is a national issue. 22 7.4 Since this Review, multi-agency practice improvements have been progressed by MK Child and Young People’s Integration Project (Health, Social Care and Education). This improved joint approach has already had a tangible positive impact on the lives of young people with complex needs. Also, following the learning event for this review a senior manager refused to place a child with significant vulnerabilities and complex needs with a provider due to lack of clarity about how the child’s needs would be met. Increased focus on the needs of the child, and robust scrutiny of the capacity of providers to provide appropriate support and meet assessed needs, is an example of practice improvement following the learning from this review. 7.5 These developments are positive, and it is necessary that practitioners and managers have the confidence to always place the needs of vulnerable young people at the centre of their decision-making when considering a residential placement if positive progress is to continue. 7.6 MK Child and Young People’s Integration Project is facilitating a shift in culture and change to systems to improve multi-agency collaboration when working with young people with complex needs. It is important that all key partners are committed to promote cultural change and practice improvement if vulnerable children with complex needs are to have the opportunity to live meaningful lives and reach their potential. 8. Learning Points 1 It is important that young people with complex needs, their family and key professionals, have a meaningful opportunity to contribute to a holistic multi agency assessment, to identify strengths, vulnerabilities, and clarify support required, prior to the identification of a potential residential placement. 2 Decision-making when identifying placements for young people with autism and additional vulnerabilities should be needs-led, this will be supported by improved communications between CSC and the Local Authority commissioning teams when making a placement request, to increase understanding about specific requirements and available resources. 3 It is essential that key partners have confidence that placements for young people with complex needs have the capacity and expertise to meet assessed needs, and specialist services are spot purchased if necessary. 4 Effective collaboration of all key partner agencies, as directed by the Transforming Care Programme, will support the prevention of inappropriate hospital admissions, and enable young people with complex needs to live to their full potential. 5 It is essential that there is a holistic multi-agency discharge plan for young people admitted to a mental health in-patient unit, to clarify the support required to prevent a further hospital admission. 23 6 When statutory visits to young people in care with complex needs and vulnerabilities are face-to-face, the opportunity for professionals to fully understand and appreciate ongoing risks and vulnerabilities will increase. 7 Professionals require appropriate knowledge, skills, and competence, to provide effective support to young people with autism and to develop a clear understanding of needs and vulnerabilities. 8 It is important that professionals have a shared understanding of the impact of autism on the behaviour, wellbeing and mental health of a young person and work collaboratively to understand what the young person may be attempting to communicate by their behaviour to develop a consistent multi-agency response. 9 It is important that multi-agency assessments of young people with autism support the development of a shared understanding amongst professionals of the key strengths, vulnerabilities, needs and risks which should inform a consistent approach to the provision of care and support. 10 When young people with autism are home-schooled, effective oversight is required to ensure that education and health care needs are met, and effective support is provided to enable the child to reach their full potential. 11 When professionals have concerns about the provision of care and support to a young person with complex needs it is important that the formal escalation policy is implemented to highlight unmet needs and practice shortcomings, effect change and prevent drift. 9. Question for the MK Together Partnership How can the safeguarding partnership obtain assurance from partner agencies that key learning from this review is effectively addressed within multi-agency improvement plans and that actions have a positive impact on the lives of children and young people? With a specific focus on: • The provision of holistic discharge plans when young people are in-patients at a mental health unit. • Improving the knowledge and confidence of practitioners to support effective work with autistic children and young people. • Ensuring that placements have the capacity and expertise to meet the identified needs of young people and supporting the spot purchase of a specialist provision when required. • Ensuring that multi-agency assessments of young people with autism promote a shared understanding among key professionals about needs and vulnerabilities. • Implementation of the formal escalation procedure when professionals have concerns about unmet needs of autistic children and young people. • Ensuring there is effective collaboration between CSC, health professionals, local authority and CCG commissioning teams when identifying placements for young people with complex needs. 24 • Development of a clear plan with young people and professionals for use in crisis to reduce the inappropriate use of emergency services, specifically A&E and the police. • Monitoring the educational and health care needs of autistic young people who are home schooled and ensuring that these are met. |
NC52222 | Death of a 4-week-old infant in April 2017. Child A was found unresponsive by their mother. Cause of death was identified as sudden unexpected death in infancy (SUDI) associated with co-sleeping. Police conducted enquiries and passed the case on to the Crown Prosecution Service. No charges were made. Child A lived with their mother and two siblings (Sibling 1 and Sibling 2). The relationship between Mother and Father 1 ended within days of Child A's birth, and Father 2 was absent from the children's lives. The siblings' school had referred the family to children's services, due to concerns around Mother's alcohol use. Children's services had conducted a child and family assessment, which resulted in a child in need plan for support around Sibling 1's behaviours. Child A's ethnicity or nationality are not stated. Learning includes: services thinking about children within the context of their family, and being mindful of repeat patterns of behaviour within families; professionals recognising when parental deflection may create risk for a child; professionals being aware of indicators of abuse, and understanding when to share information about these indicators. Recommendations include: ensure school staff have training on indicators of abuse, and have the competencies to safeguard children; information sharing training should include the directive that when parents do not give permission to share information staff consider if a child is at risk of harm, before a decision to not share information is made; when there is disparity between parent's views and those of their children, professionals should maintain focus on the child.
| Title: Report of the serious case review regarding Child A: executive summary. LSCB: Surrey Safeguarding Children Board Author: Nicki Walker-Hall Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Surrey Safeguarding Children Board Report of the Serious Case Review regarding Child A:Executive Summary Author: Nicki Walker-Hall September 2019 2 Initiation of the Serious Case Review This case was initiated by Surrey Safeguarding Children Board (SSCB) as a result of the death of Child A who died in April 2017 aged 4 weeks, the Coroner concluded death was due to SUDI1 associated with co-sleeping. The Police, having conducted their enquiries passed their file to the Crown Prosecution Service who refused a charge due to lack of evidence of suffocation. The Children There were three children in this family unit. Child A, the primary subject of this review, was a very young baby at the time of death and as a result there was limited information held by professionals. Child A’s pregnancy was unplanned. Mother attended ante-natal appointments and there were no concerns regarding Child A during the pregnancy. Child A was born by caesarean section at full term, weighing 2810 grams which was within the normal range. There were no concerns regarding Child A whilst in hospital. Child A and Mother were discharged at 3 days in line with usual practice. The relationship between Mother and Father 1 ended within days of Child A’s birth meaning Mother was a single parent to all three children. The only concern raised by Mother and professionals, related to Child A’s weight gain and feeding. Child A’s 2 older siblings had experienced domestic abuse in infancy via their father. There was no Children’s Services (CS) involvement at the time of Child A’s death. Both sibling’s attendance at school was good. Sibling 1 was described as academically bright and Sibling 2 of average ability. Sibling 2 was described as a "very happy child". Their teacher described both children as "lovely." In 2015 Mother was concerned about Sibling 1’s behaviour and sought assessments for ADHD; Sibling 1 was diagnosed with ADHD in December 2015. Mother reported Sibling 2 was a "nightmare" to get to bed, who struggled to shut off at bedtime. Mother sought an assessment for ADHD, however Sibling 2 did not meet the criteria for assessment. Father 2 was absent from the children’s lives. Siblings 1 & 2 and Mother were reportedly well supported by Mother’s parents both emotionally and financially. 1 Sudden unexpected death in infancy, or SUDI, is a broad term that covers both sudden infant death syndrome, or SIDS, and fatal sleeping accidents. Most SUDI deaths occur in a sleeping environment. 3 Summary of the Case The period covered by this serious case review covers 24 months from May 2015 until the death of Child A. At the beginning of the review period school had concerns regarding Mother’s alcohol use impacting particularly on Sibling 1, and referred the case to Children’s Services (CS). A Child and Adolescent Mental Health Service (CAMHS) assessment recognised that Sibling 1 was finding it difficult to cope emotionally and contain frustration, anger and anxiety. Siblings 1 and 2 had experienced estrangement from their father, domestic abuse and were further impacted by Mothers work patterns meaning their care was shared between Mother and Maternal grandparents, across two separate households. CAMHS reported Mother was finding it difficult to cope at times as a single parent. Strategies were recommended to school and a recommendation made that Mother attend a formal parenting class. A child and family assessment was conducted by CS; Mother indicated she was no longer drinking. The need for support around Sibling 1’s behaviours lead to the case entering Child in Need (CIN). The agreed actions from the CIN meeting centred on Sibling 1’s behaviours; there were no specific actions to address Mother’s alcohol or parenting issues. Sibling 1 continued to have behavioural issues. A decision was made to transfer the case from CS to the Extended Hours Service (EHS) as the more appropriate service to address the breakdown in relationship between Sibling 1 and Mother. One worker from EHS was to work with Mother and the Grandparents and another was to work with Sibling 1 to build / strengthen the relationship with Mother and work on Sibling 1’s sense of self-worth and self-esteem. Sibling 2 did not feature in plans. Behaviour Support intervention commenced. Progress around actions was noted however, there was no direct work taking place between the EHS worker for Mother and the Maternal Grandparents. Sibling 1’s behaviour continued to be of concern. At the end of December Sibling 1 was diagnosed with a severe degree of ADHD and placed on medication. At a CIN/ re-integration meeting held early in the new term (January) Mother indicated she was now eligible for ongoing support through an ADHD nurse and was aware of support groups for parents. The family reported they were seeking behaviour therapy privately. In March the last and final CIN meeting took place. Mother gave a positive outlook in relation to Sibling 1 and the significant improvements that had been made. EHS ended their involvement with the family. School stated that they would start to incorporate ELSA2 support (a new service) for Sibling 1 to receive support for the emotional and learning 2 ELSA - An educational psychology led intervention for promoting the emotional wellbeing of children and young people. 4 aspects of Sibling 1’s time spent at the school. It was reported by the school that there was no further report of Sibling 1 wandering around the school and that Sibling 1 was far less disruptive in classroom settings; recent incidents were not shared within the meeting. Within weeks of CIN closure, Mother took Sibling 2 to the GP requesting an assessment for ADHD. A SNAP3 assessment was arranged. In April 2016 Sibling 1 disclosed to school staff a row with Mother the previous night. Mother had left Sibling 1 home alone whilst she went to see a friend with Sibling 2. Sibling 1 had begun to worry how long Mother would be. At 9.45pm Mother still wasn’t home so Sibling 1 climbed out of the window and went to Mother’s friend’s house. Sibling 1 and Mother argued and Mother slapped Sibling 1 round the face. Mother pushed Sibling 1 against a wall banging Sibling 1’s head. Sibling 1 indicated Mother had drunk a whole bottle of wine. School did not make a referral to CS. In July Sibling 1 again arrived at school very upset. Sibling 1 disclosed a row with Mother the night before; Mother had said she would send Sibling 1 to live with Father 2 and get a dog instead. Sibling 1 shared his worries; Sibling 1 hadn’t seen Father 2 for 4 years, Father 2 used to lock Mother in the kitchen, Father 2 had nearly killed Sibling 1 when Sibling 1 was younger and hadn’t fed Sibling 1 on court order day visits. School rang Mother to discuss and she spoke to Sibling 1 who was reassured by her. School did not make a referral to CS. In August Mother attended a maternity booking appointment, she was 10 weeks pregnant. Routine questions were asked around CS involvement, Domestic abuse and substance misuse. No disclosures were made. Mother reported consumption of alcohol pre pregnancy as 4 units per week and current units as 0. Mother attended all appointments and ultrasound scans throughout the pregnancy occasionally accompanied by Father 1. In September Sibling 1 attacked Sibling 2 on the school playground; Sibling 1 was very violent and aggressive towards Sibling 2. Sibling 2 gave no response and put up no defence. Staff were shaken by the incident but Sibling 2 indicated all was fine. In November Mother attended an appointment with the GP to discuss Sibling 2 as she remained concerned that Sibling 2 had ADHD, a school questionnaire did not reveal anything abnormal. Mother was requesting a paediatric referral as CAMHS had not been helpful in diagnosing Sibling 2. GP records indicate Paediatrics triaged the referral to CAMHS who felt Sibling 2 did not meet criteria for ADHD. Self-support advice was given to the family and the case closed. In March 2017 Child A was born by planned caesarean section. Mother and Child A remained in hospital for 3 days. Following Child A’s birth both community midwives and the HV carried out routine visits in line with normal practice. The only concern noted was Child 3 SNAP – Special Needs Assessment Profile 5 A’s faltering growth. Child A’s weight was monitored by midwifery services and the feeding and well-baby clinic. When satisfactory weight gain was not achieved, Child A was reviewed twice by the GP and twice by Paediatricians on the request of midwifery, in twenty days. The HV carried out a new birth home visit seeing Mother and Child A. Mother became tearful when talking about the relationship with Child A’s father. Mother indicated Father 1 had not been supportive through the pregnancy and had left the family home the week before so Mother was coping with 3 children on her own. Mother reported she could cope as she had good support from her family. Mother was given appropriate feeding information and advice. Health promotion advice was given including risk of cot death-safe sleeping positions. When Child A was two weeks old Sibling 2 disclosed to school staff worries about how she would sleep during the forthcoming Year 5 residential. Sibling 2 disclosed struggling with sleep and reported Mother had given her some of Sibling 1’s sleeping tablets to help. Staff told Sibling 2 not to worry as they would be so busy that sleep would not be a problem. School did not make a referral to CS. Child A was reviewed regarding weight gain by the Paediatrician. Two days later, Child A was found unresponsive by Mother and an ambulance called. CPR was commenced however was unsuccessful. Ambulance staff reported a Sudden Unexpected Death in Infancy to the Police. Mother indicated she had been drinking alcohol at lunchtime and then again in the evening with a friend; totalling approximately two whole bottles of wine. Mother stated that her children did not have any contact with Child A after Child A was put into the crib that night however Sibling 1 gave an account of attending to Child A twice as Sibling 1 was unable to wake Mother, feeding Child A from a bottle on the first occasion and placing Child A on Mother’s chest to feed on the second. Summary of findings/learning The tragic death of Child A, the subject of this review, was unexpected and could not have been predicted by the professionals who had been working with the family. There is no certainty that any of the findings below would have made any difference to the tragic outcome in this case. At the time of the death there was no CS involvement. Finding 1: Within the school there was lack of clarity about what constituted a safeguarding concern. This coupled with over optimism and a lack of support and supervision for staff, lead to lack of challenge of professional’s thinking. Ultimately this led to an inconsistent approach to making referrals, resulting in some safeguarding concerns not being referred. Learning: The school was not sufficiently skilled or supported to fulfil their safeguarding responsibilities. 6 Finding 2: CAMHS decision to cease their involvement with Sibling 1 whilst a Child and Family assessment was in progress was flawed. Attendance at and contribution to the CIN plan prior to closure was essential to ensure their recommendations were taken forward by appropriate services. When Sibling 2 was referred, CAMHS did not fully link Siblings 1 & 2’s shared experiences of trauma and behavioural issues or consider referral to CS. Learning: The importance of thinking about the children within the context of their family and what is known is crucial. Services should be mindful of repeat patterns of behaviour within families. Finding 3: Mother’s view of the cause of Sibling 1’s behaviours appears to have been given more credence than the findings of the Child and Family Assessment. The lack of inclusion of fathers within assessments is reducing professionals understanding of the issues within families and the family’s functioning. The allocated worker was deflected from exploring Mothers alcohol use and parenting having accepted that a diagnosis of ADHD was responsible for all Sibling 1’s behaviours and didn’t consider the impact of Mother. Learning: Both parents/members of a child’s household need to be consulted as part of assessments in order to gain a more holistic understanding of the family. Whilst parents are to be listened to and supported it is essential professionals across all agencies confidently and competently exercise a strategy of “high support; high challenge” when engaging with adults. Professionals must be respectfully uncertain in their interactions, and recognise when deflection may be creating risk for a child, and ensure the adult does not obscure a rigorous focus on the identified issues. Finding 4: The lack of recognition that the children were at risk of harm coupled with a misinterpretation of information sharing guidance, meant professionals did not consistently share information when there were indicators of abuse. Learning: This case brings into sharp focus the importance of both recognising indicators of abuse and understanding when to share information. Whilst it is clear the concerns did not meet the criteria for s47 there was a risk to the children. Whilst parents can choose not to consent, professionals need to understand when they can override parental consent otherwise children will not be adequately protected. Finding 5: Resource issues in the form of an over stretched CS CIN service, and a lack of school nurses, and process issues in the form of, IT system issues, notification of children on CIN plans, and sharing of minutes for children experiencing domestic abuse, coupled with a lack of professional curiosity meant the multi-agency approach to safeguarding children who were not deemed as “needing protection” was not robust. 7 Learning: Children and their families who needed “Early Help”, were not receiving the right help early enough. This resulted in the statutory system becoming overwhelmed. CSC have embarked on a programme of transformation named ‘Family Resilience’ which clearly articulates the levels of need. This was signed off by SSCB in November 2018. Finding 6: Aspects of the family and its functioning impacted on professional practice. The adults within the family presented a ‘forceful’ and ‘united front’ which deflected professionals from fully addressing the impact of Mother’s behaviours on the children and considering the potential risks to the children. Learning: Working with articulate and confident families presents challenges akin to those posed by violent families; it can make professional wary and tentative in their interactions with family members. The importance of reflective supervision and managerial oversight when working with families is crucial to maintaining focus on the child. Finding 7: Whilst it is clear who prescribed Sibling 1’s medication and what is less clear is the robustness of dosage monitoring. In addition, there is no evidence available to the Lead Reviewer to indicate medication safety was discussed. Learning: Private prescribing is becoming increasingly common with families seeking private care for their children. Incidental learning within this review has uncovered current guidance does not cover the scenario in this case. Finding 8: Sibling 1 was viewed as a young carer by school when Mothers emotional needs placed Sibling 1 in that position. Sibling 1’s carer role should have featured within the CIN plan and stopped if Mother’s behaviours had been addressed. Learning: When a child takes on a caring role professionals need to question whether this is as a result of parent’s lifestyle choices. If so steps to address the root cause must be taken as part of a safeguarding plan. Finding 9: No professional involved in the care of Child A could have prevented Child A’s death had they acted differently. Mother was given appropriate advice regarding co-sleeping. Co-sleeping was specifically discussed with Mother on a number of separate occasions, including at the new birth visit. Finding 10: Sibling 1 and 2’s voices were lost when professional attention was deflected onto Sibling 1’s behaviours. Learning: Maintaining focus on the child features as an issue in many serious case reviews. When working with parents and carers professionals need to keep in mind what the child is saying. When there is disparity between parent’s views and those of their children, or 8 deflection, professionals must maintain focus on the child. Plans must include all issues raised by children and should not be considered complete until interventions have been completed. Managers overseeing plans must ensure actions are completed before cases are closed Recommendations 1. SSCB should review the training and supervision provided to schools, to ensure school staff have knowledge of the indicators of abuse and have the competencies and confidence to act to safeguard children through support and supervision. An audit of Education referrals and associated school records will provide the SSCB with an understanding of whether full and contemporaneous referrals and records are being made and whether the issues in this case are isolated to this school or reflective of all schools across the locality. 2. No service, which has been made aware of CS involvement, to discharge a child from their care whilst a Child and Family assessment is in progress without providing a written report of their involvement and recommendations for on-going work. 3. The SSCB to seek assurance from CS that there is now robust managerial oversight, that ensures fathers and household members have been consulted, and all identified issues have been addressed prior to closure of cases being managed within CIN. 4. SSCB to ensure all safeguarding and information sharing training and guidance includes a clear directive that, when parents/carers do not give permission to share information, further consideration is given as to whether the child is at risk of harm, before a decision not to share information is made. 5. The LSCB to ensure that all agencies, have robust plans and are taking action to address the resource and process issues identified in this case. SSCB to request quarterly reports from all agencies to oversee progress with a focus on outcomes for children and young people. 6. SSCB to seek assurance from children’s services that all actions on CIN plans incorporate all of the children’s expressed concerns and have been completed prior to case closure. What will the LSCB do in response to this? Surrey SCB has prepared their own document which describes the actions that are planned to strengthen practice in response to the findings and recommendations of this serious case review. |
NC044169 | Death of a 17-week-old baby girl in November 2012; death was recorded as due to unascertained causes. Child C lived with her brother, mother and mother's partner at the time of her death. Mother reportedly experienced sexual, physical and emotional abuse as a child, perpetrated by her father. Mother was 15-years-old when she became pregnant with Child C's older brother and still a teenager when Child C was born. Child C sustained a number of injuries in the months preceding her death; these were explained as either accidental or caused by Child C's older brother. Mother's partner was known to police and children's social care in a neighbouring authority and had previously been accused of engaging in sexual activity with underage girls. Significant maternal history of family violence, inconsistent parenting, anxiety and low self-esteem. Issues identified include insufficient professional consideration of the connection between the arrival of mother's boyfriend in the family and the reported challenging behaviour of Child C's brother and injuries to Child C. Adopts a systems approach to identify learning and recommendations, including: the vulnerabilities and service needs of children who become parents should be addressed from the perspective that they are children first; injuries or accidents to non-mobile infants should always be considered in the context of the child's medical and social history, developmental stage and explanation given; and assessment is a continued social work task, not a single event.
| Title: Serious case review: Child C. LSCB: South Gloucestershire Local Safeguarding Children Board Author: Andrew Haley Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review CHILD C SOUTH GLOUCESTERSHIRE LOCAL SAFEGUARDING CHILDREN BOARD January 2014 Author Andrew Haley 2 CONTENTS Page 1 Summary 3 2 The Requirement to Undertake a Serious Case Review 4 3 Summary of Individual Organisation Reviews and Terms of Reference 4 4 Family Composition 5 5 Family Involvement 6 6 The Family Story 6 7 Analysis and Emerging Themes 21 8 Conclusions and Final Remarks 38 9 References 39 10 Appendix 1 Recommendations Made in Individual Organisation Reviews of Contribution Agencies 40 11 Appendix 2 Serious Case Review Terms of Reference for Child C 48 12 Appendix 3 Agencies Who Contributed Individual Organisational Reports 54 12 Appendix 4 Glossary 55 13 Appendix 5 Overview Author Brief Biographical Note 56 3 1. Summary 1.1 This Serious Case Review was commissioned following the death at the age of 17 weeks of Child C. At the time of her death she was living in a household with her brother, her mother and her mother’s boyfriend. 1.2 The father of Child C was a young man similar in age to her mother. Although the relationship was longstanding it was not continual. They had never lived together as a family and at the time of her death her parents were not in a relationship. 1.3 Child C had been receiving help during her short life from several agencies, including Children’s Social Care. 1.4 During August 2012 her mother met a new partner, mentioned in 1.1 above, and he moved in to join the family. 1.5 On the 12th September 2012 a small bruise on the side of Child C’s head was noted and an accidental explanation was offered by the children’s mother. 1.6 Just under a month later, on the 5th October 2012, Child C was seen at the Children’s Hospital with injuries to her eyes. Her mother explained she believed the injuries were caused by Child C’s brother spraying her with hairspray. 1.7 On 31st October 2012 Child C was again taken for medical attention suffering a swelling on her forehead, said to have been the result of being dropped by Child C’s mother’s boyfriend. 1.8 On the 6th November 2012 Child C’s mother left a message for her health visitor concerned that Child C’s brother was hitting Child C and bruising her face. 1.9 On 14th November 2012 Child C was conveyed to hospital by ambulance from her home. Child C was not breathing and had been pronounced dead at home. 1.10 After Child C’s death some other observations were made during the initial post death clinical examination at the hospital and during the forensic post mortem. Blisters to her neck and ears were observed and have since been identified as possibly caused by the skin infection impetigo. Bruising was found on Child C’s scalp, thought to be some days old. 1.11 Child C’s death is recorded as due to unascertained causes. 2. The Requirement to Undertake a Serious Case Review1 1 Working Together 2013 4 Serious Case Reviews (SCR) are local inquiries into the death or serious injury of a child where abuse or neglect is known or suspected to be a factor. They are carried out by Local Safeguarding Children Board so that lessons can be learnt. The Local Safeguarding Children Board is responsible for ensuring that a review is undertaken. 2.1 Working Together 2013 is HM Government Guidance which sets out how SCRs should be carried out. 2.2 Local Safeguarding Children Boards (LSCBs) are required to maintain a local learning and improvement framework which is shared across local organisations who work with children and families. 2.3 LSCBs may use any learning model which is consistent with the principles in the guidance, including the systems methodology recommended by Professor Munro. 2.4 The case of Child C was considered by the LSCB Serious Case Review sub group in December 2012 but the final decision as to whether a SCR be undertaken was delayed pending the outcome of the post mortem. In June 2013, following receipt of the post mortem report, the SCR sub group recommended to the Chair of South Gloucestershire Safeguarding Children Board that the threshold for a Serious Case Review had been met. The Chair of the Board accepted this recommendation and decided that a Serious Case Review should be undertaken. 2.5 An independent Overview Author and Chair of the Serious Case Review Panel was commissioned. The Author is independent from any of the agencies who provided services to Child C and her family. A short biographical note on the Independent Overview Author is attached at Appendix 5. 3. Summary of Individual Organisation Reviews and Terms of Reference The time period identified for this Serious Case Review is from 1st September 2008, due to the relevance of the family context in understanding the background, until the death of Child C on 14th November 2012 3.1 Representatives from agencies who had provided services to Child C and her wider family produced Individual Organisation Reviews. These were undertaken by suitably qualified staff that had no direct involvement or management of the case under consideration. 3.2 The agency authors were tasked to look openly and critically at the individual and organisational practice to get a narrative of how the case was viewed as it unfolded; identify key practice episodes and turning points; analyse the contributory factors and interpret the broader significance from the information gathered to see whether the case indicates that changes could and should be made and, if so, to identify how those changes will be brought about. 3.3 The Individual Organisation Review provides a chronology and analysis of the agency involvement and brings together and draws overall conclusions from the involvement of the agency with Child C and her family. The Individual Organisation Review authors also had direct discussions with staff from within their agencies whom it was thought could assist with the overall understanding. The combined chronology and the Individual Organisation Reviews from each agency were considered by the Independent Author to construct the Overview Serious Case Review Report. 4. Family Composition Family Composition and Background Relationship to Subject Child C Child C’s Mother Child C’s Father Child C’s Brother Child C’s Mother’s Boyfriend Child C’s Maternal Grandmother Child C’s Maternal Grandfather Child C’s Mother’s Brother 5 5. Family Involvement 5.1 Child C’s mother and maternal grandmother were invited to contribute to the Serious Case Review process and met with the Serious Case Review Overview Author. They each provided information they thought would be helpful in these considerations. They were provided with a MBFX2 MGM MGFX MBFX1 CM Child C MGF MBF CF CB MB MBFC1 MBFC2 6 record of that meeting and corrected any misunderstandings or errors of fact. 5.2 Child C’s father was invited to participate but he declined. The Panel received communication on his behalf saying that he did not choose to participate. 6. The Family Story Child C and her Family 6.1 In order to fully understand the family functioning at the time of the death of Child C, it is necessary for us to understand the history of her mother. This report considers this context, as well as understanding the day to day life of Child C. This report looks at: what was happening for the front line professionals involved with Child C; what influenced the decisions they made; whether, if different actions had been taken, this may have altered the outcome for Child C; and what lessons need to be learned? 6.2 Munro (2008)2 notes that ‘the failure to look at history makes it easy to overlook patterns of behaviour yet these are often the most reliable warning’. 6.3 Child C’s mother is one of two full siblings, the daughter of Child C’s maternal grandmother and grandfather. Child C’s maternal grandmother met Child C’s maternal grandfather when she was 21 years and he 45 years. Child C’s maternal grandmother reports this relationship to be oppressive following on from an unhappy childhood, with little attention and support from her own parents. 6.4 Child C’s mother did not attend school until her GCSE year, being electively home educated. Child C’s mother’s brother was also educated at home but he was placed in school during his junior years as his mother found his behaviour too difficult to manage. Significantly, both Child C’s maternal grandmother and Child C’s mother report now that Child C’s maternal grandfather was physically and emotionally abusive. They said in discussion, when interviewed as part of the Serious Case Review process, that he was oppressive and overbearing, a habitual cannabis user and drank heavily. The domestic abuse was not discussed with outside agencies during this period. The Education Welfare Officer who monitored the Elective Home Education arrangements was not aware of the violence within the family. 6.5 Prior to 2005, her health records show infrequent GP appointments. In 2005 she was seen on 10 occasions with minor skin problems. In 2006 she was seen on 9 occasions with recurrent minor medical problems. In 2 E Munro Effective Child Protection Practice 2nd Edition 2008 7 2007 she was seen 15 times presenting with similar problems. On occasions the consultation was recorded as stress related and to be rooted in family and emotional problems. On one occasion Child C’s mother presented with a wrist injury as a result of a fight with her brother. In 2008, before her pregnancy with Child C’s brother, she was seen on 13 occasions. A young person aged between 5 and 25 would have an average consultation rate with GP services of 2-3 consultations per year. 3 6.6 During 2007 and 2008 Child C’s mother became an increasing visitor to her GP’s surgery. 2008 6.7 In May 2008, Child C’s maternal grandmother left the family home and took her children to live elsewhere. Children’s Social Care undertook an Initial Assessment4. No services were provided as an outcome of this assessment as Child C’s maternal grandmother was acting protectively and there was no contact with Child C’s maternal grandfather. 6.8 In August 2008 Child C’s mother’s family were referred to South Gloucestershire Children’s Social Care. Child C’s maternal grandfather had accepted a police Caution following admitting physically assaulting Child C’s mother who was 14 at the time. 6.9 Towards the end of 2008, Survive5 made a referral to Children’s Social Care. They were working with Child C’s maternal grandmother. The Survive worker enclosed the CAADA/DASH 6 risk assessment which indicated a very high risk. The risk was perceived to be from Child C’s maternal grandfather. The assessment included information that Child C’s mother, then 15 years old, was 8 weeks pregnant and that her needs required Children’s Social Care involvement and that, in their view, there was potential for significant harm. Children’s Social Care considered the information and concluded that as a Lead Professional and a CAF 7 was in place, this level of intervention was appropriate and there was no requirement for Children’s Social Care involvement. 3Trends in Consultation Rates in General Practice 1995 to 2006: Analysis of the QRESEARCH database 4 A decision to gather more information constitutes an initial assessment. An initial assessment is defined as a brief assessment of each child referred to social services with a request for services to be provided. This should be undertaken within a maximum of 7 working days but could be very brief depending on the child's circumstances. It should address the dimensions of the Assessment Framework, determining whether the child is in need, the nature of any services required, from where and within what timescales Framework for the Assessment of Children in Need and their Families HMSO 2000 5 Survive is a voluntary organisation who work with the victims of domestic abuse 6 CAADA ‐ Coordinated Action Against Domestic Abuse 7 CAF is Common Assessment Framework. An assessment following the framework undertaken by any professional working with a family, below the intervention level where Children’s Social Care become involved 8 6.10 Support was provided by the Survive service. It seems that both Child C’s mother and Child C’s maternal grandmother were and remained fearful of Child C’s maternal grandfather. This is not unusual in circumstances where abusive individuals have exercised such levels of intimidation and control. ‘All forms of domestic violence come from the abuser’s desire for power and control over an intimate partner or other family members’8. 2009 6.11 Child C’s mother’s first pregnancy was difficult. She suffered from a complication of pregnancy that caused nausea, vomiting and dehydration throughout, on occasion requiring hospitalisation. The Primary Care Individual Organisation Review author suggested that this level of sickness may have had an underlying emotional cause. 6.12 The following month Child C’s mother spoke to her Survive worker of her fears that her brother would harm her baby when born. This was a constant theme during this period because Child C’s mother also expressed these concerns to her midwife. In contrast she also spoke of the positive impact of the Family Therapy they were receiving from Child and Adolescent Mental Health Service (CAMHS)9. The issues about Child C’s mother’s brother prompted Survive to make another referral to Children’s Social Care and a subsequent discussion with the Duty Social Worker but this did not lead to any assessment by Children’s Social Care as there was a CAF arrangement in place. 6.13 The other theme raised by Child C’s mother in discussion with several professionals was the use of cannabis by Child C’s father and his family. The midwife gave appropriate advice to the mother about ensuring that Child C’s father did not smoke around the baby once it was born and not to leave Child C’s father alone with the baby. 6.14 Child C’s mother was still living in the family home at the time of the birth of Child C’s brother. 6.15 On 9th July 2009 a notification of a domestic abuse incident was received by Children’s Social Care from the police. This related to an argument between Child C’s mother’s brother and Child C’s father. 6.16 Child C’s Father later telephoned the police to express his concerns for the welfare of Child C’s brother, their 2 week old baby. His main concern was that Child C’s mother’s brother had mental health issues and was violent towards Child C’s mother and Child C’s maternal grandmother. Child C’s mother responded by taking her baby (Child C’s brother) to the police station to demonstrate he was ‘safe and well’. Officers followed their usual procedures, advising appropriate departments within the constabulary and other agencies. 8 The Survivors Handbook Women’s Aid. Jackie Barron 2009 9 CAMHS Child & Adolescent Mental Health Service 9 6.17 On the 16th July 2009 Survive rang Children’s Social Care to say that they were working with Child C’s mother and that there were complex issues which they felt required Children’s Social Care involvement. A meeting was arranged to agree what to do next. 6.18 An Initial Assessment was undertaken by a social worker on 24th July 2009 in response to recent concerns. The outcome was ‘no further action’ from Children’s Social Care. It is not clear from the records how this decision was reached. 6.19 On 28th July 2009 GP15 recorded that the child C’s mother was under more stress because her father (Child C’s maternal grandfather) had found out where the family were living. Child C’s mother was afraid that Child C’s maternal grandfather would come to the house and cause them harm. Child C’s mother told the GP that there was a police flag on the property.10 6.20 Child C’s brother was seen regularly by the Health Visitor and the Community Nursery Nurse. Child C’s brother saw GPs 3 times before his eight-week check because of minor regurgitation of feeds, on each occasion there was a normal assessment. 6.21 On 6th August 2009 Child C’s mother and Child C’s maternal grandmother attended the police station and complained to police that Child C’s aunt (father’s sister) had been sending threatening text messages. Child C’s mother was worried that the aunt may turn up at her house. Further investigation revealed there was no specific threat. 6.22 On 14th August 2009 the case was re-opened by Children’s Social Care following information received from police regarding the above complaint. 6.23 On 11th September 2009 Social Worker 6 visited the family as the allocated Social Worker following the completion of an initial assessment. There is comprehensive recording of the visit which includes information that Child C’s maternal grandmother has attended the Freedom Programme at Survive and that Child C’s mother was receiving counselling through Survive and was well supported by a Connexions worker. Child C’s mother was seeing a community nursery nurse from NHS Trust 1 and attending an educational facility for teenage mothers. Child C’s mother’s brother was reported to be attending school and had a mentor. Contact with Child C’s father was discussed. Child C’s mother felt that his family was putting pressure on her to take Child C’s brother to their home but Child C’s mother was resisting saying the family members smoke cannabis. Social Worker 6 suggested that contact take place at Child C’s mother’s family home. 6.24 During this period there was some inter-agency discussion illustrated by Social Worker 6 record of a visit to the family on 25th September 10 This is a ‘Treat As Urgent ‘marker. 10 2009 and telephone calls to the Health Visitor, Connexions and Sure Start. 6.25 GP15 saw Child C’s mother on 20th October 2009 because of recurrent abdominal pain. Increased stress levels were noted again in relation to the reported receipt of abusive and threatening texts from Child C’s father’s family who had accused her of abusing Child C’s brother. There were also concerns about Child C’s paternal grandmother who had allegedly rolled a ‘joint’ and then put her fingers in Child’s C’s brother’s mouth. GP15 sent a letter to Children’s Social Care sharing these concerns. 6.26 There was a change of social worker on 14th December 2009. 6.27 On 22nd December 2009, when Child C’s brother was 6 months old, he was reported by Child C’s mother to GP15 to have fallen off a sofa. A full examination showed no evidence of injury or bruising. GP15 contacted the Health Visitor about this incident. 2010 6.28 Social Worker 7 visited the family on the 8th February and the 3rd March 2010. The case was closed following this last visit as it was recorded the family were ‘doing very well’. Social Worker 7 discussed the possibility of a referral for an adolescent support worker at this time but expressed the view that he was concerned that Child C’s mother would be ‘flooded’ with services and this might impede the development of her coping skills. 6.29 From January to April 2010 Child C’s mother had minor medical problems which were attributed to stress. She was recorded by Health Visitor 1 to be managing Child C’s brother well with support from her own mother (Child C’s maternal grandmother). 6.30 From June to November 2010 Child C’s mother saw several GPs on 12 occasions for minor problems. 6.31 The Health Visitor recorded Child C’s brother as doing well. He had his immunisations at the appropriate stages and saw GPs with minor ailments on 3 occasions between July and October 2010. 6.32 On 29th November 2010 Child C’s brother was registered at GP Practice 3, having moved house, and was seen by a GP because of an episode where his mother was reported to have woken in the night to hear the child making a choking noise and she found a small amount of blood staining on his sheet which she thought had come from the child’s nose. Examination was normal. 6.33 In December 2010 Child C’s mother saw the GP for minor medical issues. 11 6.34 Throughout 2010 there were incidents where police were contacted by either Child C’s mother or maternal grandmother, either due to Child C’s mother’s brother’s behaviour or fears in respect of Child C’s father’s family. 2011 6.35 In January 2011 Child C’s mother again saw the GP for minor medical issues. On 28th January 2011 GP17 recorded that Child C’s mother had a history of physical abuse from her own father (Child C’s maternal grandfather), difficulty with family relationships and finding college very stressful. She was very distressed and talked of thoughts of self-harm but said she would not act upon them. The GP had a long and supportive discussion with Child C’s Mother. Details were given of a counselling service and she was asked to make an appointment to see a GP again in a couple of weeks’ time. There was no evidence of safeguarding issues being discussed with other professionals. 6.36 On the same day Child C’s mother’s brother was interviewed by police regarding damage he had caused to the homes of children from his school. There had been some unpleasantness, including threats posted on Facebook and he had responded by causing damage to the homes of those he thought were responsible. He told police he was depressed and felt suicidal. His mother (Child C’s maternal grandmother) told officers that he had ‘taken pills’ two weeks earlier. She said she was very worried and did not know what to do. 6.37 Social Work Assistant 1 was allocated to the case. Social Work Assistant 1 was the constant Children’s Social Care practitioner until the case was closed in September 2012. Other social workers worked alongside her, as illustrated below. 6.38 Child C’s brother was seen by GP1 for minor ailments in January and on 2nd February 2011 GP1 spoke to Child C’s mother over the phone about Child C’s brother, and recorded that there were “family issues”. GP1 arranged a same day appointment with the GP Nurse Practitioner 5 who did not record any discussion of these issues. 6.39 On the same day Health Visitor 2 visited and met with Child C’s mother, Child C’s brother and Child C’s maternal grandmother. She was given an account of bullying of Child C’s mother’s brother at school and the emotional issues within the family. Child C’s mother told Health Visitor 2 that Child C’s maternal grandmother was much taken up with her difficulties with her own son and as a result Child C’s mother does not feel able to talk to her about how stresses in the household are affecting her. She said she had spoken with her GP and was considering counselling. The record indicates a very adult focussed discussion and no reference to how any of this may be impacting on Child C’s brother. 6.40 On 11th February 2011, the case was closed to the lower level CAF intervention as Children’s Social Care had become involved and on 12 16th February a different social worker undertook another Initial Assessment. This was a very comprehensive assessment where Child C’s brother was reported to be attending nursery and described as happy and always smiling. Both Child C’s mother and her brother were described as presenting as very unhappy and depressed. It is recorded that there was no contact between Child C’s father and his family. The outcome of this assessment was a referral to the Adolescent Support Team for individual work with Child C’s mother and her brother. An Adolescent Support Worker 1 was assigned to Child C’s mother and another Adolescent Support Worker 2 to Child C’s mother’s brother. 6.41 On 28th February 2011 another notification of a domestic abuse incident was received from the police. This related to an incident when Child C’s mother’s brother became angry after Child C’s maternal grandmother confiscated his computer when he would not go to school, misbehaved and caused damage to the home. 6.42 Adolescent Support Worker 1 provided intensive individual work with Child C’s mother, seeing her at first weekly and then monthly from early 2011 for about 9 months. Adolescent Support Worker 1 was regularly supervised in her work by the Adolescent Team Managers, and social worker,10, who was now the allocated Social Worker. This social worker set up group e-mails between himself, Adolescent Support Worker 1, Adolescent Support Worker 2 and Social Work Assistant 1 to ensure regular communication. 6.43 In May 2011, Child C’s mother told Adolescent Support Worker 1 that she was stressed and exhausted and struggling to manage Child C’s brother. A few days later Adolescent Support Worker 1 discussed this case in supervision. The record of this made by the team manager was that this case was ‘borderline child protection’ and the direction was to seek to organise a ‘Family Support Meeting’. It was also recorded that Child C’s mother and Child C’s brother were attending ‘baby groups’ three times per week. 6.44 The focus of the work was recorded as improving Child C’s mother’s self-esteem and confidence. During this period Child C’s mother’s relationship with Child C’s father was very inconsistent ;sometimes he was seeing the child and at other times reported not to be. The issue of Child C’s mother’s brother’s behaviour was a concern and the impact that this would have on Child C’s brother. 6.45 During April, May and June, Child C’s brother was seen by a GP a few times because of eczema. The GP record shows an entry on 11th May 2011 relating to “Domestic Problems”. 6.46 On the same day police were called, presumably by Child C’s maternal grandmother, when her son, Child C’s mother’s brother caused damage in the home. He was interviewed in the presence of his father (Child C’s maternal grandfather) and the decision was that he would stay with Child C’s maternal grandfather for a few days. Police shared this information with all the usual agencies. 13 6.47 Health Visitor 2 visited later in June 2011 and found things much calmer in the absence of Child C’s mother’s brother. There was mention that Child C’s father was a regular visitor. The Health Visitor liaised with Children’s Social Care to enquire if a date for a Family Support Meeting had been agreed but learned it had not been arranged yet. 6.48 Towards the end of the month Adolescent Support Worker 1 visited and was told by Child C’s mother that she was depressed. She was finding Child C’s brother difficult to manage. She reported that all Child C’s maternal grandmother’s emotional energy was focused on Child C’s mother’s brother even though he was not living with them, to the extent that neither the maternal grandmother nor her own brother remembered her 18th birthday. 6.49 The case was closed to the Adolescent Support Team as mother was now 18 and the matter assigned to Social Worker Assistant 1 to continue to support her. There was a handover period between the two social work teams to ensure that Child C’s mother received continuity of care. 6.50 Social Work Assistant 1 said in interview that she felt she had been given sufficient information from Social Worker 10 and from an informal handover from Adolescent Support Worker 1 when fully taking over the case management. The remit given for this case was to support Child C’s mother in moving out into her own accommodation. 6.51 On 12th July 2011 Child C’s mother contacted GP 4 twice, firstly reporting that Child C’s brother had ingested half an antibiotic, in the second reporting that an antidepressant tablet was missing and it was presumed by her that Child C’s brother had possibly ingested it. This was dealt with medically by GP 4. 6.52 On 8th August 2011 Child C’s mother was diagnosed with depression and treated with antidepressant medication. At that time GP 21 recorded the history of physical and emotional abuse by Child C’s maternal grandfather since Child C’s mother had been 2 years old. 6.53 On 23rd August 2011, Child C’s mother and Child C’s maternal grandmother became involved in a dispute with another family. The result was that C’s mother assaulted an adult member of the opposing family. Child C’s brother was present during the altercation. Police received several calls from witnesses and as a result attended the scene. 6.54 Child C’s mother was arrested for assault which she admitted during interview and was given an official police caution. Officers recorded the presence of Child C’s brother and checked on the child’s welfare. 14 6.55 During her time in custody Child C’s mother made allegations against her father (Child C’s maternal grandfather) of an historical sexual assault. 6.56 Child C’s mother became distressed and said that she hadn’t seen her father since she was 14 years old because he was violent towards her. She continued by saying that her father had sexually abused her since she was about 5 years old. 6.57 Police tried to clarify what Child C’s mother was saying. She said that the incidents had merged in her memory and she could not remember much about them. The officer was left with the impression that there may have been two incidents. She decided that she did not wish to pursue an allegation. Children’s Social Care where advised of the disclosure of historic sexual abuse. 6.58 In September 2011 Child C’s mother is recorded as telling GP1 that she had been a victim of previous sexual abuse, perpetrated by her father (Child C’s maternal grandfather) and had disclosed this because she felt other girls could be at risk. GP1 provided a supportive consultation, changed her medication and informed the HV about the nature of the consultation. GP1 understood from Child C’s mother that this information had already been shared with Children’s Social Care and the Police. 6.59 Child C’s mother was supported to apply for her own housing and moved out of the family home on 18th October 2011. 6.60 On 18th November 2011 Child C’s mother attended the GP surgery and was recorded as being back in a relationship with Child C’s father and to be pregnant with Child C. On 23rd November 2011 GP 4 wrote to the community midwives advising them that there were issues contained in her records that he felt the midwives should be aware of. In this letter GP 4 asked the midwives to contact one of the GPs to discuss Child C’s mother’s case. On 1st December 2011 GP22 verbally summarised Child C’s mother’s previous history. 6.61 Subsequently, a booking letter was sent by the Community Midwives to the GP practice, but made no mention of having received any communication from the practice, although there is a copy of a Confirmation of Midwifery referral to Children’s Social Care dated 29th December 2011 in Child C’s mother’s GP record. 15 2012 6.62 During the pregnancy Child C’s mother saw a number of GPs and Nurse Practitioners because of a recurrence of extreme sickness. She had several hospital admissions. During the pregnancy she also had GP consultations for minor issues. 6.63 There is a report from Accident and Emergency at Hospital 1 dated 17th January 2012 relating to chemical burns on her arms and legs caused by an accident with caustic soda. 6.64 At a meeting with Social Work Assistant 1 on 26th January 2012 Child C’s mother said that she had again split up with Child C’s father. 6.65 On 1st February 2012 Social Work Assistant 1 had a supervision session with her Practice Manager and the agreed plan was to ‘step down’ the case to CAF, close the case to Children’s Social Care, proposing the lead professional be the Health Visitor. 6.66 Records of the Social Work Assistant 1’s visits are very focussed on Child C’s mother and her relationship with her brother (Child C’s mother’s brother) and her mother (Child C’s maternal grandmother). There are references to a rekindling of the relationship with Child C’s father and then an account where she announces the relationship is finally over. 6.67 From April 2012 Child C’s mother received support from a Children’s Centre and appointed key worker, Early Years Worker 1. Discussions were recorded about what plans were in place to care for Child C’s brother around the birth of Child C and issues raised by a crèche worker about Child C’s brother’s behaviour. A plan was put in place by the Children’s Centre to support Child C’s mother. Child C’s life 6.68 July 2012 Child C was born. 6.69 July 2012 Child C’s mother attended the Children’s Centre with Child C and it is noted that Early Years Worker 1 is considering closing the case in the future if Child C’s mother and Child C’s brother continue to progress according to plan. 6.70 The usual routine post-natal midwifery visits were undertaken. Shortly after Child C’s birth the Midwifery notes say that Child C is taking a long time to feed and although Child C looks well, Child C’s mother is low in mood and tearful at night. 6.71 A couple of days later the Early Years review records much improvement in respect of Child C’s brother: ‘development approaching more expected parameters’. 16 6.72 On 30th July 2012, Health Visitor 2 undertook the new birth visit. Child C’s mother reported being low in mood and options around appropriate support were given. 6.73 The following day at the Midwifery clinic Child C’s mother is a little more buoyant; Child C’s maternal grandmother is with her in a supportive capacity and, although still mentioning a low mood, is not now planning to discuss this with her GP. 6.74 On the same day Child C was registered at GP Practice 3. Social Work Assistant 1 visited on 1st August 2012 and Child C’s mother informed her that Child C’s father was planning to visit at the weekend. 6.75 On 6th August 2012 Child C’s mother contacted Social Work Assistant 1 expressing concerns that they had seen Child C’s father as planned and Child C’s brother had woken that night having had a nightmare saying ‘daddy hurt me’. Child C’s mother said that Child C’s father had shouted at Child C’s brother as he thought he was going to hurt Child C. Child C’s brother was not left alone with his father. Social Work Assistant 1 offered reassurance that if Child C’s brother had not been left alone with his father, it was unlikely that he had hurt him, but to contact her again if the nightmares continued. 6.76 Child C was seen at the GP surgery twice in August 2012 because of maternal concerns about vomiting. Child C was found to have a minor tongue tie and was referred to NHS Trust 2. Child C had a normal 6 week check with GP3 where no social concerns were noted in Child C’s records although social concerns were noted in Child C’s mother’s records. 6.77 On 13th August 2012 the Family Agreement was reviewed by Early Years Worker 1 who still had some suggestions to make to Child C’s mother about how she might improve her interaction with Child C’s brother and allow for her to spend more time with him. Child C’s mother said she planned to start college shortly, so no further Family Agreement review dates was made. The implication being that the input from Early Years would cease since mother had other plans. 6.78 On a home visit on 15th August 2012 ,Child C’s brother was reported to be ‘happy and bubbly’ and Child C’s mother said that Child C’s father had called round, left some money and stayed briefly. Social Work Assistant 1 discussed a Family Support Meeting to close the case and Child C’s mother is reported to have indicated she was happy with this plan. 6.79 Sometime in the latter part of August 2012, Child C’s mother began a new relationship. 17 Child C’s Mother’s Boyfriend 6.80 Mother’s boyfriend previously lived in a neighbouring local authority area which had separate records from the local authority where Child C’s mother lived. During the time period of the review and prior to his cohabitation with Child C’s mother, police attended the home he shared with his then partner and their child on four occasions between the summer of 2008 and late 2009 due to domestic violence. As a result of one of these incidents the police placed a ‘Treat as Urgent Marker’ on the property. Following one of these occasions Child C’s mother’s boyfriend admitted assault on his then partner and accepted a Caution. These matters were passed to Children’s Social Care in that area. 6.81 The neighbouring Children’s Social Care Department received one anonymous referral via NSPCC with concerns being expressed regarding the neglect of their child and in relation to the relationship between Child C’s mother’s boyfriend and his then partner. 6.82 The NSPCC contact and the four domestic violence referrals were dealt with by Children’s Social Care in a duty and assessment team. Enquiries were made with professionals working with the family and following these discussions Children’s Social Care from the neighbouring authority decided to take no further action regarding the referrals. 6.83 Police and social care records show that Child C’s mother’s boyfriend’s ex–partner (MBFX2 – see Glossary) took their child to see the GP as the child had a skin problem. He presented as fearful and when undressed he was found to have what looked like a cigarette burn and 3-4 bruises on his lower back. The mother was unable to give an explanation for the injuries. He had previous marks but Mother had previously explained their presence. 6.84 Children’s Social Care records indicate a joint decision was made not to proceed with a Child Protection medical assessment. Whilst it was considered unusual for a child of that age to have a bruise in that location, the agreed plan was that Children’s Social Care would deal with this as a single agency. 6.85 A social worker was allocated to the case. An Initial Assessment was undertaken but non-accidental injury was not substantiated. The case was then closed. Child C and Events after Mother’s Boyfriend Joined the Household 6.86 On 10th September 2012 GP 1 had a telephone consultation with Child C’s mother and Child C was prescribed Gaviscon (an antacid) for reflux, a common condition of young babies. Child C had her first immunisations at the appropriate time. 18 6.87 Also on 10th September 2012 a Children’s Centre worker contacted Social Work Assistant 1 by email to make her aware that Child C’s mother had a new boyfriend. He was described as ‘an older man who has children himself’’. The Children Centre worker said in the email ‘.I think we have to be wary. ’ This is the first reference to Child C’s mother’s boyfriend. 6.88 Social Work Assistant 1 made her final visit to the family on 12th September 2012. Child C’s mother’s boyfriend was present at this visit and introduced himself. He explained that he had met Child C’s mother when he came to do her hair as he was a mobile hairdresser. Enquiries were made about whether he ever stayed at the flat and he said he did occasionally. 6.89 Child C was described as ‘happily asleep’ on Child C’s mother’s boyfriend’s lap but a small bruise was noted on the side of her head. Child C’s mother explained that this had happened when they were all in bed together and Child C’s brother had become excited and accidentally kicked Child C. 6.90 Child C’s brother was noted to be sitting on the floor doing a jigsaw and was described as chatty and happy. 6.91 Social Work Assistant 1 made a record of her visit and recorded the bruise but did not discuss it with anyone else. 6.92 On 17th September 2012 a supervision record between Social Work Assistant 1 and Practice Manager records that the case was closed following on from earlier supervisory discussions. It was noted that Child C’s mother was well supported. Neither the presence of a new boyfriend nor the bruise was mentioned. 6.93 On 21st September 2012 Child C was seen by GP 5 because of constipation. Child C’s mother reported that Child C had been crying constantly. 6.94 On 27th September 2012 Child C’s mother contacted the Children’s Centre to say she would not be attending the Young Mums’ Group or Stay ‘n Play Plus as she is starting college. 6.95 On the following day Child C’s mother contacted Health Visitor 2 to cancel the home visit scheduled for 1st October 2012 as she was starting college. She said a combination of Child C’s maternal grandmother and friends were to look after the children on the three days she was required to attend. 6.96 Child C’s mother visited the GP surgery on several occasions around this time for consultations but these were not considered as a whole and each viewed as an individual issue. By this time during the period covered by this review, Child C’s mother had seen over 30 GPs. 19 6.97 On 5th October 2012, GP 5 spoke to Child C’s mother over the phone; she reported that Child C’s brother had sprayed hairspray in Child C’s eyes. A same day appointment was arranged with GP6. GP6 saw and assessed Child C, he records: “Brother sprayed hairspray in both eyes and face this morning”. GP 6 also makes a note which implies that he examined Child C’s abdomen but it is not clear whether Child C was undressed for the examination. GP 6 also recorded that Child C was unable to open her eyes and he referred her to the Children’s Hospital. No mention is made of safeguarding being considered. 6.98 Child C was seen in NHS Trust 2, Children’s Accident & Emergency and then at the Eye Hospital. A thorough assessment of this unusual presentation was undertaken by the Emergency Department and Eye Hospital practitioners. 6.99 The 2 letters received from these consultations were processed by GP 5 who made a written entry of “Corneal Abrasion” in Child C’s notes on receipt of these. No mention is made of safeguarding being considered. 6.100 On 11th October 2012, Health Visitor 2 visited and met Child C, Child C’s brother, Child C’s mother and Child C’s mother’s boyfriend. It became apparent that Child C’s mother’s boyfriend had moved in with them, and 2 of Child C’s mother’s boyfriend’s friends were also present. Child C’s mother spoke of concerns about Child C’s brother’s behaviour and told Health Visitor 2 of the ‘hairspray’ incident. Child C’s mother did not think the hairspray incident was malicious but did say Child C’s brother had also hit Child C with a tea towel. Health Visitor 2 gave advice about keeping dangerous materials away from children, general behaviour management strategies and the supervision of the children when together. Child C’s mother told Health Visitor 2 that her boyfriend was caring for the children during the times she was at college. 6.101 Also on 11th October 2012, the GP surgery received a discharge report from the Speech and Language service reporting that whilst Child C’s brother still had language delay, he had made good progress. On the same day Child C was seen for her second routine immunisations. 6.102 On 12th October 2012 Child C was reviewed at the NHS Trust 2 (Eye Hospital).The cause of the eye injury remained unresolved. No other indicators of abuse and neglect were evident. It was recorded that Child C’s mother was fully compliant with the required treatment plan. It was recorded that treatment had ceased the day before and Child C was discharged back to the care of the GP. 6.103 On 23rd October 2012 GP 6 reviewed the discharge letter from the Eye Hospital but this did not prompt any wider considerations, despite the unusual history. 6.104 On 31st October 2012 Child C was seen in a local Minor Injury Unit. A report from this episode was faxed to the GP practice at 10:45am on the 1st November 2012. The report states in the history: “head injury. Dropped by dad 0.75m from arms to table top…..” It was recorded that 20 no other bruises or injuries were noted but that Child C had a firm swelling to her left temple. This report was scanned onto Child C’s record on 6th November 2012 and reviewed by GP 21 on 11th November 2012. GP 21 recorded this episode as a “minor head injury”. No mention is made of safeguarding being considered. Health Visitor 2 was not advised of the minor injury unit attendance. 6.105 Children’s Social Care was only sent notification of the MIU attendance on 16th November 2012 as part of the multi-agency Rapid Response Process after Child C’s death. 6.106 On the 6th November 2012 Child C’s mother left a message on the Health Visitor telephone stating that she was concerned about Child C’s brother’s behaviour as he is particularly aggressive towards Child C. She stated that he ‘even hits her on the face causing bruising’. Health Visitor 2 was not at work and her colleague, Health Visitor 3 attempted to return the call and left a message for Child C’s mother. 6.107 Health Visitor 2 had scheduled a visit on 8th November 2012 but on 7th, Mother rang to cancel, saying she was busy with college work. She told Health Visitor 2 that Child C’s brother had become increasingly violent since she started college. Health Visitor 2 gave advice about behaviour management, how changes in the family may have unsettled her son and the importance of close supervision. Child C’s Death and Subsequent Findings 6.108 On the 14 November 2012, Child C was taken to the Children’s Hospital by ambulance having earlier been pronounced dead at the family home. 6.109 Child C’s mother is reported to have left home at 8.45am to attend college, leaving Child C’s mother’s boyfriend to care for the children. Child C’s mother’s boyfriend states that he left Child C on the bed and covered her head with a blanket, which both Child C’s mother and Child C’s mother’s boyfriend reported they usually did while she slept. He discovered her not breathing at 11.45am and called an ambulance. 6.110 On examination, Child C was found to have superficial blisters on her left ear and neck and at the back of her scalp. These were later identified as being possibly due to impetigo, a common childhood skin infection often caused by the bacterium Staphylococcus aureus, which was grown from the blisters. 6.111 The forensic post mortem did not find any natural causes likely to have caused death. 21 6.112 Bruising was also found on Child C’s scalp which was likely to have been a few days old. No explanation was given before the death. When Child C’s mother was spoken with in October 2013 by the Overview Author, she said these bruises were brought to her attention by her boyfriend, some days before Child C’s death. She reports he said Child C’s brother had caused the injuries by throwing coins at Child C. 6.113 Child C’s death is given as ‘of unascertained causes’ by the Coroner. 6.114 Police intelligence records dating from 2006 searched after the death of Child C regarding the background of Child C’s mother’s boyfriend showed that he was known to both police and Children’s Social Care in a neighbouring authority, but under a different name. This police intelligence records that complaints were received that Child C’s mother’s boyfriend had been engaging in sexual activity with underage girls. The police records show that this intelligence was passed to an experienced child protection detective. There is no record of the outcome. The same man was questioned in connection with drug offences in the area. This information would have been available to any agency who had requested it. The information was cross-referenced in police data against both names. 7. Analysis and Emerging Themes 7.1 Theme 1 - Focus on the Child 7.1.1 Keeping a strong focus on the outcomes intended for children is essential to deliver a child-focussed approach. Being able to respond promptly and confidently to safeguarding concerns is an essential requisite to maintain a child focussed approach. 7.1.2 Throughout the Individual Organisation Review reports there emerges a picture of Child C’s mother as vulnerable and in need of support. She was still a child herself when she became a mother and at that point it seems welfare agencies began seeing her as a mother first and child second. 7.1.3 There is a tendency for child welfare practitioners to focus on the adult account in assessments and often, as a study by Holland11 reported, ‘children tended to be excluded or marginalised in favour of engagement of parents in the assessment process’. The Assessment of Children In Need and Their Families12 requires for each child’s needs to be individually assessed as well as the parents capacity to meet those needs. 11 S Holland Child & Family Assessment in Social Work Practice 2004 12 Framework for the Assessment of Children In Need and Their Families HMSO 2000 22 Children Who Become Pregnant 7.1.4 Child C’s mother became pregnant for the first time aged fifteen. This in itself was a significant risk factor. She was further vulnerable as a result of her family experiences of family violence and inconsistent parenting. Home Education may well have had an impact on how her independence and autonomy developed. 7.1.5 At the point she became an adult Children’s Social Care continued a sustained period of involvement, though the approach did not take sufficient account of Child C’s mother’s status as a child or her capacity to become independent. 7.1.6 Following the birth of Child C’s brother the intention may have been to focus on him (Child C was not yet born), but the emphasis was on Child C’s mother, her self-esteem, coping ability and general level of independence. 7.1.7 A fresh Social Care assessment was certainly required at this point in order to fundamentally re-assess the circumstances, taking into account Child C’s mother’s dual status as both child and mother and Child C’s brother similarly as a Child In Need. Focus on Children and Avoiding being Distracted by Adult Issues 7.1.8 There are few practitioners who would not accept the importance of working to boost the strengths and resources of parents and families, including those in most need of support, to make situations safer and healthier for children. In this case the focus was too much towards the adults, there is little note in Children’s Social Care records of references to Child C’s brother. The response was most frequently influenced by the need which seemed most urgent. 7.1.9 The children’s circumstances were rarely mentioned within the Children’s Social Care case record, other than in relation to Child C’s mother. It is not unusual for the overwhelming needs of vulnerable parents to readily be the focus of attention for child welfare practitioners. This is reflected in many inquiry reports. 7.1.10 The Practice Manager indicated in February 2012 that the case should close in Children’s Social Care. However, it was kept open, because Child C’s mother was unwell, even though there was a perception that there was pressure to close cases. 7.1.11 The Social Work Assistant who was the case manager assumed a specific brief of supporting Child C’s mother into independence. 23 7.1.12 In Children’s Social Care safeguarding had been discussed in a supervision session between Adolescent Support Worker 1 and the team manager in May 2011. The comment that this was ‘borderline child protection’ seems to have been mitigated by the acknowledgment of services being received and a plan to hold a Family Support Meeting. The children’s circumstances were, for most of the time, viewed as a ‘low level Child In Need’. In Children’s Social Care the focus of intervention should be on providing assessments of children’s circumstances and providing access to services to improve children’s circumstances. There was insufficient clarity in the social care intervention about who was the ‘client’. Child C’s mother’s clear vulnerabilities overshadowed the requirement from the time Child C’s mother became an adult, to keep a focus on the child. In Children’s Social Care planning, the child should unequivocally be at the centre and the focus of any intervention. 7.1.13 During the early months of 2012 the Social Care plan was to close the case and step down the intervention to a CAF level despite the prevailing and emerging risk factors. The important point to make here is that the prevailing vulnerabilities of Child C and other emerging risk factors should have raised levels of intervention rather than diminish them. The arrival of a second baby to a teenage mother, a new man in the family and mother’s plan to return to education were indicators that this required allocation to a qualified social worker and re-assessment of the children’s circumstances, in order to inform a multi-agency plan to support the family. Theme 1 Learning Point (1) The focus of all agencies working with children should always be the child Theme 1 Recommendations (1) Children who become mothers and fathers should be considered by all agencies as children first and their particular vulnerabilities and service requirements addressed from that perspective. Both new child and under 18 parents are potentially children in need. (2) The focus of attention should always be the child. Where agencies provide services to both children and adults, separate but related records should be generated (3) Reflective and challenging Supervision is key for front line practitioners in ensuring the focus of interventions is on the child. 24 7.2 Theme 2 - Incidents/Injuries sustained by a non-mobile child 7.2.1 Injury 1 on 12th September 2012 7.2.2 During a visit to Child C’s home where Child C’s mother and her new boyfriend were present, Social Work Assistant 1 discussed a small bruise on the side of Child C’s head. Child C’s mother explained this was caused accidentally by Child C’s brother kicking her excitedly when they were all in bed together. This appears an unlikely cause and effect but required further consideration and investigation. Social Work Assistant 1 accepted the explanation and did not think it sufficiently unusual to advise her manager or think about the possibility of seeking advice from a paediatrician. 7.2.3 Injury 2 on 5th October 2012 7.2.4 Child C was taken to the GP by her mother with eye injuries said to have been caused by the accidental spraying of hairspray. The GP referred immediately to NHS Trust 2 and she attended Children’s A&E and the Eye Hospital. (see para 7.99 -7.104 for details). 7.2.5 This was a relatively unusual presentation for a baby. Child C was assessed by a Paediatric Emergency Nurse Practitioner and Eye Hospital specialist doctor. The Individual Organisation Review author noted ‘Further information was gained through a conversation with the Paediatric Emergency Nurse Practitioner who assessed the baby in the Children Emergency Department. Emergency Nurse Practitioner remembers thinking that the mother may have ‘jumped to the wrong conclusion’ that the baby’s red eyes were as the result of the sibling spraying hairspray into the baby’s eyes’. 7.2.6 The Emergency Nurse Practitioner had established that Child C’s mother had concerns about her elder son’s jealous behaviour of the baby, had found a can of hairspray under his bed and according to mother the 3 year old had said he had sprayed some on the baby. The Emergency Nurse Practitioner sent a discharge fax to Health Visitor 2 including information that Child C’s mother was concerned about Child C’s brother’s jealousy towards Child C. This was acted on by Health Visitor 2 but telephone liaison following this unusual incident may have been more appropriate. 7.2.7 Best practice would have also been for the Emergency Nurse Practitioner and Eye Hospital practitioners to have considered whether the explanation was reasonable as to whether a child just over 3 years could have the dexterity to depress and effectively aim a hairspray. They should also have considered 25 whether a 3 year old would have the emotional or cognitive development to make the decision to do so in relation to sibling jealousy. Mary Sheridan’s 13 Child Development Matrix seems to indicate that such fine motor skills would be unlikely to be present in a child aged less than 5 years. 7.2.8 If the likelihood or otherwise of Child C’s brother causing the injury had been reflected upon, then consideration may have been given to the possibility that another person caused the eye problem. 7.2.9 The Paediatric Emergency Nurse Practitioner thought it was more likely that the ‘red eyes’ were a result of infection, rather than chemical injury. Findings were not conclusive and further assessment at the Eye Hospital was requested. The Paediatric Emergency Nurse Practitioner also recalls in the verbal hand over to the Eye Hospital emergency department that if a chemical injury was confirmed further support would be needed from the Health Visitor. Best practice would have been for the Emergency Nurse Practitioner and Eye Hospital practitioners to have considered both explanations as potential causes. 7.2.10 Further exploration with the Emergency Nurse Practitioner during the course of the Individual Organisation Review confirmed that at this stage she did not have any safeguarding concerns but thought that support from the Health Visitor may be required in helping mother to manage her son’s challenging behaviour if a chemical injury was confirmed. There were no other ‘triggers’ in the presentation which caused the Emergency Nurse Practitioner any concern. 7.2.11 The above story is at variance with the account provided to the Author at a meeting with Child C’s Mother in October 2013. At this point she said she returned home and her boyfriend brought to her attention a ‘crusty’ residue around Child C’s eyes and said he believed the elder child had sprayed hairspray in her face. His evidence for this was, he said, the discovery of a hairspray canister under the boy’s bed. 7.2.12 Best practice would have been for practitioners at the Eye Hospital to have communicated back to practitioners in the Children’s Emergency Department or directly to the Health Visitor if this was considered as a possible cause at the time of the incident. Child C’s mother’s possible history of the incident was accepted by the Eye Hospital staff although the likelihood of an infection was favoured by the Emergency Nurse Practitioner at the Children’s Emergency Department. 13 Reports on Public Health and Medical Subjects No 102HMSO 1975 referred in Framework for Assessment of Children in need and their Families. HMSO 2000 26 7.2.13 Best practice would have been for the Emergency Nurse Practitioner and the Eye Hospital practitioners to keep both explanations as potential causes and to have liaised with Health Visitor 2 to discuss the possibility of the hairspray being the cause given that this was the explanation that Child C’s mother herself felt was the cause of the ‘sticky’ eyes. 7.2.14 In summary what happened to Child C’s eyes is unknown. There were bilateral corneal abrasions and though different explanations have been suggested, it is unclear what actually caused the small amount of corneal damage. Child C’s eyes recovered. 7.2.15 No communication back to the Children’s Emergency Department from the Eye Hospital occurred after the corneal abrasions were noted. The possibility of an inflicted injury was not considered by the practitioners in either location caring for Child C. The explanation of the hairspray was not considered causal by the Emergency Nurse Practitioner at the Children’s Emergency Department and infection was thought to be more likely. 7.2.16 Discharge information was sent from the Children’s Emergency Department to both GP and Health Visitor 2 which included information regarding the jealous behaviour of the Child C’s brother. This was acted upon by Health Visitor 2 at her next home visit. 7.2.17 Mother kept all the follow-up visits at the Eye Hospital. 7.2.18 Injury 3 was reported 31st October 2012. 7.2.19 Child C’s mother had been at college and returned home immediately noticing an ‘egg-sized’ swelling on Child C’s forehead. Child C’s mother’s boyfriend said he had dropped her and explained this in the context of a weak left arm due to epilepsy. Child C’s mother said during conversation as part of his Serious Case Review, that she insisted on seeking medical advice and so attended the Minor Injuries Unit accompanied by Child C’s mother’s boyfriend. 7.2.20 The Minor Injuries Unit was very quiet. There were no patients being treated and none waiting. Those on duty included two Emergency Nurse Practitioners, one with Paediatric specialism and a Registered Nurse. 7.2.21 Emergency Nurse Practitioner 1, who saw Child C, is an adult trained nurse but, within the Minor Injuries Unit, there is an expectation that clinicians work across the age groups. The Emergency Nurse Practitioner selected Child C from the screen which was described by the receptionist as ‘baby, bumped head’. Emergency Nurse Practitioner 1 went to the waiting area 27 to greet the family. The case was not triaged by the Registered Nurse contrary to usual practice. 7.2.22 Emergency Nurse Practitioner 1 reported undertaking a thorough physical examination and asking a range of standard questions. Both Child C’s mother and her boyfriend denied any history of social work involvement and did not reveal the previous medical history (eye incident) in respect of Child C. 7.2.23 Emergency Nurse Practitioner 1 confirmed the mother was Child C’s mother but assumed Child C’s mother’s boyfriend to be the father. During interviews held with the Serious Case Review Overview Author as part of the Serious Case Review process, Emergency Nurse Practitioner 1 recalls thinking the couple were relaxed and behaving normally. Child C presented well: ‘happy and chirpy’. 7.2.24 Emergency Nurse Practitioner 1 recorded a description of the child being dropped 0.75 metres from Child C’s mother’s boyfriend arms onto a table. 7.2.25 Munro (2008) provides a scenario( p141) where a seeming coherent account provided by a carer must be considered cautiously from all angles but that plausibility can really only be confirmed by checks with other agencies: ‘The difficulty, in practice, is to decide how long to go on checking and when to accept or not accept what seems, on the surface, a plausible account’. 14 7.2.26 Information about this attendance by Child C was not passed to the Health Visitor but it was sent to the GP. The usual expectation was that letters for both the GP and Health Visitor would be placed in the same envelope and received by each. If this information had been brought to Health Visitor 2’s attention she would have had the opportunity to consider this in the light of the recent eye injury. 7.2.27 In this case, the records show that timely communication was sent to the GP but not received by the Health Visitor. Normal practice would be to send the information to both GP and Health Visitor. The Overview author is aware that the local NHS Trust regularly audits the transfer of information from the MIU to the GP and Health Visitor. In this case the Health Visitor was not alerted but the GP was. 7.2.28 During the Serious Case review separate concerns were raised by a member of NHS staff who had already been interviewed. These were seen by the Independent Review Author who was satisfied that they did not introduce any new information and 14 E Munro. Effective Child Protection 2nd edition 2008 28 were already being dealt with through an appropriate separate process. 7.2.29 Injury 4 was reported on 6th November 2012. 7.2.30 This is the injury reported by Child C’s mother in an answer-phone message to Health Visitor 2. She said Child C’s brother was hitting Child C and even bruising her face. Health Visitor 2 was not in the office but Health Visitor 3 attempted to telephone Child C’s mother and left a message. The following day Health Visitor 2 gave advice that Child C’s mother should ensure that she supervises closely when the children are together. Health Visitor 2 expected to see Child C within the next 2 days but Child C’s mother cancelled the appointment. 7.2.31 Incident/Injury 5 on 14th November 2012. 7.2.32 This is the incident which resulted in Child C’s death and is described in detail elsewhere in this report. 7.2.33 Injury 6 post mortem. 7.2.34 Bruising to Child C’s scalp was noted following her death and has no explanation. 7.2.35 Injuries to non-mobile babies are rare: ‘Bruising in babies who are not independently mobile is very uncommon (under 1%). Around 17% of infants who are crawling or cruising have bruises, whereas the majority of preschool and school children have accidental bruises. Bruising in a baby who is not yet crawling, and therefore has no independent mobility, is very unusual.15 7.2.36 Research recently published in the USA 16 involving 401 non mobile babies with injuries found that 200 were substantiated as abused with 27.5% of these having been seen previously with bruising. The unsurprising conclusions were that in non-mobile babies there are often ‘sentinel’ or warning injuries leading to more serious injury. The advice to clinicians resulting from the research was to be alive to implausible explanations and to be prepared to think the unthinkable. 15 Core Info Child Protection Systemic Reviews 16 Dr Lynn Sheets, Professor of Paediatrics’, Medical College of Wisconsin 29 Theme 2 Learning Points The presence of injuries or incidents in non-mobile infants should always be considered in the context of safeguarding. (1) A bruise should never be interpreted in isolation and must always be assessed in the context of the child’s medical and social history, developmental stage and explanation given. The presentation of a bruise in a non-mobile infant, whilst appearing fairly minor in itself, may indicate more serious internal injuries and may have a non-accidental cause. It may also be a precursor for further injuries. A series of injuries in a non-mobile infant should set alarm bells ringing. (2) Any injury or unusual presentation in a non-mobile infant should be seen promptly by a clinician experienced and trained in examining small infants. Inflicted and neglectful causes must always be considered in the differential diagnosis, even if an accidental explanation is very plausible. Discussion with a health professional experienced in safeguarding, and multi-agency safeguarding enquiries should always be considered and discussion documented. If no discussion takes place the reason for this should also be documented. Respectful uncertainty and professional curiosity are the guiding principles here. ‘Those who don’t cruise, rarely bruise’17 NICE Clinical Guidance18 provides practitioners alerting features of child maltreatment including advising that bruising to babies who are not independently mobile should raise suspicion. (3) The post mortem examination did not determine a clear reason for Child C’s death. Nevertheless, there was a pattern of 'sentinel', or warning injuries (see paragraph 7.2.34 above) which occurred during a very short timescale which should have been investigated in a broader safeguarding context The first was noted on 12th September and there were others over a period of 8 weeks prior to Child C's death on 14th November 2012. Theme 2 Recommendations (1) A multi-agency protocol should be developed in relation to the management of injuries (incidents) concerning non-mobile babies. (2) The South West Safeguarding Procedures should be revised to reflect current research about injuries. Consideration should be given to including the local multi-agency protocol (above). (3) The phrase ‘Children Who Don’t Cruise Rarely Bruise’ should be adopted as a multi-agency guide when professionals are considering injuries or unusual presentations in non-mobile babies 17 Core Info Cardiff Child Protection Systemic Review 18 NICE Clinical Guidance revised December 2009 30 7.3 Theme 3 - The Invisibility of Men 7.3.1 The ‘invisibility’ of significant men in this family system is notable but not unusual. The welfare agencies knew very little about Child C’s maternal grandfather, Child C’s father or Child C’s mother’s boyfriend and it seems little attention was focussed upon them. Their importance to the functioning of the wider family cannot be over-estimated and the role of fathers or father-figures particularly. 7.3.2 The Children’s Social Care Individual Organisation Review author notes there were numerous opportunities for Children’s Social Care to gain a greater insight into the role of Child C and Child C’s brother’s father in this family during the course of ‘a series of Initial Assessments, particularly at the time he had sole care of Child C’s brother during the period Child C’s mother was ill in hospital. This did not happen during any of the Initial Assessments or Social Work Assistant 1’s work with the family’. 7.3.3 Since 2004 the UK Government has stated its intention to ‘support a cultural shift in all service provision to include fathers in all aspects of a child’s well-being’19. The National Service Framework for Children, Young People and Maternity Services (NSF) states: ‘The role of fathers in the parenting of their children is frequently overlooked’, it goes on to say why this is important for the child’s development. 7.3.4 The failure to recognise the relevance of male figures and engage them in assessment has been recognised as a significant shortcoming. The Serious Case Review into the death of Peter Connelly and other high profile Serious Case Reviews nationally includes similar failings in not being sufficiently questioning of males in families and missing the opportunity to identify who they are. 7.3.5 The increasing volume of research on the impact of fatherhood reflects not only on the important role men play in their children’s lives but the negative impact on children of effectively excluding them. 7.3.6 Action For Children20 make the point: ‘Too often significant male figures remain invisible within the safeguarding process. Agencies do not seek information which may prove vital in order to identify both protective and risk factors’. 19 DOH & DFS 2004:70 20 Action For Children 2009. Working with Fathers and Male Carers 31 7.3.7 A Department For Education review of the inclusion of male figures in services found that local authorities were at best ‘neutral’ with regard to men and fathers. ‘Father inclusive practice was not seen as routine or mainstream in family services’21. 7.3.8 A culture where men’s role within and around families is seen and recognised is required to be more widely embedded. The positive association of father figures in the professional’s mind and recognition of that importance is more likely to lead to a circumstance where visiting practitioners will naturally enquire about the role of men within families, their experience of parenting, involving them in assessment and asking the sort of questions they may ask mothers. 7.3.9 If this attitude was more prevalent it would more likely to have led to a natural questioning of Child C’s mother’s boyfriend and his role in this family and identifying information. 7.3.10 Professionals did not sufficiently consider the connection between the arrival of Mother’s boyfriend in the family and the reported challenging behaviour by Child C’s brother and injuries to Child C. 7.3.11 Although little is known of Child C’s mother’s boyfriend, he was a man with little experience of caring directly for children according to the neighbouring authorities records and suddenly he was caring single-handedly for two. There had been questions asked about the child care arrangements for the children whilst Child C’s mother was attending college but initially this was understood to being provided by Child C’s maternal grandmother and friends. It was not until it was happening did the Health Visitor learn that the child care was being provided exclusively by Child C’s mother’s boyfriend. This was, potentially, an opportunity to make further enquiries around his parenting experience. 7.3.12 With hindsight we know that injuries to Child C all happened following the arrival of Child C’s mother’s boyfriend in the family. The first injury was allegedly witnessed by Child C’s mother but all the following injuries and the circumstances leading immediately to Child C’s death occurred during her absence and during times Child C’s mother’s boyfriend was sole carer. 7.3.13 At the point three practitioners from different agencies learned of the presence in the household of a new man there was insufficient unease to generate an enquiry to police. Child C’s mother’s boyfriend was an unknown factor and practitioners did not ask him about his identity or background which would have 21 Page J and G Whitting. A Review of How Fathers can be Better Recognised and Supported through DCSF Policy 2008 32 been required to make enquiries of the police. This could have happened if any of the three known injuries during those weeks had caused sufficient reflection to warrant a discussion between agencies in the context of safeguarding. An awareness of the unusualness of accidental injury in a non-mobile baby would have caused this to be considered differently. At that point, if Child C’s mother’s boyfriend's name and date of birth were known and confirmed, a check by police would have revealed the Bristol based information about domestic violence and the later suspicious injuries to Child C’s mother’s boyfriend’s child 2. Such an enquiry, based initially on background checks with other agencies, would have exposed a pattern of injury and other factors which should have been considered and weighed up in a multi-agency strategy discussion and possibly a child protection conference. 7.3.14 There is a lack of clarity, certainly from social care perspective, about the threshold for information sharing by police, outside of a formal section 47 (child protection) enquiry. Theme 3 Learning Point (1) Fathers and significant male figures should always be fully included in assessments. New men joining families should always be engaged by professionals and their backgrounds researched and details recorded. Theme 3 Recommendations (1) Clarity is required between police and other agencies about the circumstances under which police can share information outside of sec 47 of the Children Act 1989. (2) Fathers and partners should be fully considered and involved in assessments of need. LSCB should promote the Engaging Fathers Programme and consult with other Authorities who have successfully engaged fathers. (3) A thorough consideration of significant others who join families or become involved in the life of children of that family needs to be emphasised as a factor in multi-agency assessments 33 7.4 Theme 4 - The Rule of Optimism, Drift and Lack of Continuity of Care 7.4.1 Between 2008 and late 2012 Child C’s mother saw over 30 GPs. The author of the Primary Care Individual Organisation Review noted ‘Throughout the period of the review the majority of primary care staff viewed members of the family in isolation to each other without placing in context the impact of factors intrinsic to either Child C’s mother, Child C’s father, Child C’s Brother or Child C on each other’. 7.4.2 The GPs and allied staff only seemed to hold a partial view and each presentation was essentially considered in isolation. The emotional and social context of Child C’s mother’s presentations was rarely considered, and safeguarding, seemingly, only by two of the GPs. GP15 considered the injury to Child C’s brother at 6 months as potentially non accidental and liaised with the health visitor. The same GP saw past the medical presentations of Child C’s mother and considered emotional origins of symptoms. As a result of Child C’s mother speaking of threats from Child C’s father’s family GP15 made a safeguarding referral. 7.4.3 According to the Children’s Social Care Individual Organisation Review author there was an extensive and competent assessment completed by Social Worker 9 in September 2011. 7.4.4 When the case was held in the Adolescent team there was good communication within Children’s Social Care. Soon after the case transferred to Social Work Assistant 1. It is the practice in South Gloucestershire Children’s Social Care for social work assistants to case manage Child In Need cases under the supervision of a Practice Manager. At interview the Practice Manager confirmed these arrangements and emphasised they do not undertake assessments. 7.4.5 In an increasing number of local authorities there is a move away from less qualified staff being case managers. The implication for doing otherwise, as illustrated in the case, is that major changes in a family's circumstances remain unassessed. To emphasise the point: during the period of Social Work Assistant 1 allocation a teenager becomes pregnant for the second time, separated from the father of the expected baby, gives birth to the baby, is suffering depression, starts a new relationship, the baby is injured; she plans to attend college; children are to be left in the care of an unknown male: none of which was formulated in an updated assessment. 34 7.4.6 There is not a straightforward link to demonstrate that good assessment leads to good outcomes for children; there is evidence to show that inadequate assessments are associated with worse outcomes22. Similarly, poor and incomplete assessments are a feature in Serious Case Reviews23. 7.4.7 The plan articulated by Children’s Social Care was to withdraw from the case because the family’s needs could readily be met through the lower level multi-agency Child Assessment Framework (CAF) process. This was the plan but what happened was withdrawal by Children’s Social Care and no action with regard to CAF. 7.4.8 The theme running through this case from Children’s Social Care perspective was that, contrary to most of the evidence, Child C’s mother was ‘doing well’. Her circumstances included being a very young mother from a troubled background, a frequent visitor to her GP, including receiving treatment for depression. 7.4.9 Fundamentally agencies have the responsibility for ensuring a work environment which contributes to good critical reasoning. Whether this is in a busy GP surgery or Social Care office. In order to minimise such tragedy which is the focus of this Serious Case Review, sufficient time needs to be provided to think, whilst accepting errors will occur. Within the system there needs to be mechanism for correcting error. Often this mechanism will be reflective supervision. 7.4.10 There were some real impacts on Social Work Assistant 1 at this time: she had significant life events outside her employment; and she was working very closely with a very traumatic case. Social Work Assistant 1 said at interview that she spent much time outside her normal working hours attending to issues related to this case. 7.4.11 Whilst Social Work Assistant 1 says she was well supported by colleagues and managers, it is clear that these events and their aftermath had a marked impact upon her. 7.4.12 There were some moments where a more curious professional response and professional conversation with a colleague may have led to a different outcome, whether that be about injuries or the identity of Child C’s mother’s boyfriend. Child C was only ever seen as ‘at risk’ from her brother and where this was known, professional advice was given. 22 FauthR, Jelicic H, Hart D,Burton S, Shemmings D, Bergerac C, White K 2010 Effective Practice to Protect Children Living in Highly Resistant Families 23 Rose W, Barnes J 2008 Improving Practice: A Study of SCR 2001‐3 35 7.4.13 Child C’s mother was seen by a range of professionals as a vulnerable young woman and provided a wide range of services in addition to those universal services. Throughout Child C’s brief life there was no real consideration of any child protection measures being required. 7.4.14 The presence of Child C’s maternal grandmother alongside Child C’s mother at meetings with professionals was too readily seen as a positive support without question. This despite Child C’s mother’s comments to the contrary and the knowledge that the maternal grandmother was substantially preoccupied by her son (Child C’s uncle, mother’s brother) and the demands of his behaviour. 7.4.15 A rule of optimism pervaded the management of this case in most quarters. Paradoxically, considerable energy from helping agencies is devoted to planning for independence for teenagers when in fact the young people concerned are well behind in their emotional and social development. The impact of Child C’s mother’s history and circumstances were readily put to one side in the light of any perceived positive element: so she was seen to be ‘doing very well’, and that meant support services could be withdrawn. Such snapshot observations were not the result of multi-agency assessment. There were some signs which led to this positive perspective, but mostly these could be equally read as negatives. It seems that the factors of running her own home and returning to education neutralised the other factors known about Child C’s mother: her emotional frailty over many years, her young age and the demands of two small children. Theme 4 Learning Points (1) Vulnerable families should be allocated to a single nominated GP and effort should be made to direct consultation appointments towards this GP so as to maintain consistency and consider presenting information in the family context. (2) Assessment is a continual social work task and not a single event. Assessments should be updated, particularly where significant changes occur in a family's circumstances. Theme 4 Recommendation (1) Before a child’s case is closed in Children’s Social Care a reflective supervision is recorded on the child’s file which includes not only positive factors but also a list of risk factors 36 7.5 Theme 5 - Silo Working 7.5.1 The Individual Organisation Review prepared by Survive comments that Team Around the Family arrangements were not robust in South Gloucestershire at the time. Meetings of professionals to share assessments and plan multi-disciplinary interventions were rare. The seeming partial information held by individual agencies easily influenced incomplete and skewed perspectives. This is all the more perplexing since many of the key agencies were co-located. On further enquiry it became apparent that although some critical agencies were co-located this did not lead to closer working together. The co-located agencies had separate reception arrangements, separate telephony and separate IT. Co-location does not in itself necessarily lead to closer working together. The implications here are that it didn’t, even though this may have been the aspiration. 7.5.2 In May 2011 there was discussion over a couple of months for the need to arrange a Family Support Meeting; this never seems to have happened. 7.5.3 There is a theme throughout the Individual Organisation Reviews and chronology of different professionals gaining an often contradictory view of exactly how well Child C’s mother was managing. Throughout the timeframe covered by this Serious Case Review, Child C’s mother visited the GP many times more than the average for her age but this was not recognised during those times. 7.5.4 Agency resources have an impact on the ability of services to effectively undertake their role. Munro 24 makes strong statements about this often ignored element within the child protective system: ‘Do staff have the resources needed to work to a good level?’ Social Work Assistant 1 was involved with Child C’s mother and her children during the first half of 2012. There had been some turbulence in the team but that was a full year before when 3 social workers left in quick succession; and a restructure, merging two social work teams was undertaken. Such turbulence can have an impact going forward on staff morale and staff in the team mentioned this when interviewed. There were up to 7 social worker vacancies around this period but they were filled by agency staff. Social Work Assistant 1 was not a qualified social worker and although very experienced had not undertaken up to date child protection training. 24 E Monro – Effective Child Protection 2nd Edition 2008 37 7.5.5 Experience on its own is not sufficient and is required to be linked to reflection. Michael Oakshott 25 focuses on the limitations of circumstances in ’.. a crowded life where people are continually occupied and engaged but have no time to stand back and think. A working life given over to distracted involvement does not allow for the integration of experience.’ 7.5.6 There was confusion from Midwifery about whether Child C’s mother’s family had an allocated social worker. When asked by the Midwife Child C mother said she had a social worker. This may have falsely assured midwives. At the time of Child C’s birth when a social work assistant was supporting the family, this role was not fully understood and was in fact described as a Family Support Worker. 7.5.7 The Early Years Individual Organisation Review writer was of the view that agencies worked well together but there was recognition that EW1 was concerned about the presence of Child C’s mother’s boyfriend but didn’t have the confidence to challenge Social Work Assistant 1 about the concerns or escalate this. 7.5.8 Risk factors were not identified and during the time things were becoming more risky for Child C, a plan decided upon at a much earlier time was executed by Children’s Social Care without a current assessment. The only agencies actively involved were from universal services. Children’s Social Care closed the case as did Early Years. 7.5.9 Child C and her brother were being supported by Children’s Social Care as Children In Need (as defined in Section 17 Children Act 1989) and as such should have been subject to a Child In Need Plan and multi-agency Child In Need Reviews where information would have been shared with mother and between agencies. 7.5.10 Child C, Child C’s mother and Child C’s brother were visible to a large range of agencies and within them a large number of professionals. Child C’s mother saw over 30 GPs during the 4 year period of this review and 12 Children’s Social Care workers. The result was that there was little insight into the family’s functioning. The information that was available was not wholly shared. Early Years, for example, knew nothing of mother’s family history; the various GPs tended to view each consultation in isolation. There was one assessment by Children’s Social Care described as ‘detailed’ but this was an Initial, rather than a Core Assessment. 25 M Oakshott The Voice of Liberal Learning 2001 38 Theme 5 Recommendations (1) CIN cases should be subject to multi-agency Child in Need reviews (2) All agencies should present case chronologies to CIN reviews 8. Conclusions and Final Remarks 8.1 This is a case where there is a complex family history which wasn't fully brought into focus by the agencies involved. This lack of a full and clear, shared picture meant that each agency only had a partial account. That said, the issues around the untimely death of Child C are, with hindsight, more straightforward. There were a series of events which if fully appreciated may have provided a better informed approach. The post mortem was not able to establish the cause of Child C’s death. This SCR is, therefore, not able to comment on whether the child’s death was either predictable or preventable. 8.2 Despite the increasing demands on a young single parent, having one child and then a second, suffering depression, having little emotional resources to support her, the contrasting professional theme was that Child C’s mother was doing well. The increasing GP consultations were not viewed in an overall context but were mostly seen as individual presentations. Those in regular contact with Child C’s mother misread the signs and in fact sometimes these signs were too readily interpreted as positives or as signs of her independence. 8.3 Child C’s mother was well ‘known’ to caring agencies during her transition from childhood to adulthood. At the moment she became pregnant, though still a child, the attitude of professionals effectively switched to view her as a mother, rather than a child who was to become a mother. Much of the intervention was focussed on Child C’s mother and her capacity to parent and to become independent, with less than equitable focus on her children and their lives. 8.4 Child C suffered a series of injuries over an eight week period and these were not fully known across the professional network. The GP practice received communication about the two incidents (injury 2 and 3) but critically, the Health Visitor was not advised of injury 3. The significance of the first ‘sentinel’ (warning) injury was not recognised by the professional who first noted it. All the injuries were viewed individually and not considered in the wider context. 8.5 The three significant men within the wider family were not drawn into any assessment of the family’s functioning and still remain, essentially, unknown. 39 8.6 The significance of injuries to non-mobile babies was not appreciated by the professionals to whom Child C was presented. Safeguarding was not considered and reflected upon. Practitioners were too ready to accept the carer’s explanation for injuries that were sustained by Child C without sufficient enquiry or reflection. The watchwords of Lord Laming: ‘respectful scepticism’ were not in practitioners’ minds when faced with injury to Child C. 8.7 In this case there were a number of connected themes which included fragmented practice, a lack of holistic assessment, multi-agency review and professional challenge. These factors undermined the potential to provide a more robust safeguarding response to Child C and her family. References 1. All Babies Count NSPCC 2. S Maguire, M Mann, J Sibert, and A Kemp. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review 3. NICE guideline When to Suspect Child Maltreatment (Clinical Guideline 89, July 2009) states that bruising in any child not independently mobile should prompt suspicion of maltreatment. See: 4. http://guidance.nice.org.uk/CG89/QuickRefGuide/pdf/English. 5. There is a substantial and well-founded research base on the significance of bruising in children. See http://www.core-info.cf.ac.uk/bruising. 6. Bruising Protocols Wessex LMC 2013 7. E Munro Progress Report – Moving to a Child-Centred System 2012 8. E Munro. Effective Child Protection 2nd edition 2008 9. E Munro. The Munro review of Child Protection 2011 10. R Dazell & E Sawyer. Putting Analysis into Assessment NCB 2007 11. Mary Sheridan Child Development matrix referenced in Framework for Assessing Children in Need and Their Families. DOH 2000 12. S Holland. Child & Family Assessment in Social Work Practice 2004 13. Arch Dis Child. 2005 February; 90(2): 182–186. Appendix 1 Recommendations Made in Individual Organisation Reviews of Contribution Agencies 1. NHS Trust 1 Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress Ensure lessons learned from reflective practice session in MIU are implemented as changes in practice Develop action plan Audit action plan via annual MIU records audit Lead Emergency Nurse Practitioner MIU (supported by Named Nurse) Can be achieved within current provision Immediate and audit by March 2014 Action plan developed and shared with all staff, September 2012. Learning shared with ED department in Frenchay and Southmead MIU at Level 3 Child Protection training commencing 27/02/14 Audit carried out Feb 2014 to ensure learning and changes in practice are embedded. Audit report shared with NBT Safeguarding Children Operational Group and Sirona Health. 40 41 Protocols to be developed regarding Information Sharing where there are new partners in household where there are vulnerability factors or present or previous CSC involvement Included in level 3 child protection training Include in briefing note sent out by Safeguarding Children Team Include in review of Child Protection Policy Named Professionals Can be achieved within current provision August 2014 Included in Level 3 Child Protection training Included in Safeguarding Children briefing to HVs and SHNs July 2013. Include in Child Protection Policy when reviewed August 2014 North Bristol NHS Trust to develop clear protocol regarding bruising in non-mobile babies As above Named Professionals Can be achieved within current provision August 2014 Task and finish group - 23/02/14 lead by Designated Doctor to include UHB and NBT Named Professional’s and other representatives. This action is now wider than NBT and included in Overview Actions 42 2. NHS Trust 2 Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress For midwives to record detailed information about the father of unborn and to identify potential safeguarding risks antenatally Targeted single agency training and reinforcement of this key message through midwifery supervision Named Midwife for UHB/Midwifery Supervisors None- This is already recommended best practice Jan 2014 Message shared through midwifery child protection link meeting (Nov 2013). There is a section in the yellow hand held notes to allow recording of fathers details. Audit Completed Dec 2013 positive results. To remain on annual midwifery audit plan To contribute to the current evidence base by ascertaining if there are any ‘red flags’ for eye injury presentations in babies To complete an activity analysis and evaluation of under 6 month babies attending CED /BEH as emergencies, including a review of Child C’s presentation Named Doctor/Nurse supported by key professionals at the BEH Protected time for the Named / BEH Professionals to complete project work. June 2015 Meeting held with key professionals from CED/BEH. Analysis completed. Action plan developed. Joint work completed in CED /BEH to review Safeguarding process for babies, based in Infant Assessment Tool. Babies are now undressed and weighed as part of the routine assessment, based on guidance within the National 43 Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) To promote best safeguarding practice in management of injuries under ones presenting with minor injuries Implementation of 'Infant Safeguarding Tool' across all Bristol urgent care/emergency departments and minor injury units CCG HIT team and designated professionals/ Named Professionals Protected time for the Named / Professionals to complete project work March 2014 Infant Tool validated through second audit. Named Nurse has presented to CED/ GP consortiums/ CPHAG/MIU. April 2014 Infant tool presented at Health Professionals meeting to develop Protocol for infants presenting with injuries. May be adopted as part of the SWCPP To clarify the use of CHIN 1 & 2 forms to promote effective information sharing both between health professionals and with Children’s Social Care To review the use of the CHIN 1& 2 Named Midwife/Midwifery Safeguarding Supervisor (NBT) This project will be undertaken by the Midwifery Safeguarding Supervisor due in post Dec 2013 June 2014 NBT have implemented the ‘Request for Help ‘form for safeguarding referrals, following the remodelling of Bristol Social Care and First Point referral form for S Glos. 44 Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress To produce an ‘options paper’ considering information sharing between Children’s Outpatients and the HV/SHN. This may also include inpatient discharge information Formation of a short life working group to explore information options within the constraints of the current information systems HV Manager NBT/Named Professionals/UHB Protected time for the Named / Professionals to complete project work End March 2014 First meeting held Nov 2013. Progress update: May 2014 Work ongoing with IT/ Safeguarding leads to work towards the long term objective i.e. the electronic transfer of information to SHN/HV. 45 3. Primary Care Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress To improve the reviewing and management of notifications received by GP’s in relation to children attending emergency settings with injuries Share the system already in use at one GP Practice in South Gloucestershire with other practices through the Lead GP Meeting Designated Nurse/Named GP None January 2014 GPs reminded at Lead GP meeting in November 2013 of the importance of having an awareness of safeguarding aspects when reviewing notifications. Audit undertaken of GP practice standards in Jan 2013/May 2014 demonstrates compliance. Self-assessment audit of individual GP competences undertaken in May 2014. Results will be shared during the training planned for 2014 which will also include all of the learning points from the SCR. 46 Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress To enhance primary care professionals assessment of injuries in infants under one year and/or injuries with unusual mechanisms Implement the use of the ‘Assessment Tool for injuries in infants under 12 months’ authored by the Named Nurse from UHB, to be circulated to all practices Designated Nurse/Named GP None As soon as available GPs reminded of importance of having an awareness of safeguarding aspects of injuries in infants under 12 months at Lead GP meeting in November 2013. Self-assessment audit of GPs competencies undertaken in May 2014 includes recognising potential indicators of child maltreatment – physical abuse and understanding the assessment of risk and harm. Results will be shared during the training planned for 2014 which will also include all of the learning points from the SCR. 47 Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress To review the guidance for GP’s about requesting case consultations to increase and enhance supervision in relation to injuries in infants under one year and/or injuries with unusual mechanisms Share reflective learning from this SCR with all South Gloucestershire GP Practices Designated and Named Professionals through Lead GP meeting and re launching supervision guidance to all practices None January 2014 GPs have been reminded through Lead GP meetings, CCG GP newsletter and re circulating safeguarding children guidance to all practices. Training planned for 2014 will include all the learning points from the SCR. In partnership with providers of health visiting services, to formalise the structure of Health Visitor and GP liaison meetings to ensure that for all children/families where there is cause for concern there is robust sharing of information Ensure sharing of good practice/meeting structure established in another South Gloucestershire GP Practices with all practices Designated and Named Professionals None January 2014 Audit undertaken of GP practice standards Jan 2013/May 2014 demonstrates compliance with the standard Discussed with Named Nurse responsible for Health Visiting. In partnership with providers of maternity services review the process and proforma for antenatal risk assessments and the sharing of information between primary care, midwives and health visitors Review the process Designated and Named Professionals None March 2014 Discussed with Named Midwives responsible for maternity services within the two main providers. To be discussed fully as an agenda item at CPHAG meeting in July 2014. 48 Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress Practices to be encouraged to consider implementing a system of identifying and allocating families of young children who are frequent users of the service, to a specific GP who should co-ordinate their care with flagging of their records to indicate which GP they should be directed to To present to a Clinical Commissioning Membership meeting and a Protected Learning Time event for all South Gloucestershire Practices Designated and Named Professionals None March 2014 This is a long term on-going project. The action planned is to encourage GP Practices to adapt the new General Medical Services for England Primary Care Contract requirement of allocating patients over 75 years to a named GP and apply this model to vulnerable families. A schedule of the dissemination of learning from the SCR at CCG meetings has been planned following publication in June until September, this issue will be a major focus of these meetings 49 4. Bristol Children’s Social Care No recommendations for action or improvement 5. South Gloucestershire Children’s Social Care Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress Assessment processes should be reviewed to ensure that men in families are considered even if they do not live in the family home Review of Assessment processes Head of Service None July 2014 A Practice note has been sent out to all staff informing them of the need to ensure that all men within families are considered within social care assessments, whether they are fathers or significant others. There will routinely be some analysis of their role and function within the family, including analysis of the risks and strengths of their parenting capacity. All agencies have been advised through the LSCB that fathers/significant others should be recorded within CAFs and consideration given to them and 50 Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress their views within CAF assessments. Father’s and significant other’s details will routinely be requested and recorded in assessments by all agencies. These details will routinely be shared with First Point by referrers, at point of referral to Integrated Children’s services and then subsequently recorded in CSS and ICS by First Point staff. A Practice note has been sent out detailing that fathers with PR should routinely be invited to all meetings regarding children ie TAC, CIN, CPC, core groups etc Significant others and fathers without PR will be invited to meetings regarding children, with the permission of the parent/carer with PR. 51 Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress CSC procedures should be reviewed to require that a re-assessment is undertaken if a new relationship starts or a partner moves into the family home Review of CSC procedures Head of Service None July 2014 This review and particular issue will be discussed at the next CSC management meeting on 6th July 14. Procedures will be amended if necessary following this meeting. The SWCPP should be reviewed to explicitly require a discussion with a Community Paediatrician if any non-mobile baby sustains an injury Review of SWCPP Shared Procedures Steering Group None September 2014 Awaiting development of procedure Processes for case closure should be reviewed to ensure that all relevant information is reviewed and signed off and that there is a clear plan in place for on-going support prior to case closure Review processes for case closure Head of Service None July 2014 A practice note has been sent out detailing that before a child’s case is closed to Children’s Social Care, the practice manager will complete a reflective supervision record on the child’s ICS file which records why the case is closing and will include not only positive factors but also a list of any outstanding risk factors. 52 Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress Step down procedures are already in place for stepping a case down from social care to CAF. This process will be reviewed and reiterated to staff over the coming month. Supervision processes should consider the emotional impact of the work being undertaken A review of supervision processes to ensure they include supporting practitioners on the managing the emotional impacts of their work Supervisors to receive guidance on any recommended changes to process Head of Service Service Managers/Principal Social Worker None None July 2014 September 2014 All CSC managers are required to complete the manager’s supervision training run by Bridget Rothwell which focuses on provision of reflective supervision within the social care context. The supervision process has been reviewed and already includes supporting staff regarding the emotional impact of their work, however this will be reiterated at the next CSC management meeting on 6th July 14. A review of the supervision policy will take place prior to September 2014 53 Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress Family Support Meetings should take place within the required timescales An audit of the timeliness of Family Support Meetings Performance and Quality Sub group None July 2014 Due to capacity issues this audit will be delayed until 2015 All CSC practitioners who are case holders should attend update safeguarding training annually. This should be considered as part of PDPR Requirement to be made explicit to Team Managers Reporting to SGSCB on training compliance shows improvement Principal Social Worker Team Managers None None March 2014 July 2014 Awaiting Principal Social Worker. Start date June 2014 To be reviewed in July 2014 6. Avon & Somerset Police No recommendations for action or improvement 54 7. South Gloucestershire Early Years Recommendation Action Required Lead Officer(s) Implications for Service Provision Timescales Progress Use of the escalation policy practice Staff to be trained in the use and appropriateness of the policy Team Managers None January 2014 Revised policy completed, awaiting final sigh off prior to staff training (August 2014) Formal sign off of all closed cases Evidence of discussion and/or meeting with Line Manager, Partner agency and family to ensure decision agreed and understood Team Managers None March 2014 All cases are discussed in supervision (documented on the “Family Case Review” form),and any actions taken i.e. continue service, referral, case closed, is detailed the “Action Plan area of the form” 8. SURVIVE No recommendations for action or improvement Appendix 2 Serious Case Review Terms of Reference for Child C Background Children’s Social Care South Gloucestershire Children’s Social Care were involved with Child C’s mother’s family in 2009 due to issues in the family of domestic violence and sexual abuse by Child C’s Maternal Grandfather of Child C’s Mother. The Case was closed in March 2010 and re-opened in Feb 2011 when individual family support was given for both Child C’s mother and Child C’s mother’s brother. Child C’s mother became pregnant by Child C’s father with Child’s Brother at age 15. Child C’s Brother was born on 26 June 2009. Child C’s Mother became pregnant again by Child C’s father and Child C was born on 17 July 2012. Six weeks after birth the case was closed by Children’s Social Care on 17 September 2012. Child C's mother’s new partner had moved into the family home at this time. Child C’s mother had started a college course and Child C’s mother’s boyfriend became the carer for the children whilst she was at college. Since the death of Child C, checks on Child C's mother's boyfriend have identified that Bristol Social Care have knowledge of his involvement in two previous relationships with women in Bristol that resulted in children. As a result, Bristol Children’s Social Care will contribute to the SCR. Health Services All the family have received primary health care services. Midwifery services were provided during both pregnancies. Family was in receipt of an enhanced health visiting service from July 2009. Child C attended A&E at NHS Trust 2 when Child C’s brother was reported to have sprayed hairspray into her eyes. Child C’s mother’s boyfriend also informed the A&E department of NHS Trust 2 at this time that Child C’s brother had been putting clothes pegs on Child C’s ears. Child C also attended the Minor Injuries Unit with both Child C’s Mother and Child C’s mother’s boyfriend. Child C’s mother’s boyfriend had said that he had dropped Child C on her head and her head had hit a bedside table and when Child C’s mother returned home she initiated the visit to the Minor Injuries Unit. On 6 November 2012 Child C’s mother left a message for the Health Visitor concerned about Child C's brother's behaviour particularly that he was being aggressive towards Child C , stating he hits on her face causing bruising. 55 56 The Incident 14 November 2012 On the 14 November 2012, Child C was brought to the Children’s Hospital by ambulance having earlier been pronounced dead at the family home. Child C’s mother is reported to have left home at 8.45am to attend college, leaving Child C’s mother’s boyfriend to care for the children. Child C’s mother’s boyfriend states that he left Child C on the bed and covered her head with a blanket, which they usually did while she slept. He discovered her not breathing at 11.45am and called an ambulance. On examination, Child C was found to have blisters on her left ear and neck and at the back of her scalp. No medical explanation has been given for these. The forensic post mortem has not found any natural causes likely to have caused death. Bruising was also found on Child C’s scalp which was likely to have been a few days old. No explanation was given before the death. Child C’s death is given as ‘of unascertained causes’. Serious Case Review Criteria It is a requirement that South Gloucestershire Safeguarding Children Board (SGSCB) should undertake a serious case review when a child dies and abuse or neglect is known or suspected in the death (Regulation 5 of the Local Safeguarding Children Board’s Regulations 2006)) This case was discussed by senior managers at a multi-agency SCR sub group meeting held on 18 June 2013. The group made a decision that the case met the criteria for a SCR. The Chair of SGSCB was advised and decided that, in his view, the criteria for Serious Case Review had been met. The SCR was initiated on the 4 July 2013. Scope of this Serious Case Review The SCR Panel expect, as a minimum, IOR authors to provide a detailed chronology that identifies critical points/key practice episodes, between 1 September 2008 until, date of death, 14 November 2012. It would be an expectation that IOR authors will use their professional judgement to locate and comment on other relevant information relating to this case, including information that has come to light since the death of Child C. This will include consideration of relevant aspects of family history, rapid response and post mortem findings. Consideration should be given to any relevant previous convictions, intelligence, matters of medical history, education and social functioning of the children’s parents/carers relevant in contextualising the life of Child C. Serious Case Review Process This SCR will be carried out in accordance with the guidance contained in ‘Chapter 4 Working Together to Safeguard Children 2013’. A SCR Panel will be established drawing upon the expertise of senior managers within agencies who have had no direct managerial responsibility for the case. This Panel will be chaired by an independent consultant who will also produce the overview report for SGSCB. Individual agencies will be required to complete an IOR for consideration by the SCR Panel. Timescale for SCR Completion The SCR will be completed within six month from initiation Agreeing Improvement Action SGSCB will oversee the process of agreeing with partners what action they need to take in light of the SCR findings. Publication of Report A report will be published and readily accessible on SGSCB’s website for a minimum of 12 months. Thereafter the report should be made available on request. The final SCR report will: provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; be written in plain English and in a way that can be easily understood by professionals and the public alike; and be suitable for publication without needing to be amended or redacted. SGCCB will consider carefully how best to manage the impact of publication on children, family members and others affected by the case. SGSCB will comply with the Data Protection Act 1998 in relation to SCRs, including when compiling or publishing the report, and must comply also with any other restrictions on publication of information, such as court orders. The SCR report will be sent to the national panel of independent experts at least one week before publication. If SGSCB considers that a SCR report should not be published, it will inform the panel which will provide advice. Purpose of this Serious Case Review The purpose of this review is to identify improvements which are needed and to consolidate good practice. This SCR will be conducted in a way that: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; 57 seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. The SCR will adopt a systems approach to the learning from the case. It will seek to look for causal explanations and explain not simply what happened but why it happened and how the systems and organisational cultures influenced the decisions and actions taken by individuals at the time (Fish, Munro and Bairstow, 2009) The cornerstone of the approach is that individuals are not totally free to choose between good and problematic practice. The standard of their performance is influenced by the nature of: the tasks they perform; the available tools designed to support them; the environment in which they operate. The approach, therefore, looks at why particular routines of thought and action take root in multi-agency professional practice. It does this by taking account of the many factors that interact and influence individual worker’s practice. Ideas can then be generated about ways of re-designing the system at all levels to make it safer. The aim is to ‘make it harder for people to do something wrong and easier for them to do it right’ (Institute of Medicine, 1999, p. 2, cited in Fish et al., 2009, p.2). Serious Case Review Panel The purpose of the SCR Panel is to bring together and collate and analyse the information contained in the IORs together with any reports commissioned from any other relevant bodies or interests. From these, the SCR Panel will commission the independent author to write the overview report and the executive summary in accordance with the agreed timescales. The Panel will agree the Terms of Reference, review the progress of the enquiries, consider drafts of the IORs and give consideration to the conclusions and recommendations prior to submission to the full SGSCB. The Panel works within the statutory requirement for the notification of concerns and will do so should any arise during the process of this review. The Panel will also consider the handling of any potential media issues. Members of the panel are: Agency/Authority Position Andrew Haley Panel Chair and Independent Lead Reviewer and Overview Report Author Avon and Somerset Police Detective Chief Inspector Avon and Wiltshire Mental Health Partnership Managing Director, AWP South Gloucestershire 58 59 Agency/Authority Position NHS Acute Sector Designated Director, South Gloucestershire Council Head of Commissioning, Partnerships and Performance South Gloucestershire Council Solicitor South Gloucestershire residents Lay Member South Gloucestershire Clinical Commissioning Group Designated Nurse for Safeguarding Children South Gloucestershire Clinical Commissioning Group Designated Doctor for Safeguarding Children South Gloucestershire Council Head of Education, Learning and Skills South Gloucestershire Council Head of Integrated Children’s Services, Bristol City Council Service Manager Aims of Individual Organisation Review Reports Individual organisation review authors must be aware of the timescales for completing the chronology and the IOR report, and raise any difficulties in meeting timescales as early as possible with their agency’s Designated Senior Manager. The Individual organisation review authors should begin quickly to draw up a chronology of their agency's involvement with the child and their family. IOR authors need to be aware how their work fits into the whole programme, e.g. the timescales for creating the merged chronology being dependent on each agency’s chronology being available. The chronology must be completed on the proforma provided and be a record of the information known and recorded at the time. Where an agency became aware of information relating to earlier events at a later date this should be recorded at that later date. The chronology is not designed to be an accurate chronology of the family history, but of the agency knowledge and action. (e.g. where a family moved house in April but the Health Visitor found out in June the chronology should record the date the Health Visitor was informed, not the date the family moved). The analysis element of the IORs, whereby the key practice episodes in the chronology is reviewed to identify how the systems and organisational cultures influenced the decisions and actions taken at the time in terms of both good and poor quality of practice is particularly important. 60 Conducting the Individual Organisational Review Authors have a responsibility to consider the statutory requirement for the notification of concerns. The emphasis of the review under systems methodology is to gain insights into how the multi-agency child protection system is functioning within South Gloucestershire. It is therefore important to study the whole system and gain insight into why particular thoughts and actions take place. When you interview each of the key professionals from your agency who worked with this family during the period under review, it would be helpful to seek answers around the following questions: Practitioners’ Narrative What do you think were the crucial moments in the sequence of events when decisions or actions were taken that you think determined the direction the case took, or the way it was handled? What were your main concerns? What were you considering and seeking to balance at the time? Did these concerns clash at all? Were there any conflicts? Were some dismissed, others prioritised? What were you hoping to achieve? What options did you think you had to influence the course of events? What was behind your thinking (reasons but also emotions) and actions at the time? What information was at the front of your mind? What was most significant to you at this point? What was catching your attention? What were the key factors that influenced how you interpreted the situation and how you acted at the time? In what ways? Prioritise aspects that were most significant? Aspects of the family Aspects of your role Conditions of work/work environment Personal aspects Your own team factors Inter-agency/inter-professional team factors Organisational culture and management Wider political context Other What things in relation to the case went well? What did you and/or others do that was useful/helpful? What enabled this to happen? Suggested changes, having thought back on this case and your role, are there any small, practical changes that you can think of that would help you or other professionals to achieve better outcomes? How do you feel now about your role, particularly, what support would you have benefited from at the time of the difficult decisions you had to make and what support would you benefit from now? 61 Appendix 3 Agencies Who Contributed Individual Organisational Reports Agency Report South Gloucestershire Council Bristol City Council NHS Trust 1 Avon & Somerset Police General Practitioner (GP) Early Years Service NHS Trust 2 Survive 62 Appendix 4 GLOSSARY SIGNIFICANT FAMILY MEMBERS Child C SUBJECT (CHILD) CB CHILD’S BROTHER CM CHILD’S MOTHER CF CHILD’S FATHER MBF MOTHER’S BOYFRIEND MGM MATERNAL GRANDMOTHER MGF MATERNAL GRANDFATHER MGFX MATERNAL GRANDFATHER’S EX PARTNER MBC1 MOTHER’S BOYFRIENDS CHILD 1 MBC2 MOTHER’S BOYFRIENDS CHILD 2 MBFX1 MOTHER’S BOYFRIEND’S FIRST EX PARTNER MBFX2 MOTHER’S BOYFRIEND'S SECOND EX PARTNER MB MOTHER’S BROTHER OTHER SGSCB SOUTH GLOUCESTERSHIRE SAFEGUARDING CHILDREN BOARD SCR SERIOUS CASE REVIEW IOR INDIVIDUAL ORGANISATION REVIEW CSC CHILDREN’S SOCIAL CARE HV HEALTH VISITOR GP GENERAL PRACTITIONER 63 Appendix 5 Overview Author Brief Biographical Note Andrew Haley trained as a teacher and a social worker. He has worked in social care for 33 years, initially as a local authority social worker and later in a range of management roles. In recent years his experience has been employed in senior interim roles, focussing on service improvement. Serious Case Review in relation to Child C Action Plan THEME 1 - FOCUS ON THE CHILD Learning Point 1 The focus of all agencies working with children should always be the child RECOMMENDATION (1) Children who become mothers and fathers should be considered by all agencies as children first and their particular vulnerabilities and service requirements addressed from that perspective. Both new child and under 18 parents are potentially children in need Desired Outcome Actions required Milestones Responsible Lead Timescale RAG Professionals will recognise the vulnerabilities of pregnant women or mothers under the age of 18 years and biological and social fathers who are under the age of 18 years Organisations providing antenatal care to review their processes to ensure parents under 18 years are identified and an assessment is undertaken. The assessment should identify any vulnerability and appropriate pathways of care offered eg Common Assessment Framework (CAF) or referral to children’s social care The following organisations will confirm that the assessment process and care pathway have been reviewed: North Bristol Trust (NBT) – University Hospital Bristol (UHB) Primary Care Designated Nurse for Safeguarding Children April 2014 Confirmation received from NBT and UHB that all women under 19yrs are identified and referred to specialist teenage midwife, specific care pathways are followed. The new S Glos Family Nurse Partnership service will also provide additional support to some teenage mothers. 1 2 Organisations providing care to children under 5 years will review their processes to ensure parents under 18 years are identified and an assessment is undertaken to identify any vulnerability and appropriate pathways of care offered eg CAF or referral to children’s social care The following organisations will confirm that assessment process and care pathway have been reviewed: Early Years NBT UHB Primary Care Service Manager - Preventative Services Designated Nurse for Safeguarding Children April 2014 April 2014 NBT Health Visiting assessment process and guidelines updated Feb 2014 in relation to parents under 18yrs. GPs identify pregnant under 18yr olds and liaise with specialist teenage midwife and health visitors and follow appropriate pathway Achieved NBT Health Visiting assessment process and guidelines updated Feb 2014 in relation to parents under 18yrs. GPs identify parents under 18 years old and follow appropriate pathways 3 Children’s social care on receiving information related to the risks to an unborn child or child under the age of 5 years will consider the age of the parents as to whether they are children themselves and offer services as appropriate to both the child subject of the referral and the child’s parents A Practice note setting out this requirement is provided to the First Point Team / North Locality Team / South Locality Team. Audit of referrals of unborn babies or children under 5 in a three month period are audited to ensure compliance Service Manager Service Manager April 2014 August 2014 Completed February 2014 Included on the Service Manager’s forward plan of audit activity RECOMMENDATION (2) The focus of attention should always be the child. Where agencies provide services to both children and adults, separate but related records should be generated Desired Outcome Actions required Milestones Responsible Lead Timescale RAG Organisations records will clearly state who the records relate to i.e. who the service is being provided for. This will be equally clear when undertaking assessments or planning interventions Organisations providing antenatal care or working with both parents and children will review arrangements for producing and recording information in records The following organisations will confirm their arrangements for producing and recording information in records: Social work Early years Head of Integrated Children’s Services Service Manager - Preventative Services April 2014 April 2014 Achieved February 2014 Achieved March 2014 4 Primary Care NBT Designated Nurse for Safeguarding Children April 2014 NBT and UHB have reviewed arrangements for producing and recording information in midwifery records. Information in mother’s records is copied to infant’s records at birth. Electronic alerts will also be used to flag infants subject to CP plans at birth. Health visiting assessments have separate sections for child and adult All GP records relate to the individual concerned. GP have been reminded to ensure that appropriate information is copied to either child(ren) or parents records 5 THEME 2 - INCIDENTS/INJURIES SUSTAINED BY A NON-MOBILE CHILD Learning Point 2 The presence of injuries or incidents in non-mobile infants should always be considered in the context of safeguarding. (1) A bruise should never be interpreted in isolation and must always be assessed in the context of the child’s medical and social history, developmental stage and explanation given. A presentation of bruise to an infant whilst a minor injury, may have a non-accidental cause. A series of injuries in a non-mobile infant should set alarm bells ringing (2) Any non-mobile child who has unexplained signs of injury, pain or other unusual presentations should be seen promptly by a Paediatrician. Clinicians should begin with an assumption that causes are non-accidental and rule this out through enquiry. Respectful uncertainty and professional curiosity are the guiding principles here. Carer explanation for injury to a non-mobile baby requires consideration by a Paediatrician and multi-agency information sharing. ‘Those who don’t cruise, rarely bruise’ (3) There was a pattern of 'sentinel' injuries which occurred during a very short timescale. The first was noted on 12 September and there were others over a period of 8 weeks prior to Child C's death on 14 November 2012 RECOMMENDATION (1) A multi-agency protocol should be developed in relation to the management of injuries (incidents) concerning pre-mobile babies Desired Outcome Actions required Milestones Responsible Lead Timescale RAG Professionals will follow a newly developed South Gloucestershire Safeguarding Children Board (SGSCB) procedure on the assessment, management and referral of children who are non-mobile who present with bruising or unexplained signs of injury, pain or other unusual presentations A SGSCB procedure will be produced by a task and finish group led by Designated Doctor for safeguarding children The draft procedure will be submitted to the SGSCB Policy & Procedure sub group for consideration and approval The task and finish group will meet in March 2014 and produce a draft procedure. The group will include representatives from NBT, Primary Care, UHB, Police and Social Work The draft procedure will be submitted to the April meeting of the SGSCB Policy & Procedures Sub Group Designated Doctor for Safeguarding Children Designated Nurse for Safeguarding Children April 2014 April 2014 An initial meeting of the task and finish group was held on 25.03.14, draft procedure produced. Further meetings required to progress. Primary Care, NBT and UHB represented on task and finish group Awaiting the draft procedure 6 RECOMMENDATION (2) Consideration should be given as to whether the local procedure developed should be included in the South West Safeguarding Procedures and therefore applicable across the region Desired Outcome Actions required Milestones Responsible Lead Timescale RAG The SGSCB procedure on the assessment, management and referral of children who are non-mobile who present with bruising or unexplained signs of injury, pain or other unusual presentations will is incorporated and visible within the South West Child Protection Procedures The SGSCB procedure will be submitted to the South West Child Protection Procedures regional group members for consideration for insertion in the South West Procedures Regional South West Child Protection Procedures meeting Head of Integrated Children’s Services June 2014 Awaiting the completed procedure RECOMMENDATION (3) The South West Safeguarding Procedures should be revised to reflect current research about injuries Desired Outcome Actions required Milestones Responsible Lead Timescale RAG The South West Safeguarding Procedures are revised referencing current research about injuries, particularly in non mobile babies Current research will be submitted to the South West Child Protection Procedures regional group with the approved SGSCB procedure The task and finish group producing the SGSCB procedure will consider available and current research and submit this with the procedure to the SGSCB policy and Practice sub group Designated Doctor for Safeguarding Children April 2014 An initial meeting of the task and finish group was held on 25.03.14, draft procedure produced. Primary Care, NBT and UHB represented on task and finish group. Further meetings required to progress. 7 The research will be forwarded to the Regional South West Child Protection Procedures meeting Head of Integrated Children’s Services June 2014 Awaiting the completed procedure RECOMMENDATION (4) The phrase ‘Children Who Don’t Cruise Rarely Bruise’ should be adopted as a multi-agency guide when professionals are considering injuries or unusual presentations in non-mobile babies Desired Outcome Actions required Milestones Responsible Lead Timescale RAG The key safeguarding message ‘Children Who Don’t Cruise Rarely Bruise’ will be utilised to launch the SGSCB procedure on the assessment, management and referral of children who are non-mobile who present with bruising or unexplained signs of injury Development of a Communications Plan for Children’s Safeguarding to complement the existing Adults’ Safeguarding Communications Plan Children’s Safeguarding Communications Plan will be drafted Children’s Safeguarding Communications Plan approved by South Gloucestershire Safeguarding Children Board The SGSCB procedure on the assessment, management and referral of children who are non-mobile who present with bruising or unexplained signs of injury will be approved and forwarded to the communications team A multi-agency launch of the SGSCB procedures as part of roll out of Communications Plan will commence Strategic Comms Strategic Comms Head of Integrated Children’s Services Strategic Comms March 2014 May 2014 April 2014 July 2014 Delay due to staff absence Communications plan currently in draft As above Awaiting the completed procedure As above 8 THEME 3 - The Invisibility of Men Learning Point 3 Fathers and significant male figures should always be fully included in assessments. New men joining families should always be engaged by professionals and their backgrounds researched and details recorded RECOMMENDATION (1) Clarity is required between police and other agencies about the circumstances under which police can share information outside of sec 47 of the Children Act 1989 Desired Outcome Actions required Milestones Responsible Lead Timescale RAG Children are safeguarded, and their welfare promoted, as a result of information being shared appropriately between agencies Engage with LSCB and single agency training leads to assess the extent to which information sharing is adequately covered in multi-agency child protection training, for example incorporating the use of scenarios to reinforce learning, including scenarios where information should be shared outside of Section 47, and gain agreement to necessary changes to course content LSCB partner agencies to review their information sharing practices and take any necessary action to ensure they comply with best practice and HM Government "Information Sharing: Guidance for practitioners and managers" Protocol to be developed re information sharing and shared with SGSCB. Detective Chief Inspector April 2014 Review has taken place and whilst existing practices are seen as effective, all will ensure there is no complacency about the possibility of individual error. A practice brief is to be disseminated in relation to what social workers and front line staff can expect from the police when requesting background checks. 9 RECOMMENDATION (2) Fathers and partners should be fully considered and involved in assessments of need. LSCB to promote the Engaging Fathers Programme and consult with other Authorities who have successfully engaged fathers Desired Outcome Actions required Milestones Responsible Lead Timescale RAG Fathers and partners should be fully considered and involved in assessments of need, which are completed by all agencies. Analysis of their role and function within the family is key, as is analysis of risks and positives and a father’s ability to assist or hinder improving outcomes for the child LSCB to promote the Engaging Fathers Programme LSCB to consult with other Authorities who have successfully engaged fathers in order to acquire best practice Father’s details will routinely be requested and recorded in assessments by all agencies These details will routinely be shared with First Point by referrers, at point of referral to Integrated Children’s services and then subsequently recorded in CSS and ICS Fathers with PR will be routinely contacted during social care assessment processes and their views incorporated in the assessment. There will Presentation re this Programme at the LSCB Consultation and report back to the LSCB Incorporate into single agency and SGSCB training Practice note to all LSCB members for dissemination Practice note for all Social care staff to be disseminated. First point will confirm that referrals include details of fathers Social care assessment protocol to be compiled Strategic Safeguarding Service Manager Strategic Safeguarding Service Manager Strategic Safeguarding Service Manager Strategic Safeguarding Service Manager Service Manager Service Manager July 2014 July 2014 June 2014 March 2014 March 2014 May 2014 To be progressed As above Achieved Achieved Achieved It is felt that compiling a protocol will not achieve the desired result – bespoke training along 10 routinely be some analysis of their role and function within the family, including analysis of the risks and strengths of their parenting capacity Fathers will routinely be invited to all meetings regarding children ie TAC, CIN, CP, core groups etc Multi agency training to be provided for all professionals working with children, regarding how best to work with and engage with fathers in assessment, as well as incorporating them into plans Review of the current Social care Child and Family assessment training program to ensure that Practice note for all Social care staff to be disseminated Practice note for LSCB members and all Social care staff to be disseminated Incorporate into CAF and SGSCB training Review of Assessing Families training program Service Manager Service Manager/ Strategic Safeguarding Service Manager Workforce Development/Service Manager Workforce Development/Service Manager March 2014 March 2014 June 2014 April 2014 with the practice note is what is required. Achieved Achieved The inter-agency CAF and SGSCB training does currently include a focus on the importance of engaging with fathers in the assessment process. In addition, these training programmes are in the process of being updated; this will mean incorporating a stronger message about how best to work with fathers. A review of the Assessing Families training programmes for social care staff, 11 sufficient emphasis is placed on engaging fathers in the current training arrangements Specific and bespoke training seminars to be rolled out to the Social work front line teams of Children Health And Disability, Through Care Team, North and South locality, regarding engaging fathers, routinely recording basic detail information in assessments and how best to incorporate them into the planning process Training will be provided at individual team meetings Service Manager May 2014 undertaken with the relevant Agency-Based Trainers, will ensure that future such courses do incorporate the required emphasis. Additionally, Refresher training is being planned to ensure already-trained staff understand the key messages in this regard. It is planned that these team-based sessions will take place once the new Principal Social Worker is in post early June 2014. This will also allow her to meet key teams as the newly-appointed Strategic Safeguarding Policy & Practice Manager. The potential for opening up such sessions to a wider audience will also be explored. 12 RECOMMENDATION (3) A thorough consideration of significant others who join families or become involved in the life of children of that family needs to be introduced Desired Outcome Actions required Milestones Responsible Lead Timescale RAG A thorough consideration within assessments completed by all professionals working with children of significant others who join families or become involved in the life of children of that family Significant other’s details will routinely be requested and recorded in assessments by all agencies. These details will routinely be shared with First Point at point of referral to Integrated Children’s services and then consequently recorded in CSS and ICS Significant others will be contacted during social work assessments processes and their views incorporated in the assessment, but only with the permission of the parent or carer with PR. There will routinely be some analysis of their role and function within the family, analysis of Incorporate into CAF and SGSCB training programme Practice note to all LSCB members for dissemination All organisations will report that their assessment process takes into account any significant other Multi agency Single assessment protocol to be compiled Workforce Development/ Service Manager Strategic Safeguarding Service Manager Strategic Safeguarding Service Manager Strategic Safeguarding Service Manager and Service Manager June 2014 May 2014 June 2014 May 2014 Where significant other’s details are provided to First Point within a contact or referral, First Point advisors have been reminded that this detail needs to be routinely recorded in Capita. Relevant inter-agency training programmes will continue to emphasise these key practice issues. Achieved Achieved Progressing as part of work in relation to Single Assessment Framework 13 risks and strengths, including analysis of their parenting capacity if appropriate Significant others will be invited to meetings regarding children, with the permission of the parent/carer with PR ie TAC, CIN, CP, core groups etc Multi agency training to be provided for all professionals working with children, regarding how best to work and engage with fathers and significant others in assessment, as well as incorporating them into plans where appropriate Specific and bespoke training seminars to be rolled out to the Social work front line teams of CHAD, TCT, North and South locality, regarding engaging fathers and significant others Practice note for all Social care staff to be disseminated Practice note for LSCB members and all social care staff to be disseminated Incorporate into CAF and SGSCB training Training will be provided at individual team meetings Service Manager Strategic Safeguarding Service Manager/Service Manager Workforce Development/Service Manager Service Manager/ Workforce Development March 2014 March 2014 June 2014 May 2014 Achieved Achieved The inter-agency CAF and SGSCB training does currently include a focus on the importance of engaging with fathers in the assessment process. In addition, these training programmes are in the process of being updated; this will mean incorporating a stronger message about how best to work with fathers. It is planned that these team-based sessions will take place once the new Principal Social Worker is in post early June 2014. This will also allow her to meet key teams as the newly- 14 Where a professional becomes aware of a significant other who has entered into a relationship with a parent and who therefore is likely to have contact with the children, they must inform and share this information with the Lead practitioner and case coordinator Practice note for all LSCB members to be disseminated in their agency Incorporate into CAF training. Strategic Safeguarding Service Manager Workforce Development April 2014 June 2014 appointed Strategic Safeguarding Policy & Practice Manager. The potential for opening up such sessions to a wider audience will also be explored. Achieved Inter-agency CAF training will continue to emphasise the need to inform the Lead Professional/Case Coordinator of any significant changes within a family context. 15 THEME 4 - The Rule of Optimism, Drift and Lack of Continuity of Care Learning Point 4 Vulnerable families should be allocated to a single nominated GP and effort should be made to direct consultation appointments towards this GP so as to maintain consistency and consider presenting information in the family context. Assessment is a continual social work task and not a single event. Assessments should be updated, particularly where significant changes occur in a family's circumstances. RECOMMENDATION (1) Before a child’s case is closed in Children’s Social Care a reflective supervision is recorded on the child’s file which includes not only positive factors but also a list of risk factors Desired Outcome Actions Required Milestones Responsible Lead Timescale RAG A Child’s situation is given careful consideration at the point of closure to Children’s Social Care – ensuring all positive and risk factors are identified Relevant Case Closure and Supervision protocols and procedures are updated. This will involve incorporating requirement to record that positive and risk factors have been considered in the decision making to close the case Briefing note is provided to all Social Care teams and relevant protocols are amended Service Manager April 2014 Achieved Note: GPs are engaged in a long term on-going project. The action planned is to encourage GP Practices to adapt the new General Medical Services for England Primary Care Contract requirement of allocating patients over 75 years to a named GP and apply this model to vulnerable families 16 THEME 5 - Silo Working Learning Point 5 RECOMMENDATION (1) CIN cases should be subject to multi-agency Chid in Need reviews Desired Outcome Actions required Milestones Responsible Lead Timescale RAG All CIN cases will have the CIN plan reviewed at a CIN review meeting every 6-12 weeks, depending on level of need which is to be decided by the Practice manager CIN reviews avoid drift and allow for structured reviewing of the plan of support. If we do not review, we cannot be sure that the plan is effective in bringing about the necessary changes and desired outcomes Whenever it becomes clear that a CIN support package is needed a CIN meeting will be convened, this can occur at any time within the single assessment period. All relevant agencies and family members (including children/YP if possible) will be invited to the CIN meeting. All CIN meetings will have an output in ICS of CIN meeting notes and a CIN plan. A CIN or CAF action plan will always be made when a CP Plan is ended, unless the case is to be closed There should be no open CIN cases which are not open to assessment, without a current CIN plan or recent CIN meeting having been held The meeting will establish and record a focussed and time limited plan of CIN support. A CIN review date will be set normally for 6-8 weeks, unless there is agreement that the case will close or step down The initial CIN meeting to review and firm up the plan will be held within 20 working days of the CP conference LSCB Performance & Quality sub group will undertake a case file audit of CIN cases to ascertain compliance Service Manager Social care Team and Practice managers Service Manager Social Care Team and Practice Managers Service Manager Social care Team and Practice managers Designated Nurse for Safeguarding Children February 2014 February 2014 February 2014 October 2014 Achieved Achieved Achieved Multi Agency case file audit on CIN Cases scheduled for the December 2014 meeting. 17 RECOMMENDATION (2) All agencies should present case chronologies to CIN reviews Desired Outcome Actions required Milestones Responsible Lead Timescale RAG Timely and effective information sharing between agencies in section 17 social care CIN work, to inform decision making and planning Social care will request a chronology of significant events from each professional/ organisation that they invite to a CIN meeting All professionals/agencies involved with a child will provide a chronology of significant events from their own records to the social worker 3 days prior to the CIN review meeting CSC management meeting – March 2014 – instruction will be given to managers LSCB members will ensure operational staff in their own agency are instructed regarding this requirement LSCB Performance & Quality sub group will undertake a case file audit of CIN cases to ascertain compliance Service Manager LSCB Lead members Designated Nurse for Safeguarding Children March 2014 March 2014 October 2014 Achieved Achieved Multi Agency case file audit on CIN Cases scheduled for the December 2014 meeting. |
NC042380 | Death of a 17-year-old boy from injuries sustained after he threw himself in front of a vehicle, in 2011. Child F's mother had died after a suicide attempt in 2006, prior to which she had had extensive involvement with children's services, police, health and mental health services, following a number of incidents of domestic abuse committed by Child F's father and mother's previous suicide attempts. History of anti-social behaviour, contact with police and periods of school exclusion. Makes recommendations covering: working with families that are hard to engage; and, improving agencies' understanding of and practice in working with families where domestic violence, mental health and substance misuse issues are present; and, the responsibility of courts for considering children's well-being when hearing domestic abuse cases.
| Title: Serious case review: Child F: executive summary LSCB: Havering Local Safeguarding Children Board Author: Bob Cook Date of publication: 2012 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Exec Summary Final 12/11/12 1 Executive Summary Serious Case Review in accordance with the guidelines laid out in Working Together to Safeguard Children 2010 Child F Deceased: 2011 aged 17 Overview report author: Bob Cook, MA, CQSW Independent Children’s Services Consultant Dd/mm/yyyy Exec Summary Final 12/11/12 2 1 Circumstances leading to a Review 1.1.1 In 2011 Child F was killed after he threw himself in front of a vehicle. In 2006 Child A's mother had died after a suicide attempt. Prior to her death there had been extensive involvement by children's services, police, health and mental health services as a consequence of a combination of domestic violence towards Ms A by her partner Mr C, Ms A's previous suicide threats and concerns about Ms A's and Mr C's substance use. 1.1.2 Following Ms A's death Child F lived initially with Mr C and Child L, the son of Mr C and Ms A, then with their father Mr R and finally with an aunt Ms E. During this period Child F often came to the attention of the police, mainly for instances of anti social behaviour, and had periods of school exclusion. 2 Review Process 2.1 Terms of reference 2.1.1 In line with 8.5 of Working Together the review should: i. establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; ii. identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and iii. improve intra- and inter-agency working and better safeguard and promote the welfare of children 2.1.2 The Havering Safeguarding Children Board (HSCB) convened a serious case review panel (SCRP) which agreed terms of reference as set out in 8.39 of Working Together and additionally including: 1. What factors helped or prevented engagement with Child F and his carers and how well were these recognised and understood by those involved at the time, in particular a. the appropriateness of help and support offered to Child F and his carers following Ms A's death including the reluctance to accept offered services b. the impact of frequent changes of address and of carer including the significance of changes in service personnel and location consequent upon such changes c. The significance of Child F's age during the period of the review. Exec Summary Final 12/11/12 3 2. Was the assessment and action robust around the decision not to intervene when Child F went to live with his step father? In particular were thresholds for intervention appropriately applied? 3. Was the significance of co-morbidity of domestic violence, mental health and drug and alcohol misuse fully understood and appropriately acted upon? 4. Given the likely impact of Mother's death on the children, how well did agencies singly and together provide services that may have prevented her death, and hence contributed to the possibility of a different outcome for Child F? 5. Did adult services understand and appropriately act upon the concerns and needs of Child F and, did children's services understand and appropriately act upon the concerns and needs of Child F’s carers? 6. Was information shared adequately and acted on appropriately 7. Specific considerations: do any issues concerning diversity emerge in the review, for example age, ethnicity, religion, disability, social exclusion? External links: was the family engaged with / known to agencies other than statutory partners? 2.1.3 Individual management reviews and chronologies on which the overview report is based were provided by the following agencies and named authors: Barking Havering and Redbridge University Hospitals NHS Trust (BHRUT): accident and emergency services North East London NHS Foundation Trust (NELFT) In and outpatient mental health services to Child F and Ms A Outer North East London Community Service (ONEL CS)1 Health visiting and school nursing services ONEL NHS General Practitioner Services: GP services in respect of several family members. NHS Havering (commissioners): Health Overview Report London Ambulance Services NHS Trust (LAS): Calls outs to several family members Metropolitan Police Service: Involvement in domestic violence incidents, anti-social and criminal behaviour of some family members, the deaths of Ms A and Child F and other crisis interventions London Borough of Havering Social Care and Learning – Children and Young People Services: Social work services to Child F, K, L and their carers; early years support for Child L London Borough of Havering Social Care and Learning – Learning and Achievement: Education and support services to Child F and Child K 1 ONEL CS is now part of the NE London Community Trust (NELCT) but the term ONEL is used as this was the name of the organisation during the period of review Exec Summary Final 12/11/12 4 2.1.4 The following agencies had very limited involvement and were therefore asked to provide background information. The reasons are considered in section 6.10 East of England Ambulance Service: Attended the road traffic incident in which Child F died Essex Probation: Supervision of Mr C Essex Children's Services and SE Essex PCT: Involvement with Child L after he and his father moved to Essex London Probation Service: supervision of Mr C 2.1.5 A format for individual management reviews (IMR’s) was provided. All authors were independent of the case and had no involvement with the family. 2.2 Parallel Investigations 2.2.1 Consideration was given to the need for a separate adult safeguarding review As a sudden untoward incident (SUI) review had been undertaken following Ms A's death the chairs of both the LSCB and the Adult Safeguarding Board agreed this report provided sufficient analysis to obviate the need for a separate review and that residual questions could be addressed in the NELFT IMR. 2.3 Serious case review panel (SCRP) membership and process 2.3.1 The SCRP comprised the following members: Legal Manager (Litigation) London Borough of Havering, Legal Services Service Manager, Safeguarding & Service Standards, London Borough of Havering Designated nurse consultant safeguarding children NHS ONEL Manager, Additional Education Needs Services, London Borough of Havering Learning and Achievement Safeguarding Manager for Adults, Children and Young People, East of England Ambulance Service NHS Trust Associate Director Children Services, ONEL CS Executive Director of Nursing Barking, Havering & Redbridge University Hospitals NHS Trust Service Manager Youth Offending Team Assistant Chief Officer Barking Dagenham and Havering LDU, London Probation Trust Detective Inspector Havering Child Abuse Investigation Team (CAIT) Consultant Psychologist, Head of Service, Havering Psychological Services 2.3.2 The panel was supported by the HSCB Business Manager, and the HSCB administrator. 2.3.3 The Panel was chaired by the independent chair of Havering LSCB, Ms Sue Exec Summary Final 12/11/12 5 Dunstall. The overview report was written by Bob Cook, an independent consultant. The overview author was in attendance at the panel to hear and respond to information about the progress of the review and to provide commentary on the quality of IMRs. The overview author was not a member of the panel. 2.3.4 The Panel met on four occasions during the course of the review to consider progress with IMRs and the overview report. 2.4 Family involvement 2.4.1 The terms of reference explicitly recognised the importance of wide family involvement and agreed the independent author of the SCR together with a member of the SCR Panel should invite Child F’s father, Mr C, Mr R, Child K, Mr and Ms E to contribute to the SCR process. All chose not to participate. 2.5 Executive summary 2.5.1 The executive summary will be published on the LSCB website following receipt of an evaluation from OFSTED. All family members consulted as part of this review will be given an opportunity to discuss the summary and the review findings before publication. 2.6 Action Plans 2.6.1 Individual agencies and the LSCB have produced appropriate action plans based on their recommendations. 2.7 Publication and media interest 2.7.1 Havering LSCB will manage family, public and media interest through a clear communication strategy. The family members will be informed of the process and findings of the SCR. 2.7.2 In line with statutory guidance the overview report will not be published to avoid concerns about possible identification and additional and unnecessary distress.2 2 Department for Education (2010). Publication of Serious Case Review Reports and Munro Review of Child Protection. Ministerial letter, circulated 10th June 2010 and retrieved 14th November 2011 @ www.education.gov.uk/.../LettertoLSCBsreReviewandSCRs10June20... Final 17/01/12 redacted August 2012 6 3 Genogram: Key carer relationship groupings 4 Summary of events 4.1.1 During the period of six months prior to agency involvement in 2006 there were three incidents of domestic violence between Mr C and Ms A, during all of which the children were in the home. The final incident led to Mr C being charged and subsequently convicted. Both Mr C and Ms A were having treatment for depression, which appeared to be largely consequential on the breakup of the marriage. Ms E had taken an overdose and expressed suicidal views. Child F's school performance was seen to be deteriorating. 4.1.2 A health visitor referral to Havering children and young people's service (CYPS) was made but described as not being a child protection concern. The referral was not followed up by either agency. When the mental health initial assessment team (MHIAT) became involved with Ms A shortly thereafter following a police referral there was no discussion with CYPS by either agency. 4.1.3 Two months later a MHIAT referral to CYPS was made but the case was not allocated for a further month, and despite diligent attempts by social worker SW1, an initial assessment did not commence for a further three weeks due to difficulties in getting Ms A to engage. 4.1.4 During this period there were three further domestic abuse incidents. There was better evidence of liaison between CYPS, MHIAT and the police. On completion of the assessment, SW1 concluded the children were at significant risk from witnessing further domestic violence and recommended a core Ms A Mr R Child F Child K Mr C Child L Mrs E Final 17/01/12 redacted August 2012 7 assessment with a view to convening a child protection conference. However a final serious domestic violence incident just after the assessment was concluded and where the children were directly involved was not investigated as a specific child protection concern or considered as sufficient grounds for a child protection conferences although Mr C was subsequently charged . 4.1.5 At this point the psychiatric diagnosis for Ms A was most concerned about her use of drugs and alcohol as a stress reaction, though later consensus was that she ceased this behaviour. 4.1.6 SW2, who undertook the core assessment, noted Ms A prevented engagement with the children and concluded Ms A's mental health impacted on her ability to care for them. SW2 also identified concerns about the children witnessing domestic violence. The case transferred to SW3 whose manager TM1 recommended a child in rather than a child protection approach. 4.1.7 Following a child in need meeting the focus shifted further away from the children to Ms A's mental health. There was close liaison and joint working between adult mental health worker MH2 and SW3, also to some extent including the health visitor HV3. Police were involved as Mr C resumed contact as soon as his bail conditions were lifted, evidencing an increased risk of further domestic abuse. This did not lead to any revision of the child in need plan and Ms A did not engage with an offered empowerment group for women who had experienced domestic abuse. 4.1.8 Concerns by both SW3 and MH2 that Ms A was a suicide risk were thoroughly followed up by mental health services. Ms A was not admitted to hospital in part due to a cautious new diagnosis by consultant psychiatrist Cpsych2 of a personality disorder, a condition less amenable to change through emergency admission. Ms A appeared better on MH2's last contact and made positive remarks about therapy. The SUI following Ms A's death noted Ms A as a moderate suicide risk and that the circumstances leading to her death could not have been predicted. 4.1.9 There was little evidence of direct work with the children during this period of intervention. Child L was offered a good programme of support by the early years centre. During this period Child F came to the attention of the police for the first time but there is no evidence this led to any reconsideration of a need for more coordinated intervention. 4.1.10 Following Ms A's death Ms A's sisters clearly blamed Mr C for Ms A's death but also recognised his significance for the children and wanted to remain on good terms with him. The children's views were ambiguous. Child F wanted to remain with Mr C but Child K appeared to vacillate between Mr C and Ms E. Child L was Mr C's birth child. 4.1.11 No formal assessment was undertaken by CYPS as to who might best be able to care for the children though support was offered to the family. Mr C took on care of Child F and K as well as Child L. Ms E offered considerable support to Mr C e.g. cooking meals for the children at Mr C's home while he was working. 4.1.12 The only person at this point with parental responsibility was Mr R who was overlooked to the extent that when he rang CYPS in effect making a child Final 17/01/12 redacted August 2012 8 protection referral about the safety of the children with Mr C his concerns were dismissed. 4.1.13 At a child in need meeting concluding CYPS involvement SW4 informed the meeting she had no role as there were no safeguarding concerns evidencing poor understanding of the history and continuing concerns about Mr C's lifestyle. Other agencies had concerns about closure but did not effectively voice these. 4.1.14 Apart from Child L, for whom there was a clear and thorough package of support, there was a lack of resolution about bereavement counselling with different views on when this should start. It is fair to say both Child F and Child K expressed some resistance to counselling. 4.1.15 Mr C was asked by CYPS to obtain a residence order but this was delegated to the early years worker for Child L, EYC1, though neither Child K nor F were within the remit of the early years centre. Mr C did not obtain a residence order or parental responsibility and this was not referred back to CYPS. 4.1.16 While the early years centre evidenced good work with Child L and held reviews the school was not invited to these though both Child F and K were discussed. At one meeting Ms E and Mr C both requested help through a CAF assessment but this was not followed up by the early years centre, missing an opportunity to engage with the family at their own request . 4.1.17 Child K left Mr C's home barely a month after closure of the case by CYPS and went to live with Ms E, later moving in with his father, as did Child F only nine months after case closure. 4.1.18 Child L was no longer in the Havering area having moved with his father to another local authority after an incident of serious violence to Mr C by an acquaintance. During this period it was not always clear with whom Child F and K were living. 4.1.19 Child F's behaviour in school and in the community continued to give cause for concern. The school endeavoured to provide counselling but did not refer back to CYPS. Police stops of Child F were treated as low threshold single incidents and police information was rarely shared with CYPS, even after Child F received a youth reprimand after being found with cannabis. 4.1.20 Child F was eventually excluded from school and placed with an alternative education provider which helped him learn a trade. This was one of the most successful interventions with Child F. This period also coincided with a reduction in Child F coming to police attention. 4.1.21 A significant opportunity for CYPS to reengage with Child F was missed when a referral was made after Child F came to the attention of health services due to an alcohol related hospital attendance. 5 Conclusions and lessons learned 5.1 Introduction Final 17/01/12 redacted August 2012 9 5.1.1 The circumstances that led to this serious case review are tragic. Both Child F and his mother took their own lives. This SCR has tried to understand whether the death of Child F was predictable and whether it could have been prevented. Some findings relate to matters where there have been changes in practice or policy. These do not require recommendations. 5.1.2 There was much debate within the HSCB at the start of the process whether, despite the manner of Child F's death, the circumstances met the criteria for a serious case review. Factors which swayed the HSCB's decision included national research findings of the often unrecognised vulnerability of older young people (Brandon et al 2010) and the HSCB's own 2011 section 11 audit3 findings of lower awareness of the ‘hidden harm’ to teenagers in some instances and in some agencies. The HSCB is to be commended for taking the view that undertaking a review could contribute both to the national debate and local circumstances on how to reduce harm to teenagers. 5.1.3 The review has highlighted a number of shortcomings in practice which contain important lessons for professionals though it cannot conclusively be said they would have prevented the circumstances in which Child F died. They included i. Poor identification and assessment that the children were at risk of significant harm as a consequence of co-morbidity of parental mental health, substance misuse and domestic violence ii. Failure to assess who might best provide care for the children following the death of their mother the quality of available care and the risks that Mr C might pose to the children as a carer iii. Failure to consider the possible underlying causes behind Child F and his brother's increasingly challenging and troubled behaviour and to provide a consistent multi agency response. 5.1.4 There were also areas in which practice was good: i. The high level of support Ms A received from mental health agencies, though ultimately unsuccessful in preventing her death. A SUI review undertaken at the time, the key findings of which were reviewed and confirmed by the NELFT IMR undertaken as part of this review, confirmed Ms A's death was not preventable ii. The levels of support provided by learning and achievement services that ensured both Child F and Child K remained in education and indeed achieved positive outcomes iii. Support for Child K and his carer, Ms E, after Child F's death. 5.1.5 From the analysis in this review, based upon the panel terms of reference, two broad themes emerge, summarised in diagrammatic form below, which interact with each other to create the potential for good or bad practice. These are: i. Understanding the co-morbidity of domestic violence, mental health and substance misuse Working with hard to engage families and individuals 3 s11 of the Children Act 2004 places a statutory duty on key organisations to make arrangements to ensure that in discharging their functions they have regard to the need to safeguard and promote the welfare of children. The quality of these arrangements is tested in audit by Local Safeguarding Children's Boards Final 17/01/12 redacted August 2012 10 5.2 Child F: Diagram of overarching interacting themes and response typology Theme 1: Understanding co-morbidity of domestic violence, mental health and substance misuse Theme 2: Working with hard to engage families and individuals Factors seen as having interacting cumulative effect Focus on impact on child Focus on underlying causes Factors seen as separate not interacting factors Response based on panicky help seeking Focus on adults needs incl. rule of optimism No mandate to engage No perceived benefit to engagement Agencies unclear about purpose Powers and resources Agencies unclear Clear mandate to engage Empowering process Agencies clear about purpose Authoritative but compassionate engagement with clear mandates and benefits Focused and continuing assessment Reflective supervision Clear roles and info sharing Knowledge of theory and research Understands underlying causes Clear about what needs to change Skills in communicating with children Good practice response Poor practice response Focus on presenting behaviours and responding to incidents rather than understanding underlying causes Adult not child focus Limited assessment Poor supervision Unclear or undifferentiated roles Limited understanding of theory, procedure, legislation Exec summary Final 11 5.3 Specific factors impacting on understanding of co morbidity of domestic violence, mental health and substance misuse 5.3.1 Research evidence is that the above three factors in combination create a "cumulative problems and adversities [that] are not uncommon and present significant risks factors for children." (Brandon et al 2010).This review has established their significance in this case especially during the intervention while Ms A was alive and, following her death, when Mr C undertook the role of carer. 5.3.2 There was poor theoretical understanding of the inter-linkage of these three factors. While their presence was identified at early stages of intervention they were initially seen as fitting child in need criteria. When police and mental health services became involved and police made referrals to domestic violence agencies neither agency contacted CYPS. When a further referral was made to CYPS, three months after the original concern there was still a delay of a further three weeks before allocation 5.3.3 It is concerning that no agency appeared to be aware of research findings that these were interacting factors that required a prompt s47 response. There were some deficiencies in national and regional policy and procedure which at that point, while identifying all three factors could be simultaneously present and have an impact on children gave no specific reference to their interactivity and how they should be addressed. Lack of clear policy and procedure must have impacted on those working with such families at the time. Detailed procedures addressing the impact of domestic violence on children were also not in existence being first produced by the London Safeguarding Children Board in March 2008. 5.3.4 The potential impact on Child F of having lived in a situation where these three factors were present for so long was also not understood when their behaviour became more challenging later on. Contemporaneous research evidence shows factors associated with experience of co-morbidity for this age group include poor school performance, emotional disturbance, conduct disorders, fear of exposing family life to outside scrutiny, school exclusion, aggression and risk of suicidal behaviour (Cleaver et al 1999) all of which were present in their behaviour. 5.3.5 Although the school was endeavouring to address the behaviour of Child F they did not seek to re-engage the multi-agency network. Havering's 2011 section 11 safeguarding audit has identified this is still an issue noting "some gaps in teachers’ understanding of the forms of maltreatment of teenagers, and the impact that might have.". 5.3.6 When a health agency later re-referred Child F to CYPS due to concerns he was "falling through the gaps" CYPS merely logged this as a contact. Neither school nor early years centre considered using CAF to re-engage the network. Of particular concern the local early warning system that could have flagged up the need for wider intervention when Child F started coming to the notice of the police for anti social behaviour did not appear to reach the anti-social behaviour panel Exec summary Final 12 5.4 Specific factors impacting on engagement with the family 5.4.1 In this case engagement focused on adults' needs and adult experience of domestic violence, mental health and substance misuse. 5.4.2 In respect of Ms A this resulted in a crisis intervention response to specific incidents precipitated by Ms A's mode of engagement of panicky help seeking, often drawing in members of her extended family and involving the emergency services then withdrawing after the crisis. 5.4.3 Mr C exercised significant control over Ms A and demanded the removal from the case of a health visitor who had shown awareness of child protection concern. This went unchallenged despite the health visitor's earlier raising of concerns with her manager even though A's sisters appeared intimidated by Mr C and Mr R seemed unable to stand up to him. CYPS, being focused on adult views and failing to understand the impact of domestic violence on the children, did not look at the competing claims of Ms E, Mr R and Mr C to care for Child F and K. CYPS simply accepted the view of the adults that Mr C's wishes should be paramount. 5.4.4 Because the focus was on the adults, children's agencies had a very limited mandate for engagement. Ms A was initially hostile to the mental health initial assessment team after they made a referral to CYPS. Neither Ms A nor Mr C allowed more than very limited access to the children. If the focus had been on child protection the family could have been required to engage through a child protection plan. In the absence of this the adults needed to see a clear purpose and benefit of engagement by CYPS which was not conveyed to them. 5.4.5 Ms A saw social work support in terms of her own needs, effectively as an adjunct to mental health involvement. Both Ms A and Mr C were willing to engage with the school and early years centre because they did see a perceived benefit in education for Child F and K and in specific help for Child L. 5.4.6 Following Ms A's death, with the exception of support for Child L which was a clear part of early years intervention, the purpose of support was unclear especially in respect of counselling for Child F with different agencies and time scales being mooted. The agencies' lack of clarity about purpose gave a confusing message to the family that inhibited understanding of the potential benefits. 5.5 General factors impacting on the interaction between co-morbidity factors and hard to engage families 5.5.1 Poor understanding of the significance of co morbidity and on how to engage resistant families was compounded by a number of general factors. 5.5.2 Firstly the quality of social work assessment, planning, supervision and handover in this case was poor. The initial assessment by social worker SW1 did locate the case within the child protection spectrum but failed to appreciate the seriousness of a further incident requiring an immediate child protection conference in line with existing procedures. Later interventions, while still recognising the presence of these factors, shifted the focus back to child in Exec summary Final 13 need. This appeared to be a decision made by the CYPS team manager TM1 who recommended a child in need meeting when the case transferred to their team. 5.5.3 There is no explanation for this change on case or supervision records and those most directly involved could not be located so could not be interviewed. It is however an example of the rule of optimism where and over focus on adults' needs practitioners may be reluctant to make negative professional judgments about a parent's behaviour to their child (Brandon et al 2010 p 55). 5.5.4 No CYPS manager attended either of the key child in need meetings that were held so there was poor managerial accountability for decision making and the minutes revealed poor structure and unclear recommendations. At the point CYPS closed the case after the children went to live with Mr C there was dissonance between what the minutes recorded participants saying and what those participants' own case notes showed. However there was no challenge to this. 5.5.5 Three different social workers during the six month period of intervention while Ms A was alive were a consequence of a structure with separate teams for duty, assessment and family support. This required a clear handover to ensure continuity. There was no evidence of clear handover between workers, managers and teams. Thus the not uncommon and legitimate structure itself created the unintended consequence of discontinuity in this case contributing to the result of an unevidenced and inappropriate change of focus from child protection to child in need. 5.5.6 There was evidence of the final allocated social worker SW4 not understanding the legal position when Mr R, the father of Child F and K and the only person actually to have parental responsibility, contacted CYPS expressing concern about Mr C's ability to care for the children. Mr R's legitimate claims to be involved were not only ignored but agencies discouraged from dealing with him. The social worker and team manager at the time were both from overseas and there are unresolved questions about their understanding of UK child care legislation as neither could be interviewed. The local authority now has a thorough induction programme for overseas workers. 5.5.7 Roles were sometimes unclear and undifferentiated .While there was some good evidence of joint working between social worker SW3, mental health practitioner MH2 and health visitor HV3 this focused on supporting Ms A. While this was appropriate for MH2 as an adult mental health practitioner, SW3 lost focus on her proper remit in respect of the children. Later HV3, though having and reporting concerns to her manager about Mr C did not escalate these when her manager failed to respond 5.5.8 MH2 did identify concerns about the children but at no point did SW3 and MH2 step back and consider their respective roles and how they should interact e.g. to consider how the changes of diagnosis in respect of Ms A might impact on the care of the children. Nor, despite her offer to visit, was MH2's mental health experience utilised by CYPS following Ms A's death in considering how to engage with the very distressed family members. Exec summary Final 14 5.5.9 Later the early years worker EYC1 who provided a good and level of support for Child L was tasked by SW4 with taking the lead role to ensure Mr C obtained a residence order in respect of Child F and K. This was inappropriate for an early years worker. Mr C did not do so and EYC1 did not re-refer to CYPS. SW4 told other agencies including school and early years centre her role was only in respect of safeguarding. 5.5.10 This was a poor understanding of the CYPS role and of threshold criteria. It effectively discouraged a re-referral to CYPS under child in need criteria, quite apart from failing to recognise existing safeguarding issues and continuing concerns about Mr C. Most concerningly, despite misgivings among participants, no agency challenged this interpretation. 5.5.11 Understanding of thresholds has been identified in a recent safeguarding inspection as a continuing concern and the s11 audit, the latter noting "evidence of the ‘understanding of’, and ‘buy in’ to thresholds at a strategic level…[but]…much more ambivalence at operational management and practice levels." 5.5.12 There was a focus on presenting behaviours and responding to incidents rather than understanding underlying causes. This particularly manifested in the approach to Ms A but also in later police and school responses to Child F's later challenging behaviour. 5.5.13 There were some deficiencies in information sharing. There was no contact with the GP for Mr C, Ms A and the children. Contact could have established Mr C's relevant medical history and looked at how the GP could support Ms A. There are particular concerns about the GP over prescribing medication to Mr C and poor record keeping where hospital information evidenced as being sent to the GP about Ms A's psychiatric treatment and references to domestic violence were not on file. 5.5.14 There were occasions when police information did not reach CYPS, resolved through a new system prior to this review, and when A&E did not pass on concerns. The social work emergency duty team did not evidence follow up requests for welfare checks. When Mr C and Child L moved to another authority information sharing seemed perfunctory. 5.5.15 Finally no presentencing reports were requested by the court for either of Mr C's two domestic abuse convictions against Ms A. Such reports could have led to intervention though the criminal justice system that could have reduced the likelihood of further violence and indeed contributed to addressing the interactive factors. 5.6 Towards better understanding of co-morbidity factors and how families may be engaged 5.6.1 This review has identified a number of possible models that could have facilitated better understanding about what was happening in the family and how to engage with them. These include the elements of authoritative practice identified in the final Munro review (Munro 2011); the interrelationship between child, family and community and how agency intervention set out in the Exec summary Final 15 government sponsored biennial reviews of serious case reviews (Brandon et al 2008, 2009 and 2010) and ensuring a binding mandate for intervention with non engaging families. 5.6.2 Central to good practice is understanding the cumulative impact of domestic violence, mental health and substance misuse on children and to look at the underlying reasons for these rather than simply responding to specific incidents. As previously argued this requires knowledge of theory and research. 5.6.3 To evaluate this would have required a continuing and focused process of assessment that took full account of the family history. As Munro put it a "critical analysis of evidence about what is happening in a child's life including recognition of child abuse and neglect" (Munro 2010). This needed the backing of a process of reflective supervision where options could be considered and challenged and direct discussion with colleagues, both informally and sometimes a strategy meeting, e.g. when considering the impact of concerns and how to reengage after Ms A's death. 5.6.4 While the concept of reflective practice is mentioned in Havering's current supervision procedures, the definition and process of how this will be applied in the supervisory context is not explicitly developed. This should be an important future area of learning and development given the highlighting of this process in the Munro review and elsewhere. A similar point has been noted in the most recent OFSTED/Care Quality Association safeguarding inspection of the HSCB area. 5.6.5 Following assessment, workers needed to be clear with family members both before and after Ms A's death about what needed to change and how to diminish "oppressive factors" (domestic violence, substance misuse, overdoses). 5.6.6 To achieve this required a focus on the children's needs and a clear mandate to engage. This needed to be authoritative, with a requirement to engage through a child protection plan but also compassionate involving purposeful relationship building with children, carers and families. 5.6.7 Even if Ms A's death could not have been prevented, authoritative engagement through a child protection plan, initiated prior to her death, would have facilitated workers in looking at what each member of the family network could offer and what the risks were after her death. This would determine who was best able to look after Child F and Child K and what support they might need. 5.6.8 The agencies needed to be clear about their own and each other's roles and purpose, especially those of children's and adult services. This needed a reflective step back, prior to meeting with the family, to discuss what the remit of each agency should be and how they would interact e.g. how and when to provide therapeutic support or how to assess risk to the children. 5.6.9 The family's strengths could have been better drawn out. These included i. The support the aunts offered each other and the children ii. The importance of Mr C to Child F and Child K Exec summary Final 16 iii. The need to have the opportunity for Child F and Child K to re-engage with their father after their mother's death iv. Respectful understanding of the grief and pressure family members were under and how this might impact on what they could offer. 5.6.10 These were all important to the boys especially as at the time the adults were giving mixed messages, discouraging Mr R and placating Mr C. Child F and Child K reflected these views but, as there was no direct discussion with them, it could not be established if this represented their true feelings and opinions. It is unlikely this was so as both boys later voted with their feet leaving Mr C and going to live with Mr R and later with Ms E. To have engaged with the boys at the time would have required skills in communicating with them to overcome their initial reluctance, and the reluctance of the adults around them. 5.6.11 This would not have meant dismissing Mr C who was an important figure in the boys' life. It would however have meant challenging him about his violence and requiring him to address this. This might have meant he would not have felt able to take on the children or be seen as appropriate to do so. It would have been better for this to have happened in a supported way which might have enabled Mr C, Child F and Child K to retain some contact rather than walking away from each other, which was the eventual outcome. The impact of losing Mr C for Child F is not known but may have been considerable given the previous closeness. 5.7 Other learning: Multi agency working with hard to engage young people 5.7.1 Much of the above has more applicability for the interventions led by CYPS when Ms A was alive and immediately after her death. Later interventions involved Child F more directly. There was good practice within the learning and achievement service and good outcomes for both Child F and K. 5.7.2 External inspection evidences very good provision and attainment in ensuring young people are in education, employment or training. There is additionally a programme of continuing improvement set out in the authority's young people's participation strategy. 5.7.3 However in this case there was, as previously argued, an over focus on incident response and managing Child F's undoubtedly troubled behaviour rather than looking at underlying causatory factors. Three factors have been highlighted in the review and fit with priority areas for the LSCB. All could have been opportunities to re-engage the multi-agency network. 5.7.4 Firstly was the failure to consider use of CAF. It is concerning that two other Havering SCRs, have also highlighted poor use of CAF as has the 2011 OFSTED/Care Quality Association inspection of safeguarding and looked after children. The 2011 Havering section 11 audit has identified continuing problems with CAF implementation and teachers' lack of confidence in using the process which resonate with the findings in this review. 5.7.5 Secondly, there was poor use of the local early warning system enforced by the police and used as an alternative to prosecution. This could have highlighted risk to Child F and his brother if fed back into the anti-social behaviour panel Exec summary Final 17 (now incorporated into the community safety partnership). 5.7.6 Thirdly there was a poor response on some specific occasions to concerns about Child F's use of alcohol and cannabis that could have led to engagement with the drug and alcohol action team (DAAT). A professionals' toolkit to aid such referrals was later introduced by the DAAT. 5.7.7 There is an added concern given the post mortem finding that Child F had been using substances prior to his death. The DAAT should review the learning from this case in respect of Child F's alcohol and substance misuse and incorporate findings into its action plan. 5.7.8 There were delays in the Child Death Overview Panel (CDOP) being informed by the Coroner's office of Child F's death. This delayed the rapid response meeting and risked adding to the family's distress. Though it cannot be evidenced this was a factor in the circumstances of this case information sharing in such circumstances has been identified as an ongoing national issue and a recommendation about disseminating learning has been made. 5.7.9 While there was no indicator that would have been apparent to any agency that Child F was about to take his own life, he was clearly in a vulnerable category requiring a range of support services and understanding by himself, his peers and family, as well as referring agencies, of how to access these. 5.7.10 Given this is the third review in the past six years in which a young person in the HSCB area took their own life it is important the HSCB considers a model of suicide intervention. This would also address concerns raised in the s11 audit about developing "a new multi-agency focus on safeguarding adolescents" and addressing "hidden harm’ to teenagers." 5.7.11 Finally it is acknowledged that, as a consequence of recent external inspection, HSCB audit findings and the current children and families transformation programme some findings of this review especially around CAF, threshold identification and reflective practice are already high on the agenda of the LSCB and its partner agencies. The recommendations in this review therefore seek to contribute to and strengthen this existing work. 6 Recommendations 1) The HSCB should strengthen its multi-agency training programme to improve understanding of and practice in working with families where domestic violence, mental health and substance misuse are present (16.3.2). This should include: i. Developing an authoritative mandate for engagement with individuals and families and their wider networks (16.6) ii. Ensuring the centrality of the child's needs and voice (16.6.7-12) iii. Understanding personal roles and those of other agencies (16.5.8) iv. Working together and sharing information in a reflective process (16.5.13-15) v. Improving co working between children's services and adult drug teams as identified in the 2011 HSCB section 11 audit (16.6.9). Exec summary Final 18 2) The HSCB should task the prevention sub-group to use the learning from this SCR to contribute to the development of a better multi-agency focus to identify and support young people at serious risk of hidden harm. (16.7.9) This should include: vi. A multi agency model of suicide intervention (16.7.8-10) vii. Developing a multi-agency understanding of young people's counselling needs and ensuring availability of this (16.3.5-7). viii. Improving the awareness of children and young people about mental ill health in themselves, their parents and carers and their peers (16.7.8) 3) The HSCB should utilise the learning from this review in taking forward strategies identified in their 2011 section 11 audit, OFSTED Safeguarding inspection and the current children and families transformation programme regarding continuing problems with CAF implementation and some agencies lack of confidence in using the process in order to improve early assessment of need (16.7.4). 4) The HSCB should utilise the learning from this review in taking forward strategies identified in their 2011 section 11 audit and the current children and families transformation programme to improve agency understanding at operational level of thresholds for child protection and children in need (16.5.10-11). This should include ensuring staff in all member agencies are aware of and confident in escalating concerns about practice set out in section 18.5 professional conflict resolution of the pan London child protection procedures (16.4.3 and 16.5.6). 6.1 Recommendations for individual agencies 5) All agencies must implement the recommendations made in their Individual Management Reviews and provide an update on their implementation to the LSCB as required. 6) All agencies must take action to ensure that learning from this review is fed back to staff members who were involved and is effectively disseminated throughout all levels of their organisation. 7) CYPS should develop a model of authoritative practice in assessment and intervention with families based on the framework set out in section 6.41 of the final report of the Munro Review of Child Protection (16.6.6). This should specifically include the following points identified in this review: ix. A clear mandate for engagement that requires and empowers families and individuals to change (16.6.7-12) x. The importance of authoritative but compassionate engagement with families to ensure focus remains on the child (16.6.6-9) xi. Evidencing, discussing and reflecting on any change in focus from child protection to child in need (16.5) xii. A clear structure and appropriate chairing for child in need meetings to maintain focus on assessment findings and future work (16.5.3) xiii. The importance of understanding family history (16.6.4) xiv. Effective management of transition between case workers and teams to ensure no loss of focus or delay in action to protect children (16.5.4) Exec summary Final 19 xv. Seeing assessment as a continuing process (16.6.4) xvi. Reflective and challenging supervision (16.6.4-5) 8) In the light of findings from this review the community safety partnership should review the operation of the red and yellow card system to ensure that the partnership is able to identify young people at significant risk and to engage appropriate agencies (16.7.5) 9) The local authority should ensure the social work emergency duty team evidence follow up of requests for welfare checks or recording why they have not been undertaken (16.5.14). 10) The DAAT should review the learning from this case in respect of Child F's alcohol and substance misuse and incorporate findings into its action plan. (16.7.6-7) 11) All contributing agencies should consider whether there are any members of staff (current or former) whose competency has been called into question by the findings of the review and decide whether any further action is required. All agencies should report back the findings to the LSCB in a way which allows the LSCB to be satisfied that appropriate action has been taken and in a way which is consistent with the legal and policy framework for personnel matters which applies in the agency concerned. 6.2 Recommendations with national implications 12) The LSCB chair should write to the Ministry of Justice to share learning from this review in respect of the responsibility of courts for considering children's well-being when hearing domestic abuse cases 13) The LSCB chair should discuss with the CDOP chair how to feed learning from this review about the impact of delay in Coroners' notifications into the current national debate. Exec summary Final 20 7 Appendices 7.1 Recommendations from IMRs MPS 1) Havering BOCU - Policy/Procedures: It is recommended that Havering Borough Operation Command Unit should review their current policy and procedures, to support the new Standard Operating Procedures regarding the allocation and investigation of Serious Personal Injury collisions. 2) Havering BOCU - Policy/Procedures: It is recommended that Havering Borough Operation Command Unit review their current policy and procedures on the investigations of sudden deaths, such as suspected suicides. CYPS 1) The children and young people's audit programme will monitor the quality of assessments undertaken in children in need cases in the duty and safeguarding teams so that the issues of concern identified in this IMR are robustly addressed. 2) Management action will be taken to remedy any identified shortfalls and learning from these audits will be disseminated and measured to ensure that they impact on practice outcomes 3) Introduce an audit of supervision that will take account of the frequency and quality of reflective supervision and how this links to improved outcomes for children and young people. 4) The issues of the co-morbidity of domestic violence, substance misuse and mental health and their impact on the outcomes for children should be included in the CYPS training programme. The impact of this learning should be evaluated to measure its impact on practice and outcomes. 5) Establish dedicated and consistent resources to work with vulnerable teenagers who may be at risk of harm Learning and Achievement Record Keeping 1) Schools to ensure that their Child Protection Officer maintains clear written records of all contacts with agencies about a child or children and that this information is shared with key staff in school on a need to know basis. 2) Schools to ensure that these records are available for review or transfer when an individual moves from post or is absent from school for a significant period of time due to ill health. Exec summary Final 21 Information Sharing 3) To ensure that the Additional Needs and Provision Partnership (Inclusion Panel) is supplied with all relevant information about the child they are reviewing, including contacts with other agencies. 4) Alternative education providers to be made aware of all relevant information about a child/young person prior to the commencement of their placement. Referrals 5) To make schools aware that if a child has previously been subject to a Children’s Plan or a CIN process and behavioural problems are linked to family concerns then the school should inform Children’s Services. 6) The use of the CAF by schools to be reviewed to identify why they may be reluctant to use the process. BHRUT 1) All staff to be made aware of key DV support services and referral pathways through training and provision of resource packs. This will enable staff to provide basic support and referral to appropriate services, and to be alert to the welfare of children in the family. 2) Generic DV posters and leaflets to be displayed in A&E areas to signpost victims to DV support so that they can make contact with DV services when it is safe for them to do so. 3) Discussion about the commissioning of a DV service in A&E, as an expansion of the existing BHRUT DV Maternity Service, to develop DV policy, procedure and protocol. This would enable a change in culture through training and leadership so that staff are alert to addressing not just the presenting issue / injury but also to considering the background issues, such as frequent attendances and concerning incidents in patient’s previous attendance, and are confident in enquiring and referring for support. 4) Symphony database to be reviewed to include the reason for previous attendance at A&E, alongside the dates of attendances. Simple one word reasons, such as ‘overdose’, ‘self harm’, ‘intoxication’, on display on the front page of the system, would provide a readily available alert to staff, of any recent concerning attendances. 5) The use of a psycho social and safeguarding assessment tool for young people should be introduced for use in A&E. Amendment to the FRAMED checklist (Royal Free Safeguarding Team, 2010) will ensure that a holistic view of the child / young person’s life is documented, which includes details on family, relationships, alcohol, mental health, education and employment, and the use of drugs. Exec summary Final 22 6) Key staff who work with families, particularly front line staff such as those in A&E, should have child protection supervision on a formal and regular basis. This will enable them to reflect and improve on their practice, in a supportive environment, with the aim of achieving better outcomes for children. NELFT 1) Clear guidance is given to NELFT that RIO is the system for recording service user information. 2) The use of RIO is audited. Through the process determine an action plan to ensure compliance. 3) Clear guidance is given to teams within NELFT to communicate with each other to promote the welfare of children 4) To develop greater understanding and communication between adult services and CAMHS 5) To enhance understanding, responsibility and action to promote children’s welfare through early intervention. 6) To develop better communication between Children services and adult inpatient services. ONEL CS 1) NELFT must ensure that staff are aware of the need to always act in the best interests of the child, assess the needs of the child in the context of their family history and understand the need for access to a protective adult 2) NELFT should remind practitioners of the importance of seeing and listening to children when there are concerns about their welfare 3) NELFT must ensure that staff are aware of the supervision policy and adhere to it in daily practice 4) NELFT must ensure that practice is sensitive to racial, cultural, linguistic and religious identity and any issues of disability of the child and family 5) NELFT should review its DNA policy for missed appointments to ensure that it is robust and offers guidance to school nursing staff when drop in sessions are not attended 6) NELFT should commission a training package on professional dangerous for relevant practitioners to include coverage of professional disagreement, the need for persistence in making referrals and the impact on professionals of being exposed to violence and intimidation 7) NELFT should commission a training package on the toxic trio – domestic abuse, drug and alcohol misuse & parental mental illness Exec summary Final 23 NHS Havering GPs 1) NHS Havering should urgently meet with Practice 1 to discuss the concerns identified in this report. NHS Havering should develop an action plan to assess clinical quality in the practice with a view to a general improvement in standards. The issues to be addressed include the generic concerns about clinical standards. In addition to this, an assessment should be undertaken in relation to GP1’s knowledge of safeguarding practice and her general understanding of the mental health issues commonly seen by GPs. 2) NHS Havering should ensure that it has an effective programme for safeguarding training for its GPs. It should assess the training to ensure that it can be reasonably certain that the level of competence achieved at the end of the training is satisfactory. GP practices to undertake the RCGPs child protection training Levels 1, 2 & 3 3) NHS Havering should arrange for GP1 to undertake a clinical audit around the prescribing of hypnotic drugs. Once the audit is completed, an appropriate clinical review should be offered to any patient considered to have inappropriate prescribing of hypnotics. 4) NHS Havering should ensure that GP1 addresses the issues of inappropriate prescribing for individual patient(s) identified in this report are addressed by inviting the patient(s) in for an assessment and referral to the appropriate specialist service. 5) NHS Havering should meet with Practice 2 and 3 to discuss the overview report and plan a learning event to address the issues identified in it LAS 1) The Trust should provide feedback to the staff involved. 2) The Trust should highlight the circumstances in the Trust’s internal magazine; personally issued to all Trust staff, so to draw attention to the need to make a referral in these circumstances. Health Overview 1) Risk assessment pro-forma to be developed and rolled out to GP practices 2) Within all health organisations there is a need to strengthen the quality of supervision in line with national guidance (Working Together 2010 and Intercollegiate guidance 2010) and better staff support as ways of promoting professional judgement or supporting reflective practice 3) Medical Director and Designated nurse (NHS ONEL) should meet with Practice 1 to discuss the concerns identified in this report and develop an action plan to Exec summary Final 24 assess clinical quality in the practice with a view to a general improvement in standards. 4) All staff to be made aware of key domestic violence support services and referral processes. 5) All health agencies to review their escalation policies for safeguarding of children and vulnerable adults and contact details of designated and named safeguarding staff to be circulated. |
NC52252 | Serious injuries to a 10-week-old infant in early 2020. Medical examinations determined that the injuries were caused by inflicted trauma. Single agency learning includes: consistency of social worker to co-ordinate holistic and purposeful assessment of parenting capacity; robust supervision and management oversight to support social workers to reflect on progress of assessment and consider likelihood and severity of risks as well as strengths and protective factors; police officers should escalate their concerns about the action or inaction of another agency where they consider that a child remains at risk of significant harm; contemporaneous and comprehensive recording of discussions, plans and agreed actions for safeguarding and promoting the welfare of children, including discharge from hospital. Learning across the partnership includes: understanding and defining levels of need/statutory threshold; there is further work to do to improve the effectiveness of multiagency strategy discussions; embracing and resolving professional differences as an opportunity to share expertise, evaluate need/risk and promote a culture of shared accountability; need for a clear process for transferring child in need cases between local authority children's social care services; shared accountability needs to operate at an individual, organisational and system level; the need for professional knowledge of safeguarding legislation, guidance and procedures. Recommendations are embedded in the learning.
| Title: Child safeguarding practice review (CSPR): Child Alex. LSCB: Somerset Safeguarding Children Partnership Author: Liz Murphy Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 | P a g e Child Safeguarding Practice Review (CSPR) Child Alex Agreed by: Somerset Safeguarding Children Partnership in May 2021 Published by: Somerset Safeguarding Children Partnership in July 2021 Authored by Liz Murphy, Independent Safeguarding Consultant 2 | P a g e 1. Executive summary. About this review 1.1. This review has been completed following a 10-week-old child, who will be referred to as Alex, presenting at hospital in early 2020 with serious injuries. Medical examinations determined that the injuries were caused by inflicted trauma; the injuries are the subject of ongoing criminal investigation. 1.2. Alex was open to Somerset Children’s Social Care as a ‘child in need’ following a referral from Somerset NHS Foundation Trust who were caring for Alex following a premature birth at 31 weeks gestation. Alex was also an open case to Children’s Social Care in another area at the time the injuries were identified. Alex’s mother had moved to Somerset whilst pregnant to live with her new partner. Alex’s birth father lived in the area that Alex’s mother had moved from. There were professional concerns that birth father posed a risk of harm to children. 1.3. The statutory safeguarding partners decided to conduct a Child Safeguarding Practice Review (CSPR) to identify what can be learnt from how the safeguarding system responded to the issues in this case. The review has been facilitated by an individual who is independent of agencies in Somerset and of the other local authority area. The CSPR covers the period from when the hospital made a referral to Somerset Children’s Social Care, when Alex was one day old, up to the date Alex presented at hospital. 1.4. In response to the referral made by the hospital, Children’s Social Care commenced an assessment, and two strategy discussions were also held. At least two of the four agencies in attendance at the first strategy discussion understood S47 enquiries would be commenced; however, the assessment continued under S17 Children Act 1989. There is a lack of consensus about the outcome of the second strategy discussion. The perspective of every agency in attendance, other than Somerset Children’s Social Care, is that the outcome was that a S47 enquiry would commence. The perspective of Somerset Children’s Social Care is that the chairperson of the meeting agreed to discuss next steps with their line manager. This led to the hospital using the ‘Resolving Professional Differences’ protocol to explore the ongoing concerns they had for Alex. The day before the second strategy discussion, mother informed Children’s Social Care that she had ended her relationship with her partner and was returning to live in the local authority area she had come from. This information underpinned a decision by Children’s Social Care that no further safeguarding action was 3 | P a g e needed from them and the case should be transferred to Children’s Social Care in the other local authority area. The other local authority area agreed to complete a Child and Family Assessment. 1.5. Alex was discharged from hospital to the care of mother and they lived in the other local authority area for three days before returning to Somerset to live with mother’s partner. During this period, and up to the point that Alex was taken to hospital, both local authorities’ Children’s Social Care services were involved and initially there was consideration of a strategy discussion being held when Alex returned to Somerset. However, this did not take place as it was decided that the case would be monitored intensively for a week and then be reviewed. 1.6. The CSPR has drawn on a range of information and sought to creatively engage the views of frontline staff during the global pandemic. Family members were invited to contribute to the review and where they chose to do so, their perspective has informed the analysis and learning. The review has adopted a systems approach by going beyond identifying what happened and exploring the context in which professionals and organisations operated. This approach helps identify the factors in the safeguarding system that support good practice and those which create unsafe conditions in which poor safeguarding practice is more likely to occur. These ‘system’ insights are in turn used to inform the actions that can be taken to prevent or reduce the risk of recurrence of similar incidents. 1.7. Agencies have ‘self-identified’ a small number of learning themes to take forward on a single agency basis. However, the majority of learning arising from this case is partnership learning, i.e. it is applicable to all agencies. There are five key learning themes which are summarised below: • Understanding and defining levels of need/statutory thresholds. Future safeguarding practice will be strengthened by practitioners defining a child’s needs rather than describing these as the numerical levels referenced in the Effective Support Framework; this will promote a more shared and consistent understanding of levels of need; including children identified as ‘child in need’. • Strategy discussions. Future safeguarding practice will be strengthened by improving the effectiveness of multi-agency strategy discussions. 4 | P a g e • Embracing and resolving professional differences. Future safeguarding practice will be strengthened by practitioners and organisations recognising that differing professional views are an asset to multi-agency working particularly given what is known from research about errors in human reasoning. Valuing differing professional views will promote and strengthen the culture of partnership working. • Case transfer. Future safeguarding practice will be strengthened by a clear process for transferring ‘child in need’ cases between local authority Children’s Social Care services’. • Culture of partnership working and shared accountability. Future safeguarding practice will be strengthened by developing the culture of partnership working and individual and collective accountability for safeguarding children. 1.8. Professional knowledge of safeguarding legislation, guidance and procedures, including in relation to the threshold and decision-making processes in relation to s47 enquiries, is a common thread running through the five partnership learning themes and thus provides an overarching learning theme. 1.9. Agencies began to act on learning following the Rapid Review held after Alex sustained the injuries; an overview of the improvement actions taken to date is provided. The review concludes with an action timeline to take forward the partnership learning; progress and impact will, in accordance with statutory guidance, be publicly reported in a future Somerset Safeguarding Children Partnership (SSCP) twelve-monthly report. 2. Story prior to the incident and around the incident 2.1 A referral was made by the Somerset NHS Foundation Trust in respect of professional concerns about birth father following his visit to the hospital one day after Alex’s birth. The referral also outlined professional concerns regarding: I. Mother recently moving to Somerset to live with a new partner who was ‘unsure about the pregnancy and birth’ II. Mother’s own childhood experiences III. Mother’s emotional health and wellbeing including treatment during pregnancy for anxiety. 5 | P a g e 2.2 The case was accepted as a ‘child in need’ referral by Somerset Children’s Social Care and a Child and Family Assessment commenced. Early on, hospital staff were advised that the case did not reach a ‘safeguarding threshold’ as Children’s Social Care had no concerns about mother. Mother had initially been advised to use the Child Sex Offender Disclosure Scheme (CSODS) to obtain information about Alex’s father. The police considered that a CSODS disclosure would not address all the risks associated with the case and as a result a strategy discussion was convened. At least two of the four agencies in attendance understood that the outcome of the discussion was that enquiries would be completed under S47 Children Act 1989. This was because mother was not consenting to an assessment. A follow up strategy discussion was to be held 14 days later because the meeting concluded that further information was needed to determine if Alex was at risk of significant harm. This suggests that not all relevant information was available to the strategy discussion. The follow up strategy discussion did not take place as planned; the allocated Social Worker then went on a period of extended annual leave which meant the case was managed via a ‘duty’ system. Of note, this was during the Christmas and New Year holiday period when the service was operating with reduced staffing levels. 2.3 Following the first strategy discussion, staff involved in the care of Alex at the hospital identified concerns about the parenting capacity of Alex’s mother as well as concerns about her partner. The concerns centred around mother’s ability to prioritise Alex’s needs and indicators of controlling behaviour exhibited by her partner. Information available to the hospital also included that mother’s partner had threatened to kill maternal grandparents and he was not ready for Alex to come home and wanted mother to ‘give’ the child away. Mother, who was then aged 20 had, during her adolescent years, been subject of a Child Protection Plan due to neglect. Her younger siblings were currently subject of a Child Protection Plan due to neglect. Furthermore, domestic abuse between mother and maternal grandmother had been reported to the relevant police force; the most recent incident took place two months prior to Alex’s birth. Records indicate both parties were under the influence of alcohol at the time of the incident. Due to depression and anxiety, mother had begun receiving therapy from adult mental health services about one year before Alex’s birth; mental health services formally ended their involvement when mother moved to Somerset. Mother’s partner was arrested for domestic abuse related offending eight months prior to Alex’s birth. The victim reported that she had experienced domestic abuse over a 6 | P a g e three-year period. Mother’s partner subsequently pleaded guilty to Assault by Beating seven months prior to Alex’s birth. 2.4 There were ongoing discussions between Children’s Social Care and the hospital, with the hospital requesting that the follow up strategy meeting be re-arranged. The meeting was held on New Year’s Eve when the usual council offices were closed, and staff did not have access to a dedicated and private workspace for such meetings. Taking a ‘systems’ perspective, the conditions an employer provides/creates are a key factor that influence how staff are able to perform their duties. This, of course, does not mean that offices should not be closed during holiday periods, but it does require organisations to consider the impact of such decisions and, as required, identify solutions, e.g. co-locate staff in a building owned by a partner agency or alternatively use virtual platforms to host meetings as a way of facilitating the participation of partner agencies. 2.5 By the time of the second strategy discussion, mother had shared with professionals that she planned to leave her partner and return to her previous address which would mean Alex and mother would live with maternal grandparents. The strategy discussion included most, but not all relevant agencies; notable omissions were the GPs for both parents who could have shared information to support the ongoing assessment. There is professional disagreement about the outcome of the second strategy meeting. All attendees other than Somerset Children’s Social Care report that a decision was made to commence a s47 enquiry. Somerset Children’s Social Care report that the chairperson agreed to discuss next steps with their line manager. It was also agreed that due to the concerns about mother’s parenting capacity that Children’s Social Care would explore a mother and baby unit for Alex and mother to live after Alex’s discharge from hospital. After the meeting, Children’s Social Care decided “no further action” as the outcome of the strategy meeting, a decision was also made not to pursue a mother and baby placement. The rationale for these decisions was that mother was moving out of the area. By the time of the Discharge Planning meeting held a few hours later, the Children’s Social Care plan for Alex was for the case to be transferred to Children’s Social Care in the local authority area where Alex and mother would live. 2.6 The decision not to complete a s47 enquiry raised significant concerns for the hospital and they requested a copy of the minutes of the second strategy discussion. At the time, strategy meeting minutes were not consistently sent to agencies who were invited/ in attendance and this meant that some of the other 7 | P a g e partners who attended the second strategy discussion were not aware that a s47 enquiry was not being completed. From the hospital’s perspective, the minutes did not reflect the discussion that took place as they record the outcome as ‘no further action from this process’. The hospital escalated their concerns about the decision not to conduct a s47 enquiry using the ‘Resolving Professional Differences’ protocol. This resulted in discussions between the hospital and Children’s Social Care, it was agreed a meeting would be held and the hospital were asked to refer Alex to Children’s Social Care in the area to which mother was returning to live. This referral was initially not accepted as the other Children’s Social Care understood that Somerset were conducting a S47 enquiry as agreed as per their understanding of the outcome of the second strategy meeting. However, due to the concern that Alex was ‘mobile’ and could fall between local authorities, the other local authority subsequently agreed to accept the referral and a Social Worker was allocated to complete an assessment. Prior to the other local authority deciding to undertake an assessment, the hospital and Somerset Children’s Social Care met. The hospital perspective is that this meeting was held under stage two of the Resolving Professional Differences protocol. The professional differences about the plan for Alex ultimately remained unresolved. The hospital escalated their ongoing concerns to an Operations Manager in Children’s Social Care, although the matter was not escalated to Senior Leaders within the hospital. The discussions between the Operations Manager and the hospital diffused the professional differences as the hospital were advised that the local authority where Alex and mother would live upon Alex’s discharge would assume case responsibility and that Somerset Children’s Social Care would conduct a home visit to Alex and mother that evening following discharge. 2.7 Alex and mother returned to live with maternal grandparents for three days before returning to Somerset to live with mother’s partner. The allocated Social Worker in Somerset returned to work the day prior to Alex’s return to Somerset. The assessment was concluded by the social worker on the day she returned and concluded that no further work was required from statutory social work services in Somerset as mother and Alex had moved out of the area. The social work assessment records Alex’s assessed level of need as ‘additional’ or level 2 as set out in Somerset Safeguarding Children Partnership (SSCP) Effective Support for Children and Families in Somerset framework; however, information provided to the review indicated that level 2 was selected in error. The actual level of Alex’s assessed need upon completion of the assessment is unclear. 8 | P a g e 2.8 Children’s Social Care in the other local authority area allocated the case so a Child and Family Assessment could commence; in response, Somerset Children’s Social Care advised that they would end their involvement. 2.9 Following Alex’s return to Somerset, Children’s Social Care established a schedule of expectations with mother which, amongst other things, required mother not to leave Alex alone with her partner. Mother was also requested to register Alex with a GP which she did three days after her return to Somerset; prior to this Alex was not registered with a GP. Somerset Children’s Social Care and Public Health Nursing (Health Visiting) liaised and initially Children’s Social Care indicated the plan was to convene a strategy discussion however, the following day, a decision was made to monitor the case intensively for one week with a view to ‘step down’ to the Family Intervention Service. 2.10 The Somerset Social Worker and the Public Health Nurse independently visited Alex at home and the Social Worker from the other area had phone contact with mother. Somerset Children’s Social Care agreed with the other local authority Children’s Social Care to take case responsibility now Alex had returned to Somerset. Seven days after returning to Somerset, Alex presented at hospital with serious and unexplained injuries 3. Application of relevant research, policy and other reviews 3.1. The subject child in this case was a young baby; Somerset Local Safeguarding Children Board (LSCB) has previously conducted Serious Case Reviews (SCRs) into the death/ serious harm of a number of very young children. The learning from these and other Serious Case Reviews, as well as research in relation to the key themes arising from this CSPR, are set out below. 3.2. Babies are entirely reliant on their parents/caregivers to keep them safe; a point highlighted by Ofsted’s Chief Inspector to the Association of Directors of Children’s Services Annual Conference in November 2020. The Children’s Commissioner1 has also highlighted younger children living in families where there are known vulnerabilities and risk factors are at greater risk compared to older children in the family. This is because very young children are fragile, cannot speak and, unlike older children, they do not attend universal services, 1 A Crying Shame. A report by the Office of the Children’s Commissioner into vulnerable babies in England. October 2018 9 | P a g e such as education. This means that despite their increased vulnerability, they can be invisible to professionals. 3.3. Babies are disproportionately represented in SCRs2 and research also provides a knowledge base to inform assessment and decision making. The risk of a child being abused within the first thirteen months of life is fourteen times higher when parents have been abused themselves as children, are under 21-years-old, have a history of mental illness or depression and are living with a violent partner3. Weak risk assessment and poor decision making were identified as a major practice theme by the Child Safeguarding Practice Review Panel in their first annual report 4 alongside poor escalation of concerns or disagreement between Children’s Social Care services and practitioners from health and education. The National Panel also report that the professionals who know the most about a child are often not those who have statutory powers to investigate and assess thus reinforcing the significance of their finding about the critical importance of comprehensive risk assessment and defensible decision making. 3.4. SCR L & J5, published in 2017 by Somerset Safeguarding Children Board, contains learning that is pertinent to the analysis of this CSPR and which is therefore still relevant to the Somerset Safeguarding Children Partnership. Key findings from SCR L & J include strengthening guidance on strategy discussions to provide clarity about when a face-to-face meeting should be held; standardising how decisions made at a strategy meeting are recorded and shared with those who participated and those involved in the case but unable to attend. Like the National Panel’s annual report, SCR L & J also identified the significance of comprehensive assessment of need/risk in relation to babies and young children, including assessing the vulnerability of young parents. 3.5. Nationally, a number of SCRs have highlighted the vulnerability of children in need when their family moves between local authority areas6. Statutory 2 Sidebotham et al (2016), Triennial analysis of serious case reviews. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/533826/Triennia l_Analysis_of_SCRs_2011-2014_-__Pathways_to_harm_and_protection.pdf 3 Risk factors of parents abused as children: a mediational analysis of the intergenerational continuity of child maltreatment (Part 1).’ Journal of Psychology and Psychiatry 46, 1, 47–57. 2005. Dixon L., Browne K.D., Hamilton-Giacritsis, C 4 The Child Safeguarding Practice Review Panel: First Annual Report. 1 Annual Report 2018 to 2019 5 https://library.nspcc.org.uk/HeritageScripts/Hapi.dll/retrieve2?SetID=68074A0F-81FD-473F-A519-176D16866D41&searchterm=somerset&Fields=%40&Media=%23&Bool=AND&SearchPrecision=20&SortOrder=Y1&Offset=2&Direction=%2E&Dispfmt=F&Dispfmt_b=B27&Dispfmt_f=F13&DataSetName=LIVEDATA 6 Johnson, Fiona and Doherty, Jane (2017) Report of the serious case review regarding Child J. Luton: Luton Safeguarding Children Board 10 | P a g e guidance7 requires the original authority to share all relevant information with the receiving local authority as soon as possible. The receiving authority should, based on a timely re-assessment of the child’s needs, consider whether support services are still required. Support should continue to be provided by the original local authority in the intervening period. 3.6. Statutory guidance7 requires the safeguarding partners to publish a threshold document which sets out the local criteria for action in relation to children and families. The professionals involved in this CSPR have had the opportunity to reflect on the SSCP Effective Support for Children and Families in Somerset and have identified that at Level 4 there is a stronger emphasis on ‘child protection’ compared to ‘child in need’, e.g. the framework does not include a definition of ‘child in need’ as set out in the Children Act 1989. In addition, the descriptors of Level 4 need are more focused on children over one year of age. 3.7. The All-Party Parliamentary Group for Children Inquiry ‘Storing Up Trouble: A postcode lottery of children’s social care’ has a range of findings that are relevant for statutory safeguarding partners to consider in both the development and oversight of the local threshold framework including: I. Evidence that thresholds for accessing Children’s Social Care are rising alongside differing perspectives between social workers and Directors of Children’s Services about whether thresholds for accessing statutory services have risen. II. Financial concerns and availability of resources at least implicitly influence decisions to intervene to support children and families. 3.8. It is important to state that this review has neither considered, nor identified, budget pressures as impacting on professional practice however, there is feedback from the practitioner survey, as well as those who contributed directly to the review, that: a) Partner agencies consider that thresholds for accessing Children’s Social Care have risen and this issue is an area of frequent professional debate and at times disagreement. 7 Department for Education (DfE) (2018) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). [London]: Department for Education (DfE). 11 | P a g e b) Volume of work in the relevant Children’s Social Care team was experienced as high during the period when Alex was discharged from hospital. Staff absence over the holiday period will also have been a factor as cases needed to be managed via a duty system. 3.9. Research and learning on thresholds can therefore highlight system conditions that can helpfully be explored at a local level to understand the context in which professionals are operating including how decision making may be influenced by these factors. 3.10. Research into patterns in human judgement/reasoning draws attention to the psychological limitations of human beings and how these can negatively affect thinking and reasoning. Given the assessment of safeguarding needs is reliant on the exercise of professional judgement, the findings from this research reinforce the value and importance of supervision and multi-agency working as tools that can be used to appraise the accuracy of an individual’s thinking or, in the words of Professor Munro8, ‘good reasoning is the responsibility of the whole agency and not the individual’. Common errors in human reasoning include tunnel vision9 which is the tendency of people under pressure to narrow down their focus as a means of making the task manageable. This has the benefit of allowing professionals to stay focused on one part of a case but has the weakness of making them slow to notice issues arising outside that narrow focus. In this case, it has been identified that the focus of the first strategy discussion was on the risks posed by birth father as opposed to a wider assessment of Alex’s needs. This ‘tunnel vision’ impacted on subsequent decision making in that an assessment of mother’s parenting capacity had not been completed prior to Alex’s discharge from hospital or case transfer. 4. Single agency learning and conclusions. 4.1. The organisations that contributed to this CSPR are set out overleaf in Table 1 alongside a summary of the key learning identified for their organisation based on their reflections of this case. Agencies also identified learning in relation to inter-agency working. There was a high level of congruity in the learning themes 8 E.Munro 2008 “improving reasoning in supervision” Social Work Now, Issue 40, August 2008, pp3-10. 9 S.Dekker (2002), The Re-invention of Human Error Technical Report 2002 -01, Ljungbyhed, Sweden: Lund University, School of Aviation. 12 | P a g e that partners identified that need to be taken forward across the partnership. These are set out at Section 5. Table 1 Agency Key learning What needs to happen Evidence the organisation will use to test that learning has been embedded Somerset Children’s Social Care Consistency of social worker to co-ordinate holistic and purposeful assessment of parenting capacity. Robust supervision and management oversight to support social workers to reflect on progress of assessment and consider likelihood and severity of risks as well as strengths and protective factors. Clear management oversight upon allocation and review of this at any key points such as worker absence or change in family circumstances. Provide high quality reflective supervision training for all supervisors – this is mandatory for those who have not had recent supervision training. Systemic training is also available to managers to support the quality of analysis and reflection within supervision. Motivational interviewing training to be rolled out to support staff and managers to work in a strengths-based way. Bi-monthly Practice Evaluations (case file audits) will consider the quality of assessments, management oversight and consistency of social work intervention. Outcome of audit of supervision in April 2021. Avon and Somerset Police Police Officers, like other professionals, should escalate their concerns about the action or inaction of another agency where Through the launch of the new process for Police Protection Powers, review the use of, and publicise, the Resolving Professional Audit use/application of Resolving Professional Differences Policy/ Procedures as part of the evaluation of 13 | P a g e they consider that a child remains at risk of significant harm. Differences policy/ procedures across the Avon and Somerset region. wider Police Protection Powers process. Other Local Authority Contemporaneous and comprehensive recording of discussions, plans and agreed actions for safeguarding and promoting the welfare of children, including discharge from hospital. For children discharged over weekend/holiday period, this information becomes more critical if EDT are to be notified or are contacted. Dedicated reflective learning event related to the findings from this CSPR will be held with multi-agency staff in the MASH with particular emphasis on the quality and depth of recording when case responsibility is not clearly held at transition points. Audit of cases where children are discharged out of hours to assess the handover to day services. Audit of cases where there is cross-boundary referral to assess the quality of planning and handover of responsibility. General dip sample audit to test the quality of “whole episode” recording. Somerset NHS Foundation Trust When recording concerns about a child, the nature of the concern and an evaluation of its impact on the child’s safety and wellbeing should be recorded rather than simply a description or narrative of what constitutes the concern. Greater use and understanding of Effective Support for Children and Families Develop a) Neonatal Intensive Care Unit (NICU) safeguarding document integral to this should be a patient/service user risk assessment tool documentation to promote clarity and analysis of level of need including risk and protective factors. Integrate the Effective Support for Children Audit of: - a) NICU clinical records b) NICU safeguarding document Safeguarding Supervision Audit Use of Effective Support for Children and Families in Somerset guidance audit. Review of Resolving Professional Differences escalations. S11 Audit 14 | P a g e in Somerset guidance to support a wider understanding of concerns/needs between agencies as well as with families. and Families in Somerset guidance within Trust Polices, Standard Operating Procedures, Safeguarding Supervision, L3 Training and referrals and reports for Children’s Social Care. Review of serious incidents to evaluate use and application of Effective Support for Children and Families in Somerset guidance. Use of situation, background, assessment and recommendations (SBAR) tool by Safeguarding Service. Somerset Public Health Nursing (PHN) Health Visitors, once aware of a baby’s admission to NICU, to participate in regular liaison with the family and NICU to build a relationship with the family and to contribute to assessments of the child’s needs and subsequent service planning. Confirm and disseminate the process for timely notifications from NICU to the PHN Service for babies that are in NICU. Develop and disseminate a narrative to inform Health Visitor (HV) contact and assessments for babies in NICU to include weekly contact with parents and NICU in addition to core contacts. Health Visitors once aware of a baby’s admission to NICU to participate in regular liaison with the family and NICU to build a relationship with the family and to contribute to Agreed process for NICU to inform PHN of babies admitted to NICU. Number of incident reports where a health Visitor has not been notified of a baby’s admission to NICU. Compliance with weekly and mandated core contact for babies in NICU. Audit of clinical records to monitor assessment of need and service planning (completed as part of annual record keeping audit). 15 | P a g e assessments of the child’s needs and subsequent service planning. Somerset and other area CCGs GP registration questionnaires to capture information about vulnerability (NB this links to learning from a previous SCR where a looked after child from another area placed in Somerset died). Explore known risks and vulnerabilities when a woman becomes pregnant/ gives birth and further develop awareness and application of pre-birth safeguarding protocol/ standard operating procedure. Discuss with GPs and Local Medical Committee (It is recognised this is a complex piece of work as the registration form is not a national form). Named GPs for Safeguarding Children in Somerset and other Local Authority area to use the learning from this case to support exercise of professional curiosity, identification of risk/vulnerability factors and application of pre-birth safeguarding protocol. Change to registration form and evidence of its use across Somerset and practice (this may take some time to fully achieve). Deep dive/audit, in conjunction with Public Health Nursing, to evaluate use of pre-birth protocol where safeguarding concerns have been identified. 4.2. The learning that will be taken forward within individual agencies will support them to deliver their statutory responsibility to safeguard children by strengthening capacity to: • Contribute to and/or co-ordinate assessments. • Exercise professional curiosity. • Explore and challenge professional thinking and decision making. • Build relationships with parents/carers. • Evaluate need/risk. • Develop plans to promote children’s safety and well-being. 16 | P a g e 5. Partnership Learning and conclusions 5.1. The analysis of multi-agency safeguarding practice in this case identifies five learning themes, with a sixth, professional knowledge of safeguarding legislation, guidance and procedures, underpinning all five themes. These learning themes have wider application and can therefore be used to improve future multi-agency safeguarding. They are set out at Table 2 below. Table 2 Learning Theme Why did the review identify this learning theme? Understanding and defining levels of need/statutory thresholds: - The analysis of this case and the findings from the practitioner survey completed as part of this CSPR, and discussions with partner agencies, indicate that there is further work to do to ensure a shared and consistent understanding of levels of need; including children defined as a ‘child in need’ in accordance with Children Act 1989. 1. In this case, the level of assessed need changed significantly and rapidly with likely or actual risk of significant harm being considered but a safeguarding response was not progressed as the level of need was then re-evaluated. To illustrate, a ‘schedule of expectations’ was put in place to manage risk however the following day, the professional thinking was to manage the case at Early Help level of need. The difference of opinion amongst professionals about Alex’s level of need following the second strategy discussion is an example of the needs of the child not being clearly defined and agreed. The review found that professionals currently use numerical ‘levels’, e.g. ‘Level 4’, to describe a child’s needs rather than describe the concerns and critically, the impact of these on the child’s health and development. This practice will impede a shared understanding of the needs of individual children and families amongst professionals. A lack of clarity about a child’s needs will in turn impact on the quality of decision making. 2. A local practice norm appears to have been established whereby ‘Level 4, currently described as ‘acute’ in the Effective Support Framework, is perceived as ‘child protection’ as opposed to a level of need that requires a statutory social work response. The review found limited understanding of the legal definition and statutory duties in relation to ‘child in 17 | P a g e need’; this is reinforced by the limited focus on ‘child in need’ in the Effective Support Framework. In this case, the local authority determined at the outset that there were no concerns about mother that met a ‘safeguarding threshold’. The focus in the first strategy discussion on the ‘child protection’ risk that father presented appears to have resulted in ‘tunnel vision’ and so a limited focus in the Child and Family Assessment on the broader risk factors that had been identified in relation to mother’s parenting capacity. 3. Family member contribution to the CSPR reinforces the need for practitioners to think holistically and define the needs of a child. In situations where a parent is considered to present a risk to a child, an assessment of the child’s need for safety, right to family life, protective factors, including the impact of any rehabilitation programme in managing risk, is a more appropriate response to securing a child’s welfare than offering advice that no contact should take place between a child and a parent who is considered to pose a risk. Strategy Discussions: - The analysis of this case, previous SCR learning and a multi-agency audit completed in November 2019, indicate that there is further work to do to improve the effectiveness of multi-agency strategy discussions. 1. Invitations – Not all relevant agencies were invited to contribute to strategy discussions; this has been identified in previous local SCR learning and audit activity. There is a need to increase understanding of the health system to move away from the current practice of one health professional being invited to represent ‘health’ and for the GP for both child and parents/carers to be routinely invited. 2. Organisation –The chairing and minuting responsibilities rest with one individual. Ideally these tasks should be separate to allow the chair to focus on facilitating the meeting. There is an inconsistent approach to distributing the record of the strategy discussions to those agencies in attendance/invited, with most partners in this and other cases, not receiving the record of the meeting. This was significant in this case as it meant that some partners were not aware a s47 enquiry had not commenced following the second strategy meeting. The working environment in the lead agency during the holiday period did not provide the conditions conducive to a good quality strategy discussion. The review has identified that a 18 | P a g e creative solution would be to co-locate staff during office shutdown in a suitable office environment in another partner agency or to use a virtual platform to host such meetings. 3. Structure – There is a need for a consistent approach to the conduct of strategy discussions, including explicit consideration of the significant harm threshold. It has been suggested that strategy discussions in respect of cases held in the First Response Team are more structured because this team has dedicated staff who regularly participate in strategy discussions. Effective strategy discussions require practitioners to have the required level of knowledge and confidence to contribute as required. In addition, partner agencies should provide the context to information held on their records, e.g. nature and details of offences committed in addition to conviction details or the impact of compromised parenting on the child’s health and development. 4. Decision making – strategy discussions should conclude with clear actions, timescales, and decision making, including the rationale for decisions made in respect of actual or likely significant harm. This is because action taken under S47 Children Act, 1989 can only be effective if it is clear, purposeful and timely. Defining why or why not the actual or likely significant harm threshold is met provides a shared framework to inform the scope of the S47 enquiry/Child & Family Assessment, future decision making and clear parameters to explore any future professional differences. 5. Governance – In this case, there is a lack of consensus about the outcome of the second strategy meeting and Somerset Children’s Social Care determined ‘no further action’ as the outcome of the strategy meeting. In the future, and as required by statutory guidance, any decision as to whether to conduct a S47 enquiry or not, should be made at a strategy discussion, involving all relevant partners. 19 | P a g e Embracing and Resolving Professional Differences: - The analysis of this case and the findings of the practitioner survey completed as part of the CSPR indicate there is further work to do to support organisations and professionals to embrace ‘difference’ as an opportunity to share expertise, evaluate need/risk and promote a culture of shared accountability. 1. The fifth learning theme for the partnership is in respect of the culture of partnership working (see page 19) or in other words ‘how’ partners work together. Research provides insight into the common errors in human thinking. Nobody is immune from making such errors and in fact, busy work environments could make them more likely. Respecting different disciplines, involving all relevant professionals and working through any differences of opinion promotes good safeguarding decisions and outcomes. This approach will maximise the capacity of the partnership to safeguard children and should mean that use of ‘formal’ resolution processes become the exception because the cultural norm is one of mutual engagement and cooperation to deliver the common purpose of safeguarding children. 2. There is also learning from this and other cases in relation to when professionals do need to use a formal process to resolve differences. Professionals responding to the practitioner survey reported varied experiences of using the Resolving Professional Difference protocol. Positively, most professionals knew about the protocol; however, those who had used the process, had mixed experiences of its effectiveness. Some of the feedback includes a perception that its use could create a barrier to positive working relationships, and it is a time consuming/ bureaucratic process. This feedback is again relevant to the culture of partnership working. Enablers to the effective use of the protocol were identified as agencies being reflective and open to differing perspectives and recognition that use of the professional difference protocol does not equate to criticism of another professional. In addition, the CSPR has identified that the language used in the document, i.e. ‘challenger’ and ‘challenged’, could convey a message that the process is adversarial as opposed to one that is designed to promote good safeguarding outcomes. 3. There were three factors that informed the use of the Resolving Professional Difference Protocol which are set out below; they remained unresolved despite the use of the Protocol: 20 | P a g e i. Different understanding about the outcome of the second strategy meeting. ii. Concerns about how safe Alex would be if discharged into mother’s care. iii. The accuracy of the record of the second strategy discussion. Despite the use of the Resolving Professional Differences protocol, there was no multi-agency reconsideration of Children’s Social Care’s decision not to complete a S47 enquiry, there was no plan in place to support mother to care for Alex upon discharge and the record of the second strategy discussion has not been updated to reflect the professional difference about the outcome of the meeting. If Alex’s needs had been more clearly defined by partner agencies at the strategy discussions, it is considered that the concerns in relation to decision-making could have been more effectively explored and resolved by partners. 4. In addition, there were gaps in the application of the protocol in this case, e.g. no manager from the agency receiving the challenge attended a meeting to explore the professional differences and there was no further escalation within the organisation making the professional challenge. Furthermore, when the matters were not resolved at stage two, the case did not formally progress to stage three and instead, further discussions took place at stage two. This indicates further work is needed to increase professional knowledge of the protocol. It is considered that the protocol would be enhanced by providing guidance on the roles of those who should be involved at the various stages of the protocol. In light of learning from this and other cases, the SSCP, in conjunction with practitioners, is reviewing the Resolving Professional Differences protocol. They may, given the feedback from practitioners, wish to take the opportunity to also review the timescales set out in the current version of the protocol as there may be times when there is a need to resolve issues sooner than the timescales that are currently prescribed in the protocol. 21 | P a g e Case Transfer Protocol: - The analysis of this case indicates that there is a need for a clear process for transferring child in need cases between local authority Children’s Social Care services. 1. In this case, the decision to transfer the case to the local authority covering the area where Alex and mother would reside after Alex’s discharge was based on the fact that Alex would not be residing in Somerset as opposed to the Child and Family Assessment being completed in full. This decision was made immediately after the second strategy discussion. However, the minutes of the second strategy meeting indicate that further information was required from Police and record the professional concerns of the hospital, Police and Children’s Social Care about Alex being discharged to mother’s care at maternal grandparents’ home. 2. Feedback to the review was that it ‘felt like there was something missing’ from the assessment. To illustrate, it was through the rapid review process initiated in response to Alex being seriously harmed that the full extent and nature of the domestic abuse concerns about mother’s partner were identified. Assessments, informed by information held by and the expertise of all partners, should be completed in full by the original authority to identify needs prior to case transfer. Family member contribution to this review reinforced this learning point, in particular for known risk indicators to inform decision making. 3. The SSCP Children Moving Across Local Authority Boundaries procedures covers child protection cases, however, it does not address ‘child in need’ cases. Guidance on this issue will assist all agencies to understand the process to follow when cases are transferred between local authority areas because children move out of the area. 4. The case transferred without determining a date of transfer of responsibility and led to two local authorities having open cases with both making contact and arranging visits to Alex. This is confusing for children and families and results in a lack of clarity about case responsibility. 22 | P a g e Culture of partnership working and shared accountability: - The learning theme that supports all the learning arising from this CSPR is in respect of the culture of partnership working and shared accountability for the partnership’s common purpose of safeguarding children. The review reinforces that shared accountability needs to operate at an individual, organisational and system level. 1. This case, like any other, illustrates that the ‘way’ partners work together is equally and arguably more important than the processes that are in place to promote the safety of children. Whilst the local authority is the lead agency in terms of safeguarding activity, all partners have a responsibility to assess need, to contribute to decision-making and to provide interventions to children and families. When exploring the culture of partnership working in Somerset, one comment made was ‘partnership is meant to be joint, some people are more equal than others’. Whilst this is feedback from one individual, it serves as a powerful reminder, that the way partners work together is fundamental to how safeguarding services are delivered and so their effectiveness. The multi-agency CSPR Panel have positively identified that a future focus on developing the culture of ‘partnership working’ will have a greater impact improving practice and outcomes than purely focusing on ‘process’ focused actions. The reviewer considers that this insight and openness is refreshing and ambitious. 2. In terms of shared accountability, the review identified that, in this and other cases, a decision to proceed to S47 enquiries appears to provide a sense of security for partner agencies that a child will be safeguarded through this process and by Children’s Social Care. S47 enquiries and Child and Family Assessments, whilst led by the local authority, require the planned contribution of relevant agencies; for s47 enquires, this should be agreed at a strategy meeting. The local assessment protocol addresses the need to plan for and secure the contribution of all relevant partner agencies to Child and Family Assessments. The review debated the extent to which a ‘refer on’ mindset exists amongst professionals and organisations; and how a cultural change programme could promote greater shared accountability for individual children and families and across the system. As a result of the reflection on this case, a Partnership Forum will be held to explore how partners work together and the experiences of children and families who receive help; this is a positive 23 | P a g e action, as is the intention to use expertise from other partnerships to shape and inform this work. 3. In terms of organisational accountability, employers have a responsibility to ensure that their staff are knowledgeable about, and can apply, safeguarding law, statutory guidance and procedures. There were examples in this case, reinforced by those professionals who contributed to the review, that there are gaps in relation to knowledge in these areas, e.g. S47 enquiry to be completed as mother not ‘engaging’ as opposed to the threshold for significant harm (actual/likely) is met. There is also learning for organisations about the environment that they provide for their staff, e.g. reflective supervision. The dissemination of learning from this CSPR provides an opportunity for organisations to review what else they can do to support practitioners to have the knowledge, tools and environment needed to support good safeguarding outcomes. Regular engagement with practitioners, especially at a partnership level, will provide the opportunity for the safeguarding leaders to be sighted on the experiences of frontline staff. 4. Finally, the statutory safeguarding partners, in their strategic leadership role, have a collective responsibility to oversee continuous improvement of the safeguarding system. An audit of strategy discussions completed in November 2019 identified similar learning to that identified by this review. This finding provides statutory partners with the opportunity to reflect on how learning from audits, and possibly learning from serious incidents, has been/is being used. Statutory partners could also explore the arrangements to evaluate the impact of training on professional knowledge and practice given the overarching learning theme identified by the review. 24 | P a g e 6. Learning already implemented 6.1. The CSPR has identified a range of activity that has been initiated in response to the incident that led to this CSPR including: • Establishing multi-agency pre-birth tracking meetings. • Reviewing the pre-birth toolkit; including discharge planning meetings. • Determining a timeframe (24 hours) for the distribution of strategy meeting minutes. • Public Health Nursing and Somerset NHS Foundation Trust have devised a process to confirm strategy meeting minutes have been received and reviewed by those who were in attendance. • Public Health Nursing and Somerset NHS Foundation Trust are developing health-specific strategy meeting guidance. • Review and update of the guidance and templates for strategy discussions for Children’s Social Care professionals and a workshop with Children’s Social Care management group to support good practice. • Practice evaluations to explore Children’s Social Care practice in relation to children under two years of age. • Multi-agency supervision provided by Children’s Social Care Quality Assurance Lead, Public Health Nursing, Somerset NHS Foundation Trust and Midwifery Named Nurses for safeguarding children; in due course, the Named Doctor from Somerset NHS Foundation Trust will also be involved in this collaborative arrangement. • Development of a module-based workbook to help professionals focus their intervention when working with families where there is an unborn baby or infant. • Discussions between CCG and Children’s Services to develop an approach to invite GPs to all strategy discussions have commenced. 6.2. At the time of writing, it is several months since Alex was injured and it is recognised that evidence of the impact of the above activity will be, at best, in its 25 | P a g e infancy, as time is needed to both embed and evaluate new ways of working. SSCP will in due course need to determine the most appropriate way to seek and provide assurance about the impact of single agency learning. 7. Action timeline for implementation of learning and development. A focused set of actions to take forward the learning has been developed by agencies in Somerset as part of this review. They are set out below along with proposed timeframes: 1. Strategy discussions a) SSCP Strategic Plan to reflect strategy discussions as a strategic improvement priority for 2021-22 and to include outcome measures to evaluate the impact of work completed. Leads - Chair of Partnership Business Group/SSCP Business Manager Deadline - 31/03/2021. b) Multi-agency task and finish group to develop a revised strategy discussion process including: (1) Template for recording the outcome; including the agreed contribution of partner agencies to any assessment of need/risk. (2) Invitation lists. (3) Template for record of the strategy discussion and timeliness of its distribution. (4) Arrangements and circumstances for dedicated minute takers to record strategy discussions. Lead – Head of Assessment and Safeguarding, Children’s Social Care Deadline – This work is already in progress, deadline for completion is 31/03/2021. c) Develop a webinar that supports front line practitioners to have the knowledge and confidence to effectively contribute to strategy discussions. Lead - SSCP Training Manager with support from Workforce Development Group. Deadline - 30/04/2021. d) Evaluate the impact of improvement activity in respect of strategy discussions. 26 | P a g e Lead – SSCP Training Manager – evaluation of impact of learning and development opportunities. Lead – Chair of Quality and Performance Subgroup Deadlines – evaluation of impact of learning and development opportunities to begin on roll out of learning and development - May 2021 onwards. Multi-agency audit to evaluate quality and effectiveness of strategy discussions to be completed by the end of March 2022. e) Somerset Children’s Social Care to provide learning opportunities for managers within the service to support them to chair and minute strategy meetings effectively. Leads - Head of Service, Quality Assurance, Children’s Social Care/Head of Assessment and Safeguarding, Children’s Social Care. Deadline - This work forms part of an ongoing rolling programme for managers, deadline for completion is 30/11/2021. 2) Levels of need/statutory thresholds a) SSCP Strategic Plan to reflect Effective Support for Children and Families in Somerset guidance as a strategic improvement priority for 2021-22 and to include outcome measures to evaluate the impact of work completed. The focus of this priority should be on defining the needs of children and families and understanding the extent to which there is shared understanding of levels of need and how assessment of need is used to inform decision making and step up/step down activity by all partner agencies. Leads - Chair of Partnership Business Group/SSCP Business Manager plan. Deadline - 31/03/2021. b) A multi-agency task and finish group to be set up to review the Effective Support for Children and Families in Somerset guidance, to include a focus on needs not thresholds and to expand on the definition of child in need. Lead – Chair of Partnership Business Group. 27 | P a g e Deadline – 31/03/2021 to establish group; 30/12/2021 to revise the Effective Support for Children and Families in Somerset guidance. c) Use local protocol for assessment to support the implementation of the practice learning in relation to planning and securing the contribution of all relevant partner agencies to assessments completed under Section 17 and 47 of Children Act, 1989 . Lead – Chair of Learning and Improvement Subgroup supported by Independent Scrutineer. Deadline – 30/04/2021 for discussion at Learning and Improvement Subgroup. 30/06/2021 for work to increase knowledge of local protocol for assessment. d) Create opportunities for frontline practitioners to learn/reflect on ‘real’ cases including the benefit of multi-agency collaboration in making decisions. e.g. Multi-Agency Professional Interest Groups (MAPIGs). Lead - Chair of Workforce Development Group. Deadline - 31/05/2021 e) The Somerset Safeguarding Children Partnership to create opportunities for multi-agency case review involving safeguarding children supervisors/ safeguarding leads, with a focus on reviewing real life cases and learning from good practice, e.g. safeguarding conversations. Lead - Chair of Learning and Improvement Subgroup Deadline - 31/05/2021 3) Professional understanding of the health system a) Statutory partners to agree a programme of activity to develop a shared understanding of the different components of the health system and the contributions they can each make to information sharing, assessment and decision making; this should include emphasising the pivotal role of GPs. Lead - Chair of Health Safeguarding Children Partnership, supported by a range of multi-agency partners as part of a workshop approach. Deadline - 30/03/2021 28 | P a g e 4) Embracing professional difference a) Statutory partners, in conjunction with frontline practitioners, to revise the Resolving Professional Differences protocol and co-produce with multi-agency practitioners the principles that should underpin the use of the protocol. Lead - SSCP Business Manager Deadline - 31/03/2021 5) Case transfer a) Statutory partners to share the learning about transferring child in need cases with the Avon and Somerset Strategic Safeguarding Partnership and explore the development of a South-West region ‘child in need’ case transfer protocol. Lead - Chair of SSCP Executive Deadline - End of April 2021 to present to Avon and Somerset Strategic Safeguarding Partnership; subsequent actions and deadlines to be agreed by Avon and Somerset Strategic Safeguarding Partnership. 6) Culture of partnership working. a) Recognising that cultural change is achieved over a sustained period, statutory partners through a weeklong Partnership Forum to explore the system conditions, including infrastructure, that will lead to strengthened partnership working and a shared accountability for improving outcomes for Somerset’s children at all levels of the system. The outcome of the Forum should inform a cultural change programme which will involve all partner agencies. Lead - Chair of Partnership Business Group Deadline - June 2021. February 2021 |
NC046081 | Serious injury of an 11-week-old baby. Mother took Child D to hospital with a fractured arm. X-rays identified a number of old fractures sustained when Child D was about one month old. Child D was taken into foster care; mother and father were arrested and charged with neglect and causing or allowing Grievous Bodily Harm (GBH). The case was later dismissed due to the non-availability of a key witness. Mother had been physically abused and neglected as a child and had spent time in care. Her family had a history of violence and criminal activity and her parents had placed pressure on her to terminate her pregnancy. The mother was 17-years-old when she became pregnant with Child D and her partner was substantially older. Identifies findings including: a target focused culture resulted in a lack of critical analysis when conducting assessments; GP's assessment of Child D's development did not consider potential child protection implications; and lack of professional consideration of the impact of living in an environment of violence and criminal activity on Child D, partly due to professionals repeated exposure and desensitisation to the issues. Uses the Social Care Institute for Excellence (SCIE) Learning Together model to pose questions to Haringey Local Safeguarding Children Board. Includes the action plan the LSCB drew out in response.
| Title: Serious case review: in respect of Child D. LSCB: Haringey Local Safeguarding Children Board Author: Ann Duncan and Ghislaine Miller Date of publication: [2015] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review under Working Together 2013 In respect of Child D Agreed at the Serious Case Review Panel May 2014 Authored by: Ann Duncan and Ghislaine Miller Independent lead reviewers 2 CONTENTS SECTION 1: INTRODUCTION Succinct Summary of the Case Methodology SECTION 2: FINDINGS Timeline of Significant Events Appraisal of Practice: a Synopsis Summary of Findings Findings in Detail 3 1. Introduction 1.1 Why this case was chosen to be reviewed On 29th April 2013 Child D’s mother noticed that Child D, then aged 11 weeks, was not moving their left arm and contacted her GP who advised her to attend the Accident and Emergency Department (A&E) Child D was admitted and was found to have a fractured left radius and ulna. A referral was made to Children’s Social Care (CSC). Child D had a skeletal X-ray that showed a number of old fractures. These included probable fractures of the 7th and 8th left ribs and of the 5th, 6th and 7th ribs. There was also a possible fracture of the left tibia. These injuries had been sustained when Child D was approximately one month old. Both Child D’s mother and her partner, Mr H, were arrested and were charged with neglect and causing or allowing Grievous Bodily Harm (GBH) to take place. The Named Doctor from the hospital made a referral to the Serious Case Review Panel (SCRP) of the LSCB to consider whether this case met the criteria for conducting a review under Working Together 2013, namely, where: (a) abuse or neglect of a child is known or suspected; and (b) there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. (Working Together to Safeguard Children, 2013:68) On the 29th May 2013 the Independent Chair of the LSCB agreed that a Serious Case Review should be undertaken. 1.2 Family Composition Family member Date of birth Child D 11 weeks old at time of admission to hospital Miss F (mother) 18 years old Mr H (father) 35 years old Mr J (maternal grandfather) 47 years old Child L (maternal uncle) 14 years old 1.3 Review Timeframe The period for review in the case chosen was 1st June 2012 to 29th April 2013 - a period of just over 11 months. This covers the period from the beginning of Miss F’s pregnancy with Child D, until the admission to hospital and the discovery of multiple injuries. 1.4 Succinct Summary of the Case (a table of key events is included in this section) 4 This case involves a family with complex needs that had been well known to CSC and the Police over a number of years. The family has a history of violence and crimes involving several family members; namely, Child D’s uncle (Child L), maternal grandfather (Mr J) and Mr H. Some of these acts of violence may have been gang and/or drug related. Miss F was taken into care at the age of ten, as a result of neglect and physical abuse by her father. She remained in foster care for a period of two years. Miss. F’s half-brother, Child L, and two half siblings were later taken into care and remain subject to Full Care Orders. At the time of her pregnancy with Child D, Miss F lived with her father in a two bed roomed maisonette. Miss F, then aged 17, was pregnant, and the father of her baby, Mr H, was 17 years older than her. He had two children from a previous relationship that were known to CSC in another local authority. Miss F’s father, Mr J, was unhappy about the pregnancy and along with his mother (Miss F’s paternal grandmother) wanted Miss F to have the pregnancy terminated, in part because the baby would be of mixed heritage. (Miss F told us this when we interviewed her) Miss F refused to have a termination, stating to the Teenage Pregnancy Midwife (TPM) that she was happy and wanted to have the baby. Mr J did not want Miss F to stay in the family home once the baby was born, so she applied for re-housing and was advised to wait until after the baby was born when she would be offered a two bed-roomed flat. Miss F attended all her antenatal appointments and engaged with the Health Visiting Service. She was referred to the Family Nurse Partnership1, but turned down their offer of support, despite two contacts with the Family Nurse, stating that she had a wide circle of friends all of whom had babies and they would give her all the support that she needed. There is evidence that Miss F was vulnerable: from the neglect and physical violence that surrounded her most of her life; from her separation from her family when placed in care; and from the care experience itself. She had self- harmed just prior to the review time line. She was also completely deaf in one ear and had only 20 per cent hearing in the other, and relied on lip-reading to communicate. Miss F’s half- brother, Child L returned to the family home in November 2012 under a Placement with Parents Agreement: he had been repeatedly absconding from his care home in the south of England and was involved in criminal activity. Miss F was 29 weeks pregnant at this point and was not consulted about the return of Child L to the 1 The Family Nurse Partnership is an intensive, structured, home visiting programme, which is offered to first time parents under the age of 20. A specially trained family nurse visits the mother regularly from early pregnancy until the baby is 2 years old and builds a close, supportive relationship with the family. 5 household, nor included in the assessment that underpinned the Placement with Parents Agreement. Baby D was born in February 2013, following a normal delivery. Following the birth Miss F and Child D received home visits by the Midwifery Service and one visit from the TPM who discharged them into the care of the health visiting service at ten days post delivery. The health visiting service completed the new birth visit and mother and Child D attended their GP for the postnatal and six-eight week developmental assessment. Child D was invited to attend a baby massage clinic. There was an incident at the family home in early March 2013 in which four men came to the house looking for a stolen mobile telephone believed to be in the possession of a friend of Miss F’s who was visiting her. The men were threatening, and according to family members returned later in the day to ‘rob the house’ and later threw a brick through the window. Mr J and Child L spent the night with friends, whilst Miss F stayed in the flat with Baby D, despite being advised to leave and continuing to receive threatening telephone calls from the men. On 29th April Child D’s mother noticed that Child D, then aged 11 weeks, was not moving their left arm, and contacted her GP who advised her to attend the Accident and Emergency (A&E) Department of the local hospital. Child D was found to have a fractured left radius and ulna and was admitted. A referral was made to Children’s Social Care (CSC). Child D had a skeletal X-ray that showed a number of old fractures. These included probable fractures of the 7th and 8th left ribs and of the 5th, 6th and 7th ribs. There was also a possible fracture of the left tibia. These injuries had been sustained when Child D was approximately one month old. Both Child D’s mother and her partner, Mr H, were arrested and placed on bail for neglect and causing or allowing Grievous Bodily Harm (GBH) to take place. This case was investigated by officers from Haringey CAIT. Despite an initial reluctance to prosecute the suspected perpetrators the CPS finally authorised charges of Cause or Allow serious physical injury, Contrary to S5 Domestic Violence, Crime and Victims Act 2004 in relation to Child D's mother and father. Mother and Father were charged on 7th October 2013. On 1st May 2013, CSC made an application for a care order to safeguard Child D. On 2 May 2013, Child D was discharged from hospital and placed in foster care. On 7th May 2013, the County Court granted an interim care order which continued for the duration of the care proceedings. On 18th December 2013, there was a fact finding hearing by the Court to determine the cause of the injuries. The Court found that: "Paragraph (P) 246 "Having reviewed all the evidence, I am unable to find, on the balance of probabilities, who inflicted the injuries on Child D" P 250 "I have considered separately the positions of Ms F, Mr J, and Child L. I find that there is a real possibility that each of them may have inflicted all or some of the injuries on Child D. I cannot exclude any of them from the pool of perpetrators". 6 P 251 "...I find that there was no medical explanation found for the injuries. The parents have not provided any or any reasonable explanation for the injuries. The parents (Miss F and Mr H), Mr J and Child L, have either caused the injuries or failed to protect Child D from the injuries. The parents failed to seek medical attention for Child D in respect of the leg and rib fractures." On 28th November 2014, there was the final hearing of the application for a care order and the Court made a Special Guardianship Order to Mr and Mrs XX, the foster carers for Child D. In parallel with CSC application for a care order, the Police undertook an investigation that led to the parents Miss F and Mr H being charged on 7th October 2013 with the criminal offence of causing or allowing a child to suffer serious physical injury, contrary to S5 Domestic Violence, Crime and Victims Act 2004. On 22nd September 2014, at the Crown Court, the case against the parents was dismissed (no case to answer) because the trial could not go ahead due to the non-availability of a key witness. The CPS appealed this decision. On 17th December 2014, the Court of Appeal dismissed the appeal and upheld the Crown Court decision. There is no dispute in any of the court papers or any other papers or evidence that the child did suffer the injuries as outlined. Timeline of Significant Events Date Significant Event 12.4.12 (Prior to review period) Referral to CAMHS from Mental Health Liaison Services at A&E NMUHT from Mental Health Liaison Nurse. Miss F presented with a stab wound to her leg, this was self inflicted and followed an argument with her father over a boy. 18.6.12 Case closed by CAMHS following three appointments with Miss F. GP informed. 22.6.12 Mr H receives a fixed Penalty Notice for smoking cannabis and in possession of a small bag. 22.6.12 Child L is missing from his Care Home and turns up at the family home. He is returned to the Care Home. 27.6.12 Miss F attends booking appointment with Teenage Pregnancy Midwife. Pressure from her father and paternal grandmother to terminate pregnancy. Housing issues. 28.6.12 Referral to CSC made by TPM due to housing situation and age of partner and family background. 28.8.12 Pre-Birth Core Assessment completed within the 7 timeframe. Case closed. Professional network to be asked to re-refer if there are any concerns nearing the birth 31.8.12 First antenatal visit by health visiting service 7.11.12 Second visit by the health visiting service 15.11.12 Mr J accompanies Children In Care Social Worker CIC SW to look for Child L who has absconded from placement. He is returned to care home, but SW discovers that Child L and Mr J are on the same train back to London. Placement with Parent Order agreed and Child L to live at home (2 bedroom house). Miss F not consulted: 29 weeks pregnant. 23.11.12 Housing appointment, Miss F advised to wait until the baby is born: will then be offered two bed roomed flat, does not tell the housing officer that Child L is already at the family home. 27.12.12 Child L arrested for breach of bail conditions. Police serve drug warrant at family home, information not shared with other agencies. 10.02.13 Baby D born, BW 3.02Kg 21.02.13 New birth visit by agency health visitor. First 2 weeks in March Consultant Radiologist indicates first fractures are likely to have happened during this period. 11.03.13 Incident at family home, four men demanding a stolen mobile phone back. Return later according to family members to rob the house and hold a knife to the throat of a friend. Brick thrown through the window. Mr J and Child L go to another house. Miss F and Mr H stay with Baby D despite being advised to leave the home. 14.03.13 Strategy Meeting held: health agencies not invited. Outcomes from the meeting are: joint visit to family home with SW for Child L and Miss F, complete initial assessment by 25.03.2013, advise Mr J to remain at friend’s address, obtain update from HV, explore housing options, special scheme to be put on Police System. 27.3.13 Miss F visits GP: post natal check, plus 6-week baby 8 check. Weight 3.48 Kg 16.4.13 Joint home visit by HV and SW invited to CHC for weight check. 23.4.13 Attended CHC for weight check; 3.92 Kgs, length 54cms 29.4.13 Child D taken to A&E: painful left arm. Admitted. CP referral to CSC. Skeletal X ray showed several fractures, some 6-8 weeks old, as well as broken arm. 29.4.13 Strategy Meeting. Parents arrested. 1.5 Methodology Statutory guidance2 requires SCRs to be conducted in a way that: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings. The following principles should underpin all reviews3: There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; 2 Working Together 2013: page 67 3 Working Together 2013: page 66-67 9 Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process. In addition, SCR reports should “Be written in plain English and in a way that can be easily understood by professionals and the public alike”4 To help ensure that this report is accessible to all readers, a guide to acronyms and terminology is provided as Appendix 2 of this report. Haringey LSCB has chosen to use the Learning Together systems model, developed within the Social Care Institute for Excellence (Fish et al., 2008) to comply fully with the requirements of Working Together 2013. The Learning Together review process is based on the following key principles: 1. Avoid hindsight bias. In order to understand why people acted as they did, it is important to avoid hindsight bias – judging their actions from the standpoint of knowing what happened later, when it is easy to see which bits of information were significant and which were irrelevant. Therefore this systems model seeks to understand the experience and the reasoning of the workers and managers who were working with the family at the time, in particular, to explore what sense they were making of the case, and the contributory factors in the work context that were influencing their practice at the time; 2. Provide adequate explanations. The model requires reviewers to appraise and explain decisions, actions and inactions in professionals’ handling of the case, and to view performance as the result of interactions between the context and what the individual brings to it. 3. Move from individual instance to the general significance. The case provides a ‘window on the system’, finding out whether weaknesses visible in the management of an individual case are widespread, and so leading to a broader understanding about what supports and what hinders the reliability of the multi-agency CP system. 4. Produce findings and questions for the Board to consider. Some findings lead to the simple recommendation of a new rule or specific action; others may require the Board to consider how to balance identified needs with other demands on agencies’ resources. 4 Working Together 2013: page 70 10 5. Analytical rigour. Qualitative research techniques are used to underpin rigour and reliability, alongside a very open process so that others can see how conclusions were reached. Full details of this review process are contained in Appendix 1 of this report. 1.6 Reviewing expertise and independence: Lead Reviewers The review was led by two independent SCIE Lead Reviewers; Ghislaine Miller and Ann Duncan. They both have extensive experience in writing SCRs/IMRs under the previous ‘Chapter 8’ framework, and have received training and accreditation in the SCIE Learning Together model. Neither has any previous involvement with this case, or any previous or current relationship with Haringey council or partner agencies. The Lead Reviewers have received supervision from SCIE as is standard. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence. Review Team This comprised 8 senior professionals (a full list is in Appendix 1 of this report) from the multi-agency services involved with the family. Their role was to provide a source of high-level strategic information about their own agencies, as well as professional expertise in their fields. Together with the Lead Reviewers, they collected data about this case, including a review of records from the organisations involved, and produced and agreed the content of this report. Full involvement of practitioners The second important group taking part in the case review was 18 front-line professionals and first-line managers (a full list is in Appendix 1 of this report) who had worked with the family in different capacities, known as the Case Group (CG). They provided a detailed picture of what happened in this individual case, and also their knowledge of the systems as a whole, to help us understand whether practice in this case had been typical or otherwise. To elicit their involvement and experiences of this case, members of the Review Team (RT) held individual conversations with the Case Group professionals. Some members of the Case Group attended two multi-agency meetings to contribute to the analysis and findings from the Review Team and Lead Reviewers. 1.7 Methodological comment and limitations 1.7.1 Participation of professionals At times during this review the lead reviewers felt that there was not always an effective response by the RT and CG members. It has been difficult to get any momentum going and attendance at the Follow on Meetings with the CG was poor. This may have been due in part to the re-organisation of CSC during this timeframe when members of staff were under threat of losing their jobs and different agencies sending new personnel. By the end of the process there were only 4 of the 8 original RT members remaining and 11 there have been 3 different representatives on the RT from the hospital. This has impacted on consistency and ownership. Despite these set backs the content and quality of the conversations and background documentation provided credible and important information in order to understand the case. The 18 conversations that took place provided rich information and proved to be a positive experience for most practitioners. The RT members embraced the conversations as a new learning tool and were impressed by the level of understanding about the development of the case that emerges from them. One social worker commented: “This was one of the best processes I have taken part in. I learnt a lot”. 1.7.2 Perspectives of the parents Child D’s parents have contributed their views to the review via a meeting held on the 7th February 2014, with the two Lead Reviewers. The purpose of the meeting was to hear the parents’ views on the services they had been provided during the period under review. 1.8 Structure of the Report The next chapter (Chapter 2) of this report begins with a summary of what happened in the case. This leads on to a presentation of the 6 priority findings. Each finding concludes with some key questions that the finding raises for the LSCB and member agencies. It is the responsibility of the LSCB to decide how best to respond to the findings, with the aim of reducing the recurrence of poor practice. The questions are intended to support their considerations. 2. FINDINGS: WHAT LIGHT HAS THIS CASE REVIEW SHED ON THE RELIABILITY OF OUR SYSTEMS TO KEEP CHILDREN SAFE? 2.1 Introduction Statutory guidance requires that SCR reports ‘…provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence. These processes should be transparent, with findings of reviews shared publicly. The findings are not only important for the professionals involved locally in cases. Everyone across the country has an interest in understanding both what works well and also why things can go wrong.’ (2013: 65) This section firstly explores the ways in which features of this particular case are common to other work that professionals conduct with children and families, and therefore how this one case can provide useful organisational learning to underpin improvement. 12 This is followed by a synopsis of the appraisal of practice, provided for the reader. This sets out the view of the Review Team about how timely and effective the interventions with Child D and the family were, including where practice fell below expected standards. Where possible, it provides explanations for this practice, or indicates where these will be discussed more fully in the findings. Finally, this section discusses 6 priority findings that have emerged from the SCR. The findings explain why professional practice was not more effective in protecting Child D in this case. It also outlines the evidence that indicates that these are not one-off issues, but underlying patterns – which have the potential to influence future practice in similar cases. We also consider what risks they may pose to the wider safeguarding of children. 2.2 What is it about this case that acts as a window on practice more widely? 2.2.1 Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including serious case reviews (SCRs) states: ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements that are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.’ 5 2.2.2 Haringey Safeguarding Children Board (LSCB) identified that the SCR of this tragic case held the potential to shed light on particular areas of practice: What has this case told us about what was known about the family Mother was a care leaver; historical abuse within the family; history of “scapegoating” of Child L, and that Miss F was pregnant and the father of the baby was 17 years older than her Miss F’s refusal to engage with appropriate support services Difficult relationship between the parents What has this case told us about communication between agencies? Was there information that agencies knew that could have prevented the injuries to Child D? What contact did agencies have with Child D during this period? What assessments were carried out to support the decision to return Child L to the household during this period? 2.3 Appraisal of Practice in this case: a synopsis 5 Working Together, 2013:66 13 This synopsis summarises what we learned about professional practice in this case and forms a context for the findings that follow in Section 2.5. It aims to capture the appraisal (or judgement) that the Review Team made about how professionals handled this case: what was good practice and what was poor practice, given what was known and knowable at the time. The findings that follow provide the explanations of the ‘why’ questions, defining what got in the way of providing more effective help. Overview In summary, the Review Team’s appraisal of how professionals handled this case was that despite the plethora of information, risk factors and family history, professionals treated this as historical and not relevant to the current situation, and consequently that this information did not appear to influence current judgements of risk. It appears that the professionals concentrated on the present and gave little weight to the past, evidencing a pattern of practice often known as ‘start again syndrome’,6 combined with a high level of professional optimism based on very little substance. Evidence from SCR’s7 and research suggest that history is an important part of assessing current and future parenting capacity and should be considered as a potential risk factor. In this case, the family dynamics were not explored and the agencies appeared to work in silos, with little information and challenge between and across agencies. Perhaps what is the most challenging for the child protection system is that, despite the presence of risk factors, professionals did not take them seriously enough, judging that the case did not meet the threshold for ongoing CSC intervention, either under section 17 (child in need) or section 47 (child protection) and so the case was closed by CSC following the Pre-Birth assessment. The family had contact with health professionals during this time focusing on maternal health and housing support, but the family told us that they felt “let down” by professionals and feel they could have “done a lot more to help them, particularly with housing issues”. The key features of how the case was handled by professionals are detailed and appraised below. 1. Lack of appropriate response by all the agencies involved to the high level of violence within and around the family, and consideration of the impact of this on a small baby. The family, well known to CSC and the Police, had a complex and violent history. Professionals in CSC had access to these documented facts but did not consider that they were of significance to the current situation, or how they might impact on the family dynamics particularly when Child L returned to the family home. When we spoke to Child D’s mother, she described Child L as being “all over the place. He came home when I was 29 weeks pregnant and that was a big risk, as he was so violent and 6 Brandon 2008 7 Brandon et al, SCR Biennal Review, 2009, DfE. 14 aggressive. [Professionals] should have thought about that before they put him back into the house”. The family did not raise this concern when the case was active. The Professionals involved in placing Child L back to the family home did not involve the police and therefore the opportunity for background checks to be carried out every person living at this address was lost. Despite these risk factors, professionals from CSC considered it safe for Miss F to live at the family home alongside Child L and his escalating anti-social behavior. When an incident happened at the family home in March 2013 involving four men (the family thought that they were members of a gang), the family was subjected to threats of violence and a brick being thrown through a window narrowly missing Child L. The family was advised to stay with friends or family at another address overnight. Mr. J and Child L did leave the family home but Miss F remained with Child D. (CSC thought that Miss F and Child D were going to spend time at the Grandmother’s home) Mr. J refused help from the police and was unwilling to give them any information on the incident. This must have been very frightening for the family and in particular Miss F with her new born baby who was one month old at the time. A Merlin was completed by the police officers and shared with Child L’s SW. Following the incident, a strategy meeting was held, the purpose of which was to share information and establish the facts about the circumstances that were giving rise to the concerns. The decision to hold a strategy meeting was appropriate, however health agencies were not included in this meeting, and it did not consider whether there was a need for a Section 47 enquiry. In discussion with the CG they were clear that the outcome of the meeting was to gather more information and hold a review meeting in one month’s time, this did not happen. This was another missed opportunity to review and assess the information and changing circumstances of this family. There appeared to be little recognition of the underlying violence that they were exposed to both inside and outside the family home. This will be explored further in Finding 4. 2. Superficial assessments carried out by professionals who appeared to be impressed with Miss F’s resoluteness, determination and aspirations for her baby and her apparent resilience to family life. However, this was a naïve approach and lacked signs of professional curiosity and healthy scepticism. The initial referral to CSC from the Teenage Pregnancy Midwife (TPM) in June 2012 was because of her family background, and because Mr. J was unsupportive of the pregnancy, he did not like the father of the baby, did not want Miss F to live in the family home after the birth of the baby, and wanted Miss F to have a termination. The TPM also noted that there was a large age difference (17 years) between Miss F and Mr. H, but there was little exploration of what this may indicate or whether there was cause for concern. This was an appropriate referral, albeit one, which did not outline sufficiently clearly the causes for concern. A Pre-Birth Assessment was initiated; the assessment was completed within the timeframe but lacked analysis and impact of her past experiences. Although the SW 15 commented on her immaturity during the first meeting, at the follow up meeting the SW was impressed with Miss F’s aspirations for her baby and determination that her baby was going to have a better life than hers. Miss F was very positive about being pregnant and spoke of going back to college after the birth of the baby. Miss F was initially wary of the SW due to her own experiences and was fearful that her ‘baby would be taken into care’. Miss F was unable to give her partner’s surname at the first meeting but did know that he had two children from a previous relationship and had been in prison. A follow up meeting was arranged with the social worker and Mr. H, accompanied by Miss F. He gave the social worker his missing personal details including his children’s names. Mr. H gave the wrong spellings of the children’s names, and the social worker thought he had done this deliberately. The SW showed tenacity in tracking down the children who were known to CSC in a neighbouring London Borough and in making a request for more information. The RT found no evidence that this had been followed up by Haringey CYPS and this should have happened to understand what involvement there had been with his previous family and if it was ongoing. Despite all of these factors; (a pregnant 17 year old leaving care, her partner 17 years older than her, and having suffered neglect and physical abuse from her father, pressure from her family to have a termination and the background of the family), the case was closed. It was deemed too early to carry out a parenting assessment and the view of the SW was that there were no current concerns. The TPM accepted this as she also felt that Miss F was engaging well with the service and the concerns were all in the past. The SW informed the Midwife and Health Visitor that the case was closed and that they should re-refer if they had any new concerns. The Review Team’s view was that this decision showed a lack of understanding of how Miss F’s past experiences, as well as current issues relating to her mental health, housing and family situation could impact on her and her child’s welfare. However, there was evidence that this is a norm in cases of this kind: the Case Group was of the view that the family circumstances were typical of many families they deal with and would not automatically meet the thresholds for intervention. There was a thread running through the assessments made by health and social care that the risks were historical and therefore not relevant to the present. Professionals failed to consider the impact of the past on Miss F and her ability to parent. The RT thought that it was poor practice that it was deemed too early to commence a parenting assessment particularly in light of Miss F’s own childhood experience of being in care herself and her lack of support and guidance; where was her ‘parenting compass’? This was a missed opportunity to build up a relationship with this young mother in order to carry out a fuller and more robust assessment of risk to herself and the baby. Information from CG members during the conversations and at the Follow On meetings identified that there is an expectation in Children’s Social Care (CSC) that staff should complete the assessments within the timeframe and close cases as quickly as possible. The timescale and organisational pressure appears to be the driver, as opposed to an 16 understanding that an assessment is an iterative process that takes time (this was confirmed by members of the RT).( See Finding 6). 3. Professional responses to Miss F’s refusal of support services resulted in an increased risk to her and her baby. The Teenage Pregnancy Midwife (TPM) had referred Miss F to the Family Nurse Partnership. This was an appropriate referral, however Miss F refused the service as she felt that she would get all the support and advice from her friends all of whom had babies. In view of Miss F’s past history and her refusal to engage with the FNP, the RT were of the opinion that a Common Assessment Framework (CAF) should have been completed by the TPM. Following her refusal to engage with the FNP she was referred to the Health Visiting Service for antenatal visits. This was good practice. The Health Visiting Service targets families with identified risk factors to carry out antenatal assessments. Miss F received two antenatal visits, HV1and HV2 and there was a plan for a third visit, this did not take place due to workload. HV1 had correctly identified the risk factors but then shortly left the service. HV2 appeared to treat the information and assessment by HV1 as historical factors and felt that Miss F was preparing well for her baby and had no current concerns. (See Finding 6). Miss F attended all her antenatal appointments and the pregnancy was progressing well. There was no liaison between the HV and TPM during the pregnancy, both the TPM and HV2 worked with the family but did not share information. The explanation given by TPM (during her conversation) was that Miss F was fully engaged with the service ,and there were no new concerns during the course of her pregnancy. HV2 referred Miss F to a variety of support services, including HARTS, Family Outreach and Family Support all of which she turned down apart from Homesafe (a service for care leavers), which she was refused as she did not meet the criteria. Families often refuse other support services but given the vulnerability of this young mum it is disappointing that the professionals were unable to persuade her to engage with these targeted services. 4. Lack of information sharing between the agencies involved, particularly when Child L returned to live in the family home under a Placement with Parent Agreement. During the review period, a number of agencies had contact with different members of the family, including CSC, the Police and health visiting. Information was not shared between these professionals, meaning that a holistic view of the risks within the family was not achieved. Child L returned to the family home under a Placement with Parent Agreement in November 2012, at which time Miss F was 29 weeks pregnant. The Children in Care (CIC) SW carried out the risk assessment but this was carried out from the perspective of Child L, who was then aged 14. There appeared to be little analysis of the possible impact that Child L might have on the family dynamics, it was known that Miss F and 17 Child L used to fight when they were younger and he was aggressive towards his half sister. This information was not shared with the Health Visitor or the First Response Team (CSC). The fact that Child L had returned to the family home was treated in isolation and because the other agencies were unaware of his return there was no opportunity to explore the changing circumstances or consider whether there were any risks for the safety of Miss F and her unborn baby. The RT felt that a professionals’ meeting should have taken place on Child L’s return. This would have allowed the professionals involved with the family to have a full understanding of the situation, explore what the potential risks might be and develop a robust plan including a police check on all members of the household. The Youth Offending Team (YOT) did not share information with other agencies involved when: Child L had breached his bail conditions. The Police did not share the information when Mr. H was caught in possession of a gun and driving without insurance (he was arrested and charged in January 2013, however the Police would be unaware of his relationship with Miss F and he gave the police a different address). A MERLIN was completed when they were called to the family home at the request of Miss F, as Child L was being very aggressive towards her, and this was shared with the SW for Child L which is the normal practice if the case is open rather than going via MASH. However given the age of the Child D the threshold to undertake a separate assessment under MASH protocol would have been reached. 5. Inadequate responses to identified needs at the new birth visit The purpose of a new birth visit carried out by health visitors is to: develop a relationship with the family; assess the growth and development of the baby, and assess the family situation. This informs a decision about the most appropriate level of intervention that will be required - universal, enhanced or enhanced plus. The visit is usually carried out between 10-14 days post delivery and takes place in the family home. The health visiting service has corporate caseloads8. The allocation of work is done by the team manager electronically and entered directly into the practitioner’s diary, the usual practice would be that this is done during an allocation of work meeting allowing face-to-face discussion and a pooling of information known about the family. However, in this case, team meetings did not take place. In this case the team manager of the health visiting service allocated the new birth visit to an agency health visitor. Given that HV2 had already visited Miss F and started developing a relationship it would have been more appropriate for the new birth visit to be carried out by HV2. Agency health visitors were being used to manage capacity, as there were vacancies within the team and a high number of births, as a consequence of this, the permanent staff held more safeguarding cases and worked with families requiring a higher level of support. 8 Corporate caseloads is when a team of health visitors work together on a shared caseload. 18 Prior to the agency HV3 undertaking the new birth visit she did not check on the electronic records 9 and was unaware of the antenatal contacts. Following completion of the new-birth visit HV3 had no concerns but having read the records and in discussion with the team manager agreed that the family required further assessment, and an enhanced service. Although this case was identified correctly as requiring ongoing support this failed to happen (due to workload and no agreed follow up time from the new-birth visit) and the next home visit by HV2 was a joint visit with the SW in April. 6. Lack of attention to indicators of safeguarding issues within primary care. After birth, Child D showed a pattern of weight gain that had fallen from the birth centile, and although this was recorded by primary care there was no follow up or referral to the health visiting service and no consideration of whether there were any safeguarding concerns. Child D’s parents also told us that they had expressed concerns to health professionals about Child D’s health, but that these were not followed up. It was unclear whether these views were expressed (and if so to which professionals) as there is no recorded documentation of these concerns. Child D was taken for a six-eight week review with the GP in March 2013. It is unclear whether the GP examined the baby naked and there is no reference made to whether Child D became distressed on handling or if any blue pigmented naevi were present.10 Child D had multiple blue pigmented naevi in the following areas (as listed in the independent Medical report): left wrist, over the left elbow, over both right and left shoulders and over the upper thoracic spine, the right ankle and over both buttocks. (These blue spots can sometimes be mistaken for bruises and should be recorded to exclude NAI.) It is now known that at the six-eight week assessment Child D would have already sustained fractures to the leg and ribs11. In our conversation with Child D’s parents, they expressed a view that they wished that Health professionals had found out about Child D’s injuries earlier. It is difficult to conjecture whether Child D’s injuries could have been detected at this stage. However, the recording does not give evidence to suggest that appropriate examinations were conducted which could have facilitated identification of these injuries. At birth, Child D weighed 3.022 Kg (9th centile), length 47cm and head circumference 34.5cm. At the six-eight week review the weight was 3.48Kg (2nd centile i.e. a fall of one centile space) and head circumference 33cm. These measurements were recorded in Child D’s Personal Child Health Record (PCHR) known as the Red Book. However, there is no evidence to suggest that the weight was plotted on to the centile12 chart: this 10 Electronic record keeping systems (RIO) introduced in 2011 has enabled robust management of work. Systems are now interrogated on receipt of the Birth Notification so that historical information forms part of a pre-visit risk assessment. 10 Blue pigmented naevi are a type of birthmark that are present at birth or appear soon afterwards, either single or multiple in number and are common in children with pigmented skin. 11 Radiologist report 12 Centile chart WHO growth charts 19 is poor practice. We also found no documentary evidence recording the feeding regime at the six-eight week review or how Miss F was coping given that she was a young mother. During the conversations it also emerged that all babies were weighed with their nappy on in this GP practice; this is poor practice and needs to be addressed urgently. The failure of Child D to maintain the birth weight trajectory, and the implausible head circumference measured by the GP, did not trigger further analysis. However, after the six week review, the GP recorded that no follow up was required. The RT were struck by the fact that little or no consideration was given to the growth of this baby and were of the opinion that a referral should have been made to the HV for further exploration and monitoring. Our scrutiny of the records suggest these checks were a tick box exercise with no analysis or consideration about the possible reasons for slow weight gain in a baby that is being bottle-fed. The apparent slowing down of Child D’s weight gain was picked up by HV2 in April when she did a joint home visit with SW, but HV2 did not discuss this discrepancy with the GP. HV2 recorded the feeding regime, that the baby had green stools and had ‘colic’. Miss F showed concern about Child D’s weight gain and attended the child health clinic as advised by the Health Visitor. Child D’s weight on this occasion was satisfactory. The reasons why health professionals did not pick up safeguarding indicators are discussed further in Finding 3 7.Inadequate Management Oversight and lack of Supervision During this case there were key opportunities for those professionals in management posts to give direction and guidance to front line staff. In particular the RT felt that the Pre-Birth Assessment should not have been signed off (the manager spoke about it being a poor assessment during the conversation but signed it off due to the pressure of meeting the target, see Finding 1). When Child L returned to live in the family home there appeared to be a lack of management oversight and no rehabilitation plan for Child L. The team manager for the health visiting service allocated the new-birth visit to be carried out by an agency health visitor rather than waiting for the health visitor who had already visited Miss F in the antenatal period to return from one days annual leave. This coupled with the fact that this case was not taken to supervision by the SW at all and the health visitor only after the joint visit with the SW in April 2014. Supervision within the arena of child protection is an important opportunity for front line clinicians to have protected time in order for them to explore any fixed thinking that they may have on the case. Health Visitors receive Child Protection supervision every three months, but can also access supervision more frequently if required. Management supervision is received monthly but can be cancelled due to pressure of work. Social Workers receive monthly supervision on their caseloads. 20 During this case, clinicians talked openly about the importance of supervision but also felt that there was insufficient time to review cases adequately. The caseworkers spoke of supervision becoming more directive; checking that plans had been followed and less focused on the emotional demands of working with children and their families. It was felt that this was due to the sheer numbers of families that needed to be brought to supervision, rather than the supervisor being unwilling to provide supportive, reflective and challenging supervision. The CG also highlighted that many families like this would not be discussed in supervision, either because the case worker did not identify the need for the case to be discussed or because the case had been assessed and closed before an opportunity to discuss in supervision presented itself. Furthermore, HV2 was a newly qualified health visitor and had a named mentor who had only been qualified a year, so was also unable to provide expert advice and guidance. The RT felt that if caseworkers had received better quality supervision it might have supported the individuals in recognising risk factors and planning interventions to mitigate against them (see Finding 6). We know that individuals cannot police their own biases or fixed views; supervision is thereforec key in helping to support staff, not just with the volume and demanding pace of work but with its nature, which regularly brings them into face-to-face contact with vulnerable adults. This will be explored further in Finding 5. 8. Good professional responses to admission of Child D to A&E. Miss F attended the hospital A&E department with Child D on 29th April. She had noticed that Child D’s left arm was ‘floppy’ and the child cried when Miss F touched the arm or tried to change the child’s clothes. An X-ray of the child’s left arm confirmed a fracture of the ulna and radius. Child D was admitted to the hospital, as there was no clear history of how the injury to the arm happened. A skeletal survey, CT head scan, ophthalmology review, blood tests and plotting of the baby’s weight and head circumference were undertaken. A referral was made to CSC. This was good practice and demonstrated that the safeguarding system worked well when a baby presented with a physical injury. 2.5 Findings The final stage in a Learning Together review is to use the case as a ‘window on the system’ (Vincent, 2004) and identify what this case has told us about more general weaknesses in the multi-agency safeguarding system. These are set out as a series of findings, which represent the main learning from this case review for the LSCB and partner agencies. Each finding is set out in a way that illustrates: How does the issue feature in this particular case? How do we know it is not peculiar to this case? What can the Case Group (those who worked with the family) and Review Team (the senior managers from each agency appointed to help with this case review) tell us about how this issue plays 21 out in other similar cases/scenarios and/or ways that the pattern is embedded in usual practice? How prevalent is the pattern? What evidence have we gathered about how many cases are actually or potentially affected by the pattern? How widespread is the pattern? Is it found in a specific team, local area, district, county, region, national? What are the implications for the reliability of the multi-agency child protection system? The evidence for the different ‘layers’ of the findings comes from the knowledge and experience of the Review Team and the Case Group, from the records relating to this case, and other documentation from agencies, and from relevant research evidence. Six priority findings were chosen because they represented areas of practice which were significant in how this case was managed, but which also reflected wider patterns of practice and the systems which underpin that practice. Finding Category Finding 1. A culture of meeting targets and timescales has resulted in a lack of critical analysis when conducting assessments: “hitting the target; missing the point. Management Systems Finding 2: A potential pattern where Looked After Children and Young People who move placements on a regular basis are not appropria tely assessed each time, resulting in a missed opportunity to review and amend the care plans in place. Multi-agency working in longer-term work. Finding 3: A potential pattern by which postnatal checks and developmental assessments undertaken in General Practice do not always consider issues relevant to safeguarding. Multi-agency working in response to incidents and crises. Finding 4: A pattern whereby practitioners have become accustomed to working with families surrounded by high levels of street and drug-related violence, meaning that this does not lead to a consideration of impact on parents and children. Multi-agency working in response to incidents and crises. Finding 5: A pattern whereby practitioners do not bring a case to supervision either because they fail Human Biases 22 to identify the need for supervision, or the case has been closed, resulting in a lost opportunity to challenge the interpretation of facts and the plan for intervention. Finding 6: A pattern whereby practitioners superficially identify risk factors but do not consider the significance or impact they might have, resulting in inappropriate levels of intervention to safeguard children. Human Biases Findings in detail The remainder of this section discusses the six priority findings in more detail. Finding 1. A culture of meeting targets and timescales has resulted in a lack of critical analysis when conducting assessments: “hitting the target; missing the point”. Assessment is a vital stage in any professional relationship with a family. It is at this point that a holistic picture of a family’s needs and strengths should be formed, and any potential risks to children identified, as a robust basis for making decisions about future service provision. This case identified a pattern in which assessments appear to be undertaken in a superficial manner, apparently driven by a need to meet prescribed timescales. This leads to an incomplete consideration of family circumstances, which can in turn mean that families experiencing high levels of risk and need do not receive the appropriate services. 1. How did this manifest in this case? Throughout this case, assessments and visits were undertaken as required, and within timescales. However, they were frequently of a superficial quality, missing out on key risk factors and opportunities to intervene. This suggested that the emphasis on timeliness of assessment has not been accompanied by an emphasis on quality. At worst, efforts to meet timescales appeared to exacerbate superficiality of engagement with the family. A Pre-Birth Assessment was undertaken by the social worker which identified some of the risks: a previously looked-after child with a history of physical abuse and neglect and, whose partner is 17 years her senior, facing a lack of support for her pregnancy from her family. However, these were treated as historical factors and the SW was reassured by the positive response and aspirations the mother had for her un-born child. Although the Manager of the SW felt that the assessment was inadequate she still signed it off in order to meet the 35-day time-scale. The view at the time of the assessment was that it was too early to undertake a full parenting assessment and as there were no current issues the case was closed and the other agencies involved 23 informed to re-refer if there were any new concerns. This short-term involvement of CSC in cases at the “front door” leaves them with a fragmented view of cases. Secondly, following the birth of the baby the health visiting service undertook the new birth visit. This should be done within 10-14 days after the birth and there is an expectation that this target is reached. The case was allocated to an agency health visitor, as the family health visitor was on one day’s annual leave. The agency health visitor was not aware of the family background and was unaware that the family had received two antenatal visits from the health visiting service. The use of agency health visitors as a way of meeting targets therefore, in this case, meant that the quality and relevance of the assessment was weakened. The six –eight week post natal check and infant review of the baby were completed within the timeframe. Sadly, in this case the poor weight gain and the discrepancy in implausible head circumference were not queried or analysed in any way, or a referral made to the HV. When the incident happened at the family home in March, a strategy meeting was held within 48 hours; unfortunately there was no health representation at the meeting despite the fact that they were involved on an on-going basis with the family and may have had relevant information to share. 2. What makes this an underlying issue? Both the Case Group members and the Review Team were very clear that there is still pressure to meet the targets across all agencies. Each organisation is monitored on a monthly basis against agreed performance indicators. During the conversations practitioners spoke about the drive to complete the assessments within the 35 day timeframe even if the resulting assessment was deemed to be poor, or lacked in-depth analysis. Health Visitors are expected to visit 95 per cent of all new births by day 14. 3. What is known about how widespread or prevalent the issue is? Members of the Review Team reported that there is evidence of significant pressure from all agencies to meet monthly targets. Within CSC there is added pressure to close cases and put the emphasis back on the other agencies to re-refer, resulting in a fragmented view of the family, little or no analysis of the family background and at times a failure to recognise the significance of the risk factors and the impact that they may have on family dynamics. This is often described as the ‘revolving door syndrome’ 13There is evidence that this is a national issue: this was something that was picked up in the Munro Review.14 13 13 June Thoburn et al, 1999, cited in Enhancing the wellbeing of children and families through effective intervention, Jessica Kingsley Publishers, 2006 14 14 The Munro review of Child Protection, Department for Education, June 2010 24 4. What are the implications for the reliability of the multi-agency child protection system? All agencies have finite resources, and must make ‘trade-offs’ to meet priorities with the resources they have. Placing a high level of emphasis on meeting timescales means that this may be ‘traded off’ against the quality of work – meaning there is insufficient emphasis on, and time allowed for, undertaking a thorough assessment of risk and need. This means that vulnerable families may be left without support. Finding 1. A culture of meeting targets and timescales has resulted in a lack of critical analysis when conducting assessments: “hitting the target; missing the point. Whilst timescales are important to ensure that cases do not drift, there needs to be a sense of proportionality, to ensure that cases are assessed rigorously, rather than being closed prematurely. This case has suggested that the emphasis on timeliness of assessment has not been accompanied by an emphasis on quality. At worst, efforts to meet timescales appeared to exacerbate superficiality of engagement with the family. ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: Is information provided to the LSCB only on meeting timescales and performance targets, masking underlying issues about the quality and effectiveness of interventions? The LSCB needs to be assured that cases are allocated in a timely way to ensure that workers have sufficient time and capacity to undertake the assessment. The practice of allocating cases by e-mail (even when workers are on leave) needs addressing. Given the National and London problems with recruitment and retention of health visitors, is there an opportunity to use the money allocated to address this problem in a more effective way? The use of agency health visitors in conducting new birth visits should be reviewed Finding 2. A potential pattern where Looked After Children and Young People who move placements on a regular basis are not appropriately assessed each time, resulting in a missed opportunity to review and amend the care plans in place. 25 Placements for Children and Young People in care should be made on the basis that it is in the best interest of the child or young person to move and that the placement will provide a stable and nurturing environment to allow the child to reach their full potential. It should not be made on the basis of poor planning and resource shortfalls. This case suggested evidence that the return of the young person to the family home appeared to be driven by expediency rather than being needs led, and based on thorough assessment. In this case, this meant that the potential risks to other family members were not considered. 1. How did this manifest is this case? Child L, Child D’s uncle, was subject to a Care Order and had his own newly allocated social worker, who was overseeing his placement in residential care. After frequent episodes of going missing, and becoming involved in criminal behavior, it appears that Child L “voted with his feet” and returned home with his father, unbeknown to the social worker. This fait accompli resulted in Child L remaining at home, under the Placement with Parents (PWP) regulations, and the allocation of an additional student social worker. The PWP assessment that should have underpinned this agreement did not take account of the fact that his pregnant sister (29 weeks) was also living there, in a 2-bedroom maisonette. There was no assessment of this “re-constituted” family (the children both now living with their father, whose care they had been removed from in the first place) or the potential risk to the (unborn) baby, either from the overcrowding, or from Child L’s “out of control’ behavior, which included drinking, drugs and criminal activity. 2. What makes this an underlying issue rather than a particular issue to the individuals involved? The RT and CG members were clear that, due to the high number of children and young people in care, time constraints meant that a full assessment was not always done for children who move frequently. The fact that this did not happen in this case and the opportunity to review all of the occupants of the household may be replicated in other cases. 3. What is known about how widespread or prevalent the issue is? The information above suggests that this issue was not restricted to this case, however it is unclear how widespread this is in terms of other Looked after Children and Young People in Haringey. 4. What are the implications for the reliability of the multi-agency child protection system? The risk is that there is an assumption that all Looked After Children and young people will have a robust assessment undertaken at each placement that clearly identifies the health needs and risks to allow rehabilitation plans to be put in place. If this does not happen there is a danger that the wider safeguarding network remains unaware of the potential risks in the current placement. 26 Finding 2: A potential pattern where Looked After Children and Young People who move placements on a regular basis are not appropriately assessed each time, resulting in a missed opportunity to review and amend the care plans in place We know that Looked after Children and Young People are vulnerable and that it is imperative that a placement is selected on the basis of providing a stable and nurturing environment. For those children that become difficult to ‘place’ it is even more important that a rigorous and full assessment is undertaken especially when the placement is back in the home that they were removed from. ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: What steps will the Board take to ascertain whether this is a more common pattern in practice? For example, an audit of Looked after Children and young people that have changed placements in the past six months could shed further light on this issue. Is the Board aware of any other children that have been placed back in the family home in the last year? Finding 3. A potential pattern by which postnatal checks and developmental assessments undertaken in General Practice do not always consider issues relevant to safeguarding? Postnatal checks and infant reviews should be part of the safeguarding ‘safety net’ by checking key indicators such as growth and developmental milestones as well as mother’s well being. This case suggested evidence that these are not being carried out and recorded thoroughly and in accordance with best practice, meaning that opportunities to identify children at risk are missed. 1. How did the issue feature in this particular case? Miss F and Child D attended their GP practice for their respective postnatal check and developmental assessment. Child D was seen first by the practice nurse who weighed and measured the baby (with nappy on, see section 6 in Appraisal of practice). The weight and head circumference were recorded in the PHR, but not on the centile charts. The practice nurse did not pick up the head circumference discrepancy at the time, although during the conversation she thought that she had recorded it inaccurately, as she was aware that in particular the head circumference was very small and might be indicative of microcephaly. The baby was then redressed by the mother and was seen by the GP for the physical examination. 27 The GP completed the physical examination and recorded that ‘no follow up was required’. Again there was no analysis of the growth and weight gain of Child D, the measurements were not recorded on the centile charts and there was no exploration of the feeding regime and how this young Mum was coping with her new baby. It is unclear whether the GP examined the baby naked and there is no reference made to whether Child D became distressed on handling or if any blue naevI were present.15 Child D had multiple blue naevi in the following areas: left wrist, over the left elbow, over both right and left shoulders and over the upper thoracic spine, the right ankle and over both buttocks. (These blue spots can sometimes be mistaken for bruises and should be recorded to exclude NAI.) The GP failed to pick up that Child D’s weight gain appeared to be slowing down and should have made a referral to the HV to monitor the weight of this baby particularly in light of Miss F’s age and background. 2. What makes this an underlying issue rather than a particular issue to the individuals involved? Postnatal checks and developmental assessments are routinely carried out in General Practice. The staff involved in these assessments must always consider the possibility that there may be safeguarding issues and must remain vigilant to them. The RT were concerned that some GP practices were isolated and did not always communicate effectively with the health visiting service. The lack of communication of potential safeguarding issues seen in this case may therefore be replicated in other GP practices. The Review Team were also aware of other cases where GPs have failed to either identify safeguarding issues or pass on relevant information to the other agencies involved with the family, including another current SCR. 3. What is known about how widespread or prevalent the issue is? The information above suggests that this issue was not restricted to the GP practice involved in this case. However, it is unclear how widespread this is in terms of other practices within the Borough or more widely. 4. What are the implications for the reliability of the multi-agency child protection system? The risk is that there is an assumption that all consultations, developmental assessments that are carried out in General Practice, by GPs, will always consider the possibility that there may be safeguarding issues and the need for referral in to CSC. This relies on the professionals working within the practice to be confident in recognising and acting on what they have observed. 15Blue pigmented naevi spots are a type of birthmark that are present at birth or appear soon afterwards, either single or multiple in number and are common in children with pigmented skin. 28 Finding 3: A potential pattern by which postnatal checks and developmental assessments undertaken in General Practice do not always consider issues relevant to safeguarding. We know that families use the services of GPs in varying ways and that the GP has at times a unique position in being able to assess and monitor the health and well being of the family (in some cases the extended family). Whilst acknowledging that GPs and practice staff have attended the requisite Safeguarding training there needs to be more challenge in how they are applying the learning into their every day practice. In particular, postnatal checks and developmental assessments should be part of the safeguarding ‘safety net’ by checking key indicators such as weight, growth and developmental milestones and mother’s well being The safeguarding system is reliant on GPs and practice staff identifying and referring cases into CSC. ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: This case has suggested that GPs may not be picking up indicators of abuse and neglect as part of postnatal checks. Could the Board take action to investigate the extent of the problem, for example through audit? How well do GPs engage with safeguarding in Haringey? Are 6-8 week reviews of babies in General Practice simply a ’tick box exercise’, rather than including an opportunity for analysis and consideration of safeguarding? Finding 4. Practitioners have become accustomed to working with families involved in, and surrounded by, high levels of street and drug-related violence, meaning that this does not lead to a consideration of impact on parents and children. Risks to children may not just come from within the home or their immediate family. Other adults with whom the family are involved, or the community at large, can also present a safeguarding risk to children, particularly where involvement is street or drug-related. It is important for the reliability of the safeguarding system that professionals are able to recognise and take steps to mitigate threats to children’s safety arising from these influences. However, this case has suggested a pattern whereby professionals do not consider risks posed by street and drug-related violence. This appears to be partly due to professional ‘desensitisation’ to this problem in some geographical areas. 1. How did the issue feature in this particular case? Child D’s environment contained significant levels of violence and criminal activity, yet these did not appear to be considered to be a risk factor for this young baby, and did not 29 lead to child protection measures being taken, or more urgent steps being taken to re-house Miss F. There were several occasions on which Police were involved with members of the family in relation to violence and criminal activity, including: Arrest of father (Mr. H) for possession of a firearm (January 2013 prior to the birth of Child D and he gave a different address, at this point it would not be known about his connection) A drug warrant served on the family home in December 2012 (before Child D was born) Police called to the house to deal with an incident of aggression by Child L towards Miss F and completed a MERLIN (see appraisal of practice) There was also an incident at the family home in which four men turned up looking for a mobile telephone, returned later possibly looking for drugs, held a knife to the throat of a friend of the family, and then threw a brick through the window narrowly missing Child L. Mr. J and Child L left to stay with friends because of the danger, but Miss F remained in the house with her young baby despite reportedly receiving death threats on her phone; CSC had advised her to leave and were under the impression that she was going to stay with her grandmother for a few days. After this incident, a strategy meeting was held. The purpose of this meeting was to share information and establish the facts about the circumstances that have given rise to the concerns, understand the level of risk which was deemed to be a low level and decide what was required. The decisions taken at the strategy meeting were to undertake a single assessment on Miss F and Child D, liaise with the HV and continue to advise Mr. J and Child L to stay away from the family home, a follow up meeting to take place in one month, this did not happen as Child D was admitted to hospital. The levels of violence in the family could also have potentially posed a risk to staff, yet these were not raised as a concern. Only one caseworker identified the potential dangerousness of the situation and refused to do a home visit. This is indicative of workers getting used to levels of violence and failing to recognise the potential risk to themselves when visiting clients homes. 2. What makes this an underlying issue rather than a particular issue to the individuals involved? The Case Group were very clear that there were many families like this on their caseloads and the circumstances were not unusual. Indeed when the case group were questioned about the incident at the family home they thought that it ‘wasn’t that bad, it was only a brick through the window’. One RT member commented that it is considered “par for the course in Haringey”. There is also evidence from recent SCR’s where violence within the family and gang affiliation is also a feature. 30 3. What is known about how widespread or prevalent the issue is? There is a high level of crime associated with drugs and gangs in this area of North London. It is unclear what numbers of children are placed at risk by this criminal activity. 4. What are the implications for the reliability of the multi-agency child protection system? A culture in which practitioners accept high levels of violence as being relatively frequent and almost “normal” potentially results in lack of identification of risk to children and contradicts the notion of safeguarding being “everybody’s business”. This increases the risks of harm to vulnerable families. Finding 4: A pattern whereby practitioners have become accustomed to working with families surrounded by high levels of street and drug-related violence, meaning that this does not lead to a consideration of impact on parents and children In this particular area of Haringey drug and street violence are so common that they have become perceived as normal. Front line members of staff are in danger of failing to fully comprehend the levels of danger and risk in some families. This not only exposes professionals to potential danger, but also leads to a minimisation of risk to some of those living in the household. ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: Does the board know if professionals are aware of gang activity? Does exposure to gang- and drug-related violence form part of safeguarding assessments? If not, should it? Do members of the LSCB consider it necessary to find new ways of raising awareness amongst agencies of the continuing high levels of violence (including gang violence) drugs and crime in the borough? Finding 5. A pattern whereby practitioners do not bring a case to supervision either because they fail to identify the need for supervision, or the case has been closed, resulting in a lost opportunity to challenge the interpretation of facts and the plan for intervention. It is well documented that in working with families to safeguard children, the sense that professionals make of information they receive will inevitably be vulnerable to common errors of human reasoning (Munro, 1999). As Munro (2008) notes: 31 ‘Psychological research has shown that people are very bad at policing their own biases. Social workers need regular critical supervision to ensure that their biases are not distorting their assessments.’ Supervision is a key mechanism by which practitioners can be challenged on the sense they are making of a case, and helped to avoid. This case suggested a pattern whereby supervision is not fulfilling this role, leaving practitioners vulnerable to predictable errors and biases in their thinking, such as the tendency to allow families to ‘start again’ (16). 1. How did this manifest in this case? The SW carrying out the Pre-Birth assessment did not take the case to supervision although she did seek guidance and direction from her line manager on an ad hoc basis. The case was closed and therefore there was no opportunity to review the case and consider all the presenting facts to determine what should be considered as historical and what was current. HV2 again did not identify this as a case that she wished to take to CP supervision during her antenatal contact but did seek supervision following the joint home visit with the SW in April; this was two weeks before Child D was admitted to hospital. 2. What makes this an underlying issue? The Review Team and Case Group are very clear that the practitioners carry a high number of families with concerns that do not meet the thresholds for intervention but continue to give cause for concern. Through further discussion with the core group it became evident that these cases were seldom taken to supervision as they already had high numbers of cases of Children with a Child Protection Plan or Children In Need. Health staff referred to there being insufficient time available in the supervision sessions to discuss the families in a meaningful way and supervisees are reliant on staff identifying and bringing the right cases to the supervision sessions. SW’s often carry out initial assessments and due to the time constraints may not receive formal supervision on the case as it has been processed and closed. 3. What is known about how widespread or prevalent the issue is? Members of the Review Team are clear that professionals from all agencies do receive supervision on a regular basis, but the time constraints and robustness are variable. Several practitioners felt the need to regularly seek “informal” supervision from their manager on an ad hoc basis; but from the managers’ perspective this was not viewed as supervision and would not have been recorded. 16 Brandon (2008) 32 There was concern expressed by the RT that a case like this one would not routinely be taken to supervision and therefore the opportunity to challenge the view or perception that the risk factors are historical and therefore not relevant is lost. 4. What are the implications for the reliability of the multi-agency child protection system? Much has been written on the benefits to both the individual and the organisation when regular supervision is given and received. It is therefore surprising to find that supervision is not always viewed positively, and indeed many of the case workers could not identify with “reflective”, “challenging” or “supportive” supervision. Professionals working with difficult and complex families need protected time to make sense of the information and changing circumstances. This can become even more important when a family has been known to agencies for ”years” to provide a critical and challenging view / perspective that allows the facts to be viewed from a different perspective. It also allows professionals to be able to communicate and express their anxieties about the work that they are undertaking with the family, and identify gaps and risks within the multi-agency system.17 Finding 5. A pattern whereby practitioners do not bring a case to supervision either because they fail to identify the need for supervision, or the case has been closed, resulting in a lost opportunity to challenge the interpretation of facts and the plan for intervention. Good supervision is fundamental to good practice: in providing support, challenge and reflection, particularly with difficult and complex families. Some complex cases do not get discussed in supervision, either because the case has been opened and closed (the complexity of the case has not been appreciated) or the choice of what cases are discussed is left to the supervisee. There is evidence of managers being under considerable pressure, with limited time to provide robust and good quality supervision, and many workers rely on ad hoc informal conversations with their manager, seeking affirmation that they are making the right decisions. Whilst this is good, there is a danger that this replaces full discussion within a formal supervision setting, where time is devoted to reflection and appraisal of practice and its effectiveness. ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: Is the LSCB assured that professionals receive timely and qualitative supervision? How will the Board review the cases that are discussed in supervision and those that are not? 17 Brandon (2008) 33 What do members of the LSCB consider needs to change in supervision to ensure that is used effectively for reflection and challenge? Finding 6: A pattern whereby practitioners superficially identify risk factors but do not consider the significance or impact they might have, resulting in inappropriate levels of intervention to safeguard children. A good assessment including family history and identification of risk factors is fundamental in ensuring that a strong and appropriate plan for the level of intervention is put in place. There is a danger that when professionals from the key agencies fail to identify the risks or understand the significance of them, children are left living in risky situations. 1. How did this manifest is this case? Throughout this case the professionals working with the family, SW’s and Health Professionals, listed the risk factors present within the family and family home but appeared unable to consider the impact that these may have on Miss F’s ability to parent, or whether the family home was a safe place for her to be. The family were well known and had a complex history (see paragraph 1.2). Miss F was a young person leaving care who was pregnant and living with her father Mr. J who wanted her out of the family home before the birth of the baby. Miss F attended for all her antenatal care, engaged with the health visiting service but turned down any additional support that would have been available through the Family Nurse Partnership. This links to Findings 1 and 5. Following the initial assessment by the SW in the First Response and the subsequent closing of the case the health visitors were reassured by her preparation for the birth of her baby and her attendance for all her antenatal appointments. The HV was unaware that Child L had been returned to the family home or that Mr H was arrested in possession of a gun in January. It is always difficult to get the balance between historical information and current presentation correct in assessing the risk but in this case the professionals appeared to be swayed by the optimism and determination of Miss F who was going to give her baby a better life than the one that she had. 2. What makes this an underlying issue rather than a particular issue to the individuals involved? Members of the Case Group were asked routinely in conversation whether they were aware of the LSCB Pre-Birth Assessment tool which was developed by the LSCB and launched in July 2012 to help professionals assess and identify risks to unborn children; 34 none were aware of it. This suggests that it is not routinely used to assess risk to unborn babies across all the agencies and therefore indicates an underlying pattern. 3. What is known about how widespread or prevalent the issue is? This is a continuing professional problem whereby professionals are constantly balancing risks and making a judgement between what is known about the family against the ‘here and now’. Inevitably getting the right balance is not always possible at the time. Research (Burton 2009)18 suggests that the human brain struggles to make sense of contradictory data, and the more incremental it is, the harder it is to make sense of that data. In this case the professionals appeared to overlook the lessons of history. Research evidence from SCR’s (Brandon et al19) suggests that history is an important part of assessing current and future parenting capacity, and should be considered as a potential risk factor. It is apparent that ‘the past is the best predictor of the future’20. This view of the family was coupled with a rule of optimism and a failure to revise judgments in light of new information. Reder et al 21 have written about a cognitive error, which results in disregarding new evidence that might challenge the current direction or concept of the case (e.g. family support as opposed to child protection). In looking at 35 cases which ended in children’s deaths, they found that, once workers have formed a view of what was going on, they typically fail to notice or give weight to evidence that challenges that picture. In some cases the behaviour springs from a pervasive belief about a family, within which new information is slotted into that version of a family’s functioning. 4. What are the implications for the reliability of the multi-agency child protection system? A fixed view of a family can permeate across agencies and regardless of the information available that should challenge this view; the view can remain set over an extensive period of multi-agency involvement. There are clear implications for effective partnerships in how children are safeguarded. Finding 6: A pattern whereby practitioners superficially identify risk factors but do not consider the significance or impact they might have, resulting in inappropriate levels of intervention to safeguard children. A safe child protection system needs to deal proficiently with risk and probability; it is not enough to respond reactively after an incident of harm has been caused to a child. 18 Burton 2009 19 Brandon et al: 2008 20 Reder and Duncan 1999. 21 Reder et al 1993 35 Time and time again through this review practitioners have failed to act on the risks to this vulnerable mother and her baby, despite all the evidence being available. Indicators of risk were ignored and assumed to be historical in nature. ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: Are members of the Board surprised that the Pre-Birth Risk Assessment Tool is not being used? Does there need to be an audit of pre-birth assessments? How can members of the LSCB be assured that professionals fully take into account family history when assessing current risk? Appendix 1 – Methodology 1. This SCR has used the SCIE Learning Together model for case reviews. This is a ‘systems’ approach, which provides a theory and method for understanding why good and poor practice occur, in order to identify effective supports and solutions that go beyond a single case. Initially used as a method for conducting accident investigations in other high risk areas of work, such as aviation, it was taken up in Health agencies, and from 2006, was developed for use in case reviews of multi-agency safeguarding and CP work (Munro, 2005; Fish et al, 2009). National guidance in the 2013 revision of Working Together to Safeguard Children (2013) now requires all SCRs to adopt a systems methodology. 2. The model is distinctive in its approach to understanding professional practice in context; it does this by identifying the factors in the system that influence the nature and quality of work with families. Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively. 3. Learning Together is a multi-agency model, which enables the safeguarding work of all agencies to be reviewed and analysed in a partnership context. Thus, many of the findings relate to multi-agency working. However, some systems findings can and do emerge which relate to an individual agency. Where this is the case, the finding makes that explicit. 4. The basic principles – the ‘methodological heart’ – of the Learning Together model – are described in summary form below: a. Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time (the ‘view from the tunnel’). What was influencing and guiding their work? 36 b. Provide adequate explanations – appraise and explain decisions, actions, and in-actions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it c. Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what bolsters and what hinders the reliability of the multi-agency CP system. d. Produce findings and questions for the Board to consider. Pre-set recommendations may be suitable for problems for which the solutions are known, but are less helpful for puzzles that present more difficult conundrums. e. Analytical rigour: use of qualitative research techniques to underpin rigour and reliability. 5. Typology of underlying patterns 5.1 To identify the findings, the Review Team has used the SCIE typology of underlying patterns of interaction in the way that local child protection systems are functioning. Do they support good quality work or make it less likely that individual professionals and their agencies can work together effectively? They are presented in six broad categories of underlying issues 1. Multi-agency working in response to incidents and crises 2. Multi-agency working in longer-term work 3. Human reasoning: cognitive and emotional biases 4. Family – Professional interaction 5. Tools 6. Management systems Each finding is listed under the appropriate category, although some could potentially fit under more than one category. 6. Anatomy of a finding For each finding, the report is structured to present a clear account of: How the issue manifests itself in the particular case In what way it is an underlying issue – not a quirk of the particular individuals involved this time and in the particular constellation of the case? What information is there about how widespread a problem this is perceived to be locally, or data about its prevalence nationally? How the issue is usefully framed for the LSCB to consider relative to their aims and responsibilities, the risk and reliability of multi-agency systems. This is illustrated in the Anatomy of a Learning Together Finding (below). 37 22 7. Review Team and Case Group 7.1 Review Team The Review Team comprises senior managers/professionals from the agencies involved in the case, who have had no direct part in the conduct of the case. Led by two independent Lead Reviewers, they act as a panel working together throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings. They are also a source of data about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints, changes in structure, and so on. The Review Team members also have responsibility for supporting and enabling members of their agency to take part in the case review. The two Lead Reviewers in this SCR are both accredited to carry out SCIE reviews, and have extensive experience in writing SCRs/IMRs under the previous ‘Chapter 8’ framework. Neither has any previous involvement with this case, or any previous or current relationship with Haringey Council or partner agencies. Ann Duncan, Independent Lead Reviewer 22 38 Ghislaine Miller, Independent Lead Reviewer Head of Safeguarding, Quality Assurance and Practice Development, Haringey Children’s Social Care (CSC) Interim Assistant Director Quality Assurance (CSC) Acting Head of Service, including First Response Team, Haringey CSC Designated Nurse for Safeguarding, NHS Haringey Clinical Commissioning Group (CCG) Consultant Paediatrician and Designated Doctor for Safeguarding, NHS Haringey CCG Named Nurse Safeguarding Children (Primary Care), NHS Haringey CCG (shadowing DN) Named GP, NHS Haringey CCG Acting Director of Operations Woman, Children’s and Families Division (SCR Panel member only) Whittington NHS Trust Interim Head of Safeguarding Whittington NHS Trust Head of Housing Support & Options, LA Housing Service Named Nurse for Safeguarding, Whittington NHS Trust Review Officer, SC&O 21(2) Crime Academy & Review group, Metropolitan Police 7.2 Case Group The Case Group are the professionals who were directly involved with the family. The Learning Together model offers a high level of inclusion and collaboration with these workers/managers, who are asked to describe their ‘view from the tunnel’ – about their work with the family at the time and what was affecting this. In this case review, the Review Team carried out individual conversations with 17 Case Group professionals. Health: GP Practice Nurse (PN) Teenage Pregnancy Midwife (TPM) Whittington Health Health Visitor Whittington Health 39 Agency Health Visitor (has now left) Nursery Nurse (has now left) HV Manager Whittington Health CYPS: Social Worker First Response Team x2 Manager of First Response Team Children in Care Social Worker x2 Children In Care Manager X2 Social Worker x2 Housing Support Case officer 8. Structure of the review process A Learning Together case review reflects the fact that this is an iterative process of information-gathering, analysis, checking and re-checking, to ensure that the accumulating evidence and interpretation of data are correct and reasonable. The Review Team form the ‘engine’ of the process, working in collaboration with Case Group members who are involved singly in conversations, and then in multi-agency ‘Follow-on’ meetings. The sequence of events in this review is shown below. Timeline to completion 29th May 2013 Extraordinary SCR sub group held - took decision for SCR to be undertaken 12th June 2013 SCR sub group decision SCR methodology should be blended approach 2nd July 2013 1st SCR panel with lead reviewer held 2nd August 2013 2nd SCR review panel held Briefing from Lead reviewer on process Decision taken not to have blended approach and to continue review as SCIE review, second lead reviewer to be identified. 2nd August 2013 1st Practitioners group meeting held Briefing from Lead reviewer on process 12th September 2nd October 2013 40 Information gathering: conversations and documentation submitted 21st October 2013 3rd SCR review panel held 29th November 2013 4th SCR review panel held 29th November 2013 3rd Practitioners group meeting held - 18th December 2013 Lead Reviewer and LSCB chair meeting discuss key lines of enquiry 20th December 2013 Findings to be circulated to review group Wk of 20th January 2014 Lead reviewers to meet with family Wk of 20th January 2014 5th SCR review panel held to review final report Wk of 3rd February 2014 Governance meeting for Agency leads (TBC - new) 5th March 2014 SCR sub group to sign off report 26th March 2014 LSCB Meeting Report to be made public date to be confirmed 8.Scope and terms of reference 8.1 Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference, such as in a traditional SCR. This enables the data to lead to the key issues to be explored 8.2 The time frame for the SCR was decided as follows: 1st June 2012 to the 29th April 2013 - a period of just over 11 months. This covers the period from the beginning of Miss F’s pregnancy with Child D, until the admission to hospital and the discovery of multiple injuries. 41 9.Sources of data 9.1 Data from practitioners Conversations with members of the Case Group; these were recorded and discussed by the whole Review Team. Two Follow-on meetings in which members of the Case Group responded to the analysis of the case and gave feedback about accuracy and fair representation of their views. In relation to the emerging findings, the Case Group were asked to comment on whether these were underlying and widespread/prevalent. In other words, could we draw conclusions about whether, and in what way, this case provides a ‘window on the system’? Members of the Case Group have also helpfully responded to follow-up queries and requests from the Lead Reviewers and the Review Team for clarification or further information, where this has been needed. 9.2 Data from documentation The Lead Reviewers and members of the Review Team reviewed the following documentation: The records of the agencies in the case, which were then translated into an integrated chronology Referral and information records (CYPS) Placement with Parents Agreement / Assessment Letter to housing from Young People In Care Team Child D’s Personal Child Health Record (Red Book) Whittington Health Supervision Policy Whittington Health Protocol for Joint Working between Children’s Community Health Services and Haringey General Practice February 2009 (amended May 2011) Whittington Health Visitor teams, by establishment and caseload size. Whittington Health protocol for managing Children with a CP Plan and Children In Need Written report from Consultant Paediatrician on Child D’s admission and copy of report from Consultant Paediatric Radiologist. 9.3. Key Practice Episodes and Contributory Factors The data from the conversations with the Case Group translates into their ‘view from the tunnel’ and thence into a selection of Key Practice Episodes (KPEs) which enable us as reviewers to capture the optimum learning from the case. These KPEs are significant points or periods in relation to how the case was handled or how it developed. Case Group members are also an invaluable source of information about the why questions – an exploration of the Contributory Factors which were affecting their practice and decisions at the time. 42 9.4. Participation The Lead Reviewers and the Review Team are grateful for the willingness of the professionals to reflect on their own work, and to engage so openly and thoughtfully in this SCR. 9.5. Data from family, friends and community As in traditional SCRs, the Learning Together model aims to include the views and perspectives of family members as a valuable element in understanding the case and the work of agencies. The two lead reviewers met with the parents of Child D on the 7th February 2014. 43 Appendix 2 – Guide to terminology Acronyms used and terminology explained 10 Statutory guidance requires that SCR reports ‘…be written in plain English and in a way that can be easily understood by professionals and the public alike.’ (2013: 70) Writing for multiple audiences is always challenging. An appendix (Appendix 2) on terminology aims to support readers who are not familiar with the processes and language of safeguarding and child protection work. 2. Haringey LSCB and SCIE are both keen to improve the accessibility of SCR reports and welcome feedback and suggestions for how this might be improved. 3. Acronyms A&E Accident and Emergency Department (hospital) CAF Common Assessment Framework CSC Children’s Social Care CYPS Children and Young People’s Services HARTS Health Access Resource team FRT First Response Team (CSC) TPM Teenage Pregnancy Midwife FNP Family Nurse Partnership PCHR Personal Child Health Record (Red Book) HV Health Visitor LSCB Local Safeguarding Children Board LT Learning Together NBV New Birth Visit SCIE Social Care Institute for Excellence SW Social Worker CIC SW Children in Care Social Worker NAI Non Accidental Injury 44 MASH Multi Agency Single Hub MERLIN Form completed by police and shared with other agencies (formally Form 78) All Action Plans/Child D final PE approved by SCR Sub Group 04.03.15/05 March 2015 Haringey Local Safeguarding Children Board Serious Case Review Child D Action Plan March 2015 Finding 1: A culture of meeting targets and timescales has resulted in a lack of critical analysis when conducting assessmentthe target; RATIONALE ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: ACTION LEAD TIMESCALE Whilst timescales are important to ensure that cases do not drift, there needs to be a sense of proportionality, to ensure that cases are assessed rigorously, rather than being closed prematurely. This case has suggested that the emphasis on timeliness of assessment has not been accompanied by an emphasis on quality. At worst, efforts to meet timescales appeared to exacerbate superficiality of engagement with the family. Is information provided to the LSCB only on meeting timescales and performance targets, masking underlying issues about the quality and effectiveness of interventions? The LSCB needs to be assured that cases are allocated in a timely way to ensure that workers have sufficient time and capacity to undertake the assessment. The practice of allocating cases by e-mail (even when workers are on leave) needs addressing. Given the National and London problems with recruitment and retention of health visitors, is there an opportunity to use the money allocated to address this problem in a more effective way? The use of agency health visitors in conducting new birth visits should be reviewed LSCB to make recommendations for the allocated money to health visitors to be used across the wider sphere of the service to address the issues of recruitment effectively. As this is nationally ring-fenced money the chair of the LSCB has written to the chair of the London LSCB, as this is a problem that applies to a number of Trusts in London. Where it is the case that a medical assessment may be necessary this will be discussed in a teleconference between the on call Comm Paediatrician, Paul Ennals Karen Miller Completed, January 2015 All Action Plans/Child D final PE approved by SCR Sub Group 04.03.15/05 March 2015 the Social Work Team Manager and, where appropriate, CAIT. After a suitable interval compliance with this recommendation will be audited Whittington Health Named Nurse to meet with First Response Head of Service and team managers to agree process for MASH health representatives (Safeguarding Nurse Advisors) to attend strategy meetings and provide health input. Finding 2: A potential pattern where Looked After Children and Young People who move placements on a regular basis are not appropriately assessed each time, resulting in a missed opportunity to review and amend the care plans in place. RATIONALE ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: ACTION LEAD TIMESCALE All Action Plans/Child D final PE approved by SCR Sub Group 04.03.15/05 March 2015 We know that Looked after Children and Young People are vulnerable and that it is imperative that a placement is selected on the basis of providing a stable and nurturing environment. For those children that become even more important that a rigorous and full assessment is undertaken especially when the placement is back in the home that they were removed from. What steps will the Board take to ascertain whether this is a more common pattern in practice? For example, an audit of Looked after Children and young people that have changed placements in the past six months could shed further light on this issue Is the Board aware of any other children that have been placed back in the family home in the last year with the statutory guidance as outlined in the IRO Handbook is embedded. Ensuring that the oversight of care plans and assessment when there is a change in care plans (particularly for those children that have placement moves or returned homed) is evident on file. The monthly audit programme will incorporate a sample of children placed at home. Social Care Finding 3: A potential pattern by which postnatal checks and developmental assessments undertaken in General Practice do not always consider issues relevant to safeguarding RATIONALE ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: ACTION LEAD TIMESCALE We know that families use the services of GPs in varying ways and that the GP has at times a unique position in being able to assess and monitor the health and well being of This case has suggested that GPs may not be picking up indicators of abuse and neglect as part of postnatal checks. Could the Board take action to investigate the extent of the problem, for example through audit? How well do GPs engage with safeguarding in Haringey and in particular through the HV/GP Cross reference ten GP case conference reports with case conference minutes to identify whether any issues were raised at the meeting Julie Thomas 31/3/15 All Action Plans/Child D final PE approved by SCR Sub Group 04.03.15/05 March 2015 the family (in some cases the extended family). Whilst acknowledging that GPs and practice staff have attended the requisite Safeguarding training there needs to be more challenge in how they are applying the learning into their every day practice. In particular, postnatal checks and developmental assessments should be part of the safeguarding key indicators such as weight, growth and developmental milestones The safeguarding system is reliant on GPs and practice staff identifying and referring cases into CSC. liaison? Are 6-8 week reviews of babies in General Practice an opportunity for analysis and consideration of safeguarding? and not recorded on the GP report. Consideration to be given to the notification dates of meetings. A report to be received from the First Response Head of Service, to explore how partner agencies can be involved on strategy discussions based on the needs of the child alongside the notification timescales of these invites. A representative of health should be part of any strategy meeting by default. Audit completed March 2014 re frequency of HV/GP liaison meetings Highlighted findings of audit in GP and HV training. Re-iterated value of liaison (both ad hoc and formal meetings) and the need for information sharing to be 2-way. HOS/First Response Geraldine Butler & Julie Thomas 31/3/15 Completed March 2014 All Action Plans/Child D final PE approved by SCR Sub Group 04.03.15/05 March 2015 Questionnaires from HVs and GPs re liaison currently being collected report due March 2015. Protocol currently being reviewed. Review the EMIS page content in relation to the 6-8 week check. The LSCB to suggest guidance following the findings. To discuss with GP CP leads in the context of the overall recording of the outcome of the 6 week review. Julie Thomas Julie Thomas 31/3/15 30/6/15 31/7/15 Finding 4: A pattern whereby practitioners have become accustomed to working with families surrounded by high levels of stree t and drug-related violence, meaning that this does not lead to a consideration of impact on parents and children RATIONALE ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: ACTION LEAD TIMESCALE In this particular area of Haringey drug and street violence are so common that they have become perceived as normal. Front line members of staff are in danger of failing to fully comprehend the levels of danger and Does the board know if professionals are aware of gang activity? Does exposure to gang- and drug-related violence form part of safeguarding assessments? If not, should it? Do members of the LSCB consider it necessary to find new ways of raising awareness amongst agencies of the continuing high levels of violence (including gang violence) drugs and crime in the Whittington health to audit supervised and unsupervised cases w/o 2/2/15. Quality and thresholds for supervision. 20 cases from each of the 4 HV teams. Karen Miller Report by 30/04/15 All Action Plans/Child D final PE approved by SCR Sub Group 04.03.15/05 March 2015 risk in some families. This not only exposes professionals to potential danger, but also leads to a minimisation of risk to some of those living in the household. borough? GPs CP leads to ask conference due in the following month to be discussed in a monthly Clinical meeting This suggestion will be floated at the GP CP lead meetings by 31/7/15. It can only apply to reviews as initial CP conferences tend to take place at short notice. 31/7/15 Finding 5. A pattern whereby practitioners do not bring a case to supervision either because they fail to identify the need for supervision, or the case has been closed, resulting in a lost opportunity to challenge the interpretation of facts and the pl an for intervention RATIONALE ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: ACTION LEAD TIMESCALE Good supervision is fundamental to good practice: in providing support, challenge and reflection, particularly with difficult and complex families. Some complex cases do not get discussed in supervision, either because the case has been opened and closed (the complexity of the case has not been appreciated) or the choice of what cases are Is the LSCB assured that professionals receive timely and qualitative supervision? How will the Board review the cases that are discussed in supervision and those that are not? What do members of the LSCB consider needs to change in supervision to ensure that is used effectively for reflection and challenge? Recommendations to be made for GPs to discuss cases where safeguarding is an issue in their regular practice meetings. In the light of responses of the above actions, the LSCB will review any needs to change supervision. Julie Thomas CYPS Gill Gibson QA and Best Practice Subgroup 31/7/15 Completed. Supervision Policy for CYPS amended and updated All Action Plans/Child D final PE approved by SCR Sub Group 04.03.15/05 March 2015 discussed is left to the supervisee. There is evidence of managers being under considerable pressure, with limited time to provide robust and good quality supervision, and many workers rely on ad hoc informal conversations with their manager, seeking affirmation that they are making the right decisions. Whilst this is good, there is a danger that this replaces full discussion within a formal supervision setting, where time is devoted to reflection and appraisal of practice and its effectiveness HV supervision effectiveness and timeliness will be audited as in finding 4 above. Karen Miller and to be presented at next LSCB QA and Best Practice sub group for sign off March 2015 Finding 6: A pattern whereby practitioners superficially identify risk factors but do not consider the significance or impact they might have, resulting in inappropriate levels of intervention to safeguard children RATIONALE ISSUES FOR THE BOARD AND MEMBER AGENCIES TO CONSIDER: ACTION LEAD TIMESCALE A safe child protection system needs to deal proficiently with risk and probability; it is not enough to respond reactively after an incident of harm has been Are members of the Board surprised that the Pre-Birth Risk Assessment Tool is not being used? Does there need to be an audit of pre-birth assessments? How can members of the LSCB be assured that professionals fully take into account family Task and Finish group to review and update suite of assessment tools (including pre-birth assessment tools) Gill Gibson March 2015 All Action Plans/Child D final PE approved by SCR Sub Group 04.03.15/05 March 2015 There will be a review of this Action Plan after six months. caused to a child. Time and time again through this review practitioners have failed to act on the risks to this vulnerable mother and her baby, despite all the evidence being available. Indicators of risk were ignored and assumed to be historical in nature history when assessing current risk? and for CYPS to re-launch validated tools LSCB multi-agency thematic audits scheduled for 2015 2016 to ensure audit tools reflect the validated tools to determine compliance and good practice. Findings should be presented to the QA and Best Practice Subgroup. Statement on Child D Monday 16th March 2015 This Serious Case Review is an inquiry into the circumstances surrounding the in April 2013. Whilst responsibility for the abuse lies firmly with those who inflicted it upon the child, this report has concluded that there have been many lessons for the agencies which had duties relating to keeping him safe. within Haringey who seek to keep children safe. Our collective role is to promote effective joint working, and to hold each other to account. Collectively, we sincerely regret that there were several areas where we could, and should, have done better. With hindsight, there were many episodes 3 months, and earlier during the child s -line staff could have acted differently. We cannot say that if they had done so, the abuse would not have happened. But we can say that many of our agencies could and should - have responded differently. We found evidence of several areas needing improvement: The quality of assessments of need of a mother, and a young child, by health visitors and social workers The process of planning for a new placement for children in care, taking account of the needs of the whole family The quality of post-natal checks in GP practice The importance of taking careful family histories, and understanding better the long-term impact on families of regular exposure to violence The need to improve the quality of supervision and management of staff who are dealing with challenging cases. We have acted to tackle the issues raised in this report, and we will continue to check that we have implemented all relevant learning. We can never guarantee that all children will be safe in the future. But when there is rigorous review when things have not gone right, and an openness to change, then we can expect that our services will continue to improve. All the agencies within the LSCB are firmly committed to this principle. If you have any queries please contact Eveleen Riordan, Interim LSCB Business Manager, in the first instance on 020 8489 1472 Sir Paul Ennals Independent Chair Haringey LSCB |
NC50664 | Serious head injuries which were potentially non-accidental to a 3-month-old child in January 2017. Child BY is a twin, born prematurely at 35 weeks' gestation, discharged from hospital into a family with co-existing domestic abuse, mental illness and substance misuse and where father had just lost his brother. Family known to Child Protection Services for two older siblings; the twins were subject to Child Protection Plans at birth; various risk assessments were carried over a two year period. Family is White British. Issues identified include: the need to consider mother's full history and understand the impact of trauma, loss and ongoing abuse and coercion; severe risk of harm is most likely where there is an absence of protective factors; the need to consider male perpetrators in assessments and address or recognise their behaviour and accountability for it. Model designed and led by reviewer to enable participants to consider the events and circumstances leading up to injuries to Child BY. Learning arising: to consider the approach to domestic abuse cases where the victim expresses a wish for the relationship to continue and how this impacts on the children; to ensure that practice and supervision are influenced by an understanding of the long term impact of unresolved childhood trauma, loss and abuse and serious and chronic domestic abuse and coercion on parenting capacity; to consider how agencies currently respond to families where neglect may co-exist with domestic abuse and that neglect is responded to as a safeguarding issue and not solely as a symptom of domestic abuse.
| Title: Serious case review report Child BY. LSCB: Blackpool Safeguarding Children Board Author: Clare Hyde Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Clare Hyde THE FOUNDATION FOR FAMILIES SERIOUS CASE REVIEW REPORT CHILD BY 1 Contents Key: Family Members .............................................................................................................................. 2 Introduction ............................................................................................................................................ 3 The SCR: Process and Methodology ....................................................................................................... 3 Independence ......................................................................................................................................... 6 Serious Case Review Panel ...................................................................................................................... 6 Confidentiality ......................................................................................................................................... 7 Family involvement ................................................................................................................................. 7 Staff involvement .................................................................................................................................... 8 Race, Religion, Language and Culture ..................................................................................................... 8 Summary of Family history ..................................................................................................................... 8 Overview of events and agency involvement ....................................................................................... 10 Analysis ................................................................................................................................................. 10 Summary ............................................................................................................................................... 32 Reframing our Response to Risk ........................................................................................................... 32 Learning arising from this Serious Case Review ................................................................................... 36 References ............................................................................................................................................ 39 2 Key: Family Members Child BY Aged 3 months at date of incident Sibling 3 Aged 3 months (Child BY’s twin) at date of incident Sibling 2 Aged 3 at date of incident Sibling 1 Aged 5 at date of incident Mother Child BY’s mother Father Child BY’s father MGM Maternal grandmother 3 Introduction 1. The subject of this Serious Case Review (SCR) is Child BY. 2. Child BY suffered serious head injuries which were potentially non-accidental on 29th January 2017. Child BY was 3 months old at the time of the injuries. 3. There was a 2 year history of agency involvement with Child BY’s family in respect of domestic abuse and Father’s offending. 4. The domestic abuse (Father was the perpetrator) was serious and involved assaults, threats to kill and use of a weapon. The abuse was the primary reason that Child BY and siblings were subject to Child Protection arrangements. 5. This SCR focused upon agency involvement with Child BY’s family and in particular Child BY’s older siblings in order to identify good practice, learning and missed opportunities to safeguard all of the children which in turn could have provided an opportunity to safeguard Child BY. The SCR: Process and Methodology 6. The Local Safeguarding Children’s Board (LSCB) agreed on the 2nd February 2017 to commission a Serious Case Review (SCR) concerning the injuries suffered by Child BY. The scope of this SCR was to cover the timeframe from 3rd December 2015 to 29th January 2017 which was the date of the injury to Child BY. (It was agreed by the SCR Panel that any significant events prior to this date would also be included within the scope). 7. The Case Review Sub Group made a recommendation that the LSCB should conduct a proportionate, appropriate and participative SCR with the emphasis upon professional involvement, to address how agencies had worked together in this case, identify any learning, aggregate lessons from individual organisations and ensure that an improvement action plan was put in place. 4 8. The SCR was designed and led by Clare Hyde MBE, independent reviewer, from The Foundation for Families (a not for profit Community Interest Company). Ms. Hyde developed a review model that would enable participants to consider the events and circumstances, which led up to the injuries to Child BY. 9. This formal process allows practitioners to reflect on cases in an informed and supportive way. Documenting the history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for Local Safeguarding Children Boards to use where it is more important to consider how agencies worked together. The detail of the analysis undertaken of the case is not the focus of the reports which are succinct and centre on learning and improving practice. However, because a review has been held, it does not mean that practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice. The role of Safeguarding Boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the review can be used to inform systems and practice development. In so doing the Board may identify additional learning issues or actions of strategic importance. These may be included in the final SCR report or in the action plan as appropriate. 10. This approach also takes account of work that suggests that developing over prescriptive recommendations has limited impact and value in complex work such as safeguarding children. For example, a 2011 study of recommendations arising from SCRs 2009 -2010, (Brandon, M et al), calls for a limiting of ‘self-perpetuating and proliferation’ of recommendations. Current thinking about how the learning from SCRs can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation rather than over complex action plans. 11. An SCR Panel was convened of senior and specialist representatives from agencies involved with the family in the time covered, to oversee the conduct and outcomes of the review. All 5 panel members (apart from staff from the older sibling’s school) were independent of the family and casework. The role of the panel was to assist the Lead Reviewer in considering the evidence, formulating the recommendations and quality assuring this report. 12. There was significant agency involvement with Child BY’s family and the following agencies were asked to provide a chronology and these were integrated into a combined chronology. • Blackpool Council Children’s Services • Blackpool Teaching Hospitals NHS Foundation Trust • Cumbria and Lancashire Community Rehabilitation Company • Lancashire Constabulary • North West Ambulance Service • NSPCC • General Practitioners for all parties • S1’s Nursery and Primary School • Providers of Independent Domestic Violence Advocate (IDVA) and substance misuse services 13. The Lead Reviewer considered the combined chronology in order to consider in detail the sequence of events and any key practice episodes that underpinned those events. 14. The SCR Panel agreed the scope of the SCR. The SCR panel also considered key lines of enquiry which were then included in the terms of reference. These included: A. Quality of risk assessments and other assessments B. Effectiveness and review of the Child Protection Plan including: C. Communication between agencies including information transfer, handover issues, recording events D. The voice of the children E. The views of family members and whether professionals effectively considered these. 6 15. The completion of the review was significantly delayed by a parallel police investigation regarding the injuries sustained by Child BY during which it was not possible to offer family members the opportunity to contribute to the review. Independence 16. An independent chair, from a partner agency without direct operational involvement with the family, was agreed by the Local Safeguarding Children Board to chair the SCR Panel. 17. The lead reviewer Ms Hyde was CEO of Calderdale Women Centre for 14 years (between 1994 and 2009) and developed nationally acclaimed, high quality services and support for at risk women and families. Ms Hyde contributed to Baroness Corston’s review of women with vulnerabilities in the criminal justice system which was commissioned by the Government following the deaths of several women in custody. 18. Ms Hyde is currently working with local safeguarding children boards and their partners to improve safeguarding outcomes for children and young people living with domestic violence, substance misuse and parental mental illness and to support the development of a multi-agency response to children and young people at risk of sexual exploitation. 19. Ms Hyde also designed and facilitated a multi-agency review of child sexual exploitation in Rochdale in 2012 and is currently the Independent Chair and Reviewer of several SCRs and a Domestic Homicide Review and has designed and led several Learning Reviews on behalf of local safeguarding children and adults boards. Serious Case Review Panel 20. The SCR Panel met on a number of occasions between May 2017 and September 2017. The subsequent agreement and publication of the report was delayed by a police investigation that concluded in the summer of 2018. 7 21. The overview report was ratified at the Local Safeguarding Children Board meeting on 7th September 2018. 22. The Panel comprised of: Clare Hyde Independent Reviewer Designated Nurse for Safeguarding (Panel Chair) Blackpool Clinical Commissioning Group Review Officer Lancashire Constabulary Named Nurse for Safeguarding Blackpool Teaching Hospitals NHS Foundation Trust Head teacher DSL/ SEND Co-ordinator S1’s primary school S1’s primary school Deputy Director Cumbria and Lancashire CRC Principal Social Worker Blackpool Council Service Manager – Duty and Assessment Blackpool Council Service Manager – Families in Need team Blackpool Council Service Manager NSPCC Designated Doctor for Safeguarding Blackpool Clinical Commissioning Group Business Development Manager Blackpool Safeguarding Children Board Confidentiality 23. Working Together to Safeguard Children 2015 clearly sets out a requirement for the publication in full of the overview report from SCRs: 24. “All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months. Thereafter the report should be made available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case.” Family involvement 25. Mother, Father and MGM were all offered the opportunity to participate in this review but declined the opportunity to do so. This report is therefore limited by the lack of a perspective from family members who were in receipt of services. 8 Staff involvement 26. The staff who were involved with Child BY’s family participated in a Learning Event in July 2017. The Learning Event was attended by practitioners who had had direct involvement with Child BY’s family, in addition to the Lead Reviewer who facilitated the event and the BSCB Business Manager. 27. Following the Learning Event, the Lead Reviewer collated the outputs from the Learning Event and from the agency chronologies and began her analysis. In reviewing the findings, the panel gave consideration to what could be done differently to further improve future practice. Race, Religion, Language and Culture 28. Child BY’s family are English White British. Whilst Mother was from a traveller family and did not live a traditional traveller lifestyle as an adult it is not known how (or if) she identified as of traveller heritage. This did not therefore inform assessments. Similarly it is not known if religion was a feature of the family’s life. The family’s first language was English. Summary of Family history 29. What is known about the family’s history is detailed below. 30. It is reported that Mother lived with domestic abuse and parental alcohol misuse as a child and also experienced the early loss of a significant family member with whom she had a very strong attachment. 31. It is believed that Child BY’s parents have been in a relationship since approximately 2008. Mother would, at that time, have been aged approximately 17 or 18 and Father 24 or 25 years old. 9 32. Mother and Father have 4 children together. Sibling 1 who was aged 6 at the time of the significant incident, Sibling 2 who was aged 2 and Child BY and his/ her twin Sibling 3 who were aged 3 months. 33. Child BY’s Father has perpetrated domestic abuse against Child BY’s mother and has been convicted of assault against her. 34. Father throughout the time scale of this SCR committed other criminal offences in addition to the domestic abuse and received further custodial sentences in 2016 (more detail given below). 35. Father had known drug and alcohol issues and was, for example, arrested for possession of cocaine and cannabis in October 2016. 36. There is very little known or recorded about Father’s childhood therefore this was not used to inform assessment of need or risk. 37. Both Mother and Father have sought help for mental health issues during the time scale of this review. 38. Although not within the timescale of this review Mother and Father separated for 8 weeks in April 2015. During this separation Father threatened to ‘slice her throat’ with a knife. 39. Also during the 8 week separation Mother was assaulted by a man with whom she had a brief relationship and by two women who were thought to be acquaintances of his. 40. Mother had a difficult relationship with her own mother MGM and this resulted in reported domestic abuse incidents (MGM was the alleged perpetrator) and periods of time during which Mother and MGM were estranged. 41. Sibling 1 and Sibling 2 became known to CSC in 2015 because of the domestic abuse perpetrated by Father which included assault and threats to kill Mother. 42. There were signs of neglect including the children being left alone and missed medical appointments. 10 43. In September 2015 Sibling 1 was found in the street at the age of 3 alone and partially dressed. The adult who found him discovered that 15 month old Sibling 2 was in the house alone crying in a cot upstairs. This led to a referral to Children’s Social Care and an Initial Assessment. 44. In December 2015 Siblings 1 and 2 became the subjects of Child Protection arrangements because of emotional abuse due to the ongoing domestic abuse between their parents (perpetrated by Father). 45. In April 2016 Mother’s pregnancy with Child BY and Sibling 3 was confirmed. 46. In August 2016 another family member made threats against mother. 47. In October 2016 an Initial Child Protection Conference was held in respect of the unborn twins. It was agreed that the twins would be subjects of a Child Protection Plan at birth. 48. Throughout the period covered by the review Father was supervised by the Community Rehabilitation Company in relation to his offending. Overview of events and agency involvement 49. Although the timeframe for this SCR was 3rd December 2015 to 29th January 2017 agency records held historical information which is relevant to the case and this has been considered. Analysis 50. The analysis is set out in response to the key lines of enquiry set by the SCR Panel which formed the terms of reference for the SCR. The analysis is informed by the chronological information provided by agencies, the views and contributions of the practitioners who attended the Learning Event, by research and by analysis of other serious case reviews and domestic homicide reviews. 11 How was risk recognised and assessed in this case? 51. The risks posed to Child BY and siblings by the adults in this case were not always recognised and assessed. 52. Domestic abuse was recognised as a primary risk to the children and was the reason that they were subject to child protection arrangements. 53. However the other risks, whilst in some instances acknowledged (such as Father’s offending) were not sufficiently recognised and subsequently assessed as a risk to the children. 54. In particular the cumulative and compounding nature of multiple risks were not sufficiently recognised. 55. The potential risks to Child BY and siblings from the adults include: Chronic and serious domestic abuse including use of a weapon and threats to kill Attempts to separate by Mother from Father Father’s drug and alcohol use Father’s offending including other offenders visiting the family home. Father’s non-compliance with his sentence conditions Non-compliance by the adults with the expectations placed on them by the Child Protection Plan. Signs of neglect including the children being left unattended. Mother’s vulnerability (she was assaulted, threatened and experienced verbal abuse from 5 people other than Father during a 3 year period) Both parent’s potential mental ill health. Mother’s own adverse childhood experiences of loss and abuse and the potential impact of these on her parenting capacity. The impact of prolonged coercion and abuse on Mother’s parenting capacity. Mother’s social isolation and estrangement from and conflict with her own family. 12 56. Research consistently highlights the increased risks to children associated with domestic abuse, mental illness and substance misuse (known as the Toxic Trio –see below) and this increased the children’s vulnerability. 57. Substance misuse is a broad term encompassing the harmful use of any psychotropic substance, including alcohol and either legal or illicit drugs. Use of such substances is harmful when it has a negative effect on a person’s life, including their physical and mental health, relationships, work, education and finances or leads to offending behaviour. 58. There is no information within agency records to suggest that any one agency or any multi-agency forum recognised the higher risk of co-existing domestic abuse, mental illness and substance misuse 59. In addition to these risks poverty and debt were an issue for the family and may have caused constant stress and anxiety to one or both of the adults. 60. Into this context of risk Mother became pregnant with twins. 61. At the point at which the pregnancy was confirmed in April 2016 there had been 12 reported incidents of domestic abuse within a 12 month period. 62. Father was also involved in criminal offences and was sentenced in June 2016 to a 12 month Suspended Sentence Order. 63. On 19th October 2016 Child BY and his/her twin were born following an induced labour at 35 weeks’ gestation due to concerns about their static growth. Both babies were admitted to the Special Care Baby Unit (SCBU) at birth. 64. In October 2016 Father reported the tragic loss of his brother and this triggered an episode of increased or resumed drug and alcohol use. He was escorted from the Special Care Baby Unit 24th October 2016 as staff observed that he appeared to be under the influence of substances. 65. At the point at which the twins were discharged from hospital the combined or cumulative risks (including their own premature births) to all of the children were considerable. 13 66. The family as a whole and the individual family members were the focus of various risk assessments / arrangements including: Multi Agency Risk Assessment Conference (in respect of the domestic abuse) Domestic Abuse Stalking and Honour Based Violence Risk Assessment OASys the offender assessment system carried out in respect of Father Child and Family Assessments carried out by Children’s Social Care Family in Need Assessment 67. In summary; there were various risk assessments carried out however none of these suitably assessed the combined, cumulative and increasing risks to the new born Child BY and his/her siblings. 68. The focus of the assessments carried out in respect of the whole family by Children’s Social Care remained largely on the domestic abuse and to a lesser degree upon Father’s drug and alcohol use. The outcome of this was that pressure was put on Mother to ensure that Father stayed away from the family home. (Father had refused to sign a written agreement to this effect). 69. However the biggest trigger for an abusive man to commit fatal violence (to adults and children) is separation or the threat of separation. Studies of estrangement and homicide have routinely found a very strong correlation (Stark 2007, Polk 1994). 70. Furthermore this approach did not recognise the ongoing coercive and controlling nature of Father’s abuse and the impact that this would have had on mother and her capacity to make decisions and to protect herself and the children. 71. The Serious Crime Act 2015 received royal assent on 3 March 2015. The Act creates a new offence of controlling or coercive behaviour in intimate or familial relationships. This closes gap in law around patterns of controlling or coercive behaviour in an ongoing relationship between intimate partners or family members. The offence carries a maximum sentence of 5 years’ imprisonment, a fine or both. 14 72. This offence is constituted by behaviour on the part of the perpetrator which takes place “repeatedly or continuously”. The victim and perpetrator must be “personally connected” at the time the behaviour takes place. The behaviour must have had a “serious effect” on the victim, meaning that it has caused the victim to fear violence will be used against them on “at least two occasions”, or it has had a “substantial adverse effect on the victims’ day to day activities”. The alleged perpetrator must have known that their behaviour would have a serious effect on the victim, or the behaviour must have been such that he or she “ought to have known” it would have that effect. 73. Coercive control and verbal threats are more positively correlated with homicide than violence alone, and should be taken very seriously (Liem and Roberts 2009, Stark 2007). 74. The criminal justice system’s assessments of Father included the potential risk he posed to the children as well as to Mother. (He was assessed as being of high risk to others). 75. His engagement with his Supervising Officer (SO) was inconsistent and he breached the requirement to attend statutory meetings with his SO. His SO was also aware that Father was present at the family home when the requirements of the Child Protection plan were that he should have no contact. 76. There does not seem to be any formal analysis of how this non engagement and non -compliance compounded or increased risks to the children. 77. The case was also considered by the Multi Agency Risk Assessment Conference (MARAC) on 2015 date? And 24 March 2016. Perception of Risk 78. Some of the practitioners who contributed to the Learning Event reflected that the way in which they perceived risk in this case was influenced by their responses to Mother and Father as individual people. 15 79. Father was described by the practitioners as physically intimidating and on occasion his behaviour was aggressive and threatening. He was also known to be violent and have used weapons and threats to kill. He was also using drugs and alcohol which made his behaviour unpredictable. This would, undoubtedly, have led to practitioners being wary of him and they may also have felt unsafe in his presence. 80. Mother was described by the practitioners who contributed to the Learning Event as ‘warm’, ‘nice’, ‘a good mum’, ‘vulnerable’ and ‘socially isolated’. She was not ever considered to be a source of risk to Child BY and the siblings and practitioners felt empathy towards her. 81. It is only by taking into account Mother’s own childhood experiences of loss and abuse and the transition from being a child living with domestic abuse to being a young adult and parent and becoming a victim of prolonged and serious domestic abuse and the other stresses that she was enduring that we might consider that her capacity to parent may have been compromised. 82. The birth of premature twins into a family where there were already several serious pre-existing risks to children was a further significant and compounding risk and placed additional strain on Mother in particular. 83. The limited research which exists on the increased risk of childhood abuse for twins shows that large families and inadequate spacing of children increase the risk of abuse. Twin births incorporate both of these factors, yet the association of twinning with subsequent abuse has not been widely explored. In one U.S. study 48 families with twins were compared with 124 single-birth families, matched for hospital of delivery, birth date, maternal age, race, and socioeconomic status. Three control (2.4%) and nine twin (18.7%) families were reported for maltreatment (P less than .001). Mothers of twins experienced greater previous parity than did control subjects (P less than .001). Twins also had significantly longer nursery stays (P less than .001), lower birth weights (P less than .001), and lower Apgar scores at one (P less than .01) and five (P less than .05) minutes. A regression analysis incorporating all of these 16 variables, however, showed that twin status was most predictive of subsequent abuse. (Increased child abuse in families with twins. Groothuis JR, et al 1982) 84. A further study showed that close spacing of children may be a significant risk factor for subsequent abuse in some families. Twin births are an extreme example of close spacing. Therefore, the authors hypothesized that twin births may predispose to an increased incidence of child abuse. Thirty-eight families with twins were compared with 97 single birth families and matched for birthdate, maternal age, race, and socioeconomic status. Families with twins experienced a significantly higher incidence of child abuse and neglect than did those with single births (p less than .003). (Increased child abuse in families with twins. Robarge JP, Reynolds ZB, Groothuis JR. 1982) 85. In summary there is cumulative risk of harm to a child when several risk factors are present in combination over periods of time. The 2011 to 2014 National Triennial Analysis of SCR’s qualifies this “ We previously noted this particularly in relation to domestic abuse, parental mental ill-health, and alcohol or substance misuse, but it also includes other risks such as adverse experiences in the parents’ own childhoods, a history of violent crime, a pattern of multiple consecutive partners, acrimonious separation, and social isolation. When presented with any of these risk factors, practitioners should explore whether there may be other cumulative risks of harm to the child, as well as any protective factors. The impact of all domestic abuse is harmful to children and a step-change is required in how we understand and respond to domestic abuse. There is a need to move away from incident-based models of intervention with domestic abuse to a deeper understanding of the ongoing nature of coercive control and its impact on women and children, and also on men”. 17 How was the voice of the child/ren heard and how is this evidenced? 86. Because Child BY and the siblings’ ages ranged from 3 months to 5 years (at the time of the injuries to Child BY) any efforts to hear their voices should have focused on their likely daily lived experience as well as direct work with the two older siblings. 87. In the case of Sibling 1 regular and repeated efforts were made particularly by the FIN workers to engage her/him and to see and speak to her/him alone. 88. However Sibling 1 was often reluctant to speak to workers and there was evidence that s/he may have been coached or coerced by Mother and/ or Father and consequently expressed fear that Sibling 2 would be taken away and that Father would be ‘locked up’. S/he also referred to ‘those nasty ladies’ when speaking about the professionals who were working with the family. 89. Coaching and coercing such a young child who would not have been able to process what was happening to her/him emotionally or intellectually was in itself an abusive act and left her/him fearful for her/his family members. 90. We know from the agency chronologies that Sibling 1 and Sibling 2 witnessed abuse and experienced neglect and that life for them before Sibling 3 and Child BY were born was likely to have been difficult and dangerous at times. 91. In September 2015 Sibling 1 at 3 years of age was found partially dressed and barefoot in the street at 8am by a member of the public. Sibling 1 managed to take the adult to the home address and told her that “little brother/ sister” was upstairs. The adult found Sibling 2 upstairs in a travel cot, crying. It is not clear how long the children had been left alone. This incident was reported to CSC. 92. Sibling 1’s behaviour was of concern to professionals and to Mother as s/he was aggressive towards Mother, Sibling 2 and towards practitioners. S/he also swore and was disobedient. 93. Practitioners focused on improving Mother’s parenting skills to enable her to manage and improve Sibling 1’s behaviour. 18 94. It was noted by a FIN worker that Sibling 1’s behaviour improved when Father was in prison i.e. out of the family home. This did not however shift the focus of interventions from Mother’s parenting skills to interventions which could have focused upon the cause of Sibling 1’s distress and provided therapeutic or other input. 95. It is particularly striking that Sibling 2 is mentioned very rarely in the multi-agency chronologies other than by his/ her nursery school who report that s/he found it very difficult to settle in nursery and was still very distressed one month after having joined. 96. Sibling 2 is also mentioned in his/ her own right in April 2016 when a FIN worker carried out a home visit. The worker recorded that Sibling 2 presented with a burn on his/ her right hand, between the thumb and fore finger; this was approx. the size of a 20p piece. Mother showed the FIN worker the cooker in the kitchen and stated that as she had open the oven door when the grill was on Sibling 2 had put his/ her hand inside and caught it on the hot grill. 97. The FIN worker gave advice to seek medical attention if the injury began to weep or become sore and updated the Social Worker. This was not further considered as a potential non accidental injury and was not discussed at the following Core Group meeting. 98. It was noted that Sibling 1’s behaviour improved when Father’s access to the family ceased due his imprisonment. It was also noted that Mother’s engagement with services improved. This observation was reflected back by the FIN practitioner to Father who became angry and aggressive. 99. Some practitioners who attended the Learning Event also reflected that mother seemed to ‘favour’ Child BY and tended to his/ her needs ahead of his/her twins’. Practitioners had partially explored this with Mother who explained that Child BY had been born first. Suggestions were made to Mother than she alternated her attention between the twins so that Sibling 3 would sometimes have his/ her needs met first. 19 100. The lived experience of Child BY and Sibling 3 as new born, premature twins is difficult but not impossible to imagine by considering their daily lives. Were their emotional and physical needs met immediately? How did Mother form attachments with them as individual babies (see comments above) and how did this inform assessments? Was the house warm, peaceful, calm? This does not seem to have been formally considered and reflected upon in a multi-agency forum such as core groups. How effectively were child protection and other processes used in this case? 101. The focus of multi-agency child protection arrangements was to support Mother to end the relationship and ensure no contact with Father. This approach did not recognise the extreme difficulty for any woman living in a situation of domestic abuse to effect any change, including the difficulties of moving out of a controlling and coercive relationship nor did it acknowledge the increased risk of any attempt to end the relationship. 102. Sibling 1 and Sibling 2 became subject to Child Protection arrangements in December 2015 because of emotional abuse. At that point Father was asked to sign a written agreement to stay away from the family home and to have no contact with the children until a risk assessment had been carried out. Both adults stated that they wanted the relationship to continue. 103. It is noted that whilst Mother reiterated her wish to continue her relationship with Father this was not explored with her by any practitioner and did not appear to influence decision making or risk assessments. 104. The outcome of the risk assessment is not clear from agency records however Father did continue to visit and stay at the family home and there was evidence that both he and Mother lied about his presence there. 20 105. Between December 2015 when Sibling 1 and Sibling 2 were made subjects of Child Protection arrangements until October 2016 when Child BY and his/ her twin were also made subjects of Child Protection arrangements there was a pattern of: Non-compliance with or refusal to sign a written agreement to restrict contact with the children by Father ( such written agreements are no longer used in Blackpool as part of child protection arrangements) The confirmed presence of Father in the family home which was, on occasion, denied by both adults. Information to suggest that Sibling 1 had been coached and coerced. A deterioration in Sibling 1’s behaviour. Reported incidents of domestic abuse. Fluctuating engagement with supporting agencies by Mother. Non -attendance for ante natal care with the twin pregnancy. Fluctuating engagement by Father with his CRC officer. Father’s further offending and association with other offenders. Father’s continued fluctuating drug and alcohol use. 106. There appears to have been a tacit tolerance of Father’s presence in the family home and yet there continued to be consensus that he should not be there. It was noted core group meetings that there should be no contact between them. (Enforcement of the written agreement that he should have no contact is not possible in UK law and even if it had been possible it may well have increased risk to Mother and the children). 107. By the May 2016 core group Father had been involved in further offending, Mother had disengaged from The Children’s Centre and Sibling 1’s behaviour had begun to deteriorate at nursery. 108. Although the twin pregnancy had been confirmed on 26th May 2016 this did not appear to have been discussed at Core Group until late August 2016. 21 109. On 31st August 2016 a request was made for a pre- birth initial child protection conference and a Child and Family Assessment. It was noted that ‘Mother is pregnant with twins and is due 22nd November 2016, but could be induced 36 weeks onwards’. 110. Quite clearly this pregnancy confirmed that Mother and Father were still in contact and in breach therefore, of the Child Protection plan but this does not seem to have been addressed. 111. The first Core Group in respect of the unborn twins was held on 17th October 2016 and it was noted that ‘Mother had missed more ante-natal appointments than she had attended’. 112. In addition it was noted that Father was now attending appointments with CRC which he had previously missed. Concerns were noted about parental honesty. It was also recorded that the Core Group were awaiting results of Father’s drug tests and that a referral to FIN had been accepted and the family were waiting for an allocated worker. A written agreement was signed stating that Father was not to live in the family home until ‘further assessments have been completed’. 113. This Core Group meeting repeated concerns and agreed and repeated actions which were very similar to those recorded at the first Core Group meeting in December 2015. The use of another written agreement despite two previous such agreements having not been adhered to throughout the previous 10 months was also agreed. 114. On 28th July 2016 a Review Child Protection Conference took place. This was an opportunity to assess progress and re-assess risk and need. The outcome of the review was that the Child Protection Plan should continue but there was no radical change in approach meaning that despite there having been no sustained improvement, fluctuating engagement and the significant new risk of a twin pregnancy and Father’s increased drug and alcohol use the plan was that Father should have no contact until a further risk assessment had been carried out. 115. This demonstrated what may have been over-optimism concerning the parents’ capacity to change but also a lack of understanding of the reality of life for Mother and the incredible 22 pressures she faced from Father, from practitioners, from the Child Protection arrangements, from her own family and from the pregnancy and impending birth of twins. 116. This may also have reflected that professionals were ‘stuck’ and were not able to devise a plan which would provide alternatives to the actions which had previously been agreed but which had not been effective in reducing risk to the children. 117. A pre-birth Child and Family Assessment commenced from 31 August 2016 and a Strategy discussion took place on 19 September 2016. Concerns were noted about Mother’s capacity to protect the children from Father's violent behaviours and other inappropriate adults. A large number of domestic abuse incidents which had been witnessed by the children was also noted. The outcome of the Strategy discussion was a decision to progress to Section 47 investigation and an Initial Child Protection Conference in respect of the twins. 118. However, it was noted that a Core Group meeting had also been held on 15 September 2016 which had recorded good positive progress being made by the parents and that there were no significant concerns. 119. The Initial Child Protection Conference in respect of Child BY and Sibling 3 was held on 6 October 2016. The Conference noted that the Father had been substance misusing and that Mother had failed to engage with ante natal care and had also disengaged from the Children’s Centre. It was also noted that neither parent attended the Conference. 120. One of the outcomes of the Conference was that information was shared with agencies to state that Father should not be living at the family home. 121. As previously observed this repeated assertion that Father presented a risk to the children and should not be living in the family home was also repeatedly breached and was clearly not effective. 122. The Discharge Planning meeting at which arrangements were made for Child BY and his/ her twin to go home from the hospital was held on 27 October 2016. A further Written Agreement was put in place for Father to have supervised contact only, for a FIN worker to 23 visit daily, and for Homestart and the Children's Centre to also provide support. Mother was advised that if Father turned up at home address she must contact the Police otherwise she would be in breach of the written agreement and legal advice would be sought by the Local Authority. 123. This Discharge Plan whilst putting daily support in place for Mother placed the responsibility upon her for keeping Father from the family home. This demonstrates the lack of understating of Mother’s position not least of which would be the very real possibility of her life (and the children’s lives) being in danger if she did attempt to prevent Father from accessing her or his children. 124. Research consistently shows that pregnancy and the post-partum period are particularly dangerous for women living with domestic abuse. For example, domestic homicide was found to be the biggest cause of traumatic death and injury in pregnant and post-partum women in the USA (Van Wormer and Roberts 2009). 125. Furthermore research and data also shows that the youngest children are at the greatest risk of injury and death. In the 2011 to 2014 analysis of Serious Case Reviews the largest proportion of cases related to the youngest children, who were aged under one year. 120 of the 293 children (41%) were aged under one year at the time of their death, or incident of serious harm; and nearly half of these babies (43%) were under 3 months old. The Triennial Review also noted “We know from our past biennial reviews that the very young are particularly vulnerable, and that premature babies, babies with a low birth weight and/or requiring initial (or in some cases lengthy) special care baby unit nursing, and babies born with neonatal abstinence syndrome potentially pose challenges to their parent(s) over and above the considerable demands of any new-born infant.” 126. On 10th November 2016 a legal planning meeting was held as pre-proceedings legal advice had been sought from Blackpool Council’s Legal Department by the family’s Social Worker. 24 127. The planning meeting must determine if the threshold criteria for an application to court under s.31 of The Children Act is met (The court can create a care order under Section 31(1) (a) of the Children Act, placing a child in the care of a designated local authority, with parental responsibility being shared between the parents and the local authority). 128. In this case the planning meeting concluded that the threshold for commencing proceedings was not met. 129. Whilst the planning meeting may have considered the likelihood of success in a court based on the risks discussed it did not fully consider all risks to the children nor the cumulative impact of those risks. This may have been because the risk assessment was poor. 130. There does not appear to have been any challenge to the advice or a decision made to proceed despite the advice. Nor did this advice prompt an urgent review of why an appropriate assessment of the risk posed by Father and of Mother’s capacity to protect had not yet taken place. 131. The first post-birth Review Child Protection Conference took place on 5 December 2016. It was noted that Mother’s day to day care of all 4 children was adequate and that she had engaged well with services. It was also noted that Father would be released from prison on 9 December 2016 (he had received a custodial sentence on 11 November 2016 for Breach of Suspended Sentence Order, for Handling Stolen Goods and for Failing to Surrender). It was also noted that he would move back into the family home upon his release. 132. The review meeting noted that when Father was back in the family home Mother withdrew her engagement with services. In other words the positive progress was made when he was not able to have any contact with the family. 133. In summary, the majority of the various multi-agency processes including statutory Child Protection visits, Core Group meetings and Review Meetings took place on time and at the correct frequency. However these various processes were not always effective at identifying, assessing, responding to and reducing risks and the cumulative impact of them. 25 134. The outcomes of agreed actions in particular in respect of written agreements and assessment of the risks posed by Father were not robustly reviewed and it was difficult to establish from agency records why this was the case. For example it was acknowledged that the written agreements had not been complied with and yet they were used repeatedly and there was no alternative put forward to try and reduce risk to the children. 135. In particular there was no evidence to suggest consideration of or exploration of the impact of Mother’s own adverse childhood experiences and years of extreme coercion, control and abuse upon her parenting capacity. 136. The various processes did not focus sufficiently upon the needs and lived experience of the children and what we know about children who are living with multiple risk factors. 137. Nor did the various assessments and processes consider the extent of the neglect suffered by the children and the focus largely remained on the contact between the adults and the domestic abuse. 138. The fact was that throughout the period of time the children were subjects of child protection arrangements they continued to live with and be harmed by ongoing domestic abuse, parental substance misuse and offending. They also suffered from neglect that may well have been a consequence of these factors. 139. In addition to the child protection and family focused arrangements Father was in regular contact with the criminal justice system for various offences including those related to domestic abuse. He received custodial and community based sentences during and before the timescale of this SCR. This meant that he was subject to various processes including pre-sentence reports and prison release plans. 140. These arrangements too would have included an assessment of any risks that Father posed to Mother and the children. 141. Father’s impending release from prison was discussed by his SO and SW2 in late November 2016. The discussion was recorded thus “E-mail from SW1 stating that she had been speaking 26 to the new social worker (SW2) and they both want to promote Father to reside in the family home over Christmas. In her view if Father was residing at his parents property with a "tag" it would be “setting him up to fail” as it would be difficult to have contact with his children. Confirmed Children's Services are supporting curfew to Mother’s address and asked if release address could be changed by the Responsible Officer if Father agrees”. 142. The communication agreed that the actions following Father’s release from prison were to include; “FIN are in daily, recommending children stay on the CP plan and that the new social worker is going to complete a thorough risk assessment with both father and mother, and that they have had no DV incidents for 11 months.” 143. It is difficult to establish how the discussions between SW1, SW2 and the SO recognised the risk Father posed to the children especially to the unborn twins. The discussions and in particular the statement ‘setting him up to fail’ acknowledged that he would breach conditions placed on him to stay away from the family home. The decision made to release him from prison to the family home unwittingly colluded with him and potentially placed the children at greater risk. 144. This significant decision was made outside of the multi-agency child protection arena however a core group meeting took place the following day on 25th November 2016 and it does not appear that Father’s release to the family address was discussed and challenged. 145. There are examples of projects which provide a service to families with children where there are domestic abuse and child safeguarding concerns and where the victim states that she wishes the relationship to continue. The Maze Project based at WomenCentre in Calderdale was a specialist project that works with women who are affected by domestic violence and their partners and children. There is currently no equivalent service in Blackpool. 146. The evaluation of this approach demonstrated improved outcomes for children and young people (and the adults) across a range of safety and wellbeing measures which included women and children leaving the relationship in a planned manner. Dr Sue Peckover 2010. 27 How did we know that what we are doing was reducing risk? 147. As previously described there was no information to suggest that risk was meaningfully and permanently reduced by any actions carried out by agencies involved with the family. 148. The measures for reviewing whether or not risk was reducing were not clearly articulated. The main identified risks were Father’s domestic abuse and drug and alcohol use. All attempts to reduce the risks focused on keeping Father away from the family home by use of a written agreement. It was apparent that this was not effective and that he was in constant contact with the family and that the relationship between him and Mother had obviously continued with her becoming pregnant with Child BY and Sibling 3. 149. However it is important to note that because not all risks were identified and the cumulative impact of all risks was not recognised the task of reviewing whether or not risk had reduced would only have been partially possible. 150. Some of the practitioners who contributed to the Learning Event described their anxiety about the risks to the family and there was consensus that any or all of the children and Mother herself could have been harmed. 151. Despite this anxiety there was no professional challenge of the multi-agency plans or decisions which largely repeated previous actions. 152. There was also no information to suggest that management oversight challenged ‘drift’ (specifically the contact of Father with the children) or that supervision enabled practitioners to explore their anxieties. 153. This case highlights a widespread problem with how the multi-agency system responds to families who share similar risks to Child BY. There is a combination of an incident by incident response and a partial understanding of risk and cumulative risk and how to assess it which can lead to lack of clarity about how to reduce and manage risk. This can, in turn, lead to an unintended increase in risk (e.g. the focus on Mother keeping Father out of the family home potentially increased the risk to her and the children). 28 154. This case also reflects a national issue which is that there are also currently few effective measures which can be put into place to protect children and their mothers in cases of sustained and determined domestic abuse, coercion and control. 155. In considering this key line of enquiry the author of this report considered that a question which could routinely be asked in cases where risks to children have been identified is ‘How do we know that what we are doing is not increasing risk’? 156. In cases where families are facing multiple risks professionals and multi-agency groups should consider the potential unintended consequence of their decisions and actions. 157. In this case pressure was put on Mother to end the relationship with a determined and violent man who had threatened to kill her and harassed and coerced her on the two occasions she had attempted to separate from him previously. 158. The support which was put in place to improve Mother’s parenting (including the NSPCC intervention which she do not engage with) may have helped her manage Sibling 1’s behaviour but may also have increased pressure on her whilst doing nothing to address the domestic abuse, coercion, drug and alcohol use and offending of her partner. Communication between agencies including information transfer/handover issues, recording events 159. There were examples of good and effective communication between agencies in this case for example on some occasions between the SO and CSC. 160. The SO’s Recording of events and communications was sometimes poor however and it was difficult to establish who had made contacts with the SO including which agency the contact had been made by. 161. On other occasions communication between agencies either did not happen or was confused and / or late/ sent to the wrong place. For example Sibling 1’s primary school did not always receive minutes of meetings including the Review Conference and the October 29 2016 Core Group meeting nor were they provided with a photograph of the other family member (see para. 46) who had been identified as a risk to Mother and children (and potentially to school staff) despite them having asked SW2 for this several times. 162. On one occasion a Core Group meeting was cancelled and re-arranged and school and other agencies were not advised of this and there was confusion about the time that the re-arranged meeting started meaning that school and other agencies did not attend. 163. The breakdowns in communication described above happened at a crucial time for the family (Father was in prison and Mother was in advanced pregnancy with the twins) and also happened as there was a change of social worker from SW1 to SW2 which may partially explain why they occurred. 164. Some of the practitioners who contributed to the Learning Event described the confusion concerning whether or not Father was ‘allowed’ to be in the family home and confusion about who was and was not assessed as safe to bring and collect Sibling 1 and later Sibling 2 from nursery and school. There were as many as 7 agencies working with the family at any one time and ensuring that the regular changes to who was and was not allowed to have contact with the children was managed through the core groups and on the whole (other than the exceptions described above) this worked well. 165. However the fundamental issue of Father being seen with Mother in and out of the family home despite written agreements being in place remained confusing and, as previously stated in this report, this was never resolved. The views of family members’ and incidents reported by the public and whether professionals effectively considered these. 166. Throughout the timescale of the SCR the agency chronologies contained references to MGM. 30 167. It was recorded that Mother and MGM’s relationship was troubled and that MGM had been abusive towards her daughter. 168. On other occasions the pair were reconciled and she was involved in her daughter and grandchildren’s lives. 169. When the relationship between MGM and Mother broke down and became abusive it appears that on some of those occasions it was MGM’s negative view of Father and his relationship with her daughter that was the source of the antagonism. For example on 15th November 2015 Mother contacted Lancashire Police reporting that MGM had visited her home and was banging and kicking at the door threatening to have the children removed from her as she was unhappy that Mother was in a relationship with Father. When the Police later spoke with MGM she reported that was concerned about her daughter. This incident suggests that MGM recognised that there was risk to the children hence her threat to ‘have them removed’. 170. On another occasion in March 2016 Mother again reported MGM to the police as she had sent abusive messages to her about Father who was, at that time in prison. 171. Also in March 2016 MGM called the police to an incident she alleged had taken place between Mother and Father. The police records indicate that MGM stated that she and Mother and Sibling 1 and Sibling 2 had been followed by Father back to Mother’s address. He took Sibling 1 and put him/ her into his car stating that no one will stop him from seeing his children. MGM claimed that Father was aggressive and shouted abuse from his car. The police attended and Mother denied that the incident had occurred and stated that MGM was lying and that she did not like Father and told lies about him. MGM stated that Father was not allowed to see Mother. Mother however stated that she and Father were friends and may become a couple in the future. 172. When the relationship between Mother and MGM broke down Mother repeatedly stated that MGM had mental health problems and this was recorded by the police. It is not clear 31 from agency records whether or not this information was ever verified however statutory health agencies have no record to indicate that MGM was assessed for or diagnosed with a mental health condition. 173. The practitioners who attended the Learning Review reflected that how MGM presented and how her concern manifested as aggressive and abusive behaviour. It was felt that this would have become a distraction from what her actual concerns were. It was also reflected that Mother may have used MGM’s ‘aggressive’ presentation to deflect professionals’ focus from herself and Father. 174. MGM had legitimate concerns about her daughter’s continuing relationship with Father. She reported incidents of domestic abuse and shared her concerns that the couple were still in contact with each other with professionals. 175. How family members’ concerns are viewed and responded to is a feature of other serious case reviews (and domestic homicide reviews). Family members often feel that their concerns are not listened to or taken seriously or taken into account in assessments of risk and need. It would be particularly difficult to express your concerns and have them taken seriously if you experience mental health issues or communication difficulties or are unable to ‘regulate’ your distress and present as aggressive. It does not mean however that your concerns are less valid. 176. It is not recorded whether or not MGM’s concerns or reporting of incidents were ever used as part of a risk assessment process nor did she appear to have been asked, formally, for her views and / or to contribute towards plans for the children. 177. There were two incidents reported by members of the public. The first in September 2015 is described earlier in this report and was the occasion that Sibling 1 was found alone and partially dressed in the street leading to the discovery of Sibling 2 also alone in his cot. 178. The second incident occurred in November 2015 when Lancashire Police received a telephone call from a member of the public that he had seen a male kicking at the front door 32 of Mother’s house and that and a female (Mother) and children were present. The children were crying. Mother initially denied that Father was present but then told the attending police officer that Father was in the kitchen. Father had left the property via the back door, but returned a short time later and denied there had been any altercation. Whilst police officers were at the address CSC also arrived. Father was asked to leave whilst a risk assessment was carried out on him. Father had just been released from prison. 179. The first incident led to an initial assessment being carried out by CSC however it was December 2015 before the children were made subjects of child protection arrangements. It is not clear what assessment of the specific risks posed by Father (and Mother) were carried out during that period of time. Summary Reframing our Response to Risk 180. In this case Mother had experienced significant historical traumas and loss and was subjected to ongoing coercion and control in her relationship with Father which had begun when she was very young. These factors are indicators that her parenting may have been compromised. 181. Factors that are known to be associated with risk to babies and very young children (Ward et al 2012) include parents who have experienced abusive childhoods themselves and have not come to terms with the abuse. Additional risk factors include domestic abuse and environmental stressors such as housing. Significant protective factors are the presence of a supportive non-partner, wider family and informal support and parent’s insight understanding and capacity to change. Severe risk of harm is most likely where there is an absence of protective factors as in this case. (Ward, H., Brown, R., and Westlake, D. 2012) Safeguarding Babies and Very Young Children. London: Jessica Kingsley Publishers. 33 182. Women with Mother’s history of extreme trauma caused by ongoing physical abuse, coercion and control (including threats to kill) may suffer from Complex Post Traumatic Stress Disorder (C-PTSD) which results from chronic or long-term exposure to emotional trauma over which a victim has little or no control and from which there is little or no hope of escape, such as in cases of domestic, emotional, physical or sexual abuse. 183. The impact of C-PTSD on parenting (and in this case specifically on being a mother) is not fully understood. 184. However there is significant research about women with similar experiences of childhood trauma and abuse which continues into adult hood and the impact that this has on parenting. 185. It is only by considering Mother’s full history and understanding the impact of trauma, loss and ongoing abuse and coercion on her capacity to parent and her ability to keep herself and her children safe that we would see the need for a much more pro-active and evidence based approach to assessing risk and need. 186. What this may mean for practice is that a highly individualised or personalised approach should be taken with women who have multiple vulnerabilities. In this case a trauma informed, gendered approach which took into account Mother’s full history had the potential to safeguard Child BY and Child BY’s siblings. 187. Mother’s apparent unwillingness to end the relationship with Father may be understood in the context of a 2013 research publication ‘Domestic Abuse Gender and Homicide’ (Monckton-Smith et al 2013) which states: “According to our research the most common safety strategy employed by domestic abuse victims is to demonstrate love, loyalty and devotion to appease the abuser. To achieve this they must give the impression, true or not, that they love him, respect him, and want him squarely in their lives and their homes. Abusers always seem to require that the object of 34 their abuse declare and demonstrate love and devotion”. If we understand this then we can refocus and reframe our attempts to protect women and children. 188. The risks to the children in this case were legitimately perceived to be presented by their Father who was a violent perpetrator of domestic abuse, using drugs and alcohol and who was a repeat offender. 189. In this case the family had a 2 year history of contact with agencies because of the domestic abuse (and Father’s other offences) but this did not lead to a holistic assessment of the multiple and ongoing risks. To be effective this would have included direct contact between professionals and Father on a regular basis with the specific aim of assessing the risk he posed to the children. 190. As previously described the focus of multi-agency child protection arrangements was to support Mother to end the relationship and ensure no contact with Father. This approach did not recognise the extreme difficulty of living in a situation of severe domestic abuse to effect any change. Nor did it acknowledge the increased risk of any attempt to end the relationship. 191. There is a need to provide long term, tailored support which show a deeper understanding of the ongoing nature of coercive control and its impact on women and children. (Holt, 2015; Humphreys and Bradbury-Jones, 2015). 192. In addition this case reflects the gendered nature of child protection work and, as described in their 2013 publication ‘Multi-Agency Working in Domestic Abuse and Safeguarding Children’ Peckover and Golding et al describe how professional and agency understanding often does not conceptualise domestic abuse in gendered terms. This may impact on child safeguarding practice in a number of ways. “For example failing to differentiate between the perpetrator and the victim when assessing parenting capacity; all too often the emphasis is placed upon the mother to protect children with shortcomings in parenting becoming the focus of attention as men disappear from the professional gaze. Indeed the most manifest impact of failing to consider domestic abuse in gendered terms is that too often 35 professionals fail to consider male perpetrators in their assessments or recognise and address their behaviour and accountability for it. The invisibility of men and failure to consider or assess the risks they pose are critical issues”. 193. In the longer term there is a need to reframe risk and our response to it by radically changing how we work with perpetrators of domestic abuse. “If we perceive domestic abuse perpetrators as one dimensionally violent, the logical solution may seem to be to punish that violence until it stops. However, if the perpetrator is perceived as dependent, dangerously manipulative and obsessive, then our solution may be different”. (Monckton Smith et al 2014) 194. Father was being managed within the criminal justice system in relation to multiple offences including those arising from domestic abuse. He was also a voluntary participant in a programme which focused on his domestic abuse however it is not clear what impact this had on Mother and the children (e.g. did it reduce incidents and risk). 195. It is not clear that the management of Father reduced risk to his children as he was impervious to any sanction other than a custodial sentence. This should have led to a reappraisal of how risk was assessed and managed and a consideration of what legal measures (and specifically the new offence of controlling or coercive behaviour in intimate or familial relationships) could be used to disrupt and prevent his contact with the children and their mother. 196. However using the criminal justice system as the only, or main, response to domestic abuse, coercion and control is neither appropriate nor effective (Hester 2013b) and should be combined with the long term, multi-agency, multi-disciplinary supports to the victims of abuse and their children which are described above. 197. In this case it is apparent that (despite the commitment and efforts of the practitioners working with the family) Child BY and siblings were living with multiple risks and endured 36 ongoing harm from their exposure to domestic abuse. The serious injuries suffered by Child BY was the ‘turning point’ for the all of the children. 198. The Independent Reviewer/ Author wishes to express her thanks to the practitioners who attended the Learning Event. Their openness and willingness to contribute was invaluable and enriched the SCR process and the learning to be gained from it. Learning arising from this Serious Case Review 199. This section focuses on how practitioners and the multi-agency system recognised, assessed and responded to need and risk in this case. 200. The LSCB should assure itself that the Domestic Abuse and Interpersonal Violence strategy and commissioned services respond effectively to cases which feature domestic abuse and consider the following: That such cases are assessed as potential coercive offences. Domestic abuse training and development content is focused on increasing the understanding of risk. For example ensure that the training is informed by the research (and other research) cited in this review particularly focusing on the risk indicators for homicide and serious harm to adults and children which arise from separation or attempts to separate. Where practitioners are working in adult focused services such as offender management, substance misuse, mental health services, and primary care services that they have sufficient information and professional support to identify and respond to the risks posed by the adults they are working with to children and young people. For example through regular training and awareness raising, opportunities for professional development and inter-agency working. 37 Using the learning from this review the LSCB and other strategic partnerships such as the Community Safety Partnership should assure themselves that work with perpetrators of domestic abuse is developed and/ or commissioned to reflect what is known about perpetrators’ behaviour and the efficacy of existing perpetrator programmes and sanctions. Using the learning from this review, the LSCB and partners should consider what their approach will be to domestic abuse child protection cases where the victim expresses a wish for the relationship to continue and specifically how this impacts on risk to the children. The LSCB should seek assurance that future risk assessments in domestic abuse child protection cases include direct and frequent contact with the perpetrator specifically to inform risk assessments (ensuring the safety and supervision of any staff working with perpetrators). The LSCB should assure itself that the impact on children of living with domestic abuse is understood taking into account how manifestations of distress may differ according to gender, age and personality and should ensure that the voices and experiences of children and young people have been observed, listened to, understood and responded to in planning and decision making. 201. It is essential that the learning from this Serious Case Review is used by the LSCB partners to assure themselves that their approach to families with similar histories to Child BY is effective. In particular how practice and supervision are influenced by the understanding of the long term impact of unresolved childhood trauma, loss and abuse, and serious and chronic domestic abuse and coercion on parenting capacity. For example, practitioners should be able to evidence that plans, risk and need assessments have taken account of these issues. 38 202. The learning from this Serious Case Review should also be used by the LSCB and partners to consider how agencies currently respond to families where neglect may co-exist with domestic abuse and ensure that neglect is responded to as a child safeguarding issue and not solely as a symptom of domestic abuse. 203. The learning from this SCR should be used by the LSCB and partners to consider current single and multi-agency approaches to ‘stuck’ case i.e. those cases where risk is not reducing, including long standing neglect cases, where sustained improvements have not been achieved or where there are long standing child protection arrangements in place. In particular the potential of focused reflective supervision, challenge, peer or independent review to re-assess such cases should be considered. 204. The LSCB and partners should assure themselves that the increased child safeguarding risks associated with twin pregnancies and births (and families with multiple young children) inform assessments and practice particularly where twins are born into families who may already have support needs. 39 References Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C. and Megson, M. (2012) New learning from serious case reviews: a two year report for 2009-11. London: Department for Education, DFE-RR226. Jessie R. Groothuis, William A. Altemeier, Joyce P. Robarge, Susan O'Connor, Howard Sandler, Peter Vietze, James V. Lustig (1982) Increased Child Abuse in Families with Twins, The American Academy of Paediatrics. Hester, M. (2013b) Who Does What to Whom? Gender and Domestic Violence Perpetrators in English Police Records European Journal of Criminology 10 (5): 623–667 Holt, S. (2015) Post‐separation Fathering and Domestic Abuse: Challenges and Contradictions. Child Abuse Review, 24(3): 210-222. Humphreys, C. and Bradbury-Jones, C. (2015) Domestic Abuse and Safeguarding Children: Focus, Response and Intervention. Child Abuse Review, 24(4): 231-234. Liem, M. and Roberts, D.W. (2009) Intimate Partner Homicide by Presence or Absence of a Self-Destructive Act Homicide Studies 13: 399 Monckton-Smith J, Williams A, Mullane F, (2013) Domestic Abuse, Homicide and Gender, Strategies for Policy and Practice Peckover, S and Golding, B and Cooling P. (2013) Multi-Agency Working in Domestic Abuse and Safeguarding Children: University of Huddersfield Peckover, S (2010) The Maze Project; An Evaluation: University of Huddersfield Polk, K. (1994) When Men Kill. Scenarios of Masculine Violence Cambridge: Cambridge University Press 40 Robarge JP, Reynolds ZB, Groothuis JR. (1982) Increased child abuse in families with twins. Research in Nursing Health Stark, E. (2007) Coercive Control: The Entrapment of Women in Everyday Life Oxford: Oxford University Press Van Wormer, K. and Roberts, A. (2009) Death by Domestic Violence Preventing the Murders and Murder Suicides Westport USA: Praeger Ward, H., Brown, R., and Westlake, D. (2012) Safeguarding Babies and Very Young Children. London: Jessica Kingsley Publishers. |
NC50843 | Concerns about the risk of sexual abuse of two half-siblings aged 10 and nearly 6 years old, and about the drift and delay in planning for their future. Involvement from Children's social care services from the time of the birth of Patrick, the older sibling, because father and grandfather both had separate convictions of sex offences against adolescent girls. Mother has learning difficulties and her first two children had been removed from her care. Multi-agency assessments on at least nine occasions during a 9-year period, followed by care proceedings being issued. Siblings subject to child protection plans three times. Delay of six months from the decision to seek interim care orders to when an application was made. Learning includes: there is a difference between the risk of reoffending and the risk of harm that a convicted sex offender might pose to a child in their family; the need for social workers to understand other agencies' risk assessments; the importance of keeping historic 'risk' alive; the importance of pre-birth assessments and child protection conferences; the effectiveness of step-down and escalation. Recommendations to the LSCB include: amend Child Protection procedures to state that when a child is subject to a child protection plan and a parent or carer is on the sex offender register, their sex offender manager should be a part of the core group; when children's names are on a Child Protection plan and there are concerns about possible sexual abuse, risk of sexual abuse is the most appropriate category.
| Serious Case Review No: 2019/C7638 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Serious Case Review concerning Patrick & Patricia 2 Independent Author: Felicity Schofield Contents 1. Introduction ........................................................................................................................................ 3 2. The Terms of Reference ..................................................................................................................... 3 3. The Process ......................................................................................................................................... 4 4. Involvement of the Family & Children ............................................................................................... 4 5. Background to the scoped period ...................................................................................................... 5 6. Patrick’s birth leading up to the birth of Patricia ........................................................................... 6 7. Case opened and closed to CSC, Patrick on a Child Protection Plan ................................................ 7 8. Case reopens to CSC; children subject to a Child Protection Plan .................................................... 9 9. Both children remained on Child Protection Plans, care proceedings were planned but not commenced ........................................................................................................................................... 10 10. Duration of the care proceedings .................................................................................................. 12 11. The Children’s Lived experience .................................................................................................... 14 12. Themes Emerging from the Review ............................................................................................... 15 Understanding the risks posed by adult sex offenders................................................................... 15 The ease with which case records summarise historical risk ......................................................... 16 The category of the Child Protection Plan ....................................................................................... 16 The use of written agreements ........................................................................................................ 17 The role and function of Core Groups ............................................................................................. 17 Escalation .......................................................................................................................................... 18 The effect of organisational change & the role of the LSCB ........................................................... 18 13. Action that has already been taken ............................................................................................... 18 14. Recommendations ......................................................................................................................... 20 3 1. Introduction 1.1 The subjects of this Serious Case Review (SCR) are half-siblings (Patrick) and his sister (Patricia), aged 10 years and nearly 6 years respectively when this review was commissioned. 1.2 This case is about the risk of sexual abuse and how that risk was assessed at various points in time from Patrick’s birth until the conclusion of care proceedings. The case is also about the drift and delay in planning for these two children’s future. 1.3 There has never been a disclosure of sexual abuse. 1.4 There was involvement from Children’s Social Care (CSC) services from Patrick’s birth onwards because both his father and the man who he knew as his grandfather had separately been convicted of sex offences against adolescent girls. In addition, Patricia’s mother was a vulnerable woman with learning difficulties whose first two children had been removed from her care. 1.5 There were multi-agency assessments on at least nine occasions during the nine year period under review which ends when care proceedings were issued. In addition, the children were subject to child protection plans during three periods. There was a delay of six months from the decision that interim care orders were to be sought to when an application was made. 1.6 During the period under review the Local Authority Children’s Services Department embarked on organisational changes which resulted in a significant deterioration in its safeguarding services. The effects of those organisational changes are evident in this Serious Case Review and the experiences of the two children. 1.7 During the Care proceedings there was criticism regarding failing to undertake a robust risk assessment of the children’s grandfather and for the lack of urgency in putting the case before the family court. 2. The Terms of Reference 2.1 The detailed terms of reference were agreed and kept under review throughout the process by the Review Panel. The purpose, framework, agency reports to be commissioned and the particular areas for consideration are all described within these. Eight agencies contributed reports to this review. 2.2 It was agreed that the scope of this review would consider eight specific points in time between Patrick’s birth and the final court hearing. These were critical points where there was, or should have been, multi-agency involvement to inform decision-making and to improve and safeguard the children’s welfare. A ninth point in time was added during the course of the review. 2.3 Given the passage of time and the organisational and legislative changes that have taken place over the last decade, attempts have not been made to understand why certain actions and decisions were taken during the first few years of the scoping period. However, it will be seen that decisions made in this earlier period had a significant effect on subsequent decision making. 4 3. The Process 3.1 Children’s Social Care Services referred the case to the LSCB and it was considered by their SCR subgroup the following month. A recommendation was made to the Chair of the LSCB that the case met the criteria for an SCR. 3.2 The Chair also agreed that this case met the criteria for a SCR and that one should be commissioned. The reasons for reaching this decision were that, despite there being no disclosure of sexual abuse, there were concerns both about multi-agency working and the long term management of risk. 3.3 The report author met with the Chair of the SCR sub-group to draft the Terms of Reference in and single agency reports were commissioned. The Overview Report writer is independent of all professional agencies in the local area, has had no previous direct involvement with or knowledge of the family who were subject to the review and has had no previous involvement in a professional capacity with safeguarding practice in the local area. She is a social worker by profession. 3.4 Working Together to Safeguard Children 2015 states that serious case reviews should: • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; • be written in plain English and in a way that can be easily understood by professionals and the public alike; and • be suitable for publication without needing to be amended or redacted. This serious case review has been undertaken in a way that ensures these principles have been followed. 3.5 Two practitioner events were held. The first event was for those practitioners who had worked with the family. Its aim was to seek their views on the emerging themes from the review. The second practitioner event did not require attendees to have any prior knowledge of the case. Its purpose was to discuss with practitioners the learning from the review in order to establish whether, given the passage of time, areas of concern which had been identified by the review were still prevalent in 2017. The practitioners’ contributions have informed the recommendations. 4. Involvement of the Family & Children 4.1 The lead reviewer met with the younger sibling’s current carers, who are members of her extended family, and with the paternal grandparents. Their views were included in the consideration of the case. 4.2 The contribution of these relatives is greatly appreciated, and it was clear that they all cared a great deal about the two children. Meeting with them served as a timely reminder about how difficult it is for families of limited means to cope with care proceedings, especially when they are not in agreement with the Local Authority. 5 4.3 The children were not interviewed as part of this review. In the opinion of the lead reviewer the younger sibling was too young. With regard to Patrick throughout the care proceedings, which lasted for a period of ten months, Patrick was aware that he might have to leave his carers with whom he had lived for over two years and this caused him a great deal of distress. 4.4 Patrick has moved more recently to live with his birth mother. It seemed inappropriate therefore to reawaken Patrick’s earlier distress by interviewing him for this review. 4.5 All family members were invited to meet with the Independent Chair in order to hear the learning from this review and this opportunity was taken up by the father and grandparents. 5. Background to the scoped period 5.1 This family had been known to Children’s Social Care services (CSC) for many years (a genogram was provided to the Review Panel to assist the review process). Prior to the birth of Patrick, the grandfather had been convicted of sexually abusing an adolescent girl, serving five years of an eight year prison sentence. During the investigation into this offence, the adolescent victim stated that she had also had sex with another family member who was living in the family home at the time. 5.2 The grandmother did not believe the allegations about her husband, even though he had admitted to them. The adolescent victim subsequently came into care and never returned home. 5.3 On the grandfather’s release from prison an initial child protection case conference was held in respect of his son (Patrick’s father) and Patrick’s father was placed on the child protection register (CPR) under the category risk of sexual abuse. 5.4 A risk assessment on the grandfather was carried out by a psychologist who concluded that the risk to Patrick’s father from his own father was low, although the risk would be greater to a female child in his care. 5.5 Patrick’s father was convicted of having sexual intercourse with a girl of fourteen years when he was aged nineteen. He was placed on the sex offenders’ register for five years. Around the same time, he developed health needs which were not well controlled. 5.6 Prior to beginning her relationship with the father of Patricia, the mother had given birth to two children. The mother struggled to meet these children’s needs and they had both come into care when they were under a year old. Both children were placed permanently with alternative carers. Analysis The importance of family history 5.8 Both parents had grown up in families with skewed sexual boundaries. In addition, Patrick’s father had been convicted of a sexual offence and Patrick’s step-mother had a history of sexualised behaviour following her own sexual abuse. It would have been reasonable to assume therefore that the parents’ childhood and adolescent experiences might potentially affect their ability to protect their children from sexual abuse. 6 5.9 The approach taken by CSC on the grandfather’s release from prison was appropriate and sought to understand the risk posed by the grandfather to his own son, Patrick’s father. CSC’s actions were informed by a forensic psychological risk assessment which specifically addressed the question of the risk posed to the father, rather than the risk of reoffending. 5.10 It is of concern that this risk assessment was neither reviewed nor updated for a further 19 years, despite the grandfather both taking over the full-time care of Patrick and playing an active role in the care of Patricia. 5.11 One of the significant messages from this review is that there is currently no agreed pathway for the updating of the risks posed by adult sex offenders. 6. Patrick’s birth leading up to the birth of Patricia 6.1 When Patrick was born the maternity hospital contacted CSC to ascertain whether it was safe for the father to have contact with Patrick given his sex offender status. After a brief delay, CSC undertook an initial assessment. The assessing social worker sought advice from both the probation service and the police regarding the potential risk posed by the father. The two organisations offered conflicting opinions, with the police sex offender unit assessing the father as posing a high risk of reoffending and probation assessing him as posing a low to medium risk of reoffending. Analysis The need for social workers to question and understand other agencies’ risk assessments 6.2 It was good practice for the maternity hospital and the police to consult with CSC when they became aware that a sex offender was caring for a baby. Similarly, partnership working continued to be effective when the health visitor alerted CSC to a significant change in the family’s circumstances. 6.3 The significant issue arising from this early period is that the discrepancy between the two risk assessments, whilst noted, was not pursued with regard to reaching an understanding of the implications for Patrick, either at that time or in the future. Not only was there a discrepancy between two agency’s risk assessments, but the social worker chose to record the risk posed by Patrick’s father as ‘low’ which did not reflect accurately the outcome of the probation risk assessment, let alone the police assessment. Unlike the risk assessment undertaken on leaving jail, these later assessments related to the risk of reoffending rather than to the specific risk that the father might pose to Patrick or subsequent children. For the next nine years this conclusion was relied upon whenever a family assessment was undertaken. 6.4 It is not suggested that a more in-depth analysis of the risks posed by the father and grandfather would have led to CSC allocating the case or putting Patrick on a child protection plan at that time. The immediate risk to Patrick from his father probably was low. However, there needed to be a better understanding of how that risk might change over time, especially given the background of intergenerational sexual abuse and Patrick’s relationship with his grandfather. 6.5 As part of this SCR, it has been established that it was quite common 10 years ago for the police and probation to reach different conclusions about the risk of reoffending. They used different 7 assessment tools. Had they been consulted, both organisations could have explained the likely reasons for their differing conclusions and would have advised a reassessment whenever the person’s circumstances changed significantly. Despite being assessed as posing a ‘low to medium’ risk, Patrick’s father was managed by probation as a ‘medium risk’ throughout his time on the sex offenders’ register. 6.6 Today, police and probation share the same risk assessment tool – Active Risk Management System (ARMS) – so some of the issues identified above would not occur. It remains of vital importance however for workers within Children’s Services to understand what such assessments mean in relation to the specific family they are working with. 7. Case opened and closed to CSC, Patrick on a Child Protection Plan 7.1 From the birth of Patricia onwards there is evidence in the children’s medical records that their medical practice were in receipt of the full facts of the safeguarding risks surrounding Patrick and his sister. 7.2 The case was reopened by CSC in April 2010 following a referral from the maternity services. The mother was pregnant, and the family were temporarily living with the grandfather and his partner. An initial child protection conference was held with Patrick becoming the subject to a Child Protection Plan (CPP). The conference recommended that a pre-birth conference would be required shortly before Patricia’s birth. Analysis The importance of keeping historic risk ‘alive’. 7.3 The majority of times that the children were seen by a GP a red ‘Safeguarding concern flag’ was in place. There were also extensive easily visible references to social work involvement including many entries from the health visitor. These items should have acted as an alert to GPs and GP Locums to understand that the children were living in an environment where safeguarding risks were being managed by the multi- agency teams lead by CSC. However, the GPs who saw the children did not appear to consider or be aware of the seriousness of the risks surrounding both children which might have led to either a differential diagnosis and/or sharing information with the Social Worker. 7.4 During the latter part of the year neither the review conferences nor the core groups nor managers took action to ensure that some of the important and outstanding actions identified at the ICPC in May had been completed. In the absence of the information which would have been available from these actions, subsequent conference decisions were based on the ‘here and now’ rather than on an analysis of the many concerning risk factors in this family’s background and the implications of these factors for these two children. The importance of pre-birth assessments and child protection conferences 7.5 In the opinion of both the author and practitioners who were consulted as part of this SCR it was an omission not to place Patricia on a Child Protection Plan at birth and quite exceptional given that her mother had had her first two children permanently removed as young babies. There is scant 8 information in the records regarding the reasons for the removal of the mother’s other children’s and no analysis regarding the risk of a repeat scenario for Patricia. 7.6 With regard to the ante-natal period and Patricia’s birth, the hospital trust procedures require a referral to their internal safeguarding team when a parent attends hospital and concerns about their presentation have been raised. It is too long ago to establish why this did not happen when the mother was admitted towards the end of her pregnancy. However, there is now a more sophisticated electronic recording system, which includes more safeguarding prompts and alerts. Midwifery staff now also have access to a shared drive which contains copies of any safeguarding plans. 7.7 Multi-Agency decisions were not made regarding the risks to Patricia both before and immediately after her birth because two child protection conferences were not attended by a sufficient number of agencies to enable decisions to be made. Given the mother’s history it would have been appropriate for the chair of the conference to take a more proactive approach in order to ensure effective, coordinated safeguarding action from Patricia’s birth onwards. The lead reviewer has been informed that attendance at child protection conferences is not a concern today and therefore no recommendation has been made in this regard. The use of written agreements 7.8 In the final few months before the case was closed to CSC seven months after Patricia’s birth, there were incidents of domestic violence between the father and his ex-partner, who was temporarily living in the family home. CSC’s response was to put in place a written agreement. However, there is no record of this agreement being monitored or of any checks that the mother in particular had the literacy skills to understand such an agreement. The use of written agreements has been highlighted in other SCRs and is one of the learning points from this review. 7.9 During this period the potential risk posed, particularly by the grandfather, gradually drifted out of consideration. For example, Patricia was seen by a health visitor at her grandparents’ home, with no concerns raised. Similarly, the social worker recorded the grandfather taking Patricia into another room to feed her, again no concerns were identified. The father’s strongly stated conviction not to let the grandfather have unsupervised access to his children had been ‘forgotten’ by family and professionals alike and both the father and grandfather had become protective factors against the mother’s vulnerability and her own ‘risky’ extended family. The effectiveness of Step-Down and Escalation 7.10 Coordinated multi-agency working below the threshold of CSC was not well embedded at the time. However, since that time, there have been some fundamental changes to the Early Help processes and the Step-Down process is now believed to be more effective. Nevertheless, at the meeting in 2017 practitioners were still expressing both confusion about the process and frustration about what they perceived as the high thresholds into CSC. 7.11 Formal escalation to more senior managers when there was a disagreement about the decision-making of a particular agency was rarely used at the time. Following learning from other SCRs, the 9 LSCB has actively promoted its Escalation Policy. However, there were still practitioners who attended the events for this review who were not familiar with it. 8. Case reopens to CSC; children subject to a Child Protection Plan 8.1 Three years after Patricia’s birth the police attended the family home following an incident of domestic violence. This incident was referred to CSC who allocated a social worker and undertook an initial assessment. The father was described as hostile and intimidating when the social worker visited him at home. Patrick was said to be living at his grandfather’s home. 8.2 Over the next few weeks, the original risks posed by the father and grandfather were recognised by the new social worker, and the team manager advised the social worker to undertake a core assessment. However, whilst this assessment was completed, it did not address the risks posed by the two men to the two children and it did not result in a plan. Analysis The understanding, investigation and response to possible sexual abuse 8.3 During this time period the potential risk of sexual abuse from paternal relatives re-emerged and was correctly identified by the chair of the case conference, the social worker and her team manager, together with other risks relating to neglect and domestic violence. 8.4 However, the category of abuse did not change which may explain why, for example, the various GPs who saw Patricia were not concerned enough to inform CSC when her parents brought her to the medical centre in January, March and April with symptoms that could be possible indicators of sexual abuse or neglect. Despite being on Child Protection Plans throughout this period, with reports being provided to case conferences in February, April and August, the GPs did not consider that these visits could have been a cause for concern. 8.5 Prior to this the social worker talked to Patrick about ‘good and bad touches’ and asked Patrick if anyone had touched him. Patrick’s negative response reassured the social worker who concluded that he had not been abused. Patrick was only seven years old with some developmental delay. His understanding of what was ‘good’ and ‘bad’ could easily have been skewed by his experiences. Social workers need to be aware of the potential distress such brief interventions might cause to a child and be very careful about drawing inaccurate conclusions. 8.6 If the child protection plan had been worked proactively and rigorously for the three months it could have provided the detailed risk assessment and clarity about the various concerns that were required by a Legal Planning Meeting (LPM). However, what actually happened was that the case was transferred to a long-term team for the required work to be done, which resulted in drift and delay. 8.7 Given Patricia’s developmental delay, it may have been unrealistic to have expected her to have provided much more information; however, there is no evidence that the social worker spent any time speaking to Patricia, as had been agreed at the three strategy discussions with the police. Given the amount of time Patricia was spending with her grandfather, a convicted sex offender who 10 had been assessed as posing a greater risk to girls rather than boys, this was a significant error of judgement. 8.8 The strategy discussions following the three referrals between March and May should have included a health representative, which would be the case today. 8.9 The attendees at the meeting in April agreed that Patricia was not being protected by the child protection plan. A Legal Planning Meeting was unlikely to have led to the immediate removal of the children, therefore there should have been a discussion about what other action could have been taken to protect the children in the short-term; for example, restricting Patricia’s contact with the grandfather and/or implementing and monitoring a written agreement. The importance of confident front line practitioners who can challenge decisions 8.10 While senior managers must be the gatekeepers of expensive resources, they should not just refuse funding without understanding the detail of the case, the consequences of their decision and offering advice about alternatives. CSC could and should have challenged this decision, supported by their colleagues in legal services and possibly the case conference chair. Instead, the decision led to further drift and delay with no agreed way forward. This impasse, does not, however explain the delay in entering pre-proceedings given that the LPM had stated that the assessments could be undertaken during that stage. 8.11 There appears to have been a culture of ‘top-down’ management within CSC during the period of restructure which had the effect of stifling professional judgement at practitioner and first line manager levels. Even service managers appeared to be ‘told’ what approach to take about cases. This culture was contrary to the recommendations of Professor Eileen Munro’s review of child protection in England, the final report of which had been published in May 2011. Her review called for a move from a compliance to a learning culture, where practitioners had the freedom to use professional expertise in assessing need and providing help. 9. Both children remained on Child Protection Plans, care proceedings were planned but not commenced 9.1 Nearly a year after Patricia’s birth the children’s situation remained seriously concerning, although there were no further reports of the previous concerns and symptoms, following the LPM and the removal of the dog from the family home. There were fewer concerns about Patrick. 9.2 Core group meetings took place on a regular basis. However, on interview, head teachers stated that whilst social workers sought information from them, they did not think that their opinions were valued or influenced decision making. They also expressed sympathy for the social workers’ situation which involved a major reorganisation, a new information system and new phone system, which was seen as a barrier to telephone and voicemail communication. 9.3 A month later the father was admitted to hospital and the grandfather arrived at the family home and removed Patricia ‘kicking and screaming’ from her mother’s care. The police were involved and considered Patricia to be safe and well at her grandparents’ house. 11 9.4 A referral was made by the hospital ward sister to the Out-of-Hours service to ascertain whether it was safe for the grandfather to have care of Patricia. The Out of Hours worker looked at CSC records and consulted her manager; the decision was reached that Patricia could stay where she was for one night on the basis that her brother was there already, assessments were (supposedly) on-going, and the police had observed her to be safe and well. The following day, the team manager agreed that Patricia could remain with the grandparents until the review case conference, due to be held a few days later. 9.5 In interview, the social worker stated that she was on leave at the time Patricia went to stay with her grandparents and was horrified to return to work to find Patricia established in their home. 9.6 The health visitor undertook a developmental review of Patricia. She was found to be functioning approximately twelve months below her chronological age. Organisational Context 9.7 During the period covered by the section above, a restructuring of Children’s Services took place. This process led to considerable instability with many workers and managers leaving the service. As a result, there were periods during which this case was managed by agency workers and managers, some of whom remained involved for only a few weeks. The staff turbulence had a serious impact on the care planning and contributed to drift, delay and a lack of clear direction at a crucial point in the case. 9.8 A new electronic recording system which had been introduced at the same time as the restructuring also contributed to social workers’ difficulties in accessing, and thus taking account of, historical information and earlier assessments. As well as exacerbating staff frustration this led to a period during which there was duplication of records and multiple ‘legacy’ documents, while records created previous to this period could only be accessed in the form of scanned casefiles which were difficult to identify and time-consuming to trawl through. 9.9 A third problem was caused by the installation of a new phone system which resulted in it being very difficult to leave messages for social work staff. 9.10 Schools reported considerable sympathy for the beleaguered social workers, often trying to find other ways of compensating for the poor service being offered from CSC. This sympathy may explain why they did not formally escalate their concerns. 9.11 The medical centre also suffered from staff shortages resulting from ill-health and as a result there were a large number of locums during this period. Analysis The relationship between the child protection processes and care proceedings 9.12 Given the close relationships between the extended family members and the Grandparents, there should have been an assessment of their ability to protect Patricia immediately after she was placed with them at the age of nearly four. As a result of that assessment the extended family members caring for Patricia could then have been given the advice they needed to keep Patricia safe. Their 12 ability to understand and follow that advice could then have contributed to the care proceedings and the recommendation for the final care plan. 9.13 In fact, over two years later, when interviewed for this review they had still not had an assessment of their ability to protect Patricia or any detailed professional guidance about how to keep her safe in the long-term. Given the carer’s own learning difficulties, one must assume that particular efforts would have had to have been made to ensure that she understood what was being expected of her. 9.14 Care proceedings were planned from the mid-year point but were not actually commenced until the following March. Throughout this time there were core group meetings and review child protection conferences. Whilst various parties expressed concern for the children’s circumstances, nothing actually changed. This delay was unacceptable and was caused, in the main, by the problems within CSC referred to above. 9.15 This was a complex case without a clear way forward. Working out the best possible approach to take for these children was simply unachievable with changes in both social workers and team managers every few weeks. 9.16 This family were predicted to contest any proposed removal of the children into foster care and therefore the Court needed to have a clear narrative regarding the risks the children were subject to. Neither the social workers nor their managers were able to articulate this in a way which satisfied firstly their own legal advisers and secondly the Court. 9.17 Changing the category of the child protection plan for Patricia to ‘risk of sexual abuse’ when she moved to live with extended family following the concerns earlier in the year might have raised awareness across the partners and might, for example, have prompted the GP to contact CSC when Patricia was brought to the medical centre with symptoms that could have indicated signs of sexual abuse. 9.18 The information at that same conference that Patricia was taking ‘naps’ with her grandfather was rightly responded to by the conference chair and resulted in Patricia being moved. However, the overall independent scrutiny and challenge which should have been provided by the conference chairs was ineffective in that agreed actions did not take place, and nothing was done to expedite this lack of progress. 9.19 It is significant that the conference the following year was chaired by a new chair as the previous chair, who knew the case well, had left. Neither of these chairs used the existing escalation process. There was no systematic handover process when independent chairs changed, and no tracking system to ensure that concerns raised by independent chairs with social workers were escalated if they were not resolved. These issues have now been addressed. 10. Duration of the care proceedings 10.1 A Children’s Guardian was appointed at the commencement of the care proceedings. Once the care proceedings began Patrick was significantly affected by the uncertainty and the prospect of having to leave his grandparents’ home. 13 10.2 At the final hearing for Patrick a care order was granted, and he was removed from the care of the grandfather and placed in foster care. By that time, Patrick had lived with his grandfather for 18 months and was desperate to remain living with him. He had repeatedly asked for, but not received, an explanation from his social worker as to why it was not safe for him to stay with his grandad. Analysis The management of care proceedings 10.3 The guidelines for the length of time to be taken by care proceedings is 26 weeks. One of the reasons for this relatively short timeframe is because of the amount of preparation and planning that is required to take place in the ‘pre-proceedings’ stage. In this case, the pre-proceedings planning had been initiated some 10 months before the proceedings commenced, which was too long for a child to remain in a situation that was believed to be causing significant harm. This delay led directly to the Court’s refusal to remove the children once the proceedings were issued. Even with this lengthy preparation period, the proceedings themselves lasted 40 weeks which, once again, was well outside the timescales. 10.4 It is common practice when care proceedings are commenced to remove child protection plans. That was not possible in this case because the children remained within their extended family. As a result, the core groups and child protection conferences continued to run alongside the care proceedings. Throughout this period concerns were raised about the ineffectiveness of the child protection plan, but the plan was not amended and nothing actually changed for the children. 10.5 Head teachers have spoken about being resigned to the fact that the staffing problems within CSC meant that they could rarely get hold of the children’s social worker. They did not consider using the escalation process. 10.6 Patricia’s statement and symptom of possible sexual abuse should have been investigated more fully given the existing concerns about the Aunt’s ability to protect her. As soon as Patricia moved to live with extended family members they should have been helped to understand the concerns about the grandfather. It is unsurprising that extended family members do not intuitively understand the secrecy around sexual abuse and the way in which children and their carers can be groomed. In the absence of this work it is difficult to understand why Patricia was not spoken to and why a strategy discussion was not held. If the Children’s Guardian had requested the outcome of the enquiries she understood to be taking place, she could have challenged the social worker’s failure to investigate them thoroughly. This was a further missed opportunity to try to understand what either had or was still happening to Patricia. 10.7 It is not unusual for Local Authorities to decide not to oppose a Guardian’s recommendation in care proceedings, even when they disagree. This is because it is widely accepted that the Court generally favours the Guardian’s opinion over that of the Local Authority. However, given the ongoing and serious concerns about the Aunt’s ability to protect Patricia, held not only by the allocated social worker but by the whole core group, the supervision order provided the ideal means to provide the specialist help recommended by the Children’s Guardian and then to monitor the carers’ ability to understand and practise what they had learnt. If those concerns still existed as the supervision 14 order was about to expire, the Local Authority would have been able to evidence better their concerns and seek either a further extension of the supervision order or variation to a care order. 11. The Children’s Lived experience 11.1 What is striking about both the subjects of this review is that they were able and willing to talk to professionals about their life at home. Despite both children having quite significant language delay, their views were quoted on a regular basis by both the teachers at Patrick’s school and the workers at Patricia’s nursery and reported to their social worker. 11.2 Although Patrick’s vocabulary was described as immature and impoverished, his school reported that he had no difficulty in speaking his mind and expressing what he wanted and was generally a happy and cheerful child who had a good attitude to his work. He enjoyed talking to school staff and had a particularly close and trusting relationship with the SENCO, often calling into her room for a general chat. Patrick was often described by his school staff as “resilient”. 11.3 Patrick talked during the earlier period of this review about the violence at home when he lived with his birth father. 11.4 Similarly whilst there are numerous statements about Patricia’s speech delay, she was repeatedly quoted with regard to her descriptions of concerning events which might indicate sexual abuse, her sexualised behaviour and her distress whilst having her nappy changed. No attempts were made to explore the various statements that she made. 11.5 However during the times that the children were on child protection plans, few opportunities were taken by the allocated social workers to spend time with either of them in order to understand what was happening to them. 11.6 There are no records of any social worker speaking to Patricia in order to understand more clearly the very concerning statements she was making to nursery workers. 11.7 Later on, as part of the care proceedings, Patrick was asked about where he would like to live on several occasions and every time he was adamant that he wanted to remain with his grandparents. The Guardian even helped him to write a letter to the Court to that effect. Presumably Patrick was led to believe that some weight might be given to his views. However, given that both the Guardian and the Local Authority thought he should move, it was extremely unlikely that his wishes would be granted. 11.8 It is difficult to imagine how Patrick must have felt after months of anxious waiting to discover that despite everything he had said, he was to leave his grandparents’ care. Whilst this may have been the correct outcome in the long-term, Patrick deserved a more timely process which should have included explanations throughout the duration of the proceedings about why it may not be possible to grant his wishes. 11.9 Patrick never did understand why he might have to move. His teacher stated that once this possibility became known to him, ‘his educational progress slowed down, his cheerfulness diminished, and he began to complain of aches, pains and anxieties as well as a series of minor 15 injuries’. Whilst the circumstances were undoubtedly difficult to explain, this could not be sufficient reason for him not to be given an explanation. 12. Themes Emerging from the Review Understanding the risks posed by adult sex offenders 12.1 There is a difference between the risk of reoffending and the risk of harm that a convicted sex offender might pose to a child in his family. Whilst this statement might seem obvious, the only time in this case when this question was asked was on leaving jail as to the risk the grandfather might pose to the father. Without this knowledge, assumptions were made about the risks posed by both the grandfather and the father from Patrick’s birth until nine years later when a specialist assessment was finally completed. These assumptions changed over time and were likely to have been inaccurate throughout that nine year period. 12.2 Social workers were tasked with updating the risk assessments on the father and grandfather on seven occasions over a nineteen month period but they were not commenced until the care proceedings had been formally initiated. 12.3 Whilst there is some guidance within the LSCB’s child protection procedures for managing individuals who pose a risk to children, it describes the current arrangements for managing offenders and was not relevant to the circumstances of this case. Not only did the social workers not have the skills to update historic assessments, but funding for externally commissioned assessments was refused. 12.4 It is pointless for case conference chairs and managers to require social workers to update and review sex offender risk assessments if there is no means by which they can achieve this requirement. 12.5 Patricia was taken to the GP with symptoms that could have indicated sexual abuse on five occasions over a period of just under two years. Despite detailed information about the family situation, on not one occasion did any of the GPs who examined her consider that this might be a sign of sexual abuse. Similarly, when the GP records were reviewed by peers they also failed to identify the need for a proactive response. 12.6 New concerns regarding Patricia, which could have been indicative of sexual abuse, occurred towards the end of the care proceedings but it was not too late to advise the Court about this new information, provided it had been fully explored. Instead, CSC failed to investigate them, and the Guardian made assumptions about their origin which were not tested and may have been inaccurate. Given the general difficulty of establishing whether or not Patricia had been or still was being sexually abused, a more robust approach was needed. Recommendations: The Local Safeguarding Children Board (LSCB) should: I. Ensure that the section of the child protection procedures regarding managing Individuals who pose a risk to children is reviewed and amended so that it includes guidance about: 16 a) Where practitioners can seek appropriate advice with regard to the risks posed by adult sex offenders and alleged sex offenders when they are not subject to MAPPA arrangements. b) How practitioners can undertake ‘persons posing a risk assessments’. ii) Amend the Child Protection procedures to state that when a child is subject to a child protection plan and a parent or carer is on the sex offender register, their sex offender manager should be a member of the core group. Children’s Services should: i) Develop criteria for the use of externally commissioned risk assessments. The CCG should: i) Review the training it gives to GPs with regard to identifying possible sexual abuse. CAFCASS should: i) Remind all Guardians that: a) They must challenge the Local Authority if new information is received and appears not to have been fully investigated. b) New information must be taken into consideration at all stages of court proceedings and especially when the parties have not agreed the final care plan. The ease with which case records summarise historical risk 12.7 During the nine year period covered by this review, there were periods when historic risk was ‘lost’ and then re-emerged. 12.8 The agencies responsible for safeguarding these children have very different recording systems, most of which have changed significantly since Patrick’s birth. Within schools there is more than one system in use. Overall, practitioners were of the opinion that their current systems enabled them to quickly identify historic risk and significant past events. The exception was practitioners in community health and in the hospital, where the identification of significant events could only be achieved by scrolling through masses of historic information. 12.9 Given the frequency with which practitioners changed both within children’s services and the GP practice in particular, it is essential that records enable a new practitioner to identify quickly the risks in a particular case. Recommendation: The LSCB should seek assurance from partners that their case recording systems enable practitioners to easily identify significant past events. The category of the Child Protection Plan 12.10 The underlying concern in the two years that Patricia was on a child protection plan was the risk of sexual abuse and yet the category for both children throughout their time on child protection plans was ‘neglect’, the most commonly used category. If the category had been changed to ‘risk of sexual abuse’ for Patricia following the concerns of signs of possible sexual abuse it might have 17 raised the awareness of the GPs, thereby prompting them to not only consider the possibility of sexual abuse when they examined Patricia but also to alert CSC of her visits to them. Recommendation: The LSCB should advise conference chairs that when children’s names are on a Child Protection plan and there are concerns about possible sexual abuse, risk of sexual abuse is the most appropriate category. The use of written agreements 12.11 The use of written agreements has been a learning point from an earlier SCR. In this case there were two occasions when written agreements were drawn up with the family but on neither occasion was there any evidence that they were ever monitored or reviewed. 12.12 It is doubtful whether a written agreement can be very effective when a number of the family members have learning difficulties. Certainly, the family’s ability to read and understand any such agreement would need to be established before it is implemented. Recommendation: The LSCB should seek assurance that the current use of written agreements by Children’s Social Care is effective and appropriate. The role and function of Core Groups 12.13 Whilst Core Groups met regularly and were generally well attended, they were more a means of sharing information rather than actively monitoring, and where appropriate, amending the detail of the child protection plan. Their role was hindered by the behaviour of the father and grandfather, both of whom have been reported to be hostile and intimidating. It is easy to see how the various social workers struggled to both effectively chair and minute meetings where the way forward was complex to establish, and the family were so disruptive. If the behaviour of the family is compromising the role of the core group, this must be addressed. If one of the head-teachers had chaired some of the meetings, for example, more might have been achieved. 12.14 Core groups were rarely minuted and practitioners advised during the practitioner events that this is still the case. The practice was, and still is, for practitioners to make their own record of a meeting. This practice means that the family do not receive a record of the meeting and individual core group members may not have a shared understanding of what decisions have been made. Recommendation: The LSCB should: a) Seek assurance from Children’s Social Care that there is a written record for all core group meetings. b) Consider whether practitioners have sufficient guidance with regard to the management of disruptive family members within core groups. 18 Escalation 12.15 The use of the Escalation Policy has been widely promoted by the LSCB following similar findings from other SCRs. However, there were still practitioners at the meetings for this review who were unfamiliar with the policy. 12.16 In this case, colleagues in other agencies seemed to be resigned to the difficulties within CSC and saw little point in escalating their concerns. The schools for example tried to compensate for what they saw as the failure of CSC to deliver a consistent safeguarding service by supporting the children as best they could from their own resources. 12.17 Similarly within CSC, case conference after case conference identified that particular actions were needed and simply noted that they were outstanding when they had not been achieved by the next meeting. 12.18 There has to be a more robust approach to not only identifying actions that have not taken place but also to identifying the reasons behind the failure, together with remedial action to move the situation forward. Recommendation: The LSCB should continue to promote the use of its escalating concerns policy. The effect of organisational change & the role of the LSCB 12.19 The problems experienced by CSC during the latter part of the review onwards are well documented. There is little doubt that the repeated changes of both social worker and team manager throughout this time prevented these children from being effectively safeguarded. There was similar turbulence within the medical centre, with seventeen different GPs having contact with the children and adults who cared for them. It is hardly surprising that each of those personnel did not gain a full picture of this complex family history before dealing briefly with the family. 12.20 What is more surprising is that the LSCB was not aware of the effects of the changes within Children’s Services and that other Board members were not escalating their concerns to the Board. The LSCB’s slow response and lack of robust challenge to the impact of these changes has been addressed as part of an overall effectiveness plan. Measures have been put in place to ensure that the LSCB can now monitor the effectiveness of front line practice and does so. 13. Action that has already been taken With regard to Patricia 13.1 The police have revisited all the existing information with regard to Patricia, her statements and her behaviour. 13.2 At the first practitioner meeting, professionals continued to express their concern about Patricia and her carers’ ability to protect her. As a result of this concern, there was a strategy meeting and a case conference. Within CSC 19 13.3 The plan template for Child Protection and Child in Need Plans has been reviewed and now focuses much more on outcomes as well as building on strengths within the family, based on the Signs of Safety Model. 13.4 Revised terms of reference have been drawn up for Legal Planning Meetings to ensure that there is an up to date assessment before entering the legal arena. There is now a case progression manager in post who is responsible for tracking all LPM decisions. Feedback suggests that this provides workers with clear guidance and is proving effective in reducing drift. 13.5 The introduction of a single assessment team has resulted in assessments of higher quality, and more manageable caseloads for social workers managing child protection and care proceedings. 13.6 Action has been taken to stabilise the workforce and address performance problems, including at management level with improved frequency and effectiveness of supervision and management oversight. 13.7 Advanced Practitioners have added capacity for reflective supervision and also provide a practice lead on a range of issues. 13.8 A new case escalation process is in place for independent case conference chairs 13.9 Senior managers have begun to move away from the previous ‘top down’ management style and to encourage more authoritative social work practice at the front line. Within the Hospital 13.10 Training has already taken place within the Maternity Service for staff ensuring that concerns are now passed to the Safeguarding Midwifery Team. An electronic Records System for safeguarding cases was introduced during the period under review. All cases and communications are now recorded on a secure database and are immediately accessible to members of the team. 13.11 Training has already been undertaken within the Emergency Department regarding staff awareness of the need to complete referral forms when concerns are raised regarding an adult’s presentation to hospital. A prompt has now been included with Emergency Department admission paperwork to remind staff to complete a referral for when safeguarding concerns are present. Monthly spot check audits are undertaken. General Practice 13.12 GPs have been asked to record who brought a child to the surgery and whether that person had parental responsibility. 20 14. Recommendations The Local Safeguarding Children Board (LSCB) should: 1. Ensure that the section of the child protection procedures entitled ‘Managing Individuals who pose a Risk to Children’ is reviewed and amended so that it includes guidance about: a) Where practitioners can seek appropriate advice with regard to the risks posed by adult sex offenders and alleged sex offenders when they are not subject to MAPPA arrangements. b) How practitioners can undertake ‘persons posing a risk assessments’. 2. Amend the Child Protection procedures to state that when a child is subject to a child protection plan and a parent or carer is on the sex offender register, their sex offender manager should be a member of the core group. 3. Seek assurance from partners that their case recording systems enable practitioners to easily identify significant past events. 4. Advise conference chairs that when children’s names are on a Child Protection plan and there are concerns about possible sexual abuse, risk of sexual abuse is the most appropriate category. 5. Seek assurance from Children’s Social Care that there is a written record for all core group meetings. 6. Consider whether practitioners have sufficient guidance with regard to the management of disruptive family members within core groups. 7. Seek assurance that the current use of written agreements by Children’s Social Care is effective and appropriate. 8. Continue to promote the use of its escalating concerns policy. Children’s Services should: Develop criteria for the use of externally commissioned risk assessments. The CCG should: Review the training it gives to GPs with regard to identifying possible sexual abuse. CAFCASS should: Remind all Guardians that: a) They must challenge the Local Authority if new information is received and appears not to have been fully investigated. b) New information must be taken into consideration at all stages of court proceedings and especially when the parties have not agreed the final care plan. |
NC52320 | Neglect of a 14-year-old girl resulting in hospitalisation in June 2020. Learning includes: early help assessments should incorporate the views of children; when a support plan is closed, any outstanding issues should be relayed to relevant professionals to ensure continuity of service provision; practitioners should make direct contact with a child to ensure their wellbeing, rather than relying solely on parents; when there are concerns around neglect, professionals should be supported to use the neglect assessment tool; ambiguous information provided by a parent/carer should be triangulated from other sources to ensure accuracy; practitioners should be professionally curious and practice respectful uncertainty to ensure that information from parents is accurate and clearly understood; agencies should seek to understand the role of adults who are connected to a child's family, including whether they have parental responsibility or not. Recommendations to the local safeguarding partnership include: seek assurance on the quality of early help assessments, ensuring that issues outlined in referrals are addressed in the assessment and support plan; accelerate the implementation of the neglect assessment tool; ensure the child's experience is sought, recorded and reflected in service provision.
| Title: Child safeguarding practice review: overview report: Child AC. LSCB: Children’s Safeguarding Assurance Partnership Blackburn with Darwen Blackpool Lancashire Author: Jenny Butlin-Moran Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review Overview Report: Child AC Author: Jenny Butlin-Moran Date: 4th March 2022 Page 2 of 17 Contents 1. Introduction ........................................................................................................ 3 2. Terms of Reference and Methodology ....................................................... 3 3. Brief Summary of the case ..............................................................................4 4. Analysis ................................................................................................................ 5 5. Detailed Analysis ............................................................................................... 6 5.2 Multi-agency response to concerns of neglect ........................................ 9 5.3 Effectiveness of inter-agency and intra-agency communication ........ 11 5.4 How professionals work with the challenge of limited engagement from parents .............................................................................................................. 13 5.5 Multi-agency response to connected persons ....................................... 14 5.6 Consideration of the voice of the child ..................................................... 15 6.0 Conclusion......................................................................................................... 16 7.0 Learning and Recommendations ................................................................ 16 Page 3 of 17 1. Introduction 1.1 Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership decided to undertake a Learning Review in respect of a young person to be known as A.C, in July 2020 as it was felt that learning could be derived from the practice in this case. 1.2 A.C. was 14 years old when she was hospitalised due to a life-threatening condition. 1.3 It was agreed that the Learning Review would consider in detail the professional involvement with A.C. and her family from September 2018 to June 2020 which encompassed the provision of a range of services from the point at which A.C. moved to secondary school to the time of the incident. 1.4 While the statutory safeguarding partners initially agreed that the circumstances of the case did not meet the threshold for a Child Safeguarding Practice Review, they subsequently agreed that it should be published as such, on the grounds of transparency. 2. Terms of Reference and Methodology 2.1 An Independent lead reviewer was appointed to lead the review.1 The Review Team2 had access to the key single and multi-agency documents in the case and met with practitioners involved with the family in reflective sessions where the case was discussed. 2.2 The predisposing risks and vulnerabilities3 that were known at the time were considered, in order to understand the case. This was followed by the consideration of the preventative and protective actions taken, in order to understand the interventions. 2.3 The agencies that had involvement reflected on the agency specific learning and shared learning within their agencies. 2.4 The Lead Reviewer sought A.C’s views and those of her Mother and they are included in this report. They were informed of the conclusions of the review and the Partnership’s response prior to dissemination. 2.5 Drafts of this report were shared with those involved as well as with the statutory safeguarding partners to ensure collaboration and ownership and provide scrutiny and challenge. The recommendations were written by the Lead Reviewer and the Review Team. 2.6 This report has been written in the anticipation that it will be published and disseminated for learning to the members of Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership and contains only the information that is relevant to the learning established during this review. 2.7 At the time of the report being written A.C. was looked after by the council and was living with foster carers. 1 Jenny Butlin-Moran is an experienced independent social work consultant who is independent of the partnership. 2 The review team was formed from senior managers from agencies who were involved with A.C and her mother. 3Complexity and Challenge: a triennial analysis of SCRs 2014-17. Marian Brandon, Peter Sidebotham et al. DfE 2020. Page 4 of 17 3. Brief Summary of the case 3.1 For the purpose of this report, the following family members are relevant: Family Member Known as Subject A.C. Mother of A.C. Mother Mother’s former partner Mother’s former partner 3.2 The family were known to a number of agencies in Lancashire during the period of the review. A.C. attended a secondary school where she received counselling, pastoral support and support from the Education Attendance Team. A.C. also received health services from the School Nursing Service and later from the Ambulance Service and the Hospital. A.C’s Mother also received support from the local Housing Department 3.3 In September 2018, A.C. started secondary school. The safeguarding records held by the previous primary school were transferred to the secondary school so that they were aware of the previous child protection plan in 2011, the recent early help support that had been provided to support A.C.’s emotional well-being following the death of her Father, poor school attendance and head lice. The school nurse for the primary school was providing support for A.C. who was underweight and providing emotional support for A.C. following the death of her Father. It was agreed with A.C’s Mother that this support would continue when A.C. moved to secondary school. 3.4 In October 2018, the school made a referral to the Children and Families Well-Being service4 (CFW) for support with housing for the family as they were at risk of homelessness and to provide A.C. with emotional support as she was grieving for her Father who had died some months earlier. An early help assessment was undertaken and support provided until a housing tenancy was secured three months later. The school counsellor worked with A.C. and this continued after the conclusion of the early help support 3.5 In January 2019, A.C. was sent home from school as she had head lice and episodes of infestation which continued and led to a number of absences from school which were addressed with A.C.'s Mother by pastoral support staff and the Designated Safeguarding Lead. A.C. was also absent from school which was reported by A.C’s Mother to be due to other health issues. 3.6 When schools were closed in accordance with the government restrictions due to the Covid-19 pandemic, the school maintained twice weekly contact by telephone and provided support for the family with food. 3.7 In June 2020, A.C. was admitted to hospital due to breathing difficulties, having collapsed at home. She presented as malnourished, had a significant infestation of head lice, and had multiple organ failure. 4 The council’s early help team. Page 5 of 17 3.8 A strategy meeting was convened and subsequently care proceedings were initiated and A.C. became cared for by a foster carer. 4. Analysis 4.1 To analyse the professional involvements and interventions with the family, consideration has firstly been given to the predisposing vulnerabilities and risks in the case, that were known or knowable to professionals involved at the time. This is followed by the preventative and protective actions taken by the agencies involved at the time. Predisposing Vulnerabilities As a young person, A.C. was dependent on her Mother to meet the majority of her basic needs. A.C’s Mother did not have a housing tenancy and was reliant upon her former partner for housing. The family had previously experienced homelessness. A.C.’s Mother had a limited support network and had experienced bereavements previously. A.C’s Mother was not in employment and was reliant upon state benefits. A.C’s Mother previously used substances and had received support for her mental health. 4.2 It is recognised that the adults’ predisposing vulnerabilities may pose a predisposing risk to the child. The following additional risks have been identified: Risks A.C. was at risk of social isolation and falling behind in her educational outcomes due to poor school attendance. A.C. was at risk of being alienated by her peers due to her persistent head lice. A.C.’s emotional well-being was at risk due to the loss of her Father. A.C. was at risk of unstable housing. Page 6 of 17 4.3 There was evidence of protective actions from the family when considering the case: Protective Actions taken by the family. A.C’s Mother consented to referrals to the Children and Families Well-Being (CFW) service andto the school nursing service. A.C’s Mother worked with the CFW in the formulation of the early help assessment and plan. 4.4 During the involvement of professionals with the family, there were both preventative and protective actions taken by the agencies involved. Preventative and protective actions taken by the agencies. There was an effective transition between the primary and secondary schools which enabled the secondary school to have a good understanding of A.C.’s needs. The school staff were available to A.C. and they were able to seek support when needed. Counselling was provided for A.C. by the school. 5. Detailed Analysis The review has established that the following areas require further analysis and provide us with the learning in this matter. 5.1 The effectiveness of early help 5.1.1 In September 2018, a member of the school pastoral team contacted A.C.’s Mother as they were concerned about A.C.’s emotional well-being due to her Father’s death in 2017. A.C’s Mother shared that A.C. never knew her Father. It was effective practice by the school to follow up their concerns with Mother as this demonstrated genuine interest in A.C.’s well-being and began forming a trusting relationship with A.C. and her Mother. 5.1.2 The following day, A.C.’s Mother contacted the Education Attendance Service and advised that A.C. would not be in school as she was very upset about her Father’s death and she would be seeing the G.P. to seek counselling for A.C. A.C’s Mother also clarified that this was to address the bullying that A.C was experiencing. A few days later the school provided counselling and peer listening services for A.C. A.C. received two counselling sessions and it was stated that A.C. was happy to self-refer if she required more. Page 7 of 17 5.1.3 In October 2018, the school made a referral to the CFW, with the consent of A.C.’s Mother, requesting support with identifying a new tenancy for A.C’s family, following concerns raised by A.C. of risk of homelessness and police involvement with her step-father. It was noted that A.C. said that her Mother did not like them talking about the family. This was an appropriate and helpful response by the school. The referral was made using the appropriate electronic form and provided appropriate historical and current information and they received prompt feedback from the council. However, the school did not advise the CFW service that A.C. was receiving free school meals and this was a missed opportunity for the CFW to include this in their assessment. 5.1.4 An early help assessment was undertaken which identified that the family was living with Mother’s former partner and their relationship was fractious. However, the assessment did not explore the relationship between them. The review learned that direct work was undertaken with A.C. to ascertain her wishes and feelings to inform the assessment which was expected practice. However, the outcome of this was not included in the narrative resulting in her views being absent. Two of the six appointments made were cancelled and re-arranged by A.C’s Mother, however this was not regarded as unusual by CFW. Consequently, the focus of the work was on supporting the identification of a new tenancy and supporting A.C.’s Mother into employment. 5.1.5 The ensuing support plan included that counselling for A.C.’s bereavement would be provided by the school and A.C.’s Mother’s benefits were reviewed to ensure that she was receiving all of her entitlements. The early help plan was reviewed twice and was closed within 3 months because a new tenancy was secured for Mother. Counselling was to be continued by the school, however, work to support Mother with gaining employment was not achieved. Prior to closing the case, A.C’s Mother was contacted by a member of the school regarding A.C’s uniform and she declined the offer of support for uniform and would not discuss further. This information was not shared with CFW and as the early help support was still in place, it was a missed opportunity to engage Mother in further discussions about her finances and provide support for A.C. 5.1.6 Whilst the early help support was helpful in securing a new tenancy, and identifying counselling for A.C, it did not address all of the concerns, including the concerns that A.C. raised about her Mother’s former partner. The assessment does not include an understanding of Mother’s partner and all of the information was self-reported, thus being totally reliant on information from A.C’.s Mother. The review found that at the time, the early help assessments focused on presenting needs rather than on exploring needs holistically. In 2020, the council’s children’s services underwent a transformation programme in which early help and children’s social work services became more aligned and resulted in holistic early help assessments being undertaken. 5.1.7 Just prior to A.C.’s move to secondary school, A.C.’s weight was reviewed by staff nurse 1 with school health who agreed with A.C’s Mother that A.C. would continue to receive support as Mother reported that she was being bullied because she was underweight. The notes recorded that A.C. was now plotting in the lower centile of the healthy range bracket for her age. A.C was subsequently seen by the staff nurse in September and then her support was transferred to the school nurse in the secondary school. 5.1.8 In September 2019, the school made a referral to the school nursing service to support the management of A.C.’s head lice. The school nursing service did not understand the level of concern held by the school about A.C’s head lice because the referral was not designated as a safeguarding referral and therefore A.C. was offered a universal service. The review learned that the service receives a high volume of requests to manage head lice and in this case they were not aware of any additional concerns to review the type of service to be delivered. Page 8 of 17 5.1.9 Staff Nurse 2 with school health promptly contacted A.C’s Mother but was unable to obtain a response . A further attempt to contact A.C.’s Mother was not made until two months later by Staff Nurse 3 and Mother agreed to support with a follow up in a week’s time. The review found that the delay in making contact with Mother was due to a change of staffing in the team. However, this led to a significant delay in improving A.C’s experience of head lice. 5.1.10 The review learned that when A.C’s Mother spoke to staff nurse 2 it would have been good practice for the staff nurse to refer to the NICE guidance5 and check that A.C.’s Mother was treating the head lice in accordance with the manufacturer’s instructions and check that all family members were routinely checking their hair. This was a missed opportunity for the staff nurse to understand why there was no sustained improvement in the treatment of the head lice and to share this with the school for further consideration. As a result, A.C. continued to have head lice. 5.1.11 In March 2020, the school made a second referral to the school nursing service by email and a school nurse responded to say that they could ring A.C’s Mother the following week , as was expected practice. A further telephone message was left for the school nurse but there was no evidence that this was listened to or responded to. 5.1.12 Later in March, the school held a meeting which was attended by the Designated Safeguarding Lead6 (DSL) and a School Nurse, the former partner of A.C’s Mother, provided their apologies. The concerns included the management of the head lice and that A.C. had inappropriately been given her sibling’s medication. The outcome of the meeting was shared with Mother by telephone who denied that she had given A.C. her sibling’s medication and was hostile and threatened to remove A.C. from the school. It was good practice to hold a meeting to discuss the concerns however, a review meeting was not scheduled which meant that the practitioners did not have a shared understanding of A.C.’s progress. The review learnt that a review meeting would have been held but shortly after the meeting, the national lockdown was instigated and the school closed. 5.1.13 During the period of lockdown, the school continued to support A.C. in accordance with government guidelines. A.C.’s needs were classed as requiring a minimum of weekly telephone contact by the school and the review found evidence of successful telephone contact with A.C’s Mother taking place up to twice per week by a learning mentor who had a good relationship with A.C’s Mother. This was good practice. A food parcel was delivered to the home and food vouchers were supplied. However, there was no consideration given to contact with A.C., such as virtual meetings using technology or a telephone call to A.C. which would have enabled professionals to hear directly from A.C. This was effective in maintaining contact with A.C’s Mother and supporting with food but was not effective in hearing directly from A.C. how she was. 5.1.14 The review recognised that at the start of the national lockdown, schools had to deal with a range of unprecedented issues in order to continue to provide education for pupils. The scale of this and the impact upon every aspect of the functioning of a school cannot be underestimated. In this case, the school had not yet developed virtual methods for communicating and teaching. Since this time, the school has improved access to technology and is able to maintain contact with children even when the schools have been required to close. 5 NICE Guidance. Head Lice management December 2016. 6 The designated safeguarding lead should take lead responsibility for safeguarding and child protection (including online safety), Keeping Children Safe in Education 2020. Page 9 of 17 5.1.15 Despite the provision of early help, there was no sustained improvement in A.C.’s outcomes over a 21-month period. 5.1.16 Learning ● Assessments should incorporate the views of children and young people to ensure that there is a lasting record for current and future reference. ● When a referral is made for an early help assessment, the assessment should address all of the issues and should be incorporated into the plan. Any new or emerging issues should be shared at meetings for inclusion in the plan. ● When a support plan is closed, any outstanding issues should be relayed to relevant professionals to ensure continuity of service provision. ● Continuity of professionals is key to ensuring a consistent understanding of the child’s needs. ● Practitioners should make contact with the child in order to ensure their safety and well-being, rather than solely through the parent. 5.2 Multi-agency response to concerns of neglect 5.2.1 The review learned that in this case practitioners did not recognise that A.C. was experiencing neglect, partly because there were periods of improvement in her circumstances. The challenge of recognising neglect has been highlighted in research; “neglect can in some cases be challenging to identify because of the need to look beyond individual parenting episodes and consider the persistence, frequency, enormity and pervasiveness of parenting behaviour which may make them harmful and abusive.” 7 5.2.2 The early help support introduced from September 2018, included a review of the benefits that A.C.’s Mother was receiving to ensure that she was receiving the appropriate entitlements. The school also provided A.C’s Mother with advice regarding support for school uniform and head lice treatment. However, there was no clear understanding of A.C.’s Mother’s financial situation and how this impacted upon her parenting. Research8 has found that “When faced with families in situations of poverty, practitioners should seek to understand the pathways through which socio-economic issues interact with other factors to influence parenting and outcomes for children. It is important neither to ignore the impacts of poverty, nor to simplistically attribute the family’s problems solely to economic hardship.” 5.2.3 By March 2020, there was evidence of emerging neglect. A.C. had persistent head lice which despite consistent attempts by school staff and some advice from the school nurse, was not clearing up. A.C. 's attendance at school had significantly deteriorated to 68.2% due to head lice and a number of minor illnesses reported by A.C’s Mother and her former partner. These minor illnesses followed a pattern of Mondays and Fridays, which was indicative of school avoidance. There was an unresolved concern that A.C.’s Mother had given A.C. her sibling’s medication. In addition, A.C’s 7 “Missed opportunities:indicators of neglect –what is ignored, why, and what can be done?” Marion Brandon, Danya Glaser et al. Research report. Department for Education. November 2014 8 “Complexity and challenge: a triennial analysis of SCRs 2014-2017.” Marion Brandon, Peter Sidebotham et al. Department for Education March 2020. Page 10 of 17 Mother was, on occasions, hostile or avoidant of support. Despite the best intentions of practitioners, there was no sustained improvement in A.C.’s well-being. 5.2.4 The school was rightly concerned about A.C.’s poor attendance but did not consider that the absences may be a means to keep A.C. from surveillance by school staff. In discussion with A.C’s Mother she confirmed that sometimes she said A.C. was ill when A.C. had head lice as she felt unable to share this with the school for fear of being judged. The triennial analysis9 identified that “attending school has the potential to decrease the child’s social isolation, and to increase opportunities for development, as well as providing respite from everyday difficulties at home.” 5.2.5 When the school was closed due to the pandemic, a learning mentor maintained regular contact with A.C.’s Mother. However, as A.C. was not spoken to directly, the school could not be reassured that A.C’s welfare was safeguarded. 5.2.6 The review learned that it would have been beneficial to undertake an early help assessment to understand A.C’s needs and formulate a plan to address them. The absence of a full assessment of A.C.’s unmet needs meant that practitioners did not have a true picture of A.C.’s lived experiences and had not considered that A.C. was experiencing neglectful parenting. This meant that the school did not consider that the concerns should be escalated to the council for early help support and/or for consultation with the MASH, nor would they have been able to clearly articulate them in the context of the multi-agency agreed threshold. The review learned that the council now offers consultation to agencies within the early help network to support early help assessments and plans. 5.2.7 The school nursing service offered support to the family but was not pro-active in following up A.C.’s progress. The service did not recognise that the lack of action taken by A.C.’s Mother was neglectful. The review learned that the school nursing service provides a responsive service and when parents do not take up the offer of support, this is usually seen in the context of parental choice rather than a neglectful act. The volume of work for the service means that it is difficult for practitioners to identify emerging neglect. 5.2.8 The review learnt that there is an agreed neglect tool kit available to all practitioners but the application of this was not considered in this case because the practitioners did not recognise that A.C’s circumstances were indicative of neglect. 5.2.9 The review found that whilst the safeguarding partnership introduced a multi-agency tool to assist practitioners in identifying and responding to neglect in July 2019, the roll-out has been slow and therefore it is not widely used by professionals. In this case, this led to a lack of a shared understanding of A.C’s lived experiences and that these constituted neglect. 5.2.10 Learning ● The safeguarding system should enable practitioners to consider that children’s needs may be neglected. ● When there are concerns that are indicative of neglect, all professionals should be supported to use the neglect assessment tool. 9 Pathways to harm, pathways to protection; a triennial analysis of serious case reviews 2011-14”. Peter Sidebotham at al. Department for Education 2017. Page 11 of 17 5.3 Effectiveness of inter-agency and intra-agency communication 5.3.1 The transitional arrangements between the primary school and the secondary school were effective. The transfer of records enabled the secondary school to have written information about the previous child protection plan in 2011, the recent early help support that had been provided to support A.C.’s emotional well-being following the death of her Father, poor school attendance and head lice. There was also a face-to-face meeting between members of the primary and secondary schools which provided the opportunity for the secondary school to explore things further. This was effective practice and meant that the school was alert to A.C’s needs. 5.3.2 The referral made by the school to the CFW service was detailed and communicated the concerns expressed by A.C. about being evicted, her Mother’s former partner and included information provided by A.C.’s Mother. However, the request for support by the school to the CFW only focused on helping A.C’s Mother to secure a new tenancy, helping her into employment and providing emotional support to A.C. Despite the concerns A.C. raised about her Mother’s former partner, these were not included in the areas to be explored in the assessment. The review found that this was because the school staff believed that the change of tenancy would reduce A.C’s concerns. The CFW service helpfully liaised with the school in order to inform the early help assessment which was expected practice. 5.3.3 The early help assessment was reviewed on two occasions at formal meetings which were attended by a member of school staff, CFW and A.C’s Mother. This enabled the progress of the issues to be considered. However, there was no clear understanding of the role of A.C.’s Mother’s former partner. 5.3.4 Prior to the closure of the early help assessment, A.C.’s Mother was contacted regarding A.C.’s school uniform but declined the offer of support and would not discuss this further. There is no record of this being discussed with the professional from the CFW and this was a missed opportunity to engage A.C.’s Mother in a discussion regarding any further support she may have required. 5.3.5 When the early help support led to the provision of a new tenancy, it was decided that the plan would be closed as the counselling for A.C. was to be provided by the school. The information obtained during the work with A.C. included her concerns about her teeth and her weight. However, as this information was not included in the assessment form, it was not known to the school and was not relayed to the school counselling service or the school nurse and therefore were not addressed with A.C. This was an oversight on the part of the CFW. The review learned that following improvements made to the service, early help work is now undertaken more holistically and therefore it is likely that this information would now be shared. 5.3.6 The school appropriately made a referral to the school nursing service to support A.C.’s Mother with managing the infestation of A.C.’s head lice. However, as the referral did not include their concerns about the family’s history, the service was not aware of the extent of the school’s concerns and offered a universal service. The school nurse promptly contacted Mother by telephone, but she did not reply, and a response was not pursued. This was not fed back to the school as was expected practice and there was no evidence that the school pursued this with the school nursing service until several months later. This led to significant delays in helping A.C. The Page 12 of 17 review learned that there had been a number of changes of staff in the school nursing service due to staff turnover which meant that the continuity of service was disrupted. 5.3.7 The school made a further request of the school nursing service in March 2020 by email and a school nurse responded to say that they could ring A.C’s Mother the following week. Again, the school nurse did not feed back to the school about the outcome of this and it was the school who pursued a response. Similarly, it is likely that the changes in staff led to a lack of continuity and understanding of A.C’s needs by the school nursing service. 5.3.8 The information about the family was provided by A.C.’s Mother and although professionals were concerned that Mother was “closed” and did not share relevant information, no attempt was made to triangulate this with any other professional for example by seeking A.C.’s Mother’s consent for the school nurse to liaise with the G.P. Research highlights the importance of this issue. “In addition to gathering and sharing information, information must be triangulated and verified. This involves seeking independent confirmation of parents’ accounts and triangulating information between professionals.” 10 5.3.9 There was good evidence of information sharing between the Education Attendance Team and the Pastoral Team. By March 2020, the school had a number of concerns regarding the head lice infestation and A.C.’s poor school attendance, and A.C. possibly having been given her sibling’s medication. A meeting was held which was appropriate but as a review meeting was not scheduled due to the school closure as part of the national lockdown it meant that the opportunity to liaise as a group and create a shared approach was missed. 5.3.10. Learning ● The school nursing service experienced a number of staff changes which meant that the practitioners did not have a clear understanding of A.C’s needs. ● The school nursing service is responsive to parents who engage but insufficient consideration is given to why parents may not engage in the offer of support from the service. ● The volume of work in the school nursing service makes it difficult for practitioners to identify emerging neglect. Therefore, when professionals seek support from the service, a detailed background of concerns should be provided. ● When information that is available to agencies is reported by parents, consideration should be given to triangulating this to inform a robust assessment and appropriate support plan. ● When there are concerns about a child’s welfare, the progress of the plan should be regularly reviewed by the relevant staff to ensure that there is a shared understanding of a child’s progress and a shared approach to managing this. 10 “Pathways to harm and protection- a triennial analysis of SCRs 2011-2014” - Department for Education 2016. Page 13 of 17 5.4 How professionals work with the challenge of limited engagement from parents 5.4.1 The review learned that on occasions, A.C.’s Mother’s behaviour towards professionals was hostile or avoidant and on occasions, contradictory. The review examined how this impacted upon the outcomes for A.C. 5.4.2 Throughout the review, professionals expressed concern that A.C’s Mother was quite closed and it was difficult to understand the family’s history and the current situation. On occasions, she provided contradictory information. For example, A.C.’s Mother advised that A.C. did not know her Father, however, A.C. was visibly upset about his loss on a number of occasions. On one occasion, A.C. brought in a note from her Mother which said she was being bullied but she didn’t feel that she was. When this was queried with A.C’s Mother, she did not respond. 5.4.3 From January 2019, A.C. developed persistent head lice and the school staff had a number of discussions with A.C.’s Mother to try to address this in the longer-term. Initially, A.C’s Mother presented as embarrassed but there were several episodes of her using abusive language towards staff which resulted in a letter from the head teacher. Despite this, staff continued to contact Mother and raise concerns with her although they were not resolved. 5.4.4 As a result of A.C’s Mother’s inability to make sustained improvements for A.C. and her hostility towards staff on occasions, school staff spoke to A.C ’s Mother’s former partner by telephone instead of Mother as they felt that he was more amenable. However, this was not appropriate as he was no longer in a relationship with A.C.’s Mother and did not have parental responsibility for A.C. and therefore could not make decisions about her. This also meant that the focus of improving A.C’s well-being moved from A.C.’s Mother to Mother’s former partner and was likely to have deflected from identifying that A.C.’s needs were being neglected by her Mother. 5.4.5 In January 2019, A.C. began to have a number of absences from school which were reported by her Mother to be for minor illnesses and combined with absences due to head lice, her school attendance began to suffer. These absences were promptly followed up by a member of the Education Attendance Team however, by the end of March 2020, A.C.’s school attendance had deteriorated to 68.2 %. No consideration was given to the absences being a warning indicator of wider concerns nor to triangulating the information with health agencies. 5.4.6 In March 2020, a meeting was held between the DSL and the school nurse to which Mother and her former partner provided apologies. The outcomes from the meeting were discussed with A.C.’s Mother in a follow-up telephone call and she threatened to remove A.C. from the school as she felt she was being accused of being neglectful. The review learnt from discussions with A.C’s Mother that she felt “judged” by school staff. Shortly after this, the school closed due to the national lock down and its communication with A.C’s Mother was limited to telephone calls by the learning mentor. As A.C. was not in school, all of the communication was with A.C’s Mother who shared some information which reassured the learning mentor. It is likely that the impact of the pandemic upon children, families and the community and the school closure prevented professionals from challenging A.C’s Mother. Page 14 of 17 5.4.7 The review learned that the school nursing service and the school have systems in place to provide clinical supervision and this helps to provide professional challenge and support for practitioners. 5.4.8 Learning ● Ambiguous information provided by a parent/carer should be triangulated from other sources to ensure that it is accurate and provides a shared understanding. ● Practitioners should be professionally curious and practice respectful uncertainty to ensure that information provided by parents/carers is accurate and clearly understood 5.5 Multi-agency response to connected persons 5.5.1 The review learned that during the scoping period, A.C.’s Mother was living with her ex-partner. A.C. told a member of staff that she was concerned about visits from strangers to the house who argued with him and that he had threatened people (including her granddad) with a machete and had destroyed her grandmother’s furniture with a knife. The school was aware that Mother had previously been in domestically abusive relationships. 5.5.2 The referral made by the school to the CFW service included information about Mother’s former partner. However, the referral did not include supporting A.C.’s Mother with managing the situation with her former partner. This meant that when they undertook the early help assessment, they did not seek to understand more about Mother’s current relationship and how this was impacting upon A.C. and instead focused on securing an alternative tenancy as a solution. 5.5.3 Following the tenancy being awarded to A.C’s Mother, her former partner continued to be a feature in the family’s life. In February 2019, A.C.’s Mother was contacted by the Pastoral Team and advised that A.C. was to be sent home because she had head lice. A.C.’s Mother was verbally abusive and put the phone down and consequently a call was made to Mother’s former partner as a means to address the concerns because A.C’s Mother had named him as an emergency contact. This was inappropriate as he was not responsible for A.C. and was not responsible for making improvements to her well-being. 5.5.4 It is of note that Mother’s former partner was referred to as “step-father” in the school’s records seen by the review team and was consulted on a number of occasions about A.C. by the Pastoral Team. This was inappropriate as they had not been married, they were no longer in a relationship, he did not have parental responsibility for A.C. and was not in a position to make decisions. Given that professionals did not have a clear understanding of Mother’s relationship with her former partner, it was concerning that they treated him as if he had responsibility for A.C. 5.5.5 The early help support plan was closed in January 2020 when A.C.’s Mother was allocated a housing tenancy. However, Mother’s former partner continued to be present on a number of occasions during contacts with Mother. None of the school professionals sought to clarify this with Mother as they were aware that historically their relationship was “on-off.” The review learned from discussions with A.C’s Mother that her former partner had found it difficult to dis-engage with her and told people they were still in a relationship when they weren't, which she had found difficult to manage. 5.5.6 Mother had previously provided his contact details as an emergency contact and did not remove them once she obtained her own tenancy and therefore, they believed that it was still Page 15 of 17 acceptable to contact him in Mother’s absence. A.C’s Mother advised the review that she had not always been aware that the school was contacting him. Given Mother’s history of domestically abusive relationships, it was concerning that their relationship was not explored further. 5.5.7 In this case, the involvement of Mother’s former partner deflected from Mother’s inability to address the concerns regarding A.C.’s care for which she was responsible. 5.5.8. Learning ● Agencies should seek to understand the role of adults who are connected to a child’s family including whether they have parental responsibility or not. ● Where a connected person does not have parental responsibility, they should not be involved in making decisions about a child except in emergency situations. 5.6 Consideration of the voice of the child 5.6.1 A.C. was an articulate young person who was able to verbalise her views. A.C approached members of the school staff when she needed support and shared personal information about herself and her family. A.C. also communicated her views non-verbally- practitioners spoke of how A.C. wore a hooded top which covered her hair and they felt this demonstrated her embarrassment about the head lice. A.C. informed the review that she had found it relatively easy to speak to school staff. 5.6.2 From the point A.C. moved to secondary school, staff were alert to her needs because this had been provided by the primary school and the school promptly made a referral to the CFW service when it became apparent that A.C.’s family needed support outside of the school’s system. 5.6.3 The school also ensured that A.C. received counselling and this was made available to her as required although A.C. informed the review that she had not found it particularly helpful. A.C. attended a meeting at school in March 2020. This was good practice and demonstrated a commitment to listening to A.C. and to meeting her additional needs. 5.6.4 The review learned that the school applied a “RAG rating” to identify the level of support to pupils during the school closure and A.C. was awarded an amber rating as they were concerned about her welfare. The school helpfully arranged for a learning mentor, with whom A.C’s Mother had a positive relationship, to undertake the telephone calls to her. However, given the lack of availability of virtual means to communicate with children at that time, the school staff were not able to hear A.C’s voice. The review learned that this is now in place and pupils were communicated with during subsequent school closures. 5.6.5 However, it is recognised that virtual forms of communication provide only a limited means to safeguard a child’s welfare. This was explored by the Association of Directors of Children’s Services (ADCS) in some research undertaken about the impact of the pandemic. 11 “Using electronic communications, such as Skype and WhatsApp, as a means of ‘visiting’ children in need 11 ADCS Discussion paper: Building a Country that Works for All Children Post Covid-19 July 2020. Page 16 of 17 or in care may not be as effective if there isn’t a safe, quiet space to talk openly at home or if families do not have access to the right technology to engage.” 5.6.6 The CFW service undertook a RADAR assessment12 with A.C. to seek her views as part of the early help assessment and support. This enabled A.C. to explore her feelings and for CFW to identify a suitable resource to support her. However, A.C.’s views were not fully incorporated into the early help assessment nor the plan and this meant that they were not available to the wider professional network at the time or for future reference. 5.6.7 The school nurse provided support to A.C. via her Mother and did not hear directly from A.C. how her head lice was being treated. During March 2020, A.C’s Mother told the school nurse that A.C. had been treating the head lice herself. A.C’s Mother advised the reviewer that given A.C’s age she found it difficult to supervise her treating her hair. This meant that professionals had a clearer understanding of why the head lice treatment was ineffective. If the school nurse had spoken to A.C. directly following the first referral it is possible that this information would have been known to the nurse much earlier and corrective action could have been taken. 5.6.8 The school nurse did not have any contact with A.C. during the period of the school closure because the service did not recognise the extent of the concerns and A.C was being provided with a universal service. This was a missed opportunity to review the progress of the treatment of A.C.’s head lice and to listen to her. 5.6.9 Learning ● A child’s views should be incorporated into the written assessment and plan in order they are available for current and future reference. ● The lack of contact with A.C. by school nursing service meant that they did not have a clear understanding of the impact of the head lice and how it was being managed. 6.0 Conclusion 6.1 The service provision by agencies during the period of the review identified some good and conscientious practice that was child focused. All of the practitioners presented as dedicated individuals who worked hard to safeguard A.C’s well-being. 6.2 Despite the best efforts of the practitioners involved, A.C. experienced serious harm and this review has identified a number of areas of learning about the effectiveness of the safeguarding system in Lancashire. 7.0 Learning and Recommendations 7.1 The main issues that have been identified as learning from this case have been highlighted within the analysis (section 5.) The Lead Reviewer and the Review Team have considered the learning and have identified questions and recommendations for the Children’s Safeguarding Assurance Partnership in the areas thought to be of most importance. 12 A RADAR assessment is part of the assessment used to understand a child’s perspective. Page 17 of 17 7.2 The Triennial Review 13 states that ‘good quality SCRs should incorporate particular characteristics. These include lessons learned which are clearly linked to the findings of the review; findings and questions for the LSCB, to promote deeper reflection on the lessons of the review, and leading to a response and action plan developed by the Board to address that learning; specific recommendations where there is a clear case for change, again with a response and action plan developed by the Board; and a strategy for dissemination and learning of the lessons that will reach relevant practitioners and managers within the Board’s constituent agencies’. Whilst this review was not a mandatory review, it is arguable that the same principles apply. 7.3 The recommendations for the Children’s Safeguarding Assurance Partnership are directly linked to the learning areas of; Recommendation 1: Effectiveness of early help The Children’s Safeguarding Assurance Partnership should seek assurance as to the quality of early help assessments, with a particular focus on ensuring that the issues outlined in the referral are addressed in the assessment and support plan. Recommendation 2: Multi-agency response to concerns of neglect The Children’s Safeguarding Assurance Partnership should accelerate the implementation of the neglect tool for use by professionals and seek assurance that it is being used effectively. Recommendation 3: Effectiveness of inter-agency and intra-agency communication The Children’s Safeguarding Assurance Partnership should promote the triangulation of information by agencies when information is provided by parents/carers and there are unresolved concerns. Recommendation 4: How professionals work with the challenge of limited engagement from parents The Children’s Safeguarding Assurance Partnership should reinforce with professionals the need to practice respectful uncertainty when working with parents/carers. Recommendation 5: Multi-agency repsonse to connected persons The Children’s Safeguarding Assurance Partnership should reinforce with professionals the need to ensure that there is a clear understanding of the role of connected persons in the child and parent’s life, particularly where they are assuming some responsibility for a child. Recommendation 6: Consideration of the voice of the child The Children’s Safeguarding Assurance Partnership should seek assurance from agencies that consideration is given to ensuring that the child’s experience (in accordance with their age and understanding) is sought and recorded and is reflected in the provision of services. 13 Complexity and challenge: a triennial analysis of SCRs 2014-17. Brandon, Sidebotham et al. Department for Education March 2020. |
NC52390 | Significant and chronic neglect of four siblings over many years. Mother and father were estranged and had lived apart. Children were placed on a child protection plan on two occasions under the category of neglect. Several recordings and anonymous referrals regarding the poor living conditions at the mother's home. Mother displayed disguised compliance in telling professionals this would be improved, as well as not bringing children to medical appointments. Two of the children were reported to be soiling themselves daily at school. The eldest sibling committed intra-familial child sexual abuse (CSA) on his three younger siblings on numerous occasions from 2012 to 2016. Both parents were charged with neglect offences. Learning includes: practitioners should improve their awareness and personal knowledge in being able to recognise and identify symptoms of CSA and neglect; risk assessments must be carried out with the rationale recorded and supervised; 'was not brought' is a more relevant term than 'did not attend' as the emphasis is placed on the parent or carer who does not bring a child to an appointment. Ethnicity and nationality not stated. Recommendations include: all safeguarding partner agencies ensure that staff are aware of the signs and symptoms of CSA and know what to do if they are seen or suspected; assure that staff complete background chronologies on their case files on children and families subject to child protection enquiries; ensure that staff capture the voice of the child in safeguarding cases and focus on the experience and impact on children.
| Title: Serious case review for the Children of Family Y: overview report. LSCB: Gloucestershire Safeguarding Children Board Author: David Byford Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Gloucestershire Safeguarding Children Board SERIOUS CASE REVIEW for THE CHILDREN of FAMILY Y OVERVIEW REPORT Independent Overview Author - David Byford A GLOUCESTERSHIRE SAFEGUARDING CHILDREN BOARD COMMISSION Page 2 of 23 Table of Contents Chapter 1 – Overview Report ............................................................................................ 3 Introduction ............................................................................................................................ 3 Background ............................................................................................................................. 3 Court Proceedings and Outcome .............................................................................................. 4 Further disclosures by the younger sister. ................................................................................. 5 Periods of concern and key areas of consideration .................................................................... 6 Chapter 2 – Initiation of the Serious Case Review .............................................................. 6 Terms of Reference (summarised) ............................................................................................ 6 Agency involvement................................................................................................................. 7 Scope of the review ................................................................................................................. 7 Family Composition and Children subject to the review ............................................................ 8 Methodology ........................................................................................................................... 9 Chapter 3 - Analysis of Key Events ..................................................................................... 9 Chapter 4 - Findings and lessons learnt with suggested recommendations for the consideration of LSCB ..................................................................................................... 15 FINDING 1 – Governance and Supervision ............................................................................... 15 FINDING 2 - Signs and symptoms of Child Sexual Abuse and Child Neglect ............................... 16 FINDING 3 – Referrals, risk assessments and sharing information ............................................ 16 FINDING 4 - Multi-Agency Child Protection Safeguarding chronologies .................................... 17 FINDING 5 - Record Management ........................................................................................... 17 FINDING 6 – Child focused and capturing the voice of the child ............................................... 18 FINDING 7 – Learning from SCRs ............................................................................................. 18 FINDING 8 – Was Not Brought (WNB) ..................................................................................... 19 FINDING 9 – Police Protection ................................................................................................ 19 FINDING 10 – Child Medical Examinations .............................................................................. 19 FINDING 11 – Legal Proceedings ............................................................................................. 20 FINDING 12 – Professional curiosity, optimism and disguised compliance ................................ 20 Predictability and Preventability ............................................................................................ 21 Opportunities to intervene prior to abuse .............................................................................. 21 Engagement with professionals - Practitioners Event .............................................................. 21 Voice of Mother, Father and elder half-siblings ....................................................................... 22 Culture and Diversity ............................................................................................................. 22 Previous SCR’s ....................................................................................................................... 22 Professionals Overriding Responsibility .................................................................................. 23 Page 3 of 23 Chapter 1 – Overview Report Executive Summary Introduction 1.1 This Serious Case Review was commissioned by Gloucestershire Safeguarding Children Board (GSCB) in respect of four children referred to as ‘The Children of Family Y.’ A decision was made by the LSCB to anonymise the report and remove all geographical references, to ensure the family cannot be identified due to the nature and vulnerability of the children and the fact that they are all at various stages of therapy and other support as a result of their experiences. 1.2 The four children had been known to Children’s Social Care (CSC) since 2008. They were all victims who suffered from significant and chronic neglect over many years. 1.3 It transpired that the eldest sibling (male) committed intra-familial Child Sexual Abuse (CSA) on his three younger siblings (one female and two males) on numerous occasions over a period of time from 2012 to 2016. He subsequently pleaded guilty to all the offences charged against him at Court. 1.4 Mother and Father, the parents of the four children were estranged and had not been in a relationship for many years prior to the disclosure of CSA. Mother has other children by another relationship who are half-siblings to the four children. After the police investigation, both parents were subsequently charged with neglect offences committed against the children and pleaded guilty to the charges at Court. 1.5 The case was considered by the LSCB SCR Sub-Group. As a result, the Independent LSCB Chair made the decision on the 11th December 2017 that the criteria were met to commission the SCR. The criteria is in accordance with s5(2)(a) and (b)(i) LSCB Regulations 20061 and Working Together to Safeguard Children 20152: - ‘Abuse or neglect of a child or young person is known or suspected and the child or young person has died or been seriously harmed and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child or young person.’ Background 1.6 The family, consisting of three male children and one female child who were all victims of serious neglect over many years. The eldest male is both a victim of this neglect and also the perpetrator of intra-familial child sexual abuse. Professionals for many years failed to take effective action and there were missed opportunities to ensure they were appropriately safeguarded and protected. 1.7 A chronology of the key events and professional practice was analysed within the review. These show the contact with agencies and practitioners and the concerns raised of extremely poor conditions of the home and serious neglect issues. Mother consistently 1 2006 Section 5 (2) (a) and (b) (i) Local Safeguarding Children Board Regulations 2 Working Together to Safeguard Children, 2015, Guidance - HM Government March 2015. Page 4 of 23 failed to provide care and support for the children; even with agencies providing family support. 1.8 The local CSC record a number of referrals and contacts. Each referral resulted in an initial assessment (IA) at the time being completed but no intervention offered to the family by CSC. The concerns that led to these referrals focused on neglect and very poor home conditions. When the social worker (SW) visited the home, Mother made reassuring statements about improving the home situation. The children were initially seen to be in good health although living in a poor environment but, there was no evidence in the assessments, of hearing the children’s voice or of them having been spoken to by professionals. 1.9 The children were placed on a Child Protection Plan (CPP) on two occasions under the category of neglect. The first CPP was closed despite the circumstances of the home conditions and the neglect of the children still being present. There appears to have been an over optimistic approach by professionals that Mother would improve and sustain improvements which, she never did on any occasion. 1.10 Two of the children attending School 1 were reported to be soiling themselves on a daily basis and both had persistent headlice. The female child was referred to an incontinence team, but she was not brought (WNB) to the appointments by her Mother. 1.11 Mother was also informed on several occasions to make appointments with the family GP for this child regarding her encopresis (soiling) and with her dentist, as she had severe dental decay. Mother said she had contacted the GP and both she and her daughter were given medication. The Social Worker (SW) followed up with the GP to see if Mother had complied with the advice and found she had not seen the GP. Mother was displaying disguised compliance traits and was often untruthful to professionals. 1.12 Soiling is a possible sign and symptom of CSA which professionals did not recognise or consider in their interaction and assessments with the children. There was no professional curiosity displayed and assessments were lacking in quality and depth. It is evident the voice of the four children were not effectively obtained to understand their perspective of life. 1.13 Comments made by court officials when the eldest sibling later appeared at the Crown Court to answer to his criminal charges were, the home environment conditions were filthy and the children often went hungry, there was little or no supervision by any grown-up, including their elder adult half- siblings, with no boundaries or rules put in place. The children were being left to look after themselves and even had to put themselves to bed. The Court heard the lack of rules at home and the general neglect the accused had suffered, were principal reasons he behaved as he did, to abuse his younger siblings. It was accepted he had a very difficult childhood which, all four children had suffered. Court Proceedings and Outcome The elder sibling 1.14 He was charged with several counts of rape and causing a child to engage in sexual activity that he committed against his siblings between 2012 and 2016. He pleaded guilty to all the charges made against him. He was subsequently sentenced at Court. To ensure his identity is protected, the full details of his sentence has been redacted. Page 5 of 23 Mother. 1.15 In court, Mother was described as totally neglecting of her four children, who were left to fend for themselves in a ‘filthy and squalid’ family home. The children lived without boundaries or rules and did not know the difference between right and wrong. She failed to provide even the most basic things and ‘very much’ seriously neglected them. 1.16 Mother was charged with several counts of neglect against her children from 2008 until 2016. She pleaded guilty to the offences charged against her and was sentenced to a term of imprisonment. The full details of her sentence has been redacted to preserve anonymity. Father. 1.17 The court heard, he rarely visited the home and when he did, he was pretty cross and ‘nasty.' He pleaded guilty to one count of neglect from 2008 until 2011 against the eldest child only, which was accepted by the court. He received a suspended prison sentence, again the full details of his court sentence has been redacted. Half-Sibling 1. 1.18 It was believed Mother and the elder half-sister knew about the sexual abuse by the eldest child taking place in the family home. Police conducted a sexual abuse investigation and a decision was made that no charges would be preferred against her. Further disclosures by the younger sister. 1.19 The younger sister, in 2018, after the terms of reference (TOR) period of this SCR, made further disclosures of sexual abuse by her elder brother on her. This was not proceeded with after advice was obtained from the Crown Prosecution Service (CPS) as there had already been a been a conviction at Court and a decision was made that no further charges against him would be preferred. 1.20 The younger sister also alleged her elder half-brother sexually abused her elder brother. The half-brother was arrested by police and denied any offence. The elder brother was spoken to by police about the allegation but did not make any disclosures. No Further Action (NFA) was taken. Purpose of the review 1.26 The purpose of this SCR is to: - Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children and young people. Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result, and, As a consequence, improve inter-agency working and better safeguard and promote the welfare of children and young people. Page 6 of 23 Periods of concern and key areas of consideration 1.27 There are five periods of concern identified for the children for consideration. These concerns are detailed within Chapter 3, Analysis of Key Events and Analysis of Professional Practice. The periods of concern are: - Period 1 - History and background of family. Period 2 - TOR scoping period commencement. CP concerns and action taken. Period 3 - The Children of Family Y disclosure of CSA. Period 4 - Police Criminal Investigation and outcome for children. Findings 1.28 The serious case review identified the following findings which are expanded upon within Chapter 3, Key Events and Chapter 4, Professional Practice and within the Findings and LSCB Overview Report and Individual Agency Recommendations in Chapter 5 and 7. The findings are: - Finding 1 - Governance and Supervision Finding 2 - Signs and symptoms of Child Sexual Abuse and Child Neglect Finding 3 - Referrals, Risk assessments and sharing information Finding 4 - Multi-Agency Child Safeguarding chronologies Finding 5 - Record Management Finding 6 - Child focused and hearing the Voice of the child. Finding 7 - Learning from SCRs. Finding 8 - Was Not Brought (WNB) Finding 9 - Police Protection Finding 10 - Child Medical Examinations Finding 11 - Legal Proceedings Finding 12 - Professional curiosity, optimism and disguised compliance Conclusion 1.29 It took a significant event of the disclosure of CSA before the children were finally protected from their ongoing neglect, health concerns and poor home conditions which professionals were focusing on. Professionals in their interaction with the children did not consider whether their presentation were possible signs and symptoms of CSA. Chapter 2 – Initiation of the Serious Case Review Terms of Reference (summarised) 2.1 The review process was conducted in line with the principles for SCR’s set out in Working Together to Safeguard Children 20153 and aims to contribute to learning and improvement through consolidating good practice and identifying where practice can be improved. The principles, set out in the statutory guidance, are: - There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; 3 Working together to safeguard children 2015, Guidance - HM Government March 2015. Page 7 of 23 The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process; The review will recognise the complexity of safeguarding children and seek to understand not only what happened but why individuals and organisations acted as they did. Agency involvement 2.2 The following agencies were involved in the SCR process and completed Individual Management Reports (IMR) or a summary of their agency involvement: - Local Authority Children’s Social Care - IMR completed. Local Authority Care Services - IMR completed. Local Authority Hospitals NHS Foundation - IMR completed. Local Authority NHS Foundation Trust - IMR completed. Schools 1 and 2 (Redacted) - IMR completed. Local Clinical Commissioning Group (CCG)- IMR completed. Local Authority Police - IMR completed. Youth Support Services - Summary provided. Local Authority Housing Department - Summary provided. Ambulance Service- Summary provided. Youth Offending Team - Summary provided. Scope of the review 2.3 The review covers the period from 4th October 2012 (a joint home visit (HmV) between police and CSC) until Interim Care Orders (ICO) were obtained for the children in 2017. General Terms of Reference for Review 1.1 To establish whether there are lessons to be learnt from the circumstances of the case about the way in which local professionals and agencies work together to safeguard children and young people and promote their welfare 1.2 To consider whether there are any specific cultural issues within one agency that may have affected decisions made by another agency 1.3 To review the effectiveness of procedures (both multi-agency and those of individual organisations) and understand what is present in our safeguarding system to enhance or hinder good practice. 1.4 To inform and improve local inter-agency practice. 1.5 To improve practice by acting on learning (developing best practice). Page 8 of 23 1.6 To prepare or commission a summary report which brings together and analyses the findings of the various reports from agencies in order to make recommendations for future action. Specific Terms of Reference for Review 1.7 To examine the quality of risk assessment and understanding of the Levels of Intervention guidance. 1.8 To consider how and when the child’s views and experiences were considered and taken into account in the decision-making process. 1.9 To examine the level and quality of partnership working. 1.10 To consider whether recommendations from previous reviews involving chronic neglect have been implemented and whether there is any evidence of a change in working practices. 1.11 To consider whether professional differences occurred, and if so, how they were responded to. 1.12 To consider all agencies understanding of when information can and is shared. 1.13 To examine professional understanding of the signs and indicators of CSA. 1.14 To consider how information known about the older siblings to this group of children (not within the scope of the review) and their lived experiences as children was used to inform risk assessments and planning. Family Composition and Children subject to the review Subjects of SCR Date of Birth (Redacted) Male Eldest – Perpetrator of CSA and Victim of Neglect. Female Victim Male Victim Male Youngest - Victim Family Members Mother Father (estranged and not in a relationship with Mother) 3 elder half siblings Paternal Grandfather Paternal Aunt Independent Overview Author 2.4 Independent Overview Author (IOA and Lead Reviewer), David Byford, was appointed to carry out the SCR and has met all deadlines set by the LSCB. Page 9 of 23 Methodology 2.5 The LSCB agreed a mixed methodology to understand professional practice contextually, to identify factors which influenced agencies and professionals in their decisions taken and, the nature and quality of work with the family. The IOA identified through the initial agency submissions and again after a practitioner’s event, that further information was required. This additional information was provided within the agency final submissions. 2.6 In carrying out this review the following approaches were made: - A research and review of local and national safeguarding policies and procedures, care plans, CIN review meetings and consideration of previous LSCB SCR’s, previous Ofsted Inspections together with additional research of guidance material. Analysis of agency SCR submissions to ensure compliance with the TOR and statutory requirements. A Practitioners Event was held. Publication 2.7 The intention of the Local Safeguarding Board is to publish locally a highly anonymised version of the report. In the future a copy of the full report with all geographical reference removed to preserve the identity of the family and children concerned will be lodged with the NSPCC to ensure that the learning can be shared. The reasons for this approach is to protect the identity of the children who are all being supported to overcome the impact of these events and it will take some time for these interventions to be successful. Chapter 3 - Analysis of Key Events 3.1 The key events together with the input from the agencies and practitioners participating in this review, are further analysed within this section. It has been summarised and outlines the key events to show how the concerns over the five periods of identified concern developed, together with the professional action taken. DATE/YEAR KEY EVENTS - PERIOD OF CONCERN History and background of family Period 1 October 2008 Initial police referral to CSC. Issues are: - Concern of poor home conditions. Neglect of children. First Initial assessment (IA) undertaken. CSC closed the case with NFA. Mother declined a CAF. Police made a referral having attended the family home following the arrest of an elder half sibling in relation to a burglary. They were appalled at the living conditions, describing as filthy, untidy, with animal mess and food on the floor. The bedrooms were in a poor state with worn mattresses, and mouldy blackened windows. There was no food in the kitchen cupboards. It was suspected by police; the elder half sibling may have committed the crime due to survivalist reasons (a term suggesting the need to feed and care for himself) but this comment was not expanded upon. The Local Authority CSC completed an IA. There was no intervention offered to the family by CSC. The children were seen to be in good health, but there is no evidence in the assessments the children were spoken to about their lives. Mother felt that she will manage to put things straight and would not need a Common Page 10 of 23 Assessment Framework (CAF). No Further Action (NFA) was taken. 2009 Concerns were made by neighbours, stating one child was looking withdrawn pale and neglected and one who was quite young looked tired with bags under her eyes. It was alleged the family were living in squalor. CSC record NFA. February 2010 Initial assessment (2) CSC received an anonymous referral stating the house was disgusting and the children are very dirty, had head lice and sores, also new baby in the house. IA and recorded as NFA. Health Visitor (HV) telephoned CSC stating the house was in need of decoration but was not dirty or unsanitary in anyway. The second youngest male sibling was being cared for well. No further rationale recorded. NFA. September 2010 Initial Assessment (3) CSC received an anonymous call received concerning the state of the children. The girl had ‘disgusting hair with head lice,’ the house was described as a mess and not liveable. Outcome: An IA completed. Case was not felt to meet the threshold for services, a final home visit (HmV) was made and referral sent to a children’s centre to work with family. NFA and case closed 29/11/2010. Comment: The assessment did not take into account the pattern of referrals indicating that the children were often dirty, and the home conditions were unacceptable and to a poor standard. Later in the month CSC received a further anonymous referral regarding neglect. Advice given to family and case closed, NFA. December 2010 Initial assessment (4) CSC obtain information regarding home conditions and concerns for one of the children with a HmV requested under section 17. Outcome- IA completed case closed, NFA. February 2011 Initial assessment (5) Concerns regarding one of the children’s teeth and personal hygiene. An IA was completed and a School Nurse (SN) engaged. The case was again closed to CSC and NFA taken. Analysis of background period There were five IA’s carried out during this first period which were all subject to NFA being taken. There was no professional curiosity or supervision oversight evident. The continuing concerns of serious neglect, persistent health issues and extremely uninhabitable home conditions persisted which, the children were expected to live in. There was too much practitioner optimism allowed of Mother who agreed to improve the home environment and the health and neglect issues of the children. No improvements ever occurred, and the account of Mother (who was displaying disguised compliance), showed she could not or would not provide care and support to her children. Father of the children was not present in the family home but had contact. It was believed he was aware of his children’s neglect and the worrying health issues yet, did not attempt to relieve their suffering and provide the necessary care and support for them. There were numerous missed opportunities to safeguard the children and is a failure by agencies. There should have been an Initial Child Protection Conference, (ICPC) held with the evidence available on numerous occasions. Police had an opportunity to use their powers of Page 11 of 23 police protection but did not do so however, they followed up their concerns about the home conditions and appropriately referred the case to CSC. No practitioner ever considered invoking escalation policies as the children were left in such neglectful conditions and is a finding in this review for learning. In conclusion, this period reported health concerns on four occasions, as alluded to above, there were five IA’s with seven occasions when CSC took NFA and closed the case, (seven reported neglect concerns and five reported concerns of the unhealthy environment of the family home). It is clear these concerns remained and never improved throughout this period despite professionals working with the Mother. The voice of the child was never effectively heard. TOR scoping period commencement. CP concerns and action taken Period 2 2012 and 2013 Analysis of events in 2012 and 2013 (Information obtained from the female child’s 2017 disclosure to Police states it was around, September 2012 when she said the CSA commenced as admitted to by her elder brother subsequently at Court. It is placed in chronological order to show the start of events occurring in the family during the time of professional involvement). During this timescale the focus remained on the home environment and not on the children. Neglect issues for the children still persisted. In October 2012 a core assessment first notified practitioners of her regular soiling. An ICPC was held and the children were placed on a CPP for neglect. At the first RCPC the children were removed from the CPP which is considered premature as the soiling and the poor home environment still existed. Initial work was held to capture the voice of the children but from December 2012 to March 2013, no further work was carried out with children. Mother declined support from MH services for herself with no consideration of the impact this decision may have had on her parenting of the children. 2014 Analysis of events in 2014 The female child’s incontinence continued on a daily basis at school and both she and her younger brother had persistent headlice. Throughout, Mother never took appropriate action to address these concerns including taking her to her dentist for her severe dental decay. Mid-term the female child had an initial assessment with a psychiatrist who records the condition could be a sign of abuse which, was not followed up or shared. There were two CIN meetings held until September when the CIN process was closed. This was a wrong decision as concerns still prevailed with over optimism of Mother’s ability to make improvements to care for her children which she had never managed previously. A new SW Manager was appointed and in the following two months, home visits still observed poor home conditions which the children were Page 12 of 23 being expected by professionals to live in with NFA taken. 2015 Analysis of events in 2015 As in the preceding periods, the same concerns continued without being resolved with no improvement of the home conditions; the worrying concern of neglect and health issues for the children were still apparent. Mother failed to focus on the welfare of the children. There was no consideration to utilise police powers of protection at a home visit where police described the home was poor and inhabitable. They however referred to CSC who conducted a followed up at the family home and as a result further CIN meetings recommenced which were not effective. School 1 were escalating concern to CSC regarding the two children who were soiling themselves on a daily basis and the female child’s tooth decay remained outstanding. She WNB to appointments as agreed by Mother who was displaying disguised compliance. This child was also beginning to have behaviour issues at school towards other pupils. Concern with the previous history of the PGF was addressed by professionals as he posed a possible risk to children. Work by an FSW commenced with the family who reported in December further decline in the home conditions. The Children of Family Y were all made subject to a second ICPC and were placed on a CPP for neglect and continued on the plan at a RCPC. There was a lack of urgency for the children and a three-month delay in actioning legal planning. The family’s case should have been brought to the attention of the Head of Service earlier in order for scrutiny and oversight of safeguarding action being taken and is subject to the Findings and LSCB OV Report Recommendations in Chapter 4. Up to June 2016 Analysis of events in 2016 until Period 3 Environmental health visited the property and reported there was a little improvement. A GP referred the female child for additional support and a Care Coordinator (CC) was allocated for Cognitive Behaviour Therapy (CBT). She WNB for five dental appointments and the dentist refused to offer any more. During a SW home visit in March, Mother was challenged about this and offered excuses. A second RCPC made a decision for the children to remain on the CPP for neglect. Legal proceedings were to commence for neglect of medical, mental health and environment as there was no sustained change. This was an appropriate decision but was allowed to drift with missed opportunities to take action much earlier. School 1 reported the sister stole her brother’s toast money as she was hungry as she did not have breakfast in the mornings. School records do not show any action taken regarding this possible neglect issue. The FSW reported Mother, from April was struggling. Mother did not turn up at court for a fraud offence and a warrant was issued for her arrest, but due to the fact she was the sole carer for the children NFA was taken on the failure to Page 13 of 23 appear. The sister WNB to a CBT therapy session but this was followed up and she was later taken in May 2016. She reported a good relationship with her family although had difficulty with her elder brother. She described difficulty in sleeping and often woke in the middle of the night, often due to needing the toilet and at other times due to having nightmares. The CC was attempting to ascertain if there were any underlying causes such as CSA. It was a missed opportunity to consider the concerns further with other professionals. Mother later took a drug overdose. The hospital clinicians offered Mother support by the Mental Health Liaison Team (MHLT) but this was not taken up by her and again the outcome was not assessed of the likely impact upon her children. A core group meeting later confirmed there was no improvement with the home. The Children of Family Y - Disclosure of CSA. Period 3 18/05/2016 First allegation of CSA made by the youngest sibling against his elder sibling. When the FSW was at the family home, one of the younger brothers made the first allegation of CSA against his eldest sibling. The FSW informed the SW who made the decision to visit the younger brother at school the following day when he again confirmed the disclosure. The disclosure should have prompted an immediate referral and SD with Police as there is a clear disclosure of a criminal offence being alleged and the potential safety of the children in the family home. There was no risk assessment of the concern regarding a half Sibling response to the disclosure. She was reported to have shouted and grabbed him by the head, to stop him from being able to talk to the FSW. 23/05/2016 Criminal investigation and care proceedings commenced. A SD was held due to the disclosure. The child disclosed sexual acts of abuse which happened in his elder brother’s room. Mother apparently witnessed and shouted at him. Furthermore, care pre-proceedings started. Mother was reported to be facing eviction for non-payment of rent. Police instigated a criminal investigation into the CSA disclosure. All three sibling were subsequently interviewed by police and disclosed sexual abuse by the elder brother against them. He was moved to live with Father. May/June 2016 A parenting assessment was completed for the unsafe and unhygienic home conditions. It was observed that one of the younger males displayed sexualised behaviour. The response from Mother and an older half-sibling suggested this behaviour was not unusual practice in the home. June 2016 The eldest sibling was ABE interviewed as a suspect. Initial Family Court pre-proceedings took place and during this period Police conduct an ABE interviewed with eldest male. He claimed the allegations were all made up and these three younger siblings were just trying to get him into trouble. September 2016 RCPC held and the family RCPC held and a decision was made for the children to remain on the CPP for Neglect. Mother had not attended any core groups Page 14 of 23 evicted from their home. with no sustained change in conditions noted. The review LPM was held and the decision taken to issue care proceedings. Mother requested the children be placed in care due to being homeless as the family were being evicted on the 27/09/2016. Mother said she did not think she could do the best for her children and that they should go into foster care. School 1 report throughout this month report one child was still presenting in a dirty condition and the young girl was persistently soiling herself with both having headlice. She had behavioural issues with other children. The family were evicted and went to live with the MGF. The eldest boy remained with his Father after the CSA disclosure. The MGF thought a Family Group Conference (FGC) would be a good thing but never occurred. November Mother requested children to be placed into voluntary care for a second time. Mother again requested for her children to be taken into care under Section 20. Three were moved to foster placements. Two were placed together. School 1 report they were concerned regarding the girl’s swearing and threatening to harm others school pupils. (no outcome is known). CSC chase up Legal Services as the Court paperwork was not being progressed. The three are voluntary accommodated under a Section 20 agreement given by Mother. All three children were placed with foster carers with two residing together. Later the foster carer for the girl child reported an increase in her soiling and it was too much to manage and gave notice. It was felt she needed a sole carer for her condition. December 2016 Safeguarding concerns as eldest sibling staying with his PA with younger children in the home. A Paternal Aunt (PA) disclosed eldest boy has been staying at her home in her son’s bedroom instead of the MGF. This had not been known before and raises concerns about the risk to her child. Comment: This was a failure by practitioners to carry out an effective risk assessment. The young girl was later moved in this month, to a separate placement due to her complex soiling needs. At this new placement she later alleged CSA by her elder brother. 14/01/2017 The second youngest male sibling alleged his elder sibling sexually abused him. At a SD, information from a foster carer was the second youngest disclosed he had seen the older brother since being in care at the MGF home previously. There was further discussion and that child made a disclosure regarding sexual activity of his older brother and of him acting inappropriately towards him later confirmed in an ABE interview with Police. He was ABE interviewed by police later this month. Police Criminal Investigation and outcome for subjects Period 4 January 2017 The older child was arrested for serious sexual offences against his Page 15 of 23 siblings. Mother was arrested for child neglect and perverting the course of justice, as one child disclosed, she was aware of what the older child was doing to him. Father was later arrested for Neglect. February 2017 ICO was granted in Family Court for the three younger siblings Care proceedings were held. The Judge granted ICOs for the three younger siblings. He would not grant an ICO for the elder boy as he was with his MGF who would not pass assessment. The Judge gave the local authority until 08/03/2017 to find a placement. March 2017 An ICO was granted in the Family Court for Eldest sibling. A placement was found for the elder boy and an ICO granted. He was moved to the placement on this day. The three youngest siblings remained with their current foster placements with the eldest boy in a separate foster placement. Mother in court, agreed to the actions taken. She admitted to the neglect of the children, failing to meet appointments and did not raise her depression as mitigation. Chapter 4 - Findings and lessons learnt with suggested recommendations for the consideration of LSCB 4.1 This chapter outlines the findings and suggested recommendations identified from the analysis of the key events and professional practice. They are produced for the consideration of the LSCB to reflect and implement any learning from this SCR. The findings have been summarised and the fuller version is available to the Local Authority for promulgating the lessons to be learnt from this SCR. The findings with the recommendations below have been accepted by the Safeguarding Board. The LSCB SCR Overview Report Recommendations overarch, encompass and support Individual Agency Recommendations which are included within the Action Plan that accompanies this review, as follows: - FINDING 1 – Governance and Supervision What are the issues and what should be considered? This review has identified concerns as to the function of the governance of CP cases with previous history of concerns, including effective supervision of all child safeguarding meetings and the appropriateness of scrutiny of the decisions made. If Initial Assessments identify similar concern that was previously closed with NFA taken, there should be a consideration to treat the case as high-risk until circumstances confirm to the contrary. This is a safeguard for the child or young person and supports practitioners and the LA in the action and decisions taken. There was no consistent management oversight, particularly in early interaction with professionals working with the family. LSCB Overview Report Recommendation (1) for Child Protection Safeguarding Partners It is recommended that all local authority Child Protection Safeguarding Agency Partners review the standards of supervision to ensure all child protection meetings, capture the overall picture of safeguarding concerns, ensuring: - An improvement of supervision, including supervision of supervisors, in single assessments, chairs of safeguarding meetings, including CP Plans and CIN meetings and child protection cases, to ensure the wider picture of a safeguarding case particularly those determined high-risk, are captured and acted upon. Page 16 of 23 Before closure of a referral, safeguarding risk assessment or meeting, consideration as to the causation of presenting concerns must have considered CSA, Neglect and all other signs and symptoms of abuse before closure, subject to management oversight. Identifying high-risk cases with historical concerns (regardless of the length of the intervening period) with repeating safeguarding concerns, are scrutinised by senior management and referred to the Head of Service if necessary, whose decision is final. Escalation policies must be used where there is a disagreement as to process or course of action taken. FINDING 2 - Signs and symptoms of Child Sexual Abuse and Child Neglect What are the issues and what should be considered? There is a need for practitioners to improve their awareness and personal knowledge in being able recognise and identify the signs and symptoms of CSA and neglect. The persistent squalid state of the family home, the presentation of the children at school; the young girl’s persistent soiling; her brother’s soiling, were all health concerns; the lack of urgency for her to attend her GP due to severe tooth decay; her stealing food at school because she was hungry, the failure by Mother to improve the home environment , are together all signs of neglect. This was a failing by professionals in this SCR, to consider or share the wider concerns for children or young people, a theme in other, SCR’s. By utilising the Local Authority Neglect Toolkit will assist practitioner’s awareness in capturing the evolving safeguarding concerns much earlier, in order to signpost the most appropriate pathway, service and support required to protect C&YP. The Local Authority LSCB should ensure there is a clear pathway for children and young people. LSCB Overview Report Recommendation (2) for Child Protection Safeguarding Partners It is recommended all Child Protection Safeguarding Agency Partners and relevant voluntary organisations within the local authority area, assure the Local Safeguarding Children Board that their staff are aware and compliant with the following safeguarding concerns: All safeguarding partners agencies must ensure staff are made aware of the signs and symptoms of CSA and know what to do if they are seen or suspected. Where relevant, staff must utilise the Neglect Toolkit in order for practitioners to identify and capture evolving safeguarding concerns at a much earlier stage, in order to safeguard the welfare of children and young people. FINDING 3 – Referrals, risk assessments and sharing information What are the issues and what should be considered? Generally, there was a distinct lack of credible risk assessments in the SCR. Risk assessments must be carried out with the rationale recorded and supervised. Significantly, the younger brother made an allegation of CSA against the eldest to the FSW at a home visit in May 2016. The FSW did not immediately refer the disclosure or call a strategy meeting with police and GCSC. The disclosure was repeated to the SW at school the following day. The disclosing child was allowed to go home without the necessary protection for him and his siblings put in place. On both occasions no risk assessment was carried out and can be construed as a failure to protect him and his other siblings. These were missed opportunities and from a police perspective, the ability to obtain or preserve best evidence may have been compromised. A care coordinator dealing with the young girl’s soiling condition subsequently considered and asked underlying questions of possible other causes for her toileting issues. Again, this was a missed opportunity to share the professional’s views and opinions. Furthermore, a Hospital Trust Clinician identified severe dental decay who did not consider communicating the information as a potential Page 17 of 23 child protection referral to CSC, as the child was likely to need additional support. Regular communication and information sharing between agencies may have resulted in a different outcome being taken for the removal of the children from the family and the earlier recognition of the signs and symptoms of CSA. LSCB Overview Report Recommendation (3) for all Child Protection Safeguarding Partners It is recommended all Child Protection Safeguarding Agency Partners and relevant voluntary organisations within the local authority area, assure the Local Safeguarding Children Board their staff are aware and are compliant with the following requirements: To comply with national and local Safeguarding policies, procedures and guidance in relation to referrals, risk assessments and the requirement to share child protection safeguarding information or possible concerns. When there is a disclosure of an allegation of a crime which impacts on a child or young person, an immediate referral must be made for a strategy discussion, to consider initiating or planning whether a Section 47 Investigation is required. This is in conjunction with any criminal investigation in order to identify the most appropriate action required to be taken to protect and support a child or young person and to preserve potential evidence. FINDING 4 - Multi-Agency Child Protection Safeguarding chronologies 4.1 What are the issues and what should be considered? Multi-Agency chronologies were not completed in this SCR. This is recommended learning from previous serious case reviews that safeguarding chronologies should be completed. There were overwhelming historical and current concerns (during the TOR period under review) of the family, in respect of a poor home environment, continuing health and neglect issues with initial assessments being opened and closed with no further action taken where, the worrying concerns persisted with no improvements noted. LSCB Overview Report Recommendation (4) for all Child Protection Safeguarding Partners It is recommended all Child Protection Safeguarding Agency Partners and relevant voluntary organisations within the local authority area, assure the Local Safeguarding Children Board that their staff complete background chronologies on their case files on children and families subject to child protection enquires, in order practitioners have the fullest information available to make informed decisions of the most appropriate action required to be taken. FINDING 5 - Record Management What are the issues and what should be considered? Agency IMR’s indicated a deficiency in record keeping, with no recorded rationales of action taken or why actions made are not concluded or followed up with outcomes recorded. Some agencies addressed this within the Individual Agency Recommendations. There is a need however, for the Local Authority to ensure all safeguarding partners involved in the SCR, have robust record keeping and management systems in place. Records of minutes of safeguarding meetings should be completed diligently and shared with participating agencies. Some IMR’s raised the concern they were not receiving them or when they did it was after some delay. LSCB Overview Report Recommendation (5) for all Child Protection Safeguarding Partners It is recommended all Child Protection Safeguarding Agency Partners within the local authority area, assure the Local Safeguarding Children Board of the following requirements: Page 18 of 23 Their recording keeping, and management systems are robust, comprehensive and up to date and, Minutes of safeguarding minutes are promptly completed and shared with involved safeguarding partners. FINDING 6 – Child focused and capturing the voice of the child What are the issues and what should be considered? Multi-agency meetings and core groups must be child focused and consider all presenting options including a child or young person’s health concerns and in the young girl’s case, the behaviour displayed at school including her aggressiveness towards others and why she kept a screwdriver under her pillow at night. These are all possible warning signs that something was not right. The persistent soiling were further possible signs and symptom of CSA or that other forms of abuse could be taking place. These issues were not considered and is also discussed in Finding 2 above. The voice of the children was not captured particularly in the early years of professional interaction both in interaction with practitioners and in initial assessments. “Think children first” is an emphasis on the priority of a child’s welfare over parents with professional curiosity and disguised compliance awareness and training. Practitioners were overly optimistic and believed Mother would take her children to health and dental appointments and to clean the family home which was in an intolerable condition. She never complied. There must be proactive engagement with children which appears lacking in this case. LSCB Overview Report Recommendation (6) for all Child Protection Safeguarding Partners It is recommended all Child Protection Safeguarding Agency Partners and voluntary organisations within the local authority area, assure the Local Safeguarding Children Board they have reminded their staff of their duty in safeguarding cases to ensure the voice of the child is captured and are focused on the experience and impact on children, as identified in learning from previous serious case reviews. FINDING 7 – Learning from SCRs What are the issues and what should be considered? All safeguarding agencies must remind staff of the requirement to make themselves aware and to comply with the learning from previous SCR’s. The NSPCC,4 on their website every year, publishes recent learning from SCR’s. The learning from two recent SCR’s contained in the conclusions, highlight the same concerns are replicating themselves in this review. IMR Authors acknowledge this aspect and have addressed the concerns within their SCR IMR submissions and agency recommendations. LSCB Overview Report Recommendation (7) for all Child Protection Safeguarding Partners It is recommended all Child Protection Safeguarding Agency Partners and relevant voluntary organisations within the local authority area, assure the Local Safeguarding Children Board they have informed all supervisors and staff of the need for all practitioners to have the required knowledge and awareness of recent learning from previous serious case review publications, in order to ensure their decision making and actions to safeguard children and young people that similar concerns are not being repeated 4 NSPCC Yearly audit of published SCR’S. Page 19 of 23 FINDING 8 – Was Not Brought (WNB) What are the issues and what should be considered? Consensus of opinion of practitioners within the SCR and during the practitioners’ event held, consider WNB a more relevant terminology rather than Did Not Attend (DNA). DNA gives an emphasis on a child not attending an appointment, but as in this case, it is the parent or carer who generally does not bring the child or young person to an appointment. It is suggested the Local Authority adopt WNB as policy. LSCB Overview Report Recommendation (8) for all Child Protection Safeguarding Partners and the Local Authority It is recommended all Child Protection Safeguarding Agency Partners and relevant voluntary organisations and the local authority, assure the Local Safeguarding Children Board of the following requirements: The local authority adopts the more appropriate terminology of ‘Was Not Brought’ (WNB) instead of ‘Did Not Attend’ (DNA) which unjustly places an emphasis on a child when it is the parent or guardian who does not bring a child or young person to an appointment. All safeguarding partners have suitable policies in place if a child is persistently, WNB to appointments. There must be supervision oversight to consider if this indicates harm to a child and the details recorded within the child’s chronology. FINDING 9 – Police Protection What are the issues and what should be considered? The Police IMR identified that police officers could have utilised their powers of police protection on several occasions when the children were found in squalid unhealthy condition within the family home. It was suggested this may be a lack of knowledge by some police officer of their powers and may require additional training. This was not systemic however, as police officers on other occasions did show professional scrutiny and appropriately invoked police protection. (There is no requirement for a LSCB Overview Report recommendation as this has been addressed by a Police Recommendation). FINDING 10 – Child Medical Examinations What are the issues and what should be considered? There was concern raised by Local Authority Care Services when a CSC social worker contacted a Consultant Paediatrician to request medical examinations when, there was a significant period since the last physical contact between the abuser and his younger siblings. There is a need to seek clarity and agree a clear memorandum of understanding between Health, Police and CSC to ensure the correct procedure is taken within the Local Authority. LSCB Overview Report Recommendation (9) for Local Authority, Children’s Social Care, Police Service and Care Services It is recommended Children’s Social Care, the Police Service and Care Services, within the local authority area, assure the Local Safeguarding Children Board there is an agreed memorandum of understanding, in the correct procedures and action to be taken for the completion of children and young people’s medical examinations, to ensure clarity of the purpose and achievable objectives. Page 20 of 23 FINDING 11 – Legal Proceedings What are the issues and what should be considered? From the time of the decision to the issue of initial care proceedings for the four children, there was some drift. There was also a lack of information on the progress which IMR Authors and attendees at the SCR Practitioners Event commented upon. There is a need that CSC should ensure there is communication with Legal Services in order to obtain regular updates on the progress and where there are delays, these are kept to a minimum and the progress shared to interested parties in the family’s legal proceedings. LSCB Overview Report Recommendation (10) for the Local Authority Children’s Social Care and Legal Services. It is recommended the Local Safeguarding Children Board require the local authority Children’s Social Care and Legal Services agree regular communication and updates on the progress of family cases in legal care proceedings. This is in order to keep any delay to a minimum and for interested parties to the proceedings to receive regular information of the progress of the case. FINDING 12 – Professional curiosity, optimism and disguised compliance What are the issues and what should be considered? There was a consistent lack of professional curiosity and scrutiny displayed in the assessment of child protection concerns apparent throughout the SCR for the children. There were missed opportunities for supervisors and practitioner’s professionalism to consider and capture the wider picture of other possible factors of the abuse and neglect the children were having to live with. Failings which should not be reoccurring as there is clear learning from other SCR’s which were replicated within this review. Furthermore, Mother was displaying clear disguised compliance practices. There was too much professional optimism on Mother who always ignored advice and persistently failed to support and protect her children. She openly lied to practitioners about taking her children to appointments. Persistently the children WNB to GP and Dental appointments and she failed to make improvements to address the uninhabitable home which the constant neglect and health concerns the children had to suffer over a long period of time. LSCB Overview Report Recommendation (11) for all Child Protection Safeguarding Agency Partners It is recommended all Child Protection Safeguarding Agency Partners and relevant voluntary organisations within the local authority area, assure the Local Safeguarding Children Board that staff have supervision oversight on their child protection safeguarding cases, to ensure there is professional curiosity displayed, and not a propensity to have an over optimistic view of compliance by parents and carers with disguised compliance challenged where displayed. Individual Agency Recommendations 4.2 The participating agencies to the SCR for the children have identified learning for their respective agencies during the SCR process. Their recommendations have been agreed by Agency Heads of Service and Senior Management and will form part of a LSCB SCR Action Plan that will follow this overview report. They have been agreed by this SCR to be relevant and necessary. 4.3 Specified questions posed in the TOR in Chapter 2 were addressed within IMR’s and taken into consideration and subject to the Findings and Recommendations above. Page 21 of 23 Chapter 5 – CONCLUSIONS 5.1 This SCR Overview Report for the Children of Family Y is LSCB’s response to establish future learning to provide explicit child protection safeguarding within the local authority area. Learning has been identified before within national SCR’s which have not been taken into consideration as mentioned within the narrative of this report. This SCR re-emphasises and addresses the previous learning supported by the additional findings and recommendations within this review. Predictability and Preventability 5.2 The circumstances of the serious neglect, escalating health concerns and inhabitable home conditions of the children were identified back in 2008. Despite continual interaction through the following years with CSC, health providers, school and police, there was an over reliance on a Mother who continually displayed disguised compliance, (and Father to a lesser but still a significant extent) to make and sustain improvements to her children’s life which she failed to do, even when support was provided and offered. 5.3 The Analysis of Key Events and Professional Practice outline the continual and repetitive child protection concerns. It was not until late in December 2016 when the intra-familial CSA disclosure against the eldest sibling came to notice, when appropriate action was taken to protect them. 5.4 More worryingly, the signs being displayed by the children in particular the young girl, were clear signs and symptoms of CSA. CSA was not considered by practitioners and we know in hindsight, the perpetrator started to sexually abuse his siblings from 2012 until May 2016. 5.5 In conclusion the neglect, health concerns, poor home conditions and missed CSA (from 2012) should have been both predictable and preventable with the amount of contact and interaction with professionals from 2008 until the disclosure (neglect continued after the CSA disclosure until 2017) when the children were all placed in foster care. Opportunities to intervene prior to abuse 5.6 There were numerous missed opportunities to take safeguarding action throughout agency involvement with the family, as outlined in the analysis of Key Events in Chapter 3 and within the Findings in Chapter 4. LSCB OV Report and Individual Agency Recommendations will hopefully address the concerns for robust safeguarding action to be taken in future child protection cases. Engagement with professionals - Practitioners Event 5.7 A Practitioners Event was held that was well received and attended by agency practitioners involved in the SCR. It was hosted by the LSCB, LSCB Business manager, the SCR Chair and the Lead Reviewer. The issues submitted for discussion was elicited from the analysis of agency submissions. Practitioner’s views were taken into consideration and identified further analysis and where relevant to the review are subject to the Findings and LSCB OV Report Recommendations in Chapter 4 and within the Individual Agency Recommendations which form part of an Action Plan accompanying this SCR. Page 22 of 23 Voice of Mother, Father and elder half-siblings 5.8 Mother, Father and Sibling 1 were offered the opportunity to participate in the review but the LSCB received no response. Therefore, their views cannot be incorporated and questions as to the care and support provided to the children have not been obtained. Advice from CSC not to communicate for purposes of the review with any of the siblings was accepted and complied with. Local and National Safeguarding Policies and Procedures 5.9 A vital element identified in this SCR was the requirement for practitioners to have the knowledge and awareness of local and national Safeguarding Policy and Procedures. There is a need to ensure compliance and now the requirement to utilise the local authority Neglect Toolkit and to recognise and act upon the signs and symptoms of CSA. Culture and Diversity 5.10 Culture and diversity was not an identified issue within this SCR. Previous SCR’s 5.11 SCR 1 (Redacted) - This was a case where the children fostered were seriously neglected by the foster carer. Recommendations within the SCR resonate with this case in that the chronologies and interventions of partner agencies should be shared. This did not consistently happen in this review. A further recommendation was regarding multiple medical needs and for health professionals to co-ordinate and follow up the medical appointments. In this case there were numerous failures of WNB to attend GP appointments, continence and dental appointments for treatment. 5.12 SCR 2 (Redacted) - There are many similarities with the four children’s experience, including being part of a large family who were neglected over many years. There were numerous indicators of neglect which are consistent with this case, including tooth decay, severe and persistent head lice, missed health appointments and poor hygiene. Parents and carers making small changes were not sustained as was the case with Mother in this review, bringing the focus back to her own needs with excuses and failures to build a relationship with her children and failing to understand their needs from their perspective. 5.13 There was extensive work undertaken within social work teams to share the learning and recommendations from previous SCR’s. The key themes and which are also findings in this SCR were: - Listening to children and seeing the child’s world. Levels of need and the limitations of an incident led approach to child neglect. The impact of professionals feeling overwhelmed or desensitised, and the challenge of working with parents who are manipulative or show disguised compliance. Professionals not feeling valued and listened to, and the lack of a culture of resolving professional disagreements. Understanding neglect. Comment: There was no evidence in any case notes or meeting minutes that professionals reflected on the recommendations from previous SCR’s as it applied to these four children. Neglect was allowed to continue, and it took an incident and disclosure of CSA for professionals to act more decisively. Learning from previous SCR’s must be considered and Page 23 of 23 acted upon if similar concerns are evident and repeating themselves. It is the professional’s own responsibility to ensure this is done. The failure to learn from SCR’s was an element of the Alan Wood’s review (2017) into LSCB’s. Professionals Overriding Responsibility 5.14 As stated within Working Together to Safeguard Children 2015,5 professionals working within CP must ensure compliance with the following doctrine: - Local Authorities have overarching responsibility for safeguarding and promoting the welfare of all children and young people in their area. They have a number of statutory functions which make this clear6, and this guidance sets these out in detail. This includes specific duties in relation to children in need and children suffering, or likely to suffer, significant harm, regardless of where they are found, under s17 and s47 of the Children Act 1989. Comment: It is clear that standards of child protection fell short of this expectation. The fundamental responsibility for safeguarding and promoting the welfare of all children and young people was not consistently followed which, the agencies and professionals who participated in the SCR have addressed for learning. (See Findings and LSCB OV Report in Chapter 4). Professionals must ask themselves. Would I live or leave my children in circumstances these four children faced on a day to day basis, suffering neglect, worrying health concerns and living in an appalling uninhabitable family home? From the information this SCR has obtained, the answer must be a categoric ‘no.’ This SCR hopes to ensure this does not happen again if lessons from this review and other SCR’s are complied with in the future by professionals and effective management oversight ensures compliance. If the disclosure of child sexual abuse had not been made, the likelihood is, these children would have continued to have a neglectful life, living in a poor home environment, harmful to their health. Overview Report submission to the LSCB 5.15 This serious case review is submitted to the Local Safeguarding Children’s Board for their information and consideration of promulgating the lessons to be learnt from the suggested enclosed findings and recommendations. 5 Working Together to Safeguard Children 2015 - HM Government March 2015 6 Children Act 1989 and 2004. |
NC044931 | Death of a 3-year-old Somalian boy, Child H, and serious injury to his 2-month-old brother, in March 2013. Father has been charged with Child H's murder and his surviving siblings have been taken into care. Family had previously been separated by civil war in Somalia and spoke minimal English. Significant history of domestic abuse including an incident leading to mother spending three months in a women's refuge. Issues identified include: insufficient attention paid to past incidents of domestic abuse; professional focus on the emotional impact on children of living with domestic abuse, not on the increased risk of physical harm; lack of reassessment of the family's situation despite indicators of increased risk of harm including overcrowding and new and stressful family relationships; and inadequate range, availability and quality of interpreters. Uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to Lambeth Safeguarding Children Board.
| Title: Dib u eegidda kiiska daran: Ilmaha H. LSCB: Lambeth Safeguarding Children Board Author: Sally Trench and Ghislaine Miller Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Lambeth SCR Child H Confidential draft report 8 January 2014 1 Guddiga Dhawritaanka Carruurta ee Lambeth Dib u eegidda Kiiska Daran Ilmaha H Qoreyaasha: Sally Trench iyo Ghislaine Miller Dib u eegeyaasha Hoggaanka haya ee SCIELambeth SCR Child H Confidential draft report 8 January 2014 2 Tusmada Cinwaan Bog 1. Horudhac 4 1.1 Sababta loo doortay in kiiskan dib loo eego 4 1.2 Soo koobidda yar ee kiiska 4 1.3 Xubnaha qoyska 5 1.4 Waqtiga muhiim ah 5 1.5 Nidaamka waxqabadka 5 1.6 Dib u eegidda khabiirnimada iyo madaxbannaanida 7 1.7 Talobixinta takhasus leh 8 1.8 Faallada iyo xuduudda nidaamka waxqabadka 8 1.9 Qaabka warbixinta 9 2. Natiijooyinka: Waa maxay waxa ay dib u eegidda kiiskani ka muujisay ku kalsoonaanta nidaamyadeena loogu talagalay in carruurta lagu ilaaliyo? 10 2.1 Horudhac 10 2.2 Maxaa kiiskan ku jira ee ka dhigaya mid laga eegan karo habdhaqanka ka jira meelaha kale? 10 2.3 Qiimaynta habdhaqanka ka mid ah kiiskan: warbixin kooban 12 2.4 Soo koobidda natiijooyinka 17 Faahfaahinta natiijooyinka 19 2.5 Natiijada 1. Caadada ay xirfadleyaasha hay'adaha dhammaantood u leeyihiin in ay diiradda saaraan saamaynta shucuureed ee ay carruurta u leedahay ku noolidda rabshadda gurigu, iyaga oo aanan eegayn sida ay ugu sii suurogal badan tahay in ay waxyeellada jirku iyaga gaarto, ayaa horjoogsanaysa in si buuxda loo fahmo halisaha ku wajahan. 19 2.6 Natiijada 2. Hababka, loogu talagalay in lagu soo ogaado qaladaadka fikirka insaanku, miyay si fiican oo joogto ah uga hirgalaan hay'adaha dhexdooda? Marka aanay sidaas ahayn, waxaa sii suurogal badan in aanan la ishortaagin go'aannada qalad ah. 24 2.7 Natiijada 3. Noocyada, diyaar ahaanta iyo tayada turjumaannada ee waqtiga xaadirka ah ayaa dhibaato ah; shaqada sii qorshaysan way u kala duduwan tahay, xaaladaha degdeg ah marka ay yimaaddaanna, aad ayay u liidataa waxa ayna sidaas u keenaysaa halista ah in aanay taageero helin 28 Lambeth SCR Child H Confidential draft report 8 January 2014 3 isticmaaleyaasha adeegga ee aanan luqadda Ingiriisiga ku hadlin, taas oo xirfadleyaasha aad iyo aad ugu adkaynaysa in ay waqtiga habboon ku fuliyaan qiimayn ama natiijo waxtar leh. 2.8 Natiijada 4. Sida looga war hayo marka aanay soo noqnoqod lahayn dhacdooyinka rabshadda gurigu, waxa ay xirfadleyaashu badi aaminaan in ay carruurtu ku wanaag qabaan guriga oo/ama waxa ay u arkaan in ay tiro yar yihiin sababaha ay ugu baahan yihiin in ay si go'an ula hawlgalaan waalidka. Waxa ay taasi keentaa in aanay fahan dheeraad ah ka helin sababaha ka dambeeya iyo waxyaabaha dhaliya dhacdooyinka rabshadda guriga, iyo heerka dhab ah ee halista ay kuwaasi carruurta u suurtogelinayaan. 32 2.9 Natiijada 5. Dadaalka ay shaqaalaha daryeelka bulsheed iyo booliisku ugu jiraan in ay xirfadleyaasha caafimaadka ka helaan sharraxaadda cad ee sababta dhaawaca jirka ee carruurta, ayaa khilaafsan caadada ay xirfadleyaasha caafimaadku u leeyihiin in ay bixiyaan natiijooyin kaladuwan oo keenaya in wax kaste uu suurogal yahay ilaa meesha laga saarayo. Waxa ay taasi sii suurtogelinaysaa isfahanwaaga ku saabsan halisihii hore iyo kuwa mustaqbalka marka la wado baaritaannada ilaalinta carruurta. 37 2.10 Natiijada 6. Mudnaanta yar ee Kooxda Goobjoog ah ee Xaaladda degdeg ah (Emergency Duty Team) (EDT) ay ka muujiyaan ka jawaabcelinta codsiyada baaritaannada macluumaadka ee caadi ah marka baahiyaha kale loo eego, iyo la'aanta nidaam ka mid ah Kooxaha Taageerada Qoyska iyo Ilaalinta Carruurta oo bilowga maalinta si caadi ah loogu soo qaado macluumaadka ay kooxda EDT habeenkii hore diiwaangeliyeen, ayaa naaqusaysa wadaagga macluumaadka ee waqtiga habboon, xataa mararka ay jiraan xaaladaha loogu baahan yahay jawaabcelin degdeg ah. 42 3. Gabagabaynta 48 Tixraacyada 49 Lifaaqa 1: Hawsha dib u eegidda SCR oo faahfaahsan 52 Lifaaqa 2: Qaamuus-yaraha 62 Lifaaqa 3: Tirakoobyada ku saabsan rabshadda guriga 64 Lifaaqa 4: Casharrada hore loo bartay iyo isbeddellada la hirgeliyey si habdhaqanka loo wanaajiyo 66 Lambeth SCR Child H Confidential draft report 8 January 2014 4 1. Horudhac 1.1 Sababta loo doortay in kiiskan dib loo eego Guddiga Dhawritaanka Carruurta ee Lambeth (Lambeth Safeguarding Children Board) waxa uu ku go'aan gaaray in uu qabto Dib u eegidda Kiiska Daran (Serious Case Review) (SCR) maxaa yeelay xaaladda kiiskan ayaa buuxinaysa shuruudaha soo socda: (a) xadgudubka ama dayacaadda ilme ayaa laga war hayaa ama lagu tuhunsan yahay; oo (b) (i) ilmaha ayaa dhintay; ... waxaana jirta sabab looga walaac qabo habka ay dawladda hoose, shariigyadeeda Guddiga ama dadka kale ee muhiim ah u wada shaqeeyeen si ay ilmaha u dhawraan. (Working Together to Safeguard Children (Wada Shaqayn si Carruurta loo Dhawro), 2013:68) 1.2 Soo koobidda yar ee kiiska Kiisku waxa uu ku saabsan yahay qoys Soomaaliyeed oo ku nool xaafadda Lambeth. Waxa ay hore ugu noolaayeen Soomaaliya, halkaas oo ay ku lahaayeen laba gabdhood oo waaweyn, waxa ayna ka dib dhaleen wiil, Ilmaha H, oo dhashay sanadkii 2009kii. Waxa ay waalidku kala maqnaayeen sanado farabadan sababta oo ahayd dagaalkii sokeeye ee ka jiray waddankooda. Waxaa dib la isugu keenay London horraantii sanadkii 2011kii goortaas oo Hooyo ay Aabbe la degtay aqal ay la wadaagayeen xubnaha qaraabadiisa shishe. Saddexda carruur ah waxa ay dhammaantood xilligaas sii joogeen Afrika; waalidku ma ogayn halka ay labada carruur ah ee ugu weyn joogeen, Ilmaha H waxa uu isaguna qaraabo la joogay Itoobiya. Xirfadleyaashu waxa ay ugu lug yeesheen sababta oo ahayd caadada rabshadda guriga iyo xadgudubka ee si dhakhso ah uga soo shaac baxday xiriirka ka dhexeeyey Hooyo iyo Aabbe. Waxaa taas ka mid ahayd taageero Hooyo la siiyey, dhammaadkii sanadkii 2011kii goortaas oo ay uur weyn lahayd iyada oo sidday Walaalka 1, si ay guriga qoyska uga tagto ka dib weerar daran oo loola tagay, oo ay muddo saddex bilood ah ku jirto xarun hoysiin haween oo ku taallay xaafad kale oo London ka mid ah. Ka dib markii ilmuhu dhashay, waxa ay xirfadleyaashu ugu sii lug lahaayeen sababta oo ahayd waalidka oo heshiiyey waxa ayna Hooyo ku noqotay xaafadda Lambeth, waxa ayna labadooduba ka dib diideen in ay rabshadda gurigu hore u dhexmartay. Waxaa ilmaha la geliyey Qorshaha Ilaalinta Carruurta (Child Protection (CP) Plan) taas oo ku salaysnayd qiimaynta halista rabshad dheeraad ah, waxa ayna xirfadleyaashu ku dadaaleen in ay waalidka kala shaqeeyaan hirgelinta qorshahaas. Sanadkaas gudihiisa, Hooyo ayaa dhakhso uur kale u yeelatay. Xoogaa ka hor intii aanay dhalin ilmaheeda xiga (Walaalka 2), waxa uu Aabbe Itoobiya ka soo qaaday Ilmahoodii H oo saddex jir ahaa. Sidaas darteed, bishii Jannaayo 2013, qoyska ayaa ballaartay waxa ayna yeesheen saddex carruur ah, oo ahaa saddex jir iyo wixii ka yar. Carruurtu waxa ay dhammaantood xilligaas ku jireen Qorshooyinka Ilaalinta Carruurta. Lambeth SCR Child H Confidential draft report 8 January 2014 5 Horraantii bishii Maarso 2013, isaga oo laba bilood jira, waxaa ilmaha ugu yar gaaray dhaawac daran, waxaana la jiifiyey isbitaal ku yaalla xaafad ku xigta. Toddobaad ka dib, walaalkiisa 3 jir ahaa ayaa u dhintay dhaawacyo gaaray muddadii uu Aabbihiis hayey. 1.3 Xubnaha Qoyska Xubinta qoyska Da'da bishii Maarso 2013 Aabbe 42 Hooyo 40 Ilmaha H Da'diisa 3 sano iyo bar markii uu dhintay Walaalka 1 14 bilood Walaalka 2 2 bilood Labada carruur ah ee ugu waaweyn ee waalidku ay dhaleen qoyska uguma imanin xaafadda Lambeth, lamana garanayo halka ay joogaan. 1.4 Waqtiga muhiim ah Dib u eegidda SCR waxaa lagu baarayaa habdhaqanka xirfadleyaasha ee u dhexeeyey bishii Febraayo 2011 (markii ay Hooyo Ingiriiska timid) iyo maalintii ay taariikhdu ahayd 11kii Maarso 2013 (taariikhdii uu Ilmaha H dhintay). 1.5 Nidaamka waxqabadka Hagista qaanuuneed ayaa dhigaysa in dib u eegidyada SCR lagu qabto hab: Lagu aqoonsanayo xaaladaha adadag ee ay xirfadleyaashu ku wada shaqeeyaan si ay carruurta u dhawraan; Lagu doonayo in si sax ah loo fahmo ciddii wax qabatay iyo sababaha aasaasi ah ee keenay in shakhsiyaadka iyo ururradu ay la yimaaddaan habdhaqanka ay muujiyeen; Lagu doonayo in habdhaqanka loo fahmo sida ay u arkaan shakhsiyaadka iyo ururrada ku lug lahaa xilligii habdhaqanku yimid halkii dib looga ogaan lahaa; Si cad u muujinaya habka loo soo qaado macluumaadka loona baaro; oo Loo adeegsanayo cilmibaarista iyo daliilka kiiska ee habboon si loogu hago natiijooyinka. (WT 2013: 67) Waa in mabaadii'da soo socda lagu taageero dib u eegidyada dhammaantood: Waa in la caadaysto in si joogto ah cashar looga barto oo wax looga wanaajiyo dhammaan ururrada ka wada shaqeeya si ay u dhawraan una abaabulaan wanaagga carruurta, iyada oo la soo ogaanayo fursadaha suurtogelinaya in sal laga dhigto waxa waxtar leh oo la abaabulo habdhaqanka fiican; Lambeth SCR Child H Confidential draft report 8 January 2014 6 Xeeladda laga muujiyo dib u eegidyadu waa in ay ku toosnaato baaxadda iyo heerka adayga ee arrimaha la baarayo; Dib u eegidyada kiisaska daran waa in ay hoggaamiyaan shakhsiyaad ka madaxbannaan kiiska dib loo eegayo iyo ururrada waxqabadyadooda dib loo eegayo; Xirfadleyaashu waa in ay si buuxda uga qayb galaan dib u eegidyada oo loogu baaqo in ra'yiga ay ka qabaan ay dhiibtaan iyaga oo aanan ka cabsi qabin in lagu eedeeyo waxqabadyada ay si daacad ah u sameeyeen; Qoysaska, xataa carruurta nool, waa in loogu baaqo in ay ra'yi ka dhiibtaan dib u eegidyada. Waa in ay fahmaan sida ay uga qayb geli doonaan waana in si hagaagsan oo dareen badan loo maamulo rajooyinka ay qabaan. Waxa ay taasi muhiim u tahay si loo hubiyo in ilmuhu uu hawsha bartamaha ugu jiro. (WT 2013: 66-67) Maxaa dheer, waa in warbixinnada dib u eegidda SCR “…lagu qoro Ingiriisi cad oo loo qoro si fudud in ay xirfadleyaasha iyo shacabkuba u wada fahmaan” (WT 2013: 70) Si loo hubin karo in dadka oo dhan ay warbixintan akhrisan karaan, waxaa Lifaaqa 2 ee warbixintan lagu bixiyey hagaha xuruufaha soo gaabinta ereyada iyo ereyada takhasus leh. Guddiga LSCB ee Lambeth waxa ay doorteen in ay isticmaalaan qaabka nidaamyada Waxbarashada Wadajir ah (Learning Together), ee laga soo saaray Machadka Heerka sare ee Daryeelka Bulsheed (Social Care Institute for Excellence) (Fish et al., 2008) si gebi ahaan loo buuxiyo shuruudaha Wada Shaqaynta 2013. Hawsha dib u eegidda Waxbarashada Wadajir ah waxa ay ku salaysan tahay mabaadii'da daruuri ah ee soo socda: 1. Ka fogow eexashada dib ka ogaanshaha. Si loo fahmo sababta ay dadku ula yimaaddeen habdhaqanka ay muujiyeen, waxaa muhiim ah in laga fogaado eexashada ama dhan u iilashada dib ka ogaanshaha – waxqabadyadooda oo laga go'aan gaaro iyada oo la og yahay wixii ka dib dhacay, markaas oo ay fududdahay in la arko qaybaha macluumaadka ee muhiim ahaa iyo kuwii aanan macne lahayn. Sidaas darteed waxaa la rabaa in qaabkaas nidaamka lagu soo fahmo dhacdada iyo fikirka shaqaalaha iyo maamuleyaasha iyagu qoyska xilligaas wax u qabanayey, gaar ahaan, si loo baaro fahanka ay kiiska ka qabeen, iyo arrimaha macne u lahaa shaqada ee xilligaas saamaynayey habdhaqankooda; 2. Bixi sharraxaad hagaagsan. Qaabka waxaa loogu baahan yahay in dib u eegeyaashu ay qiimeeyaan oo ay sharraxaan go'aannada, waxqabadyada iyo waxqabad la'aanta ka mid ahaa sida ay xirfadleyaashu kiiska ula macaamileen, oo ay hawlfulinta u eegaan mid ka timid xiriirrada ka dhexeeya macnaha guud iyo waxa uu shakhsigu ku daro. Lambeth SCR Child H Confidential draft report 8 January 2014 7 3. Ka wareeg dhacdada gaar ah oo uga wareeg ahmiyadda guud. Kiisku waxa uu yahay 'daaqad laga eego nidaamka jira', soo ogaanshaha haddii ay faafsan yihiin cilladaha ka muuqda maamulka kiiska gaar ah, iyo gaaridda ka dib ee fahan guud oo laga helo waxa taageera iyo waxa waxyeelleeya ku kalsoonaanta nidaamka ilaalinta carruurta ee CP ee hay'ado farabadan. 4. Soo saar natiijooyin iyo su'aalo ay Guddigu ka fiirsadaan. Natiijooyinka qaarkood waxa ay keenaan talo fudud oo ku saabsan xeer cusub ama waxqabad gaar ah; kuwa kale waxa ay u baahan karaan in ay Guddigu ka fiirsadaan sida la isugu dheellitiri karo baahiyaha la soo ogaaday iyo meelaha kale ee loogu baahan yahay ilaha dhaqaale ee hay'adaha. 5. Baaris adag. Farsamooyin cilmibaaris oo tayo leh ayaa loo isticmaalaa si loogu taageero adkaynta iyo ku kalsoonaanta, oo la barbar wado hawl aad u furan si ay dadka kale u arki karaan sida gabagabooyinka loo gaaray. Faahfaahinta dhammaystiran ee hawshaas dib u eegiddu waxa ay ku jirtaa Lifaaqa 1 ee warbixintan. 1.6 Dib u eegidda khabiirnimada iyo madaxbannaanida Dib u eegeyaasha Hoggaanka haya Dib u eegidda SCR waxaa hoggaamiyey laba Dib u eege oo Hoggaanka haya oo madaxbannaan, khibrad leh lana aqoonsaday ee machadka SCIE, Sally Trench iyo Ghislaine Miller. Waxa ay labadooduba khibrad ballaaran u leeyihiin in ay qoraan dib u eegidyada SCR/IMR oo loo adeegsado qaabkii waxqabadka ee hore ee 'Tuduca 8', waxaana loo tababbaray oo loo aqoonsaday qaabka Waxbarashada Wadajir ah ee machadka SCIE. Midkoodna hore uguma lug lahayn kiiskan, oo xiriir hore ama hadda ah lama lahayn Kawnsalka Lambeth ama hay'adaha ay iskaashadaan. Dib u eegeyaasha Hoggaanka haya waxaa kormeeray machadka SCIE sida caadi ah. Waxa ay taasi taageeraysaa adkaynta hawsha baarista iyo ku kalsoonaanta natiijooyinka ee gunta kaga xiran daliilka. Kooxda Dib u eegidda Waxaa kuwaas ka mid ahaa 9 maamule sare oo ka socday adeegyada hay'ado farabadan ee ku lug lahaa qoyska. Waxa ay kaalintoodu ahayd in ay noqdaan il laga helo macluumaad istaraatijiyeed oo heer sare ah oo ka diyaar ah hay'adahooda gaarka ah, iyo weliba khabiirnimo xirfadeed oo ay ka bixiyaan laamaha shaqada ee iyaga u gaar ah. Iyaga oo wadajir ula shaqaynaya Dib u eegeyaasha Hoggaanka haya, waxa ay soo qaadeen macluumaadka ku saabsan kiiskan, xataa dib u eegidda diiwaannada hay'adaha, waxa ayna soo saareen oo ay isku raaceen waxyaabaha ku qoran warbixintan. Ku lugyeelashada buuxda ee xirfadleyaasha Kooxda labaad ee muhiim ah ee ka qayb qaatay dib u eegidda kiisku waxa ay ahaayeen 25 xirfadleyaal saf hore iyo maamuleyaal koowaad oo iyagu qoyska wax ugu qabtay kaalinno kaladuwan. Waxa ay sawir faahfaahsan ka Lambeth SCR Child H Confidential draft report 8 January 2014 8 bixiyeen waxa ka dhacay kiiskan gaarka ah, iyaga oo weliba ku deeqay aqoonta ay ka leeyihiin nidaamyada guud ahaan, si ay nooga caawiyaan in la fahmo haddii habdhaqanka laga muujiyey kiiskani uu yahay mid caadi ahaan u jira iyo haddii kale. Si loo fahmo ku lugyeelashadooda kiiskan iyo waayo aragnimada ay u lahaayeen, xubnaha Kooxda Dib u eegidda (Review Team) ayaa wadahadallo gaar ah la yeeshay xirfadleyaasha Kooxda Kiiska (Case Group). Kooxda Kiisku waxa ay weliba ka qayb qaateen laba kulan oo hay'ado farabadan si ay ra'yi uga dhiibtaan baarista iyo natiijooyinka ka yimid Kooxda Dib u eegidda iyo Dib u eegeyaasha Hoggaanka haya. 1.7 Talobixinta takhasus leh Maamulaha guddiga LSCB ee Lambeth ayaa qaban qaabiyey gargaar takhasus leh oo ku saabsan taariikhda iyo dhaqanka Soomaaliyeed si loogu taageero sida loo turjumayo habdhaqanka xirfadeed ee kiiskan. Ururka Horumarka Soomaaliyeed (Somali Development Group), urur samafal ah oo ka jira Bristol, ayaa tababbar nus maalineed ah ugu deeqay Kooxda Dib u eegidda (iyo kulan ka gaaban oo loogu talagalay Kooxda Kiiska). Waxaa tababbarkaas laga helay fikrado aad iyo aad waxtar u leh oo ku saabsan dhinacyada kaladuwan ee taariikheed, diimeed, iyo dhaqameed ee nolosha iyo waayo aragnimada Soomaaliyeed, sida Saamaynta dagaalka sokeeye ee socday waqti ka badan 20 sano iyo barakaca xubnaha qoyska Kaalinta ay ragga/aabbeyaashu ku leeyihiin nolosha qoyska iyo bulshada Dhanka kale, kaalinta badi ka hoosaysa ee haweenka iyo carruurta Isticmaalka caadi ah ee qaadka oo maandooriye ah iyo saamayntiisa Kooxda Dib u eegiddu waxa ay og yihiin in sawirka iska dhaqanka badan ee la siiyey uusan ku toosnayn dhammaan Soomaalida London ku nool, ama dhammaan Soomaalida dalkooda ku nool. Wixii kiiskeena khuseeya, waxa ay taasi caawisay in dareen dhaqameed laga muujiyo sidii habdhaqanka xirfadeed loo qiimeeyey. Tusaale ahaan, waxa ay fikrad ka bixisay soo dhexgalka 'bulshada Soomaaliyeed' ee ku saabsanaa rabshadda guriga ee Hooyo ay ka warbixisay. Gaar ahaan, waxa ay taasi tilmaantay in la filanayo in xaaladda Hooyo ay ahayd mid aad iyo aad u daran oo rajo lahayn si ay uga cararto gurigii lagu qabay (bishii Noofembar 2011), sidaas oo ay xadgudub daran ugu geysatay caadooyinka qoyska iyo bulshada. Wakiilka ka socday Ururka Horumarka Soomaaliyeed ayaa weliba gargaar ka bixiyey arrimaha ay ka mid ahaayeen talada ahayd in aanan turjumaanno rag ah loo isticmaalin haweenka ku jira xaaladda Hooyo (taas oo u dhacday si joogto ah marka kiiskan la eego, sababta oo ahayd waayidda turjumaanno haween ah). 1.8 Faallada iyo xuduudda nidaamka waxqabadka 1.8.1 Ka qaybqaadashada xirfadleyaasha Dhimashadii Ilmaha H waxa ay shoog ku ahayd shaqaalaha qoyska wax u qabanayey, waxa ayna taasi u keentay saxariir iyo caloolxumo farabadan. Lambeth SCR Child H Confidential draft report 8 January 2014 9 Sidaas darteed, shaqaalaha hawsha ku lug lahaa waxaa sida lama huraan ah ku adkayd oo badi xanuun u lahayd in ay si waxtar leh uga qayb galaan hawsha dib u eegidda SCR ee macnahaas ku xiran. Hase ahaatee, waxa ay si masuul ah uga qayb qaateen wadahadallada gaarka ah iyo wadahadallada kooxeed, halkaas oo ay ka xasuusteen go'aannadii ay kiiska ka gaareen iyo waxqabadyadii ay ka sameeyeen. Dib u eegeyaasha Hoggaanka haya iyo Kooxda Dib u eegiddu waxa ay gebi ahaan ku farxeen xirfadlenimada, aqoonta iyo khibradda ay Kooxda Kiisku u keeneen dib u eegidda iyo kartida ay u lahaayeen in ay sidaas furan oo fikir badan u xasuustaan shaqadii ay qabteen muddadii dib u eegiddan SCR. Dhowr xubnood oo ka mid ahaa Kooxda Kiiska ayaa sheegay in ay waayo aragnimo fiican ka heleen in ay gargaar ka bixiyaan casharka laga baranayo masiibada timid. Waxa ay Kooxda Dib u eegiddu waxaas oo dhan ka heleen fahan sii qotodheer siina macne badan oo ku saabsan waxa soo gaaray qoyskan iyo xiriirrada dhawritaanka iyo taas sababteeda, waxa ayna taasi noo suurtogelisay in aan qaadanno casharka ka muuqda warbixintan. 1.8.2 Fikradaha maqan ee waalidka iyo carruurta Booliisku waxa ay sheegeen in xaaladda waalidka oo ah dembiilaha eedaysan iyo markhaatiga dacwadda dembiyeed ay keentay in aanay suurogal noqon karin in ay iyagu ka qayb qaataan dib u eegidda SCR. Waxa ay taasi ka dhigan tahay in fikrad daruuri ah ay ka maqan tahay dib u eegidda kiiskan. Dib u eegidda SCR waxaa suurogal u noqon weydey in ay ka faa'iido hesho gargaarka waalidka ee ku saabsan waxtarka ay u yeelatay wadashaqayntii ay la galeen xirfadleyaasha, dhibaatooyinka iyaga ku adkeeyey in ay ka qayb qaataan dadaallada loogu jiray in iyaga laga taageero daryeelka iyo ilaalinta carruurtooda, ama sida ay u maamuleen islafalgalladii ay la yeesheen shaqaalaha. Ka dib marka la dhammaystiro dacwadda dembiyeed, waxaa waalidka la weydiin doonaa haddii ay rabaan in ay la kulmaan Dib u eegeyaasha Hoggaanka haya si ay u dhiibtaan ra'yiga ama fikradaha ay arrimahaas ka qabaan. Haddii ay taasi suurogal tahay, waxaa la soo diyaarin doonaa qoraal siyaado ku ah warbixintan, si loo muujiyo casharka dheeraad ah ee la bartay. Labada walaalo ee Ilmaha H ee soo haray aad ayay u da' yar yihiin oo suurogal ma aha in la weydiiyo fikradaha ay qabaan ama waayo aragnimadooda. 1.9 Qaabka warbixinta Tuduca xiga (Tuduca 2) ee warbixintani waxa uu ku bilaabmayaa soo koobidda waxa dhacay ee kiiskan ku saabsan. Waxaa lagu soo ogaanayaa afar marxaladood oo kaladuwan oo ku saabsan xiriirka ay xirfadleyaashu la yeesheen qoyska waxaana lagu muujinayaa go'aannada ku saabsan habka shaqada loogu qabtay marxalad kaste. Waxaa taas lagu gaarayaa soo bandhigidda lixda natiijo ee mudnaan leh. Natiijo kaste waxaa lagu soo gabagabaynayaa su'aalo daruuri ah oo natiijadu ay u jeedinayso guddiga LSCB iyo hay'adaha xubin ka ah. Guddiga LSCB ayay u taallaa in ay ka go'aan gaaraan sida ugu fiican in natiijooyinka looga jawaab celiyo, iyada oo ujeeddadu ay tahay in la yareeyo soo noqnoqodka Lambeth SCR Child H Confidential draft report 8 January 2014 10 habdhaqanka liita. Waxaa su'aalaha loogu talagalay si loogu taageero waxyaabaha ay ka fiirsanayaan. 2. Natiijooyinka: Waa maxay waxa ay dib u eegidda kiiskani ka muujisay ku kalsoonaanta nidaamyadeena loogu talagalay in carruurta lagu ilaaliyo? 2.1 Horudhac Hagista qaanuuneed ayaa dhigaysa in warbixinnada dib u eegidda SCR ‘…lagu bixiyo baaris macquul ah oo ku saabsan waxa dhacay ee kiiska ku jira, iyo taas sababteeda, iyo waxa loo baahan yahay in la sameeyo si loo yareeyo halista soo noqnoqodka (WT 2013: 71). Hawlahaasi waa in ay noqdaan kuwo cad, iyada oo natiijooyinka dib u eegidyada lala wadaago shacabka. Natiijooyinku muhiim uma aha oo keliya xirfadleyaasha xaafadda ee kiisaska ku lug leh. Dhammaan dadka dalka jooga ayaa dan ka leh in ay fahmaan waxa waxtar leh iyo weliba sababta ay qaladaad u iman karaan.’ (2013: 65) Qaybtani waxa ay marka hore baaraysaa sifooyinka ka mid ah kiiskan gaarka ah siyaabaha ay caadi ugu yihiin shaqada kale ee ay xirfadleyaashu u qabtaan carruurta iyo qoysaska, iyo taas awgeed sida kiiskan keli ah looga baran karo cashar urureeda oo lagu taageero wanaajinta. Marka xigta, warbixin kooban oo ku saabsan qiimaynta habdhaqanka ayaa akhristaha loogu deeqay. Waxa ay taasi qeexaysaa ra'yiga ay Kooxda Dib u eegiddu ka qabaan sida ay waxtar u lahaayeen ee waqtiga habboon loogu qabtay gargaarrada loogu deeqay Ilmaha H iyo qoyskiisa, xataa meelihii uu habdhaqanku ka hooseeyey heerkii laga sugayey. Marka habboon, waxaa sharraxaad laga bixinayaa habdhaqankaas, ama waxaa la tilmaamayaa halka ka mid ah natiijooyinka ee taas lagu sii faahfaahin doono. Ugu dambayn, waxa ay qaybtani ka hadlaysaa lix natiijo oo mudnaan leh oo ka soo shaacbaxay dib u eegidda SCR. Natiijooyinka waxaa lagu macnaynayaa sababta habdhaqanka xirfadeed uusan waxtar dheeraad ah ugu lahayn ilaalinta Ilmaha H ee kiiskan ka mid ah. Waxaa weliba lagu qeexayaa daliilka tilmaamaya in aanay arrimahaasi ahayn kuwo mar keliya dhacay, laakiin caadooyin aasaasi ah – kuwaas oo suurogal ah in ay saameeyaan habdhaqanka mustaqbalka laga muujiyo kiisaska la mid ah. Waxa aan weliba tixgelinaynaa halisaha ay kuwaasi u keeni karaan dhawritaanka kale ee carruurta. 2.2 Maxaa kiiskan ku jira ee ka dhigaya mid laga eegan karo habdhaqanka ka jira meelaha kale? 2.2.1 Hagista qaanuuneed ee ku saabsan fulinta hawlaha waxbarashada iyo wanaajinta ee lagu dhawrayo laguna ilaalinayo carruurta, xataa dib u eegidyada kiiska daran (SCR-yada) ayaa sheegaysa: Lambeth SCR Child H Confidential draft report 8 January 2014 11 ‘Dib u eegidyada laftigoodu ma aha dhammaadka. Ujeeddada dib u eegidyadani waxa ay tahay in la soo ogaado meelaha loo baahan yahay in la wanaajiyo oo la isu keeno habdhaqanka fiican. Guddiyada LSCB iyo ururrada ay iskaashadaan waa in ay natiijooyinka ka soo baxa dib u eegidyada ku beddelaan barnaamijyo waxqabad oo keenaya in la gaaro wanaajin waarta iyo ka hortagga dhimashada, dhaawaca daran ama waxyeellada gaara carruurta.’ (Wada Shaqayn, 2013:66) 2.2.2 Guddiga Dhawritaanka Carruurta ee Lambeth (LSCB) ayaa soo ogaaday in dib u eegidda SCR ee kiiskan murugada leh ay suurogal tahay in ay ilays saarto meelo gaar ah oo ka mid ah habdhaqanka xirfadeed: Sidee ayay u fiican tahay shaqada aan waqtiga xaadirka ah u qabanno qoysaska Soomaaliyeed ee ku nool Lambeth, xataa kuwa ay saameeyeen dagaalka sokeeye iyo haajiraadda khasabka ahayd, iyo weliba kuwa ay ka dhex jirto rabshadda gurigu (DV)? Sidee ayuu nidaamka Qorshooyinka Ilaalinta Carruurta, Shirarka iyo Kooxaha Daruuri ah ugu fiican yahay in uu carruurta badbaadada u ilaaliyo, gaar ahaan marka ay waalidku diiddan yihiin in hawshaas loo qabto? Sidee ayay u fiican tahay shaqada dhexmarta hay'adaha iskaashada, xataa adeegyada ilaalinta carruurta ee CP ee daruuri ah, si looga jawaabceliyo dhaawacyada shakiga leh ee gaara carruurta yar yar iyo dhallaanka? 2.2.3 Kiiskani waxa uu tusaale u yahay dhibaatooyinka ay xirfadleyaashu kala kulmaan dadaallada ay u galaan si ay carruurta u dhawraan oo ay u ilaaliyaan marka ay ku jiraan xaaladaha rabshadda guriga iyo xadgudubka ee dhexmara waalidka. Taas waxaa loo xallin karaa si iska caadi ah haddii rabshadda la qirto oo lammaanaha lagu xadgudbay uu rabo in uu ka tago lammaanaha rabshadda leh isaga oo si cad uga go'aya. Hase yeeshee, waxaa rabshadda guriga caadi u ah in dhibbanuhu uu badi ku noqdo lammaanihiisii rabshadda lahaa – sababta oo ah cabsi, shaki, iyo/ama dareennada daacadnimada ee iskhilaafsan ee uu u qabo carruurtiisa iyo lammaanaha. Arrimo camali ah, bulsheed iyo dhaqameed ayaa weliba raad ku yeesha go'aannada dhibbanaha – gaar ahaan, marka uu qofkaasi ku tiirsan yahay lammaanihiisa si uu xaq ugu yeesho in uu Ingiriiska joogo. Inkaste oo halis loogu jiro in rabshaddu ay mustaqbalka sii socoto, waxaa laga yaabaa in ay faa'iidooyin kale leedahay ku noqoshada xiriirku: ka fogaanshaha dhaleecaynta ka timaadda qaraabada iyo bulshada; dadaal loogu jiro in bulshada la dhexgalo; baahida loo qabo ehel kula jooga; iyo taageerada maaliyadeed ee camali ah. Waxaa xirfadleyaasha u ah hawl adag oo taxaddi leh in ay si hagaagsan u fahmaan arrimahaas mudnaanta leh ee isbarbar socda iyo dareennada daacadnimada ee iskhilaafsan si loo qiimeeyo halista waxyeellada suurogal ah in ay gaarto carruurta xaaladda ku jirta. Waa mid ku sii xun shakiga laga qabo halista iyo khatarta ee sifo u ah laantan shaqada. Aasaaska ku xiran daliilka cilmibaarista ee diyaar ah ayaa laga helaa calaamado wax lagu garto, laakiin sidaas laguma taageeri karo Lambeth SCR Child H Confidential draft report 8 January 2014 12 saadaalinta sax ah ee lammaaneyaasha goor dambe waxyeellayn doona carruurtooda. Rabshadda gurigu keli ahaan uma dhacdo; qoysaska waxaa badi ku wajahan dhibaatooyin iyo khasaarooyin kale, oo aad dhab u ah. Marka kiiskan la eego, waxa ay kuwaasi ku xirnaayeen dadaalka loogu jiray in la hubiyo in qoysku uusan burburin taas oo macnaheedu ay ahayd haajiraadda khasabka ahayd iyo kala lumiddii ku timid dagaalka sokeeye. Arrimahaas kaladuwan dhammaantood ayaa isbarbar socda oo u baahan feejignaanta shaqaalaha, maxaa yeelay waxa ay muujinayaan kartidooda xirfadeed si ay u fahmaan xaaladda iyo dhibaatooyinka ay u leedahay badbaadada iyo wanaagqabka carruurta ku jirta. Sidaas darteed waxa uu kiisku soo jeedinayaa su'aalo daruuri ah oo ku saabsan sida uu nidaamkeena ilaalinta carruurtu waxtar ugu leeyahay si jawaabcelin waxtar leh waqtiga habboon loogu deeqo carruurta ku nool xaaladaha rabshadda guriga, taas oo ay macne u tahay haajiraadda keentay in xubnaha qoyska, ee dad waaweyn iyo carruurba ah, ay ku kala lumaan dagaalka sokeeye goor dambena isu soo noqdaan. Hannaanku waxa uu ku sii adag yahay in ay xirfadleyaashu wax ka qabtaan haddii, sida kiiskan, uusan jirin soo noqnoqodka laga war hayo ee dhacdooyinka rabshadda guriga. Khaas ahaan, waxa uu kiiskani lahaa dhowr dhibaato ama taxaddi oo adag kuwaas oo hay'adaha dhawritaanka ee ka shaqeeya Lambeth iyo xaafadaha ku ag yaalla ay si joogto ah ula kulmaan, iyaga oo kala kulma meelaha ka mid ah habdhaqanka xirfadeed ee caadi ah ee soo socda: Shaqada laga qabto rabshadda guriga, ee loo qabto waalidiin ama rabshadda yaraysanaya ama diiddan, oo aanan rabin dadaalka loogu jiro in la qiimeeyo halista uu geysanayo nin rabshad leh. Shaqada lagu xallinayo rabshadda guriga ee hore u dhacday, iyo halista soo noqoshadeeda mustaqbalka, muddada aanay jirin dhacdooyin laga war hayo. Tixgelinta saamaynta ay rabshadda gurigu u leedahay carruurta – waa maxay nooca halisaha jira? Shaqada loo qabto qoysaska ka soo jeeda bulsho (marka kiiskan la eego, Soomaaliyeed) oo lagu garanayo dhaqanka asturnaanta qoyska iyo awoodda ragga. Dhibaatada adag ee shaqada waxaa badi ka sii darta luqadda Ingiriisiga ee ay sida yar ugu hadlaan dadka waaweyn iyo carruurtu. Ka jawaabcelinta dhacdo degdeg ah oo ku xiran ilaalinta carruurta iyada oo ay jiraan baahiyo farabadan oo isbarbar socda, iyo ahmiyadda ay leedahay in la hubiyo wadaxiriirka waqtiga habboon si waxtar leh u dhexmara hay'adaha dhammaantood. Xiriirrada ka dhexeeya xirfadleyaasha (gudaha iyo dibadda kulannada rasmi ah), arrimaha ku saabsan habdhaqanka iyo xilsaarista xirfadeed, iyo kaalinnada ahmiyad sare leh ee kormeeridda iyo maaraynta maamuleyaasha. 2.3 Qiimaynta habdhaqanka ka mid ah kiiskan: warbixin kooban Jawaabcelinta ay xirfadleyaashu qoyska siiyeen waxa ay u kala baxdaa afar Lambeth SCR Child H Confidential draft report 8 January 2014 13 marxaladood oo kaladuwan muddo guud ahaan ku dhow laba sano: 1. Jawaabcelinnada xirfadeed ee laga bixiyey weerarrada rabshad leh ee uu Aabbe Hooyo ku qaaday, xataa muddadii ay uurka ku sidday Walaalka 1 (gugii 2011 ilaa horraantii 2012kii) 2. Jawaabcelinnada xirfadeed ee la bixiyey ka dib dhalashadii Walaalka 1 markii Hooyo ay Aabbe ku noqotay (jiilaalkii 2012) 3. Shaqada muddada dheeraad ah ee qoyska loo qabtay ee taas ku xigtay (gugii 2012 ilaa jiilaalkii 2013) 4. Dhaawaca gaaray Walaalka 2, dhimashadii Ilmaha H iyo jawaabcelinta xirfadleyaasha (horraantii gugii 2013) Tayada habdhaqanku way kaladuwanayd marxaladahaas gudahood: jawaabcelinnada laga bixiyey dhacdooyinka ee marxaladda 1 iyo jawaabcelintii ugu horraysay ee ka dib dhalashadii Walaalka 1 ayaa habboonaa oo tayo sare lahaa. Hase yeeshee, waxa ay u muuqatay in xirfadleyaasha ay aad ugu adkayd in ay shaqada muddada dheeraad ahayd u qabtaan qoyska – gaar ahaan sida ay wax uga qaban lahaayeen arrimaha rabshadda guriga muddadii aanay jirin dhacdooyin rabshad leh oo laga war hayey, iyada oo weliba goortaas ay labada waalid diiddanaayeen rabshadda guriga ee hore u dhacday taas oo si dhammaystiran loo diiwaangeliyey oo la ogaa in ay dhacday. Ugu dambayn, jawaabcelinnada ka dib dhaawicii gaaray Walaalka 2 ayaa muujiyey macluumaadka sida liidata ay isku weydaarsadeen kooxaha iyo hay'aduhu, oo baaritaankii Qodobka 47 ee sharciga ee ka dib dhaawicii gaaray Walaalka 2 looma qabanin si ku toosan hagista qaanuuneed. Marxaladaha kaladuwan ee ku lugyeelashada waxaa lagu sii faahfaahinayaa halkan hoose waxaana la tilmaamayaa halka laga helayo sharraxaadda lagu bixiyey natiijooyinka gudahooda. Marxaladda 1 – jawaabcelinnada xirfadeed ee laga bixiyey weerarrada rabshad leh ee hooyo loo geystay Gugii sanadkii 2011, ka hor intii aanan laga war helin in ay Hooyo uurka ku sidday Walaalka 1, waxa ay ka soo warbixisay weerar rabshad leh oo uu Aabbe ula tagay. Booliiska ayaa si hagaagsan wax uga qabtay weerarka Hooyo guriga loogu geystey, taas ka dib oo ay ka noqotay eedihii ay Aabbe ku sheegtay. Goor dambe sanadkaas, markii ay Hooyo ku jirtay saddexdii bilood ee ugu dambeeyey uurkii ay ku sidday Walaalka 1, xirfadleyaasha ayaa si dhakhso ah oo waxtar leh uga jawaabceliyey xaaladda dhibaatada lahayd ka dib weerar kale oo rabshad leh oo Hooyo loo geystey, xataa hanjabaadda in la dili doono Hooyo iyo ilmaha ay uurka ku sidday, taas ka dib oo ay guriga qoyska ka carartay. Waxaa ka dib iyada laga taageeray in ay ka tagto lammaanaheeda oo ay Lambeth SCR Child H Confidential draft report 8 January 2014 14 badbaadada u ilaaliso ilmaha ay uurka ku siddo. Shirka qiimaynta halista ee hay'ado farabadan (MARAC) ayaa qayb ka ahaa qorshayntaas, taas oo tilmaamaysay halista aad u weyn ee ay Hooyo waxyeello ugu jirtay. Goor dambe, markii ay Hooyo go'aansatay in ay dib ugu noqoto Aabbe xaafadda Lambeth gudaheeda, waxaa si fiican loo qabtay shaqada labada xaafadood si loo hubiyo in soo noqoshadaasi ay leedahay badbaadada ugu suurogal badan iyada oo la sii wadayo in la ilaaliyo Hooyo iyo ilmaha (markaas dhashay). Marxaladda 2 – jawaabcelinnada xirfadeed ee la bixiyey ka dib dhalashadii Walaalka 1 Walaalka 1 ayaa dhashay bishii Jannaayo 2012. Taas ka dib, habdhaqanka xirfadeed ayaa intii hore fiicnaa. Xirfadleyaashu waxa ay si huran ugu dadaaleen in ay Hooyo ugu deeqaan aqoonta ay ka qabeen halisaha jiray, si iyada looga taageero in aanay ku noqonin gurigii ninkeeda, iyaga oo weliba si fiican wax uga qabtay kiiska laga soo wareejinayey xaafadda ku xigta ee London. Qiimaynta Daruuri ah ee Hooyo iyo dhallaanka ayaa la qabtay ka dib markii ay ku soo noqdeen xaafadda Lambeth, iyada oo si hagaagsan loogu taliyey in la qabto Shirka Koowaad ee Ilaalinta Carruurta (Initial CP Conference), iyada oo islamarkaana la qorsheeyey kulanka qorshaynta sharciyeed (kulan uu hoggaamiyo Adeegga Carruurta iyo Dhallinyaradu (Children and Young People's Service) (CYPS), oo lala yeesho lataliyeyaasha sharciyeed, si looga fiirsado haddii ay habboon tahay in lagu dhaqaaqo dacwadda maxkamadda qoyska si ilmaha loo ilaaliyo). Markii la qaban waayey kulanka qorshaynta sharciyeed waxaa laga faa'iidaysan waayey fursadda loo haystay in la baaro heerka halista, iyo noocyada waxqabadka ee suurogal ahaa. Marxaladda 3 – Shaqada muddada dheeraad ah ee qoyska loo qabtay Ka dib dhalashadii Walaalka 1 ee bishii Jannaayo 2012, waxaa la bilaabay in muddo dheer qoyska shaqo loo qabto. Xilligaas, labada waalid waxa ay diideen in ay yimaaddeen dhacdooyinkii hore ee rabshadda gurigu. Muddadaas gudaheed, Kooxda Dib u eegidda ayaa u aragtay in jawaabcelinta xirfadleyaashu ay ahayd mid aanan u adkayn oo u awood badnayn sidii laga sugayey. Waxaa taas ugu badnaan sabab u ahayd diiradda ay xirfadleyaashu saareen waqtiga xaadirka ah halkii ay ka baari lahaayeen dhacdooyinkii hore si ay u yareeyaan halista soo noqoshadooda mustaqbalka. Sidaas darteed, dhacdooyinka rabshadda guriga ee aanan laga war haynin in ay xilligaas dhaceen ayaa xirfadleyaasha si qalad ah u fahansiisay heerka halista carruurta ku wajahnayd, iyaga oo weliba u arkayey in uusan jirin wax ay shaqadooda sal uga dhigaan. Waxaa taas lagu sii macnaynayaa Natiijada 4. Ahmiyadda iyo saamaynta ay qoyska u lahaayeen dhacdooyinkii Soomaalinimadooda gaar ahaan ku soo maray (matalan dagaalka sokeeye iyo kala maqnaanshihii muddada dheer ee xubnaha qoyska, iyo weliba kaalinta bulshada Soomaaliyeed ee xaafaddu ay ku lahayd qoyska iyo awoodda lammaaneyaasha ragga ah) oo intii hore la baaray, ayaanan la sii dabagalin – inkaste oo la soo sheegay in 'odeyaasha beeshu' ay galeen kaalinta dhexdhexaadinta waalidka si ay ugala hadlaan rabshadda guriga. Lambeth SCR Child H Confidential draft report 8 January 2014 15 Muddadii 9ka bilood ee ka dambaysay Shirkii Koowaad ee Ilaalinta Carruurta ee loo qabtay Walaalka 1 ayaa lagu arkay isbeddello waaweyn oo ku yimid guriga qoyska sida uuraysiga Hooyo iyo goor dambe dhalashadii Walaalka 2, iyo imaanshihii Ilmaha H oo 3 jir ahaa oo ka yimid Itoobiya (halkaas oo uu la joogay saaxiibbo ama qaraabo) isaga oo qabay waxyaabo u muuqday nabarro ku yaallay wajigiisa iyo calaamado ku yaallay jirkiisa. Isbeddellada qoyska ku yimid waxaa ka mid ahaa buuxdhaafa daran ee guriga iyo xiriirro qoys oo cusub oo cadaadis badan – iyada oo aanay ugu dhib yarayn maamulka saddex carruur ah oo yar yar oo 3 jir ah ama ka yar. Waxyaabahaas oo dhan ayaa tilmaamayey halista sii kordhaysa ee waxyeellada gaari karaysay Hooyo iyo carruurta. Hase yeeshee, xirfadleyaashu ma qabanin dib u qiimaynta xaaladda ee loogu baahnaa xaaladda isbeddeshay ee qoyska. Aabbe ayaa, gaar ahaan, weli ahaa shakhsi aanan la garanayn oo kama qayb qaadanin baarista halista ama taariikhdiisa shakhsi ahaaneed. Jawaabcelinta xirfadeed waxaa khasaare u keentay xaqiiqada ah, inkaste oo aqoon laga lahaa dhinacyo farabadan oo ka mid ah rabshadda guriga, in dadka qoyska wax u qabanayey aanay dhammaantood si ku filan uga war haynin aasaaska ku xiran daliilka ee ku saabsanaa halista sii kordhaysay ee waxyeellada jirka ee waqtigaas gaari karaysay carruurta. Waxaa taas lagu sii faahfaahinayaa Natiijada 1. Xilliyadii kulannada Kooxda Daruuri ah iyo Shirarka ilaalinta carruurta ee CP, waxaa si tartiib tartiib ah loo dareensanaa in ay xaaladdu meel fiican qoyska u marayso, waxaana lagu rajo qabay in horumar la gaarayo, iyada oo dhab ahaan Qorshooyinka ilaalinta carruurta ee CP aanan si dhammaystiran loo hirgelinayn. Dhacdooyinka rabshad leh ee sida laga war hayey aanan dib u imanin (Natiijada 4) waxaa ka sii dartay la'aanta muran iyo dood ku saabsan fahanka ay xiriirrada xirfadeed kala soo baxayeen horumarka qoyska, iyaga oo shakhsi ahaan qabanaya kormeerid xirfadeed ama adeegsanaya caadada wanaagsan ee doodda iyo muranka hay'adaha farabadan. Waxaa taas lagu sii baarayaa Natiijada 2. Markii Ilmaha H uu Ingiriiska yimid, dhaawacyada wajiga kaga yaallay waxaa eegay xirfadleyaal kaladuwan, sida Booqdaha Caafimaadka (Health Visitor), Hawlwadeenka Bulsheed (Social Worker), oo iyagu ku taliyey in waalidku ay u geeyaan Takhtarka Guud (GP) si uu u eego; goor dambena Ummuliso iyadu Hawlwadeenka Bulsheed (SW) ee qoyska kala xiriirtay walaaca ay qabtay. Baaritaanka Qodobka 47 ee sharciga lama qabanin, sida la sugayey in loo sameeyo ilme qaba dhaawacyo aanan la garan karin. Guddoomiyaha Shirka ayaa taas u aragtay wax aanan lagu qancin karin waxa ayna codsadtay in si degdeg ah loo qabto baarista caafimaadka ee ilaalinta carruurta (CP). Marxaladda 4 – Dhaawaca gaaray walaalka 2 iyo jawaabcelinta xirfadeed Bishii Maarso 2013, Walaalka 2, oo waqtigaas laba bilood jiray, ayaa la jiifiyey isbitaalka isaga oo lugta ka jabay, dhaawacaas oo ah mid aad iyo aad u daran oo aanan caadi u ahayn ilmaha da'daas jooga. Jawaabcelinnadii ilaalinta carruurta ee taas ka dambeeyey ayaa si liidata la isugu duway oo, waxaa jiray waxyaabo muhiim ahaa oo ka mid ahaa, oo aanan waafaqsanayn hagista qaanuuneed. Lambeth SCR Child H Confidential draft report 8 January 2014 16 Wadaagidda macluumaadka ku saabsanaa Walaalka 2 ayaa lala raagay waqti hore, oo daruuri ahaa. Waaxda gurmadka degdeg ah ee isbitaalka (A&E) dhexdeeda, nidaamka 'digniin bixinta' ee elektaroonig ah ee loogu talagalay carruurta ku jirta Qorshooyinka CP waxaa ka maqnaa liiska habboon ee magaacda ee Lambeth, ka dibna macluumaad toos ah oo qoyska ku saabsan ayaa dhowr saacadood laga heli waayey Kooxda Goobjoog ah ee Xaaladda degdeg ah (EDT). Taas sababaheeda waxaa lagu sii faahfaahinayaa Natiijada 6. Turjumaanno habboon ayaanan diyaar ahayn taas oo keentay in dib u dhac weyni uu ku yimid sidii loo maqli lahaa sharraxaadda ay waalidku ka bixinayeen dhaawaca dhallaanka. Waxaa nidaamyada turjumaannada lagu sii faahfaahinayaa Natiijada 3. Waxa ay taasi keentay in shaqaalaha waaxda gurmadka degdeg ah iyo qaybta isbitaalku aanay haysanin macluumaad ku filan si loogu hago qiimayntooda halista jirtay. Inkaste oo ay sidaas ahayd, haddana tallaabada uu qaaday Kalkaaliyaha caafimaadka ee Magacaaban (Named Nurse) si subaxnimadii hore ee maalintii xigtay uu u soo saaro liiska waxqabadyada ayaa waxtar lahayd oo habboonayd. Macluumaadka ka yimid kooxda EDT ee daryeelka bulsheed ee ku saabsanaa 'dhaawaca shaki leh' ayaanay si dhakhso ah u arkin kooxda hawlaha bulsheed maalintii xigtay (Natiijada 6 ayaa weliba lagu baarayaa sida macluumaadka ay wax uga qabtaan adeegyada saacadaha aanan la shaqaynin). Baaritaankii Qodobka 47 ee sharciga ee ka dib la qabtay, ee ay hoggaaminayeen Kooxda Taageerada Qoyska iyo Ilaalinta Carruurtu (Family Support and Child Protection Team) (FSCP), ee kiiska loo xilsaaray, ayaanan u dhicin si waafaqsan hagista ku jirta Wada Shaqaynta iyo Nidaamyada CP ee London. Booliiska islamarkaaba lalama xiriirin si loo qabto Wadahadal ku saabsan Xeeladda. Taas halkeeda Hawlwadeenka Bulsheed (SW) ayaa waalidka ku booqday isbitaalka oo waraystay, iyada oo uu la joogo Diiwaanhayaha Carruurtu (Paediatric Registrar). Laguma guul gaarin in Kulanka Xeeladda ku saabsan (Strategy Meeting) la qabto ilaa laba cisho ka dib, waqtigaas socday oo markaa tilmaamayey in aanay xaaladdu darnayn, waxaana muddadaas suurogal noqotay in wixii daliil ah la xumeeyo ama la seego. Ma jirin maamule ka socda kooxda FSCP oo si joogto ah u hayey kaalinta maaraynta iyo hagista ee baaritaanka dhowrkii cisho ee taas ku xigay. Markii Walaalka 2 la jiifiyey qaybta isbitaal, waxaa la isku raacay in uu joogay meel nabad ah. Xirfadleyaasha daryeelka bulsheed iyo caafimaadka iyo booliiska (ka dib markii laga soo qayb geliyey, Kulankii Xeeladda ku saabsanaa gudihiisa) ayaa seegay in ay xaaladdaas ku xiran halista joogto ah ee ku wajahnayd labada walaalo ee markaas uu Aabbe keligiis hayey. Lama samaynin booqashada guriga si xaaladdooda loo soo eego, ka sokow mar ay Booqdaha Caafimaadku u tagtay ka dib markii ay fasax ka soo laabatay goor dambe toddobaadka gudihiisa, goortaas oo ay cidba weydey. Waxaa loo baahnaa in qiimaynta halista lagu sameeyo kartida uu Aabbe u leeyahay in uu carruurta daryeelo muddada ay Hooyo maqan tahay, laakiin taasi ma dhicin. Kulanka Xeeladda ku saabsanaa ee lala raagay ayaa diiradda saaray sababta suurogal ah ee dhaawaca gaaray Walaalka 2. Hase yeeshee si cad looma Lambeth SCR Child H Confidential draft report 8 January 2014 17 muujinin go'aankii lagu gabagabeeyey ee lagu sheegay haddii dhaawacu uu ahaa mid aanan shil ku imanin iyo haddii kale, taas sababaheeda oo lagu sii baarayo Natiijada 5. Taariikhaha kala duduwan ee ay waalidku dhacdada ka bixiyeen si ku filan loogama fiirsanin, oo xubnaha Kulankaas Xeeladda ku saabsanaa si cad taas ugama hortagin oo uma shaki gelinin sidii looga baahnaa. Taas awgeed, waxaa si qalad ah hoos loogu dhigay halisihii carruurta oo dhan ku wajahnaa, inkaste oo uu jiray daliil kale oo tilmaamayey in halista waxyeellada ee carruurta ku wajahnayd ay aad u weynayd. Inkaste oo uu jiray daliil muhiim ah oo dheeraad ah oo tilmaamayey xadgudubka jirka iyo dayacaadda, haddana taas wax lagama qabanin markii la waayey fikrad caafimaadeed oo cad. Maalintii xigtay, Walaalka 1 iyo Ilmaha H ayaa laga qaaday baaritaannada caafimaadka ee CP oo uu qabtay Takhtar xirfad gaar ah u leh Caafimaadka carruurta ee Bulshada (Community Paediatric Consultant). Kuwaas ayaa la qabtay, inkaste oo turjumaankii la diyaariyey uu iman waayey (dhibaato hore loogu arkay kiiskan), iyada oo Aabbe uu afhayeen u noqday carruurtiisa. Waxaa caddayd in loo baahnaa in baaritaannada si degdeg ah loo qabto. Hase yeeshee, maadaama ay suurogal ahayd in Aabbe uu ahaa 'qofka laga walaac qabo' ee xaaladda ka mid ahaa, waxaa habboonayd in Ilmaha H (maadaama uusan Walaalka 1 weli hadalka baranin) loo qaban qaabiyo in keligiis lala hadlo isaga oo uu turjumaan la joogo islamarkii suurogal ahayd. Ilmaha H waxaa waaxda gurmadka degdeg ah ee isbitaalka la keenay sax ahaan hal toddobaad ka dib markii walaalkiisa ka yar isbitaalka la jiifiyey. Waxaa geeridiisa lagu dhawaaqay saacad ka dib. 2.4 Soo koobidda natiijooyinka Kooxda Dib u eegiddu waxa ay mudnaan siiyeen 6 natiijo si guddiga LSCB ay uga fiirsadaan. Waxa ay kuwaasi ku saabsan yihiin afar ka mid ah lixda qaybood ee caadooyinka aasaasi ah (fiiri Lifaaqa 1). Natiijada Qaybta Natiijada 1. Caadada ay xirfadleyaasha hay'adaha dhammaantood u leeyihiin in ay diiradda saaraan saamaynta shucuureed ee ay carruurta u leedahay ku noolidda rabshadda gurigu, iyaga oo aanan eegayn sida ay ugu sii suurogal badan tahay in ay waxyeellada jirku iyaga gaarto, ayaa horjoogsanaysa in si buuxda loo fahmo halisaha ku wajahan. Shaqada hay'ado farabadan muddada dheeraad ah ee shaqada Natiijada 2. Hababka, loogu talagalay in lagu soo ogaado qaladaadka fikirka insaanku, miyay si fiican oo joogto ah uga hirgalaan hay'adaha dhexdooda? Marka aanay sidaas ahayn, waxaa sii suurogal badan in aanan la ishortaagin go'aannada qalad ah. Fikirka insaanka: dhan u iilashada garaadka iyo shucuurta Natiijada 3. Noocyada, diyaar ahaanta iyo tayada turjumaannada ee waqtiga xaadirka ah ayaa dhibaato ah; shaqada sii qorshaysan way u kala duduwan tahay, Nidaamyada maamulka Lambeth SCR Child H Confidential draft report 8 January 2014 18 xaaladaha degdeg ah marka ay yimaaddaanna, aad ayay u liidataa waxa ayna sidaas u keenaysaa halista ah in aanay taageero helin isticmaaleyaasha adeegga ee aanan luqadda Ingiriisiga ku hadlin, taas oo xirfadleyaasha aad iyo aad ugu adkaynaysa in ay waqtiga habboon ku fuliyaan qiimayn ama natiijo waxtar leh. Natiijada 4. Sida looga war hayo marka aanay soo noqnoqod lahayn dhacdooyinka rabshadda gurigu, waxa ay xirfadleyaashu badi aaminaan in ay carruurtu ku wanaag qabaan guriga oo/ama waxa ay u arkaan in ay tiro yar yihiin sababaha ay ugu baahan yihiin in ay si go'an ula hawlgalaan waalidka. Waxa ay taasi keentaa in aanay fahan dheeraad ah ka helin sababaha ka dambeeya iyo waxyaabaha dhaliya dhacdooyinka rabshadda guriga, iyo heerka dhab ah ee halista ay kuwaasi carruurta u suurtogelinayaan. Shaqada hay'ado farabadan muddada dheer ee shaqada Natiijada 5. Dadaalka ay shaqaalaha daryeelka bulsheed iyo booliisku ugu jiraan in ay xirfadleyaasha caafimaadka ka helaan sharraxaadda cad ee sababta dhaawaca jirka ee carruurta, ayaa khilaafsan caadada ay xirfadleyaasha caafimaadku u leeyihiin in ay bixiyaan natiijooyin kaladuwan oo keenaya in wax kaste uu suurogal yahay ilaa meesha laga saarayo. Waxa ay taasi sii suurtogelinaysaa isfahanwaaga ku saabsan halisihii hore iyo kuwa mustaqbalka marka la wado baaritaannada ilaalinta carruurta. Shaqada hay'ado farabadan ee lagaga jawaab celinayo dhacdooyin iyo xaalado dhibaato ah Natiijada 6. Mudnaanta yar ee Kooxda Goobjoog ah ee Xaaladda degdeg ah (EDT) ay ka muujiyaan ka jawaabcelinta codsiyada baaritaannada macluumaadka ee caadi ah marka baahiyaha kale loo eego, iyo la'aanta nidaam ka mid ah Kooxaha FSCP oo bilowga maalinta si caadi ah loogu soo qaado macluumaadka ay kooxda EDT habeenkii hore diiwaangeliyeen, ayaa naaqusaysa wadaagga macluumaadka ee waqtiga habboon xataa mararka ay jiraan xaaladaha loogu baahan yahay jawaabcelin degdeg ah. Tani waa natiijo loogu talagalay Daryeelka Bulsheed ee Carruurta. Shaqada hay'ado farabadan ee lagaga jawaab celinayo dhacdooyin iyo xaalado dhibaato ah Kooxda Dib u eegiddu waxa ay si taxaddar leh uga fiirsadeen haddii maamulka daran ee baaritaanka Qodobka 47 ee sharcigu uu yahay caado ay ku shaqeeyaan Kooxda FSCP ee gaar ah, iyo haddii ay suurogal tahay in ay dad kale sidaas sameeyaan. Waxa ay niyaddu noogu degtay laba siyaabood oo aanay xaaladdu sidaas ku ahayn: 1) kooxda laga hadlayo dib ayaa loo habeeyey oo waxaa iminka u jooga maamuleyaal cusub, iyo 2) adeegga Hubinta Tayada (Quality Assurance) ayaa shaqo baaris sameeyey, isaga oo fiiriyey sida kooxaha CSC gebigood looga qabto baaritaannada Qodobka 47 ee sharciga. Waxaa taas lagu soo ogaaday in kooxaha dhexdooda si fiican Lambeth SCR Child H Confidential draft report 8 January 2014 19 looga fahansan yahay oo looga raaco nidaamyada CP ee rasmi ah, inkaste oo la aqoonsaday in ay kaladuwan yihiin xirfadaha iyo khibradda gaar ah ee shaqaalaha kaladuwan. Qaybta CSC ee Lambeth waxa ay sheegtay in siyaado loo fiirin doono kooxahaas ay ka jiraan baaritaannada Qodobka 47 ee sharciga ee ugu tiro yar, si loo hubiyo in habdhaqanka xirfadeed loo digtoon yahay oo uu sax yahay marka la qabanayo waajibkaas qaanuuneed. Faahfaahinta natiijooyinka Qaybtan waxaa lagu muujinayaa casharka ugu muhiimsan ee guddiga LSCB iyo hay'adaha ay iskaashadaan ay ka qaadanayaan dib u eegidda kiiskan. Natiijo kaste waxaa loo qeexay hab lagu caddaynayo: Sidee ayay dhibaatadu uga muuqataa kiiskan gaar ah? Sidee ayaan u og nahay in aanay ahayn cillad u gaar ah kiiskan? Maxay Kooxda Kiiska (dadka qoyska wax u qabtay) iyo Kooxda Dib u eegiddu (maamuleyaasha sare ee hay'ad kaste ee loo magacaabay si ay gargaar uga bixiyaan dib u eegidda kiiskan) nooga sheegi karaan sida dhibaatadaasi ay uga jirto kiisaska/hannaannada kale ee la mid ah iyo/ama siyaabaha ay caadadu ugu xiran tahay habdhaqanka xirfadeed ee caadi ah? Sidee ayay caadadu u badan tahay? Waa maxay daliilka aan soo qaadnay ee ku saabsan tirada kiisaska ee caadadu ay dhab ahaan iminka saamayso ama saamayn karto? Sidee ayay caadadu u faafsan tahay? Ma waxaa laga helaa koox gaar ah, xaafad gaar ah, degmo, gobol, qaranka? Waa maxay dhibaatooyinka ay u keenayso ku kalsoonaanta nidaamka ilaalinta carruurta ee hay'ado farabadan? Daliilka loo hayo 'lakabyada' kaladuwan ee natiijooyinku waxa uu ka yimid aqoonta iyo khibradda Kooxda Dib u eegidda iyo Kooxda Kiiska, diiwaannada ku saabsan kiiskan, iyo dukumeentiyada kale ee ka yimid hay'adaha, iyo daliilka cilmibaarista ku salaysan ee habboon. Lix natiijo oo mudnaan leh ayaa la soo doortay maxaa yeelay waxa ay muujinayeen meelaha ka mid ah habdhaqanka xirfadeed ee muhiim u ahaa sida kiiskan loo maamulay, iyaga oo laakiin weliba muujinayey caadooyinka habdhaqanka xirfadeed ee dadka kale iyo nidaamyada lagu taageero habdhaqankaas. Qaybtan inteeda kale waxaa lagaga hadlayaa lixda natiijo. 2.5 Natiijada 1. Caadada ay xirfadleyaasha hay'adaha dhammaantood u leeyihiin in ay diiradda saaraan saamaynta shucuureed ee ay carruurta u leedahay ku noolidda rabshadda gurigu, iyaga oo aanan eegayn sida ay ugu sii suurogal badan tahay in ay waxyeellada jirku iyaga gaarto, ayaa horjoogsanaysa in si buuxda loo fahmo halisaha ku wajahan. Waxaa la hayaa daliil cilmibaaris ku salaysan oo si cad u tilmaamaya halista dheeraad ah ee waxyeellada jirka ee ay carruurtu ku jiraan ee uga timaadda ragga rabshad ula taga lammaaneyaashooda haweenka ah (matalan Stark and Flitcraft, 1996; Bowker et al, 1998) sida ku xusan sanduuqa buluugga ah Lambeth SCR Child H Confidential draft report 8 January 2014 20 ee hoose. Haddana waxaa kiiskan sifo u ahayd sida yar ee aasaaskaas aqoonta loogu toosiyey habdhaqanka xirfadeed. Walaaca laga qabay waxyeellada jirku waxa ku saabsanaa hooyada, kuma saabsanayn carruurta. Sidee ayay dhibaatadu uga muuqatay kiiskan gaar ah? Xirfadleyaasha qoyska ku hawlanaa waxa ay noo sheegeen, waxaana taas muujinaya diiwaannada kiiska, in aanay u arkayn in ay carruurtu halis ugu jireen waxyeellada jirka maadaama ay la noolaayeen aabbe dhawaan xaaskiisa rabshad u geystey. Waxa ay taasi run u ahayd dhammaan marxaladaha kiiska ka mid ahaa. Markii ugu horraysay ee Imaha H uu dalkan yimid isaga oo qaba waxyaabo u muuqday nabarro wejiga kaga yaallay iyo calaamado jirkiisa ku yaallay, lama qabanin Kulanka Xeeladda ku saabsan. Xirfadleyaasha isaga arkay xoogaa ka dib markii uu halkan yimid cidba ma weydiinin haddii uu Aabbe dhaawacyada u geystey, inkaste oo ay ogaayeen in Aabbe dhowr toddobaad uu hayey Ilmaha H, oo uu Aabbe hore weerar ula tagay Ilmaha H hooyadiis. Xirfadleyaasha midkood, Ummulisada, ka dib markii ay Ilmaha H ku aragtay booqashada guriga, ayay la xiriirtay hawlwadeenka SW ee qoyska si ay ugu sheegto walaaca ay qabtay. Waxaa la sugay ilaa Shirkii CP (oo la qabtay ku dhawaad laba toddobaad ka dib markii ugu horraysay ee hawlwadeenka SW uu arkay Ilmaha H) si loo codsado Baarista caafimaadka ee CP, waxaana sidaas samaysay Guddoomiyaha Shirka. Shirkaas gudihiisa, Ilmaha H, ka dibna dhallaanka cusub ee Walaalka 2, ayaa la geliyey Qorshooyinka CP, iyaga oo la hoos geliyey qaybta Xadgudubka Shucuureed. Taariikhda rabshadda guriga ee jirtay xirfadleyaasha kuma dirqinin in ay su'aalo ka jeediyaan haddii ay suurogal tahay iyo haddii kale in Aabbe uu carruurta u geysto waxyeello jirka ah. Waqti daruuri ahaa oo kiiska ka mid ahaa, ka dib markii Walaalka 2 la jiifiyey isbitaalka, xirfadleyaasha isbitaalka iyo Kooxda FSCP waxa ay annaga noo sheegeen in aanay tixgelinin in ay suurogal ahayd in labada kale ee carruur ah aanay nabad u ahayn in lagu dhaafo daryeelka Aabbe. Go’aannada ay gaareen iyagu, xataa dhammaan dadkii u joogay Kulankii Xeeladda ku saabsanaa ee isbitaalka lagu qabtay, ayaa si sahlan uga soo qaaday in Aabbe uu karti u lahaa in uu iyaga ugu deeqo daryeel hagaagsan. Lama qabanin qiimaynta kartida uu Aabbe u leeyahay in uu carruurta si hagaagsan u daryeelo, xataa halisaha laga yaabo in uu iyaga u keenayo maadaama uu yahay qof weyn oo hore rabshad u geystey. Isla sidoo kale xilliyo kale oo daruuri ahaa, xirfadleyaashu waxa ay gebi ahaan diiradda saareen halisaha ay Hooyo ugu jirtay rabshad uga timaadda Aabbe. Waxa ay xaaladdu sidaas ahayd bilowgii kiiska markii Hooyo iyo dhallaanka (Walaalka 1) ay ka baxeen xarunta hoysiinta haweenka ayna ku noqdeen guriga si ay Aabbe ula noolaadaan. Taas awgeed, waxa ay xirfadleyaal farabadan noo sheegeen in ay aad uga naxeen oo ay ula yaabeen dhimashadii Ilmaha H, waxaana iyaga ku adkayd in ay rumaystaan in ay taasi dhacday. Lambeth SCR Child H Confidential draft report 8 January 2014 21 Waa maxay aasaaska ku xiran daliilka ee ku saabsan rabshadda guriga iyo halisaha ku wajahan carruurta? Ingiriiska: Wixii khuseeya boqolkiiba 40 ilaa 70 kiisaska haweenka lagu xadgudbo, waxaa si toos ah xadgudubka jirka loogu geystaa carruurta laftigooda (Stark and Flitcraft, 1996; Bowker et al, 1998). Maraykanka: Wixii khuseeya qoysaska la kulma xadgudubka guriga ee waalidka waxaa ku darsan boqolkiiba 30 ilaa 60 oo ah sicirrada xadgudubka jirka ee carruurta. (matalan, Barnett et al, 1997). Sahamin qaran oo laga qaaday in ka badan 6,000 oo qoys oo Maraykan ah, waxa ay cilmibaareyaashu ku soo ogaadeen in boqolkiiba 50 ragga badi weerar u geystay xaasaskoodu ay weliba xadgudubka jirka u geysteen carruurtooda (Edleson, 1995). Daraasad laga qaaday sifooyinka waalidiinta iyo lammaaneyaasha ayaa lagu muujiyey sida caadi ah ee ay isula socdaan rabshadda guriga ee dadka waaweyn iyo dhanka kale waxyeellada jirka iyo dayacaadda carruurtu (Hartley, 2002/2009). Austraaliya: Waxaa dhowr daraasad oo kala qiyaas duwan ka soo baxay natiijooyin kuwaas la siman, iyaga oo qeexaya halista aad u sii weyn ee ay carruurtu ugu jiraan xadgudubka jirka marka ay ku jiraan guryaha uu joogo nin rabshad leh. Ilaa sanadihii ugu dambeeyey, taas si fiican looma aqoonayn, oo halista rabshadda ka timaadda dadka waaweyn waxaa laga soo qaadayey in ay ka duwan tahay halisaha waxyeellada jirka ee carruurta gaarta (Tomison, 2000). Sidee ayaan u og nahay in aanay ahayn cillad u gaar ah kiiskan? Markii la sii baaray waxa sabab u ahaa halisahaas ku wajahnaa carruurta ee la aqoonsan waayey, waxaa Kooxda Dib u eegidda u caddaatay in shaqaalaha hay’adaha kaladuwan aanay ka war haynin daliilka cilmibaarista ku salaysan ee baaxad weyn ee diyaar ahaa ee ku saabsanaa halisaha ku wajahan carruurta waalidka rabshadda guriga geysta. Wadahadalladii shakhsi ahaan lala yeeshay iyo wadahadalladii kulannada dib u eegidda wadajir ahayd, xubnaha Kooxda Kiisku waxa ay gebi ahaan ku sheegeen in aanay iyagu isku xirayn rabshadda guriga ee dhexmarta dadka waaweyn iyo halista dheeraad ah ee rabshadda jirka ee loo geysto carruurta. Waxa ay taasi ka soo horjeeddaa halista xadgudubka shucuureed, taas oo ay siyaado ugu kalsoonaayeen oo ay u aqoonsadeen carruurta ku nool reerka ay ka dhex dhacdo rabshadda gurigu1. 1 Carruurta ku nool guryaha, ay ka dhacdo rabshadda DV waxaa iminka loo gartaa in ay “halis ku jiraan” sida uu dhigayo Sharciga Korsashada iyo Carruurta ee 2002dii soo baxay. Tan iyo 31kii Jannaayo 2005, Qodobka 120 ee sharcigaas ayaa qeexitaanka sharciyeed ee waxyeellaynta carruurta kordhiyey oo ku daray waxyeellada uga timaadda arkidda ama maqlidda habdhaqanka xun ee dadka kale loo geysto. Waxaa taas ka mid noqonaysa arkidda xadgudubka guriga. Lambeth SCR Child H Confidential draft report 8 January 2014 22 Waxa ay taasi Kooxda Dib u eegidda u tilmaantay in dhibaatadu aanay ahayn cillad ku xiran shaqada xirfadeed ee laga qabtay kiiskan gaarka ah, laakiin in ay tahay wax laga yaabo in uu raad ku yeesho sida ay xirfadleyaashu uga shaqeeyaan kiisaska kale ee ay ka jirto rabshadda dhexmarta waalidka. Waa maxay tirada kiisaska ee ay taasi saamayso, oo sidee ayay caadadu u faafsan tahay: xaafadda, gobolka, qaranka? Waxaa sanadba sanadka ku xiga sii kordhaysa tirada dhibbaneyaasha iyo qoysaskooda ee hay’adaha loo soo gudbiyo ayna ka war hayaan, iyada oo ay rabshadda gurigu ka mid tahay noloshooda. Tirakoobyada la hayo ayaa tilmaamaya in ay taasi run u tahay qaranka isla sida ay run ugu tahay xaafadda Lambeth2. Xaafadda Lambeth kelideed, sanadkii tagay ku dhawaad 400 oo carruur ah ayaa lagu qiyaasay in ay ku nool yihiin guryo ay saamayso rabshadda guriga ee ugu daran – kuwaas oo laga wado hawlaha MARAC. Sidaas darteed waxaa aad u badan tirada kiisaska ee laga yaabo in ay natiijadaasi khusayso – fiiri Lifaaqa 3 si aad faahfaahin dheeraad ah u hesho. Waxaa cad in rabshadda gurigu ay badan tahay marka tirada la eego, xaafad ahaan oo ay ku faafsan tahay Ingiriiska. Waxaanan sidaas u fududayn in la soo ogaado sida ay dhab ahaan u faafsan tahay wacyi la’aanta xirfadeed ee ku saabsan halista waxyeellada jirka ee ay siyaado ugu jiraan carruurta la nool qof weyn oo rabshad leh. Waayo aragnimada dheeraad ah ee xubnaha Kooxda Dib u eegiddu ay xaafadda ka heleen ayaa tilmaamaysa in caadada loo leeyahay in diiradda la saaro saamaynta shucuureed ee ay carruurta u leedahay ku noolidda rabshadda gurigu ay korodhay oo ay la socoto mudnaanta siyaado loogu siiyo mawduuca iyo tababbarka ku xiran xaafadda Lambeth gudaheeda, London gebigeed iyo qaranka oo dhan. Guud ahaan ayaa taas loo dhiirrigeliyey waxaana laga soo qaaday horumar wax ku ool ah. Kooxda Dib u eegiddu waxa ay xaqiijiyeen in xiriirka ka dhexeeya rabshadda guriga iyo xadgudubka jirka ee carruurta loo geysto si joogto ah loogu daro tababbarka guddiga LSCB ay ka bixiyaan Lambeth ee ku saabsan rabshadda guriga. Hase yeeshee, hore looma ogayn in qaybtaasi ay ka lumayso habdhaqanka xirfadeed. Waa maxay dhibaatooyinka ay u keenayso ku kalsoonaanta nidaamka Ilaalinta Carruurta ee hay'ado farabadan? Nidaamka nabad leh waxa uu u baahan yahay in xirfadleyaashu ay aqoon u yeeshaan aasaaska ku xiran daliilka cilmibaarista ee ka jira laantooda shaqada, si ay kaas ugu hagi karaan habdhaqankooda xirfadeed. Marka la eego tirada sii kordhaysa ee qoysaska la og yahay in ay la kulmaan rabshadda guriga ee uga timaadda lammaane rag ah oo qof weyn ah, waxaa siyaado muhiim u ah in xirfadleyaashu ay fahmaan daliilka cusub ee ka diyaar ah qaybtaas shaqada. Kiiskani waxa uu muujiyey in qaybo ka mid ah aasaaska ku xiran daliilka si fiican loo garanayo, gaar ahaan wixii khuseeya suurogalka xadgudubka shucuureed ee carruurta gaara. Haddana hawsha dib u eegidda SCR waxaa 2 Tirakoobka Carruurta Baahi qabta ee wax laga beddelay ee bisha Abriil 2013 ayaa qaranka oo dhan ka soo qaadi doona macluumaadkan ku saabsan carruurta laga og yahay dhanka daryeelka bulsheed. Lambeth SCR Child H Confidential draft report 8 January 2014 23 weliba lagu soo ogaaday in qaybo kale oo ka mid ah daliilka aanan weli la baranin: khaas ahaan, waxaanan habdhaqanka xirfadeed lagu hagayn daliilka cilmibaarista ee joogto ah ee ku saabsan halista waxyeellada jirka ee siyaado ugu wajahan carruurta la nool qof weyn oo rabshad leh. Waxa ay taasi ka dhigan tahay in ay suurogal tahay in wixii qiimayn iyo qorshooyin ah aanan laga muujinin halisaha la xiriira jirka ee carruurta ku wajahan, sidaas oo ay suurogal ku sii tahay in carruurta lagu dhaafo halista waxyeellada. Natiijada 1. Caadada ay xirfadleyaasha hay'adaha dhammaantood u leeyihiin in ay diiradda saaraan saamaynta shucuureed ee ay carruurta u leedahay ku noolidda rabshadda gurigu, iyaga oo aanan eegayn sida ay ugu sii suurogal badan tahay in ay waxyeellada jirku iyaga gaarto, ayaa horjoogsanaysa in si buuxda loo fahmo halisaha ku wajahan. Hay’aduhu dhammaantood waxa ay shaqaalahooda u abaabulaan oo ay ka sugayaan habdhaqanka xirfadeed ee ku toosan daliilka jira. Barnaamijyada tababbarka ee ay qabtaan guddiga LSCB ee Lambeth waxa ay ujeeddadoodu tahay in taas lagu taageero iyada oo xirfadleyaasha loogu deeqayo aqoonta ugu cusub ee ku saabsan ilaalinta carruurta ee CP. Dib u eegidda kiiskan waxaa lagu soo ogaaday in waqtiga xaadirka ah, dhammaan xirfadleyaasha Lambeth iyo xaafadaha ku ag yaalla aanay muujinayn in ay si kalsooni leh oo cad u fahansan yihiin aasaaska ku xiran daliilka ee ku saabsan halisaha waxyeellada jirka ee ku wajahan carruurta ku nool reeraha ay ka jirto rabshadda guriga ee dhexmarta dad waaweyn. Waxa ay taasi ka dhigan tahay in ay suurogal tahay in wixii qiimayn iyo qorshooyin ah aanan laga muujinin halisaha la xiriira jirka ee carruurta ku wajahan, sidaas oo ay suurogal ku sii tahay in carruurta lagu dhaafo halista waxyeellada. Haddii halisahaas siyaado loo fahmi waayo, waxa aan filan karnaa in ay suurogal noqoto in xirfadleyaasha hay’adaha iskaashada ay seegi doonaan halisaha la xiriira jirka ee carruurta ku wajahan, kuwaas oo sii kordhi doona marka qofka weyn ee rabshad leh uu ilmaha keligiis hayo. Arrimaha ay Guddiga iyo hay’adaha xubin ka ah u baahan yihiin in ay ka fiirsadaan: Miyay natiijadaasi ka yaabisay Guddiga? Xiriirka u dhexeeya rabshadda guriga iyo xadgudubka jirka ee carruurta loo geysto ayaa muddo badan qayb ka ahaa tababbarka ay guddiga LSCB ka bixiyaan Lambeth ee ku saabsan rabshadda DV. Miyaa si caadi ah loo qiimeeyaa waxtarka tababbarka? Miyay jiraan habab kale oo lagu kordhin karo wacyigelinta shaqaalaha ee ku saabsan aasaaska ku xiran daliilka ee dhankaas ka jira? Ilaa intee hay’adaha kaladuwan dhab ahaan looga taageeraa habdhaqanka xirfadeed ee ku toosan daliilka jira? Miyay hay’adaha xubin ahi og yihiin sida kaas looga abaabulo goobahooda shaqada loona mudnaan siiyo? Sidee ayay shaqaalaha iyo maamuleyaasha diyaar ugu tahay soo Lambeth SCR Child H Confidential draft report 8 January 2014 24 koobidda aasaaska ku xiran daliilka cilmibaarista ee dhinacaas ka jira? Miyaa isticmaalidda daliilka cilmibaarista si caadi ah looga xoojiyaa loogana taageeraa darajooyinka kaladuwan ee xirfadeed iyo habdhaqannada kormeeridda/maamulka? Sidee ayay iskaashatada hay’ado farabadan u caddayn karaan in siyaado looga war hayo halisaha dhinacaas ka jira? 2.6 Natiijada 2. Hababka, loogu talagalay in lagu soo ogaado qaladaadka fikirka insaanku, miyay si fiican oo joogto ah uga hirgalaan hay'adaha dhexdooda? Marka aanay sidaas ahayn, waxaa sii suurogal badan in aanan la ishortaagin go'aannada qalad ah. Waxaa si caadi ah loo garanayaa in marka shaqo loo qabanayo qoysaska si carruurta loo dhawro, fahanka ay xirfadleyaashu ka qaataan macluumaadka ay helaan iyo sida ay kuwaas u isticmaalaan ay aakhirka si lagama maarmaan ah ugu nuglaan doonaan qaladaadka caadi ah ee fikirka insaanka (Munro, 1999). Sida Munro (2008) loogu qoray : ‘Cilmibaaris cilminafsiyeed ayaa lagu muujiyey in dadku ay si aad u liidata isaga ilaaliyaan in ay dhan u iilanaadaan ama eexdaan. Hawlwadeennada bulsheed waxa ay si daruuri ah ugu baahan yihiin in si joogto ah loo kormeero si loo hubiyo in dhan u iilashadoodu aanay qaldin qiimaynta ay sameeyaan.’ Labada hawlood ee daruuri ah ee ‘hubin iyo isku dheellitirid’ ee lagu caawin karo dib u eegidda go’aannadu waa kormeeridda xirfadeed iyo caadada muran ama dood la is dhaafsado oo laga muujiyo shaqada hay’adaha farabadan. Ujeeddada kormeeriddu waxa ay tahay si kiisaska looga bixiyo fikrad cusub, oo badi qof sare laga helo, iyo si loo suurtogeliyo in laga fiirsado oo laga hortago fikirka iyo go’aannada xirfadleyaasha marka loo baahdo. Sidoo kale, xiriirrada hay’adaha farabadan waa in ay ku hawlgalaan hab lagaga hortago ama lagaga doodo laguna baaro fikirka iyo go’aannada. Hase yeeshee, dhowr sifo iyo dhacdo oo kiiskan ka mid ahaa ayaa soo saaray su’aalo muhiim ah oo ku saabsan sida ay kiiskan ugu fiicnayd hirgelintii hababkaas caado dheeraad ah lahaa ee loogu talagalay in lagu bixiyo dhaleecayn iyo dood iyo sida ay guud ahaan ugu fiican tahay. Sidee ayay dhibaatadu uga muuqatay kiiskan gaar ah? Kiiskani waxa uu lahaa dhowr sifo oo ay xirfadleyaashu ku jahwareereen, sida diidista joogto ah ee rabshaddii uu hore Aabbe Hooyo u geystey – taas oo la ogaa in ay dhacday. Waxaa taas siyaado ku ahayd in xirfadleyaasha oo dhan, xataa kuwii waalidka waqti kooban la kulmay, ay guud ahaan u muuqatay in ay dadkaasi ahaayeen waalid fiican oo taxaddar leh. Markii waqti la joogay, ee aanan laga war helin dhacdooyin kale oo rabshadda DV ah, xirfadleyaasha ayay niyaddu u degtay. Markii la heli waayey kormeerid tayo fiican oo ka jirta hay’adaha iyo weliba wadahadal iyo muran ama dood dhexmara hay’adaha farabadan ayaa keentay in jawaabcelinnadaasi ay sii socdeen iyaga oo aanan waxtar lahayn. Waxa ay taasi run ahayd, xataa markii xaaladda qoysku ay aad isu Lambeth SCR Child H Confidential draft report 8 January 2014 25 beddeshay (iyada oo ay yimaaddeen Ilmaha H iyo ilmaha xoogaa ka dib dhashay), taas oo keentay in culays badani uu saarmo qoyska buuxay. Guddoomiyaha Shirka Ilaalinta Carruurta ayaa u muuqatay in ay qaadday kaalin ‘kormeerid’ oo muhiim ahayd, iyada oo waalidka iyo xirfadleyaasha wada xasuusisay heerka rabshadda ee hore Hooyo loogu geystay. Waxa ay dadka weydiisay sababta aanan daliilkaas ahmiyad dheeraad ah loo siinayn, waxa ayna sida sax ahayd tilmaantay in diidista dhacdooyinka ee waalidku ay shaki sii gelinayso daacadda iyo furnaanta ay xirfadleyaasha u muujiyeen. Sidaas darteed, waxa ay noqotay qofka ugu badnaan digniin ka bixiyey kana hortagay ra’yiga fiican ee ay waalidku qabeen. Shirarka CP gudahooda waxaa taas iyada ku taageertay talobixinta hawlwadeenka SW ee ahayd in carruurtu ay weli u baahnaayeen Qorshooyinka CP. Iyada oo taas liddi ku ah, tayada kormeeridda gaar ahayd ee hawlwadeenka SW ayaa keentay in aanan la soo ogaan oo aanan lagu dhaqaaqin baahida loo qabay qiimaynta joogto ah ee halista. Kooxda Dib u eegiddu waxa ay sugayeen in kormeeridda xirfadeed lagu baaro xiriirka gaar ah ee ay shaqaaluhu la yeeshaan waalidiinta iyo carruurta, iyo sida ay taasi u saamayso macluumaadka ay helaan, sida ay kuwaas u fahmaan iyo sida ay u isticmaalaan; waxa ay taasi gaar ahaan muhiim ugu ahayd kormeeridda Hawlwadeenka Bulsheed ee ugu muhiimsanaa. Hase yeeshee, kormeeridda kiiskan ee kooxda FSCP waxaa la kala wareejiyey saddex jeer muddo 11 bilood ahayd, oo waxaa aad u yaraa waqtiga loo qoondeeyey. Wadahadalladii lala yeeshay Maamulaha Kooxda iyo Maamule Ku-xigeenka Kooxda ayaa muujiyey in kiiskan laga soo qaaday mid halis yar oo si fiican u socda. Waxaa gebi ahaan 35 daqiiqo ku eekayd kormeeridda rasmi ahayd ee kiiskan muddadii 3 bilood ahayd ee ka horraysay dhimashadii Ilmaha h. Sawirkaas oo kale ayaa run ahaan ka muuqday kormeeridda dhawritaanka ee Booqdaha Caafimaadka, goortaas oo aanan la tixgelinin dib u qiimaynta halisaha. Kooxda Dib u eegiddu waxa ay weliba sugayeen in ay siyaado u murmaan una doodaan xiriirrada xirfadeed, si ay u sheegaan una baaraan farqiyada u dhexeeyey fikradaha xirfadeed ee ay qabeen. Kulannada Kooxda Daruuri ah, oo loo qabto si ka tiro badan Shirarka Ilaalinta Carruurta, ayaa noqon lahaa halka habboonayd in taas lagaga hadlo. Laakiin isla sida kormeeridda, taasi aad ayay kiiskan uga maqnayd. Sidee ayaan u og nahay in aanay ahayn cillad u gaar ah kiiskan? Iyada oo qayb ka ahayd hawsha dib u eegidda kiiska, Kooxda Dib u eegidda ayaa Kooxda Kiiska weydiiyey dadka caadi ahaan doodda ama muranka dhaliya. Jawaabta la bixiyey waxa ay ahayd: ‘Een, Guddoomiyaha Shirka CP ayaa sidaas sameeya’. Waxa ay taasi tilmaamaysaa in nidaamyada kormeeridda iyo wadahadallada hay’ado farabadan ee ka muuqday kiiskan gaar ah aanay ahayn kuwo ka duwan habdhaqanka caadi ah. Waxaa taas taageeraysa shaqo baarista gudaha ee dhawaan lagu sameeyey kormeeridda ka jirta CSC, taas oo lagu soo ogaaday in dhankaas looga baahan yahay wanaajin iyo xoojin dheeraad ah. Waxaa la soo ogaaday in habdhaqanka xirfadeed uu kaladuwanaa oo uusan si siman u dhacayn, iyada oo shaqaalaha qaarkood ay helayeen kormeerid fiican oo joogto ah, kuwa kalena Lambeth SCR Child H Confidential draft report 8 January 2014 26 aanay helayn. Dhowr kiis oo dib loo eegay, waxaa ka jiray fursado dib u qiimayn oo la seegay, kuwaas oo habboonayd in kormeeridda lagu soo helo. Waa maxay tirada kiisaska ee ay taasi saamayso, oo sidee ayay kuwaasi u faafsan yihiin – xaafadda, gobolka, qaranka? Kormeeriddu qayb kama aha shaqada kooxaha xirfadeed dhammaantood. Hase yeeshee, wixii khuseeya hay’adaha daruuri ah ee ka shaqeeya ilaalinta carruurta (daryeelka bulsheed, caafimaadka iyo booliiska), waa qayb daruuri ah oo ka mid ah shaqadooda, waxa aanay markaa muhiim u tahay kiisas tiro badan. Waxaa la hayaa daliil tilmaamaya in qaranka ay ka jirto dhibaatada la’aanta kormeerid hagaagsan. Sida lagu qoray dib u eegidda lagu sameeyey dib u eegidyada kiiska daran ee Brandon et al. (2008): ‘Baarista qotodheer ee dib u eegidyada qodobka 47 ayaa lagu soo ogaaday dhowr meelood oo laga walaac qabo oo ku saabsan kormeeridda lagu sameeyo shaqaalaha safka hore, gaar ahaan hawlwadeennada bulsheed. Shaqaalaha waxbarashada, caafimaadka iyo qaybta samafalka ayaa weliba la soo ogaaday in ay u baahan yihiin in ay helaan taageero, kormeerid iyo gaar ahaan talobixin ku saabsan ilaalinta carruurta. Qaybahaas shaqada qaarkood waxaa laga yaabaa in ay kormeeriddu u lahayn mudnaanta ay u leedahay daryeelka bulsheed ee carruurta oo sidaas darteed lama filanayo in ay sidaas ugu dhacdo.” (2008:92) Marka la eego xaaladda hay’adda ee shaqada farabadan, shaqada shucuur badan, qaabka ururka ee isbedbeddelaya iyo waajibaadka sharciyeed, waxaa ugu nuglan dhinacyada daruuri ah ee ka mid ah kaalinta kormeeraha. Waxaa cilmibaaris lagu muujiyey in ‘bey’addaas qaska badan’3 dhexdeeda ay kormeereyaasha iyo dadka la kormeero labadooda suurogal ka tahay in ay ansixiyaan xeeladda uu mid kasteba muujiyo halkii ay kormeeridda uga dhigan lahaayeen fursad ay kaga hortagaan oo ay ku su’aalaan fikradaha hore loo haysto. Ansixinta noocaas ahi waxa ay muuqan kartaa hab taageero leh oo lagu sii socdo marka lagu jiro waxa loo arko xaalad aanan la maamuli karin. Waxaa meel kale lagu qoray (Rushton and Nathan, 1996), waqti ka dib marka la eego culayska saaran ilaha dhaqaale ee diyaar ah, in dhinacyada maamulka kiiska ee kormeeriddu ay badi hormaraan waxqabadyada muhiim ah ee ka fiirsashada, iyo ka hortagidda, go’aannada lala yimaaddo. Waxaa jira kulanno farabadan oo ay ka qayb galaan hay’ado kaladuwan, sida Kulannada Xeeladda ku saabsan ee ka mid ah shaqada CP ee xaaladda dhibaato ah (baaritaannada dhacdooyinka), iyo kulannada si joogto ah loo qabto (Shirarka iyo Kooxaha Daruuri ah) ee loogu talagalay si loogula socdo laguna maamulo Qorshooyinka CP. Kaasi waa qaab qaranka ka jira, waxaana lagu taageeraa hagista qaanuuneed. Kartida ay kooxahaasi u leeyihiin in ay fuliyaan hawsha muranka ama doodda xushmayn leh ee adag ayaa muhiim u ah xaafadda iyo weliba dalka oo dhan. Waxaa annaga noo suurtogeli weydey in aan daliil ka soo helno tayada waxqabadka ee kooxahaas ee xaafadda ama meelo kale. 3 Hughes and Pengelly (1997) Lambeth SCR Child H Confidential draft report 8 January 2014 27 Waa maxay dhibaatooyinka ay u keenayso ku kalsoonaanta nidaamka ilaalinta carruurta ee hay'ado farabadan? Nidaamyadeena dhawritaanka ee hay’ado farabadan waxaa loogu talagalay in ay yeeshaan hawlo hubin iyo isku dheellitirid oo iyaga ka mid ah si la isaga ilaaliyo qaladaadka la og yahay in ay ka iman karaan go’aannada ay shakhsiyaadku gaaraan. Gaar ahaan, kormeeridda gooni ah iyo kulannada hay’ado kaladuwan ay ka qayb galaan ayaa loogu talagalay in ay noqdaan habab lagu hubiyo in go’aannada la baaro oo laga hortago, si loo hubiyo in shakhsiyaadka iyo kooxuhu aanay yeelanin caadooyin fikir oo qalad ah dhanna u iilan ama eexasho leh. Haddii hababkaasi ay si fiican u hirgeli waayaan, xirfadleyaasha gaar ah iyo kooxda hay’adaha farabadan ee ilmaha ku hareersan, ayay taasi halis u gelinaysaa in ay ku dhacaan ‘dabinnada’ si fiican loo garanayo ee fikirka insaanka sida go’aannada oo ay dib u qiimayn waayaan marka ay helaan daliil cusub, ama hadallada ay waalidku dhacdooyinka ka sheegaan oo ay iska aqbalaan (Munro, 1999). Marka dambe, waxa ay taasi keeni kartaa in shakhsi ahaan iyo koox ahaanba la gaaro go’aanno liita. Natiijada 2. Hababka, loogu talagalay in lagu soo ogaado qaladaadka fikirka insaanku, miyay si fiican oo joogto ah uga hirgalaan hay'adaha dhexdooda? Marka aanay sidaas ahayn, waxaa sii suurogal badan in aanan la ishortaagin go'aannada qalad ah. Waxaa si caadi ah loo garanayaa in marka shaqo loo qabanayo qoysaska, fahanka ay xirfadleyaashu ka qaataan macluumaadka ay helaan iyo sida ay kuwaas u isticmaalaan ay aakhirka si lagama maarmaan ah ugu nuglaan doonaan qaladaadka caadi ah ee fikirka insaanka (Munro, 1999). Waxa aan weliba og nahay in aanan annagu ka adkaan karin dhan u iilashada garaadkeena; sidaas darteed, si loo sameeyo nidaamyo nabad leh waxaa loo baahan yahay in lagu daro habab taas lagu tixgelinayo. Labada hawlood ee daruuri ah ee ‘hubin iyo isku dheellitirid’ waa kormeeridda xirfadeed iyo wadahadallada hay’adaha farabadan ay ka yeeshaan kiiska, iyada oo midna hawsha u keenayso indho cusub tan kalena dood cusub. Dib u eegiddani waxa ay tilmaamaysaa in hababkaasi aanay waqtiga xaadirka ah si fiican ugu hirgelin kiisaska oo dhan, taas oo xirfadleyaasha halis u gelinaysa in ay ku dhacaan ‘dabinnada’ si fiican loo garanayo ee fikirka insaanka, taas oo ka dib keenaysa in la gaaro go’aanno liita. Arrimaha ay Guddiga iyo hay’adaha xubin ka ah u baahan yihiin in ay ka fiirsadaan: Maxay guddiga LSCB ka garanayaan kormeeridda laga bixiyo hay’adaha dhexdooda? Miyay hay’aduhu leeyihiin qaab lagu joogteeyo kormeeridda iyo tusaale ku saabsan waxa habboon in ay khusayso? Lambeth SCR Child H Confidential draft report 8 January 2014 28 Miyay hay’aduhu si cad u og yihiin dhinacyada kormeeridda ee mudnaan la siiyo iyo kuwa la iska dhaafo? Sidee loo ogaan karaa wanaajinta habdhaqanka xirfadeed ee dhankaas laga sameeyo? Waa maxay tababbarka u diyaar ah kormeereyaasha dhawritaanka, ee kaalintaas ku cusub? Sidee ayay u fiican tahay taageerada ay kulannada hay’adaha farabadan ee daruuri ah ka bixiyaan sidii looga hortagi lahaa dadka lala shaqeeyo shakina looga yeelan lahaa waalidiinta iyaga oo la xushmaynayo? Waa maxay nidaamyada guddoominta kulannada daruuri ah ee CP? Miyay kuwaasi ku toosan yihiin ujeeddada laga leeyahay? Miyay Guddoomiyeyaasha Kulannada Xeeladda ku saabsan, Shirarka CP iyo Kooxaha Daruuri ah si joogto ah u noqdaan ‘cadow taageere’, si ay uga hortagaan fikradaha ay hore u qabaan shakhsiyaadka iyo xirfadleyaasha kaladuwan ee qoyska ku lug leh? Miyay dhiirrigeliyaan doodda xushmayn leh laakiin furan? 2.7 Natiijada 3. Noocyada, diyaar ahaanta iyo tayada turjumaannada ee waqtiga xaadirka ah ayaa dhibaato ah; shaqada sii qorshaysan way u kala duduwan tahay, xaaladaha degdeg ah marka ay yimaaddaanna, aad ayay u liidataa waxa ayna sidaas u keenaysaa halista ah in aanay taageero helin isticmaaleyaasha adeegga ee aanan luqadda Ingiriisiga ku hadlin, taas oo xirfadleyaasha aad iyo aad ugu adkaynaysa in ay waqtiga habboon ku fuliyaan qiimayn ama natiijo waxtar leh. Shaqada ilaalinta carruurta waxaa daruuri ah oo ka mid ah in si sax ah loo fahmo dhacdooyinka soo maray carruurta, damacooda iyo dareennadooda, iyo fikradaha ay waalidku qabaan. Waxa ay taasi gaar ahaan adag tahay marka qoysasku aanay af Ingiriisi ku hadlin. Goortaas, waxaa lagama maarmaan ah in ay diyaar ahaadaan adeegyo turjumaan oo madaxbannaan oo la heli karo waqtiga loo baahan yahay. Kiiskani waxa uu shaaca ka qaaday dhibaatooyinka ka jira in waqtiga habboon la helo turjumaanno, loogu talagalay kulannada iyo xiriirrada maamulka muddada dheer, iyo weliba xaaladaha daran. Waxa ay kuwaasi keeneen dhacdooyin kaladuwan oo ahaa habdhaqan xirfadeed oo aanan hagaagsanayn welibana nabad ahayn. Markii dhacdooyinkaas lagala hadlay, xubnaha Kooxda Dib u eegidda iyo Kooxda Kiiska waxa ay labadooduba la yaabeen in ay kuwaasi yimaaddeen, iyo sida ay u horjoogsadeen baaritaanka waxtar leh ee dhaawacyada jirka ee gaaray carruurta xaaladda ku jiray iyo kuwii gaari kari lahaa. Sidee ayay dhibaatadu uga muuqatay kiiskan gaar ah? Waxaa kiiskan si daruuri ah loogu baahnaa in turjumaanno la isticmaalo. Labada waalid waxa ay luqaddooda hooyo ahayd af Soomaaliga. Aabbe, oo Lambeth SCR Child H Confidential draft report 8 January 2014 29 Ingiriiska dhowr sano joogay, ayay suurogal u ahayd in uu ku hadlo oo uu fahmo xoogaa Ingiriisi ah, oo gaarsiisnaa heer ‘lagu shaqayn karo’. Hase yeeshee, Hooyo ma garanayn wax Ingiriisi ah markii ay London timid. Muddo ka dib, waxa ay u muuqatay in ay qayb ka baratay xirfadaha luqadda Ingiriisiga, laakiin kuwaasi aad ayay weli ugu koobnaayeen. Waxa ay turjumaan ugu baahnayd dhammaan xiriirrada ay la yeelato xirfadleyaasha. Ilmaha H sidoo kale kuma hadli karayn wax Ingiriisi ah markii uu London yimid; waxa ay ahayd markii ugu horraysay ee uu Ingiriiska yimid. Waxa aan halkan hoose ku bixinaynaa oo keliya laba tusaale, midka hore oo ku saabsan wadaxiriirka lala galay Ilmaha H maadaama ay suurogal ahayd in uu ilmahaasi dhibbane u noqday weerarka jirka, kan labaad oo ku saabsan wadaxiriirka lala galay waalidkiisa maadaama ay suurogal ahayd in ay geysteen weerarka lagu qaaday walaalkiis, Walaalka 2. Tusaalaha koowaad waxa uu ku saabsan yahay imaanshihii Ilmaha H goortaas oo la arkay in uu qabo nabarro ka muuqday wajigiisa. Lama qabanin baaritaanka Qodobka 47 ee sharciga, inkaste oo isaga lagaga fiirsaday Shirkii Dib u eegidda CP ee loo qabtay Walaalka 1, kaas oo dhacay laba toddobaad ka dib. Goortaas, Guddoomiyaha Shirka CP ayaa codsatay in Ilmaha H islamarkaaba laga qaado baarista caafimaadka ee CP. Waxaa turjumaan loo diyaariyey baaritaanka caafimaadka laakiin isagu ma imanin, taas oo keentay in Aabbe – ‘qofkii laga walaac qabay’ ee suurogal ahaa – uu ilmaha u noqdo turjumaan iyo afhayeen. Waxa ay taasi islamarkaaba ilmaha u diidday cod madaxbannaan, taas oo laga sugayey baarista caafimaadka ee CP. Waxaa xaaladdaas dib loogu celiyey goortii labadii baarista caafimaadka ee CP ee ka dib loo qabtay Ilmaha H iyo Walaalka 1, goortaas oo turjumaanka la diyaariyey uusan mar labaad imanin. Tusaalaha labaad waxa uu ku saabsan yahay jawaabcelinta xirfadeed ee laga bixiyey dhaawaca gaaray Walaalka 2 markii uu joogay waaxda gurmadka degdeg ah ee isbitaalka ku yaallay xaafad deris ah. Markii Walaalka 2 – oo ahaa dhallaan laba bilood jiray – ay waalidku halkaas keeneen isaga oo lugtu jaban tahay, shaqaalaha caafimaadku waxa ay u baahnaayeen in ay sida ugu dhakhso badan ee suurogal ah waalidka u weydiiyaan sharraxaadda wixii dhacay. Si ay taas u sameeyaan, waxa ay isticmaaleen haweeney ay Aabbe ilma adeer ama ilma abti ahaayeen si ay Hooyo wax ugu turjunto, dhanka telefoonka. Isla sidii Ilmaha H, isticmaaliddaas xubin qaraabada ka mid ah ayaa keentay in ay suurogal yarayd in ay iyadu dareento in ay si furan uga hadli karaysay waxa dhacay. Inkaste oo waaxda gurmadka degdeg ah ay xilligaas ka jireen nidaamyo lagu isticmaalo adeegga turjumaadda telefoonka ee caadi ahaa, haddana shaqaalaha caafimaadka carruurtu waxa ay tilmaameen laba dhibaato oo shaqaalaha u diiday in ay taas isticmaalaan. Marka hore, labada telefoon waxa ay waqtigaas yaalleen miiska soo-dhawaynta ee buuqa badan, taas oo aanan sirta lagu ilaalin karin. Marka labaad, waxaa caadi ahayd in dib u dhac lagala kulmo helidda adeegga. Sidee ayaan u og nahay in aanay ahayn cillad u gaar ah kiiskan? Gargaarka laga helay xubnaha Kooxda Kiiska ayaa si cad u muujiyey in dhibaatooyinka kor ku xusan ay caadi yihiin, oo aanay si xun u taaban uun kiiskan keli ahaantiis. Waxa aan xubnaha Kooxda Kiiska iyo Kooxda Dib u eegidda ka barannay in hay’adaha dhammaantood, iyaga oo laga reebi karo Lambeth SCR Child H Confidential draft report 8 January 2014 30 booliiska, ay ku adag tahay in ay helaan turjumaanno si joogto ah u bixin kara adeeg heer sare ah oo loogu talagalay shaqadaas dhib badan. Waxaa jira nidaamyo qandaraas oo kaladuwan oo ay hay’aduhu dhammaantood u haystaan adeegyada turjumaannada. Hase yeeshee, halkii ay taasi ka ahaan lahayd dhibaato aasaasi ah oo ka jirta sidii iyaga loo heli lahaa waqtiga loo baahan yahay, waxa ay xubnaha Kooxda Kiisku tilmaameen in ay aad uga fududdahay in la hubiyo in adeeg joogto ah oo la isku hallayn karo loo helo shaqada sii qorshaysan marka loo barbar dhigo shaqada degdeg ah ama dhakhso badan. Sababaha taas ka dambeeyey waxaa ka mid ahaa tirada yar ee turjumaannada tababbar leh iyo la’aanta turjumaanno kaladuwan (matalan, dhanka jinsiga turjumaanka), gaar ahaan wixii khuseeya luqadaha dadka laga tiro badan yahay. Qof Kooxda Kiiska ka mid ah ayaa tusaale ku bixisay in uu jiro turjumaan keliya ee afka Fiyatnamiiska oo ka shaqeeya xaafaddeeda oo dhan, sidaas darteed waxaa qofkaas la sii diyaarsadaa oo uu mashquul yahay dhowr bilood ka hor. Ka qaybqaateyaashu waxa ay tilmaameen in ay nidaamyadu u fiican yihiin turjumaannada loo sii diyaarsado muddooyin kaladuwan – tusaale ahaan, marka loogu baahan yahay shaqada joogto ah ee qoys loo wado, Shirarka CP iyo Kooxaha Daruuri ah. Waxa ay taasi keenaysaa in ay tiro yaraadaan turjumaannada diyaar ah, oo marar dhif ah yimaadda saacadda sax ah ee loo baahan yahay, marka loo rabo arrimaha sida baaritaannada CP ee degdeg ah – sida imaanshaha waaxda gurmadka degdeg ah ee isbitaalka, waraysiyada Qodobka 47 ee sharciga iyo baarista caafimaadka ee ilaalinta carruurta, iyo guud ahaan waxqabadyada saacadaha aanan la shaqaynin. Waa maxay tirada kiisaska ee ay taasi saamayso, oo sidee ayay kuwaasi u faafsan yihiin – xaafadda, gobolka, qaranka? Imisa kiis ayaa turjumaanno u baahan oo sidaas darteed suurogal ay tahay in ay dhibaatadaasi saamayso? Isla sida xaafado farabadan oo London ku yaalla iyo magaalooyinka kale ee Ingiriiska, Lambeth waa xaafad laga helo jinsiyado farabadan. Waxa ay si joogto ah ugu jirtaa qiyaasta boqolkiiba 10 ah ee ugu sarraysa tirada muhaajiriinta caalamiga ah ee sanadkii kaste (fiiri Wararka ugu door roon ee Tirakoobkii 2011kii). Dadka luqadda Ingiriisigu ay u tahay luqaddooda hooyo ee xaafadda ku nool waxa ay ka soo dhaceen boqolkiiba 76.2 ee shacabka oo ay ahaayeen sanadkii 1992kii, waxa ayna gaareen boqolkiiba 51.5 sanadkii 2012kii. Kooxda Dib u eegidda waxaa u suurtogeli weydey in ay helaan macluumaadka ku saabsan tirada baaritaannada ilaalinta carruurta ee xaafadda Lambeth ee ay ku jiraan carruur iyo/ama qoysas turjumaanno u baahan, laakiin waxa ay ku qiyaaseen in la filanayo in ay kuwaasi aad u tiro badan yihiin. Sidee ayay u faafsan tahay dhibaatada ka jirta helitaanka turjumaannada marka loo baahdo? Kooxda Dib u eegiddu ma helin macluumaad lagu kalsoonaan karo oo su’aashaas ku saabsan laakiin sida kor ku qayaxan, gargaarka laga helay Kooxda Kiiska ayaa tilmaamay in dhibaatooyinka ka jira helitaanka turjumaannadu ay ku faafsan yihiin xaafadda Lambeth, iyada oo weliba aanan la kala dooran karin jinsiga turjumaanka diyaar ah. Waxaa la filanayaa in dhibaatooyinkaasi ay sidoo kale u haystaan dawladaha hoose ee Lambeth SCR Child H Confidential draft report 8 January 2014 31 kale ee London iyo dalka oo dhan ee dad kaladuwan ay ku badan yihiin, laakiin Kooxda Dib u eegiddu ma hayaan macluumaad rasmi ah oo taas ku saabsan. Waa maxay dhibaatooyinka ay u keenayso ku kalsoonaanta nidaamka Ilaalinta Carruurta ee hay'ado farabadan? Wadaxiriirka lala yeesho carruurta iyo xubnaha qoyskooda ayaa daruuri u ah shaqada dhawritaanka iyo ilaalinta carruurta. Marka lagu jiro xaafad iyo magaalo dhaqanno badan, waxaa lama huraan ah in loo baahan doono in wadaxiriirka lagu suurtogeliyo oo lagu taageero adeegyo turjumaan oo tayo sare leh, welibana madaxbannaan oo loogu talagalay luqado kaladuwan. Marka la eego nooca shaqada, waxaa loo baahan yahay in adeegyadaas la helo waqtiga loo rabo shaqada sii qorshaysan iyo weliba midda aanan qorshaysnayn, ee degdeg ah. Hase yeeshee, waxa ay natiijadani muujinaysaa in xaaladdu aanay marwalba sidaas u ahayn hay’adaha Lambeth, iyo isbitaalka ay qoyskani tageen. Noocyada, diyaar ahaanta iyo tayada turjumaannada ee waqtiga xaadirka ah ayaa u kaladuwan shaqada sii qorshaysan, laakiin wixii khuseeya soo gudbinta dhakhso ah ee ilaalinta carruurta iyo xaaladaha kale ee degdeg ah ee yimaadda, sida carruurta dhaawacyo qaba ee taga waaxda gurmadka degdeg ah ee isbitaalka, xaaladdu way u sii daran tahay, iyada oo adeegyada ay si caadi ah ugu adag tahay in ay helaan turjumaanno tayo fiican leh oo ay isku hallayn karaan. Waxaa sidaas ku sii suurogal yar in ay tayo hagaagsan yeelan doonaan qiimaynta halista ee daruuri ah ee xaaladahaas loogu baahan yahay, iyo go’aannada taas ku salaysan, si loogu taageero shaqadaas dhib badan. Waxaa markaa dhici karta in dadka labada dhinac ka soo jeeda ay si xun isu fahmaan iyo, mararka qaar, in waalidku ay xirfadleyaasha been uga sheegaan waxa dhacay. Natiijada 3. Noocyada, diyaar ahaanta iyo tayada turjumaannada ee waqtiga xaadirka ah ayaa dhibaato ah; shaqada sii qorshaysan way u kala duduwan tahay, xaaladaha degdeg ah marka ay yimaaddaanna, aad ayay u liidataa waxa ayna sidaas u keenaysaa halista ah in aanay taageero helin isticmaaleyaasha adeegga ee aanan luqadda Ingiriisiga ku hadlin, taas oo xirfadleyaasha aad iyo aad ugu adkaynaysa in ay waqtiga habboon ku fuliyaan qiimayn ama natiijo waxtar leh. Turjumaannada tayo fiican leh, ee la heli karo waqtiga loo baahan yahay, ayaa si daruuri ah qayb uga ah nidaamka nabad leh ee wax loogu qabto qoysaska nuglan ee ka soo jeeda asallo jinsiyadeed oo kaladuwan, taas oo gaar ahaan muhiim u ah xaafadda Lambeth ee jinsiyado badan. Waxaa dib u eegiddan lagu soo ogaaday in tirada yar ee guud ee turjumaannadu ay keenayso in caadi ahaan hore loogu diyaarsado turjumaannada fiican, oo kuwaas loo waayo arrimaha degdeg ah ama dhakhso ah ee ay ka mid yihiin waraysiyada CP, baarista caafimaadka ee CP, iyo imaanshaha waaxda gurmadka degdeg ah ee isbitaalka. Lambeth SCR Child H Confidential draft report 8 January 2014 32 Waxa ay taasi yaraynaysaa ku kalsoonaanta in nidaamka ilaalinta carruurta ee hay’ado farabadan uu si fiican u hirgalo, taas oo horjoogsanaysa kartida ay xirfadleyaashu u leeyihiin in ay wadaxiriir waxtar leh la yeeshaan carruurta iyo waalidkaba taas oo markaana suurtogelinaysa in carruurta ay u korodho halista waxyeelladu. Arrimaha ay Guddiga iyo hay’adaha xubin ka ah u baahan yihiin in ay ka fiirsadaan: Miyay Guddigu ka war hayaan meelahaas dhibaatadu ka jirto ee ka mid ah adeegyada turjumaannada? Waa maxay ra’yiga ay Guddigu ka qabaan saamaynta ay taasi ku leedahay shaqada CP, gaar ahaan shaqada CP ee dhakhso ah? Miyay taasi tahay xaalad la aqbali karo? Waa maxay carqaladaha hortagaan wanaajinta xaaladdaas (xataa maalgelinta)? Ma jiraa waxqabad ku baahsan London oo waxtar yeelan kara – matalan, xaafado kaladuwan oo shaqaalaha loo diro? Miyay Guddigu ka war hayaan sida loo qabto qiimaynta baahiyaha adeegyada turjumaannada iyo haddii ay xaaladda ku filan yihiin? Miyay hay’adaha Guddigu hore u wadaageen macluumaadka ku saabsan sida ay u hirgalaan qandaraasyadooda kaladuwan iyo adeegyadooda turjumaannadu – iyo sida loola socdo? Waa maxay fursadaha diyaar ah ee lagu xallin karo tirooyinka dhiman ee lagu soo ogaaday dib u eegidda kiiskan? Sidee ayuu dabagalka qandaraasyadu ugu fiican yahay in lagu soo ogaado marka ay xaaladdu fiican tahay, wanaajin u baahan tahay, ama wanaajin lagu sameeyey? Miyaa loo baahan yahay in wax laga beddelo macluumaadka la soo qaado lana baaro? Khadka luqadda ee Language Line ayay dhowr hay’adood si joogto ah u isticmaalaan. Ma jirtaa hagis ku saabsan xaaladaha aanay taasi ku filnayn – matalan, marka ay muhiim tahay in calaamado kale laga helo ilmaha ama qofka weyn iyaga oo fool-ka-fool loola hadlo? 2.8 Natiijada 4. Sida looga war hayo marka aanay soo noqnoqod lahayn dhacdooyinka rabshadda gurigu, waxa ay xirfadleyaashu badi aaminaan in ay carruurtu ku wanaag qabaan guriga oo/ama waxa ay u arkaan in ay tiro yar yihiin sababaha ay ugu baahan yihiin in ay si go'an ula hawlgalaan waalidka. Waxa ay taasi keentaa in aanay fahan dheeraad ah ka helin sababaha ka dambeeya iyo waxyaabaha dhaliya dhacdooyinka rabshadda guriga, iyo heerka dhab ah ee halista ay kuwaasi carruurta u suurtogelinayaan. Shaqada ilaalinta carruurta waxaa loogu baahan yahay in ay xirfadleyaashu isku dayaan in ay mustaqbalka saadaaliyaan, iyaga oo qiyaasaya Lambeth SCR Child H Confidential draft report 8 January 2014 33 waxyeellada iyo halisaha waqtiga xaadirka ah ku wajahan carruurta. Wixii khuseeya kiisaska rabshadda guriga, waxaa taas ka mid ah in lala shaqeeyo waalidka si loo baaro dhacdooyinkii hore si markaa fahan dheeraad ah looga helo sababaha ka dambeeya iyo waxyaabaha dhaliya rabshadda iyo ahmiyadda ay u leeyihiin si loo yareeyo halista weli jirta iyo dhacdooyinka suurogal ah in ay mustaqbalka yimaaddaan. Waxa uu kiiskani shaaca ka qaaday in xirfadleyaasha hay'adaha farabadan ay caado u leeyihiin in ay ahmiyad weyn siiyaan haddii la og yahay in ay rabshadda gurigu waqtiga xaadirka ah socoto, marka loo barbar dhigo eegidda waxa dhacdooyinkii hore ee rabshadda gurigu ay ka sheegayaan halista iminka jirta iyo midda mustaqbalka iman karta. Waxa ay taasi keenaysaa dhibaatooyin ka yimaadda kalsoonida iyo xirfadaha shaqaaluhu ay u leeyihiin in ay hirgeliyaan dhinacyada ka mid ah qorshooyinka ilaalinta carruurta ee ku saabsan rabshadda guriga, marka dhibaatada ugu weyn ee laga walaac qabo ay u muuqato in ay 'maqan tahay' ama ay dhammaatay. Waxaa markaa iman karta fikrad qalad ah oo la samaysto oo ah in halisuhu ay yaraadeen iyada oo ay dhab ahaan weli suurogal tahay in ay halistu weyn tahay, marka ay xirfadleyaashu fahmi waayaan sababaha ka dambeeya iyo waxyaabaha dhaliya rabshadda. Xataa marka shaqaaluhu ay ka war hayaan in ay halistu weli jirto, haddana waxaa 'xayirmi' kara kiisaska, iyada oo xirfadleyaashu aanay hubin sida ay xaaladda u beddeli karaan. Sidee ayay dhibaatadu uga muuqatay kiiskan gaar ah? Walaalka 1 ayaa la geliyey Qorshaha CP, kaas oo ka dib wax laga beddelay si loogu daro labada carruur ee kale. Waxaa kaas loogu talagalay in lagu ilaaliyo carruurta iyada oo la adeegsanayo laba xeeladood oo isbarbar socda: taageerada qoyska ee la siiyo labada waalid, iyo tallaabooyin wax lagaga qabto rabshadda guriga ee ka dhex jirta qoyska. Waxaa loo baahnaa in Hooyo ay aqbasho oo ay hesho talobixin ay isku ilaaliso oo uga timaadda adeegga takhasus leh ee rabshadda DV, GAIA. Waxaa weliba lagu adkeeyey in 'Aanan lala iman karin rabshadda DV oo dheeraad ah ama muran gacan la isula tago haba yaraatee, taas oo weliba aanan ka dhici karin meesha uu joogo Walaalka 1'. Bayaanka ku saabsanaa xaaladda iman karta ee ku jiray diiwaannada Kooxda Daruuri ah ayaa tilmaamayey, haddii qoysku ay taas addeeci waayaan, in lagu fikiri doono in tallaabo sharciyeed laga qaado. Waxa ay qoysku si fiican uga qayb galeen qaybihii taageerada qoyska ee qorshaha, laakiin sidaas uguma dhaqaaqin tallaabooyinkii ku saabsanaa rabshadda guriga. Tusaale ahaan, Hooyo waxa ay diidday in ay u tagto adeegga GAIA sidii looga rabay. Waqtigaas gudihiisa, ma imanin dhacdooyin kale oo rabshadda guriga ahaa oo laga war hayey. Maadaama uu fogaa waqtigii ay dhacdadii hore timid, ee aanan dhacdooyin kale laga war helin, niyadda ayaa u degtay xirfadleyaasha intooda ugu badan waxa ayna la ahayd in ay yaraatay sababta loogu baahnaa in tallaabo adag laga qaado qoyska, oo kooxda hay'adaha farabadan dhexdooda diiradda lagu hayo rabshadda guriga. Hadba sidii ay u sii durugtay dhacdadii rabshadda guriga ee ugu horraysay, ayay dadka qoyska wax u qabanayey u sii qaateen fikradda ah in aanay jirin sabab loogu baahan yahay in carruurtu ay ku sii jiraan Qorshooyinka CP – inkaste oo aanan dhab ahaan si fiican looga war haynin xiriirka ka dhexeeyey waalidka iyo caadada uu aabbe rabshadda u lahaa. Lambeth SCR Child H Confidential draft report 8 January 2014 34 Waxa uu kiiskani lahaa sifo si gaar ah xirfadleyaasha ugu adkayd in ay maamulaan: waalidka oo ku adkaysanayey in aanay iyaga weligood rabshadi dhexmarin. Xirfadleyaashu waxa ay ogaayeen in aanay taasi run ahayn, marka la raaco taariikhda ay hayeen booliiska, isbitaalka iyo shaqaalaha xarunta hoysiinta haweenku, laakiin waxa ay ku guuldarraysteen in ay waalidka midkood ku dirqiyaan in uu si furan ula sii eego taariikhdii hore iyo halista mustaqbalka. Markii ay baarayeen wixii ka dambeeyey diidista in si ku filan oo waxtar leh looga qayb qaato dib u raacidda taariikhda rabshadda guriga iyo baarista halista joogto ah ee qoyska ku wajahnayd, waxa ay Kooxda Dib u eegiddu ka wada hadleen dhibaatada ka imanaysay rabshadda hore ama hadda ee ay waalidka gebi ahaan diiddanaayeen. Gargaarka laga helay CSC ayaa shaaca ka qaaday in diidistaas dhacdooyinka, iyo wadahadalka ku saabsan rabshadda DV, ay ku sii xumayd dhacdooyinka kale ee rabshadda ee aanan soo shaac bixin ka dib markii ay waalidku isku soo noqdeen. Waxa ay taasi tahay xaalad caadi u ah shaqada laga qabto kiisaska rabshadda DV, markaas oo dhacdooyinka kale ee rabshadda ee dhab ahaan yimaadda ama suurogal ah ay qariyaan dembiilaha iyo dhibbanaha labadooduba (iyo mararka qaar weliba carruurtooda). Waxaas oo dhan waxaa laga fahmayaa sababta ay u sii adkaatay, ee laga yaabo ay u ahmiyad yaraatay, in laga hortago diidista waalidka ee dhacdooyinkii rabshadda ee ugu horreeyey, ama run ahaan dhibaatada halista weli jirtay. Hadba sidii ay u sii durugtay dhacdadii keentay in Hooyo ay ka cararto rabshadda DV, waxaa sii yaraatay saamaynta ay dhacdadaasi lahayd. Ficilcelinta xirfadleyaasha ayaa tilmaamaysa, halkii ay ugu xirnaan lahayd xirfadaha maqnaa, in dhibaatada aasaasi ah ay siyaado ugu xirnayd fikradda rabshadda laga samaysanayey (dhacdo ahaan ama hawl ahaan) iyo dhibaatooyinka taas uga yimid fahanka halista. Sidee ayaan u og nahay in aanay ahayn cillad u gaar ah kiiskan? Kooxda Dib u eegidda iyo Kooxda Kiiska ayaa gartay in caado hore loo yaqaannay ay ka muuqatay sida ay xirfadleyaashu kiiskan uga jawaabceliyeen dhanka qiimaynta halista rabshadda guriga. Dhowr dib u eegid ee SCR ayaa muujiyey in ay adag tahay in ay xirfadleyaashu ka hortagaan oo ay la murmaan waalidka u muuqda in ay addeecid leeyihiin oo ay wax maqlayaan ('addeecidda beenbeen ah'). Iyada oo taas siyaado ku ah, marka ay jirto diidista joogto ah ee rabshadda guriga ee waqtiga xaadirka ah, waxaa shaqaalaha ku adag in ay si firfircoon oo digtooni leh u wadaan qiimaynta dhacdooyinka suurogal ah ee mustaqbalka, sababaha ka dambeeya iyo waxyaabaha dhaliya, sidaas darteedna halista weli ku wajahan waalidka/dhibbaneyaasha iyo carruurta. Dadka dib u eegiddan ka qayb qaatay ayaa sharraxay in maxkamaduhu ay ku dhiirrigeliyaan in sidaas diiradda loo saaro rabshadda DV ee hadda jirta ee laga war hayo iyaga oo sidaas ku soo ogaada heerka halista ee ku xiran dhacdooyinka dhab ahaan yimaadda halka kuwa suurogal ah. Marka aanay jirin dhacdooyin kale oo laga soo warbixiyo, CSC iyo hay'adaha ay iskaashadaan ayaa u arka in daliilka loogu baahan yahay si waalidka loogu sii adkeeyo in ay dhammaystiraan Lambeth SCR Child H Confidential draft report 8 January 2014 35 tallaabooyinka laga sugayo, ama loogu guuro goobta maxkamadda, uu sii daciifayo hadba Shir kaste oo dhaca. Waqti ka dib, iskaashatada xirfadeed ayay badi niyaddu u degtaa marka ay iman weydo rabshad kale oo guri oo laga war hayo, iyo marka carruurta loo arko in ay meel fiican marayaan oo ay waalidku u muuqdaan in ay si fiican u daryeelaan. Marka aanay jirin dhacdooyin rabshad oo laga war hayo, waxa ay u muuqataa in ay sii yaraanayso sababta loogu baahan yahay in la hirgeliyo qorshaha ama tallaabooyinka laga qaado xaaladaha yimaadda – inkaste oo aanan laga war haynin heerka dhab ah ee halista jirta oo ay dhici karto in ay taasi weli weyn tahay. Run ahaan, waxaa sii yaraanaya fursadaha ka jira hawsha si rasmi ah loo qaban karo (matalan, iyada oo la adeegsado dacwadda maxkamadda). Kooxda Dib u eegiddu waxa ay si taxaddar leh uga fiirsadeen sida fiican ee ay xirfadaha iyo waayo aragnimada shaqaaluhu iyaga ugu diyaariyaan si ay shaqo waxtar leh uga qabtaan qaybtaas shaqada ee dhib badan, waxa aanan aqoonsannay in shaqaaluhu ay leeyihiin xirfado kaladuwan. Laakiin waxa ay u muqataa in xaaladaha diidista dhacdooyinka ee caadi ahaan ka jira kiisaska rabshadda DV – oo lagu daray la'aanta dhacdooyin kale oo laga war hayo – ay weli dhibaato ballaaran ku tahay shaqaalaha iyo maamuleyaashooda, sidii ay ula hawlgeli lahaayeen waalidka oo ay qiimayn hagaagsan uga samayn lahaayeen halista jirta. Sida kor ku qayaxan, waxaa jiray arrin kale oo dhibaato dheeraad ah u keenay kiiskan, kaas oo ahaa Hooyada oo ka noqotay dhacdadii rabshadda DV ee ay hore u sheegtay. Waxaa jira sifooyin la garanayo oo caadi u ah shaqada laga qabto kiisaska dayacaadda ee soo noqnoqod leh, goortaas oo ay adkaan karto in la sii wado hawlo wax ku ool ah – ilaa marka ay 'dhacdo' kale timaaddo, taas oo lagu xiri karo tallaabada ilaalinta ama badbaadinta ee ay ururradu qaadaan. Waa maxay tirada kiisaska ee ay taasi saamayso, oo sidee ayay kuwaasi u faafsan yihiin – xaafadda, gobolka, qaranka? Waxa ay natiijadani ku saabsan tahay caadada ay xirfadleyaashu u leeyihiin in ay heerka halista carruurta ku wajahan u qiimeeyaan si ku salaysan haddii la og yahay in rabshadda gurigu ay waqtiga xaadirka ah qoyska ka dhex socoto, halkii ay ka fahmi lahaayeen haddii ay suurogal tahay in ay taasi dhacdo iyo sida ay u dhici karto marka la eego xaalad mustaqbalka iman karta. Sida lagaga hadlay Natiijada 1, rabshadda gurigu waxa ay ku badan tahay oo ay ku faafsan tahay Ingiriiska (fiiri tirooyinka ku qoran Lifaaqa 3). Xaafadda Lambeth gudaheeda, sanadkii tagay ku dhawaad 400 oo carruur ah ayaa lagu qiyaasay in ay ku nool yihiin guryo ay saamayso rabshadda guriga ee ugu daran. Waxa ay taasi tilmaamaysaa in ay suurogal tahay in dhibaatadaasi ay saamayso kiisas iska farabadan. Annaga suurogal nooma noqonin in aan soo ogaanno sida ay u faafsan tahay caadada ay xirfadleyaashu u leeyihiin in ay diiradda saaraan dhacdooyinka rabshadda guriga ee dhab ahaan hadda jira, halkii ay ka eegi lahaayeen sababaha ka dambeeya iyo waxyaabaha dhaliya dhacdooyinkii hore iyo kuwa mustaqbalka iman kara. Lambeth SCR Child H Confidential draft report 8 January 2014 36 Waa maxay dhibaatooyinka ay u keenayso ku kalsoonaanta nidaamka ilaalinta carruurta ee hay'ado farabadan? Nidaamka ilaalinta carruurta ee nabad leh waxaa loogu baahan yahay in si fiican wax looga qabto halista iyo suurogalka; kuma filna in si ficil celin ah looga jawaabceliyo dhacdada waxyeellada ee ilmaha loo geysto. Hase yeeshee, waxa ay natiijadani diiradda saaraysaa in jawaabcelinnada xirfadeed ee laga bixiyo rabshadda guriga ee ka dhex jirta qoysasku aanay si fiican ugu hirgelin si hore loogu dhaqaaqo hawlaha carruurta dan u ah. Ogaanshaha rabshadda guriga ee waqtiga xaadirka ah qoyska ka dhex socota ayaa badi lagu qiimeeyaa heerka halista loo arko in ay carruurta ku wajahanto iyo baahida loo qabo hawlgal go'an oo lala yeesho waalidka, iyada oo markaa si xun loo fahmo sababaha ka dambeeya iyo waxyaabaha dhaliya dhacdooyinkii hore iyo kuwa mustaqbalka iman kara. Kiiskani waxa uu tilmaamayaa dhan u iilasho caadi ahaan ka jirta sida ay xirfadleyaashu wax uga qabtaan kiisaska rabshadda guriga iyada oo markaa waqtiga xaadirka ah loo tixgeliyo si ka badan waqtigii tagay. Markaa kiisaska rabshadda guriga ee aanan lahayn soo noqnoqodka dhacdooyinka ayaa badi laga soo qaadaa in ay halistu ka yaraatay oo aanan sidii hore loogu baahnayn in la hirgeliyo hawlaha la xiriira rabshadda guriga. Natiijada 4. Sida looga war hayo marka aanay soo noqnoqod lahayn dhacdooyinka rabshadda gurigu, waxa ay xirfadleyaashu badi aaminaan in ay carruurtu ku wanaag qabaan guriga oo/ama waxa ay u arkaan in ay tiro yar yihiin sababaha ay ugu baahan yihiin in ay si go'an ula hawlgalaan waalidka. Waxa ay taasi keentaa in aanay fahan dheeraad ah ka helin sababaha ka dambeeya iyo waxyaabaha dhaliya dhacdooyinka rabshadda guriga, iyo heerka dhab ah ee halista ay kuwaasi carruurta u suurtogelinayaan. Nidaamka ilaalinta carruurta ee nabad leh waxaa loogu baahan yahay in si fiican wax looga qabto halista iyo suurogalka; kuma filna in si ficil celin ah looga jawaabceliyo dhacdada waxyeellada ee ilmaha loo geysto. Hase yeeshee, waxa ay natiijadani diiradda saaraysaa in jawaabcelinnada xirfadeed ee laga bixiyo rabshadda guriga ee ka dhex jirta qoysasku aanay si fiican ugu hirgelin si hore loogu dhaqaaqo hawlaha carruurta dan u ah. Ogaanshaha rabshadda guriga ee waqtiga xaadirka ah qoyska ka dhex socota ayaa badi lagu qiimeeyaa heerka halista loo arko in ay carruurta ku wajahanto iyo baahida loo qabo hawlgal go'an oo lala yeesho waalidka, iyada oo markaa si xun loo fahmo sababaha ka dambeeya iyo waxyaabaha dhaliya dhacdooyinkii hore iyo kuwa mustaqbalka iman kara. Kiiskani waxa uu tilmaamayaa dhan u iilasho caadi ahaan ka jirta sida ay xirfadleyaashu wax uga qabtaan kiisaska rabshadda guriga iyada oo markaa waqtiga xaadirka ah loo tixgeliyo si ka badan waqtigii tagay, oo si ku filan loogama hortago oo loogama doodo diidista dhacdooyinka ee waalidka. Markaa kiisaska rabshadda guriga ee aanan lahayn soo noqnoqodka dhacdooyinka ayaa badi si qalad ah looga soo qaadaa in ay halistu ka yaraatay waxaana sidaas lagu yareeyaa Lambeth SCR Child H Confidential draft report 8 January 2014 37 walaaca laga qabo iyo tallaabada loo baahan yahay in laga qaado. Arrimaha ay Guddiga iyo hay’adaha xubin ka ah u baahan yihiin in ay ka fiirsadaan: Miyay Guddigu garanayaan in ay taasi tahay caado la yaqaanno? Sidee xirfadleyaasha looga taageeri karaa in ay diiradda ku hayaan rabshadda guriga marka aanan la ogayn in ay dib u dhacday muddada ay xirfadleyaashu qoyska ku hawlan yihiin? Waa maxay nooca macluumaadka ee loo baahan yahay in la soo qaado si Guddiga loo ogaysiiyo haddii shaqada dhinacaas laga wanaajiyey? Waa maxay nooca qiimaynta halista ee 'ugu yaraan' loo baahan yahay in laga qaado dembiilaha si loogu taageero Qorshaha CP ee waxtar leh? Oo waa maxay sida habboon in taas marwalba looga muujiyo Qorshooyinka CP? Sidee ayaa xiriirrada hay'adaha farabadan looga caawin karaa in kiisaska 'xayiran' ay u horumariyaan si lagu yaraynayo halista waxyeellada ee carruurta ku wajahan? 2.9 Natiijada 5 – Dadaalka ay shaqaalaha daryeelka bulsheed iyo booliisku ugu jiraan in ay xirfadleyaasha caafimaadka ka helaan sharraxaadda cad ee sababta dhaawaca jirka ee carruurta ayaa khilaafsan caadada ay xirfadleyaasha caafimaadku u leeyihiin in ay bixiyaan natiijooyin kaladuwan oo keenaya in wax kaste uu suurogal yahay ilaa meesha laga saarayo. Waxa ay taasi sii suurtogelinaysaa isfahanwaaga ku saabsan halisihii hore iyo kuwa mustaqbalka marka la wado baaritaannada ilaalinta carruurta. Xiriirrada dhawritaanka ee hay'adaha farabadan ayaa u baahan in ay si waxtar leh u wada shaqayn karaan una wada xiriiri karaan marka ay ka jawaabcelinayaan dhacdooyinka daran ee ilaalinta carruurta. Hawsha lagu maamulo laguna qabto baaritaannada Qodobka 47 ee sharciga iyo baaritaannada dembiyeed waxaa ku lug leh waaxda daryeelka bulsheed, booliiska iyo xirfadleyaasha caafimaadka (iyo laga yaabo dad kale, taas oo kiiska ku xiran). Waa in ay wadajir u qorsheeyaan oo ay u qabtaan hawlaha loo baahan yahay si loogu baaro habka suurogal ah in ay dhaawacyadu u yimaaddeen iyo goorta ay yimaaddeen, cidda laga yaabo in ay kuwaas keentay, iyo si carruurta loogu hubiyo badbaadadooda degdeg ah iyo mustaqbalka. Taasi waa hawl dhib badan, maadaama ay shaqaalaha kaladuwan la yimaaddaan xirfadahooda gaar ah, khibraddooda iyo aqoontooda takhasus leh, iyada oo hay'adaha ilaalinta carruurta ee hoggaanka haya (daryeelka bulsheed ee carruurta iyo Booliisku) ay masuul ka yihiin in ay jiheeyaan hawsha Qodobka 47 ee sharciga. Habka loo qabtay baaritaankii ka dambeeyey markii Walaalka 2 la keenay waaxda gurmadka degdeg ah ee isbitaalka ayaa muujiyey caadooyin ka jira Lambeth SCR Child H Confidential draft report 8 January 2014 38 wadaxiriirka ka dhexeeya xirfadleyaasha caafimaadka, daryeelka bulsheed iyo booliiska oo suurtogelinaya xaaladaha qarsoon ee qaladaad u keeni kara hawshaas daruuri ah. Sidee ayay dhibaatadu uga muuqatay kiiskan gaar ah? Ka dib markii Walaalka 2 la keenay waaxda gurmadka degdeg ah ee isbitaalka isaga oo jirka ku qabay dhaawac daran, waxaa la qabtay Kulanka Xeeladda ku saabsan oo lala raagay. Waxa ay ujeeddada kulanku ahayd in la isweydaarsado macluumaadka iyo fikradaha laga qabay halista iyo in laga go'aan gaaro baaritaanka dheeraad ah ee loo baahnaa in la qabto. Haddana goortaas, waxaa diiradda ugu badnaan la saaray fikradda ay shaqaalaha caafimaadeed ka qabeen dhaawaca jirka ee gaaray Walaalka 2. Gargaarka laga helay Kooxda Kiiska ayaa shaaca ka qaaday in xirfadleyaasha kulanka ka qayb galay ay fikrado kaladuwan ka qabeen waxa ay sheegeen dadka ay la shaqeeyaan iyo waxa ay uga jeedeen. Iyada oo ugu muhiimsan, dadka ka socday caafimaadka iyo kuwa ka socday daryeelka bulsheed ee carruurta iyo booliisku waxa ay kulanka kala baxeen fahanno kaladuwan oo ku saabsan haddii sababta keentay dhaawaca Walaalka 2 ay ahayd mid shil ku timid ama mid aanan shil ku imanin (NAI). Takhtarka qalliinka ee Xirfad gaar ah u leh Addimada (Consultant Orthopaedic Surgeon) ee dhallaanka ayaa u arkayey in uu si cad u sheegay in aanan weli la hubin sababta dhaawaca. Hase yeeshee, shaqaalaha aanan caafimaadka ku hawl lahayn waxa ay fikradda takhtarka qalliinka u qaateen in ay ka dhignayd in 'marka la isku dheellitiro dhaawacu uu ahaa mid shil ku yimid'. Haddana waqtigaas dadka labada 'dhinac' ka soo jeeday midna ma ogayn fahankaas kaladuwan ee xaaladda laga qaatay. Fikradda shaqaalaha caafimaadeed ay ka qabeen dhaawaca ee carrabka lagu saaray kulanka dhexdiisa ayaa weliba dadka ka jeedisay dhinacyada kale ee muhiim ah ee ka mid ah qiimaynta halista ee habbonayd in laga wada hadlo, sida sharraxaadda kaladuwan ee ay waalidku bixiyeen, horumarka laga gaaray xaqiijinta sharraxaaddooda, iyo halisaha weli ku wajahnaa carruurta kale. Sidee ayaan u og nahay in aanay ahayn cillad u gaar ah kiiskan? Hawsha Kooxda dib u eegidda waxaa muhiim u noqotay in ay dhibaatadaas hoosta ka eegaan. Wadahadallada ka dhex dhacay Kooxda Dib u eegidda iyo Kooxda Kiiska ayaa lagu xaqiijiyey fikradda ah in, adeegga CYPS iyo Booliiska dhexdooda, uu aad u weyn yahay dadaalka ay u galaan in ay shaqaalaha caafimaadka ka helaan macne cad oo ay ka bixiyaan sida uu dhaawaca jirku u yimid. Taasi waa wax la fahmi karo, maadaama fursadaha suurogal u ah ee ay ku ilaalin karaan ilmaha ay xaaladdaasi halis u keenayso waxa ay ku salaysan yihiin daliil cad oo sax ah oo, tusaale ahaan, maxkamadda lala tagi karo. Ka qaybqaateyaasha waxa ay la ahayd in ay taasi muhiim ugu sii tahay dhaawacyada jirka, marka loo barbar dhigo kiisaska ku saabsan xadgudubka galmeed ee laga shaki qabo ama heerka daryeelka ee aanan la aqbali karin. Wadahadalka dhexmaray Kooxda Dib u eegidda ayaa weliba lagu xaqiijiyey in ay iskhilaafsan yihiin baahidaas ay shaqaalaha daryeelka bulsheed iyo booliisku u qabaan in ay sharraxaad cad ka helaan shaqaalaha caafimaadka, Lambeth SCR Child H Confidential draft report 8 January 2014 39 iyo caadooyinka xirfadleyaasha caafimaadka laftigooda. Gargaarka laga helay ka qaybqaateyaasha ayaa shaaca ka qaaday sida uu takhtarka qalliinku u sheegay fikradda ay shaqaalaha caafimaadku ka qabeen kiiskan, iyo in ay taasi caadi tahay. Takhtarka qalliinka ee Xirfad gaar ah u leh Addimada ee dhallaanka ayaa sheegay in 'ay dhici karto in dhaawacu uu ku toosan yahay sheekada waalidka'. Isla sida xubnaha Caafimaadka ee Kooxda Dib u eegidda, waxa uu isagu bayaankaas u fahmayaa in uusan meel keliya ku tilmaamayn sababta dhaawaca laakiin ay weli bannaan tahay. Waxa ay iyagu taas u arkayeen marxalad ka mid ahayd nidaamka lagu bixiyo 'natiijooyin kaladuwan' – waxaana ka mid ah mabda'a dhigaya in 'wax kaste uu suurogal yahay ilaa meesha laga saarayo'. Hase yeeshee, shaqaalaha aanan caafimaadka ku hawl lahayn ayaa bayaanka takhtarka qalliinka u qaatay in uu ka dhigan yahay in 'marka la isku dheellitiro dhaawacu uu ahaa mid shil ku yimid'. Qof Kooxda Dib u eegidda ka mid ahaa oo ka socday dhanka Caafimaadka ayaa si fiican khilaafka u soo koobay: “Marka aan waayo aragnimadayda dib u raaco, taasi waa khatar caadi ahaan ka jirta kulannada xeeladda ku saabsan waana natiijo meelo kale lagu toosin karo. Sababta ay taasi ku timaaddo waxa weeyaan takhaatiirta oo aanan si fiican u fahansanayn in hawlwadeennada bulsheed iyo booliisku ay sugayaan in ay ka maqlaan fikrad cad oo ay ku qorshayn karaan baaritaanka intiisa kale (oo haddii ay taas maqli waayaan waxaa laga yaabaa in aanay baaritaanka hore u socodsiin karin) welibana hawlwadeennada bulsheed iyo booliiska ayaanan garanayn in ay suurogal tahay in dhegeysanayaan wadahadal ku saabsan fikradaha la qabo halka go'aanka kama dambays ah. Dhab ahaan, helitaanka fikradda go'an waa hawl badi lagu celceliyo – oo ka kooban dad soo baara taariikhda, dad kale oo codsada gargaar takhasus leh oo dheeraad ah ama baaritaanno dheeraad ah. Waxaa loo baahan yahay in loo dulqaato (loona qorshaysto) shakiga jira si hawshaasi ay u dhici karto”. Xubnaha Kooxda Dib u eegiddu waxa ay taas ka arkeen hadba sida ay xirfadleyaasha caafimaadku ugu sii khibrad leeyihiin shaqada ilaalinta carruurta, in ay ku sii fiican yihiin in ay ka gudbaan farqiga u dhexeeya fikradaha kaladuwan ee ay dadku sugayaan, iyaga oo macneeya marxaladaha ka mid ah hawsha lagu gaaro natiijooyinka kaladuwan oo dadka taxaddar kula taliya marka habboon. Waa maxay tirada kiisaska ee ay taasi saamayso, oo sidee ayay caadadu u faafsan tahay – xaafadda, gobolka, qaranka? Waxaa la filanayaa in kiisas farabadan ay ka muuqato dhibaatada ka jirta qiimaynta haddii dhaawacyadu ay keenayaan walaaca ku saabsan ilaalinta carruurta iyo haddii kale. Waxaa aad u farabadan soo gudbinta ilaalinta carruurta ee loo soo diro adeegga CYPS iyo shaqada CP ee ay ku lug leeyihiin hay'adaha la kaashado, waxa ayna aad u korodhay sanadihii ugu dambeeyey. Jadwalka hoose ayaa ka hadlaya tirada baaritaannada Qod47 (iyada oo qaar farabadan oo kuwaas ka mid ah lagaga jawaabceliyey 'dhacdooyinka' waxyeellada jirka) ee laga qabtay Lambeth iyo dalka oo dhan saddexdii sano ee ugu dambeeyey ee laga helay tirakoobka la hayo. Lambeth SCR Child H Confidential draft report 8 January 2014 40 Sanadka Lambeth Ingiriiska Caddadka Ingiriiska ee 10,000kii carruur 09/10 402 89,300 81.1 10/11 561 111,700 101.1 11/12 729 124,600 109.9 Isha: Wasaaradda Waxbarashada (Department for Education) Waxa aan annagu weliba haynaa daliil tilmaamaya in jahwareerka ka dhex yimaadda daliilka caafimaadeed iyo noocyada kale ee ku saabsan jiritaanka xadgudubku uusan ku koobnayn xaafadda Lambeth. Dib u eegidyada SCR ee dhawaan laga qabtay dalka oo dhan ayaa lagu soo ogaaday habdhaqan xirfadeed oo noocaas oo kale ah, iyada oo sharraxaadyada kale ee ku saabsanaa waxyeellada jirka qalad loo fahmay ama si fudud loogu aqbalay (matalan, Daniel P, Keanu W, Victoria C). Dib u eegiddan iyo mid kale oo ka mid ahayd Waxbarashada Wadajir ah, oo laga qabtay meel kale oo dalka ka mid ah, ayaa dhibaatadaas si sax ah loogu soo ogaaday: caado ay kooxda hay'adaha farabadan u leeyihiin in ay sugaan go'aan hubaal ah oo lagu sheego in dhaawacu uusan ahayn mid shil ku yimid ka hor inta aanay ku dhaqaaqin tallaabada ilaalinta ama badbaadinta. Dib u eegidyadan nidaamyada, waxaa noogu suurtogashay in aan ku sii fogaanno annaga oo baarayna caadooyinka iyo sababaha aasaasi ah ee xeeladaha kaladuwan ee ay xirfadleyaasha hay'adaha kaladuwan hawlahaas ka muujiyaan iyaga oo fahanno kaladuwan ka haysta. Waa maxay dhibaatooyinka ay u keenayso ku kalsoonaanta nidaamka ilaalinta carruurta ee hay'ado farabadan? Dhaawacyada jirka ee carruurta gaara ee bilowga la garto in aanay shil ku imanin ayaa ah wax dhif ah oo badi dhicin. Waxaa ka badan in sababta dhaawacyada jirka lagu macnayn karo waxyaabo kaladuwan. Sidaas darteed nidaamka nabad leh waxaa loogu baahan yahay habab lagu kalsoonaan karo oo ay xirfadleyaasha kaladuwan ku muujin karaan khabiirnimadooda gaar ah ee ku saabsan qorshaynta iyo qabashada hawlaha loogu baahan yahay baarista halka laga yaabo in ay dhaawacyadu ka yimaaddeen iyo goorta ay yimaaddeen, cidda laga yaabo in uu iyaga keenay, si markaana loo hubiyo badbaadada degdeg ah iyo mustaqbalka ee ilmaha iyo walaalihiis. Waxaa fursado shil ku iman karo keeni karta caadada dadaalka ay waaxda daryeelka bulsheed iyo booliisku u galaan si ay fikrad hubaal ah u helaan kaas oo barbar socda caadada ay shaqaalaha caafimaadku u leeyihiin in ay waxwalboo suurogal ah tixgeliyaan ilaa la beeninayo, iyada oo dadka labada dhinac ka soo jeeda midkoodna uusan garanayn farqiga u dhexeeya. Waxa ay taasi horjoogsanaysaa wadaxiriirka iyo wadashaqaynta waxtar leh ee loogu baahan yahay qaybtaas shaqada ka mid ah ee dhib badan welibana daruuri ah. Lambeth SCR Child H Confidential draft report 8 January 2014 41 Natiijada 5. Dadaalka ay shaqaalaha daryeelka bulsheed iyo booliisku ugu jiraan in ay xirfadleyaasha caafimaadka ka helaan sharraxaadda cad ee sababta dhaawaca jirka ee carruurta ayaa khilaafsan caadada ay xirfadleyaasha caafimaadku u leeyihiin in ay bixiyaan natiijooyin kaladuwan oo keenaya in wax kaste uu suurogal yahay ilaa meesha laga saarayo. Waxa ay taasi sii suurtogelinaysaa isfahanwaaga ku saabsan halisihii hore iyo kuwa mustaqbalka u iman kara ilmaha ku jira baaritaannada ilaalinta carruurta. Xadgudubka carruurtu ma wato calaamad si cad loogu garto. Waxa ay taasi run u tahay dhaawacyada jirka ee ilmaha gaara, iyo weliba dhibaatooyinka shucuureed ama habdhaqanka ee ka muuqda. Waxaa caadi ah in ay jiraan sharraxaadyo kaladuwan oo laakiin si siman suurogal u ah oo laga bixin karo sababaha keenay kuwaas oo uu ka mid noqon karo dhaawaca aanan shil ku imanin ee ilmaha loo geystay. Sidaas darteed nidaamka nabad leh waxaa loogu baahan yahay baaritaannada ilaalinta carruurta ee lagu muujiyo aqoonta xirfadleyaal kaladuwan ay ka qabaan hawshaas dhib badan. Waxa ay natiijadani shaaca ka qaadaysaa caadada saamaysa sida loogu kalsoonaan karo hirgalka baaritaannada ilaalinta carruurta, sababta oo ah farqiga u dhexeeya rajooyinka kaladuwan ee ay waaxda daryeelka bulsheed, booliiska iyo xirfadleyaasha caafimaadku ka sugayaan hawsha wadaxiriirka. Shaqaalaha daryeelka bulsheed iyo booliisku waxa ay shaqaalaha caafimaadka ka sugayaan in ay sharraxaadyo cad ka bixiyaan sababaha dhaawaca jirka, iyada oo dhanka kale ay xirfadleyaasha caafimaadka caadi u tahay in ay macne aanan sidaas u caddayn ka bixiyaan waxyaabaha suurogal ah. Dhammaan dadka hawsha ku lug leh ayaanan ka war haynin farqigaas u dhexeeya, taas oo sii suurtogelinaysa in si xun loo fahmo oo wax looga qabto halisihii hore iyo kuwa mustaqbalka ku wajahan carruurta laga hadlayo. Arrimaha ay Guddiga iyo hay’adaha xubin ka ah u baahan yihiin in ay ka fiirsadaan: Miyay taasi tahay dhibaato ay Guddigu ka war hayaan? Haddii ay haa tahay, sidee ayaa loo arkaa in ay u faafsan tahay? Qaybtaas ka mid ah habdhaqanka xirfadeed miyay tahay mid lagaga shaqeeyo tababbarka/siyaasadaha/nidaamyada hadda jira? Waa maxay kaalinta uu Guddoomiyuhu ku yeelan karo Kulannada Xeeladda ku saabsan iyo Shirarka CP si uu wanaajinta u taageero (matalan, dhammaadka kulanka, soo koobidda wixii laga fahmay ee la isku raacay, iyo taxidda go'aannada ka dambeeya)? Waa maxay kaalinta ay isbitaalka iyo/ama xirfadleyaasha bulsheed ee Magacaaban yeelan karaan si ay wanaajinta u taageeraan? Miyay habboon tahay in kalkaaliyaha caafimaadka iyo takhtarka magacaaban ay kaalin gaar ah yeeshaan marka ay jiraan i) fikrad hubaal ah oo aanan laga qabin sababta dhaawaca shaki leh iyo/ama ii) muran dhexmara shaqaalaha caafimaadka iyo xannaanaynta oo ku saabsan sababta dhaawaca shaki leh? Lambeth SCR Child H Confidential draft report 8 January 2014 42 Miyay Guddigu u arkaan in ay jiraan carqalado gaar ah oo horjoogsanaya dadaalka loogu jiro in qaybtaas shaqada loo wanaajiyo habdhaqanka xirfadeed? Sidee ayay Guddigu u ogaan karaan haddii la wanaajiyey qaybtaas ka mid ah habdhaqanka xirfadeed ee hay'adaha farabadan? Fikrado ku saabsan tababbarka: Isticmaalidda iskayeelka – matalan, ka mid ah Kulanka Xeeladda ku saabsan ee loo qabto kiisaska noocaas ah Tusaalooyinka kiisaska uu ka jiro/weli ka jiro shaki ku saabsan sababta dhaawaca Waxyaabaha ay kalkaaliyeyaasha caafimaadka/takhaatiirtu u sheegaan xirfadleyaasha kale ee ku saabsan waxa ka mid ah shakiga ka jira dhaawaca iyo taas sababteeda Waxyaabaha ay Hawlwadeennada Bulsheed iyo Booliisku u sheegaan shaqaalaha caafimaadka ee ku saabsan dhammaan noocyada arrimaha halista keenaya ee suurtogelin kara in kiiska go'aanno laga gaaro (iyo dhanka kale). 2.10 Natiijada 6. Mudnaanta yar ee Kooxda Goobjoog ah ee Xaaladda degdeg ah (EDT) ay ka muujiyaan ka jawaabcelinta codsiyada baaritaannada macluumaadka ee caadi ah marka baahiyaha kale loo eego, iyo la'aanta nidaam ka mid ah Kooxaha FSCP oo bilowga maalinta si caadi ah loogu soo qaado macluumaadka ay kooxda EDT habeenkii hore diiwaangeliyeen, ayaa naaqusaysa wadaagga macluumaadka ee waqtiga habboon xataa mararka ay jiraan xaaladaha loogu baahan yahay jawaabcelin degdeg ah. Tani waa natiijo loogu talagalay Daryeelka Bulsheed ee Carruurta. Wixii khuseeya kiisaska dhammaantood, laakiin wixii gaar ahaan khuseeya arrimaha ilaalinta carruurta ee degdeg ah, isweydaarsiga macluumaadka sax ah waqtiga habboon, ee dhexmara hay'adaha dhammaantood, ayaa daruuri u ah si shaqo nabad leh looga qabto qaybtaas shaqada ee dhib badan. Habeennada iyo maalmaha wiikeendiga, waxaa hawlgala nidaamyo gooni ah oo ka duwan kuwa caadi ah waxaana caadi ahaan jooga shaqaalo ka tiro yar sida caadi ah oo shaqada qaban kara. Waxaa daruuri ah in nidaamyada lagu codsado laguna gudbiyo macluumaadku ay sida ugu suurogal badan waxtar u yeeshaan oo la isugu hallayn karo. Kiiskani waxa uu shaaca ka qaaday laba meelood oo ay tabardarro gaar ahi ka jirto oo ka mid ah hirgelinta caadi ah ee nidaamyada saacadaha aanan la shaqaynin. Waxa ay kuwaasi ku xiran yihiin a) caadooyinka ku saabsan sida codsiyada macluumaadka loo kala mudnaan siiyo; iyo b) nidaamyada ay shaqaalaha maalintii ku qaataan farriimaha habeenkii hore. Lambeth SCR Child H Confidential draft report 8 January 2014 43 Sidee ayay dhibaatadu uga muuqatay kiiskan gaar ah? Kiiskan marka la eego waxaa jiray laba jeer oo ay si cad u dhaceen calaamadaha nuglanaanta ee natiijadani ay ka hadlayso. Markii Walaalka 2 la keenay waaxda gurmadka degdeg ah ee isbitaalka isaga oo jirka ku lahaa dhaawac daran, nidaamka caadi ahaan loo adeegsan lahaa si shaqaalaha waaxda gurmadka degdeg ah looga wargeliyo in ilmuhu uu ku jiray Qorshaha Ilaalinta Carruurta ayuu si ku meelgaar ah uga maqnaa liiskii ugu dambeeyey ee elektaroonig ahaa ee magaacda carruurta ee Lambeth. Waxa uu kaasi ahaa waqti gaaban, laakiin waxa ay taasi markaa keentay in la hakiyo kartidii loo lahaa in la soo ogaado halista ay carruurtu ku jireen. Goortaas, ahmiyad gaar ah ayay taasi lahayd maxaa yeelay waxa ay waalidku (si qalad ah) shaqaalaha isbitaalka ugu sheegeen in aanan laga ogayn dhanka CSC. Kooxda Dib u eegidda ayaa ogaatay doorka daruuri ah ee ay leeyihiin nidaamyadaas macluumaadka iyo digniin bixintu, marka la xasuusto in badi loo baahan yahay in si dhakhso ah loo gaaro go'aannada ku saabsan dhawritaanka carruurta (matalan, waalidka oo loo oggolaado in ay iyaga isbitaalka ka qaadaan oo ay guriga geeyaan). Sidaas darteed waxaa Kooxda Goobjoog ah ee Xaaladda degdeg ah ee Lambeth loo diray codsiga macluumaadka. Marka la xasuusto xaaladda daran ee ilmaha lagu keenay, waxaa si dhakhso ah loogu baahnaa macluumaadkaas. Halkii ay sidaas ka ahaan lahayd, waxaa lix saacadood lala raagay jawaabtii ka timid kooxda EDT. Waxa ay taasi keentay in Walaalka 2 laga qaaday waaxda gurmadka degdeg ah ee isbitaalka oo lagu wareejiyey qaybta isbitaal ee addimada ka hor intii aanan isbitaalka loo soo dirin macluumaadka faahfaahsan ee ku saabsanaa qoyska iyo Qorshaha CP ee carruurta u yaallay. Dhacdadaas ugu horraysay waxa ay ka sii dartay subaxnimadii maalintii ku xigtay goortaas oo diiwaangelintii laga sameeyey wadahadalkii uu Hawlwadeenka Bulsheed ee kooxda EDT la yeeshay isbitaalka aanay waqtigii habboonaa soo qaadin Hawlwadeenka Bulsheed ee loo xilsaaray ee ku jirtay kooxda maalintii, ama cid kale oo kooxdeeda ka mid ahayd. Waxa ay taasi keentay in hawlwadeenka SW aanay ka war haynin taladii lagu sheegay in arrinkaasi uu ahaa mid ku saabsanaa ilaalinta carruurta, oo loo baahnaa in si dhakhso ah looga wargeliyo Kooxda Baaritaanka Xadgudubka Carruurta ee Booliiska (Police Child Abuse Investigation Team) (CAIT). Waxa ay markii ugu horraysay ka war heshay dhaawacii gaaray Walaalka 2 iyo walaaca ay takhaatiirtu qabeen duhurkii maalintii ku xigtay markii ugu horraysay ee isaga la keenay waaxda gurmadka degdeg ah. Sidee ayaan u og nahay in aanay ahayn cillad u gaar ah kiiskan? Sida qayb ka ahayd hawshii dib u eegidda kiiska, dadkii ku lug lahaa ayaa baaray sida ay labadaas dhacdo gaar ugu ahaayeen kiiskan, ama u matalayeen nidaamyo iyo habdhaqanno caado dheeraad ah leh. Wixii khuseeya dib u dhaca ku yimid ka jawaabcelinta codsiyadii macluumaadka ee waaxda gurmadka degdeg ah, xubnaha Kooxda Kiiska iyo Kooxda Dib u eegidda, oo ay ka mid ahaayeen xubnaha kooxda EDT, ayaa xaqiijiyey in uu caadi yahay dib u dhaca waqti badan ee ka yimaadda ka Lambeth SCR Child H Confidential draft report 8 January 2014 44 jawaabcelinta codsiyada macluumaadka saacadaha aanan la shaqaynin. Shaqaalaha telefoonka ee lagala hadlo codsiga ugu horreeya ee baaritaanka macluumaadka ayaanay suurogal u ahayn in ay laftigeedu bixiso macluumaadka la rabo. Waxa uu qofkaasi joogaa xarun wicis oo ma arki karo kaydka macluumaadka ee elektaroonig ah ee adeegga CYPS markaana suurogal uma aha in uu hubiyo haddii macmiilka laga war hayo ama haddii ilmuhu uu ku jiro Qorshaha CP. Waa in uu qofkaasi codsiga u gudbiyo hawlwadeenka bulsheed ee kooxda EDT ee kelidiis goobta jooga. Waxa ay taasi marka ugu horraysa tilmaamaysaa sifada aasaasi ah ee ay dhibaatadaasi leedahay, iyo markaa suurogalka soo noqnoqodkeeda. Gargaarka laga helay Kooxda Kiiska iyo Kooxda Dib u eegidda ee shaaca ka qaaday hawsha jawaabcelinta kooxda EDT, ayaa weliba suurtogeliyey in sharraxaad laga helo caadooyinka ku saabsan sida ay shaqaalaha kooxda EDT u kala mudnaan siiyaan codsiyada macluumaadka ee kaladuwan. Isaga oo kelidiis shaqaynaya, waa in hawlwadeenka bulsheed ee kooxda EDT uu mudnaan kala siiyo oo uu kala horraysiiyo soo gudbinta kaladuwan ee soo gaarta habeenkii. Gargaarka laga helay ka qaybqaateyaasha ayaa lagu soo bandhigay sawir tilmaamaya darajada degdegga ee iska caadi u ah ee la isticmaalo, iyada oo qiimaynta caafimaadka maskaxda ee qofka weyn ama meel geynta degdeg ah ee ilmuhu, ay hor maraan codsiyada 'baaritaannada macluumaadka ee caadi ah' – sidaas oo laga soo qaaday in ay ahayd wicistii ugu horraysay ee isbitaalku. Maadaama ay kuwa hore u baahan yihiin waqti badan si loo dhammaystiro, waxa ay taasi markaa keeni kartaa in dhowr saacadood la sugo jawaabta codsiga baaritaannada macluumaadka, sida kiiskan nooga muuqatay, si kastoo uu u daran yahay dhaawaca ilmaha gaaray. Isticmaalka caadi ah ee darajadaas jawaabcelinta ayaa markaa suurogal yarayn doona in dhaawacyada jirka ee carruurta gaara si caadi ah loogu arko xaalad degdeg ah oo si dhakhso ah wax looga qabto. Wixii khuseeya dib u dhaca ku yimid in shaqaalaha maalintii ay soo qaataan farriimihii habeenkii hore, ka qaybqaateyaasha hawsha dib u eegidda kiiska ayaa weliba tilmaamay sababta dib u dhacaas ka dambaysa iyo markaa suurogalka in dhibaatadu ay dib uga dhacdo kiisaska kale. Ka qaybqaateyaashu waxa ay noo sharxeen in kooxda EDT ay kooxda maalintii ugu gudbiyaan macluumaadka iyaga oo diiwaanka ay ka hayaan wixii habeenkii hore ama wiikeendigii dhacay toos u geliya Qaabka waxqabadka (Framework), kaydka macluumaadka ee elektaroonig ah ee adeegga – taas oo kiiskan loo sameeyey. Nuglanaanta nidaamku waxa ay ka imanaysaa xaqiiqada ah in Kooxaha FSCP dhexdooda uusan ka jirin nidaam caadi ahaan la adeegsado oo la isku hallayn karo oo lagu hubiyo in diiwaannada kooxda EDT ee ku jira Qaabka waxqabadka la soo qaato 9ka subaxnimo maalin kaste. Hawlwadeennada Bulsheed marwalba xafiiska kuma soo horreeyaan; waxaa laga yaabaa in ay ku maqan yihiin booqasho guri, ama kulan; dhab ahaan, waxaa dhici karta in ay ku maqan yihiin jirro ama fasax, oo si cad looma sheegin qofka ka masuul ah in uu Qaabka waxqabadka u fiiriyo kooxda oo dhan subax kaste. Waxa ay taasi keenaysaa in aanan si fiican la isugu hallayn karin habka macluumaadka degdeg ah looga helo kooxda dhexdooda. Waxaa sidaas ku imanaysa in Lambeth SCR Child H Confidential draft report 8 January 2014 45 habka dhawritaanka ee keliya ee la adeegsan karo uu noqdo in shaqaalaha kooxda EDT ama dadka kale ee ku lug leh, sida isbitaalka marka kiiskan la eego, ay kooxda maalintii wacaan si ay uga waraystaan, taas oo aanan caadi ahaan dhicin. Waa maxay tirada kiisaska ee ay taasi dhab ahaan saamayso ama saamayn karto? Ka qaybqaateyaasha hawsha dib u eegidda kiiska waxa ay la ahayd in la filan karo in Lambeth iyo meelaha kale ay ku badan tahay tirada kiisaska ay ka jirto dhibaatada la raagidda wadaagga macluumaadka iyo jawaabcelinta ka dib marka la yimaaddo adeegyada saacadaha aanan la shaqaynin. Waxaa annaga noo suurtogeli weydey in aan macluumaad rasmi ah ku helno waqtiga noo yaallay laakiin guud ahaan waaxyaha gurmadka degdeg ah ee isbitaalladu waa meelo aad u buuq badan habeenkii iyo maalmaha wiikeendiga, markaana waxaa sidaas oo kale u badnaan karta baahida suurogal ah in loo qabo macluumaadka ku saabsan carruurta iyo badbaadadooda. Sidoo kale guud ahaan, qulqulka macluumaadka u kala wareega kooxda EDT iyo kooxaha FSCP ee maalintii waxa uu u dhacaa si joogto ah oo badan. Macaamiisha dad loo xilsaaray – carruurta iyo qoysaska – ayaa qayb weyn ka ah shaqada saacadaha aanan la shaqaynin, oo waa in macaamilooyinkaas kooxda EDT dhammaantood loo diro kooxaha maalintii 9ka subaxnimo Isniinta ilaa Jimcaha. Waxaa annaga noo suurtogeli weydey in aan soo helno tirooyin la hubo. Sidee ayay caadadu u faafsan tahay – xaafadda, gobolka, qaranka? Sidoo kale marka dhinacan la eego, waxaa adkayd in laga helo macluumaad sugan laakiin Kooxda Dib u eegidda waxaa la ahayd in ay caadi tahay in kooxaha EDT ee xaafadaha London gudaheedu ay la kulmaan shaqo culus oo uu joogo shaqaale keliya saacadaha aanan la shaqaynin, markaana waxaa khasab ku noqota in uu mudnaan siiyo codsiyada qaarkood oo uu mudnaan yareeyo kuwa kale. Annagu ma helin cilmibaaris lagu muujinayo haddii uu caadi ahaan u jiro fikirka shaqaalaha kooxda EDT ee xaafadda Lambeth ee keena in ay mudnaan yar siyaan ka jawaabcelinta codsiyada baaritaannada macluumaadka ee caadi ah marka loo eego baahiyaha kale ee jira. Kooxda Dib u eegiddu waxa ay rajaynayaan oo ay sugayaan in codsiyada baaritaannada macluumaadka ee ku saabsan dhallaanka yimaadda isaga oo dhaawacyo jirka ku leh si toos ah loogu yeelo mudnaan sare, laakiin suurogal uma noqonin in ay soo ogaadaan haddii ay xaaladdu dhab ahaan sidaas ka tahay London ama dalka oo dhan. Gargaarka laga helay Daryeelka Bulsheed ee Carruurta ayaa lagu tilmaamay in la'aanta nidaam si caadi ah bilowga maalinta loogu soo qaado macluumaadka ay kooxda EDT diiwaangeliyaan aanay ahayn sifo ka mid ah dhammaan kooxaha daryeelka bulsheed. Kooxda Dib u eegidda waxaa loo sheegay Kooxda Soo gudbinta iyo Qiimaynta (Referral and Assessment Team), oo ah 'albaabka hore' ee adeegga CYPS, sida ka duwan Kooxaha FSCP, in uu ka jiro nidaam la yaqaanno oo subax kaste lagu soo qaado wixii soo gudbin ah ee ka yimaadda kooxda EDT. Waxaa sidaas sameeya Lambeth SCR Child H Confidential draft report 8 January 2014 46 shaqaalaha goobjoog ah ee ay shaqadiisa tahay in uu sidaas sameeyo 9ka subaxnimo si dhakhso ah. Marka soo gudbintu ay ku saabsan tahay qoys hore looga war hayo, waxaa macluumaadka loo gudbiyaa shaqaalaha u xilsaaran ee ka mid ah kooxda habboon. Waa maxay nooca halista ay caadadaasi u keenayso hirgalka nabad leh ee lagu kalsoonaan karo ee nidaamkeena? Nidaamka nabad leh ee loogu talagalay ilaalinta carruurta waxaa loogu baahan yahay in laga helo jawaabcelin loogu kalsoonaan karo saacadaha aanan la shaqaynin isla maalmaha toddobaadka caadi ahaan la shaqeeyo. Haddana, habeenkii iyo maalmaha wiikeendiga, Adeegyada degdeg ah ee CP Booliiska iyo CYPS waxaa hawlgeliya shaqaale aad uga tiro yar shaqaalaha hawlahooda qabta maalmaha toddobaadka la shaqeeyo. Isla waqtigaas, waxa ay si joogto ah uga shaqeeyaan xaalado halis leh oo degdeg ah, oo waa in ay macluumaadka ku gudbin karaan hab waxtar leh waqtiga habboon. Labada meelood ee nuglanaanta nidaamku ka jirto ee caadadaas laga helay ayaa muujinaya in gudbinta iyo soo qaadista macluumaadka kooxda EDT ay saamayn karaan a) mudnaanta yar ee la siiyo ka jawaabcelinta 'baaritaannada macluumaadka ee caadi ah' iyo b) habdhaqanka aanan la isku hallayn karin ee lagu soo qaado macluumaadka degdeg ah ee kooxda EDT islamarka ugu horraysa – 9ka subaxnimo maalinta xigta ee la shaqeeyo. Meelahaas nuglanaantu ka jirto waxa ay suurtogelinayaan in macluumaadka muhiim ah ee ku saabsan carruurta iyo qoysaska aanan waqtiga habboon la wadaagin, markaana aanan lagu hagin jawaabcelinnada xirfadeed ee daruuri ah. Natiijada 6. Mudnaanta yar ee Kooxda Goobjoog ah ee Xaaladda degdeg ah (EDT) ay ka muujiyaan ka jawaabcelinta codsiyada baaritaannada macluumaadka ee caadi ah marka baahiyaha kale loo eego, iyo la'aanta nidaam ka mid ah Kooxaha FSCP oo bilowga maalinta si caadi ah loogu soo qaado macluumaadka ay kooxda EDT habeenkii hore diiwaangeliyeen, ayaa naaqusaysa wadaagga macluumaadka ee waqtiga habboon xataa mararka ay jiraan xaaladaha loogu baahan yahay jawaabcelin degdeg ah. Tani waa natiijo loogu talagalay Daryeelka Bulsheed ee Carruurta. Baahida loo qabo in gargaar waxtar leh waqtiga habboon la siiyo carruurtu kuma koobna saacadaha xafiisku furan yahay ee maalmaha toddobaadka la shaqeeyo. Sidaas darteed nidaamka nabad leh waxaa loogu baahan yahay in adeegyada saacadaha aanan la shaqaynin ay u hirgalaan si la isugu hallayn karo oo wax loogu qaban karo carruurta timaadda habeenkii, maalmaha wiikeendiga iyo xilliyada fasaxa. Waxa uu kiiskani shaaca ka qaaday laba caado oo ay ku yar tahay ku kalsoonaanta macluumaadka loo diro ama laga helo Kooxda Goobjoog ah ee Xaaladda degdeg ah ee Lambeth. Lambeth SCR Child H Confidential draft report 8 January 2014 47 Waxa ay kuwaasi yihiin a) mudnaanta yar ee Kooxda Goobjoog ah ee Xaaladda degdeg ah ay siiyaan ka jawaabcelinta codsiyada 'baaritaanka macluumaadka ee caadi ah' iyo b) la'aanta nidaam ka mid ah Kooxaha FSCP oo, bilowga maalinta, si caadi ah loogu soo qaado macluumaadka ay kooxda EDT habeenkii hore diiwaangeliyeen. Waxa ay labadooduba horjoogsadaan qulqulka waqtiga habboon ee macluumaadka degdeg ah, sidaas oo xirfadleyaasha ka mid ah adeegyada kaladuwan (laakiin badi meelaha caafimaadka) ay ugu suurogal yar tahay in ay qiimayn habboon ku sameeyaan halista, waxa ayna keenaysaa in carruurtu ay ku sii jiraan xaaladaha laga yaabo in aanay nabad lahayn. Arrimaha ay Guddiga iyo adeegga CYPS u baahan yihiin in ay ka fiirsadaan Miyay dhibaatadaasi tahay mid la og yahay – adeegga CYPS dhexdiisa? Guddiga LSCB dhexdooda? Miyay Guddiga/adeegga CYPS waafaqsan yihiin in kuwaasi ay yihiin cillado nidaam oo aad u daran? Miyaa la aqbali karaa in adeegyada saacadaha aanan la shaqaynin ay dhowr saacadood sugaan macluumaad fudud, sida haddii uu jiro Qorshaha CP? Maxaa hore loo qabtay si loo tixgeliyo sida loo wanaajin karo qulqulka waxtar leh ee waqtiga habboon dhexmara adeegyada saacadaha aanan la shaqaynin iyo maalintii? Miyaan cashar ka qaadan karnaa nidaamyada fiican ee ka jira kooxaha EDT iyo adeegga CYPS ee xaafadaha kale ee London? Ma waxaa jira dhibaatooyin gaar ah oo taas horjoogsanaya – matalan, shaqaalaha telefoonka ee qaada codsiyada macluumaadka oo aanan arki karin kaydka macluumaadka ee adeegga CYPS? Miyay suurogal tahay in shaqaalaha telefoonka ee kooxda EDT uu ka jawaabi karo su'aalo fudud sida 'ma ku jiraa Qorshaha CP' – isaga oo aanan u baahan in uu la tashado hawlwadeenka bulsheed ee goobjoog ah? Maxaa wanaajin u noqon kara labadaas meelood ee nuglanaantu ay ka jirto oo sidee ayay Guddigu u ogaan karaan in ay xaaladdu sidii hore ka wanaagsan tahay? Ma waxaa jira dhibaatooyin ku saabsan ilaha dhaqaale ee diyaar ah oo saamayn leh? Lambeth SCR Child H Confidential draft report 8 January 2014 48 3. Gabagabaynta Dhimashada murugada lahayd ee Ilmaha H ee saddex jir ahaa waxa ay keentay dhowr tallaabo oo sharci ah. Waxaa aabbihiis si rasmi ah loogu eedeeyey dilkiisii, waxaana dacwaddiisa loo qorsheeyey in ay maxkamadda soo marto horraanta sanadka 2014. Walaalihii ka haray waxaa laga qaaday qoyska oo waxaa la geliyey daryeelka Kawnsalka Lambeth. Waxaa dib u eegiddan lagu soo ogaaday dhowr arrimood oo saameeyey shaqada ay xiriirrada xirfadeed ee dhawritaanka carruurtu u qabteen qoyska Ilmaha H. Waxaa lagu baaray go'aannada iyo waxqabadyada dadkii kiiska ku lug lahaa, iyo sababaha kuwaas ka dambeeyey. Waxaa weliba lagu baaray waxa uu kiiskani nooga sheegay dhinacyada uu nidaamka ilaalinta carruurta ee hay'ado farabadan ka daciifsan yahay kana nugul yahay. Waxaa jirta qayb daruuri ah oo sheekadan ka mid ah oon weli la garanayn. Lama soo qaadin fikradda ay waalidku qabaan, iyaga oo waxyaabo badan qariyey muddadii ay xiriirka la lahaayeen hay'adaha iyo shaqaalaha xirfadeed. Waxaa nasiib darro ah, in hawsha caddaaladda dembiyeed ee weli socota ay keentay in aanan weli fursad loo helin si loo waraysto Hooyo iyo Aabbe. Maadaama aanan iyaga laga haynin ra'yi iyo warbixin, waxa aanan weli suurogal ahayn in si buuxda loo fahmo qoyska iyo sida ay ula hawlgaleen xirfadleyaasha. Weli lama oga haddii waalidku ay si uun gargaar uga bixin doonaan dib u eegidda ka dib marka dacwadda dembiyeed la dhammaystiro. Dib u eegidda kiiska 'nidaamyada' ku saabsan, kiiska gaarka ah waxa uu noqdaa mid laga eego nidaamyada xaafadda ka jira, si casharro dheeraad ah looga qaadan karo. Kiiskan gudihiisa, waxaa lagu soo ogaaday lix natiijo oo mudnaan leh, oo la xiriira: Fahanka xirfadleyaasha ee ku saabsan halista waxyeellada jirka ee ku wajahan carruurta ku jirta qoysaska ay ka jirto rabshadda guriga ee dhexmarta lammaaneyaasha Kaalinta kormeeridda iyo kooxaha hay'adaha farabadan si ay uga fikiraan ugana hortagaan go'aannada Tayada iyo diyaar ahaanta turjumaannada, gaar ahaan xaaladaha degdeg ah gudahooda Dhibaatada xallinta rabshadda guriga markii ay hore u dhacday ee aanay soo noqonin Fahanka kaladuwan ee shaqaalaha caafimaadka iyo daryeelka bulsheed ay ka qaataan kaalinta iyo macnaha fikradda caafimaadeed marka laga go'aan gaarayo sababta suurogal ah ee dhaawacyada yimid, iyo tallaabooyinka ka dambeeya, iyo Wadaagga macluumaadka ee dhexmara Kooxaha Goobjoog ah ee Xaaladda degdeg ah iyo kooxaha kale iyo hay'adaha. Guddiga LSCB waxaa loo soo bandhigayaa natiijooyinkaas iyo su'aalaha la socda si ay uga fiirsadaan marka ay ka go'aan garayaan sida ugu fiican in ay uga jawaab celiyaan, taas oo hore loogu socon doono si loo xoojiyo oo loo horumariyo shaqada xiriirrada hay'adaha farabadan ee Lambeth iyo isbitaallada dawladaha ku ag yaalla. Lambeth SCR Child H Confidential draft report 8 January 2014 49 Tixraacyada Barnett, O., Miller-Perrin, C., Dale, R.D., Family Violence across the Lifespan: An Introduction (Rabshadda Qoyska ee Nolosha oo dhan: Horudhac), Sage Publications, 2010 Bowker, L. H., Arbitell, M., McFerron, J. R., ‘On the relationship between wife beating and child abuse’ (Ee ku saabsan xiriirka ka dhexeeya garaaca xaaska iyo xadgudubka carruurta), ee K. Yllo & M. Bograd (Eds.), Feminist perspectives on wife abuse (Fikradaha simista haweenka iyo ragga ee ku saabsan xadgudubka xaaska) (bog.90-113), Sage Publications, 1988. Brandon, M., Thoburn, J., Lewis, A., Way, A., Safeguarding Children with the Children Act 1989 (Dhawritaanka Carruurta ee loo adeegsado Sharciga Carruurta ee 1989kii soo baxay), London: The Stationery Office, 1999 Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C., Black, J., Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews (Fahmidda Dib u eegidyada Kiiska Daran iyo Saamayntooda: Kaladhigdhigga Laba sanadle ah ee Dib u eegidyada Kiiska Daran), 2005 – 07, University of East Anglia/DCSF, 2009 Edleson, J.L., Peled, J., Jaffe, P.G. (Eds), Ending the cycle of violence: Community responses to children of battered women (Joojinta wareegga rabshadda: Jawaabcelinnada bulshada ee ku toosan carruurta haweenka la garaaco), Sage Publications, 1995 Farmer, E. iyo Owen, M., Child Protection Practice: Private Risks and Public Remedies (Habdhaqanka xirfadeed ee Ilaalinta Carruurta: Halisaha Khaas ah iyo Daawooyinka Shacabka), London, HMSO, 1995 Fish, S., Munro, E., Bairstow, S., SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews (Warbixinta 19 ee SCIE: Waxbarashada wadajir ah si carruurta loo dhawro: dhisidda xeeladda nidaamyada hay'adaha farabadan ee ku toosan dib u eegidyada kiisaska), Social Care Institute for Excellence (SCIE), 2008 Fish, S., Munro, E., Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews (Hagaha 24 ee SCIE: Waxbarashada wadajir ah si carruurta loo dhawro: dhisidda xeeladda nidaamyada hay'adaha farabadan ee ku toosan dib u eegidyada kiisaska), Social Care Institute for Excellence (SCIE), 2009 Hartley, C.C., ‘The Co-occurrence of Child Maltreatment and Domestic Violence: Examining Both Neglect and Child Physical Abuse, Child Maltreatment (Wada imaanshaha Habdhaqanka xun ee Carruurta loo geysto iyo Rabshadda Guriga: Baarista Dayacaadda iyo Weliba Xadgudubka Jirka ee Carruurta, Habdhaqanka xun ee Carruurta loo geysto), 2002; 7; 349, iyo Sage Publications 2009 (http://www.uk.sagepub.com/pricefamchnge4e/study/articles/06/Hartley.pdf) Hughes, L., iyo Pengelly, P., Staff supervision in a turbulent environment: managing process and task in front-line services (Kormeeridda shaqaalaha ku Lambeth SCR Child H Confidential draft report 8 January 2014 50 jira bey'ad qas badan: nidaamka iyo hawsha maamulka ee adeegyada safka hore), London: Jessica Kingsley London CP Procedures (Nidaamyada CP ee London), 3rd Edition, 2007 Lord Laming, The Victoria Climbie Inquiry Report (Warbixinta Baaritaanka Victoria Climbie), The Stationery Office Limited, London, 2003 Munro, E., ‘Common Errors of Reasoning in Child Protection Work’, Child Abuse and Neglect ('Qaladaadka Caadi ah ee Fikirka Shaqada Ilaalinta Carruurta gudaheeda', Xadgudubka iyo Dayacaadda Carruurta) , Vol 23, No 8: 745-758, 1999 Munro, E., ‘A systems approach to investigating child abuse deaths’ (Xeeladda nidaamyada ee ku toosan baaridda dhimashooyinka xadgudubka carruurta), asal ahaan laga soo saaray Wargeyska Ingiriiska ee Hawlaha Bulsheed, 35 (4), bog. 531-546, Oxford University Press, 2005 Munro, E., ‘A systems approach to investigating child abuse deaths [online]’ (Xeeladda nidaamyada ee ku toosan baaridda dhimashooyinka xadgudubka carruurta [internetka]), London: LSE Research Online, 2007 Munro, E., ‘Lessons learnt, boxes ticked, families ignored’ (Casharro la bartay, sanduuqyo sax loo calaamadeeyey, qoysas la iska indho tiray), The Independent, 16kii Noofembar 2008 Ofsted, Learning Lessons, taking action: Ofsted’s evaluation of serious case reviews 1 April 2007 – 31st March 2008 (Barashada Casharro, qaadista tallaabo: Qiimaynta Ofsted ee dib u eegidyada kiiska daran 1 Abriil 2007 – 31kii Maarso 2008), Reder, P., Duncan, S., iyo Gray, M., Beyond Blame: Child Abuse Tragedies Revisited (Eed Ka fog: Masiibooyinka Xadgudubka Carruurta oo Dib loogu noqday) , Routledge, 1993 Reder, P., iyo Duncan, S., Lost Innocents: A Follow-up Study of Fatal Child Abuse (Dadka beri ah ee Lumay: Daraasadda Labaad ee Xadgudubka Carruurta ee Dhimasho keenay), London: Routledge, 1999 Regan, L., ‘Children and Domestic Violence: Its Impacts and Links with Woman Abuse’ (Carruurta iyo Rabshadda Guriga: Saamynteeda iyo Xiriirrada ay la leedahay Xadgudubka Haweenka) dukumeentiga laga soo bandhigay Shirkii Saamaynta ay Rabshadda Gurigu ku leedahay Carruurta, London, Oktoobar 2001 Rushton, A., iyo Nathan, J., “The Supervision of Child Protection Work” (Kormeeridda Shaqada Ilaalinta Carruurta), The British Journal of Social Work, Vol 26 (3): 357-374 Lambeth SCR Child H Confidential draft report 8 January 2014 51 SCIE At a Glance 01: Guide to Learning together to safeguard children: developing a multi-agency systems approach for case reviews (SCIE oo la Soo Koobay 01: Hagaha Waxbarashada wadajir ah si carruurta loo dhawro: dhisidda xeeladda nidaamyada hay'adaha farabadan ee ku toosan dib u eegidyada kiisaska), Social Care Institute for Excellence (SCIE), 2008 Stanley, N., Children Experiencing Domestic Violence: A Research Review (Carruurta La kulanta Rabshadda Guriga: Dib u eegidda Cilmibaarista), Dartington: Research in Practice, 2011 Stark, E., iyo Flitcraft, A., Women at risk: domestic violence & women’s health (Haweenka halis ku jira: rabshadda guriga iyo caafimaadka haweenka), Sage Publications, 1996 Tomison, A., ‘Exploring family violence: Links between child maltreatment and domestic violence’, Issues in Child Abuse Prevention ('Baarista rabshadda qoyska: Xiriirrada u dhexeeya habdhaqanka xun ee carruurta loo geysto iyo rabshadda guriga', Dhibaatooyinka ka jira Ka hortagga Xadgudubka Carruurta), no. 13: Melbourne: Australian Institute of Family Studies, 2000 Topping, A., “Domestic violence figures are disturbingly high, says charity” (Tirooyinka rabshadda gurigu aad ayay u sarreeyaan waana wax laga argagaxo, ayay tiri hay'ad samafal ah), The Guardian, 7dii Maarso 2013 www.womensaid.gov.uk: Home/Domestic Violence A-Z/Children (Guriga/Rabshadda Guriga Gebi Ahaan/Carruurta) Working Together to Safeguard Children (Wada Shaqayn si Carruurta loo Dhawro), DCSF, 2010 Working Together to Safeguard Children (Wada Shaqayn si Carruurta loo Dhawro), DfE, 2013 Lambeth SCR Child H Confidential draft report 8 January 2014 52 Lifaaqa 1 – Nidaamka waxqabadka 1. Dib u eegiddan SCR waxaa loo isticmaalay qaabka Waxbarashada Wadajir ah ee SCIE ee loogu talagalay dib u eegidyada kiisaska. Kaasi waa xeeladda 'nidaamyada' ee laga helo aragti iyo hab lagu fahmo sababta ay u yimaadaan habdhaqanka fiican iyo midka xun, si loo soo ogaado taageerooyinka waxtar leh iyo xalalka dhaafaya kiiska keli ah. Intii hore waxaa loo isticmaali jiray hab lagu qabto baaritaannada shilalka ka yimaadda noocyada kale ee shaqada halis badan, sida dayuuradaha, waxaana ka dib bilaabay in ay isticmaalaan hay'adaha Caafimaadka, oo laga bilaabo sanadkii 2006dii, waxaa loo horumariyey si loogu isticmaalo dib u eegidyada kiisaska ee shaqada dhawritaanka iyo CP ee hay'adaha farabadan (Munro, 2005; Fish et al, 2009). Hagista qaran ee saxiddii 2013kii ee Wada Shaqayn si Carruurta loo Dhawro (2013) ayaa iminka dhigaysa in dhammaan dib u eegidyada SCR loo adeegsado qaab waxqabad oo nidaamyada ku toosan. 2. Qaabku waxa uu ku duwan yahay xeeladda uu ka muujiyo sidii xaaladda loogu fahmi lahaa habdhaqanka xirfadeed; waxa uu sidaas ku sameeyaa isaga oo lagu soo ogaado arrimaha ku jira nidaamka ee saamayn ku leh nooca iyo tayada shaqada qoysaska loo qabto. Ka dib waxaa xalalka diiradda loo saaraa sidii dib loogu hagaajin lahaa nidaamka si loo yareeyo arrimaha khasaaraha keena, iyo si loo fududeeyo in xirfadleyaashu ay u dhaqmaan si nabad ah oo waxtar leh. 3. Waxbarashada Wadajir ah waa qaab ka jira hay'ado farabadan, oo suurtogeliya in xaaladda iskaashiga dib loogu eego oo lagu baaro shaqada dhawritaanka ee hay'adaha oo dhan. Sidaas darteed, natiijooyinka qaar farabadan waxa ay la xiriiraan shaqada hay'ado farabadan. Hase yeeshee, waxaa dhici karta oo yimaadda qaar ka mid ah natiijooyinka nidaamyada oo la xiriira hay'ad gaar ah. Marka ay xaaladdu sidaas tahay, natiijadu taas si cad ayay u shegaysaa. 4 Mabaadii'da aasaasi ah – 'bartamaha nidaameed' – ee qaabka Waxbarashada Wadajir ah – waxaa lagu xusay halkan hoose iyaga oo la soo koobay: a. Ka fogow eexashada dib ka ogaanshaha – fahan sida ay xaaladdu ugu eekayd shaqaalihii iyo maamuleyaashii waqtigaas qoyska wax u qabanayey ('muuqaalka wadiiqeed'). Maxaa saamaynayey shaqadooda ee ay ku toosnayd? b. Bixi sharraxaad hagaagsan – qiimee oo macnee go'aannada, tallaabooyinka, tallaabo la'aanta xirfadleyaashii ku hawl lahaa kiiska. Hawlfulinta u tixgeli in ay tahay natiijada ka timaadda xiriirrada u dhexeeya xaaladda iyo waxa uu shakhsigu ka qabto c. Ka wareeg dhacdada gaar ah oo uga wareeg ahmiyadda guud – bixi 'daaqad laga eego nidaamka jira' oo lagu muujiyo waxa xoojiya iyo waxa daciifiya ku kalsoonaanta nidaamka CP ee hay'adaha farabadan. d. Soo saar natiijooyin iyo su'aalo ay Guddigu ka fiirsadaan. Waxaa laga yaabaa in talooyinka hore u diyaar ah ay ku habboonaadaan Lambeth SCR Child H Confidential draft report 8 January 2014 53 dhibaatooyinka xalalkooda la og yahay, laakiin sidaas waxtar uguma leh xujooyinka keena arrimo siyaado u dhib badan. e. Baaris adag: isticmaalka farsamooyin cilmibaaris oo tayo leh si loogu taageero adkaynta iyo ku kalsoonaanta. 2.4 Noocyada caadooyinka aasaasi ah 2.4.1 Si natiijooyinka loo soo ogaado, Kooxda Dib u eegiddu waxa ay isticmaaleen noocyada caadooyinka aasaasi ah ee islafalgalka ee SCIE ee ku jira habka ay u hirgalaan nidaamyada ilaalinta carruurta ee xaafaddu. Miyay kuwaasi taageerayaan shaqada tayo fiican leh ama suurogal yaraynayaan in ay wadashaqayn waxtar leh yeeshaan xirfadleyaasha gaar ah iyo hay'adahoodu? Waxaa kuwaas lagu soo bandhigay lix qaybood oo guud oo loo kala saaray dhibaatooyinka aasaasi ah: 1. Shaqada hay'ado farabadan ee lagaga jawaab celinayo dhacdooyin iyo xaalado dhibaato ah 2. Shaqada hay'ado farabadan muddada dheeraad ah ee shaqada 3. Fikirka insaanka: dhan u iilashada garaadka iyo shucuurta 4. Islafalgalka Qoyska – Xirfadlaha 5. Qalabka 6. Nidaamyada maamulka Natiijo kaste waxaa la hoos geliyey qaybta ku habboon, inkaste oo qaarkood la hoos gelin karo dhowr qaybood. 1. Habka dhismeed ee natiijada Natiijo kaste, waxaa warbixinta loogu qaabeeyey si loogu soo bandhigo hadal cad oo ku saabsan: Sida ay dhibaatadu uga muuqato kiiska gaar ah Sida ay u tahay dhibaato aasaasi ah – oo aanay ahayn cillad u gaar ah shakhsiyaadka markaas ku lug lahaa iyo xaaladda kiiska u gaar ah? Waa maxay macluumaadka jira ee ku saabsan sida loo arko in ay dhibaatadu ugu faafsan tahay xaafadda, ama macluumaadka ku saabsan sida ay qaranka ugu badan tahay? Sida waxtar leh ee dhibaatada loogu qaabeeyey guddiga LSCB si ay uga fiirsadaan iyaga oo ku eegaya ujeeddooyinkooda iyo waajibaadkooda, halista iyo ku kalsoonaanta nidaamyada hay'adaha farabadan. Waxaa taas lagu muujiyey Habka dhismeed ee Natiijada Waxbarashada Wadajir ah (halkan hoose). Lambeth SCR Child H Confidential draft report 8 January 2014 54 'Habka dhismeed' ee natiijada Waxbarashada Wadajir ah Maxaan sal ka dhiganaynaa? Waa maxay dhibaatooyinka ay u keenayso ku kalsoonaanta nidaamka ilaalinta carruurta ee hay'ado farabadan? Hawsha gudaheed halkee ayay taasi ka dhacdaa? Qaabaynta nidaamyada: halisaha iyo khatarta Maxaa laga og yahay sida ay dhibaatadu u faafsan tahay ama u badan tahay? Kulannada kooxda dib u eegidda ee ugu dambeeya Khibradda shaqaalaha (kooxda dib u eegidda iyo kooxda kiiska) Macluumaadka hawlfulinta xaafadda (kooxda dib u eegidda) Daliilka qaran Cilmibaarista habboon Maxaa ka dhigaya mid aasaasi ah (halkii ay ka ahaan lahayd dhibaato u gaar ah shakhsiyaadka ku lug leh?) Waxaa diiradda loo saaray kulankii labaad ee 'dambe' ee shaqaalaha lala yeeshay 'Muuqaalka wadiiqeed' iyo kaladhigdhigga Dhacdooyinka Habdhaqanka xirfadeed ee Daruuri ah xataa soo ogaanshaha arrimaha suurtogeliyey Sidee ayay dhibaatadu uga muuqatay kiiska? Wadahadallo gaar ah iyo kulankii ugu horreeyey ee 'dambe' 1.5 Kooxda Dib u eegidda iyo Kooxda Kiiska 1.5.1 Kooxda Dib u eegidda Kooxda Dib u eegidda waxaa ka mid ah maamuleyaal sare oo ka socda hay'adaha ku lug lahaa kiiska, oo iyagu aanan qayb toos ah ku lahayn waxkaqabashadii kiiska. Iyaga oo ay hoggaaminayaan laba Dib u eege oo Hoggaanka haya oo madaxbannaan, waxa ay iyagu yihiin gole wada shaqaynaya muddada dib u eegidda, soo qaadaya oo baaraya macluumaadka, welibana gaaraya go'aannada gabagabada ah ee ku saabsan caadooyinka iyo natiijooyinka guud. Waxa ay weliba yihiin il laga helo macluumaadka ku saabsan adeegyada ay matalayaan: siyaasadahooda ku saabsan xeeladda, nidaamyadooda, xeerashooda, iyo xaaladda ururka ee la xiriirta dhibaatooyin ama duruuf gaar ah sida ilaha dhaqaale ee xaddidan, isbeddellada qaabka dhismeed ee ururka, iyo wixii la mid ah. Xubnaha Kooxda Dib u eegiddu waxa ay weliba masuul ka yihiin in ay xubnaha hay'addooda ka taageeraan oo ay u suurtogeliyaan in ay dib u eegidda kiiska ka qayb qaataan. Labada Dib u eege ee Hoggaanka haya ee ku jira dib u eegiddan SCR waxaa labadoodaba loo aqoonsaday in ay qabtaan dib u eegidyada SCIE, waxa ayna khibrad ballaaran u leeyihiin in ay qoraan dib u eegidyada SCR/IMR oo loo adeegsado qaabkii waxqabadka ee hore ee 'Tuduca 8'. Midkoodna hore uguma lug lahayn kiiskan, oo xiriir hore ama hadda ah lama lahayn Kawnsalka Lambeth ama hay'adaha ay iskaashadaan. Lambeth SCR Child H Confidential draft report 8 January 2014 55 Ghislaine Miller, Dib u eegaha Hoggaanka haya ee madaxbannaan ee SCIE Sally Trench, Dib u eegaha Hoggaanka haya ee madaxbannaan ee SCIE Agaasime Ku-xigeenka Ku meelgaar ah Waalidnimada Carruurta La Daryeelo iyo Urureed Adeegga Carruurta iyo Dhallinyarada (CYPS) ee Lambeth Takhtarka Xirfad gaar ah u leh carruurta iyo Takhtarka u Magacaaban CP iyo Dhawritaanka Isbitaalka St. George's Hospital (SGH) Kalkaaliyaha caafimaad ee Xirfad gaar ah leh, Kalkaaliyaha caafimaadka ee u Xilsaaran CP Ururka Xilsaarista Daawaynta (CCG) ee Lambeth ee adeegga NHS Takhtarka Xirfad gaar ah u leh carruurta iyo Takhtarka u Xilsaaran Dhawritaanka, Ururka CCG ee Lambeth ee NHS Kalkaaliyaha caafimaad ee ka Magacaaban Ururka isbitaal, Dhawritaanka Carruurta Ururka isbitaal ee Guy’s and St. Thomas’ NHS Foundation Trust Madaxa adeegga EYFS iyo Daryeelka carruurta Waxqabadka Hore ee Meel ku toosan Adeegga CYPS ee Lambeth Sarkaalka Dib u eegidda Darajada L SC&O 21(2) Akaadamiyadda Dembiyada iyo Cuntubka Dib u eegidda Booliiska London Sarkaalka Hubinta Tayada Adeegga CYPS ee Lambeth Madaxa Adeegga Hubinta Tayada iyo Maamulaha Guddiga LSCB Adeegga CYPS ee Lambeth 1.5.2 Kooxda Kiiska Kooxda Kiisku waa xirfadleyaasha toos ugu lug lahaa qoyska. Qaabka Waxbarashada Wadajir ah ayaa soo bandhigaya in si badan hawsha looga qaybgeliyo oo lala shaqeeyo shaqaalahaas/maamuleyaashaas, oo iyaga la weydiiyo in ay tilmaamaan 'muuqaalka wadiiqeed' – ee ay ka qabeen shaqada ay qoyska waqtigaas u qabteen iyo waxa taas saamayn ku lahaa. Lambeth SCR Child H Confidential draft report 8 January 2014 56 Wixii khuseeya dib u eegidda kiiskan, Kooxda Dib u eegiddu waxa ay wadahadallo gaar ah la yeesheen 25 xirfadleyaal oo ka mid ah Kooxda Kiiska, waxa ayna heleen qoraallo laga sameeyey 3 kale oo wadahadal oo lala yeeshay xubnaha xafiiska takhtarka ilkaha. Caafimaadka: Takhaatiirta Guud (x2) Takhtarka Xirfad gaar ah u leh carruurta (Daawaynta Degdeg ah), SGH Diiwaanhayaha Carruurta, SGH Takhtarka qalliinka ee Xirfad gaar ah u leh Addimada, SGH Takhtarka Xirfad gaar ah u leh carruurta ee Bulshada, ururka isbitaal ee Guy’s and St Thomas’ NHS Foundation Trust Kalkaaliyaha caafimaad ee Magacaaban, SGH Ummulisada, ururka isbitaal ee Guy’s and St Thomas’ NHS Foundation Trust Booqdaha Caafimaadka, ururka isbitaal ee Guy’s and St Thomas’ NHS Foundation Trust Booqdaha Caafimaadka, ururka isbitaal ee Guy’s and St Thomas’ NHS Foundation Trust Adeegga CYPS: Madaxa Adeegga, Kooxaha CPFS, Adeegga CYPS ee Lambeth Maamule Ku-xigeenka Kooxda (x2), Kooxda CP&FS, Lambeth Maamulaha Kooxda, Kooxda CP&FS, Lambeth Hawlwadeenka Bulsheed, Kooxda CP&FS, Lambeth Maamule Ku-xigeenka Adeegga, Kooxda Xaafadeed, Westminster Isuduwaha Dhawritaanka ee Sare, Adeegyada Dadka waaweyn iyo Bulshada ee Lambeth Guddoomiyaha Shirka CP Maamulaha Kooxda, kooxda EDT Hawlwadeenka Bulsheed ee Xilliyeed, kooxda EDT Sanadaha Hore iyo Waxbarashada: Maamulaha Dugsi, Dugsiga Hoose Hawlwadeenka Gacanfidis, Xarunta Carruurta Macallinka Dugsiga xannaanada Booliiska London: Askariga Booliiska, Kooxda Baaritaanka Xadgudubka Carruurta Lambeth SCR Child H Confidential draft report 8 January 2014 57 (CAIT) Askariga Booliiska, Cuntubka Badbaadada Bulshada Askariga Booliiska, Cuntubka Rabshadda Guriga iyo Dembiyada Neceybka (dhanka telefoonka) Dib u eegidda kiiska waxaa nuqullo looga soo diray wadahadallo uu adeegga NHS London, la yeeshay: Takhtarka ilkaha Shaqaalaha soo-dhawaynta, xafiiska takhtarka ilkaha Maamulaha Xafiiska takhtarka ilkaha 1.6 Qaabka hawsha dib u eegidda Dib u eegidda kiiska ka mid ah Waxbarashada Wadajir ah waxaa ka muuqata in ay taasi tahay hawl lagu celceliyo oo macluumaad lagu soo qaado, lagu baaro, lagu fiiriyo dibna loogu fiiriyo, si loo hubiyo in daliilka sii badanaya iyo fahanka macluumaadka laga helo ay sax yihiin oo ay macquul yihiin. Kooxda Dib u eegiddu waxa ay yihiin 'matoorka' hawsha, iyaga oo wadajir ula shaqeeya xubnaha Kooxda Kiiska oo keligood wadahadallo lala galo, ka dibna iyaga oo ku jira kulannada 'Dambe' ee hay'adaha farabadan. Waxaa halkan hoose ku xusan sida ay isugu daba xigeen dhacdooyinka dib u eegiddan ka mid ahaa. Taariikhda Dhacdada 23.04.13 Kulanka baarista baaxadda ee dhexmaray Dib u eegeyaasha Hoggaanka haya, Guddoomiyaha guddiga LSCB iyo Maamulaha 13.05.13 Kulanka soo bandhigidda ee loogu talagalay Kooxda Dib u eegidda 23.05.13 Kulanka soo bandhigidda ee loogu talagalay Kooxda Kiiska – si loo macneeyo qaabka/habka Waxbarashada Wadajir ah, iyo hawsha dib u eegidda kiiska ee ay ka qayb qaadan doonaan. 14, 17, 18 iyo 28.06.13 Wadahadallo afar cisho lala yeeshay xubnaha Kooxda Kiiska (kulanno gaar ah oo qiyaas ahaan 1.5 saacadood lala yeeshay xubin kaste oo ka mid ah Kooxda Kiiska; waxaa caadi ahaan qabta laba qof oo ka mid ah Kooxda Dib u eegidda) 26.06.13 1) Tababbar maalin nuskeed ah oo loogu talagalay Kooxda Dib u eegidda, oo uu bixiyey Ururka Horumarka Soomaaliyeed 2) Kulanka kaladhigdhigga ee Kooxda Dib u eegidda (1) 01.07.13 Kulanka kaladhigdhigga ee Kooxda Dib u eegidda (2) Lambeth SCR Child H Confidential draft report 8 January 2014 58 15.07.13 Kulanka ugu horreeyey ee Dambe (Kooxda Dib u eegidda iyo Kooxda Kiiska) Kulankan dhexdiisa, kooxdu waxa ay ka wada shaqeeyaan soo ogaanshaha Dhacdooyinka Habdhaqanka xirfadeed ee Daruuri ah (KPE-yada) ee kiiska ka mid ahaa ee saamayn ku lahaa sidii kiiska wax looga qabtay iyo/ama natiijadii kiiska qiimaynta habdhaqanka xirfadeed ee ka mid ahaa KPE-yadaas tixgelinta waxa waqtigaas saamayn ku lahaa shaqada/shaqaalaha ('muuqaalka wadiiqeed') FG, Sida waxbarashada ku toosan, Kalkaaliyaha caafimaad ee u Xilsaaran iyo Takhtarka u Xilsaaran ee isbitaalka SGH ayaa laga marti qaaday kaas iyo kulankii labaad ee Dambe si ay goobjoog uga ahaadaan. 24.07.13 Kulanka kaladhigdhigga ee Kooxda Dib u eegidda (3) 29.07.13 Soo bandhigiddii warka cusub ee Dib u eegeyaasha Hoggaanka haya ay u sameeyeen Kooxda Hawlfulinta ee guddiga LSCB 09.08.13 Kulanka labaad ee Dambe (Kooxda Dib u eegidda iyo Kooxda Kiiska) Kulankan dhexdiisa, waxaa kooxda lagu siiyey daabacaadda koowaad ee warbixin lagu qeexayo caadooyinka iyo natiijooyinka aasaasi ah ee soo shaac baxaya, waxaana la weydiiyey in ay ka fiirsadaan haddii ay kuwaasi gooni u yihiin kiiskan gaarka ah ama ay siyaado u jiraan oo ay caado yihiin. 09.08.13 Kulanka kaladhigdhigga ee Kooxda Dib u eegidda (4) 15.08.13 Hubinta Tayada: kulanka kormeeridda ee loogu talagalay Dib u eegeyaasha Hoggaanka haya ee ay la yeesheen SCIE (Dr. Sheila Fish) 06.09.13 Kulanka Kooxda Dib u eegidda (5) – si ay uga fiirsadaan daabacaadda koowaad ee warbixinta ugu dambaysa 10.09.13 Kulanka Kooxda Hoose ee dib u eegidda SCR – si ay uga fiirsadaan daabacaadda koowaad ee warbixinta ugu dambaysa 26.09.13 Kulanka lala yeeshay Guddoomiyaha Guddiga LSCB, DCS, iyo DCS Ku meelgaar ahaa (ee hore). Codsashada in Kooxda Dib u eegiddu ay warbixinta saxaan oo ay ka dib isu raacaan. Guddoomiyaha guddiga LSCB ayaa Wasaaradda waxbarashada ee DfE ka wargeliyey dib u dhaca ku yimid Lambeth SCR Child H Confidential draft report 8 January 2014 59 dhammaystiridda warbixinta. 6.12.13 Kulanka ugu dambeeyey ee kooxda dib u eegidda La xaqiijin doono Kulanka guddiga LSCB – si ay uga fiirsadaan daabacaadda koowaad ee warbixinta ugu dambaysa La xaqiijin doono Warbixinta ugu dambaysa, oo u diyaar ah soo saarista, ayaa loo dirayaa Wasaaradda Waxbarashada (DfE) 1.7 Baaxadda iyo xadka hawsha 1.7.1 Marka la raaco xeeladda nidaamyada ku salaysan waxa ay taasi dib u eegeyaasha ku dhiirrigelinaysaa in ay hawsha ku bilaabaan baaritaan furan halkii ay uga dhaqaaqi lahaayeen su'aalo hore loo dejiyey oo ku jira xadka hawsha, sida ka dhacda dib u eegidda SCR ee caadi ah. Waxa ay taasi suurtogelinaysaa in macluumaadku ay dadka u hoggaamiyaan dhibaatooyinka daruuri ah ee loo baahan yahay in la baaro. Dib u eegiddan SCR gudaheeda, waxa aan annagu ku aragnay oo aan ku baarnay su'aalaha (Baaragaraafka 1.1.2) oo ay guddiga SCB ee Lambeth soo jeediyeen oo ay ku tilmaameen in dan gaar ah laga leeyahay. 1.7.2 Waqtiga lagu daboolayo dib u eegidda SCR waxaa lagu go'aamiyey sida soo socota: Bishii Febraayo 2011 (goortii ay Hooyo Ingiriiska timid) ilaa maalintii ay taariikhdu ahayd 11kii Maarso 2013 (taariikhdii uu dhintay Ilmaha H) 1.8 Ilaha macluumaadka 1.8.1 Macluumaadka ka yimid xirfadleyaasha Sida kor ku xusan, wadahadallo lala yeeshay xubnaha Kooxda Kiiska; waxaa kuwaas qoray oo ka wada hadlay dhammaan Kooxda Dib u eegidda. Laba kulan oo Dambe oo xubnaha Kooxda Kiisku ay kaga jawaabeen kaladhigdhiggii kiiska ayna ku bixiyeen fikradcelin ku saabsan sax ahaanta iyo muujinta caddaali ahayd ee fikradahooda. Wixii khuseeya natiijooyinka soo shaac baxay, Kooxda Kiiska waxaa la weydiiyey in ay faallo ka bixiyaan haddii kuwaasi ay ahaayeen kuwo aasaasi ah oo faafsan/badan. Marka si kale loo dhigo, miyaan go'aanno gabagabo ah ka gaari karnaa haddii kiiskan laga helayo 'daaqad laga eego nidaamka jira', oo sidee ayay taasi u tahay? Xubnaha Kooxda Kiisku waxa ay weliba si waxtar leh uga jawaabceliyeen weydiimihii iyo codsadiyadii dambe ee ka yimid Dib u eegeyaasha Hoggaanka haya iyo Kooxda Dib u eegidda si wax loo kala caddeeyo ama macluumaad dheeraad ah loo helo, markii taas loo baahnaa. 1.8.1.1 Dhacdooyinka Habdhaqanka xirfadeed ee Daruuri ah iyo Arrimaha Saamayn leh Macluumaadka ka yimid wadahadalladii lala yeeshay Kooxda Kiisku waxa ay isu turjumayaan 'muuqaalka wadiiqeed' ee ay qabeen iyo markaa xulka Lambeth SCR Child H Confidential draft report 8 January 2014 60 Dhacdooyinka Habdhaqanka xirfadeed ee Daruuri ah (KPE-yada) ee annaga oo ah dib u eegeyaasha noo suurtogelinaya in aan casharka ugu fiican ka qaadanno kiiska. KPE-yadaasi waa goorar ama waqtiyo muhiim ah oo la xiriira sida kiiska wax looga qabtay ama loo horumariyey. Xubnaha Kooxda Kiiska ayaa weliba ah isha qiime badan ee macluumaadka ku saabsan su'aalaha sababta lagu raadinayo – baarista Arrimaha Saamayn leh ee waqtigaas ku raad yeeshay habdhaqankooda xirfadeed iyo go'aannadooda. 1.8.1.2 Ka qaybqaadashada Dib u eegeyaasha Hoggaanka haya iyo Kooxda Dib u eegiddu waxa ay xirfadleyaasha uga mahadnaqayaan in ay rabeen in ay dib uga fiirsadaan shaqadooda gaar ah, oo ay sidaas furan ee fikir badan uga qayb galeen dib u eegiddan SCR. Duruufta murugo lahayd ee dhimashada ilmaha keentay ayaa hawsha uga dhigtay mid xanuun badan xubnaha Kooxda Kiiska intooda ugu badan ama gebigood. Hase ahaatee, waxa ay jawaabcelin fiican ka bixiyeen wadahadalladii gaarka ahaa ee ay ka qayb qaateen, kuwaas oo lagu soo xasuustay kalintii ay ku lahaayeen sheekada ilmaha ku saabsan, iyo wadahadalladii kooxeed oo mararka qaar dhib badnaa. Dhowr ka mid ah ayaa sheegay in ay dareen fiican ka heleen in ay gargaar ka bixiyaan casharka masiibada timid laga qaadanayo. Kooxda Dib u eegidda ayaa waxaas oo dhan ka helay fahan sii qotodheer oo sii macne badan oo ku saabsan waxa soo gaaray qoyskan ee ka dhex dhacay xiriirrada dhawritaanka, waxa ayna taasi noo suurtogelisay in aan qaadanno casharka ku xusan warbixintan. 2 Macluumaadka laga helay dukumeentiyada Dib u eegeyaasha Hoggaanka haya iyo xubnaha Kooxda Dib u eegidda ayaa eegay dukumeentiyada soo socda: Diiwaannada hay'adaha ku jiray kiiska, oo ka dib lagu beddelay taxane taariikheed oo isku darsan Diiwaannada soo gudbinta iyo macluumaadka (adeegga CYPS) Soo koobidda wareejinta (adeegga CYPS) Qoraallada laga sameeyey kulannada: Shirarka CP, Kooxaha Daruuri ah, MARAC Warbixinnada loogu talagalay Shirarka CP Qorshooyinka iyo Heshiisyada Qoran ee CP Qiimaynta Daruuri ah (adeegga CYPS) Diiwaannada faahfaahsan ee booqashooyinka guriga ee CP (adeegga CYPS) Warbixinta Caafimaadka ee CP ee loogu talagalay MA (6dii Diisembar 2012) Diiwaanka natiijada Weydiimaha Qob47 bishii Maarso 2013 Diiwaanka Wadahadallada Xeeladda ku saabsan bishii Maarso 2013 Lambeth SCR Child H Confidential draft report 8 January 2014 61 Diiwaannada faahfaahsan ee kooxda EDT, 4/5 Maarso 2013 Diiwaannada faahfaahsan ee jiifinta isbitaalka iyo daryeelka Walaalka 2 Wadaxiriirka email ee maamuleyaasha adeegga CYPS ee ku saabsanaa dhacdooyinka bishii Maarso 2013 Warbixinnada Caafimaadka ee CP ee loogu talagalay MA iyo Walaalka 1 (8dii Maarso 2013) Maxaa dheer, Dib u eegeyaasha Hoggaanka haya waxa ay akhriyeen qoraalladii Golihii dib u eegidda SCR ee maalintii ay taariikhdu ahayd 26.03.13, iyo dukumeenti gaaban oo loo soo saaray si kulankaas dhexdiisa lagaga fiirsado, xataa daabacaadda koowaad ee Xadka Hawsha. 1.8.3 Macluumaadka ka yimid qaraabada, saaxiibbada iyo bulshada 1.8.3.1 Isla sida ka dhacda dib u eegidyada SCR ee caadi ah, qaabka Waxbarashada Wadajir ah waxaa loola jeedaa in lagu daro ra'yiga iyo fikradaha xubnaha qaraabada kuwaas oo qayb qiime badan ku leh fahmidda kiiska iyo shaqada hay'adaha. Dib u eegiddan gudaheeda, xaaladda waalidku ay ku yihiin dembiile iyo markhaati ka mid ah dacwad dembiyeed ayaanay suurogal ku ahayn in waqtiga xaadirka ah iyaga wadahadal loogu baaqo. Waxaa la rajaynayaa in mustaqbalka, mar uun ay suurogal noqon doonto in labada waalid lala galo wadahadal ku saabsan waayo aragnimada ay ka heleen wadashaqayntii ay hay'adaha la galeen. Lambeth SCR Child H Confidential draft report 8 January 2014 62 Lifaaqa 2 – Hagaha ereyada takhasus leh Xuruufaha soo gaabinta ereyada ee la isticmaalay iyo ereyada takhasus leh oo la macnaynayo 1. Hagista qaanuuneed ayaa dhigaysa in warbixinnada dib u eegidda SCR ‘…lagu qoro Ingiriisi cad oo loo qoro si fudud in ay xirfadleyaasha iyo shacabkuba u wada fahmaan.’ (2013: 70) Waxaa marwalba adag in dad kaladuwan wax loo qoro. Lifaaqa (Lifaaqa 2) ku saabsan ereyada takhasus leh waxa ay ujeeddadiisu tahay in lagu taageero akhristeyaasha aanan aqoonin nidaamyada iyo hadallada shaqada dhawritaanka iyo ilaalinta carruurta. 2. Guddiga LSCB ee Lambeth iyo SCIE waxa ay labadooduba rabaan in ay wanaajiyaan kartida akhriska warbixinnada dib u eegidda SCR waxa ayna soo dhawaynayaan fikradcelinta iyo talooyinka ku saabsan sida taas loo wanaajin karo. 3. Xuruufaha soo gaabinta ereyada A&E Waaxda Gurmadka Degdeg ah (isbitaalka) CSC Daryeelka Bulsheed ee Carruurta CYPS Adeegyada Carruurta iyo Dhallinyarada DTM Maamule Ku-xigeenka Kooxda DV Rabshadda guriga ED Waaxda gurmadka Degdeg ah FSCP Kooxda Taageerada Qoyska iyo Ilaalinta Carruurta GSTT Ururka isbitaal ee Guy’s and St. Thomas’ Hospital Trust HV Booqdaha Caafimaadka IDVA Hay'adda Rabshadda Guriga ee Madaxbannaan LSCB Guddiga Dhawritaanka Carruurta ee Xaafadda LT Waxbarashada Wadajir ah MARAC Shirka Qiimaynta Halista ee Hay'ado Farabadan SCIE Machadka Heerka sare ee Daryeelka Bulsheed SGH Isbitaalka St. George’s Hospital SW Hawlwadeenka Bulsheed TM Maamulaha Kooxda 4. Ereyada takhasus leh Sharciga Carruurta ee 1989kii soo baxay: Marka adeegyada daryeelka bulsheed ee dawladda hoose ay qoys wax u qabanayaan, sharciga ugu muhiimsan ee lagu taageero awooddooda iyo waajibaadkoodu waa Lambeth SCR Child H Confidential draft report 8 January 2014 63 Sharciga Carruurta, ee 1989kii soo baxay. Qodob gaar ah oo Sharciga ka mid ah ayaa lagu soo hadal qaaday warbixintan oo dhan: qodobka 47. Qod47: Waxa uu kani qeexayaa waajibaadka Booliiska iyo adeegga CYPS ka saaran in ay ka jawaab celiyaan warbixinta lagu sheego in 'ilme ku nool, ama jooga, xaafaddooda uu qabo, ama laga yaabo in ay gaarto, waxyeello weyn.' Marka ay xaaladdaasi timaaddo, waa in weydiimo la qabto si looga go'aan gaaro tallaabada loo baahan yahay in la qaado si loogu dhawro ama loogu abaabulo wanaagga ilmaha. Kulanka Xeeladda ku saabsan: Kani waa kulanka (ama mararka qaar wadahadalka telefoonka) ee lagu bilaabo hawsha qod47. Ka dib marka la helo soo gudbinta ku saabsan ilaalinta carruurta tallaabada ugu horraysa waxa weeyaan in adeegga CYPS uu la xiriiro Booliiska oo uu qabto Kulanka Xeeladda ku saabsan si loo qorsheeyo qofba waxa uu qaban doono muddada la wado weydiimaha ku saabsan ilmahaas/carruurtaas. Nidaamyada Ilaalinta Carruurta ee Rasmi ah: Shirarka Ilaalinta Carruurta, Kooxaha Daruuri ah iyo Qorshooyinka Ilaalinta Carruurta waxaa lagu 'nidaamiyaa' hagista qaanuuneed (Wada Shaqayn, soo saaris kaste). Waxa ay yihiin nidaamyada rasmi ah ee hay'adaha farabadan ay ku soo ogaadaan, ku qiimeeyaan kuna qorsheeyaan ilaalinta carruurta gaara xadka ugu hooseeya ee 'halis ugu jira waxyeello weyn'. Isaga oo soo hoos galaya guddiga LSCB, adeegga CYPS ayaa masuul ka ah qaban qaabinta iyo taageeridda hawlahaas. Hawlwadeenka bulsheed ee adeegga CYPS ayaa loo magacaabaa in uu yahay 'hawlwadeenka daruuri ah' (key worker) ee u xilsaaran carruurta ku jira Qorshooyinka Ilaalinta Carruurta. Amarrada maxkamadda: Sharcigu waxa uu awood noocyo kale ah siinayaa maxkamadaha – si ay u bixiyaan amarro ilaalin ah oo noocyo badan, xataa Amarka Badbaadinta Degdeg ah (Emergency Protection Order) (qod44) – iyo awood ay dawladda hoose u yeelato in ay amarrada noocaas ah dalbato. Booliiska ayaa awood u leh (Ilaalinta Booliiska) amar la'aantiis in ay qaadaan ilme halis ugu dhow waxyeello weyn oo si degdeg ah u gaarta oo ay geeyaan meel nabad ah. Faahfaahinta sida loo qabanayo baaritaanka, ama weydiinta, Qod47 waxaa laga helayaa Wada Shaqayn, soo saaris kaste. Lambeth SCR Child H Confidential draft report 8 January 2014 64 Lifaaqa 3 - Tirakoobyada ku saabsan rabshadda guriga Macluumaadka qaran: Tirooyinku waxa ay muujinayaan in ‘…13,500 oo qof – oo boqolkiiba 80 haween ahaa – ay rabshadda guriga ka wargeliyeen Talosiinta Muwaadiniinta (Citizens Advice) sanadkii ugu dambeeyey. Dhacdooyin tiradoodu tahay 3,300 ayaa laga soo warbixiyey intii u dhexeysay Oktoobar iyo Diisembar 2012, waxaa ku korodhay boqolkiiba 11 marka loo barbar dhigo isla muddadaas sanadkii ka horreeyey.’ (Topping, 2013) Isla maqaalkaas wargeyska Guardian gudihiisa, waxaa lagu sheegay tirooyin ka yimid Wasaaradda Gudaha (Home Office) oo qeexaya in sanadkii ugu dambeeyey 1.2 milyan oo haween ah ay lammaaneyaashooda kala kulmeen rabshadda DV, xataa rabshadda galmeed. Women’s Aid.org.uk: Waxaa cilmibaaris lagu muujiyey in rabshadda gurigu ay saamayn karto afartii haweenba mid mar uun noloshooda, taas oo aanan ku xirnayn da'da, dabaqadda bulsheed, jinsiyadda, naafonimada ama habnololeedka. Rabshadda gurigu waxa ay ku toosan tahay inta dhexeysa boqolkiiba 16 iyo rubuc dhammaan dembiyada rabshad leh ee la diiwaangeliyo, iyo boqolkiiba 10 wixii wicis ah ee laga soo diro xaaladaha degdeg ah. Sanad kaste oo keliya, waxaa yimaadda 13 milyan dhacdo oo kala gooni ah oo ku saabsan rabshadda jirka ama hanjabaadda rabshadda oo haweenka uga yimaadda lammaaneyaasha hadda ama lammaaneyaashii hore. (Wasaaradda Gudaha, 2004; Dodd et al., 2004; Dobash iyo Dobash, 1980; Walby iyo Allen, 2004) Tirakoobyada ku saabsan rabshadda guriga: Imaanshaha iyo badnaanta rabshadda guriga: Guud ahaan Sanadkii 2011/12, haweenka boqolkiiba 7.3 (1.2 milyan) iyo ragga boqolkiiba 5 (800,000) ayaa soo sheegay in ay la kulmeen xadgudubka guriga. Haweenka boqolkiiba 31 iyo ragga boqolkiiba 18 ayaa la kulmay xadgudubka guriga tan iyo markii ay 16 jir ahaayeen. Waxa ay taasi ku toosan tahay 5 milyan oo haween ah iyo 2.9 milyan oo rag ah. Sanadkii 2011/12, booliisku waxa ay soo sheegeen ku dhawaad 800,000 oo dhacdo oo rabshadda guriga ah. Qiyaas gaaraysa boqolkiiba 65 ayaa ku korodhay tirada ciqaabmarinta ku saabsan rabshadda guriga intii u dhexeysay 2005/06 iyo 2010/11 waxaana taas ku toosnayd qiyaasta ah boqolkiiba 99 oo ku korodhay tirada eedaysaneyaasha dembiga lagu helay. Inkaste oo ay xaaladdu sidaas tahay, haddana tirada dadka lagu soo helay dembiga rabshadda guriga ee shantii sano ee ku dhammaaday sanadkii 2011 waxa ay ku taagnayd oo keliya boqolkiiba 6.5 dhacdooyinka laga soo wargeliyey booliiska – inkaste oo ay qiyaastaasi halkaas aad uga sarraysay Lambeth SCR Child H Confidential draft report 8 January 2014 65 oo ay ku beegnayd boqolkiiba 70 dadka dembiga si rasmi ah loogu eedeeyey. Haweenka ayaa si ragga aad uga badan halis ugu jira in ay dhibbane u noqdaan dhacdooyinka farabadan ee xadgudubka, xadgudubka guriga ee noocyo badan (xadgudubka lammaanaha, xadgudubka qoyska, weerarka galmeed iyo dabasocodka), iyo gaar ahaan rabshadda galmeed. Tirakoobyada Lambeth: waxaa ku jira calaamado kaladuwan oo muujinaya heerka rabshadda DV: Soo gudbinta loo soo diro adeegga CYPS ee ku lug leh rabshadda DV: boqolkiiba 19 Tirada qorshooyinka CP ee ku lug leh rabshadda DV: boqolkiiba 61 Tirada guud ee wicista sanadkii ugu dambeeyey khadka caawinta ee rabshadda DV ee qaran ay u direen degganeyaasha xaafadda Lambeth: 1,696 wicis (30,424 wicis oo ka yimid London gebi ahaan). Tirada wicista ee Lambeth ka timid ayaa ku jirtay safka saddexaad marka London loo eego iyada oo ay ka horreeyeen xaafadda Croydon (1747) iyo Lewisham (1699) Jadwalka hoose ayaa lagu bixiyey tirada soo gudbinta loo soo diray MARAC laga bilaabo sanadkii 2007 ilaa waqtiga xaadirka ah. Waxa ay taasi muujinaysaa tirada sii kordhaysa ee dhibbaneyaasha la soo gudbiyo ee loo arko in ay 'halis weyn ugu jiraan waxyeello daran ama dhimasho', ee loo sameeyey qorshooyin ilaalin oo lagu dejiyey kulannada MARAC dhexdooda. Muddo Taariikh Tirada soo gudbin dhibbane Tirada carruurta ku xiran Abr 07 – Maar 08 47 59 Abr 08 – Maar 09 156 171 Abr 09 – Maar 10 307 328 Abr 10 – Maar 11 341 400 Abr 11 – Maar 12 286 361 Abr 12 – Maar 13 396 388 12 bilood wareega Aug 12 – July 13 408 391 Lambeth SCR Child H Confidential draft report 8 January 2014 66 Lifaaqa 4 - Casharrada hore loo bartay iyo isbeddellada la hirgeliyey si habdhaqanka looga wanaajiyo hay'adaha oo dhan Lifaaqan waxaa lagu faahfaahinayaa tallaabooyinka hore loo qaaday ee ku habboon afar ka mid ah lixda natiijo ee mudnaan leh. Natiijada 1: Caadada ay xirfadleyaasha hay'adaha dhammaantood u leeyihiin in ay diiradda saaraan saamaynta shucuureed ee ay carruurta u leedahay ku noolidda rabshadda gurigu, iyaga oo aanan eegayn sida ay ugu sii suurogal badan tahay in ay waxyeellada jirku iyaga gaarto, ayaa horjoogsanaysa in si buuxda loo fahmo halisaha ku wajahan. Guddiga LSCB: Ayaa ansixiyey oo bilaabay isticmaalidda qalabka qiimaynta halista ee hay'adda Barnardo oo si gaar ah loogu eego halisaha xadgudubka jirka ee toos ah ee carruurta ku wajahan. Adeegga CYPS: Tan iyo markii dib u eegiddan la qabtay, Guddoomiyeyaasha Shirka CP ayaa la weydiiyey in ay shirka ku eegaan qaybta la geliyo carruurta ku jirta Qorshooyinka CP oo ay carrabka saaraan xiriirka u dhexeeya rabshadda DV iyo xadgudubka jirka iyo qiimaynta halista. Ururka isbitaal ee GSTT: Ururka isbitaal ee GSTT ayaa qabtay tababbar loogu talagalay xirfadleyaasha bulshada oo ku saabsanaa weydiinta caadi ah iyo isticmaalidda qiimaynta halista ee hay'adda Barnardo bishii Maarso/Abriil 2013. Isbitaalka SGH: Qorshe waxqabad ayaa la dejiyey ka dib hawl Cashar Wanaajin oo kiiskan lagaga jawaabceliyey. Waxaa kaas ka mid ahaa isbeddellada soo socda: o Qalabka qiimaynta halista oo laga bilaabay waaxda gurmadka degdeg ah si loo isticmaalo marka dhaawaca aanan shil ahayn ee NAI uu yahay hal shay oo lagu macnayn karo cabashada jirta (faahfaahin dheeraad ah ayaa ku jirta qorshaha waxqabadka). o Takhtar xirfad gaar ah leh oo hoggaanka u haya dhawritaanka carruurta, gaar ahaan dhinacyada caafimaadka siyaado ugu xiran, matalan, turjumidda dhaawaca, oo loogu talagalay laan kaste oo caafimaad oo la soo ogaado. o Takhtarka xirfad gaar ah leh oo la soo helo oo laga wargeliyo islamarka ilmaha la keeno mar kaste oo laga walaac qabo dhawritaanka carruurta. o Kooxda qaybta isbitaal oo qiimaynaya halisaha ku wajahan badbaadada ilmaha ee qaybta isbitaal dhexdeeda marka dhaawaca NAI uu suurogal yahay waxa ayna hirgelinayaan tallaabooyinka habboon, matalan, ilmaha oo la jiifiyo meel u dhow saldhigga kalkaaliyeyaasha caafimaad, yaraynta booqdeeyaasha. Natiijada 3: Noocyada, diyaar ahaanta iyo tayada turjumaannada ee waqtiga xaadirka ah ayaa dhibaato ah; shaqada sii qorshaysan way u kala duduwan tahay, xaaladaha degdeg ah marka ay yimaaddaanna, aad ayay u liidataa waxa ayna sidaas u keenaysaa halista ah in aanay taageero helin Lambeth SCR Child H Confidential draft report 8 January 2014 67 isticmaaleyaasha adeegga ee aanan luqadda Ingiriisiga ku hadlin, taas oo xirfadleyaasha aad iyo aad ugu adkaynaysa in ay waqtiga habboon ku fuliyaan qiimayn ama natiijo waxtar leh. Isbitaalka SGH: Telefoonnada loo isticmaalo Khadka luqadda ee Language Line (iyo ujeedooyin kale oo sir ah) ee waaxda gurmadka degdeg ah waxaa la geeyey labo qol oo dhan u yaalla. Natiijada 4: Sida looga war hayo marka aanay soo noqnoqod lahayn dhacdooyinka rabshadda gurigu, waxa ay xirfadleyaashu badi aaminaan in ay carruurtu ku wanaag qabaan guriga oo/ama waxa ay u arkaan in ay tiro yar yihiin sababaha ay ugu baahan yihiin in ay si go'an ula hawlgalaan waalidka. Waxa ay taasi keentaa in aanay fahan dheeraad ah ka helin sababaha ka dambeeya iyo waxyaabaha dhaliya dhacdooyinka rabshadda guriga, iyo heerka dhab ah ee halista ay kuwaasi carruurta u suurtogelinayaan. Adeegga CYPS: Waxa uu ku dhaqaaqayaa hirgelinta buuxda ee qaabka Calaamadaha Badbaadada (Signs of Safety) oo lagu xoojin doono tayada qiimaynta halista, suurtogelin doona in si ka fudud ay waalidku u fahmaan meelaha walaacu ka jiro, looguna qaabayn doono Qorshooyinka CP si natiijada siyaado diiradda loogu saaro. Natiijada 5: Dadaalka ay shaqaalaha daryeelka bulsheed iyo booliisku ugu jiraan in ay xirfadleyaasha caafimaadka ka helaan sharraxaadda cad ee sababta dhaawaca jirka ee carruurta, ayaa khilaafsan caadada ay xirfadleyaasha caafimaadku u leeyihiin in ay bixiyaan natiijooyin kaladuwan oo keenaya in wax kaste uu suurogal yahay ilaa meesha laga saarayo. Waxa ay taasi sii suurtogelinaysaa isfahanwaaga ku saabsan halisihii hore iyo kuwa mustaqbalka marka la wado baaritaannada ilaalinta carruurta. Adeegga CYPS: Dhacdada ka dib, waxaa adeegga CYPS gudihiisa dib looga bixiyey hagis la siiyey kooxaha hawlaha bulsheed oo ku saabsan baahida loo qabo in isla maalintaas la diiwaangeliyo natiijooyinka iyo tallaabooyinka daruuri ah ee ka soo shaac baxa Kulanka Xeeladda ku saabsan, oo kuwaas la siiyo dadka isla maalintaas jooga. Taas ayaa baaris lagu soo hubiyey waxaana la soo ogaaday in ay ka dhacdo kiisaska la eegay. Isbitaalka SGH: Qorshe waxqabad ayaa la dejiyey ka dib hawl Cashar Wanaajin oo kiiskan lagaga jawaabceliyey. Isbeddelladu waxa ay ku xusan yihiin dhanka sare, Natiijada 1 hoosteeda. |
NC043376 | Summary of a review investigating the sexual abuse of seven boys (unrelated) who were looked after by their local authority at different times after September 1999, focusing particularly on the barriers that discourage children (including when they become adults) from disclosing their abuse. The perpetrator was a foster carer who was subsequently imprisoned for 13 life sentences. The foster carer and his wife had been de-registered in 2006 following the disclosure that he had invited a foster child to view pornographic material. Points of learning included the importance of encouraging children to express their views and wishes, particularly at important points of transition; the importance of developing trusting relationships and communication with vulnerable children; and ensuring that investigations responding to inappropriate sexual behaviour are jointly planned from the outset. A full overview report has also been published.
| Title: A serious case review 'DN11': the executive summary LSCB: Nottinghamshire Safeguarding Children Board Author: Peter Maddocks Date of publication: 2012 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 16 Nottinghamshire Safeguarding Children Board A Serious Case Review ‘DN11’ The Executive Summary July 2012 Page 2 of 16 Index 1.1 Introduction .................................................................................................3 1.2 Rationale for conducting the serious case review.................................................3 1.3 Communication and contact with the children subject of the review.......................4 1.4 Details of the timescale and conduct of the serious case review .............................5 Former Foster Carers ............................................................................................7 Looked After Children ...........................................................................................8 Wider issues to consider........................................................................................8 Agency specific issues ...........................................................................................9 1.5 Summary of the serious case review .................................................................9 1.6 Good Practice ...............................................................................................9 1.7 The summary of the events examined by the review..........................................11 1.8 Key themes from the review..........................................................................13 1.9 Key areas for learning...................................................................................14 1.10 Recommendations ......................................................................................15 Recommendation one.........................................................................................15 Recommendation two.........................................................................................15 Recommendation three.......................................................................................16 Recommendation four ........................................................................................16 Recommendation five .........................................................................................16 Page 3 of 16 1.1 Introduction 1. The serious case review examines the circumstances of the exceptional and very grave sexual abuse of unrelated boys who were looked after by the local authority at different times after September 1999. 2. The perpetrator (FC1) was a longstanding married white male foster carer who is now imprisoned for 13 life sentences having pleaded guilty to over 50 offences. In addition to the seven children who are the subject of this serious case review, a further ten children, who had not been looked after, disclosed sexual abuse that led to FC1’s conviction. All of the children are white boys from English speaking homes. 1.2 Rationale for conducting the serious case review 3. Although FC1 was convicted in relation to the abuse of sixteen children, for the purpose of this serious case review, the focus is on seven looked after children who were placed with FC1 and FC2 in their capacity as approved foster carers. Six of the subject children made complaints of sexual abuse that resulted in criminal charges. The seventh provided information that was treated as evidence of bad character. Although the abuse of all the children is equally serious the purpose for undertaking a serious case review is described in national guidance1. 4. In this particular case, the NSCB has conducted the review because children have been harmed as a result of being subjected to sexual abuse whilst being looked after by the local authority. It is for this reason that it is the seven looked after children who are the focus and the subjects of the review. 5. The serious case review has examined a great deal of detailed information from several agencies; nine of those services provided comprehensive individual management reviews in accordance with national guidance and local standards. The police also provided information about their criminal investigation that included evidence from the interviews they completed with FC1 and the statements provided by the young people. 6. This detailed work has not identified an occasion when evidence in the form of disclosures by children or from other sources could have identified FC1’s criminal activity before 2010 and when he was no longer a foster carer. 7. FC1 and FC2 were de-registered as foster carers in 2006. This had followed the disclosure that FC1 had invited a foster child to view pornographic material. This information was investigated under the appropriate procedures of the Nottinghamshire 1 Working Together to Safeguard Children 2010; chapter eight. Page 4 of 16 Safeguarding Children Board (NSCB) and involved the relevant services including the police and children’s social care services. 8. The decision to de-register FC1 and FC2 meant that no further children were placed with FC1 or FC2 after 2006. 9. None of the children2 who were abused had felt able to disclose their abuse until FC1 was no longer a foster carer and then only after the death of his wife FC2 in 2010. The first disclosure that led to the prompt investigation and prosecution of FC1 was made by a young person who had never been looked after by FC1 or by the local authority in any other setting. 1.3 Communication and contact with the children subject of the review 10. As part of the planning and conduct of the serious case review, careful thought has been given throughout to the communication with the seven children, several of who are now in their twenties and the youngest are now in their adolescence. 11. Six of the children received a personal visit on behalf of the panel together with a letter explaining the purpose and work of the serious case review. The person making that visit was drawn from either the police or children’s social care and was based on who had the better contact with specific young people. The seventh young person was content to receive his letter by post and did not want a personal visit from either the police or Children’s Social Care (CSC). 12. The letter invited each of the young people to meet with the independent author of the overview report and a representative of the NSCB. SCRP were concerned to ensure that all these contacts were handled with great sensitivity and that none of the young people were placed under any pressure to contribute to the review if they did not feel able to do this. For that reason, no other contact or follow up was made during the review. 13. All of the young people are being contacted again at the conclusion of the review. They will be offered an opportunity to receive written information and to meet with the author and a representative of the NSCB. Contact will be maintained with all the young people; some of this reflects ongoing statutory support and help. 14. The barriers that discourage children (including when they become adults) from disclosing their abuse is one of the key lines of enquiry for this review. The sexual abuse 2 The term child, children and subject children is used throughout this report to emphasise that at the time the FC1 committed his offence all of his victims were young. The use of the term child in this executive summary and the main overview report is intended to remind and emphasise that at the time of the events taking place all the subjects were children who should have expected trusted adults such as a foster carer to keep them safe. Given the fact that the offences span a period of several years, many of the ‘subject children’ are now young men. Page 5 of 16 of children is an insidious and secret form of abuse. Abusers will use a range of methods and techniques to hide their abuse and prevent their victims disclosing it. 15. FC1 used a variety of techniques to prevent the children he sexually abused from disclosing any information that could have led to his detection before the first disclosure that led to his conviction. Once the first disclosure was made, this enabled the police and children’s social care services to respond promptly and it encouraged other children to provide information. 16. The fact that the abuse involved a man sexually abusing and in some of the cases raping boys is a particular factor explored in the analysis of the main overview report. Sexual abuse of any child is very damaging with long lasting consequences; for young boys who are abused by an adult male, it can have particular significance in terms of them being able to tell somebody about what has happened, and is exacerbated when the abuser should be a trusted adult. Chapter three of the overview report provides a summary of relevant research and studies. 17. The final chapter of the overview report includes reference to two other serious case reviews and an independent report related to sexual abuse by a foster carer (one of these had adopted the child) in other parts of England. 1.4 Details of the timescale and conduct of the serious case review 18. The serious case review was commissioned by Mr Chris Few, the independent chair of the NSCB, on the 19th May 2011. A serious case review panel was convened comprising of representatives as listed below. The chair of the NSCB asked an independent lay member of the NSCB to participate in the work of the panel to provide additional independence and challenge to the discussion and analysis. Position Organisation Group Manager Safeguarding and Independent Review and Quality Assurance Nottinghamshire County Council (NCC) NSCB Business Manager NSCB NSCB Development Manager NSCB Service Director Children’s Social Care, NCC Service Director Education, Standards and Inclusion, NCC Operations Manager Nottingham and Nottinghamshire Futures Consultant Paediatrician and Designated Doctor NHS Nottinghamshire County Designated Nurse Safeguarding Children, NHS Nottinghamshire County Page 6 of 16 Position Organisation Superintendent Nottinghamshire Police Manager CAFCASS Deputy Director Quality and Governance NHS Nottinghamshire County Deputy Director of Nursing Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) Associate Director of Social Care Nottinghamshire Healthcare Trust (NHCT) Head of Service Out of area YOS Lay Member NSCB 19. In line with national requirements for the completion of serious case reviews two persons independent of any of the services involved were appointed to chair the serious case review panel and author the overview report. 20. Ann Domeney was appointed in June 2011 as the independent chair for the serious case review panel. She is a former Deputy Director of Children’s Social Care Services for a large county council in England. She is a qualified and General Social Care Council (GSCC) registered social worker with over twenty five years of experience of social care with children and families. She was Head of Social Care for Children and Families for over nine years in two local authorities. She has considerable experience of both contributing to and chairing serious case reviews. 21. Peter Maddocks was appointed in June 2011 as the independent author for the overview report and this executive summary. He has over thirty-five years experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local as well as work with national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the GSCC. He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several Local Safeguarding Children Boards (LSCB) in England and Wales. He led a national review of fostering arrangements that contributed to the development of the national programme, Quality Protects. He has also chaired fostering as well as adoption panels and acted as the agency decision maker for the approval of foster carers. 22. The following agencies had contact with the family at various times. As will be seen two of these agencies are based outside of Nottinghamshire. Contact was made with the respective LSCBs for those areas to engage their participation in the review process. All Page 7 of 16 agencies conducted management reviews of their agency’s actions and decision making which contributed to the overview report’s analysis and findings; a) CAFCASS (Children and Family Court Advisory and Support Service) b) Out of area Youth Offending Service3 c) Nottinghamshire Children, Families and Cultural Services (NCFCS) Social Care4 d) NCFCS Education Standards and Inclusion Service e) NHS Nottinghamshire County – GP Services f) Nottinghamshire Healthcare NHS Trust g) Nottingham Futures (advice, information and guidance service commonly referred to as Connexions) h) Nottinghamshire Police i) Rotherham and Doncaster and (NHS) South Humber Foundation Trust (RDaSH) 23. In compliance with national guidance a health overview report was provided on behalf of the various health services that contributed to the review. The overview report for the entire serious case review was presented to the Nottinghamshire Safeguarding Children Board in December 2011. 24. The chair of the NSCB agreed to a short extension to the submission of the serious case review reports to the Department for Education and Ofsted in recognition of the complexity of material covered in this review and to ensure appropriate quality assurance had been completed taking account of the Christmas and New Year period. This short delay and the circumstances were communicated to the Department of Education and Ofsted. 25. All of the report authors, together with the overview author, were required to collate information and provide analysis in response to several key lines of enquiry identified by the panel and agreed by the NSCB. The key lines of enquiry, which are additional to the terms of reference set out in national ‘Working Together to Safeguard Children 2010’’ guidance were; Former Foster Carers 26. Identify and evaluate the quality and effectiveness of the approval process, the support and supervision of FC1 and FC2, the provision and take up of training and the fostering review process. Is there evidence of information sharing and multi-agency working in these areas? Indicate whether practice in this area was in accordance with local and statutory guidance in place at that time. 3 The Youth Offending Service was involved with one of the young people. 4 This IMR covers services provided by the fostering team who had the most contact with FC1 and FC2; the team provided supervision and support to the carers. The IMR also covers work by the young people’s social workers who were responsible for oversight of planning and support for individual young people. Page 8 of 16 27. Identify and evaluate how any concerns about the behaviour of, and care by, the foster carers were analysed, understood and responded to by professionals and agencies (including concerns about non-co-operation and possible abuse). Indicate whether these concerns were dealt with in accordance with local and statutory guidance in place at that time. 28. Identify and evaluate the response to the specific concerns raised in 2006 which resulted in the de-registration of FC1 and FC2. Indicate whether these concerns were dealt with in accordance with local and statutory guidance in place at that time. Looked After Children 29. Identify and evaluate the frequency, nature and quality of professionals’ contact with the children and specifically whether they were seen alone. 30. Identify and evaluate the extent to which the views of the children were ascertained, heard, recorded and responded to appropriately by professionals. 31. Identify and evaluate how concerns raised by children (if there were any) were responded to, including whether information about those concerns was shared with other professionals 32. Identify and evaluate the extent to which birth parents, family and the young person, contributed to the planning and reviewing of services. This should include, where appropriate, the placement choice and how their contribution impacted on the outcomes for that child. 33. Identify and evaluate the effectiveness of multi-agency working, including Looked After Reviews and compliance with local and statutory guidance in place at that time. 34. Were the services provided sensitive to the needs and vulnerabilities of the child? Wider issues to consider 35. Was practice sensitive to the gender, racial, cultural, linguistic and religious identity of those involved? Were there any issues of disability of the child and family, and were they explored and recorded? 36. Were assessments and decisions made in an informed and professional way? Did actions accord with assessments and decisions made? Were appropriate services offered/provided? Page 9 of 16 37. Were senior managers and other organisations and professionals involved at points in the case where they should have been? Was there sufficient management accountability for decision making? 38. Whether current working practices could be changed to increase the likelihood of children disclosing abuse in the future. Agency specific issues 39. Police; Information gathered by the police during the most recent investigation should be reviewed and any information relevant to the key lines of enquiry identified above should be made available to the Serious Case Review Panel (SCRP). 40. Children’s social care should make enquiries to establish whether existing foster carers, including FC1 and FC2, were reviewed when revised processes for approval were introduced. 41. Children’s social care should review all information that they hold about looked after children that have been placed with FC1 and FC2. Any issues or key points identified should be included within their Individual Management Review (IMR). They should also make recommendations to the serious case review panel (SCRP) about the inclusion of any additional subjects. Similarly children’s social care should review all information that they hold about other children abused by FC1, who were known to them, for the same purpose. 1.5 Summary of the serious case review 42. The serious case review panel identified several examples of good practice. 1.6 Good Practice 43. The serious case review panel aimed to be very challenging of services with a view to achieving good learning from their examination of events through hindsight. Several examples of good practice were identified by the review. These examples included; a) Providing an additional social care professional to work with one of the children to help encourage him to share his feelings and to talk with a trusted adult; b) The evidence of very impressive practice with regards to communicating with birth parents and families. c) The sensitive planning by fostering staff and the children’s social workers regarding placement choice for some of the children when they had to move between placements. Page 10 of 16 d) Examples of the children and young people being asked about what they wanted in a placement or family when talking about long term placements. e) Efforts were made for the children to be provided with consistent carers both for their full time placements and support care placements, wherever possible. f) A social worker spoke directly with one of the boys about why he did not want to go to stay with FC1 and FC2. Despite this opportunity to discuss what was happening when he was in placement with them he did not say anything of significance with regards to being sexually abused whilst there. g) There were good examples of child focused confidential health provision being offered by the school nursing service, GPs and Child and Adolescent Mental Health Service (CAMHS) workers. It is evident even in the period before 2005 that children were being seen alone and offered the opportunity to discuss issues in confidence. h) CAMHS services for some of the children offered extensive individually tailored support for young people where they were seen alone and allowed opportunities to express fears, wishes and feelings in depth. Child friendly techniques were employed such as drama therapy, art therapy and life story work. i) Nurses routinely made personal introductions to the child and their carers together with other professionals who might be working with the child. j) There was concerted effort by education welfare staff to make links with other agencies, share concerns and instigate an intervention in regard to one of the boys in particular. k) Medical records of looked after children were requested by fast track by receiving GP practices and should be routine practice. l) There was good communication with dental services by the school nurse to facilitate access to dental care. m) One of the boys attended a medical with his best friend; good attention was paid to issues of confidentiality and being sensitive to his decision to involve a best friend. n) The drama therapy work was a particular example of good practice in the CAMHS work. 44. The IMRs, with the exception of CAFCASS and the NHCT, have identified recommendations to implement learning for their specific services as a result of the review. The health overview author has also provided recommendations to support work across the collective health community. All of these recommendations are collated into an integrated action plan. Progress against these actions will be monitored by the NSCB or relevant LSCB for those agencies not based in Nottinghamshire. 45. Although none of the services identify any occasion when a professional could have identified the abuse being committed by FC1, a number of the authors do provide Page 11 of 16 reflection about the way in which some of the children’s behaviour changed and was noticed by people including foster carers and teaching staff. 46. There is clear evidence that individual practitioners across several services made concerted efforts to talk with children. This recognised the complexity of need for some of the children. At no time did a child disclose FC1’s abuse until 2010. 1.7 The summary of the events examined by the review 47. FC1 and FC2 were approved as foster carers by the local authority from 1982 until 2006 when they were de-registered. FC1 and FC2 were a childless couple and had little or no previous experience of looking after children before their approval as foster carers. It is acknowledged that many children are successfully fostered by individuals and couples who have not had children and is therefore not meant to imply that childlessness was an indicator of concern in this case. 48. The assessment of FC1 and FC2 more than complied with the national standards and regulations that applied at the time; several aspects of the local practice exceeded the historical standards and requirements. FC1 and FC2 were the subjects of appropriate reassessments as required by subsequent legal changes and the introduction of revised national standards. 49. The support and reviewing arrangements for FC1 and FC2 generally complied with and could exceed relevant national and local standards. The fostering service responsible has been assessed by the regulator as providing a good service; this signifies that it is doing significantly more than the legal minimum required. It was noted by the panel that the records of some important activity such as some annual reviews as well as the original fostering assessment had gaps; although this deserves attention in the relevant IMR it is not a factor in the overall management and oversight or the conclusions of the review generally. 50. During the initial placements the supervising staff and children’s social workers provided suitable oversight of the placement arrangements and took appropriate action to address identified areas of development with FC1 and FC2; an example was in their management of children’s behaviour. 51. FC1 and FC2 were reluctant to take up training opportunities and to participate in foster carer support networks despite regular encouragement from their supervising social workers. It is acknowledged that this reluctance would not be accepted under current arrangements for foster carers. Some aspects of their care routines in early placements were insensitive and did not reflect advice and guidance. They showed some unwillingness to develop their own safe caring practices although they had a framework of guidance and advice from professional staff. Page 12 of 16 52. For the majority of the time FC1 and FC2 provided short term and respite placements. They were increasingly used to provide support for children placed with longer term carers as well as responding to short term needs. Some of the looked after children who were abused by FC1 had been looked after for several months and had more complex needs. 53. No evidence has been identified to confirm that FC2 was aware of FC1’s sexual abuse of children. The abuse apparently occurred when FC2 was not at home or with FC1. FC2 had an evening job for several years. 54. In 2006 the long term foster carer of a child who was not abused overheard a conversation that indicated that FC1 had invited a looked after child to view a pornographic video and had invited another to also watch a pornographic video. This conversation was appropriately reported to the supervising social worker and led to an investigation that resulted in FC1 and FC2 being deregistered as foster carers. No further placements of children were made. 55. The process to investigate the allegation that FC1 invited a child to watch pornography in 2006 was underpinned by Inter-agency Child Protection Procedures. Whilst there are elements of the process adopted that could have been managed differently the panel did not hear any information that would support a conclusion that had the enquiries into the incident in 2006 been managed in another way a different outcome would have resulted. This position is further supported by the findings of the Ofsted inspection of Fostering services in October 2011 which concluded that arrangements to keep looked after children safe were good and that any allegation made by a child or young person was investigated in line with safeguarding procedures. 56. It is important to note that FC1 and FC2 did not foster again following the initial allegation and that the Council took appropriate action in deregistering FC1 and FC2 as foster carers. 57. Appropriate consideration was also given to the protection of other children who were not looked after by the Local Authority. 58. The panel also considered whether the response to another similar allegation would be different if it was made in 2011. IMR authors noted a number of improvements in inter-agency working that would indicate a joint investigation response would now be undertaken. 59. In 2010 FC2 died. She had poor health for a number of years. After FC2 died a child who had not been looked after by the Local Authority made the first disclosure of sexual abuse. This led to a criminal investigation and the subsequent conviction of FC1. Page 13 of 16 1.8 Key themes from the review 60. Without the disclosure made in 2010 there had been no previous opportunity to know about FC1’s criminal abuse. The research evidence that has been collated with the panel for the purpose of the review confirms that the sexual abuse of children is seriously under reported. It is a particular problem for boys who are sexually abused by other males. 61. The research summarised in chapter three of the main overview report describes several barriers for children who have suffered sexual abuse; amongst the most significant are being able to trust another person enough to tell them about what has happened or is happening; a fear of not being believed or taken seriously; children also worry about losing control of the information. 62. For boys who are abused, the problems are further compounded by other concerns that include a fear of being branded as ‘gay’ or feeling un-masculine. This was considered to be an important factor for several of the children who came from communities that had very defined and traditional cultural and social understanding about men and reflected a local industrial heritage of manual work and physical strength. 63. Other factors that prevent children from disclosing their abuse is their degree of understanding about what is happening; for some younger or less mature children, their knowledge about what is abusive behaviour has not yet developed (one of the children referred to discovering that the abuse was wrong during subsequent sex education). 64. Research also describes the range of behaviours exhibited by the perpetrators of sexual abuse; in this case it ranged from making some of the children feel ‘one of the boys’ whilst others described intimidation and fear. 65. Although none of the boys made disclosures, some of the IMR authors were able to reflect with hindsight the extent to which some of the children’s behaviour could be seen as symptomatic of abuse. This is borne out by the research evidence again, as well as the statements made by some of the boys to the police. 66. The large numbers of children placed with FC1 and FC2 over the years meant that coordination of information about the behaviours of children with the details of carers was not routine; in other words, the changed behaviour of some of the children could not be easily linked with specific placement and therefore patterns could not be discerned and was not available to the investigating team in 2006. 67. The panel also examined evidence from investigations in other areas of the UK including two other serious case reviews that have concerned the sexual abuse of children by a foster carer. Themes to emerge from that work included foster carers who became Page 14 of 16 established and trusted with a reputation for forming relationships with children. Although the 2006 investigation ensured that FC1 and FC2 did not foster children again, with hindsight it could be seen that FC1 was able to present himself as a foster carer who had made a serious ‘foolish mistake’ regarding pornography rather than something far more sinister. 1.9 Key areas for learning 68. This serious case review will not repeat recommendations previously made to the NSCB. For example, significant work is taking place in regard to support for vulnerable children in education and the local authority are implementing a major strategy for their looked after services. 69. A considerable range of learning has been identified through the review and is addressed in the IMRs and the overview reports. 70. Some of the most important points of learning from the review identified through the IMRs and from examining other reviews and research are; a) The importance of continuing to encourage children to express their views, wishes and feelings and particularly at important points of transitions such as movements between placements; b) The importance of appropriately trained professionals having the skills, experience and workload capacity to spend time with vulnerable children developing relationships of trust and open communication; c) Ensuring that when responding to information that suggests inappropriate sexual behaviour, the investigations are jointly planned from the very outset and that particular care is given to managing potential mindsets towards trusted adults who have been known for many years; d) Maintaining minimum standards and expectations with foster carers in terms of the training and participation in support and development and their safe care practices; e) Recognising that children who become looked after, especially at older ages, may have significant needs as a result of attachment difficulties, experience of neglect and abuse that makes them more vulnerable; when social workers have to take action to remove children from their families, this can create a barrier for the children being able to trust the social worker; this highlights the potential value of having access for example to appropriately prepared and supported independent persons; f) Vulnerable children need access to good quality schools and educational provision that has the capacity of responding to complex and at times challenging behaviour; Page 15 of 16 g) The importance of staff and carers having appropriate levels of understanding about how poor or challenging behaviour can be symptomatic of abuse that may not just be related to historical information already known to the professionals; h) The risks that can be associated with children in placements for short periods of time; the value and importance of children’s carers, parents or professional staff reporting and discussing any changes in behaviour that is noticed; i) The sexual abuse of children and male abuse of boys in particular have lasting consequences on the emotional and mental health of children; the majority of abused children will never disclose their abuse and may require support as adults from a wide range of services that may include mental health and substance misuse. 71. Many changes have occurred at both the local and national level since the events that are examined by this review. For example, the introduction of new oversight and co-ordination arrangements through the local authority’s designated officer (LADO) provides additional oversight and guidance when concerns are raised about the behaviour of trusted adults. The strategic function of the LADO also ensures that learning is co-ordinated across relevant settings including social care, schools and youth organisations where adults are in close contact with children. Further changes have also taken place in CSC and the police as a result of the response to inspections and previous reviews. 1.10 Recommendations 72. Having considered the overview report, the Nottinghamshire Safeguarding Children Board and the local agencies have agreed to take the following action to improve future practice. This action is in addition to the agency action plans being implemented by services as a result of their individual management reviews. Recommendation one The Director of Children’s Services should provide information to the Nottinghamshire Corporate Parenting Panel on the availability and use of advocacy arrangements and independent people for looked after children and whether any further development of such arrangements are required as a result of this review. Recommendation two The Director of Children’s Services should provide a report to the Nottinghamshire Corporate Parenting Panel describing if any further action is required for the management and oversight of short term or respite care placements for children. Page 16 of 16 Recommendation three The Director of Children’s Services should ensure that an appropriate briefing is provided to the Children in Care Council with a view to consulting that council and other children and young people about how their views, wishes and concerns are included in the annual review of foster carers. Consultation should also include any additional suggestions for encouraging children and young people to raise concerns if and when this occurs. The outcome should be reported to the Nottinghamshire Corporate Parenting Board. Recommendation four A summary of the key learning from this review as it relates to the needs of men who have been sexually abused and may require help and support should be provided to the members of the Nottinghamshire Safeguarding Adults Board (NSAB). Recommendation five The Director of Children’s Services should provide information to the Nottinghamshire Safeguarding Children Board regarding any ongoing contact with the children and young people who were abused by FC1 and the arrangements for future follow up and consultation. Consideration should be given to any additional and independent sources of support including counselling that may be required An action plan has been developed in response to these recommendations. This describes clear arrangements for improving practice and the expected timescales for completing this work. Implementation of the actions above and those in IMRs will be monitored through the NSCB Standing Serious Case Review Subgroup. The impact on local practice of these actions, and actions already taken by agencies, will be evaluated by the NSCB Performance and Quality of Subgroup. Actions that relate to agencies located in other LSCB areas will be monitored by the LSCB responsible for that area. Signed Chair of the NSCB July 2012 |
NC50688 | Death of a 17-year-old boy from fatal injuries incurred by jumping from the roof of a building in December 2017. Child CB struggled with his identity and did not want others to know he was adopted. His overall wellbeing and behaviour was impacted by attachment difficulties first identified in 2009 when a CAMHS referral was made. He suffered emotional and physical harm before moving to foster care in September 2014 when relationship with adoptive family (White British) broke down. He had five foster carers and it is unclear how well they were able to respond to and cope with his difficulties. Issues identified include: to seek assurance that the preparation, training and ongoing development and support of foster carers enables them to offer long term, stable and therapeutic placements to children who share Child CB's vulnerabilities; to review what support and development arrangements are currently in place for adopted children and adoptive parents for children with adverse childhood experiences, attachment and identity issues. Model: developed to enable participants to consider events and circumstances which led up to the death of Child CB. Recommendations include: to review existing arrangements for care leavers and ensure that the care plan considers the young person's views; to review current suicide prevention strategies; to include known suicide risk factors for children and young people into ongoing staff development and training; focus on the impact of cannabis and other substances on mental health and other outcomes for children and young people, the potential interactions of cannabis with prescribed mental health (and other) medications and agency responses.
| Title: Serious case review: Child CB. LSCB: Blackpool Safeguarding Children Board Author: Clare Hyde Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. BLACKPOOL SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW CHILD CB 1 Contents Key: Family Members ............................................................................................................................... 3 Key: Acronyms ........................................................................................................................................ 3 Introduction ............................................................................................................................................ 4 The SCR: Process and Methodology ...................................................................................................... 4 Independence ......................................................................................................................................... 7 Serious Case Review Panel ..................................................................................................................... 8 Confidentiality ........................................................................................................................................ 9 Family involvement ................................................................................................................................ 9 Staff involvement ..................................................................................................................................... 9 Race, Language and Culture ................................................................................................................... 10 Summary of Child CB’s history ............................................................................................................... 10 Overview of events and agency involvement ..................................................................................... 11 Analysis .................................................................................................................................................. 11 Consideration of Key lines of enquiry.................................................................................................. 13 Post Adoption Support and Interventions ...................................................................................... 13 Was Child CB enabled to understand his identity? ..................................................................... 13 How well did professionals understand Child CB’s behaviour, attachments and identity anxieties? ...................................................................................................................................... 16 Interventions ........................................................................................................................................ 35 CAMHS Provision .............................................................................................................................. 42 What was the impact of the move between geographical areas for Child CB? ............................. 44 Was there one ‘trusted professional’ in Child CB’s life post adoption breakdown? ..................... 46 2 How effective was multi-agency working in ensuring a co-ordinated response to Child CB’s needs? .............................................................................................................................................................. 47 What was the interplay between medical diagnoses, medication and other therapies? ................. 49 Risk taking behaviour ........................................................................................................................... 51 How effectively did agencies understand and respond to risk taking behaviour? .................... 51 Responses to the risk of suicide ........................................................................................................... 54 How effectively did agencies respond to indications of low mood, self-harm and suicidal ideation? ....................................................................................................................................... 54 Was the immediate response to the suicide attempt on 15 December 2017 effective and did it fully consider his mental health? ................................................................................................. 57 How did Child CB’s wishes and feelings influence assessments and responses? .............................. 60 How did practitioners ensure that Child CB was listened to and understood? ......................... 60 Further Analysis .................................................................................................................................... 62 Summary ............................................................................................................................................... 64 Learning and Recommendations arising from this Serious Case Review ........................................... 65 References ............................................................................................................................................ 69 3 Key: Family Members Child CB Aged 17 Sibling 1 Now aged 16 F Father M Mother BF Birth Father Key: Acronyms CAMHS Child and Adolescent Mental Health Service CASHER Child and Adolescent Support and Help Enhanced Response IRO Independent Reviewing Officer SNP School Nurse Practitioner SS Secondary School SW Social Worker CSC Children’s Social Care 4 Introduction 1. The subject of this Serious Case Review (SCR) is Child CB. 2. Child CB suffered fatal injuries after jumping from the roof of a building in December 2017. 3. Child CB was aged 17 when he died. 4. In September 2014 Child CB was placed in accommodation using Section 20 of the Children Act 1989 when his relationship with his adoptive family broke down. 5. Child CB remained in the care of the local authority until his death. 6. This SCR focuses upon agency involvement with Child CB and his family in order to identify learning, good practice and missed opportunities to safeguard Child CB. The SCR: Process and Methodology 7. The Independent Chair of the Local Safeguarding Children Board (LSCB) agreed on 30th January 2018 to commission a SCR concerning the tragic death of Child CB. The scope of this SCR was to cover the timeframe from September 2013 to 21st December 2017 which was the date of Child CB’s death. (It was agreed by the SCR Panel that any significant events prior to this date would also be included within the scope). 8. The Case Review Sub Group made a recommendation that the LSCB should conduct a proportionate, appropriate and participative SCR with the emphasis upon professional involvement, to address how agencies had worked together in this case, identify any learning and good practice, aggregate lessons from individual organisations and ensure that an improvement action plan was put in place. 5 9. The SCR was designed and led by Clare Hyde MBE, independent reviewer, from The Foundation for Families (a not for profit Community Interest Company). Ms Hyde developed a review model that would enable participants to consider the events and circumstances, which led up to the death of Child CB. 10. This formal process allows practitioners to reflect on cases in an informed and supportive way. Documenting the history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for LSCBs to use where it is more important to consider how agencies worked together. The detail of the analysis undertaken of the case is not the focus of the reports which are succinct and centre on learning and improving practice. However, because a review has been held, it does not mean that practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice. The role of Safeguarding Boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the review can be used to inform systems and practice development. In so doing the Board may identify additional learning issues or actions of strategic importance. These may be included in the final SCR report or in the action plan as appropriate. 11. This approach also takes account of work that suggests that developing over prescriptive recommendations has limited impact and value in complex work such as safeguarding children. For example, a 2011 study of recommendations arising from SCRs 2009 -2010, (Brandon, M et al), calls for a limiting of ‘self-perpetuating and proliferation’ of recommendations. Current thinking about how the learning from SCRs can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation rather than over complex action plans. 6 12. An SCR Panel was convened of senior and specialist representatives from key agencies involved with Child CB and his family in the time covered, to oversee the conduct and outcomes of the review. All panel members were independent of the family and casework. The role of the panel was to assist the Independent Reviewer in considering the evidence, formulating the recommendations and quality assuring this report. 13. There was significant agency involvement with Child CB’s family and the following agencies were asked to provide a chronology and these were integrated into a combined chronology. • Blackpool Council Children’s Services • Blackpool Teaching Hospitals NHS Foundation Trust • Central Manchester University Hospitals NHS Foundation Trust • Children and Family Court Advisory and Support Service (Cafcass) • General Practitioner • Greater Manchester Police • Lancashire Care NHS Foundation Trust • Lancashire Constabulary • Manchester City Council Youth Justice Service • North West Ambulance Service • Residential children’s homes – one in Blackpool and one in Manchester • Schools - three secondary schools, a Pupil Referral Unit, a Further Education (FE) provider and the Blackpool Council Virtual School 7 14. The Independent Reviewer reviewed the combined chronology in order to consider in detail the sequence of events and any key practice episodes that underpinned those events. 15. The SCR Panel agreed the scope of the SCR. The SCR Panel also considered key lines of enquiry. These included: Post Adoption Support and Interventions Effectiveness of interventions Timeliness of interventions Service provision Assessments Risk taking behaviour Responses to the risk of suicide How did Child CB’s wishes and feelings influence assessments and responses? Independence 16. An independent chair, from a partner agency with no direct operational involvement with the family was agreed by the Local Safeguarding Children Board to chair the SCR Panel. 17. The Lead Reviewer, Ms Hyde was Chief Executive Officer of Calderdale Women Centre for 14 years (between 1994 and 2009) and developed nationally acclaimed, high quality services and support for at risk women and families. Ms Hyde contributed to Baroness Corston’s Review of Women with Vulnerabilities in the Criminal Justice System which was commissioned by the Government following the deaths of several women in custody. 8 18. Ms Hyde is currently working with LSCBs and their partners to improve safeguarding outcomes for children and young people living with domestic violence, substance misuse and parental mental illness and to support the development of a multi-agency response to children and young people at risk of sexual exploitation. 19. Ms Hyde also designed and facilitated a multi-agency review of child sexual exploitation in Rochdale in 2012 and is currently the Independent Chair and Reviewer of several SCRs and a Domestic Homicide Review and has designed and led several Learning Reviews on behalf of local safeguarding children and adults boards. Serious Case Review Panel 20. The SCR Panel met on a number of occasions between February 2018 and July 2018. 21. The overview report was ratified at the Local Safeguarding Children Board meeting on 7th September 2018. 22. The Panel comprised of: Clare Hyde Head of North West Lancashire (Chair) Independent Reviewer HM Prison and Probation Service Designated Doctor for Safeguarding Blackpool Clinical Commissioning Group Designated Nurse for Safeguarding Blackpool Clinical Commissioning Group Head of Safeguarding Blackpool Council Educational Inclusion Officer Blackpool Council Named Nurse for Safeguarding Children and Adults Blackpool Teaching Hospitals NHS Foundation Trust Counselling Team Leader Blackpool Teaching Hospitals NHS Foundation Trust Service Manager Cafcass Designated Doctor for Safeguarding Fylde and Wyre Clinical Commissioning Group Clinical Pharmacist General Practice representative Specialist Safeguarding Children Practitioner Lancashire Care NHS Foundation Trust Review Officer Lancashire Constabulary Business Development Manager Blackpool Safeguarding Children Board 9 Confidentiality 23. Working Together to Safeguard Children 2015 clearly sets out a requirement for the publication in full of the overview report from SCRs: 24. “All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months. Thereafter the report should be made available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case.” Family involvement 25. The independent chair and one other member of the SCR Panel met with Child CB’s parents in June 2018. 26. Child CB’s parents were able to share information and their reflections about Child CB’s life and how agencies had worked with them. Where relevant this is referred to within the body of this report. Staff involvement 27. The staff who were involved with Child CB and his family participated in a Learning Event in May 2018. The Learning Event was attended by practitioners who had had direct involvement with Child CB and his family, in addition to the Independent Reviewer who facilitated the event and the BSCB Business Development Manager. 10 28. Following the Learning Event, the Independent Reviewer collated the outputs from the Learning Event and from the agency chronologies and began her analysis. In reviewing the findings, the panel gave consideration to what could be done differently to further improve future practice. Race, Language and Culture 29. Child CB was White British. His adoptive family are White British and their first language is English. Summary of Child CB’s history 30. What is known about Child CB’s history is detailed below. 31. Child CB and his siblings were taken into the care of the local authority in 2004. 32. Child CB was aged 3.5 at the time. He and one sibling who was then aged 2 were adopted by the same family. 33. Child CB and his family first asked for help in respect of difficulties they were experiencing in 2009. 34. In September 2014 the adoption broke down and Child CB became accommodated by the Local Authority. 35. He moved from foster care (5 placements in total) to residential care firstly in Manchester and then to a residential placement in Blackpool in 2017. 11 Overview of events and agency involvement 36. Although the timeframe for this SCR was from September 2013 to 21st December 2017 agency records held historical information which is relevant to the case and this has been considered. Analysis 37. The analysis is set out in response to the key lines of enquiry set by the SCR Panel which formed the terms of reference for the SCR. The analysis is informed by the chronological information provided by agencies and the views and contributions of the practitioners who attended the Learning Event. (Please note the responses to each individual key line of enquiry are presented in chronological order). 38. The analysis also takes particular account of and reflects what is known about the following issues which were relevant to Child CB’s life experiences: 39. The disruption (or breakdown) of adoptions and why this happens. The author of this report has drawn from the findings of a major 2014 UK study which included 390 adoptive parents caring for 689 children, most of whom were teenagers. Beyond the Adoption Order: challenges, interventions and adoption disruption J Selwyn et al 2014 40. The mental health and wellbeing of children who have experienced adversity in childhood and what is known about the mental health and emotional wellbeing of children and young people who become looked after and/or adopted (quite often as a consequence of their adverse childhood experiences) and learning from other serious case reviews. 12 41. The impact of neglect and other adverse childhood experiences such as loss and physical abuse is well researched and provides a useful gendered focus on how childhood traumas can manifest throughout a person’s life. These include: Conduct disorders including anti-social personality disorder, border line personality disorder, oppositional defiance disorder Psychotic illness Attention Deficit Hyperactivity Disorder Post-Traumatic Stress Disorder Drugs and alcohol Learning disability Acquired brain injury Speech and language difficulties Physical health problems Suicide rate 8-12 times than seen in the community 42. The mental health of looked-after children is significantly poorer than that of their peers, with almost half of children and young people in care meeting the criteria for a psychiatric disorder (in comparison one in ten non-looked-after children and young people suffer from a diagnosable mental health disorder). Office of National Statistics, Mental health of children and young people in Great Britain, 2004 (August 2005). 43. A Department of Health review on measures to prevent suicide in England noted that “looked after children and care leavers are between four and five times more likely to self-harm in adulthood. They are also at five-fold increased risk of all childhood mental, emotional and behavioural problems and at six- to seven-fold 13 increased risk of conduct disorders”. Preventing Suicide in England: A cross-government outcomes strategy to save lives. 44. The analysis also takes into account what is known about attachment. The term ‘attachment’ refers to the physical and emotional support which children depend on from the key adults who take care of them. Attachment theory says that children who are securely attached have higher self-esteem and empathy, and can deal with stress more effectively. Looked-after children are more likely to be affected by attachment difficulties which can have a negative impact on their mental health and subsequent behaviour. 45. What is known about the impact of adolescent drug use on mental health is also reflected in the analysis. Consideration of Key lines of enquiry Post Adoption Support and Interventions Was Child CB enabled to understand his identity? 46. Identity formation begins in childhood and takes on increased importance and prominence during adolescence (Grotevant, 1997). Fundamentally, the act of establishing identity involves an adolescent answering the question, “who am I?” in relation to various different aspects of life and different contextual environments. This may have a significant impact on children who are adopted as their potential understanding of their life, which is dependent on knowledge of the self, family, and society, may be incomplete. Ultimately, when individuals form their identity, they often need to have coherent stories to create and understand the meaning of their 14 life and to link their identity to their past, present, and future. (with reference to Parenting Advice for Foster Carers and Adopters) 47. It follows that identity development may be more difficult for an adopted person because of the additional issues related to adoption, such as why he or she was placed for adoption, what became of the birth parents, does he or she have siblings. 48. Often accompanying these issues of identity are issues of self-esteem. A number of studies have found that adopted persons often score lower on measures of self-esteem and self-confidence (Borders, Penny, & Portnoy, 2000; Sharma, McGue, & Benson, 1996). This may reflect the fact that some adopted people may view themselves as different, out-of-place, unwelcome, or rejected. Some of these feelings may result from the initial loss of birth parents and from growing up away from birth parents, siblings, and extended family members. They also may be caused by an ongoing feeling of being different from non-adopted people. 49. It is not clear from the agency records what formal work was done with Child CB leading up to and in the years following his adoption to enable him to understand his identity as he grew up. It is recorded that some ‘life story’ work was undertaken with Child CB between the ages of 12 and 13 but by this time Child CB and his family were experiencing difficulties. 50. Prior to Child CB and his sibling being adopted by M and F they report that they were told that both children had suffered neglect and possible physical abuse. The impact of neglect on child development and potential future attachments or mental and emotional health issues was not discussed in any depth with M and F during or after the adoption process. 15 51. When M and F asked for help between 2009 and 2014 they said that professionals often made them feel as if their parenting was at fault and that they were not helped to understand the possible causes of Child CB’s difficulties. M and F did state that a CAMHS practitioner had been helpful and had explained attachment theory to them which increased their understanding of Child CB’s behaviour and their own responses to it. 52. This case highlights the complex and often considerable post adoption support needs of the whole family i.e. parents, adopted children, siblings and that these needs can change significantly over time. 53. We know from agency records that Child CB did not want others to know that he was adopted. He was extremely distressed when his younger sibling and another birth sibling (who had been adopted by a different family) joined his school in 2013 and other pupils were becoming aware of this. 54. Some of the practitioners who contributed to the Learning Event also stated that Child CB struggled with his identity and was distressed when he learned via social media that his birth father had had more children after Child CB and his siblings had been removed from his care. 55. Following Child CB becoming accommodated by the Local Authority in September 2014 there is no specific reference to therapeutic work carried out with Child CB which focused on supporting him with issues specifically relating to his identity however it was clear from conversations with the practitioners that some of them spent time listening to and discussing this issue with Child CB. 16 How well did professionals understand Child CB’s behaviour, attachments and identity anxieties? 56. Child CB’s overall wellbeing and behaviour was impacted upon by his attachment difficulties and his anxieties concerning his identity. 57. It is clear from the agency chronologies and from the accounts of some of the practitioners who contributed to the Learning Event that there was some understanding of the underlying causes of Child CB’s difficulties. 58. Attachment was identified as an issue in 2009 by a Children’s Social Care (CSC) Adoption Support Social Worker when Child CB’s behaviour was first reported as challenging by M and F and a referral to CAMHS was made. 59. The family attended an initial appointment with a CAMHS practitioner in October 2009 and the practitioner documented that Child CB may have attachment issues due to neglect by his biological parents. 60. The outcome of the CAMHS assessment was a suggestion to M that the family access post adoption support however M was reluctant to do so and CAMHS closed the case in February 2010 having received no response to attempts to contact M and F. 61. Between October 2009 and September 2013 there is no agency record of the family requesting or accessing support in respect of Child CB. 62. Child CB began secondary school (SS1) in September 2012 and his Year 7 records indicate that his behaviour was sometimes an issue. 63. Child CB’s attendance at SS1 however was not an issue and he was rarely absent. He appeared to have been able to build trusted relationships with school staff including the Pastoral Care practitioner and the School Nurse Practitioner (SNP) who demonstrated good understanding of some of his difficulties. 17 64. In September 2013 Child CB was seen by a paediatrician in an epilepsy clinic following a referral by his GP for dizzy spells. During the appointment M stated that she was concerned that there had been some behaviour issues at school and that Child CB could get angry. M felt that this could be due to some of the children making fun of him for being adopted. No medical needs were identified and the paediatrician referred Child CB to the community clinic so that a more in-depth psychosocial assessment (and a review of the dizzy spells) could be carried out. 65. This suggests that the paediatrician understood that the underlying causes of Child CB’s difficulties were not physical. 66. Also in September 2013 M made contact with the Post Adoption Support Team following a physical altercation between Child CB and F following which Child CB had been found by his parents with a dressing gown cord tied around his neck and it appeared that he had tried to asphyxiate himself (Child CB denied that this had been his intention). 67. This incident led to a strategy discussion between CSC, Child CB’s school and the adoption team. During the assessment which followed Child CB stated that F had pushed him however no S47 enquiry was instigated. 68. By 17th September 2013 an assessment concluded that ‘Relationship issues to be addressed through therapeutic plan. Child in need plan to be developed. Business proposal for commissioning specialist service to be drafted by the adoption team’. 69. On 30th September a Child in Need Plan was in place and this identified that ‘Child CB would access CAMHS, and a referral to ‘Theraplay’ would be made to improve relationships, Life Story work to be completed with Child CB, parents to be provided with advice and guidance in respect of attachment and adoption’. 18 70. This plan clearly recognised that Child CB was experiencing attachment and identity difficulties and that his parents needed support. 71. However Child CB’s behaviour continued to deteriorate at school and at home and his distress increased (it was during this period that his siblings joined his school and were discussing their adopted status with other pupils). 72. In November 2013 Child CB and M and F attended an appointment with CAMHS and it was agreed that further support would be offered however there is no record to indicate that there were further appointments offered and Child CB was discharged from CAMHS in February 2014 (the reason for the discharge is not recorded). 73. In March 2014 Child CB telephoned emergency services and stated that he had taken an overdose of ibuprofen and co-codomol. He was admitted to hospital and was seen by a CAMHS practitioner on the ward. He was discharged later that day and a follow up appointment was made with CAMHS for 5 days later. 74. At that appointment Child CB was seen by a CAMHS practitioner with his mother. Child CB reported that he felt his mother was "smug" when she said things and insulted his birth mother. A risk management plan was agreed for safety at home. Child CB stated that he was unsure if he would engage with CAMHS again but would consider it. M stated that she would like support. 75. It was agreed that a further appointment would be offered with the CAMHS family therapist. 76. On 3rd April 2014 Child CB was taken to A & E by a family friend after stating that he wanted to harm himself. He was again admitted to hospital. 77. Child CB was discharged home to the care of his parents on 8th April and the family were seen again by CAMHS on 10th April where it was recorded that ‘Child CB and 19 parents attended follow up ward appointment…. Child CB reports that his Dad gets angry in his face and can push and poke him. Mother reported that she feels unsafe at home as Child CB can be unpredictable. Safety plan discussed and has CAMHs partnership appointment’. This information was not shared with CSC. 78. On 25th April a CSC record indicates that ‘The support from the post adoption support team ceased on the 22/04/2014 in order that CAMHs can begin work with the family via Family therapy (27/05/2014). Much work has been completed by post adoption services in relation to attachment, emotional responses to adoption/birth family. It has been identified that there is a real risk of adoption breakdown. M has been referred to Women's Aid as a result of being subject to Child CB’s violent behaviour. Outcome of this assessment was case to close to CSC and a referral to Early Assessment Team (EAT) be made for any additional support’. 79. Child CB and his parents attended a CAMHS appointment on 28th April. Child CB stated that he did not want a relationship with his parents. 80. Child CB and his parents attended a further CAMHS appointment on 20th June 2014. Concerns persisted that the adoption was breaking down. Child CB requested to be seen on his own and reported that he no longer want to live with his parents. He felt they had let him down. He stated that he did not feel that there was any point attending CAMHS sessions if it was ‘all to do with staying with his adoptive parents’. 81. On 4th July 2014 Child attended a CAMHS appointment and was seen alone. It was recorded that ‘Child CB remains adamant he does not want to live with his adoptive parents. Child CB reports that he feels his parents don’t care or love him could not clarify why, appeared to be driven by the desire to get away from family home and could not recognise that he may contribute to some of the conflict. Child CB then 20 asked for session to end as he did not feel he was getting support to be removed and saw no point in further sessions’. The CAMHS practitioner discussed this with M and arranged a further appointment with both parents and the SW. 82. Throughout July 2014 there were incidents including a further referral to CSC by SS1 following an argument between Child CB and his mother outside school, Child CB going missing from home and absconding from SS1. This led to ‘Edge of Care’ support being put into place for the family. This is a CSC service that works with children and families where there is a risk of relationship breakdown that would result in the child becoming looked after. 83. On 29th July 2014 during a home visit by the ‘Edge of Care’ team, Child CB disclosed that he had argued with F over his pierced lip which resulted in F grabbing him by the shoulder and punching him with a clenched fist in the hip. As a result of this a Strategy Discussion was held and Child CB underwent a safeguarding medical which concluded that Child CB’s injuries were consistent with his account of being punched. 84. The CSC records state that ‘It is believed the situation is now untenable with frictions in the home resulting in situations where there is a risk of physical harm to Child CB and to incidents where Child CB could be criminalised for incidents involving his mother. The outcome recorded was that the concerns were substantiated but not judged to be at risk of significant harm. Consent to be obtained from Senior Manager to accommodate’. 85. Throughout August and September 2014 there were further violent incidents in the family home and Child CB was allegedly assaulted by F and in turn was allegedly abusive to M. 21 86. During the same period CSC were making efforts to find a suitable foster placement for Child CB. 87. On 22nd September 2014 Child CB’s first Foster Placement began. 88. In summary from as early as 2009 until he became a Child Looked After in 2014 Child CB was exhibiting his distress and difficulties in behaviours which manifested as aggressive, self-harming and suicidal. 89. During this period of time before the adoption broke down, not all practitioners demonstrated that they understood Child CB’s anxieties and identity issues and crucially it appears that he himself did not feel understood for example he told the SNP in March 2014 that he “had not wanted to engage with CAMHs previously because he felt like he was being told something was wrong with him rather than being asked what he wanted”. 90. During 2013 and 2014 professional focus was often on how to support M and F to manage Child CB’s behaviour rather than recognising that Child CB’s behaviour was a manifestation of his distress. There were interventions which took place with the specific intention of focusing on Child CB’s attachment and identity anxieties however it is not clear how their effectiveness was measured. 91. Child CB undoubtedly suffered significant emotional and physical harm during the period of time that efforts continued to be made to stop the adoption breaking down and he was also at risk of harming others. 92. This next section of the report focuses on the period of time from which Child CB became accommodated by the Local Authority until his death. 93. Child CB was fostered by 5 different foster carers (one was a ‘respite’ carer therefore intentionally short term and he did not stay for more than a few hours at 22 another foster placement) between September 2014 and October 2016. It is not clear from agency chronologies how well each foster carer understood Child CB’s difficulties and the impact this had on how well they were able to respond to and cope with the behaviours which resulted from them. 94. It is apparent from the agency chronologies however that Child CB’s difficulties continued throughout his time in foster care with one hospital admission in May 2015 when he reported feeling suicidal and a further admission in August 2016 which followed him drinking household bleach and telling his foster carer that he wanted to kill himself. 95. Following the August 2016 admission Child CB and his SW attended an appointment with a consultant psychiatrist . The consultant psychiatrist agreed that Cognitive Behavioural Therapy would be helpful but also prescribed medication which was Fluoxetine, Risperidone and Circadin1. Following this appointment the consultant psychiatrist diagnosed ‘significant attachment disorder, recurrent depressive disorder, social anxiety and challenging behaviours’. 96. This diagnosis (and the prescription of medications) was significant and is an indication of how difficult foster carers would have found it to understand and manage Child CB’s needs and behaviours. 97. It is not clear from agency chronologies how well the pattern of failed attachments was recognised and responded to by practitioners or by the foster carers themselves. It is also unclear whether Child CB was helped to recognise and understand this pattern and he was very distressed when two of the foster placements ended. 1 The prescribed medication is described in detail in para. 234-241. 23 98. The practitioners who contributed to the Learning Event spent some time considering the shortage of specialist/ appropriate foster placements in the Borough (and nationally) and also discussed the capacity and willingness of foster carers to care for children and young people who share Child CB’s life experiences and difficulties. 99. Child CB began attending another secondary school (SS2) in September 2015 which coincided with a change in foster carer (this move was out of Borough and also necessitated a change of health provider). 100. By November 2015 Child CB was stating that he was unhappy at the new school. 101. A Child and Family assessment was completed in March 2016 to reassess Child CB’s current needs and to address concerns surrounding placement breakdown/contact with birth and adoptive family. The assessment identified the patterns in Child CB’s behaviours in relation to the breakdown of foster placements but it is not clear how (or if) interventions were put in place to address this as a manifestation of Child CB’s attachment and identity issues. 102. Child CB’s fourth foster placement broke down following an incident during which Child CB was arrested in possession of a knife at the foster carer’s home. He was under the influence of a ‘legal high’ at the time. There were increasing concerns surrounding alcohol and drug misuse at this point (Child CB had been severely intoxicated on two occasions and also admitted to being a regular cannabis user). 103. In summary, two of Child CB’s potentially long term foster carers were managing Child CB’s difficult behaviour and his mental and emotional distress. The placements subsequently broke down and were unable to offer him stability. The underlying 24 causes of his behaviour and distress which led to the placements breaking down remained unaddressed as he moved into residential care. 104. In October 2016 Child CB began his placement in a Manchester Children’s Home (MCH). This placement lasted until August 2017 which was the longest period of time Child CB spent in a placement. 105. It is apparent from the information contained in the chronology provided by the MCH and from the contributions made by practitioners at the Learning Event that staff there were able to build trusted relationships with Child CB and demonstrated understanding of his underlying attachment and identity anxieties. 106. As well as managing Child CB’s behaviours and responding to his day to day needs the staff co-ordinated interventions to try and address some of Child CB’s needs. For example Child CB accessed the ‘in-house’ counsellor for 4 sessions until he then disengaged. 107. It is of note that during his time as a resident at the MCH Child CB refused all appointments with CAMHS and did not attend the majority of other health appointments which were made for him nor did he during his time at the MCH state that he wanted to kill himself or make any attempt to do so. 108. This suggests that this was the most settled Child CB had been since before the breakdown of his adoption despite the fact that there were many incidents of challenge and behavioural and relationship difficulties for him during the same period. 109. On 2nd December 2016 during his placement at the MCH information was shared with Child CB by his SW about his birth father. Later on the same day Child CB left the home and on his return staff had suspected that he was under the influence of 25 alcohol. Child CB passed out and paramedics were called. Child CB was recorded to have been ‘abusive to paramedics, rude to staff, tried to leave hospital but escorted back in, returned to home 3am has food, chats to staff re his past- quite emotional goes to bed 4.14 checked on several times through the night’. 110. There is nothing in the information provided by the MCH or by CSC which explicitly connects the sharing of information about his birth father with Child CB’s intoxication and hospitalisation later on the same day. In other words the understanding of cause and effect was not demonstrated and Child CB was not therefore helped to explore why he had responded in the way he had. 111. In March 2017 an assessment of need was completed by CSC. The outcome was to look at supporting Child CB into semi-independent accommodation. Following the assessment of need the analysis stated 'Although Child CB presents as confident and mature, my analysis would be that this is how he would like to present however he has low self-esteem and still suffers from emotional problems. He can be absolutely deliriously happy one minute and change to being abusive and out of control. I feel Child CB needs further input with CAMHS however he is refusing to attend.' This analysis presents a ‘picture’ of Child CB’s behaviour and presentation but does not demonstrate understanding of the root causes of Child CB’s difficulties or put into place alternatives to CAMHS despite acknowledging that he needed ‘further input’. 112. Whilst Child CB was a resident in the MCH he attended two schools. 113. He attended the first school (SS3) as a ‘guest pupil’ and was temporarily excluded on several occasions during the 3 weeks he attended. His behaviour was aggressive towards other pupils and staff. There is nothing in the agency chronologies which records how Child CB felt about the exclusions or the impact they had on him. 26 114. Child CB began as a permanent pupil at the third school which was a Pupil Referral Unit (PRU) on 6th February 2017 and remained a pupil there until June 2017. In March 2017 his school report stated that Child CB was ‘Working at grades - Maths, C; English, C; Science, C. 'Valued member of the group and contributes in all lessons.' 'Recently nominated for a The Manchester College Award for 14-16 year old students.' 'If Child CB continues to work at his current rate I have no doubt that he will do well in his GCSEs.' 115. A day after his report was issued Child CB’s behaviour began to deteriorate in lessons and he was excluded for one day following him being rude, aggressive and threatening towards a member of staff on 21st March 2017. 116. There were further incidents of disruptive, rude and threatening behaviour during May 2017 but they did not lead to exclusions. 117. Despite these incidents on 1st June Child CB was awarded the ‘Most Outstanding Pupil Award’ by the college of which the PRU was part. 118. Whilst there is no record in the PRU’s chronology to indicate that specific work was carried out with Child CB, in respect of the underlying causes of his difficulties, the fact that he achieved significant success there and responded well to staff suggests that they were able to manage his anxieties and other behaviours. This in itself suggests that the staff who worked with Child CB had a good level of understanding about his attachment and identity anxieties and how his behaviours might be affected by them. 119. Throughout July and August 2017 discussions were held with Child CB about his move to semi-independent living arrangements (he was by then aged 16) and the prospect of this caused him significant anxiety. 27 120. Shortly after these discussions (during which Child CB stated that he would rather be placed in a foster home) he began to say that he wanted to return to Blackpool and a move to a children’s home in Blackpool (CHB) was arranged and took place on 22nd August 2017. 121. It is of note that on the evening of his first day in this placement, Child CB and another young male resident (Child X) returned to the home together and were under the influence of cannabis. 122. It was apparent from reading the chronology provided by the CHB and from the accounts of staff who attended the Learning Review that Child CB’s anxiety about moving towards independence was increasing. Staff understood this and it was noted that Child CB often sought staff out for reassurance. 123. Many care leavers feel ill-equipped to deal with the responsibility of managing accommodation, maintaining education or finding work and the challenges of accessing services and systems that are complex and often inflexible. Their experience contrasts with that of most young people, a fifth of whom remain living with parents until at least age 26 and most of whom receive practical and emotional support, retaining the option to return home for short or long periods of time long after they move out. (Research in Practice, 2017) 124. The anxiety and pressure experienced by Child CB in relation to his move to semi-independent and independent living was discussed in some detail by the practitioners who contributed to the learning event. The disparity between children in foster care who may stay in their foster placements until the age of 21 (or beyond in some cases) and those in residential care who move to semi-independent living arrangements from the age of 16 or 17 was noted. 28 125. The CHB staff understood that this was causing Child CB increasing anxiety. A record from the CHB states ‘This was significant to Child CB when he was interviewed prior to his 17th birthday by the housing officer who wanted to arrange tenancy training for him. Staff became aware that Child CB’s anxiety levels increased. Child CB explained to staff following the interview with housing that he was not fully aware that he would be having his own tenancy before he was 18 and this made him very anxious’. 126. In September 2017 Child CB was enrolled at College and disclosed to them that he was a Child Looked After and he was allocated a pastoral mentor. 127. During August and September 2017 Child CB reported that he was having difficulty sleeping. He was also noted to be using cannabis regularly. 128. By the end of September Child CB’s behaviour was becoming problematic at college. His attendance had fallen and he was unmotivated. 129. On 1st October it was noted by a staff member at the CHB that Child CB was still pre-occupied with how he would cope with independent living and that it was at the ‘forefront of most of his thinking’. 130. During September, October and part of November 2017 Child CB was in a relationship with a young woman. The relationship was volatile and at one point the young woman told Child CB that she was going to kill herself. This caused Child CB significant distress. The relationship ended following several ‘crises’, including an altercation between Child CB and her father. 131. At one point in October 2017 the relationship ended briefly and Child CB told staff that he was having panic attacks, felt anxious all the time, was in low mood and 29 tearful. (The relationship resumed shortly afterwards and finally ended in November 2017). 132. Child CB spoke to a GP via telephone on 20th October 2017. Child CB advised that he had stopped taking his medications "late last year" (i.e. 2016) but now symptoms have recurred. The GP restarted fluoxetine and risperidone (4 weeks of each were issued) and asked Child CB to make a review appointment when he collected the prescription. 133. By the end of October 2017 Child CB stated that he wished to move back to Manchester and continued to be anxious and agitated. 134. On 3rd November Child CB admitted to a member of staff at the CHB that he was using cannabis as a way of managing his anxiety. He was offered a referral to a substance misuse service but this was declined. 135. By 9th November 2017 Child CB’s attendance at college had fallen further to 62% because of his anxiety and poor sleep. 136. Also on 9th November Child CB confided in a member of staff at the CHB that he had self-harmed the prior evening. 137. On 10th November staff received a telephone call from M and F to arrange a visit with Child CB. Child CB agreed to this. (Child CB had contact with M and F in July 2017 and this was recorded as having been positive). 138. On 18th November Child CB told staff that he had again self-harmed. Staff noted that the incidents of self-harm coincided with cannabis use. The CHB chronology notes that ‘Staff discussed again with Child CB the impact on his mental health that smoking cannabis could have. Child CB was not ready to listen and didn't agree to the effects such as paranoia and disrupted sleep patterns’. 30 139. Child CB further self-harmed on 20th November 2017. He had been issued with a formal warning by the CHB concerning cannabis use on the same day. 140. On 21st November a staff member at CHB contacted CSC and shared information that Child CB is presenting with ‘low mood, not really engaging and superficial self-harmed last night. However when staff ask how he is he reports he is fine although he has stated he does want to see GP to look at an increase in medication. Reviewed case notes, recent split with girlfriend, move of area (uncertainty if right decision)’. It was agreed that Child CB would be monitored hourly and staff would ‘explore feelings and offer distraction techniques, if any indication of suicidal thoughts/unable to keep himself safe - advice provided to present at A&E or call ambulance if refuses. Urgent GP appointment to be made tomorrow.’ 141. On 22nd November 2017 Child CB was visited by M and F and he was noted to have been preoccupied by fears that his ex-girlfriend’s dad was going to beat him up (Child CB had sent abusive or threatening text messages to her). Immediately following this visit Child CB left the CHB and returned later under the influence of substances. 142. The staff at the CHB emailed the SW on 23rd November to request that he was referred to the ‘ADHD Clinic’ (Attention Deficit Hyperactivity Disorder). It is not apparent from the agency chronology what the rationale for this was. CSC forwarded the email to the CLA Nurse who responded by telephoning the CHB and advising that a referral to the Single Point of Access for mental health services would be more appropriate. 143. On 27th November Child CB was visited at the CHB by a housing officer. It was unfortunate that the SW who was also due to be present was prevented from 31 attending. Child CB was therefore seen alone by the housing officer who was arranging ‘tenancy training’ for him. 144. On 28th November Child CB went to meet his parents for a meal. He was caught smoking cannabis by staff at the CHB later that day and was asked to move off site. 145. By 30th November Child CB’s attendance at college had fallen to 53%. The college had arranged with Child CB’s Guardian and Child CB a ‘Fitness to Study’ meeting however Child CB stated that he would not attend. (Fitness to Study is the college process for supporting students whose attendance or progress at college is being affected by long-term medical conditions. The aim of a Fitness to Study meeting is to identify how best college can support a student with a long-term medical condition so they can keep up to date with their studies. At the meeting, support needs are identified and any additional support/reasonable adjustments are put in place). 146. On 1st December following a key work session with a staff member from the CHB it was recorded that ‘Child CB felt that he was not in control of his life and was struggling with anxiety and depression. He was offered the mental health crisis team number and staff asked him to call them which he declined as he said he had a GP appointment on 7th December’. 147. On the same day Child CB rang his social worker to ask him about the possibility of his friend's mum fostering him in Manchester. He was unable to contact the SW after 2 calls so spoke to a duty SW who advised that Child CB give SW’s phone number to the potential foster carers. 148. During this time it was noted by staff at the CHB that Child CB was increasing his use of cannabis and was often in the company of Child X when he did so. 32 149. In early December 2017 Child CB’s SW left his position and his replacement was not due to start in post until 8th January 2018. During a key work session with Child CB on 6th December Child CB was advised that he could contact an advocate about not having a social worker but did not wish to do so nor did he want to complete a goal and support plan. It was noted that he was agitated and anxious. 150. On 7th December Child CB was seen by a GP (supported at the appointment by the CHB staff). He admitted to the GP that he had been having suicidal thoughts and that he had self-harmed. He said that he "wants to die but does not want it to be painful or messy". After talking to the GP he agreed to access Youtherapy for counselling. The GP also prescribed propranolol. Child CB’s prescriptions at this point were Fluoxetine, Risperidone, and Omeprazole and Domperidone. 151. A member of staff from the CHB took Child CB straight to Youtherapy and Child CB spoke to a counsellor and agreed to return on 15th December. Child CB is recorded as saying that he ‘felt a bit better after talking to the counsellor and agreed to keep going’. 152. On 8th December 2017 a staff member at the CHB discussed with Child CB the use of cannabis and how it would be affecting his mental health. She repeated suggested referrals to the Young People’s Substance Misuse Service, to contact Mental Health Crisis team or speak to the GP, all were declined by Child CB. It was noted that Child CB appeared very low in mood and that he was taking all of his medication but was still using cannabis daily. (He continued to smoke with Child X despite numerous warnings from staff). 153. By 12th December 2017 Child CB was adamant that he would not return to college stating that he would look at alternatives in January 2018. 33 154. On 13th December 2017 Child CB attended an appointment at Youtherapy and was seen by a counsellor with his support worker from the CHB. The agency chronology records that ‘He reported feeling low in mood. He felt like he wanted to die but did not feel like he was able to kill himself. He said nothing specific had happened recently but he felt anxious and low. He reported that he just wants to stay in bed, has split up from his girlfriend recently and didn't want to go to college. Reported some of her friends have threatened him, he wasn't concerned about the threats but was worried he would retaliate so he was staying away. Did not want to take support services numbers and said he would speak to support workers in placement as he trusts them’. A further appointment for initial assessment was planned for 15th December. 155. This was the second occasion upon which Child CB was seen by a counsellor from the Youtherapy service. 156. On 14th December Child CB was visited by an advanced practitioner (social worker) and a Social Work Assistant. They discussed moving back to Manchester with him and said that it could take approximately 16 weeks to do a family needs assessment for fostering purposes. They talked with Child CB about how he was feeling and said they would call back the day after. 157. Child CB was visited soon after this by an 18 year old female who stayed until the CHB curfew of 11.00pm. Child CB was ‘acting boisterous. His mood seemed to have changed as he had been very low during the day’. Staff observations noted that Child CB and Child X appeared "high" but there was no smell of cannabis. Child CB left the CHB at 1.22am without informing staff that he was going out and at 1.30am the CHB manager received calls and texts from an unknown female stating that Child CB had 34 written a suicide note and was heading for a building where he was going to kill himself by jumping off the roof. The CHB Manager immediately alerted staff to check his whereabouts and to check his room for a suicide note. The note was discovered and 999 was called immediately. The further response to this suicide attempt is covered elsewhere in this report. 158. On 20th December 2017 Child CB attended an assessment appointment with a Youtherapy Counsellor. Child CB discussed his past and recent thoughts of suicide but said he felt better that day. The Counsellor discussed counselling and what it could offer and Child CB agreed to attend the next appointment. 159. Also on 20th December Child CB attended a consultation appointment with his GP. The consultation notes record: ‘Problem: Suicidal ideation (review). Still feeling extremely low. Unsure what he might do. Some anxiety, but main complaint is his low mood. No real plans for the future, states he might go to college and get a job, but no idea at present in which area etc. Good eye contact. Brief short answers. Seems rational. Recent risky behaviour. Review in due course. In the meantime increase his fluoxetine from 40 to 60, mentioned to his support worker (over the phone) as they keep the meds. Prescription for fluoxetine and risperidone’. 160. An administration note records that the GP spoke to Single Point of Access (for (adult) mental health services) SPA regarding Child CB and was advised that he was attending Youtherapy. It was agreed that if Youtherapy ‘find that he is unmanageable they will refer him to SPA’. 161. On 21st December 2017 Child CB and Child X had a serious argument which resulted in threats and violence and the police were called by staff at the CHB. It was noted at approximately 11.30 pm that Child CB smelt of alcohol and appeared to be under the 35 influence. The police left the CHB at 11.44 pm and Child CB then left the CHB at 1.22 am telling staff that he was going for a walk. He subsequently took his own life. (The response to Child CB leaving the CHB is discussed elsewhere in this report) 162. In summary the placement at the CHB represented a period of significant anxiety and pressure for Child CB. The challenges he faced occurred almost daily and included his troubled relationships with his girlfriend, his peers within the CHB (particularly with Child X) and at college and with his parents. 163. It was during this same period that Child CB’s use of cannabis increased significantly and the impact of this on his mental health was a concern to staff. The effect of using cannabis whilst taking other ‘mental health’ medications is discussed elsewhere in this report. 164. All of these challenges were in addition to what the staff at CHB recognised as extreme anxiety about his transition to independent living and his ability to cope with this. 165. The staff at CHB recognised the underlying causes of his anxieties and that his use of cannabis may have been exacerbating them and made attempts to engage Child CB with support for his mental health (with limited success) and for his substance use which he rejected. 166. In effect this left staff at the CHB ‘fire-fighting’ almost daily incidents which often involved a crisis point for Child CB. Interventions 167. This section provides an analysis of interventions including: Overall effectiveness in achieving stated aims 36 Timeliness Reviews Contingency plans 168. Between 2013 and 2014 interventions (which included work carried out by the Post Adoption Support team and CAMHS) focused, in the main, on preventing the breakdown of the adoption. 169. In that sense interventions were not effective as the adoption did breakdown after a 12 month period of escalating physical and verbal and emotional abuse which included alleged assaults against Child CB by F and alleged assaults by Child CB against M. 170. Throughout this period of time Child CB consistently told professionals that he did not want a relationship with his parents and that he wanted to leave the family home. There were incidents reported by Child CB of his parents making fun of him for attempting suicide and being unkind about his birth mother which were an indication that Child CB was suffering emotional harm. 171. A Child in Need plan was put into place in September 2013. This plan set out that Child CB would access CAMHS; that a referral to ‘Theraplay’ to improve relationships would be made and that life story work was to be completed with Child CB. It also set out that M and F would be provided with advice and guidance in respect of attachment and adoption. 172. The Child in Need Plan was appropriate at this stage however by January 2014 there were clear indications that Child CB’s behaviour was deteriorating and his distress increasing which was also an indication that the outcomes set out in the plan were not being achieved and that a review was required. 37 173. In April 2014 following Child CB’s admission to hospital for risk of self- harm the SNP made a referral to CSC reporting that the family were ‘in crisis’ and the adoption was breaking down. The SNP reported several incidents of Child CB being violent and concerns about how his parents dealt with his behaviour including their use of physical chastisement and restraining. The SNP reported that she and a staff member from SS1 had been attending Child in Need meetings with a post adoption SW and parents but she was concerned that things were escalating. The SNP reported that she was aware of Child CB’s A and E attendance (feeling that he was going to self-harm) and that she had also sought advice from the hospital’s Safeguarding Team. 174. This was a clear and appropriate referral to CSC. The SNP also spoke to Paediatric Liaison2 at the hospital to share concerns and to advise that she had made a referral to CSC. The SNP also shared that Child CB had stated his father had physically restrained and/ or assaulted him due to escalating behaviour. 175. On 4th April 2014 a Safeguarding Medical was completed and bruises consistent with the explanation Child CB had given were noted. There is no information in CSC records to indicate that this led to a strategy meeting and no information regarding the outcome of the medical is contained in Child CB’s medical notes. 176. Child CB was discharged to his parents’ care on 8th April 2014. A Safeguarding Nurse telephoned the SW to clarify whether he could be discharged home as he was medically fit and was advised that it was ‘fine for him to be discharged home to his 2 Paediatric liaison is provided by the safeguarding nurse who is on duty and is to ensure that there is effective two way communication and sharing of information between hospitals and community services which enables children and their families to receive appropriate care and support. 38 parents and the assessment will continue’. The SNP was also informed of Child CB’s discharge. 177. Given that this was the third time in 2 months that Child CB had attempted suicide or indicated that he wished to harm himself and that a safeguarding medical had noted bruises consistent with Child CB’s allegations of an assault; the discharge home without a Strategy Meeting taking place was unsafe. There is no indication that interventions and contingency plans were considered and put into place to address the risk of physical and emotional harm or risk of suicide. 178. In June 2014, which was within 8 weeks of his discharge home, Child CB alleged that F had assaulted him by punching his head and banging him into a wall during an argument. 179. A S47 enquiry was carried out following the allegation. The outcome of this was that the assault could not be confirmed as the incident had not been witnessed. However no safeguarding medical took place. CSC records state ‘It was clear there had been an argument between Child CB and F but it was not felt this fell into the realms of significant harm. The incident was witnessed by sibling who stated he didn't witness Child CB being hit in the face by F. Assessment to be undertaken and Child in Need plan to be developed. A referral was also to be made for Family Group Conference and Women's Aid to complete a visit to the home address. School and school nurse spoken to in respect of the S47 Enquires. No medical convened, however both School and School Nurse state they do not believe Child CB would fabricate due to his nature. Child CB was seen and spoken to at school in relation to the incident. Information was shared with CAMHS’. 39 180. The focus of professionals’ considerations appeared to be whether or not a physical assault had taken place and whilst this could not be confirmed it was clear that Child CB was suffering ongoing emotional harm but this does not appear to have been given equal focus. 181. CSC records indicate that a Child in Need Plan was in place by 19th June 2014 however the assessment (referred to above) carried out by CSC did not conclude until July 2014. It is difficult to see therefore how this plan and the proposed interventions were based upon a thorough analysis of risk and need. 182. Between July and August 2014 Child CB was reported missing from home on 2 occasions and also absconded from school. CSC records indicate that the Child in Need plan was to continue. 183. A Child in Need meeting took place on 17th July 2014 and it was agreed that a referral would be made to Edge of Care for support. The SW was to refer to family group conference and mediation support. Child CB declined to attend the family group conference and there is no record to indicate that mediation was made available or taken up. In other words the interventions that were planned do not appear to have taken place. 184. Following Child CB becoming a child looked after in September 2014 it is difficult to see from CSC and other records which interventions were carried out as direct work with Child CB. 185. Following a self-harm (or possible suicide attempt) in August 2016 Child CB received a diagnosis of significant attachment disorder, recurrent depressive disorder, social anxiety and challenging behaviours. It is difficult to ascertain from agency records how this significant diagnosis was translated into interventions or led 40 to a review of plans (including his placement and support that his foster carers may have needed). 186. Interventions which were planned specifically to address Child CB’s emotional and mental health needs were (on the whole) to make referrals to CAMHS but once Child CB became a child looked after he did not voluntarily attend a planned CAMHS appointment and would not engage with the CAMHS practitioner who attended the MCH in order to see him. (CAMHS interventions are referred to in more detail elsewhere in this report). 187. School, college and the MCH and CHB provided daily interventions which had immediate impact e.g. persuading Child CB to remain in school, accompanying Child CB to medical appointments, providing emotional support and reassurance. 188. However a significant number of these interventions were unplanned and were often in response to Child CB’s behaviour, anxiety and distress. 189. In that sense the ‘daily’ interventions were based on a clear understanding and analysis of need but it is difficult to see how what was learned from the daily patterns of risk and need were reflected in formal plans for Child CB. 190. For example it was apparent that the planned move to independent living for Child CB was causing him extreme distress and anxiety and Child CB sought reassurance from the CHB staff about this. It is also recorded that Child CB’s SW and the CHB manager shared concerns that Child CB would not cope well and that his mental health needs remained un-addressed. 191. This did not lead to a reappraisal of risk and need or a review of the plan to move Child CB into independent living arrangements. 41 192. Although Child Looked After (CLA) Reviews took place on a regular basis they were not always effective at reviewing progress and putting into place contingency plans. For example in August 2015 Child CB was discharged from CAMHS. This was an unsettled period for Child CB and his patterns of behaviour strongly suggested that an intervention was required and that his foster carer at that time also required support. No alternative to CAMHS was proposed and no support put in place for his foster carer. 193. A further example is that at the CLA Review of 3rd November 2015 which Child CB attended alongside his foster carers, school, school nurse and CSC; discussions were held regarding CAMHS closing the case with no recommendations of support. ‘It was identified that Child CB had three changes in social worker since the 22nd July 2015 and that although his care plan was one of long term foster care, this placement would be reviewed in six months and could possibly lead to a placement move’. This was a lack of long term stability and planned interventions to support his emotional and mental health needs or identify support for his foster carers. 194. When Child CB had moved back to Blackpool Child CB’s Independent Reviewing Officer (IRO) visited him for a pre CLA Review meeting. Child CB shared that he was questioning whether he had made the right choice in returning to Blackpool stating that ' the grass is always greener'. Given that the last Child and Family Assessment was completed in March 2016 and the high level of anxiety this planned move to independent living was causing Child CB an updated assessment may have provided a clearer understanding of Child CB’s needs. 195. Also of note was the overall length of time it took the local authority to begin care proceedings for Child CB. This was highlighted In November 2016 when a Guardian 42 was appointed for Child CB at the beginning of care proceedings. The Guardian expressed concern that it had taken two years for proceedings to be brought, during which time there had been several foster placement breakdowns leaving Child CB 'treading water with no proper plan'. 196. In summary there were a large number of assessments which took place during the timescale of this SCR and these often led to interventions being put into place. The effectiveness of the interventions and Child CB’s lack of engagement does not appear to have led to reconsideration of how his ongoing mental and emotional health needs could be met. CAMHS Provision (NB. 3 different CAMHS services were involved in this case) 197. CAMHS provision is given specific consideration within this analysis as it was a potentially important source of help and support for Child CB, his family and his foster carers. 198. Child CB was referred to the CAMHS service as early as 2009 and CAMHS are mentioned a total of 193 times in the multi-agency chronology covering the period 2009 to 2017. (As a comparator Children’s Social Care are mentioned 161 times in total). 199. The CAMHS service is an NHS service which provides assessment and treatment to children and young people for their emotional, mental and behavioural difficulties. 200. In March 2015 the Department for Education and the Department of Health jointly published new statutory guidance on Promoting the health and well-being of looked-after children. The guidance recognised that almost half of children in care have a 43 diagnosable mental health disorder. The guidance also recognises that CAMHS is an important source of help and support for children in care. 201. Prior to Child CB returning to Blackpool in 2017 a referral to CAMHS seemed to be the default plan when considering responses to his emotional and mental health needs. However Child CB did not engage well with CAMHS in the way that it was offered to him; even when a CAMHS practitioner visited the MCH in an attempt to see him. 202. This reluctance to engage could have been due in part to Child CB’s perception that CAMHS had not listened to him and that his earlier visits to CAMHS had been to tell him what was ‘wrong’ with him and to ensure that he stayed with his parents. 203. Given the high level of risk and need in leaving Child CB’s mental and emotional health needs unmet, an urgent reconsideration by whom, how and when a service was provided should have been considered. Looked-after children are best supported when professionals collaborate and services are tailored to the needs of the individual; in this case a high risk young person who rejected ‘mainstream’ mental health services. 204. Child CB did access counselling or therapeutic support via the MCH ‘in-house’ counsellor and just before his death with a Youtherapy counsellor. 205. This demonstrates that he was able to engage (albeit briefly) with mental and emotional health services and this could have prompted a reconsideration of how support should be offered to him on a longer term basis. 206. The CAMHS practitioners involved with Child CB work within an established ‘system’ and did make efforts to engage him within the confines of the ‘system’. 44 207. There are examples across England of CAMHS teams which work in different ways to provide a service to children in care however the fundamental learning from Child CB’s case is that CAMHS was repeatedly offered, rejected and re-offered to Child CB and this did not prompt a reconsideration of how his significant mental and emotional needs could be met. What was the impact of the move between geographical areas for Child CB? 208. Once Child CB moved back to Blackpool there was an immediate difference in what would have been available to him had he remained in Manchester as children and young people can access CAMHS until they are 18 but only until they are 16 in Blackpool. (This should change in Blackpool in April 2019 when CAMHS is planned to be open to children up to the age of 19) 209. Following the publication of the March 2015 Department for Education and the Department of Health statutory guidance on Promoting the health and well-being of looked-after children, the House of Commons Education Committee published its Fourth Report on the Mental health and well-being of looked-after children (2015-2016). 210. The above report refers to the November 2014 Health Committee report on CAMHS which revealed problems throughout the system from early intervention to the transition to adult services. The Committee concluded that “there are serious and deeply ingrained problems with the commissioning and provision” of CAMHS. 211. Some of these problems relate to access to and eligibility for CAMHS and the Committee recommended that looked after children should be able to access CAMHS in a ‘timely manner’ and up to their 25th birthday if necessary. 45 212. Child CB’s mental and emotional health difficulties escalated upon his return to Blackpool and he was not able to be referred to CAMHS because he was over 16 (a referral was made to the Youtherapy service however and Child CB did engage with this service briefly before he died). 213. This ‘cut off’ point for access to a child and adolescent services at the age of 16 does not recognise that the period of transition from childhood to adolescence for many children can be characterised by confusion, a lack of coordination and participation. It is known that mental health needs become more acute as children progress through adolescent years and that this can become critical as they are leaving care. Yet it is then that they would also have to transition from CAMHS to adult mental health services and possibly lose the continuity of relationships with CAMHS practitioners. At present when a child reaches 16 there should be a carefully planned transition to adult services. This includes meetings to discuss the young person’s issues following a referral into adult services and a gradual transfer of care. 214. For children in residential care as opposed to foster care this age limit is all the more inequitable as they face the additional pressures of moving into independent or semi-independent accommodation right at the moment they can no longer access CAMHS. 215. Other differences were noted between the two areas’ school exclusion and other policies and in particular how Blackpool’s policy and practice specifically relate to children in care. There is no record to indicate how school exclusions impacted upon Child CB but they may well have increased his anxiety and distress. 216. There are lessons to be learned about how information was shared when Child CB moved between placements and between geographical areas. 46 217. In particular information was not immediately shared about the risk of self-harm and suicide with either residential care provider which in turn meant that the police in both Manchester and Blackpool were also not immediately informed that Child CB was extremely vulnerable. This is particularly important if a child or young person who is ‘flagged’ as at high risk of self-harm goes missing from home or school and how the police prioritise such children. 218. Communication between CSC and CAMHS as he moved area was also an issue and led to ‘waste’ in the system with CAMHS not being aware that Child CB had moved to Manchester or when he subsequently returned to Blackpool. 219. Residential service provision does not appear to have created issues for Child CB when he transferred to the CHB from Manchester in the sense that emotional and practical support continued to be offered to Child CB by staff at the CHB on a daily basis. Was there one ‘trusted professional’ in Child CB’s life post adoption breakdown? 220. Forming trusted relationships must have been extremely difficult for Child CB because he experienced a rapid change in foster carers, a change in SWs, a change in schools and moved from Blackpool to Manchester and then back to Blackpool within a very short period of time. This would undoubtedly have exacerbated his attachment and identity difficulties. 221. Despite this Child CB did demonstrate that he could form trusted relationships with professionals for example with the SNP and other staff at SS1. 47 222. Child CB had a period of relative stability whilst at MCH and achieved several personal goals (and an academic award) whist he was there which indicates that he had at least one trusted relationship. 223. Child CB also sought out staff at the CHB for advice and support and was able to confide in them when he had self-harmed. 224. However there was not one single professional with whom Child CB had frequent, close contact that remained ‘with him’ throughout the period of time considered by this serious case review. How effective was multi-agency working in ensuring a co-ordinated response to Child CB’s needs? 225. Child in Need (CIN) arrangements were the forum for multi-agency working between 2013 and 2014. 226. Agency chronologies refer to the plans setting out what work / support was needed for Child CB and his family. This included life story work and work with M and F around attachments and identity issues. It is not clear from the records who carried out this work or how they contributed to the subsequent CIN meetings. 227. On occasion multi-agency work was not fully inclusive; for example only SS1 and the post adoption Social Worker contributed to the crucial assessment which took place following Child CB’s admission to hospital following the third incident relating to self-harm/ suicide. CAMHS did not contribute and were unable therefore to share their assessment that Child CB was at ‘high risk’ of further harm. 228. When Child CB was in foster care there appears to have been no co-ordinated multi-agency response to address Child CB’s ongoing attachment, anxiety and 48 identity difficulties or any additional support needs of his foster carers in meeting his needs and coping with his behaviour. 229. Whilst Child CB was in residential care there was ongoing multi-agency working which included residential care staff, health, education and CSC. Some of this work was in response to crisis points and other incidents. 230. One major impact on Child CB’s mental health and emotional wellbeing was his use of cannabis particularly when he returned to Blackpool and it was noted that he was using it regularly. 231. There is nothing to suggest that multi-agency discussions were held in respect of this. For example there was no discussion with the police by either CSC or the CHB to consider whether or not the supply of drugs from a neighbouring house could be disrupted and whether or not there were alternatives to repeating offers of referrals to a substance misuse service to Child CB. 232. It is also not clear that any discussions took place or that any advice was sought in respect of the potential interplay between cannabis and Child CB’s prescribed medication. 233. Assessments of risk and need were carried out regularly whilst Child CB was in residential care but it is difficult to see how they translated into long term multi-agency planning. Child CB remained at high risk of self-harm especially in the time he spent at the CHB and yet one of the principle causes of his distress, which was his planned move to independent living, was not reassessed despite an acknowledged risk that he would find this difficult to cope with. 49 What was the interplay between medical diagnoses, medication and other therapies? 234. In August 2016 Child CB was diagnosed for the first time by a psychiatrist as having a significant attachment disorder, recurrent depressive disorder, social anxiety and challenging behaviours. 235. Following this consultation the psychiatrist prescribed Child CB with Fluoxetine, Risperidone and Circadin as well as agreeing that Cognitive Behavioural Therapy (CBT) would be appropriate. 236. In November 2016 Child CB was also prescribed zopiclone. 237. In December 2017 Child CB was prescribed propranolol. 238. The prescribed medications are described by the NHS as: Fluoxetine is a type of antidepressant known as an SSRI (selective serotonin reuptake inhibitor). It is often used to treat depression and sometimes obsessive compulsive disorder and bulimia. It usually takes 4 to 6 weeks for fluoxetine to work and common side effects include feeling sick, headaches and trouble sleeping. They are usually mild and go away after a couple of weeks. Risperidone is an antipsychotic medicine sometimes prescribed to treat episodes of mania or hypomania. Circadin is used to treat sleep disturbances and is not licenced to treat people under the age of 55. Circadin is sometimes used to treat the symptoms of ADHD in children. Its effectiveness as a sleep aid or as a treatment for ADHD in children is not robust. Zopiclone is a type of sleeping pill that can be taken to treat bad bouts of insomnia. The NHS states that this medication is not suitable for people under 50 18. It is usually prescribed for just 2 to 4 weeks. Common side effects are a metallic taste in a person’s mouth, a dry mouth, and daytime sleepiness. The advice is also not to drink alcohol whilst taking zopiclone. Having them together can make a person go into a deep sleep where they find it difficult to wake up. Propranolol is a beta-blocker (beta-adrenoceptor blocking agents) and works mainly by decreasing the activity of the heart by blocking the action of hormones like adrenaline. They are often prescribed to treat heart and circulation problems and less commonly to treat anxiety. Side effects can include insomnia and depression. 239. The potential side effects of the medications are not insignificant and in some cases (as with Propranolol) may have increased Child CB’s disturbed sleep patterns and depression. 240. Whilst the agency chronologies show that Child CB did not take his medications on a regular basis (and did not take them at all for long periods of time) the potential side effects of using cannabis, alcohol and other substances alongside the prescribed medications does not appear to have been considered by practitioners. It does not appear from the agency chronologies that Child CB’s use of cannabis and alcohol was shared with his GP by Child CB or by practitioners. 241. In summary; CB was prescribed a significant amount of medication aimed at addressing the impact of his mental health conditions. Ongoing supervision of this treatment proved difficult due to the engagement issues described elsewhere in this report but would normally be desirable to monitor their effectiveness and safety. Furthermore whilst these medicines may have helped manage the impact and consequence of CB’s attachment disorder they would not in themselves have dealt 51 with the underlying problem – which required engagement with other therapeutic approaches. 242. Child CB’s psychiatric assessment of August 2016 diagnosed significant attachment disorder, recurrent depressive disorder, social anxiety and challenging behaviours. 243. However a note following a psychological assessment which was carried out in January 2017 to inform care proceeding stated ‘Placement suitable, they also have semi independence. Look towards semi independence after GCSEs and established friendship group. Look towards contact real father, letter off father first prior to GCSEs. Review of medication, won't engage in therapy and the psychologist agrees he doesn't need therapy, or medication’. 244. The contradictory psychological assessments must have been confusing for Child CB but there is nothing on record to show how this was discussed with him and what his feelings were about either assessment. 245. There is also nothing within the agency chronologies to suggest that the latter assessment was shared with health practitioners and how it influenced prescribing and other health care decisions. Risk taking behaviour How effectively did agencies understand and respond to risk taking behaviour? 246. Child CB’s risk taking behaviour was sometimes within the realms of ‘common’ but nonetheless concerning teenage behaviour for example returning home late, drinking alcohol and smoking cannabis. 52 247. The agency response to ‘common but concerning’ teenage behaviour differs between children in care and those who are not with every incident of late return home or returning home intoxicated recorded and shared for looked after children. 248. There were occasions upon which Child CB’s alcohol consumption placed him at significant risk however and these incidents were crisis incidents and responded to appropriately. It is not clear from agency records how information about the risks of such high levels of alcohol was shared with Child CB, or how his use of alcohol was ‘mapped’ against crisis points in his life. For example Child CB was hospitalised after consuming high levels of alcohol on the same day he discovered via social media that his birth father had had more children. 249. The agency response and in particular the criminal justice response to Child CB on the occasion he was in possession of a knife in his foster carer’s home resulted in Child CB being convicted of a criminal offence. 250. At that point in time Child CB was highly vulnerable and extremely distressed. The Howard League for Penal Reform published a briefing in July 2017 which highlighted the issue faced by children in care “In some cases children in care are at risk of being criminalised. Challenging behaviour must be recognised for what it is. Children’s homes and police ought to respond sensitively so that children do not have their life chances blighted by an unnecessary criminal record.” 251. However it is also the Crown Prosecution Service and the judiciary who must be aware of the impact of the criminalisation of looked after children and take this into account in their decision making. 252. Child CB’s increasing use of cannabis when he returned to Blackpool was notable. 53 253. There appeared to be a degree of tolerance of the use of cannabis and/or alcohol by Child CB and others who were resident in the CHB. Whilst the use of cannabis and alcohol was not allowed on the premises, staff were aware that Child CB (and Child X) were visiting a neighbouring house to access drugs. 254. It is not clear from the agency chronologies whether or not there was a multi-agency response to this for example work with the police to investigate and disrupt potential drug dealing from the neighbouring house. 255. Child CB’s increasing use of cannabis as a coping/ self-medicating mechanism and his deteriorating mental health and disengagement from education may have been linked. 256. Research has consistently shown the negative effect of cannabis use on mental health and other adverse impacts. The Royal College of Psychiatrists produced a leaflet on cannabis use which states “Even though cannabis can produce relaxation, if higher amounts are consumed, it can have the opposite effect by increasing anxiety. Some cannabis users may have unpleasant experiences, including confusion, hallucinations, anxiety and paranoia, depending on their mood and circumstances. Some users may experience psychotic symptoms with hallucinations and delusions lasting a few hours, which can be very unpleasant. Even though these unpleasant effects do not last long, since the drug can stay in the system for some weeks, the effect can be more long-lasting than users realise. Long-term use can have a depressant effect and reduce motivation.” 257. Child CB was repeatedly offered a referral to a substance misuse service which he declined. He was also advised by staff at the CHB that cannabis was having an adverse effect on his mental health. 54 258. Addressing Child CB’s use of cannabis should have been a priority focus in multi-agency plans and in the analysis of risk and need. Responses to the risk of suicide How effectively did agencies respond to indications of low mood, self-harm and suicidal ideation? 259. On 25th March 2016 Child CB was taken by ambulance to hospital following him taking an overdose of ibuprofen and co-codomol. He was seen by a CAMHS practitioner the following day whilst still in hospital and discharged the same day. 260. The hospital shared this information with the SNP but do not appear to have shared the information with CSC. It is also not clear that the SNP shared the information or discussed this incident with CSC. 261. On 3rd April Child CB attended A & E with a friend of M’s stating that he felt like harming himself. He was admitted to an adolescent ward. 262. The SNP had telephoned both CSC and the hospital on the same day to discuss her concerns about the escalation of risk and shared information that Child CB had told her that F had hit/restrained him and he subsequently underwent a safeguarding medical. 263. Child CB was visited on the ward by a SW but is recorded as having refused to engage. 264. Child CB was discharged from hospital to his parents care on 8th April. 265. A CSC record of the 25th April 2014 records ‘that the support from the post adoption support team ceased on the 22/04/2014 in order that CAMHS can begin work with the family via Family therapy (27/05/2014) Much work has been 55 completed by post adoption services in relation to attachment, emotional responses to adoption/birth family. It has been identified that there is a real risk of adoption breakdown. M has been referred to Women's Aid as a result of being subject to Child CB’s violent behaviour. Outcome of this assessment was case to close to CSC and a referral to Early Assessment Team (EAT) be made for any additional support’. 266. The decision to close the case to CSC followed an assessment which had included only SS1 and the post adoption SW. The decision and the way it is recorded makes no reference to the outcome of the safeguarding medical or to managing the risk of suicide and self-harm. 267. Following that decision Child CB and his parents were effectively left without support or any other intervention (other than an initial CAMHS appointment on 28th April 2014) and on 18th May 2014 M contacted CSC stating that Child CB’s behaviour was out of control and the family felt at risk from him. M presented as very distressed and reported that he was physically and verbally abusive towards her stating that ‘he is on Facebook claiming his parents are abusing him, whereas she reports that they are fearful of him’. The outcome of this contact was a referral to EAT for checks, prior to identification of support for family in crisis. 268. On 10th August 2016 following his admission to hospital after claiming to have drunk bleach, Child CB was assessed by a CAMHS practitioner. The practitioner recorded that ‘Child CB Disclosed previous self-harm and admissions to hospital. Has been under Blackpool CAMHS but hadn't found it helpful. Declined appointment with psychiatrist. States low in mood has symptoms of anxiety/ panic attacks. Denies any suicidal intent. Admits cannabis use and drug use in the past. Denies current use. Poor sleep. Poor appetite and difficulty concentrating. Very few coping strategies. 56 Discharged back to foster care - appointment made with consultant which Child CB agreed to look at medication. Follow up appointment with CAMHS practitioner made for one week. Child CB signed a Consent to Share Information. Liaison with Social Worker and information and key contact numbers given if he feels he needs support before his appointment. Care plan completed. Risk assessment completed. Considered to be at high risk of further harm to himself - at present has stopped self-medicating with drugs and denies thoughts to harm himself’. 269. CSC were aware that Child CB had been admitted to hospital for this third episode of self-harm/ attempted suicide (the foster carer had informed them), however no strategy meeting was called although it is clear from agency records that CMAHS shared their assessment with CSC that Child CB was at high risk. 270. Child CB was discharged from hospital and there was no further planned CSC contact until a CLA Review which took place 2 months later in October 2016. 271. It is difficult to see how this was an appropriate response to the assessed high risk of Child CB further self-harming. 272. Following the August 2016 admission and Child CB’s move to residential care in Manchester he did not disclose that he had self-harmed or discuss suicide until November 2017 when he self-harmed at CHB. 273. Child CB disclosed that he had self-harmed 3 times during November 2017. This was a period of time during which he was facing several pressures which are described elsewhere in this report. Staff at the CHB noted and recorded Child CB’s cannabis use and contacted the SW to request an urgent mental health referral. 57 Was the immediate response to the suicide attempt on 15 December 2017 effective and did it fully consider his mental health? 274. The immediate response to Child CB’s suicide attempt was effective in that the CHB Manager succeeded in engaging him when he answered her telephone call. At this point he was on the roof of a building. The CHB Manager recalls that she talked calmly to Child CB to let him know that he was loved and to keep him engaged. Child CB ended the call. By this point the police had arrived and managed to ‘talk him down’. 275. The Police records state ‘Lancashire Police received a telephone call from staff at CHB stating that Child CB, a resident, had left the home feeling depressed and stating that he was going to go to the multi-storey car park. Police Officers attended the Car Park where Child CB was sat on a ledge on the top floor of ****. Officers engaged Child CB in conversation and he came off the ledge fairly quickly. He was escorted by officers from the car park where officers were joined by care staff from CHB. Child CB agreed to attend Blackpool Victoria Hospital voluntarily in order to undertake a mental health assessment. Police escorted Child CB to hospital where he was left in the care of the hospital and care staff. The care staff stated that they had found a note left by Child CB in the home stating that he was going to kill himself by jumping off the roof of ****’. 276. The CHB record of what followed states ‘The police and staff took Child CB to hospital where he waited to be seen until approx. 4.00am. He eventually discharged himself as he was not willing to wait any longer. Child CB disclosed to manager the next day that he had been planning this for a week. At A & E the police spoke to reception, Child CB became agitated at the length of time that he had to wait, staff 58 persuaded him to stay until 4.00am but A & E could not give staff a time estimate for Child CB to be seen. The receptionist referred to another member of staff and he was advised that they would not be long in seeing him and could he wait a little longer. Child CB wanted to leave at 4.00am, staff could not prevent him from leaving. Reception asked Child CB if he was discharging himself and Child CB agreed. Child CB and staff were advised to contact the Child and Adolescent Support and Help Enhanced Response (CASHER) team later in the day. Child CB said he was tired and embarrassed’. 277. The practitioners who contributed to the Learning Event and the SCR Panel members spent some considerable time considering whether or not Section 136 of the Mental Health Act (MHA) could have been used in this case. 278. The police can use Section 136 of the MHA when a person is in public. Police can use this section if they believe a person has a mental illness and needs care or control. This section of the MHA relates to moving or holding someone in a ‘place of safety’. A place of safety can be a person’s home, hospital or a police station. The police can move people from one place to another. 279. Whilst in a ‘place of safety’ a mental health assessment is carried out and a person can be kept on this section for up to 24 hours. This can be extended for 12 hours. After the mental health assessment a person may stay in hospital under a different section of the Mental Health Act. 280. In Child CB’s case the police officers who attended were reassured that Child CB was in a safe place as they left him in the A & E department with staff from the CHB. 59 281. When Child CB refused to wait to be seen, staff from the CHB and/or A& E could have recalled the police and considered the use of Section 136 (or other Mental Health act powers) to detain him until he had undergone an assessment. 282. CB was in the department for 2 hours and it is unclear if he was waiting for an assessment from the medical team or the mental health team (this service is provided by Lancashire Care Foundation Trust). At the time of the incident a paediatric “did not wait” protocol was in place following recommendations from a Children Looked After and Safeguarding Children Care Quality Commission (CQC) inspection in May 2017, it is not evident that this protocol was followed, as he was over 16 years. However, as he was under 18 years his attendance was followed up immediately the same morning via the paediatric liaison service (described earlier in the report). 283. A strategy meeting was held between the Police and CSC on 15th December and a decision made to undertake S47 enquiries. 284. Information was shared during the strategy meeting that Child CB had told the CHB Manager that he had planned his suicide for a week. It was also noted that Child CB had been ‘under CAMHS’ but that he was no longer eligible for CAMHS because he was 17. It was noted that Child CB would be attending a GP appointment the same day and an appointment would made for him to access Youtherapy or SPA (consideration was also given to whether he could be detained under the Mental Health Act). Practical arrangements were also discussed in respect of monitoring Child CB’s safety and whereabouts. It was also noted that after he had self-discharged from hospital Child CB had continued to inform staff at the CHB that he 60 intended to kill himself. It does not appear from the agency records that Child CB’s regular use of cannabis was discussed. 285. In summary, this was a serious pre-meditated suicide attempt made by a young person with a history of previous attempts and self-harm who was still stating that he wished to kill himself. Effectively at this point in time Child CB was not receiving any mental health interventions and had a history of rejecting or not fully engaging with support or interventions offered to him. How did Child CB’s wishes and feelings influence assessments and responses? How did practitioners ensure that Child CB was listened to and understood? 286. The practitioners who contributed to the Learning Event described Child CB as very bright and engaging and as a young person who was very particular about his appearance. It was apparent from listening to them that Child CB was, at times, also able to communicate his wishes and feelings. 287. There are several examples throughout the lengthy agency chronologies which demonstrate that Child CB was sometimes listened to and understood. 288. There were also, as previously discussed, practitioners with whom he was able to form trusted relationships and the agency chronologies record Child CB’s own words on occasion. 289. There are other examples; for instance when a SW visited Child CB in hospital in April 2014 when he expressed that he might harm himself he refused to speak to her. No further attempt was made to speak to him and yet the assessment 61 concluded and a CIN plan was developed which effectively could not reflect Child CB’s wishes and feelings. 290. A further instance was the management of the crisis point for Child CB of his birth siblings becoming pupils at his school. Plans do not appear to have been influenced by Child CB’s wishes and feelings despite him being very clear about the cause of his distress. 291. It is also clear that there were occasions upon which Child CB himself did not feel listened to or understood and this was particularly apparent during the period of time that attempts were being made to prevent the breakdown of the adoption. 292. One further critical issue for Child CB was the planned move to independent and fully independent living (by the age of 18). Despite his extreme anxiety about this and despite the SW’s own opinion that he would not cope well there was no re-consideration of this plan. In essence his legitimate concerns were listened to and understood but this did not lead to a change in plan for him. It is difficult to know what impact this had upon him. 293. There were also examples of practitioners ensuring that Child CB’s voice was heard in multi-agency arenas. One practitioner who was able to form a trusting relationship with Child CB was the SNP at SS1. She shared her concerns about the risks to Child CB within the home on more than one occasion. She also challenged the decisions and actions of other practitioners when Child CB had alleged an assault by F. In other words the SNP had listened to and believed Child CB and remained focused on him and the possible underlying causes of his behaviour and distress. 294. There were also many occasions upon which practitioners had to balance Child CB’s perfectly understandable, age appropriate frequent changes of mind about where he 62 wanted to be or what he wanted to do especially in respect of his post-school plans and moving from Manchester to Blackpool and then wishing to return to Manchester with what was believed to be in his best interests. Further Analysis 295. Stability is important for any child, and unwanted moves or school changes and the disruption they can bring can be particularly difficult for children in care. Stable relationships and a secure environment provide a sense of belonging and identity. Where there is instability, relationships with trusted adults and other children suffer which can compound existing attachment and identity issues. 296. The Children’s Commissioner for England Stability Index 2018 indicates that that older children – especially those entering care from the age of 12 to 15 – are most at risk of instability, and may need extra support to prevent placements breaking down. 297. The breakdown or disruption of an adoption rarely if ever happens ‘out of the blue’. Adoption provides a stable family for many children who are unable to return home. Adoptive parents commit themselves and their resources to children who need the same kind of family experiences as any child, but often also need much more due to their often traumatic early childhoods. Given what we now know of the challenges and impact on adoptive parents and the pain and distress of young people who struggle to live in a family, efforts to improve pre adoption ‘preparation’ and post adoption support should be a priority within adoption teams. 298. Similarly the capacity and willingness of foster carers to provide therapeutic and stable placements for children who share Child CB’s vulnerabilities is an issue which 63 contributes to the lack of stability for children and further compounds existing attachment and anxiety difficulties. 299. Serious Case Reviews provide useful analysis of cases involving suicide nearly all of which related to adolescents, and the majority related to boys. The analysis of SCRs identified a number of warning signs that a young person was considering suicide. These are listed below and those which applied to Child CB are in bold type: disclosures of suicidal feelings - often verbal, but also letters, suicide pacts or pieces of creative writing change in sleep patterns - sleeping more or less than usual change in appetite - eating more or less than usual sudden mood swings - in some cases a notable uplift in mood preceded a suicide attempt feelings of hopelessness, rejection or being a burden to others self-neglect - often signalled by a decline in personal hygiene and appearance self-harm - often through deliberate cutting, but also aggressive acts such as hitting walls withdrawing from family and friends and stopping engagement with support services 300. There are other important indications of suicide risk which also applied to Child CB and these include: Previous suicide attempts Substance misuse / increased substance misuse 64 301. These warning signs present a useful way for practitioners working with children and young people to reflect on overall patterns of behaviour and changes in behaviour. Summary 302. Child CB had a very difficult start in life. The impacts of his early experiences of neglect and possibly abuse were manifest in some of his behaviours and difficulties. 303. The breakdown of his adoption followed at least 4 years of escalating difficulties for him and his family and happened when he was facing all of the additional challenges that adolescence brings. 304. Child CB had many vulnerabilities and they were often compounding. These have been detailed throughout this report and included: Adverse childhood experiences Removal from birth family Diagnosed significant attachment disorder, recurrent depressive disorder, social anxiety and challenging behaviours Breakdown of his adoption Becoming a looked after child as an adolescent Breakdown of foster placements Drug and alcohol use Transition from care to semi-independent/ independent living His age and his gender 305. Child CB had expressed his thoughts that he wanted to die and had made a serious attempt to take his own life on at least one occasion before he actually did so. 65 306. His mental and emotional health had deteriorated rapidly following his return to Blackpool and this report has detailed the pressures and difficulties he was facing. 307. There is a strong likelihood that the method he chose to help him deal with these pressures and difficulties i.e. cannabis and alcohol compounded this deterioration and this was also an important indication that his distress was increasing. 308. There is no doubt that Child CB was cared for and loved by his family and by the practitioners who worked with him and the author wishes to express her condolences and thank them for their courage and honesty in sharing their experiences and their views during this review. 309. However there is also important learning from this review which will be applicable to other children and young people in Blackpool and this is detailed below. Learning and Recommendations arising from this Serious Case Review a. Given what is known about the difficulties faced by children and young people who share Child CB’s vulnerabilities and the transition to semi or fully independent living it is recommended that BSCB review existing arrangements for care leavers with specific regard to the statutory guidance (Children Act 1989 Volume 3, January 2015) which states, “No young person should be made to feel that they should leave care before they are ready. The role of the young person’s IRO will be crucial in making sure that the care plan considers the young person’s views”. In other words, IROs have a critical statutory role and responsibilities in ensuring young people’s successful transitions to adulthood. The IRO should therefore be consulted prior to a planned move and, as soon as possible following, an unplanned move. They should ensure that the care plan considers the young person’s views. Whilst these 66 recommendations will be enhanced by the new provisions contained within the Children and Social Work Act 2017, including the extension of support to all care leavers to 25 years of age (from April 2018), the Local Authority should review sufficiency in respect of appropriate provision for care leavers to include staying close options. b. The results of the systematic reviews and meta-analysis confirm that suicide attempts are more than three times as likely in children and young people placed in care compared to non-care populations. Within this cohort suicide rates differ between boys and girls with boys more at risk. Targeted, gender specific interventions to prevent or reduce suicide attempt in this population (and those at risk of becoming looked after children) may be required. It is recommended that BSCB and partners review current suicide prevention strategies in order to ensure that they specifically recognise and respond to the additional vulnerabilities of CLA. c. It is recommended that BSCB and partners seek assurance from partners about the way in which CAMHS is offered to children and young people who share Child CB’s vulnerabilities (some of whom may be CLA) including the age at which a child or young person can access CAMHS and the transition to adult services. (This should take into account the acknowledged view that childhood ends at the age of 18). There are examples of effective practice from elsewhere in England which show that, for example, co-locating CAMHS practitioners within CLA teams has been successful in engaging children and young people who have previously rejected services. d. It is recommended that health and social care commissioners review what therapeutic (and other) services are available for CLA or for those who share Child CB’s vulnerabilities recognising the inherent difficulties in engaging children and 67 young people who may have severe attachments disorders and that this are reflected in how services are designed and offered. e. The known suicide risk factors for children and young people which are detailed in this report, together with the warning signs that a young person may be considering suicide, should be included in ongoing staff development and training and reflected in assessments, analysis of risk and need and supervision. f. The BSCB and partners should seek assurance that the preparation, training and ongoing development and support of foster carers enables them to offer long term, stable and therapeutic placements to children who share Child CB’s vulnerabilities. This review should in particular, reference what is known about Adverse Childhood Experiences (ACES) and attachment and identity. g. The BSCB and partners should similarly review what support and development arrangements are currently in place for adoptive parents and adopted children and for those who wish to adopt children who share Child CB’s vulnerabilities including Adverse Childhood Experiences, attachment and identity and consider ongoing support for whole family/ individual family members which recognises periods of challenge and transition such as adolescence. h. The BSCB and partners should seek assurance that cannabis use (and other substance misuse) is currently responded to in the CLA cohort of children and young people. This should include a specific focus on the impact of cannabis and other substances on mental health and other outcomes for children and young people, the potential interactions of cannabis with prescribed mental health (and other) medications and what single and multi-agency responses are possible. 68 i. The BSCB should share the learning from this Serious Case Review with the Pan Lancashire Suicide Prevention Operational Group and seek assurance that suicide prevention measures are in place (or under consideration) in publicly accessible buildings. 69 References Borders, L. D., Penny, J. M., & Portnoy, F. (2000). Adult adoptees and their friends: Current functioning and psychosocial well-being. Family Relations, 49, 407–418. Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C. and Megson, M. (2012) New learning from serious case reviews: a two year report for 2009-11. London: Department for Education. Grotevant, H. D. (1997). Coming to terms with adoption: The construction of identity from adolescence into adulthood. Adoption Quarterly, 1, 3–27. Health Committee, Third Report of Session 2014-15, Children’s and adolescents’ mental health and CAMHS, HC 342, p 3 The Howard League for Penal Reform (2017). Ending the Criminalisation of children in residential care (Briefing 1). London: Howard League Office of National Statistics (2005). Mental health of children and young people in Great Britain, 2004. London: ONS. Preventing Suicide in England: A cross-government outcomes strategy to save lives, DFE-RR226. Price C, Hemmingsson T, Lewis G, Zammit S, Allebeck P. Cannabis and suicide: longitudinal study. Br J Psychiatry (2009) 195:492–710.1192/bjp.bp.109.065227 Sharma, A. R., McGue, M. K., & Benson, P. L. (1996). The emotional and behavioural adjustment of United States adopted adolescents: Part I. An overview. Children and Youth Services Review, 18(1/2), 83–100. Selwyn J, Wijedasa D, and Meakings S (2014), Beyond the Adoption Order: challenges, interventions and adoption disruption. University of Bristol School for Policy Studies Hadley Centre for Adoption and Foster Care Studies |
NC048266 | Alleged sexual abuse of an adolescent boy by foster carers in two separate placements between 2013 and 2015; a criminal investigation was initiated but neither foster carer was charged with criminal offences. Child PB became looked after aged 12 due to behavioural problems. His first long-term foster carer (FC1) requested that the placement be ended, citing ill health. PB was placed in a residential educational setting, living with a second foster carer (FC2) during weekends and holidays. His behaviour deteriorated and he was moved to a permanent residential placement. PB went missing several times, returning to FC2 although this was not always reported. On one occasion FC2 told police he hadn't seen PB, but PB was found hiding undressed at FC2's home. Despite FC2 being suspended as a foster carer, PB was persistently found at FC2's home. Weeks later, following therapeutic support, PB disclosed sexual abuse by both FC1 and FC2. Key findings include: although the disclosures have not led to prosecutions, the actions and behaviours of both foster carers should have led professionals to consider at a much earlier stage whether they could keep children in their care safe and whether they posed a risk to children placed with them. Recommendations include: ensure foster carer assessments and reviews are robust, thorough and appropriately challenging; ensure supervision files have carefully maintained chronologies to support supervision and review so that any emerging concerns or issues can be addressed; ensure all practitioners have a sound understanding of the range of characteristics, motivations and behaviours of people who seek to sexually abuse children.
| Title: Serious case review: the placements of Child PB. LSCB: Trafford Safeguarding Children Board Author: Trafford Safeguarding Children Board Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review The placements of Child PB March 2017 SCR Trafford/ Fostering/December 2016 - amended March 2017 2 Contents 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 2. The circumstances which led to this SCR 3. The approach used 4. Scope and terms of reference 5. Cross Boundary Issues 6. Significant Events 7. Appraisal of Practice and Processes 8. The Recruitment and Selection of foster carers. 9. The Fostering Panel and the Agency Decision Maker 10. PB’s placements with FC1 and FC2 11. Supervision of Foster Carers 12. Annual Foster Carer Reviews 13. Communication and collaboration between agencies 14. Managerial Oversight 15. The views of PB and family 16. Summary Appendix 1: Recommendations for Trafford Safeguarding Children Board and the Local Authority Key: (names have been anonymised) Mother: MPB Stepfather: SFPB Subject: PB First Foster Carer FC1 Second Foster Carer FC2 Supervising Social workers SSW1 and SSW2 Social Worker SW SCR Trafford/ Fostering/December 2016 - amended March 2017 3 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 1.1. The main responsibilities of Local Safeguarding Children Boards (LSCBs)1 are to co-ordinate and quality assure the work of member agencies to safeguard children. The statutory guidance2, which accompanies legislation and underpins the work of LSCBs, is very clear in its expectation that LSCBs should maintain a local learning and improvement framework so good practice can be identified and shared. 1.2. In situations where abuse or neglect of the child is known or suspected, and children die or are harmed, LSCBs are required to undertake a rigorous, objective analysis of what happened and why, to see if there are any lessons to be learnt which can be used to improve services in order to reduce the risk of future harm to children. There is an expectation that these processes, known as Serious Case Reviews (SCRs) should be transparent with the findings shared publicly. 2. The circumstances which led to this Serious Case Review (SCR) 2.1. In the summer of 2012, the mother (MPB) and stepfather (SFPB) of child PB requested help from Children’s Social Care (CSC) because they were unable to manage his behaviour. The family were offered support through the Child in Need process, but in February 2013, PB aged 12 years old, became a looked after child under section 20 of the Children Act 1989 and was placed with foster carers. Later, at different times, PB was placed with Foster Carer FC1 and Foster Carer FC2. 2.2. PB was placed with FC1, a newly approved single foster carer, in May 2013 and he remained there until January 2014, when FC1 advised the authority that due to his ill health he was unable to continue caring for PB. PB was moved a short time later and placed with other foster carers. 2.3. FC2 had been approved in February 2013 as a single foster carer. PB was placed with FC2 in March 2014, where he remained for several weeks until moved to a residential school as a weekly boarder and returned to FC2 only at weekends. In November 2014, CSC made a decision to place PB in a 52-week residential placement, which also offered education. PB persistently absconded from this placement and frequently returned to the home of FC2. 2.4. Residential staff and social workers had growing concerns about the possibility that FC2 was colluding with PB during the times he was missing, and these were confirmed when, in February 2015, despite his presence being denied by FC2, police found PB hiding, partially clothed, in an upstairs bedroom in FC2’s home. FC2 was subsequently served with an abduction notice and was later de-registered as a foster carer. 2.5. Further placement breakdowns occurred for PB before he was placed in secure accommodation amid concerns about his safety, and his aggressive and sexualised behaviour. PB made progress in this secure placement with the help of a therapeutic support worker from Barnardo’s and, after several sessions, he told this worker that FC2 had on several occasions made sexual overtures and tried to encourage him to engage in sexual activity. The Police were informed and a criminal investigation was initiated. 1 Children Act 2004, s14 2 Working Together to Safeguard Children 2015. HMSO SCR Trafford/ Fostering/December 2016 - amended March 2017 4 2.6. In December 2015, PB told his key worker that when living with FC1, he had watched a scary movie and slept in the bed of FC1 and had woken the following morning to find the foster carer touching his genitals and told him to stop. PB later found FC1 collapsed on the floor and contacted a friend’s mother for help. PB said he had forgotten about the incident until he had read court documents [relating to charges against FC2] and a reference to ‘grooming’ and this had triggered the earlier memory. This information was passed to the Police and FC1’s foster care registration was suspended pending further enquiries. 2.7. Neither foster carer was charged with a criminal offence, but following internal inquiries which examined the actions and behaviours of FC1 and FC2, the Chair of Trafford Safeguarding Children took a decision in February 2016 to commission a Serious Case Review so that a thorough and objective analysis of actions and decisions taken by professionals in respect of both foster carers could be undertaken. 2.8. The Lead Reviewer sought further clarification of the rationale for commissioning a Serious Case Review. Statutory guidance states that Serious Case Reviews should be undertaken when abuse or neglect of a child is known or suspected and there is cause for concern about the way in which the authority, their Board partners and other relevant persons have worked together to safeguard children.3 At the point at which the decision was taken to undertake a SCR, the LSCB had information which raised significant concerns about the safety and wellbeing of a looked after child whilst in the care of FC1 and FC2. Several professionals were involved with PB, mainly from different areas within the Local Authority - the children in care team, the fostering and adoption team and children’s homes – each of which had quite different perspectives. Police were also involved with PB as were education and health albeit to a much lesser degree. 2.9. What was not clear prior to beginning the SCR was how agencies and specifically the professionals within those agencies, had worked together to safeguard this young person. The guidance clearly states that ‘where a case is being considered under regulation 5 (2) (b) (ii), unless there is definitive evidence that there are no concerns about inter-agency working, the LSCB must commission an SCR’. This is the threshold, which was applied in this case and together with the fact that PB was a looked after child, provided the rationale for the decision to commission an SCR. In effect however, the lessons emerging from this review impact predominantly on Fostering Services within Trafford. 3. The approach used 3.1. A small Review Team of Senior Managers was established and their role was to provide strategic information about the involvement of their service/agency and to identify learning for their agency through the submission of an Agency Learning Report. Independent Chair Linda Richardson Safeguarding Development Manager Trafford Safeguarding Children Board Acting Joint Director Children’s Social Care Trafford Council Designated Nurse (Safeguarding Children and LAC) Trafford CCG Head of Service (Children in Care) Trafford Council Detective Inspector Public Protection Oldham Police 3 Regulation 5 of the Local Safeguarding Boards (LSCBs) Regulations 2006 SCR Trafford/ Fostering/December 2016 - amended March 2017 5 Interim Head of Service (MARAS) Trafford Council 3.2. Members of the Review Team also identified frontline practitioners and first line managers who were known to PB and both foster carers. These practitioners formed the ‘Practitioner’s Group’ and they met on two occasions and offered valuable insights through group discussions and individual conversations with members of the Review Team. Manager Residential Placements (RP1) Trafford Council Supervising social worker – MDFC programme Trafford Council Supervising social worker 2 Trafford Council Independent Reviewing Officer Trafford Council LAC Nurse Pennine Care Foundation Trust Social Worker (3) Trafford Council Manager Trafford Council Practitioner CAMHS (did not attend) Police GMP 3.3. In August 2016, Trafford commissioned an independent review to consider FC1’s continued suitability as a foster carer. This was concluded in November 2016. The Review Team agreed that the outcome of that internal investigation should be considered before the SCR was finalised. 3.4. Both FC1 and FC2 were offered the opportunity to contribute to this report. FC2 did not respond to overtures by TSCB but FC1 met with the Lead Reviewer and the Interim Lead for Looked After Children in late February 2017, on a date selected to accommodate FC1’s working commitments. The comments of FC1 are included on page 29 of this report. 4. Scope and Terms of Reference 4.1. The Review Team began the process with an open enquiry rather than a detailed pre-determined set of questions from terms of reference. However, key lines of inquiry for this review quickly emerged around the recruitment and supervision of the foster carers, placement matching and the challenges for professionals in being curious and maintaining an open mind when supervising foster carers. 4.2. The Review Team were mindful of the need to keep the scope of this review clearly focused; this was not about PB’s journey through the care system or the decisions which were taken in regard to his welfare and safety, although inevitably some pertinent questions needed to be asked in relation to some placement decisions. 4.3. Both FC1 and FC2 denied the allegations made by PB, which he has not retracted, and although the allegations can be neither proven nor dismissed with absolute certainty, it is incumbent upon the local authority to consider whether the allegations could have any basis whatsoever. The Review Team thought it essential that any reader of this report understands the context in which it was commissioned and the statutory duty placed upon local authorities to take all reasonable steps to safeguard and promote the welfare of children and young people in their care. The CPS, the Police and the judicial system all operate from the principle of what can be proved in a court of law; i.e. the standard of proof being ‘beyond all reasonable doubt’. In civil cases, such as those initiated in social work and care settings, a lower standard of SCR Trafford/ Fostering/December 2016 - amended March 2017 6 evidence is required and this works on the principle of ‘the balance of probabilities’ i.e.: is what is alleged more likely to have happened than not? 4.4. Internal reviews of both FC1 and FC2 as foster carers led Trafford Council to the conclusion that both FC1 and FC2, notwithstanding the allegations made by PB, were dishonest in their dealings with the local authority, behaved in ways which were not in keeping with safe practice and caused, or may have caused, harm to a child or children in their care. The Serious Case Review was therefore commissioned in order to provide a rigorous analysis of the actions and decisions of professionals and the systems which informed those actions, to determine if the selection, recruitment and supervision of the foster carers, together with the decisions to place PB in their care, was in line with good practice and fostering standards. 4.5. The review period for the SCR was from 2013 when both foster carers were approved, to December 2015 when FC1 was suspended from his fostering role. 5. Cross boundary Issues 5.1. FC2 was well known in a professional capacity in another local authority. Although several meetings took place between the two authorities, there was no representation from the other authority on the Review Panel despite a high profile role held by FC2 in that area. Only at the end of the review process did it become apparent that no formal invitation had been extended to the LSCB in that area, thereby missing a useful opportunity to share learning across the two authorities. However, a subsequent meeting took place between senior managers and a decision taken that the report would be shared with that authority prior to publication. 6. Significant Events May 2012 Talks began with FC2 about becoming a foster carer. June 2012 FC2 began ‘Skills To Foster’ training Feb 2013 FC1 observed in a professional setting in response to application to become foster carer Feb 2013 PB became a Looked after Child on a s20, CA 1989 (12 years old) Feb 2013 FC2 approved as foster carer. May 2013 FC1 approved as foster carer and placement commenced with PB. June 2013 Complaints from MPB concerned that PB was posting messages and images on You Tube. Discussions with FC1 about importance of restricting and monitoring access to Internet June 2013 PB confirmed he was happy in placement June 2013 Complaint by MPB that FC1 allowed PB to shave off eyebrows. FC1 admits to SSW that he gave PB his electric shaver as it was ‘safer’ July 2013 FC1 advised SSW that PB is scared of dark July 2013 Complaints from MPB that PB was again accessing Internet. MPB and SFPB requested change of placement. FC1 informed and shared this information with PB. SSW again discussed access to Internet and importance of boundaries for PB. July 2013 PB was in altercation with local youths. PB slightly hurt. FC1 did not report until following day. July 2013 FC1 left PB alone upstairs with friend. PB accessed Internet. FC1 said he was unaware of this. SCR Trafford/ Fostering/December 2016 - amended March 2017 7 Aug 2013 FC1 told PB that he would like to care for him on long term basis Aug 2013 FC1 advised SSW that was emotionally exhausted caring for PB who did not appreciate all the things that he did for him. Aug 2013 FC1 recorded hearing PB snoring and talking in his sleep saying ‘Get off me, leave me alone”. Few days later FC1 recorded ‘no more snoring, but PB kicked covers off, so I covered him up again.’ Sept 2013 School report PB: theft of food and fighting. Behaviour deteriorated during term. Oct 2013 PB refused to go to school and damaged furniture in FC1’s home. He later apologised. FC1 said he needed time out to support sick relative. PB moved to respite carers who advised that PB had money and cigarettes and did not know where he got these. FC1 later reported that he noticed £40 missing from his wallet but did not report this at the time. Sept/Oct Two periods where both PB and FC1 were poorly so did not attend work/school. Later in the month PB refused to attend school. October FC1 attended for blood tests re his weight loss. PB stayed with respite carer so FC1 could support ‘Aunt’ who later died. Nov 2013 Fostering Panel agreed an exemption so two children could be placed in the care of FC1. Concerns about his ill health noted. Nov 2013 FC1 informed Supervising Social Worker that PB was in his bedroom again this morning claiming that he wanted to be near FC1. Nov 2013 FC1 reported that his test results were negative. PB reported to again be using Facebook. Images seen by family members of PB drunk. FC1 insisted someone else was using PB’s account. Nov 2013 MPB complained after contact visit, that PB has too much information about FC1’s ‘cancer’ and the ‘dry skin hanging off his back’. FC1 said he had never discussed his concern that he could have cancer with PB, but that PB may have seen a lump on his back when they went swimming. Dec 2013 FC1 reported he was finding it difficult to manage PB’s behaviour. Alleged that PB struck him in the face when he refused to buy cigarettes and intimated that he had stolen money before from FC1 but he had not reported these as he did not want to get PB into trouble. Jan 2014 Meeting with SSW - FC1 reported poor health and requested end of placement. PB later contacted SSW saying he found FC1 collapsed on floor. SSW spoke with FC1 who claimed he was fine, had taken two tablets belonging to the ‘Aunt’ (who had died) and they had affected him. Refused to seek medical attention. Feb 2014 PB was moved to different placement FC1 later advised he was well after resting. YP2 was placed with FC1 for short break. FC1 advised SSW that he had been diagnosed with a specific medical condition. Mar 2014 PB was placed with FC2. Decision was made early in placement that PB’s needs would be best met by educational setting and returning to live with FC2 only at weekends and holidays. June 2014 FC2 advised that PB refused to return to school. FC2 requested additional support. PB later absconded from school and turned up at the home of FC1 who did not report until the following day. July 2014 An allegation was made against FC2 that he allowed two young people previously in his care, to access and drink alcohol in his home. PB was moved to respite placement whilst further inquiries were underway. Investigation concluded that allegations could not be substantiated. July 2014 PB’s placement with FC2 resumed. SCR Trafford/ Fostering/December 2016 - amended March 2017 8 Oct 2014 FC2 reported that PB had threatened him with violence and was abusive Oct 2014 PB telephoned SSW very distressed saying FC2 had told him ‘no-one wanted him’. PB rang off and went missing; he was thought to have returned to the home of FC1. He later returned to FC2. Nov 2014 Placement with FC2 ended following a decision that PB needed a 52-week residential placement. Nov 2014 FC2 made requests to SW, that he be supported to seek Special Guardianship Order for PB. This was refused. Nov – Feb 2015 PB went missing several times. Records indicated PB turned up at home of FC2 ‘most days’. FC2 was advised that he must immediately contact the residential placement if PB turned up at his house. SSW very concerned about FC2’s mental state and advised him to see his GP. Jan 2015 CSC records refer to being concerned at PB mixing with older men and querying whether PB should have ongoing contact with FC2. Feb 2015 Concerns began to emerge that FC2 did not always report that PB was at his home. PB frequently reported missing. Feb 2015 FC2 met PB and bought clothing which PB told staff was a ‘Valentine’s gift’. Feb 2015 PB again was reported missing and Police call at home of FC2. FC2 denied he had seen PB. Police find PB hiding undressed in wardrobe. FC2 is served with an abduction notice and advised he must not have contact of any sort with PB, or any of the young people who had been placed in his care, or any young person under the age of 18. FC2 intimated that the police officer had misunderstood his response when asked if he had seen PB. Feb 2015 FC2 was suspended as a Trafford Foster Carer. Feb 2015 (Various dates) FC2 called Police to inform them that PB was again at his home. FC2 advised Police that he had a specific medical condition brought on by stress. FC2 called Police to advise that PB was again outside his home. Mar 2015 (Various) PB was reported missing. Neighbour reported FC2 leaving house with a young male. FC2 called Police to say that PB was outside with house with another male. April 2015 Envelope with £30 inside arrived for PB at placement from someone with reversed initials to that of FC2. PB later told his mother that the money was from FC2. May 2015 FC2 advised there would be no further action in respect of the abduction charge. He was given notice that under no circumstances was he to have any contact with PB. FC2 signs the notice. June 2015 FC2 was de-registered as a Foster Carer for Trafford Council. July 2015 PB made an allegation of sexual abuse against FC2 Dec 2015 PB made an allegation against FC1 who was suspended as foster carer. June 2016 Crown Prosecution Service PS took a decision not to prosecute either FC2 or FC1. August 2016 Trafford commissioned an independent investigation into FC1 7. Appraisal of practice and processes 7.1. The Review Team were mindful of the dangers of hindsight bias but wanted to understand why certain actions and decisions in relation to the foster carers and PB’s placements may have made sense at the time and importantly, what systemic factors in place then could still be SCR Trafford/ Fostering/December 2016 - amended March 2017 9 impacting upon practice in 2016. In this respect, the findings from this review should be seen as a ‘window’ on existing processes and practice rather than a review of what happened in only in this case. The Review Team also considered the ways in which agencies worked together and the extent to which they shared their concerns and collaborated, although much of this review was linked to the recruitment, selection and supervision of two foster carers who, at different times, cared for PB. 7.2. From studying key documents and listening to the views and experiences of practitioners, the Review Team identified several key areas to be explored in greater detail to better understand the actions and decisions of professionals working with both foster carers and with PB and whether there was sufficient consideration given to any risks which these carer may have posed to any child placed in their care. 7.3. This report relates to a review of the systems and processes in place at the time, the review was not required to offer comment upon Trafford’s decision to de-register either FC1 or FC2 as foster carers. 8. The recruitment and selection of the foster carers. 8.1. The last detailed independent regulatory inspection of Trafford’s fostering service took place in June 2011. Although there was reference to some assessment reports of foster carers needing to be more evaluative, the overall quality rating was good. In 2015, the Ofsted inspection also rated the fostering service as ‘good.’ This review has however highlighted a number of areas where practice in the existing arrangements for recruitment and supervision of foster carers could be improved. It should be stressed, that although this report links the two single male foster carers, there is no evidence that they were personally acquainted prior to their registration as individual foster carers. 8.2. Fostering regulations contain checks and balances designed to make the recruitment and selection of foster care as safe as possible and it is the way in which these were interpreted and implemented in Trafford that is an aspect of this review. Abuse by foster carers is rare, but there are additional and much more generally applicable reasons why professionals need to remember how vulnerable children in public care are and why service provision needs to actively promote measures to keep them safe. 8.3. Both adults individually expressed an interest in fostering children in 2012 and had relevant and recent experience of working with children and vulnerable young people. After some preliminary contacts, the fostering service commenced its formal approval process for both individuals in line with fostering regulations.4 The personal references obtained for both carers were very positive and commended each applicant in term of their skills, knowledge, and expertise. A comment of a referee in relation to FC1 highlighted his lack of a support network in undertaking such a demanding role but otherwise no concerns were raised by those providing references for either applicant. FC2 had worked in a semi-professional capacity in another authority for several years in another authority. An independent social worker who had chaired meetings attended by FC2 and who had worked alongside him remembers a 4 The Care Planning, Placement and Case Review and Fostering Services (Miscellaneous Amendments) Regulations 2013 amended the Fostering Services (England) Regulations 2011 SCR Trafford/ Fostering/December 2016 - amended March 2017 10 conversation when she was asked about FC2 as part of his recruitment process. She does not however recall being asked specifically to provide a verbal reference in terms of his suitability to foster and has not had sight of, nor signed any record, which relates to that conversation. 8.4. Requesting verbal references is in line with regulations, but these should always be written up and copied to the referee so there is agreement as to what information has been shared. There are considerable benefits in receiving all references in writing and especially so, when prospective carers are professionals already working with or for the benefit of children and young people. 8.5. Whilst it is unlikely that a written reference from social work colleague in the other authority would have highlighted the discrepancies which later came to light in terms of what FC2 was telling different colleagues about his lifestyle and relationships, there are significant benefits in always requiring written references as this offers greater scope for more considered and carefully thought through comments by referees. Recommendation 1: Where a prospective foster parent works directly with or on behalf of children and young people, formal references should always be requested from a senior professional in their agency in addition to any other references and these references should always be submitted in writing. 8.6. From the assessment records for both foster carers, it is clear that the information gathered as part of the assessment process was extremely positive for both applicants and indicated both adults were effective and thoughtful communicators, with many skills and much to offer children who might be placed in their care. The assessment reports for both applicants are however largely descriptive and rely heavily on self-reported information but without any meaningful critical analysis of their qualities, skills and resilience, which are needed by foster carers. Given that neither the fostering panel, nor any line managers challenged these assessments, the lead reviewer concluded that these were considered to be of an acceptable standard to the fostering service and would therefore suggest there is value in the service considering future assessments in the light of comments made in this report. 8.7. FC1 advised SSW1 during the assessment process that he had been estranged from his family for over 30 years, directly because of telling his family he was gay. The Review Team was told there was no attempt to seek out any family member as according to FC1, there had been no contact for such a long time and he did not know where they were living. Clearly, this was a difficult issue and one which required sensitive handling but if a prospective foster carer has no references from family members due to family conflicts, there should at least be some consideration as to how and if the ‘other’ side of the story can be explored. 8.8. Whilst it will not always be possible to seek references in these circumstances or indeed make contact with estranged family members, the Review Team considered that much more could have been done to explore this issue with FC1. Although he lived for many years with a close family friend and her husband, there is no evidence that FC1’s estrangement with his family was discussed with this person who may have been able to offer a view and perspective about what happened in the family. The Skills to Foster assessment format used by Trafford and other councils, is designed to highlight the applicant’s skills, abilities, qualities and previous experiences that are relevant to the fostering task. It also allows for the identification of areas SCR Trafford/ Fostering/December 2016 - amended March 2017 11 that require further training, acknowledging that at this stage, applicants will not be fully versed in all aspects of the role. Applicants need to demonstrate an understanding of how their own upbringing and personal past experiences influence their attitudes and their behaviour in respect of bringing up children. Exploring an applicant’s experiences of previous relationships, whether positive or negative, is a useful way of identifying their values and attitudes to family life and relationships. 8.9. Assessments are not just a method by which information is collected about someone's life it is in the telling of this story that social workers move beyond the content to explore the gaps and themes that emerge. As well as helping applicants 'tell their story', the assessing social worker is exploring how applicants have dealt with and experienced attachment, loss and transition; their experience and management of adversity; identifying factors of resilience and the quality of the important relationships in their life. There is a clear sense from records that FC1 did not want to explore the issue of his past and said clearly that he ‘did not need to go back there’. This was not however pursued as would be expected given the relevance of these experiences to the fostering role. The fact that FC1 had experienced ‘rejection’ from his family was seen as strength and evidence of a resilient nature, which was thought, would enhance his capacity to relate to children with similar experiences. This - and it would be the same for any prospective carer- was a flawed assumption, which was neither challenged nor tested. 8.10. Holistic assessment links strengths to negative life experiences and measures the resolution of hardship, disadvantage and pain rather than the event itself. Most importantly, the applicant and the worker must be able to reflect on how this experience may impact on caring for a child in care. Sometimes the factors that motivate and empower carers are the same ones, which present challenges or appear to undermine their suitability to care for others. It would have been helpful if the assessment had encouraged FC1 to talk more about his family to explore how his own experience of having a secure base in childhood made it more or less difficult to cope with the issues of loss and separation which came later in his life; whether and how these had been resolved and what potential difficulties FC1 could foresee occurring as a result of those experiences. 8.11. Records attest that these issues were not explored and so an opportunity was lost amid a view that FC1’s experience could only enhance his role as a foster carer. Later evidence emerged that despite all he said, FC1 found it difficult to deal with conflict and struggled to apply boundaries or assertively challenge unacceptable behaviours. It is possible that these traits stemmed from past experiences and may have usefully been explored had there been more in depth discussions about experiences of rejection and the impact of handling conflict and challenging situations. 8.12. There is a plethora of research and guidance which outlines how the subjects of gender, sex, and sexuality need to be firmly and permanently placed within the assessment process for all applicants to foster. The assessments for both prospective carers did not completely ignore issues around sexuality; they simply referred to it, but almost in passing. The assessments should have explored the experiences of each applicant; their own response when ‘discovering’ they were gay, how they felt about relating to birth parents of children in their care and how would they deal with schools, playgroups, childminders and other professionals. The assessment could also have addressed how homophobia and heterosexism had impinged SCR Trafford/ Fostering/December 2016 - amended March 2017 12 on their lives; how they dealt with this, what coping devices they used and what impact this could have on their roles as foster carers. This was a weak area in the assessment of both carers and particularly so for FC2, whose description of his sexuality raised a number of issues that suggested a sexual immaturity yet to be developed. This is a particularly pertinent point of an assessment for an adult being assessed to specifically care for adolescent children. 8.13. The debate about whether or not the assessment of LGBT5 prospective carers should be the same or different from that undertaken with heterosexual carers has been evident in the literature for some time. The consensus from the publications reviewed is that all assessments need to be enabling, rigorous, and analytic, covering all subjects considered with all foster carers; but in addition social work assessments of LGBT applicants should think through the areas pertinent to a person’s gender and sexuality relevant to them becoming foster carers. 8.14. Research6 shows that historically social work has negatively discriminated against gay foster carers and as a result social workers today can experience anxiety about appearing homophobic which can then lead to practice that is insufficiently discerning and discriminating. This is, however, just as worrying as someone who is overtly prejudiced and was clearly evidenced in the Wakefield Inquiry7 (2007) where growing concerns about the behaviours of a gay foster couple were not addressed by social workers, who were fearful of being accused of being homophobic. 8.15. The challenge of ensuring that assessments do not ignore nor over-focus on sexuality was explored in detail as part of this SCR. Whilst most practitioners, and also the Chair of the Fostering panel when she reflected, thought that so much more could have and should have been explored with both males as prospective carers, the views were expressed that any risks that the applicants posed or may have posed to children placed in their care, would have been unlikely to emerge at the early stage of the assessment process. The Review Team concurred with this view but felt that the learning from these discussions had implications for future assessments of LGBT adults as prospective foster carers. Recommendation 2: The fostering service in Trafford should: a) ensure that all assessments of foster carers are thorough, robust, and appropriately challenging with information being sought from a wide range of sources. b) ensure there is adequate guidance for assessing LGBT applicants8 - there would also be merit is using this guidance as an opportunity to train panel members. c) undertake a review of panel membership to ensure it represents and reflects the diverse community it serves. 5 Lesbian, Gay, Bisexual, Transgender 6 Sexual Identities and Sexuality in Social Work: Research and Reflections from Women in the Field Priscilla Dunk-West (2016) 7 Independent inquiry report into the circumstances of child sexual abuse by two foster carers in Wakefield Parrott Brian, McIver Annie, Thoburn June (2007) 8 British Association of Fostering and Adoption (BAAF) offer excellent resources in this area. SCR Trafford/ Fostering/December 2016 - amended March 2017 13 8.16. Both foster carers were approved by the Fostering Panel: FC2 in February 2013 and FC1 in May 2013. Each applicant had independently attended ‘skills to foster’ training, received excellent references and sound medical reports with no contra-indications to fostering. 9. The Fostering Panel and the Agency Decision Maker 9 9.1. The functions of the fostering panel in respect of cases referred to it by the fostering service are to consider each fostering application for suitability and to recommend whether or not a person is suitable to be a foster parent. The Panel plays an important quality assurance role in assessing the continued suitability of foster carers at the first annual review and for any further reviews which are complex or involve allegations, otherwise the Panel assesses the suitability of foster carers every 3 years. The Panel also considers exemptions to normal fostering limits, and any specific issues identified during the assessment and review process. 9.2. Trafford’s Fostering Panel has a central list membership of 9 members. It has an independent chair and two independent vice chairs both of whom have social work backgrounds. The role of Panel adviser is shared between two team managers from Children’s Services who advise on protocol, procedure, legislation and policy; they quality assure the reports prior to be tabled for the Panel meeting. There is not a legal representative on the Panel but there is access to legal advice as and when required. Panels also need to have access to a medical advisor who has a clinical role and is expected to offer advice and guidance on any matter relating to health and well-being of foster carers. In Trafford, this role has traditionally been perceived by the panel and managers within the authority to be held by the LAC Nurse, an issue addressed later in this report. The Agency Decision Maker is the person within a fostering service who makes decisions on the basis of recommendations made by the Fostering Panel. They hold a senior management position within the authority and take into account the Panel's recommendation before proceeding to make a decision. 9.3. FC2 was approved at Panel in February 2013. He gave a reassurance that he would fit his busy professional life around children and confirmed he had a large family from who he received support. He was noted to be very quiet at panel, almost shy, but he was thought to have many skills and experiences to offer children. He was unanimously recommended for approval by the Panel and subsequently by the Agency Decision Maker, as a specialist foster carer for one child of either gender 9 – 17 years. FC1 was also unanimously recommended for approval by the panel in May 2013 and, although there were some questions about the lack of a support network, FC1 gave assurances that he had in fact lots of support from colleagues and friends, although no further details were provided or requested. It was suggested that that FC1 should be linked with a ‘buddy’, but this does not appear to have been progressed. FC1 was approved by the Agency Decision Maker for one child aged 10-18 years. 9.4. The Review Team concluded that although some queries were raised and tentatively explored, the Fostering Panel could usefully have adopted a far more challenging and questioning approach to the assessments of both foster carers, specifically in relation to the level of 9 The Agency Decision Maker is the person within a fostering service and an adoption agency who makes decisions on the basis of recommendations made by the Fostering Panel (in relation to a fostering service) and the Adoption Panel (in relation to an adoption agency). The Agency Decision Maker will take account of the Panel's recommendation before proceeding to make a decision. The Agency Decision Maker can choose to make a different decision. SCR Trafford/ Fostering/December 2016 - amended March 2017 14 reliance on self-reported information, the particular issues related to diversity, and the fact that both applicants would be learning parenting skills for the first time as untested carers. Again, whilst there is no evidence that such challenges would have influenced the decision to recommend approval for the applicants as foster carers, there may well have been a more realistic understanding about their immediate support needs and therefore greater oversight of their developing role as foster carers. 9.5. Fostering Panels for FC1 and FC2 took place about 3 months apart, and it was noticeable that comments were made which suggested that Trafford were fortunate to be able to attract such skilled and knowledgeable individuals to the foster care role. The comment that both individuals ‘almost seemed too good to be true’ is in no way an indictment on the quality of foster carers either locally or nationally, but such views should perhaps always be tempered with a degree of respectful caution. 9.6. Recruiting and retaining sufficient foster carers remains an ongoing challenge for all fostering services across the UK10. The number of children coming into the care system is increasing and many fostering services struggle to find enough foster carers and especially those who are interested in caring for adolescents. Fostering services need to ensure that systems are in place to ensure that critical appraisals of prospective applicants suitability are not unduly influenced by the need to recruit more carers or by the perceived status or experience of the applicants however ‘good’ they appear. 9.7. The Chair of the Fostering Panel has worked for Trafford previously, as have many others who sit on the Panel. Care needs to be taken to ensure that that the work of the Fostering Panel is subject to a regular audit of its membership processes and decision-making to ensure that it retains its independency and ability to challenge the local authority. 10. PB’s placements with FC1 and then later with FC2 10.1. Research 11 highlights that matching a child with a foster carer is one of the ‘turning points’ in a child’s life. Successful matching depends on good assessments, clear support plans, careful decision-making, and a high level of information sharing between professionals. Although there is little research that links specific elements of matching practice to successful outcomes, there are studies that identify the factors involved in disruption and these include behavioural problems and mismatching of child to foster carer. There is also general agreement about the parenting characteristics that help to support children and young people in foster care: these include sensitivity, consistent boundary setting, tolerance, and resilience. 10.2. PB told the Lead Reviewer that when he was told he was being moved to the different placements with FC1 and FC2, all he knew was the name of the foster carer and that each carer was single and lived alone. He said he thought that if he really didn’t want to go somewhere he wouldn’t really make a difference ‘as they made all the plans and what I want doesn’t matter’. He did agree he had wanted to be moved from his first foster placement, because they were too strict and that he was moved. PB said he never however wanted to go to the educational placement as ‘it was too far’. With foster placements, PB said he often 10 Fostering Network report 2015 11 Schofield et al (2011) Randall, (2013).Quinton, (2012) SCR Trafford/ Fostering/December 2016 - amended March 2017 15 ‘didn’t know what it would be like until he got there’. PB said he couldn’t remember if he knew that FC1 and FC2 were gay and shrugged his shoulders when asked if it would have made a difference to him accepting the placement. He said that his Independent Reviewing Officer (IRO) would always ask him about his placements before his review but he never had any complaints except for his very first placement. When asked by the Lead Reviewer which placement he would return to if given the chance, he immediately said ‘FC2’… and then added ‘because he let me do whatever I wanted’ 10.3. PB was the first child placed with FC1 and appropriate details were shared by the SSW and PB’s social worker at the time about the PB’s needs and the challenges FC1 would be likely to face. Clearly, given his employment history and experience in a professional role with vulnerable young people, FC1 was thought to be well placed to offer care to PB and provide well defined boundaries, and be sensitive to his needs he had however no parenting experience or contact with young people outside his work setting and as the placement progressed it became evident that FC1 struggled to cope with PB’s behaviour and failed to report concerning behaviours to his social worker. Despite the breakdown of PB’s placement with FC1, PB was placed again with a single male foster carer with very limited experience of parenting and without as far as the Review Team could ascertain, the benefit of any end of placement review or learning from the placement with FC1. The Review Team was not confident that the matching for FC2 was well considered. 10.4. Questions were asked of the practitioners about how risk assessments and safe care issues around sexuality are promoted for all fostering placements. A specific question was asked about the issues involved in placing a single male adolescent in the care of a single male gay foster carer. Some practitioners found this question uncomfortable but it actually led to some helpful discussions around the difficulties in talking about sex and sexuality in fostering situations. The discomfort for some stemmed from an assumption that implicit in such a question was a suggestion that male children may not be safe if placed with single gay males. The discussion was helped by changing the question and asking what risk factors would naturally be explored if a teenage girl was placed with a single male carer. What emerged from the discussions were three issues which may well be worthy of further exploration amongst practitioners and managers in Trafford: • The fear of being accused of homophobia can seriously impinge on professionals’ confidence to explore issues around sexual behaviour and attitudes when placing children with LGBT foster carers. (FC2 had been known to accuse others of this) • There is a lack of confidence for some professionals in approaching issues of sex and sexuality frankly with all foster carers, regardless of their sexuality • Safe Care policies do not encourage discussion around these topics in sufficient depth but the policy and references to it, can give the impression that these sensitive issues have been explored and addressed. SCR Trafford/ Fostering/December 2016 - amended March 2017 16 10.5. Different studies12 have highlighted the importance of children and young people being prepared before being placed with LGBT foster carers. Experience of foster carers suggested that individual children and young people responded differently to being placed within a LGBT household, but even though many children had no discriminatory preconceptions, preparation was still considered extremely important. There was no evidence in the records provided to the Review Team that this issue had been discussed with PB before the commencement of either placement and the views expressed in the practitioners group suggested that perhaps social workers did not always recognise the value and relevance of such conversations. Recommendation 3: Social workers should be reminded that they are responsible for talking with children about proposed placements and in general the lives and lifestyles of the carers with whom they will be living. The responses of the children should be noted and monitored, the Review Team could find no evidence that this is routinely done in Trafford and there would be benefits in further discussions around this issue. 10.6. PB experienced at least 14 placements between 2013 and 2015, an exceptionally high number of moves and transitions. PB’s first placement when he came into the care system was a planned short-term placement, but his later placement with FC1 was expected to continue whilst possibilities for re-integration into his family were explored. Records refer to several occasions when FC1 told PB that he wanted the placement to be a permanent one. After 8 months, PB was told by his social worker that he could no longer live with FC1 due to his poor health, yet PB became aware that FC1 continued to foster other children. It is not difficult to imagine how he must felt upon learning that other young people were being placed in the care of FC1 whilst he had been required to move on. According to his LAC reviews, PB was very clear in discussions with his IRO that he wanted to continue to live with FC1, but was advised that this was not possible. 10.7. Despite Trafford’s LAC procedures and national guidelines, there was no ‘end of placement’ review when PB’s placement with FC1 ended in February 2014. If this happened the Review Team could find no evidence that such a meeting had taken place and although FC1 said he thought he could remember a meeting, he could not recall who attended. End of placement or disruption meetings as they are sometimes called offer important opportunities to examine the extent and nature of a child’s challenging behaviour and this can help with decisions about future matching. Placements can break down for a variety of reason; the term ‘disruption is used to describe an event otherwise referred to as a ‘placement breakdown’ or a placement ending that was not part of the Child’s Care Plan, either in the ending itself or in the timing of the termination. The objective of ‘disruption’ or ‘end of placement’ meetings is to look at the sequence of events and to learn from the experiences in order that a child’s future needs can be met and the carers can be appropriately supported to recover and learn from the experience. The Review Team could find no evidence that these meetings had occurred when 12 (1) The recruitment, assessment, support, and supervision of lesbian, gay, bisexual and transgender foster carers Helen Cosis Brown, Judy Sebba and Nikki Luke (2015) Hill, N. (2013). (2)Proud parents: Gay men and lesbians share their experiences of adopting and long-term fostering, London: BAAF. SCR Trafford/ Fostering/December 2016 - amended March 2017 17 PB’s placements with FC1 and FC2 ended despite them being a crucial part of a child’s journey through the care system and are key to future stability and permanence. 10.8. Records state it was not only FC1’s health which contributed to the move it was also the difficulties the foster carer was experiencing with PB’s challenging behaviour. The following month PB was however, placed with FC2, again a single carer and growing concerns about his ability to manage PB’s behaviour began to surface which contributed to the decision, in November 2014 to end the placement. In conversation, PB asked the Lead Reviewer why he had been moved so many times. This appeared to be a genuine question borne more out of curiosity than resentment; PB said he did not know why certain placements had ended or why he had not been allowed to ‘properly’ live with FC2. 10.9. Ten LAC reviews13 took place in respect of PB between March 2013 and December 2015, each was chaired by the same Independent Reviewing Officer (IRO) who met with PB on 12 different occasions, usually just before or soon after the LAC review. Records refer to the attempts made by the IRO to ensure that PB was listened to and his voice heard. 10.10. It emerged that the IRO had raised a number of concerns in relation to PB, which he considered were not being addressed and a decision was therefore taken by himself and the IRO manager to instigate the Dispute Resolution process. In line with agreed procedures, a meeting was arranged with key parties but the Team Manager failed to attend the meeting and the IRO manager escalated the issue to the (Acting) Director of Children’s Services. The response of the Acting Director was to advise that some of these issues were being addressed and another meeting was not the best use of time. This was not in accordance with procedures. Whilst it appears the IRO contacted the Director (Acting) of Children’s services directly rather than routing his concerns through the Head of the Fostering Service, the Review Team was concerned to note that the agreed process was not followed and this raises important concerns not only about the Dispute Resolution process itself but also raises questions about how well the local authority and senior managers supports and values the roles of IROs. 10.11. If the system for escalating concerns is not followed then this significantly impacts upon the ability of the IROs to quality assure practice and act as driving force in identifying systemic weaknesses in the authority. The Review Team was of the view that if senior leaders within Children Services do not utilise the expertise and knowledge of IROs and do not respond to their concerns about practice and decision-making, then this leaves looked after children even more vulnerable. The Review Team was concerned to note that had due process being followed in response to the IRO’s concerns, the issues relating to FC2 and possibly FC1 may have been addressed much earlier. Recommendation 4: As a corporate parent, the local authority should ensure that the IRO role and function is better understood by key professionals and managers and explore ways to ensure and support more effective challenge about care planning and decision-making. 10.12. The notes from the LAC meetings do not directly comment upon the quality of care offered or seen to be offered by FC1 or FC2 and although there are references questioning whether FC2 13 A looked-after child (LAC) review is a regular meeting that brings together those people who are closely concerned with the care of the child who is being looked after. SCR Trafford/ Fostering/December 2016 - amended March 2017 18 was able to apply appropriate boundaries, this was not explored in any depth in the review meetings. 10.13. Throughout the period under review, the IRO received only one request from the Fostering Service to contribute to the Annual Review of one of the carers with whom PB was placed (FC2). This is not good practice as IRO’s are well placed to offer invaluable and independent insights into care aspects of a child’s plan. This is an issue which the IRO service should address. The IRO for PB was clear that he was not given any information or had identified any concerns, which may have indicated that either foster carer posed or was posing a risk to PB. Recommendation 5: Trafford’s Independent Reviewing Unit should ensure regular scrutiny of annual reviews of foster carers and ensure these are robust, thorough, and challenging. 11. Supervision of the Foster Carers 11.1. The Review Team accessed information about the foster carers and their working relationships with their supervising social workers between 2013 and 2015 when both carers were deregistered. 11.2. Records relating to PB’s placement with FC1 show that during the 8 months that PB lived with FC1, some concerns emerged about the lack of supervision of PB and failure to appropriately apply boundaries and manage PB’s behaviour. Specifically, concerns emerged about PB having access to Facebook and posting images and messages whilst living with FC1. FC1 suggested that PB’s Facebook had been hacked but confirmed there had been times when PB was not supervised and may have had access to the Internet and social media. 11.3. FC1 reported health difficulties in November 2013 and informed his SSW that he had been diagnosed with a specific medical condition and was undertaking further medical tests. FC1 attributed his deteriorating health to possibly being due to stress caused in trying to manage PB’s behaviour. PB’s placement with FC1 ended in January 2014, several days after PB found him collapsed on the floor. FC1 gave notice that he was unable to continue with the placement due to ill-health. He was not however asked by his SSW to undergo a medical examination to confirm his fitness to foster and a short time later, he advised he was feeling much better and agreed to a respite placement for another young person. Further placements followed and then a young person was placed in his care in May 2014 where he remained until FC1’s suspension in December 2015. During this time, fostering records indicate several occasions where FC1 was challenged about not reporting significant events, not following procedures and disagreeing with safe practice requests from SSW. These were each dealt with as individual incidents and did not lead, as they should have done, to a review of FC1’s role as a carer. 11.4. During the time PB was placed with FC2, fostering records also indicate concerns about FC2’s ability to manage PB’s behaviour and his disregard to follow agreed sleeping arrangements for children placed in his care. An allegation that he had provided alcohol to two YP who had been placed in his care led to a brief suspension prior to PB’s placement. This matter was addressed through appropriate procedures involving the LADO but it was not proven and FC2’s suspension was lifted. When PB’s placement with FC2 ended in November 2014. PB continued to abscond from his residential placement and turn up at FC2’s home, Despite being informed SCR Trafford/ Fostering/December 2016 - amended March 2017 19 that he was to report every occasion when PB arrived at his house, residential workers and the social worker began to worry that FC2 was colluding with PB and allowing him to stay overnight at his house. These concerns were verified when police found PB hiding in a bedroom in FC2’s who had told police he had not seen PB. 11.5. As mentioned earlier in this report, many things become clear with hindsight, but the Review Team nevertheless wanted to understand why patterns and concerns highlighted in this review were not identified or actioned at the time. It is acknowledged that foster carers will not always do the ‘right’ thing; they will make errors of judgment and find themselves responding to situations in ways, which they later come to regret, but the key question for social workers is whether lessons are learnt so mistakes are not repeated. There is evidence in records, which suggests that both foster carers misled workers whilst appearing to work in partnership and stressing how much they were doing for the young people in their care - arguably, a form of disguised compliance, which can be used to keep professionals at a distance. It seemed to the Review Team that at times there was less emphasis on the needs of PB and a greater emphasis on meeting the needs of the carers. 11.6. The various incidents, recorded in Section 5 14, which prompted intervention, by social workers/supervising social workers, were clearly dealt with on an incident-by-incident basis and consequently a holistic picture for either foster carer did not emerge. The recording systems on Liquid Logic were not used effectively to produce tight and succinct chronologies from which clear patterns of behaviour and related incidents could be seen, and purposefully addressed. Yet from the simple and relatively brief chronology of significant dates outlined in Section 5, patterns of behaviour can clearly be discerned. 11.7. Both foster carers at different times, failed to report significant incidents, changes in sleeping arrangements and threatening behaviours towards themselves and each appeared to have agreed a ‘pact’ on occasions with PB, ‘not to say anything’ [to the SSW/SW]. These are behaviours which do not support healthy relationships and which cannot be condoned under any circumstances. Without easily accessible and succinct chronologies in foster care files, social workers did not recognise emerging patterns of concerning behaviour. When concerns are dealt with on an incident-by-incident basis, children in placements can be highly vulnerable. 11.8. The Review Team were not confident that the 'daily records' pertaining to PB whilst on placement with FC1 and FC2 were regularly scrutinised in ways which may have alerted professionals to the need for further conversations with the foster carers about their care of PB. Significant efforts were needed to track down these records, which were eventually located. They were not however held or copied onto PB’s file despite the fact they contained significant information about PB during his placements. The Review Team were told that social workers would be expected to transfer significant details to children’s case records but these were more often identified though conversations and feedback about issues rather than as a result of social workers reading foster carer’s daily recordings. Neither do these records appear to be routinely scrutinized by foster carers, although the Review Team was told they were sometimes used in supervision processes. The Review Team acknowledged that such records would not be read on a daily or even a weekly basis but were assured there was a process 14 There were other reported incidents/concerns, which relate to young people not subject to this SCR. SCR Trafford/ Fostering/December 2016 - amended March 2017 20 whereby significant information was passed to and discussed with the child’s social worker. There were however, a number of comments in FC1’s daily recordings, which, with hindsight, would have been worthy of further discussion. FC1 said however that his notes were rarely seen or asked for. The Review Team was of the view that the purpose of keeping these ‘daily records’ and the processes for reviewing and sharing their contents could usefully be reviewed in Trafford. Recommendation 6: Trafford Fostering service should ensure that all supervision files for foster carers contain easily accessible, purposefully prepared, and carefully maintained chronologies to support supervision and reviews of foster carers. There should be evidence of, and reference to foster carer’s daily records so any emerging concerns or issues can be addressed. 11.9. Without a doubt, the issue of FC1’s health needs should have been properly addressed. Much of the information shared with the SSW was self-reported by FC1; his refusal to seek medical treatment when he had had fainted and been found by PB was accepted too readily and led to no further action by SSW. The frequency with which FC1 was reporting health concerns should have led to a health review being commissioned by his GP to ensure he was fit to foster. In effect, when such a health report was requested in September 2016 it transpired that according to his GP records, FC1 had not had any significant health issues since he began fostering in 2013. 11.10. Whilst FC2 was a foster carer with Trafford, he was well supported by his Supervising Social Worker and there is evidence of this on the electronic recoding system (Liquid Logic). There is also evidence that both foster carers made full use of the support offered to them as foster carers. Reports, emails, and case notes seen by the Review Team evidence that both foster carers were polite and accommodating to the needs of the department, and highly appreciative and complimentary of the support they were receiving. Neither foster carer regularly attended the foster care support group despite being encouraged to do so. 11.11. At different times both foster carers were keen to demonstrate their understanding of the needs of children placed in their care, but also on occasions disregarded directions or procedures and when challenged, argued that their decisions had been made solely in the interests of the young person. FC1 could not, for example, accept the need for different changing rooms for himself and an adolescent boy when they went swimming; FC2 made decisions, despite being told otherwise, that it was ‘safer’ for PB to sleep in his house than for him to ‘run’ if FC2 reported him missing. Whilst it is entirely appropriate for foster carers to query why certain decisions make sense, the continued and ongoing disregard for plans and procedures by both foster carers should have raised concerns. It is of course, with the benefit of hindsight that the behaviours of both foster carers, examined in a different light, are now viewed as manipulative and dishonest; the question is why were they not seen as such at the time? 11.12. Munro (2010)15 argues that professionals should always take time to step back and question the assumptions, which underpin their actions and decision-making, a form of reflection she 15 Munro, Eileen (2010) Learning to reduce risk in child protection. British Journal of Social Work SCR Trafford/ Fostering/December 2016 - amended March 2017 21 describes as ‘double loop’ learning. The Review Team questioned some of the assumptions made by professionals in relation to both FC1 and FC2 in that until PB began to go missing and later made allegations in respect of both carers, there were no significant concerns identified although there was a recognition that both foster carers struggled to manage difficult behaviours and did not always follow agreed procedures. The recognition that fosters carers may not be all they appear to be, or that a child may be at risk in a foster placement is entirely dependent on the professionals’ inherent willingness to entertain the possibility that such things do happen. 11.13. Munro’s research suggests that professionals need to take active steps to work against ‘our human tendency to seek only the information that we wish to find’, and confirms the dangers of a tendency to ‘stick to what we think we know’ and carry on with plans without question or challenge. Fish (2009)16 writes ‘one of the most common, problematic tendencies in human cognition ... is our failure to review judgments and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.’ 11.14. There is a sense that when the foster care assessments were undertaken, professionals were delighted to have attracted such skilled, insightful and reflective applicants to the fostering service in Trafford and they remained intensely supportive to both carers despite some behaviours which should have led to a reappraisal of their roles as foster carers. It is not the intention to replicate comments already made earlier in this report in relation to the assessments but the Review Team wanted to stress the importance of professionals keeping an open mind and a degree of healthy scepticism in any work involving the need to make judgment calls. Confirmation bias can, without access to quality and reflective supervision, too easily occur when professionals rely more on evidence that is consistent with existing views or preconceptions and place less emphasis on evidence, which contradicts this view. 11.15. PB made direct disclosures about both foster carers, which have not led to prosecutions. However, the Review Panel recognised that this does not mean that PB’s account of what happened to him is not true. The panel certainly found evidence to support the view that the actions and behaviours of both individual carers should have led professionals to consider at a much earlier stage whether FC1 and FC2 could keep children in their care safe and whether they themselves posed a risk to children placed with them. 11.16. Erooga17 reports on research into a range of what are termed ‘manipulation styles’. He describes the ways in which perpetrators who were working in a professional role with children seek to create a positive impression among some co- workers, in order to draw them closer, or to undermine the credibility of those who might have suspicions or might be able to act in a protective role. These behaviours included: • Being overtly altruistic and thoughtful about the needs of children • Stressing their own ‘integrity’ and expertise 16 Fish, S., Munro, E. and Bairstow, S. (2008) Learning together to safeguard children: developing a multi-agency systems approach for case reviews, London: Social Care Institute for Excellence. 17 Towards safer organisations: Using the perspectives of convicted sex offenders to inform organisational safeguarding of children Marcus Erooga (2012) SCR Trafford/ Fostering/December 2016 - amended March 2017 22 • A pretence of being ‘put upon’ suffering either in their own past or in their present role by taking on extra work or duties • Presenting themselves as ‘broad minded’ or liberal in attitude • Obstructing or blocking approaches and withdrawing from contact with colleague’s altogether (for example by avoiding training and supervision). 11.17. Behaviour fitting these categories has been described at various points in the preceding paragraphs. New evidence that challenges an established viewpoint is known to have far less impact than it should because people are unwilling to let go of established beliefs. Munro argues that the single most pervasive bias in human ‘avoidance is ‘forgetting the evidence’, ‘rejecting the evidence’ and ‘reinterpreting’ as reasons why it happens. It is perhaps not insignificant that professionals who knew both FC1 and FC2, acknowledged the difficulty they were experiencing in accepting the possibility that the actions of both foster carers were intended to deliberately cultivate a favourable impression in order to deflect or dampen any criticism about their behaviours. Professionals acknowledged feelings of discomfort when they accepted the possibility that they, as adults, could also be ‘groomed’ by perpetrators intent on throwing them ‘off guard’. 11.18. Without ongoing learning and development opportunities, professionals may overlook or be unaware of how perpetrators can condition professional networks so they can more easily operate without impunity in a professional context. This leaves children vulnerable. Recommendation 7: Trafford Safeguarding Children Board should ensure that all practitioners and especially those within the fostering service have a sound understanding of the range of characteristics, motivations and behaviours of people who seek to sexually abuse children and have opportunities to discuss these challenges within multi-agency settings. 12. Annual Foster Carer Reviews ‘Foster carer reviews are the central building blocks to monitoring and improving the quality of foster care and in doing so the quality of experience for foster children’ 18 12.1. The relationship between the foster carers’ original assessment and subsequent reviews is of fundamental importance as the first foster carer review offers an opportunity for a formal re-consideration and is the time when the assessment of a carer’s potential is ‘tested out’ against the reality of practice. Foster carer reviews are subject to statutory regulation under the Fostering Service Regulations 2011, Regulation 28. This Regulation states ‘Reviews must take place not more than a year after approval, and thereafter whenever the Fostering Service consider it necessary, but at intervals of not more than a year”. 12.2. Annual review meetings are expected to be given high priority and planned well in advance and should only be cancelled, delayed or re-organised in exceptional circumstances. The first Annual Reviews for both foster carers were however out of timescale; FC1’s first review was 4 months overdue and FC2’swas 3 months overdue; later reviews were also not on time and were deferred as a result of incomplete or missing papers. The Review Team was informed that at the time there were capacity issues. The Chair of the Fostering Panel who has retained this post for several years agreed that practice at that time tended to rely on fitting reviews 18 British Association of Adoption and Fostering SCR Trafford/ Fostering/December 2016 - amended March 2017 23 into existing timetables which caused inevitable delays, but that practice has now changed and additional panel meetings are arranged as and when needed, in order to meet demand. The issue of incomplete or missing paperwork was raised with the Chair, who advised that when this happened, which was not often, the issue was taken forward by the Panel Adviser. However she agreed there would be benefit in the Chair escalating concerns on a more formal and independent basis, if an issue led to a Panel meeting needing to be deferred or being unable to make a decision. 12.3. The Review Team had access to reports and panel minutes for the reviews for both FC1 and FC2. The very positive perceptions of the carers formed during both fostering assessments clearly influenced social workers and members of the fostering team to conclude that both individuals would bring much to the fostering role and had the potential to enhance the lives of children placed in their care. 12.4. The first review provided an opportunity for reflection on the issues raised at the point of approval. For FC1 there were clear references to the fact that without a support network, the demands on him would be considerable. FC1 gave an assurance that he had support, but the language he used at approval and at review was revealing; he spoke of receiving support not from ‘friends’ but from ‘colleagues’; he did not attend fostering support groups, despite the suggestion that he do so and he was not in contact with any member of his family, insisting he was unaware of where they lived or what happened to them. This would seem to describe a person who did not have access to any support networks. Whilst not suggesting that such individuals do not have the potential to make good foster carers, this issue should have been explored in detail during the assessment process, challenged by the fostering panel when it was not and then most certainly picked up at his review which took place almost 16 months later. To expand on the training, FC1 undertook 4 online courses. He also attended 4 half day training courses and a 20 week program alongside other foster carers. 12.5. The Panel did not challenge or question the reoccurring issue of FC1’s health concerns, which seem to fluctuate amid various hospital and GP appointments, medical tests and scans. Such were his health needs that PB’s placement came to a relatively abrupt end after FC1’s alleged fainting episode and after 8 months, PB was moved to a different placement. This did not lead the fostering service to seek a medical report to ensure that FC1 was fit to foster and nor were they challenged by the fostering panel (or indeed by the IRO) when this had not happened. Reading the minutes from the foster panel meetings, there is almost a sense of admiration that FC1 was so ‘selfless’ that he placed the needs of the department above concerns for his own health. At no time, however, did the panel seek assurance about FS1’s health and his fitness to continue in his role as a foster carer. This was an omission on their part. Once PB had left his care, FC1 seemed to make a swift recovery which led to the department placing another young person in his care only weeks later and without any medical assurance that he was now well enough to continue in a fostering role. SCR Trafford/ Fostering/December 2016 - amended March 2017 24 12.6. Both foster carers referred to stress, fatigue, and general ill –health at various times to explain why they acted as they did or why they did not act at all. The Fostering Panel were well placed to ask for medical reports from their respective GPs, but there is no record of them doing so. Medical advice, when required is provided to the Panel by the LAC nurse, and this is not appropriate. The Review Team would recommend that the Fostering Panel ensures it is supported by a Medical Adviser with a much wider knowledge base than that which can confidently be provided by a nursing practitioner with responsibility for meeting the health needs of looked after children. The Medical Advisor is a clinical role that should provide brief written reports to the panel on the health of prospective carers. This should include interpretation of health and lifestyle information provided by the applicant and their GP. From time to time, it may be necessary to liaise with specialists about health issues identified; these actions would have been particularly relevant in relation to FC1’s health concerns. Recommendation 8: When a placement ends unexpectedly due to health concerns of a foster carer, or there are ongoing health issues of a foster carer or noted by the supervising social worker, a medical report should always be sought from the foster carer’s GP. Recommendation 9: The local authority should, together with Fostering Service and Fostering Panel a) ensure that an experienced Medical Advisor is identified to support the work of the Panel in addressing and confirming the health needs of prospective and current foster carers. b) Cease, with immediate effect, to refer to the LAC Health nurse as the Medical Advisor 12.7. Foster panels are required to place the needs of children at the centre of their work and there was evidence in this review that in relation to PB this did not happen. There is for example no feedback report from PB in FC1’s annual review, which captures his perceptions as to why the placement ended and the manner in which it happened. There is no reference in any of the minutes from review meetings to the voice of the child and this is a significant omission. The Review Team could find no evidence of any disruption or end of placement meetings. 12.8. In a review such as this the ‘why’ questions are crucial to understanding why certain decisions would have made sense at the time. It appeared to the Review Team from talking with individuals who knew the carers and from reading reports and minutes of meetings that the need for professional curiosity and healthy challenge from panel members was overshadowed by the professional persona of both individuals, their clearly articulated confidence and their employment history. The very positive perceptions identified at the assessment stage appear to have been strengthened because of the success of the initial placements and it is possible that this led to a degree of complacency, which was promoted through the very positive reports from social workers and supervising social workers. SCR Trafford/ Fostering/December 2016 - amended March 2017 25 13. Communication and collaboration between agencies. 13.1. Prior to entering the care system, PB and his family were offered support through Child In Need arrangements, but SFPB described the support offered as ‘pointless’ and that it ‘didn’t change anything’. MPB said PB’s behaviour ‘only seemed to get worse’ and consequently PB became a looked after child in February 2013 after his mother and stepfather said they could no longer manage his behaviour. There is no indication that any multi –agency work with the family occurred once PB entered the care system, despite there being frequent references in his Care Plans indicating the goal of him returning to live with his family at some future point. Whilst the focus of this review was not PB’s journey through the care system, there are nevertheless issues, which are worthy of comment. 13.2. Parents experiencing difficulties in managing the behavior of their children frequently seek a solution from Children’s Services. This can include a request that the child be accommodated elsewhere for a period of respite, or sometimes for a more permanent solution. For the majority of children who become looked after, return home will be the preferred pathway to permanence. The Review Team were told that this was what PB wanted but he was realistic enough to understand that without the agreement of his stepfather, it was unlikely to happen. In order for PB’s return to his family to happen, it would have been necessary to develop child- and family-centred approaches to his placements so that the issues that led to his coming in to the care system could be addressed. The Review Team could find no evidence of this work being undertaken or considered necessary and yet it appeared that neither was there any plans made to establish permanency for PB. 13.3. In one care plan, it was stated that that at the age of 13, PB needed a stable and nurturing environment and the likely duration of any placement would be until he was 18. The risks associated with entering the care system at a time of significant emotional and psychological development, together with his experience of loss and rejection does not appear to have led to any specific or focused therapeutic intervention. 13.4. The Review Team had access to numerous LAC review minutes and various Care Plans, which the Lead Reviewer found confusing, unhelpful, and certainly not child-friendly. These were largely task focused with very little consideration about what PB might be feeling and what life was like for him moving from placement to placement. There was little to evidence, until the work with the Barnardo’s worker began that any professional had managed to establish a working relationship with him. There is a wealth of research, which indicates that the best chance of adolescents responding to relationship-based practice is when it is consistent, holistic, and available over a long period on their own terms if possible. The Review Team considered that when young people enter the care system, they could often thought to be in a safe and secure place and therefore become less of a priority for their social workers. Yet, the risks that LAC adolescents face are particularly complex and wide-ranging and there is no reason to believe they are any less harmful, on the whole, than those experienced by young children not in the care system. 13.5. Despite PB’s numerous placements there was very little analysis in LAC meetings about PB’s placement breakdowns and whilst the precipitating incident was often clear, there was little evidence of PB’s view as to what had happened, despite the contacts made by the IRO. SCR Trafford/ Fostering/December 2016 - amended March 2017 26 Questions must be asked as to whether the existing systems for LAC reviews actually work or whether they may alienate young people and may inadvertently lead to them feeling stigmatised and alienated by the process. 13.6. PB was reported missing to police on 36 occasions between December 2012 and March 2015 and was arrested numerous times for assault, criminal damage, and possession of cannabis. There is evidence of some joined up practice in the response to PB going missing from care; the police, social workers and education staff collaborated on developing and implementing a Missing from Care (MfC) strategy and multi-agency meetings were held on 10.12.14 and 11.2015. 13.7. There was however clearly scope for better communication between the key agencies. When PB turned up at the home of FC2, after being reported missing, police officers were initially unclear as to whether, given this was a registered foster carer, he could be allowed to stay there. On two occasions, 2nd and 4th December, police advised residential staff that they considered PB safe in the care of FC2 as he was a foster carer with the authority and therefore would not collect him reasoning there was a greater risk of him absconding if they returned him to his residential placement. The MfC action plan created later in December 2014 still listed FC2 as a friend who could be contacted, but also stated that PB was not allowed stay at his address. It does not however, offer any rationale for this and police records suggest that although CSC had some concerns about FC2 they could not ‘articulate these to officers’. This was not helpful and better communication by CSC about their growing concerns may well have alerted police much earlier to the risks FC2 posed to PB. 13.8. On 13.2.15, PB was subject to a CSE risk assessment, which indicated medium risk. There was however no reference to FC2, despite the fact that he would persistently turn up at the foster carer’s home and there were by then significant concerns that FC2 was colluding with PB and allowing him to stay overnight. 13.9. PB’s health needs were regularly assessed by the LAC nurse who met PB on several occasions and discussed with him smoking, his occasional use of cannabis, his girlfriend and sexual health all part of a regular health assessment. On her first meeting with PB at the home of FC2, the LAC Nurse recalled she was surprised to be left alone with PB for his health assessment when FC2 left to attend a meeting. She thought this highly unusual but did not think to share this as she noted that PB seemed very settled with FC2. The health records indicate no concerns were raised. 13.10. The first allegation against FC2 was made to a specialist foster programme team manager by a parent who alleged that FC2 had supplied alcohol to her child and another child whilst on placement. The allegation was inappropriately dealt with as a complaint and as there appeared to be no evidence to support the allegation, no further action was taken. When evidence later emerged through ‘Facebook’ the allegation was only then referred to the Local Authority Designated Officer (LADO) in the other local authority and FC2 was suspended from his fostering role in Trafford. Following further enquiries, FC2’s role in providing or allowing the alcohol to be consumed could not be substantiated so this to led to no further action on the part of the fostering service and FC2 suspension was lifted. The Review Team could find no trace of any case recordings in Trafford and despite the outcome, it would have been appropriate to monitor the extent to which FC2 was supervising young people in his care, the SCR Trafford/ Fostering/December 2016 - amended March 2017 27 Review Team was informed that as the allegation was ‘unfounded’, no further action was deemed necessary. 13.11. The allegation made against FC2 in July 2015 against FC1 in December 2015 was each referred to the LADO and appropriate strategy meetings took place at which both authorities were represented. 13.12. Questions were asked during the review process why PB was not able or willing to talk about the experiences he later described to his key workers. Research suggests that for many young people a consistent long –term relationship with a professional is the most important factor in talking about worrying or abusive experiences19, whilst an occasional one off conversation is unlikely to elicit an accurate picture of what might be happening. This possibly explains why PB was so willingly to talk with the Barnardo’s worker and his key worker both of whom he appeared to know and trust. Building relationships of trust is at the core of all successful interventions and this is perhaps more pertinent for adolescents for whom volatile developmental changes are coupled with their movement out of the family and into wider social networks. 14. Managerial Oversight 14.1. High quality, reflective supervision is central to providing good support for professionals working to improve outcomes for children and young people. There is a wealth of research and literature to assist managers to develop high quality supervision across agencies20.The best supervision offers both managerial oversight and constructive challenge to practitioners, using evidence based research to help the practitioner decide what sort of support is required for individual children and their families. 14.2. The supervision notes seen by the Review Team suggest that more could be offered to social workers in the fostering service by way of opportunities for reflective practice. Effective professional supervision plays a critical role in ensuring a clear focus on a child’s welfare. Supervision should support professionals to reflect critically on their views, assumptions, and judgements and the review team considered that improved practice in the delivery and the recording of supervisory practice would be of benefit. 14.3. Several of the practitioners recalled feeling uneasy and a little uncomfortable when meeting FC2, for example, ‘he used my name at every opportunity…it just felt odd’. Another practitioner said ‘I just didn’t warm to him…there was just something’. These comments however were shared with the benefit of hindsight, the dangers of which have already been mentioned in this report. None of the practitioners, although claiming to have experienced some of these feelings at the time, raised concerns with colleagues or their managers. One practitioner told the reviewers. “What would I have said? There was nothing to actually say? Another practitioner upon being told of PB’s allegations was recorded as saying ‘Yes, I knew it!’ 19 Rees G, Gorin S, (2010) Safeguarding Young People ; aged 11.- 17 years The Children’s Society 20 Staff Supervision in Social care,” Tony Morrison, 3rd edition and “The Impact of Supervision on Child protection practice –a study of Process and Outcome” 2003.Jane Wonnacot; Effective supervision in social work and social care, Professor John Carpenter and Caroline Webb SCIE Briefing 2012 SCR Trafford/ Fostering/December 2016 - amended March 2017 28 14.4. Personal perception of issues, “warning signs” and gut feelings about applicants are sometimes a starting point for looking deeper into specific areas, but there was little to evidence in any records that practitioners working alongside FC1 and FC2 considered or suspected at any point that they were not acting in the best interests of PB or other children in their care. Even accepting the above comments were how practitioners actually felt at the time rather than using hindsight to express what they think they should have felt, the questions in the practitioners group were centred around the difficulty in sharing ‘gut feelings’ when so much practice needs to be evidence based. 14.5. It is here that quality supervision plays its part and supports good practice by encouraging a process of examining, the thoughts, feelings, actions, and reactions evoked in the course of working closely with foster carers, young people, families and even colleagues. Respectful uncertainty, intuitive reasoning, and critical reflection are practice skills that practitioners need to use and apply in all aspects of their work but these will be of little benefit if opportunities to discuss and test them are not available. 15. The views of PB and his family The perspective of PB 15.1. PB agreed to speak with the Lead Reviewer in the presence of his therapeutic worker from Barnardo’s (B1). It was agreed beforehand that the purpose of the conversation was to listen to PB’s views about his placements but that the detail pertaining to his allegations would not be part of any discussion. 15.2. PB clearly had a warm and respectful relationship with B1 and made several references throughout the conversation to the work they were undertaking together. PB offered a clear and coherent account of his various placements and the pros and cons of each place he had lived. He could not recall being given specific information about FC1 or FC2 other than they ‘lived on their own’ and couldn’t recall whether he knew they were gay or not. He shrugged when asked if it would have made a difference to him staying there. PB expressed mixed feelings about living in secure accommodation and said ideally he would like to go back to the North to be near his family. He said he had not liked the specialist foster programme as there were ‘too many rules’ and he wasn’t allowed a phone or use of the Internet. PB said that he had been upset and angry when the placements ended with FC1 and FC2 as it was ‘easy’ and he liked living with those carers. Reflecting on this, PB acknowledged that this was because there weren’t any rules and he could do, as he wanted. He said other foster carers were too strict. Although he had met his Independent Reviewing Officer (IRO) a few times, he said he hadn’t told him much about [those] foster placements. He said he hadn’t wanted to move so far away from where his family were living. 15.3. PB asked the Lead Reviewer why he had been moved so many times. He said he thought it was probably to do with his behaviour but then sometimes he had to move because his foster carers had gone on holiday and that didn’t seem fair. With the help of his therapeutic worker, PB shared his struggle with managing his emotions and said he knew that ‘flying off the handle’ usually got him into trouble. He talked a little about his family background. The conversation ended after almost an hour, by this time although PB had been willing to talk, he was clearly beginning to tire of the conversation. He asked why FC1 and FC2 had not been charged after SCR Trafford/ Fostering/December 2016 - amended March 2017 29 what he had told social workers and we spoke for a brief time about the justice system. B1 suggested that he could pick up some of the issues with her and if he wanted she would pass on any additional comments to the reviewer. Perspectives of Mother (MPB) and Stepfather (SFPB) 15.4. The Lead Reviewer met with the mother and stepfather of PB so their views could be incorporated into this report. They were open about the difficulties they had in managing PB’s behaviour over a number of years and explained they had requested that he be accommodated by the local authority when he had physically assaulted his younger step-brother. 15.5. The couple said they did not receive any effective help during the years when they were trying to cope with PB’s behaviour; they acknowledged they had been offered parenting sessions but considered that this was a waste of time as it was PB’s behaviour that needed to change. They were kept informed about PB and his fostering placements but considered that the authority took no notice of their views when they explicitly said that PB should remain with his [first] foster carers as they provided the boundaries that their son needed. They said they had complained several times about PB being on Facebook although he was on a SPECIALIST FOSTER PROGRAMME and should only have limited and supervised access to the Internet. They said FC1 allowed PB to shave his eyebrows and even gave him the shaver with which to do it. The reason, they said why PB liked living with both foster carers was that he could do as he pleased and had them ‘wrapped around his finger’. They said they had shared their concern about whether a single carer would be able to effectively manage PB’s behaviour. 15.6. MPB said that when they first met FC2, she felt uneasy and did not ‘take to him’. Both adults recalled that on their first visit to the home of FC2, he told them that their son was gay and indicated that he was in ‘a relationship’ with the other child who present.21 They didn’t believe this and thought it an odd thing to be told by a foster carer and although they discussed this with the social worker nothing came of this. They were not surprised when they learnt of the allegations made by PB against FC2. 15.7. Both MPB and SFPB believed that PB needed firm boundaries and these had clearly not been provided by FC1 or FC2. They offered examples of when foster carers, FC1 and FC2 had colluded with PB and said their concerns were not addressed by social workers, even when PB was ‘supposedly’ on the SPECIALIST FOSTER PROGRAMME. They recalled that the IRO had indicated that PB needed a safe place, which offered clear boundaries, and they had supported the idea of a full time residential/education placement but social workers disregarded their views and PB was allowed to go home at weekends to FC2. 15.8. Asked what they thought may have helped, the parents said earlier assistance with PB’s behaviour, and some sort of help which would have helped them understand his behaviour would have been of immense benefit. They pointed out that they had three other children and there were no concerns about their behaviour. Perspectives of FC1 21 This issue was followed up by social workers but no additional information could be found and the young person to whom this was thought to refer denied any sexual relationship with PB. SCR Trafford/ Fostering/December 2016 - amended March 2017 30 15.9. FC1 met with the Lead Reviewer and the Interim Lead for Looked After Children in late February 2017. The Lead Reviewer explained that the purpose of the meeting was only to discuss the SCR process and offer FC1 the opportunity to comment on the findings and related recommendations and there would be no discussion of PB, the allegations he had made or any subsequent procedures in relation to those allegations. FC1 said he was in contact with FC2 and was aware of all that had happened. 15.10. FC1 said he accepted the findings and recommendations in the report and as he had provided some written comments these were used to structure the conversation. Some of these points were related to an ongoing process related to FC1’s de-registration as a foster carer but these were not discussed. 15.11. FC1 said that despite his delight at being accepted as a foster carer, he was surprised that the vetting process had not been more challenging and indicated that he had said as much to his supervising social worker. He said he had expected far more discussion around the fact that he was a single male carer and in particular more probing about his sexuality and the extent to which this could have impacted on his role as a foster carer. He gave an example of the sort of things he asked when interviewing staff in the work place. FC1 explained that he had been very concerned at being asked, on what was his very first placement, to be a specialist carer for PB and believed this had directly contributed to the deterioration of his health. He said he found PB’s behaviour very challenging and his failing health during the placement meant he was unable to care for PB. He pointed out that his health quickly improved once PB had left his care and said he was surprised that he had not been sent for a medical before his next placement, as this would have been appropriate. FC1 also expressed surprise that his daily records were not routinely read by either PB’s social worker or his supervising social worker as this would have testified to the difficulties he was experiencing. FC1 said he had expected more support than had been offered but thought he was just expected to ‘get on with it’. He expressed thanks for the opportunity to discuss his views. 16. Summary 16.1. Whilst evidence shows that the overwhelming majority of foster carers offer safe care, it is important for professionals to acknowledge the risk, albeit a small one, that abuse may occur in any form of substitute care. Looked after children are vulnerable whatever their persona or presenting behaviour and robust care plans are essential to not only safeguard the child from further abuse and harm but also to help build resilience and help young people to learn coping strategies. Actions in care plans must be implemented, closely monitored, and regularly updated. 16.2. An awareness of patterns of manipulative behaviour should inform the recruitment, approval and continuing monitoring and supervision of all those working with children, especially foster carers who have the day to day care of some of society’s most vulnerable children, and of necessity with little direct supervision of their work. LR/End December 2016 SCR Trafford/ Fostering/December 2016 - amended March 2017 31 Appendix 1 Recommendations for Trafford and the Local Authority Recommendation 1: Where a prospective foster parent works directly with or on behalf of children and young people, formal references should always be requested from a senior professional in their agency in addition to any other references and these references should always be submitted in writing Recommendation 2: The fostering service in Trafford should: a) ensure that all assessments of foster carers are thorough, robust, and appropriately challenging with information being sought from a wide range of sources. b) ensure there is adequate guidance for assessing LGBT applicants22 - there would also be merit is using this guidance as an opportunity to train panel members. c) undertake a review of panel membership to ensure it represents and reflects the diverse community it serves. Recommendation 3: Social workers should be reminded that they are responsible for talking with children about proposed placements and the [general] lives and lifestyles of the carers with whom they will be living. The responses of the children should be noted and monitored, the Review Team could find no evidence that this is routinely done in Trafford and there would be benefits in further discussions around this issue. Recommendation 4: As a corporate parent, the local authority and its senior managers should ensure that the IRO role and function is utilised effectively so that challenges about care planning and decision-making are acknowledged and addressed. Recommendation 5: Trafford’s Independent Reviewing Unit should ensure regular scrutiny of annual reviews of foster carers and ensure these are robust, thorough, and challenging. Recommendation 6: Trafford Fostering service should ensure that all supervision files for foster carers contain easily accessible, purposefully prepared, and carefully maintained chronologies to support supervision and reviews of foster carers. There should be evidence of, and reference to foster carer’s daily records so any emerging concerns or issues can be addressed. Recommendation 7: Trafford Safeguarding Children Board should ensure that all practitioners and especially those within the fostering service have a sound understanding of the range of characteristics, motivations and behaviours of people who seek to sexually abuse children and have opportunities to discuss these challenges within multi-agency settings. Recommendation 8: When a placement ends unexpectedly due to health concerns of a foster carer, or there are ongoing health issues of a foster carer or noted by the supervising social worker, a medical report should always be sought from the foster carer’s GP. Recommendation 9: The local authority should, together with Fostering Service and Panel, a) ensure that an experienced Medical Advisor is identified to support the work of the Panel in addressing and confirming the health needs of prospective and current foster carers. b) Cease, with immediate effect, to refer to the LAC Health nurse as the Medical Advisor 22 British Association of Fostering and Adoption and Adoption (BAAF) offer excellent resources in this area. |
NC043756 | Serious injury of a 2-month-old baby boy in September 2011. Child S was found home alone with visible bruising. Examination later revealed multiple injuries including fractures and a brain injury. Child S and both his half siblings were subject to child protection plans at the time of the incident. Mother pleaded guilty to wilful cruelty and three counts of grievous bodily harm, for which she received a community sentence. Mother was subject to a child protection plan as a child and lived in foster care for two years from the age of 5. Mother had learning and emotional difficulties and a history of domestic abuse and alcohol misuse. Mother told GP that Child S was unwanted and she was considering adoption. Mother was well known to agencies, including police, and was arrested two years prior to the incident for being drunk in charge of a child. Identifies lessons for practice concerning insufficient recognition and assessment of risk factors including: resistance, parental vulnerabilities due to childhood experiences, bruising to non-mobile infants, alcohol misuse, the impact of learning disability on parenting capacity and the meaning of the child to the mother. Makes various interagency and single agency recommendations.
| Title: Overview report on the serious case review relating to Child S: executive summary and overview report. LSCB: Surrey Safeguarding Children Board Author: Jane Wonnacott Date of publication: [2014] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Overview report on the SERIOUS CASE REVIEW relating to Child S Executive Summary and Overview Report Report Author Jane Wonnacott MSc MPhil CQSW AASW In-Trac Training and Consultancy Ltd 2 CONTENTS EXECUTIVE SUMMARY Page 1. Introduction 2. Case summary 3. Review findings 4. Conclusion and recommendations 3 5 10 15 OVERVIEW REPORT 1. Introduction 2. The serious case review process 3. Family background 4. Professional involvement with Child S and his family 5. Thematic analysis of professional practice 6. Lessons learnt 7. Conclusion 8. Overview recommendations 9. Individual management review recommendations 17 18 24 25 53 73 74 75 79 3 EXECUTIVE SUMMARY 1. INTRODUCTION 1.1 This serious case review was undertaken because of a critical incident in September 2011 when a two month old baby, Child S, and his one year old half sibling (Half Sibling 2) were found home alone and Child S was seen to have a bruise on his forehead. He was subsequently found to have serious injuries including fractures and brain injury. Both children and their half sibling age four (Half Sibling 1) were subject of child protection plans at this time. Mother, who lived alone with the children, was charged with Grievous Bodily Harm and Neglect. Mother pleaded guilty to wilful cruelty and three counts under section 20 of grievous bodily harm and in September 2013 received a community sentence. 1.2 At the point of the critical incident, the case was referred to the Surrey Serious Case Review Group whose initial conclusion was that the criteria for a serious case review were not met. Further information was requested and the case was kept under continual review. As a result of additional information requested from both Health and Social Care the decision was made in October 2012 that the criteria for a serious case review had been met. A panel, chaired by the independent chair of Surrey Safeguarding Children Board, was appointed to oversee the serious case review process and an independent author commissioned to provide the final overview report. It was agreed that the review would be completed as far as possible prior to the criminal proceedings and immediate action taken to rectify any practice problems identified by the review. The final review report would be finished at the close of the criminal proceedings when family members would have an opportunity to contribute their views. 1.3 It should be noted that this review took place in line with the guidance set out in Working Together 2010 as the current guidance (Working Together 2013) was not in place at point the review started. This means that the information obtained for this overview was gained from individual management review reports and the overview author did not talk directly to any of the practitioners 4 involved. The potential limitations of this process have now been recognised nationally and locally in relation to understanding “why” events occurred. Where there are gaps in information this has been identified within the report and relevant recommendations made. Current reviews within Surrey are ensuring that a more flexible approach is taken which includes full involvement of practitioners and opportunities for lead reviewers to talk directly to those who had contact with the family. 1.4 The panel agreed the terms of reference for this review. Individual management review reports were requested from all organisations that had significant contact with Mother and her three children from the time that she was pregnant with Half Sibling 1. All individual management review authors attended a full day meeting of the serious case review panel in order to discuss their reports, hear from other individual management review authors and identify emerging lessons from the process. Final individual management review reports, recommendations and action plans were scrutinised by the panel and the information used to inform the final overview report findings, recommendations and composite action plan. 1.5 A health overview report was prepared by the designated nurse in order to inform health commissioners of the issues from the review and any actions to be taken at the point health services are commissioned. This has informed this final review report. 1.6 A report, recommendations and action plan was received by Surrey Safeguarding Children Board on 25 May 2013. Following conclusion of the criminal proceedings family members (Mother, Aunt and Maternal Grandmother) were offered an opportunity to contribute to the review. Mother was not at home at the appointed time but Maternal Aunt met with the overview author and the Surrey case review officer. We are very grateful for her time and input and have referred to the content of the discussion within the body of the report. 1.7 The final report was received by Surrey Safeguarding Children Board on 21st November. It was agreed that the Quality Assurance and Evaluation sub 5 group would continue to hold individual organisations to account for the implementation of individual management review action plans as well as oversee the actions required in relation to overview report recommendations and provide regular updates on progress to Surrey Safeguarding Children Board. 1.8 Following the acceptance by Surrey Safeguarding Children Board, a letter was received from foster carer who had looked after Child S following the child’s removal from home. Whilst some of the issues raised in the letter fell outside the scope of this review, it was necessary to obtain some further information from Kingston Hospital. This did not affect the findings and recommendations from this review but did cause a delay in publication. 2. CASE SUMMARY 2.1 A review of the records revealed that Mother had been known to the locality team as a child. She was on a child protection plan for sixteen months from the age of two and placed in foster care on a care order from the age of five to seven. Records indicate that as a result of her experiences she suffered mild learning disabilities and emotional difficulties and was the subject of a statement of special educational need. There was no further involvement beyond universal services until May 2006, when mother was twenty three, although health records do note information from Mother that she was homeless from the age of sixteen following physical abuse within her home. 2.2 Just prior to the birth of Half Sibling 1, when Mother was pregnant, Children's Social Care was notified by the Surrey Police of allegations of domestic violence against Mother. However, at this time the main issue was seen to be housing and there was no further action. 2.3 Half Sibling 1 was born in September 2007, following which there were further allegations of domestic violence. There were also the first indications of Mother’s reluctance to engage with services, with Half Sibling 1’s first health check and immunisations being late. At this point Community Health Provider 6 1 had assessed Mother as needing an enhanced health visiting service and referrals were made to Children's Social Care by Surrey Police and the health visitor. A strategy discussion was held but there was no further action by Children's Social Care until January 2008 when Mother receive d a police caution for being unfit to look after a child due to drunkenness. This incident took place out of hours and Half Sibling 1 was placed with Maternal Grandmother overnight, being returned by the social worker to the care of Mother the next day after hearing Mother’s version of events. 2.4 A child protection conference was held in February 2008 and Half Sibling 1 was made subject of a child protection plan under the category of neglect. At the review child protection conference in June 2008, the social worker and the health visitor recommended a change from a child protection plan to a child in need plan. There is evidence of effective challenge from the conference chair who felt that a child protection plan was still required since there was insufficient progress and little evidence of sustainability in respect of domestic abuse, use of alcohol and engagement with a parenting programme. 2.5 Prior to the next review conference there were three domestic abuse incidents. Police expressed concern about the state of the home and during the second and third incident noted that Mother had been drinking and kept changing her account. However, although concerns about alcohol were noted, the social worker assessed that the child protection plan was progressing well, Half Sibling 1 was thriving and the case could be managed as child in need rather than child protection. However, it was the decision of the conference chair in October 2008 that Half Sibling 1 should remain on a child protection plan under the category of emotional harm, rather than neglect, as the primary concern had shifted to Half Sibling 1’s continued exposure to domestic abuse. 2.6 Following the child protection conference Mother moved accommodation, and responsibility for health visiting moved from Community Health Provider 1 to Community Health Provider 2. A family health needs assessment noted that Half Sibling 1 was attaining normal development. 7 2.7 Throughout this period and up until the review child protection conference in February 2009, there were no reported incidents of domestic abuse and both social work and health visitor records note that Half Sibling 1 was making good progress and Mother’s engagement with the child protection plan was positive. At the review conference the decision was made to remove Half Sibling 1 from a child protection plan, and a child in need plan was put in place. 2.8 In May 2009 there were two incidents on the same day where the Surrey Police were aware that Mother was drunk when caring for Half Sibling 1. On the first occasion she was with Father of Half Sibling 1 and on the second Police were called to Mother’s flat and found her to be apparently drunk and unconscious on the sofa. Half Sibling 1 was found lying face down on a mattress in the bedroom, wearing a soiled nappy. Mother was arrested and charged with child neglect, Half Sibling 1 was removed to the care of Maternal Grandmother and a written agreement was put in place. 2.9 The Crown Prosecution Service decided that the case for child neglect was not made out. Mother could not be charged with being drunk in charge of a child since the incident had taken place within the family home. Half Sibling 1 remained living with Maternal Grandmother until July 2009 when she was returned to the care of her Mother. During this period Mother was encouraged to seek help with her alcohol misuse and saw the GP, who noted from Mother’s own self-report, ‘binge drinking’. She was referred to alcohol misuse services where she was seen in August and assessed (again via self-report) as showing no signs of drink dependency or binge-style use. In August Half Sibling 1 was noted to be thriving in Mother’s care. 2.10 Children's Social Care closed the case in November 2009. At this point the Surrey Police had been told by Mother during a domestic dispute that she was pregnant but she denied this when asked by the health visitor. It became clear in January 2010 that Mother was pregnant with Half Sibling 2 who was born in June 2010. Throughout this pregnancy Mother attended no antenatal care appointments. Children's Social Care were briefly involved again following a referral both from the hospital midwife and the police after another 8 incident of alleged domestic violence. By August 2010, when Half Sibling 2 was two months old, Children's Social Care had formed the view that Mother was doing well and the case was closed. 2.11 From this point until Mother’s pregnancy with Child S there were two further domestic disputes recorded by the Surrey Police, and Half Sibling 1 started nursery. Like Half Sibling 1, Half Sibling 2’s registration with the GP was delayed and she also was not taken by Mother to arranged appointments for immunisations. Regular visits and weighing by the health visitor and nursery nurse revealed concerns about Half Sibling 2’s failure to thrive and developmental delay. 2.12 By January 2011, when Half Sibling 2 was seven months old, Mother was pregnant and approached Children's Social Care as she did not wish to keep the baby and her sister wanted to adopt the child. A joint assessment was carried out by a social worker from the adoption team and assessment team; the resulting initial assessment recommended that Mother and her sister be given advice about private adoption, and the case closed. 2.13 At the point of closure the health visitor noted that Half Sibling 2 had two bruised eyes, which Mother explained had occurred as a result of a fall from a sofa. Due to developmental delay Half Sibling 2 was a non-mobile infant at this point. The assessing social workers were also aware of these bruises, but neither they nor the health visitor felt that they warranted further action at that time. 2.14 During her pregnancy with Child S, Mother attended no antenatal appointments. The case was once more opened by Children's Social Care and concerns noted about the physical environment within the home and Mother’s alcohol use, which continued throughout her pregnancy. These concerns continued after the birth of Child S and a tight visiting plan was agreed between professionals when Child S returned home from hospital. It is clear that at this point Mother was very unhappy about the involvement of Children's Social Care. An unannounced visit by the social worker found all three children in the home alone, with Mother having ‘popped out for two 9 minutes’. During this visit Child S was noted to have an injury to his toe. No action was taken in respect of the children being home alone or the injury. 2.15 A child protection conference took place in August 2011 and all three children were made subjects of a child protection plan under the categories of neglect and emotional abuse, and case transferred from the Children's Social Care assessment team to the child protection and proceedings team. 2.16 A legal planning meeting took place at the end of August when Child S was six weeks old, the conclusion of which was that more information needed to be collated before a decision could be made. The Children's Social Care individual management review outlines a number of concerns about the effectiveness of this meeting with a lack of chronology and social workers attending without a well organised and documented case. There were also differences of opinion between social workers, with the assistant team manager from the assessment team feeling there was sufficient evidence to support legal intervention, whereas workers from the child protection and proceedings team (who had begun working with the case more recently) felt unconvinced due to Mother’s ‘recent engagement’. 2.17 A pattern of missed appointments continued, along with Mother’s clear reluctance to work with social workers. Child S at the age of eight weeks had failed ten health appointments, a concern which was notified to the health visitor by the GP. 2.18 During a home visit the health visitor noted an injury to the hand of Child S and also that he appeared to be in pain when the injury was dressed. This was communicated to the social worker and Mother was encouraged by both the social worker and the health visitor to take Child S to the GP. This appointment was not kept and the next day the family support worker conducted an unannounced visit to the home. Half Sibling 2 could be heard crying but no adult was in the flat. When Mother returned, the flat was found to be in a very poor state. Child S’s injured finger was apparent, as was a bruise on his face covered by cream. Mother could give no explanation for the bruise. The family support worker alerted the social worker, Child S was 10 taken to Hospital 2 and initial examination revealed injuries indicative of physical abuse. The decision was made by the Local Authority to issue care proceedings in respect of all three children. 3. REVIEW FINDINGS 3.1 This review identified a number of areas of practice where lessons could be learned and work with children and families improved. Many of these lessons relate to the need for a better recognition and response to the various factors that indicated potential risk to children. Alongside these there are other lessons relating to the skills and support that practitioners need in order to be able to work effectively in such complex situations. Recognising risk 3.2 There were a number of factors present in this case which are known to be associated with risk to children, yet these were not adequately assessed as a whole and a judgement made as to how safe the three children were in their mother’s care. Because this assessment did not take place, plans to protect the children were not sufficiently robust, particularly in relation to measuring whether sufficient change had taken place to reduce the risk of harm. 3.3 Factors that should have alerted professionals included: Mother’s unwillingness to engage with services and failure to access antenatal care, particularly during the second and third pregnancies Persistent misuse of alcohol whilst caring for the children Recurrent allegations of partner violence Half Sibling 2 ’s failure to thrive and developmental delay Failure to provide adequate supervision and leaving the children at home alone Bruising and injuries on non-mobile infants Mother’s potential vulnerabilities due to her childhood experiences 11 3.4 There is little evidence that assessments at any time adequately analysed the interaction between these known risks and the protective factors within the environment. The accumulation of risk factors over time was not recognised and by the time of the legal planning meeting less than a month prior to the significant injuries, the information had not been collated by social workers and presented in a way that allowed the lawyer to make a reasoned decision at that point as to whether the threshold for proceedings had been met. Failure to provide adequate evidence to such meetings at that time is recognised as a problem by Children's Social Care who have taken steps to re focus on the importance of chronologies and ensure that legal planning meetings do not take place within adequate written evidence being provided. Recognising the significance of history 3.5 Information was available to Health and Children's Social Care about Mother’s experience of abuse in her own childhood and her time as the subject of a care order. The files were not retrieved from archive in order to inform assessments and known information was not used effectively either as part of the analysis of risk or to understand of Mother’s response to help being offered. A consideration of family history and current family relationships was important since Maternal Grandmother was source of support and had sole care of Half Sibling 1 for three months. 3.6 It was clear to the serious case review panel that retrieving information could be time consuming and, in the case of Mother’s education records, the panel were not able to retrieve these at all due to an administrative problem. This process needs to be addressed and in order to do this understanding the current barriers to retrieval is important since busy practitioners need smooth, efficient systems in order to support them in their work. The impact of alcohol use on parenting capacity 3.7 In this case alcohol use was overt and happening throughout the last pregnancy. Despite this overt use, in combination with other stressors, practitioners did not at any time appear to define this clearly as a child 12 protection issue and work together with substance misuse services to pool information and fully assess the risk of harm. 3.8 Why this is the case needs further exploration, starting with the recognition that alcohol is a socially acceptable drug and therefore may be less likely to cause alarm than illegal drug use. It is of note that a framework to assist assessment in cases of substance misuse was in place as part of child protection procedures during the timeframe for this review. At no time was this used in this case, possibly as alcohol was not viewed in the same way as other substances (such as illegal drugs) which were believed to be the focus of the framework. Bruising and injuries in children who are not independently 3.9 Where bruising is seen in children who are not independently mobile, this should raise concerns and prompt professionals to consider the possibility of abuse. In this case there were three instances where injuries were seen and immediate action was not taken under child protection procedures. Surrey Safeguarding Children Board therefore needs to raise awareness of the significance of bruising and injuries in non-mobile babies and take steps to ensure that all practitioners are aware of the action to take if this is found to be present. Recognising the interface between child neglect and physical abuse 3.10 Although actions were taken by social workers in respect of physical neglect there was insufficient understanding in Health and Social Care that chronic neglect may be associated with physical abuse. As a consequence the signs and indicators of physical abuse were missed. Meaning of the child 3.11 Whereas Mother’s relationship with and care of Half Sibling 1 did not cause significant concern, there were clear indications that her feelings towards her younger two children were more complex. In respect of Half Sibling 2 Mother initially denied she was pregnant and then avoided antenatal care. There was 13 a reported adversarial relationship with Half Sibling 2’s father and Mother told the health visitor that she was disappointed that Half Sibling 2 looked like him. Child S was known to be unwanted and Mother had considered adoption. 3.12 All these factors should have informed professional assessments when Half Sibling 2 was failing to thrive and injuries were noted both on Half Sibling 2 and Child S. Professionals should have been alert to the fact that in this case there is evidence that both babies may have had a particular meaning to Mother which led to them being more at risk of harm. Supervision of the health visitor and within Children's Social Care did not enable exploration of this aspect of the case. Assessing the impact of learning disability on parenting capacity 3.13 Records within the locality team indicated that Mother may have had learning disabilities and she told the health visitor that she was unable to read or write and therefore ignored mail. The nature and extent of any disabilities were not assessed and this information used to inform assessments and the help given to the family. Working with fathers 3.14 There are three fathers in this case, although the identity of the father of Child S has not been confirmed. Where the identities of the fathers are known the impression from the records is that they were mainly thought of in terms of potential risk, rather than having anything positive to contribute to assessments and plans. This has been a feature of previous serious case reviews in Surrey, and Surrey Safeguarding Children Board will need to understand why previous actions as a result of the reviews have not made a positive impact on practice in this case Working with resistance 3.15 There are numerous examples throughout the chronology and individual management reviews of Mother failing to engage with services and/or being openly hostile and resistant to help. Equally there are other occasions where 14 she appeared to develop reasonable working relationships with individuals but still there was little evidence of sustained improvement in her capacity to provide safe, appropriate care for her children. 3.16 Mother’s resistant or avoidant behaviour is most striking in relation to the number of failed health appointments. However, there was insufficient analysis of implications of missed appointments for the children and of lack of antenatal care. 3.17 Working with resistance requires workers to have highly developed interpersonal skills as well as to manage their emotions effectively in order to prevent either collusive or overly oppressive styles of interaction. There is no evidence that supervision in Health or Children’s Social Care explored the impact of working with resistance on the practitioner and the effect that this could have on professional responses. Working effectively together within and between organisations 3.18 There are some examples of effective communication as well as a number of instances where a greater degree of positive inter- or intra- agency work would have helped to identify risks. Generally, however, communication issues were not a major feature of this serious case review. Management and supervision 3.19 It is apparent that at several points in this case there were opportunities for managers and/or supervisors to make a positive difference through encouraging staff to critically reflect on their practice. This should have included an exploration the factors that may have affected their decision making including values, attitudes, assumptions, knowledge, experience and workload. The importance of effective management and supervision was particularly apparent in the case of the health visitor and the newly qualified social worker. In the later situation, the history of the case should have led to recognition by managers that it was too complex for a newly qualified social worker without intensive support and supervision, yet there is little evidence of effective supervision or management oversight. 15 Learning lessons from previous SCRs – barriers to improving practice 3.20 Many of the issues identified within this serious case review are similar to those that have been identified before, both within Surrey and elsewhere within England. There is little indication that these lessons from previous reviews have been used to inform practice. Further work is therefore needed by the Safeguarding Children Board to understand the barriers to embedding learning into practice and ways of overcoming these. 4. CONCLUSIONS AND RECOMMENDATIONS 4.1 The conclusion of this review must be that there were a number of missed opportunities to prevent the serious injuries to Child S, as well a delay in acting when injuries were apparent. Missed opportunities pre-date Child S’s birth with evidence that more effective risk assessments from the time of Mother’s first pregnancy may have resulted in different actions when Mother was known to have been pregnant with Child S. In particular, prior to Child S’s birth, there was a failure to recognise the likely significant harm experienced by Half Sibling 2. 4.2 The most significant missed opportunities were: Lack of any risk assessment at the point that Mother was charged with child neglect. This assessment could have been used to inform the decision to close the case when mother was known to be pregnant with Half Sibling 2 No action taken to assess risk at the point that Mother was enquiring about the adoption of unborn Child S and bruising was noted on the face of Half Sibling 2 who, at that point, was a non-mobile infant No action taken to consider removal of the children who had been left at home alone and to arrange a child protection medical to examine the injury to Child S’s toe in August 2011 Failure to act immediately when the Child S was found with an injury to his hand and was clearly in pain. 16 4.3 There is little learning about risk to children that is new in this case. The issues that have emerged have been known for several years both from research and previous local reviews, yet did not consistently inform actions. As a consequence, many of the recommendations will focus on reminding organisations and practitioners of the knowledge and skills that should be utilised in everyday practice. However, this needs to take place alongside a deeper exploration by the Surrey Safeguarding Children Board of the barriers that prevent known knowledge being implemented in practice. 4.4 Specific recommendations have been made to improve practice. These have been developed into an action plan which is in the process of being implemented and will be actively monitored by Surrey Safeguarding Children Board. 17 OVERVIEW REPORT 1. INTRODUCTION 1.1 This serious case review was undertaken because of a critical incident in September 2011 when a two month old baby Child S and his one year old half sibling (Half Sibling 2) were found home alone and Child S was seen to have a bruise on his forehead. He was subsequently found to have serious injuries including factures and brain injury. Both children and their older half sibling (Half Sibling 1) were subject of child protection plans at this time. Mother was charged with Grievous Bodily Harm and Neglect. She later (at the point of trial) pleaded guilty to wilful cruelty and 3 counts under section 20 of grievous bodily harm and in September 2013 received a community sentence 1.2 The case was referred to the Surrey Strategic Case Review Group whose initial conclusion was that the criteria for a serious case review were not met. The Strategic Case Review Group frequently reviewed the case and considered further evidence including an individual management review by Health. In February 2012, the group agreed that the evidence from the individual management review did not meet the criteria for a serious case review and therefore the recommendation of the group was that a Serious Case Review should not be undertaken by the Surrey Safeguarding Children Board. 1.3 Following further discussion, in April 2012 the Independent Chair of Surrey Safeguarding Children Board Chair requested Children’s Social Care to undertake a review of their practice in response to the contact by Mother in April 2011 when she was pregnant with Child S. Following the conclusion of the criminal investigation in August 2012 and the information contained in the subsequent chronologies requested by the Serious Case Review Group and discussed in October 2012, a recommendation was made that a serious case review be undertaken. Alex Walters, Surrey Safeguarding Children Board Independent Chair, agreed to hold a Serious Case Review on 24 October 2012. 18 1.4 The reason for the review was that a child had sustained a potentially life threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children.1 2. THE SERIOUS CASE REVIEW PROCESS 2.1 It should be noted that this review took place in line with the guidance set out in Working Together 2010 since the current guidance (Working Together 2013) was not in place at point the review started. This means that the information obtained for this overview was gained from individual management review reports and the overview author did not talk directly to any of the practitioners involved. The potential limitations of this process have now been recognised nationally and locally in relation to understanding “why” events occurred. Where there are gaps in information this has been identified within the report and relevant recommendations made. Current reviews within Surrey are ensuring that a more flexible approach is taken which includes full involvement of practitioners and opportunities for lead reviewers to talk directly to those who had contact with the family. 2.2 A serious case review panel was appointed to oversee the review. The panel members for this review were: Alex Walters, Chair Surrey Panel Chair Safeguarding Children Board Safeguarding Board Manager Surrey Safeguarding Children Board Designated Nurse for Child NHS Surrey Protection Detective Inspector Public The Surrey Police Protection and Investigation Unit 1 HM Government (2010) Working Together to Safeguard Children London DCSF Paragraph: 8.11 19 Safeguarding Children Advisor SCC Early Years and Child Care Service South-East Area Education Officer Schools and Learning Manager SCC Legal and Democratic Services Area Head of Service SCC Children’s Services Terms of reference and scope of the review 2.3 It was agreed that the purpose of the review would be to: establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and improve intra- and inter-agency working and better safeguard and promote the welfare of children. 2.4 The following specific issues were identified as needing to be considered from the preliminary review of information available to the Strategic Case Review Group; 1. Was any information known by any agency about parental mental health issues, and or substance abuse, if so was appropriate consideration given to how this impacted on parenting capacity? 2. Was any information known by any agency about domestic abuse or parental antisocial behaviors, if so was appropriate consideration given to 20 how this impacted on parenting capacity and were appropriate referrals made? 3. Was the level and extent of agency engagement and intervention with the family appropriate? 4. Did agencies communicate effectively and work together to safeguard and promote the children’s welfare? 5. Were appropriate assessments undertaken in a timely manner, was the quality adequate and did they include all historical information? 6. Were fathers and extended family members included in assessments? 7. Were the decisions and actions that followed assessments appropriate and were detailed plans recorded and reviewed? 8. Were any safeguarding issues in respect of Child S, Half Sibling 1 and Half Sibling 2 identified and acted on appropriately and in a timely way by all agencies? 9. Were missed appointments and failure to engage considered as indicators of neglect? 10. Were the children’s views and wishes sought and taken account of in assessments and planning? Did this include the presentation of young non-verbal children being fully considered? 11. Was race, religion, language, culture, ethnicity or disability a factor in this case and was it considered fully and acted on if required? How was the uniqueness of this particular family recognised? 12. Were there any organisational or resource factors which may have impacted on practice in this case? 21 13. Were appropriate management/clinical oversight (supervision) arrangements in place for professionals making judgments in this case? 14. How did the multiagency system enhance or impede effective practice and outcomes for this family? 15. Consideration should also be given to the areas identified in Working Together 2010, page 245, for analysis of involvement that is not covered by the above specific issues 2.5 Authors of individual management reviews, serious case review panel members and the author of the overview report were also asked to bring to the attention of the serious case review panel chair any other matters identified which appeared to fall within the scope of the review if they thought that there were lessons to be learnt either for an individual agency or for the Surrey Safeguarding Children Board. 2.6 Authors of individual management reviews who identified other significant issues not falling within the scope of the review were asked to bring them to the attention of a senior manager within their agency. Consideration was also to be given to the findings of recent serious case reviews both locally and nationally. 2.7 It was noted that the terms of reference were provisional and would be amended if new information came to light Time period for the review 2.8 The principal focus of the serious case review was identified as from 1 January 2007, the start of the pregnancy for Half Sibling 1 to the 16 September 2011, the day after the three children were removed from the family home. The review invited all agencies to provide a summary of all 22 significant events and relevant family history outside the specific scope and timescale, where this would help to inform the overall analysis. Information gathering 2.9 Contributing agencies were asked to identify an individual management review author to compile: a chronology of the agency’s contact with the family using the SSCB template an analytical IMR and an agency action plan to address any learning arising. 2.10 Individual management review authors were required include the following: five components: Introduction Narrative Analysis of involvement Lessons learned / findings or conclusions Recommendations 2.11 Individual management review reports were requested and received from: 1. Community Health Provider 1 in respect of health visitor involvement from March 2007 – November 2008 2. Community Health Provider 2 in respect of health visitor involvement from November 2008 onwards 3. Hospital 1 in respect of midwifery involvement 4. Hospital 2 in respect of midwifery involvement with the youngest child 5. The locality Team in respect of involvement by Children's Social Care and Legal Services 6. Education in respect of nursery involvement with the oldest child 7. Locality GPs 8. The Surrey Police 23 2.12 Reports for information were received from: 1. The Housing Trust 2. Domestic Outreach Service Council 2.13 A full integrated chronology some three hundred pages long was prepared and used as the basis for understanding the way in which professionals worked with the family and each other in this case. 2.14 All individual management review authors attended a full day meeting of the serious case review panel in order to discuss their report, hear from other individual management review authors and identify emerging lessons from the process. This aspect of the review took place as a result of learning and feedback from previous serious case reviews. Further information, where this was required, was sought by the panel and provided by the authors. Final individual management review reports, recommendations and action plans were scrutinised by the panel and the information used to inform the final overview report findings, recommendations and composite action plan. 2.15 A health overview report was prepared by the designated nurse in order to inform health commissioners of the issues from the review and any actions to be taken at the point health services were commissioned. This has informed this final review report. 2.16 A report, recommendations and action plan was initially received by Surrey Safeguarding Children Board on 25 May 2013 and work began to implement the recommendations. A final report, following conclusion of the criminal proceedings was received on 21 November 2013. Following the acceptance by Surrey Safeguarding Children Board, a letter was received from foster carer who had looked after Child S following the child’s removal from home. Whilst some of the issues raised in the letter fell outside the scope of this review, it was necessary to obtain some further information from Kingston 24 Hospital. This did not affect the findings and recommendations from this review but did cause a delay in publication. Family involvement in the review 2.17 Relevant family members were made aware of the serous case review process but due to the pending criminal proceedings no further contact with the family was possible until they concluded. Following conclusion of the criminal proceedings family members (Mother, Aunt and Maternal Grandmother) were offered an opportunity to contribute to the review. Mother was not at home at the appointed time but Maternal Aunt met with the overview author and the Surrey case review officer. We are very grateful for her time and input and have referred to the content of the discussion within the body of the report. The overview report 2.18 This overview report has been prepared by Jane Wonnacott, Independent Consultant, who has extensive experience of completing serious case reviews. 2.19 Since the report has been prepared with the knowledge that it will become a public document, personal family information and specific geographical details and organisational titles that may identify the family has been kept to the minimum, although there is full disclosure and discussion of relevant professional interaction with the family. The individual management review process has confirmed that issues of practice and performance have been addressed by individual agencies. 3. FAMILY BACKGROUND 3.1 The Mother of the three children who are subjects of this review was born in Surrey and was the middle child of three. She has an older sister, and a 25 brother twelve years younger than her. The locality team have records of involvement with the family when Mother was a young child, which were retrieved from archive in order to assist this review. 3.2 Mother was on a child protection plan for sixteen months from the age of two due to concerns about emotional abuse and neglect by her parents. The case was closed to Children's Social Care three months after Mother was removed from the child protection plan. 3.3 When Mother was five and half years old Maternal Grandmother asked for her to be placed in foster care as she was unable to cope with her behaviour. Due to further concerns about abuse, the Local Authority was granted a care order and Mother remained in foster care until aged seven when the care order was discharged. Records indicate that as a result of her experiences she suffered mild learning disabilities, emotional difficulties and a statement of special educational need. There was no further involvement beyond universal services until May 2006 just prior to the time frame for this review, although health records do note information from Mother that she was homeless from the age of sixteen following physical abuse within her home. 4. PROFESSIONAL INVOLVEMENT WITH CHILD S AND HIS FAMILY 4.1 Between May 2006 and February 2007, prior to the birth of Half Sibling 1, Surrey Police noted seven calls from Mother alleging domestic violence. During one call she informed the police officer that she was pregnant, a domestic abuse risk assessment was completed and assessed Mother as high risk. Support was offered by Surrey Police domestic violence team and a notification sent to Children’s Social Care. 4.2 A further call from Mother to the police resulted in another notification being sent to Children’s Social Care since Mother was alleging that Father of Half Sibling 1 had kicked her and she was now homeless. She was noted to 26 possibly be intoxicated. There is no record that Children's Social Care responded to the police notification and the Children's Social Care individual management review comments that this was because the incident was prior to Mother having any children. However, a previous police notification had noted that Mother was pregnant and it would have been appropriate for Children's Social Care to consider whether an assessment was necessary. 4.3 Mother was seen for a pregnancy assessment at Hospital 1. This resulted in a referral to both Children’s Social Care and a health visitor in the area of Community Health Provider 1 due to the fact that she was sleeping on her parents’/friends’ sofas. There is no record that any questions were asked about potential domestic violence at this point. 4.4 In April 2007, the midwife made a referral to the locality team, expressing concern that Mother was thirteen weeks pregnant and homeless. The midwife asked for support in finding suitable accommodation for Mother prior to the birth of her child. The midwife was advised that there was no role for Children's Social Care as it was deemed to be a housing matter but to re-refer if there were still concerns nearer the birth. There is no indication that the information from the hospital was considered in the light of previous information about Mother’s childhood experiences or the more recent Police notifications. 4.5 In May 2007 Mother moved to a hostel and in July she was referred to an organisation offering support with practical tasks. However, evidence from the records indicated that Mother declined to engage with the support on offer. 4.6 Half Sibling 1 was born at Hospital in September 2007 and the next week the health visitor completed an initial assessment resulting in the family being offered an enhanced health visiting service. The health visitor had been Mother’s health visitor when she was a child and therefore had knowledge of the family history and circumstances that had led to Mother’s time in care. There is no evidence that the implication of this was discussed with any other professional. 27 4.7 During November 2007 Surrey Police were called three times to Mother’s flat. On one occasion she was found to be intoxicated and the father of Half Sibling 1 found to be in possession of drugs although he denied assaulting Mother. On the second occasion Mother alleged Father 1 was an illegal immigrant and on the third occasion Father of Half Sibling 1 assaulted a Police officer. On the first and third occasions, a child at risk notification for was sent to Children's Social Care. Half Sibling 1 was, however, noted to be well cared for. 4.8 The third incident was followed up by a Strategy Discussion and a risk assessment was recommended at this point. However, there is no record of a risk assessment or an initial assessment on the Children's Social Care files. 4.9 During December 2007 the Borough Council informed both the health visitor and Children's Social Care that Mother was to be declared intentionally homeless for rent arrears caused by cancellation of her housing benefit. Records show that Mother had not engaged with housing officers, cancelling appointments and stating that the baby had GP appointments. In fact, during this period, the health visitor became aware that Mother had not attended the GP or local hospital and had not commenced Half Sibling 1’s immunisations. A referral was made to Children's Social Care, followed up by a telephone call. It appears that Children's Social Care decided initially not to take any action but the health visitor strongly objected and a social worker visited the home. Half Sibling 1 was noted to be a happy baby and Mother had made arrangements to repay her rent arrears. Mother at this point had still not registered Half Sibling 1’s birth and the baby was not registered with the GP, nor had immunisations commenced. 4.10 Half Sibling 1 (age seventeen weeks) was seen by the GP for her six-eight week developmental check. She was also assessed by the health visitor who spoke with Mother about her non-compliance. At this point Mother told the health visitor that she was unable to read or write and tended to ignore mail. 28 There is no evidence that at this point or later any organisation verified this information or established the extent of any learning difficulties. 4.11 One evening in January 2008 Surrey Police were called to a domestic incident in the street which resulted in Mother receiving a police caution for being unfit to look after her child, and a drugs offence. The emergency duty team were contacted and Half Sibling 1 was taken into Police Protection and was briefly placed with Maternal Grandmother. Following a home visit during the day the social work heard Mother’s description of events and agreed that Half Sibling 1 could be returned to Mother’s care. There is no record of contact with the health visitor regarding this incident until five days later. 4.12 A ‘update’ strategy discussion was held in February 2008 and it was agreed that the criteria were met for a child protection conference. When Mother was called to inform her of this decision, she said she was too busy to see the social worker that week, and that the home visit would therefore have to be the next week. There was communication between the GP and health visitor at this point regarding Mother’s arrest, and the GP left a message for the social worker to call him back, leaving a mobile number should this be needed. There was no record of any call back from Children's Social Care. 4.13 A Core Assessment was completed in February 2008. The Children's Social Care individual management review author comments that the assessment was not analytical, repeated the observations made by referrers and relied on Mother’s own views regarding her parenting capacity. The report for the initial child protection conference did contain some information about Mother’s own experience as a child, including the fact that she was subject of a care order, but this information is described by the individual management review authors as ‘superficial’. 4.14 It seems as though the social worker misunderstood the purpose of the child protection conference as the health visitor was not initially invited as she was not expressing concerns. When this was queried by the Children’s Services Safeguarding Unit she was subsequently invited and attended the conference 29 where Half Sibling 1 was made subject of a child protection plan under the category of neglect. The important role of the conference in ensuring information is shared was apparent as it was only at the conference that the health visitor became aware of five previous domestic abuse incidents that she had previously not known about. After the conference the health visitor wrote a letter to the Named Nurse, expressing her concerns regarding lack of professional communication and stating that she felt the Children's Social Care were minimising the concerns surrounding the baby’s well-being. The Named Nurse forwarded this letter to a Children’s Services service manager, but there is no evidence in the health services records of any response to this letter. It should be noted that around this time there were a number of management changes within Children's Social Care that may have contributed to this outcome. 4.15 In April 2008 the case was transferred from the Children's Social Care assessment team to the locality team. No transfer summary was completed. Child protection practice within Surrey at this time had been identified by external inspection as poor and the practice in this case was symptomatic of the conditions of the time with a delay in the first statutory child protection visit after the conference. There is however evidence of the new social worker engaging with Mother, discussing the requirements of the child protection plan and making a referral to a parenting group. 4.16 There is evidence of one core group meeting taking place prior to the review conference, with the second meeting being cancelled by Children's Social Care. It is unclear from the records how effectively the core group worked together to identify the change that should be evident in order to improve outcomes for Half Sibling 1. 4.17 At the review child protection conference for Half Sibling 1 in June 2008, the social worker and the health visitor recommended a change from a child protection plan to a child in need plan. There is evidence of effective challenge from the conference chair who felt that a child protection plan was still required since there was insufficient progress and little evidence of 30 sustainability in respect of domestic abuse, use of alcohol and engagement with the parenting programme. 4.18 In June 2008, police visited Mother following a call asking for help. When the police visited, Mother was not found to be at risk but concern was noted about the state of the room including a mattress that was on the floor with food around it. Children's Social Care was notified and a social worker contacted Mother by telephone and reminded her of the next core group meeting three days later. The discussion at the core group did not reflect the police referral as the child protection plan was noted to be going well and that Mother and Half Sibling 1 would be moving to a new flat. This optimism was reflected in a social work supervision record which noted ‘house move imminent, and plan progressing very well’. 4.19 Social work visits during this period noted no concerns about the care of Half Sibling 1 and recorded that there was no contact with Father of Half Sibling 1. However, in August the police notified Children's Social Care of a domestic abuse incident where Mother had alleged assault by her ex-partner (Father of Half Sibling 1). The police records note that Mother had been drinking and kept changing her account and that Half Sibling 1 appeared well but cried when Mother raised her voice. There is no evidence that the health visitor was aware of this incident. 4.20 A duty social work visit took place three days later and Mother reassured the social worker that Half Sibling 1 had not witnessed the assault. Half Sibling 1 was noted to look happy, her bedroom clean and nicely decorated, and Mother appeared sober. A further visit by the allocated social worker took place five days later which also noted no concerns. Supervision the same day notes that the dominant concern was alcohol and that the Maternal Grandmother was supportive. Mother had been referred to an alcohol treatment service and the outcome of their assessment was awaited. There was also a note to ‘talk to legal’. 31 4.21 A further supervision record in Children's Social Care in September 2008 noted that the plan was going well and should be moved to a child in need plan at the next conference. The analysis of the alleged assault was that ‘There had been “one minor incident that did NOT place [Half Sibling 1] at risk”’. This analysis does not appear to have focused on Mother’s alleged intoxication or Half Sibling 1’s response when she raised her voice. 4.22 In September 2008 Surrey Police received a further call from Mother alleging domestic violence but the alleged perpetrator had left the address. She was noted to sound drunk. The records sent to Children's Social Care stated that the flat was not in good condition. A visit by a social worker to Mother two days later appears not to have included discussion about this incident, and notes that Half Sibling 1 was ‘truly thriving’ in her new home and that the house was decorated to a good standard. 4.23 A child protection conference in October noted continued evidence of domestic abuse and use of alcohol although Mother had made progress in other areas. Once again the health visitor was unaware of the domestic abuse incidents prior to the conference. The Chair formed the view that Half Sibling 1 should remain on a child protection plan under the category of emotional harm, rather than neglect, as the primary concern had shifted to Half Sibling 1’s continued exposure to domestic abuse. 4.24 Twelve days later the social worker visited the home and explained to Mother that they and their manager were surprised at the continuing child protection plan and that they had spoken to the Chair, who had agreed to bring the next conference forward to three months. The view of the social worker and their manager remained positive about progress. Half Sibling 1 was noted to be ‘well, happy, and advanced for her age’ and Mother described as ‘a natural mother’. A supervision record noted that although the police had concerns about Mother’s continued involvement with Father, these concerns were based on ‘feeling’, not evidence. 32 4.25 As Mother had moved accommodation responsibility for health visiting services transferred to another area (Community Health Provider 2) and the new health visitor completed a home visit to Mother. At this visit Mother told the health visitor about an extensive history of neglect and abuse in her childhood, continuing into adult relationships. A family health needs assessment noted that Half Sibling 1 was attaining normal development. 4.26 The health visitor discussed the case in safeguarding supervision in December 2008 and noted ‘good interaction between Mother and child’. It was agreed that health visiting contact with the family should be combined between two health visitors with the second health visitor covering from time to time, due to the primary health visitor working part time. 4.27 The core group in December 2008 was cancelled due to staff sickness and the next meeting took place in January. Throughout this period and up until the child protection conference in February 2009, there were no reported incidents of domestic abuse and both social work and health visitor records note that Half Sibling 1 was making good progress and Mother’s engagement with the child protection plan was positive. At the review conference the decision was made to remove Half Sibling 1 from a child protection plan and a child in need plan was put in place. 4.28 Eleven days after the child protection conference, police received a report of a domestic incident at Mother’s address. As a result of this incident, Father of Half Sibling 1 was sectioned under S136 of the Mental Health Act and taken to hospital, and a domestic abuse risk assessment assessed Mother as a high risk repeat victim. Social work visits continued and Mother was put in touch with domestic violence outreach although they were unable to engage with her at this point. 4.29 A child in need meeting received many positive reports about Mother’s ability to care for Half Sibling 1. The agreed action plan was for Mother to be assisted in liaising with Housing regarding the maintenance of the flat and to attend the domestic violence outreach team in order to discuss the 33 appropriate order to decrease the likelihood of Father of Half Sibling 1 returning to the home address. Once the court order was in place, Mother was to contact the social worker so that they could carry out their last home visit and close the case. This plan to close the case if an injunction was obtained was agreed in supervision with the social worker the next day 4.30 Ten days after the child in need meeting in May 2009 Mother made a 999 call to the Surrey Police during which she appeared to be intoxicated. When the police attended they found Mother was drunk and was pushing Half Sibling 1 in a pram in the company of Father of Half Sibling 1. She was warned about her behaviour and Father of Half Sibling 1 said that he was looking after his child and there was no indication that he had been drinking. A child at risk notification was completed for Half Sibling 1. 4.31 On the evening of the same day the police were alerted to concerns about Mother’s behaviour and when they visited her address, Mother was inside, lying on the sofa and would not open the door. The police forced entry and Mother appeared unconscious through drunkenness and, once roused, became aggressive towards the police. Half Sibling 1 was found lying face down on a mattress in the bedroom, wearing a soiled nappy. It is recorded that she appeared unfazed by the incident. Mother was arrested for child neglect and Half Sibling 1 was passed into the care of Maternal Grandmother. In interview, Mother denied being drunk and was bailed with one bail condition not to remove or attempt to remove Half Sibling 1 from the care of Maternal Grandmother. At this point Mother informed the police that she would get the child back, and the police immediately made Half Sibling 1 the subject of police protection. 4.32 The next social work visit was four days later when Mother and Half Sibling 1 were seen at the home of the Maternal Grandmother. Mother continued to deny her drunkenness and claimed that Father of Half Sibling 1 had only been there to help her. She was informed that the local authority would be seeking legal advice and convening a strategy meeting. No assessments were 34 proposed in relation to Maternal Grandmother’s capacity to look after Half Sibling 1. A written agreement was put in place which stated: (i) Mother to fully co-operate with Surrey Police investigations and not to remove Half Sibling 1 from Maternal Grandmother’s care (ii) Mother to contact her GP to seek help with alcohol misuse (iii) Mother to seek an injunction order in relation to Father of Half Sibling 1 (iv) Mother’s contact with Half Sibling 1 to be supervised by Maternal Grandmother (v) Any failure to follow any of the above may lead to the local authority instigating Public Law Outline protocol with likely risk of family court proceedings being issued 4.33 A copy of the written agreement was sent to Mother’s GP and the health visitor was informed of recent events by telephone. 4.34 The same day as the social work visit there is a record that the domestic violence outreach team spoke to Mother following a self-referral. No outreach support was required as the issue was a dispute with a neighbour. 4.35 On 9th June CPS advised the police that it was not in the public interest to charge Mother, as provisions for an offence of neglect were not made out and the matter was best dealt with by social services. 4.36 At a social worker visit to the Maternal Grandmother’s, contradictory information was given to the social worker by Maternal Grandmother and Mother. Mother told the social worker that she had contacted the domestic violence outreach services to seek support in gaining an injunction against Father of Half Sibling 1 and that she had spoken to the GP about her alcohol abuse. Maternal Grandmother, however, spoke privately to the social worker confirming that Father of Half Sibling 1 still lived with Mother and that Mother had threatened Maternal Grandmother saying she would not speak to her if she told anyone. There is no evidence within the chronology that Mother had spoken with the GP. 35 4.37 The next day the social worker checked with domestic violence outreach who confirmed that Mother had not sought advice from them about an injunction. A referral was made to the team by the social worker and during a telephone conversation Mother was advised that she would not be able to apply for a non-molestation order at that time as there had not been any recent abuse and she did not have Father of Half Sibling 1’s address. She was advised to report any incidents to the Police and contact the team again if the situation changed. Despite this advice, Mother continued to inform Children's Social Care that she was in the process of obtaining an injunction and had consulted with the GP who was referring her to alcohol rehabilitation. There is no evidence of such a referral in the chronology. 4.38 In supervision it was noted by the social worker and their supervisor that Mother and Maternal Grandmother were only superficially compliant with the plan. In the light of this, there appears to have been no discussion as to whether it was safe for Half Sibling 1 to remain with Maternal Grandmother. At the beginning of July 2009 the decision within Children's Social Care, following a management discussion, was that work needed to continue under the written agreement and child in need plan which would be reviewed at the start of August. 4.39 In July, Mother was seen at the GP surgery and noted to have ‘problems with Social Services in relation to looking after baby daughter’. Binge drinking was also noted and she was referred to Alcohol Misuse Services. The next day, the GP received a letter from the social worker requesting information regarding alcohol misuse and its impact on parenting but there is no record of a response to this letter. 4.40 The health visitor discussed the case in safeguarding supervision during July and the action agreed was for the health visitor to liaise with the worker regarding plans, and to see Half Sibling 1 at Maternal Grandmother’s home. 36 4.41 From this point it seems that Children's Social Care was planning for Half Sibling 1 to be returned to Mother. The understanding was that Father of Half Sibling 1 was not living with Mother and that she should ‘if possible’ seek an injunction/non-molestation order. Mother was noted to be aware of the consequences should she break the written agreement. There is an e-mail on file from the conference chair to the social worker expressing concerns that the original issues that had led to the child protection conference had not been resolved, and advising the social worker to discuss further with their manager. The social worker was reminded to consider the plan in the light of earlier serious case reviews. 4.42 The Domestic Abuse Outreach Service received two contacts from the social worker asking about the possibility of a non-molestation order. A worker met with Mother but since the situation was the same as at the point of the previous contact (i.e. no further incidents and ex partner’s address not known) the advice remained that it was not possible to apply for a non-molestation order. 4.43 Half Sibling 1 was returned to the care of Mother at the end of July 2009, the reason apparently being that Maternal Grandmother had a holiday booked. In August the case was transferred to a family support worker. During this period there were generally positive reports about Half Sibling 1’s progress and at a child in need meeting Half Sibling 1 was reported to be thriving in Mother’s care whilst supported by Maternal Grandmother. 4.44 During August, GP records note that Mother was seen in August by alcohol misuse services and assessed (again via self-report) as showing no signs of drink dependency or binge-style use. 4.45 In November 2009 Mother called the police to a domestic dispute over payment for a puppy. During this event, Mother disclosed that she had just found out she was pregnant. Children's Social Care were informed as the police had noted that the address was in a poor condition with rubbish on the 37 floor. In addition, the puppy had urinated on the floor and appeared to be undisciplined. 4.46 When the health visitor visited, Mother denied being pregnant. The social worker attempted to visit the next day, but there was no answer and, following a planned home visit, the case was closed. 4.47 It is now clear that Mother was pregnant as in January 2010, the GP referred Mother to hospital for antenatal care. The expected date of delivery was July 2010. In March 2010, Hospital 1 referred to both the health visitor and Children's Social Care in view of Mother’s previous history. 4.48 In March, Mother called the Surrey Police with various allegations about Father of Half Sibling 2. A child at risk notification was completed for Half Sibling 1, and a domestic abuse risk assessment completed with Mother being assessed as high risk. A referral was sent to the domestic violence outreach team. The next day, Children's Social Care noted the child and risk form and recorded that the police had no concerns about the children and apparently decided that an immediate social work visit was not necessary. 4.49 A member of the domestic abuse outreach team spoke to Mother on the phone. They were informed by her there was now no problem as her partner had left and she was therefore told to ring the team if her partner continued his abusive behaviour and she wanted to apply for an injunction. 4.50 During March, as a result of the police notification, Children's Social Care contacted the midwife at the hospital to discuss the organisation of a multi-agency meeting. A letter was sent to Mother with a date for an initial assessment. 4.51 Mother again called the police in April 2010 reporting a dispute with a neighbour. An appointment was made for a Neighbourhood officer to attend the address but Mother cancelled the appointment as the situation seemed to have been resolved. No further action was taken. 38 4.52 During April Mother missed two antenatal appointments at the Hospital. The midwife contacted Children's Social Care and was advised that a new social worker had only just been appointed to the case. A management review of the case in Children's Social Care in April 2010 recorded an agreed action plan that a core assessment was to be completed, that more information was required about Father of Half Sibling 2, and more information was required about Mother’s alcohol consumption. 4.53 At a strategy meeting in April it was decided that the threshold for S47 enquiries was not met, and social work visits should continue to complete the core assessment. The Children's Social Care individual management review notes that during this period the social worker formed a good relationship with Mother. 4.54 By the end of May Mother had not attended any of her antenatal appointments and Children's Social Care were informed. During this period there was clear evidence that Mother was giving contradictory information to various professionals. 4.55 The information obtained by the social worker from Mother was generally positive, with Mother stating that she had no further contact with Father of Half Sibling 2 and that she was no longer drinking alcohol or taking drugs. Half Sibling 1’s development appeared good and the home was described as clean and tidy. There is no evidence in the chronology that a pre-birth assessment was completed. 4.56 Half Sibling 2 was born in June 2010 in Hospital 1. It was clear that Father of Half Sibling 2 was in contact with Mother at this point and there is evidence that the social worker liaised with the hospital, the health visitor and the police regarding any potential risks from Father of Half Sibling 2. The message from the police that there was nothing to indicate that Father of Half Sibling 2 would pose a risk. 39 4.57 Prior to Half Sibling 2 leaving hospital, a discharge planning meeting took place and a written agreement was signed by Mother. 4.58 At the first health visitor visit, the health needs assessment was not updated. During the visit Half Sibling 1 was seen to help herself to meat from the fridge and eat from the packet. Mother said she had not eaten her dinner. On respect of Half Sibling 2 initial reports from the midwife and the health visitor indicate that she was feeding well and gaining weight. 4.59 By August, the health visitor records note that there was some uncertainty as to whether Mother was feeding Half Sibling 2 appropriately and she was asked to reduce feeds. Follow up was arranged by a nursery nurse who, when they visited, recorded that there was some difficulty in establishing a picture of feeding from the Mother. At the end of August the locality team, following consultation with the health visitor and the police, decided that Mother was doing well and that the case should be closed. 4.60 At the start of September 2010 the health visitor made an unplanned home visit to ask Mother to sign the paperwork for a nursery placement for Half Sibling 1. The health visitor records note that she thought she could smell alcohol on Mother’s breath but did not challenge her about this. Other concerns known to the health visitor at this point were the fact that Half Sibling 2 was not registered with a GP, nor had she commenced immunisations. This did not happen until November 2010. 4.61 The nursery conducted a pre-admission home visit. There are no records of this visit, but the workers involved do recall that the flat was grubby and that they considered that Mother might have possible learning difficulties. They assumed that the health visitor would pick up on the concerns around the grubby flat. There was therefore a missed opportunity at this point to join up information between the health visitor and early years provider. This would have been particularly helpful as, although the nursery did not identify any concerns, a pattern emerged of non-attendance with no reason for absence 40 recorded; for example, in November she was noted to have attended two out of three sessions and in December 2010 two out of five sessions. 4.62 There were two police contacts regarding Mother in October 2010; firstly, Mother reported a male (not one of the babies’ fathers) trying to get into the flat. The male, aged 19, was drunk and handed by the police back to his mother. On the second occasion, a neighbour called to say there was a disturbance at the address with a male banging on the door. Mother informed the police that there no problems. There was a further incident in November when Mother reported eggs being thrown at her front door. 4.63 Half Sibling 2 missed three appointments for her second set of immunisations and these were not given until 25 August 2011. In addition, the health visitor recorded a falling centile for weight for Half Sibling 2 at a visit in December 2010. Mother failed to attend clinic appointments and when Half Sibling 2’s weight was reviewed at the end of January 2011 it was noted between the 2nd and 9th centile, having been at the 25th centile at birth. There were a number of attempted contacts but Half Sibling 2 was not weighed again until April 2011, when she was below the 9th centile and by June 2011 her weight had fallen to the 4th centile. At an unplanned home visit by the health visitor there was a noted inconsistency between the amount Mother stated Half Sibling 2 was eating and the recorded weight and she was defensive when asked about Half Sibling 2’s diet. 4.64 The health visitor recalls that as a result of these concerns she had considered a referral to Children's Social Care, and discussed Half Sibling 2’s weight loss with the GP who advised waiting for a further review of her weight. There is no record of this verbal communication within the GP records and the health visitor did not take any further action in respect of a referral. 4.65 During this period where there were concerns about Half Sibling 2’s failure to thrive. In January 2011, Children's Social Care contact centre received a telephone call from Mother’s sister who informed them that Mother was pregnant with her third child and that her sister wanted to be a private foster 41 carer for the child when it was born. Mother and Half Sibling 1’s history was reviewed and, in the light of concerns, it was decided that a pre-birth assessment was required if the pregnancy were to continue. 4.66 A phone call was made to Mother by Children's Social Care in February 2011, during which it was confirmed that Mother had not yet decided whether to give up her unborn child. She agreed to a pre-birth assessment and to Children's Social Care contacting her GP to establish whether the pregnancy was still ongoing after a couple of weeks. This pre-birth assessment did not take place as the assessment team social worker (who had been qualified for one month) was advised by her manager that an initial assessment was all that was required in view of the nature of the self-referral. The social worker requested information from the school and GP but did not receive information from either of them and the health visitor indicated to the social worker that she did not have any concerns. 4.67 At the beginning of April, Mother telephoned Children's Social Care, explaining that she was five months pregnant but she didn’t wish to keep the baby and that her sister wanted to adopt the child. According to Maternal Aunt, at this point the plan was for her to take the baby home from hospital and she therefore began to prepare for this by buying baby equipment. 4.68 A week later a visit was carried out jointly by the newly qualified social worker from the assessment team and a social worker from the adoption and permanency team. Half Sibling 2 was with Maternal Grandmother and was not seen at this visit. The resulting initial assessment recommended that Mother and her sister be given advice about private adoption and the case closed. The initial assessment did acknowledge that both parties would need post-adoption support, and the assessment team social worker assumed that this would be carried forward by the adoption team. 4.69 Maternal aunt’s recollection of this event is that she and Mother were told that they should contact the permanency team when the baby was born. No 42 advice was given at that stage about what to do about finance, legal and practical arrangements at the point that she took the baby from hospital. 4.70 Meanwhile also in April, following a home visit, the health visitor recorded that Half Sibling 1 said that she had seen ‘Dad’ outside although this was denied by Mother. Health visitor records note bruising to both eyes that had almost faded, the explanation given by Mother that this had been caused by a fall from the sofa. No further action was taken by the health visitor in respect of this information. The health visitor at this point was unaware of the pregnancy and did not find out about this until a phone call from the social worker later that day. As well as informing the health visitor about the pregnancy, and their plan to close the case, Children's Social Care also sent a fax to the GP informing them that Mother was due to give her baby up for adoption within her own family. 4.71 The chronology notes that the social worker contacted the health visitor two days later for more information regarding the bruising on Half Sibling 2’s face. It is not clear how the social worker knew of this bruising since Half Sibling 2 had not been present during the social work visit and there is no record of the health visitor discussing the bruising with another professional. The health visitor informed the social worker of Mother’s explanation that she had left Half Sibling 2 on the nook of the settee when she went to fetch her nappy and Half Sibling 2 had taken a tumble, bruising her nose and the surrounding area. The health visitor said it was healing at the moment and it was mother’s judgement rather than the bruise which was a cause for concern. The health visitor stated that in spite of this she felt Mother tried her best, talked to her own mother and sought advice when she was worried. The social worker’s view at this time was that Mother presented as acknowledging that she had difficulties, was determined to improve, could not countenance a termination and wanted to do her best for her unborn baby. There is no record that any further action was taken by either the social worker or the health visitor in respect of two bruised eyes on a non-mobile baby. 4.72 The case was closed by Children's Social Care six days later. 43 4.73 During this period Half Sibling 1 continued at Nursery with continuing absences, the reasons for which were not recorded 4.74 In June 2011 that the health visitor visited Mother to follow up on news of the pregnancy. Mother was not home and the health visitor received information Mother had not attended any antenatal appointments during this pregnancy. This was followed up with Hospital 1 to confirm that Mother was not booked for antenatal care. The health visitor arranged for Mother to see the GP who confirmed that she was 31 weeks pregnant; the baby was unwanted, and her sister was planning to adopt. A referral was made to Hospital 1 for maternity care. The referral letter referred to a concealed pregnancy. 4.75 At this point Half Sibling 2’s weight had dropped to the fourth centile, and the health visitor planned weekly weighing and Mother was asked to take Half Sibling 2 to the GP. There is evidence of some improvement in feeding and weight gain although Half Sibling 2 was on several occasions reported to be staying with a friend of Mother’s when home visits were made and it is therefore not clear whether the weight gain was in fact due to Mother’s actions. 4.76 Due to Mother’s non-attendance at antenatal appointments, Hospital 1 contacted the referral information officer at Children's Social Care and was informed that the agency was aware of the pregnancy and an initial assessment would be carried out as Mother had told the midwife that she was going to keep the baby. However, the case was not allocated due to an ‘exceptional volume of cases’. 4.77 Mother’s antenatal care was transferred to Hospital 2 as this was more convenient for her and Children's Social Care were informed that Mother had failed to attend five appointments and had no antenatal care. The Hospital 2 midwife had tried to visit three times, without success and the midwife was concerned there was no plan post-birth. 44 4.78 Although the case could not be allocated, the assistant team manager from Children's Social Care conducted a home visit in order to ensure that the children were seen. The assistant team manager gathered comprehensive information in respect of the recent history and identified concerns about the condition of the home that was so poor that Mother was instructed to clean it that night with the help of the Maternal Grandmother. 4.79 A follow up visit was conducted the next day and concerns about the state of the kitchen and bathroom had been addressed by Mother. A strong smell of alcohol was noted from Mother and when confronted, she said she had vodka and Red Bull. There was an open can of rum and cola, plus two cans in the fridge and another glass of vodka and Red Bull. These were disposed of in the presence of the social worker. 4.80 The next day the nursery nurse conducted a planned home visit and it was noted that Half Sibling 2 had gained no further weight. She was now sitting but unstable (Half Sibling 2 was 1 year 1 month at this point). On the same day a strategy discussion took place between Children's Social Care and the police, without the involvement of health professionals. A single agency investigation was agreed (records indicate that the health visitor received a copy of the strategy meeting minutes a month later). 4.81 The health visitor telephoned the social worker to share concerns about: Mother systematically failing to engage with the service. Not booking herself in until she was 32 weeks pregnant and saying she had registered the pregnancy with the GP and hospital which was not true. The health and development needs of Half Sibling 2, including failure to thrive. Half Sibling 1 was noted to be doing quite well. During this call the social worker was noted as saying that she felt that the children should be removed from their Mother’s care although there is no evidence that this was the formal position of Children's Social Care at that time. 45 4.82 The health visitor discussed the case in safeguarding supervision in July 2011 and the resulting action plan was for the health visitor to liaise with the social worker and community midwife regarding the interagency plan. 4.83 Child S was born on the way to Hospital 2 in July 2011 and was placed in the Special Care Baby Unit. It would appear Maternal Aunt received a call from Mother saying that the baby had been born and named. It was at this point that Aunt said that she realised that she would not be taking Child S home with her from hospital. 4.84 Hospital records note that Child S was extremely jittery, had increased muscle tone, and neonatal drug withdrawal observations were commenced. Information from Kingston Hospital indicates that all diagnostic tests were to the expected standard. These observations relate to the impact of drug rather than alcohol use on the baby and Child S did not require any treatment. Contact was appropriately made with the social worker to discuss the need for a discharge planning meeting. At this point there is some confusion within the Children's Social Care records as to whether formal section 47 (child protection) enquires had been commenced as there is a note that ‘single agency investigation had just been agreed in view of the concerns while completing the IA’, but no record of this decision being made as a result of a strategy discussion involving police and health colleagues. 4.85 The social worker made an unannounced visit to Mother and thoroughly checked the state of the home. During this visit Mother (who was noted to be under the influence of alcohol but not drunk) was informed that this was a child protection investigation and that the condition of the home was not acceptable. Issues recorded were: Empty vodka bottle in the bin Mother’s explanation for drinking vodka was that she was drinking so she could get more strength and keep awake Mould in the fridge 46 Not enough food in fridge and cupboards 4.86 The social worker informed the team manager that it was not safe for Half Sibling 1 and Half Sibling 2 to remain in the home in the state it was in (Child S was still in hospital) and that Maternal Grandmother was not able to have the children to stay although she would visit that evening and help Mother clear up. This course of action was agreed by the team manager. 4.87 The next day when the social worker visited a lot of progress was noted but the kitchen needed to be cleaner. Half Sibling 2 was noted to be dressed appropriately but was again in a car seat. The social worker visited again at 18.00 hrs and was satisfied that the property was now in a hygienic state. 4.88 The discharge planning meeting at Hospital 2 included hospital staff, the health visitor, social worker and Mother. Child S was noted to be fit for discharge from a medical point of view and the social worker’s view was that there was no evidence to show that Mother would directly or deliberately harm Child S and he could therefore be discharged. Concerns were noted as. Lack of time for Mother to bond with Child S Mother not coping with child care, and a premature baby could aggravate the situation Financial difficulties Mother not maintaining property in an acceptable state Mother’s smoking presenting a hazard to Child S 4.89 The action plan from the meeting was: Matron to see if Maternal Grandmother could support with child care on Saturday so that Mother could have at least 24 hrs with Child S under observation and go through the discharge protocol Child S to be discharged the following Sunday Social worker and family support worker to visit the family 2-3 times per week (Monday, Wednesday and Friday) 47 Health visiting team and nursery nurse to visit on Tuesday and Thursday for the first week Mother to register the birth within the first week Social Worker to liaise with management regarding financial help with travel. Initial child protection conference to be convened Mother to keep all appointments Mother to give basic care to her children and ensure home was safe and hygienic. 4.90 Child S was cared for by Mother overnight prior to his discharge home on Sunday when he was twelve days old. The visiting pattern between professionals started as planned the next day and no concerns were noted in the Children’s Social Care records. On the Tuesday the health visitor records note that Mother stated doubts about her ability to maintain adequate care, Half Sibling 2 had not been taken for medical appointments and Half Sibling 1 (age 3 years 11 months) was playing outside unsupervised. When Mother was asked about this she said that Half Sibling 1 was used to this and would return. Half Sibling 1 was then noted to say that she was hungry and helped herself to food from the fridge. These observations were not shared with Children’s Social Care. 4.91 On Wednesday during the social work visit, Half Sibling 2 was not there and was reported to be with a friend of Mother’s, Half Sibling 1 was playing outside supervised by a neighbour and the property was clean and presentable. Half Sibling 2 was also not there the next day when the health visitor called and Mother was noted to talk negatively about Half Sibling 2 as a baby. 4.92 The family support worker visited on Friday and made a detailed record of the visit. Mother was noted to have ‘excellent interaction’ with all her three children although there is no detail as to what this meant. The state of the home was not as bad as previously but there were indications that Mother was finding maintaining standards a struggle. 48 4.93 During the following weekend the community midwife made two planned home visits. On the first occasion, Mother did not allow the midwife into the house as family and friends were visiting and on the second no one was at home. The community midwife visited again on Monday and let the health visitor and social worker know that were no midwifery concerns. 4.94 On the Monday there was also a visit to the home by the family support worker together with the social worker. There were no improvements in the condition of the home since Friday and Half Sibling 2 was noted to be lying in her cot. The record notes concern about her developmental delay, and that she was always found without much attention. Her upper feet were also noted to be dirty. 4.95 The health visitor visited as planned on the Tuesday. Maternal Grandmother was looking after the children whilst Mother was reported to be out registering Child S’s birth. Maternal Grandmother was recorded as telling the health visitor that Mother did not feed the children properly. There is a record in the Children’s Social Care file of a text message from the health visitor saying all was going well for Child S. It noted little weight gain for Half Sibling 2 and that she had stayed at a friend of Mother’s from Tuesday to Friday the previous week. The message also noted that the health visitor would be visiting again on Wednesday the following week. 4.96 On the Tuesday there is a record by a new social worker that they had found this case allocated to them in their work tray. It is not clear from the chronology why there was a change of worker at this point. There is also a note that the record of outcomes for was overdue and that this would be completed with a view to progressing the case to initial child protection conference. 4.97 The chronology then indicates that the same social worker who had visited on the Monday visited the home on the Wednesday as Half Sibling 2’s feet were 49 cleaner than on the last visit. Half Sibling 2’s weight was discussed and Mother was noted to be interacting well with her. 4.98 A nursery nurse visited on the Thursday and a family support worker on the following Monday. During the visit by the family support worker, Mother said she would not be able to attend the forthcoming child protection conference as she could not get all children ready and out of the house for a 09.20 hrs meeting. Later that evening Mother called the Surrey Police reporting an assault by a neighbour and was found by the Police to be intoxicated. The police report notes that the officer concerned did not believe that the children were present at the time and therefore did not notify Children's Social Care. 4.99 The planned visit by the health visitor that week was cancelled by Mother but the social worker called unannounced to share the child protection conference report. There was no reply, and whilst the social worker was there Mother returned saying she had popped out for two minutes. The children were sleeping inside the house. Child S was four weeks old at this point. 4.100 The focus of the visit was the fact that Mother did not wish to attend the child protection conference as she felt judged and also did not have anyone to leave the children with. During the visit it was noted that the children had not had anything to eat that morning except biscuits and Mother said that she would give them eggs and bread when the social worker left (the time of visit is not clear). Half Sibling 1 pointed out a cut on Child S’s toe, an injury for which Mother had no explanation other then he might have cut himself with his nails. The social worker reported this to the assistant team manager who asked for the injury to be bought to the attention of the child protection conference and for the family support worker to care for the children to enable Mother to attend. There is no confirmation that the issue about the children being left alone was shared with the manager or considered to be serious child protection concern. 4.101 Mother declined the offer of a family support worker to care for the children during the child protection conference and reiterated the fact that she did not 50 want to face professionals who were going to tell her that she was a bad parent. At the conference in August 2011, all three children were made subject of a child protection plan under the categories of neglect and emotional abuse. The plan was very similar to previous plans and included Mother to ensure children’s needs were met and comply with announced and unannounced visits Professionals to work together to ensure that the children’s needs and developmental milestones were met To consider engaging with alcohol and domestic abuse services 4.102 There is no evidence at this point that any assessment had included consideration of parental motivation to change or the extent of Mother’s alcohol misuse. 4.103 It should be noted that no one from Half Sibling 1’s nursery attended the conference or sent a report. It seems that the nursery was notified verbally that the case was child protection just before the school holidays in July and received a formal letter to the conference during August. This was not opened by the school until September. 4.104 The same day as the conference, the case was transferred to the child protection and proceedings team in Children's Social Care. A planned home visit took place by the new social worker during which Mother continually stressed that she did not need support, asked the social worker to leave because she said they were upsetting her and said she would not let anyone from the social worker’s team into the home. A planned health visitor visit for the next day was cancelled by Mother as was a planned visit by the nursery nurse two days later. Mother did attend a core group meeting where she was noted to be resistant and defensive. 4.105 A legal planning meeting took place at the end of August when Child S was six weeks old, the conclusion of which was that more information needed to be collated before a decision could be made. The Children's Social Care 51 individual management review outlines a number of concerns about the effectiveness of this meeting with a lack of chronology and social workers attending without a well organised and documented case. There were also differences of opinion between social workers, with the assistant team manager from the assessment team feeling there was sufficient evidence to support legal intervention, whereas workers from the child protection and proceedings team (who had begun working with the case more recently) felt unconvinced due to Mother’s ‘recent engagement’. 4.106 At the age of six and half weeks Child S’s weight gain was noted by the health visitor to be good. Half Sibling 2 (now age fourteen months) was recorded as now being on the 9th centile and regularly staying with a friend who had two children. The social worker visited the same day and Half Sibling 2 was noted to be crawling and there were some positive aspects in the home environment such as it being ‘clean and tidy’, the temperature in Child S’s room being ‘about right’ and food not out of date in the fridge. Other issues noted were mould in some of the rooms and the fact that the cooker was not working and Mother was relying on a microwave. 4.107 Mother was not in for the next planned home visit by the health visitor and she did not keep an appointment with the GP for Child S’s developmental check the same day. She also failed to take Child S to an appointment at Hospital 2. Child S at the age of eight weeks had failed ten health appointments, a concern which was notified to the health visitor by the GP. 4.108 A social work record notes the failed appointments and the social worker rang the nursery to ascertain whether Half Sibling 1 was attending and was informed that Half Sibling 1 was not expected to resume nursery until later in September. 4.109 Later that day the social worker and a new family support worker made an unannounced visit. The records describe the house as dirty and cluttered and she was made aware that the condition of the flat was not acceptable. The 52 issue of the missed appointments was discussed and Mother is noted to have made excuses. 4.110 The health visitor visited two days later and Mother was noted to be upset as the visit was early and unexpected. She was also noted to be tearful and angry and not wanting social work intervention. On the visit the following was observed: Half Sibling 2 good weight gain Half Sibling 2 immature crawling and not pulling to stand as had been reported by Mother Half Sibling 2 – no further immunisations Child S weight static (unusual in a bottle fed baby) Child S – injury to right hand which Mother could not account for. Child S described as tense and rigid and screamed in pain when the health visitor bathed the wounds The health visitor communicated the outcome of this visit to the social worker immediately and the social work records note all of the above issues plus the fact that the health visitor said Child S was a tense little boy who had not started making eye contact and that Mother had said she would not open the door to the family support worker as working with her was optional. As well as speaking to the social worker the health visitor also alerted a covering colleague since she would be out of the office the following day 4.111 Following the conversation with the health visitor, the social worker called Maternal Grandmother to advise her of the latest concerns. The social worker was unable to get through to Mother on the phone and agreed with Maternal Grandmother that her sister would call at the house at 15.00 hrs and ask Mother to ring the GP for an appointment. The next day the health visitor was informed by the GP surgery that Mother had rung to ask for an appointment for an infected hand, had declined an early appointment and accepted one at 16.50 hrs. However, when the health visitor spoke to Mother, she said she could not attend the GP’s surgery that day. She was strongly advised by the health visitor to attend the next morning at 09.00 hrs. 53 4.112 The day after the call from the health visitor advising of Child S’s injury and the other concerns the family support worker conducted an unannounced visit to the home. Half Sibling 2 could be heard crying but no adult was in the flat. When Mother returned the flat was found to be a very poor state. Child S’s injured finger was apparent as was a bruise on his face covered by Sudocrem. Mother could give no explanation for the bruise. The family support worker alerted the social worker 4.113 Child S was taken to Hospital 2 and initial examination revealed a fractured skull, old and new bleeds and a blood spot at the back of his eye. Child protection medicals were also carried out on Half Sibling 1 and Half Sibling 2 who were found to be medically fit. Half Sibling 1 was removed from home into the care of Maternal Grandmother and Half Sibling 2 also removed into the care of a family friend (for whom the required assessments were undertaken) until foster placements were found. The decision was made by the Local Authority to issue care proceedings in respect of all three children. 5. THEMATIC ANALYSIS OF PROFESSIONAL PRACTICE Recognising risk 5.1 Individual risk factors will be explored in more detail later in this section, however, it is important not to lose sight of the whole picture and to consider the opportunities available to practitioners to recognise the accumulating concerns over time and assess the potential risk to the children. There were a number of factors present in this case which are known to be associated with risk to children, yet these were not adequately assessed as a whole and a judgement made as to how safe the three children were in their mother’s care. Because this assessment did not take place plans to protect the children were not sufficiently robust particularly in relation to measuring whether sufficient change had taken place to reduce the risk of harm. 5.2 Examples of accumulating concerns are: Alcohol misuse when caring for child and/or pregnant (all three children). 54 Recurrent allegations of partner violence (Half Sibling 1 aged one noted to cry when Mother raised her voice). Ongoing lack of engagement with a variety of services but most significantly lack of antenatal care during second and third pregnancies and delayed GP registration and immunisations for all the babies. Lack of provision of appropriate food and supervision after the birth of Half Sibling 2 with Half Sibling 1 noted to be helping herself to food, playing outside unsupervised / hungry. Half Sibling 2’s failure to thrive and significant developmental delay. Lack of evidence of emotional bond between Mother and Half Sibling 2 with Half Sibling 2 being looked after for long periods by others. Mother wishing to give Child S up for adoption when she found she was pregnant. Bruising on a non-mobile baby (Half Sibling 2’s two bruised eyes). Child S being a ‘jittery’ baby (possibly associated with Mother’s alcohol use). The stress associated with caring for three babies under the age of four at the time of Child S’s birth. Mother’s expressed doubts to the health visitor about her ability to maintain adequate care following the birth of Child S. Half Sibling 1 playing outside unsupervised following Child S’s birth and saying she was hungry. Children found by a social worker at home alone whilst Mother ‘popped out’ one month before the significant incident. 5.3 There is little evidence that assessments at any time adequately analysed the interaction between known risk and the protective factors within the environment. The need for such an approach became particularly acute following the birth of the second and third children when stressors within the family environment increased, yet there is little evidence of an associated increase in factors that were likely to reduce the likelihood of harm. 55 5.4 Factors that are known to be associated with risk to babies and very young children (Ward et al 2012)2 include parents who have experienced abusive childhoods themselves and have not come to terms with the abuse, substance misuse, intimate partner violence and environmental stressors such as housing. Significant protective factors are the presence of a supportive non-partner, wider family and informal support and parent’s insight understanding and capacity to change. Severe risk of harm is most likely where there is an absence of protective factors particularly evidence of the parent’s capacity to change. 5.5 In this case a number of risks were present yet there was little evidence of the mitigating effect of protective factors. Misuse of alcohol is a theme running throughout the chronology with no evidence of willingness on Mother’s part to address this and there is consistent evidence of no engagement with services. In addition it is likely that she was adversely affected by her own childhood experiences and there was no attempt to understand these or the impact they may have on her as she became a parent. There was an overreliance on the support of Mother’s family as the one protective factor, without any evidence of a detailed assessment of family dynamics and relationships. 5.6 Within this overall context, the accumulating concerns from the birth of Half Sibling 1 onwards should have worried professionals. Not all concerns were known to social workers, particularly when the case was closed to Children's Social Care two months after Half Sibling 2’s birth until Mother‘s pregnancy with Child S. During this period it was the health visitor who had most contact with the family and was aware of the concerns about failure to thrive. Surrey Local Safeguarding Children Board has been assured through its routine monitoring mechanisms that relevant action has been taken by the health organisation involved in order to improve the knowledge and skill of practitioners. 2 Ward, H., Brown, R., and Westlake, D. (2012) Safeguarding Babies and Very Young Children. London: Jessica Kingsley Publishers. 56 5.7 By the time of the legal planning meeting at the end of August 2011 all the information should have been collated by social workers and presented in a way that allowed the lawyer to make a reasoned decision as to whether the threshold for proceedings had been met. Instead, at this point there were disagreements between the assistant team managers from assessment team and child protection and proceedings team and they did not present sufficient documentary evidence to the meeting. 5.8 Disagreements appear to have been influenced by the fact that the child protection and proceedings team had recently taken over the case and were more optimistic that recent changes could be sustained. Children’s Social Care are also aware that at that time there was inconsistent practice in relation to the quality of evidence provided to legal planning meetings and this was also affected by a lack of focus on the importance of chronologies within the service (which has now been addressed by a Children's Social Care recommendation). Steps have now been taken to ensure that no legal planning meeting takes place without the necessary written documents being provided as evidence prior to the meeting. Recognising the significance of history 5.9 There was no indication that at any time practitioners sought relevant information about Mother’s experience as a child and used this to inform an assessment of the support she was likely to need as a parent in her own right. This was despite it being known by social workers and health visitors that she had been in care as a child. Where information was already known to individual practitioners due to their previous involvement (in this case the first health visitor) the significance was not recognised; neither was the information shared appropriately with others in the network. The historical information was particularly significant in respect of the quality of support that might have been available from the wider family and their role in providing alternative care for Mother’s children. The health visiting records contain information that Mother moved out of home as a teenager due to abuse and in June 2009 it was recognised that both Mother and Maternal Grandmother were only superficially compliant with the child protection plan, yet there is no evidence 57 that this superficiality was understood in terms of previous information relating to previous family history and relationships. 5.10 When the decision was made to place Half Sibling 1 with Maternal Grandmother there was no information available to the emergency duty team on the electronic records about the suitability of this placement, nor was there any further assessment by social workers of her as a carer when Half Sibling 1 was placed there for two months. There was also no detailed exploration of history at the point that Mother’s sister was being put forward as a possible adoptive parent. 5.11 It was only when the information about family history was sought for this serious case review that the similarity between Mother’s own experience as a child and her parenting of her own children was recognised. Paper files had to be retrieved from archive for this data to be available even though by this point all three children had been removed from Mother’s care. Despite the serious injury and removal of the children no one had accessed this significant information and it seems that at no point did anyone consider the question of missing information. 5.12 Why this was the case in Children's Social Care seems to stem from the fact that information was not retrieved at the point of first contact and from then onwards it was assumed that assessments contained all relevant information. The challenges of maintaining a questioning mind-set are illustrated by the comment of one social worker that an assessment had already been undertaken, they assumed they therefore had all relevant information and it was therefore not their role to undertake another assessment. A child protection conference chair also commented that they were reliant on information provided to them and they were unaware of the extent of Mother’s history. 5.13 It was clear to the serious case review panel that retrieving information could be time consuming and in the case of Mother’s education records, the panel were not able to retrieve these at all due to an administrative problem. 58 Understanding the barriers to retrieval within the administrative system is important since busy practitioners need smooth efficient systems in order to support them in their work. The impact of alcohol use on parenting capacity 5.14 Unlike many cases where alcohol use is hidden or minimised, in this case alcohol use was overt and happening throughout the last pregnancy. Despite this overt use combined with other stressors, practitioners did not at any time appear to clearly define this as a child protection issue and work together with substance misuse services to pool information and fully assess the risk of harm. 5.15 There are ten instances within the chronology where Mother is noted to be drunk when pregnant and/or actively looking after one or more of her children. On all but two occasions records are clear that Children's Social Care were informed and from time to time there is mention in social work records or assessments that alcohol use was factor affecting parenting. However, at no time were the actual risks associated with alcohol use articulated and analysed. The reason for this seems to be that social workers were lulled into a false sense of security by a lack of concern expressed by the GP or the alcohol misuse service. Both these services relied on self-reporting by Mother whereas social workers and police officers had clear evidence of significant use that was directly impacting on parenting capacity. 5.16 Prior to the birth of Half Sibling 2 even where alcohol misuse was suspected, professionals were distracted from naming the risk and challenging Mother. For example in August 2008 Mother was found to be drunk whilst looking after Half Sibling 1 and it was noted that Half Sibling 1 cried when Mother raised her voice. Alcohol was recognised to be a concern but this did not detract from the dominant social work view that there were no concerns about the care of Half Sibling 1 or her safety. Again, in September 2008, Mother was again drunk when caring for Half Sibling 1 but two days later the social worker noted that Half Sibling 1 was ‘truly thriving’ in her new home. 59 5.17 The failure by the health visitor to speak to Mother about her alcohol use when she thought she could smell alcohol on her breath at an unplanned home visit when Half Sibling 2 was three months old highlights the need to equip professionals with the knowledge, confidence and skills to address concerns about alcohol use. This failure to address the issue was despite knowledge that alcohol misuse had been a previous concern. 5.18 A similar lack of focus on alcohol as a significant cause for concern can be seen eight days prior to the birth of Child S when Mother was noted by the social worker to smell strongly of alcohol and she admitted drinking vodka and Red Bull. Other alcohol was seen in the flat and was disposed of in the presence of the social worker. At this time the focus was on the lack of hygiene within the flat and there is also evidence of lack of appropriate stimulation for Half Sibling 2 who was sitting in a car seat. It is also significant that Half Sibling 1 appears to be worried about her Mother as she is noted to be playing outside and occasionally coming in to ‘check on her mum’. There is little evidence that the extent of alcohol use was shared by the social worker with health professionals who should have been made aware of the extent of alcohol use this late in pregnancy. Risks were also not properly analysed in the light of the care being given to the children. 5.19 It is hardly surprising that Child S was a ‘jittery baby’, yet the risks associated with Mother’s alcohol use continued to be minimised. The comment at the discharge planning meeting that it was safe for the baby to return home as Mother would not deliberately harm him does not take account of the unintentional harm associated with alcohol use and young babies. 5.20 Brandon et al (2013)3 in their study of neglect and serious case reviews note that professionals can be falsely reassured by an apparently good relationship between parent and baby and comment, ‘A good relationship between a baby and parent cannot keep the infant safe for example when co-sleeping with a 3 Brandon, M., Bailey, S., Belderson, P., and Larsson, B. (2013) Neglect and Serious Case Reviews. University of East Anglia/NSPCC. Page 77 60 parent who has consumed drugs or alcohol’. Assessments therefore need to look both at the intrinsic risks associated with parental behaviour, alongside parent/child relationships and day to day care. In this case in respect of Half Sibling 1 the focus was on the latter two issues at the expense of the former. By the time Half Sibling 2 was born there was sufficient evidence to suggest that all three aspects of care were compromised. 5.21 Police consistently recorded concerns about alcohol when Mother was found drunk and apart from one occasion (when the officer did not believe the children to be present) notified Children's Social Care. Mother received a police caution for being unfit to care for a child when under the influence of alcohol and drugs and on another occasion was arrested for child neglect whilst unconscious, apparently through alcohol, whilst caring for a child. It is clear that on the latter occasion the Surrey Police took this matter particularly seriously and a file was submitted to the CPS. The Police had been unable to charge Mother with being drunk in charge of a child as this offence is only applicable when the carer is drunk in a public place. In this instance Mother was drunk (unconscious) in her own home and therefore neglect was the only applicable offence. It was however the view of the CPS that the case for neglect was not made out and the serious case review panel were disappointed that this decision meant mother was not held to account for her actions at this time. 5.22 Following Mother’s arrest for neglect (as a result of being drunk within the home) and the placement of Half Sibling 1 with Maternal Grandmother, Half Sibling 1 was returned home to Mother two months later at the point that Maternal Grandmother was due to go on holiday. It seems that decision making may have been influenced by neither the GP nor alcohol misuse services expressing any major concerns and viewing Mother’s alcohol use as ‘binge drinking’. 5.23 This concern about health and social care workers not seeing or addressing parental alcohol misuse is recognised in a report by Alcohol Concern and The 61 Children’s Society (2010)4. They note children in families where alcohol is a serious issue for parents is frequently not addressed ‘until problems escalate, and even then, parental alcohol use is not always recognised or recorded’. There is clear evidence in this case of a lack of rigour and persistence in addressing issues relating to alcohol. The health visitor smelt alcohol but did not challenge Mother and the plan in August 2011 said that Mother should ‘consider’ engaging with alcohol and domestic abuse services rather than this being seen as an essential element of safe care. 5.24 Why this is the case needs further exploration by the Surrey Safeguarding Children Board, starting with the recognition that alcohol is a socially acceptable drug and therefore may be less likely to cause alarm than illegal drug use. Another possible explanation is a reliance on ‘experts’, with the first health visitor telling the individual management review author that they did not recall being asked by the child protection conference to explore the role of alcohol in Mother’s life, and that in any case she would have challenged this as she felt that she was not an expert in this area. It is of note that a framework to assist assessment in cases on substance misuse was in place as part of the locality child protection procedures during the timeframe for this review. At no time was this used in this case, possibly as alcohol was not viewed in the same way as other substances (such as illegal drugs) which were believed to be the focus of the framework. 5.25 As a result of a lack of focus on the impact of alcohol misuse on parenting Children's Social Care apparently did not consider inviting alcohol misuse services to child protection conferences nor to work effectively together to carry out joint assessments. As a result the alcohol misuse service only had Mother’s self-report rather than the full history known to Police and Children's Social Care. It seems the GP also did not consider the full picture and ensure that this was known when a referral was made to the specialist service. 4 Delargy A. et al (2010) Swept Under the Carpet – Children Affected by Parental Alcohol Misuse. Alcohol Concern & The Children’s Society 62 Bruising and injuries in children who are not independently mobile 5.26 Where bruising or injuries are seen in children who are not independently mobile, this should raise concerns and prompt professionals to consider the possibility of abuse. In April 2011, when Half Sibling 2 was nine months old and not able to sit independently, the health visitor noticed two bruised eyes and too easily accepted the explanation given that she had fallen off the sofa. At this point Half Sibling 2 was known to be failing to thrive and living in circumstances where there were a number of stressors. Good practice would have been to refer formally to Children's Social Care and request a medical examination. 5.27 Communication in respect of the bruising to Half Sibling 2 appears muddled with one of the social workers responsible for talking to Mother about the proposed adoption of her third child asking the health visitor for information about the bruise. According to records this social worker had not seen Half Sibling 2 and it is not therefore clear how they came by this information. Having been reassured by the health visitor that Half Sibling 2 was not seriously harmed and Mother ‘tried her best’, the management decision within Children's Social Care was to speak to Mother and encourage her to take her child to the doctor. The discussion with Mother did not take place until the next day and records refer to a general discussion about Mother taking her children to the doctor. There was no follow up to ensure that the advice had been heeded and in fact, since the focus was on the adoption request, the case was closed five days later. There is no indication that either the health visitor or the social worker carrying out the initial assessment assessed the bruising from an understanding of the rarity of bruising in non-mobile infants (less than 1%)5 or within the context of previous concerns about parenting and Half Sibling 2’s failure to thrive. The social worker involved at this point was very newly qualified and there was a lack of robust supervision which allowed for critical reflection on the information available. More effective 5 Maguire, S., Mann, M.K., Sibert, J., and Kemp, A. (2005) ‘Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Archive of Disease in Childhood. 90 182-186 63 support and supervision at this point may have reduced the likelihood of the apparent over reliance by the social worker on the opinion of the health visitor. 5.28 There were two unexplained injuries to Child S that came to the attention of professionals. The first injury was a cut on his toe when he was one month old, seen by a social worker. The context for this visit was that the previous day’s visit by the health visitor had been cancelled by Mother and when the social worker arrived, the children had been found at home alone whilst Mother ‘popped out’. The management decision was that the injury should be brought to the attention of the child protection conference the next day, whereas a more appropriate response would have been to arrange a medical examination and to consider emergency removal at this point. 5.29 The second unexplained injury was first seen by the health visitor the day before the serious injuries were identified. Child S is noted to have an injury to his right hand and significantly, is described a tense and shaking when first held. This information was conveyed verbally to a social worker but its potential seriousness appears not to have been understood since the response was to ask Maternal Grandmother to ensure that Mother took Child S to the GP. An unexplained injury in a young baby subject of a child protection plan, especially where this is the second injury in a short space of time, should have immediately prompted a child protection medical examination. 5.30 The family support worker acted promptly the next day in respect of the finger injury and the bruise on Child S’s face covered with Sudocrem and as a result all three children were removed from Mother’s care. T his was good practice in line with procedures which needs to be promoted by Surrey Safeguarding Children Board through raising awareness of the significance of bruising in non-mobile babies and taking steps to ensure that all practitioners are aware of the action to take if this is found to be present. 64 Recognising the interface between child neglect and physical abuse 5.31 It is notable that the health visitor told the review that they had not clearly understood the link between chronic neglect and physical abuse. Although this was not articulated in the same way by social workers, practice evidence would suggest a similar lack of understanding. Comments within the social work records noted the quality of the home environment and immediately before and after the birth of Child S and social workers were diligent in making expectations clear to Mother and following through on agreed actions. However, both social workers and the health visitor were less robust in their response to evidence of physical injuries such as the bruising to Half Sibling 2 and the injury to Child S’s finger. There was insufficient understanding that chronic neglect may be a driver for physical abuse and the association between the two (Brandon et al 2013)6. This is similar to the ‘neglect mind-set’ which precludes other forms of harm being considered (Brandon et al 2009)7 and indicates the challenge in working with complex situations which require the practitioner to hold a number of possibilities in mind. 5.32 In this case it is possible that Mother’s feeling that she could not cope (as expressed to the health visitor) was confirmed to her by her struggle to provide basic care leading to frustration and blaming/punishing the child. This is similar to the ‘care conflicts’ described in a previous study of child deaths (Reder et al 1993)8. The lack of focus on the relationship (specifically bonding and attachment) between Mother and her younger two children appears to have prevented consideration of the possibility that she could deliberately harm her child. The fact that there has been knowledge in the child protection field for some twenty years that could have informed practice in this case is testament to the need for organisations to ensure practitioners have sufficient knowledge and then support them to apply this in practice through effective management and supervision. 6 Brandon, M., Bailey, S., Belderson, P., and Larsson, B. (2013) Neglect and Serious Case Reviews. University of East Anglia/NSPCC. Page 64. 7 Brandon, M., Bailey, S., Belderson, P. Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C., and Black, J. (2009) Understanding Serious Case Reviews and their Impact. DCSF- RR129 page 50 8 Reder, P and Duncan, S and Gray, M (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge. 65 Meaning of the child 5.33 Assessments in this case would have benefitted from consideration of the potentially different meaning that each child had for Mother. The significance of understanding the meaning of individual children within families has been recognised as an important aspect of child protection practice over several years9,10. All children will have psychological meaning to their parents and in most cases this is not at all problematic. However, there can be problems where children have negative associations such being unplanned or unwanted, the result of rape or violence, or are perceived to be difficult or problematic from birth. In this case there is evidence that both Half Sibling 2 and Child S may have had a meaning which contributed to abuse and/or neglect. 5.34 In respect of Half Sibling 2 Mother initially denied she was pregnant and then avoided antenatal care. There was a reported adversarial relationship with Half Sibling 2’s father and Mother told the health visitor that she was disappointed that Half Sibling 2 looked like him. All these factors should have informed professional assessments, when Half Sibling 2 was failing to thrive and there it was clear that she was frequently being looked after by carers other than her mother. 5.35 Child S’s was an unwanted pregnancy and it was unlikely that, given the family history and relationships, adoption by Mother’s sister would be smooth. It was not good practice to close the case after an initial assessment with records showing that advice had been given about private adoption. Maternal Aunt recalls being told to contact Children's Social Care again when the baby was born and feeling surprised that no advice had been given such as what to do about finance and practical arrangements when she took the baby from hospital. The case should have been kept open throughout the pregnancy in 9 Reder, P., Duncan, S., and Gray, M. (1993) Beyond Blame: Child Abuse Tragedies Revisited: London: Routledge 10 Reder, P and Duncan, S. (1995) ‘The Meaning of the Child’ in Reder, P and Lucy, C. (eds) Assessment of Parenting. London: Routledge. 66 order to ensure that any necessary pre-birth assessments were carried out. The reason that did not happen seems to have been due to a lack of easily available background information to inform the initial assessment process as a result of the changeover from one electronic system (Swift) to another (ICS). There were also pressures on staffing at the time which meant that the case was allocated to a new social worker who received no effective supervision. 5.36 Even if the pre birth assessment had occurred, once it was clear that Mother was keeping Child S, her feelings toward this baby should have been explored and Mother’s previous request to have him adopted by a family member should have informed a more thorough assessment of Mother‘s capacity to bond with the baby and provide appropriate emotional warmth and safe care. Assessing the impact of learning disability on parenting capacity 5.37 Records within Children's Social Care show that Mother had mild learning disabilities, emotional difficulties and a statement of special educational need and she told the health visitor that she was unable to read or write and therefore ignored mail. The nature and extent of any disabilities were not assessed and this information used to inform the help given or the risks to the children. Whilst learning disability does not alone increase risk, attention does need to be paid to ensuring that the right type of support is in place. Additionally, the presence of a learning disability may ‘compound other difficulties affecting the lives of families’11, and in this case the possibility should have been considered as one of the many interacting risk factors and actively excluded or included as a significant factor. Working with fathers 5.38 There are three fathers in this case, although the identity of the father of Child S has not been confirmed. Where the identities of the fathers are known and in some cases considerable efforts made to locate their whereabouts, the impression from the records is that they were mainly thought of in terms of 11 McGaw, S. Newman, T. (2005) What Works for Parents with Learning Disabilities. London: Barnados. Page 7 67 potential risk, rather than having anything positive to contribute to assessments and plans. 5.39 In some records fathers are absent, for example there is no reference in health visitor records at time of Half Sibling 1’s birth as to whom her father was or, indeed, who was Mother’s partner at that time. Engaging with fathers has been a theme from previous Surrey serious case reviews and the requirement to include fathers and male carers in assessments has been reinforced via the delivery of serious case review findings workshops, circulation of learning from serious case review leaflets, inclusion of a training course in the annual training programme with a focus on engaging fathers, audits included in the quality assurance programme and activity via area groups to identify barriers. Further consideration needs to be given as to how to most effectively work with fathers particularly where they are seen as peripheral to the lives of their children or a potential risk. Working with resistance 5.40 There are numerous examples throughout the chronology and individual management reviews of Mother failing to engage with services and/or being openly hostile and resistant to help. Equally, there are other occasions where she appeared to develop reasonable working relationships with individuals but still there was little evidence of sustained improvement in her capacity to provide safe appropriate care for her children. The one organisation that that she approached consistently of her own volition for help was Surrey Police in relation to threats of violence or altercations with neighbours and acquaintances. 5.41 Mother’s resistant or avoidant behaviour is most striking in relation to the number of failed health appointments which are too numerous to mention individually. Despite this being a known risk factor there was insufficient analysis of implications of lack of antenatal care for Mother or postnatal care for the babies. Specific examples of resistant behaviour are: 68 Half Sibling 1 not registered with a GP until seventeen weeks old; immunisations and eight week check overdue despite reminders (similar delay in respect of Half Sibling 2) ‘Too busy’ to see a social worker (February 2008) No antenatal care for second and third pregnancies Giving contradictory information to different professionals Informing Children's Social Care that she had seen the GP when she had not Giving unclear information to professionals e.g. note from health visitor that there was ‘some difficulty in establishing a picture of feeding from mother’ Avoiding midwives visits after the birth of Child S Overt hostility to social work intervention after the birth of Child S 5.42 At no time is there any evidence that the cumulative effects of her behaviour were analysed in terms of potential risk nor were the reasons for resistance explored and attempts made to address them within child protection or child in need plans. For example, it is likely that the extended family had views about social work intervention from past experience and that this would have affected the response of both Mother and Maternal Grandmother. In such a situation resistance should have been assumed, explored openly with Mother and plans set out clearly what was expected and contingencies for situations where change was not achieved. Discussions with Maternal Aunt confirmed that this would have been the best approach. 5.43 The eight steps identified by Ferguson (2011)12 on working with involuntary clients may therefore have provided a useful framework in this case: 1. Recognise authority and assume conflict and not co-operation 2. Encourage openness and honest expression of feelings 3. Identify what the resistance is really about and what is working well 4. Identify the dangers to the children 12 Ferguson, H. (2011) Child Protection Practice. Basingstoke: Palgrave Macmillan. 69 5. Identify what is not negotiable 6. Identify what is negotiable 7. Formulate a child protection plan 8. Be clear about criteria for progress 5.44 Some workers developed particular tactics for managing Mother’s reluctance to engage. For example, the first health visitor asked Mother to attend clinic rather than arrange a home visit and risk the family not being there with the attendant consequence that the home environment was not seen. 5.45 There were latterly examples of social workers being clear about expectations in relation to basic hygiene and being persistent in following up tasks set. However, the work did not take place within an overall understanding of the reasons why non-cooperation was likely, all the potential risks to the children; for example those associated with alcohol misuse or lack of emotional warmth. 5.46 Working with resistance requires workers to have highly developed interpersonal skills that allow for authoritative practice (Forrester et al 2012)13. Such skills will require workers to effectively manage their emotions in order to prevent either collusive or overly oppressive styles of interaction, yet there is no evidence that supervision in Health or Children’s Social Care explored the impact of working with resistance on the practitioner and the effect that this could have on professional responses. Management and supervision 5.47 It is apparent that at several points in this case there were opportunities for managers and/or supervisors to make a positive difference through encouraging staff to critically reflect on their practice. This should have included an exploration the factors that may have affected their decision making including values, attitudes, assumptions, knowledge, experience and 13 Forrester, D., Westlake, D., and Glynn, G. (2012) ‘Parental Resistance and Social Worker skills’ Child and Family Social Work. 17 118-129. 70 workload. For example the nursery staff visiting the home could have been encouraged to explore their views regarding the physical environment and their assumption that the health visitor would be dealing with any issues. Hospital staff could have been encouraged to consider whether further follow up was needed after referrals had been made to Children's Social Care and on many occasions, health visitors and social workers could have been challenged to consider whether they were being over optimistic about Mother’s capacity to parent, their use of research knowledge to inform analysis and the correct use of child protection procedures. 5.48 The importance of effective management and supervision was particularly apparent in the case of the newly qualified social worker. The history of the case should have led to recognition by managers that it was too complex for a newly qualified social worker without intensive support and supervision. The management advice that a pre-birth assessment was not required was inappropriate but the newly qualified worker would not have felt confident to challenge this. Supervision did not explore the potential implications of bruising on a non-mobile infant and support the social worker in taking positive action to safeguard the child. 5.49 The panel have received information from Children's Social Care that they are adopting the recent national guidance in respect of supporting and assessing newly qualified social workers. This assessed and supported first year in employment (ASYE) should ensure improvements in the quality of supervision and opportunities for reflective practice in the future. It will be important that the implementation of the ASYE year is carefully monitored including receiving feedback from newly qualified social workers regarding the quality of supervision they receive. This is not specifically in the Children's Social Care action plan and is therefore subject of an overview report recommendation. 5.50 Health provider 2 has reflected on the lessons emerging from the review in relation to supervision practice and there is a comprehensive action plan aimed at improving the quality of supervision in the future. 71 Working effectively together within and between organisations 5.51 There are some examples of effective communication as well as a number of instances where a greater degree of positive inter- or intra- agency work would have helped to identify risks. 5.52 Surrey Police did consistently notify Children's Social Care of domestic disputes and violent incidents affecting the children. During earlier episodes the health visitor was not informed but procedure has now changed and health organisations receive the same notification of a child at risk as Children's Social Care. 5.53 Midwifery departments in hospital also consistently made appropriate referrals to Children's Social Care when Mother was pregnant and there were clearly potential risks. However, there was less evidence of any challenges to Children's Social Care when referrals were not acted upon. 5.54 There was some degree of misunderstanding within Children's Social Care about the purpose of a child protection conference in 2008, when the health visitor was not initially invited because they had no concerns. Following on from child protection conferences, records do not show evidence of effective core group working. There is little to indicate that the child protection plan was translated into a detailed working tool and that criteria for change linked to outcomes for the child were clearly articulated. 5.55 The potential importance of information held within school nurseries does not appear to have been fully appreciated by either the nursery staff or others. The nursery did not recognise the significance of non-attendance by Half Sibling 1 and there is no evidence that the nursery was approached for information until a child protection conference was convened. There was an opportunity at the time Mother was first pregnant with Child S to liaise with the nursery and information at this time would have revealed no concerns about Half Sibling 1’s care but a pattern of continuing absences. It appears that there was no thought given at the point of telephone contact at the end of July 2011 between the social worker and the child protection liaison officer in the 72 nursery to ensuring that information from the nursery would be available to the child protection conference despite the intervening school holiday. As well as lack of proactive liaison there is also evidence within the Children's Social Care records (although not mentioned within the nursery report) of a less than helpful response from the nursery when a social worker rang in early September to ask whether Half Sibling 1 was attending. Good child protection practice depends upon positive working relationships and the detail of the interaction would indicate evidence of poor communication and problematic professional relationships between Half Sibling 1’s nursery and Children's Social Care. 5.56 Assumptions were made about roles and responsibilities with the nursery nurses visiting the home at the point of Half Sibling 1’s admission assuming that the health visitor would pick up concerns about grubby flat. A more appropriate response would have been to contact either the health visitor or Children's Social Care to discuss their concerns. 5.57 In June 2011 no health professionals were involved in the strategy discussion despite knowledge that there were concerns about lack of antenatal care and significant health visitor involvement. Government guidance at this time was clear that strategy discussion should include ‘local authority children’s social care, police, health and other bodies as appropriate’.14 Learning lessons from previous SCRs – barriers to improving practice 5.58 Many of the issues identified within this serious case review are similar to those that have been identified before both within Surrey and elsewhere within England. There is little indication from the chronology that lessons from previous reviews have been used to inform practice. For example, within Surrey the Child B review in 2008 highlighted alcohol misuse, the use of chronologies and using historical records; the Child T review in 2008 noted the need for improved risk assessments particularly in situations of domestic violence and drug and alcohol misuse. In addition more recent reviews have 14 HM Government (2010) Working Together to Safeguard Children. Paragraph 5.56. 73 resulted in the Surrey Safeguarding Children Board promoting the involvement of fathers in assessments. The social worker in July 2009 was reminded by the conference chair to consider the plan in the light of earlier serious case reviews, but there is little evidence that this occurred. 5.59 There is some evidence that the working context up to 2009 may have affected the capacity of both health and social care to work with families in line with known good practice since at this time Surrey was responding to an adverse Joint Area Review report which affected all organisations. There was also adverse publicity regarding Children's Social Care which resulted in several management resignations, changing line management and structural change which impacted on capacity in all parts of the organisation. These factors are likely to have affected the capacity of the organisations to learn lessons and improve practice. However, by 2010/11 new management arrangements were in place and there was a greater degree of stability, yet child protection practice, particularly in relation to effective risk assessments and use of child protection procedures (particularly strategy discussions and medical examinations) was not evident. Further work is therefore needed by the Safeguarding Children Board to understand the barriers to embedding learning into practice and ways of overcoming these. 6. LESSONS LEARNT 6.1 One fundamental reason for the practice problems appears to be a loss of focus particularly within Health and Children's Social Care on basic child protection practice. Social workers did not consistently follow child protection procedures particularly in relation to conducting child protection enquiries and taking immediate emergency action when young children were found at home alone. Appropriate medical examinations were not arranged where there were injuries, and strategy discussions did not include health professionals. Recognition of the signs and indicators of abuse appears to be lacking in health and social care particularly in relation to the significance of injuries in non-mobile babies and health professionals did not alert Children's Social 74 Care early enough to concerns about Half Sibling 2’s failure to thrive and developmental delay. 6.2 In addition it appears from this review that the utilisation of current knowledge in relation to the overall assessment of risk is not well enough developed. There were too many examples from 2007 through to 2011 of situations where risks were either not noticed or were not responded to particularly in relation to parental alcohol misuse and failure to engage with services. Organisations need to therefore ensure that practitioners are aware of and use the most appropriate frameworks within their own context and that these are informed by an up to date evidence base. 6.3 The complexity of this situation undoubtedly affected responses and there is a need to support practitioners in working with complex situations where they may be many different issues to address. This must include the opportunity for skill development in working with highly resistant families, alongside supervision which addresses the emotional impact of this work as well as allowing time for examination of the biases and assumptions that may be driving practice. In this case there is little evidence of either the required skills or effective supervision with the result that practitioners focused on neglect at the expense of risk of physical harm and did not work effectively with Mother in relation to her failure to engage with the services provided. 7. CONCLUSION 7.1 The conclusion of this review must be that there were a number of missed opportunities to prevent the serious injuries to Child S as well as a delay in acting when injuries were apparent. Missed opportunities pre-date Chid S’s birth with evidence that more effective risk assessments from the time of Mother’s first pregnancy may have resulted in different actions when Mother was known to have been pregnant with Child S. In particular prior to Child S’s birth there was a failure to recognise the likely significant harm experienced by Half Sibling 2. 75 7.2 The most significant missed opportunities were: Lack of any risk assessment at the point that Mother was charged with child neglect. This assessment could have been used to inform the decision to close the case when mother was known to be pregnant with Half Sibling 2 No action taken to assess risk when bruising was noted on the face of Half Sibling 2 who, at that point was a non-mobile infant At the point mother was asking about adoption, insufficient attention being paid to the underlying reasons for her request and the likely impact on her capacity to safely care for Child S when she decided to keep him. No action taken to safeguard the children who had been left at home alone and to arrange a child protection medical to examine the injury to Child S’s toe in August 2011 Failure to act immediately when the Child S was found with an injury to his finger and was clearly in pain 7.3 There is little learning about risk to children that is new in this case. The issues that have emerged have been known for several years both from research and previous local reviews yet did not consistently inform actions. As a consequence, many of the recommendations will focus on reminding organisations and practitioners of the knowledge and skills that should be utilised in everyday practice. However, this needs to take place alongside a deeper exploration by the Surrey Safeguarding Children Board of the barriers that prevent known knowledge being implemented in practice. 8. OVERVIEW RECOMMENDATIONS 8.1 There was inadequate recognition by a number of professionals of the significance of the interacting risk factors in this case including: failure to engage with services, lack of antenatal care, substance misuse, domestic violence, ambiguous feelings towards two pregnancies and a troubled parental history as a child. 76 Recommendation one 8.2 Surrey Safeguarding Children Board should assure themselves that Children's Social Care, Health Organisations and those responsible for providing domestic abuse, substance misuse and mental health services to adults are using evidence based tools to assess potential risk to children and that these are embedded in practice and practitioners are trained in their use. 8.3 Practitioners did not fully appreciate the implications of parental misuse of alcohol and take action to reduce risk to the children. Recommendation two 8.4 Surrey Safeguarding Children Board should raise awareness across the partnership of the impact of parental alcohol misuse and take steps to ensure that: Commissioners of alcohol misuse services assure themselves that these services are fit for purpose in respect of their role in safeguarding children and that they provide advice and consultation to professionals working with children as well as direct work with parents. The roles and responsibilities of professionals in both adults and children’s health and social care services are clear in respect of parental alcohol misuse Specialist alcohol misuse services are invited, and contribute to child protection conferences where alcohol misuse is an issue Child protection plans adequately address and measure change where alcohol misuse is an issue 8.5 Practitioners in Children’s Social Care and Health did not recognise the significance of bruising/injuries in non-mobile babies and the panel are aware that this is also an issue in a concurrent serious case review. Recommendation three 8.6 Surrey Safeguarding Children Board should raise awareness regarding the significance of bruising in non-mobile babies and take steps to ensure that all 77 practitioners in partner agencies, and particularly in Health and Children's Social Care are aware of the steps to take if this is found to be present. 8.7 Practitioners in Children’s Social Care and Health did not ensure that when a child on a child protection plan sustains an injury this is examined by a suitably qualified and experienced doctor. Recommendation four 8.8 Children’s Social Care and Health organisations should reinforce the correct use of child protection procedures where there is suspected physical abuse, including ensuring that child protection medical examinations are carried out. 8.9 Accessing mother’s own historical records presented challenges to the review team and this lack of access also fundamentally impacted on practitioners in this case. Recommendation five 8.10 Surrey Safeguarding Children Board should require all partner organisations to review their processes for accessing historical family information and ensure that all practitioners are aware of the process and retrieve and analyse information when a parent has been in the care of the local authority, on a child protection plan as a child, or subject of a Statement of Educational Need. 8.11 This case has features similar to those found in previous serious case reviews in Surrey including: engaging with fathers, recognising the significance of family history, risk assessment in situations of domestic violence, substance misuse and working with resistant families. Recommendation six 8.12 Surrey Safeguarding Children Board should take steps to understand the barriers to implementing learning from serious case reviews and develop a strategy to address any barriers identified. 78 8.13 Working with resistant families requires practitioners to have highly developed interpersonal skills supported by effective supervision which addresses the emotional impact of such work on the practitioner. Recommendation seven 8.14 Surrey Children's Social Care and Community Health Organisations should review their staff development programmes and assure the Surrey Safeguarding Children Board that these include support or practitioners in developing and sustaining skills in working with avoidant families. Recommendation eight 8.15 All organisations should ensure that practitioners receive effective supervision which enables them to reflect critically on the factors that may be impacting on their practice including the emotional impact of the work, personal biases and intuitive responses. Recommendation nine 8.16 Surrey Children's Social Care should ensure processes are in place for monitoring the effectiveness of the ASYE programme which includes a focus on the appropriateness of case allocation and the quality of supervision and management oversight in individual cases. 8.17 When the case was closed to Children's Social Care there were missed opportunities for a more structured approach to the assessments undertaken and help given to the family. Recommendation ten 8.18 Surrey Safeguarding Children Board should promote the use of early help assessments. Health organisations in particular should ensure that these assessments are routinely used where there are concerns about a child and inform decisions about when a referral should be made to Children's Social Care. 79 Recommendation eleven 8.18 Surrey Safeguarding Children Board should require partners to ensure that when a case is closed by Children's Social Care but support is still required, “step down” procedures ensure that appropriate help is provided to the family underpinned by a clear outcome focused plan. 9. INDIVIDUAL MANAGEMENT REVIEWS RECOMMENDATIONS Ashford and St Peter’s Hospitals NHS Foundation Trust 9.1 Ensure that a robust system of delivering and monitoring safeguarding supervision is developed and implemented in the organisation 9.2 Improve training and awareness in safeguarding updates to view the patient receiving antenatal care holistically and not in isolation. 9.3 Review and redevelop maternity documentation that supports a holistic approach during the antenatal assessment. 9.4 Review and raise awareness of best practice guidelines for documentation. 9.5 Review and strengthen the management processes within the organization for patients who ‘did not attend’ appointments and late antenatal bookings. 9.6 Development and implementation of internal referral form for Named Midwife and Named Nurse. 9.7 Develop a system to enable all referrals that are made to external agencies can be tracked and monitored. Central Surrey Health 9.8 Review safeguarding supervision within Central Surrey Health 9.9 Establish clear understanding of roles and responsibilities when providing Safeguarding advice and support to practitioners. 80 9.10 Review safeguarding training provision within Central Surrey Health. 9.11 Review family health needs assessment 9.12 Review current links and care pathways between Health Visiting service (0-19 teams) and local maternity units. 9.13 Evidence that the organisation has a robust process for following disciplinary processes where there are concerns regarding professional practice or record keeping. Elmbridge Housing Trust 9.14 All front line officers involved in housing management at Paragon CHG undertake regular Safeguarding training. 9.15 Managers in all agencies work more closely together and encourage greater liaison at the front line. 9.16 Tenancy Service Officers ensure they undertake and record all Starter Tenancy Monitoring visits in first year of the tenancy. 9.17 Any incomplete referral for temporary or permanent housing be returned to the originator for completion of all background information Surrey Children’s Services 9.18 A chronology to be started at an early point in the life of the case and to be a piece of ongoing work and a tool for analysis and supervision. 9.19 For supervision notes to address each aspect of the plans and record the risks and to outline a clear plan of work. 9.20 Where there are issues of domestic violence and alcohol abuse for cases not to be closed until the parent has provided clear evidence of a sustained commitment to change. 81 9.21 Where a parent of a child referred to children’s Services has themselves been known to the Local Authority as a consequence of Child Protection concerns, has been on a Child Protection Plan, or Looked After: Their own early history should be examined with a view to an assessment of their own patterns of childhood attachment. 9.22 For training to be delivered to workers about disguised compliance. 9.23 For training and assessment tools to be available to workers in the effects of alcohol abuse on parenting that enables them to understand how they can address these issues without reliance on specialist agencies. 9.24 For supervision to retain a focus on the difference between the child’s presentation and the parent’s behaviour so as to enable workers not to be deceived by one into believing that the other is not problematic. 9.25 For an effective system of liaison between transferring and receiving teams to be established to minimise hiatus and re-evaluation. For instance to enable family support workers to continue visiting during the handover period to enable the same frequency of visiting during allocation processes. Surrey Education 9.26 Consider if systems can be developed to monitor and manage poor attendance of early years children under statutory school age in both the maintained and PVI sector. 9.27 Evaluate and monitor new non-attendance process for early years. 9.28 Ensure all early years settings have sufficient processes in place to provide adequate responses during holiday periods for child protection matters. 9.29 Evaluate effectiveness of the current information gathering and sharing processes used by early year’s settings. 82 9.30 Develop the tools necessary to ensure a consistent approach across all sectors. 9.31 Joint working between Early Years and Children’s Services of placements in high quality early years settings for LAC and CIN children. 9.32 Early years sector management to review record retention procedures by all categories of early years settings to ensure DPA is observed and complied with. Surrey GPs 9.33 All GP practices have an in-house protocol for the appropriate follow-up of children whose parents/carers repeatedly failure to attend for planned appointments, including immunisations, 9.34 All GP practices are aware of appropriate Read coding and data entry in relation to current and past safeguarding children concerns. Surrey Police 9.35 The Head of Public Protection should ensure that all PPIU staff including supervisors and managers receive appropriate specialist training to equip them for investigating incidents of domestic abuse. 9.36 The Head of Public Protection should ensure all officers employed in the role of PPIU supervisor have received appropriate training to enable them to carry out / review DASH risk assessments and identify cases that should be referred to a MARAC. Virgin Care 9.37 That all Virgin Care 0-19 practitioners are able to utilise a child focused family needs assessment tool to determine plan of health intervention. |
NC52247 | Overdose of medication by an adolescent girl in 2019. Charlie's mother was found unconscious by ambulance services after taking a drug overdose, and had reportedly given Charlie tablets. Family were known to health services and children's services. Mother had problematic drug issues, using prescription opioids and illicitly obtained drugs. Charlie had a history of poor school attendance and repeated hospital attendances and was suspected to have been the subject of fabricated or induced illness (FII). Ethnicity or nationality are not stated. Learning is embedded within the review. Recommendations include: review data to benchmark the number of families with children who could be affected by parental opioid prescribing; parental substance misuse guidance should include further guidance regarding safeguarding concerns arising from parental dependence on prescribed drugs; a designated doctor review Charlie's medical records to establish lessons on identifying and responding to indicators of FII, particularly in older children and adolescents; agencies identify how to improve practitioner engagement with fathers in safeguarding and child protection work; regular dip-sample audits of cases where child protection enquiries have concluded with substantiated concerns but where the decision was made not to proceed to a child protection conference.
| Title: Child safeguarding practice review: Charlie. LSCB: St Helens Safeguarding Children Partnership Author: Isobel Colquhoun Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child Safeguarding Practice Review Charlie This Child Safeguarding Practice Review has taken steps to preserve the anonymity of the children in this family by representing the children by names chosen at random. The names chosen do not necessarily reflect the children’s true gender. In addition, the review has avoided the use of exact dates and has removed details about local services which could contribute to the recognition of the children and family. This document is classified as “Protected” and therefore may be circulated freely to selected partners and partnerships where Information Sharing Agreements are in place and registered with the St Helens Safeguarding Children Partnership Business Manager. This is not a public document. Neither the report nor any of its contents may be disseminated further without the prior agreement of the originator . 2 1. Background to review 1.1 In 2019, the ambulance service attended Charlie’s family home, following a 999 call by her sibling, Frankie. Charlie’s mother (MC) was unconscious: it was reported that she had taken an overdose of drugs. Charlie was present, and the ambulance crew was informed that MC had ‘given her tablets’. Charlie was fully conscious but feeling unwell: her speech was slurred, and she was lethargic. 1.2 MC was taken to a local hospital where she was intubated on the Intensive Care Unit. On her way to hospital; Charlie lost consciousness. FC was told about what had happened but said that he would not attend as he was at work ‘over 100 miles away’. 1.3 The local authority notified Ofsted of an incident of serious harm to a child and the Safeguarding Children Partnership (SCP) undertook a rapid review of the facts readily available to local agencies and organisations providing services to children and families. 1.4 The Rapid Review Panel of the SCP concluded the circumstances of the case met the criteria for a local safeguarding children practice review (previously known as a serious case review), facilitated by an independent reviewer. This recommendation was endorsed by the SCP Chair, the Strategic Director for People’s Services, St Helen’s Council. This decision was communicated to the national panel of independent experts on serious case reviews where it was endorsed. 1.5 The SCP agreed that the review should be conducted using a hybrid systems method. The review would take account of complexity of the circumstances in which professionals work. It would seek to understand both what happened and why. A learning event for practitioners and first line managers would provide the opportunity for learning for those working with the family. Single agency analyses would promote learning at organisational level from the case. The final review report would seek to reflect that learning in the context of lessons for multi-agency practice and recommendations for change. 1.6 A Safeguarding Children Practice Review Panel (SCPRP) of senior managers from relevant agencies and organisations was established to oversee the conduct of the review. 1.7 A learning event from practitioners and managers was held in December 2019. With the exception of GP services, this event was well-attended by representatives of agencies and organisations which had been involved with the family. Attendance by practitioners and first line managers who had had direct contact with family was reduced, however, by a combination of staff turnover and the nature of family’s contact with health services. All participants engaged constructively in building case detail. As individuals, participants were open about their own agency’s practice and were respectfully enquiring of others. As a group, they impressed by their capacity to identify both case specific and wider learning. 3 1.8 In January 2020, a structured conversation between Named GP for safeguarding children, the Designated Safeguarding Nurse (CCG) and relevant members of the GP practice. The resulting report has informed this review. 1.9 The final key lines of enquiry for the review were: a) In as much as can be ascertained from information available, how effective were assessments and services in the pre-review period? b) During the review period; how effectively did agencies evaluate mother’s strengths and vulnerabilities and the impact that these had on her ability to care for her children? Specifically consider MC’s prescribed and illicit drugs use. c) How well did agencies understand father’s circumstances and the role that he had in caring for the children and keeping them safe? d) How well did agencies understand grandparents’ circumstances and the role that they played in caring for the children and keeping them safe? e) What did agencies understand about allegations of sexual harm relating to individuals in this family and how did that affect professional practice? f) How well did agencies understand the children’s needs and the risks of harm to which they were exposed? In particular, what assessments took place in respect of Charlie’s attendances at hospitals with acute symptoms which were medically unexplained? g) How well did agencies understand the everyday lives of the individual children in the family, including the nature of sibling relationships? h) What did agencies understand about allegations of sexual harm relating to individuals in this family and how did that affect professional practice? i) How effective was single- and multi-agency communication during the review period? In particular, how effective was communication between adult-focused services and child-focused services? j) How effective were single- and multi-agency services in promoting the children’s welfare and in keeping them safe? 1.10 Throughout the review, the SCPRP met regularly to consider the emerging picture of local safeguarding practice. In February 2020, additional specific questions were sent to public health, St Helens Clinical Commissioning Group (CCG), the local substance misuse service and to Children’s Social Care (CSC). Their responses have also informed learning and recommendations. The SCPRP contributed to the final analysis and the construction of the recommendations of this review. 1.11 The detail which underpinned the learning from the key lines of enquiry has been shared with the Safeguarding Children Partnership. The Partnership has confirmed that the findings of the key lines of enquiry are consistent with the analysis and recommendations which follow. 1.12 The review process was actively supported by the Safeguarding Partnership dedicated staff within the local authority. 4 1.13 As criminal investigations and care proceedings were active during most of the period of the review, the decision was taken not seek the involvement of the child and/or family members in the review until those processes had come to an end. 5 2. Analysis 2.1 A challenge to this SCPR has been the degree to which the recorded family history is characterised by gaps and uncertainty about both what happened and why it happened as it did. The key lines of enquiry revealed a significant absence of multi-agency work. This had a number of consequences for developing a picture of Charlie and her family as well as for examining safeguarding practice. 2.2 Incidents and events that were likely to be multi-dimensional in their origins were not recognised as such. Instead, they were managed as if they were simple, single-issue problems rather than being representative of an underlying complexity of family circumstances and relationships. There was a focus on medical issues both in respect of MC and in relation to Charlie. While this should have increased joint-agency analysis and planning; it did not. 2.3 In addition, there was a weak application of locally and nationally agreed thresholds for assessment and interventions by the local authority. This meant that the children and family did not receive the service that they might have expected, and, at the same time, parents were not adequately challenged about the care they were giving their children. There is very little evidence, however, that partner agencies expressed dissatisfaction with decisions made by CSC or that they escalated any concerns they might have. 2.4 From the point at which this SCPR began, St Helens SCP has been keen to ensure that the lessons from this case can be translated into specific actions which will make a difference to outcomes for children and families locally. As a consequence, the SCPR has identified specific lessons in respect of parental problematic drugs use and relating to a child’s attendance at hospital with clinically unexplained symptoms. 2.5 At the same time, it has been evident that there were many shortcomings in general safeguarding practice in this case. It is acknowledged, however, that the nature of many of those shortcomings is already known to the Partnership and that, in many instances, improvements are being made. This has been taken into account in the analysis and recommendations which follow. Finally, as poor school attendance was an issue for Charlie, this is considered as a potential safeguarding matter. Parental problematic drugs use 2.6 A key feature of this case was MC’s problematic drug use. MC had initially been prescribed drug treatment for pain management but, over time, she both sought access to additional opioids through medical channels and supplemented her use with illicitly obtained substances. Although there were allegations that MC’s drugs use was having a negative impact on family life; no professional had a clear picture of its effects on her functioning as an individual and as a parent. As a consequence, the potential impact of their mother’s accumulating difficulties on the children’s lives was not recognised. This is a common 6 characteristic of safeguarding work where parental substance misuse is a feature of family life. 2.7 In 2014, the NSPCC published a summary of the key issues identified in learning from serious case reviews . On one level, had safeguarding practice in this case taken account of the lessons contained in that summary, it is likely that the risks for the children could have been recognised more quickly and addressed more thoroughly. Circumstances were perhaps complicated, however, by the fact that the drugs in question were believed to be primarily prescribed rather than illegal drugs obtained by street purchase. 2.8 From contact with professionals at all levels in different agencies during the course of this review, it has become clear that there is: a) Limited general knowledge about the nature, purpose and efficacy of opioid treatment; b) Limited awareness of how to form a comprehensive picture of the impact of prescribed drugs on an individual’s behaviour and consequent safety concerns; c) Uncertainty about how to identify and respond to indicators that patients are seeking to ‘top up’ their prescribed drugs either through medical routes or by illicit means; d) Lack of knowledge about the link between prescribed drugs use and illegal drugs misuse; and, e) Little recognition of the implications for children living with parents with problematic prescribed drugs use. 2.9 It is notable that there have been very few high-quality research studies on medicine dependence and withdrawal, and their prevention and treatment, in the last 10 years. The following, however, describes some of what is known nationally about opioid prescribing. It also provides a summary of information that has been made available to the review about local arrangements about developments at a local level to support individual patients; to reduce harm in the population; and, to safeguard the children of substance misusing parents. These are the details which have informed subsequent recommendations. a) Opioid prescribing: the national picture 2.10 In September 2019, Public Health England (PHE) published an evidence review of dependence and withdrawal associated with some prescribed medicines which included a literature review of the effectiveness of certain drug treatments used in the management of mental health and chronic pain. 2.11 This report1 revealed that 5.6 million adults in England (13% of the adult population) received one prescription or more for opioids between 2017 and 2018. Although long-term prescribing of opioids for chronic, non-cancer pain is not beneficial for most patients; 1 The information which follows is taken from a summary provided on www.nhs.gov.uk 7 researchers estimated that around 500,000 were taking opioids continuously for at least 3 years (from 2015 to 2018). The report also identified inequalities in prescription rates based on gender, age and local levels of poverty. 2.12 The report is clear about effectiveness of particular drug therapies when used as recommended and cautions that that ‘inappropriate limiting of medicines may increase harm, including the risk of suicide, and lead some people to seek medicines from illicit or less-regulated sources’. Nevertheless, it suggests that local areas should review both prescribing practice and the availability of alternative treatments, as well as considering what more can be done to educate and support patients. 2.13 The lessons from this report have particular significance in St Helens as the local Clinical Commissioning Group (CCG) is ranked 7th out of all CCGs in England for opiate prescription and is the highest prescribing CCG in Cheshire and Merseyside. b) Opioid prescribing: the situation locally i. Individual patients: prescribing practice 2.14 In response to questions from SCPRP, St Helen’s CCG acknowledges that reducing opioid prescribing is a local priority. Within the CCG, it is the role of Medicines Management Team both to support the commissioning of effective services and treatments and to assist individual clinicians to prescribe the most cost-effective, evidence based and safe medicines. 2.15 To support clinicians in reducing their overall levels of opioid prescribing, the Medicines Management Team has introduced a number of initiatives including education sessions; a prescribing incentive scheme; and, the sharing of prescribing data. The CCG recognises, however, that ‘reducing patients off opioids is slow and time consuming for clinicians’, particularly within the context of high levels of deprivation locally. 2.16 The CCG reports that some GP practices are considering developing ‘opioid contracts’ with patients. To date, safeguarding children issues have not consistently been taken into account in relation to opioid use. To begin to address this gap, therefore; the Named GP, the Designated Nurse and Assistant Director of Medicines Management plan to incorporate safeguarding children and awareness of young carers into any parental opioid contracts. 2.17 It is notable that no clinician contacted the Medicines Management Team in respect of MC during the review period. ii. Individual patients: identifying those seeking additional prescription drugs 2.18 MC sought additional drugs from the GP for a variety of reasons which led to daily prescriptions; she attended the Urgent Treatment Centre (pre-review period) asking for 18 prescriptions; she phoned the police and reported that her cousin had stolen a safe with 8 her medication; and, she appears to have manufactured opportunities to obtain additional drugs through ambulance services or ED. 2.19 It has been said in learning summaries that there should have been an MDT to coordinate and oversee MC’s medications, but no clear process has been identified in respect of expectations of agencies and organisations in that regard. This was discussed in the SCPRP and it was agreed that there would be merit in the CCG developing a Drug-seeking Patient Policy. Examples of such policies are available elsewhere. The CCG representative on the SCPRP has agreed to pursue this locally. iii. Individual patients: prescribed opioid use supplemented by drugs acquired elsewhere 2.20 The local substance misuse service (commissioned by Public Health) reports that of the 995 people in structured treatment at present, 79 have declared requiring support with medication, even if that was not their primary reason for entering the service. 2.21 The service currently has the same pathway for assessment and risk management for those struggling either with prescribed or illicitly purchased medication. If, however, individuals are addicted to a medicine which is currently prescribed by their GP or through a pain management clinic, they remain under the governance of the GP, but additional support would include: i. Clinician to clinician advice in relation to prescribing and community-based reduction; ii. Assessment, referral, preparation and aftercare for inpatient detoxification; and iii. Access to ‘recovery’ interventions. 2.22 The same service would be available for individuals who are receiving a GP prescription for pain killers and were then ‘topping up’ their supplies through the internet or from over the counter pharmacies. 2.23 Parents who are prescribed opioids are also provided with safe storage, a home environment assessment and information regarding the potential harm of medication. The substance misuse services states that all staff are trained to service standard levels on safeguarding and the risks associated with substance use. The service also has a specialist family team which includes three senior social workers. 2.24 As with the medicine’s management team; there was no referral to, or professional consultation with, the substance misuse team in respect of MC during the review period. c) Reducing harm from prescribed opioids in the population 2.25 There is currently no specific local drugs strategy in St Helens. Strategically, reducing harm from alcohol has been identified as a priority by the People’s Board and the Public Health response to SCPRP indicates that local partnership action has focused on this during the last 12 months. It is noted, however, that the Partnership is currently reviewing its terms 9 of reference along with the Community Safety Partnership. This would offer an opportunity to consider a joint strategic approach to reducing harm from both alcohol and drugs in 2020. The SCPRP would strongly support this action. 2.26 In the meantime, PH is supporting a dedicated task group, led by the CCG, to review the levels of opioid prescribing in St Helens and to reduce any associated risk. 2.27 The SCPRP is not aware of any specific actions being taken locally to raise awareness of the issue of opioid addiction. In their responses, both the CCG and GP referred to the Faculty of Pain Medicine’s webpages Opioid Aware. The SCPRP was of the view that this information, while useful, would be unlikely to be accessed by a high proportion of people affected. 2.28 At a service commissioning level, the CCG intends to review the effectiveness of its commissioning of pain management services and to ensure that patients have access to psychology and physiotherapists. d) Safeguarding children 2.29 As already noted, the focus on an adult’s health and substance misuse can prevent the needs of, and risks to, children in the family being recognised and addressed. 2.30 In December 2018, HM Government (PHE) published guidance for local authorities in respect of safeguarding and promoting the welfare of children affected by parental alcohol and drug use. This guidance recommends having a local protocol whose purpose is to safeguard and promote the welfare of children and young people, including young carers, whose lives are affected by substance misusing parents or carers. It should also promote effective communication between adult drug and alcohol services and adult, children and family social care services, and set out good working practice for the services involved. 2.31 The substance misuse service reports that, in St Helens, there is no formal protocol. It states, however, that the guidance was the foundation for the Building Bridges Project which is delivered by the substance misuse team and is funded by Public Health England. The Building Bridges Project is a partnership between PHE, the service misuse service and CSC. The substance misuse service gives examples of the ways in which it is working in line with the government’s good practice guidance. There is little evidence, however, that practitioners and managers in CSC are aware of the expectations of joint working contained in that agreement. 2.32 CSC has provided details to the review of practitioner training ‘Assessing the impact of substance misuse on parenting and childcare’ which is available as part of the training matrix. It is noted that practitioners are also able to access Research in Practice and to seek additional advice, guidance or training through the Principal Social Worker and Workforce Development Team. As already described, however; the evidence from this 10 case review is that CSC practitioners and managers did not ensure that assessments of the impact of MC’s substance misuse met the expected standard for practice in this area. 2.33 As the focus of any CSPR is on learning, with a view to reducing the likelihood of similar incidents in the future; in this case, the Safeguarding Children Partnership needs to be satisfied that professionals working with children and families should be aware of the problems which can result from parental dependence on prescribed opioids. They should know what steps they need to take to ensure that a comprehensive picture is developed of the impact of opioid dependence on the individual’s behaviours and of any consequent safety concerns. They should also understand how to ensure that the impact on children’s lives is understood and, where necessary, addressed. 2.34 Although current local child protection procedures refer to parental substance misuse as including prescribed drugs, where there is dependent use; this review suggests that additional specific information would be helpful both for primary and secondary health care and social care practitioners. 2.35 Recommendation 1: Although it is accepted that the level of opioid prescription is high in St Helens, the demographic details of the affected cohort of patients are not known. It is recommended, therefore, that the SCP asks PH to provide the data that it needs to benchmark the number of families with children who could be affected by parental opioid prescribing, with a view to determining what action might be required. 2.36 Recommendation 2: Alongside disseminating learning from this review; the SCP should: a) quickly revise its current procedures in respect of Parental Substance Misuse, to include more detailed guidance in respect of identifying and responding to safeguarding concerns arising from parental dependence on prescribed drugs; and, b) require agencies and organisations to provide details of how they are implementing the Parental Substance Misuse guidance and what steps they are taking to assess its impact on practice. 2.37 Recommendation 3: Before March 2021, the Safeguarding Children Partnership should undertake a multi-agency audit of cases where substance misuse is a feature of family life. That cohort of cases should, if possible, contain examples of parental dependence on prescribed drugs. Responding to a child’s attendance at hospital with clinically unexplained symptoms 2.38 During her lifetime, Charlie has had repeated hospital attendances to exacerbation of asthma. More recently, she began to attend with symptoms that were not medically explained. The SCPRP discussed this situation at length but was unable to draw definite conclusions about the implications for safeguarding practice. There were a number of factors which contributed to this. 11 2.39 Firstly, it is acknowledged that adolescents experiencing medically unexplained symptoms are not unusual, with an estimate between 10-25% of adolescents reporting recurrent chronic somatic complaints only a small proportion of which have an identifiable medical cause. 2.40 In Charlie’s case, however, she was suspected to have been the subject of fabricated or induced illness in the past and there are features of her recent presentations in hospital which could suggest that this might have been a continuing issue. At the same time, there was a considerable gap between the original concerns which could suggest the contrary. 2.41 Similarly, the review suggests that MC’s own presentation with ill health and her particular relationship with Charlie may have influenced how Charlie revealed her own emotional state. It is notable, however, that during the years following suspicions about fabricated or induced illness, there were no satisfactory assessments of Charlie’s needs or family relationships. 2.42 Finally, it is notable that the local Safeguarding Children Partnership has not been able to recruit to the role of designated doctor. This leaves a gap in necessary safeguarding expertise particularly in respect of medical issues. 2.43 Despite being uncertain as to underlying factors which might have led to Charlie’s presentations at hospital, therefore, the SCPRP remains concerned that there may be unidentified practice issues in respect of fabricated or induced illness. It is acknowledged that this has been identified as an area for improvement in the recent past. At the end of 2014, St Helens LSCB undertook a SCR in which fabricated and induced illness was the principal concern. Findings in that case were similar to concerns which were then identified in a multi-agency review undertaken in 2019. 2.44 Following the review of 2019, the Safeguarding Children Partnership agreed to undertake a multi-agency audit of cases where fabricated or induced illness had been identified as a risk; to measure compliance with procedures and to ensure that children’s general safeguarding and welfare needs had been adequately addressed and recorded. It is important that the findings of that audit are translated into effective actions. 2.45 In order to be satisfied, however, that potential learning from this particular case is identified; the SCP has secured funding for ‘designated doctor hours’ to support the implementation of the following recommendation. 2.46 Recommendation 4: The Safeguarding Children Partnership should commission a short life group to be overseen by an agreed ‘designated doctor’. The purpose of that review would be to conduct a medical review of Charlie’s records and to establish what, if any lessons there are for professionals, in respect of identifying or responding to indicators of fabricated or induced illness, particularly in older children/adolescents. 12 Basic Safeguarding Practice 2.47 In addition to issues arising from maternal drug use and questions about Charlie’s attendance at hospital with clinically unexplained symptoms; this review has revealed many shortcomings in basic safeguarding practice, particularly within the local authority. The majority of these have been acknowledged by CSC. 2.48 As has already been noted, key features of practice included the tendency to treat each reported incident or referral as a single issue to be resolved as quickly as possible. There was little reference to previous history or information which might have been held by partner agencies. Family relationships and family functioning were not understood, so that key safety plans over-estimated Charlie’s father’s motivation to keep his children safe and the nature of the support which grandparents were able to offer. In addition, little real knowledge was gained about the children’s experience; their family relationships and friendships; or, about their opinions, feelings or wishes. No child in need plan was established and no child protection conference took place, although both were possible outcomes during the review period. While this might not have prevented the precipitating incident with its serious medical and legal consequences; it could have provided an earlier insight into underlying causes of difficulties in the family and an assessment of the prospect of change. 2.49 As the analysis was developing; the SCPRP requested further information from the local authority in respect of improvements which have already been made or are planned, following focused visits by Ofsted in July 2018 and November 2018, and an inspection of children’s social care services in September 2019. The purpose of that request was to ensure that recommendations from the review tie in with, wherever possible, existing action plans. In addition to specific questions in respect of the response to referrals and to the quality and outcomes of assessments; the local authority was asked to give brief details of any cultural or organisational issues which might have contributed to practice shortcomings; and, to identify any systemic changes that have been made to support social work practitioners undertaking assessments of need and risk of harm. 2.50 A full response was received describing the changes to which the Council Cabinet and Chief Executive have committed in order to modernise Children’s Services. Reference is also made to the overarching improvement plan, overseen by the Children’s Improvement Board, and to the key principles which underpin the management and leadership approach. ‘Signs of Safety’ is being implemented as the practice model and it is anticipated that this ‘way of being’ will be embedded in all aspects of practice across the partnership. Changes are also being made to improve accountability for decision-making; to overcome inconsistency in the quality of management supervision and oversight; and to embed audit and a quality assurance framework. At the same time, additional permanent funding allows increased service options and more manageable individual caseloads for social workers. Social workers have also been provided with IT equipment and mobile phones to enable more efficient and flexible working arrangements. Arrangements have been established to provide feedback from frontline practitioners to senior managers. 13 2.51 These changes, if effective and sustained, should provide an environment which will make good practice more likely. 2.52 In January 2020, however, the Head of Service for Safeguarding and Quality Assurance presented an audit of assessments to the local Improvement Board. This audit had been prompted by data which indicated that, during the year, a high percentage of referrals closed on completion of assessment, with no services being offered. This was a feature of practice in this case. The audit confirmed concerns about the application of thresholds and concluded that the quality of assessments; management oversight; and, the quality assurance of assessments were poor. 2.53 Accurate assessments of need and of risk of harm are crucial to multi-agency safeguarding and child protection. The SCP should be satisfied that anticipated practice improvements within CSC are being delivered. 2.54 Recommendation 5: An audit of assessment (CSC/ January 2020) made six recommendations for action to improve the quality of assessments. They include proposals with implications for both single-agency and multi-agency practice. It is recommended that the SCP requires the local authority to report, by December 2020, on the implementation of the six recommendations made. 2.55 “It is now well established that fathers matter to children’s wellbeing. When fathers are positively involved in their children’s lives, their children are more likely to do better at school, have better relationships with their peers, have better mental health and are less likely to be in trouble with the police. When social workers work with fathers to improve their involvement with children, they can help to improve outcomes for children”2. 2.56 Research has consistently found that child protection work tends to focus on mothers, with fathers having a peripheral presence in case files, child protection conferences and home visits. In this case, assumptions were made about father’s capacity to keep his children safe and there was insufficient challenge to him when he demonstrated that they were not his priority. This issue of ‘hidden males’ is generally well-known to safeguarding practitioners, but individual and joint practice may still be influenced by unconscious personal biases and by the weight of cultural norms. It is also acknowledged that, in some cases, involving the father might require additional safeguards to avoid putting the mother and children at risk. 2.57 The SCPRP was reluctant to make a recommendation which would be in effect ‘more of the same’ and unlikely to make a difference, while recognising that, in a context of a shared emphasis on improving the quality of assessments overall; there are opportunities to focus on improving this area of practice. 2 https://www.communitycare.co.uk/2018/02/19/working-fathers-key-advice-research/ 14 2.58 Recommendation 6: The SCP should require agencies and organisations to identify how they intend to measure and improve practitioner engagement with fathers in safeguarding and child protection work. 2.59 Recommendation 7: The SCP should ensure that all multi-agency audits commissioned by the Partnership take account specifically of the engagement of fathers in safeguarding processes. This will allow the Partnership to measure improvements in practice over time and to identify where further action may be required. 2.60 Improving the involvement of children in assessments of their needs and in managing risks to them is a crucial factor in improving safeguarding and child protection practice. It is a key finding of this SCPR. Again, however, practitioners and managers are aware that children and young people should be continually involved in work with them and their families. They generally understand that children should have the opportunity to describe things from their point of view and to have information fed back to them in a way that they can understand. Practitioners and managers know that there should always be evidence that ‘the child’s voice’ has influenced decisions that professionals have made. And yet, this appears to be difficult to achieve in reality. This is also reported to be reflected in practitioner responses to multi-agency ‘Working Together’ training. 2.61 As before, the SCPRP is reluctant to repeat recommendations or duplicate work already in hand. At the same time, it is keen to make use of the opportunities for change which are currently available. A slightly different approach is, therefore, recommended. 2.62 Recommendation 8: Arrangements should be made to feedback the findings of this review specifically to St Helens ‘Voice of the Child Champions Group’ so that they understand the key issues and challenges of the case. Following that, colleagues from the multi-agency partnership should be recruited to contribute to planning and delivering a 'Speed Resources' event. That event should target multi-agency practitioners to share tools/resources to improve participation of children in safeguarding/ child protection processes. 2.63 The question which was raised in the course of this review about assessments of need closing with no further action has already been considered by the audit report prepared by CSC for the Improvement Board and which forms the basis of Recommendation 5. 2.64 In addition, the key lines of enquiry highlighted that decisions were made not to progress to child protection conference, although the child protection concerns had been substantiated. It is the legitimate function of CSC team managers to make this decision but, in this case, their rationale was not entirely evident. At the same time, referrers (or members of strategy meeting) appear not to have challenged that decision, although it is not clear that they were aware of the outcome. Ensuring that children who need the protection of a multi-agency plan is another of the most important planks in the child protection framework. It is currently not known to the SCP in what proportion of child 15 protection enquiries, where initial conference did not follow, concluded that concerns were substantiated. 2.65 Recommendation 9: The SCP should ask the local authority to undertake and report on regular dip-sample audits of cases where child protection enquiries have concluded with concerns being substantiated but there being a decision not to proceed to child protection conference. Dip-sample should focus on the rationale for decision-making and the level of consultation with the referrer/other professionals involved with the family. 2.66 Recommendation 10: The SCP training manager should disseminate the pan-Merseyside multi-agency training course in respect of professional challenge to relevant practitioners and managers in the local area. Improving this area of practice would support efforts to ensure consistent application of thresholds of need and support across the borough. 2.67 Finally, concerns were noted in the key lines of enquiry about the impact that Charlie’s poor school attendance had on both her education and on professional understanding of the levels of her vulnerability. Further information was, therefore, requested by the SCPRP about Charlie’s levels of attendance throughout her school life as that might be an indicator of how her care was being managed at home. Charlie’s poor attendance was thought to be a factor in her reported difficulties in making friends. Charlie attended 3 primary schools. In Y4 her attendance fell below 85% and in Y5 there was a further fall to less than 65%. In Y6, Charlie’s attendance was 75%. 2.68 The local authority Education Welfare Service has provided details of expectations of schools and governing bodies in respect of identifying pupil absence related to illness or medical conditions and of providing co-ordinated support to children and parents. It would be anticipated that support plans would be reviewed on a regular basis with health professionals being invited to show progress or to identify changes that are needed to be meeting the individual child’s current presenting needs. The need to consider referrals to any other support services, such as Early Help, CSC, or CAMHS is also highlighted. 2.69 No evidence has been made available to the review in respect of compliance with those expectations. 2.70 Recommendation 11: The SCP should audit school compliance with local authority guidance in respect of children who are absent from school due to illness or medical conditions under S175 of the Education Act 2002, as a basis for determining what, if any, further action may be required. 16 3. Summary of Recommendations Recommendation 1: Although it is accepted that the level of opioid prescription is high in St Helens, the demographic details of the affected cohort of patients are not known. It is recommended, therefore, that the SCP asks PH to provide the data that it needs to benchmark the number of families with children who could be affected by parental opioid prescribing, with a view to determining what action might be required. Recommendation 2: Alongside disseminating learning from this review; the SCP should: a) quickly revise its current procedures in respect of Parental Substance Misuse, to include more detailed guidance in respect of identifying and responding to safeguarding concerns arising from parental dependence on prescribed drugs; and, b) require agencies and organisations to provide details of how they are implementing the Parental Substance Misuse guidance and what steps they are taking to assess its impact on practice. Recommendation 3: Before March 2021, the Safeguarding Children Partnership should undertake a multi-agency audit of cases where substance misuse is a feature of family life. That cohort of cases should, if possible, contain examples of parental dependence on prescribed drugs. Recommendation 4: The Safeguarding Children Partnership should commission a short life group to be overseen by an agreed ‘designated doctor’. The purpose of that review would be to conduct a medical review of Charlie’s records and to establish what, if any lessons there are for professionals, in respect of identifying or responding to indicators of fabricated or induced illness, particularly in older children/adolescents. Recommendation 5: An audit of assessment (CSC, January 2020) made six recommendations for action to improve the quality of assessments. They include proposals with implications for both single agency and multi-agency practice. It is recommended that the SCP require the local authority to report, by December 2020, on the implementation of the six recommendations made. Recommendation 6: The SCP should require agencies and organisations to identify how they intend to measure and improve practitioner engagement with fathers in safeguarding and child protection work. 17 Recommendation 7: The SCP should ensure that all multi-agency audits commissioned by the Partnership take account specifically of the engagement of fathers in safeguarding processes. This will allow the Partnership to measure improvements in practice over time and to identify where further action may be required. Recommendation 8: Arrangements should be made to feedback the findings of this review specifically to St Helens ‘Voice of the Child Champions Group’ so that they understand the key issues and challenges of the case. Following that, colleagues from the multi-agency partnership should be recruited to contribute to planning and delivering a 'Speed Resources' event. That event should target multi-agency practitioners to share tools/resources to improve participation of children in safeguarding/child protection processes. Recommendation 9: The SCP should ask the local authority to undertake and report on regular dip-sample audits of cases where child protection enquiries have concluded with concerns being substantiated but there being a decision not to proceed to child protection conference. Dip-samples should focus on the rationale for decision-making and the level of consultation with the referrer/other professionals involved with the family. Recommendation 10: The SCP training manager should include the pan-Merseyside multi-agency training course in respect of professional challenge to relevant practitioners and managers in the local area. Improving this area of practice would support efforts to ensure consistent application of thresholds of need and support across the borough. Recommendation 11: The SCP should audit school compliance with local authority guidance in respect of children who are absent from school due to illness or medical conditions under S175 of the Education Act 2002, as a basis for determining what, if any, further action may be required. Isobel Colquhoun Independent Reviewer 9 March 2020 18 Appendix 1 List of Acronyms SCP – Safeguarding Children Partnership SCPRP - Safeguarding Children Practice Review Panel CCG – Clinical Commissioning Group CSC – Children’s Social Care PHE – Public Health England ED – Emergency Department MDT – Multi Disciplinary Team PH – Public Health LSCB – Local Safeguarding Children’s Board |
NC048177 | Death of a 6-year-old girl in October 2013 from a head injury. Father was charged with her murder and child cruelty. Mother was charged with intending to pervert the course of justice and child cruelty. Child D's sibling was placed in foster care. Child D had previously been on the child protection register under the category of physical abuse, after being hospitalised with head injuries in February 2007. Child D's father was convicted of GBH and Child D was placed in the care of her maternal grandparents. Following new medical evidence, father's conviction was quashed and a high court judge ruled the parents were not culpable of involvement in Child D's injuries. The judge appointed an independent social work agency to work with the family and Child D returned to live with her parents in November 2012. Child D was no longer subject to any orders and children's services did not have a formal role with the family. Parental history of: mental health problems; criminal behaviour; frequent hospital attendance for injuries and illnesses; lies and deception including mother concealing the birth of Child D's sibling; and use of complaints and threats of legal action against professionals. Learning points include: focus on the child's needs and experiences at all times, regardless of how demanding the parents are; when working with independent social work agencies, consider issues around quality assurance of practice, accountability, how they are selected and how they work in a multi-agency context. Recommendations include: clarify the courts' responsibility to LSCBs in respect of serious case reviews; following an unexpected court judgment, which has the potential to raise concerns for children, convene a multi-agency meeting to discuss future actions, roles and responsibilities and establish the means by which agencies can share information about and respond to any escalation of concern.
| Title: Child D: a serious case review: overview report. LSCB: Sutton Local Safeguarding Children Board Author: Marion Davis Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child D Overview Report April 2016 Final Page 1 of 56 CHILD D A SERIOUS CASE REVIEW OVERVIEW REPORT Marion Davis C.B.E. Copyright of this report is with Sutton LSCB Child D Overview Report April 2016 Final Page 2 of 56 1. INTRODUCTION ..................................................................................................................... 3 2. SUMMARY .............................................................................................................................. 5 2.1. Critical Incident leading to the SCR ................................................................................... 5 2.2. Family Tree ....................................................................................................................... 5 2.3. Narrative of Events ........................................................................................................... 5 3. ANALYSIS: General Questions .............................................................................................. 13 4. ANALYSIS: Specialist Questions ........................................................................................... 15 5. INVOLVEMENT OF FAMILY MEMBERS ............................................................................... 28 6. INVOLVEMENT OF PROFESSIONALS ................................................................................ 31 7. FINDINGS .............................................................................................................................. 31 8. LEARNING POINTS .............................................................................................................. 36 9. RECOMMENDATIONS .......................................................................................................... 38 10. CONCLUSIONS ..................................................................................................................... 39 11. APPENDICES ........................................................................................................................ 40 Appendix A - Biographies ....................................................................................................... 40 Appendix B - Terms of Reference Serious Case Review (SCR) ............................................. 41 Appendix C - Child D SCR Panel ........................................................................................... 46 Appendix D - Summary of Learning Points ............................................................................. 47 Appendix E - Summary of IMR recommendations .................................................................. 48 Appendix F - LSCB Action Plan – Child D .............................................................................. 51 CONTENTS Child D Overview Report April 2016 Final Page 3 of 56 1. INTRODUCTION 1.1. Between 25 November 2013 and 18 August 2014 Sutton Local Safeguarding Children Board (LSCB) conducted a Serious Case Review (SCR) in respect of the death of Child D. The case met the legal requirement to undertake a SCR (Reg. 5 of the LSCB Regulations 2006) i.e. where a child has died and abuse or neglect is known or suspected. The Review was conducted under the statutory guidance of ‘Working Together to Safeguard Children 2013’1, applying the principles of learning and improvement from that guidance. The report was reviewed following the publication of ‘Working Together 2015’2 to consider revised SCR guidance to prepare for the publication of the overview report. ‘Working Together’ states: “SCRs and other case reviews should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at that time rather than using hindsight; Is transparent about the way data is collected and analysed and; Makes use of relevant research and case evidence to inform the findings.” 1.2. The Terms of Reference do not refer to a specific methodology, but the LSCB, through the SCR Panel, wanted the SCR to take a broad view of systemic issues that had a bearing on the case, as well as practice issues. It confirmed that the involvement of family members and of professionals was an important part of the Overview Review process. 1.3. A Serious Case Review Panel was established, chaired by the then Independent Chair of Sutton’s Local Safeguarding Children Board (LSCB), Kevin Crompton. All relevant agencies involved with Child D and the family were invited to be part of the Panel and Individual Management Reviews (IMRs); background reports were requested from 20 agencies. 1.4. The Judiciary declined to undertake an IMR with the office of the President of the Family Division writing on 27 March 2014 that “For constitutional reasons it would not 1 HM Government (2013) Working together to safeguard children: a guide to interagency working to safeguard and promote the welfare of children, London: The Stationery Office. 2 HM Government (2015) Working together to safeguard children: statutory guide to interagency working to safeguard and promote the welfare of children, London: The Stationery Office. Child D Overview Report April 2016 Final Page 4 of 56 be appropriate for the judiciary to produce an Individual Management Review.” Copies of the relevant Judgements in the case were provided. The Independent Social Work Agency, ‘Services for Children’ (S4C), was unable to produce an IMR as there was no independent person in their organisation who had not been involved in work on the case; but they provided a background report detailing their work and made all their reports available to the Overview author. 1.5. Agencies were asked to produce their IMRs by 14 March 2014 and extensions were granted to 30 April 2014. There was significant delay to 06 June 2014 in receiving S4C’s report and to 30 June 2014 in the production of the IMR by the Police due to a lack of capacity in the Metropolitan Police Service to undertake this work. A Health Overview Report was also produced to summarise the involvement of all the health organisations involved with the family. The SCR Panel met on 7 occasions; the membership of the panel is contained in Appendix C; and the Overview Report was accepted by the Sutton LSCB on 10 September 2014. 1.6. Altogether 19 IMRs and the background report were submitted to the SCR Panel. Most responded well to the Terms of Reference in respect of the areas in which the agency had a direct contribution to make, giving chronological accounts, reviewing practice and undertaking an analysis of events. The Health Overview report was thorough in quality assuring the reports of health organisations, being explicit where there were shortcomings and commenting on the effectiveness of each IMR. Only one IMR was inadequate, that of the Chelsea and Westminster Hospital NHS Foundation Trust, which was written in two separate parts and had significant errors, including wrong names and dates of birth of family members. 1.7. Several IMRs went to great lengths to cover the complexity of the case, probing what actually happened and drafting clear recommendations. Those which are particularly thorough in their analysis and gave good consideration to the learning from this Review include Legal Services, London Probation Trust, Epsom and St. Helier University Hospitals NHS Trust, Sutton and Merton Community Services, General Practice and Cafcass. 1.8. Marion Davis was commissioned to write this Overview Report. She is a qualified social worker and senior children’s social care professional with over 30 years experience. She is independent of all the organisations involved in this Review and had no previous knowledge of the family. A full biography is provided in Appendix A. 1.9. The full Terms of Reference for this SCR were agreed at the SCR Panel on 16 January 2014 and are reproduced in Appendix B. The SCR covered the period from 01 January 2000 up until the death of Child D on 28 October 2013. In addition to a list of standard questions to address, IMR authors were asked to consider 6 specific Child D Overview Report April 2016 Final Page 5 of 56 questions of particular pertinence to this case. These are contained within the Terms of Reference. 1.10. The family of Child D was informed of and involved in the review as appropriate. 1.11. The Independent Reviewer and the Sutton LSCB would like to offer their condolences to the grandparents, who contributed to this review, on the sad death of Child D. It is important to acknowledge the work of all the professionals and support staff who have enabled this report to be produced and the contribution of individuals, organisations and the family to the content of this complex review. 2. SUMMARY 2.1. Critical Incident leading to the SCR Child D was aged 6 years and 10 months and living with the mother (who will be referred to as Ms M), father (who will be referred to as Mr F) and younger sibling (who will be referred to as Child S) at the time of death. On the day of the incident, an ambulance was called to the family home where Child D was found to be non-responsive and to have a head injury. CPR was administered, the child was taken to Hospital 1 and shortly afterwards was declared dead. Post-mortem results show that Child D died of a head injury. An inquest was opened and adjourned. A criminal investigation was initiated, with Mr F being charged in March 2014 with the murder of Child D and Ms M with intending to pervert the course of justice. Both parents have been charged with child cruelty. 2.2. Family Tree [REDACTED] 2.3. Narrative of Events The history and multiple nature of agencies’ involvement with the family is a long and complex one. Given that a fully integrated chronology has been compiled and that there is a significant amount of detail in the IMR / background reports, it is not proposed to reproduce the full history of Child D’s life and that of the child’s family here. This narrative is intended to provide some contextual information and a description of key events. Child D Overview Report April 2016 Final Page 6 of 56 2.3.1. Prior to Child D’s birth and parental backgrounds. Ms M, mother of Child D, had a difficult relationship with her parents, particularly her father. She was married in 2000, but was divorced by the time she met Mr F in 2006. There were no children of this marriage. She is recorded as having a history of depression. She has held various jobs, most recently working as a full-time graphic designer. In respect of Mr F’s health, records describe a pattern of frequent injuries related to alcohol, assaults and fights as well as a history of depression. Police and Probation records show a long history of offending, including a 3 year 11 month prison sentence for armed robbery with violence and witness intimidation, charges of ABH and an assault on a pregnant ex-girlfriend. Many other alleged incidents did not proceed to court as witnesses / alleged victims would not pursue a case against Mr F. He frequently breached community orders and failed to co-operate with Probation staff. He reported a history of being sexually abused as a child by a relative, had a history of self-harm and was referred for psychotherapeutic help. Mr F appears not to have held employment for many years. The relationship between Ms M and Mr F appears to have been casual in that they did not live together and were separated by the time of Child D’s birth. Ms M was supported by her mother at the birth (which was a ventouse3 delivery) but agreed that Mr F should be enabled to play a role in Child D’s life from the very early stages if he wished. 2.3.2. Early months At 5 weeks old, Child D was staying overnight with the father and suffered burns to both index fingers and forehead, said to be caused by rolling into a radiator. Ms M took Child D to the GP the next day but there was no referral to Children’s Services and no follow up. One week later, on 15 February 2007, when Child D was again staying with the father, Child D was taken to Epsom and St Helier Hospital after he noticed the baby “suddenly soft and limp”. This was a life-threatening event and during scans and investigations Child D was found to have sub-dural haematomas4, retinal haemorrhages and suffered seizures. The child was also discovered to have an unusual combination of a laryngeal cleft and a cyst at the back of the tongue. Children’s Services were contacted as the injuries were believed to be non-accidental; discussions with the Police took place and a child protection investigation was initiated. The medical information from several scans (in more than one hospital) was complex but at a Strategy Meeting on 27 February 2007 it was concluded that the injuries were not accidental. A Child Protection Conference was held on 08 March 2007 which placed Child D on the Child Protection Register in the category of physical abuse. Child D 3 A ventouse is a vacuum device used to assist the delivery of a baby (an alternative to a forceps delivery) 4 A subdural haematoma is a collection of blood on the brain and is usually the result of a serious head injury. National Library of Medicine. July 2012. Child D Overview Report April 2016 Final Page 7 of 56 was made subject of an Interim Care Order on 09 March 2007 and was discharged from hospital into a foster care placement on 16 March 2007. Ms M and Mr F did not accept the medical opinion regarding the cause of Child D’s injuries and there were doubts as to whether the grandparents (Mr GF and Mrs GM) were able to contemplate that these were caused by the father. An adoption plan was considered for Child D, but subsequently Mr GF and Mrs GM were joined to the court proceedings and assessed as potential carers for Child D. This plan was supported by the Child’s Guardian (CG1), and Child D moved to the home of Mr GF and Mrs GM on 24 July 2007. They subsequently applied for a Special Guardianship Order. Ms M and Mr F were enabled to have contact with Child D, separately, as they stated they were not in a relationship, but these visits were frequently cancelled by the parents (CG1 noted that by March 2008, Ms M had missed 13 contact visits with Child D) and were often a source of tensions between family members. 2.3.3. 2008/9 First set of Court Proceedings January 2008. Within the Care Proceedings a finding of fact hearing determined that Child D’s injuries were caused by Mr F and that Ms M had failed to protect Child D. February 2008. A Consultant Forensic Psychiatrist was commissioned by the Court to undertake a risk assessment on both parents. In March 2008 the Psychiatrist’s reports on each parent were presented to the court, having had access to a wide range of background material. In respect of Mr F his family, employment and criminal history are covered. It notes there are significant discrepancies in his and the Police accounts of the seriousness of the assault on his former girlfriend and there were discrepancies in his account given to the Judge regarding Child D’s injuries. He also denied he had been abused as a child. He admitted to having a temper. There was no evidence of any symptoms of mental disorder. The conclusion (bearing in mind the timing of this assessment being after Judge 01’s finding of fact against him, but before his criminal conviction for injuring Child D) was that “the potential risk to a child in his unsupervised care would have to be said to be high”. This was further judged to be compounded by his level of denial. In respect of Ms M the report again details her family, employment and relationship history. It notes that no symptoms of mental disorder or clinical depression were found and also records that Ms M had no intention of resuming a relationship with Mr F. The report concludes “If any evidence of a closer relationship did emerge at any stage, given the level of risk posed by [Mr F], I would have very significant concerns about [Child D]. April 2008. Judge 01 ruled Ms M out as a suitable long term carer for Child D. August 2008. Special Guardianship Order awarded to Mr GF and Mrs GM. March 2009. Mr F was found guilty of GBH in respect of Child D’s injuries and was sentenced to 18 months in prison. Child D Overview Report April 2016 Final Page 8 of 56 During this period Child D made good progress with the grandparents, including being supported through regular medical appointments. Parents often missed contact sessions with Child D, with Ms M having no contact between May and December 2009. 2.3.4. 2009 – 2012: Events that changed the plan Mr F was released from prison on 30 June 2009 on bail pending an appeal against his conviction for GBH in respect of Child D’s injuries. Child S, full sibling to Child D, was born in Worthing (although it took some time to establish that Mr F was the father). Ms M had concealed the pregnancy and birth from agencies in Sutton and from her family, and Child S’s existence was only discovered when Ms M was arrested on 07 February 2010 for shoplifting and had a young baby with her. At this point Ms M tried to evade Children’s Services by claiming to have moved to Liverpool. On 21 March 2010 Ms M and Child S were located by the Police in Sussex; there were concerns about Child S e.g. being found in filthy clothes, which suggested neglect and the child was removed into Police Protection. Child S was placed in foster care and Care Proceedings were commenced. On 17 June 2010 the Court of Appeal quashed Mr F’s conviction for GBH on the basis of new expert medical evidence which raised areas of doubt. During 2010/2011 both Ms M and Mr F were convicted of criminal offences, had numerous health problems (including Ms M having 16 hospital admissions in 8 months) and a poor record of contact visits. During January 2012 Child S had a period of serious illness but still Ms M declined to visit. In May 2011 Ms M was successful in her application to re-open the Finding of Fact in respect of Child D’s 2007 injuries. Full hearing scheduled for one year hence. 08 May 2012 – 05 July 2012 High Court Hearing which concluded in the overturning of the previous Finding of Fact. This meant that the parents were found not to be culpable of involvement in Child D’s injuries and had suffered a miscarriage of justice. Judge 02’s judgement was based on extensive and complex medical evidence by expert witnesses. After the conclusion of the Court Hearing the children were not subject to any orders, and Children’s Services did not have a formal role with the family as the court had found that the threshold criteria were not met. The Local Authority was required by the court to send a letter to all agencies who had worked with the family to inform them of Mr F’s quashed conviction and exoneration and directing that this letter should be prominently referenced in their files. It included the statement “[The Judge] concluded that not only was she satisfied that [Mr F] had never caused harm to his child, in fact there was an innocent explanation for his child’s suspected injuries.” During the above hearing the Judge appointed an Independent Social Work Agency, Services 4 Children (S4C), as she believed that work between the parents and the Local Child D Overview Report April 2016 Final Page 9 of 56 Authority would be “doomed to failure”. S4C was appointed to carry out an assessment of Ms M and Mr F with a view to the rehabilitation of Child S to Ms M (potentially with support from Mr F). S4C is a small Independent Social Work Agency with just two social workers who, since their establishment in 2008, have carried out over 30 cases for courts and local authorities in respect of a range of issues, many of which feature in this case. The Letter of Instruction issued to S4C covered such matters as the timescale for reunification, contact between Child S and Child D and other family members and “the various help, support and services that the mother, alternatively the mother and the father, will need to realise the reunification of [Child S] to her/their care.” At this point the parents stated that they had no plans to co-habit. In the course of a subsequent hearing in September 2012 the remit of the assessment was broadened to include Child D moving to the parents’ care and the Court approved a new plan of work to form the basis of a second Letter of Instruction to be issued to S4C. The draft court order records that “the maternal grandparents agree in principle to [Child D] returning to the parents’ care.” After brief introductory visits and with significant supportive input from the foster carer, Child S was placed with Ms M and Mr F on 08 October 2012. According to S4C Ms M and Mr F responded well to caring for Child S. Their background report states “In the first phase observations were made that indicated Mr F and Ms M had sufficient parenting skills to take on the care of [Child S]. The observations of contact were that Mr F and Ms M sufficiently understood the needs of [Child S].” They note that in the lead up to Child S being placed, Mr F took the primary role in introductions as Ms M was on a training course, did not free herself from work commitments as planned and was evasive when challenged about this (She was encouraged to specify dates she would not work in order to prioritise the children’s moves but did not, in the event, do so). Nor was their accommodation ready in the necessary timescales and Mr F and Ms M had not managed important practicalities such as the switching on of utilities and the arrival and assembly of a bed. The September 2012 court report of S4C stated “[Child D’s] position is yet to be fully ascertained” and no direct work had started with the child, but there was mention that a move to live with the parents and sibling could take some time. S4C became involved in mediation work between the parents, grandparents and extended family and were concerned about the potentially harmful effect on Child D of extended introductions in a climate of tension. Originally S4C had no predetermined plan or instruction to place Child D with the parents. They acknowledged the importance of the bond with the grandparents who had cared for Child D for more than five years, and hoped that it would be possible for the parents and grandparents to cooperate in an extended family arrangement whereby Child D would have the benefit of long term stability and might move between carers easily when Child D wished as the child got older. They had not appreciated the depth of the rifts and hostility between Mr GF (and Mrs GM) and Ms M (and Mr F) that they believed made it Child D Overview Report April 2016 Final Page 10 of 56 impossible to realise such an arrangement. Despite a range of sessions of mediation which aimed to bring family members together around Child D’s wellbeing, some of which brought positive steps forward, they eventually had to conclude that this was unlikely to be achieved. S4C’s September 2012 report says Mr F stated that he might have to “fight” for Child D through a residence order application. He behaved forcefully at times including “bouts of extreme shouting” which S4C worked hard to try to ameliorate, and there are accounts of similarly intransigent views from Mr GF. By the time they submitted their report to the court on 13 September 2012 S4C concluded that an amicable transition was unlikely, and “Therefore the possibility of someone having to grieve the loss of [Child D] is real.” Despite saying at this stage that they reserved a view about who this ‘someone’ would be, the plan soon shaped up to entail a placement of Child D with the parents and her sibling. An extract from the draft order of the court proceedings between 25 and 28 September 2012 states “There shall be a continuation of the assessment of Services for Children in respect of [Child D], to encompass when and how [Child D] shall be returned to the care of the parents”. Direct work with Child D continued as did work on the fractured family relationships but S4C determined that the effect of the ongoing tensions on Child D was detrimental and led them to condense the introductions from a previously mooted period of a year, down to the end of 2012 and then an even shorter timescale. The reunification programme was accelerated and the move was scheduled for 09 November 2012. It had been planned that during the first weekend in November that Child D would spend extensive time with the parents including an overnight stay. This did not happen as the parents had moved to their new house but were without power, they made themselves unavailable for any contact and S4C were unable to talk to either of them. At this stage the parents expressed their lack of readiness for Child D’s move. S4C’s November report says “The cancellation of [Child D’s] contact on the weekend of 4 November was not prioritising [Child D] and the child’s feelings. However the overwhelming stress of the situation meant that for a brief period [Child D] got lost in it all.” During the last few days prior to moving to the parents’ home, concern was expressed by a number of agencies, including Child D’s school and a paediatrician who had seen the child that week, about the speed at which the move was happening and Child D’s lack of preparedness for it. It was suggested that Child D’s Guardian, CG2, might meet with the child, but due to sickness she was unable to do so. The move went ahead on 09 November 2012. 2.3.5. 2012 – 2013 - Period from children’s return to parents to death of Child D In October 2012 Child S’s early weeks in the parents’ care seem to have been uneventful and S4C were positively surprised by the few adjustments and difficulties Mr F and Ms M had experienced and particularly impressed by the way a previously very poor sleeping pattern had settled. Child D Overview Report April 2016 Final Page 11 of 56 However, in November 2012, only 4 days after Child D was placed, both Ms M and Mr F telephoned S4C to express concern about Child D’s behaviour. They alleged the grandparents had not brought Child D up properly. The report of the conversations suggested Child D was upset, thought that going home would happen, was constantly lying, told tales on Child S, was fussy about eating and responded with a “no” to everything. Mr F is reported as describing Child D as “an odd child”. There appears to be a marked difference in the parents’ descriptions of their children’s personalities with Child D presenting them with more challenges. On 04 December 2012 Ms M presented at St. Helier Hospital with the two children who were hungry and were fed by a nurse. After being told that Children’s Services were to be informed, Ms M left the hospital in the early hours of the morning, taking the children to Mr F. Ms M was later admitted to the hospital and found to be pregnant but wished to conceal the pregnancy from her family and partner. On 5 January 2013 Ms M was pregnant and admitted to Chelsea and Westminster Hospital for gynaecological investigations. Child S was admitted on social grounds, Ms M saying there was no-one to look after the child, having given false details, and failed to mention the existence of Child D. A few days later, once correct data was ascertained, Children’s Services were contacted and it was suggested by hospital staff that Ms M was exhibiting bruising (this was not substantiated and later withdrawn). In the course of trying to locate Child D on 08 January 2013 it was established that Child D was not in school and a home visit only elicited an angry response from Mr F refusing to deal with Children’s Services. S4C were asked to try to make contact with the parents and the Police to do a home visit which they did but found no one at home. S4C made contact with both Mr F and Ms M by phone and also spoke to Child D – it was established that Ms M had collected Child D from Mr F and was staying in a hotel overnight with the children before going to stay with a friend in Portsmouth for a break. S4C were told that the relationship was in difficulties and the couple had separated. Ms M then failed to attend her appointment with S4C on Friday 11 January 2013. Discussion between the Police and Children’s Services resulted in an agreement to convene a Strategy meeting if the children had not returned by Monday. This was not necessary as contact was made and no child protection investigation was required. During early 2013 Ms M had various hospital contacts, the family’s tenancy went into rent arrears, Child S’s attendance at nursery was very poor, Child D’s school attendance declined and there were missed medical appointments (both of which had been close to 100% whilst in the care of the grandparents). Children’s Services held a professionals’ meeting on 28 January 2013 which resulted in an offer of multi-agency support to the parents, but there were deemed insufficient grounds to justify a statutory intervention. No response was received from the family to this offer and professionals believed that the parents would not voluntarily engage with any agency at this stage (with the exception of S4C). S4C describe the events of January 2013 when the parents separated as having threatened the whole arrangement, but believed that the parents had learned from it. They did however have concerns at Ms M’s “evasive flight strategy” and the impact it could have on the children, especially if Mr F was not present in the household. Ms M was urged to Child D Overview Report April 2016 Final Page 12 of 56 take up the offer of counselling. Child D’s education and low attendance is commented on but it was believed that the parents were addressing this. Ms M was again admitted to Chelsea and Westminster Hospital on 27 March 2013 with bleeding attributed to a termination of pregnancy. She gave false information, including denying that she had children or that she had previously been in that hospital. However, several days later staff recognised her and contacted Children’s Services out of hours emergency duty team and the Police. At the request of the hospital the Police made two or three home visits on 31 March 2013, initially finding no-one at home but returned and found Mr F and the children there. The Police reported that the children were “safe and well” and there were no concerns. A Senior Practitioner in Sutton’s Children’s Social Care was asked to consider whether an assessment or intervention should be undertaken. After reviewing the records, liaison with S4C and with senior managers it was concluded that there was no evidence to justify a formal investigation. Subsequently a nurse telephoned the Multi Agency Safeguarding Hub (MASH) on 04 April 2013 to report that Ms M was being discharged and there was a suspicion that she had been raped. No supporting evidence was brought forward and there was confusion as to the origin of this information. Without something more concrete to go on and nothing to suggest that Mr F was the alleged perpetrator it was considered there was still insufficient evidence to instigate any safeguarding procedures in respect of the children. S4C concluded their work with the family in March 2013 and submitted a report to Children’s Services dated 12 April 2013. The report is generally very positive regarding the development of the relationship between Child D and Child S. It also describes how the parents had made shifts in their outlook and S4C observed not only their appropriate attention to the children’s everyday needs but also an enjoyment of their parenting and shared activities with the children and a setting of boundaries where needed. On their final contact with the family S4C say they “were able to see [Child D and Child S] and their parents in a relaxed state” “smiling and happy” which “was in the opinion of S4C attributable to the care being offered to them at that time”. Parents continued to be resistant and hostile to any Children’s Services involvement and Mr F submitted complaints. The final contact between Children’s Services and the parents was in May 2013 when the MASH received a copy of a letter from the Consultant Ophthalmologist to the parents regarding Child D having missed appointments. The Social Worker in the MASH sent a standard letter to the parents offering help and stating that no action would be taken at this time. This resulted in a very aggressive telephone call from Mr F followed by a formal complaint from his lawyer. Mr GF and Mrs GM maintained contact with Child D and Child S but many contacts were cancelled by the parents. Child D Overview Report April 2016 Final Page 13 of 56 In June 2013 Child D was seen by the GP with facial bruising and grazing; an accidental explanation by Child D, in the presence of the father, was accepted and no further action was taken. At around the same time at a contact session the grandparents thought that Child D had facial bruising and scratches but this was concealed by face paint and they were not allowed to speak with the children alone. During this period Ms M was suffering from depression and receiving medication and Mr F was not complying with requirements from the Probation Service and was made subject of a suspended sentence. Most professional contacts with Child D and the family during the last months of the child’s life were with universal services – mainly the school, but also with the school nurse and the health visitor and with housing (in connection with the continuing rent arrears on the family home). Child D died on 28 October 2013 at Hospital 1. At the time of Child D’s death, Child S was present at the hospital and well cared for by staff, but there was no medical examination. Ms M subsequently declined permission, an Emergency Protection Order (EPO) was obtained, Child S was placed in foster care and when examined the following day bruising to the back was recorded. On 11 March 2014 Mr F was charged with the murder of Child D and also faces a charge of child cruelty. He was remanded in custody. On 22 April 2014 Ms M was charged with intending to pervert the course of justice and also faces a charge of child cruelty. She was remanded on bail. Child S continues to be placed in foster care. 3. ANALYSIS: General Questions IMR authors were asked to address a set of standard questions (see Terms of Reference in Appendix B). Not all 13 questions were relevant for all agencies and responses are detailed in the IMRs and will not be repeated in full in this Overview Report. Key points of what worked well or at least satisfactorily include: In the majority of the numerous professional contacts with Child D and the family over the period covered by this Review, practitioners acted with sensitivity to the children’s needs and in accordance with agency policies and procedures in respect of safeguarding. Senior Managers were appropriately involved in most instances and there is evidence that many examples of assessment and decision making were conducted in an informed and professional way. Child D Overview Report April 2016 Final Page 14 of 56 Resource issues and organisational difficulties do not appear to have played a major role in service delivery to this family. The L.B of Sutton Children’s Services was subject to a Notice of Improvement between September 2012 and March 2014 which inevitably caused some turbulence in the organisation, but at practitioner level this does not appear to have had a significant impact on this case for those working at the front line. Whilst there were a high number of social workers involved in this case over six and a half years, many of these held specialist roles (e.g. permanency, multi agency safeguarding hub and looked after children) and there were no gaps when the case was unallocated. Whilst multi-agency practice was not always as good as it should have been, the deficits were not of a nature to expose a child to risk. IMR authors have appropriately highlighted where better compliance with guidance and further embedding of good practice are required. There are references to a number of instances where professionals in various agencies appropriately consulted line managers and safeguarding specialists and received appropriate advice, supervision and support in dealing with concerns, dilemmas and complex issues. Examples of good and effective practice are recorded in respect of a number of professionals in several agencies and it is clear that many individuals made strenuous efforts to act in Child D’s interests in the face of extreme resistance and hostility from the parents. Key messages of professional concerns include: The Health Overview author questions whether the incident when Child D, aged five weeks, sustained burns to the forehead and index fingers, allegedly by rolling on to a radiator, should have been referred to Children’s Services as this was an incident involving injuries to a non-mobile baby. The Legal IMR makes reference to issues of capacity within the team at the time and questions whether not appointing a Queen’s Council (QC), as other parties did, may have had a detrimental bearing on the case. It concludes that there was no evidence to support that the case was handled anything but appropriately, but queries whether the status of the advocate might have resulted in them being regarded as less influential in the court arena. The delay of a year in listing the re-hearing of the Fact Finding in the High Court was not helpful. The only other organisational factor of note is the absence on sick leave of the second Children’s Guardian (CG2) during the key period July- December 2012. Whilst she was away from work for planned surgery, her work was not reallocated or covered by her manager, and although she attempted to undertake elements of the role whilst on sick leave, her engagement and contact with Child D was not at the level needed, nor at the level she would have wished to provide at the crucial point when Child D was returning to the parents. The Cafcass IMR author comments on this shortfall and that the supervision of a case of this complexity was not sufficient. Child D Overview Report April 2016 Final Page 15 of 56 Although several key professionals engaged in purposeful direct work with Child D, there is a general absence of focus on Child D and Child S as individuals and their wishes, feelings and characters do not feature strongly in material I have read. Much more narrative and professional attention is paid to the parents’ behaviour and the impact of this will be referred to later. Some practice issues have been raised in respect of information sharing and recording and, amongst others, the Health Overview report clearly documents instances where procedures were not followed. These predominantly, but not entirely, relate to events in 2007 and multi-agency policy and practice is reported to have improved in the intervening years. Analysis of reports suggest that across and within agencies there were elements of silo-working and some opportunities for triangulation of information and good handover were not pursued. 4. ANALYSIS: Specialist Questions. 4.1. Child D’s father’s conviction for shaking the child as a baby was overturned by the courts and Child D, along with Child S, returned to live with their parents. An Independent Social Work Agency was appointed to work with the family. Did these decisions have an impact on the way the agencies worked further with the family? The overturning of Mr F’s conviction for GBH in respect of Child D’s injuries as a young baby and the letter that was directed by the Court in September 2012 to be sent to all relevant agencies outlining the parents’ exoneration, undoubtedly had a very significant bearing on this case. It meant that the parents could no longer be regarded as having harmed or failed to protect Child D and that any future concerns could not take these past events, that had been previously considered as a serious non-accidental injury, into account. There was an expectation that support and help would be offered to the family to enable the return of the children to their parents to be successful, but acceptance or not of any support was left to the parents to decide. Without the previous conviction on the record, the threshold for statutory intervention was deemed not to have been met and therefore the Court made no orders in respect of the children and discharged those that were prevailing at the time. Staff from various agencies have expressed surprise, and in some cases incredulity, that the children were placed with their parents without, for example, a supervision order or child protection plan and felt this removed a “protective framework” to work within. This was, however, the logical conclusion of the quashing of the conviction and the re-hearing of the Finding of Fact. Some agencies, less used to dealing in the court arena, found this extremely hard to comprehend. Furthermore, any future intervention with the family that was not agreed by the parents would need to meet the “significant harm” threshold anew. As the L.B of Sutton Children’s Social Care IMR says “this made anything short of Section 47 [child protection] impossible". Child D Overview Report April 2016 Final Page 16 of 56 The impact of the court case gave a strongly empowering message to the parents and an equally disempowering message to professionals. Many IMR authors refer to professionals feeling “powerless” or “paralysed”. The appointment of an Independent Social Work Agency to work with the family seems to have compounded this feeling as many agencies were generally unfamiliar with such an organisation and it effectively distanced the Local Authority social workers, with whom partners were used to working with, from the case. As the Health Overview report says: “Health professionals perceived that they were disempowered as part of this arrangement, they were unclear of their remit and what plan of care was in place for the children; in the main they felt or were excluded from any decision making and partnership with the ISW Agency”. One of the hospital IMRs states “it is the opinion of Consultant Paediatrician 3 that this decision had a huge impact on the way agencies worked together with the family and a new independent social worker had been allocated to the family. CP 3 was not contacted by the independent social worker as part of any monitoring or assessment undertaken”. The Health Overview Report summarises the position as follows “However the absence of a child protection plan or a court order, and the presence of an Independent Social Work Agency, should not have deflected health professionals from their core work to safeguard and promote the welfare of children. In this case it did not, but this set of circumstances appears to have been more challenging than the experiences of working with a local CSC [Children’s Social Care]”. The Local Authority ceased to be a party to the family court proceedings on 28 September 2012, when the remaining issues were dealt with in private law proceedings, through to the final review hearing on 11 December 2012. During this period there was a lack of clarity on the part of several agencies regarding the role of the Local Authority vis-a-vis the role of S4C. According to the Children’s Social Care IMR a social work team manager “noted her concerns that Services for Children had not kept Children’s Services updated with their preparations for Child D to return to live with the parents. She was also concerned that they had not completed mediation work between the parents and the maternal grandparents”. Similarly, S4C allege that they did not receive good communication from Children’s Services. School and health professionals were confused and it was difficult for agencies to operate in a co-ordinated way. Two agencies dealing with Mr F, Probation and the Mental Health Trust, report that if Mr F’s conviction for GBH had not been overturned, their subsequent handling of his involvement with them would have been different in view of the risk he would have been considered to pose. 4.2. Were there occasions where child protection processes should have been followed but were not as a consequence of the legal judgement? Child D Overview Report April 2016 Final Page 17 of 56 The view from the IMRs seems to be that despite the lack of statutory orders and the unfamiliarity of working with an Independent Social Work Agency, agencies still did follow standard procedures when concerns arose. For example, Consultants still pursued matters when parents failed to attend or to take up Child D’s appointments. The most testing time to consider whether child protection concerns were followed up was in January 2013 when Ms M was admitted to Chelsea and Westminster Hospital with Child S, giving false information with no mention of Child D, whose whereabouts were unknown for a short period of time. Initially there were claims that Ms M had severe bruising (which was later not confirmed) and the hospital social worker referred concerns to Children’s Services. Contact was made with the school and a home visit was made to the family home where Mr F was very angry and was only prepared to speak to the social worker from S4C. The link was made to S4C who made contact by telephone with Mr F and Ms M (although she then failed to keep her appointment with them). The Police were also involved in making a visit to the home and discussed the situation with social workers, concluding that a strategy meeting would be held if Child D hadn’t been spoken to after the weekend. Legal advice was also sought regarding whether any escalation of matters was appropriate. Essentially, there was good liaison and follow up by all relevant agencies to conclude this incident. Likewise when Ms M was admitted to the hospital in March 2013, again giving false information, there was liaison and follow up between Children’s Services, the Police, and the hospital due to a verbally reported suspicion by a nurse that Ms M may have been raped. Without any evidence being produced that rape had taken place (let alone that Mr F was involved) the social worker, in appropriate consultation with line managers, after much reflection, concluded, correctly, that there were no grounds for formal intervention. One incident that I and the Health Overview author have concerns about is on 25 June 2013 when Child D was taken to the GP by Mr F with quite severe bruising and grazes to the face. Questions were asked of Child D in the presence of the father, and the explanation seemed plausible, but the GP did not fully examine the child or refer to Children’s Services, which the Health Overview author believes did not meet expected safeguarding procedures. 4.3. There were a number of contacts between agencies regarding Child D and Child S after they returned to live with their parents in October and November 2012. Were these contacts handled and responded to in an appropriate and timely way? As referred to in the previous section, some key contacts in respect of child protection concerns were responded to well. Most agencies completing IMRs had little contact after the children went to live with their parents. There is a strong view from some health professionals that they were excluded by the Independent Social Work Agency in that when S4C was the lead agency they did not consult professionals, who in some cases had known Child D for years, or inform them of what was happening. Child D Overview Report April 2016 Final Page 18 of 56 There are suggestions that failure to pick up the fact that Child D was not being brought to medical appointments (e.g. for eye checks) was not followed up swiftly enough by the GP and that Child D should have been seen prior to issuing a sick note relating to the low level of school attendance. The Health Overview Report concludes that “communication during this period was at best challenging and at worst absent”. 4.4. Was information received by different agencies following Child D’s return home considered collectively and triangulated? Could this have made a difference? Some agencies were unaware that Child D had gone to live with Ms M and Mr F, some were unclear of the dates of the children’s return home, and several conveyed that they believed that the two children had returned on the same date, rather than Child S on 08 October 2012 and Child D on 09 November 2012. Consultant Paediatrician 3 is of the opinion “that an opportunity should have been available to consider information shared collectively; it may have made a difference to Child D’s welfare.” Most organisations assumed the Local Authority would share the relevant information, but given they did not have parental responsibility or any other locus in the case after the end of the September 2012, it could be argued that it was the responsibility of the parents themselves (who had parental responsibility by this stage), or the Independent Social Work Agency, to inform the relevant organisations of the moves of the children. Neither S4C nor the parents did this and on reflection it would probably have been helpful for there to have been a forum for multi-agency discussion about the changed circumstances for the children and the roles of the professionals. To the surprise of some professionals, once the children were living with their parents and certainly during the last few months of Child D’s life, the main agencies in touch with the family were universal services, predominantly Child D’s school. Two examples of attempts to co-ordinate support to the family during this period are of note. Firstly a “professionals meeting” was convened on 28 January 2013 to respond to concerns from Child D’s school. It was attended by Children’s Services staff, S4C and the school, but not health professionals, and a letter was sent offering a range of supports to Mr F and Ms M. These included: a nursery place for Child S, individual or couple counselling and support from the School Nurse and Health Visitor. There is no record of any response from the parents. In April 2013, and for the rest of the term, Child D’s school continued to have concerns about the low level of attendance and tried to follow this up through discussion with the parents and by organising a Common Assessment Framework (CAF) meeting. The response from the parents to these offers of support included aggression, evasion, and the cancelling of meetings (even when arranged at their convenience) which continued up to the time of Child D’s death. Child D Overview Report April 2016 Final Page 19 of 56 4.5. Would any other advice, information, support or intervention have prevented the child’s death? IMR authors and the individuals they and I interviewed have pondered this question long and hard. Most concluded that once the Court conclusion was reached and an Independent Social Work Agency was undertaking work to the exclusion of Children’s Services, there was little that could be done to prevent Child D’s death. Professionals who had read the Judgement (from the High Court hearing ending July 2012) concluded that it handed all the power to the parents and did not leave “even one per cent chance that it might be different”. Given the known pattern of the parents’ behaviour – lies, aggression, threats, missed appointments, “disguised compliance” and resistance, one IMR author commented that “The decision made that allowed the parents to dictate who they will and will not work with is extremely concerning practice that had a monumental impact for Child D and all professionals involved and should be reviewed with courage and conviction to shape future decision making “. On a specific level, Legal Services considered whether the decision not to appoint a QC to represent the Local Authority’s case had a bearing on the outcome, but concluded there was nothing that would suggest that the Senior Counsel was “anything but effective” or that there was anything lacking in the way the case of the Local Authority was presented in Court. The Metropolitan Police Service IMR stated that there did not appear to be anything likely to have made a difference, and the Children’s Services IMR author concluded it was difficult to think of an acceptable intervention that would have been protective. 4.6. The Finding of Facts against the parents following the hearing in January 2008 before Judge 01, were set aside by Judge 02 in the High Court on 06 July 2012 following a re-hearing. Were judicial decisions following all court hearings reasonable? The re-hearing of the fact finding took place between 08 May 2012 and 05 July 2012, the majority of the time being taken up with evidence from some 14 medical experts with specialties ranging from neurosurgery to ophthalmology and radiology. Other consultants who knew Child D were on standby to give evidence but were not called. The evidence was complex as was the detail of Child D’s pre-disposing factors of a ventouse delivery, cleft abnormalities and a laryngeal cyst, but was quite a different set of expert presentations from that given to the court in the previous findings of fact before Judge 01 in 2008. Furthermore, it is suggested that, whilst uncertainties remain, there had been significant advance in medical research and knowledge between the 2008 and 2012 judgements. What was not at issue was the chronic haemorrhaging in Child D’s brain with inter-cranial bleeds and re-bleeds of different ages, retinal haemorrhages and seizures. Various causations were considered including an airway obstruction giving rise to an increase in venous pressure and shaking or impact. The scans could not definitively show whether the trauma was accidental or non-accidental. Child D Overview Report April 2016 Final Page 20 of 56 The Judge weighed the evidence, some of which was new, alongside Mr F’s account and concluded that on the balance of probabilities, the medical evidence did not support a finding that Mr F had intentionally shaken Child D. She stated she accepted Mr F’s account and confirmed that she believed there was an innocent explanation. In respect of the radiator burns Child D suffered to the index fingers and forehead when the child was five weeks old and non-mobile, Judge 02 accepted Mr F’s account, describing his actions as those of an inexperienced parent and due to carelessness rather than recklessness and says “I make no finding of culpability of the father in respect of the burns”. The Legal IMR author says “Based on all the expert evidence before the Judge this [the conclusion that the injury was not a non-accidental one] was not an unreasonable decision”. I agree with this conclusion. The Local Authority sought counsel’s advice on whether the judgement might be appealable and whilst it was considered to be “thin on analysis” there were not sufficient grounds for an appeal. Having made this judgement on the medical experts’ evidence, the Judge considered other evidence, documenting matters such as the parents’ histories of offending, the concealment, both of Child S’s existence and of the DNA evidence confirming Mr F’s paternity, missed contacts, alleged domestic violence and the lies and evasion in dealing with authorities. She concluded that the Local Authority’s case did not prove the threshold criteria in the proceedings. However she then went further than making a non-finding against Mr F and exonerated the parents of all wrongdoing stated that they had suffered a miscarriage of justice and should be completely exonerated. She also required the Local Authority to send a letter, to be displayed in files of all relevant agencies that had dealings with Child D, to ensure that the past conviction and fact finding was not to be taken into consideration in future dealings with the family. The way in which the approved judgement of the hearing reads is interesting. The Judge accepts that the parents have no trust in the Local Authority and that any “assessment or work to be done would be doomed to failure if it were to be managed by the Local Authority” and agrees the recommendation by the Guardian that S4C be appointed. There is no record that the Judge considered another Local Authority Children’s Services be approached to carry out the assessment. A Letter of Instruction, previously referred to, was agreed by all parties, and described the work S4C was to carry out. S4C did not have a comprehensive picture of the complicated background to this case and were told, when they enquired about other information, that the detail contained in the July 2012 Judgement should be sufficient. It might be suggested that they should have requested more information about the parents’ criminal, health and social backgrounds, but on the other hand they could not have been specific as they did not know what they did not know. Child D Overview Report April 2016 Final Page 21 of 56 In addition to the clauses of the Letter of Instruction it was also recommended that there be some form of assessment of Ms M’s emotional state by a psychologist or psychiatrist, but this never happened as Ms M appears not to have agreed to it. In her conclusions the Judge works through the parents’ shortcomings and in many instances frames them in the context of being victims of a wrongful conviction and the difficulties they have suffered as a result, and seems ready to accept their explanations for their unhelpful behaviour. She states “I was impressed by the father” and refers to the parents “opening up” and states that once free from the “shadow of blame” “They are going to change”. The IMR author for Children’s Social Care makes a strong statement in response to this question. “Judge 02 having decided that the medical evidence in respect of the injury to Child D did not hold, then chose to ignore all the other evidence”. “She chose to dismiss the evidence of the parents’ hostile and non-cooperative behaviours and appeared to conclude that it was to be expected given that Children’s Services had removed their children”. In the absence of an IMR or other report from the Court it is difficult to conclude just what weight was given to the non-medical evidence and it is not clear that the Judge would have necessarily been aware of the full scale of such factors as: Parents’ criminal behaviour: Firstly, Mr F’s 18 convictions including several between 2010 and 2012 and several which are offences against the person and 1 warning. Secondly, Ms M’s shop lifting incident in 2010 which led to the discovery of Child S and her 2011 conviction for benefit fraud. Long term mental health problems: Records refer to Mr F’s long term involvement with psychiatric services, including a history of self-harm and depression (including medication until he ceased this in August 2013), and to Ms M’s history of depression. Both have a history of failing to attend appointments for counselling and therapeutic help. Both parents’ numerous hospital attendances: For injuries and illnesses, which for Ms M include lacerations to legs, arms and head, bruising (including serious facial bruising), falling down stairs (twice), gynaecological problems, at least 2 terminations, over-use of opiate medication for pain, potential fabricated illness. The number of missed contacts with professionals: Particularly by Ms M, giving reasons such as work commitments, illness and holidays, and that after missing a significant number of contacts, Ms M and Mr F continued to demand an increased level of contact with Child D. The scale of lies and deception: Including the concealment of Child S’s birth and paternity, including during the first court hearing, giving false names, addresses, GP details and refusing to give agencies details of their whereabouts, giving untrue locations or making themselves unavailable on telephone numbers given and at times to suit them. Child D Overview Report April 2016 Final Page 22 of 56 The frequent use of complaints: Or the threat of complaining against professionals, (including Ms M making 8 visits to the Patient Advice and Liaison Service at one hospital alone) and threats of legal action. What is not prominently considered is what the impact of the above behaviours, which were entrenched over a number of years, might be on the children and whether the parents had the capacity to put the children’s needs and interests above their own. The Health Overview Report includes a comprehensive “Lessons Learnt” section which covers mental health, alcohol and domestic violence issues and the factors that fit within the experience of working with uncooperative families. It concludes, however, that at the time the bigger picture was not aggregated. Moving on from the Judgement made in July 2012 there was then a further hearing from 25 to 28 September 2012. As per the Letter of Instruction, S4C submitted an interim report on 17 August 2012 and another on 13 September 2012. The latter report details the work undertaken by the two S4C social workers with the parents, grandparents and the two children; it does not appear that information was sought from the many organisations, who had years of knowledge and experience of the family. One paediatrician took the initiative to contact S4C to express her concerns about Child D’s move and shared the information that the child had ongoing health needs that required monitoring. This was new information to S4C but the paediatrician did not feel listened to and no other health professionals were contacted. In addressing the issues of Child S’s return to the mother/parents, the help and services proposed to support this, and the contact with Child D, S4C’s report stated that direct work with the parents and grandparents was yet to be completed and concluded there was still some way to go in determining Child D’s future. S4C stated that resolving issues between the grandparents and parents were unlikely to be resolved without the assistance of family therapy and “Repairing such damaged relationships via long term family therapy is unlikely to be achievable in a reasonable timescale for [Child D]”. Even accepting that it was unlikely to be “an amicable transition”, S4C were giving active consideration to Child D moving from the grandparents’ care to being placed with the parents. In September 2012 lawyers for Mr GF and Mrs GM informed the Local Authority that they were prepared to consider returning Child D to the parents if it were in the child’s interest. At the hearing on 28 September 2012 the grandparents’ representative informed the court and parties that this was the case. The Judge agreed to the implementation of the plan put forward by S4C, including stating in the judgement “There shall be a continuation of the assessment by Services for Children ....to encompass when and how [Child D] shall be returned to the care of the mother”. Whilst accepting that the introductions of Child S to the parents were going well, with the positive support of the foster carer, it is perhaps surprising that the judgement talks, not Child D Overview Report April 2016 Final Page 23 of 56 about “if” [Child D] returns to the mother / parents but “when and how”. The parents’ original application only requested that Child S was moved to their care and for there to be increased contact with Child D so this was a significant shift. Given that these parents had only cared for their children separately, for a few weeks / months respectively, it might have been expected that there would be a more comprehensive parenting assessment and a detailed analysis of Child D’s attachment to the grandparents who had cared for the child continuously for over 5 years of the child’s life. S4C acknowledge that Mrs GM had been Child D’s primary attachment figure and health professionals and the school expressed unanimously positive views about the grandparents devotion and their commitment to Child D’s development and progress whilst in the extended family’s care, including keeping the many medical appointments, enabling excellent school attendance and promoting social activities with children of the child’s own age. The longer term emotional impact of Child D’s moving away from this stable and supportive environment is not comprehensively considered. During Child D’s introductions to the parents there was a stage in early November 2012 when both Child D and the parents were said not to be prepared for the move, it is surprising that there was not a pause for reflection. Arguably in any introductory programme (e.g. to adopters, birth parents or kinship carers) there might have to be a slowing of the pace in order to be sure that everyone is comfortable and committed to the placement and there can be an exploration of what might be learned from the hiatus. S4C, however, took the view that the tensions between the parents and grandparents and the uncertainty were becoming intolerable for Child D and that delay would be harmful to the child. Even without using the benefit of hindsight this decision has to have some question marks attached to it. At the hearing at the end of the September 2012 the Local Authority ceased to be a party to the proceedings as only private law matters remained to be concluded. The final hearing was held on 11 December 2012 when in respect of Child D a Residence Order was made to the parents (with contact to the grandparents) and the Special Guardianship Order to Mr GF and Mrs GM was revoked. It is perhaps surprising that the Local Authority did not convene a de-brief meeting (after the July or September hearings) to discuss the outcome of and learning from the case. It is believed that there was a meeting within the Local Authority Legal team but no record of it has been located. A wider meeting might have led to a multi-agency plan of how to work with the family, to share information and concerns across partners and to give consideration as to how to maximise the protection of the children in the future. 4.7. To what extent was domestic violence an issue in this case and were agency responses appropriate? There are many references in professionals’ dealings with Mr F and Ms M that express concerns about domestic violence being an issue between them, but much less conclusive information. Child D Overview Report April 2016 Final Page 24 of 56 What we do know is that Mr F was convicted of a serious assault on a pregnant ex-girlfriend and received a prison sentence. He was also involved in a number of other incidents brought to the attention of the police as either the instigator or victim of assaults. The Police IMR states “[Mr F] was a violent man who clearly saw the solution to difficulty in his life in confrontation and the use of violence”. In 2008 when the Police witnessed Mr F verbally abusing Ms M, they had to formally warn him before he desisted and left the scene. We also know that Ms M reported having experienced domestic violence in her first marriage. Various hospitals treated Ms M for injuries and the incidence of these seems exceptionally high: i) Epsom and St Helier Hospital – several occasions during 2009-2012 but no evidence of domestic violence enquiries being initiated. ii) Kings College Hospital – 3 admissions in 2010/2011, one recorded as a suspected broken nose following an assault (which Ms M said she reported to the police but this has not been verified), one for alcohol-related dizziness and the other for a fall down stairs. Again there is no record of her having been questioned about domestic violence. iii) Guys and St. Thomas’ Hospital – there was a direct recognition of the possibility that Ms M had experienced domestic violence and she was showing signs of being reluctant to return home. Even after staff had witnessed Mr F being aggressive to her on the ward where she was an in-patient and staff had a direct conversation with her, she denied any concerns at home. Staff appropriately involved the Mozaic Team (hospital based advocacy for victims of domestic violence) but no disclosure was forthcoming. iv) Chelsea and Westminster Hospital – January 2013. Ms M was admitted (with Child S, claiming there was no-one to look after the child, and she was pregnant). When the hospital contacted Children’s Services it was initially stated that there were concerns about Ms M having bruising, but this was later withdrawn as unable to be substantiated. v) Chelsea and Westminster Hospital – March/April 2013. Ms M was admitted with “post abortion bleeding”; she was asked about sexual assault and after being initially reluctant to discuss the topic, denied it. In a telephone conversation with Children’s Services a few days later a member of hospital staff expressed concern that Ms M had been raped, but the veracity of this allegation was doubtful and it was not possible to proceed to investigation. vi) There were also many presentations to GPs for injuries and depression, but no domestic violence enquiries are noted. It is recorded that Ms M had at least two terminations, possibly more, between 2010 - 2013 and suffered complications of pregnancy and other gynaecological concerns. She was also adamant that she did not want Mr F or her family to know that she was pregnant. These Child D Overview Report April 2016 Final Page 25 of 56 behaviours may be indicative of domestic violence as it is well researched that domestic violence can increase in pregnancy.5 No-one at the time had an overview of the very high number of hospital attendances by Ms M for injuries, and there may be others of which we are unaware. Those known included lacerations to the legs, arms, head, bruising to the back and face, suspected broken nose, broken ankle etc. A range of explanations was given, two being assaults by unknown assailants, and Botox injections were said to be the cause of bruising close to her eyes. This was one of a number of explanations for events that were accepted by the Judge. Several IMRs have made recommendations about policy and practice in respect of domestic violence, including the adoption of routine enquiry to promote disclosure, including in universal services. However most IMR authors believe that even if this approach had been used at the time, it would not have produced any different responses from Ms M or Mr F. Whilst there is therefore no conclusive evidence of domestic violence found to be a feature in this case, the combined information raises concerns that it may have occurred and at the very least is highly suggestive of unhealthy power and control issues in the relationship with the potential for aggression and violence. S4C comment in their reports on Mr F’s tendency to interact in a verbally aggressive manner, including a pattern of sustained shouting or bursts of temper, without any reference to how this might have been considered to have an adverse impact on the children. No agency reflects on the potential impact of the repeated parental injuries (several reported to be linked to alcohol and assaults) on the parenting of the children and the possibility of them suffering neglect as a consequence. 4.8. To what extent did the manner of the parents’ interaction with agencies impact on this case? Are there learning points to be taken from this? As previously documented, Mr F had a long history of responding to people in a confrontational and aggressive manner, which extends to a history of violence to prison staff. There are numerous incidents reported in the IMRs such as this one from Probation describing Mr F as “uncooperative during this order and ..... he has been aggressive on at least three occasions with three different members of staff. [Mr F] has stated clearly that he will not talk about his private life as we are not trained psychologists. He has been a difficult man who manipulated and directed the supervision sessions”. Throughout his years of involvement with Probation, he was breached on many occasions for non-compliance with court orders and returned to court, faced with alternative disposals but rarely maintained any commitment to measures such as “Thinking Skills” or “Anger Management” that might have helped him. 5 1. Women’s Aid report 2010. 2. British Journal of Obstetrics and Gynaecology 2004, Lorraine Bacchus, Gill Mezey, Susan Bewley and Alison Haworth. " Prevalence of domestic violence when midwives routinely enquire in pregnancy Child D Overview Report April 2016 Final Page 26 of 56 These characteristics of non-cooperation, manipulation and attempting to control others run through the descriptions of many agencies. A number of hospital staff felt threatened and unsafe, one to the extent of needing to be escorted to her car through fear of meeting Mr F. Ms M and Mr F, sometimes together and sometimes separately, would be verbally aggressive to professionals, refusing to cooperate and threatening them with complaints, legal action, referral to their professional body and exposure in the media if their demands were not met. Several social workers experienced this behaviour, for example when a worker in the MASH sent a standard letter to Ms M and Mr F regarding Child D’s ophthalmology appointments being missed and offering help. The response was a very aggressive phone call from Mr F, followed up by an e-mail from his solicitor to Sutton Legal Services demanding an apology. Interestingly it is noted in the Legal IMR that Mr F’s legal team could also be very demanding and their e-mails and phone calls were perceived by the Local Authority lawyers as bullying and harassing in nature. Witnesses in court have also reported on the adverse tone of questioning and were left feeling dealt with in an unprofessional manner. Ms M and Mr F were difficult to manage as patients of the NHS, submitting multiple complaints to PALS (including 8 times by Ms M in the course of one hospital admission when she did not like being challenged about her demands for opiates and her wish not to be discharged), telling lies and giving false information. There were many more examples of avoidant behaviour - not attending appointments or answering phone calls (even when the times had been arranged at their convenience) and constant changing GP surgeries and hospitals. Despite the detail in a high number of IMRs it is still very likely that it has not been possible to collate the complete picture of agencies these parents were in touch with, so it was no wonder that professionals on the front line struggled at the time to piece the jigsaw together. On some occasions the parents used “disguised compliance”, appearing, for example, to welcome offers of help and support from the Health Visitor who made a home visit after the children had returned home, but they then never took it up. On other occasions such as dealing with their rent arrears and the concerns that Child D’s school had regarding the level of attendance, Mr F and Ms M would do just enough to keep professionals from escalating concerns to a higher level. However, more often the parents’ modus operandi was openly resistant and non-compliant and they achieved some success in keeping agencies at bay. A notable example is the concealment of Child S’s existence, which but for Ms M’s criminal activity in being arrested for shoplifting, might have succeeded for much longer, and on another occasion Ms M was successful in taking legal steps to prevent the Local Authority having access to her medical information – hence some of the information in this report is likely not to have been known to the Court. Child D Overview Report April 2016 Final Page 27 of 56 S4C express an interesting view of Ms M and Mr F’s interaction with agencies. S4C were aware from their early work with this case that the two different behaviour styles of the parents kept agencies away. They characterise these styles as “evasion” and “aggression” respectively. The parents refused to work with the Local Authority Children’s Services saying they were fearful and mistrustful of them. S4C were able to work with the parents, even though, at times, they also experienced a level of evasion and a presentation from Mr F which is described as aggressive. They describe him as getting very angry and remaining so for 10 – 15 minutes before it abated, but at other times he conducted himself with “charm and directness”. They continue “The parents’ interaction with agencies kept them away and there was little that could be done about this whilst their duties were of a non Child Protection nature”. “The interaction of S4C was being sanctioned and backed up by the court who had exonerated the parents. Therefore there was less resistance to this from the parents”. Many professionals have struggled to understand the continued level of hostility demonstrated by Mr F and Ms M after the children moved to live with them and they seemed to have had all their wishes and demands met. As the Children’s Social Care IMR remarks the parents were “if anything less cooperative and more hostile “. It may only be speculated whether this behaviour was a smokescreen to distract attention from what was really happening in the household. There remain unanswered questions about what was actually happening when the parents kept Child D off school and cancelled contacts with the grandparents. After the judgement exonerating Mr F and Ms M there was a great deal of interest in this case, not just from local media, but also national newspapers and journals, and the parents appeared on breakfast TV and used the services of the publicist Max Clifford. At the time of writing, professional studio photographs of the family and details of the case could still be found through the internet and social media channels. Local Safeguarding Children Boards have procedures and training that provide information and guidance regarding work with families who are reluctant, resistant or hostile because of the well documented risks such parents can pose to children, and Sutton LSCB has run training on these themes. Good practice would suggest that where parents are considered to be threatening or hostile, any presumption that they are different with their children should be rigorously tested. As the Health Overview states, “Reports did not consider what it would be like for a child living in a highly volatile environment where tempers and behaviour was unpredictable.” In this case there is plenty of evidence that there were professionals who remained alert to the concerns for Child D and Child S, and who continued to liaise with partners to share information. The professionals meeting held on 28 January 2013 is one such example where Children‘s Services, S4C and the school came together (although it is not clear why the Health Visitor who had been in close contact with the school was not included). At its conclusion a letter Child D Overview Report April 2016 Final Page 28 of 56 was sent to the parents offering an appropriate range of supports, but again there is no record of help being taken up. A few weeks after this, on 07 March 2013, S4C ceased their involvement and although agencies, particularly Children’s Services, responded appropriately to new information, it was never of a scale to trigger a statutory intervention. It is observed that new incidents were dealt with individually and sequentially rather than being aggregated into a picture of wider concern. This left only universal services in contact with Child D, mainly the school. Apart from Child D’s poor attendance from the time of beginning a second primary school in January 2013 until the death, there were few problems identified; the school worked hard to maintain a relationship with the parents and to pay close attention to Child D’s progress. By all accounts Child D presented at school as a happy child, including in the company of the parents. The school had tried to organise a CAF in April 2013 as a means of addressing the low attendance and thought they had secured the involvement of the parents, but Ms M cancelled at the last moment, asking for the reasons for the meeting to be put in writing to show her solicitor. After further prevarication and unauthorised absence in the autumn term, a meeting date had been reset for November 2013. Given the habitual response from these parents it is important to ask whether their behaviour made the children less visible and their needs less central. One can try to imagine how two young children might have experienced life in a household where parents were behaving in this manner, spending so much of their time and energy avoiding engagement with people who could have been sources of support. It would appear that their exoneration of causing harm to Child D and their high profile in the media as victims of a miscarriage of justice did little to bring about the change that the Judge had predicted. 5. INVOLVEMENT OF FAMILY MEMBERS 5.1. Letters were sent to Mr F, Ms M, Mr GF and Mrs GM informing them of the decision to undertake a SCR. Because of the parallel criminal investigation, the parents were not invited to take part in this review. Mr GF and Mrs GM were invited to become involved, which they accepted and the Overview Author and a representative of the Local Authority met with them at their home on two occasions during the completion of the report. They were joined by Mrs GM’s sister (Mrs GA) and their support worker from the voluntary organisation, Victim Support. 5.2. Given that the grandparents had cared for Child D for over five years they were able to describe Child D vividly and showed us many photographs of their grandchildren and told us about Child D’s life with them. They described the child as a happy and outgoing child and they made sure that progress was maximised by prioritising attendance at all medical appointments, ensuring health issues were monitored (e.g. Child D’s sight and developmental progress checks to assess whether an overdose of radiation the child had received from a hospital scanner as a baby was causing any difficulties.) They spoke proudly of Child D’s progress at school and both they Child D Overview Report April 2016 Final Page 29 of 56 and Child D seem to have built good relationships with staff and other children. Mr GF and Mrs GM spoke positively of the help they had received from a number of professionals and had felt secure that Child D would remain with them for the rest of her childhood. Mr GF and Mrs GM’s negative views about Mr F and Ms M were strongly expressed (never referring to them by their names) and if anything their opinions about Ms M were even more vehement than about Mr F. They did acknowledge that the relationship with their daughter had been very difficult for many years. 5.3. Understandably the grandparents were in a state of grieving the loss of a much loved grandchild and were experiencing sadness combined with anger as they grappled with questions about how the death could have happened. They said it had felt like bereavement when Child D left them to go to live with the parents and the death was a double loss. They described their motivation for getting involved in the SCR as achieving “Justice for [Child D]” and made it clear that they hold a range of parties, including the Judge and lawyers, responsible for the death as they “did not heed the warnings”. Mr GF and Mrs GM had spent their life savings (£80k) on legal representation at the High Court hearing and Mr GF told us how, when invited to make a statement near the end of the case, he had spoken to the court in the strongest of terms about the risks to Child D returning to Ms M and Mr F, warning the court “that they may have blood on their hands”. 5.4. The period leading up to Child D’s return to the parents was a very difficult one for Mr GF and Mrs GM and they did not find the relationship with S4C easy. They stated that Child D was often unhappy to meet with the social workers, hiding behind curtains when they were expected and talking about not wanting to leave. Most of all they were disappointed that in their view the S4C social workers were unable to see the dangers that the parents posed to Child D. Mr GF and Mrs GM talked about the planned introductions to the parents not working with no overnight stays taking place and the timescale being rushed. They were positive about Child D’s developing relationship with Child S but did not believe that their grandchild wanted to leave them and told us that Child D had asked if it was possible to see the Judge. Mr GF and Mrs GM felt that S4C dismissed these concerns and relayed that the S4C social workers had told them not to discuss the move with Child D, whereas they wanted to prepare Child D properly. They even believe that with the latter stage of introductions being compressed, that on the day Child D moved, the child thought it was only for a sleepover. 5.5. Mr GF and Mrs GM conveyed their worries to the head teacher at Child D’s school, who in turn discussed the grandparents’ concerns with S4C on their behalf. Child D Overview Report April 2016 Final Page 30 of 56 Alongside the concerns expressed by the school regarding Child D’s feelings about the move and the proposed handover at the school, the grandparents were surprised that there was no clarity about matters such as the details of Child D’s routine, the readiness of the bedroom and favourite belongings to be taken to the new home. A number of the contentions made by the grandparents are contradicted by S4C who were involved in the detailed management of Child D’s move. However Mr GF and Mrs GM tried hard to participate in discussions and meetings about tensions and difficult relationships in their family in order to help Child D’s transition. Two days before the move Mr GF and Mrs GM took Child D for a routine monitoring appointment with the Consultant Paediatrician and told her about the move (she had not been informed from any other source). She was gravely concerned not only at the planned move but also that Child D seemed to be behaving out of character- wasn’t smiling or wanting to draw pictures- and so she contacted S4C to make her views known. The grandparents also commented that at a similar time Child D’s ophthalmologist had commented that Child D’s sight was “down” and that the child seemed unhappy”. However despite these various expressed concerns the move went ahead on 09 November 2012 with the grandparents taking Child D to school as usual, saying goodbye to their grandchild there and Mr F and Ms M collecting Child D from school in the afternoon. Both the school and S4C have commended the grandparents for the exemplary way in which they handled this event. 5.6. After the move it was planned by S4C that there would be no face to face contact for four weeks to enable Child D to settle with the parents. Mr GF and Mrs GM kept a written log of their contacts with Child D between the return and the death and it reads as a catalogue of promised contacts followed by cancellations by the parents, with approximately fifty percent of arranged calls or visits being achieved. They did not see Child D at Christmas nor on the child’s sixth birthday. They also established that Child D was not being taken to medical appointments and noticed that her squint had worsened and there were concerns about the child not wearing glasses regularly. Their perception is that Child D had lost weight and looked less well. During 2013 a number of joint family outings took place and on two of them Child D was wearing face paint and Mr GF and Mrs GM thought they could detect signs of bruising and scratches but were prevented from speaking to Child D on their own. Their last contact with their grandchild took place on the day before Child D died and they describe Child D as “unkempt, bedraggled and discolouration showing on face ....”. This was during half term so Child D was not in school. When asked why they did not raise any concerns about their observations, either directly with the parents or to professionals, Mr GF and Mrs GM responded saying that they were afraid to say anything as they believed they would lose all contact with their grandchildren. Child D Overview Report April 2016 Final Page 31 of 56 6. INVOLVEMENT OF PROFESSIONALS 6.1. It is good practice for an Overview Report to have input from professionals who have been involved in the case so as to test out material gathered in the course of the review and probe areas where there may be a lack of clarity or a divergence of opinion and the need to explore why certain things happened. 6.2. I was able to interview (in person or on the telephone) fourteen professionals from 7 different agencies and wish to thank them for their time and reflective thoughts on the work with this family, the services provided to them and the developing themes from this review. 6.3. This was clearly an overwhelming case for many individuals and the impact of Child D’s death has been significant, with a number of people giving long and careful thought as to whether, and how, the outcome might have been different. 6.4. The views of these individuals included perceptions about how frustrating, and on occasions frightening the parents could be to work with, how difficult the process of the High Court case was to deal with and the constraints that its outcome placed on working with concerns about the risks posed to Child D in living with the parents. 6.5. I have striven to accurately represent the views of these professionals in the body of the report. 7. FINDINGS 7.1. This SCR is different from many in that neither the IMRs nor the Overview Report have found a catalogue of practice issues to address. This is not to suggest that everything was perfect or that there is no room for safeguarding practice to improve across the agencies involved. 7.1.1. Indeed it is important to highlight the instances where practice was less than satisfactory: GPs not making a referral to Children’s Services about injuries that might have been suggestive of child protection concerns a) in February 2007 when Child D, aged five weeks, had radiator burns to fingers and forehead and b) in June 2013 when Child D had bruises and grazes. Lack of communication and triangulation across agencies and some non-adherence to child protection procedures (these are detailed in the IMRs and occurred mainly, but not solely, in 2007). The work of the Guardian (CG2) not being covered by Children and Family Court Advisory Support Service (CAFCASS) when she was off sick between July and December 2012. Although she tried to carry out her duties at times during this Child D Overview Report April 2016 Final Page 32 of 56 period, this was not a satisfactory arrangement for a professional whose role is crucial in representing the children’s interests. Child S not being examined when Child D was admitted to hospital and died of suspected non-accidental injuries. S4C conducting their work without the benefit of full background information and there being a lack of clarity about the respective roles of the Independent Social Work Agency and the LA Children’s Services. The absence of a debrief or multi-agency planning meeting after the conclusion of the High Court case. 7.1.2. These examples are highlighted for agencies to reflect on and take action as appropriate, but do not, when taken individually or in sum, suggest that had they not been present, that the outcome for Child D would necessarily have been different. 7.1.3. Indeed agencies were asked, in Specific Question 4.5, whether any other actions or interventions could have prevented Child D’s death and all have found it difficult to cite actions that they believe would have made a difference. 7.2. The unanimous view of the various report authors and staff interviewed is that the outcome of this case hinged on the Judgement from the High Court in July 2012. Professionals and family members alike believe that this was the crux of the matter. 7.3. After careful consideration I believe that Judge 02’s finding of fact (or non-finding), based on the balance of probabilities, was not unreasonable. It was almost entirely based on the experts’ medical evidence which was weighed at length and in great detail, and some believe that the other information about the parents’ suitability to care for their children was not so thoroughly considered or else that the parents’ explanations were too readily accepted. 7.3.1. However the Judge articulated that she wished to go further than the fact finding and her direction of a letter regarding Mr F’s exoneration goes much further in stating that he “had never caused harm to his child, in fact there was an innocent explanation for his child’s suspected injuries”. 7.3.2. According to many professionals it was this statement that left them feeling “powerless to act” despite their remaining sense of unease about the safety of Child D returning to the parents. 7.3.3. The Probation IMR is one that expresses this well. “The over-riding issue in this case is the acquittal for GBH against Child D. It confirmed Mr F as a satisfactory parent. It rationalised his failure to comply ...and served to place the subject of child welfare “off limits” to those supervising Mr F”. It also refers to “his intention to make professionals “pay” for the trauma they had caused him”. Child D Overview Report April 2016 Final Page 33 of 56 7.3.4. Once it was deemed that the Local Authority had failed to prove the threshold of significant harm (actual or likely) in respect of Child S, no orders could be made to govern the future work with the family. This meant that, despite their best efforts and use of their professional judgement, when agencies were unable to find sufficient evidence to undertake a statutory intervention, there was little they could do in the face of parental opposition to voluntary engagement. 7.3.5. In another recently published SCR6 (the only one I have found with similar characteristics, where a finding of fact asserted a parent’s “innocence” of causing an injury and the child was subsequently killed by the same parent), there is a reflection that the court outcome undermined professional judgement. Whilst in both cases this does not appear to have prevented professionals from exercising “respectful uncertainty” in their approach with parents, they felt as though there was nowhere to go with their concerns. 7.3.6. The Derby SCR went so far as to suggest that a “Lesson Learnt” should be “Professionals should treat court decisions for what they are; a legal finding not a manifestation of truth”. 7.4. Another crucial factor was the appointment of an independent social work agency to undertake the work in place of the Local Authority’s Children’s Services (because it was believed the parents’ mistrust of the Local Authority would make working together untenable). This disconcerted professionals, to a greater degree than expected, perhaps because agencies did not know the individuals in S4C, had no previous experience of an independent social work agency and, more importantly, had not seen any plan that they were working to, let alone any indication of whether and how they would be involved. Some, for example the Health Visitor, had expected to be contacted and several health professionals were surprised that S4C did not seek their views or direct engagement. 7.4.1. It is evident that both Children’s Services and S4C expected more communication from the other and this lack of a defined working relationship led to confusion such as who was responsible for informing other agencies about the plan of work, the progress towards it, the dates when the children would return home, and the outcomes of legal processes such as the revocation of the SGO. 7.4.2. S4C was seen as working to the Court’s agenda, which is accurate in the sense that they were commissioned by the Court and were asked, via a Letter of Instruction (agreed by all parties), to carry out specific tasks such as determining the speed of Child S’s return to the parents and the package of help, support and services to be offered to the parents in order to enable this to be successful. When the new element 6 Derby Safeguarding Children Board. Serious Case Review in respect of DD12 (18.02.14) Child D Overview Report April 2016 Final Page 34 of 56 of returning Child D to the parents was introduced into the case, events moved at a faster pace with S4C communicating to parties in late October that a move was planned for November in order to resolve the uncertainty. They outlined their plan of visits for six weeks after the move and a one-off session with a psychotherapist but there was not a plan comprising a package of long-term support or oversight of any kind as Mr F and Ms M did not believe this was necessary. S4C have said that with hindsight they would have formalised this further. 7.4.3. Whilst the Court provided the framework, particularly determining in late September 2012 that Child D as well as Child S should move to their parents, S4C are clear that if they had had any concerns about either child’s wellbeing or best interests that they had avenues to raise this and would have done so. They do, however, acknowledge that more joined up working might have made for greater clarity in their work. 7.4.4. The task of an author of an Overview Report is not just to describe what happened in this case, but also to reflect on why it happened and I shall try to address the key findings from the Review in this way. a) Why does it appear that no-one had the “big picture” overview of what was happening in this case? Reasons may be: the number of agencies involved (including outside of the Borough and the wider London area) after the outcome of the court hearing in July 2012, the judgement was interpreted as sending out a signal for agencies to “back off” the deliberate actions by the parents to ensure that the pieces of the jigsaw were not put together (by giving false details, the concealment of Child S, use of multiple hospitals and GPs etc.) b) Why were the children less of a focus (“less visible”) than they might have been? Reasons may be: the parents’ behaviour was so demanding to deal with, leading in some instances to “anxiety” and “paralysis” there was no tangible evidence of abuse or risk to the children; the prospect of emotional abuse or neglect being harder to assess, especially when workers had no ability to demand access to the children links are not evidenced to messages from research regarding the impact on children of parents who exhibit resistant and confrontational behaviour Child D Overview Report April 2016 Final Page 35 of 56 c) Why were multi-agency professionals not more confident in pursuing concerns after the children went home? Reasons may be: there was “nowhere to go” (no legal framework to intervene) without the parents’ agreement there was no unequivocal evidence of abuse or neglect to the children arising from the parents’ behaviour and the concerns that are documented about Child D’s low level of school attendance and missed medical appointments did not warrant a statutory intervention. The evidence from both S4C and the school that the children were happy and doing well, including positive interactions with their parents fear of threats and complaints from parents. One professional who offered support to the parents said “the parents told me if I persisted, I was setting myself up for big trouble”. It is important to observe that despite such threats professionals were not deterred from continuing to try to protect the children d) Why was the Judge so ready to accept the parents’ explanations, and to believe, once exonerated, that they would change? it is difficult to respond to this question in the absence of any analysis that would have come to the SCR if there had been involvement from the Judiciary or Courts’ Service via an IMR or attendance at the SCR Panel e) Why was no multi-agency meeting held either in July or September 2012 after the conclusion of the Court Case? This could have helped in understanding and communicating the legal ramifications of the judgement and the implications for practice. Reasons may be: shock? One professional described this event as “losing the unloseable case” and others disagreed with the outcome and may have maintained the narrative that Mr F was responsible for the injuries to Child D and the Judge had “got it wrong” there was no set framework for such a meeting (in the same way that exists for example for Strategy Meetings or Child Protection Conferences) Children’s Social Care felt they had been excluded from or marginalised in managing the case and that it was for S4C to take the lead role 7.4.5. To conclude, the High Court judgement had a profound impact on this case in the messages it gave both to the family and to professionals. It is not possible to assess the extent to which individual professionals did or did not feel disempowered, and many continued to work determinedly with the family. However it certainly appears to have made securing the parents’ cooperation even more difficult, and there were Child D Overview Report April 2016 Final Page 36 of 56 serious consequences from the Judgement (or at least from its interpretation), even if they were unintended. 8. LEARNING POINTS 8.1. Even where a series of individual contacts or interventions with a family pay due regard to safeguarding issues and are delivered to a good, or at least satisfactory, standard, children may not always be protected. There needs to be greater attention paid to the bigger picture and a wider lens used to see who else may be able to supply information or expertise in complex cases. A summary of the learning points in this section can be found in Appendix D. 8.2. The focus on the child’s needs and experiences must never be lost, however demanding or distracting parents may be. The child’s voice needs direct consideration when assessing his or her journey through receiving help and services (Munro7). There was little evidence in this Review of truly child-focused work that heard what the child said and paid heed to the theoretical frameworks that should underpin practice. In this case, issues around the importance of attachment (particularly of Child D to the grandparents) should have been of higher profile, with greater consideration given to Child D’s long term wellbeing and likely emotional response to moving quickly from the security of five years in the grandparents’ care to parents and a sibling that the child did not know very well. 8.3. There are learning points about working with an independent social work agency, both in terms of how that experience should have been more co-ordinated in this case. Whilst S4C was the lead agency, they did not consult professionals who in some cases had known Child D for years, or inform them of what was happening. 8.3.1. Given that various independent professionals are more often being commissioned to work in child care cases, and the government’s recent consultation paper on the potential outsourcing to private and voluntary sector organisations of children’s services, including child protection elements, this is an issue that LSCBs and their constituent partner agencies need to think about. Issues about quality assurance of practice, accountability and how independent social work agencies are selected need to be considered, alongside how the agency works in a multi-agency context. 8.3.2. In this case it is clear that the Court commissioned S4C (on the recommendation of the Guardian and her legal representative) with an initial agreed Letter of Instruction. By the time the second hearing had concluded at the end of September 2012, the Local Authority ceased to be a party and there is some ambiguity about who agreed 7 Professor Eileen Munro, The Munro Review of Child Protection: A child-centred system (2011), DfE Child D Overview Report April 2016 Final Page 37 of 56 the second Letter of Instruction, commissioned the work and to whom S4C reported. S4C believes that after November 2012 the Local Authority was the “sole commissioner” of their work; although the Local Authority was paying their costs, they query the “sole commissioner” status. What is evident is that reporting arrangements should have been clearer. 8.3.3. It would appear that S4C’s role changed from initially one of assessment (firstly in respect of Child S’s return to the mother/parents, the contact with Child D and support to the family, and secondly an assessment of how Child D should move to the parents care) to a role much more akin to case-holding social work. This latter phase covered the direct work with Child D, the management of the move and the majority of the monitoring of the family between the time the children were placed and S4C’s withdrawal from the case in March 2013. This shift in role from assessment to social work service provision was not well understood by various parties in the case. 8.3.4. Both S4C and Children’s Services believe their dialogue should have been more regular so as to remain up to date on events in a planned way, rather than responding to individual events (although it does appear that communication and cooperation at these times was reasonably effective.) 8.4. In respect of the contribution of an independent social work agency to a SCR, this case has exposed a gap. It has been usual for a SCR to request IMRs from all agencies involved in a case, with the expectation that an independent IMR author will be appointed, who has knowledge of the relevant profession/organisation but no connection with the family or line management of the case. Whilst Working Together 2013 gives LSCBs more flexibility and discretion over the style and methodology underpinning a SCR, many are still finding the compilation of comprehensive IMRs a useful way to proceed. In the case of a small independent social work agency such as S4C, there may be no-one independent of the case in the organisation who can undertake this task. Even if the agency was to pay another professional to complete the report, there may be questions about their independence. S4C corresponded with BASW and the chair of the SCR Panel about the difficulty of producing an IMR and eventually the two social workers who comprise S4C produced a background report which contained some analysis of their role and responded to some of the questions posed in the Terms of Reference. I am unaware whether this is an issue that has cropped up in other SCRs but it might be helpful for consideration on a national level, especially as independent contractors within children’s services are likely to continue to be part of the landscape. 8.5. Too often in the work in this case (and arguably in the SCR itself) there was a loss of focus on Child D, with the child’s vulnerabilities, needs, wishes and feelings appearing to be overtaken by a concentration on the behaviour, demands and challenges of the adults. There was no reference to the adverse impact on the children of living with a Child D Overview Report April 2016 Final Page 38 of 56 parent who interacted in a verbally aggressive manner, including a pattern of sustained shouting or bursts of temper. 9. RECOMMENDATIONS 9.1. A number of IMRs have produced relevant and thoughtful recommendations, though not all have chosen to do so, and these are produced in Appendix E. As Overview Report writer I have made an additional five recommendations below. Sutton LSCB considered and endorsed these recommendations on 10 September 2014 and confirmed that they cover the important issues arising from the review and that they are able to be implemented. The LSCB will ensure that the learning from this review is disseminated in a timely way, informs training and practice and ultimately contributes to improved outcomes for children. 9.2. OVERVIEW REPORT RECOMMENDATIONS 9.2.1. All agencies should reinforce the importance, throughout their work, of focusing on the needs of the child at the centre of a case and good practice in the direct recording of the child’s voice should be adopted. 9.2.2. When working with parents who are resistant and hostile, professionals should not be deflected or distracted by parental behaviour and should focus on assessing the potential risk posed to children in these families by emotional abuse or neglect. The adequacy of multi-agency training in this topic should be assessed. 9.2.3. When outcomes from court cases occur which are not expected by key agencies, and may have the potential to raise concerns for children, the Local Authority should convene a multi-agency meeting to share information arising from the unexpected outcome. This should provide clarity about future actions, roles and responsibilities of various organisations and establish communication channels that can respond to any escalation of concern. 9.2.4. Given that working with independent social work agencies and other independent professionals is likely to continue to be a feature of children’s services work, there is a need for clarity regarding respective roles and responsibilities and accountability so that it is clear who is doing what in a multi-agency context. The Local Authority should take the lead in defining how commissioning, contracts and communications will be managed. 9.2.5. The position of the Courts, specifically the Judiciary, in respect of SCRs should be clarified. In this case the request for an IMR was declined; no other form of report, Child D Overview Report April 2016 Final Page 39 of 56 other than a copy of the Judgement, was provided and there was no representation from the Courts Service (HMCTS) on the SCR Panel. Given the significance of Court judgements in this case, this lack of engagement raises questions that require serious consideration at a national level. The findings of this SCR should be brought to the attention of the President of the Family Division and the Family Justice Council. They should be asked to respond and to clarify the responsibility of the courts to LSCBs in respect of Serious Case Reviews. 10. CONCLUSIONS 10.1. All SCRs are unique, but this was an exceptionally unusual case and an overwhelming one for many involved. The factors that cause it to be so include: The number of agencies involved (and hence the volume of IMRs and number of professionals in contact with family members over the period concerned) The extreme level of avoidance, deception and resistance from the parents, who were often evasive, contradictory and aggressive and who regularly resorted to complaints and threats. This pattern of behaviours was sustained even after the parents’ exoneration and the children were returned to live with them The use of an independent social work agency in the assessment and the management of the reunification of the children to their parents, and the exclusion of the Local Authority Children’s Services from this role Despite a significant range of concerns and worrying incidents (albeit below the threshold for statutory intervention) being documented by agencies before and after Child D went to live with the parents, the effect of the court judgement and exoneration, combined with the parents refusal of any voluntary engagement with support services, meant that no intervention that might have made a difference was possible The Judge in the High Court case pronounced with perhaps undue certainty that the parents’ previous patterns of behaviour would change. She said “Now they have been unburdened from the shadow of findings against them” “They are going to change”. Sadly this did not turn out to be the case. Child D Overview Report April 2016 Final Page 40 of 56 11. APPENDICES Appendix A - Biographies Christine Davies, CBE was appointed the Independent Chair of the LSCB in Sutton in April 2014. Christine had previously worked with Children’s Social Care Services as the Chair of the Improvement Board, and is now steering and strengthening the effectiveness of Sutton’s multi-agency safeguarding partnership. Christine has extensive experience in Education and Children’s services leadership and delivery and is a current Trustee of the Early Intervention Foundation (EIF) and a member of the Youth Justice Board for England and Wales. She has created, developed and delivered national organisations and local services, securing a national reputation for excellence and performance. Christine has worked with every Local Authority in England and many in Wales, over 80,000 schools, Health Services, Police Authorities, Children’s Charities and the voluntary sector. She has advised the UK Government for over 14 years, covering education; safeguarding and child protection; child poverty; early years; special educational needs; early intervention and youth offending. Christine Davis, CBE, Independent Local Safeguarding Children Board Chair, which is a statutory function under Working Together Guidance (2013, 2015) Kevin Crompton had a successful 30 year career in the public sector including posts as Chief Executive in Haringey (3/10 -9/12) and Luton (11/05-02/10). In 2012, Kevin set up Kevin Crompton Solutions LTD to offer leadership and management services. He was the independent Chair of Local Safeguarding Children Boards in Sutton, Merton and Northamptonshire until he took up the post of Director of Children’s and Adults’ Services for Bedford Borough Council in spring 2014. Independent Local Safeguarding Children Board Chair until March 2014 and SCR Panel Chair until June 2014 Marion Davis, CBE is a qualified and registered Social Worker with over 30 years experience in children's social care. She held a range of practitioner and management appointments before serving as Director of Children's Services in Warwickshire from 2005 - 2011. She was President of the Association of Directors of Children's Services for 2010/11. Since taking early retirement she has worked as an independent children's services consultant, including having been an independent chair of an LSCB and acted as an adviser to the House of Commons Education Select Committee. She was awarded the CBE for services to children and young people in the 2012 New Years Honours. Marion Davis has declared her independence from the London Borough of Sutton and confirmed that she had no previous knowledge of this case prior to being commissioned by Sutton LSCB to become the Child D Independent SCR overview author. Independent SCR Overview Author Child D Overview Report April 2016 Final Page 41 of 56 Appendix B - Terms of Reference Serious Case Review (SCR) CHILD D Agreed following the third meeting of Serious Case Review Panel 16th January 2014 Introduction Child D died of a head injury in 2013 following an incident at the child’s home. The child’s father was arrested and a criminal investigation is ongoing. Child D was known to a range of agencies since shortly after the birth and had previously been a Looked After Child. The history of agency involvement, both local and national, is long and complex. There is the potential for national media focus on the case as the family and their situation had been reported on in 2012 when Child D returned to the parents’ care. Ofsted have been advised that we anticipate that the review may take longer than the standard six months. 1. Purpose of the SCR In line with the government’s guidance in Working Together to Safeguard Children 2013, the SCR will aim: To establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children. To identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result. To improve inter-agency working and better safeguard and promote the welfare of children. 2. Scope of the Serious Case Review: The Serious Case Review will look in depth at all agency activity and involvement from 1st January 2000 until 28th October 2013. Attention should be paid to times of transition between agencies and within agencies. 3. Chronology and Individual Management Review (IMR) Each agency will complete an Individual Management Review which will follow the guidance below. Prior to that each agency must produce a chronology of all activity from 1st January 2000 until 28th October 2013. A common template will be provided by SLSCB and will need to be used by all agencies. 4. Analysis: Each IMR author to address the following Working Together Standard Questions: Were practitioners aware of and sensitive to the needs of the children in their Child D Overview Report April 2016 Final Page 42 of 56 work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? When, and in what way, were the child(ren)’s wishes and feelings ascertained and taken account of when making decisions about the provision of children’s services? Was this information recorded? Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare? What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way? Did actions accord with assessments and decisions made? Were appropriate services offered/provided, or relevant enquiries made, in the light of assessments? Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? Where relevant, were appropriate child protection or care plans in place, and child protection and/or looked after reviewing processes complied with? Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded? Were senior managers or other organisations and professionals involved at points in the case where they should have been? Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? Was there sufficient management accountability for decision making? Child D Overview Report April 2016 Final Page 43 of 56 5. Specific Questions to consider in this case I. a. Child D’s father‘s conviction for shaking the child as a baby was overturned by the courts and Child D, along with Child S, returned to live with their parents. An independent social work agency was appointed to work with the family. Did these decisions have an impact on the way agencies worked further with the family, and b. Were there occasions where child protection processes should have been followed but were not as a consequence of the legal judgements? II. There were a number of contacts between agencies regarding Child D and Child S after they returned to live with their parents in October and November 2012. Were these contacts handled and responded to in an appropriate and timely way? III. a. Was information received by different agencies following Child D’s return home considered collectively and triangulated? Could this have made a difference? b. Would any other advice, information, support or intervention have prevented the child’s death? IV. The finding of facts against the parents following the hearing in January 2008 before Judge 01, were set aside by Judge 02 in the High Court on 6th July 2012 following a re-hearing. Were judicial decisions following all court hearings reasonable? V. To what extent was domestic violence an issue in this case and were agency responses appropriate? VI. To what extent did the manner of the parent’s interaction with agencies impact on this case? Are there learning points to be taken from this? Child D Overview Report April 2016 Final Page 44 of 56 6. Organisations to be involved in this SCR IMRs or background reports will be requested from the following agencies in relation to their involvement with the family / household members (see 10): Cafcass Chelsea and Westminster NHS Trust Epsom and St. Helier University Hospitals NHS Trust Farnborough hospital, Kent General Practitioner Housing Needs and Homelessness Prevention Judiciary London Ambulance Service London Borough of Sutton Children and Young People Learning Directorate London Borough of Sutton Education Service London Probation Trust Metropolitan Police Service Other Health Trusts as identified Services for Children (S4C) South London Legal Partnership South West London and St George’s Mental Health NHS Trust St. George’s Hospital Sutton and Merton Community Services Royal Marsden NHS Foundation Trust Sutton Clinical Commissioning Group Sutton Housing Partnership The Evelina Hospital West Sussex Hospital 7. Involvement of the family Members of the family will be contacted where possible and informed of the nature and purpose of the Serious Case Review by the LSCB Business Manager and the Independent Chair of the Serious Case Review. Family members will subsequently be invited to participate in the review process by the overview author. 8. Legal Advice. The panel will be supported as necessary by a legal advisor from the Local Authority team who was not involved in this case as required. 9. Timescale The Serious Case Review, having commenced on 25th November 2013 will be concluded by 22nd April 2014 and submitted as a final report before 14th May 2014 Child D Overview Report April 2016 Final Page 45 of 56 To ensure this timescale is met the following dates have been agreed for IMR authors: Agency chronology to be provided to the LSCB Business Manager: 24/01/2014 Draft IMRs to be provided to the LSCB Business Manager: 28/02/2014 Final IMRs to have been approved within agency and submitted to the LSCB Business Manager: 31/03/2014 Health Overview to be completed by 31/03/2014 Draft overview report submission date: 14/04/2014 Final overview report: 25/04/14 10. Family members Each agency to compile a chronology and management review of their involvement with family members The records to be accessed by each IMR author are those of Child D, Child S, Mr F, Ms M Child D Overview Report April 2016 Final Page 46 of 56 Appendix C - Child D SCR Panel Independent Chair, LSCB and SCR Panel Chair Independent Overview Report Writer Cafcass: Service Manager, National Improvement Service Children and Family Court Advisory Support Service Health: Clinical Children’s Services Director, Sutton and Merton Community Services Royal Marsden NHS Foundation Trust Designated Nurse Safeguarding Children - Sutton CCG Designated Doctor - Sutton CCG Named Nurse for Safeguarding Children, St George’s Hospital Named Nurse, Safeguarding Children Epsom and St Helier NHS Trust Head of Paediatric & Neonatal Nursing Epsom and St Helier University NHS Trust Associate Medical Director, NHS England Sutton Council: LSCB Business Manager Head of Quality Assurance Practice Lead & Team Manager, Social Care and Education (Legal Services) Executive Head of Safeguarding Strategic Director Police: DI - Metropolitan Police Service DI - Specialist Crime and Operations Education: Head, Primary School 1 Education, Safeguarding and Well-being Lead Probation: Assistant Chief Probation Officer Other: Social Care IMR writer Specialist Crime Review Group (IMR author) Health Overview Report writer Child D Overview Report April 2016 Final Page 47 of 56 Appendix D - Summary of Learning Points Item Learning points Ref.8 1. There needs to be greater attention paid to the bigger picture and a wider lens used to see who else may be able to supply information or expertise in complex cases. 8.1 2. The focus on the child’s needs and experiences must never be lost, however demanding or distracting parents may be. 8.2 3. The child’s voice needs direct consideration when assessing his or her journey through receiving help and services (Munro). 8.2 4. There was little evidence of truly child-focused work that heard what the child said and paid heed to the theoretical frameworks that should underpin practice. 8.2 5. The importance of attachment of Child D to the grandparents should have been of higher profile. 8.2 6. The work with the independent social work agency could have been more co-ordinated 8.3 7. Consideration needs to be given to how independent social work agencies can contribute to a SCR 8.3 8. There are issues about quality assurance of practice, accountability and how independent social work agencies are selected and commissioned, alongside how the agency works in a multi-agency context 8.3 9. There are unanswered queries about ‘sole commissioner status’, and ambiguity about to whom S4C reported. What is evident is that the reporting arrangements should have been clearer. 8.3 10. The shift in the independent social work agency’s role from assessment to social work service provision was not well understood by various parties in the case. 8.3 11. The dialogue between S4C and Children’s Services should have been more regular to remain up to date on events in a planned way, rather than responding to individual events 8.3 12. In the case of a small independent social work agency, there are learning points regarding how independent social work agencies in general can contribute to a SCR. There may be no-one independent of the case in the organisation who can undertake this task. 8.4 13. There was a loss of focus on Child D, with the child’s vulnerabilities, needs, wishes and feelings appearing to be overtaken by a concentration on the behaviour, demands and challenges of the adults. 8.5 14. There are important lessons to be learnt about working with resistant and hostile parents and not losing sight of how the child experiences these behaviours. 8.5 8 Section in chapter ‘Learning Points’ Child D Overview Report April 2016 Final Page 48 of 56 Appendix E - Summary of IMR recommendations The IMR recommendations are the responsibility of each agency to implement, and the oversight and scrutiny of a detailed action plan is the responsibility of the Case Review Group. INDEPENDENT MANAGEMENT REVIEW (IMR) RECOMMENDATIONS Item Recommendations 1. Cafcass 1.1 The Children’s Guardian to seek supervision on complex cases. 1.2. Liaison to take place with the IRO whilst children are accommodated. 1.3. Comprehensive information about relevant aspects of parents’ past histories being established. 1.4. Consideration of the risks to the child’s safety and welfare where the parents do not co-operate with the Local Authority. 2. EDUCATION 2.1 All schools maintain the levels of Safeguarding/CP training for their staff and the specific training for Designated Persons. 2.2 Record keeping content should be adjusted so that all information is passed from one school to another, including where there is engagement of an independent social worker supporting a family. 2.3 Information sharing protocol and expectations should be drafted as a model for all schools to use and share with independent social work providers in future. These should include the process by which schools will make complaints about independent social workers and how to escalation concerns to the local statutory services. 3. HEALTH 3.1 Health Overview Sutton CCG 3.1.1 Agencies involved in this review should be reminded of the theoretical frameworks to inform professional practice and these re-launched through a variety of mechanisms including: Safeguarding training Safeguarding supervision processes Reflective practice opportunities Feedback from learning reviews, including this Serious Case Review Audit processes 3.1.2 Sutton CCG require each agency within their health economy to increase staff competency relating to the co-existence of domestic abuse, mental ill health and substance misuse, and to provide evidence of compliance on a quarterly basis via safeguarding metrics. 3.1.3 Sutton CCG Board must understand and be assured that appropriate governance arrangements are in place to code safeguarding issues in GP Independent Services. 3.1.4 Sutton CCG Board requires each agency within their health economy to provide evidence of direct discussions with children and young people during healthcare contacts. 3.2 Epsom and St. Helier University Hospitals NHS Trust 3.2.1 Develop a Trust Domestic Violence and Abuse Policy in accordance with NICE guidance published in February 2014 3.2.2 Develop a rolling programme of Domestic Violence and Abuse training. 3.2.3 Continue dip sample audit of ED and maternity records so that staff respond appropriately when coming into contact with people who experience domestic violence and abuse. Child D Overview Report April 2016 Final Page 49 of 56 3.3 St. George’s Healthcare NHS Trust 3.3.1 The introduction of ward risk assessment tool 3.3.2 The involvement of the named doctor in complex cases. 3.3.3 Learning from this IMR is summarised and widely shared throughout the paediatric workforce, in particular the emergency department consultants, consultant paediatricians and their teams. 3.4 Chelsea and Westminster Hospital NHS Foundation Trust 3.4.1 Develop a rolling programme of Domestic Abuse awareness training 3.4.2 Develop training for leads (Domestic Abuse leads) to be support in wards and departments in leading Domestic Abuse advice 3.4.3 Define organisational response and responsibilities for supporting people at risk of domestic abuse 3.4.4 Appoint a Hospital based Independent Domestic Abuse advocate with administrative support to co-ordinate training and engagement 3.4.5 Enhance documentation of disclosures of Domestic Abuse and how information can be shared with appropriate agencies 3.4.6 To enable staff to be aware of the services and resources available to support a person’s disclosure of domestic abuse and their onward access to advocacy services (see IDVA) action above. For staff to be competent to conduct the Co-ordinated Action Against Domestic Abuse (CAADA) – DASH Risk Assessment Tool. Clarify referral process to MARAC. 3.4.7 Review escalation procedure in Child and Young People’s Safeguarding Policy 3.4.8 Adult DNA (Do Not Attend) follow up procedure to be put in place. 3.5 GP Services: Sutton and Merton 3.5.1 GPs should attain Level 3 training in Safeguarding of Children and needs to be a priority. 3.5.2 All practices should give priority to the summarisation of the medical records of children newly registered with the practice 3.5.3 Priority should be given to recruit a Named GP for Safeguarding Children in Sutton. 3.6 South West London and St. George’s Mental Health Trust 3.6.1 All current and historical safeguarding or welfare concerns should be included in referrals to Improving Access to Psychological Therapies (IAPT) services. 3.6.2 Historical or overturned safeguarding concerns should be reviewed and confirmed with the referrer. 3.7 Sutton and Merton Community Services (hosted by Royal Marsden NHS Foundation Trust) 3.7.1 Review of the role of the link health visitor with allocated GP practice 3.7.2 SMCS safeguarding team to monitor the quality of record keeping and information sharing when conducting safeguarding supervision with practitioners, raising competency issues early with the support of the Universal service managers 3.7.3 Transfer of records and information from the health visiting service to the school nurse service needs to be revisited and strengthened. 3.7.4 ‘Silo’ working is evident throughout the SMCS IMR and needs to be addressed. 3.7.5 Routine enquiry to be introduced within SMCS to improve the communication and outcomes of clients experiencing domestic abuse. 3.8 Western Sussex Hospitals NHS Trust 3.8.1 Refer all women who book late in pregnancy to Children’s Social Care and inform relevant agencies as outlined in the Trust safeguarding policy. 3.8.1 The Maternity Division is to implement guidelines to follow if antenatal appointments are missed. Child D Overview Report April 2016 Final Page 50 of 56 4. LEGAL 4.1 Issues of competency within a team need to be dealt with effectively and quickly before they start having an impact on team morale and upon clients’ confidence within the legal team. 4.2 When considering choice of counsel in complex proceedings, there should also be consideration of influence in the court arena, perception of the Local Authority, status of other representatives and past experience of working closely with lawyers within the team as well as cost considerations. 4.3 When allocating a complex and lengthy matter to a locum in the team, consideration should be given to extending their notice period to ensure there is time for an effective hand over. 4.4 Ensuring the management of the child care legal team is undertaken by an experienced child care lawyer with sufficient experienced lawyers to deal with complex cases at a senior level. 4.5 To have in place a strategy to deal with difficult and aggressive telephone and email correspondence to lawyers within the team to ensure that the team feel supported whilst they work. 5. POLICE 5.1 The manager of the Sexual Offences, Exploitation and Child Abuse command Croydon & Sutton Child Abuse Investigation Team ensure that a record is created of the Initial and Review conference process that took place in respect of Child D. 6. PROBATION 6.1 There need to be clear probation policies on (i) the retention of records of supervision where individuals are acquitted after statutory contact has begun and (ii) on the way probation staff use this material to inform later periods of statutory contact. 6.2 The need to respond to information received, even where it is obviously incorrect, so that there is a clear audit trail on record. 7. SOCIAL CARE 7.1 Children’s Services should formally meet with their legal teams after care proceedings particularly where they have been unsuccessful in achieving the desired outcome to debrief and ensure lessons are learned and entrenched in future practice. 7.2 Where care proceedings have been unsuccessful, Children’s Services should meet with partner agencies to consider learning points and to consider how they can best safeguard the child(ren) in the future. 7.3 In complex cases, strategy meetings should take precedent over strategy discussions, whereby all agencies involved in the case are invited to take part in the discussion, share information and chronologies, to enable more robust decision making to take place Child D Overview Report April 2016 Final Page 51 of 56 Appendix F LSCB ACTION PLAN – CHILD D RECOMMENDATION RATIONALE ACTION LEAD BY WHEN INTENDED IMPACT 1. All agencies should reinforce the importance, throughout their work, of focusing on the needs of the child at the centre of a case, and good practice in the direct recording of the child’s voice in case recording should be adopted. The Munro review of Child Protection emphasises the importance of providing a continuum of support from early help to specialist services; and front-line practitioners not losing sight of the welfare and protection needs of the child. 1.1 To seek assurance that each agency within the partnership has robust practice guidance that sets out clearly the expectations for practice to be child centred with standards for recording in place. Chair of LSCB Policy and Practice sub-group. June 2015 Where gaps are identified in policy and practice appropriate challenge will be presented to the agency for action to improve practice. 1.2 To undertake a thematic audit of safeguarding partnership working for children under the age of 5 years old. Chair of LSCB Quality & Assurance subgroup Sept 2015 Evidence about the effectiveness of child centred work and case recording to provide assurance to the LSCB about effective child-centred practice. Child D Overview Report April 2016 Final Page 52 of 56 RECOMMENDATION RATIONALE ACTION LEAD BY WHEN INTENDED IMPACT 1.3 Each agency identifies improvement targets for their service, as required, based on thematic case audit findings. This work is co-ordinated within the QA subgroup. Chair of LSCB Quality & Assurance subgroup Sept 2015 Case files capture clear evidence of direct engagement with children that outlines their needs, wishes and feelings. 1.4 To review the LSCB training offer to incorporate effective observation and inter-action with children, including GP bespoke training. Chair of LSCB Learning & Development sub-group. Sept 2015 Evidence of impact of training on practice is evaluated and is judged effective. 2. When working with parents who are resistant and hostile, professionals should not be deflected or distracted by parental behaviour and should focus on assessing the potential risk posed to children in these families to emotional abuse or neglect. The adequacy of multi-agency training in this topic should be assessed. It is well established that the complexities of the adults’ problems can undermine children’s welfare and protection needs. Practitioners are all too often able to describe parental behaviours and circumstances that pose challenges to their practice. 2.1To review the current LSCB training offer to incorporate effective approaches to working with highly resistant and hostile families targeted at professionals and managers. Chair of LSCB Learning & Development sub-group. May 2015 Training evaluation evidences increased confidence in staff, and improved skills to effectively identify, assess and engage hostile and challenging adults. Child D Overview Report April 2016 Final Page 53 of 56 RECOMMENDATION RATIONALE ACTION LEAD BY WHEN INTENDED IMPACT SCR findings identify the need to identify and effectively engage hostile and resistant parents. 2.2 To raise awareness about risk indicators from national SCR findings into parental behaviour that pose risks to babies and young children. Chair of LSCB Learning & Development sub-group. June 2015 Professionals within the Sutton LSCB partnership are able to identify and work effectively with highly resistant and hostile families with appropriate support. 3. When outcomes from Court cases occur which are not expected by key agencies, and may have the potential to raise concerns for children, the Local Authority should convene a multi-agency meeting to share information arising from the unexpected outcome. This should provide clarity about future actions, roles and responsibilities of various organisations and establish communication channels that can respond to any escalation of concern. There is new learning from this case about independent social workers and specific issues that arise in multi-agency working within a local context that is not familiar to external organisations. 3.1 To ensure risk assessments inform decisions to convene multi-agency meetings following the outcome of court cases. This applies when there is dissent on the part of the Local Authority. Head of Quality Assurance, People’s Services Sutton Council July 2015 Where risk is still identified, following the outcome of legal proceedings, the risk is assessed and escalated appropriately. Child D Overview Report April 2016 Final Page 54 of 56 RECOMMENDATION RATIONALE ACTION LEAD BY WHEN INTENDED IMPACT 3.2 To issue practice directive that emphasises this requirement within children’s social care. Head of Quality Assurance, People’s Services Sutton Council May 2015 There are clear lines of accountability for initiating multi-agency case management meetings, and providing feedback to LSCB partners. 4. Given that working with independent social work agencies and other independent professionals is likely to continue to be a feature of children’s services work, there is a need for clarity regarding respective roles and responsibilities and accountability so that it is clear who is doing what in a multi-agency context. The Local Authority should take the lead in defining how commissioning, contracts and communications will be managed. There is new learning arising from this serious case review in respect of commissioning processes to clarify roles and responsibilities within the LSCB partnership. 4.1 To review the commissioning arrangements of expert assessments of independent providers to ensure contractual arrangements are robust, and linked to the service specification. Executive Head of Safeguarding, People’s Services Sutton Council May 2015 Evidence to provide assurance to the LSCB about effective commissioning processes for expert assessment and other external social work services. 4.2 To provide assurance to the LSCB that robust and safe service specification is in place for commissioned expert assessment Head of Quality Assurance, People’s Services Sutton Council May 2015 Child D Overview Report April 2016 Final Page 55 of 56 RECOMMENDATION RATIONALE ACTION LEAD BY WHEN INTENDED IMPACT and/or other external social work services. 5. 5. The position of the Courts, and specifically the Judiciary in respect of SCRs should be clarified. In this case the request for an IMR was declined; no other form of report, other than a copy of the Judgement, was provided and there was no representation from the Courts Service (HMCTS) on the SCR Panel. Given the significance of Court judgements in this case, this lack of engagement raises questions that require serious consideration at a national level. The findings of this SCR should be brought to the attention of the President of the Family Division and the Family Justice Council. They should be asked to respond and to clarify the responsibility of the courts to LSCBs in respect of Serious Case Reviews. Although there is learning from a previous SCR into the failure of the Crown Prosecution Service to contribute information to the SCR (Nottingham 2014), there is no collective evidence bank of the impact of decisions within the judiciary system on LSCB child protection systems. 5.1 To share the findings of this SCR with the President of the Family Division and the Family Justice Council. Independent LSCB Chair Within 1 month of publication of the overview report Sutton LSCB and other LSCBs in England are clear about the expectations of statutory organisations to contribute to SCRs and IMRs. Child D Overview Report April 2016 Final Page 56 of 56 RECOMMENDATION RATIONALE ACTION LEAD BY WHEN INTENDED IMPACT 5.2 To ask the President of the Family Division and the Family Justice Council to respond to, and clarify the responsibility of the Courts to Sutton LSCB in respect of the Serious Case Review. As above 5.3 To share the response with the London Safeguarding Board for consideration of national policy making. As above This action plan is reviewed quarterly by the relevant LSCB subgroups, alongside individual agencies’ IMR action plans. The progress of implementing the recommendations is reported to the Chair’s Group, which reports to the Independent LSCB Chair. |
NC047213 | Suicide by hanging of a 15-year-old girl at her school in June 2013. Child T and her siblings were the subject of child protection plans in Greenwich and Lewisham. Family had a history of: domestic violence, sexual abuse, parental neglect, regular house moves and changes of mother's partners. Child T moved in with her maternal grandmother in mid 2010, after which point children's social care involvement ceased, until an incident shortly before her death when she was assaulted by an uncle. Child T disclosed self-harm to teachers, including two overdoses, leading to support from the school's pastoral and counselling services. She was referred to child and adolescent mental health services shortly before her death. Uses the SCIE Learning Together method. Poses questions for the Local Safeguarding Children Board to consider including: whether professionals are uniformly well equipped to understand and respond to self-harming behaviour in adolescents; whether there is a tendency for professionals, especially when under pressure, to respond to immediate safeguarding concerns whilst failing to recognise the significance of historical abuse; and whether the referrals process is robust enough to predict and offset likely human error in data recording. Also considers the need for support for professionals after a tragic incident, in this case the impact on school staff.
| Title: Serious case review: Child T: Overview report. LSCB: Greenwich Safeguarding Children Board Author: Sally Trench, Fran Pearson Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Greenwich Safeguarding Children Board Serious Case Review Child T Authors: Sally Trench and Fran Pearson SCIE Learning Together Lead Reviewers June 2014 2 This Serious Case Review ( SCR) looked at the final three years of Child T’s life and made a number of recommendations in relation to how professionals working with young people can better understand some of the issues that can lead to self-harm and suicide. There has been a delay in publishing this review as we have been awaiting the inquest into Child T’s death and to ensure that if there were any other issues arising from the inquest that this could be used to inform further lessons to be learnt. This delay does not mean that the recommendations from the review have not been acted upon and changes made. At the inquest into her death the Coroner concluded that Child T had committed suicide. She found that there had not been any failings by the agencies involved with Child T leading up to her death that had caused or contributed in any way to the suicide. The coroner also found that Child T had been appropriately responded to and well supported by professionals working with her. She further acknowledged that through the Serious Care Review and other individual agencies’ reviews there had been intensive investigation into the situation and therefore did not find it necessary to duplicate this work by making additional recommendations. The SCR and the inquest both concluded that Child T’s death was not preventable. The Greenwich Safeguarding Children Board (GSCB) will continue to raise awareness of deliberate self-harm and monitor the response of agencies to this to ensure that young people, like Child T get the best possible support and help. Nicky Pace Independent Chair GSCB 18th February 2016 3 Contents Title Page Introduction 4 Why the case is being reviewed 4 Succinct summary of case 4 Family composition 5 Time frame 6 Organisational learning and improvement 6 Methodology 6 Reviewing expertise and independence 7 Methodological comment and limitations 8 The Findings 11 - 33 Introduction 11 What is it about this case which makes it act as a window on practice more widely? 11 Appraisal of professional practice in this case: a synopsis 12 Finding 1 19 Finding 2 26 Finding 3 29 Learning additional to the Findings 32 Conclusion 33 References 35 Appendix 1: Acronyms and Terminology 36 Appendix 2: The Learning Together model and process 37 4 Introduction 1. Why this case was reviewed 1.1 Child T was a 15-year old girl who committed suicide by hanging at her school in June 2013. Greenwich Safeguarding Children Board (GSCB) determined to conduct a Serious Case Review (SCR) because the criteria for undertaking a review of this nature had been met: (a) abuse or neglect of a child is known or suspected; and (b) (i) the child has died; ... and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. (Working Together to Safeguard Children, 2013:68) The guidance states further that an LSCB should always undertake a Serious Case Review to examine the actions of professionals or agencies involved and identify any learning that can be shared and implemented. 2. Summary of the case 2.1 Child T came from a large family, whose life was characterised by continual moves around London and elsewhere in the country. Her early years were disrupted not only by these moves, but by her mother’s changing partners, and the chronic sexual abuse she suffered from her two older male siblings, beginning at a very young age and continuing for several years. Child and Adolescent Mental Health Services (CAMHS) were offered and taken up briefly at this point. Social care agencies were involved with the family over two decades, in relation to domestic violence, neglectful care and sexual abuse in the wider family, across and within generational groups. As a result, T and her siblings were made the subject of Child Protection (CP) Plans in both Greenwich and Lewisham. 2.2 At the age of 11, T ran away from her mother’s care, and chose to live instead with her maternal grandmother and an aunt who was in her early 20s, and thus not many years older than T. From that point, T had little contact with her mother, although parental responsibility remained with her, or her siblings. Child T’s safety being assured at this time, she was no longer subject of a CP Plan, nor was there any further involvement from Children’s Social Care (CSC) after mid-2010. 2.3 T’s life in her grandmother’s home was very different, by being both more caring and more structured: for example, her aunt told T that she was expected to attend school 100% of the time and T was determined to achieve this. She herself wanted her life to change, and for there ‘to be a new T’. This was successful, in that her first years of secondary schooling were 5 settled, and T was able to make impressive progress in both her academic studies and to enjoy and excel at creative subjects, especially music. 2.4 The descriptions of T by school staff and by her grandmother and aunt were very similar. All who knew her felt she was a “‘very, very special girl”, an “amazing”’ young woman, talented and bright. Her aunt said that, “whatever she put her mind to, she would go above and beyond to achieve it, and would often be amazing at it”. Aunt described T as ”caring, kind and considerate – the most selfless person she had ever known”. This was echoed by what school staff told us, that T was universally popular and indeed loved throughout the school community. 2.5 In Year 10 however, T’s progress began to falter, and she became increasingly distressed and unable to cope with her life. Home had become less happy with the arrival of an uncle, not many years older than T who was described by T’s aunt as controlling and aggressive towards all members of the household. T was beginning to tell some trusted people at school about her previous experiences of abuse, and about her growing level of self-harm (severe cutting and two instances of self-poisoning), but she remained very guarded about her suicidal intentions. 2.6 During Year 10, T was supported by the school’s pastoral and (latterly) counselling services, and at the time of her death she had just become an out-patient of the local Child and Adolescent Mental Health Service (CAMHS) in Greenwich. 2.7 Shortly before her death, T was attacked and verbally abused at home by her uncle. He was removed by police, and left the country. It is the view of her family, in retrospect, that although T was already depressed, this incident was the trigger for her suicide. 3. Family Composition Family member in T’s household Child T (subject) Maternal Grandmother Maternal aunt Maternal uncle (in the household for the past few months only) In separate household Mother Stepfather Sibling 3 Sibling 4 Two more siblings live elsewhere 6 4. Time frame 4.1 This SCR examines professional practice with T and her family over nearly three years, between the point at which Greenwich CSC received notification that MGM and T had moved back into the borough, and her death. 5. Organisational learning and improvement 5.1 Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including SCRs, states: ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements that are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.’ (Working Together, 2013:66) 5.2 The GSCB identified that the SCR of this tragic case held the potential to shed light on particular areas of practice: How well do all services, including schools and CAMHS, respond to the numbers of children and young people with deliberate self-harm and suicidal ideation? How good are we at assessing and responding to risk for young people where there has been a previous suicide attempt and/or a disclosed history of sexual abuse (CSA)? Should there be a wider safeguarding network in such cases? Were there services missing for this young person which should have been involved? Had they been asked to be involved? How well supported was the school in their caring for Child T? 6. Methodology 6.1 This review was conducted using the Social Care Institute for Excellence’s (SCIE) Learning Together methodology (Fish, Munro & Bairstow 2008). Learning Together reviews seek to understand professional practice in context; the review identifies the factors in the system that influence the nature and quality of work with families. Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively. To help all readers, a glossary (of acronyms and terminology) is provided as Appendix 1 of this report. Details of the model and this process are contained in Appendix 2 of this report. 7 7. Reviewing expertise and independence Lead Reviewers 7.1 The SCR has been led by two people independent of the case under review and of the organisations whose actions are being reviewed. Sally Trench and Fran Pearson are both accredited to carry out SCIE reviews, and have extensive experience in writing SCRs/IMRs under the previous ‘Chapter 8’ framework in Working Together, 2010. Neither has any previous involvement with this case. Neither has any previous or current relationship with Greenwich Council or partner agencies, apart from the fact that Sally Trench was the overview author for a previous Greenwich SCR. 7.2 The lead reviewers have received supervision from SCIE as is standard for Learning Together accredited reviewers. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence. Review Team 7.3 The Review Team is comprised of senior managers from the agencies involved in the case, who have themselves had no direct part in the conduct of the case. Led by independent Lead Reviewers, they act as a panel working together throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings. They are also a source of data in themselves, about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints, changes in structure, etc. The Review Team members also have responsibility for supporting and enabling members of their agency to take part in the case review. The Review Team were: Manager, GSCB Named Nurse Safeguarding Children, Oxleas NHS Foundation Trust Senior Child Protection Officer, Academy Schools Trust Reviewing Officer, Specialist Crime Review Group SC&O 21(2) Head of Service, Greenwich CAMHS Safeguarding and Partnerships Leader, Greenwich CSC Named Nurse, Safeguarding Children Lewisham and Greenwich NHS Trust Named GP, Lewisham Case Group 7.4 The Case Group is comprised of the professionals who were involved in some way with Child T and her family. By attending meetings and taking part in 8 individual ‘conversations’ with members of the Review Team, they provide the data about the case: what happened, how, why, what were the contributory factors affecting their work and their view of Child T and her family? The Case Group contribute to the working out of this material, and to the analysis of what aspects of the case are part of wider patterns, which affect the work of agencies more generally. To elicit their involvement in this case, members of the Review Team held individual conversations with the Case Group professionals. The Case Group also attended two multi-agency meetings to contribute to the analysis and findings from the Review Team and Lead Reviewers. The people who took part as members of the Case Group were: Principal, School Assistant Principal, School School Counsellor Two teachers Pastoral Manager, School GP CAMHS Social Worker CAMHS Psychiatric Registrar CAMHS Consultant Psychiatrist Two Team Managers, Children’s Social Care Consultant Paediatrician Emergency Department Nurse 8. Methodological comment and limitations The scope of the SCR 8.1 Child T’s large family were known to universal and targeted services, including CSC, for most of her early life (until her move to live with MGM). It appears that she and her siblings experienced persistent neglectful care and abuse, exposure to domestic violence, a changing population of fathers/stepfathers, and continual moves – with the consequence that their education was badly affected. Child T and her two younger siblings were sexually abused over a long period by her two older brothers. 8.2 In the immediate aftermath of Child T’s death, action was taken to safeguard and promote the welfare of the remaining children in the family, and exploration of agency records prompted a number of questions about this history and how risks to the children were handled in the past, not just in Greenwich but in a number of local authorities. The SCR process thus had to start with a decision about what was the appropriate time frame and focus of the SCR and it was agreed by the SCR Panel that the period to be reviewed was the last three years of Child T’s life, or when she moved back into the Greenwich area. 9 8.3 The unique purpose of a systems review is how it analyses current arrangements and practice, so that changes can be made to improve services now and in the future. This report has thus focused on the recent period of Child T living with her grandmother in Greenwich, and examines the work of Greenwich agencies during that time. It acknowledges that the family history is of critical importance in understanding T’s breakdown and suicide. However, it was decided by the GSCB that it would not be appropriate to try to trawl back further in time, an exercise which would potentially cover two decades and an unknown number of local authorities. Personnel, policies and procedures, and legal frameworks have all changed during those years, so that there would be limited relevance for those who are currently involved in safeguarding children. The timing of the SCR 8.4 There is often a balance to be struck at the outset of a Serious Case Review between unnecessary delay in commencing the process and the capacity of staff to participate to the best of their ability following the death of a child. All staff were affected by T’s death and school staff particularly so because they arguably knew her best. This did impact upon their ability to reflect more objectively on circumstances at the time and in retrospect, this process would have benefited from a slightly later start. Family involvement 8.5 Child T’s grandmother and mother were informed about this SCR. 8.6 As in traditional SCRs, family members are normally invited to participate in the SCIE Learning Together process by meeting with the Lead Reviewers. In this case, this offer had to be postponed, because of other legal processes involving family members. 8.7 After the completion of court proceedings, individual letters were sent to Child T’s mother, grandmother and aunt, inviting them to meet with the Lead Reviewers and giving them an opportunity to provide their perspective on the work that was carried out with them and with Child T during the last three years of her life. 8.8 In the event, only T’s Grandmother and Aunt were able to take up this offer. We are very grateful for their willingness to meet with the Lead Reviewers. This was likely to have been especially testing for them, as one of the meetings coincided with the anniversary month of Child T’s death. We would want to thank them for their valuable contributions and providing the Review with their personal insights of Child T as well as giving us their experiences of the professionals’ involvement with Child T. 8.9 It should be noted that the family’s personal views and information about services received were not available for the work of the Review Team and the 10 Case Group, during their analysis of material for this report. This final version of the report (November 2015) now has their views woven into relevant sections. We have also included at various points their descriptions of Child T, for whom they had been the primary carers for several years, and whom they loved dearly. The absence of the Police from the Case Group 8.10 The Independent Police Complaints Commission carried out an investigation in this case. This was triggered automatically, in the circumstances of a sudden and unexpected death occurring within a certain number of days of a Police officer having had contact with a victim. This affected the participation of Police officers in this case review. There was a Police representative in the Review Team, but not in the Case Group. The absence of the School Nurse from the Case Group 8.11 The School Nurse was not involved until later in the review process since she was no longer working in the school and, at the outset, believed not to be contactable. When contact was made, one of the Lead Reviewers was able to meet with and talk to her, so her perspective has been included although she was not part of the group process. 11 The Findings What light has this case review shed on the reliability of our systems to keep children safe? 9. Introduction 9.1 A case review plays an important part in efforts to achieve a safer child protection system. To maximise the likelihood of organisational and individual change it is necessary to understand what happened and why in a particular case and then to go further and reflect on what this reveals about deficits and vulnerabilities in the child protection system more broadly. The particular case acts as a “window on the system” (Vincent 2004). 9.2 Case Review findings therefore need to say something more about the local area/agencies and their usual patterns of working. Findings exist in the present and potentially impact in the future. They can also be expressed indicatively, as questions, if the evidence base for the prevalence of an issue is not clear but the Finding itself is agreed to be valid. 9.3 In order to help identify the nature of a Finding and thereby assist the LSCB to focus remedial action to a particular part of the child protection system, the Learning Together model uses 6 broad systems patterns: Innate human biases (cognitive & emotional) Family –professional interaction Responses to incidents Longer term work Tools Management systems 9.4 It is not an expectation that every pattern will feature in a review and there is overlap between them. The Findings, however, critically highlight for the GSCB how effective the child protection system was at the time of Child T’s death. For a more detailed explanation about how Findings are constructed, see Appendix 2. 10. What is it about this case which makes it act as a ‘window on the system’? 10.1 The most fundamental learning from this case concerns the challenges which face all professionals when working with young people who self-harm, where the degree to which they are vulnerable may not always be obvious. There is an associated lesson around the need to appreciate the relevance of more historical records or information, where harmful or abusive actions may remain hidden, and there may be no obvious immediate concern. 12 10.2 The numbers of adolescents who deliberately self-harm are growing in many areas, including Greenwich and neighbouring authorities. Agencies and individual professionals are searching for how to manage these levels of need and how to work together better to help and protect these young people. The universal settings most affected by this phenomenon are schools. 11. Appraisal of professional practice in this case: a synopsis 11.1 Those who knew and worked with Child T were committed to doing their best for her and consistently prioritised her wellbeing. They were thoughtful about her and her family circumstances, even if they did not know all the details of these. Among those who knew her best (the school staff), however, there were some untested assumptions about T’s care and insufficient understanding about the level of risk to her emotional wellbeing and her safety, especially during the period (mid-Year 10) when her self-harming began to increase in severity. After her first overdose (April 2013), she commenced twice-weekly sessions with the school Counsellor, but was not referred to specialist mental health provision for a further month, until after her second overdose. At that point, the appropriate range of agencies became involved in trying to support and safeguard T. 11.2 Sadly, the discovery of T’s farewell letters found after her death, show that she was determined to end her life. The Review Team is unable to state categorically that this might have been prevented by other actions or decisions; we simply cannot know. 11.3 This case was untypical of many which are the subject of a SCR: until very late in the time frame reviewed, there was no multi-agency network working with Child T and her family. This was in contrast to Child T’s early childhood, when she had suffered long-term abuse and neglectful care, and when CSC and partners in various local authorities (due to frequent family moves) were involved. 11.4 In the past three years, the professionals who knew Child T and her family remained largely unaware of her history of abuse. She was a child with “invisible, interior wounds”1 similar to many others who suffer from post-traumatic stress disorder (PTSD). The Review Team asked the question: what might one expect for a child with a history of serious and prolonged sexual and emotional abuse who had had limited therapeutic input to deal with these experiences? As it emerged in this story, there was an unknown degree of harm to Child T’s emotional well-being and her ability to grow into a healthy young woman. This lack of awareness of T’s persistent and underlying distress was true for her close family as well. 1 Charlotte Higgins, ‘The Road Home’, The Guardian 30th November 2013 13 The family’s return to Greenwich 11.5 At the beginning point of this case review, Greenwich CSC were informed of T and MGM’s move back into Greenwich by Lewisham CSC. The letter of notification from Lewisham made a brief reference to T’s troubled history and to previous CP Plans, but went on to state that T was now ‘happy and settled’ with her grandmother. 11.6 The Review Team have been unable to explain why the letter, dated April 2010, was not received by fax in Greenwich until July 2010, despite checking with Lewisham. 11.7 Although T’s current and previous surnames were both supplied in Lewisham’s letter (given as, e.g., ‘Smith/Jones’), an administrative error was made at the point of uploading this information onto CSC’s electronic database, Frameworki, when only her current surname was recorded. Consequently a search was conducted against one name only, and thus, T’s (and her family’s) extensive history with Greenwich CSC was not discovered and read, as would normally be expected as part of determining what kind of response to make. The Review Team do not consider that this error had an impact on the outcome of later events but the likelihood that errors such as this will be made is a vulnerability in the system which is explored further in Finding 3. 11.8 The CSC Contact & Referral Team telephoned the family home and spoke to T’s aunt (not to the young person), who reported that they did not need social work help. 11.9 T’s school were aware of her extra needs as a pupil whose primary education had been severely disrupted by the family’s continual moves. But her needs as a child with severe psychological damage were not fully known at this point. Finding 2 deals with these circumstances: how, in secondary schools, CP records may not be reliably received from primary schools, and may not be proactively used as a tool for supporting pupils in need or at risk of harm. 11.10 When T arrived in Year 7, her academic attainment was very poor, and she was described as ‘semi-literate’. The school are rightly proud of how they enabled T to learn and achieve very highly in her academic work, and to develop her enjoyment of expressive activities such as music. The school became a haven, where she felt comfortable and safe with other pupils and staff. On many levels, the school did an outstanding job for T. 11.11 This view of the school’s work with T was echoed by her grandmother and aunt, who praised staff for supporting T to flourish in all aspects of school life, and to achieve excellent exam results – including, poignantly top scores in her science GCSE exams, published after her death. Grandmother and aunt felt that the response to T in Year 10, when pastoral and counselling staff 14 became involved, was appropriate and more likely to succeed (than a referral to another agency) because of T’s attachment to known figures. 11.12 Things gradually changed for T in Year 10, a time of greater academic pressures and expectations on her (and all pupils). Staff noted that her good standards of work were slipping, and that she was no longer coping in the way she had hitherto. She began to rely very heavily on the attention and support of two young teachers, one of whom had taught her and had also been her Learning Mentor. Their professional boundaries with T – including the amount of their time she regularly absorbed – were increasingly tested. This resulted in a close relationship between the pupil and the teachers. T was over reliant and too emotionally attached to her teachers, and they did not always maintain a distinct professional distance. 11.13 These are circumstances which, to varying degrees, can and do arise in schools and other settings. But T’s dependence on and attachment to these two teachers were extreme, as was the amount of time she spent with them. The teachers did not recognise that the degree to which they were taking personal responsibility for T was concerning; they did not flag this up with senior staff, nor was it noticed by anyone else until late in the school year, when T’s self-harming behaviour escalated. At that point, the Assistant Principal (the Child Protection Lead in the school) and later the Principal, when he became involved, took decisive action to protect the teachers, and to relieve them of the sense of responsibility they felt towards Child T. To a degree, this plan succeeded, though it did not prove possible to remove the teachers’ ongoing feelings of distress and anxiety about their pupil, for whom they had developed a strong sense of personal responsibility, as well as affection. 11.14 In the second half of the year, T revealed to these two teachers and to her Pastoral Manager that she had been self-harming by cutting herself, all over her body. The Assistant Principal then convened a meeting to which T’s grandmother and aunt were invited. Grandmother recalled being shocked to be told that children who self-harm by cutting are advised about the importance of using sterile materials. (The Review Team were told that this was included in the staff training on responding to DSH, and indeed it features as advice widely available online, about how to deal with children or young people who are cutting themselves, alongside a suggestion ‘not to express shock or disapproval’.) Later, Grandmother was advised by the CAMHS team about removing sharp objects entirely from T’s environment, something which seemed more relevant to her. 11.15 From this point, the Pastoral Manager for T’s year group became a more regular link for T, whom she could access when she felt the need for ‘time out’, and as the person who dressed her cuts when they became severe. This was a clear opportunity to refer for more specialist help, and the fact that the school did not do so is an indicator that they underestimated the seriousness 15 of what they were looking at. Finding 1 explores professional (mis)understanding of self-harming in greater detail. 11.16 The Pastoral Manager did make a referral to the School Counsellor, because of concerns about both T’s declining school performance, and her self-cutting. T started seeing the Counsellor in April 2013, but did not disclose the increasing severity of her self-harm. It is still not completely clear to the Review Team why this information was not shared, nor why there were no regular meetings of those involved in supporting T within the school. The Pastoral Manager understood from this point onwards that T’s self-harm was being dealt with by the Counsellor, whom she saw as more qualified than she was to assess how to respond to T’s behaviour. 11.17 There is evidence that T valued her twice-weekly school counselling sessions, but also evidence that she remained guarded about many aspects of her distress, the degree of her self-harm, and her intentions of suicide. A referral to the School Nursing Service, at the very least, should have been made at the point when T’s self-cutting was first discovered; and certainly, an urgent referral to the School Nurse or directly to a specialist mental health service such as CAMHS was needed when T’s degree of self-harming required her to have her wounds dressed by the Pastoral Manager. There was a clear, presenting need and information was not appropriately shared at this point. 11.18 In this period (between January and May 2013), the regular School Nurse was on planned absence, and although cover was available, this did not involve the regular presence of a well-known individual in the school, as a resource for both pupils and staff colleagues. In T’s case, there seems to have been no use made of the School Nursing Service at all, either to be involved in meetings about T, or to make an assessment of her emotional state and the possible need for a referral for a mental health assessment. 11.19 As T’s apparent level of distress grew, it became more difficult for teachers, support staff, and senior management in the school to find a consistent way to respond to her, as well as to share information about what was happening for her. 11.20 It is concerning that the school did not make a referral to or seek advice from specialist adolescent mental health services, in what was emerging as a complex mental health condition. The time frame for such action was relatively short, with the deteriorating situation becoming clearer in early spring. But, as already noted above, discussion with a specialist was essential at the point when T’s cutting became severe, and extended to all parts of her body. This was the responsibility of those with a ‘duty of care’ towards her and something that a School Nurse, had they been consulted, would almost certainly have done, in line with due process. NICE guidance is helpful and clear about T’s needs at this point: 16 ‘All people who have self-harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.’ (2004:64) 11.21 There is an overlap here with Finding 2, as a clearer understanding of T’s history of abuse and neglect in early childhood might have assisted the school in comprehending the origins of T’s distress and the importance of making a referral for specialist help. First overdose 11.22 At the end of a school day, T told the two teachers about her overdose of 8 Paracetamol tablets, adding that ‘Pastoral’ had telephoned NHS Direct and had been advised that this amount was ‘within her daily limit’ – the implication being that no specialist medical service was required. The teachers looked after T, whilst contacting the Assistant Principal, who informed T’s grandmother about what had happened. 11.23 In the course of this case review, it has emerged that the Principal, the Assistant Principal, and all other interested parties believed that NHS Direct had been contacted by someone in the school, and that they had given advice that it was safe for T not to have medical attention on that day. It has come to light over the course of this Review that this was assumption rather than fact. NHS Direct have no record of any contact and no-one in the school can remember calling them. 11.24 T’s first description of the number of pills she had taken was later revealed to be lower (by at least half) than the real picture. This was a mental health crisis for T and the fact that she was not assessed at this point by any medical professional was another missed opportunity. Despite the confusion about advice from NHS Direct, it was the school’s duty of care to have immediately arranged for T to be taken to A&E. School staff did contact T’s grandmother, and requested that T be taken to her GP, and this was agreed. 11.25 The School Nurse was clear when spoken to as part of this Review that, had she been there and known of this overdose, she would have ensured that this would happen – that any young person in such circumstances would be taken to hospital in order to receive the appropriate attention. This action is in line with NICE guidance, which states: “Refer to an emergency department urgently unless you are sure this isn’t necessary.” (2012:8) 11.26 T’s second overdose (again disclosed to a teacher) did result in decisive and appropriate action by the school. T was sent to hospital in an ambulance, and was seen by medical staff and then was assessed by a member of the CAMHS team. The assessment specifically addressed the issue of whether there was an ‘immediate risk of suicide’, and whether T needed to be 17 detained in hospital under a section of the Mental Health Act 1989. The decision was that this threshold had not been met, and a ‘safety plan’ was agreed between the CAMHS team, Grandmother and T prior to her discharge home from hospital. This plan included a number of immediate, follow-up meetings with T by the CAMHS team. A link was also made by that team with T’s grandmother, to support her to monitor the ongoing risk of self-harm within their home. This was good practice, and in line with NICE guidance regarding the treatment of young people who self-poison (2004:66-67). 11.27 In conversation with T’s grandmother for this case review, she reflected that she felt that T should have been detained in hospital (‘sectioned’) at this juncture. She now feels that this would have been “the only thing that could have stopped T from taking her life.” 11.28 The Review Team has been unable to establish whether T was physically examined in hospital in a way that would have revealed how she was cutting herself all over her body, increasingly severely. This was not documented in the notes of the Emergency Doctor who initially saw Child T, and he is no longer available to be asked about this. Although she was admitted because of an overdose, the Review Team are of the view that this more holistic kind of physical examination would have better informed an assessment of risk. 11.29 A final point about the actions following T’s admission to hospital: a discharge notice of this episode was sent from the hospital Paediatric Liaison Officer to the School Nurse via her individual work email. In the absence of the SN, who was still on leave, this meant that an urgent notice was not picked up in a timely way. It is not known whether an ‘out of office’ message was triggered or whether this contained any re-routing instructions due to annual leave and even if it had, such messaging would not continue to recur over a longer period. This is an example of the kind of routine practice to which everyone is prone, particularly where professional relationships are well established. It is deserving of some thought in terms of guidance to staff around notifications and the different priorities that may need to be attached to these. 11.30 The CAMHS Team were involved for the last 3 weeks of T’s life, and appropriately met with T herself, and liaised frequently with family members and other professionals, especially the School Counsellor. Their discussions continued to address the level of ‘chronic risk’ of self-harm which CAMHS believed to be present for T. Both T’s Counsellor and family members were given information about how to remain alert and keep T as safe as possible, while therapeutic input could be put in place. It is clear from the records that these discussions were held on a regular basis. 11.31 Despite this, it has emerged that some members of the school community and family members now feel critical of mental health services for either “not finding out how bad T was” and/or not “telling them that T was suicidal”. 18 This may reflect a real difficulty in how aspects of high risk are communicated by mental health professionals, and how they are understood, not just by lay persons/family members, but also by professionals such as school staff. 11.32 As part of trying to understand more about why T had overdosed, the SW in the CAMHS team tried to retrieve background information from Lewisham CSC, understanding that T’s history was a critical factor in her degree of disturbance. In contributing to this case review, the psychiatrists referred to very young victims of sexual abuse as being likely to “retain a deep and negative sense of their worth”, and this sadly seems to have been true for T, despite all the progress she had made and the warm and close relationships she had developed as a young teenager. 11.33 In her return-to-work week, the School Nurse was alerted to T’s second overdose (by the hospital Paediatric Liaison Officer, not by school managers), and therefore arranged to see her in school. T met with the School Nurse, but did not want any further help from her, as she was already involved with the School Counsellor and, now, with the CAMHS team. 11.34 In a significant turn of events, it was an ‘incident’ which prompted a referral back into CSC. This was the physical and verbally abusive attack on T by her young uncle who had been staying in the household for several months. In response, Borough Police arrested the uncle and held him in custody. A CAIT officer contacted CSC about this by telephone on the following morning (12/06/12). A Section 47 (formal child protection) investigation could have commenced immediately, but it was agreed between the police officer and the receiving duty worker to await the written referral before the next steps of the investigation. 11.35 The next day (a Thursday), CSC received the Police Merlin report and a faxed school referral about the same incident, but there was no verbal communication to/from the referrers. The administrator as required uploaded the police report and the referral from the school onto the electronic case management system. When the team manager noted the referrals, later on the following day, she made a risk assessment and judged appropriately, in the context of the incident, that T was not at immediate risk of harm. She saw that a Section 47 investigation was required, but in the circumstances (T being protected by family members), she decided that this would be followed up on the next working day (after the week-end). This was a decision made in relation to the presenting information CSC held at the time. 11.36 Despite the continued error on the electronic system about T’s full name and a failure to link her with her previous family records, there was a mention of previous CP concerns in the school’s referral. The Team Manager appropriately determined to research the history further with Lewisham, as there was clearly an unexplained gap in information about T’s past. 19 11.37 The CP referral was passed on to the Assessment Team on the 3rd working day (Monday) after the initial telephone call from the Police, and there was a further delay for two reasons: 1) CSC attempted to speak to the allocated police officer, who was not available until the following morning; and 2) the most appropriate and skilled worker for the case was not available until the next day to meet with T and her family. To wait one day for the right person to be allocated and to visit was an appropriate decision to make at the time, as there was no current risk from the uncle, and no known immediate risk from further self-harm. Sadly, T died before a meeting took place. 11.38 It would be an inappropriate use of hindsight to conclude that different decisions or other courses of action would have stopped T from taking her life, notwithstanding the fact that opportunities to bring in skilled professional support were not taken in a timely way. There was strong evidence that T wished to keep her final intention secret, and that her suicide was planned, and tragically, was something that she wished for. Findings in detail Each of the review Findings are laid out applying the Learning Together ‘anatomy’ (see Appendix 2), which names the fundamental issue and why it matters, seeking also to understand the degree to which the issue might be replicated throughout the multi-agency child protection system. Where evidence for replication requires further exploration and corroboration by the LSCB the Findings are expressed indicatively, as questions. 12. Finding 1: Professionals are not uniformly well enough equipped to understand self-harming behaviour, meaning that the response they offer is unlikely to be either confident or consistent. 12.1 This review has explored what may get in the way of more effective collaboration across agencies about responding to DSH, whether via consultation, referrals for individual children, or advisory input to staff. It particularly questions the baseline understanding in schools, where staff have more contact with young people than any other setting, yet perhaps do not have the professional skills and experience to know how to respond to a young person who is self-harming, beyond what might be basic guidelines (e.g., not to react in a shocked manner). The emotional impact on teachers and other staff can be powerful and distressing. However, the issue is not likely to be exclusive to schools: typically, much self-harming behaviour is kept secret, but there are many more young people in recent years who do disclose DSH to staff at school, in other youth settings, to GPs, and elsewhere. One of the messages from the participants in this case review is 20 also that numbers of young people with DSH are rising locally. There is also a noticeable trend being reflected on a national basis. 12.2 The need for improvement in recognition and effective response is becoming more urgent in the face of a significant increase in recent years of numbers of young people who self-harm. It is possible too that this may, perversely, inhibit referrals to specialist services such as CAMHS. The argument is that the numbers are too great to be able to refer them all – perhaps with the assumption that many referrals would fail. 12.3 Elsewhere, in all settings, there is pressure on resources and service provision which will inevitably affect how well episodes of DSH are managed, when they come to light. Added to this is the awareness that a significant proportion of self-cutting remains hidden from professionals in all settings. How did the issue feature in this particular case? 12.4 The issue highlighted by this Finding is manifested most clearly in the way that the school in this case for a long time managed T’s behaviour itself, in full knowledge that she was self-harming, rather than seek the support of other agencies or make a referral for specialist help. They did not appear to equate her behaviour with suicidal ideation nor did they see it as a safeguarding issue which warranted specialist intervention. This led the Review Team to question whether there was sufficient awareness generally of thresholds for upward referral, but a more fundamental issue may be the lack of understanding that safeguarding thresholds apply to self-harming behaviour. 12.5 Child T gradually disclosed to school staff her self-cutting, which became more severe over time. Near the end of her life, she took two overdoses. School staff were clear that concerns and information about T were to be shared with the Designated CP Lead (the Assistant Principal), who together with the Pastoral Manager and the Counsellor was planning and monitoring how the school dealt with T. The School Nursing Service was not consulted about T’s self-cutting even when the Pastoral Manager was dressing her wounds for her. An earlier assessment for a mental health referral, which would be part of this service’s area of expertise and responsibility, was not apparently considered or sought, nor was any advice sought from a social worker. It was only when T took a second overdose that she was sent to hospital and then received a mental health assessment, including her level of risk of further self-harm. From this point, there was helpful communication between school and T’s CAMHS social worker. 12.6 An important and associated issue in the school was the degree to which two young teachers were drawn into befriending and supporting T, as well as worrying about her and going several ‘extra miles’ to try to help her. This was not well picked up by the school, although measures were put in place latterly to try to restore appropriate working boundaries. Research evidence 21 suggests that complex circumstances, such as a young person self-harming, can be overwhelming and anxiety-provoking for teaching staff, of any age and experience. They may, for example, struggle to go against the wishes of a young person – in this case, one who was afraid of being ‘locked up’ in a mental hospital. 12.7 Responsibility for T was therefore ‘held’ by the school beyond an appropriate threshold for too long. There were no timely discussions with any child mental health specialists about how T’s difficulties were being approached and managed, nor did the school, as Lead Professional, attempt to co-ordinate a multi-agency assessment to address T’s wider support needs. The level of T’s self-harming behaviour became sufficiently concerning to warrant consideration of a referral to Children’s Social Care as well as to CAMHS, but this was not done, even on a level of advice seeking. (NOTE: This review found that the relevant staff in T’s academy did not know about the CSC Consultation Line which is available for informal discussion and this has now been remedied.) Family members (Grandmother and Aunt) were involved in a school meeting, but there is evidence from our interviews with them that they, like school staff, remained uncertain in their understanding of T’s self-harming behaviour (cutting and overdoses). This is an area where mental health specialists can and should be helpful, by addressing the need to explain simply and communicate clearly and effectively with the young person, non-specialist professionals, and family members. 12.8 T’s school does have a policy for responding to DSH, which is not widely known to all members of staff, including the Counsellor and Pastoral Manager, and is therefore not being well used. However, school staff did understand that any incident of harm which came to their notice should be reported directly to the CP Lead, and this guidance was followed. But the need for a referral of T onwards to specialist services was not understood or acted upon in a timely manner and the case was not appropriately referred until the most senior member of the school became involved (and then, as the result of T’s second overdose). How do we know it is not peculiar to this case? 12.9 The Review Team came to the view that the responses to T were not unique in this school, and unlikely to be unique in other schools and other settings. There are a number of reasons for this. Emotional impact of DSH 12.10 Given the typical age of onset of DSH, teachers in secondary schools are often the first professional to become aware of a child or young person’s self-harming. This is likely to create not only uncertainty about what to do, but other very difficult emotions. Best (2005), in looking at pastoral care in education, noted the following in relation to responses to deliberate self-harm: 22 “There is also evidence that many teachers are in fact ill-prepared to manage such emotionally distressing situations, expressing feelings of ‘sorrow, alarm, panic, anxiety, and shock…” (2005:7) These reactions may be additionally complicated by pleas from a young person to keep the behaviour secret – either from other professionals or from his/her family. The complexity of confidentiality guidelines is another area which affects professionals in schools and in health settings. Knowledge and confidence about what to do 12.11 The Review Team were told that there is a DSH policy in the school, but two important members of staff were not aware of this: the Pastoral Manager and the school Counsellor. Their decision-making about what information to share and when to make referrals (including among themselves) was not always clear, so that, for example, the increasing severity of T’s self-cutting was not known to all members of the small group who were involved with her care. 12.12 For many other children and young people, their self-cutting is more superficial than in T’s case, and this spectrum may add to uncertainty about what to do and when for this growing group. 12.13 This review has suggested that there is also a need for clear and consistent guidance for professionals in various settings – though, perhaps most relevantly in secondary schools – regarding what to do for the victim in cases of self-poisoning. This should include, for example, that the young person should automatically be taken to a hospital A&E department, where the relevant forensic tests could be carried out, alongside a psychiatric assessment. Guidance such as this would relieve staff of the difficult responsibility of assessing and then deciding what to do with the young person (as after Child T’s first overdose), in a highly-charged emotional situation. Uncertainty about when to refer to specialist services? 12.14 This case has demonstrated that appropriate and timely referrals to specialist services are not always made. The Principal of the academy and the Review Team member representing education (from another secondary academy) suggested another factor: the amount of DSH in the school – ’30 to 50 per year’ in T’s school. It would not be possible, they suggested, to refer all of these pupils to CAMHS. But, how do they decide which children are at greater risk and do need referrals? 12.15 Research briefings on this subject (SCIE, 2005, NSPCC, 2009, and NICE, 2011) suggest that the School Nurse has a key role in determining what is appropriate for a young person: counselling within the school, or a complex mental health assessment by CAMHS. The SN has the advantage of close links with other parts of the Health service, and of professional supervision to 23 guide her in such assessments. In addition, he/she can bring an overview and a sense of balance, from working in other schools and other pupil populations. 12.16 A school or academy with a lower level of SN time (the minimum provision is 1 or 1.5 days per week, depending on the size of the school) will find it harder to get this essential input. Might this, along with no regular CAMHS support, contribute to a culture within schools which is slower to seek advice from, or make referrals to, outside agencies? What numbers of cases are affected, and how widespread is the pattern: local, regional, national? 12.17 Rising numbers of children and adolescents who self-harm are creating ‘pressure on services and affecting the assessment and treatment of self-harm episodes’ (SCIE:8). This is a pattern which affects all areas of the country. Locally 12.18 Referrals for all CAMHS ‘self-harm emergencies’ in Greenwich and neighbouring boroughs Bexley and Bromley are predicted to have risen by an average of 32% in the year 2012/13. Other London LSCBs are noting similar increases, and are focusing on training and guidance for staff (e.g., Ealing, Harrow, Hillingdon). The SCIE briefing paper suggests why this is essential: 12.19 Given that a history of DSH, especially repeated episodes, is a significant risk factor for suicide, “It is…important to be able to recognise self-harm amongst children and adolescents and the risk factors associated with these actions. Social care, health and education professionals may all be involved in identifying and managing self-harm among children and adolescents.” (SCIE:5) The London Safeguarding Children Board are responding to this growing area of concern across London, with the establishment of a working group to develop a multi-agency protocol about how to respond to deliberate self-harm in children and young people. Greenwich’s Safeguarding and Partnerships Officer is a member of this group, and has also been a member of the Review Team for this SCR. Nationally 12.20 Suicide is the main cause of death in adolescents in this country, but different parts of the UK show significant variations in the trends for suicide among young people.2 Similarly, the prevalence of DSH among adolescents is high, 2 Over the last 30 years the number of suicides among 15 to 19 year olds has decreased in England and Wales whereas it has increased significantly (by 315 per cent) in Northern Ireland. In Scotland, the five-year average rate in 2011 was 77 per cent higher than 1984, but the rate has been on a downward trend since 2003. For 10 to 14 year olds the rate has remained relatively stable in England and Wales, has increased in Scotland (though has 24 and there are indications that it is rising steeply. In the past year, DSH as a reason for contacting ChildLine jumped by 41% (= 13,500 more young people). This was the largest year-on-year increase among the top 5 reasons for young people to contact ChildLine. These referrals have risen steadily since the mid-90s. 12.21 The NSPCC research briefing gives figures for the incidence of DSH from different studies, ranging between 1/15 to 1/10. It also includes some startling figures for responses to anonymised surveys, with rates far higher than this (up to 70% - CASE Study, 2005). Much of self-harming remains hidden, so anonymised surveys are an important source of evidence about prevalence. What are the implications for the reliability of the multi-agency Child Protection system? 12.22 There is a large amount of research evidence available to help professionals in all agencies respond more effectively to children with DSH. It is important, in particular, for key staff to access and understand the evidence which reflects higher levels of risk – e.g., the link between overdoses and suicide, and persistent DSH and suicide (SCIE, 2005). 12.23 In the context of an apparent rise in the incidence of DSH, professionals need to work together more effectively so that in all settings there is an appropriate, consistent and well-informed response to situations of risk. Otherwise, harmful behaviour in children and young people will continue to occur without adequate protective interventions, including early multi-agency collaboration, and timely referrals to specialist services in circumstances of greater risk. 12.24 Greenwich CSC have done a great deal of work on improving multi-agency communication and collaboration, so that an increasing number of children receive early help. There is a local Prevention Strategy, with key themes around building resilience, prevention and protection, which is well understood by most agencies and professionals. A Consultation Line for professionals to talk to social workers about cases without having to make a referral has been in place for some time. CAMHS have provided a ‘pathway’ document to guide and support appropriate consultations and referrals. All these developments demonstrate a commitment to improve the flow of multi-agency collaboration. In addition, there has been highly positive feedback to a recent GSCB survey, asking agencies whether they are confident about when and how to make referrals to partner agencies. Whether this groundwork is sufficiently strong to support an improved decreased in the last three years) and has increased significantly (by 221 per cent) in Northern Ireland. In 2011, the five-year average rate for 15 to 19 year olds was 157.2 per million in Northern Ireland, 108.9 per million in Scotland and 36.8 per million in England and Wales. For 10 to 14 year olds, the five-year average rate in 2011 was 18 per million in Northern Ireland, 6.7 per million in Scotland and 1.7 per million in England and Wales. (NSPCC, How Safe Are Our Children?, 2013) 25 recognition and response specific to DSH is a question for the GSCB to determine. Finding 1: Professionals are not uniformly well enough equipped to understand self-harming behaviour, meaning that the response they offer is unlikely to be either confident or consistent. This is compounded by the significant and rising numbers of children who self-harm. Numbers of children who self-harm are increasing. Those who do it to a level requiring admission to hospital are recorded in public health statistics relating to ‘non-accidental injury’. There are many more who might not require hospitalisation but for whom self-harm has become a routine way of coping with anxiety. Harm is more often than not hidden. It is not easy to distinguish between self-harm as an extreme coping mechanism and self-harm as an indication that someone is failing to cope. The trajectory between self-harm and suicide does not come with an easy-to-follow or inevitable roadmap. Given that it is not likely to be possible to provide every child who thinks about and/or acts out self-harming behaviour with immediate or consistent access to specialist support, it is vital that professionals who are not specialists are helped to understand and work with it. If not, the more routine support that is provided to vulnerable children will not necessarily be timely or helpful and in more extreme cases may unknowingly make matters worse. Questions and issues for the Board and member agencies to consider Does the Board agree that this Finding is important? How much is known about the growth of DSH and the different ways in which it may manifest itself, both locally and in the London region? How might the Board assure itself that there is a good level of awareness in universal services of thresholds and pathways for specialist support, specifically in relation to DSH? What kind of interventions and longer term support might be most effective in working with young people who self-harm? Which agencies could usefully be involved in discussions in relation to this? Has the direct experience and feedback from young people who self-harm ever been sought? How might the Board support staff, particularly in secondary schools where this issue is likely to arise most often? Is there evidence to support the suggestion that the growing number of young people who self-harm is deterring school staff from referring to CAMHS? How can the Board make best use of the knowledge of specialist services to raise the awareness of self-harming among other professional groups? Is there a way to assess, and if necessary challenge, how well local schools are using appropriate specialist resources for pupils with DSH? Can the Board establish (and promote) what is ‘working well’ where there are regular links between CAMHS and schools? 26 How can the Board promote better awareness of the CSC Consultation Line, as a means of supporting appropriate referrals? How will the Board assure itself that understanding of the nature of self-harm has improved and there is a greater consistency of response to children and young people? 13. Finding 2: Is there a tendency for professionals, especially when under pressure, to react only to immediate safeguarding concerns, risking the invisibility to the system of vulnerabilities due to historical abuse? 13.1 The review has found that, despite there being extensive records about this young person and her history of prolonged abuse within her family, this critical information remained unaccessed by the agencies who were involved with her. The information existed, but it was not explored. This meant that the level of her vulnerability was invisible, and when she began to break down, there was no fully-informed response to her behaviour. 13.2 We have expressed the Finding as indicative because the degree to which it is widespread is unclear. It was manifested in this case within the school but the tendency illustrated by this Finding is a systems vulnerability for any organisation, particularly at the point when an initial assessment of risk is made. The need to know and understand the child’s personal history is critical in every case, but especially those where the harm to the child was severe and prolonged, and has remained unresolved. These are circumstances associated with higher risks of serious self-harm and suicide (NSPCC, 2009) How did the issue feature in this particular case? 13.3 In her first year at secondary school, T was still on a CP Plan in Lewisham, though this ended shortly when she began living with her grandmother. This meant that there was a CP file in the school, and at that time, a school representative would have been invited to CP Conferences for T. Thus, it seems likely that her CP file was ‘live’ at that time, and known to at least the CP Lead in the school, if not others. Once T was no longer subject of a CP Plan, the file ceased to be active. 13.4 The school changed its status (twice) in the next two years and the new senior management team were not aware of the contents of the CP file. The file was not proactively sought out until after T’s death. These records contained extensive descriptions of the abuse and neglect which T experienced throughout her early childhood, and therefore would have shed light on T’s needs and her level of vulnerability, both at home and at school, further strengthening the argument to seek specialist support. 13.5 When information about Child T came to Greenwich CSC in July 2010, this did not indicate current CP concerns although it flagged T’s history of traumatic 27 and severe sexual abuse within her family. These were followed up in a ‘checking’ telephone call with a member of the household and reasonably not considered to constitute a current or pressing need at the time, but, unlike the system within the school, the existence of prior history was flagged in the notification and its importance thereby acknowledged. How do we know it is not peculiar to this case? 13.6 The Review Team recognised the tendency to react to the immediate rather than give full consideration to previous history to be a vulnerability, especially at times when volumes of cases are high and/or when people are more busy than usual, making it less likely that the links between current presentation of clients or patients, and their previous history, will be properly considered by professionals. There are a number of factors that compound this: a) ‘History fades’ very easily. Personnel change in all agencies, and there may be no one around anymore with direct knowledge of the family members or the case history. This being so, systems need some kind of alert to remind a service of ‘invisible’ difficulties, and links among large extended families – for example, a flag on a system to show that a child is vulnerable or a visible note on a pupil’s school record to show the existence and whereabouts of a child protection file. b) Chronologies are a key tool for social workers in accessing complex histories and recognising patterns of behaviour. However chronologies are not consistently created and used which makes it more difficult to understand how the past is affecting the children and to inform what needs to happen to safeguard and promote the child’s welfare. c) The ‘here and now’ picture of cases has greater impact on the response of agencies, and reassurance about current events can be persuasive. In addition, presenting incidents tend to elicit a positive response in more cases than ongoing concerns, even when these are possibly linked to past abuse. 13.7 In addition, the Review Team noted a ‘lack of curiosity’ which can result in not trying to find out whether a child was previously known when they come to notice and investigating that to inform an assessment of need in the present. The same issue applies to the fact that a CP record for a child in a school may not be known to senior school managers, especially if they were not in post when the child, and his/her CP file, arrived in the school. Rather than proactively identifying and reading all CP files as a preventative measure, this case suggests that the records may not be consulted unless an issue precipitates this. Pressure of workload and/or assumptions as to the reasons for particular behaviours are likely to have an inhibiting effect on this professional curiosity. 28 What numbers of cases are affected, and how widespread is the pattern: local, regional, national? 13.8 The Review Team saw the factors listed above as generalisable across the country. They are not peculiar to local agencies, and they apply to the significant number of families whose complex vulnerabilities and problems persist, or re-emerge, over time. The issue has been highlighted before in research pulling together issues that surface in Serious Case Reviews, particularly in relation to the recognition and response to chronic neglect. If practice is appropriately child-focussed, a natural question to ask is whether there is any more information available that would help to determine whether a child is safe. 13.9 Secondary schools receive high volumes of pupils transferring in each year – sometimes not in a timely way. However, not all pupils have a CP record, in addition to their academic ‘school’ record, so it should be feasible for this smaller number of records to at least be known to the CP Lead in a school. 13.10 The issue is also a potential vulnerability within CSC and or MASH systems for processing referrals through the front door, in the context of a service which receives roughly 8,000 contacts/referrals per year. At times of high incoming work, there will inevitably have to be some prioritisation in terms of which referrals are subjected to the most complete background research. The process of selection, again inevitably, is likely to focus on those with the higher immediate presenting need. A high volume of referrals is a continuous reality in Greenwich and this, in combination with the movement of families across and between authority areas, makes for complex on the spot decision-making. What are the implications for the reliability of the multi-agency Child Protection system? 13.11 There are a number of inherent challenges for agencies in retaining an awareness of longstanding and complex family histories. It may prove even harder in families where sexual abuse of children is endemic, but remains largely secret. Achieving a better long-term awareness is not easy, but nor is it impossible, if the importance of the history is understood, and the records are accessible. 13.12 This case has shown how a known past history of abuse can go unnoticed over time, and how the ongoing vulnerability of a child can remain hidden. The implications are that the risks of various kinds of behaviour – including self-harm or abuse towards others – are poorly understood and left unaddressed. 29 Finding 2: Is there a tendency for professionals, especially when under pressure, to react only to immediate safeguarding concerns, risking the invisibility to the system of vulnerabilities due to historical abuse? An initial assessment of risk is key to determining what happens next in terms of levels of professional support and/or statutory intervention. In pressurised conditions, this assessment can become a binary decision: is this child at immediate risk of harm, or not? Clearly, there are shades of vulnerability in between these – for example, the presence of ongoing emotional support needs resulting from prior experiences of abuse. These needs not only impact on a young person’s current wellbeing, but also make them vulnerable to more serious harm in the future. An effective assessment and ‘triage’ system should be able to identify and respond to these intermediate levels of need, for example by advising referral to higher or lower tier services as appropriate. Where this does not occur, young people with longstanding vulnerability, but not immediately high levels of risk, may not receive the support they need to prevent worsening need and protect them from more serious harm. Questions and considerations for the Board - Does the Board recognise this finding to have been an issue at the time? Is still an issue? - Have there been any previous efforts to tackle it and how assured is the Board that these have been effective? - How might the CP element of records held by schools be made more accessible and their transfer more timely? - How might schools assure themselves that pupils’ CP records have been reviewed/, the implications of their content understood and that the necessary communication has taken place with other professionals? - How can schools develop systems for achieving this, especially when senior managers change? - Are current arrangements for triage of incoming CSC referrals fit for purpose in the context of this finding? 14. Finding 3: Is the process for oversight of CSC referral and response robust enough to predict and offset the likelihood and impact of human error in data recording? 14.1 It is inevitable and therefore predictable that people will make the odd error when inputting data into a database, particularly when the task is so routine that concentration lapses and/or when otherwise distracted or under pressure. This human susceptibility is not such a problem if organisations have mechanisms in place to be able to detect errors in a timely way. 30 How did the issue feature in this particular case? 14.2 The letter from Lewisham informing Greenwich that T was moving back into the borough contained two surnames for T, clearly designated as such. The administrator logging the details onto the CSC electronic record noted one surname only. Led by this, the manager did not identify that there was a duplicate record, although the Lewisham letter made it clear that the family were previously known to Greenwich. This meant that the existing extensive personal and family records for T were not linked to the new referral. The agreed process is that all names should be checked. 14.3 When the CP referrals were received from the police and the school in June 2013, following an attack on T by her young uncle, T’s family history was again not flagged up on the system. This time, the Duty Manager did query this gap, since the referrals mentioned a history of abuse. She determined to follow this up with Lewisham. The relevant records were found, in Greenwich, after T’s death. How do we know it is not peculiar to this case? 14.4 This Finding is expressed as indicative because we do not have the firm evidence to point to other examples of errors being made, both in the specific context of the CSC front door or in equivalent triage settings within health, education, police or other organisations. It is named because it can be evidenced in this case and because of the likelihood of its occurrence elsewhere. 14.5 It is also possible that the management oversight of work at the point of entry can be affected by the manner in which a referral is made. There are different processes for responding to referrals depending on whether they are made by telephone or in writing. Had a telephone referral been made (in addition to the written referral) by the school, it would have been responded to by a social worker on the same day. There are more social workers to pick up telephone referrals or people calling into the office than there are managers to handle the volume of written notifications and written referrals. There is potential for a busy manager receiving a high volume of incoming notifications and written referrals not to notice if the detail in the referral does not quite match what has been recorded on the electronic system. 14.6 The Review Team were told about why a written referral may be preferred to a telephone conversation, although it is important to stress that this factor was not an issue in this case. Multi-agency colleagues in the Case Group spoke about their common difficulty when trying to make a referral to Greenwich CSC via the front-door contact centre. Frequently, their attempts failed. The telephone line is significantly over-busy, and, in their experience, it is not unusual for a call to be cut off after waiting for some time to be connected to the relevant team. This creates a potential barrier for multi- 31 agency working at the critical point of referral and makes it more rather than less likely that a referral will end up being made in writing. The Council collect data about the efficiency of their front-door telephone system, and these are generally positive; however, this conflicts with the ‘lived experience’ of those who took part in this case review (including the results of recent ‘mystery shopping’). 14.7 The CSC Consultation Line, in contrast, provides straightforward access to this service, and is very well used by multi-agency partners. The fact that it was not known to key staff in the school in this case (Pastoral Manager and Counsellor) suggests that more work is needed to promote and maintain awareness of the service. 14.8 Informally and outside agreed procedures, an administrator will sometimes immediately alert a busy Team leader to a written referral that they feel needs immediate attention, but this cannot be relied upon. It is more likely that ‘informal’ processes will be resorted to at times of high pressure/high demand and more necessary therefore that there is sufficient management oversight to pick up any errors of judgement and/or recording resulting from this approach. What numbers of cases are affected, and how widespread is the pattern: local, regional, national? 14.9 It is widely known that databases are only as good as the data you put in them. This is true for electronic systems in use across agencies and services around the country. 14.10 The majority if not all contacts and referrals are uploaded onto electronic systems now in every public-facing organisation. The likelihood that an uploading error will at times be made, combined with the probability of distraction under different types of pressure – time, volume, task, personal – is a challenge for the system. What are the implications for the reliability of the multi-agency Child Protection system? 14.11 A combination of a predictable human error in uploading data, and a lack of rigour in interrogating databases, means that important information about children is not always retrieved. The consequence of errors in these early steps is that critical information about a child or family remains unavailable for making appropriate responses to their needs and risks. Errors are more likely to be made when people are working under high pressure. The capacity of management to monitor contacts/referrals, especially when these are written rather than verbal, is a critical factor in ensuring accuracy and timeliness in picking up urgent child protection concerns. 32 Finding 3: Is the process for oversight of CSC referral and response robust enough to predict and offset the likely impact of high volumes of incoming work and to be able to consistently pick up predictable human error? Human error is entirely predictable in the context of data-inputting, and electronic systems are designed in ways to make them more or less proficient in helping to reduce its likelihood. Error is also more likely at times when volume of work is particularly high. Both these factors are intrinsic to ‘front door processes’ for receiving referrals and as such, the management oversight of the process should be able to a) predict how errors may happen; b) expect that they are more likely when the system is under pressure; and c) contingency-plan different means by which incoming work can be overseen so that the consequence of an error made at this early stage does not then impact unnecessarily on professional assessment and decision-making. Questions and issues for the Board and member agencies to consider - Does the Board recognise this as a real or potential issue, in relation to CSC first response processes and more widely? - What kind of oversight is routinely provided in relation to administrative functions at the front door? - Is the Board assured that these work well enough when the ‘system’ is under pressure? - What might be getting in the way of effectively addressing the issue? - How might the Board be assured that the issue has been addressed? 15. Learning additional to the Findings 15.1 Support for staff after a tragic incident The brave participation of staff in this case review, so soon after the death of Child T, made the Review Team acutely aware of the impact it had had on many individuals, in various settings. 15.2 School staff inevitably had the most difficult experience, especially since T’s suicide happened on the school site, and her farewell letters were addressed to the people she knew there. We learned that the school had arranged for the offer of immediate and ongoing counselling support from an independent source, which was undoubtedly a compassionate and appropriate action. This was made available to pupils and staff in all areas of the school, and several types of counselling were offered, bespoke to the needs of staff. For example, a religious counsellor was offered to a member of staff with strong religious beliefs. What we found surprising was that, of the six members of the Case Group who took part in conversations and the Workshop Day, none 33 had used this service. And yet, there was evidence of the ways in which T’s death continued to trouble and affect them. 15.3 This led us to thinking about a different approach, which ensured that agency leaders and staff would ‘model’ the use of a counselling service, so that it became an expected way to respond. Through a member of the Review Team, we heard about how an emergency fire service has a regular structure in place for debriefing fire officers after an incident, both in a group and as individuals. It is expected that the group will participate in this. 15.4 The Review Team also learned that, in other non-school settings, even where there had been little or no personal contact with Child T, some professionals experienced considerable shock and upset about what had happened, and anxiety about how well they had carried out their professional task and whether they would be blamed in any way. We found that the needs of these less involved staff had not been recognised and some had been left without support or advice. 16.5 Can the GSCB assist in any way – by helping agencies to: avoid assumptions about who will need support/help; think about the needs of ‘leaders’ and senior managers, who may feel they have to be ‘strong’ for others, and who may not get enough help themselves for their own recovery; and ensure there is pro-active support for the agencies most clearly and directly affected, with the expectation that staff will access help? 16. Conclusion 16.1 All Serious Case Reviews are required to report and learn from what happened in a particular child or family’s story. This systems review has also tried to move beyond what happened to Child T, in order to analyse how well Greenwich safeguarding systems are working more generally, and how they might be improved. 16.2 The principal learning from this review has focused on the issues of working with children and adolescents who deliberately self-harm. This work poses complex challenges for the wide range of professionals involved with these young people, most of whom are not specialists in this field and who need considerable support and clear guidance in order to respond effectively. 16.3 The incidence of DSH continues to grow locally and elsewhere, and the circumstances like those of Child T will inevitably be repeated – in a number of settings, but principally in secondary schools. It is hoped that the GSCB will find this review useful in considering ways to support multi-agency collaboration in this complex and distressing area of work, especially for school colleagues. 34 16.4 The story of Child T remains at the heart of this Serious Case Review. It became clear after her death, from the messages that she left, that she was no longer able to carry on living, and that she was determined to keep the intention of suicide secret from her family and from the school staff who knew her best. She was effective in this, in that professionals and family members alike have spoken of ‘a huge shock when T died’. 16.5 It has not been possible to conclude that T’s death was preventable. There were missed opportunities which could have led to a more coordinated effort to evaluate further risk of self-harm. This in turn may have enabled a more informed and joint effort to manage Child T’s growing distress which could have helped to keep her safer. However, this too is only a hypothesis, born of the wishes of hindsight. We can point to what other appropriate help might have been offered to T, but we cannot with any certainty say that the outcome would have been different. 35 References Best, R. (2005) Self-harm: A Challenge for Pastoral Care. Pastoral Care in Education, 23 (3), 3-11 Child and Adolescent Self-harm in Europe (CASE) study, 2005 Childline helpline statistics, 15/11/13 Community Care, “Community Care survey exposes how rising thresholds are leaving children in danger”, 20th November 2013 Fish, S., Munro, E., Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009 Higgins, C., ‘The Road Home’, The Guardian, 30th November 2013 London Child Protection Procedures, London Safeguarding Children Board, 2010 NICE, CG16, Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care, 2004 NICE, CG16 (as above), Quick Reference Guide, 2012 NSPCC, How Safe Are Our Children?, 2013 NSPCC, Young people who self-harm: Implications for public health practitioners, March 2009 SCIE Research briefing 16: Deliberate self-harm (DSH) among children and adolescents: who is at risk and how is it recognised?, 2005 Working Together to Safeguard Children, Department for Education, 2013 36 Appendix 1 Acronyms and Terminology ACAN Adolescents with Complex and Additional Needs Team (within Greenwich CAMHS) CG Case Group CAIT Child Abuse Investigation Team (Metropolitan Police) CAMHS Child and Adolescent Mental Health Services CASE study Child and Adolescent Self-harm in Europe study, completed in 2005. A 7-year international research project funded by the European Commission Daphne Programme and coordinated by the National Children’s Bureau. CP Child Protection ED Emergency Department (hospital) EIT Early Intervention Team (from CAMHS) GP General Practitioner/family doctor GSCB Greenwich Safeguarding Children Board HV Health Visitor LSCB Local Safeguarding Children’s Board LT Learning Together (model for case review) NSPCC National Society for the Prevention of Cruelty to Children PTSD Post-traumatic stress disorder SCIE Social Care Institute for Excellence SCR Serious Case Review SN School Nurse SW Social Worker RT Review Team TAMHS Targeted Mental Health Services for schools WT Working Together to Safeguard Children, 2013 National statutory guidance for multi-agency safeguarding children 37 Appendix 2 The Learning Together model and process of this SCR 1. This SCR has used the SCIE Learning Together (LT) model for case reviews. This is a ‘systems’ approach which provides a theory and method for understanding why good and poor practice occur, in order to identify effective supports and solutions that go beyond a single case. Initially used as a method for conducting accident investigations in other high risk areas of work, such as aviation, it was taken up in Health agencies, and from 2006, was developed for use in case reviews of multi-agency safeguarding and CP work (Munro, 2005; Fish et al, 2009). National guidance in the 2013 revision of Working Together to Safeguard Children (2013) now requires LSCBs to use systems principles in carrying out SCRs. 2. The LT model is distinctive in its approach to understanding professional practice in context; it does this by identifying the factors in the system that influence the nature and quality of work with families. Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively. 3. LT is a multi-agency model, which enables the safeguarding work of all agencies to be reviewed and analysed in a partnership context. Thus, many of the findings relate to multi-agency working. However, some systems findings can and do emerge which relate to an individual agency. Where this is the case, the finding makes that explicit. 4. The basic principles – the ‘methodological heart’ – of the LT model – are described in summary form below: a. Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time (the ‘view from the tunnel’). What was influencing and guiding their work? b. Provide adequate explanations – appraise and explain decisions, actions, in-actions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it c. Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what bolsters and what hinders the reliability of the multi-agency CP system. d. Produce findings and questions for the Board to consider. Pre-set recommendations may be suitable for problems for which the solutions are known, but are less helpful for puzzles that present more difficult conundrums. 38 e. Bonus principle: use of qualitative research techniques to underpin rigour and reliability. 5. Typology of underlying patterns 5.1 To identify the findings, the Review Team has used the SCIE typology of underlying patterns of interaction in the way that local CP systems are functioning. Do they support good quality work or make it less likely that individual professionals and their agencies can work together effectively? They are presented in six broad categories of underlying issues: 1. Multi-agency working in response to incidents and crises 2. Multi-agency working in longer term work 3. Human reasoning: cognitive and emotional biases 4. Family – Professional interaction 5. Tools 6. Management systems Each finding is listed under the appropriate category, although some could potentially fit under more than one category. 5.2 Anatomy of a finding For each finding, the report is structured to present a clear account of: How the issue features in the particular case? In what way it is an underlying issue – not a quirk of the particular individuals involved and in the particular constellation of the case? What information is there about how widespread a problem this is perceived to be locally, or data about its prevalence nationally? How the issue is usefully framed for the LSCB to consider relative to their aims and responsibilities, the risk and reliability of multi-agency systems. This is illustrated below in the Anatomy of a LT finding. |
NC52424 | Death of a child in June 2018 due to significant non-accidental injuries. The stepfather was found guilty of the murder of Child LS, the mother was found guilty of causing/allowing their death, and both parents were found guilty of multiple counts of child cruelty. Issues include: that an early help intervention may have provided support to mother and her children, as there were indications that mother was struggling to cope; Child LS's personal circumstances and developmental issues meant that there should not have been a gap in their nursery education; whether or not any professional intervention could have prevented the injuries to LS. Recommendations include: review training provided to agencies regarding the thresholds for early help, and ensure that agencies are aware of their responsibilities to apply thresholds correctly; the local authority ensures that funded nursery provision is promoted and encouraged, particularly for families with vulnerable children; remind agencies of the need to include the voice of the child when recording information.
| Title: Serious case review: Child LS. LSCB: Sandwell Safeguarding Children Board Author: Stephen Ashley Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Sandwell Safeguarding Children Board Serious Case Review Child LS Lead Reviewer: Stephen Ashley 2 Table of contents SECTION ONE – INTRODUCTION 3 1.1What this review is about 3 1.2 Why this review was conducted 3 1.3 How this review was conducted 4 1.3.1 The Review Panel 4 1.3.2 The Terms of Reference 4 1.4 Methodology 5 1.4.1 Chronologies 5 1.4.2 Learning Event 6 1.4.3 Family Engagement 6 1.4.4 Parallel Investigations 6 1.5 How this report has been structured 6 1.6 Key individuals 6 SECTION TWO – THE STORY OF CHILD LS 7 2.1 Introduction 7 2.2 What was the world like for LS? 7 2.3 The background of LS’s family 7 2.4 LS’s Story 8 SECTION THREE – ANALYSIS OF SIGNIFICANT ISSUES 11 3.1 Introduction 11 3.2 Significant Issues 11 3.2.1 Significant issue one 11 3.2.2 Significant issue two 13 3.2.3 Significant issue three 13 SECTION FIVE – VOICE OF THE CHILD 14 SECTION SIX – KEY FINDINGS 15 SECTION SEVEN – RECOMMENDATIONS 15 3 Section One – Introduction 1.1 What this review is about This serious case review concerns a child known for the purpose of this review as LS. Sandwell Safeguarding Children Board (SSCB) agreed this case met the criteria laid down in Working Together to Safeguard Children 2015 for a serious case review to be conducted. The serious case review was commissioned under the auspices of the previous Safeguarding Children Board and complied with Working Together 2015. Safeguarding Children Boards were abolished as a result of updates to the Children and Social Work Act in 2017 which led to changes to all local safeguarding structures. The review was completed in March 2019 however was transferred to the new multi-agency safeguarding arrangements of Sandwell Children’s Safeguarding Partnership following its inception in April 2019 for ratification and publication. All subsequent references to legislation refer to the guidance and structure that were in place at the time of initiation of this review in 2018, which was under the jurisdiction of the Safeguarding Children Board and Working Together 2015. The brief circumstances of this case are as follows: LS was born in 2015. LS had two older siblings and one younger sibling. LS lived at home with Mother, Stepfather and siblings, with LS’s Father having limited contact. LS had no contact with agencies other than ‘universal’ services and some contacts with medical professionals that were not regarded as out of the ordinary. LS and the younger sibling had been seen by health visitors two months before his death and by a specialist nurse practitioner on the day the fatal injuries occurred. No concerns were raised about LS’ condition or treatment. In June 2018 LS was taken to the urgent care walk-in centre by his Mother suffering from vomiting. LS was thoroughly examined by the specialist nurse practitioner and diagnosed with a stomach upset. LS showed no signs of distress and there was no evidence of any visible injuries. LS returned home with Mother who left LS in the care of Stepfather whilst she collected LS’s siblings from school. When LS’s Mother returned, LS was found to be unresponsive. An ambulance was called and LS was taken to hospital where he sadly died. A post-mortem revealed that the cause of LS’s death was significant injuries that were non-accidental and a police investigation was initiated. The siblings of LS were taken into the care of the local authority where they remain. 1.2 Why this review was conducted The Independent Chair of the SSCB agreed with a recommendation of the Serious Case Review Panel that this case should be the subject of a serious case review; under the requirements of the Local Safeguarding Boards Regulations 2006, section 5(1) (e) and (2). The statutory basis for conducting a serious case review (SCR) and the role and function of a Local Safeguarding Children Board is set out in law by: The Local Safeguarding Children Board Regulations 2006, Statutory Instrument 2006/90. Regulation 5 requires the Local Safeguarding Children Board (LSCB) to undertake a review where – 4 (a) abuse or neglect of a child is known or suspected; and (b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Guidance for Local Safeguarding Children Boards (LSCBs) conducting a serious case review (SCR) is contained in Chapter 4 of Working Together to Safeguard Children 2015 [referred to as Working Together]. This version of Working Together was used when deciding upon the serious case review process, as it was the most current at the time decisions were taken around the review process (published in March 2015). The purpose of this serious case review is to establish the role of services and their effectiveness in the care of LS, whether information was fully shared by the professionals involved and child protection procedures were appropriately followed. This process ensures that any deficiencies in services can be identified and lessons learned, to minimise the risk to other children or young people. 1.3 How this review was conducted 1.3.1 The Review Panel The lead reviewer/author was Stephen Ashley who has extensive experience in the compilation of high-level reports into child protection issues, having been a senior police officer for thirty years and worked for Her Majesty’s Inspectorate of Constabulary. He has conducted several serious case reviews and is the independent chair of two safeguarding children boards. The lead reviewer is independent of Sandwell Safeguarding Children Board in accordance with Working Together to Safeguard Children 2015 chapter 4 (10). In addition, a review panel was established. Meetings were held at regular intervals and the panel was consulted about the progress of the review and provided further information where appropriate. The panel included a senior manager from each of the key agencies. The Sandwell Safeguarding Children Board (SSCB) business unit supported the panel. 1.3.2 The Terms of Reference This SCR has been conducted using a methodology adapted to suit the circumstances of this review and is described in more detail in the next section. The methodology established how well systems have worked, and where they can be improved. It is not a criminal or disciplinary review designed to attach blame to individuals. The review covers the period from May 2014, the point at which LS’s Mother reported her pregnancy, to June 2018 when LS was taken to hospital with significant injuries. This period was selected following a Serious Case Review Panel meeting and is of a sufficient range to include all of the engagement that LS had with agencies in Sandwell (both pre and post birth). Whilst this period was the basis for the review, contextual and relevant information falling outside of this period was also included. 5 The review was conducted in a way which: • recognised the complex circumstances in which professionals work together to safeguard children, • sought to understand precisely who did what, and the underlying reasons that led individuals and organisations to act as they did, • sought to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight, • was transparent in the way data is collected and analysed, • made use of relevant research and case evidence to inform the findings. Agencies that are involved in child safeguarding are required to follow the statutory guidance laid down by government. The guidance is called Working Together to Safeguard Children. It contains all the processes that agencies are required to follow. Working Together has been through several iterations. This review benchmarks against the statutory guidance contained in Working Together to Safeguard Children 20151. This is the version that professionals would be working to during the timeframe of this case. The review worked to terms of reference agreed with the Chair of the SSCB. The author took full cognisance of the annual reports of the national panel of independent experts on serious case reviews. 1.4 Methodology The methodology agreed by the Sandwell Safeguarding Children Board (SSCB) review panel is based on a model consistent with the requirements of Working Together 2015. It ensures that: • a proportionate approach is taken to the SCR, • it is independently led, • professionals who were directly involved with the case are fully engaged with the review process, • families are invited to contribute. As the review was being undertaken it became clear that the police investigation and any subsequent criminal proceedings would take a considerable time. The relevant information required to complete the review was completed in 2019 under the previous structure of the SSCB and the report was ratified in 2020 by the SCSP. In line with guidance, it was agreed with the National Panel for the review to be embargoed until the criminal proceedings concluded. This has now taken place and additions have been made to this report only regarding the outcome of the trial. 1.4.1 Chronologies Agencies were asked to compile a report detailing their contacts with the individual involved in this case, resulting in a combined chronology of events. In addition, each agency was asked 1 Working Together March 2015 - https://www.gov.uk/government/.../working-together-to-safeguard-children--2 6 to highlight areas of concern and good practice. Where appropriate, an action plan, detailing those areas for improvement, and the work being undertaken to address those issues, was included. 1.4.2 Learning Event A learning event has not been conducted in this case. Contact with professionals was limited at the request of West Midlands Police. The senior investigating officer conducting the police investigation determined that a learning event may prejudice any future trial process and so would not be conducted. Given the time frame it was determined that a learning event would not assist the review in this case. 1.4.3 Family Engagement It would be best practice to seek the views of the family involved in the case, however this was not possible due to the ongoing police investigation. Following the conclusion of the trial, birth Father has been informed of the publication of this SCR. 1.4.4 Parallel Investigations A criminal investigation into the circumstances of LS’s death was launched immediately in June 2018, with charges brought against Mother and Stepfather in March 2021 for murder and child cruelty. Both defendants entered ‘not guilty’ pleas and stood trial between November 2021 and April 2022 when verdicts were reached. Stepfather was found guilty of the murder of LS and three counts of child cruelty, and Mother was found guilty of causing/allowing the death of LS and three counts of child cruelty. Both were sentenced in May 2022: Stepfather received life imprisonment with a minimum term of 24 years, and Mother received 11 years imprisonment. 1.5 How this report has been structured Following the introduction, section two provides a history of the subjects involved in this review and is the story of what happened to LS over the timeframe agreed within the terms of reference. It provides a synopsis and tries to paint a picture of the world into which LS was born, and the living circumstances during this period. Where an event or issue has proved to be significant, it is highlighted, and any pertinent questions are raised at that point. These areas of significance are analysed in greater depth in section three. Section three analyses the significant issues exposed in section two and explains WHAT happened and WHY. From this analysis, the key themes are discussed in section four and the voice of the child in section five. Section six contains the key findings. The recommendations in section seven have been developed from these findings taking account of the work carried out by agencies since these events occurred. This report has been written so that it can be read by the public without redaction. As a result, the names of the main subjects are not used and there are no dates that might readily identify any members of this family. 1.6 Key individuals PERSON RELATIONSHIP LS Subject of this review F1 Mother of LS 7 S1 Sibling 1 S2 Sibling 2 S3 Sibling 3 M1 Father of LS M2 Stepfather of LS, partner of F1 GM Maternal grandmother of LS Section Two – The Story of Child LS 2.1 Introduction This section follows the story of LS over the review period. Those events of significance are highlighted and examined in greater depth in section three. This section begins with a pen picture of the world that LS was born into and the background of this family. It is intended to provide a degree of context around the circumstances in which LS and this family were living. Finally, this section contains a chronological story of the events of LS’s life. 2.2 What was the world like for LS? When LS was born, together with Mother, he initially resided with maternal Grandmother. LS’s Father was estranged from Mother and whilst they had some contact, Mother stated that Father had not seen LS “for some time” at the time of this death. LS’s Father did attend the hospital at the time of LS’s death. At some point LS moved with F1 and siblings in to a first floor flat with F1’s new partner. Whilst the flat was described as “cluttered” by professionals, the conditions did not cause concern to midwives or health visitors. LS was always taken for appointments with health professionals and received treatment for some minor ailments such as nappy rash. In April 2018 LS was seen by a health visitor who was visiting F1 and S3 and took the opportunity to examine LS. Whilst there were some concerns around the development of LS’s speech, he was described as “a happy little boy who was very sociable. He was seen engaging with family members, was well dressed and eating a breakfast bar”. The evidence is that LS was well cared for and was sociable and happy. 2.3 The background of LS’s family F1 gave birth to two children prior to the birth of LS in 2015. Whilst F1 refused to name LS’s father, there was an initial assumption that M1 was the father of all 3 children. It is now known that this is not the case though M1 is known to be the father of LS. F1 had no criminal convictions but was a user of cannabis. F1 stated she used cannabis on a daily basis to: “cope with life”. F1 did not report any domestic abuse against her and had not been engaged with services except those universal services that might be expected. M2 had convictions for drugs offences and it is believed he has a child but does not have contact with that child. 8 There are no reports that F1 suffered any form of domestic abuse by M1 or M2. Professionals dealing with F1 and her children were unaware of any history of M1 and M2. F1 gave birth to her first child at 17 years old. There are no reports that S1 required any care other than the universal services that were offered. S1 developed normally and when F1 gave birth to a second child, there were no issues with development and no professionals raised concerns about either child. In 2012 there was a referral to Children’s Social Care by S1’s school when F1 failed to collect S1 from school. A friend of F1 contacted the school to advise them that F1 had overslept. F1 later collected S1 from school. The school did not report any safeguarding concerns regarding the family, and this appears to have been a one-off incident. The school informed F1 they had made the referral and stated they would monitor the situation moving forward. Children’s Services decided there was no requirement for further intervention and closed the case. In summary, F1 had never had any interventions by agencies other than the universal services that might be expected. F1 had given birth to two children and had attended appointments. No professionals had raised any concerns regarding the way in which S1 and S2 were cared for. The one exception to this being a referral to Children’s Social Care when F1 attended late to pick up S1 from school. At that time there was no evidence of any safeguarding concerns. 2.4 LS’s Story F1 attended her general practitioner (GP) in July 2014 and provided a positive pregnancy test. Whilst she was reporting her pregnancy relatively late, she stated that she was superstitious having had two previous miscarriages. F1 was seen for the usual antenatal appointments and was in receipt of ‘universal’ services. F1 said that she had good family support but rarely saw the father of the child. Whilst F1 made regular visits to the GP with her other children, regarding usual childhood illnesses, there was nothing unusual reported by professionals throughout the pregnancy. F1 gave birth to LS in 2015 and there were no unusual circumstances or concerns raised. F1 was discharged to GM’s address. F1 and LS were referred to the health visiting service under the category of ‘universal’ services. Shortly after the birth LS and F1 were visited at GM’s home by a health visitor. Usual advice was given including safer sleeping advice and information regarding immunisations. F1 reported that LS slept in her bed due to a shortage of space. F1 stated that she would only be staying at GM’s home on a temporary basis. Shortly afterwards, F1 attended a baby clinic where advice was given about a nappy rash and F1 provided her new address. F1 registered with her new GP. When LS was 3 months old F1 attended another clinic and advice was given regarding an umbilical hernia. F1 and LS attended baby clinics on a regular basis and there were no issues reported as LS progressed normally. F1 took LS to the GP on two occasions suffering from nappy rash and a cough, and he was described as: “well, comfortable and alert”. LS was described by the GP as: “a lovely, plump and happy baby”, who was laughing with the GP and sibling. 9 When seen aged 5 months at baby clinic LS was found to be progressing normally and was at normal weight. Throughout the remainder of 2015 F1 continued to be seen regularly by health professionals. LS did have some minor childhood illnesses (coughs and nappy rash), including two GP attendances when LS was described as “wheezy” and having a high temperature. LS was reported by the GP to be: “well, active, happy and smiling”. At the age of 10 months LS was admitted to hospital overnight for observations having attended both the GP and emergency department with a respiratory infection. One sibling was seeing professionals with regard to speech difficulties, and the other sibling was being seen by health professionals regarding behavioural concerns. A health visitor undertook LS’s ‘9-12-month development review’ during a home visit in 2016. The health visitor summarised the visit in the following terms: “mostly normal development, milestones strategies given to [F1] to increase [LS’s] confidence for walking skills and reduce time in baby walker”. LS received all immunisations in the prescribed times and progressed normally. In 2016 following a disclosure made by S1 an Early Help referral2 was made by school to Children’s Social Care who, after discussion, considered that no further action was required and closed the case with a note that: “School to continue to monitor then follow up with Child Protection procedures (MARF) if further disclosures made and there is a need for statutory intervention”. In autumn 2016 LS was taken to the emergency department suffering from a minor head injury and a week later was taken to the GP suffering from sickness and diarrhoea and was seen by the nurse practitioner. Nothing significant arose from these two visits. In 2017 during the 2-year developmental review, it was noted that LS was not reaching some expected areas of development and had some speech and language difficulties similar to the older sibling. A follow-up developmental check was agreed, and an appointment arranged for two and a half months later. Over the next two months F1 and LS began to miss appointments and did not present for the development check follow-up appointment. No explanation was given for this. F1 brought LS for the developmental check aged two and a half and he was found to be progressing satisfactorily. The reason for missed appointments was not explored. In summer 2017 F1 was pregnant. F1 missed a number of appointments including LS’s parents’ evening and a parents’ lunch club. Nursery conducted a WellComm screening, an assessment on communication and language. LS’s progress was reported as ‘red’ meaning a child not reaching the expected developmental milestone according to their age. When F1 attended nursery, she said that she did not have time to discuss the issue. By autumn 2017 F1 had failed to attend a number of appointments at LS’s nursery for lunch clubs, parents’ evenings and workshops. In early 2018 F1 gave birth. Shortly afterwards, a health visitor attended F1’s home to conduct a new birth visit. F1 reported that she had the support of her Mother and Sister and that for 3 Early Help - is an approach to working with children and families who are below the threshold of social care intervention but require a multi-agency approach that stops problems emerging and supports families to improve their situation. 10 reasons that she did not disclose, LS was being cared for by grandparents. There was no indication as to whether this was a short-term placement. The health visitor was concerned at the lack of support but reported that the home was: “acceptable, clean and warm but the furniture was worn and tired”. The health visitor also reported that: “[ F1] was very cheerful and felt well obstetrically. It was also noted that children were very polite and mother was clear with her boundaries”. At the time of this visit S1 and S2 were present and F1 explained that the school had allowed her to keep the children at home because she would have transport problems in the bad weather conditions. This was confirmed by professionals at the school. In March 2018 LS’s nursery place was terminated due to funding issues. F1 was seeking alternative funding but there was no nursery provision for LS while this situation was being resolved. It is documented in LS's record that LS was seen opportunistically by the health visitor during a routine home visit to see S3 for the ‘’6-8-week check” in 2018. All of the children were present. It is recorded that F1 was bonding well with S3 and states that F1 was: “looking at [S1] lovingly”. LS was described as: “happy and sociable, engaging with family members”. It is recorded that LS was: “well dressed and eating a breakfast bar”. It was recorded that LS was engaging with F1. The health visitor recorded that LS’s speech was not clear, but F1 was reluctant to initiate speech and language therapy as LS could be understood by family members. F1 stated she was supported by family members including her siblings, parents and other family members. F1 was asked routine questions about domestic violence and FGM but stated that she was not affected by either. It was also reported that she had: “'No previous mental health concerns in the past nor at this present time”. On the day LS died F1 took LS to the urgent care walk-in centre with a history of vomiting on and off for 5 days. LS was seen by the specialist nurse practitioner. It is recorded that on examination LS was alert and aware. It is documented that: “[LS’s] temperature was 36.7 (normal), blood sugar was 4.8, chest clear, ENT clear, no rash, no headache, no abdomen pain. Abdomen described as soft with no guarding or rebound. No indication of appendicitis or acute abdominal problems. No red flag issues. [LS] recording as drinking and passing urine. Documented that [LS] was safety netted. Diagnosed viral gastroenteritis”. At the appointment F1 was advised by the specialist nurse practitioner that: “If no improvement to attend A and E. Prescribed dioralyte sachets”. F1 returned home with LS who was left in the care of M2 whilst she went to pick up S1 and S2 from school. Significant Issue one F1 did not seek help but there were signs she may have been struggling to cope. An Early Help intervention may have provided support to F1 and the children. Significant Issue two Given F1’s personal circumstances and the developmental issues faced by LS, there should not have been a gap in the nursery education. 11 When F1 returned to her home she found LS in an unresponsive state and an ambulance was called. LS was taken to hospital but was sadly deceased. A post-mortem revealed that LS had suffered blunt force injuries including: three broken ribs; front and rear bruising to the head; damage to the top lip and tooth; significant internal injuries to the abdomen and liver and bowel. These were non-accidental injuries and M2 was subsequently found guilty of LS’s murder and F1 of causing/allowing the death. Section Three – Analysis of Significant Issues 3.1 Introduction This section provides further depth and analysis to the significant issues that have been identified in section two. Where appropriate it provides the basis for the key findings in section six and recommendations in section seven. 3.2 Significant Issues 3.2.1 Significant issue one F1 did not seek help but there were signs she may have been struggling to cope. An Early Help intervention may have provided support to F1 and the children. F1 had two children prior to the birth of LS. The contacts that agencies recorded as having had with her do not reveal anything particularly unusual. S1 and S2 did have various issues that required some intervention. S1 had issues with speech and development and S2 had some behavioural issues. However, F1 attended appointments and sought help. Whilst F1 was caring for her children alone, she reported having support from grandparents, siblings and other family members. F1 never reported being the subject of domestic abuse even when asked during a routine health appointment. F1 regularly used cannabis but professionals were previously unaware of this information that has only come to light since the death of LS. F1 had never reported suffering from any particular health or mental health issues. When LS was born there was nothing evident that caused any concern to health professionals. Whilst LS did have some developmental issues these were being addressed by F1 and appropriate professionals. In 2016 an Early Help referral was made by school regarding S1 which was investigated by Children’s Social Care, but the case was closed with an expectation that the school would report further concerns if they arose. This was not an unreasonable course of action: this was Significant Issue three Following the death of LS, a lengthy police investigation commenced and the focus of that investigation was the timeline from when LS was seen alive and well at the urgent care walk-in centre and the discovery that LS was seriously injured. Was there any professional intervention at that time that could have prevented the catastrophic injuries to LS? 12 the first occasion the school had registered any concerns other than the one occasion where F1 was late to collect S1 from school. These factors resulted in the case being closed. However, by spring 2017 professionals began to see a change in the interaction they had with F1. Whereas F1 had previously kept appointments and interacted with professionals, over a period of two months F1 stopped attending important engagements. Over a 5-month period in mid-2017 F1 missed 12 appointments. These included LS’s parent’s evening and an opportunity to discuss LS’s developmental issues. In the summer of 2017 F1 was pregnant. At this point it seems she and the children may have benefitted from an Early Help intervention. This would have provided opportunities for agencies to engage with F1 and provide her with support. When F1 had given birth to S3 she stated that she had been allowed by the school to keep her children at home for a week because she would be unable to get them to and from school in the bad weather, having just given birth. When LS and S3 were born, health visitors expressed concern that F1 did not receive sufficient support but were reassured by F1 who stated she had sufficient help and support from friends and family. Furthermore, in March 2018 LS was not at nursery because funding had not been made available or arranged by F1. This may have been another sign that F1 was having some difficulty in coping. The Local Safeguarding Children Board is responsible for a threshold document that determines the level of care provided to families. There are differing levels and professionals are provided with a matrix to help them judge at what level a family may require an intervention. In this case it may have been determined that F1 and her family required a ‘Universal Plus’ level of service. This is defined as: “...needing some additional support without which they would be at risk of not meeting their full potential. Their identified needs may relate to their health, educational, or social development, and are likely to be short term needs. If ignored these issues may develop into more worrying concerns for the child or young person. These children will be living in greater adversity than most other children or have a greater degree of vulnerability than most if their needs are not clear, not known or not being met and multi-agency intervention is required, a lead professional will be identified to coordinate a plan around the child.” The following are some of the risk factors that apply under the requirement for Universal Plus services that would have applied to F1 and her children: • Requiring support to provide consistent care e.g. safe and appropriate childcare arrangements; safe and hygienic home conditions; adequate diet. • Poor engagement with universal services likely to impact on child’s health or development. • Parents/carers have had additional support to care for previous child/young person. • Parent requires advice on parenting issues. • Lack of response to concerns raised about child’s welfare. • Parents/Carers request advice to manage their child’s behaviour. • Some support from family/ friends. • Large family with multiple young children. • Families affected by low income/living with poverty affecting access to appropriate services to meet child’s additional needs. • Adequate universal resources but family may require help. • The child’s current rate of progress is inadequate despite receiving appropriate support and are not thought to be reaching educational potential. • Slow in reaching developmental milestones. 13 • Not attending routine appointments e.g. developmental checks. • Missing set appointments across health including antenatal, hospital and GP appointments. • Is susceptible to minor health problems. • Behavioural difficulties requiring further investigation/diagnosis.” The threshold document states: “...that in these circumstances an Early Help Note should be completed to capture and record needs. If at any time the outcome indicates a need for multi-agency services, an Early Help Assessment should be completed with consent and in collaboration with family/child/young person. Complete assessment on the Early Help System to request a Team Around Family (TAF) Meeting/Forward EH1 form to MASH Early Help Desk. A Lead Professional will be responsible for coordination of the episode. Reviews to take place at least 3 monthly.” The point of note is that to access Early Help F1 would have had to have provided consent. The evidence is that F1 had demonstrated on a number of occasions that she preferred to keep her family issues within her own control. It is reasonable to assume that F1 would have been unlikely to have accessed Early Help, and at no stage was there evidence to take child protection to a higher level. Conclusion: There were sufficient grounds for a health visitor and/or a teacher at S1 or S2’s school or LS’s nursery to have submitted an Early Help Note which they did not do. It is highly unlikely that an Early Help intervention would have affected the final outcome in this case. 3.2.2 Significant issue two Given F1’s personal circumstances and the developmental issues faced by LS there should not have been a gap in nursery education. At the end of March 2018 LS was no longer at nursery school. It seems that F1 had not arranged funding or funding was not available. The nursery noted that LS was due to return under Nursery Education Fund (NEF) plus funding when F1 had made the necessary arrangements. This required F1 to apply for a place under the Sandwell NEF scheme. It is unclear why the application was not made, but it resulted in LS being out of nursery. Whilst the responsibility for application was with F1 it is unfortunate that LS suffered a break in the continuity of nursery education. It should of course be noted that there is no legal requirement for a child of that age to attend nursery education. Summary: LS had a break in nursery education and professionals should ensure that the systems in place for families are easy to follow and reminders are made to ensure parents make applications for free nursery places in the required time. The fact that LS was not in nursery did not affect the final outcome in this case. 3.2.3 Significant issue three Following the death of LS, a lengthy police investigation commenced and the focus of that investigation was the timeline from when LS was seen alive and well at the urgent care walk-in centre and the discovery that LS was seriously injured. Was there any 14 professional intervention at that time that could have prevented the catastrophic injuries to LS? The most significant factor in this case remains the timeline over which LS received catastrophic injuries. LS and F1 visited the urgent care walk-in centre on the same morning of this death. F1 stated that LS had been vomiting sporadically for the previous 5 days and was unable to keep down any food. LS was examined by a nurse practitioner. This was reasonable and accepted practice. In fact, this had been the case on a previous occasion when F1 had taken LS to the urgent care walk-in centre with an upset stomach. The nurse practitioner conducted all of the expected tests. There was nothing to indicate that LS could be suffering from any of the injuries later found at the post-mortem. Police investigations included an examination of CCTV at the surgery. LS is seen to be active and showing no obvious signs of injury. LS engaged well with Mother and professionals. Later that afternoon LS was taken to hospital and found to have catastrophic injuries including a mouth injury and severe internal injuries and broken ribs. It is inconceivable that these injuries had been inflicted before the attendance at the urgent care walk-in centre with F1. The post-mortem found that there were some older injuries but a routine examination would not have found these. Summary: F1 took LS to the urgent care walk-in centre on the same morning of this death. LS was thoroughly examined and was not at that time suffering from the catastrophic injuries later found through the post-mortem examination. It is perhaps worth commenting on the length of time taken to complete the police investigation. The police investigation was complex and protracted. The medical evidence was a particular issue. In particular, there were very few medical experts in the field who were able to provide the required evidence in a timely manner due to the demands they faced. One example was finding a consultant who could give an expert opinion on injuries that involve damage to a child’s ribs. There is only one such person currently available nationally. Despite the complexity and length of the investigation, the outcome was the successful conviction of the person responsible for murdering LS. Section Five – Voice of the Child There is evidence that the voice of the children in this case was listened to. F1 took her children to the urgent care walk-in centre regularly and these visits were taken seriously. F1 reported that S1 had speech issues and S2 had behavioural difficulties. These were taken seriously, and appropriate referrals were made. When S1 complained of being assaulted by Father, a referral was correctly made, and the matter taken seriously. Similarly, LS was taken for checks and when seen by a midwife during the home visit for the younger sibling when the midwife also took the opportunity to speak with LS. Whilst there is evidence that the voice of the child was considered there is little evidence of it being recorded by professionals and this is an area for improvement. 15 Section Six – Key Findings The overall finding of this review is: Tragically, LS was murdered by Stepfather and Mother was found guilty of causing/allowing this death. Both Mother and Stepfather were also found guilty of multiple counts of child cruelty. LS received universal services from agencies. There were no missed opportunities for professionals to intervene and prevent the death of LS. Section Seven – Recommendations 1. The LSCB should review training provided to agencies, regarding the thresholds for Early Help, and ensure that agencies are aware of their responsibilities to apply thresholds correctly. 2. Sandwell Council should be asked by the LSCB to give assurance that funded nursery provision/childcare is promoted and take up encouraged, particularly within families with children who are vulnerable. 3. Agencies should be reminded by the LSCB of the need to include the voice of the child when recording information and include this issue in section 11 and section 175 audits. |
NC51270 | Death of a young boy as a result of injuries sustained as a consequence of his mother's actions. Mother arrested and charged with Child K's murder; she pleaded guilty to manslaughter on the grounds of diminished responsibility. Psychiatrists concluded that she was suffering from an acute mental disorder at the time of the incident. Father was a registered sex offender following conviction at age 16 and was subject to an indefinite Sexual Offences Prevention Order. Child K was subject to a Child Protection Plan when a few months old and his sister from birth due to risk of sexual abuse and neglect. Ethnicity or nationality of Child K is not stated. Learning: a more thorough assessment of mother's background would have identified high risk factors including a family history of mental illness and childhood abuse; no-one knew the mother used illegal drugs and parents were not challenged regarding their lack of engagement with the drug project; the risk the father posed to his child was not assessed by the time Child K was born; concerns about the family were not discussed at the multi-disciplinary team meetings held at the GP practice; parents were often not present for planned visits. Recommendations: practitioners must be provided with appropriate knowledge and skills to identify those at risk of developing mental health problems; relevant learning is disseminated to organisations, such as faith establishments, that are likely to encounter people at times of crisis; provide information to be used by GPs when referring women for terminations.
| Serious Case Review No: 2019/C7893 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Unnamed Safeguarding Children Board Serious Case Review concerning Child K Overview Report January 2019 Serious Case Review concerning Child K; Overview Report Page 1 of 38 Table of Contents Page 1. The child and the circumstances leading to decision to carry out a Serious Case Review 2 2. The Review Process 2 3. The Facts - Summary of Agency Involvement 4 4. Analysis 12 5. Previous Serious Case Reviews 27 6. Learning from the Review 27 7. Action Taken by Agencies Since the Events Considered in this Serious Case Review 30 8. Recommendations 31 Appendices Appendix 1 – Key Lines of Enquiry Appendix 2 – Recommendations from Agency Reports Serious Case Review concerning Child K; Overview Report Page 2 of 38 1. The child and the circumstances leading to the decision to carry out a Serious Case Review 1.1 Child K died as a result of the injuries sustained as a consequence of his mother’s actions. His mother was arrested and charged with Child K’s murder. She subsequently pleaded guilty to manslaughter on the grounds of diminished responsibility. Psychiatrists concluded that she was likely to have been suffering from an acute mental disorder at the time of the incident and she was given an indefinite hospital order by the Court. 1.2 Child K was the first child of his parents and spent the whole of his short life living with them both. His mother was 21 years of age at the time of Child K’s birth and his father was 19. Child K had a younger sister . Prior to Child K’s birth, the family was referred to Children’s Social Care due to concerns relating to his father’s history. Child K was made subject to a Child Protection Plan when he was a number of months old and his sister was made subject to one at birth. Both children remained subject to these plans at the time of Child K’s death. 2. The Review Process 2.1 Chapter 4 of Working Together to Safeguard Children 2015, states that Serious Case Reviews and other case reviews should be conducted in a way which: ➢ Recognises the complex circumstances in which professionals work together to safeguard children. ➢ Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. ➢ Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. ➢ Is transparent about the way data is collected and analysed. ➢ Makes use of relevant research and case evidence to inform the findings. 2.2 In order to meet these requirements this Serious Case Review has been undertaken using a ‘systems approach’1, as recommended by Munro (2011) and authorised within Chapter 4 of Working Together to Safeguard Children 2015. 2.3 A Serious Case Review Panel with the following membership was established to oversee the review: • Independent Lead Reviewer & Overview Report Author • Director of Improvement – Action For Children • Head of Safeguarding - District Care Foundation Trust • Named Nurse –Teaching Hospitals Foundation Trust • Early Years Manager - Children’s Services, Local Council 1 The systems approach “focuses on a deeper understanding of why professionals have acted in the way they have, so that any resulting changes are grounded in practice realities” (Munro, 2011). It “looks for causal explanations of error in all parts of the system not just within individuals” (Munro, 2005). Serious Case Review concerning Child K; Overview Report Page 3 of 38 • Head of Service, Social Work – Children’s Services, Local Council • Designated Doctor – Clinical Commissioning Group • Deputy Designated Nurse - Clinical Commissioning Group • Neighbourhood Director – Local Housing Provider • Deputy Team Leader Social Care - Legal Services, Local Council • Head of NIPS – National Probation Service • DCI Safeguarding –Police • Board Manager Safeguarding Children’s Board • Named Professional for Safeguarding Adults, • Local Ambulance Service NHS Trust 2.4 The Review Panel decided that the review should consider a period from when the mother first attended an antenatal appointment to the day when Child K died. Agencies which had been involved with the family between these dates were asked to provide chronologies and brief reports of their involvement including relevant background information which pre-dated this time period. In analysing their involvement the agencies were asked to consider 16 key lines of enquiry agreed by the Lead Reviewer and Serious Case Review Panel (appendix 1). The key learning from these reports has been used to inform this Overview Report. 2.5 Reports were provided by the following agencies: • Action For Children • District Care NHS Foundation Trust • Teaching Hospitals NHS Foundation Trust • Children’s Social Care, Local Council • Children’s Social Care, Local Council – Independent Review Team • General Practice • Local Housing Provider • Legal Services, Local Council • Police • Ambulance Service NHS Trust 2.6 Chapter 4, paragraph 10 of Working Together to Safeguard Children 2015 lists seven “principles for learning and improvement” that should be applied to all reviews. One of these is that “professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith”. In carrying out this review the Lead Reviewer held a ‘Learning Event’ to which front staff and their managers were invited. This helped the Lead Reviewer to gain a greater understanding of the context in which practitioners worked with the family and the reasons for the decisions they made and the actions they took. This in turn has assisted with drawing out relevant learning and recommendations for action and as such has been an important part of the systems approach that has been used. Serious Case Review concerning Child K; Overview Report Page 4 of 38 2.7 Another principle is that “families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively”. The Safeguarding Children Board Manager met with the father to make him aware of the Serious Case Review and to invite him to meet with the Lead Reviewer so that he could contribute to the review. However, the father decided that he did not want to contribute in any way. The Designated Doctor for the CCG, who is also the Chair of the Serious Case Review Sub-Group spoke to the Consultant Forensic Psychiatrist in the secure hospital with a view to discussing how the mother could contribute to the review. However, it was the view of the psychiatrist that the mother’s mental health was not strong enough for her to contribute. The Lead Reviewer and Safeguarding Children Board Manager did meet with the maternal grandmother, who had been present in the property when Child K had died. 2.8 Police provided the Lead Reviewer with the Serious Case Review with information gathered during the criminal investigation about contact the family had with a local church in the weeks prior to Child K’s death. As part of this Serious Case Review, the Lead Reviewer met with two the Interim Safeguarding Lead/0-30 Pastor and the Community Outreach Pastor from the church to discuss this further. Relevant learning is included within this report. 2.9 The Lead Reviewer has also been given access to a final psychiatric report and two addendum reports written following an assessment undertaken by a consultant forensic psychiatrist on the instructions of relevant police force. Relevant findings from this assessment are included within this Overview Report. 3. The Facts - Summary of Agency Involvement 3.1 This section of the report provides a factual summary of key areas of agency involvement with the family. It is not a comprehensive record of all contacts with the family but focuses on those episodes that are considered to be significant to the way the case developed. 3.2 Key Practice Issue 1 - Supervision of Sexual Offences Prevention Order 3.2.1 Three years prior to the death of Child K, the father was convicted of a sexual offence against a twelve year old girl committed the previous year when the father was 16 years of age. He was sentenced to a Youth Rehabilitation Order with a supervision requirement. He was also made subject of an indefinite Sexual Offences Prevention Order (SOPO) and as such has been required to comply with the provisions of the sex offender register since that date. This has entailed unannounced visits from police public protection officers (PPO) and regular Sex Offender Register Reviews. During the period covered by this Serious Case Review, these reviews were undertaken in February, July, August and November xxxx and March, June and September xxxx. Two PPOs were involved in undertaking these visits and reviews. Serious Case Review concerning Child K; Overview Report Page 5 of 38 3.2.2 The father’s PPO first became aware of his relationship with the mother when carrying out a Sex Offender Register Review. The mother was present during the visit and the PPO made her aware that the father was subject to a SOPO. 3.3 Key Practice Issue 2 - Antenatal and postnatal health care in relation to Child K 3.3.1 Child K’s mother accompanied her sister to an ante-natal appointment with a specialist midwife. During this appointment Child K’s mother informed the midwife that she herself was pregnant. Later that month, she attended a booking appointment with a midwife and was found to be approximately 19 weeks pregnant. She named the father but he was not present at the appointment. The midwife was not aware that the father was subject to a Sexual Offences Prevention Order and could only have been aware of this, at that time, if the mother had shared the information. 3.3.2 The mother attended for a scan the following month but did not then engage with Maternity Services for three months when she attended an antenatal appointment. During the three month period between the scan and the antenatal appointment she was sent a midwifery appointment three times but did not attend and was not present on four occasions when the midwife tried to undertake a home visit. Three more antenatal appointments were arranged by the midwife and the mother did not attend any of these, although on the second date the midwife managed to contact her and she attended later that day. On the final occasion, the father attended and said that the mother had not done so because she was having pain. This was four days before Child K was born. No particular health concerns arose during the pregnancy 3.3.3 During the same period health visitors tried three times to undertake an antenatal core appointment. They was unable to gain access on the first two occasions but managed to do so on the third. 3.3.4 Child K was born in hospital and discharged home the following day. Community midwives carried out four postnatal home visits to Child K and his mother and he was taken to two clinic appointments. 3.3.5 Child K was taken on schedule for his 8 week baby check and for his first and second set of primary immunisations. He was never taken for a third set of primary immunisations because by that time his mother refused them for fear of them causing harm. 3.3.6 The health visitor completed a birth visit at which both parents were present. She made two unsuccessful attempts to undertake a follow up visit and on the second occasion saw the father who she found to be confrontational. The health visitor carried out a joint visit with the community resource worker in May and further visits in July and August. From late September to early November the health visitor made Serious Case Review concerning Child K; Overview Report Page 6 of 38 three unsuccessful attempts to visit the family and two attempts to contact them by phone. 3.3.7 In November the health visitor visited and assessed the mother’s maternal mood which showed high anxiety. At this point the mother disclosed a history of anxiety from a young age and that she had been prescribed antidepressants by the GP but had run out of medication. The father did not engage much with the visit until the health visitor discussed Child K’s nutrition, when he interrupted her and asked what was wrong with his current diet. 3.3.8 Early the following year the health visitor undertook a developmental assessment for Child K and at this visit Mum stated she was pregnant, but did not know how many weeks. 3.4 Key Practice Issue 3 - Antenatal and postnatal health care in relation to Child K’s Sister 3.4.1 The mother saw a GP with a late period and symptoms of pregnancy, the GP asked her to undertake a home pregnancy test and return if positive. The mother did not return but six weeks later, the mother told the health visitor she was pregnant. The following day the health visitor asked the GP to do a pregnancy test; this was positive and an examination suggested that the mother was approximately 20 weeks pregnant. Over a month later, the mother attended a midwifery booking appointment having failed to attend twice. Five days later she had a scan and was found to be 37 weeks pregnant. A female child was born at full term and discharged home with her mother two days later. They were discharged from midwifery care when the baby was two weeks old. 3.4.2 The baby did not have an 8 week baby check and her only contact with a GP during Child K’s lifetime was when she was four months old. She was not taken to three booked GP appointments prior to this and missed an appointment with a Nurse Practitioner the week before Child K’s death. By the time of Child K’s death had not yet received any childhood immunisations. 3.4.3 Following the birth of Child K’s sister the health visitor visited approximately monthly although on occasion there was no reply when she visited the home and she had to rearrange the visit. The health visitor also undertook assessments of the mother’s maternal mood and postnatal attachment. 3.5 Key Practice Issue 4 - Family Support and Child Protection 3.5.1 Within two weeks of the mother attending the maternity booking appointment for her pregnancy with Child K, Children’s Social Care, the Police and the midwife were all aware that she was pregnant and that the father was a registered sex offender. As a Serious Case Review concerning Child K; Overview Report Page 7 of 38 result of becoming aware of this information, Children’s Social Care referred to Legal Services for a Legal Gateway Meeting at which it was agreed that the threshold for Public Law Outline (PLO) was met and that a pre-birth assessment should be undertaken. The Social Work Team referred the family to a Family Centre for pre-birth work to form part of the assessment. A community resource worker was allocated to undertake this work and carried out the first visit nearly three months later. 3.5.2 The PLO meeting was held following the Legal Gateway Meeting and a review meeting was arranged for three months later with the intention that the pre-birth assessment would be completed by that date, In the event, the PLO review did not take place and the pre-birth assessment was not completed until three days after Child K was born. 3.5.3 One month after the cancelled PLO review meeting and just two days before Child K was born, a strategy meeting was held at the Multi-agency Safeguarding Hub (MASH). A decision was taken to progress to an Initial Child Protection Conference but this did not take place. 3.5.4 Maternity staff at the hospital informed Children’s Social Care of Child K’s birth and were told that he could be discharged with his mother as she would be supervising his contact with his father. Two days later a telephone discussion took place between Police and Children’s Social Care regarding whether the father could continue to live in the family home. Following a home visit Children’s Social Care decided that the father could remain there but could not have unsupervised contact with Child K. The parents agreed that the mother would supervise all contact. 3.5.5 Three months later another strategy meeting was held and a decision reached again that the case would be taken to Initial Child Protection Conference. The subsequent Conference was held the following month and it was agreed that Child K would be subject to a Child Protection Plan due to the risk of sexual abuse but with neglect also highlighted. A risk assessment relating to the father was finalised when Child K was 7 months old and determined that he should not have unsupervised contact with Child K. A contract of expectations remained in place which required the mother to supervise all contact between Child K and his father. 3.5.6 Prior to the birth of Child K’s sister, an Initial Child Protection Conference was held in respect of the unborn baby and a Review Child Protection Conference in respect of Child K. It was agreed that both children would be subject to Child Protection Plans due to being at risk of sexual abuse with neglect also a concern. 10 days later Child K’s sister was born and the following day the social worker advised Midwifery staff that when the baby was ready to be discharged she could go to the family home with her mother. Following the Child Protection Conference, the social worker referred the family to the local children’s centre which was managed and run by Action for Children. The family was invited to attend groups at the children’s centre and a family support worker was allocated to work with them. Serious Case Review concerning Child K; Overview Report Page 8 of 38 3.5.7 Two months later, the social worker commenced another risk assessment of the father. The father missed two assessment sessions but attended rearranged sessions and a number of months later it was agreed that he could have unsupervised contact with the children. 3.5.8 Both children remained subject to Child Protection Plans at the time of Child K’s death although the social worker had told the mother just four days previously that they were considering recommending that the case be stepped down to Child in Need. 3.6 Key Practice Issue 5 - Anxiety and depression reported by the mother 3.6.1 A year before the death of Child K, the mother presented at the GP practice with low mood and disclosed physical abuse as a child. She denied thoughts of deliberate self harm or suicide and said that she did not want to undergo counselling. GP5 prescribed 21 days of antidepressant and asked the mother to come back for review in three weeks. 3.6.2 In total the mother received three prescriptions for the antidepressant, totalling 81 days’ supply. The GP tried to arrange an appointment to review the medication after the second prescription was issued but the mother did not respond to these attempts. The third prescription was issued when the mother requested this when attending an appointment with Child K. She told GP5 that she had found the medication to be helpful and that she was not crying or feeling as low as she had been. 3.6.3 In between the second and third prescriptions, the mother’s mental health was discussed at a Review Child Protection Conference and one action from the Conference was for health visitor 2 to assess the mother’s maternal mood on the next visit to identify any low mood. Health visitor 2 did this using GAD-72 and PHQ-93 screening tools and the scores were indicative of high anxiety. The mother disclosed history of anxiety from a young age and said that she had been prescribed anti-depressants by the GP but had run out of medication. Health visitor 2 discussed a referral to Improving Access to Psychological Therapies (IAPT) but the mother 2 GAD-7 is a screening tool and severity measure for General Anxiety Disorder. It involves the patient answering seven questions relating to anxiety over the previous two weeks with each having the answers ‘not at all’, ‘several days’, ‘more than half the days’ and ‘nearly every day’. These answers elicit scores of 0, 1, 2 and 3 respectively and the scores are aggregated to give an overall score. Scores of 5, 10 and 15 are taken as the start points for mild, moderate and severe anxiety. Source: https://patient.info/doctor/generalised-anxiety-disorder-assessment-gad-7 accessed 24 August 2018. 3 PHQ-9 is a Patient Health Questionnaire used to monitor the severity of depression and response to treatment. It involves the patient answering nine questions with each having the answers ‘not at all’, ‘several days’, ‘more than half the days’ and ‘nearly every day’. These answers elicit scores of 0, 1, 2 and 3 respectively and the scores are aggregated to give an overall score. Scores of 5, 10, 15 and 20 are taken as the start points for mild, moderate, moderately severe and severe depression. Source: https://patient.info/doctor/patient-health-questionnaire-phq-9 accessed 24 August 2018. Serious Case Review concerning Child K; Overview Report Page 9 of 38 declined saying that she did not like to talk about her feelings but was happy to continue to talk to health visitor 2. 3.6.4 The next reference to the mother’s mental health was during a Midwifery booking appointment 4½ months later. During the appointment the mother said she had been involved with mental health services and had been taking Fluoxetine for five months but had stopped taking it two to three months previously. The midwife asked the questions within the NICE guidance on mental health in pregnancy and the mother answered no to all of these and said that she did not want any support. 3.6.5 When Child K’s sister was nearly five weeks old, health visitor 3 carried out a home visit when the whole family and the maternal grandmother were present. The maternal grandmother reported that the mother had been feeling low and encouraged her to tell the health visitor about this. The mother said that she sometimes woke up feeling low and seemed to think her feelings were related to the housing situation and not being able to let the children out or look out of the window. Health visitor 3 encouraged her to apply for a house with a garden, and the maternal grandmother agreed and suggested that the family would be better living nearer her as they would have more support. 3.6.6 A Core Group meeting took place when Child K’s sister was 6 weeks old where reference was made to the mother feeling low and an agreement that professionals and the father would monitor this. Two weeks later health visitor 3 carried out a further home visit and assessed the mother’s mental health using GAD-7 and PHQ-9 screening tools gaining scores of 1 and 4 respectively. These scores are within the normal range and the mother described herself as okay. 3.6.7 Over a month later, the mother again told health visitor 3 that she felt low when she woke up but she attributed this to her housing situation and said that she felt better when she got up. The health visitor completed the maternal post natal attachment scale which did not highlight any concerns. The next visit by health visitor 3 was the following month and the record does not include any reference to the mother’s mental health. The record does show that the mother was still unhappy with her housing situation and wanted to move. 3.7 Key Practice Issue 6 - Termination of pregnancy 3.7.1 The mother underwent a termination of pregnancy the month before Child K died. She had previously failed to attend two appointments at the clinic having been referred by her GP. None of the other practitioners working with the family knew about this pregnancy or the termination until after Child K had been killed. 3.8 Key Practice Issue 7 - The mother’s mental health during the last five weeks of Child K’s life. Serious Case Review concerning Child K; Overview Report Page 10 of 38 3.8.1 Week One: mother phoned a church and spoke to a member of staff for between 30 and 40 minutes. During the homicide investigation the staff member provided an account of this contact to the police. 3.8.2 At the beginning of the phone conversation the staff member considered the mother to be very distressed, confused and struggling to get her words out. As the conversation progressed the mother calmed down a little and started to discuss her brother. She said that he had been ill for a long time with what the doctors had said was a mental health issue but she thought he had been possessed by a demon. The mother said that her family and partner thought she was crazy but she knew something bad was happening and she needed to stop it but did not know what to do. The staff member asked a number of questions such as whether the mother had a social worker or if she had been diagnosed with any physical or mental health conditions. The staff member did not know whether the mother had any children and no mention was made of this during the telephone call. The staff member and mother arranged to meet the following Sunday at the church. 3.8.3 Five minutes after the call was ended, the father phoned the staff member and said that he did not understand and did not know what was happening. An hour or so later the father came into the church and asked to speak with a pastor. He was told that this was not possible, that Sunday had been arranged and that was all that they could do. He said this was fine and left. 3.8.4 The staff member was unwell on the following Sunday and unable to keep the appointment. The staff member sent a text message to the mother and offered to meet during the week instead. No response was received to the text message and no further contact was received from either parent. 3.8.5 The day after the mother had phoned the church social worker 5 carried out a home visit and saw all the family members. The record makes reference to the property not being as tidy as it had been recently with clutter around the living room but good conditions in the rest of the property. The parents said that Child K had just made the mess. The record gives no indication that there was any concern regarding the mother’s mental health and there is no reference to her having contacted the church the previous day. 3.8.6 Week Two: the health visitor visited the home and the mother spoke about finding comfort in reading the Bible and that her faith in God had been renewed. She referred to being hurt by her sister’s boyfriend when she was 2-3 years old and described physical symptoms of dizziness, chest pains and difficulty catching her breath. The health visitor did not have any particular concerns about the mother’s mental health during this visit but advised her to see the GP regarding her physical health symptoms. Serious Case Review concerning Child K; Overview Report Page 11 of 38 3.8.7 The following day, a Core Group meeting was held which was attended by the social worker, health visitor and the father. There is no indication in the record as to why the mother did not attend and no reference to any concern about her mental health or behaviour. 3.8.8 Week Five, the social worker undertook a home visit and saw the whole family. The parents told the social worker that they were planning to marry. This was considered by the social worker to be a generally positive meeting. The social worker said that if progress against the child protection plan continued they would recommend that the case stepped down from Child Protection to Child In Need. The social worker recorded that the home conditions appeared good and the children well cared for. 3.8.9 Two days before Child K’s death, the family visited a different church to the one the mother had phoned the previous month. The parents told someone who was working at the church that they wanted the children to be baptised. They were spoken to in an office and their details were taken. They were told that the relevant person from the church would be in touch. The parents were observed to be calm, smiling, happy and grateful and the children to be happy, smiling and well behaved. 3.8.10 During the homicide investigation the father, maternal grandmother and maternal aunt provided information about the mother’s behaviour changing in the four weeks or so leading up to Child K’s death. This included her talking about God and the Devil and stating that the Devil was inside her brother, who had long standing mental ill health and had recently been detained in a mental health setting. The brother had spoken with the mother about religion and God in what was described as an obsessional and irrational way and had provided her with religious literature. None of this information was shared with any of the agencies working with the family prior Child K’s death and professionals who met with the mother during the last few weeks of Child K’s life did not identify any changes in her behaviour. The maternal grandmother was present in the property when Child K was killed. She subsequently told the Lead Reviewer that she had not seen the mother much for a few weeks prior to this day but on arriving at the property she noted that conditions had deteriorated in respect of cleanliness and tidiness. She also noted that the mother was not properly dressed and was behaving strangely, running around the property and talking about the wind. 3.8.11 The maternal grandmother also told the Lead Reviewer that, after Child K died, the father told her that the mother had been behaving strangely for a period of time. He cited her standing outside at 3:00 a.m. staring at the sky and an occasion when she had attempted to walk in front of a car with a pram. The maternal grandmother told the Police that the father had made her aware of concerns about the mother’s behaviour approximately three weeks before Child K’s death, and the maternal aunt had done so the following week. 4. Analysis Serious Case Review concerning Child K; Overview Report Page 12 of 38 This section contains an analysis of aspects of this case by considering the key themes to emerge. Theme 1 – Mother’s Mental Health: what was known, how it was assessed and the action taken as a result. 4.1.1 Psychiatrists have concluded that Child K’s mother was suffering from an acute mental disorder when she killed her son. From the information provided to this review and to the criminal investigation by a church and family members, it appears that during the last few weeks of Child K’s life there were occasions when his mother was distressed and/or exhibited unusual behaviour. This information was not shared with any of the professionals working with the family and none of the professionals who visited the family home ever had any concern, from their own observations, that the mother was experiencing significant mental health problems or that she might represent a risk to her children. She was seen by a social worker one day after she had spoken to the church worker and again four days before she killed Child K. She was also seen by a health visitor nine days after she had spoken to the church worker. Both the health visitor and the social worker had met with the mother on a number of occasions prior to these visits so they were familiar with how she usually presented. Neither had any concerns about her mental health during these visits; indeed they found both parents to be in a good frame of mind, talking positively about the future. It is evident from how the mother presented during these visits, and the observations in the second church, two days before Child K was killed, that the mother was not in a state of constant mental distress during the final weeks of Child K’s life. Equally it seems highly likely that she suffered mental distress on more than one occasion during this period. 4.1.2 The GP appointment referenced in 3.6 was the first time within the period covered by this review, that the mother had disclosed anxiety and depression to anyone from any of the agencies involved. Anxiety and depression screening carried out by both Maternity and Health Visiting Services during her pregnancy with Child K and following his birth had not indicated any concern. 4.1.3 There were a number of missed opportunities during the GP consultation in referenced in 3.6. It is reasonable to expect a GP, when assessing and treating depression in an adult, to establish whether they have parenting responsibilities and how their depression impacts on their ability to discharge those responsibilities. However, there is no documentation regarding the impact of the mother’s depression on her ability to parent which suggests that this was not assessed. 4.1.4 Furthermore, at the time of the appointment the notes suggest that the GP did not recognise the mother’s presentation as being postnatal depression. The risk factors for antenatal depression are broadly social vulnerability, childhood abuse, domestic abuse and a previous history of depression. Risk factors for postnatal depression are antenatal depression or previous depression. Bereavement by miscarriage, stillbirth or neonatal death is also more likely to lead to mental health problems in both parents. Serious Case Review concerning Child K; Overview Report Page 13 of 38 NICE guideline CG192, published December 2014 states that for suspected mental health problems in pregnancy or the postnatal period, women should have a comprehensive mental health assessment to support accurate diagnosis and ensure early appropriate treatment. In this case, the GP enquired about suicidal thoughts but overall there was not a comprehensive assessment of risk. 4.1.5 The likely impact of what was believed to be depression, on the mother’s family was not assessed and it appears that the GP did not have an understanding of her home situation. Had this been explored it would have become apparent that she had a young child to care for. There were at this point multiple entries in the child safeguarding node in the mother’s record which should have been visible to the GP unless they had not been granted access rights to view the template. This is a risk for locum GPs, as each Practice they work in must separately grant them the rights to view safeguarding information. With the exception of one part time salaried GP, all of the GPs in the Practice with which the family was registered are locums. It is not known whether the locum GP was able to view the relevant safeguarding records during this consultation. 4.1.6 Routine enquiry about drug and alcohol use should take place at every consultation with a mental health focus. However, there is no documentation regarding the mother’s drug or alcohol use. 4.1.7 Child K’s mother’s attendance was not communicated from the GP to health visitors or Children’s Social Care. No measures were put in place to keep her and her family safe with regards to her mental illness. Better communication between agencies at this stage could have raised awareness of the mother’s vulnerability and enabled a plan of support to be agreed. 4.1.8 Notwithstanding the absence of communication from the GP concerning the mother’s presentation, agencies became aware of it when the mother told the community resource worker that she had run out of her anti-depressant tablets. This resulted in the health visitor undertaking an assessment eight weeks after the mother had seen the GP. If the health visitor had been told by the GP about the mother’s presentation the health visitor may have undertaken the home visit sooner. Although the mother did not want to be referred to Improving Access to Psychological Therapies she did talk about her feelings and the health visitor’s view was that they had a positive discussion and the mother had engaged with this. 4.1.9 Once agencies were aware of the mother’s attendance at the GP her maternal mood was assessed periodically by the health visitor. These assessments indicated varying levels of anxiety and depression but did not raise significant concerns. The mother did not receive any medication after November xxxx and refused all offers of talking therapies. The mother herself identified her property housing situation as being a significant factor affecting her mood although she also told the GP and midwife about abuse she had suffered as a young child. Serious Case Review concerning Child K; Overview Report Page 14 of 38 4.1.10 Although the mother’s apparent anxiety and depression was discussed at Core Group meetings it did not feature in social work assessments. Therefore it appears that the possible impact on the care of the children was not appropriately assessed. This is a significant omission and is of particular significance in this case where the mother was expected to supervise all of the father’s contacts with his children. 4.1.11 The mother was already pregnant with Child K’s sister by the time of the GP appointment in referenced in 3.6. However, the GP did not know about the pregnancy and therefore could not factor it into any assessment of the situation. It is not known whether the mother suspected she was pregnant at that time. When she presented to GP12, referenced in 3.4.1 with a history suggestive of being several months pregnant, GP12 did not demonstrate awareness that the mother already had a young child on a Child Protection Plan and had recently been taking an antidepressant. This suggests a lack of professional curiosity in not establishing the psychosocial situation. The situation warranted a degree of urgency in confirming the pregnancy, as this would require urgent referral for antenatal care as well as a referral to children’s social care for a pre-birth assessment. Mother’s last prescription for a 28 day supply of antidepressant had been issued 10 weeks previously. There is no evidence that the risk of psychological deterioration from an abrupt discontinuation of an antidepressant in pregnancy was considered by the GP. 4.1.12 The maternity booking appointment took place when the mother was over 36 weeks pregnant. At this appointment the mother herself told the midwife that she had been involved with mental health services but had stopped taking anti-depressants two to three months previously. Screening questions indicated that she was not depressed at that time and the mother said she did not want support with her mental health. 4.1.13 Although professionals believed that the mother was experiencing anxiety and depression it appears that no-one considered whether she might go on to develop an acute mental health disorder. This review has identified historical issues that suggest the mother was at risk of mental ill health. Firstly, there is a history of mental health problems in the mother’s family which suggests there might be a genetic predisposition to mental ill health. Secondly, historical Children’s Social Care files show that both parents had experienced parental conflict, domestic violence and neglect in their childhoods. The mother was subject to a child protection plan under the category of emotional abuse when she was five years old and there were concerns when she was around 15 years old about her becoming involved with child sexual exploitation. 4.1.14 The psychiatrist who assessed the mother on the instructions of the Police believed that the symptoms she exhibited were consistent with paranoid schizophrenia. The psychiatrist further believed that when the mother presented at the GP some months Serious Case Review concerning Child K; Overview Report Page 15 of 38 after Child K’s birth, the symptoms she described were most likely due to a prodromal4 phase of schizophrenia rather than anxiety and depression. The mother described to the psychiatrist considerable drug use from 17 years of age, including cocaine, cannabis and amphetamines. She also told the psychiatrist that she continued with frequent use of cannabis and occasional use of amphetamines throughout both pregnancies and that she had used amphetamines on the day she killed Child K. The psychiatrist believed it likely that the paranoid schizophrenia was exacerbated by drug use. Toxicology tests were not undertaken when the mother was arrested but she did test positive for cannabis and amphetamine after she was charged. Agencies’ knowledge of and response to parental drug use is considered in Section 4.2 of this report. 4.1.15 The psychiatrist also believed that the termination of pregnancy was a significant stressor for her and a significant factor in exacerbating her underlying condition. After Child K’s death, the maternal grandmother told the PPO that the mother felt bad about having a termination, described ‘killing the child’ and expressed concern that the maternal grandmother would be angry with her for what she had done. The maternal grandmother told the Lead Reviewer that the mother had the termination because she felt unable to manage a third child at that stage and could not afford to do so. The maternal grandmother added that the termination had a big impact on the mother and she was upset and distressed afterwards with a feeling of guilt. Because none of the agencies who were working with the family, other than the GP, knew about the termination they were not able to factor this into any assessment or consider whether to provide additional support. 4.1.16 The referral from the GP in respect of the termination was made by letter, which is the usual practice for such referrals. The referral did not contain any information about the mother’s existing children, including that they were subject to Child Protection Plans. It is not routine for such information to be included. Adult nurses, such as those at the clinic do not have any access to SystmOne, the information system used by GPs and health visitors, and therefore they would not have been able to use this to find out about the Child Protection Plan. Safeguarding children is everybody’s business and it is the view of the Review Panel that it would be appropriate for the clinic to be informed when a woman whose children are subject to Child Protection Plans is referred for a termination. This would enable the staff at the clinic to make further enquiries if they have concerns. 4.1.17 The referral from the GP did share some historical concerns, identifying abuse the mother had suffered during her childhood. It also made reference to PHQ-9 and GAD–7 scores but did not include any explanation of what the scores would indicate for someone not familiar with using these tools or assessing mental health. It did not make reference to the medication that the mother had been prescribed the previous year. Nine months had passed since the GP had issued a prescription for 4 A phase that refers to the early symptoms and signs of an illness that precede the characteristic manifestation of the acute fully developed illness. Serious Case Review concerning Child K; Overview Report Page 16 of 38 antidepressants and the mother had not consulted the GP about her mental health throughout that time. Nevertheless, if the family had been discussed at the GP practice’s multi-disciplinary team meetings, as would have been appropriate given the family circumstances, the GP may have been aware of the mother’s on-going reports of anxiety and depression. This is information that it would have been appropriate to share with the clinic. Prior to undergoing the termination, the mother will have attended a pre-assessment clinic where she should have been asked about any factors that might pre-dispose her to mental health problems. This Serious Case Review has not had access to the mother’s psychiatric records as it was deemed that she was not well enough to give consent. Therefore the Lead Reviewer does not know what information was gleaned about the mother’s pre-disposition to mental health problems. It has, however, been reported that the mother declined any follow up from the clinic after her termination. 4.1.18 The mother did not inform any of the professionals working with her that she was pregnant and planning to have a termination. Similarly she made no mention of this afterwards. Clearly, a woman’s decision to terminate a pregnancy is a sensitive and highly confidential issue that should not be shared unnecessarily. This review does not suggest that GPs should routinely share information about terminations with other health professionals or with Children’s Social Care even when other children in the family are subject to Child Protection Plans. However, GPs should always consider whether information should be shared in individual cases in order to protect children. 4.1.19 It is unfortunate that no-one who had concerns about the mother’s mental health in the last few months of Child K’s life shared their concerns with any of the services involved. Throughout the period covered by this review, the parents displayed limited engagement with agencies and were selective in what information they shared. For most of the period covered by this review, the father was not allowed to have unsupervised contact with his children. It is therefore reasonable to surmise that he would have been reluctant to share any information that might cast doubt on the mother’s fitness to provide the necessary care as he would be concerned that this might result in the children being removed. 4.1.20 The church worker who spoke to the mother had concerns about her mental health but did not ask the mother whether she had any childcare responsibilities and appears not to have considered whether the mother’s mental health might constitute a risk to any children. Although the acting safeguarding lead at the church has told the Lead Reviewer that staff receive annual training in safeguarding children it is not expected that staff will proactively ask people about their childcare responsibilities even when they have concerns about that person’s wellbeing. 4.1.21 During the period covered by this review there were occasions when the mother acted in ways that could have been judged as not in her children’s best interests. For example, she was late in disclosing that she was pregnant with both pregnancies but especially the second one, she missed antenatal and postnatal appointments, did not Serious Case Review concerning Child K; Overview Report Page 17 of 38 take Child K for his third immunisations and did not take Child K’s sister for her 6-8 week check or for any of her immunisations. In addition, she did not always take notice of advice given by health professionals, such as safe sleeping advice. However, there is no indication that any of these acts resulted from a wish to harm either child and the failure to attend for immunisations appears to have been a decision made by both parents because they were distressed when Child K suffered the usual side effects to the immunisations he had. Furthermore, several professionals commented positively on both parents’ interactions with the children. Theme 2 – What was known about parental drug use, were appropriate enquiries made and action taken? 4.2.1 During a review conducted two years prior to the death of Child K, the PPO noted a ‘faint odour of cannabis’ in the parents’ property. The father admitted using cannabis and was warned about the potential legal consequences of this. Subsequently the father was always open with the PPO that he used cannabis but he would not talk about his use and became hostile when asked about it. 4.2.2 The initial social work assessment found no evidence of the mother currently misusing drugs, but identified she had used cannabis in the past. It was identified in the same assessment that the father used both illegal and legal drugs, such as cannabis, tobacco and alcohol. He self reported having used cocaine in his past and it appeared that his substance misuse was more extensive than the mother’s. Both parents were referred to a drugs and alcohol project for an assessment and support, but they both failed to attend. However, despite this action being included in the multi agency child protection plan, neither parent was challenged about their non-engagement with the project and no further action was taken about possible drug use. 4.2.3 A referral was also made to the local authority drug and alcohol team to assist in contributing to the parenting assessment. It is not clear what happened to this referral as they did not undertake an assessment, nor is there any evidence that they contributed, or were consulted, in respect of future assessments. 4.2.4 Past and current drug use, of either parent, did not form part of the social work assessment or safety plan. There was no cross referencing to the impact that cannabis can have on brain development and the risk to increase mental health issues, especially in young people. These issues would have been considered as part of a drug use and parenting assessment that was requested prior to Child K’s birth, had it taken place. 4.2.5 Information was shared about the father’s cannabis use at the initial child protection case conference referred to in 3.5.5 . Health visitor 2 asked him about this at a subsequent visit and he reported that he had stopped smoking cannabis prior to Child K’s birth. Serious Case Review concerning Child K; Overview Report Page 18 of 38 4.2.6 No agencies ever had concern that the mother was misusing drugs or alcohol and during visits to the property, including unannounced visits by the PPOs, practitioners did not notice the smell of cannabis or see any drugs paraphernalia. Furthermore, no-one observed either parent to be under the influence of alcohol or drugs at any time. 4.2.7 The mother’s GP had no knowledge of the mother misusing substances and, as identified in section 4.1 of this report, routine enquiry about drug and alcohol use did not take place as it should have done at consultations with a mental health focus. Theme 3 – The Response to the Initial Referral to Children’s Social Care and Subsequent Child Protection Processes 4.3.1 The reason the family was referred to Children’s Social Care when the mother was pregnant with Child K was that the father was subject to a Sexual Offences Prevention Order. This was an appropriate referral and it was made in a timely fashion. There was some good information sharing at this time. However, at the point of the duty social worker review in the MASH, no statutory checks were undertaken other than with the Police in respect of the father. Checks should have been undertaken with all agencies involved with either parent, or where there might be a presenting issue that could impact on parenting ability. 4.3.2 There was a lack of clarity of the risk posed by the father to the unborn baby and a lack of understanding by the social work staff of what the respective professionals involved and previously involved with the father were saying about his risk level and what that meant. The confusion started in the Assessment team where a student social worker was allocated the case alongside an experienced social worker and although the student social worker liaised with the relevant police personnel and the Youth Offending Team there is no coherent sense of what risk the father might pose to the unborn baby. At this point an assumption was made that the mother would be parenting the baby on her own. 4.3.3 Following a pre-assessment, Children’s Social Care commenced the PLO process, having sought legal advice to confirm that the threshold was met, and referred for a pre-birth assessment. The PLO process was premature at this stage. It would have been more appropriate if Section 47 enquiries had been undertaken to establish risk and gather all relevant information from other agencies. If necessary, the case could then have progressed to an Initial Child Protection Conference and the completion of a social work assessment, including an assessment of possible risks posed by the father as a result of his previous offence. When any risks had been established, a decision could have been made, before the baby’s birth, as to whether the father could live in the household or not. If it was decided that he could not live in the household and the parents were not co-operating, then PLO could have been initiated at that stage. (For action taken since this time see Section 7). Serious Case Review concerning Child K; Overview Report Page 19 of 38 4.3.4 After the PLO meeting the case was transferred to a long-term social work team which was also in line with the procedures in place at that time. After this transfer there was significant delay in starting the pre-birth assessment with no meaningful work being undertaken by the social worker or the community resource worker until more than two months later. This delay included 18 days between the PLO meeting and case transfer and a further 16 days between transfer to the long-term team and allocation to a social worker. This also included a bank holiday period which inevitably added a further delay. Subsequently, the social worker had difficulty contacting the parents and a period of sick leave. In addition there were low numbers of staff available to cover the work and the team manager was inexperienced and fairly new to the Local Authority. Although social worker 1 had made a referral to the family centre, the community resource worker’s first contact with the family was not until nearly three months later. After this first contact, the community resource worker had difficulty securing the parents’ engagement and some planned assessment sessions did not take place because the parents were not at home. Because of the above delays the pre-birth assessment was not completed before the PLO review. 4.3.5 The PLO review meeting was cancelled because the social worker was on sick leave and the team manager was otherwise engaged. Both the social worker and the team manager subsequently stated that they did not know that the meeting had been scheduled for that date which suggests a communication breakdown when the case was transferred to the team. If the meeting had taken place it would have highlighted the delay in completing the assessment and provided an opportunity to take stock of the situation. Children’s Social Care should have set a new date for the review meeting but this was never done. Therefore the PLO process came to a halt although it was not formally ended. (For action taken see Section 7) 4.3.6 Children’s Social Care and Midwifery Services have a joint protocol for a pre-birth safeguarding plan to be considered prior to a birth in cases where there are child protection concerns. The purpose of this plan is to identify what, if any, safety plans are needed in the hospital at the time of the birth to protect the baby and others. No safeguarding birth plan was completed for Child K even though Children’s Social Care had identified at the point of referral that the father posed a potential risk to his child. 4.3.7 The strategy meeting in referenced in 3.5.3 was held because the social worker’s view, from the assessment, was that an Initial Child Protection Conference should be held due to a lack of engagement from the parents. The strategy meeting should have involved Children’s Social Care, Police and the Midwifery Service as a minimum. Given the involvement of the Health Visiting Service during the antenatal period it would have been prudent to have also involved that service. In practice the meeting only involved the Police and the social worker. Despite the outcome of the strategy meeting, an Initial Child Protection Conference was not arranged. Social worker 2 left the job within days of this meeting and it appears that the recommendation to convene an Initial Child Protection Conference was not passed on to the team manager or an agency social worker who took over from social worker 2. Serious Case Review concerning Child K; Overview Report Page 20 of 38 4.3.8 As explained in paragraph 4.2.2, decisions should have been made before Child K was born as to whether he required a Child Protection Plan and whether his father could live in the same home as him. However, because of the omissions and delays within the child protection process, and some uncertainty about whether the parents were living together, this had not been done. This was a far from satisfactory situation and one that should not have arisen. On the day the mother went into labour, social worker 2 told the team manager that the outcome of her assessment was that the mother could parent the baby as a single parent but that there would need to be an Initial Child Protection Conference. However, it quickly became evident that the parents intended to live together and it appears that there had been no planning for this scenario. Children’s Social Care was initially of the view that Child K’s father should not be allowed to remain in the property but the PPO made representations on his behalf that he be allowed to remain there. Following a visit by the social worker to the parents it was agreed that he could remain there but that he would only have supervised contact with Child K. The PPO’s view was that the potential escalation of risk that would be caused by the father’s sudden homelessness was greater than any potential risk he posed to his son, which the PPO considered to be very low. 4.3.9 The decision that Child K’s father could remain in the family home was a risky decision for a number of reasons. Firstly, at the time Child K was born, Children’s Social Care had not undertaken a risk assessment of his father. Secondly, Child K’s mother had told the health visitor that she did not know why the father was not allowed to be with her and, the community resource worker told their manager that the mother appeared not to understand the risk posed to the child by the father. Therefore the mother’s willingness to adhere to the agreement should have been questioned. Thirdly, irrespective of the parents’ willingness to adhere to the agreement it was unrealistic to expect them to be able to do so whilst the father was living in the family home. It could be anticipated that this would put added stress onto the parents and increase the likelihood of them displaying disguised compliance, whereby they tried to demonstrate that they were complying with the contract of expectations whilst not actually doing so. Children’s Social Care reports that at the time of Child K’s birth it was not uncommon for contracts of expectation to be used in this way. It is now expected that there will be a full assessment using the Signs of Safety approach. 4.3.10 The decision to hold a second strategy meeting was reportedly made because the agency social worker was concerned that the parents were not engaging well with the health visitor and her, and not accepting advice. As with the previous strategy meeting, this one only involved the Police and social worker and there was no input from the health visitor, although this would have been appropriate. The subsequent Initial Child Protection Conference should have been held within 15 working days of the strategy meeting but did not take place for 27 working days. Serious Case Review concerning Child K; Overview Report Page 21 of 38 4.3.11 It is thought unlikely that the family would have been referred to Children’s Social Care if the father had not been a registered sex offender. Therefore, a crucial part of any assessment should have been on whether he would constitute a risk to his child. However, the risk assessment of the father was not started until after Child K was born and had not been completed at the time of the Initial Child Protection Conference. At the Conference, the mother still did not accept that the father presented a risk of harm due to his sexual offending and the father was noted as being difficult to work with. The Conference did not grip the issue of non co-operation or non acceptance of the concerns by the parents and agreed that Child K’s father should continue to live in the family home with all contact between him and the child should be supervised by the mother. Several recommendations were made at the Conference but they were not sufficiently SMART. They are specific about the staff concerned in a specific activity but do not have timescales or clear indicators of progress, making them hard to measure. 4.3.12 The agency social worker tried to undertake a risk assessment of Child K’s father but he did not initially co-operate and failed to attend some planned assessment sessions. The assessment was finally concluded but the risk had not been fully assessed due to the father’s non-cooperation. Because of this it was concluded that any contact between Child K and his father should continue to be supervised by Child K’s mother. As a result of this outcome, the father refused to work with the social worker and this led to the next change of social worker. 4.3.13 After a further change of social worker, a second risk assessment of the father was completed. This assessment was undertaken in liaison with the PPO, it explored the father’s background and experiences and his more recent relationships. The outcome of this assessment was that the father was to be allowed unsupervised contact with his children. However, this risk assessment did not consider specific risk, risk of relapse or safety plans if risks developed. Children’s Social Care did not request a full copy of the Active Risk Management System (ARMS) assessment from Police. However, the Police provided summaries which indicated that the father’s risk level was reducing because of the positive impact on his motivation of having a child and being in a relationship. 4.3.14 When the Initial Child Protection Conference did take place, some concerns were noted regarding lack of stimulation of Child K, him being weaned prematurely and the father’s cannabis use. As a result neglect was highlighted as a concern in the Child Protection Plan. It is also clear that there were many examples of the parents not engaging with services, not taking their children to medical appointments and not accepting advice (see section 4.4). Nevertheless, it has been suggested by practitioners involved that these concerns alone would not have met the threshold for Child Protection or even Child in Need support and that, if the father had not been a registered sex offender, the family would probably have been supported at the level of Early Help. This reinforces the view that there was a lack of clarity and focus on the risks and what needed to change. Serious Case Review concerning Child K; Overview Report Page 22 of 38 Theme 4 – Communication Gaps 4.4.1 There were several examples of practitioners communicating well, particularly when the mother’s pregnancy with Child K was first known about. However, this Serious Case Review has identified several occasions when practitioners did not appropriately share significant information about the family. 4.4.2 The mother self-referred to Maternity Services when she was pregnant with Child K. At the time of this booking there was an expectation that following all self-referrals to the Maternity Service, the maternity administrator should contact the registered GP practice to seek further information, including past medical history and any previous safeguarding concerns. However, there was no robust system in place for this and it was not routinely done, including in this case. (For action taken see Section 7) 4.4.3 Maternity Services did refer the mother to the Health Visiting Service but did not include information about the father being a registered sex offender, even though this information was known to the midwife. The health visitor had made two unsuccessful attempts to visit the family to undertake an antenatal visit before finding out, from a colleague, that the father was a registered sex offender. At the time the referral was made, the Health Visiting Service was undergoing organisational change. Health visitors had previously been attached to and based in specific GP practices and it was straightforward for midwives to know which health visitor to contact with information such as this. It was suggested, at the Learning Event, that the midwife may not have known which health visitor to contact with information about father’s status. If the health visitor had been made aware of the father’s status and the subsequent safeguarding concerns she would have followed guidance in the Health Visiting Standards and Safeguarding Children’s Policy relating to no access visits where there are safeguarding concerns. This may have resulted in the antenatal visit being carried out sooner than it was. 4.4.4 The mother moved home and changed GP Practice before health visitor 1 ever managed to meet with her. This necessitated a change of health visitor. There was a delay of more than two weeks before health visitor 1 handed over to the new Health Visiting Team and it appears that there was no robust system in place for Health Visiting Teams to be informed when families register with a new GP within the area. Again the implication of this for the family was a further delay in the antenatal contact being undertaken. This further contributed to a period of two months between the initial planned antenatal contact and the actual visit. 4.4.5 There is no evidence of communication or handover from the midwife to health visitor 2 after Child K was born. The Health Visiting Standards (2011) recommends that a communication system is set up with the midwife to enable a safe handover of the care between professionals. Serious Case Review concerning Child K; Overview Report Page 23 of 38 4.4.6 The decision as to whether or not the father could live in the family home was not clearly communicated to all relevant agencies. For example, the Health Visiting records contained conflicting information. It is not clear whether this was due to poor communication or a lack of clarity over the decision. 4.4.7 Neither child’s GP record contains any evidence of them being discussed at practice safeguarding multi-disciplinary team meetings. These meetings are reportedly held every two months by the GP practice although no minutes are available for any meetings held during the period covered by this review. In view of the father’s status as a registered sex offender and subsequently the children being subject to Child Protection Plans such discussion should be expected. 4.4.8 Paragraph 4.1.7 notes that GP did not inform the health visitor of the mother’s disclosure of anxiety and depression in September. Once the health visitor became aware that the mother had been prescribed antidepressants by the GP it would have been good practice for her to talk to the GP about the mother’s mental health. The health visitor did not do this and therefore there was a breakdown in communication on both sides. 4.4.9 When the GP referred the mother to Maternity Services in connection with her pregnancy with Child K’s sister, the GP did not make reference to mother’s recent presentation with anxiety and depression or to Child K being subject to a Child Protection Plan. Fortunately, the midwife noted on the maternity records that there had been safeguarding concerns during the mother’s pregnancy with Child K and investigated this further. This was good practice. 4.4.10 Paragraphs 4.1.15 to 4.1.17 of this report discuss the information sharing in connection with the termination that the mother had. This identifies that the GP did not inform the clinic of the mother’s anxiety and depression or that her children were subject to Child Protection Plans. 4.4.11 A number of practitioners commented on having difficulty making contact with Children’s Social Care in connection with this and other cases. A particular problem was that phone calls and emails would go to an individual practitioner’s voicemail and inbox. If that practitioner was away from work no-one else picked up the messages. It was evident from discussions at the Learning Event that there was no consistent method used by practitioners to escalate concerns when they were unable to contact a member of staff in Children’s Social Care. Records provided to this review detail occasions when the health visitors left message s for social workers and did not receive a response for several days. (For action taken see Section 7) 4.4.12 There were at least two occasions when communication broke down within Children’s Social Care as a result of changes of social worker. After the initial PLO meeting the case was transferred to a long-term assessment team. The date of the PLO Review Meeting was not passed on with the result that it was cancelled. When SW2 left the Serious Case Review concerning Child K; Overview Report Page 24 of 38 decision to hold an Initial Child Protection Conference was not passed on and the Conference was not arranged. Theme 5 - Lack of Engagement by the Parents and the Agency Response to this Lack of Engagement 4.5.1 Throughout the period covered by this review there were times when agencies found it difficult to engage with the parents. The mother presented late when pregnant with both Child K and his sister and missed the first two appointments for a termination. Numerous appointments with Maternity and Health Visiting Services were missed and the mother did not attend the GP Practice for a planned review of her antidepressant medication. 4.5.2 The specialist midwife at the One Stop Clinic displayed good proactive practice when the mother attended with her sister and said that she was pregnant. The specialist midwife knew that the mother’s sister was difficult to engage and thought that the mother may be similar. Therefore the midwife ensured that the mother knew that she had to attend a booking appointment at the hospital. 4.5.3 Health Visiting and Maternity staff demonstrated perseverance in trying to contact the family. This included repeated visits, attempted phone calls and liaising with other professionals. However, health visitor 1 did not follow the Health Visiting Standards (2011) that were in place at the time of the pregnancies. These advise that after two no access visits for the antenatal contact the address should be checked with Child Health and the GP and a letter sent to the family outlining the purpose of the antenatal visit. The current Health Visiting Standards (2017) recommend that after one no access antenatal visit checks should be made with other agencies involved and a further appointment offered; if there is still no access the non-engagement pathway should be followed. The protocol in Maternity Services is that if a woman does not engage on three separate occasions, they are referred back to the GP. In this case, the midwife did not refer back to the GP but went beyond what was expected and continued to try to make contact. This was due to the midwife’s concern for the unborn baby. Following another unsuccessful attempt to visit the midwife sought supervision from the safeguarding midwife; this was appropriate action to take. 4.5.4 The parents were not always present for planned sessions with the social workers and community resource worker. This included sessions planned as part of the pre-birth assessment and the risk assessments of the father. The parents’ non-engagement contributed to the delays in the completion of these assessments. 4.5.5 As explained in Section 4.2, Children’s Social Care referred both parents to the drug project shortly after the PLO meeting. They did not engage with the project and there is no evidence that they were challenged regarding their lack of engagement. Serious Case Review concerning Child K; Overview Report Page 25 of 38 4.5.6 The parents did not consistently engage with the GP Practice when their children had appointments. When child K was 6 months old, the health visitor noted that Child K had a yellow tinge to his skin and had to persevere before the parents took him for a GP appointment. There were three consecutive missed GP appointments for Child K’s sister and she was never taken for an eight week check (although it is not clear if this was ever offered) or for immunisations. Child K was not taken for his third immunisations. There is no evidence to suggest that the GP Practice had a robust mechanism in place to deal with children not brought to appointments. Two of the three missed GP appointments were followed up with a single text message but there is no evidence that a clinician reviewed Child K’s sister’s records after her missed appointments or that there was any communication with the health visitor. There is also no documented acknowledgement from the Practice that the missed appointments posed a potential risk to the health and wellbeing of the sister of Child K or that they constituted potential neglect. The missed appointments do not appear to have been put into context with the children being subject to Child Protection Plans. The GP Practice did make several attempts to engage the mother in a review of her antidepressant medication. 4.5.7 The family did not engage well with the female family support worker who was in initially allocated to work with them from Action for Children. There is evidence that the family support worker was tenacious in her attempts to engage with the family and case file notes indicate a series of texts, telephone calls and attempts to visit the home. Information was posted to the family after these unsuccessful attempts to undertake a home visit. Following discussion at a Core Group meeting referred to in 3.6.6, a decision was taken to reallocate the family to a male family support worker. The rationale for this appears to have been that a priority action was to engage the father and there was a history of non-engagement and a level of hostility from him towards professionals, particularly females. It appears that this strategy had some success in respect of improving engagement and that the male worker had started to establish a positive relationship with both parents. However, there does not appear to have been full consideration of how the plan for a male worker would fit into the wider plan of protection for the children, or how it may potentially collude with the father’s perception of females rather than challenging it. Furthermore, the promotion of the father’s role within the family appears to be at odds with the agreement that was in place at that time that he could not have unsupervised contact with the children. An additional concern with this decision was that there were no male staff within the Family Support Team so a worker from the Action for Children Health Team at the children’s centre was allocated this work. However, staff within this team do not have monthly structured case supervision in the way that Family Support Team staff do. 4.5.8 It was suggested at the Learning Event that the parents’ level of engagement varied depending on their feelings towards the individual practitioners although this is difficult to evidence. However, there does appear to have been better engagement, with fewer missed appointments than there had been previously. Serious Case Review concerning Child K; Overview Report Page 26 of 38 4.5.9 On some occasions the parents’ non-engagement manifested itself in confrontational behaviour or a refusal to accept advice regarding childcare. For example, when health visitor 2 shared public health information regarding safe sleeping and immunisations the parents disputed this and the mother said that she listened to the advice given but chose not to act on it. It is reported that on at least one occasion, as referred to in 3.3.7, this had an impact of the delivery of service, when health visitor 2 had concerns about the home conditions but did not feel she could address these because of the parents’ confrontational approach. 4.5.10 The mother consistently refused offers of support with her anxiety and depression, telling the GP, health visitor and midwife at various times that she did not want support. She also refused any follow up after the termination. Theme 6 - Drift & Delay 4.6.1 This report has identified several areas of delay in the work that Children’s Social Care undertook with this family. These have been considered in the preceding analysis and relate to the PLO process, the pre-birth assessment, risk assessments and Initial Child Protection Conference. Once it was decided at the Initial Child Protection Conference that a Child Protection Plan was required a Core Group meeting should have been held within 10 days and subsequent Core Group meetings should have been at least once every six weeks. These timescales were not met. 4.6.2 A particular challenge for Children’s Social Care in this case was the frequent changes of social worker. The change from social worker 1 to social worker 2 was due to a planned transfer to the long-term team. Subsequently the family was allocated to five different social workers between the time period covered in this review. There is evidence of communication breaking down at times when the social worker changed and this problem will have been exacerbated because there are big gaps in the case recording. Furthermore, changes of staff are always like to cause a degree of disruption whilst relationships are developed and trust is hopefully built up. Theme 7 – Did agencies recognise and assess risk in respect of maternal cousin (L) having contact with Child K’s mother? 4.7.1 L is a maternal cousin of Child K and at the time of his death, she was subject to a Care Order and placed at home with her parents. She was present in the address when Child K died, as she was visiting with the maternal grandmother. 4.7.2 This review has found that the identified risk factors in this case were primarily around the father’s sexual offending history and not around the mother. Indeed the mother had been assessed as being able to safely supervise contact between the father and their children. No-one working with the family had concerns that the mother might develop an acute mental health disorder and they did not observe any concerning behaviour from her in the weeks leading up to Child K’s death. People who did Serious Case Review concerning Child K; Overview Report Page 27 of 38 observe such behaviour did not share their concerns with agencies. Consequently, it is the view of this review that no information was available that she should have led professionals to have concern that L, or any other children, might have been at risk having contact with Child K’s mother 5. Previous Serious Case Reviews 5.1 Three years before the death of Child K, another child also died locally in similar circumstances. The Safeguarding Children Board undertook a Serious Case Review in relation to the death of this child. 5.2 Although the family circumstances for the two cases were quite different, both reviews found that the respective mothers were suffering from an acute mental disorder at the time they killed their children. Both reviews have also found that none of the practitioners who were working with the mothers were aware that they were suffering from these mental disorders or had noticed any significant changes in their presenting behaviour. Similarly both reviews have found factors within the mother’s lives and backgrounds that made them high risk of experiencing mental health problems. 5.3 A further finding in both reviews is that there was insufficient communication between the GPs and health visitors. 6. Learning from the Review 6.1 The reason the family was referred to Children’s Social Care when the mother first became pregnant with Child K was that the father was a registered sex offender. Had it not been for this, it is likely that services would have been provided at the level of Early Help. However, the tragic event that led to this Serious Case Review being undertaken had no direct connection with the father’s history but was due to Child K’s mother suffering from an acute mental disorder that no-one working with her had anticipated. 6.2 This review has considered the dual aspects of the mother mental health and the child protection process in detail and has identified the main issues that impacted upon these. The learning points that emerge from the analysis are set out below. 6.3 Mother’s mental health i. Notwithstanding concerns about some aspects of the mother’s care of the children, no agency ever had concerns that she would deliberately harm either child. ii. Professionals working with the family understood that the mother had suffered with anxiety and depression at times since Child K had been born. However, the GP did not identify this as postnatal depression which impacted on the response that was provided. Furthermore, the possible impact on her care of the children was not appropriately assessed. Serious Case Review concerning Child K; Overview Report Page 28 of 38 iii. The psychiatrist who assessed the mother on the instructions of the Police believes the symptoms she described were most likely due to a prodromal phase of schizophrenia rather than anxiety and depression. iv. Child K was killed whilst his mother was suffering from an acute mental disorder but no-one ever identified the mother as being at high risk of suffering an acute mental disorder. It is believed likely that this was due to paranoid schizophrenia exacerbated by drug use. v. A more thorough assessment of the mother’s family history, including use of historical information, should have led to identification of high risk factors with regard to her mental health, including a family history of mental illness and childhood abuse. vi. Practitioners were not aware of any recent history of drug use by the mother. vii. The termination of pregnancy is believed to have been a significant stressor for her and a significant factor in exacerbating her underlying condition. Other than the GP, no-one working with the family knew of this termination. viii. For a period of several weeks immediately before Child K’s death, there were times when the mother displayed disturbed behaviour but this was not seen by any of the practitioners who were working with the family. ix. No-one who witnessed the mother’s disturbed behaviour reported it to any of the agencies involved with the family. x. The long-standing arrangement that the father could not have unsupervised contact with his children is likely to have contributed to the father’s unwillingness to share concerns about the mother’s mental health. xi. The church worker who spoke to the mother whilst she was distressed did not seek to establish whether she had any caring responsibilities. 6.4 Parental drug use i. There was some knowledge that the father used cannabis on a regular basis but no-one knew that the mother used illegal drugs and no signs of drug use were noted in the property or in the parents’ presentation. ii. The parents were not challenged regarding their lack of engagement with the drug project. iii. Past and current drug use, of either parent, did not form part of the social work assessment or safety plan. iv. It is likely that drugs were a significant contributory factor in the mother’s mental disorder when she killed Child K. v. Drug taking can have a rapid and significant impact on a person’s behaviour and presentation. Where there are concerns that a service user may be using drugs it is useful to undertake unannounced visits and visits at different times of the day. 6.5 Child Protection Process i. The initial referral to Children’s Social Care was timely and appropriate but the early use of PLO was premature. Serious Case Review concerning Child K; Overview Report Page 29 of 38 ii. Significant delays arose including delays completing the pre-birth assessment and the risk assessment of the father and in holding an Initial Child Protection Process. As a result of these delays, suitable plans to keep Child K safe were not in place when he was born. iii. The initial reason for the family being referred to Children’s Social Care was that the father was a Registered Sex Offender and his partner was pregnant. However, the risk he may pose to his child had not been assessed by the time the child was born. iv. Even when a risk assessment was undertaken it is not evident that it was appropriately focussed on the father’s sex offending. v. The pre-birth assessment did not consider the parent’s own childhood experiences. vi. It is not clear what decisions or actions resulted from the pre-birth assessment. vii. Recommendations made at the Initial Child Protection Conference, and subsequent Review Conferences were not sufficiently SMART. viii. The expectation that Child K’s mother would be both able and willing to prevent her partner from having any unsupervised contact with Child K and later also with his sister was unrealistic and not based on a robust assessment of risk. ix. Throughout the period that the father was unable to have unsupervised contact with his children he was concerned about the risk of them being removed from him. This is likely to have impacted on his willingness to share concerns about the mother’s behaviour in September and October xxxx. x. Health Services were not as involved in the Child Protection Process as would have been appropriate. In particular, midwives and health visitors were not included in the strategy meetings. xi. Children’s Social Care has now made significant changes to the PLO process and the use of contracts of expectation. 6.6 Interagency Communication i. There were several occasions when information was not shared appropriately between agencies. This included information about the mother’s mental health and the father’s status as a registered sex offender. ii. Despite the concerns about the family, they were not discussed at the safeguarding multi-disciplinary team meetings held at the GP Practice. iii. Agencies sometimes had difficulty contacting the social workers. iv. There were breakdowns in communication within Children’s Social Care when changes of social worker took place. 6.7 Lack of engagement by the parents i. The parents were often not present for planned visits and frequently did not attend meetings. ii. They were sometimes confrontational with practitioners working with them. iii. They would not always accept advice regarding the care of the children. iv. Agencies demonstrated perseverance in trying to engage with the parents but did not always follow organisational protocols for non-engagement. Serious Case Review concerning Child K; Overview Report Page 30 of 38 v. The parents did not consistently engage with the GP Practice when their children had medical appointments. The GP Practice appears not to have had a robust mechanism in place to deal with children not brought to appointments or to have identified them as possible neglect, despite the children being subject to Child Protection Plans. 6.8 Drift and Delay i. There was considerable drift and delay from Children’s Social Care. Problems were exacerbated by frequent changes of social worker and scarce records. 7. Action Taken by Agencies Since the Events Considered in this Serious Case Review 7.1 The Teaching Hospitals NHS Foundation Trust reports that a robust system has now been put in place to ensure that on receipt of the self-referral documentation, the maternity administrator will generate a letter to the GP practice. This letter informs the GP about the referral to Maternity Services and requests that the GP “notify the Maternity Service of pertinent medical history, medication and safeguarding concerns that can assist the midwifery and obstetric teams.” Notwithstanding this letter, the Maternity Service does not always receive an appropriate response from the GP practice. (See Paragraph 4.3.2 and Recommendation 6) 7.2 Children’s Social Care has significantly changed its procedures relating to PLO. At the time the decision to commence PLO was authorised by the service manager in consultation with Legal Services. The tracking process lay with the service manager/team manager and social worker. All decisions for PLO need to go through Legal Gateway Panel for authorisation and their progress is tracked by the Panel. Pre-birth risk assessments are managed more tightly and the Pre-birth Protocol is clear about the need for early Initial Child Protection Conference so that there is an interagency decision. (See Paragraphs 4.2.2 and 4.2.3) 7.3 Children’s Social Care has made changes to address the issue of people having difficulty making contact with individual social workers. This includes systems that allow managers to override voicemails and access email accounts if staff are absent from work. In addition, a duty system is now in place in each social work team so that practitioners can contact the duty worker if the allocated staff member cannot be contacted. However, practitioners from other agencies are not confident that that these changes have resulted in significant improvements. It is suggested that Children’s Social Care should ensure that partner agencies are informed that there is now a duty system in each locality team and that the duty officer can be contacted if there are difficulties contacting the named worker. (see Paragraph 4.3.12 and Recommendation 6) 7.4 The ‘Signs of Safety’ model is now used within the local authority and partners. This is a strengths-based approach to child protection casework that provides opportunities Serious Case Review concerning Child K; Overview Report Page 31 of 38 for a more focused approach to setting and achieving goals. Relevant staff have been trained to use the ‘Signs of Safety’ model but work is required to ensure that its effective use is embedded in practice. 8. Recommendations 8.1. Individual agencies have already made changes to practice which address some of the learning from this review and these are described in section 7 of this report. Agencies have also made single agency recommendations within their individual reports. These are attached at as appendix 2. The Lead Reviewer makes the following additional recommendations to the Safeguarding Children Board and individual agencies: 1. The Safeguarding Children Board should seek assurance from partner agencies that practitioners are being provided with appropriate knowledge and skills that will help them identify people who are risk of developing mental health problems and know what action to take when they have concerns. 2. The Safeguarding Children Board should make links with the church where the mother presented in a distressed state to support the church in providing robust and appropriate safeguarding training to all staff and volunteers and to ensure that staff and volunteers at the church know who to contact if they have any safeguarding concerns. 3. The Safeguarding Children Board should ensure that relevant learning from this review is disseminated to organisations, such as faith establishments, that are likely to encounter people at times of crisis. 4. The Safeguarding Children Board should seek information from Children’s Social Care about the impact of the substantial practice changes reported in Section 7 and Appendix 2 of this report. 5. The Safeguarding Children Board should seek assurance that Signs of Safety is being appropriately embedded across the partnership. 6. Children’s Social Care should ensure that partner agencies are aware of the changes made to contact arrangements for social work staff and the action that should be taken if someone is unable to make contact with the allocated worker within a reasonable timescale. 7. The Clinical Commissioning Group and the Teaching Hospitals NHS Foundation Trust should develop a referral form to be used by GPs when referring women for terminations. This should include information relating to any other children the woman has and whether they are subject to Child Protection or Child in Need Serious Case Review concerning Child K; Overview Report Page 32 of 38 processes. It should also provide information about any identified mental health risks for the woman being referred. 8. The Safeguarding Team for the Clinical Commissioning Groups should recommend to all GP Practices that they have a process in place to respond to letters received from Maternity Services which request the “pertinent medical history, medication and safeguarding concerns that can assist the midwifery and obstetric teams” in the case of women who self-refer to Maternity Services in connection with their pregnancy. i. The Teaching Hospitals NHS Foundation Trust should undertake an audit of compliance during 2019 and present the results to the health safeguarding group. 9. The Safeguarding Team for the Clinical Commissioning Groups should recommend to all GP practices that they use the Clinical Commissioning Groups’ ‘Was Not Brought’ policy when children are not brought to appointments. 10. The Safeguarding Team for the Clinical Commissioning Groups should recommend to all GP practices and to NHS Trusts using SystmOne, that all locum doctors should be given access to the Safeguarding template on SystmOne. 11. The Head of Prevention and Early Help within Children’s Services should have regard to the recommendations made within the Action for Children report (see Appendix 2) to inform the operation of children’s centres now managed by the Local Authority. Serious Case Review concerning Child K; Overview Report Page 33 of 38 Appendix 1 – Key Lines of Enquiry The key lines of enquiry considered within the agency reports: 1. Describe and analyse the way in which organisations, identified as part of the review, interacted and worked with Child K and his immediate family and with each other. Consider these interactions in the organisational contexts and of the policy and procedural frameworks that applied at the time. In addition, the author should analyse the impact on the family, intended and unintended, of these interactions with professionals and organisations. 2. Were single and multi-agency assessments and interventions child focussed, accurate and acted upon? Did agencies recognise and assess risk in respect of Child K? Please detail each individual risk that was identified and how each was assessed. 3. Describe and analyse the parenting capacity of Child K’s parents. In particular did agencies consider historical information with regards to the parents of Child K which could have identified potential harm or concerns around their parenting of the child? (Including history of mental health, medical conditions and interest in faith aspects) 4. Was the parenting capacity of Birth Father assessed effectively? What influence and risks did he present to Mother, Child K and his sister? 5. What, in this case, reassured practitioners that Child K and his sister were safe and well? Were any signs of abuse missed by practitioners? 6. Did agencies have any knowledge or concern that either parent was misusing drugs. If so, what was the response and was it appropriate? 7. What can we learn from our response to Child K and his family and from the engagement with the Mother of Child K and extended family in fully understanding vulnerability, harm, risk and effective interventions? 8. Explore whether Mother and father/ or extended family were able to withhold concerns or deceive agencies, why this was able to happen and whether there are lessons that can be learnt. 9. Explore if agencies recognised and assessed risk in respect of Child L in relation to contact with Child K’s mother and being present at the time of the death of Child K. 10. Explore whether agencies responded in a timely manner to the incident leading up to the death of Child K. 11. Were appropriate assessments and measures in place to protect vulnerable adults and children within the home of Child K? 12. Was professional practice informed by appropriate and effective supervision? 13. Was professional practice and supervision informed by research and evidence based practice? 14. Were single and multi-agency communications and information sharing appropriate, accurate and acted upon? How well was information shared, understood and responded to between agencies? Include consideration of communication between practitioners working with both the immediate and the extended family. 15. Determine whether the National, Regional and Local policies, procedures, thresholds and practice expectations of the agencies in use were followed during this period. 16. Consider whether there are any common themes from previous serious case reviews or critical incident reviews and the effectiveness of agency’s actions in relation to these. Serious Case Review concerning Child K; Overview Report Page 34 of 38 Appendix 2 – Recommendations from Agency Reports Action For Children Number Recommendation i. The Operational Director for Children’s Services in the local authority should ensure that Action for Children workers holding case work responsibilities have access to monthly case file supervision as already required by Action for Children’s Supervision Policy in order to ensure manager oversight, track progress against outcomes selected, and offer an opportunity for reflective case discussions. ii. Ensure that on all occasions, historical information should be obtained to give the service a thorough understanding of the case history, as a minimum the record of the last Child Protection Case Conference discussion and the Safeguarding Plan should be sought if not readily shared by the referrer, in line with Action for Children’s existing policies. If not made available, then steps to escalate this to senior managers within the local authority should be taken. iii. The Service Manager should ensure that all staff within Children’s Centres have practice discussion sessions on working with mental health issues and use the online learning materials available in Action for Children to this end. iv. If Action for Children is requested to undertake work contrary to that set out in a Child Protection Plan or any other legal arrangement such as license following release from custody, work should be undertaken only after agreement with a responsible manager in the local authority. The Operational Director should ensure that in cases where agreement cannot be reached, Action for Children’s existing escalation procedure should be followed. v. The Head of Safeguarding should develop a flowchart to indicate the nature of key child protection processes and expectations of all agencies within these and incorporate into the Safeguarding Framework. District Care Foundation Trust Number Recommendation i. HV teams need to review the process of how they are notified of movements within the area by GPs ii. HV teams need to ensure that they are involved in safeguarding meetings with GP practices. iii. HV record templates need a prompt to ask parents about their own experience of childhood/being parented iv. HVs need to record relevant adults in the groups and relationships in records of children on CP plans and consider completing a genogram Serious Case Review concerning Child K; Overview Report Page 35 of 38 v. HVs need to take/create opportunities to use routine enquiry in regards to domestic abuse vi. HVs need to consider opening records for fathers (with their permission) if they are present at visits vii. HVs need to transcribe information from texts sent and received from parents into the records viii. Consideration needs to be given as to how the Care Foundation Trust monitors safeguarding supervision compliance Teaching Hospitals NHS Foundation Trust Number Recommendation i. Improved partnership information sharing between heath partners in relation to sharing of historical safeguarding information. ii. Improved inter-agency information sharing between professionals where there is on-going Children’s Social Care involvement. iii. Recognition of the impact and information that all professionals working with families hold when completing multi agency assessments, including the consideration and invitation to child protection conferences/review process. Children’s Social Care Number Recommendation 1 Assessments should cover childhood experiences of the parents and relevant history and the impact this may have on parenting 2 Assessments need to identify with families using the Signs of Safety model what we are worried about and what is being assessed so that families are clear what they need to change or improve. 3 Team Managers and Practice Supervisors will be reminded of the requirement for regular monthly supervision for all social workers, that is recorded on case files (more frequently for newly qualified staff) 4 Children’s Social Care will offer and encourage all families to accept a family group conference or family network meeting at the start of the pre birth assessment process or parenting assessments to ensure that wider family members are consulted with as part of the process. 5 Contract of expectations/written agreements should not be used routinely but only used in exceptional circumstances as a very short term measure where Signs of Safety planning needs to be reinforced. 6. Assessments of parent’s ability to supervise contact safely should take into account the impact on them and the reality of this in practice. Serious Case Review concerning Child K; Overview Report Page 36 of 38 Clinical Commissioning Group Number Recommendation i. CCG Clinical Leads should design a clinical template to aid GPs in completing a thorough maternal post-natal check. The template should include contraception advice, incorporate the Whooley questions and GAD2, and contain links to guidance on assessment and management of postnatal depression. ii. CCG Safeguarding Children team to raise awareness of the assessment and management of peri-natal mental illness by incorporating this subject into level 3 safeguarding children training. iii. To aid information sharing between health partners in relation to sharing of historical safeguarding information (see Teaching Hospital Foundation Trust recommendation i) the CCG suggests partnership work with Teaching Hospital Foundation Trust to modify the Teaching Hospital Foundation Trust Maternity referral form to include prompts for maternal mental illness, child safeguarding concerns, CSC involvement. When a woman self-refers to midwives, midwives and GPs should have an accepted method of communication to share any history of mental illness and any safeguarding concerns. iv. When there is a change in practice management a handover should take place, which includes passing on current safeguarding policies and record of staff training. How to do this: Feedback to the GP Practice. How to measure this: Check practice policy in place following this feedback. v. The GP Practice to have a robust system in place to ensure locum GPs and all new staff members are manually enabled to view entries in the safeguarding children template. How to do this: feedback to the GP Practice. How to measure this: Check practice policy in place following this feedback. Housing Providers Number Recommendation i. There were four recommendations for housing providers ii. iii. iv. Legal Services Number Recommendation i. The use of a shared /inter agency electronic record system which could enhance and improve communication. The shared record system could contain a basic log of Serious Case Review concerning Child K; Overview Report Page 37 of 38 actions and interventions that have been carried out so that professionals are aware of each other's actions. This could provide real time information on the progress of cases particularly those without court deadlines. It would not rely on services having to respond to email or telephone requests for updates or instructions and would highlight inactivity and or assist in prioritising those cases where interventions are required. Police Number Recommendation i. That the Force consider how to ensure that PPOs are fully aware of all available information from the incident logging database about the RSOs they manage prior to completing risk assessments and management plans; ii. That the Force audit attendance at domestic abuse incidents to ensure that Force policy re completing full research on involved persons is being complied with and if not considers what remedial action is required to achieve this; |
NC043730 | Serious and prolonged sexual exploitation of 6 adolescent girls at the hands of a number of men, who subsequently received criminal convictions. Many of the young people had learning difficulties and many became pregnant. History of recurrent attendances at A&E and frequent incidences of young people missing from home. Families of the young people were known to a wide range of services and two siblings of one young person were subject to child protection plans. Issues identified include: not speaking to the child; inadequate assessments; professional optimism over parents' ability to keep their children safe; lack of information sharing; lack of processes around sexual exploitation; unqualified staff; and inadequate supervision. Contains multi-agency and single agency recommendations covering: working with teenagers; developing knowledge, skills and processes around child sexual exploitation; placing young people at risk of sexual exploitation with specialist foster carers rather than semi-independent living accommodation; and having a twin safeguarding focus when working with teenage parents and their children.
| Title: The overview report of the serious case review in respect of Young People 1,2,3,4,5 & 6. LSCB: Rochdale Borough Safeguarding Children Board Author: Sian Griffiths Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. RBSCB Overview Report 20th December 2013 This report has been redacted for Legal reasons The Overview Report of the Serious Case Review in respect of Young People 1,2,3,4,5 & 6 This report has been commissioned and prepared on behalf of Rochdale Borough Safeguarding Children Board and is available for publication. RBSCB Overview Report 1 Contents Page Glossary 3 1 Introduction 4 1.1 Circumstances that led to the Review 4 1.2 Terms of Reference 5 1.3 Membership of the Serious Case Review Panel 9 1.4 Timescale for the Serious Case Review 11 1.5 Methodology 11 1.6 Parallel Processes 14 1.7 The Young People’s Contribution to the Review 15 2 : Factual Information 2.1 Genogram 16 2.2 Composite chronology of significant events 20 2.3 Relevant ethnic, cultural or other equality issues 20 2.4 Information provided by the Young People and their families 22 2.5 Relevant Historical and Contextual Information 25 3. Summary of information known to the agencies 3.1 Information known to Agencies during the timescale of the SCR 26 3.2 History of Criminal Investigation and development of Span 28 4 Critical Analysis 4.1 Introduction 31 4.2 Strategic Leadership in relation to Child Sexual Exploitation during the timeframe 32 4.3 The Operational Response : Recognition of Child Sexual Exploitation and the Warning Signs 41 4.4 The Operational Response : Understanding and engaging with the Young People 54 4.5 The Operational Response : The effectiveness of Multi Agency Working 71 4.6 The Operational Response : The Effectiveness of Intervention 83 4.7 The Operational Response : The Context – Race, Class, Gender and Culture 103 4.8 The Operational Response : Responding to the Individual and making the links between then 110 4.9 Concluding Comments 113 5. Multi Agency Recommendations 116 6. Individual Agency Reports and Recommendations 119 RBSCB Overview Report 2 6.1 Action for Children 119 6.2 Barnardo’s 121 6.3 CAFCASS 122 6.4 Connexions 123 6.5 Crown Prosecution Service 125 6.6 Children’s Social Care (Targeted Services) Rochdale MBC 126 6.7 Children’s Social Care (Safeguarding Children Unit) 131 6.8 Early Break (Young People’s Drug and Alcohol Service) 133 6.9 Education Welfare Service 135 6.10 GP Services Rochdale 138 6.11 Greater Manchester Police 139 6.12 Pennine Acute NHS Hospitals Trust 142 6.13 Pennine Care NHS Foundation Trust 144 6.14 RMBC Homelessness Service/Rochdale Borough Housing 146 6.15 Schools 147 6.16 Youth Service 150 6.17 Youth Offending Team – Rochdale MBC 151 6.18 Heywood, Middleton and Rochdale PCT (Commissioning) 153 Endorsement of Rochdale Safeguarding Children Board Chair Bibliography Appendix A : Terms of Reference Appendix B : Full Glossary of Codes for Professionals and Family Members Appendix C : Comprehensive Chronology RBSCB Overview Report 3 GLOSSARY SUBJECTS YP1 YP2 YP3 YP4 YP5 YP6 An anonymised list of other family members can be found at the end of this report. Other Acronyms: A & E Accident and Emergency ACPO Association of Chief Police Officers CAF Common Assessment Framework CAFCASS Children and Family Court Advisory and Support Service CIT Crisis Intervention Team CSE Child Sexual Exploitation CPS Crown Prosecution Service CSC Children’s Social Care DPP Director of Public Prosecutions FWIN Force Wide Incident Notice (Police record of incident) GP General Practitioner HFU Homeless Families Unit HCPC Health and Care Professions Council IMPACT Improving Attendance Co-ordination Team Meeting IMR Independent Management Review LSCB Local Safeguarding Children’s Board OFSTED Office for Standards in Education PCT Primary Care Trust PPIU Police Public Protection Investigation Unit SARC Sexual Abuse Referral Centre SCR Serious Case Review SCRSP Serious Case Review Screening Panel SEN Special Educational Needs TOR Terms of Reference nb: Appendix D provides a list of explanations for professional terminology, statutory procedures and processes referred to within the body of the report.RBSCB Overview Report 4 1. INTRODUCTION This Serious Case Review has been prepared in relation to 6 Young People who were subject to serious and prolonged Child Sexual Exploitation during their teenage years. Of the six young people subject to this review, 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 All the young people and their families had significant contact with statutory health and social care services, as well as with the police and a number of non-statutory services The purpose of the Serious Case Review is to identify whether agencies which provided services to these 6 Young People, acted appropriately and to establish what needs to be learned from their experience, to consider and reappraise practice. The Review will identify wider learning for Rochdale based on the experiences of these young people; however it cannot be and does not attempt to be a comprehensive analysis of Child Sexual Exploitation in Rochdale. Neither is the purpose of this Review to be ‘part of any disciplinary inquiry or process relating to individual practitioners’1, which clearly remains the responsibility of employing agencies. 1.1 Circumstances that led to this Review 1.1 In December 2010, a major police investigation, Operation Span, was instigated in relation to the sexual exploitation of a number of young people in the Rochdale Borough. Over the following year the Serious Case Review Screening Panel (SCRSP) reviewed the information provided by the police and other agencies in relation to the Operation and the impact on a number of young people. In December 2011 the SCRSP reached the conclusion that the grounds may have been reached to undertake one or more Serious Case Reviews. 1.2 However, at this stage the SCRSP were also of the view that the current SCR model was unlikely to provide the necessary learning for agencies within a suitable timeframe and therefore recommended that an alternative form of review be undertaken. The Chair of the LSCB agreed with the recommendation of the SCRSP and initiated a preliminary Learning event which was followed by a ‘Gap Analysis’ and a published report2 prior to any further decisions as to whether one or more Serious Case Reviews should be undertaken. 1.3 Following this preliminary review the Chair of the Board asked the SCRSP to reconsider the need for a Serious Case Review and having done so to identify those cases which would provide the greatest learning. The SCRSP subsequently identified 6 Young People whose 1 Working Together 2010:234) 2 RBSCB Sept 2012 RBSCB Overview Report 5 experience was considered likely to provide the fullest learning for agencies within Rochdale. The SCRSP recommended to the Chair of the Board that a joint SCR in relation to the 6 young people should be undertaken. 1.4 The decision was formally taken by the Chair of the Board in September 2012 that a Serious Case Review should be undertaken in relation to the young people and one other. As was required at the time, OFSTED and the Department for Education were informed of the decision to undertake a Serious Case Review on 17th September 2012. 1.5 An Independent Chair and an Independent Author for this Overview Report were formally appointed at the end of September 2012 and the Serious Case Review Panel (SCRP) was at that point established to manage the process with representation from the relevant agencies. 1.2 The Terms of Reference of the Review 1.2.1 The Terms of Reference for the Serious Case Review, which fully set out the scope and context of the Review are attached as Appendix A. A summary of the Terms of Reference is as follows: 1.2.2 The Terms of Reference were established by the Serious Case Review Screening Panel in line with the requirements of Working Together 20103, which states that a Serious Case Review must: Establish what lessons are to be learned from the case about the way in which local practitioners and organisations work individually and together to safeguard and promote the welfare of children Identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result Improve intra and inter agency working and better safeguard and promote the welfare of children 1.2.3 The Terms of Reference highlighted that: “The prime purpose of a Serious Case Review (SCR) is for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children. The lessons learned should be disseminated effectively, and the recommendations should be implemented in a timely manner so that the changes required result, wherever possible, in children being protected from suffering or being likely to suffer harm in the future. It is essential, to maximise the quality of 3 HM Govt (2010:234) RBSCB Overview Report 6 learning, that the child’s daily life experiences and an understanding of his or her welfare, wishes and feelings are at the centre of the SCR, irrespective of whether the child died or was seriously harmed.” 1.2.4 The Terms of Reference were discussed in some detail in the Serious Case Review Panel as a result of which a number of amendments were suggested and adopted by the Serious Case Review Screening Panel. Whilst this at times undoubtedly caused some confusion and difficulties, particularly for IMR authors who were not directly involved in all the discussions, refining the Terms of Reference was crucial in order to accommodate new information as it arose in the early months. 1.2.5 In addition to the overall Terms of Reference the following Key Lines of Enquiry were identified for specific consideration by the Individual Management Reviews: Key Lines of Enquiry 1. Recognition a) Comment on your organisation’s ability to recognise child sexual exploitation at an operational level and to proactively intervene to safeguard victims and support their families b) When did your agency first recognise that child sexual exploitation was happening in these cases; and when did you identify that abuse as organised .What was the agency response following this understanding 2. Intervention a) Consider and comment on the timeliness and quality of intervention, including early intervention services, offered to the subjects of this review by your agency. This should specifically include consideration of:- i. CAF process ii. Teenage pregnancy services iii. Children missing from home iv. Children missing from education v. Learning disability services vi. Physical disability services vii. Drug and alcohol support services viii. Recognition of any grooming and recruitment behaviour of the young people ix. Any other relevant early intervention issues RBSCB Overview Report 7 b) Consider and comment on the effectiveness and development of your agency’s strategic approach to CSE during the period of the review. c) Consider the effectiveness of any services provided to the subjects in relation to their own children, given the history of CSE. This ToR does not seek to review the services provided to any of the subjects’ children directly, but to consider any learning for services regarding the implications of the subjects’ experience as they moved into parenthood. d) What protocols, policies and procedures nationally were in place that would have informed and guided operational staff when undertaking assessments, interventions and escalation of CSE cases locally? e) Consider and comment on the effectiveness of procedures, risk assessments and individual interventions that were in place within your organisation to ensure that Looked After Children living within the Rochdale Borough receive equity of service. In addition, what procedures are in place within the organisation to respond when a Looked after Child is reported as missing from home? f) Comment on the level and impact of managerial oversight, control and challenge to case work with regard to child sexual exploitation. ( at all levels of your organisation) 3. Diversity a) Consider how the ethnic and cultural background of both perpetrators and victims of CSE influenced practice and decision making within your organisation; and how the organisation responds to issues of equality and diversity. b) Did assessment and intervention at an operational level fully reflect consideration of ethnicity, cultural, equality and diversity? 4. Partnership working a) Consider what barriers existed within the review period to inhibit appropriate information sharing in both inter agency and multi-agency settings and identify the barriers to effective inter-agency and multi-agency working specifically related to child sexual exploitation. Identify any good practice examples of interagency work. b) CSC & Police – comment on the interface between your agencies in determining the operational lead and subsequent actions to safeguard children/young people with consideration to the criminal/safeguarding threshold. 5. Context a) Identify whether there were lessons available from contemporary serious case reviews which, if learnt, would have better informed practice and decision-making in these cases? RBSCB Overview Report 8 b) Consider, from your agency’s perspective, the single and multi-agency reviews that have been completed into CSE within Rochdale, with specific reference to the findings and learning identified relevant to your agency. 6. Overview Author Specific Terms of Reference Consider national direction and relevant frameworks available to strategic leads and practitioners with regard to child sexual exploitation during the review period. 1.2.6 The Terms of Reference (ToR) identified that the time period for consideration by the Serious Case Review should start at the beginning of 2007, the year in which the Safeguarding Board began work on Child Sexual Exploitation. The ToR would finish at the end of the trial which led to the conviction of 9 men for related offences. Any relevant historical information which was outside of the agreed timeline was required to be included in summary form. 1.2.7 It was recognised that the Terms of Reference were not suitable for the Crown Prosecution Service as it does not provide a direct service to individuals. A series of questions, based on the issues identified with the Terms of Reference was therefore produced in order to enable the CPS to produce a report that reflected the concerns of the SCR panel. 1.2.8 There was considerable debate within the SCR Panel with regard to the timescale of the Review. In particular, Greater Manchester Police suggested their preferred approach which was to identify separate timescales for each of the young people to encapsulate their experience from 10th birthday until their 18th birthday. After considerable discussion the majority view of the SCR Panel was that the timescale should remain as identified but with the requirement for all agencies to provide summary information regarding any significant contact prior to the timescale identified. In reaching this conclusion the SCR Panel was of the view that : A longer timescale would be unlikely to provide proportionately increased learning and would be likely to necessitate a longer period for completion of the Review. Identifying 6 different timescales would make a complex Review considerably more complex and there could be as much information lost as gained. The decision regarding which young people should be the focus of the Review had been taken to ensure a cross section of all the agencies and lead to an understanding of their response at different points in the young people’s lives. RBSCB Overview Report 9 This was subsequently formally agreed by the SCR Screening Panel 1.2.9 The Panel reviewed the time period during the SCR process to ensure that it was still considered fit for purpose in the light of emerging information. The Panel remained satisfied that the timescale had been appropriately identified. 1.2.10 The agreed timescale was therefore: 1st January 2007- 31 May 2012 1.3 Membership of the Review Panel The Serious Case Review Panel was made up as follows: Agency or Organisation Role Audrey Williamson Independent Chair Action for Children Head of Safeguarding Barnardo’s Assistant Director Children’s Services, Barnardo’s (North West) CAFCASS Head of Service, Greater Manchester, CAFCASS Connexions(up to April 2013, when replaced by Positive Steps) Connexions Service Manager until April 2013 Assistant Director, Early Help and Schools, post April 2013 (commissioner) Crown Prosecution Service Crown Prosecutor Head of CPS North West Complex Casework Unit Early Break Chief Executive Early Help and Schools Assistant Director Greater Manchester Police Detective Superintendent, Specialist Protective Services Greater Manchester Probation Trust Assistant Chief Executive Heywood, Middleton and Rochdale CCG Designated Nurse for Safeguarding, Heywood, Middleton and Rochdale Heywood, Middleton and Rochdale CCG Designated Doctor for Safeguarding, Heywood, Middleton and Rochdale Rochdale Children’s Services Safeguarding Unit Manager Rochdale Children’s Services Interim Assistant Director Rochdale Boroughwide Housing Homelessness Service Manager Pennine Care NHS Foundation Trust Acting Head of Safeguarding Children RBSCB Overview Report 10 Pennine Acute Hospital NHS Trust Head of Safeguarding Youth Service Senior Youth Officer Youth Offending Service Service Manager The SCR Chair agreed that occasional substitutions could be made for the named panel members within individual agencies, but there would be an expectation that substitutes would be kept to a minimum, fully briefed and able to contribute fully. Also in attendance at the Panel meetings were the following: Sian Griffiths, Independent Overview Author Rochdale Borough Safeguarding Children Board Business Manager Rochdale Metropolitan Borough Council Principal Solicitor Administrator, Rochdale Borough Safeguarding Children Board Advisor from The National Working Group (Tackling Child Sexual Exploitation), a charitable organisation formed from a UK network of practitioners working on Child Sexual Exploitation. From the outset it had been the intention to include on the Panel a member of the Multi-Faith partnership in Rochdale, but no-one could be identified to undertake this role. A decision was therefore taken to appoint a Special Advisor to the Panel to act as an independent ‘critical friend’ in relation to issues of race and diversity. The Special Advisor appointed has significant relevant experience including: employment as a Service Lead for a national mental health charity; employment as a Chaplain in Her Majesty’s Prison Service; Chair of a divisional police Independent Advisory Group; Chair of a Registered Charity working with young people and their communities. Audrey Williamson is the Independent Chair of this Serious Case Review. Ms Williamson qualified as a social worker in 1981 and is registered with the Health and Care Professions Council. Ms Williamson has worked in Social Care in a number of local authorities in the North West and was a senior manager in both children and adult social care services before becoming independent in 2011. Ms Williamson is the Independent Chair of Warrington, Halton, Cheshire West and Chester Safeguarding Children Boards . Sian Griffiths is the Independent Author of the Overview Report. Ms Griffiths works as an Independent Social Worker. She is not employed by any Local Authority or Agency other than for commissioned pieces of work of an independent nature. Ms Griffiths has been a qualified social worker since 1987, working both in the Probation Service as a practitioner and manager and later as a Family Court Advisor in CAFCASS. Ms Griffiths is registered with the Health and Care Professions Council. She has previously authored Overview Reports for Serious Case Reviews for a number of Safeguarding RBSCB Overview Report 11 Boards and is accredited by SCIE to undertake Learning Together Reviews adopting a systems learning approach. 1.4 Timescale for undertaking the Review Rochdale Borough Safeguarding Children Board recognised that given the complexity of the Review, in relation to 6 young people over a 6 year period, a timeframe longer than the standard 6 months required by Working Together 20104, would be required to complete the Serious Case Review and submit the Overview Report to OFSTED and the Department of Education. A submission date was therefore initially set for October 2013 and the Department of Education informed. The complexity of the Review led to some delay and it was ultimately presented to the Rochdale Safeguarding Children Board on 15th November 2013. The Department of Education was informed of the new date. 1.5 Methodology of the Review 1.5.1 This Serious Case Review was conducted in line with the requirements of Working Together 2010. The Review Panel was aware of the ongoing redrafting of Working Together and the development of a systems model for undertaking SCRs. Both the Independent Chair and Independent Author of the Review had been trained in the SCIE Learning Together model. The possibility of adopting such a methodology was therefore considered, but following clear advice from the Department of Education the Review was undertaken, as required, in line with existing statutory guidelines. 1.5.2 The SCR Panel therefore confirmed that the framework for the Review should be that required by Working Together. However, the underlying principles adopted as far as practicable reflected the Systems learning model as outlined in the recently published Munro Report.5 In particular IMR authors were encouraged to reflect with practitioners on the context of their decision making at the time, in order to maximize the learning from this review. It was further agreed that in line with developing thinking regarding the most effective means of embedding learning arising out of Serious Case Reviews, this Review would not necessarily produce recommendations to the Board which met the ‘SMART’ criteria, but recommendations which focused on the most significant challenges for the Board to consider and respond to. The intention being to ensure ownership of the actions resulting from the Review and strive for “more considered, deeper learning to overcome the perennial obstacles to good practice”.6 4 HM Government (2010) Working Together to Safeguard Children, Chapter 8 5 Munro (2011) 6 Brandon et al (Sept 2011:2) RBSCB Overview Report 12 1.5.3 The Panel was also explicit in its view that any early lessons identified during the Review should be responded to in practice without delay where this was possible. Agencies were required to provide the Panel and the Board with updates regarding any early learning during the process including a written update prior to the Overview Report being presented to the Board. Where this was provided it is referenced during Section 6 of the Review. 1.5.4 The Panel requested and received Individual Management Reviews from the following agencies: Action for Children Barnardo’s CAFCASS Crown Prosecution Service Early Break Education Welfare Service GP Services Rochdale Greater Manchester Police Pennine Acute Hospital NHS Trust (Community and Mental Health Services) Pennine Care NHS Foundation Trust Rochdale Boroughwide Housing Rochdale Metropolitan Borough Council Children’s Social Care (Targeted Services) Rochdale Metropolitan Borough Council Children’s Social Care (Safeguarding Children Unit) Rochdale Connexions Trust Schools Youth Service Youth Offending Team 1.5.5 It had been expected that information regarding the involvement of the Local Authority’s Legal Services department with the young people would be contained within the CSC IMR, but this was not the case. Requests were made to CSC for the IMR author to include the information and access to Legal Services files was agreed, but this was not taken up. Therefore a short factual report was requested from Legal Services in relation to their involvement with the young people concerned and this was produced. 1.5.6 Information was sought from the following organisations who confirmed that they had no relevant knowledge of the Young People or their families during the time period identified: RBSCB Overview Report 13 Community Safety Partnership Rochdale Metropolitan Borough Council Adults Social Care 1.5.7 Information was also sought from four Local Authorities who were believed to have relevant contact with one or more of the YPs. Authority A provided some historical information regarding 111 and her family. Authority B and Authority C provided short reports in relation to their involvement with 111. These authorities have been anonymised to protect the identity of the young people. None of the information provided by these authorities identified the need for an IMR. 1.5.8 A Health Overview Report was commissioned from Heywood, Middleton and Rochdale NHS Clinical Commissioning Group to encompass the IMRs of the NHS providers listed above. The report was authored by the Designated Nurse who was also a member of the Serious Case Review Panel. 1.5.9 The Serious Case Review Panel met on the following dates: 6th November 2012 (half day meeting) 18th December 2012 (half day meeting) 8th February 2013 (half day meeting) 21st March 2013 (full day meeting) 22nd March 2013 (full day meeting) 10th April 2013 (half day meeting) 8th May 2013 (half day meeting) 11th June 2013 (half day meeting) 20th August 2013 (half day meeting) 26th September 2013 (half day meeting) 9th October 2013 (half day meeting) 28th October 2013 (half day meeting) 1.5.10 Two structured meetings were also held on 6th November 2012 and 8th February 2013 to brief and then update IMR authors on their role and identify any process problems. IMR authors were also provided with individual feedback on their reports. Authors had access to ongoing advice and support from Panel members and the Independent Chair and Author. As a result all the IMRs were resubmitted following first drafts and several of the resubmitted IMRs provided a subsequently improved depth of learning. 1.5.11 The Overview Author, alongside publicly available information, was provided with the following internal documents: Greater Manchester Police: Operation Span, Peer Review RBSCB Overview Report 14 Greater Manchester Police: Internal Review of Operation Span, April 2011 (Exec Summary) Pennine Care NHS Foundation Trust Crisis Intervention Team Records Review 1.5.12 The Overview Author met with and interviewed: Chair of Rochdale Safeguarding Children Board, Nov 2010-Nov 2012 Named Nurse, Child Protection, (retired) Designated Nurse, Child Protection (retired) Jane Booth, current Chair of Rochdale Safeguarding Children Board Jim Taylor, current Chief Executive, Rochdale Metropolitan Borough Council Some written information was also provided by the Assistant Director of Children’s Services 2009-2012, in response to specific questions. 1.6 Parallel Processes 1.6.1 Police investigations were ongoing during the period that this report was undertaken, including the possibility that one or more of the young people would as a result become a witness in future court proceedings. 1.6.2 During the course of this Review Greater Manchester Police Professional Standards Branch, overseen by the Independent Police Complaints Commission have been undertaking an internal investigation regarding a number of officers. It is anticipated that this will be completed in late 2013. 1.6.3 Children’s CSC have, prior to and during the course of this Review, undertaken a number of internal proceedings in relation both to managers and front line practitioners. The outcome of these proceedings has included disciplinary action and referral to the Health and Care Professions Council (HCPC), the regulatory body for Social Workers. 1.6.4 The Local Authority had commissioned a report by an Independent Consultant which was published in May 20137. The primary purpose of this report was: 7 Klonowski, May 2013 RBSCB Overview Report 15 To highlight opportunities which the Council and its partners may take to reduce the risks and ensure the safety of children and young people within the borough of Rochdale. To review the interactions and supporting processes within the Council departments and between the Council and external agencies. 1.7 Young People’s Contribution to the Review 1.7.1 In line with the expectations of Working Together (March 2010) early consideration was given by the panel to seeking a contribution to the Review by the Young People. 1.7.2 The Panel agreed that the 6 Young People’s contribution to the Serious Case Review would be sought. The Chair of the Panel wrote to the young people and the Board Business Manager and the Head of the Safeguarding Unit also met with them to explain the SCR process and to ask if they would be willing to contribute to the Serious Case Review. Not all the Young People were willing at that point to confirm if they would take up the opportunity to contribute their views to the Review. 1.7.3 The Independent Chair, Independent Author and Safeguarding Board Business Manager arranged a consultation meeting with the National Working Group Youth Participation Officer. The purpose of the meeting was to consider how best to ensure that they were approached and spoken to appropriately and their needs considered. 1.7.4 A number of attempts were made by the Independent Chair and the Safeguarding Board Manager to meet with the young people subsequently, including letters, telephone calls and visits to the young people’s home addresses. As a result, meetings took place with 111 and 111 and with 1111’s parents. The Independent Chair also undertook two substantial telephone conversations with the mother of 1111111111. However,111111111111111111 chose not to meet with the members of the Review team at this time. 1.7.5 The Serious Case Review Panel considered it particularly important that opportunities to seek the Young People’s views should continue to be offered even after the conclusion of the formal process. It was also the Panel’s view that the young people should be provided with a meaningful opportunity to have access to the final report and if they wished for support to be provided to enable them to fully understand and respond to the Review, particularly given the level of detail involved. Prior to the conclusion of the Review itself therefore the Independent Chair recorded the agreement of the key agencies that this would be undertaken as long as it was experienced as helpful by the Young People. RBSCB Overview Report 16 2.1 Genograms Three Genograms can be found on the following pages in relation to the young people. The information contained represents the end of the period reflected in the timeline. Not all individuals have been included for ease of understanding.RBSCB Overview Report 17 Genogram 111111 RBSCB Overview Report 18 Genogram 11 RBSCB Overview Report 19 Genogram 111111 RBSCB Overview Report 20 2.2 COMPOSITE CHRONOLOGY OF SIGNIFICANT EVENTS A full chronology of significant events was prepared to inform this review. Each individual agency provided a chronology as part of their IMR and also provided brief historical information which whilst outside the timeline provided relevant contextual information for the Review. 2.3 RELEVANT ETHNIC, CULTURAL OR OTHER EQUALITIES ISSUES 2.3.1 In line with the requirements of Working Together, IMR authors and the authors of both the Health Overview and this Serious Case Review Overview Report were directed specifically to consider any particular issues of race, culture, language, religious identity or disability which was of significance to the family. 2.3.2 Those agencies who recorded information regarding diversity identified the young people as white British. 2.3.3 Information about the perpetrators’ race, culture and ethnic background as understood by the Services involved at the time, is limited. Men are frequently referred to as ‘Asian’ without specifying what this meant, or indeed why it was considered significant to record it. Within this review the term ‘Asian’ or other references to race or ethnicity, will be used where it was the term used either by Services or by the subjects and their families. Analysis of the use of this term and what it signifies will be included in Section 4 (Critical Analysis). 2.3.4 Greater Manchester Police identified the men who were convicted at the trial in February 2012 as British Pakistani. Information since provided by the Greater Manchester Probation Trust has established that 1 of the men identified himself as Afghani, 1 as Bangladeshi, 1 as Punjabi and 5 as of Pakistani origin. However another man, AdultD who was separately convicted of sexual activity with a child and sexual assault was White British. 2.3.5 All the young people were brought up in economically impoverished areas of the borough where there was significant intergenerational disadvantage. The 2010 Index of Multiple Deprivation results placed Rochdale borough as the 29th most deprived out of 326 districts in England (DCLG website8). 2.3.6 There is only one reference to suggest that religion may have been a significant feature in any of the Young People’s lives. This was a comment by 111 made to a Connexions Personal Advisor, that her father blamed her for her pregnancy and then had influenced her to have the baby because it was “their religion” There is no further information as to what religion this was or how significant it was to 8 https://www.gov.uk/government/organisations/department-for-communities-and-local-government RBSCB Overview Report 21 111. No other information regarding the place of religion in the young people’s lives has emerged. 2.3.7 1111111111111111111111111111111111111111111111111111111 111111111111111111 111111111111111111111111111111111 111111111111111111111111111111111111111111111111111111111 111111111111111111111111111111111111111111111 111 111111111111111111111111111111111111111111111111111 2.3.8 111 was assessed as having moderate learning difficulties in 1111 when assessments were undertaken as part of court proceedings, but no previous reference to this has been identified. 2.3.9 There are various references to 111 as having learning difficulties/disability. Information as to the extent of any difficulties is variable 11 11111111 1111 she was described by the Children’s Guardian as having a moderate-significant learning disability making it difficult for her to achieve significant changes to her behaviour. In November of the same year she was referenced in Pennine Acute Health Trust records as having a mild learning disability. 2.3.10 111 was also recorded as having learning difficulties. She had a statement of Special Educational Needs and was identified as ‘School Action Plus’ due to behavioural difficulties, comprehension and interaction while she was at school. Information from the school also described her mother as having Special Educational Needs, although no further information has been provided. Two other children of the family were noted as ‘having Special Educational Needs’. 2.3.11 The terms ‘Learning Difficulties’, ‘Learning Disability’ and ‘Special Educational Needs’ have particular definitions in certain contexts, predominantly in Education or Health policy and procedures. However, they are also often used interchangeably and less precisely which can lead to misunderstanding about what is intended.9 The terminology of Learning Difficulties and Learning Disabilities is used within the Review as identified within the information provided by agencies, otherwise the wider term Learning Difficulties will be used in the Review. 2.3.12 Little information is recorded about 11111 health, although there is reference 11 111 111111111 1111111111111111111. 2.3.13 1111is recorded as having serious learning difficulties. She spent some time in an independent school for children with behavioural, emotional and social needs and was subject to a statement of Special Educational Needs. She is also known to have 1111111 111111111111111 1111111111111111111111111. 2.3.14 111 was subject to a statement of Special Educational Needs; due it appears primarily to low attendance at school and the consequent 9 Se Appendix D for more detail. RBSCB Overview Report 22 impact on basic skills including literacy and numeracy. She also suffered from asthma. 2.4 Information provided by the Young People and their families 2.4.1 111111111111111 provided the following information and views to the Review: 2.4.2 111 described her family as complicated and said that there were lots of problems in the family relationships before she or 1111111111 were subject to the abuse. She believed that the family had needed help from agencies when they were all much younger and said that her mother had asked for help many years ago, but this had not been provided. 2.4.3 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.4.4 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.4.5 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.4.6 111111111111111 provided the following information and views: 2.4.7 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 RBSCB Overview Report 23 2.4.8 1111111111111 provided the following information: 2.4.9 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.4.10 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.4.11 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. 2.4.12 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.4.13 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.4.14 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.4.15 1111s parents contributed the following information and views: 2.4.16 1111 parents felt that agencies had really failed to work together, to listen to them or to keep them informed. 1111 father said that he spoke to CIT regularly and had had between 40&50 phone calls with Children’s Social Care alerting them to the problems they were having with 111, including her uncontrollable drinking, running away and difficult behaviour. 2.4.17 They had been told that CIT had informed CSC that their daughter was being groomed and so they should have done something. They RBSCB Overview Report 24 also understood that the school had been pressuring Children’s Social Care to take action. They said that if they had had family who lived away from the area they would have sent their daughter to them in order to get her away from it. But as they did not have anywhere to send her they begged CSC to help them and asked that they remove 1111. 2.4.18 111 father described being told by Social Workers that his daughter was a child prostitute and was angry that he accepted this because he did not know that it was wrong and feels that Social Workers gave him bad information. He has felt guilty since that because of what he was told he also thought his daughter was a prostitute. 2.4.19 Their experience of the police was that the police officers who attended and who would return their daughter to them were good but that the Police and CSC weren’t good in 2008 They felt that things had changed when the new CPS Chief Crown Prosecutor for the North West looked at the case again, which they understood was as a direct result of CIT putting pressure on him. They also felt that the police who took over in 2010 were good and he is still in touch with DC5 who had since left the Police Force. 2.4.20 111s parents said that she had only been friends with 111 for about 6-10 weeks before the problems started. They had met her when she came to their house and thought that she was ‘OK’. When 111 first moved out and went to live with AdultD her father went to meet him and had thought that he was OK and she would be safe there. But then the police would remove her from the house and bring her back. One police officer said he would not let his own daughter stay with that family and the parents also believed that Children’s Social Care knew about the family and did not tell him. 1111 said that in response to what the police officer had told him, he said he would lock his daughter in her room, but the police officer said he could not do that as it would be false imprisonment. 11111 said that there were no boundaries in Adult D’s house, with pornography on the television all the time and very sexual behaviour. 2.4.21 111 parents spoke emotionally about trying to bring their daughter back from AdultD’s house, waiting outside in the car for her, not knowing what else to do. 2.4.22 11111 parents recognised that 1111 was also a victim of the abuse, but do not feel able to forgive her for the way she recruited the other girls. He believes that she should have been charged even though she was a victim herself. 2.4.23 They said that sharing information between the agencies was problematic and that the way they responded was not acceptable. 1111 mother said that sexual exploitation was still going on, but they did feel that agencies’ responses had improved and they were more RBSCB Overview Report 25 responsive now. They felt happy about the Social Worker who was now working with them and their grandchild who they feel has tried to put things right. 2.4.24 1111’s parents believe that she is still suffering from post-traumatic stress disorder. They also felt strongly that the way services responded was because of their attitudes to class “it’s what they expected of our children”. 2.5 RELEVANT HISTORICAL INFORMATION Agencies were required to provide a summary of any relevant information known to them prior to the period identified as the focus of this report. The purpose of the information which is summarised in this section is to provide historical background information to better provide a context as to the young people’s experience. Replacement for redacted Section 3 3 INFORMATION KNOWN TO AGENCIES DURING THE TIMESCALE OF THE SCR As with all SCRs a comprehensive chronology was prepared and detailed the relevant contact episodes between YPs1-6 and each agency. Each IMR and the Health Overview Report included a full detailed chronology and narrative containing all the information regarding the agencies’ involvement with each of the young people individually. The detail cannot be published for legal reasons. This section therefore provides a summary of the young people’s experience collectively during the period under consideration. Section 4 will critically analyse the detail of events and contacts with agencies. 3.1. YPs1-6 had considerable involvement with a very wide range of services in Rochdale including Children’s Social Care(CSC), Health Services; the Police and voluntary organisations. The young people came from three different families. They did not all know each other, but there were some links between them. All of the six young people experienced significant and serious sexual exploitation at some time during the period under consideration by a group of “Asian”10 men in Rochdale and elsewhere, who they met in takeaways and through contact with taxi firms. The impact for all of the young people has been considerable. 10 The term Asian is used within this Review where this is the terminology used by the agencies involved with YP7. RBSCB Overview Report 26 3.2. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 3.3. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. The mother of some of the young people repeatedly raised concerns, for example with the police, about the men they were spending time with and their safety. On a number of occasions allegations which can now be clearly seen as being about sexual exploitation and assault, were made by some of the young women. There was also a significant amount of information that should have alerted agencies to the likelihood that the young women were experiencing some sort of serious abuse, whether or not this was understood at the time to be child sexual exploitation. There was however a pattern of these allegations either not being properly referred to the lead statutory agencies (Police and CSC) or investigations not being effectively concluded when referrals were made. 3.4. A number of the young people 111111111111 at an early age and required access to other health services which would be expected to raise concerns about their well-being given their young chronological, emotional and developmental ages. There was repeated information being provided to and between various agencies about the young people being involved in sexual activity with a number of older ‘Asian’ men. It was also the case that some of the young people were said to be involved in sexual activity with a white man and his sons, with whom they were loosely connected and where they lived for periods of time. Sometimes the information about sexual activity with older men included information about violence or threatening behaviour to the young people. Another feature was a pattern of attendance at Accident and Emergency Departments, frequently in the early hours of the morning, sometimes following injuries or overdoses. Mental health services had some involvement as a result. 3.5. Two of the young people, who were siblings, and became subject to Child Protection Plans for an extended period as a result of the police being given specific information regarding the possible sexual exploitation of a number of young people. This resulted in a lengthy police investigation by detectives in Rochdale, but none of the men RBSCB Overview Report 27 concerned were charged at that time, as a result of the advice of the Crown Prosecution Service. This was due to a significant degree to the CPS view of the young people’s credibility as witnesses. This investigation was subsequently re-opened in what was to become known as Operation Span and ultimately led to the prosecution and conviction of a number of men in 2012. Throughout the time the young people were on Child Protection Plans there was information to indicate that they continued to be abused. 3.6. At times the young people were unable to live in their family homes and spent periods living in hostels or supported accommodation. 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. 3.2 History of the Criminal Investigation and development of Operation Span 3.2.1 The purpose of this section of the Review is to consider the role played by the Police in the multi-agency response and safeguarding of the 6 young people as a result of their investigations, culminating in Operation Span. It is important to state that it is not its role to detail and analyse the response of the Police primarily from a forensic perspective. This section will provide factual information about actions taken, analysis will be considered in Section 4. 3.2.2 Operation Span was the major police investigation established in late 2010 as a result of a recognition that organised child sexual exploitation was taking place in Rochdale. With hindsight the Police have identified that there was relevant information known to the family of 1111111 as far back as 2002. By 2004 the Police recorded that 11111111111111 was believed to be having sex with ‘Asian’ men. There was reference to her ‘prostituting’ herself by both family and the Police and this information was referred to the Public Protection Unit, but there is no record of any further response. 3.2.3 Similar information began then to be identified both by the Police and by other agencies in relation to all the young people subject to this Review and has been noted in Sections 2 and Sections 3.1-3.6. Other young people, not subject to this Review, were also being identified in similar terms. 3.2.4 In February 2007 DCI1 from the Rochdale Division had written to the CPS raising concerns about the CPS decision not to prosecute following an allegation of physical and sexual assault against 111 in RBSCB Overview Report 28 October 2005 (See Section 2.4.1). In this letter the DC1 identified an awareness of potential child sexual exploitation within Rochdale. 3.2.5 During 2008 and 2009 investigations were undertaken by Rochdale Division CID into the rape and sexual exploitation of a number of young girls, including 111111111111111111. These investigations arose in part out of the events of August 2008 involving 11111111111 as well as incidents involving other young people. The initial investigation centred around two takeaways in the Heywood area of Rochdale in which girls were supplied with food and alcohol and sometimes drugs, in order to procure sexual acts with a number of ‘Asian’ males. 3.2.6 During these investigations it was also identified that 111 had also been exploited by a white man, AdultD, as had 111111111111 . There was no known connection between the ‘Asian’ males and AdultD, the connection instead arising in relation to the victims, not the perpetrators. The crime report written as a consequence by DC6 in August 2008 was the first evidence of an operational police officer, identifying to more senior officers that this appeared to be “part of a larger scale sexual exploitation case with other potential victims”. 3.2.7 Two men, 1111111111111111111111111 were arrested and interviewed following interviews with 111. In July 2009 DS1 submitted a request for advice to the CPS as to whether they should be prosecuted for rape. The case was reviewed by a Senior Crown Prosecutor, CPS4 who sought a second opinion from CPS6 as he was required to do given the allegation. The decision from the CPS was not to prosecute as 111 was considered an ‘unreliable witness’. 3.2.8 1111 had also been arrested 111111111111 for causing criminal damage and theft at the takeaway. She was bailed and a file sent to the CPS for authorisation to charge her, but this was refused by the CPS. However in 111111111111 CPS was informed by 111’s solicitor that 111 had been summonsed for criminal damage. The CPS contacted the police and the charge was subsequently discontinued. 3.2.9 The Police investigation into possible sexual exploitation of young people by both the group of ‘Asian’ men and by AdultD continued throughout 2009 and was undertaken by Rochdale CID. Video interviews were undertaken with a number of young people, although many of the victims would not engage with the police. 3.2.10 In February 2010, a second investigation was in effect begun, led by DI1, the officer in charge of the Public Protection Investigation Unit in Rochdale Division. The Sunrise team was also now in operation and was based within the PPIU. In April 2010, DI1 sent a Divisional Investigative Assessment report to her line manager, a member of the Senior Leadership Team for the division. The nature of a DIA report being to ensure that any investigation ‘which may represent a threat to the division and or the Force, or is too big or too complex for the RBSCB Overview Report 29 Division to investigate themselves” is formally assessed. In this report DI1 requested additional resources to investigate child sexual exploitation in Rochdale either from within the division or from the wider Force. No extra resources were provided and the report was not submitted to Force Command as would have been required for any consideration of further resources from the wider Force. 3.2.11 In September 2010 the PPIU at Rochdale began the first of a series of interviews 111111111 which took place over a 7 month period. This was effectively a re-documenting and assessing of the allegations made 11111111 in 2008, but now with specialist child protection officers conducting the interviews. During this period AdultD was also re-interviewed following further disclosures 11111 , however this was not progressed to a charge until August 2011, due to a decision by the Reviewing CPS lawyer to concentrate initially on the larger group of offenders who were subsequently covered by Operation Span. 3.2.12 In December 2010, a Gold meeting11 took, place chaired by the Assistant Chief Constable, ACC1, the investigation was designated a “critical incident’. As a result a dedicated investigation team, Operation Span, was set up and a new Senior Investigating Officer, DSuper1, was appointed. The team was overseen by an Assistant Chief Constable, and moved from the Rochdale Division into a Force Major Incident Team. DSuper1 contacted the CPS lawyer, CPS8, in December asking for a reconsideration of the evidence obtained from the second investigation. CPS8 subsequently wrote to the then Chief Crown Prosecutor for the North West, CCPS1NW, and the then Head of the CPS Complex Casework unit, CPSCCU1 identifying “widespread child exploitation in the Rochdale Division” and the need to review previous charging decisions. As a result the case was transferred to the CPS Complex Casework Unit and allocated to CPS2. 3.2.13 An experienced Detective Constable, DC5 was appointed specifically to work with 1111111111111 as it was recognised that they had very little trust in the police. In February 2011 a decision was made in consultation with the CPS 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 3.2.14 In June 2011 the Chief Crown Prosecutor for the North West overturned the decision taken by CPS4 in July 2009 regarding the charging of 11111111111111111. The two men were prosecuted and convicted at the trial in February 2012. 11 Gold Meetings are a Police Force Leadership level response to a potentially critical incident. RBSCB Overview Report 30 3.2.15 This investigation led to the trial of 10 men at Liverpool Crown Court in February 2012 and the conviction of 9 of the defendants in May 2012. 1111111111111111 were all identified as victims of these 9 men. 3.2.16 AdultD was also convicted of offences 111111 following a trial and sentenced to 4 years imprisonment111111111111111. RBSCB Overview Report 31 4 CRITICAL ANALYSIS 4.1 Introduction 4.1.1. This analysis is based on the individual Agency contributions to the Review, additional material and meetings with key personnel as identified in the methodology, discussions held within the SCR Panel and the author’s own contributions. 4.1.2. IMR authors were required to structure their reports using the Key Lines of Enquiry established within the Terms of Reference as these represented the starting hypotheses. All of the Terms of Reference, including the Key Lines of Enquiry which provided the working hypotheses for consideration within this review have been considered and used as the starting point for this analysis. 4.1.3. This Review, which has considered the experience of 6 young people over a period of more than 5 years, has generated a very significant body of material. The IMRs have analysed the actions of their agencies in considerable, often forensic, detail. The focus of this Overview Report is not to provide a comprehensive analysis of all this information but to summarise the effectiveness and standards of practice and to draw out the key learning both for individual agencies and the multi-agency safeguarding partnership. 4.1.4. IMR authors were specifically asked to ensure that key people were interviewed and that there should be a focus on not simply what had happened, but why people thought practice and processes had either been effective or ineffective and what might have for example affected decision making. A significant number of key personnel have either since left the authority or as a result of internal proceedings not been in a position to be interviewed. This inevitably leads to some gaps in our understanding. 4.1.5. The critical analysis will therefore be structured using a number of significant themes which have emerged, using examples to evidence learning. The themes do not exist in isolation but are inter-related. Information provided outside of the timeline identified for Review (see Section 2.4), is subject to analysis in this section only where it provides significant contextual information, or leads to learning for current practice that would not otherwise be identified. A summary analysis of each agency’s involvement with the young people and contribution to this Review is included in Section 6, including details of what actions have been taken to improve services since these events took place. RBSCB Overview Report 32 4.2 Strategic leadership in relation to child sexual exploitation during the time frame “Effective leadership sets the direction of an organisation, its culture and value system, and ultimately drives the quality and effectiveness of the services provided.”12 4.2.1. The Overview Report was specifically required to consider the response of agencies to child sexual exploitation in Rochdale during the identified time period, from both an operational and strategic perspective. An analysis of the strategic response by Rochdale Borough Safeguarding Children Board and its relevant partner agencies is fundamental both in its own right but also in order to understand the context within which operational decisions relating to the young people were made at all levels and as a result provide some insight into why those decisions were made. This section will summarise the status of knowledge and policy development prior to and during the time line of this review and consider the strategic Rochdale response within this context. 4.2.2. The exploitation of children for the sexual gratification of adults is far from a new phenomenon, but what is comparatively new is a shift in societal understanding of this phenomenon. As recently as 5 years ago, the sexual exploitation of children was largely defined as child prostitution, by implication a disturbing social evil rather than something that was recognised unequivocally as child abuse. In May 2000 Supplementary Guidance to Working Together13, was published entitled “Safeguarding Children Involved in Prostitution”. The guidance required services to “treat such children as children in need, who may be suffering, or may be likely to suffer, significant harm”. However, the guidance also explicitly rejected arguments to decriminalise ‘child prostitution’ stating that: “The Government recognises there may be occasions, after all attempts at diversion out of prostitution have failed, when it may be appropriate for those who voluntarily continue in prostitution to enter the criminal justice system in the way that other young offenders do” . 12 Laming (2009:14) 13 Working together to safeguard children: statutory guidance regarding inter-agency working to safeguard and promote the welfare of children RBSCB Overview Report 33 New Guidance was produced in 2009, with a shift in terminology, now being entitled “Safeguarding Children and Young People from Sexual Exploitation” and with a less ambiguous approach to the safeguarding requirements. 4.2.3. Nevertheless, there was also a growing body of knowledge about the sexual exploitation of children by groups of adults, for example in children’s homes, but also as a result of a small number of high profile cases in towns and cities in the region. In 1999 5 men were charged, and 2 convicted at Leeds Crown Court following the sexual exploitation of 20 girls in a room above a taxi office. In Blackpool in 2003 following the disappearance of 14 year old Charlene Downes the police investigation identified widespread sexual exploitation in the town and Project Awaken, a specialist multi-agency team was set up in response and further convictions followed. In Keighley, West Yorkshire 2 men were convicted in 2005 following a major police investigation of up to 50 men believed to be involved in sexual exploitation. In 2007 major police investigations in Oldham, Blackburn and Sheffield all resulted in convictions of men involved in similar patterns of exploitation. This therefore was not a new or unknown phenomenon and it would be reasonable to expect that it would feature in Board discussions. 4.2.4. It has already been publicly acknowledged that although during these years there was developing national and regional evidence of patterns of Child Sexual Exploitation, professionals in Rochdale were generally not skilled at recognising or responding to CSE.14 There were relevant local multi-agency policies available, for example in relation to sexual abuse or sexually active under 18 year olds which would have provided help and direction. However, in common with the picture nationally,15 there were no policies specific to Child Sexual Exploitation or prioritisation of this issue from a strategic perspective effectively creating a vacuum in relation to local direction and offering some insight into why operationally practice in relation to CSE was often so weak. 4.2.5. In 2009 in response to the new Working Together Supplementary Guidance, the Safeguarding Board developed its own CSE multi-agency protocols in relation to Child Sexual Exploitation, but the absence of any arrangements to monitor the use of these protocols meant that the Board and its constituent agencies had no knowledge of their impact. It was not until 2012 that the Safeguarding Board produced its first Child Sexual Exploitation Policy and Procedure and a Performance Framework was put in place. 14 RBSCB CSE Themed Review Sept 2011 15 Barnardo’s (2011:2) RBSCB Overview Report 34 4.2.6. In effect, prior to 2007 there was no evidence of any leadership role taken by the Board with regard to CSE and no local guidance regarding either good practice or procedures was made available for staff. None of the agencies had CSE policies or procedures. In 2007 a CSE protocol was produced by the Board largely reflecting current government policy; providing information regarding warning signs and requiring practitioners to use the current Child Protection procedures should they have a concern. Also in 2007 the Safeguarding Board set up a Sexual Exploitation Working Group (SWEG) led by the Head of Service for Children’s Social Care. The Group’s remit included gathering and analysing information about the incidence of the sexual exploitation of children in the Borough and in 2008 a Sexual Exploitation Steering Group (SESG) was set up to: provide guidance and direction to the SEWG; report the findings of the survey to the Board; make recommendations for improvements. This effectively marked the starting point at which CSE was identified as a developmental task for the Board, however there is little evidence that this was led from the top or prioritised at a senior strategic level. 4.2.7. In June 2008 a report was provided to the Safeguarding Board which identified that 50 children were believed to be affected by, or at risk of, sexual exploitation in the Borough. This was noted to be a similar number to neighbouring authorities. The report further stated that the current level of intervention did not appear to be protecting the children and that there was a lack of a co-ordinated multi-agency approach. The conclusion of the report was that a multi-agency team (which eventually became the Sunrise team) should be established to respond to CSE in the Borough. 4.2.8. Progress in setting up the Sunrise Team was very slow from the outset with several months’ gap before the next planning meeting took place. The team did not ultimately become operational until January 2010. There had been significant problems reaching agreement between the agencies over the funding arrangements and then problems recruiting a Social Worker to the team. Having been recruited the Social Worker left after approximately 6 months in post, reportedly unhappy that the time intended for his specialist role was eroded by his being overloaded with other work. No information has been provided that would dispute this analysis, and this therefore provides further evidence that at this time there remained an inability to prioritise CSE at a senior managerial level. 4.2.9. A number of agencies and contributors, including the Designated Nurse, DesNCP and the named nurse, NNCP, both now retired, have described a lack of priority given to the issue of CSE at the Board. During 2009 following the agreement to set up the Sunrise team, three Board Meetings took place, but at none of them was CSE RBSCB Overview Report 35 minuted as having been discussed. Concerns were also expressed to this Review by DesNCP that the amount of time spent at the Board and amongst agencies on the funding arrangements distracted the focus from the needs of the young people. 4.2.10. The Sunrise team consisted of a Detective Constable from Greater Manchester Police, a Social Worker (Senior Practitioner), a Crisis Intervention Team Worker and a Drugs and Alcohol worker from Early Break. The team was located in the Police Public Protection Investigation Unit, but the workers remained the responsibility of their own agencies. A significant number of agencies and individuals have expressed concern about the slow development of the Sunrise Team even when it was established, including its lack of managerial oversight. Early Break was one of the agencies which described considerable frustration about cancelled meetings, lack of leadership and a failure to include their service in work undertaken to develop protocols for the team, to which they had committed a worker. 4.2.11. A report on the Sunrise team’s progress was undertaken for the Board in May 2010 and it was immediately apparent that the creation of a dedicated team had already led to the identification of a number of children at risk and referral of a ‘significantly increased number’ into statutory agencies. However, the report also identified significant vulnerabilities in relation to the work including lack of a clear management structure, operational guidance or supervision of staff as well as insecure funding. Of note was that members of the team were still working as individuals, in part because issues of confidentiality had not been resolved and there was a lack of co-ordination and problems with adherence to Safeguarding Board policies. 4.2.12. The first Independent Chair of the Board, described a continuing absence of any responsibility being taken for oversight of the team by the key agencies. A new manager was appointed to the Sunrise Team and although supervision was to be provided by CSC, this did not appear to lead to improvements, particularly in regard to the development of policies, procedures and establishing the remit of the team. The Chair reminded the senior strategic managers in CSC of the new manager’s need for support, but without success. Eventually the Chair met with the newly appointed manager herself on three occasions to support her in the task. The Chair was acutely aware that this was outwith her role, but nevertheless felt that given the inexperience of the manager who had been appointed and the absence of any progress in resolving the operational issues for the team, the risks of not doing so were greater. 4.2.13. Whilst the creation of a specialist team is generally viewed as best practice given the complex nature of Child Sexual Exploitation, it is crucial that it is part of an overarching strategy including clear guidance regarding the roles and responsibilities of other agencies and practitioners. It is not evident that there was any underpinning RBSCB Overview Report 36 strategy within which Sunrise played its part. Rather it appears that the development of Sunrise was developed before there were any strategic agreements as to how the team would fit into the broader picture of multi-agency working. This included weaknesses across the wider remit of the Local Authority, for example in relation to linking work within the wider community or disruption activities with the licensing authorities. 16 The lack of such a strategy can only be seen as a significant failing in the collective leadership, leadership which should have been provided by the core statutory agencies. This lack of leadership had significant consequences for the quality of operational delivery and provides some explanation as to why practice in relation to CSE failed to improve and was so poorly co-ordinated until comparatively recently. 4.2.14. A repeating concern that has been raised within this Review has related to the ability of the Board to meet its statutory functions, ie: co-ordinating multi-agency work and ensuring its effectiveness.17 An understanding of the history and functioning of the Board is helpful in providing context to the difficulties it continued to experience in progressing the work of the agencies. From 2004 Boards were permitted, but not required to appoint Independent Chairs, an approach which has subsequently been recognised as creating a weakness in ensuring accountability and establishing strong partnership working. The Board had not had an Independent Chair, prior to August 2010. It had, since its inception, been chaired by either the Director or Assistant Director of Children’s Services. 4.2.15. A number of agencies and contributors have commented on the central role held by Children’s Services in decision making on the Board during this time to the unhealthy exclusion of other partners. The practice of appointing Chairs exclusively from Children’s Social Care is likely to have been a contributory factor to the poor functioning of the Board, particularly with regard to a culture of shared responsibility. 4.2.16. The first Independent Chair of the Safeguarding Board was appointed in August 2010. She was informed that the Board had not evolved adequately from when it was an ACPC (Area Child Protection Committee) and was asked to review the Board structure and function. In consultation with the then Executive she established a new 2 tier structure alongside and a new multi-agency quality assurance framework. A survey of staff across agencies which was undertaken later that year by the Board confirmed this perspective that staff viewed Children’s Services, as in effect the Board. The Independent Chair described what she believed were long established cultural and practical problems in partnership working at a senior level 16 see RBSCB (2012) and Klonowski (2013) 17 Sections 14 & 14a Children Act 2004 RBSCB Overview Report 37 combined with external political and economic pressures which provide some insights into why the Board was proving so ineffective. These perspectives were also reflected by a number of other contributors as well as some of the factual information provided. They include: Role and status of Children’s Social Care on the Board. A lack of political interest in the activities of the Board and the significance of prioritising child protection and responding to sexual exploitation. Historic and continuing political instability, with frequently changing or hung leadership in the council. Major resource issues, with the Local Authority required to make spending reductions of £52 million for the 2011/12 financial year. This was as a result of the Comprehensive Spending Review, a freeze on Council Tax and increased demand for social care services.18 The level of the funding cuts had come as a significant shock to the Authority. As a result of the spending review, major organisational change and loss of senior staff was being planned across the council. 4.2.17. Irrespective of the predominant role of Children’s Social Care on the Board prior to 2010, there was representation from all the key partner agencies and as such it could have been expected that developments would be cascaded through from strategic to operational managers and to front line staff. What has been of particular concern however is the lack of evidence that there was a clear channel of communication from Board members to their agencies. As such there existed a disconnect between information being presented and discussed at the Board and actions taken at an operational level within the agencies. A further example of this is that despite the June 2008 report being received by the Board and identifying the need for a specialist team, there is no evidence that this knowledge at a strategic level impacted on the response of agencies to the crucial allegations made by 111 in August 2008 4.2.18. A crucial example of this disconnect was the lack of response by Rochdale’s Senior Leadership Team (SLT) in 2010 to DI1’s request for additional resources for the police investigation. The Police IMR analyses this episode in detail, from the production of a comprehensive report by DI1 to the failure of the SLT to refer the investigation upwards to the Force Task Co-Ordinating Group responsible for allocating Major Incident Teams in complex cases. The decision not to refer upwards by the SLT has been acknowledged by them as a mistake and clearly identified by the IMR as an error of judgement. The Police have separately provided information to this Review about organisational changes which mean that such a request 18 Rochdale Borough Council Annual Report 2010/2011. RBSCB Overview Report 38 would be received directly by the Head of Serious Crime Division and the Head of the Public Protection Division for assessment. The effectiveness of this is illustrated in a number of significant Operations including investigations of child sexual exploitation, which have since been resourced centrally. Given these changes no further recommendations have been made in this Review. 4.2.19. Within individual agencies there are several examples of gaps, either in the knowledge of operational managers as to what was being considered at Board level, or the priority that they believed they should give it. For example the YOT deputy managers could not recall ever discussing the cases subject to this SCR during formal supervision sessions with the YOT Service Manager and there is no evidence that information about developments at the Board was cascaded down the management structure to practitioners. There has been considerable discussion as to where the responsibility for this lies not least in the Home Office Select Committee19 and also in the Report commissioned by Rochdale Borough Council and published in May 201320. Little that is helpful can be added to these discussions other than to reiterate that the disconnect referred to, with its consequent implications for YP1-6, is quite apparent in the information provided to this Review. 4.2.20. It is also apparent from the brief history provided that the Board, irrespective of the best intentions and hard work of some individuals within it, had struggled to achieve a meaningful role in providing leadership and accountability for the multi-agency partnership. The shift to appointing an Independent Chair appears to have marked the beginning of an important change. However, like any significant organisational change this was not easy to achieve. What has been informative in observing the process of the current review is that both within the IMRs and within the SCR panel itself there remains a significant cultural theme by which the Board is seen as external to its partnership members, raising questions about the degree to which there is a sense of collective ownership and responsibility. 4.2.21. What has also become very clear during the course of this Review is that it was not only in relation to Child Sexual Exploitation that there was an absence of leadership by strategic managers. In considering the service provided to these young people, there is a noticeable absence of any evidence that there was senior strategic management awareness of the quality of safeguarding practice or a proactive focus on supporting best practice at an operational level during the relevant timeframe. A quality assurance framework is understood to have been developed for CSC by the first Independent Chair prior to her appointment into that role. After her appointment a separate 19 Parliament: Home Affairs Minutes of EvidenceHC68 20.11.2012 20 Klonowski, 2013 RBSCB Overview Report 39 performance framework was developed for the Board itself, there has been no evidence provided that these were implemented. 4.2.22. There has, during the last year, been a major shift in the policy and practice approach to Child Sexual Exploitation, marked by formal reports to the Board by both the Sunrise team and Children’s Social Care in June 2013 and a formal launch of the policy and procedures in July 2013. The Sunrise team is now established with clear governance, including protocols and procedures and is managed by the GMP Divisional Commander. The team is now more clearly set within a strategic framework, with specific pathways for referral and allocation of individual young people to a qualified social worker within the team. A measure of its progress can be established by assessing it against the Barnardo’s checklist : Q: What system is in place to monitor the number of young people at risk of child sexual exploitation? A: The RBSCB has a full developed CSE performance framework and CSE report card. The framework is reported to the Board quarterly and a risk register is in place. Q: Does your LSCB have a strategy in place to tackle child sexual exploitation? A: The RBSCB has a CSE strategy the implementation of which is overseen by the CSE Subgroup and reported to the Board every quarter. The strategy is informed by local learning, national drivers, research and good practice examples Q: Is there a lead person with responsibility for coordinating multi-agency response? A: The Sunrise team (multi-agency CSE team) has a service manager. The Strategic lead for CSE is the Divisional Chief Superintendent from GMP Q: Are young people able to access specialist support for children at risk of child sexual exploitation? A: The Sunrise team is able to respond on an individual needs basis to young people at risk of CSE. The team comprises SW’s, health workers, Police officers, youth workers, and has input from YOT, EWS. The RBSCB has undertaken a CSE briefing programme (see table below) Q: How are professionals in your area trained to spot the signs of child sexual exploitation? Workstream Numbers Trained RBSCB CSE Agency Awareness Raising activity for staff & volunteers Face to face training = 5,609 Memo / online training = 16,757 RBSCB Overview Report 40 RBSCB CSE Seminars 89 RBSCB Specialist 1 Day Training for Managers 42 Youth Service Parental awareness sessions Parents / carers attended = 195 Young people attended = 31 RBSCB & Education PHSE Leads in schools 50 CSE In PHSE Sessions in schools 760 RBSCB & Youth Services Young People’s awareness Raising activity in schools (NB completed April 2012) Young people 9,019 TOTAL Numbers Professionals 22,547 Young People 9,810 Parents / Carers 192 RBSCB Overview Report 41 4.3 The operational response: recognition of child sexual exploitation and the warning signs 4.3.1. As has already been noted, general professional understanding and therefore recognition of CSE was at a comparatively early stage in 2007. Accessible mainstream research was limited and the terminology of ‘child prostitution’ used in government guidance (and reflected in the RBSCB CSE protocol of 2007) was unhelpful by current standards although it was updated in 2009. However, the Supplementary Guidance to Working Together, which included information on identifying children ‘involved in prostitution’, had been available since 2000 and should have been a key reference document for agencies involved in safeguarding children. 4.3.2. The route to recognition of CSE was as a result of either direct allegations or by significant warning signs and indicators which could have triggered a hypothesis of CSE or some other form of significant abuse in the young people. What has become evident in relation to all these young people, is that despite considerable information being available to many of the agencies that they were extremely vulnerable and that there was evidence they were involved sexually with older men, the possibility that they were experiencing sexual exploitation was not recognised by the key statutory agencies until the middle of 2008. It is also the case that agencies also often failed to understand the degree to which the young people continued to be exploited even when child protection procedures had been initiated. 4.3.3. The practitioners first known to have ‘named’ what was happening were the sexual health workers within the Crisis Intervention Team (CIT), who stated explicitly that the young people were being exploited. This team had regular contact with young people specifically in relation to sexual activity and as such were perhaps in a position to see patterns of behaviour more clearly than some other agencies. In 2006 CIT contacted Children’s Social Care twice stating their concerns that 111 was being sexually exploited. CSC concluded that no Strategy Meeting or assessment was necessary nor was any action required other than offering support. 4.3.4. The response by CSC to this and the level of understanding it revealed was wholly inadequate given the nature of CITC’s referral which stated: “I believe that 111 is being sexually exploited and manipulated by a number of adult men. I also believe much of 1111s sexual activity is non-consenting and done under duress and threats of violence. I also believe 111 is given substantial amounts of drugs and alcohol in order to further impair her judgement.” The reason that CSC noted for not taking further action was that there was inadequate evidence regarding sexual exploitation, but in the absence of a proper investigation it is difficult to see how this conclusion was reached. Given that the information being provided by CIT identified potential RBSCB Overview Report 42 criminal offences against children, it was incumbent on CSC to contact the police and initiate a S47 enquiry, instead of which it would appear that a decision was made solely by CSC. Given the very limited information available it is difficult to conclude why this specific judgement was reached. However, the contributory factors which are likely to have undermined good practice include: lack of knowledge base regarding CSE and the controlling nature of the men’s relationship with the young people; lack of good supervision and support; lack of agency understanding of CSE. 4.3.5. The unclear way in which CIT at times shared concerns with other agencies is considered further in Section 4.5. On this occasion CIT recorded that this particular information had been shared with the PPIU although the exact nature of what was shared is unclear. Whether the police should have taken action on this particular occasion is therefore difficult to judge. Nevertheless there is evidence that CIT did share concerns with the police prior to 2007 but that this did not lead the police to consider criminal investigation. Other agencies also recorded their understanding that this lack of active response by the Police was because 111 was over 16 and therefore there was little action that could be taken. Exactly what had been said by the Police that led to this understanding is unknown, but what is clear is that the Police were struggling to recognise the nature of CSE or to know how to intervene effectively at this time. 4.3.6. Greater Manchester Police had access to information from as early as 2004111111111111111111111111111111111111111111111111111111111111. The police were frequently contacted by the family and the IMR notes that their mother’s “repeated and clearly expressed concern that her daughter was consorting with middle aged Asian males was regularly recorded but rarely caused anyone to examine or action these reports.” The IMR suggests that the frequency of 111 being missing from home led to a sense of apathy amongst police officers and as a result there was no consideration of any further action as long as she or her siblings were “alive and returned home”. 4.3.7. At this time no specific local procedures existed in relation to children missing from home and therefore there was, for example, no trigger point at which the Police would have been expected to refer a young person who was frequently missing to Children’s Services. Given the passage of time it is difficult to reach any conclusion as to whether this gap has implications for current practice. The Police deal with very high numbers of missing people with approximately 12,000 children being reported missing per year across Greater Manchester21. However, GMP did have a dedicated Single Point of 21 A standardised approach to dealing with missing and absent people of all ages across Greater ManchesterPart A:Children and Young People (2012) RBSCB Overview Report 43 Contact (SPOC) for Runaways and no information has been provided as to why consideration was not given to making a referral to Children’s Social Care. In particular the SPOC, or the PPIU might have been able to recognise a concerning pattern of behaviour even though this evaded the attending police officers. Rochdale Safeguarding Board and Greater Manchester Police now work to the Greater Manchester policy regarding missing children22 As a result, frequent episodes of running away from home is now recognised as a potential indicator of child sexual exploitation and with hindsight this episode typifies the warning signs which are now more widely understood than was the case at the time. 4.3.8. Two incidents involving 11111 that took place prior to the timeline for this review are of particular concern and need further examination in relation not only to the response of the Police, but also of the CPS. These are of particular note given that the combined response of the Police and the CPS had a significant impact on the way in which events subsequently unfolded. 4.3.9. In September 1111111111111111 family reported to the police that she had been raped. There was no evidence of any investigation of this allegation at the time and in the words of the Police IMR “the fact that she was alive and had returned home appears to have been sufficient for police purposes to treat the incident as having been concluded”. An officer from PPIU who subsequently visited the family was also reassured by the sisters that they were just friendly with a group of ‘Asian’ males, which given the age difference and the concerns of their mother should have triggered a much more inquisitive mindset. 4.3.10. Less than a fortnight later the police were contacted by 111’s mother reporting her as having been driven off by three adult males and found111 in a distressed state above Rochdale. On this occasion there was a police investigation and a file of evidence was sent to the CPS, which decided not to authorise a charge. A significant factor in the decision making by the CPS was the perception of 111’s credibility,111111111111111111111111111111111111111111111111111. The CPS advice was therefore based very considerably on consent by 111 although given that she had also been physically assaulted , sustaining injuries the issue of consent could not have been an issue in relation to this allegation. It was also the case that the issue of consent did not need to be a consideration given her that 1111111 16.23 The CPS IMR further notes that the CPS focus appeared to be in looking for failings in the prosecution case rather than considering the weaknesses in the case for the defence. It is indicative of the approach taken that in assessing the evidential 22 as 27 23 Sexual Offences Act 2003 RBSCB Overview Report 44 criteria the lawyer noted: “the aggrieved is a young lady who is known for going with men and in particular Asians in this type of situation.” 4.3.11. Although a Detective Chief Inspector from Rochdale did subsequently write in general terms to the CPS with concerns, no formal appeal was made by the Police against the CPS decision, as they were entitled to do. The failure by agencies to pursue their concerns with other agencies is a repeating theme of this Review. Since these events there has been significant recognition by the CPS of the failings in their decision making at the early stages of these young people’s experience and the need for a shift in mindset, policy and procedures. New guidance24 from the CPS emphasises the requirement for periodic proactive joint review of cases by police and CPS lawyers in cases of child sexual abuse. The CPS is also developing a new approach to enable victims to appeal against decisions in their cases. 4.3.12. Whilst this is likely to provide an important safeguard in future decision making, it is the view of the author that the significance of the lack of police challenge to the CPS, which has been acknowledged as a feature of this case, requires more than a reliance on CPS procedures and merits active consideration on the part of Greater Manchester Police. This episode combined with the frustrations regarding allocation of resources felt by two experienced Police Officers, one of whom DI1, was evidently particularly committed to pursuing the investigation of CSE, suggests that this is part of a wider difficulty in challenge within the Police. GMP has provided examples to the Review to evidence that it is making progress in creating a significant shift in culture to encourage greater challenge and where necessary escalation by officers. However this issue is a longstanding and complex challenge for the Police which like any organisational cultural change will require persistence and objective review in the long term. A specific recommendation is therefore included in this report at Section 6.11 to establish a system which will monitor and review the use of escalation with regard to safeguarding cases both internally and to the CPS. This can then be linked to the escalation policy of the RBSCB. Such a recommendation is clearly not intended as a ‘quick fix’, but as a supporting contribution to a wider approach to organisational change given the experience of these young people. 4.3.13. A further defining incident also took place in August 2008 111111111111111111 were found at a takeaway and specific allegations of sexual abuse were then made to the police by 111 and other young people. This resulted in the first explicit police and multi-agency recognition that child sexual exploitation had taken place. From this point on police investigators appear to have understood that they were dealing with Child Sexual Exploitation. It should also have led, and as we now know, could have successfully led to criminal 24 CPS: Guidelines on Prosecuting Cases of Child Sexual Abuse Oct 2013 RBSCB Overview Report 45 convictions. A police investigation took place although it was nearly 12 months before a file of evidence was sent to the CPS for a decision regarding charging. That the investigation took this length of time is of concern and has been considered in the police IMR which concludes that it was in significant part due to a lack of resources being provided for this investigation. 4.3.14. The investigation was taken over by a Detective Sergeant from CID in the autumn of 2008. This officer unlike his predecessor had no specialist child protection expertise and it is likely that this impacted on the progression of the investigation. The officer had initially believed he would be able to manage the investigation alongside other work, but by January 2009 had recognised that it was too complex for him to work on alone and wrote to the Detective Inspector seeking additional resources. In his e-mail he described this as “a lengthy enquiry with numerous people to arrest. It will have a high profile within Social Services with many multi-agency meetings.” One multi-agency meeting did take place as a result, but the investigating officer never received a response from the Detective Inspector regarding the issue of resources and so he carried on the investigation without the benefit of further resources. 4.3.15. The investigating officer with hindsight regrets that he did not pursue the matter further, again illustrating a lack of a culture of internal challenge within the police. What it further illustrates is that at middle management level in the Rochdale Division there was a failure either to recognise or to prioritise child sexual exploitation at this time. As has been noted previously, it further illustrates the gap between what was taking place at Board level and the way in which operational decisions were impacting directly not only on this investigation but the also on Police capacity to engage some of the young people in their investigations subsequently. 4.3.16. The file of evidence having been submitted to the police in August 2009, a decision was again made by the CPS not to charge the two alleged offenders. The CPS IMR analyses this decision in detail and identifies some key errors in the way the judgement was reached. These included a mistaken view that DNA evidence could have been effected by cross contamination and a focus again on the credibility of 111 as a witness. The IMR points out that the DNA evidence would in any event clearly have proved that an offence of Sexual Activity with a Child under 1625 had taken place. But also considers that had further information been sought about the pattern of abuse against the young people “the broader picture of child sexual exploitation would have emerged”. 4.3.17. It is apparent that the CPS analysis of the evidence was significantly influenced by perceptions regarding 111’s credibility and a lack of understanding of sexual exploitation. The CPS lawyer, as was 25 Section 9 of the Sexual Offences Act 2003. RBSCB Overview Report 46 required, sought a second opinion, however as this opinion did not review any of the evidence, it was in the words of the IMR author “’devoid of value”. Given that the first lawyer was comparatively inexperienced the lack of any meaningful oversight of his decision making was particularly significant. It is notable that the lawyer providing the second opinion stated “It is a tragic case that one so young has fallen into this lifestyle and has been taken advantage of in this way.” This again demonstrated a failure either to recognise or to understand the nature of sexual exploitation and an assumption that 111 was making a choice, despite the fact that she had made a specific allegation of rape. The concept of being ‘taken advantage of’ should have been understood in that context. The failure to progress to criminal charges left the young people distrustful of the Police and more vulnerable to being exploited. 4.3.18. In contrast there was a totally different response by the CPS when contacted by Operation Span officers in December 2010. CPS lawyers on this occasion immediately gave the case a high priority and started from the viewpoint that 2009 decision should be overturned and the two men prosecuted. The lawyer allocated, CPS2, provided what is described as an excellent analysis of the evidence which in turn meant it was decided by the Chief Crown Prosecutor for the North West to overturn the original decision. 11111 Father told the Review that this decision was a direct result of pressure on the Chief Crown Prosecutor by CIT, but no other evidence has been provided to corroborate this view. A separate decision was also taken, despite some difficulties with the evidence, to charge AdultD. 4.3.19. Although it would be speculating to suggest a specific reason for the change in response at this point by the CPS, it is probable that a number of factors came together including: Quality of the police investigation and evidence provided. Growing understanding of the phenomenon of child sexual exploitation in the intervening period. Knowledge base, attitudes and skills of individuals within the CPS. 4.3.20. The response of Children’s Social Care to the young people in the early years repeatedly showed a lack of understanding of CSE both at the point of initial assessment and also in relation to repeat exploitation. The predominant response by staff in CSC was not to identify that the young people required safeguarding, but rather to focus on the problematic behaviour of the young people with limited evidence that practitioners analysed what was underneath the behaviour. This response did not represent an individual failure by individual practitioners but a pattern across a number of workers over time, unchallenged by their managers, suggesting that the problem was an organisational one. Examples include: July 2004: 15 year old 111 accommodated overnight after being taken into police protection. 111 spoke of wishing she was dead RBSCB Overview Report 47 and there was information that she was frequently in cars with adult males. 2007: information provided by CIT that 111, who was 15 years old, was 16 weeks pregnant, suffering from a sexually transmitted infection and had an older sister who had reportedly been sexually exploited 2009: Initial assessment of 111 concludes she is no longer at risk of sexual exploitation as her parents were protective and she had some support from agencies 4.3.21. The CSC IMR identifies a number of explanations as to why CSE was not recognised. Conversations with three social workers who were part of the duty and assessment team at the time suggested that the following factors influenced the practice: high workloads and difficult work environment lack of challenge by managers in relation to assessments focus on younger children in the wake of the death of Baby Peter lack of staff training on CSE a view that extra familial sexual abuse was primarily the role of the police. These explanations are certainly likely to have been part of the underlying context, although given the passage of time and the degree to which memories will have been influenced by the professional and public focus on these events, the degree played by hindsight in some of these reflections is difficult to assess. The high workloads in the duty and assessment team were specifically confirmed in the OFSTED inspection in 2009 and this led to a decision by the authority to increase staffing numbers. Other factors that impacted negatively on front line practice included: the lack of any assessment tool which would have helped to identify that aspects of behaviour were symptomatic of child sexual abuse Absence of child focused supervision by front line managers However relevant these explanations, they still fail to fully illuminate why child protection professionals faced with young people displaying a wide range of worrying warning signs, did not recognise that they might be experiencing significant harm. There has been considerable comment on the concept that Social Workers and others simply assumed that the young people were making a ‘lifestyle choice’ and this will be considered further in Section 4.4. 4.3.22. Whilst CIT, the Police, the CPS and Children’s Social Care were presented with direct allegations of exploitation many of the other agencies were aware of a range of information and warning signs which should have triggered greater concern and reflection as to what was happening in these young people’s lives, irrespective of whether RBSCB Overview Report 48 the concept of CSE was familiar at that time. Whilst there is now much greater professional awareness of the sort of indicators to look for26 many of the behaviours and indicators were visible to the different agencies. The Rochdale Borough Safeguarding Children Board, Multi Agency Protocol on Child Sexual Exploitation, 2007 included a section on Recognition which listed indicators including: physical symptoms eg sexually transmitted infections or bruising suggestive of either physical or sexual assault reports from reliable sources suggesting the likelihood of involvement in prostitution repeatedly consorting with adults outside the usual range of social contacts repeatedly consorting with children known to be involved in prostitution persistent absconding or late return a history of sexual abuse or poor self-image. Had practitioners referred to these Board procedures many of those agencies individually would have identified several of these indicators as being visible in the young people. Whether staff were familiar with this protocol is unclear but it has been suggested that it was not widely known or used. There is also no evidence that this information was either known or used by front line managers. 4.3.23. The Education Welfare Service for example has specifically noted that there was no process for the recognition and recording of Child Sexual Exploitation within supervision meetings at this time. This was despite the involvement of two senior managers from that agency on the Safeguarding Children Board during this period, which could have been expected to raise awareness of CSE. However, it is also the case that the focus for most Education Welfare supervision was largely on dealing with ‘next steps’ in difficult cases. The service has reported limited capacity given rising caseloads to consider any wider welfare issues or to look more broadly at the effectiveness of strategies in working with young people. As such the absence in any capacity to reflect on CSE in supervision was part of a wider problem for the service which has led to a Recommendation by that agency. 4.3.24. This further reinforces what has already been identified regarding the gaps in effective communication at a strategic level and the lack of a policy focus on CSE at this time. This will inevitably have been one of the reasons why the level of recognition was so limited. The absence of any system for audit regarding implementation or compliance meant that agencies themselves would not have been able to explain whether their staff were aware of the existence of the policy and if not, why staff were failing to make use of this tool. 26 reference Barnardos etc here RBSCB Overview Report 49 4.3.25. Significant information was available within the School setting and in relation to Education Welfare regarding concerns 1111111111111111111 from at least 2004. These were predominantly concerns about behaviour and absence from school, but also related to explicit racist attitudes and aggression towards ‘Asian’ pupils and that the girls were sexually active at a very young age. Several senior school staff did identify these as safeguarding concerns, even though they often did not fully recognise that Child Sexual Exploitation was taking place. Referrals and specific concerns about neglect were raised with Children’s Social Care but generally failed to lead to an effective response. The reasons for this will be considered further in section 4.5. 4.3.26. All of the young people had a high level of contact with a range of health provision and there was evidence of general recognition that the young people were vulnerable and had particular needs. However, this was not in the early stages, other than by CIT, translated into a recognition of CSE. 4.3.27. All the young people attended A&E on a number of occasions. in particular had periods of very frequent attendance often late at night, yet there is very little evidence that the underlying reasons for this was questioned by staff or by her GP who was routinely informed of the attendances. The recent “Shine a light” report27, a survey of Health Professionals prepared on behalf of the National Working Group commented that lack of recognition of CSE was felt to be a common problem nationally rather than something unique to a particular group of staff: “One Named Nurse for a Hospital Trust felt that A&E is the riskiest place in the hospital but there was a lack of awareness around CSE in that department. An experienced A&E Charge Nurse had said “when it comes to sexual exploitation, we do not know what we are doing”. A&E staff feel that they are just too busy to look fully into cases and “opportunities are missed when teenagers want to talk.” 4.3.28. A very significant indicator of sexual exploitation is early sexual activity, symptoms of sexually transmitted diseases and pregnancies at a young age. These were frequent features of the young people’s contact with health services, but nevertheless did not trigger consideration of Child Sexual Exploitation. 4.3.29. Two of the young people, 111111111111 accessed termination of pregnancy services at quite a young age and these occasions both created opportunities for those working in health to consider what was happening to them and what their wider needs were, but there is little evidence that this was the case. 111, who was then 14 years old, asked the School Health Practitioner for a pregnancy test which proved positive and was then referred to CIT. 111 told CIT that she 27 Shine a Light NWG 2013 RBSCB Overview Report 50 had had sex two weeks previously with a 21 year old man, that she had not seen him since and that she did not want her mother to know. The option of termination was discussed with her, but there is no evidence that the fact that this 14 year old girl had had sex with a man considerably older than her was pursued any further. It is of further note that three days later CIT recorded that a Strategy Meeting about sexual exploitation had taken place at which 111’s sister, 111 was discussed but no apparent connection was made with the circumstances of 111’s pregnancy and there is no evidence that this information was shared at the meeting. 4.3.30. 111 subsequently attended at the hospital for a termination. It is of concern that the focus appears to have been purely on the clinical need. There is no evidence that consideration was given to safeguarding concerns despite 111s age, the stated age of the father and her known home circumstances. Neither was evident curiosity aroused by the fact that she attended with a man identified as her uncle (father’s stepbrother.) This man’s name was not recorded, but it was stated “is supporting her but is known to the Child and Family Team”. This is unfortunately ambiguous as it is not clear if it intends to convey positive or negative knowledge. The fact that 1111 also had a sexually transmitted infection should also have triggered professional curiosity and concern as to whether this was in fact her first sexual encounter. 4.3.31. 111 was assessed during Court Proceedings 11 1111 as having a moderate learning disability, although there is no information that this was recorded in any previous health records. Nevertheless that several health professionals were unable to identify that 111 might be a young person with additional needs is of concern. It is also of interest that 111s notes include the following comment: “looks mature for her age”. The notes provide no explanation as to why this was relevant to the clinical decision, or whether in fact a judgement had been made linking 111’s sexual and emotional maturity with her outward appearance. 4.3.32. In February 2009 the 13 year old 111 also sought a termination. At the initial appointment with her GP it was noted that she did not appear to understand the implication of her pregnancy and both the GP and the practice nurse referred to her baby like behaviour. The Practice nurse also questioned her competence to make the decision. 111 told the GP that the father was “an older Asian male”. 4.3.33. 111 subsequently attended the Pennine Acute Hospital Trust for a termination accompanied by her mother. 111 was described as appearing to be finding the process very difficult and was aggressive. As a result an assessment was arranged a few days later with an adolescent psychiatrist who concluded that 111 did have capacity to consent to the termination. In any event 111’s mother also countersigned the required consent form. It was following this that the Police requested, and received from PAHT, the foetal material RBSCB Overview Report 51 resulting from the termination as potential evidence in relation to Operation Span. 4.3.34. 111’s GP had contacted the allocated social worker as 111 was subject to a Child Protection Plan, but there is no evidence in the IMR as to whether this was known to the hospital medical staff, or that hospital staff contacted Children’s Social Care or considered the implications. As with 111 the phrase “looks mature for her age” is included in the notes, with no explanation of its relevance. Given 111’s age, her evident vulnerability, her additional needs and the description of the father, good practice would have been to make further enquiries or refer to Children’s Social Care for a fuller assessment. 4.3.35. The Panel, and the Independent Author, considered that there was inadequate information regarding these events within the IMRs. As a result Pennine Acute, Pennine Care and Greater Manchester Police were all given the opportunity to provide further information and additional information was submitted by each of the agencies by the Panel members for each agency. 4.3.36. Pennine Care provided further information about the assessment undertaken by ConsPsych1, which had not been included in the IMR. The information is detailed and specific including reference 111’s views and evidence that ConsPsych1 sought reassurance that she had support. However, what has been acknowledged is that although the psychiatrist did consider 111’s wider welfare and recorded that others were involved, there is no evidence that ConsPsych1 adopted a pro-active role by contacting Children’s Social Care or the Police herself and sharing her knowledge and any concerns directly. In reviewing this episode, Pennine Trust has acknowledged that their Consent to Examination and Treatment Policy makes no reference to Safeguarding and that this is a weakness which is now being reviewed. 4.3.37. Greater Manchester Police have acknowledged that whilst their request to the hospital for the foetal material was lawful, and that they believe that the officer was acting in good faith, with hindsight this had not been handled in the most sensitive way and there was a lack of focus on the ethical issues. The Police Officer was concerned to find evidence as part of a serious criminal investigation. However, 1111 should have been informed. In any event the DNA testing was not able to identify a specific ‘offender’ at that time. However the sample was retained and in the Operation Span investigation it was confirmed that it linked to a man who was subsequently convicted of offences against 111. Whilst GMP describe information being given to 111 and her mother 11 111and obtaining express permission to resubmit the retained material for further testing obtained from 111, along with a DNA sample from 111 herself, her comments after the trial suggest that this remained an issue of concern for her. 4.3.38. GMP have informed the Review that in 2009 there was little guidance as to how to deal with such a sensitive subject, but this has since RBSCB Overview Report 52 been recognised as a weakness and in 2010 GMP produced a Human Tissue Act Policy which is itself currently under further review. 4.3.39. The Pennine Acute Trust IMR identified within its IMR a clear underlying theme of “poor recognition and practice regarding social issues and lack of recognition regarding child protection issues in young people particularly within the acute Accident and Emergency setting.” However the lack of any analysis by the IMR of the safeguarding practice within the setting of gynaecological or genito-urinary medicine represents a significant gap in the Trust’s learning. The reasons why there was no evident focus on the young people’s welfare concerns, not simply on the clinical or legal issues, within these departments, with their very different roles, procedures, focus and pressures from the A&E department therefore remains unknown. 4.3.40. The Pennine Acute Trust has stated that it was satisfied that it met all its required standards in relation to 111’s competence to consent to treatment. However this does not adequately answer the questions about whether health professionals concerned at this key point in 111’s story took a proactive approach towards her safeguarding, whether they knew or considered the implications of 111 being subject to a Child Protection Plan. The Health Overview has, as a result of this further information provided a Recommendation to health commissioners to review health services which provide sexual health services to young people and consider the extent to which safeguarding and child protection are considered as part of sexual health assessments. 4.3.41. The Pennine Acute Trust also provided additional information to this Review about the way in which the issue of 111’s termination and the subsequent request by the police was managed. The Trust has identified that ConsGyn1 ‘liaised’ with CIT, the GP, CSC and the Police. No further information of note has been provided, for example: the nature of any communication; who was spoken to and at what point; what was the purpose or outcome of liaison. Neither is there any corresponding information from any of the agencies concerned which might provide that information. What is therefore still missing is any evidence as to what impact this activity had on PAHT’s professional contribution to safeguarding, or whether the liaison was in fact purely related to the clinical role and the legal issues raised by the Police. The lack of any detailed information regarding what issues were taken into account in responding to the Police’s request, and also what focus there was on the safeguarding and ethical concerns for 1111 means that the quality of PAHT’s safeguarding practice in this setting remains unclear and an opportunity for wider learning has been lost. 4.3.42. This Review therefore recommends to Pennine Acute Health Trust that it gives further consideration to the implications of these episodes 111111111111111 4.3.43. The issue of the terminations has been considered in detail as they are particularly powerful examples of a gap between the response to RBSCB Overview Report 53 clinical need and the ability to recognise CSE and take a proactive role in safeguarding. They are not however the only examples which might have led to a consideration of some form of abuse or exploitation and led to action such as a referral to Children’s Social Care or consideration of a CAF including attendances for: repeated requests to the GP by 111 for emergency contraception episodes of self harm overdoses depression poor self care 4.3.44. Nevertheless there was also a not insignificant number of occasions when both health staff and others identified significant concerns about the young people, even though they may not have linked these to CSE. These included: 111111111 a Midwife identified a range of concerns regarding 111’s social history, including: father’s drug abuse; father of baby unaware of pregnancy; incidents of domestic violence within the family. Identification by 111’s school 11 1111 that outside of school she was “exposed to risks beyond her capabilities” Police and CPN raising concerns in 111111111 regarding home conditions 11111111 including Domestic abuse and drug and alcohol use. 4.3.45. The failure to connect these events in the young people’s lives with the possibility of sexual exploitation is likely to have been influenced by a number of factors. One recurring feature is the limited expectations of these young people evidenced by a range of professionals, which will be discussed in more detail subsequently. Another is the lack of CSE specific knowledge. What has also been identified is a particular impact within Rochdale as a result of national health policies on local priorities and culture. 4.3.46. Commissioners of sexual health services are required to ensure that health practitioners pay due regard to reduction of teenage pregnancy and sexually transmitted infection rates. Between 2000 and 2010 the UK had the highest rates of teenage pregnancy in Western Europe. Rochdale Borough in turn was identified as having one of the highest rates of teenage pregnancy nationally. There was also a greater than average incidence of sexually transmitted infection in young people below the age of 18 years locally. The drive to reduce teenage pregnancy, whilst commendable in itself is believed to have contributed to a culture whereby professionals may have become inured to early sexual activity in young teenagers . The culture from the top of organisations concerned with teenage pregnancy focused on meeting targets for the reduction of teenage conception and RBSCB Overview Report 54 sexually transmitted diseases sometimes to the detriment of an alternative focus - the possibility that a young person has been or is at risk of harm and action other than clinical responses are required 4.3.47. Irrespective of whether individual agencies or practitioners consciously identified that the young people were at risk of or experiencing CSE, what should have been clearly evident was that all the young people were extremely vulnerable. Whether or not it the label of CSE was in common use, there were significant indicators that the young people might be experiencing sexual abuse as well as at times, direct evidence of abuse. In particular the two sibling group 11111111111111 lived within families where there were longstanding problems including domestic violence, indicators of neglect, and in the case of 111111 the children had been subject to Child Protection Plans due to previous allegations of sexual abuse and neglect. All 6 young people evidenced challenging and worrying behaviour including being missing from home and very early sexual behaviour. 4.3.48. What should have been recognised, irrespective of the degree of understanding of CSE was that these were vulnerable young people, experiencing neglect and lack of parental care at a level which should have triggered safeguarding proceedings. Where this was recognised it failed to lead to effective intervention the reasons for which are explored further in the following sections. 4.4 The operational response: Understanding and engaging with the young people 4.4.1. Closely linked to the initial capacity to recognise CSE as a risk to the young people, was the degree to which the agencies showed an understanding of the young people’s lives and were able to build relationships with them. Whilst with hindsight we can readily recognise the indicators of what was happening, it would not always have been easy to reach a conclusion at the time that the young people were being sexually exploited. There was however enough shared knowledge over several years to identify that these were young people with longstanding problems and needs. 4.4.2. What was needed was a determination to understand those problems, including seeking to understand why the young women appeared to be living so much outside the home and what was the relationship between their family experiences and their “challenging behaviour” outside of the family. Professionals needed to adopt a determined and persistent approach in order to understand the young people and to engage their trust and involvement. Again the picture is mixed both between agencies and within agencies. There are however some common themes which are repeated throughout the 5 year period and with each of the 6 Young People, suggesting that where there were problems these were not simply a result of individual shortfalls in RBSCB Overview Report 55 practice, but part of a wider collective inability to understand and engage with the young people. Assessment: “Children in families without detailed assessment are four times more likely to suffer repeat abuse”28 4.4.3. The most critical weaknesses lay in the quality and timeliness of statutory assessments undertaken by Children’s Social Care. There were too many occasions when despite significant information having been provided by the young people or by others, Children’s Social Care failed to meet basic standards of practice in assessment and as a result were unable to understand their experience or establish trust and confidence in the young people. 4.4.4. Two Initial Assessments took place in quick succession in relation to 111 following the initiation of the police investigation focussed around the takeaway in 1111111. The first Initial Assessment undertaken in 111111 concluded that a Strategy Meeting was required, although the assessment itself is described by the IMR author as “minimal in content with no evidence of having used the assessment of needs triangle framework or having seen 111”. An Initial Assessment is by its nature a first brief assessment and there may have been difficulties meeting with 111 in the timescale required. However, there is nothing to suggest that attempts to meet her were actually made or that there was any acknowledgement that this was a significant gap in the Assessment that would need to be met before further decisions were taken. 4.4.5. What is inexplicable however is that the subsequent S47 Core Assessment, which took a further two months, was also completed without any contact with 111 and that both assessments were countersigned by the Social Worker’s manager. There is a fundamental expectation that children, including babies and very small children will be seen by the assessing Social Worker. Ascertaining a child’s wishes and feelings is a requirement of the Children Act 1989 and there is statutory guidance regarding the assessment process which constitutes an absolutely basic tool of social care assessments.29 For a Social Worker not to speak to a young person directly about experiences of which only she had full knowledge, is very hard to understand and appears to have set the tone for future engagement with her. 4.4.6. The assessment concluded that although the concerns that 111 had been sexually abused were substantiated she was not considered to be at continuing risk of harm. Such a conclusion, shows the serious shortfall in understanding of Child Sexual Exploitation and given the lack of involvement of 111 in the assessment, represents a disregard for her ability to contribute to the process and a failure to recognise 28 C4E0 knowledge Review 2010 29 Dept of Health 2000 & Working Together (2000 & 2010) RBSCB Overview Report 56 that she was likely to be the most important source of information. The assumption, frequently repeated in other assessments, was that 111’s parents could protect her, whereas even the limited information about the family history that was available might have suggested otherwise. There is also no reference to Social Work involvement in an Achieving Best Evidence30 interview which should have taken place. 4.4.7. The second Initial Assessment that took place in relation to 111 was in 1111111111 following a referral from the school after 11 had disclosed that she had had sex with 111111111 “well known family”. 111 was 15 years old. Again, the Social Worker did not meet 111, only with her parents. Her parents suggested that 111 had ‘fabricated’ the disclosure. There is no evidence that the Social Worker explored with the parents why they would think their daughter would invent these allegations, or why they did not appear to be more concerned about her being at risk. 111’s parents also reassured the Social Worker that they “took on board the seriousness of the allegations”. These two statements would appear to be quite contradictory and the Social Worker should have made efforts to speak to 111 by herself and reflected on the fact that this was a second allegation of possible sexual exploitation, this time involving different perpetrators, about whom there appeared to be some previous information. Again the assessment, which concluded with a recommendation for Intensive Family Support appeared to be focussed on 111 family, not on 111 and her needs. Again, the assessment was countersigned by the Social Worker’s manager in effect endorsing the assessment as being of the required standard. 4.4.8. Subsequent assessments in relation to 11111111 were focussed on her child, with the view of the social worker recorded that the concerns about 111’s contact with Adult D which led to the referral on this occasion did not warrant further investigation. Later in 2010 Action for Children raised concerns with CSC about 111’s emotional well-being and use of alcohol and agreed after discussion with the duty Social Worker to undertake a CAF. Whether, given what was known about 111’s previous history it would have been more appropriate for CSC to undertake an Initial Assessment at that point is probably debateable. However, the outcome of the CAF was for a referral to Children’s Social Care. An Initial Assessment was undertaken and concluded with a referral for family support. No information has been provided as to the content or quality of the assessment. It appears from the records that it was completed within one day and there is no information as to whether 111 was part of the assessment or what other information formed part of the assessment. It is noted however by the IMR author that the focus was on 111’s son. Another Initial Assessment took place in 1111111, but again there is minimal information as to content or quality, although again the focus appears to have been on 111’s 1111 30 RBSCB Overview Report 57 4.4.9. As such there were 4 formal assessments undertaken in relation to 1111 but very little evidence that any of these assessments were of a good quality or that 111 was properly engaged in the process. 4.4.10. Information regarding the assessment process for the other young people paints a very similar picture of limited historical context, no reference to chronologies, very little if any evidence of the wishes and feelings of the young people obtained and an over reliance on parental assurances. Historical information was known to Children’s Social Care regarding the family of 1111111111111 yet there is minimal evidence that this contributed to various Initial and Core Assessments which were undertaken. Significant historical information seems not to have been collated or understood, for example in July 2004 111 spoke of wishing she was dead which should have raised significant concerns, particularly given the specific reference to ‘setting fire to herself”. Nevertheless the Initial Assessment focussed on how her mother managed this behaviour, and failed to grasp the level of risk and need that 111 was demonstrating. 4.4.11. 1111111 had been subject to Child Protection Plans when they moved from Area D to Rochdale and there was evidently quite a lot known about the family, including concerns about parenting and risks to the children. In 111111111 there was a referral from the school in relation to 111. It was recorded that an Initial Assessment was initiated, but no evidence of it having been completed, although the outcome was a referral to CAMHS. There is no information in the records provided about what actions were taken in order to complete the assessment or whether 1111 was seen. 4.4.12. Another Initial Assessment was undertaken in 1111, on this occasion it would appear in relation to both 111111111. The assessment noted ongoing concerns about the mother’s chaotic lifestyle, poor home conditions, substance abuse and the children witnessing domestic violence. Again there is no information as to whether either of the young people was interviewed as part of the assessment. 4.4.13. What was notably lacking in these assessments was any sophisticated reflection about the young people’s family dynamics and what this might reveal about their current behaviour and circumstances. There is no evidence that any tools were used to contribute to the assessment for example, self-assessment questionnaires, genograms or chronologies, which given the complex history of this family would have helped provide a more robust basis for assessment. 4.4.14. Social Work Practitioners were also provided with completely inadequate management support and oversight. No evidence has been provided of meaningful, challenging or reflective supervision in relation to assessments. Direct evidence shows us that assessments which fell significantly below minimum standards were nevertheless countersigned by managers, in effect confirming to practitioners that they were meeting the standards required of them. Where there is RBSCB Overview Report 58 information recorded about supervision it is largely functional, detailing new pieces of information or confirming that an assessment was due for completion. There is no evidence of any professional discussion, which given the nature of assessment teams with their high work throughput and the complexity of the work undertaken is of particular concern. 4.4.15. The absence of meaningful supervision has been noted in the IMR but is not subject to a recommendation. However the supplemental report submitted by CSC has explicitly recognised this as an area of learning which requires urgent action and this is therefore included as a recommendation within this report (See Section 6.6) 4.4.16. The absence of assessment of the young people’s family dynamics led to a failure to understand their current problems in any context; a failure to recognise when their needs were not being met in the home including the existence of neglect; and also a failure to properly understand the families’ ability or commitment to protecting their children outside the home. 4.4.17. This Review has exposed significant shortfalls in assessment practice, not only in relation to the specific issue of Child Sexual Exploitation but also in regard to deep rooted family problems and neglect. Individual social workers have a professional responsibility for the quality of their practice, and in this case failings in the professional standards of some Social Workers have resulted in formal action by the Local Authority, as well as referrals to their professional body. However, the scale of the failings must indicate fundamental organisational problems. 4.4.18. A key indicator as to why the quality of assessments was so poor has been identified in information provided by the previous Assistant Director of Children’s Services. The Review was informed that the Borough had operated a policy for a number of years of investing in non-qualified social work staff. This policy was in the context of economic savings, but was also part of a wider decision in principle to move towards a more diversely qualified social care work force. It has been confirmed by staff working in the authority at the time that these staff were not simply providing different skills and experience, but required to take on aspects of the role that had previously been undertaken by Social Workers. This approach at times included, amongst other tasks, the completion of Initial Assessments. Parenting Assessments were also undertaken by non-social work qualified staff. It is likely that some of the staff undertaking Parenting Assessments had other relevant qualifications and may have been appropriately skilled and qualified, but this has not been evidenced. 4.4.19. The practice of delegating social work tasks to such staff was specifically criticised by OFSTED inspectors in 2009 and 2010. On at least two occasions non-social work qualified staff are known to have been required to undertake Initial Assessments (January 2007 para 3.2.3 and February 2010 para 3.4.46). Statutory guidance is explicit: “The Initial Assessment should be led by a qualified social worker who RBSCB Overview Report 59 is supervised by a highly experienced and qualified social work manager.”31. This practice, which the Review has been informed was ended in 2010 by the Assistant Director at the time, was dangerous, compromised both the young people and the staff concerned and was outwith statutory requirements. That such an approach was seen as appropriate provides an insight into the degree of focus on the quality of assessments undertaken by Children’s Social Care and the priority given to them by the organisation at this time. 4.4.20. This analysis has focussed on the quality of assessments provided by Children’s Social Care’s because of their pivotal role in the Child Protection process; however, problems with assessment were not unique to that agency. There were also significant problems in the quality of assessments undertaken by the YOT team, which given the social work component of this service is also of concern. The service uses nationally agreed tools for assessment, yet also acknowledges that assessments of vulnerability in particular were “worryingly inconsistent” with one practitioner rating 111 as ‘high risk’ and another as “not applicable”. 4.4.21. The YOT IMR has identified that this was a result of two particular issues: a capability issue in relation to one non-social work qualified staff member and the use of separate information systems for staff working with non-statutory and statutory orders. It has also emerged; as a result of this Review that there was confusion about who was responsible for the supervision of PAYP workers employed by the Youth Service but seconded to the YOT team. YOT managers appeared to be unaware that case supervision for this group of staff was their responsibility according to the Service level agreement and it is worrying that this had not been identified previously. PAYP workers formal supervision was sporadic and for several months did not include any discussion of 111. Whilst the worker felt supported on an individual level by the YOT Deputy Manager, what was missing was in depth discussion of cases on a regular basis to allow the worker to reflect and to ensure proper managerial oversight. 4.4.22. Whilst it remains unclear as to why workers did not routinely communicate with each other or why, at an operational or strategic management level, these problems appear to have been either unrecognised or unresolved, the YOT IMR has identified that these issues have now been resolved. In the last 4 years the YOT has been subject to 3 full inspections. These have reported marked improvements in management oversight, assessments and interventions. and the performance of the YOT in safeguarding young people has been graded as ‘Good’ on the past two occasions. Given this, no further recommendation will be made within this Review. 31 Working Together (2010; 147) RBSCB Overview Report 60 4.4.23. Whatever the actual quality of YOT practitioners’ individual understanding of the young people was at the time, there is little in the information provided to this Review to evidence that their knowledge and assessments were of a high quality. For example 111 attended a school for children with emotional and behavioural difficulties and was identified as having Special Educational Needs, information which was known to the YOT workers. Yet at no point did the YOT assessment identify the possibility of Learning Disability or Difficulties. Equally there is no evidence of any significant reflection as to the root causes of 111 often quite disturbing behaviour, such as her repeated assaults on teaching staff and her racist comments. What is instead presented in the YOT IMR is a somewhat narrow focus on the defined ‘offending behaviour’ with little accompanying context or recognition that the organisation was working with children in need. 4.4.24. That there was such a narrow focus on offending behaviour needs to be understood in the context of the national policy imperatives with regard to youth offending. Reform of the Youth Justice system began in the late 1990s culminating in the Crime and Disorder Act 1998. This resulted in a fundamental change from a ‘welfare’ approach focussed on the needs of young people to one overriding objective: “to prevent offending by children and young persons”32. This shift in policy has created a significant tension in managing the national policy requirements regarding Youth Crime whilst also responding to the safeguarding needs of young people. It has been acknowledged by the Service Manager that like other authorities the YOT in Rochdale found this a difficult tension to manage. The impact of these at times contradictory requirements on YOT staff is believed to have contributed to the poorer standards of practice when judged from a safeguarding, rather than an offending perspective. 4.4.25. Across the services there was a range of information about the young people’s families which should have led both to greater concern about the care they were receiving and to a more sophisticated and holistic understanding of their experience. What focus there was on family members was primarily in relation to the parents, particularly the mothers, and any immediately visible siblings. In common with what is known from many other Serious Case Reviews33 men in the family are often in effect invisible as was the case for 111111111111111, with professional involvement focussed on the young people’s mothers. There was however rich information regarding the wider family that either was not effectively shared or appears not to have been given any meaningful consideration. Examples of information that should have triggered further interest include: 111’s brothers had been involved with the YOT team over a 5 year period, but there is no evidence of links having been 32 Crime and Disorder Act, 1998 Section 37 33 ref biennials RBSCB Overview Report 61 made with 111’s experience or this knowledge about the family shared in child protection meetings. 1111111111 had previously had a child taken into care, which could have informed understanding of her own experience of being parented. Lack of analysis of 1111’s ambiguous relationship with her parents for example: her father accompanying her into the GP consultation regarding a gynaecological complaint; her unwillingness to allow her father to attend the CAF meeting 11 1111; information provided to Early Break about parental alcohol use; negative attitude towards 111 and her child. 1111’s periods of homelessness, her relationship with her grandmother and her parents‘ response. Violence from 1111’s brothers towards her. Reference to 111‘sleeping with her brother’ 4.4.26. As well as a lack of reflection on these and a range of other potential concerns, there is evidence that various professionals including social workers, health professionals and YOT staff were inconsistent in following up or checking information. During the course of this Review information has been sought from AuthorityA Children’s Social Care in relation to 111, but there is no evidence that any such attempts were made during assessments of 111’s needs. The first time the involvement of the family with services in AuthorityA appears to have been challenged with 1111 is by the Children’s Guardian appointed to represent 111111, evidencing that such a challenge was possible by practitioners, not simply with the benefit of hindsight provided to this Review. Whilst the information provided was not of the most serious nature it did contribute to an understanding of the family functioning and raise questions about the openness and honesty of 11111 in particular. 4.4.27. It is important here to acknowledge the potential reasons as to why a practitioner from CAFCASS was able to recognise and challenge this issue, when CSC practitioners were not. The nature and function of the Children’s Guardian’s role was specifically to review the management of a case from Child 1111’s perspective with the benefit of all the relevant information collected and working within a very different organisational and legal context. In particular the Children’s Guardian was not required to manage the competing pressures of maintaining a relationship with family members in order to achieve improvements. Managing these competing needs over time is recognised as one of the most difficult features of child protection social work and requires skilled practitioners, with manageable workloads and effective supervision. It is clear that one or more of these positive factors were frequently absent providing some explanation for what was in hindsight poor practice. RBSCB Overview Report 62 4.4.28. What is particularly apparent in relation 111111111 is that they often appear to have sought refuge with wider family members, but this was not in fact safe. 1111111111 was on a number of occasions turned to both by the family and by Social Workers, for support 111111111111111111111111111111111111111111111111.1111111 However, given the difficulties apparent within the family as a whole, including conflict between 111111111 and her sisters, it is concerning that there was such limited assessment of her and her husband’s suitability until 2008. 111111111111 had caused criminal damage at her brother in law’s takeaway, information that would have been available to CSC from her previous convictions. The YOT worker at the time was concerned about this offence and believed that there was information that was not being shared, but was unsuccessful in her attempts to find out more from 1111 and her family. 4.4.29. A viability assessment was undertaken 111111 in relation to the couple as potential carers for 11111’s son, the conclusion of which was negative. No information is available as to why this was the case, nor is there evidence that the assessment contributed to further understanding of any of the 3 young people. In 2011 an allegation of sexual assault was made by 1111 against 11111111111111111. Whilst this is information based on hindsight and it would be unreasonable to presume that it could have been detected at the time, the lack of any form of assessment represented a missed opportunity to understand the complex dynamics of this family and any risks within it. 4.4.30. It is however the lack of understanding and analysis of the role of AdultD that is of particular concern. It is remarkable that so little professional curiosity was aroused by 1111111 relationship with their uncle. This should have been subject to much more detailed scrutiny not least because of the trickle of worrying information about sexual activity in his house. Moreover it is surprising that there was no evident concern as to why two young teenagers would prefer to live with a relative considerably older than themselves rather than with their own parents. Given the previous history of sexual abuse in the extended family the willingness of the young people’s mother to allow them to stay with an older male relative and his teenage/adult sons should have raised alarm. Instead it is recorded by CIT in 2009, and was apparently unchallenged, that 1111111 approved of 111 living with AdultD and that it helped “family dynamics”. 4.4.31. In each of the families there was also either direct evidence or unresolved questions about the existence of what is often referred to as the “toxic trio” – parental mental health, domestic abuse and substance misuse34. Whilst these issues were referenced within several of the assessments undertaken, there is little evidence that they played a part in understanding the young people’s overall 34 Brandon et al 2008 p55 & Cleaver et al (2011), Working Together (2006:156) RBSCB Overview Report 63 experience and the particular risks to children when there is a combination of such problems. 4.4.32. Too often professionals, not least Social Workers, allowed themselves to be reassured by family members that they would protect their children, even when previous reassurances had proved to be ineffective. Reassurances may have been well intentioned, but previous evidence should have alerted professionals to the likelihood that they would not in themselves lead to a change in behaviour by the adults in managing the safety of their children. There were however also several examples of clearly collusive behaviour in particular by the mother of 1111111 for example in providing 1111 with alcohol and in her approach to her daughters contact with several men, including AdultD. 4.4.33. What has become all too apparent in analysing the approach of agencies to these young people during the time scale of this review is that with the exception of 1111 there was significant evidence for much more co-ordinated multi-agency involvement in their families at a much earlier stage in their lives. This was also particularly commented on by the mother of 111111111 who believed that they had needed help when the three siblings were much younger. 4.4.34. A number of agencies had information about the young people’s lives prior to the timeline, including concerns about the parenting capacity of their parents and significant indicators of neglect from early in these young people’s lives. Whilst it would not be reasonable to assume that professionals involved with the young people in their earlier childhood could have anticipated that they particularly would become victims of CSE, there was significant information in these families pointing towards the need for early intervention and planned support and preventative work at a much earlier stage. 4.4.35. What we are able to see with hindsight is that by the point at which agencies did intervene more actively the problems had become increasingly entrenched and the young people’s vulnerabilities had been effectively identified by men whose motivation was to exploit them. Engagement: “The attitudes and behaviour of individual practitioners have a major effect on whether families engage”35 4.4.36. The absence in several of the social work assessments of any involvement of the young people has already been noted. What is also equally striking however is a similar absence of evidence that many social work staff, particularly those responsible for case management really knew the young people as individuals or had been 35 Fauth et al C4EO Safeguarding Knowledge Review 2010 RBSCB Overview Report 64 successful in establishing a meaningful working relationship with them over the longer term. 4.4.37. Assuming that recordings accurately represent the actions of practitioners, it would appear that CSC staff with direct responsibility for assessment or case management often had a minimal level of contact with the young people. What can instead be seen is a pattern of home visiting being undertaken by others, such as family support workers or Out of Hours teams and at times lengthy gaps where no direct contact with the young person took place. This approach reflects an organisational structure established over years within Children’s Social Care. This structure was designed to use support teams, providing short term task centred inputs, teams which had initially been developed to provide early help and short term task centred work. However, a clear pattern that has emerged, in common with other recent Serious Case Reviews in Rochdale is that teams such as the Family Support Team or the Out of Hours team were in practice being used to prop up overwhelmed duty and assessment teams – colloquially the ‘front door’ of Children’s Social Care. 4.4.38. Whilst a team approach clearly does have a legitimate place, the consequence here too frequently was a lack of any effective personal engagement between the key Social Worker and the young person leading to distrust, ineffective intervention and at times direct hostility, a pattern which is likely to have become self-perpetuating both for the young person and the practitioner. There is no evidence that Social workers adopted a conscious case management approach or understood the risks to their personal relationship with the young people and their families. More importantly there is no evidence that they were encouraged to do so by their immediate managers, and on the contrary the service design supported this approach. 4.4.39. Records evidence little sense that the key Social Workers were able to work alongside the young people, that they were able to empathise with them or connect with them in any meaningful way. Working with adolescents requires differences in approach to working with young children; issues of respect and trust are of crucial importance and take time and commitment to build. Whilst the time available to the Social Workers concerned will undoubtedly have been very limited, there were nevertheless missed opportunities to engage and no evidence of creative practice. Home visits as recorded frequently reference little or no discussion with the young people themselves, there is rarely evidence that the young people were seen alone or in environments where they might feel more at ease. 4.4.40. In the case of 111 for example it is apparent that routine practice was to visit only on the day of a Core Group or Child Protection Conference, giving the impression that the priority was to meet statutory minimum requirements at times suitable to professionals rather than considering what might achieve the best response from the young person. There is little to suggest that serious attempts were made to engage the young people in the Child Protection RBSCB Overview Report 65 meetings, rather there appears to simply be an acceptance that they will not attend. 4.4.41. Whatever the strengths and weaknesses of individual practitioners, the general lack of relationship building must be seen in the context of wider workloads and the expectations of both practice management and strategic leadership. Building relationships with young people is time consuming and requires commitment from a senior level in order for practitioners to be able to prioritise such an approach. What has been stated quite explicitly on a number of occasions within this Review is that in the context of the resources available, the priority for the department was in relation to babies and young children, not adolescents. In this context it is not perhaps surprising that time spent building relationships with ‘difficult’ teenagers was not a priority, particularly when those teenagers themselves had babies who needed protecting. 4.4.42. However it is important to record that as with other professionals quite a mixed picture emerges, with some workers showing signs of persistence in their attempts at engagement even in the face of at times quite difficult, openly negative responses from the young people. Some workers from both the CSC family support team and from the Young Person’s support team in particular showed such persistence, in one case despite having received threats from the young person concerned. A particularly positive view regarding the specialist Sunrise Social Worker has been stated within the CSC IMR and by others. In the absence of information directly from the individual, his manager or feedback from the young people, it is difficult to assess what enabled this Social Worker to be more effective in his engagement but may well have included: specialist role allowing skill development with client group dedicated time and resources Individual skills of the practitioner active seeking out of the young person and their family It is reported that the individual left in frustration at the role being diluted and the short time that he was in post means that an analysis of the components of success is difficult to achieve. It is also difficult to know what the longer term outcomes would have been. However, research in relation to young people’s views of social workers and professionals provides a clear picture of what young people seek “”someone who is friendly, nice, funny and respectful…someone they could rely on”36 4.4.43. It has also been noted that other professionals had very mixed success in establishing meaningful engagement with the young people and evidenced differing amounts of effort in trying to achieve 36 Rees et al (2011:65) RBSCB Overview Report 66 engagement. The potential strengths of the voluntary sector in working with this age group were reflected in Early Break’s greater success in developing trust and maintaining relationships over time. Early Break workers demonstrated a degree of persistence despite experiencing not infrequent rejection by the young people. Practitioners were consciously aware that when young people pushed them away this might be part of testing them out rather than a permanent refusal to engage. This was not to say that Early Break demonstrated a perfect model of success, but for example with 111 their approach led to her seeking their help at a time when she felt able to do so. 4.4.44. The Social Worker’s role by its very nature can create a barrier with a young person and one approach is to work closely with the young person and a professional with whom they have established a trusting relationship. It is unfortunate that this approach was not adopted more routinely in these cases, and indeed that there appeared to be something of a hierarchical approach presented by some CSC staff. This was evidenced most explicitly when 111 was instructed to move from Early Break to the adult substance misuse service without any discussion between the Social Worker, 111 and Early Break as to how this would affect 111’s work with Early Break. 111’s subsequent comments to the Early Break worker powerfully reflect her sense of having no control of the decisions being made about her and give an insight into the limited nature of her relationship with her Social Workers. What is commendable is that the Early Break worker supported 1111 in this change of service provision despite their misgivings. 4.4.45. Not only did distant this style of working create the conditions for a poor relationship between Social Workers and the young people, it also limited the capacity of social workers to observe and understand the young people within their families which could have led not only to a more trusting relationship but also to a recognition that significant neglect was a feature in their lives. “Being in a position to observe and witness the parent–child relationship directly enables an experienced worker to gauge the presence of disorganised attachment behaviours which are linked, according to two robust review studies, to both family risk factors and child maltreatment”37 4.4.46. There were other examples of positive and age appropriate engagement with the young people including: support provided to 111 by CIT after her child was removed, including providing advice about legal representation. Positive feedback by 111 about her relationship with Connexions staff and CIT CIT2 supporting 111 during video interviews 37 C4EO (2010:11) RBSCB Overview Report 67 Positive relationship with PC6 during Operation span Persistence and concern demonstrated by school health practitioners. Connexions worker supporting 111 to attend an interview at the college Positive encouragement by GP to 111 attend alcohol and mental health services 4.4.47. The YOT IMR identifies that 111’s engagement with their service was ‘very good’. However there is no definition of ‘very good’ and how this conclusion has been reached. There is a noticeable absence of any ‘picture’ of 111 which would demonstrate that her personality, wishes and feelings were known and considered significantly by the organisation. In the absence of this information the Review would challenge the YOT service as to what constitutes meaningful engagement with the young people it works with. The analysis provided by the YOT IMR is very focussed on national standards, policy and procedure with considerably less analysis on the effectiveness of direct work with the young people. As has previously been noted reflecting national policy expectations. Discussion with the current Service Manager suggests that there has been in recent years a significant focus on ‘compliance’ with and completion of orders and it may be that this focus has been to the detriment of developing a culture of meaningful engagement or a focus on outcomes. 4.4.48. What is apparent from the actions of professionals who achieved the greatest success with the young people was their persistence, a more creative approach than offering formal appointments and an active approach to following up missed appointments. The key issue of persistence in working with those who may be viewed as ‘difficult to engage’ is reflected in lessons from a previous SCR prepared by the same author for Rochdale SCR (A,B, C) 4.4.49. There is little doubt that all the young people will have challenged professional capacity and at times patience. Child protection work is by its nature emotionally draining, can be difficult and at times dangerous. The nature of the young people’s experiences did not lead to them being easy to form relationships with. However, the very reasons that will at times have made them difficult to work with, were the reasons that professionals needed to try particularly hard to attempt to engage with them. What was needed was the ability to see past the “challenging behaviour” as to why these young people were behaving in ways which were damaging to themselves and at times to others. Understanding the young people’s behaviour RBSCB Overview Report 68 4.4.50. Whilst we have limited information about the young people’s personalities, their expectations of themselves, their hopes, aspirations, and strengths, a very striking picture has been presented across agencies of the behavioural challenges they posed both to themselves and others. This picture is one that has been identified across a number of Serious Case Reviews “agencies focused on the young person’s challenging behaviour, seeing them as hard to reach…rather than trying to understand the causes of the behaviour and the need for sustained support”38. Recorded comments by some of the professionals displayed a level of frustration with the young people and their families which at times appeared negative and judgemental. One particular example is the response of a Social Worker to another professional’s concerns about 111 that “CSC had been there before on several occasions and it had not made a difference”. Had professionals understood both that the young women were subject to serial exploitation and the impact of this exploitation upon them, it is possible that a less skewed picture of their behaviour might have emerged. 4.4.51. The young people often exhibited ambiguous behaviour towards the men who were abusing them: frequently returning to them, repeating patterns of behaviour; being unwilling to engage with the police or other authorities; appearing inconsistent in their accounts. One small, but powerful illustration of this is an occasion in 2009 when 111 was seen on CCTV stroking the face of a man who she later said had kidnapped and sexually assaulted her. It was exactly such actions as this that tended to lead to judgements about the young people’s credibility and on this occasion it was considered to be a false allegation. Whilst it is not possible to know the truth of this particular incident, what we now know about the way young people adapt to being abused would tell us that this behaviour does not in itself rule out the possibility that 111 was subject to abuse by the man concerned. 4.4.52. The impact of early trauma in young children’s lives is increasingly well understood through research and the development of Attachment Theory. What practitioners were clearly much less able to recognise was the impact of trauma on the behaviour of this group of adolescents. Basic child development theories should have to some degree alerted at least some of the professionals to the difficulties the young people would be facing by the very nature of moving from childhood to adulthood. Similarly applying a good knowledge of child development would have helped contextualise some of the behaviour – for example that a problem in adolescence can be understood as a reflection of a “well-established pattern of family communication rather than simple a symptom of adolescence itself. 39 38 OFSTED, Oct 2011 39 Daniel et al, 2010 RBSCB Overview Report 69 4.4.53. However, there are a number of examples when the approach of professionals started from a very particular adult context which presumed the young people should have an understanding of complex situations in the way that they were seen by the professionals. One example of this is a Social Work assessment which refers to 1111’s: “failure to see the seriousness of becoming pregnant at 13 years old “. This represents a significant absence of understanding and analysis as to the implications of her real age, her developmental age, her personal experience or her learning difficulties, instead viewing her response simply as a failure to take her situation seriously. 4.4.54. Whilst clearly not all the professionals involved with these young people could be expected to have a strong grounding in the relevant research, children’s Social Workers and those whose primary client group was young people, for example the YOT team, CAMHS, educational staff, should be expected to have some underpinning knowledge as well as access to training and information about key messages from research. Whilst clearly this must have been the case for some workers, the overall impression is that there was limited knowledge across many of the services and no evidence that research or practice based information was, for example, drawn on in supervision or other case discussion. No direct information has been provided about the existence of a sound practice knowledge base with regards to child development for this age group and this is an area for future development. Multi-agency recommendation 5 4.4.55. There is now a growing body of research and knowledge on the impact of trauma as it relates to the victims of sexual abuse, knowledge which would have been unfamiliar to most staff at the time and which is only now becoming more widely understood. Access to this knowledge had it been available would have offered practitioners a different way of understanding the young people’s behaviour. Such an understanding could in turn have led to more effective interventions and assessment of how to work with the young people to improve their safety. 4.4.56. The research identifies that in order to survive traumatic experiences behaviour which appears contradictory and difficult to understand may be exhibited by the victims. The phenomenon can result in the victim “experiencing positive feelings toward their victimizer, negative feelings toward potential rescuers, and an inability to engage in behaviours that will assist detachment or release”40 Other common responses include: “revictimization, self-injurious and self-harming behaviours and externalizing the trauma by victimizing others”41. With the benefit of hindsight these are powerfully accurate depictions of the behaviour displayed by the young people and a crucial lesson for 40 Lodrick (2007) quoting Carnes, 1997 41 Lodrick (2007) quoting van der Kolk & McFarlane, 1996 RBSCB Overview Report 70 services in Rochdale is to integrate this knowledge into working practice. 4.4.57. This research base also provides a very particular insight into the experience of 111 and other young people who have been abused and themselves become complicit or active in the abuse of others. All the young people needed to find ways to survive, both practically and emotionally, within this dysfunctional world where they were repeatedly being abused. Practical and safe options for young people who cannot live within their own families are very limited, as the often unsuccessful attempts by housing staff to find some of the young people accommodation demonstrates. Where young people’s education has been disrupted, they are less likely to have employment and therefore a means of sustaining themselves economically. There may be nowhere in their family or friendship network that provides a safe haven. One means of survival for some young people is to protect themselves by aligning with the abusers. 4.4.58. The experience of those working directly with these and other young people was that those who did become a contributor to the abuse struggled to understand their own behaviour, a struggle mirrored in the reactions of professionals, such as police officers, who simultaneously had to work with young people both as victims and potential abusers. This response adds further complexity to the task of working with these young people and requires sensitive and careful support by agencies of those involved in the work. In developing policy and practice with regard to CSE, the Board should include consideration of the support needs of staff working in this field. 4.4.59. A further common theme amongst agency responses which demonstrated the lack of understanding as to the nature of child sexual exploitation was a focus not on their vulnerability but their ‘high risk’ behaviour. There are repeated comments made to and about the young people based on a view that it was within their power to ‘keep themselves safe’. A similar frequently made comment was in relation to the young people ‘engaging in risky behaviour’, suggesting that this was something they could chose not to do. Research tells us that there is a tendency to presume that young people are more in control of their worlds than is actually the case and that professionals are less likely to recognise when young people are at risk.42 This is a presumption that young people then internalise. 4.4.60. The young people were frequently advised about the need to take responsibility for their actions, to protect themselves, to stop certain behaviours. However it is apparent that much of the time the young people did not view themselves as being at risk and often appeared to believe they were in control of the situation themselves. For all these reasons an approach which instructs young people to remove themselves from the danger is reminiscent of some similar responses 42 Rees (2011) RBSCB Overview Report 71 to the victims of Domestic Violence and is unlikely to be effective as it fails to recognise the power dynamic of the abusive behaviour, the victims’ adaptive behaviour as a survival mechanism and their actual level of control over the world they inhabit. 4.4.61. What was required and was not within the power of individual practitioners was a complex multi-agency approach, including disruption techniques, prosecutions and intensive packages of support. 4.5 The operational response: The effectiveness of multi-agency working. 4.5.1. The effectiveness of multi-agency interventions with the young people, including management of child protection plans, will be examined in section 4.6. However, the wider picture of the functioning of multi-agency working merits separate analysis. 4.5.2. The expectation that agencies work together in order to safeguard children has long been established as a fundamental requirement of good practice embedded within statutory policy and guidance and underpinned by evidence.43 However, problems in multi-agency working remain a repeating feature for criticism and have been found to represent the most frequent recommendation in Serious Case Reviews.44 The quality and effectiveness of relationships between agencies fundamentally affects the provision of services intended to safeguard children. Achieving good quality multi-agency working is a “skilful and challenging activity involving considerable demands at both practice and policy levels…enhancing service provision when done well…frustrating and disempowering when delivered ineffectively”.45 On the evidence of this Serious Case Review this experience is mirrored in Rochdale. 4.5.3. Relationships and partnership working between the agencies at an operational level reflected many of the same problems that have been highlighted at the strategic level. Operationally, there is evidence of good communication and good partnership working, however, this was inconsistent and partial, with agencies too often failing to share information in a timely way or working together effectively. The result was a patchwork of good practice interspersed with significant gaps. These problems can be seen amongst and between different agencies, although some particular trends emerge. Examples of the gaps include: 43 Davies and Ward (2012:136) 44 Brandon et al (2011: 2) 45Family Policy Alliance 2005, quoted in Morris (2008:1) RBSCB Overview Report 72 Pupil Referral Unit sharing information with Connexions regarding 111’s pregnancy CSE involvement but with no evidence that they then sought information as to the outcome. Lack of co-ordinated approach towards information sharing with other agencies by Education Staff at the Learning Centre attended by 111. Identified as a result of not having a designated Child Protection lead in the school. Absence of proactive information sharing by CAMHS with other agencies Absence of information exchange between CSC and YOT regarding 111’s offending in 1111 GP not informing CSC of referral for 111 to mental health services in 1111111 Sunrise team reporting concerns to LSCB about schools but not sharing this with the schools themselves. 11111111 CIT wrote to a GP with concerns about one of the young people, but there is no information that they had referred to CSC 4.5.4. There has been a consistent comment made by several of the agencies that they were excluded from information by Children’s Social Care and by other ‘key agencies’. It is not always clear to whom the latter refers but would appear to include the police, CIT and the Sunrise Team. It is a positive outcome from this Review that these frustrations have led during to significant reflection by some of those agencies regarding the way in which they were able to assert their role in the multi-agency partnership, including for example in relation to escalating concerns. Early Break for example has produced 2 related recommendations as a result. 4.5.5. Irrespective of the part played by other agencies there is supporting evidence of poor information sharing and inter-agency liaison by CSC at a level of frequency which suggests that this was indeed part of a wider feature of that agency’s approach to multi-agency working. Examples include: Lack of information sharing from CSC to CIT regarding decision to remove 1111’s child Relevant practitioners not being informed of, or invited to, LAC reviews regarding 111’s child Social workers not returning calls even when urgent messages left. Social Worker refusal to speak to CIT in February 2009 regarding 111 on the basis the case had been closed. CSC unilaterally insisting on a change of Alcohol service provider for 111. Information about 111s child being in foster care not being shared by CSC with CIT. RBSCB Overview Report 73 4.5.6. The experience of some practitioners and agencies was that they were treated in a peremptory and dismissive fashion by children’s Social Workers and that there existed within Children’s Social Care a culture of not valuing other organisations, especially but not exclusively the third sector. As a number of the key CSC practitioners involved in these incidents are either no longer working for the authority or were subject to other internal procedures, it was not possible for the IMR author to explore with them their perspective on how they responded to other agencies limiting our capacity to understand what was happening at the time. 4.5.7. Nevertheless, some of the examples provided do suggest that some Social Workers presumed ‘seniority’ over other partners and asserted this in a fashion which did little to develop positive working relationships. Both good multi-agency work and effective intervention with families rely on strong inter personal skills not least from social Workers who are recognised as having a key role in enabling the partnership to work. It is therefore of concern that a number of professionals have been left with a significantly negative experience of Children’s Social Care practitioners. Understanding why this happened in relation to individual Social Workers is of less value in improving future practice than understanding why it went unchallenged by either frontline managers or by senior management. Team managers should reasonably be expected to have known the culture of their immediate working environments and personal styles of practitioners within their teams. If this was not the case it suggests there was an absence of focus within the organisation on the environmental factors that will support practitioners in achieving good practice. It is further indicative of the culture at a senior management level within Children’s Social Care that Early Break experienced a failure to respond even when challenges were made at a senior management level, leaving them feeling that there was no further action they could take. 4.5.8. Although direct information from practitioners is limited, there is evidence of other factors which impacted on the inter-agency difficulties at the time. A key issue which appears to have created barriers was the absence of any protocol as to what information should be shared when child sexual exploitation was under investigation. The Youth Service for example identified that there was a lack of any clear processes for reporting or sharing “non-referral intelligence and information around CSE” until 2012. This has been identified by several of the agencies as creating a barrier to information sharing. 4.5.9. It is known that on least one occasion CITC was unwilling to share information with Police and Children’s Social Care. This was on the basis of ‘client confidentiality’ in that CITC did not feel it should be shared without the individual’s consent, but was also due to concern that it might result in a direct approach by the police, leaving the RBSCB Overview Report 74 young person at risk. This resulted in a direct instruction from the named nurse and Director of Delivery that the information should be shared, but clearly leaves open the unanswered question as to whether and to what extent this had occurred on other occasions. On another occasion at a multi-agency strategy meeting minutes produced by the Police were recalled and agencies told they should not be saved or used. 4.5.10. Other problems arose as a result of the knowledge base of a number of individuals, particularly those in roles which might not have provided them with the opportunity for safeguarding training. Particular examples included Greater Manchester Police CID officers; social work trainees and some YOT staff without relevant professional qualifications. This highlights the importance of putting in place a means to ensure that all such staff are supported in understanding and dealing with safeguarding requirements, whether by specific training, mentoring or other forms of supervision and management oversight. A multi-agency recommendation has been made which addresses this gap. Multi-agency Challenge 3 4.5.11. Where good communication across agencies was apparent this was often a consequence of relationships between individuals, rather than due to systemically embedded agency relationships or culture. Rochdale Borough Housing in particular has reflected that there was a lack of good ‘structured’ relationships with other key agencies, such as CSC and a reliance on ad hoc links between individuals. Housing staff interviewed felt that where there was good communication for example it was ‘based on personal relationships between officers rather than being an organisational priority.” Another example is described by Early Break who identified a particularly helpful relationship with a police officer PC6 and there is clear evidence within this review of this officer actively working with others. Good personal relationships can undoubtedly strengthen multi-agency work However, reliance on personal relationships as the predominant means for achieving communication creates vulnerabilities. 4.5.12. In complex work environments staff, particularly when they are under pressure, may take short cuts to achieve a particular goal. The disadvantage of the reliance on personal relationships is that it leads to a risk that professionals use their personal judgement as to how and with whom they should raise concerns, which may or may not lead to the right outcome. Formal child protection systems are intended to be, transparent and accountable, with good working relationships supporting those systems, rather than replacing them. What appears to have been lacking however, was any wider reflection on the effectiveness in practice of the systems in place or any means for identifying warning signs of weakness in the way the system was working. RBSCB Overview Report 75 4.5.13. Conversely by identifying some of the good practice examples it is possible to see particular features that supported good practice: August 2010 – Connexions sharing information with all known relevant agencies regarding the links between 11111111111. Practitioner supported by clear supervision and management oversight. Routine sharing of information between A&E and GP services: supported by established recognised processes. Joint meetings with various professionals and 111 4.5.14. Problems within multi-agency working however, were not limited to relationships and communication. There is additionally a significant thread of information running through the agencies responses to the young people regarding at times very poor compliance with basic Child Protection and safeguarding procedures. What is of significant concern is that the poor implementation of child protection processes and the absence of effective adherence to the Board’s procedures clearly impacted not only on the individual service received by the young people, but also on the capacity of agencies to make links between them and learn from their experience. 4.5.15. LSCB procedures are designed to enable all agencies to understand their roles in multi-agency safeguarding and are the cornerstone of child protection. It has been identified, not least in the Children’s Social Care IMR that there were a worrying number of occasions when it is clear that both social workers and their front line managers failed to work to their own procedures. This involved a number of different occasions, suggesting that there were both weaknesses in individual practice, but also key failures in the working of systems designed to provide checks and balances and included: strategy meetings not arranged for 111 in 2008 a manager ‘logging’ concerns about CSE for 1111 rather than ensuring they were investigated. Lack of response to referrals eg by SchoolD in 11111. 4.5.16. The reasons for individual gaps in practice standards are not always easy to ascertain, but there are a number of factors that repeatedly emerge. It has been identified for example that the Multi-agency procedures had only just been published in May 2007 and therefore were not fully embedded. However, as these examples and others relate to core functions of children’s social work this can only be considered a partial explanation. 4.5.17. In 2009 an unannounced OFSTED inspection of the Contact, Referral and Assessment arrangements identified a number of problems including: Thresholds not being fully understood by partner agencies. Variable quality of Initial and Core Assessments RBSCB Overview Report 76 Lack of systematic recording of children’s views Poor record keeping Supervision falling below agency standards These findings are entirely reflected when considering the service provided to YP1-6, confirming again that problems were not case specific but part of a much wider problem within Children’s Services. 4.5.18. Weaknesses in adhering to agency and Board Child Protection procedures can also be seen across other agencies. Whilst there are a range of examples, a number of repeating patterns can be detected. In common with many other Serious Case Reviews, it is apparent that there were problems with the understanding by other agencies of the thresholds for referral to Children’s Social Care. Action for Children is explicit in their view that thresholds for referrals were high, which is clearly born out when considering the response to these young people. 4.5.19. Comment has already been made about a theme of professionals and agencies failing to recognise that the young people were at serious risk which should have led to a Child Protection referral. It should be noted that many of the agencies did make various appropriate referrals to Children’s Social Care in relation to these young people during this time period. However, there were also other occasions when there were professional concerns about the young people which it might have been anticipated would have led to a referral or other contact with CSC, but this did not take place These included: 11111111111 School Health practitioner noting 8th incidence of domestic abuse in relation to 111. Information not forwarded to CSC 111111111 Health visitor informing YOT about 1111 possible pregnancy and concerns about her capacity to look after a child. No record of referral to CSC 11111111111: No contact by school with CSC following evidence of 111 self-harming and with suicidal thoughts. 11111111111111: letter from ‘psychiatric services’ to GP 1111 outlining a considerable number of problems within the family which were impacting on 1111 mental health. 11111111111: concerns noted by CSC about the late sharing of information by CIT 4.5.20. A related pattern emerges by which agencies when they do refer the young people request ‘family support’ from Children’s Social Care rather than making a formal safeguarding referral: May 2007 HV refers 111 for family support 1111111 Midwife completes a Special Circumstances Form listing a range of concerns and refers 111 for family support RBSCB Overview Report 77 11111111 Housing officer makes a referral for Family Support 4.5.21. Whilst understanding each event individually has not been practically possible given the passage of time and the methodology used by this type of Review, there are nevertheless some possible explanations as to why agencies operated in this way. The narrative outlined in this Review evidences a pattern of CSC not responding to the referrals as safeguarding and agencies subsequently not referring further concerns. The frustration of the referring agencies is often very apparent and it has been noted by agencies that this resulted in them not referring again in the future. National research has drawn attention to a recurring theme whereby agencies in particular schools, GPs and other health workers, do not make referrals to CSC due to low expectations of what will be achieved combined with the perceived damage making a referral can cause to their ongoing engagement with families. 46 A specific example of this is recorded by CIT who noted that disclosing information about 111 might lead to her disengaging from services. 4.5.22. There was no evidence of any established process or culture whereby agencies could seek advice and support from Children’s Social Care as to how to respond to concerns, to discuss whether the issue of concern was likely to meet statutory thresholds or consider alternative ways of responding, such as the use of a CAF. On the one occasion when a Social Worker did suggest a CAF (August 2010 regarding 111) this clearly failed to recognise the Young Person’s safeguarding needs and in any event led following the CAF meeting to a referral for an Initial Assessment. Action for Children specifically notes that its staff perceived thresholds in CSC to be high and concludes that this may have been a reason why they did not refer on some occasions when with hindsight it would have appeared the right course of action. Where agencies are unclear about the thresholds for referral, or perceive that thresholds are too high, this conscious or unconscious decision not to refer again is likely to become one of the ways in which agencies respond. 4.5.23. An area of particular concern is the frequency of non-compliance by the Crisis Intervention Team in working to the Board’s Child Protection Procedures and the absence of a fundamental understanding of their role in working as part of a partnership. CIT stood out as having been the first service to recognise explicitly that the young people were being exploited and that this was placing them at significant harm. This team clearly played a crucial role in identifying CSE and in supporting young people. However the serious gaps in their partnership working ultimately contributed to the collective failure to meet these young people’s needs. 4.5.24. A particular problem was CIT’s approach to making referrals and contacting Children’s Social Care which led to considerable confusion. 46 Davies and Ward (2012:47) RBSCB Overview Report 78 CITC has given evidence to the Home Affairs Select Committee that the team had made 103 referrals to CSC as well as 181 ‘alerts’ in relation to these and other young people. Pennine Care as a result undertook a validation exercise consisting of a full audit of all information that was shared by the team. CITC’s evidence and the subsequent audit refers to all the young people the team worked with, not only to YP1-6. 4.5.25. The audit defined a referral as one of the following: a Multi-agency referral form a communication by phone (verified by an entry in the case note); letter or fax termed “Referral” or the inclusion of an expression of absolute vulnerability to sexual exploitation. An ‘alert’ was defined as: a telephone call sharing additional concerns or intelligence in relation to a previously known subject a communication by letter or fax documenting intelligence or sharing additional concerns. 4.5.26. The conclusion of the Pennine Care analysis was that overall approximately half the number of referrals stated were actually made to Rochdale Borough Council (ie Children’s Social Care or the Safeguarding Children Board) and approximately one third of the alerts as stated. The analysis also ‘identified a significant number of instances when a disclosure by a client was of such concern that it should have been formally referred in line with the multi-agency safeguarding procedures however the author cannot find any evidence of any such referral.” This picture is replicated in relation to the young people subject of this Review. The audit specifically analysed the referrals and alerts made by CIT purely in relation to the 6 young people subject to this Review .There were a total of two referrals to the police and 4 referrals to Children Social Care. This analysis is congruent with the information provided to this Review 4.5.27. The referrals to CSC and the police were as follows: February 2006, 111: referral to CSC following concerns regarding vulnerability to sexual exploitation (not clear exactly what was stated) Sept 2007, 1111: referral to CSC for Family Support. May 2008 1111: referral to CSC re domestic violence and threats from father of 111’s unborn child August 2008 1111: referral to CSC and to the police following disclosures that 1111 was sleeping with multiple ‘older Asian men’ January 2009 111: statement of disclosures by 111 forwarded to police and CSC RBSCB Overview Report 79 August 2010 111: unclear, appears to be liaison with police regarding the making of a statement by 111. 4.5.28. There is an evident disparity between the numbers of referrals that CITC believed the team had made and the number actually made. This can in part be explained by a practice of sending letters to a range of people and teams within Children’s Social Care and also to the Board, who did not have a function in safeguarding individual children. Some letters were addressed ‘To Whom it May Concern’ rather than to a named person and there is, for example, no evidence that letters were actually received by the Safeguarding Board. Undoubtedly a letter clearly identified as a referral should have been forwarded to the Duty and Assessment team for action, irrespective of where it was first received within Children’s Social Care. But the method of communication means that subsequently there is no clear audit trail of communications and information sharing or any mechanism to follow up actions. It is also apparent it was often not evident to the recipient of the information that it was intended as a formal referral. 4.5.29. This presents a much more confused picture than has previously been placed in the public domain. Referrals were made by CIT in relation to three of these young people. The rate of referral was on average once a year, which quantitatively would not be considered unusual. Nevertheless it is also the case that CIT regularly spoke to a range of agencies, including CSC about their concerns for the young people. They also produced written reports within various processes such as Child Protection proceedings. This analysis therefore does not deny that they spoke out about their concerns or that these should have been taken much more seriously by Children’s Social Care in particular. However, it provides a quite different view on the way that CIT sometimes worked outside the safeguarding process, their effectiveness in making themselves heard and the clarity about what action they felt was required. 4.5.30. Other problematic practice included: CIT staff gathering information themselves about the activities of perpetrators rather than passing this immediately to the relevant agencies, particularly police and children’s social care (see July 2008 response to 1111 Lack of referral to CSC or police in relation to 13 year old 111 regarding under age sexual activity. Name of uncle attending with her not recorded. Lack of effective record keeping, use of tools such as genograms eg no connection was made between two of the siblings who had been referred and disclosed underage sexual activity within a short period. 4.5.31. It has also been identified explicitly within the Pennine Care IMR, and is reflected within other agencies’ responses, that CIT staff were seen as the experts on CSE both by themselves and by others. CIT staff RBSCB Overview Report 80 are described by Pennine Care as “considering themselves as ‘sexual exploitation workers’ rather than ‘sexual health workers’. This was a misunderstanding of the CIT’s role and individual practitioners’ qualifications. CIT was commissioned to address the issue of high levels of teenage pregnancy and sexually transmitted infection, as part of the national drive to reduce both of these in young people. They were commissioned to work with vulnerable young people, but not to provide a specialist service to the victims of sexual exploitation. Whilst CIT workers had clearly gained some valuable practice experience of working with the victims of CSE, they had no specialist qualifications and had received no specialist training. 4.5.32. Of greater concern was that the team operated almost wholly outside of any managerial oversight and appeared content to work in this way. The Trust has been unable to confirm that Team members had any Safeguarding training and, it is known, for example, that they were not included in briefings regarding the launch of a Multi-Agency Referral form in 2009 and were not instructed to use it for a further 9 months. The Trust’s focus at this time was on multi-agency safeguarding training for Health visitors and school nurses and CIT was not prioritised. Whilst the CIT co-ordinator was rightly critical of this, there is no evidence that she or other members of the team asked for training when they knew that other teams were receiving it. 4.5.33. Neither did the team receive any formal supervision, although CITC provided oversight and direction to team members and ad hoc advice was sought from the Named Nurse. At that time Trust policy was that safeguarding supervision was only provided to School Health Practitioners and Health Visitors. Some conversations took place between the CIT co-ordinator and the Named Nurse regarding safeguarding, but there is no record of these discussions and the experience of the Named Nurse was that the CIT co-ordinator was resistant to offers of supervision. This has been further confirmed within the Pennine Care IMR which stated that the Co-ordinator made it clear in interview for this Review that she “holds the view that the benefits of supervision would have been questionable, given her expressed perception that the organisational experts on CSE were the Crisis Intervention Team alone”. 4.5.34. What is now apparent is that there was a fundamental mismatch between the views of the Crisis Intervention Team as to their role and the understanding of the commissioners of how this had been developed. “The significant role that this service was to make in the recognition and response to child sexual exploitation was not envisaged. This continued to go unrecognised by strategic leads as the information was not escalated to them by any of the services. (Health Overview report). What is revealed is a crucial absence of management involvement in the working of this team, combined with a team culture of strong self-belief and of resistance to inclusion within many of the organisational processes resulting in a practice model RBSCB Overview Report 81 which was contradictory and not subject to challenge. The style of the CIT Co-ordinator was not experienced as inclusive by many of the agencies and the outcome was that some of the important information held by the team did not impact effectively either with colleague practitioners or at a strategic level. 4.5.35. Another gap in effective partnership working that has been highlighted in this Review relate to the expectations which existed between those agencies who refer to services and those agencies who receive referrals in regards to what action will be taken. In the context of multi-agency safeguarding there is a responsibility on both parties to share responsibility for ensuring that referrals are properly processed. However on a number of occasions this process did not work effectively most notably when referrals were made to CAMHS by non-health agencies. CAMHS practice was, and it is understood still is, to assume that the referrer will “support” the referral. This is not an unreasonable expectation as it avoids the use of referral on as means for agencies to abdicate their own responsibility. From a more positive perspective, shared responsibility can increase the likelihood of appointments being kept, which is particularly important when referring to a specialist and high demand agency such as mental health services. 4.5.36. What is apparent however is that whilst there is evidence of some joint working, CAMHS on a number of occasions did not provide information to the referrer either about whether the referral had been processed or alternatively whether appointments were being kept. Referrers therefore were often not aware that their support was required, with schools in particular frustrated to discover that a case had been closed due to lack of attendance when they may have been able to support engagement had they known of the problems. Referrals were made to CAMHS regarding 111111111111111 from different agencies including schools, the Police and GPs. However, information was often not provided to the referrer as to the outcome, or whether the Young Person failed to keep appointments until the point that a decision had been made to close the case (with the exception of the GPs). Because of a lack of information provided by CAMHS this Review has been significantly reliant on information provided by other agencies. It is not clear if there is any explicit agreed protocol between CAMHS and other agencies in this regard, and if so how such a protocol takes into account safeguarding issues 4.5.37. This therefore raises a question as to whether all agencies accept they have shared responsibility when referrals are made. It would be reasonably anticipated that the young people subject to this Review might not respond consistently, if at all, to formal appointments being offered. There were some practitioners who were in a position to support and encourage their engagement with CAMHS, for example the School Health Practitioners. What appears to have been lacking is a shared commitment to achieving this, possibly as a result of a RBSCB Overview Report 82 defensive decision by CAMHS as to how to manage its resources. If this is the explanation, it is not in keeping with the requirement to contribute to safeguarding as a partnership. The result in the cases of these young people was considerable confusion and frustration between agencies, lack of a clear route for information sharing with appropriate safeguards for confidentiality, and possibly a failure to engage the young people with a key service. Given these unanswered questions both Pennine Care and the Board will need to satisfy themselves that basic Child Protection requirements are being met in the work of CAMHS. Multi-Agency Recommendation 3 4.5.38. A mixed picture of the effectiveness of multi-agency working by the GPs involved is also apparent and reflects experience common across Serious Case Reviews and other analyses of multi-agency working. The IMR for the GP Service has identified that in the early stages covered by this review there was a lack of knowledge about child sexual exploitation and a lack of clarity about the role of the GP in child protection and safeguarding. Although there is a range of evidence about liaison by GPs with other health professionals, there is no evidence of direct involvement of GPs in Child Protection procedures. Whilst it is recognised that there are real practical difficulties for GPs in attending CP conferences, there is also a lack of consistent information sharing beyond the health family. There is evidence that a GP shared share some information with the Social Worker, but it is difficult to detect a clear auditable path of information exchange leaving open the possibility that information which should have been passed on was missed. 4.5.39. Conclusion: The familiar, nationally experienced, disparity between the universal acceptance of the theory of multi-agency working and the evident difficulties in achieving it in practice are reflected in the organisational and the strategic practice in Rochdale as illustrated in this report. The picture of multi-agency working across the services as experienced by these 6 young people suggests the need for a comprehensive reappraisal at Board level of how this is managed locally rather than a reactive ‘bolting on’ of further training, policies or other safeguards. It is the view of the author of this report that without a radical reappraisal of the way agencies in Rochdale work together, individual policy or practice improvements, however well considered, ultimately risk failure if these are not underpinned by a shared and active commitment to making multi-agency working a reality at a strategic level. Multi-Agency Recommendation 2 RBSCB Overview Report 83 4.6 The operational response: The effectiveness of intervention 4.6.1. A considerable proportion of agency involvement with the young people involved responding to referrals and making assessments. But the young people were also in receipt of a range of services and interventions with differing degrees of effectiveness. As with the process of recognition, assessment and engagement, services provided cannot simply be dismissed as inadequate. There is evidence in a number of agencies that services were provided which were positive, met agency standards and showed a determination to try to help the young people and meet their needs. However, the quality of intervention was very variable and overall was often ineffective. 4.6.2. Each of the agencies has reviewed its individual actions and identified recommendations for learning (see Section 6). It is not the intention of this Section to consider all 17 agencies individually, but rather to consider patterns across the agencies and how they did or did not work together in providing services to the young people. 4.6.3. It is apparent from this Review that there were numerous opportunities for agencies to intervene throughout the young people’s lives. The quality of assessments undertaken in response to referrals, the lack of understanding of Child Sexual Exploitation as a child protection issue, rather than just a concern for the Police and the lack of recognition of the safeguarding needs of adolescents meant that the young people were frequently not recognised as being at risk of significant harm. There was evidence on a number of occasions and in relation to many of the agencies that the young people should have met the threshold of a risk of significant harm and yet only two of them, 111111111 were subject to child protection planning throughout the 5 years covered by this Review. 4.6.4. Behaviour Management: One theme that surfaces time and again across a number of the agencies was that intervention was frequently intended to manage the behaviour of the young people, or to help their families manage that behaviour. This approach was the prevalent response with young people being viewed as problematic and referred to in terms of “hard to reach” “rebellious” “challenging behaviour” rather than by attempting to understand the behaviour and provide sustained support.47 In understanding why this might have been the case, it should be recognised that there is a significant body of evidence regarding wider societal attitudes to young people which are often punitive and critical. 4.6.5. A frequent feature of the ‘behaviour management’ approach was to simply tell the young people that they must stop behaving in certain 47 OFSTED (2011:18) RBSCB Overview Report 84 ways. This can be seen across the agencies from CIT, to YOT workers to children’s Social Workers. Frequently the young people were told that certain behaviour was ‘risky’ which was both self-evident and yet meaningless in the context of the dynamics of Child Sexual Exploitation. It is of interest that even CIT who were believed to have expertise in CSE are recorded as having spoken to the young people in these terms. Such a didactic approach is generally likely to be ineffective, not least with teenagers who are particularly resistant to simply accepting adult instruction and by the nature of their developmental stage are more likely to challenge or reject adult views on what is acceptable behaviour. For these 6 young people who had also experienced adults as often dangerous and untrustworthy, the likelihood of responding to adult instructions simply to behave differently was even less likely. 4.6.6. On occasion this instructional approach also had a threatening or punitive feel to it that also is unlikely to have been constructive. In January 2009 111 was “spoken to about the need to protect herself and the baby and was told how seriously a new/further referral to CSC would be treated”. Social Workers will sometimes need to explain to parents what the potential implications may be if there are new concerns about a child, but this needs to be managed in a sensitive way. We know from 111’s discussions with other workers that she experienced this as threatening and disempowering and it simply had the effect of making her anxious about CSC involvement and closed down communication. 4.6.7. Time and again this behaviour change was intended to be achieved by referring the young people and their families to the Family Support teams, and these referrals were made both by Duty and Assessment Social Workers and by other agencies. This is reflective of the research available in relation to interventions with adolescents, which identifies that typically the focus of work with adolescents has been on their “ behavioural and emotional problems rather than on abuse and neglect” 48. Little evidence has been provided of conscious, clearly articulated and recorded decision making as to whether the young people might meet the Significant Harm threshold. 4.6.8. Referral for Family Support: The absence of intervention by Children’s Social Care at a number of crucial points in the young people’s lives is apparent within this Review. When CSC did intervene it predominantly did so by referring the young people on for another team to manage the behaviour. Most often that would be the Child and Family Support Team, on other occasions the Young People’s Support Team, the Intensive Support Team or the Child and Adolescent Mental Health Team. 4.6.9. In the absence of good quality assessments of the Young People, there was also at times a confusion of purpose in relation to the 48 Rees et al (2011) RBSCB Overview Report 85 referrals for intervention. For example the making of a referral to a parenting programme for 111 in 2010 is of questionable value when it was apparent from the evidence at the time that the main risks to her parenting of her child were her alcohol use and her emotional distress. Similarly unclear was a decision by a social worker to refer 111 to CAMHS and to Positive Activities for Young People in order to “help 111 understand her behaviour and gain control over her actions.” There was no evidence that the agency itself had any real understanding of 1111’s behaviour, as evidenced by the apparent conviction that simply referring her to these agencies would enable to control what was happening to her. This routinised approach to referring on to other services continued time after time with no assessment of whether it was proving effective. 4.6.10. The reasons for this are likely to be several, including pressures of work, agency culture, poor supervision, lack of confidence or skills in working with this age group, and possibly most significantly a lack of available services relevant to this age group. What has also been identified is that from 2010 onwards the focus at the most senior level of Children’s Services was on managing less children in care and, in particular, encouraging ‘family based support’ for teenagers. Social workers were therefore being given a clear message from senior management about the approach to intervention with this age group. 4.6.11. The IMR for Children’s Social Care has in particular highlighted the impact on decision making for these young people of the “Supporting Children and Young People to Remain within their Family’ policy, informally referred to as the ‘non-accommodation policy’ This policy was in place between September 2006 and October 2012, when it was rescinded. The policy had clearly caused serious misgivings amongst practitioners and other agencies for some time. The policy lays out a very strong argument for keeping children, and especially young people with their families, with little balance in relation to identifying the risks for some of these young people. It includes a very prescriptive procedure for any applications for a child to be accommodated and the statement: that: “apart from situations where children and young people are very vulnerable and cannot live with their families, the Authority WILL NOT LOOK AFTER(sic) children/young people on a long term basis.” The CSC IMR concludes that this policy “seemed to significantly limit the safeguarding options of social workers and their managers in the Duty and Assessment Team to remove young people from harmful situations”. It is important to note that this policy reflected national government priorities at the time. Whilst the general concern about this policy’s impact on accommodating children is a legitimate one, no specific evidence has been provided that this was a direct factor with individual young people subject to this review. 4.6.12. Duty and Assessment social workers were responding to referrals about these 6 young people almost entirely at Level 2/3, ie below the threshold at which Child Protection Proceedings would have been considered. It is therefore difficult to make a causal link with the ‘non-RBSCB Overview Report 86 accommodation policy’ and the response to these young people. 1111 and her child were accommodated with foster carers under S20 of the Children Act, the intention being for this to continue for two years. The focus of this decision however was the safeguarding of 1111’s child. When the placement broke down further Child Protection planning related only to 111111, not to 111 herself, who was viewed as having discharged herself from care and no further option of accommodating her appears to have been considered. 4.6.13. The only young people who were considered to be at risk of Significant Harm and therefore subject to Child Protection Plans were 1111111111111. There is no evidence that S20 or Care proceedings were ever considered for 11111111111 and therefore, again, the issue of long term accommodation would not have arisen. There is one reference in 2009 to a residential placement being found for 111 but there is no evidence that this was ever pursued and the degree to which the ‘non-accommodation policy’ prevented her being accommodated is difficult to assess. If anything the fact that this was not pursued is consistent with the general pattern of poor planning and drift that featured throughout 111’s Child Protection plan. Nevertheless, although making a direct causal link with the ‘non-accommodation policy’ is problematic, it clearly had a significant impact on the general approach to interventions with young people and even if it was not a conscious reaction must have influenced the mindset of Social Workers regarding thresholds for intervention. 4.6.14. The actual content of the work that was to be undertaken by the Family Support teams remains largely undefined. There is no evidence as to whether the intervention was: based on a particular model; underpinned by any particular knowledge base; targeted at the particular needs of young people or had an identifiable practice framework. Records of the work undertaken by Child and Family Support Workers show little evidence of a plan of work being reviewed over time. In the absence of such a plan it appears to rely significantly on the individual skills, creativity and common sense of the Family Support Workers, some of whom clearly worked hard to engage with and help the families, others who struggled with the task. 4.6.15. These interventions via Family Support whilst providing some short term help were largely ineffective in establishing support and the safeguarding of the young people in the long term. One of the explanations for this continuing pattern is the absence of any identifiable management overview of the effectiveness of interventions other than on a very short term basis. General practice nationally for family support teams which was apparent here, was for them to offer a short term, task centred service focussed on helping parents to improve their parenting skills and helping the young people to change their behaviour. However, what was absent was any evidence that managers either at team, middle or senior level, reflected on whether this approach was effective. Research as to where this approach was successful has identified the key components that were required for positive outcomes including: RBSCB Overview Report 87 Systematic assessment of family functioning Problems identified, goals set, work planned, clear agreements drawn up Work with parents; emphasis on appropriate parenting including behaviour management through positive reinforcement, boundary setting, developing routines Work with young people, exploring views, identifying triggers to conflict and behaviours that are dangerous, being alert to any evidence of abuse Using sessional staff to befriend young people, build self-esteem and engage them in positive local activities. 4.6.16. Conversely the research identified that the outcomes were poorer when: parents and young people could not be engaged or showed no motivation to change the young people remained in involvement with ‘antisocial peer groups’ young people’s mental health difficulties or parental conflict was chronic or severe Short term interventions were the main response to chronic or severe difficulties.49 4.6.17. Whilst some of the positive components did feature there is no evidence that they were part of a comprehensive and systematic approach. There is significant evidence that the components likely to lead to poorer outcomes were however in place. There is further no evidence that at any point during these young people’s journey through the system, that any consideration was given as to the effectiveness of repeated referral to the Child and Family Support team or Young Person’s Support team. 4.6.18. If we ask why individual responses were ineffective, one of the reasons we must consider is the apparent absence of any culture of reflection or review by operational managers in relation to young people’s experience of these services and their effectiveness. This in turn leads to a similar question regarding the focus of Senior Management. The lack of any clear framework or culture focussing on practice effectiveness is apparent not simply in relation to the specialist needs of these young people, but across wider service provision and child protection practice. Until 2010 there was no framework in place requiring a specific planning process for those identified as being a ‘Child in Need’. No evidence has been provided that there was a performance framework in place which focussed on the effectiveness of interventions and there was no meaningful 49 Rees et al (2011;103) RBSCB Overview Report 88 contact between senior management and frontline staff. Given the particular difficulties of working with such adolescents there is a heightened requirement for an evaluative culture to be built in.50 Without such a culture it becomes more apparent why at the front line the practice appeared to be simply to provide ‘more of the same’ irrespective of its long term impact. 4.6.19. Co-ordination of planning. The effectiveness of individual agencies’ interventions in relation to long term outcomes for the young people is not easy to assess because of the chronic nature and complexity of the young people’s problems. What was required was well co-ordinated and intensive support across a range of services but this was noticeably lacking. Given the number of agencies involved at any one time, the route for co-ordination would have been either through a CAF, through a clearly managed Child in Need Plan or Child Protection procedures. 4.6.20. It is evident that the level of need and the risk of significant harm in relation to these young people would have effectively precluded the use of a CAF in most circumstances. There is reference to use of a CAF on a small number of occasions, but due to a lack of recording, there is no evidence of a clear sense of purpose or proper review. From the information available, the CAF initiated in relation to 11111111presents as being confused, both in terms of the process and the content. Agencies recorded different understandings as to why the CAF was initiated, whether it related to 1111 or her child and who was the lead practitioner. The CAF meeting then recommended an Initial Assessment suggesting either confusion about its role, or more likely, that agencies were trying to use the CAF process to reinforce previous attempts to make child protection referrals to CSC. The Initial Assessment resulted in a referral for Family Support, with the CAF appearing to continue alongside but without any clear link between the two processes. 4.6.21. This episode highlights the difficulties the agencies clearly had in establishing a clear co-ordinated approach to managing interventions. Why the CAF process was so limited is likely in part to have been because it had not been effectively rolled out or embedded into routine practice. This has been confirmed in the unannounced OFSTED inspection of December 2009, which referred to the CAF being under-utilised by agencies. 4.6.22. Similar problems can be identified across the health provision. A range of services were involved with each individual young person and yet there was no overall co-ordination of the healthcare provision. Whilst individual health professionals communicated with each other there was no evidence that staff ever met together as a team to consider what needed to be done, who should do it or how the various interventions could be best co-ordinated. 50 Rees (2011:97) RBSCB Overview Report 89 4.6.23. It is also evident that it was not only the professionals but more importantly the young people who found this lack of co-ordination difficult to deal with. 111 in particular spoke to Early Break at around this time, and described feeling overwhelmed by all the agencies involved. The Early Break worker spoke to Action for Children to try to see if the numbers of appointments for 111 could be reduced as they clearly felt this was having a negative impact on 111. However, in the absence of any clear process this does not appear to have been taken any further. The Early Break worker spoke of a culture of services “dipping in and out of 111s life”, a perception which is supported by the information available to this Review. 111 also spoke of feeling overwhelmed by professionals, leading her to avoid meetings ‘She wanted people to go away and stop ‘stressing her out’” 4.6.24. What is apparent from this inability to co-ordinate at a multi-agency level is a sense of helplessness by agencies leading to individualised working interspersed with often unsuccessful attempts to make child protection referrals to Children’s Social Care. 4.6.25. Similar problems with a lack of planning and co-ordination are visible at points when the young people were viewed as meeting the threshold of ‘Child in Need’. What is noticeable is that there is rarely, if ever, a consciously articulated identification that any of the young people should be considered a Child in Need or that there should be any planning process as a result. As previously noted, the young people were on a number of occasions referred for Family Support, but there is nothing to suggest that this was seen as part of an overall plan to meet their needs. Rather it appeared as a stand-alone response with both the Family Support workers and other agencies attempting to link together at times, but without any overall sense of co-ordination. When there were attempts at co-ordination by Children’s Social Care, these were generally reactive responses by individual practitioners, not part of a planned and structured response or with any formal involvement of qualified Social Workers. 4.6.26. In 2007 the Safeguarding Board had launched its ‘Threshold Model for Safeguarding and Promoting the Welfare of Children’ which outlined how services should work together to meet children’s needs. The policy referred to the need for a designated lead professional in ‘complex cases’. However the policy did not establish how this professional would be identified or provide any help and guidance in putting a meaningful multi-agency system in place. Neither was there any requirement to develop Child in Need Plans. That individual practitioners working across a very wide range of agencies would be able to set up and co-ordinate such a system on a case by case basis was unrealistic and provides considerable insight into why practitioners frequently failed to work in a co-ordinated fashion across agencies. 4.6.27. The lack of any expectation to work to a clear plan for a Child in Need also impacted on provision at the end of other formal interventions. When 111 left the foster care provided for her and her child she was RBSCB Overview Report 90 deemed to have voluntarily discharged herself from Care. She was allocated a support worker from the Young Person’s Support team, whose main focus appeared to be arranging accommodation. However, 111 had been accommodated as a result of being “at risk of sexual exploitation and unable to put Child11111 ’s needs before her own”. Her child’s needs were responded to through the child protection processes, however, there is no evidence that risk of further sexual exploitation was considered or any plan put in place to meet 111’s needs. 4.6.28. The lack of any ‘step down’ planning is also apparent when 111 was removed from the Child Protection Plan. 111 was removed from the plan because it was concluded that there was a lack of evidence that she met the threshold of being at risk of significant harm. Her wider welfare needs and vulnerabilities did not lead to recognition that she remained a Child in Need and no planning took place to help manage the transition. It appears that two of the factors which contributed to this response to 111 were her age, in that she had recently become 17, and her difficult sometimes aggressive behaviour towards professionals as noted in some meetings. 4.6.29. A related and significant feature of the young people’s experience of agencies was the impact of a constant turnover in allocated practitioners within some agencies. This is most dramatically evidenced in the turnover of social workers involved with 1111111. During 2010 111 had 4 different allocated Social Workers as well as contact with at least two duty workers. Over the course of her involvement with CSC she had contact with at least 13 Social Workers and Family Support Workers and 4 managers had responsibility for overseeing the work with her. The Child Protection Conference Chair in October 2010, specifically acknowledged to the family that this was unacceptable. 4.6.30. Children’s Social Care was not alone in this turnover of staff. Education Welfare acknowledged that, in part due to cuts in its budget it struggled to ensure a consistent approach. The YOT IMR has also recognised that it suffered from a similar problem. What is of concern however is that this issue was identified for the YOT in a previous Serious Case Review (Child A) in 2010. There is no evidence that the recommendation from that Review which was to: ‘examine if a single allocated case manager would be more beneficial from the young person’s perspective”, has been acted upon and the IMR for this Review has made a recommendation, not to change the practice but again to: “Review effectiveness of multiple workers working with young people”. This suggests a passivity of approach to learning from Reviews and the author would therefore suggest that the Safeguarding Board is particularly scrupulous in holding this agency to account as a result of this Review. 4.6.31. The nature of service provision and the range of needs that the young people presented with meant that there would always need to be a significant number of professionals and agencies involved with them. RBSCB Overview Report 91 However, there is no evidence that any of the responsible managers considered how best to manage this, how changes of practitioner could be minimised or what would be the impact on the young people or the quality of assessment and intervention as a result. There are a number of probable explanations for the high turnover of allocated workers, including: staff shortages; high usage of agency and interim staff; organisational redesign to deal with staff shortages or other policy changes; specialisation of job roles. 4.6.32. Child Protection Planning: When the young people did become subject to Child Protection processes, these were of a poor quality marked by drift, poor adherence to procedures intended to act as checks and balances, a lack of planning or review and poor recording. 4.6.33. During the time period identified for this Review, 1111111111111 were identified by Rochdale as having crossed the threshold from Child in Need to Child at Risk of suffering significant harm and therefore subject to Child Protection Plans in their own right. 11111 was very briefly a Looked After Child having been voluntarily accommodated in foster care in response to concerns about her own child. 111’s children were subject to Child Protection proceedings, but she was not, despite consistently extremely worrying behaviour including aggression, self-harm and other indicators of serious emotional distress. 111’s child was subject to Child Protection Planning but she was not. 4.6.34. 1111111111 both became subject to a Child Protection Plan in 111111111111, having been involved with a range of services, including Family Support, and been subject to a previous plan in 1111 when they moved to the area from AreaD. Information from that time and the intervening years suggests that there were significant problems within the family throughout their childhoods and a number of referrals had been made previously. The view of the IMR author for Children’s Social Care was that the Child Protection plans in 1111 were ended prematurely and that there was a case at that time for removal of both girls as a consequence of “neglectful parenting, lack of supervision, and minimisation of the risks of potential sexual abuse from extended family members.” What becomes apparent is that the young people’s needs had been badly met for some considerable time prior to them being subject to child sexual exploitation and that neglect in different forms was a feature of much of their lives. 4.6.35. The ultimate trigger for initiating Child Protection procedures was referral by the Police and CIT in August and September 2008 specifically identifying that the two young people were amongst a group of girls being sexually exploited. 111 was also involved in this investigation but was not made subject to Child Protection procedures. The rationale in the Initial Assessment for 111 being that although the concerns about sexual exploitation were substantiated she was not considered to be at risk of ongoing harm as her parents were believed to be protective and in any event did not want involvement with Children’s Social Care. This illustrates a recurring RBSCB Overview Report 92 theme in the assessments of the young people, in that all too often parental reassurances were accepted and little effort was made to understand the risks from the young person’s point of view. Again 1111 was assessed as being ‘out of parental control’ rather than being vulnerable to further abuse. 4.6.36. However, it is also important to note that 111’s parents have a very different perspective in that they told this Review that they made numerous phone calls to Children’s Social Care and “begged” the department to take 111 into care in order to protect her. 4.6.37. It is clear that along with the central issue of Child Sexual Exploitation there was significant historical information that should have informed the Child Protection Plans for 111111111. However, the Core Assessment was not completed until 5 months after the Initial Child Protection Conference took place and as such there was no comprehensive assessment on which to base the Plan. This appears to have set the scene for the following year that 111 was subject to a CP plan and the four and a half years during which 111 was subject to a Plan. The Plans did not refer to Child Sexual Exploitation or include the criminal investigation as a core element, they had no clear outcomes or detailed actions as to how the young people could be protected and supported and all the actions identified were the responsibility of their mother who had shown she was unable to keep her children safe. 4.6.38. Whilst the key role for assessment sat with the Social Worker, what is also apparent in the following months and years is the ineffectiveness of the multi-agency group whose role it was to manage and oversee the plan. Child Protection Conferences did not review the plans against the actions, core group meetings were not always well attended, there was poor recording of meetings and an absence of police involvement in the core group. There was frequently no obvious outcome from meetings which often appeared to be a predominantly a discussion of what had happened without any evidence of active review and planning. A sense of helplessness is described by the IMR Author about the discussions held within Strategy and other meetings. The impression given through these records was that ‘nothing could be done’. 4.6.39. The rationale for decisions was often unclear and intervention lacked direction. There was reference for example to a possible foster placement or therapeutic community for 111, about which 111 herself was positive, however there is minimal further reference to this in the records and eventually it is just noted as no longer being necessary. 1111111111111 care proceedings were initiated, but it is difficult to detect what in particular triggered this action or what was felt to be fundamentally different about the risk she faced. There is no clear explanation for these decisions; rather it appears that it is simply a response to the passage of time. 4.6.40. What also emerges is a pattern of referring to Legal Gateway meetings as if these would provide an answer to the difficulties rather RBSCB Overview Report 93 than recognising their role as being the provision of legal advice to the social work practitioners and managers. SW4 is noted on a number of occasions as referring at Child Protection conferences to the need for a Legal planning or Gateway meeting to plan “a way forward”. On one occasion she stated that 111 was “crying out for some sort of support and containment”. This comment in particular suggests that it was not something the social worker, her manager, or possibly even the Child Protection planning process believed they were able to address. 4.6.41. One of the most powerful examples of the collective inability to effectively assess and manage the risks facing 11111, was the multi-agency response to information known about AdultD. From 2008 onwards the agencies were provided with a series of concerns about this man and the risk he posed to young people, yet decision making was inconsistent and unclear and there is little evidence of any structured assessment of the risk he might pose to these or other young people. That the young people concerned were already known to have been sexually abused and exploited and were to some degree estranged from their own families should have identified them as particularly vulnerable to being further abused. 4.6.42. A summary of what is known and what action was taken is as follows: April 2008 111 told school she had had drink spiked whilst at AdultD’s August 2008 111111111111 known to be living with AdultD’s Oct 2008 111 told school she had sex with AdultD’s son. AdultD’s family said to be well known to CSC. 1111 living with AdultD Oct 2008 Police report identifies AdultD known to pose a potential risk of sexual abuse Oct 2008 111 refuses bail if she is not allowed to live with AdultD Nov 2008 SW notes ‘concerns’ about young people visiting AdultD Nov 2008 SW states may give agreement to 1111 staying with him if he sorts out the bedroom and reminds him of responsibility to keep 111 safe Jan 2009 Core Group. Recorded that 111 at AdultD, no reference to a decision as to whether this has been agreed by SW/Core group Jan 2009 CITC and Police inform SW of 111111111111111111111111111111111111111111111111111111111111111. No reference to any decision/advice by CSC as to contact between AdultD and children. Feb 2009 CP Review informed AdultD is being investigated. No reference to any safeguarding action re risk he may pose to children March 2009 11111 informed CSC that AdultD had been arrested for “running a prostitution ring from home”. . No direct evidence of information sharing between the Police and CSC. YOT stated AdultD on 13.03.09, questioned about sexual activities with a minor and bailed until 11th April 2009 March 111 arrested for enticing girls, including111, into prostitution. Bailed to RBSCB Overview Report 94 2009 AdultD’s home. condition of no contact with 1111 July 2009 111111111111111111 known to be living with AdultD August 2009 Child Protection Review Conference. Concerns about AdultD again recorded. It was said that previous allegations against him had not progressed due to lack of evidence but the police continued to gather evidence about him August 2009 111 staying at AdultD’s and unresolved confusion as to whether it was allowed. CIT records refer to an “Emergency Strategy Meeting” and a ‘procurer order in place in relation to the property’ August 2009 Dissension Panel: Stated AdultD was not blood relative, He had been issued with a Final warning under Section 2 of the Child Abduction Act in respect of harbouring a child under 16. The Panel considered there were risks relating to him that were not being adequately addressed. August 2009 111 asked SW to help her find independent accommodation as she no longer wanted to stay at AdultD’s. SW was concerned that 111 was too vulnerable to consider an independent tenancy and there were concerns about AdultD, but she could remain there temporarily until appropriate alternative available. June 2010 111 Core Group meeting. Still said to be visiting AdultD, but he had been “checked out by police” July 2010 111111111 and school asked SW what advice was re AdultD. SW said this would be discussed at Core Group meeting July 2010 111 Core Group Meeting. No record of advice/discussion. Oct2010 AdultD arrested, daughter taken into care 15 October 2010 Mother 11111111 told not to allow 1111 to have contact with AdultD November 2010 Core group. SW says there can be no contact with under 16s due to bail conditions. January 2011 CP Review: SW says there can be no contact with under 16s due to bail conditions April 2011 Information received that 111 seeing AdultD’s sons with her mother’s agreement. No action taken. 4.6.43. What this chronology illustrates is: an absence of any formal risk assessment process on which decisions could be based; a pattern of delaying decision making, for example adjourning decisions to the Core Group; discussions either not taking place at Core Group or a decision not being taken; contradictory decisions being made regarding the risk to 111 of living at the address. RBSCB Overview Report 95 absence of liaison between the police and children’s services about the risks that AdultD might present and no evident attempt to collate information about what was known about him to inform safeguarding decisions, as opposed to charging or bailing decisions. 4.6.44. It is not always easy to identify what information was available to members of the Core Group as a whole, for example whether they knew that family members had been told by the Social Worker in July 2010 that the Core Group would make decisions about the appropriateness of contact. Clearly if such information was not properly shared by the Social Worker this would have undermined the group’s effectiveness. In any event there is little evidence of a culture of reflection and challenge in the group. 4.6.45. Information was clearly available and known at the time that would have indicated that AdultD presented a significant risk to children. Comments have been made that AdultD and his family were “well known” to the police, Children’s Social Care and within the local community. There is no curiosity about why the young people, particularly 111 who was not related to this man would prefer to live at this address rather than with their immediate family and what that might indicate about the quality of relationships with their parents. That the lack of curiosity may have reflected a lack of practitioner time and therefore capacity to respond should not be discounted. 4.6.46. The difficulties in finding suitable accommodation for this group of young people is evident on a number of occasions and identified in the Housing IMR. The young people were also often unwilling to accept alternatives offered to them as in their judgement these alternatives represented a worse option. It is possible that the difficulties agencies experienced in finding accommodation may have impacted consciously or unconsciously on their judgement about the motivation of AdultD. This combined with other weaknesses in the working relationship between the young people, their families and practitioners, not least the Social Worker may also have impacted on their ability to focus on the risks to the young people in this setting. 4.6.47. The Social Worker who was key to this process no longer works with the Authority having been subject to a disciplinary process which is yet to be completed. As such it has not been possible to obtain any direct information which could help to explain a standard of practice which appears so poor with hindsight. Contributory factors as identified elsewhere, such as high caseloads, lack of organisational prioritisation of adolescents and lack of knowledge regarding sexual exploitation may have played a part. 4.6.48. However, the gap in the quality of practice that could reasonably be expected of an experienced social worker remains stark. If this approach to practice was significantly the result of poor skills on behalf of an individual social worker, it leaves unanswered the question as to why management oversight had failed to recognise the quality of practice, to challenge the thinking or to intervene. There is RBSCB Overview Report 96 no evidence that the social worker sought help and advice or that active supervision was provided to her in relation to this case. During the time period this took place the Social Worker herself had become a team manager. There is no evidence available to this Review as to what supervision, if any she received in this role. 4.6.49. What is also of concern during this period is the quality of liaison between CSC and the Police, which is very variable. Whilst there is evidently some contact between the two services, it is inconsistent and there is little evidence that whatever information exchange there was regarding the risk presented by AdultD resulted in any effective protection for these or potentially other young people. 4.6.50. The Police IMR notes that there were 40 Child Protection Conferences for 11111 but provides no record of their attendance or other involvement. The exception to this lack of records is one occasion when the Police representative dissented from the decision to remove 1111 from the child protection plan. The IMR suggests that problems with the migration of data when IT systems were updated may account for the significant gap in the records for this time. 4.6.51. If this is the case, this loss of information represents a serious weakness for the Police and has been identified in at least one previous Serious Case Review. Information from other agencies does evidence that there was some attendance at Child Protection conferences and Core Groups by the police, but also records that concerns were also raised in late 2009 due to the lack of Police attendance. Given the gaps in information the reasons for the Police absences remain unexplained. As a result the Review has been left with an incomplete and unsatisfactory picture of the involvement of the Police in the routine Child Protection processes. 4.6.52. Safeguarding the young people’s children. A marked recurring theme in the young people’s experience is the shift in agency response when they become parents. An identifiable pattern which has emerged in this Review, a pattern which has also been specifically commented on by 111, is the difference in approach adopted to the young people’s children in contrast to that adopted for the young people themselves. 4.6.53. One of a number of examples of this was in 2008 when Action for Children made a referral to Children’s Social Care in which a range of concerns were identified both about 1111 care of her child, but also regarding indicators that 111 was experiencing sexual exploitation. This was shortly afterwards followed by a referral from CIT also identifying sexual exploitation. The focus of the Initial Assessment was on 111’s Child who was then made subject to a Child Protection Plan under the category of neglect. In the absence of any plan to respond to the safeguarding needs of 111 The Chair of the Child Protection Conference specifically recommended that 111 also be allocated a social worker. However although the case was allocated, no strategy meeting ever took place and 111’s safeguarding RBSCB Overview Report 97 needs were not assessed. The focus remained on her child or on her parenting. 4.6.54. Another conspicuous example of this focus on safeguarding the baby rather than the adolescent mother was 111111 when 111 took an overdose. An Initial Assessment for 111 concluded that although she was in a “fragile emotional state” she was not currently at risk. However a Core Assessment was undertaken with regard to 111’s child because of his mother’s fragile emotional state. Although she was nearly 18 at this point, 111 was still herself a child. 4.6.55. Whilst it was clearly right that agencies assessed and responded to the needs of the young people’s children, the contrast with the way they were themselves assessed and responded to is noticeable. Other agencies also recognised that they tended towards a similar approach at times in more easily recognising the babies’ needs. Action for Children for example also acknowledged that the focus of both their referrals regarding 111 and 111 was primarily on safeguarding the children rather than the young people. 4.6.56. As has already been noted there is explicit evidence that the organisational priority within CSC was on young children not on adolescents and this evidently had a significant impact on the quality of the intervention with the young people. However, the Pennine Acute IMR also articulated another explanation of this pattern which adds to our understanding: “there was an underlying sense that something tangible can be done to protect the babies whereas the solutions and options available to protect the young people in what was becoming a deeply entrenched pattern of exploitation and abuse was far more challenging and uncertain.” 4.6.57. What we know from research is that these concerns represent commonly experienced problems and failings in providing services to this age group. Evidence from research identifies a reluctance to intervene with young people51 for reasons that mirror what was at times taking place with these young people. The response to the young people’s babies throws into stark relief the difficulty experienced by many agencies not only in how they related to and understood the young people, but also their confidence and ability when it came to intervening with young people. Working with young people who have been sexually exploited requires particular strengths and skills in workers which requires support and development in training and by their agencies. 4.6.58. There is a strong body of research to identify that the sort of weaknesses seen here in the provision of services to this group of young people represents a common pattern. The 2012 Government review of Child Protection concluded there was: “a worrying picture 51 OFSTED 2011 Turney et al 2011 RBSCB Overview Report 98 with regard to the protection and support of this group. This is characterised by a lack of services for adolescents, a failure to look beyond behavioural problems, a lack of recognition of the signs of neglect and abuse in teenagers, and a lack of understanding about the long-term impact on them “52. 4.6.59. Adequate age appropriate services, specialist help and assessment tools are often lacking given the focus on younger children and early support for families with young children. At a national policy level this age group is largely the subject of concern in relation to their perceived impact on others, such as offending and anti-social behaviour, rather than in relation to their own welfare needs, as such reflecting wider societal attitudes. This then is mirrored in the provision of services and policies at a local level. 4.6.60. At the level of direct practice, the lack of expertise, ability and at times empathy in working with young people has been evident in several of the agencies and with some individual practitioners. Maintaining a sustained relationship over time with young people who have had very damaging experiences is genuinely difficult. The way in which the young people’s distress is demonstrated combined with a common pattern of testing of the relationship with workers by rejection can lead the worker to “feel as depressed, as chaotic and as confused as they (the young people) do.”53 It is crucial, that as 111 stated, any focus on the young people’s vulnerabilities does not become a diversion from the responsibility of their abusers. However, services and individual practitioners will serve those young people better if their skills and understanding of this age group are improved and simplistic beliefs about the needs of young people are challenged. 4.6.61. A further insight into why the intervention with these young people was so limited has been identified by a number of the agencies. The Child Protection System has been developed primarily to focus on abuse within the home, rather than by non-family members. This was reflected most explicitly in the organisational approach of the police at that time. The investigation into offences against children could either have been undertaken by CID officers who had no background in safeguarding, or by the Police Public Protection Investigation Unit, which had a much clearer understanding of children’s needs and safeguarding. The key factor that determined which of these would undertake the case was whether the offender had ‘care, custody and control’ in relation to the victim – that is whether it was or was not taking place within the family. 4.6.62. Whilst this distinction between inter-familial and extra-familial abuse has now been recognised as unhelpful by all the agencies, careful consideration is nevertheless required as to how best to mobilise services to support young people experiencing sexual exploitation. 52 HM Government 2012 53 Pearce (2009: 151) RBSCB Overview Report 99 There are aspects of the Child Protection process which do not lend themselves well to engaging with young people and this Review would urge consideration of whether other routes than Child Protection planning may need to be considered in the future. 4.6.63. What is also of note is that no information has been provided to this Review which demonstrates that agencies working with these young people looked outwards to learn from the experience of others as to how to approach Sexual Exploitation. As has been noted a number of authorities locally had gained considerable knowledge, but there is nothing to suggest that any of these were approached for help or advice. It is not possible to know why this did not take place, although the lack of good critical supervision, the lack of recognition that each case was part of a wider picture and resource pressures may well have contributed to what appears to have been a fairly insular approach to the problem at the time. 4.6.64. Similarly, despite the involvement of a project run by Barnardo’s who have been leaders in recent years in developing our knowledge and understanding of CSE, the connection was not made either by staff in the project, or by other agencies that this organisation could offer expertise. Barnardo's has recognised that because the project was focussed on meeting adult needs their staff did not have expertise in this area. It has therefore been decided not to provide such projects again in the future. However it is perhaps a lesson to national voluntary organisations to ensure that their national policy imperatives are well integrated with locally provided services. 4.6.65. Challenge and escalation. In common with other serious case Reviews, what is also evident here on too many occasions is a lack of critical but constructive challenge within agencies and across agencies. This can be seen both on an individual basis but also in the work of the Safeguarding Children Unit54 which had a role in ensuring checks and balances were in place, but clearly struggled to fulfil this role effectively at times. 4.6.66. It is important to note that there were challenges made, some of which were successful. For example in 2008 when the CSC Social Worker expressed a firm view at the initial Child Protection Conference that 111’s needs could be met within a Child in Need Plan, other conference members disagreed with this assessment and she was as a result made subject to a Child Protection Plan. 4.6.67. On a number of occasions individual agencies or professionals felt unhappy with significant decisions that were taken in relation to the young people but seemed unable to translate these concerns into effective challenge. Sometimes these concerns were not communicated outside of the agency for example one of the YOT workers, PAYP2, commented that it was unclear in Core Group meetings how 111 was to be kept safe. There is no evidence 54 This is now known as the Safeguarding Children Unit RBSCB Overview Report 100 however, that his concerns were raised in the meetings themselves. Whether this was a lack of confidence in relation to that individual worker, or a lack of understanding of participants role in the Core Group is not known. This worker attended meetings with the YOT Case Manager, who would have had a more senior role and might have been expected to raised these concerns, if he did not feel able to. Again, however, it suggests that there was an absence of managerial oversight either in reviewing the individual worker’s contribution in the Core Group or in ensuring their concerns were taken up through management structures. 4.6.68. On other occasions practitioners expressed their concern but either could not or did not follow up those concerns when they were dissatisfied with the outcome. Examples include: October 2008, referral made by CIT to CSC regarding 111. No action taken by CSC as they had recently undertaken an initial assessment. No follow up by CIT 2009 both the School Head and the school health practitioner expressed their unhappiness about CSC decision to end their involvement with 111. But there is no evidence that this led to other action 2008 a Child and Family Support Worker challenged 1111’s Social Worker after he refused her request to make a referral to mental health services. However, he would not accept her view that such a referral was necessary. The CFSW did not take this further. 4.6.69. A particular example is the challenge by the Core Group of the recommendation by Children’s Social Care to remove 111 from her Child Protection Plan. A number of the agencies present would not agree to this recommendation as a result of which the decision was referred to the Dissension Panel, a meeting of senior managers whose role was to reach a decision in these circumstances. This panel confirmed that 111 should remain on the Plan and identified a significant range of concerns about the effectiveness of the work undertaken to date and the ongoing risks to 111. Having received a clear message from the Dissension Panel what is then surprising is that when just 3 months later 111 was removed from the plan, the agencies who had previously objected to this course of action did not do so again. There is no information that any new course of action was considered in relation to 111 in the light of the Panel’s comments. In a Child Protection meeting two months later there is nothing in the records to confirm that 1111 was discussed. 4.6.70. Two possibilities suggest themselves as an explanation. Firstly that those who had dissented felt that the Panel process had in reality achieved little and the impetus to challenge further was lost. Alternatively, given that a particular note was made of 111’s abusive behaviour in the group and that she presented as confrontational with professionals it may be that a sense of professional helplessness as RBSCB Overview Report 101 to how to intervene took over. There is no evidence that the Dissension panel had any further involvement in 111s case and no other evidence of management oversight. Given the comparatively unusual fact of a dispute between professionals in a Child Protection Conference, some form of review of the longer term outcome for 111 at a more senior level should have been considered. 4.6.71. That individuals such as these did challenge decisions which they felt were not in the young people’s interest is of course positive. However what they clearly did not either feel able to do or believe they should do was take their concerns to their manager or through agency or Board escalation procedures. In the case of the Child and Family Support Worker’s challenge the response of the Social Worker as it is recorded was very clearly intended to close down any further challenge and specifically referred to the position of a Conference Chair to reinforce the position taken. It is possible that a CFSW in these circumstances would not feel able to question the Social Worker further. 4.6.72. A number of the individual agencies have made recommendations regarding escalation of concerns and this is also identified for further consideration by the Board in Section 5. 4.6.73. The role of the Child Protection Unit Reviewing Service. The function of the Unit was to provide Independent Reviewing Officers to chair Looked after Children Reviews and to Chair Child Protection Conferences and Reviews. The role is intended to act independently of Children’s Social Care front line functions and provide a quality assurance function in relation to individual cases. 4.6.74. This unit has rightly come under scrutiny given the limited evidence of effective oversight or challenge from those chairing the conferences. There are a number of occasions when Conference Chairs and IROs raised criticisms or concerns about the progress of work with the young people but there is no evidence that these concerns were pursued effectively outside the meetings. These included: September 2008: Conference Chair states that there should be a strategy meeting and allocated social worker for 111 October 2010 re 111: Concerns about the number of social workers involved and the failure to undertake statutory visits. Evidence in minutes of meetings that the IROs were frustrated at the lack of progress in safeguarding 111 in particular 4.6.75. However there were also a number of times when there is no record that the Chairs or IROs raised issues that would have been within their remit to comment on or to escalate to team managers including: Failure by the Social Worker to meet with the young people as part of the Initial Assessment Decision to discontinue the CP plan in relation to a younger sibling of 1111111 despite no Core Assessment having been completed. RBSCB Overview Report 102 Poor quality of Child protection Plans, often incomplete and with no identified outcomes. Lack of exploration of the dynamics of the exploitation including that of older ‘Asian’ males and young white working class victims. 4.6.76. In April 2010 there was a specific recording by the Chair of a Strategy Meeting that: “Enquires to be made as to why a team manager from CSC (Children’s Social Care) has not attended today’s meeting. If sexual exploitation in Rochdale is to be tackled, it needs the commitment of CSC….. the Assistant Director of CSC needs to be made aware of the situation and his support given”. The frustration of the Chair is palpable, yet there is no evidence that this was followed up after the meeting. 4.6.77. The IROs/Chairs confirmed during the IMR process that they had referred a number of their concerns to their manager, but received little feedback as to the outcome. It has not been possible to ascertain what then happened as the manager concerned no longer works for the authority and could not be contacted. There is no evidence of any correspondence between the Head of Safeguarding, who had operational responsibility for the Unit and Senior managers in Social Care of the increasing concerns during 2008 and 2009. The Reviewing Officers believed that the Head of Safeguarding would share their concerns, but were unclear if this happened. Some of the IROs also described a lack of supervision. Nor is there any evidence of formal meetings between staff in the Safeguarding Unit about the level and form of child sexual exploitation. 4.6.78. In attempting to understand why the IROs/Chairs seemed to find it difficult to escalate or press their concerns to a conclusion, particularly given that they were clearly frustrated and concerned about the practice that they were seeing, it is also important to understand the organisational context in which they worked. When the role was initially established it was viewed predominantly as facilitative, ensuring that there was an independent element to the chairing of Reviews. The role of professional challenge was not so explicitly required as it is now. Particularly since a strengthening of the statutory requirements upon the role in 2008 and the introduction of guidance for IROs produced in 2010 4.6.79. Further undermining their independence and confidence to challenge practice was the management structure that existed within Children’s Social Care at the time. Until 2011 this unit was managed by the same Senior Manager who also had overall responsibility for operational service delivery. Such a system is fundamentally flawed in that it builds in a conflict of interests. Should IROs wish to raise concerns or complaints, they would not be doing so to their own independent manager, but to the manager operationally responsible for the practice under scrutiny and also responsible for them as individual workers. RBSCB Overview Report 103 4.6.80. No formal process existed for escalating concerns until 2012, which also throws light on why concerns were not evidenced in any of the information available, and more importantly, why individual IROs may not have felt encouraged to raise their concerns. The conclusion of the IMR was that: “the Reviewing Officers felt that they had neither the status or the management support necessary to challenge the poor quality of the work they were seeing”. 4.7 The operational response: The context- Race, Class, Gender and Culture 4.7.1. As has been identified in Section 2.3 all of the 6 young people faced particular pressures and challenges in their lives as a result of aspects of their family experience, their gender, class and economic disadvantage as well as personal attributes such as learning disabilities. What is to some degree missing from this Review, given the level of involvement of the young people, is their own perspective on their lives and how these factors may have influenced events. 4.7.2. Learning Difficulties: A feature that has been identified in relation to all of the young people, with the exception of 1111, is some degree of learning difficulties and the way in which such difficulties were recognised and responded to by services. 1111s mother in particular commented that agencies had not understood the extent of her daughter’s difficulties and this is reflected in much of the evidence provided to this review. That 5 of the 6 young people did have learning difficulties is particularly pertinent in the context of what is known about the way in which victims of sexual abuse, including sexual exploitation are targeted. Information about the experience of young people with Learning Difficulties is under-researched however, it has been identified that young people with Learning Disabilities are at particular risk of being identified for grooming and exploitation.55 4.7.3. There were references by a number of agencies to either learning ‘disability’ or ‘difficulties’ in relation to 111111111111111111111 What is of some concern is that there was frequently a lack of clarity not only about terminology, which is used in different ways by different agencies and individuals, but more importantly what it meant in relation to the young people’s lives and their ability to work with agencies. The starting point for these young people should have been some form of diagnostic and more importantly functional assessment, as to the nature of their Learning Difficulties. The importance of assessment is both to enable a better understanding by services as to the needs of a young person, but is also the key to accessing specialist services. 55 Shine a Light (2013:16); University of Bedfordshire (2011:49) RBSCB Overview Report 104 4.7.4. Each of the young people’s needs and abilities were different, but what they had in common was that there was either a lack of understanding of those needs or no evidence that those needs were taken into account when providing services or other interventions. 111’s experience highlights both these concerns. The first recording was by the midwifery service which recorded in 111111. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.7.5. Although 111’s learning difficulties were noted by some agencies, predominantly within health, there is little evidence that it impacted on the way in which those agencies intervened or assessed her capacity to ‘protect herself’ or any impact on her capacity to consent to sexual activity. There is no evidence of a holistic assessment or a co-ordinated multi-agency approach to her safeguarding or welfare needs. 111 was almost entirely absent from school from the age of 14 and prior to that her attendance had been very poor. What this meant and how it impacted on her learning difficulties was noted but otherwise largely unknown and little considered. It would be expected that given her absence from school for such extended periods the Education Welfare Service might have had considerable contact with her. However, because neither their records nor the school records have been located there is no information regarding their role. 4.7.6. The issue only became significant to services in 2008 in relation to care proceedings regarding 111’s child. In the psychological assessment for these proceedings she was described as having moderate-significant learning difficulties suggesting that she would “have significant cognitive deficits that impact upon her everyday functioning. It is highly probable that such cognitive deficits would have been evident from an early age …….an initial assessment by an educational psychologist with a view to implementing the statementing process should have been requested by the headmaster of [111’s] junior school. If there was no such assessment then sadly [111] has been failed by the educational system’. The absence of the school records means that it has not been possible to address these criticisms. 4.7.7. Two months prior to the psychological assessment a Social Worker had assured another agency that 111 had no learning difficulty, which raises concerns both about that worker’s own knowledge base and a lack of awareness of the limits to that knowledge. What is more concerning is that there is nothing within the information from Children’s Social Care that shows whether the psychological assessment impacted on the way in which the agency planned its work with 111 at that time or in the future. Neither was there any RBSCB Overview Report 105 information to suggest that this was shared with the Housing Department who continued to record 111 as having a mild learning difficulty, or with other key agencies such as CIT or the Police who appeared to be equally unaware of the possibility of such a learning difficulty. 4.7.8. The existence or degree of significance of the learning difficulties for some of the young people was evidently either completely unrecognised or significantly underestimated by most of the agencies. Agencies including the Police, YOT, Barnardo’s, CIT, recorded nothing to suggest that they had understood Learning Difficulties might be of significance for some of the young people. Whilst non-specialist practitioners cannot be expected to assess learning difficulties, the presentation, behaviour and level of understanding exhibited particularly by 111 and 111 might have been expected to lead to more reflection on possible underlying problems. 4.7.9. The IMRs have provided little in the way of explanation for this lack of knowledge and recognition. However, it is not improbable that the factors which have repeatedly been identified by this Review as contributing to the quality of assessment and intervention will also have been operating in relation to learning difficulties. Nevertheless this should act as a reminder again to agencies of the need for staff to be alert both to the indicators of learning difficulties and also to the need to consider how this should impact on their interventions. 4.7.10. Specifically with regard to child sexual exploitation the information from this review again underlines the additional vulnerability of young people with learning difficulties. 11111 mother spoke about her daughter simply not understanding what was happening in relation to the perpetrators. Others have commented on the need to learn how to educate this group of children and young people in the dangers of sexual exploitation, in a way that they can absorb the information given and subsequently put that information into practice 56. As the agencies within Rochdale continue to roll out education to schools and the public, this is a factor that will need taking into account. 4.7.11. Views of the young people in the context of background and class. When considering the young people’s identity and how this may have affected the response from services, what has been apparent to this Review is that judgements were made, again both consciously and unconsciously, about the young people, given their background and class. A number of the IMR authors have recognised that these young people were disadvantaged from many perspectives, socially, educationally, economically and by the nature of their experiences within their families. This was also understood at the time by many practitioners and there is evidence of some good consistent work with the young people as a result. For example Connexions Personal Advisors attempted to work constructively encouraging ability and the possibility of positive future options. 56 Shine a Light RBSCB Overview Report 106 4.7.12. However, the response of many of the agencies too often suggests that there were limited expectations of the young people, their families and what life was likely to hold for them. The reactions of agencies suggests a high level of tolerance towards damaging and worrying experiences, parenting and life chances, that in other settings in the community would simply be seen as unacceptable. One of the most powerful examples of this relates to the response to the young people when they attend A&E as summarised by the Pennine Acute IMR: “the discharge from A/E in the early hours of the morning to an unknown destination is worthy of more reflection in terms of equality of service provision………….. consideration perhaps should be given to the exploration of whether the same response would have been afforded a young person from a different social background.” 4.7.13. The Youth Service described the young people as living in areas of significant intergenerational disadvantage. The approach that agency adopts and which serves as a good model to all agencies working in disadvantaged communities, is that their service should “aspire to the same standards and outcomes in all communities and (not) accept something different because it is claimed to be normalized within a particular community”. 4.7.14. As has been widely noted prior to this Review, there were references to the young people’s lifestyle or to them making lifestyle choices. Such references have been identified within this Review and have been evidenced across a number of agencies. Undoubtedly there are occasions when this was openly dismissive or judgemental, but equally if not more frequently, the context suggests a lack of thought on behalf of the person making the statement; the use of unhelpful shorthand, or a sense of helplessness as to how the situation could be changed. It is crucial that agencies do not simply focus on ‘stamping out’ the self-evidently unacceptable and judgemental attitudes of a small number of practitioners, but focus rather on changing the much more widely held and deep rooted attitudes in agencies, which often reflect those of the society from which practitioners are drawn 4.7.15. The concept of ‘lifestyle’ is likely to have been used as shorthand for a range of behaviours – sexual activity, alcohol and drug use, friendships seen to be negative, early teenage pregnancy. Whilst it was often legitimate for professionals to be concerned about the impact of some of these behaviours both on the young people and on their children, by summarising them as “lifestyle” with its implications of free choice and the potential for moral judgement, they betrayed and reinforced the concept that the young people had the freedom to make meaningful choices about the way they could live their lives. Given their economic, social and family backgrounds and the corrosive effect on the self of sexual exploitation this was fundamentally misconceived. In the words of 1111’s father “it’s what they expected of our children” RBSCB Overview Report 107 4.7.16. A repeating feature of the young people’s presentation was a high level of racism particularly towards ‘Asian’ people and this was something the agencies clearly failed to make sense of or respond to in a way which created an opportunity for the young people to explain their feelings. 4.7.17. 111 in particular caused a number of concerns in school as a result of her openly racist attitude and language towards staff and students including what is described as “signs of obsessive behaviour towards Asian Students”. The school clearly took action, including eventually arranging for her to be transferred to another school, but what is not clear is how they understood 111’s responses and whether there was any attempt to engage her in discussion. 4.7.18. The contradiction between the overt racism and aggression they often displayed and the young people’s assurances that the ‘Asian’ men were their friends should have triggered curiosity. That it did not could be a result of the repeating pattern of contributory factors identified throughout this Review which impacted on the quality of assessment and intervention. However, as identified in the example above it is likely also to have been affected by other factors. Racist language and behaviour was used within the young people’s families and it may be that professionals accepted this as normal within those families, and possibly within their community’s culture. As identified in the example above, there were frequent occasions when the young people were challenged about their racism, but what appeared to be lacking was either the skill or the confidence to challenge in a way which opened up discussion rather than closing it down. 4.7.19. All of the agencies taking part in this Review have concluded that the service they provided was unaffected by the race of the men who were exploiting the girls. None has identified any apparent evidence to the contrary and most offered evidence of relevant policies and practice to demonstrate that their services are provided on an equal basis. There has been no direct evidence of what has been defined by some commentators as ’political correctness’ – in other words an over-sensitivity about race leading to a conscious unwillingness to recognise or respond to the abusive actions of the men concerned because they were ‘Asian’. 4.7.20. A Review of this nature, particularly when conducted under the spotlight of intense political and media attention, is unlikely to provide a fertile opportunity for individual practitioners to publicly expose their views, including the limits on their understanding about race, in this setting. In particular opening up for public criticism what for most people are complex, often contradictory views about race and difference, knowing that they will be quickly judged by those whose own views are not subject to the same scrutiny is particularly difficult. 4.7.21. Whilst there is no suggestion being made here that agencies have been anything other than genuine in concluding their services were not affected by race, it is the view of the author that this is unlikely to represent the real complexity of working in health and social care in a RBSCB Overview Report 108 racially diverse society. Evidence from across society as a whole, and health and social care services in particular, consistently show that attitudes to race, religion and other differences within communities do affect the way services are provided. 4.7.22. To some extent the lack of explicit evidence about the way in which the men were viewed is likely to be a consequence of a lack of information about them. There was very little direct interaction with the men concerned other than by the police and staff from Action for Children and Barnardo's who provided supported housing to the young people. There is minimal recorded information about the men from other agencies and as such limited opportunity to reflect on what that information might tell us about attitudes, whether explicit or more hidden. But other information was known about them, including their age in relation to that of the young people. 4.7.23. What has however been very striking throughout this Review is the frequency with which the men are recorded as “Asian”. The use of this term suggests that it meant something to those conferring it, but what it meant has not been made explicit, although IMR authors were encouraged to discuss this with staff. Using racially descriptive terms with little awareness of why they are being used, or how they might be received, is commonplace. However, the regularity of this term recorded in agency documentation suggests that either consciously or otherwise it was intended to convey a particular meaning. What is of concern, is that it was either not considered important to understand what this was, or it was too difficult to understand. 4.7.24. What is absent is any evidence that practitioners attempted to understand why the fact that the men were ‘Asian’ might in fact have been relevant and legitimate for consideration. There is little evidence that practitioners asked questions as to why quite well established social and racial boundaries were being crossed so frequently. Questions could have been legitimately asked as to whether ‘friendships’ between middle aged ‘Asian’ men and predominantly socially disadvantaged and ‘challenging’ white teenagers required further examination. Questions as to why these two groups who would not typically have significant social contact, had become so closely linked. Asking such questions may have led to the recognition that the girls were being targeted and groomed by the men. The degree to which workers understood the communities they worked in may also have contributed to the failure to recognise the unusual patterns of interaction between these two groups. 4.7.25. However, the fact that agencies considered they were not influenced by the men’s race in itself raises questions for those agencies. Firstly it is unlikely even in the least prejudiced workforce that staff will never be influenced by issues of racial difference. In this particular context – the sexual abuse of young girls by men of a different ethnic background, in a community where there has at times been openly racist attitudes and confrontation between different groups, a RBSCB Overview Report 109 completely ‘colour blind’ approach even if it existed, is potentially dangerous. 4.7.26. In depth analysis of the psychology and motivation of the men, or the causes of sexual offending is not within the remit of this report, whose focus is the way that agencies responded to the young people. However, some consideration is helpful as far as it contributes to the understanding and practice of staff within Rochdale, and beyond. That these young people were exploited by a group of men predominantly, but not exclusively from a South East Asian background, cannot be discounted and points towards the need for further analysis and research as to what significance this did or did not hold. However, a simplistic view that the mere fact of being ‘Asian’ is in itself explanatory of their behaviour, is dangerous not only because it is unjust and offensive to the wider community who share a South East Asian heritage. It is also dangerous because such simplistic presumptions represent a meaningless over generalisation, that is positively unhelpful if we wish to understand why these men behaved in the way they did and therefore help to protect other potential victims. Such an approach fails to consider the combination of personal, cultural and opportunistic factors that are understood to create the conditions for sexual offending57 including: Personal histories and early life experiences Attitudes to children and gender, including any familial or cultural component of such attitudes Attitudes to sexuality Access to vulnerable young people Barriers to offending What we do know in the Rochdale setting, is that many, if not all of these men worked within the night time economy, out of sight of their families, and of much of the wider community. What we do not know is how they were influenced by their experience of culture or how they were able to rationalise what is widely recognised across mainstream cultures as seriously transgressive behaviour. 4.7.27. Although statistical information with regard to sexual offending and ethnicity will always have inherent problems, what is known is that 80.9% of convicted sex offenders in England and Wales are identified as white, and as such focussing on race in isolation is of limited value. Professionals and society need to be aware that sexual offending does exist across all societies and cultures and that a focus which only recognises the possibility for abuse within a particular culture will fail to protect children and young people of all backgrounds. Professionals and the wider public instead need to be alert to the potential for abusive behaviour across communities and develop 57 See for example, Briggs, D in Calder (2009) RBSCB Overview Report 110 knowledge and confidence in challenging behaviour that suggests acceptable boundaries between adults and young people are being crossed. 4.7.28. Initial consideration was given to the Overview Author seeking meetings with the men to identify any lessons about how they had operated and what if anything could be learnt about prevention as a result. However, it was recognised that this was outside the normal remit of a Serious Case Review and required a separate piece of work if it was to be effective. Both Greater Manchester Police and Greater Manchester Probation Trust are currently undertaking analysis of patterns in relation to the perpetrators’ behaviour which is being shared with the Board to increase future understanding. 4.7.29. Whilst it is an uncomfortable conclusion to reach, the evidence suggests that there was a collective failure to recognise that the young people were vulnerable to abuse by a range of men irrespective of race or culture. Not only were services slow to recognise the abuse being perpetrated by the group of ‘Asian’ men who were convicted at Liverpool Crown Court in May 2012, they were slow to recognise the abuse being perpetrated against them by members of their own families and by AdultD, all of whom were white men. 4.8 The operational response: Responding to the individual and making the links between them. 4.8.1. That agencies responded to the Young People’s abuse on a predominantly individualised model for a considerable period had a profound effect on identifying both the victims and the perpetrators. The initial response was damagingly slow to identify and respond to the network of abuse, which necessitated not only a major police investigation but also a co-ordinated multi-agency response. Whilst in theory this network may have been recognised with the production of the report to the Board in 2007, in practice there was little evidence of the impact of this knowledge on service provision to these young people until comparatively recently. 4.8.2. The Crisis Intervention Team from quite an early stage recognised that there was a wider picture beyond the abuse of individual young people. They were able to make links between different men and these and other young people and evidently by 2008 understood that the exploitation was part of a network of men and that the girls were being taken to other towns in Lancashire and Yorkshire to be further exploited. 4.8.3. It is difficult to identify precisely when there was the first clear evidence of a conscious multi-agency operational recognition that the young people were victims of organised child sexual exploitation in Rochdale. There were discussions about sexual exploitation amongst different agencies and references to multi-agency meetings RBSCB Overview Report 111 from early in this timeline. For example In February 2007 there was a record by CIT of a ‘Multi-Agency Strategy meeting re multiple abuse of vulnerable young women’. However there was no further information to confirm the nature of this meeting within the IMRs, who called it or who attended and the only reference to it was by the authority’s legal department. 4.8.4. The first point at which there is incontrovertible evidence that the Police and Children’s Social Care recognised that the abuse consisted of a number of men abusing a number of young people was in August 2008 when a strategy meeting took place with regard to 111111111111111 and three other girls. The meeting was chaired by the Independent Reviewing Service as was the second meeting in September of that year. By this point it is explicitly noted that the young people were being sexually exploited. It was also recognised that 111 appeared to play some role in coercing the younger girls into sexual activity with the men. 4.8.5. Strategy meetings. When meetings did take place there was often a level of confusion about their purpose and how they linked with other procedures. Even the use of the term “Strategy Meeting” was unhelpful as a description of meetings intended to consider a strategic response to CSE as it affected a number of young people. This is the established terminology for the joint investigation processes between Police, Children’s Social Care and other appropriate agencies, as part of Section 47 enquiries and Police investigations into possible criminal acts against children. It has been difficult within this Review to identify which function some ‘Strategy Meetings’ were serving and is likely to have been equally difficult at the time. Neither did there seem to be any pathway for continuing to meet to consider the wider concerns once decisions had been made in relation to the response to the individual young people. 4.8.6. Identifying the multi-agency meetings which specifically considered CSE as a phenomenon relating to more than one individual has proved very difficult given the lack of coherent information across the agencies. For example the meetings in February and April 2007 are only clearly identified in information provided to the Review by the Legal department and were not evident from the IMRs. This lack of transparency and of any robust audit trail recording these meetings will have contributed to confusion at the time as well as in retrospect. The meetings that are understood to have taken place are as follows, but it is not possible to be sure that this is a complete list: Three meetings between February and April 2007 regarding 11 young people June 2007 Multi agency meeting regarding 11111 Aug/September 2008 2 strategy meetings relating to 6 young people March 2010 Sunrise Team Strategy meeting RBSCB Overview Report 112 April 2010 Child Exploitation Strategy Meeting Aug 2010 Multi Agency Strategy meeting at Sunrise. 11th February 2011 CSE Strategy Meeting – Police and Children’s Social Care 4.8.7. What is apparent is that there was no clear or regular programme of Strategy Meetings prior to the Sunrise team coming into operation and no other means of developing a specific multi-agency approach to CSE. It has been reported by one of the IROs that it had been intended to undertake further Strategy Meetings during 2008 and 2009 in relation to 1111111111111, but that agencies did not attend. It has not been possible to corroborate this from information provided by other agencies, but whatever the reason, it is evident from the information provided here that there were no recorded meetings between September 2008 and March 2010. 4.8.8. Each of the police investigations beginning in 2008 was attempting to identify the extent of the offences, the victims and the offenders with varying success. However there is no clear evidence that the key agencies, including the police, were systematically mapping the links between the young people and the identified perpetrators as part of an overall multi-agency strategy. 4.8.9. When multi-agency meetings did take place, it is often difficult to identify who attended and why some agencies were involved but not others. For example a multi-agency meeting took place at Middleton Police station, where the Sunrise team was located on 18th August 2010, however no minutes of this meeting are available, apparently because they were withdrawn by the Police. There is no reference to this meeting by the Police themselves. Others, for example, the YOT set up their own meetings, to which they invited other agencies. Frequently these agencies would not then attend, but in the absence of any multi-agency agreement about the status of these meetings, this is not particularly surprising. 4.8.10. Prior to the Sunrise team becoming operational in January 2010, the IROs were required to chair the CSE Strategy meetings. The Review was told by the IROs that this decision was taken by Children’s Social Care. No other information has been provided as to who made this decision or on what basis. In the event this was a crucial decision which placed responsibility for the overview and co-ordination of the multi-agency response not even with middle managers, but with practitioners, albeit experienced practitioners. It was absolutely vital that there was leadership of these meetings by senior management. IRO’s did not have the authority, the seniority or the power to unlock budgets and other resources which was necessary for these multi-agency meetings to be effective. The decision to use IROs to chair these meetings also suggests that the meetings were viewed as not being fundamentally different to the Strategy Meetings within routine Child Protection process. In other words that at a strategic level there RBSCB Overview Report 113 was a failure to recognise the complexity and significance of CSE within the Borough and the need to adopt a different approach. 4.8.11. Attendance at these meetings was by invitation and again there is no evidence of any lead from strategic managers as to how this would be decided, what the foci of the meetings should be or how strategic managers or the Board would be kept appraised of what was taking place. A number of agencies have identified frustration that they were not invited to these meetings, but there is limited evidence that these concerns were pursued through the Board at the time. . 4.8.12. A further resultant problem was that the IROs felt under increased pressure because of the numbers of Strategy Meetings they were then chairing and the complexity of the cases. It was also clearly minuted at the Sexual Exploitation meeting held in April 2010, that agencies were struggling to respond to CSE due to a lack of basic resources. The IRO who was chairing the meeting stated that “The lack of resources has led to a situation whereby information gathered cannot progress and there is going to be a delay in addressing the issues. With more resources children would not be at long term continued risk. Outcomes are being improved but not at the level professionals would like”. The IRO also raised serious questions about the level of commitment of Children’s Social Care, however there is nothing to suggest that this was consequently taken up with managers. 4.8.13. The key factor in understanding agencies inability to co-ordinate a multi-agency approach without doubt is a result of the absence of Strategic management. Without clear leadership, oversight and access to resources individuals within agencies were faced with an impossible task. 4.9 Concluding comments 4.9.1 Whilst the experience in Rochdale during these years has rightly raised serious concerns at a national level, it would be mistaken to consider that Rochdale was or is unique either in the prevalence of CSE in its community or in the difficulties that agencies experienced in responding to that abuse. The critical Barnardo’s report Puppet on a string, published in 2011 concluded that there was a “shocking lack of awareness that stretches from the frontline of practice to the corridors of government.” and as such to consider that Rochdale’s experience was unique to this Borough would be to fundamentally misunderstand the prevalence of CSE and the slow development of good practice at a national level. 4.9.2 This Review nevertheless has catalogued a widespread pattern of weaknesses and failures both in relation to agencies and to individual practice. These together acted to undermine the system’s ability to protect and safeguard the young people over a period of years. The RBSCB Overview Report 114 multi-agency response to the needs of these 6 young people provides a very mixed picture. The key failings in practice are all too evident, although some are much easier to see in hindsight than was the case at the time. 4.9.3 Some practitioners and agencies evidently fell below acceptable practice standards at some times. Many of those mistakes have been recognised and acknowledged both by individuals and by the agencies and have had consequent effects on employment as well as public confidence. There is however also evidence of empathetic, concerned responses by some practitioners who were clearly trying to respond to and build relationships with the young people. 4.9.4 It should also be recognised that harm to the young people was both as a result of the sexual exploitation to which they were subject, but also harm to their welfare as a result of other life and childhood experiences. Successful intervention with the young people to protect them from the corrosive nature of the abuse they were suffering once it had been established could not have been guaranteed, even if best practice had been adopted. However, it is clear that time and again the possibility of such intervention was missed 4.9.5 This however, is on its own merely a description of what went wrong and seen in isolation tells us little about why there was such a significant failure to protect these young people. What has been identified throughout this review is a repeating theme of factors which impacted on the quality of practice in particular including: Policy and procedures either not available or poorly understood and implemented at the front line. Absence of high quality supervision, challenge and line management oversight Resource pressures and high workload in key agencies, including CSC safeguarding teams, A&E, Police, contributing to disorganisation and at times a sense of helplessness. Policies, culture and attitudes within many agencies which were actively unhelpful when working with adolescents. Performance frameworks focussed on quantitative practice not on quality of practice or understanding the child’s journey through services and outcomes. 4.9.6 What is indisputable is that the repeating nature of these failures exposes fundamental problems and obstacles at a strategic level in Rochdale, not simply in relation to individual practice. That the failings took place over a period of 5 years in relation to 6 young people who were in contact with at least 17 different agencies makes it absolutely clear that the problems were much more deep rooted than can be explained as failings at an individual level. It is also important to note that the experiences of these 6 young people whilst fundamentally important in their own right are accepted by agencies within Rochdale as being indicative of the experience of other young people at the time. RBSCB Overview Report 115 What resulted represents a culture and a pattern of leadership that individuals were either unwilling or unable to change. 4.9.7 It is self-evident that the specific areas of weakness as identified in this review require speedy resolution where this has not already been taken, whether this be in relation to individual performance or procedural or policy weaknesses. However focussing on individual weaknesses will simply repeat the patterns of previous learning and reviews, and risks failing to identify the fundamental underlying problem. This problem which time and again has been identified when the Review asked why the identified problems took place brought us back to the following key issues: Longstanding failings in leadership and direction at the most senior levels of key agencies Longstanding difficulties in achieving effective multi-agency working at the most senior levels reflected in operational practice. Failure by strategic managers to focus on routine safeguarding practice, to understand how it was delivered. Lack of an evaluative culture focussed on the experience of young people, outcomes and the effectiveness of interventions. Under-resourcing resulting in high workloads, decision making influenced significantly on managing budgets to the detriment of practice which would meet children’s needs 4.9.8 It is of interest that some agencies, although not without their own problems, seemed able to provide a fundamentally more constructive service to the young people, not least in the capacity of their staff to understand and engage with those young people. The assessment of one panel member, which is worthy of consideration, is that one of the features several of these agencies had in common was “a foot in the outside world”. From this perspective it would seem that a significant contributory factor to the fundamental weaknesses in practice was that the history and complex dynamic of established agencies within Rochdale had resulted in a level of dysfunction when attempting to work collectively which was stronger than any individual’s attempts to untangle it. 4.9.1 Could the abuse have been predicted or prevented? In reflecting on whether or not it should have been possible to protect the young people from the abuse they experienced, the answer must be: it should have been possible to have prevented a significant part of the abuse that took place. There were two different routes that should have led to prediction and prevention. 4.9.2 Firstly 5 of the young people were, for several years prior to being sexually exploited, clearly in need of early help and at times intervention by safeguarding agencies to protect them from highly damaging experiences such as neglect, domestic violence, parental mental health problems and substance misuse. Had there been a RBSCB Overview Report 116 properly co-ordinated package of both support and assessment which recognised these risks, it must be possible that the vulnerability of these young people could have been assessed and responded to at a much earlier stage. 4.9.3 Secondly, given the highly organised, determined and manipulative behaviour of the perpetrators, it would be unrealistic to imagine that their behaviour could have been predicted and that all harm to all the young people they abused could have been prevented. However, had the sexual exploitation been recognised and responded to at the earliest stages, these young people may have been protected from repeat victimisation and other young people may also have been protected from becoming victims. 5 MULTI AGENCY RECOMMENDATIONS 5.1. Rochdale Borough Council and agencies responsible for child protection in the Borough have been under considerable scrutiny over the years since these events fully came to light. This Serious Case Review is the latest in a series of reviews that have taken place, each of them with a slightly different focus, but inevitably with many of the same conclusions being drawn. A significant amount of remedial activity has been required both of individual agencies and of the Safeguarding Board in response to the failings identified regarding these 6 Young People, as well as many others. 5.2. Shortly after this Review was initiated the Local Authority was subject to an improvement notice as a result of an OFSTED Inspection which judged the overall effectiveness of the Council’s arrangements to protect children to be inadequate. A new CSC Senior Management team was appointed and was taking up post at the point this Overview report was being finalised. The work is still to be completed but it is known that it has been focused on many of the issues that have been considered within this report. Other agencies have also been subject to formal scrutiny during the timeframe that this Review was undertaken including an Inspection of Rochdale YOT team. Children’s Social Care and Greater Manchester Police agencies have also been dealing with staff performance issues arising out of this review and other reviews of the response to child sexual exploitation. 5.3. In relation to child sexual exploitation, the OFSTED inspection concluded that there had been “steady progress” in the response of the Board to CSE during the previous 2 years. OFSTED noted that there had been: Extensive training on risk indicators and triggers with multi-agency staff Awareness raising with young people RBSCB Overview Report 117 Increased identification of young people at risk through the sharing of intelligence between partners Increased disruption activity It is recognised that there is further work to do, and that CSE remains a priority for the Board. 5.4. It is now incumbent on the Board and its members alongside the Local Authority to map the activity that has already taken place, to scrutinise that activity in the light of this review and identify what is already in place or being put in place to meet the gaps and what further action is therefore required. Given the range of bodies that is setting tasks for the Board and its partner agencies a prioritisation exercise by the Board will be vital. The Review has identified the following areas for attention that will need mapping against the activity already in train: Prioritisation of CSE by the LSCB including tracking of the link between strategic intentions and operational outcomes. Reviewing the current state of understanding, identification and practice regarding CSE across agencies, including the effectiveness of Child Protection processes for the victims of CSE. Early intervention Improving understanding and responding to neglect across the age range. Improving non-specialist understanding of learning disability/difficulties Maximising the engagement of Board members in its task Joint planning with the Local Authority for community development regarding CSE. Review at both strategic and practice level of the degree to which services embed adequate understanding of local communities and cultures. Review and develop a skill and knowledge base for practice in relation to working with adolescents. Development of agency and practice skills and confidence in working in a diverse community. Review of escalation policies and their effectiveness and work on inter agency professional challenge Qualitative and outcome based assessment of functioning of the Sunrise team. However this Review is firmly of the view that it is the foundations of good multi-agency child protection practice that the Board and its partners need to RBSCB Overview Report 118 focus on with greatest care if the areas of weakness which have been identified can be effectively addressed. Multi-Agency Recommendation 1: In the light of the areas of weakness identified within this Review Rochdale Safeguarding Children Board (RBSCB) to map and scrutinise work on practice improvement that has already taken place and identify what further action is now required. Multi-Agency Recommendation 2: RBSCB to put in place independent measures to test the extent to which the restructuring of the Board and other related developmental activity has led to improvements in multi-agency working at all levels. Multi-Agency Recommendation 3: As a matter of urgency RBSCB to seek evidenced confirmation from each of its partner agencies that they are fulfilling their Section 1158 requirements as set out in Working Together to Safeguard Children (2013). Multi-Agency Recommendation 4: RBSCB to establish a framework for direct communication between the Board, service users and front line practitioners in order to develop a shared understanding of the way in which services are provided to children ; the strengths, vulnerabilities and effectiveness of front line practice; and the impact on outcomes for children. Multi-Agency Recommendation 5: The Board to review the skills, knowledge base and priority partner agencies afford to working with Adolescents. 58 Section 11 of the Children Act 2004 places duties on a range of organisations to ensure their services are discharged with regard to the need to safeguard and promote the welfare of children. RBSCB Overview Report 119 6 INDIVIDUAL AGENCY SUMMARY OF INVOLVEMENT, REPORTS AND RECOMMENDATIONS A brief overview of the involvement and key issues identified in relation to each agency is provided in this section. All of the agencies through the production of their IMRs have identified learning and provided recommendations for their agency as follows: 6.1 Action for Children Action for Children has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Head of Safeguarding. The author has had no operational responsibility in the case nor any direct involvement with the Young People or their families and as such met the criteria for independence. The Report was countersigned by the Director for Practice Improvement. The countersigner had no direct knowledge or involvement with the services provided to the young people or their family. 6.1.1. Action for Children provided supported housing and tenancy support services for 111111111111111 the longest involvement being with 111 who remained at the project for nearly a year, whereas 111 and 111 remained only a matter of months. The young people were in the same facility but at different times. Action for Children staff were aware at the point of referral that 111 had probably been subject to sexual exploitation, but did not have similar information regarding 111 and 111 on referral. The project generally liaised as required with other agencies, complied with policies and procedures and attempted to engage and support the young women 6.1.2. The IMR appropriately identified both strengths and areas for improvement in their practice and linked these clearly to learning and recommendations. In particular it recognises that there were occasions with hindsight when concerns about 111’s vulnerability and the possibility that she was being sexually exploited should have been discussed with Children’s Social Care, or the police. It would appear that the agency understanding of Child Sexual Exploitation was developing during the period and there was a clearer understanding of the issue within the project in relation to 11111111. It was also identified that the individual actions were taken to improve the safety of the young women, but that this tended to be reactive and there was no recognition at the time of the possibility that the project might be targeted by men for sexual exploitation. 6.1.3. The recommendations for action for Action for Children are as follows: RBSCB Overview Report 120 1: Action for Children should understand the scale and nature of concerns around CSE being faced by our services. Relevant services should be supported in increasing their ability to recognise child sexual exploitation. Staff in services where Action for Children support or provide tenancies to vulnerable young people, similar to SHS1, should be given the opportunity to consider the following issues; • Thresholds for referral to statutory agencies, including Children’s Services. • Assessment of need of those referred to the service and ensuring that the service offered addresses these needs. • Consideration of practice in identifying risk of sexual exploitation and domestic violence. • Issues relating to ethnicity and vulnerability to sexual exploitation. • Consideration of the use of tenancy warnings. 2: To ensure a consistency of knowledge and understanding of child sexual exploitation within Action for Children, all relevant staff should receive specific learning and development on Child Sexual Exploitation. 3: Action for Children should review and amend all relevant internal reporting processes to ensure that they address Child Sexual Exploitation. 4: The information and learning from this review would be of benefit to all operational staff. To ensure that this takes place all organisational Safeguarding meetings should be briefed on the learning from this review. 5: A review of Action for Children’s Retention and Destruction of Records Policy should take place to consider any changes needed and carry out any relevant actions. 6: Action for Children should review and implement any changes necessary to their policy, procedure and guidance with regards to child sexual exploitation. 7: Action for Children ensure that all services that provide supported lodgings, addresses young people who are missing in a way that is consistent with regulated services. 6.1.4 Action for Children provided the following information in relation to actions already taken arising out of this review: Action for Children has delivered workshops on CSE at all its safeguarding meetings at both organisational and divisional level. We have undertaken an exercise to establish the amount of CSE RBSCB Overview Report 121 all our services our experiencing, and will be using this to focus our strategy for increasing the skills needed to deal with CSE amongst our varying services. We have ensured that all of our staff have been made aware of the issues of CSE and how this might affect their service users. We have made changes to a number of our policies to support positive practice across our many services. We have also started the commissioning process to deliver training to targeted groups of staff across the organisation.” 6.2 Barnardo’s Barnardo’s has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Assistant Director, Children’s Services, North West. The author has had no operational responsibility in the case or any direct involvement with the Young People and their families, and as such met the criteria for independence. The Report was countersigned by the Assistant Director of Children’s Services, Cumbria, who had no direct knowledge or involvement with the services provided the Young People. 6.2.1. Barnardo’s provided a short term Resettlement Support Service (Fresh Roots) to 111 for a period of 7 months during 2009 and 2010, to 111 for a period of 4 months in 2010, and a residential placement for 111 for 2 months in 2011. Work with 111 was in relation to practical problems and finished due to her lack of engagement. No information was provided to the project that would have alerted it to child sexual exploitation in relation to 11111111 The project worker allocated to 111 had information about domestic abuse and there are some gaps in information as to how this was responded to. The accommodation provided for 111 was outside of Rochdale specifically in response to her being a victim of sexual exploitation. 111’s tenancy was ended due to her alcohol use and its effect on her behaviour to other residents and staff. 6.2.2. Barnardo’s IMR acknowledges that despite its organisational knowledge about CSE at a national staff in these projects did not have particular awareness or expertise. This was felt, in part, to be as this was an adult rather than a child focussed service. Barnardo’s no longer runs this service and has now decided not to engage in similar projects in the future. It has nevertheless has identified general organisational learning for its recommendations. 6.2.3. The recommendations for action for Barnardo’s are as follows: 1. All project workers and team managers in the NW region to have CSE training. RBSCB Overview Report 122 2. The regional CSE services to review cases where service users have a learning disability. 3. All NW services to ensure that service referral forms and risk assessments take into account any issues of Domestic abuse 4. Lone worker policy to be reviewed at Rachel House 5. Rachel House to review monitoring system for updated risk assessments. 6.2.6 Barnardo's has provided the following information in relation to actions already taken arising out of this review: 1 Managers from Barnardo's CSE service have implemented training for team managers in the NW Regions. Training of project workers from generic services has commenced and the implementation will continue to be implemented across 2013 and early 2014. 2 Specialist services have concluded a review. A group involving staff working across CSE and disability issues has been formed to review the suitability of practice materials as a result of this review. 3 A group have been formed to given consideration to the current domestic abuse risk assessment framework used for 1:1 case work. A revised version of this documentation is being developed which will incorporate the recommendation. 4 Lone worker Policy has been reviewed and an updated policy has been in place since July 2013 5 Risk assessments updated and new review arrangements are in place from July 2013 6.3 CAFCASS CAFCASS has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Service Manager, National Improvement Service. The author has had no operational responsibility in the case or any direct involvement with the Young People and their families and as such met the criteria for independence. The Report was countersigned by the Head of Service (Corporate Services). The countersigner had no knowledge or involvement of the services provided to the Young People and their families. 6.3.1. Children’s Guardians from CAFCASS had involvement with 111111111111111111. With the exception of 111, the role of CAFCASS was to represent the children of the Young People in Care Proceedings and to assess the Young People’s parenting capacity. RBSCB Overview Report 123 CAFCASS was appointed to represent 111 when Care Proceedings were taken in relation to her. On each occasion, it was already identified that the Young People had been subject to sexual exploitation. The fact that there were links between the young people was not directly relevant to the role of CAFCASS, who are required to consider the needs of the individual child within proceedings. 6.3.2. The service provided by CAFCASS was of the expected standard. The IMR has identified some general learning with regards to the impact of Child Sexual Exploitation for victims who then become parents and makes an appropriate recommendation. 6.3.3. The recommendation for action for CAFCASS is as follows: 1. To develop and mandate the use by professional staff an e-learning module on child sexual exploitation, incorporating learning from this SCR (together with other SCRs to which CAFCASS is contributing and literature/research). 5.3.5 CAFCASS has provided the following information in relation to actions already taken as a result of this Review: The e – learning module is well underway but not yet completed. Nationally the Head of Service (Corporate Services) is also preparing an update to his presentation learning from SCRs which is delivered to all teams by local Service Managers. 6.4 CONNEXIONS Connexions Rochdale has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Service Manager. The author has had no operational responsibility in the case or any direct involvement with the Young People and their families and as such met the criteria for independence. The Report was countersigned by the local Connexions Manager. The countersigner had no knowledge or involvement of the services provided to the Young People and their families. 6.4.1. Connexions Rochdale provided Education/Training and Employment advice and support to all the young people subject to this Review. The service included routine careers advice within schools as well as more individualised support. Connexions only had knowledge that Child Sexual Exploitation was a concern in relation to three of the young people, having been told specifically either by the young person themselves or by other professionals. It is acknowledged that there was other information that might now be understood as warning signs, such as early teenage pregnancy. However in the context of their role and limited information it would not be reasonable to judge that Connexions should have identified the information earlier. There RBSCB Overview Report 124 is recognition by Connexions that CSE was not an issue which was well understood at the time and acknowledgement that the agency has learnt from the experiences of these young people. 6.4.2. Connexions workers generally met their service standards; they demonstrated a degree of persistence in their attempts to engage with the young people and proactive liaison with other agencies. There is evidence of meaningful line management involvement and that safeguarding procedures were followed. Connexions has identified some inconsistencies in practice including: not confirming information provided by young people with other services and making assumptions that statutory services were aware of information; on one occasion an advisor failing to refer to the historical case file. 6.4.3. The recommendations for action for Connexions Rochdale are as follows: 1. Where information about a client is received from or passed on to another agency, a key contact from that agency should be identified and any information received/actions requires should be routinely followed up. 2. Client intervention notes and information received from/passed on to other agencies need to be thorough and detailed to ensure other workers that conduct future interventions have a clear understanding of clients’ circumstances. Additionally it is vital that time is taken prior to an intervention to read previous contact details. 3. Lessons learnt from the SCR to be presented to all Positive Steps Advisers/Managers as part of Refresher CSE Training. 6.4.4. Connexions has provided the following information in relation to actions already taken as a result of this Review: Since the move over from Careers Solutions/Connexions to Positive Steps in April this year, Positive Steps is currently undertaking a review safeguarding policies and procedures and staff training requirements/refresher training to ensure there is a consistency of practice / level of understanding following the acquisition of both the Rochdale and Tameside contracts. Approach to CSE will be a key feature of this, and the Action Plan submitted in relation to IMR 1-6 and IMR 7, will be incorporated into the process. There will specifically be refresher CSE training following the conclusion of this SCR. In the meantime, a primary feature of the Action Plan following IMR 1-6 was the need to identify key contacts from other agencies where information was either passed on or received and any actions required should be routinely followed up. In addition, the need to ensure client intervention notes were clear and thorough enough to ensure effective continuity of practice should alternative Advisers become engaged with the client, is being monitored via the process of verification audits being conducted by Team RBSCB Overview Report 125 Managers on client records completed by Advisers and via monthly Caseload Management reviews conducted every 6 weeks.: 6.5 Crown Prosecution Service (CPS) The Crown Prosecution Service has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by a recently retired Deputy Director of the CPS Special Crime Division. The author has had no operational responsibility in the case or any direct involvement with the Young People and their families and as such met the criteria for independence. The Report was countersigned by the Chief Crown Prosecutor CPS North West having been agreed by the Director of Public Prosecutions (DPP). The countersigner had no knowledge or involvement of the services provided to the Young People and their families prior to June 2011, when he made the decision to prosecute the men who were later convicted of offences against the girls. Given the oversight of the DPP however, the panel was satisfied that the criteria for independence is met. 6.5.1. The CPS provided advice and authorisation to the police regarding criminal charges relating to 1111111111 as well as other victims of child sexual exploitation within Rochdale as part of Operation Span. 6.5.2. The Crown Prosecution Service had no previous experience of involvement in a Serious Case Review and was initially unfamiliar with the expectations. The CPS was also hampered in its analysis by its file retention policy which meant that they were significantly reliant on information provided to them by the police as a number of their own files had been destroyed. However an independent author was ultimately commissioned and undertook a thorough and critical review of the work undertaken by the service. 6.5.3. Recognition of CSE in relation to the young people by the CPS in the early years was very poor. As a result a significant opportunity to prosecute some of the men concerned following allegations made in 2008 was missed and this had a direct impact on the willingness of at least one of the Young People to trust the criminal justice system in subsequent years. The agency has been very open both publicly and within this Review regarding its failings at this time but has since demonstrated considerable changes in both approach and practice and high level strategic leadership. 6.5.4. The CPS practice in relation to 111 effectively highlights the stark difference between good and poor practice in relation to vulnerable young people experiencing sexual exploitation. Two particularly significant lessons for the CPS are recognised: RBSCB Overview Report 126 The successful prosecutions in 2012 can be seen as a model for how to build a constructive case leading to conviction in comparison with the approach to the allegations in 2008/9. An approach which focuses on victims’ troubled backgrounds or inconsistent responses as a reason to doubt their credibility fails to understand that issues such as this are a feature of their vulnerability to abuse. Prosecutors are now encouraged to “ build a case which looks more widely at the credibility of the overall allegation rather than focusing primarily on the credibility and/or reliability of the child or young person” 6.5.5. As a result of a number of high profile sexual abuse cases, including the experience of YP1-6, the CPS has begun a series of major changes to its practice in relation to sexual abuse. Recommendations made within the CPS IMR will be contributing to these changes. 6.5.6. The recommendations for action for the CPS are as follows: 1. CPS to draft new prosecution specific guidance on sexual offences concerning children. 2. A training package is to be prepared, delivering practical advice and guidance to front line police and prosecutors dealing with child sexual exploitation cases. 3. A national network of Child Sexual Abuse trained prosecutors is to be established with Nazir Afzal as the CPS Champion. 4. Guidance be produced as to the material to be considered when a second opinion is sought and that the Advice Review Checklist to be written to reflect national CPs policy. 5. The CPS should review its policy on file retention to see whether the current guidelines are adequate. 6.5.7. The CPS included information regarding actions taken as a result of this Review within the body of the report. The following additional information has also been provided: As a direct result of Operations Span and Bullfinch (the “Oxfordshire Grooming Case”) the Director of Public Prosecutions has issued Guidelines on Prosecuting Cases of Child Sexual Abuse. A training aid has been distributed to managers in the North West Area. In addition this aid has been circulated to a national network of CPS prosecutors so that lessons learnt locally can be of benefit nationally. 6.6 Children’s Social Care (Targeted Services) Rochdale Children’s Social Care (Targeted Services) has provided a chronology and Individual Management Review for this Serious Case Review. RBSCB Overview Report 127 The report has been prepared by an Independent Safeguarding Adviser. The author has had no operational responsibility in the case or any direct involvement with the Young People and their families and as such met the criteria for independence. The Report was countersigned by the Interim Assistant Director for Rochdale Children’s Social Care. The countersigner had no knowledge or involvement of the services provided to the Young People and their families. Subsequently Children’s Social Care re-considered the report and concluded that it failed to analyse a number of key aspects of the service’s work. The Independent Author was not willing to make changes at what was a very late stage and the Panel agreed that CSC could provide an additional document, alongside, not instead of, the IMR already produced. This document, whose purpose was to highlight further areas of learning, was undertaken by a new Interim Assistant Director who had not had previous involvement with the case. It is of concern that the IMR countersigning process had not been effective, probably reflecting Children’s Social Care continuing difficulties in committing adequate time and resources to the SCR process, in the context of other demands on that agency. The decision to provide a further report has however ultimately demonstrated awareness by CSC of the breadth of improvements in practice required as a result of this Review and a willingness to acknowledge these openly. 6.6.1. As had been anticipated by Children’s Social Care given previous reviews of their involvement with CSE, significant weaknesses in the service provided to these 6 young people have been identified in some detail. It is unfortunate that there are some important gaps in information and it is not always clear whether these represent a gap in recording, a lack of activity or that the information was not included in the IMR. Despite these gaps, there is considerable evidence about repeating key themes in CSC’s response to these young people and 6.6.2. Children’s Social Care had involvement with all 6 of the young people at varying times: 6.6.3. 111111111111 and their family are first known to have come to the attention of Children’s Services in 2004. The first record of a referral to Children’s Social Care regarding the oldest child, 111 , was in March 2004, although there is no reference to this in the information provided by CSC themselves. 111 was subject to a number of Initial Assessments and received Family Support Services, but was never considered a child at risk of serious harm and therefore was not subject to a Child Protection Plan. 6.6.4. A referral was made to Children’s Social Care in relation to 111 in January 2007 as a result of which Family Support was offered. There were a number of subsequent referrals but from the beginning of 2008 CSC involvement was focussed on 111’s parenting capacity in relation to her child. She was never herself identified as a child at risk of significant harm. RBSCB Overview Report 128 6.6.5. 111 first became known to CSC in September 2007 when she was pregnant with 111111. The focus of CSC involvement was in relation to her child who was 111111111111. 6.6.6. 1111: CSC first had contact with 111 in August 2008 following a referral from the police and was subject to an Initial Assessment. No further safeguarding action was taken but she had contact with the Family Support Team. There was further contact as a result of an Initial Assessment in October 2008, which resulted in referral to Family Support until January 2009. This was followed in February 2009 by a pre-birth assessment. Initial Assessments took place in February and September 2010 the second of which led to further referral for short term Family Support. In January 2011 another Initial Assessment was undertaken leading to a S47 Core Assessment in relation to 111’s child and later to Child Protection plan, but no further action for 111 herself. 6.6.7. 111111: Children’s Social Care in Rochdale first had involvement with 111111 when the family moved from AreaD and the children were transferred in on a Child Protection Plan in January 2005. The case was closed at the end of 2005 and the next contact was an Initial Assessment in March 2007 regarding 111, but no ongoing contact with CSC. Another Initial Assessment was completed in 2008, it would appear in relation to both children, although this is not explicitly identified. 111 was assessed as a Child in Need under S17 of the Children Act, but the subsequent involvement by CSC is not made explicit. The next contact was August 2008, when two Initial assessments were undertaken and in October both girls were made subject to Child Protection Plans. 111 remained on the plan throughout the remaining period under consideration; 1111’s plan was discharged in November 2009. 111 had further involvement with CSC in 2010 in relation to her own child who was also placed on a Child Protection Plan. 6.6.8. The IMR openly identifies a significant number of failings in practice both at a practice and a strategic level, these are commented on in some detail within the body of the Overview Report, but include: Lack of organisational priority regarding CSE An unstable Duty and Assessment team and a chaotic duty system Lack of staff training in awareness and recognition of CSE Focus on intra-familial sexual abuse as the responsibility of CSC and PPIU and extra ( ‘Stranger’) familial abuse as the province of the Police, Poor multi-agency working and ineffective information sharing Failure to make links and identify networks with victims and perpetrators Prejudicial value judgments at an institutional and individual level Failure by professionals to understand the dynamics of power imbalances inherent in child sexual exploitation. RBSCB Overview Report 129 the timeliness and quality of intervention to safeguard them from child sexual exploitation was inadequate 6.6.9. The recommendations for action for Children’s Social Care are as follows: 1. That addressing child sexual exploitation remains a top priority for Children’s Social Care by including it in the agency’s annual business plan 2. That a CSC performance management and quality assurance/audit framework be developed and implemented into the effectiveness of the current arrangements for recognising and responding to Child Sexual Exploitation in Rochdale ,that includes the work of the Sunrise Team, and for the results to be reported to the Children’s Services Senior Management and the RBSCB. 3. That all Children’s Social Care practitioners, first and second line managers, new workers and agency staff have received training in the dynamics of child sexual exploitation, are aware of current policies and procedures and are able to recognise it and intervene appropriately. 4. That child sexual exploitation training addresses with CSC professionals any prejudices or negative stereotyping in their work with child sexual exploitation victims. 5. That child sexual exploitation training includes awareness that learning difficulties and disabilities can be a factor in a young person’s vulnerability and for this to be included at an early stage in any assessment of need and risk. 6. That arrangements are made for young people to participate in the safeguarding process and that they are seen and spoken to and their wishes and feelings ascertained in a timely manner. 7. That CSC consider the efficacy of, where appropriate, placing young people at risk of child sexual exploitation who have young children, with ‘special’ foster carers as an alternative to semi-independent living accommodation. 8. That policy and practice maintains a twin safeguarding focus on both the young person at risk of CSE as a parent and the child of the young person. 9. That CSC incorporates all relevant lessons from the Derby SCR (2010) into its current learning around policy and practice in regard to child sexual exploitation. RBSCB Overview Report 130 10. That CSC incorporates any relevant learning and good practice into its current learning around policy and practice in regard to child sexual exploitation from other ‘Good Practice’ LSCBs/CSCs and groups such as:The National Working Group for Sexually Exploited Children and Young People’ 6.6.10. Children’s Social Care, as a result of the supplementary report that was produced after the completion of the IMR have also identified two further recommendations: 1. Prioritise the on-going training and development of practitioners and managers in the early identification, assessment of neglect and the adoption of effective evidence based interventions. 2. The development and implementation of supervisor development programme which focusses on the on the delivery of effective casework supervision. 6.6.11. Children’s Social Care has provided the following information in relation to actions already taken arising out of this review: The effective and early identification and addressing of child sexual exploitation is a top priority of local authority and is included in the Service Improvement Plan and the CSE Strategy which are reported to the Children’s Safeguarding Board A new quality assurance framework has been developed and is in place. This framework which uses auditing, direct observation and service user feedback includes testing the effectiveness of recognising and responding to Child Sexual Exploitation. The training of all practitioners and managers in recognition, assessment and response to child sexual exploitation has been completed and is now part of the mandatory induction programme for all news starters. This training addresses possible belief systems about child sexual exploitation, the dynamics involved and the role that learning difficulties can play as vulnerability factor. All children referred to Children’s Social Care are screened for risk for child sexual exploitation. Revised arrangements ensure that the young people are now properly supported to engage with the safeguarding processes and their wishes and feelings are sought. The development of a bespoke placement service for vulnerable young people who are at risk of CSE is being led by the Local Authority Commissioning Manager for Placements. RBSCB Overview Report 131 6.7 Children’s Social Care – Children’s Safeguarding Unit Children’s Social Care Children’s Safeguarding Unit (IRO Reviewing Service) has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by an Independent Consultant in Child Protection. The author has had no operational responsibility in the case or any direct involvement with the Young People and their families and as such met the criteria for independence. The Report was countersigned by the Service Manager, Children’s Safeguarding Unit. The countersigner had no knowledge or involvement of the services provided to the Young People and their families as she was not in post at the time of the events under Review. 6.7.1. The Safeguarding Children Unit within Children’s Social Care was responsible for providing Independent Reviewing Officers (IROs) for Looked After Children reviews and Chairs for Child Protection Conferences and Reviews. The Reviewing Service was involved with 4 of the young people and, 1111111111111 children. The IROs also undertook the role of Chair for some of the Sexual Exploitation Strategy Meetings held in relation to a larger group of young people. The IMR has clearly outlined a range of gaps and failings in the IROs’ practice which contributed to the ineffective nature of the response by the multi-agency group who were attempting to assess and protect these young people through formal procedures. In particular it concludes that: There was frequently a difference of perspective between the Reviewing Service and the professionals involved in Child Protection Conferences and Reviews as to how to respond to the young people. However the IROs were unable to challenge this effectively, not least because of the lack of power of their role culturally and within the organisation at that time. The Safeguarding Unit IROs did not have the expertise, resources or status to properly manage the strategic meetings regarding CSE which they were required to chair. There was a marked lack of challenge by IROs both about the progress of individual cases and of the strategic response of Children’s Social Care more widely. 6.7.2. The IMR provides clear recommendations and direction to the Safeguarding Unit as to the improvements required. 6.7.3. The recommendations for action for the Children’s Safeguarding Unit are as follows: RBSCB Overview Report 132 1. The Safeguarding Unit IRO Service needs clarification of their role and further development of their quality assurance role. 2. The specific role of the Reviewing Officers in “Strategy Meetings” should be clarified. 3. Management arrangements need to be in place to ensure that there is an appropriate escalation within the Reviewing Service, when there are concerns about safeguarding issues. 4. Child Protection Plans should not be discontinued at the first CP Review, or if the core assessment has not been completed, unless there are alternative legal plans in place to safeguard children. 5. Children who have been or are being sexually exploited should be assessed as children in need or in need of protection and offered services to support them where appropriate. 6. There should be a clear distinction between safeguarding plans for young mothers who have been sexually exploited and CP Plans for their children. 7. Child Protection Conferences should ensure that information about historical abuse is available to the Conference. 6.7.4. The Children’s Safeguarding Unit has provided the following information in relation to actions already taken arising out of this review: Within the timeframe of the review and since, there has been a number of changes at the safeguarding unit which correspond with recommendations made within the review: 1. A new agenda and template of minutes for conferences provides greater scrutiny of child protection cases and to the wishes and voice of the child or young person. It also ensures children are discussed separately and that specific recommendations are SMART so decision making is more robustly tracked. 2. The safeguarding unit is also piloting a separation of chairing roles so there are now designated chairs for CP conferences and IRO’s for LAC reviews. This pilot started in September and will be evaluated in January. This is to look at whether developing specific expertise will better support the new escalation processes agreed for child protection and allow for a stronger quality assurance framework around conferencing 3. The advocacy service for Rochdale children has been extended to support children who are subject to child protection plans and the advocate has supported children to either attend conference or to RBSCB Overview Report 133 have their views clearly stated. Reports from the advocate are produced with recommendations for the senior leadership team. 4. The unit has also appointed a quality assurance officer who has introduced a new quality assurance framework to ensure that there is regular feedback from both conferences and from looked after reviews for, children and parents. The reports produced from this feedback are shared at senior management team meetings to ensure that gaps in service are addressed and themes are reviewed again at regular intervals to examine progress. 5. The unit has increased its capacity with the introduction of a team manager for the IRO and conference review service and three additional IRO’s to ensure that case loads reflect recommendations within the IRO handbook and IRO’s are able to greater develop their quality assurance and challenge role. 6. The unit has also introduced an escalation procedure in relation to child protection conferences and has reviewed the dispute policy for looked after children. As a result a new section within the recording system of ICS has been added so that IRO’s and conference chairs can now record escalations directly on the child’s file for both child protection and looked after reviews. Monthly reports of the escalations are produced and themes are identified and actions agreed via the senior management team. 6.8 Early Break Early Break has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Business Manager for East Lancashire. The author has had no operational responsibility in the case or any direct involvement with the Young People and their families and as such met the criteria for independence. The Report was countersigned by the Chief Executive. The countersigner had some limited involvement as a line manager of one of the workers, but there is no evidence to suggest that this has impacted on the role’s independence. 6.8.1. Early Break is a specialist young people’s drug and alcohol service and had involvement with 1111111111111 during the time period for this Review. Early Break had fairly limited involvement with 111, who referred herself to the service wanting to talk about the impact of her father’s heroin use, but only kept two of the 5 appointments offered and did not respond to attempts to contact her. During one of the appointments 11111111111111111 was also seen, though it is not identified which one.111 was referred to the service by her school. An Early Break worker who was seconded to the YOT team worked with her, but had little contact with her as she did not keep appointments. RBSCB Overview Report 134 111 was referred to Early Break by Accident and Emergency following an overdose, but did not respond to attempts to contact her. 6.8.2. Early Break’s main contact was with 111 who was initially referred to them by her school, but did not take up the referral. 2 years later she was re-referred by an Early Break Outreach worker, when she did engage with the service. There is evidence of a good level of support being offered to her combined with clarity about the safeguarding implications for her and her child, during a period when 111 was experiencing significant distress. 111 had spoken about the sexual exploitation at an early stage and this was a major focus of the service’s intervention. It would appear from her response to staff that they were able to establish a trusting and positive relationship with her. The Early Break worker also fulfilled an advocacy role for 111 in relation to formal proceedings for her child. 6.8.3. Early Break identified considerable frustration amongst their staff about what they believed was the unwillingness of statutory agencies, particularly Children’s Social Care, to properly keep them informed and treat them as partners, particularly Children’s Social Care. Reflecting on how the organisation could have escalated and responded to this has been a key learning point for the agency. 6.8.4. Early Break was mostly confident about the organisation’s awareness and recognition of Child Sexual Exploitation both at the time and currently 6.8.5. The recommendations for action for Early Break are as follows: 1. Early Break to establish a formal process for the dissemination of learning from SCR 2. Early Break to review its current locality based process for recording and reporting of CSE. These to be recorded in one central place and the workforce to be updated on them. 3. Early Break’s workforce to reflect on their own organisational culture and how they also experience other organisational cultures in relation to CSE. Workers to also identify areas of tension and explore these in relevant supportive forums e.g. supervision 4. Early Break to establish clear escalation processes for safeguarding issues and complaints about other organisations 5. To share the good practice identified with 111 with the Early Break workforce and how this matches current recommended practice 6. Early Break workers to undertake training on power in relationships and apply learning to all cases especially CSE ones. 7. Early Break to review how it works alongside the YOT. To specifically focus on statutory and voluntary appointments and how and where the service is delivered from RBSCB Overview Report 135 6.8.6. Early Break provided the following information in relation to actions already taken arising out of this review: Each geographical area has met and discussed CSE how they would identify it, who they would speak to and who they would report to. This is an on-going piece of work and we aim to develop an area guide for each locality, overseen by our operational managers. A safeguarding escalation process has been written. This is currently going through the service Clinical Governance framework for ratification. A process pathway has been developed for the service in relation to learning from SCR and how this learning is disseminated across the service. This is also awaiting ratification. A full service training event is occurring on the 6th September 2013 which is being led by the service appointed CSE workers who are based within the CSE teams in our respective areas. This training will build on previous service training events on CSE. Audits have been undertaken on case work recording, good practice and individual feedback has been shared with all staff 6.9 Education Welfare Service 6.9.1. Rochdale Borough Education Welfare Service has provided a chronology and Individual Management Review for this Serious Case Review. 6.9.2. The report has been prepared by a School Improvement Officer, who is not a member of the Education Welfare Service The author has had no operational responsibility in the case or any direct involvement with the Young People and their families, and as such met the criteria for independence. 6.9.3. The Report was countersigned by the Senior School Improvement Manager who had no direct knowledge or involvement with the services provided the Young People. 6.9.4. The Education Welfare Service had no involvement with 111111111111111 during the timeline of this Review, but did have contact with all three previously and noted them as having attended school erratically and not being easy to engage with. The Service did have contact with 111111111111111 and their family during the time period. 111 was of particular concern in that she had significant levels of absence from school and this eventually led to the involvement of the IMPACT (Improving Attendance Co-ordination) Team and RBSCB Overview Report 136 consideration, but not activation of legal proceedings against 111111. Reference to 1111 is largely in relation to her sister and there is no evidence of direct work with her in her own right. There is little information about involvement with 111 whose attendance was also low, but there is reference to her siblings also being known to the Education Welfare Service. 6.9.5. The IMR’s analysis was seriously undermined by problems with the quality of and frequency of recording. For example, the author was unable to establish the service’s level of understanding of Child Sexual Exploitation, but notes that there was no evidence of any strategic approach to CSE at that time. 6.9.6. The IMR specifically identified unacceptable practice within the study centres whereby young people were registered using inaccurate codes suggesting they were present, when in fact they were not. This was identified during an inspection in 2009 and clear instruction given as to the proper use of codes. 6.9.7. The two most significant lessons for the Education Welfare Service: Significant problems with the accuracy and quality of recordings and resultant impact on the service’s ability to review practice, analyse its effectiveness or track the progress of referrals to other services and therefore whether there is a need to escalate any concerns. The practice of using attendance codes at school learning centres in a way which was misleading 6.9.8. These and other areas for improvement are appropriately subject to recommendations 6.9.9. The recommendations for action for the Education Welfare Service are as follows: 1. All pupil files whether paper or electronic must contain sufficient detail including full names of adults and their job titles to enable support and supervision meetings to evaluate the impact of the work being carried out, to make accurate and well informed decisions as to necessary referrals and to embed good practice identified across the service. Discussions which are held informally should always be logged. 2. Support and supervision sessions should be maintained at their current frequency but should include a focus on recording what has been successful, possible through a case study model, to enable the embedding of successful practice and to promote reflection in other challenging cases. The current effective practice in support and supervision should be developed into a fit for purpose case management process. 3. A challenge and escalation policy should be established to ensure consistent good practice and confidence in resolving issues where RBSCB Overview Report 137 partner agencies, including schools are not seen to be working in the best interests of children and young people. 4. Service policy and practice should enable all service members maintain a focus on the wider welfare of young people in order to have a holistic view of their well-being. 5. A focus on training and monitoring schools in the use of code ‘B’ in registers to ensure its use is appropriate and accurate. 6.9.10 The Education Welfare Service has provided the following information in relation to actions already taken arising out of this review: Recommendation 1: Education Welfare Staff have undertaken training in the summer term 2013 on the required recording standards in the Education Welfare Service. All EWS case files are now electronic and all interventions are now logged on individual pupil log sheets. Standards for recording will be monitored during supervision sessions and there will be regular dip samples of case files to ensure recording standards have been embedded. Recommendation 2: Supervision sessions continue to be maintained at the current level; however the reduction of Senior EWOs within the service may impact on this action point. Recommendation 3:. The policy will form part of the wider ‘Education’ challenge and escalation policy which is currently being developed by the Education Safeguarding Officer in conjunction with the EWS, schools’ partnership and Head of Schools. This deadline for the action point will need to be extended. Recommendation 4:. Work is being undertaken to look at the best ways to gain feedback from young people and their families about the holistic approach to young people and families by officers in the Education Welfare Service. The service is currently working with advocates within the Stronger Families programme. Recommendation 5:. The monitoring of schools use of the ‘B’ code continues to be challenged by staff within the service and escalated to senior management team for intervention. Further action on this will be explored in Attendance Leaders meetings which are due to be set up during the Autumn Term 2013. RBSCB Overview Report 138 6.10 GP Services The GP Service has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Clinical Lead for Safeguarding, NHS Heywood, Middleton and Rochdale Clinical Commissioning Group, also a GP. The author has had no operational responsibility in the case or any direct involvement with the Young People and their families, and as such met the criteria for independence. The Report was countersigned by the Executive Nurse for the Clinical Commissioning Group, who had no direct knowledge or involvement with the services provided the Young People. 6.10.1. The Young people were registered at different times with 4 GP practices and sought consultation and treatment for a range of needs including sexual health, ante-natal care, mental health and chronic illnesses. GPs were also provided with routine information from other health services, including CAMHS and A&E about the young people. 6.10.2. GP services had explicit information that 1111111111111111 were at risk of sexual exploitation after 2007. The GPs also had significant information that could have helped them identify the possibility of sexual exploitation at earlier points and in relation to 1111111111. However there appeared to be a lack of knowledge about CSE and the focus on clinical responses rather than holistic responses means that the young people’s wider safeguarding needs were generally not recognised. 6.10.3. The review of the GP Services has identified the following key lessons: need to consider not only the clinical but the wider needs of young people presenting with sexual health needs lack of recognition by GPs of indicators of sexual abuse in young people The need for better understanding of sexual abuse generally and CSE more specifically Improved understanding of role of GPs in child protection and when action is required. 6.10.4. The recommendations for action for GP Services are as follows: 1. The Pan Manchester Protocol for the Management of Sexually Active Young People under the age of 18 years needs to be distributed to all GP surgeries in the borough with audit to be completed after six months to ensure that policy is embedded into practice. 2. Training in CSE and child protection for GPs needs to be reviewed to ensure that key risk indicators are recognised and the role of the GP is emphasised. Recognition of child abuse as a differential diagnosis also needs to be included. Safeguarding training for GPs RBSCB Overview Report 139 needs to be audited to ensure that outcomes of training are changing clinical practice. 6.10.5. The GP Service has not provided information in relation to actions already taken arising out of this review 6.11 Greater Manchester Police Greater Manchester Police have provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by two Review Officers and the Force Review Officer working as a team. The authors had no operational responsibility in the case or any direct involvement with the Young People and their families and as such met the criteria for independence. The Report was countersigned by a Detective Chief Superintendent, Head of the Public Protection Division who had no direct knowledge or involvement with the services provided to the young people and their families. 6.11.1. Greater Manchester Police IMR has robustly and openly identified a number of significant concerns about the response of the Force to these young people. These include: A failure to recognise Child Sexual Exploitation in the early stages. Individual decision making that with hindsight has been recognised as flawed eg the absence of challenge to the CPS decision not to prosecute in 2009 Lack of resources and managerial support for the investigations initially led by CID in August 2008 and later by the PPIU, despite the officers in both cases formally seeking further resources and help. The use of CID officers without training or familiarity with safeguarding and partnership working to investigate child sexual exploitation cases. Lack of managerial oversight and challenge in relation to the investigations in 2008 and 2009. A lack of strategies to respond to frequent ‘runaways’. The possibility that the lack of response to the young people was in part a result of discriminatory attitudes towards them. A lack of disruption strategies during the early period. Evidence of a focus on Performance targets meant that child sexual exploitation was not afforded appropriate priority RBSCB Overview Report 140 6.11.2. The focus of the Police IMR is significantly on the effectiveness or otherwise of the investigation, which eventually became Operation Span and whilst this has identified some important learning and is rightly of major concern, this is not always balanced proportionately with equal reflection on the police role in working as part of the multi-agency partnership. The IMR makes a number of critical comments about multi-agency working, but does not always provide adequate analysis of its own role within that partnership. 6.11.3. Consequently the IMR whilst having considerable strengths also has some gaps in relation to the following areas: GMP role in relation to routine multi-agency work with the young people 4Detail and analysis regarding its involvement with the young people from a welfare/safeguarding perspective following the commencement of Operation Span Consideration of the police role in effective joint working with Children’s Social Care (ToR 4(b) 6.11.4. Despite the areas for learning identified, only one recommendation has been made by Greater Manchester Police. That is: That the Head of Greater Manchester Police Public Protection Division ensures the continued participation of GMP in Project Phoenix and ensures that all agreed recommendations or directives arising out of the project are implemented by Greater Manchester Police within a realistic time scale. 6.11.5. The Serious Case Review Panel has raised questions about the adequacy of this stand alone recommendation in isolation to address all the concerns raised. It was the panel’s view that it is over optimistic to believe that the complex difficulties of responding to CSE can be responded to by one approach. It is accepted that the Police have made a significant commitment to the Sunrise team and investigation of CSE in both Rochdale and across Greater Manchester. However, the Panel was concerned that Project Phoenix is still in the early planning stages, that it may or may not ultimately be adopted and that it does not take into account the particular needs of Rochdale or the local multi-agency arrangements. 6.11.6. Two further recommendations have therefore been made for the Police by this Overview Report: 1. GMP to establish a system which will monitor and review the use of escalation with regard to safeguarding cases, both internally and to the CPS. 2. GMP to commit to developing and maintaining the Sunrise team and to working proactively with RBSCB to ensure a cohesive approach pending any final agreement and implementation of Phoenix within Rochdale. 6.11.7 Following presentation of the Overview Report to the RBSCB on 15 RBSCB Overview Report 141 November 2013, the Divisional Commander, GMP Rochdale, has submitted the following additional recommendations : 1. CSE and safeguarding children to remain as a priority for GMP and included in the Rochdale divisional delivery plan to support the PCC Police and Crime Plan. 2. To ensure all staff are trained to a minimum required standard and are aware of local safeguarding board procedures. 3. Provide all new operational staff working in Rochdale with induction training in CSE and multi-agency safeguarding children procedures 4. GMP to commit to developing and maintaining the Sunrise Team and to work proactively with the RBSCB to ensure a cohesive approach pending any final agreement and implementation of Phoenix within Rochdale. 5. GMP to re-emphasis the escalation process for the review and professional challenge of CPS decisions. 6. Ensure all officers investigating CSE within the Sunrise team have suitable accreditation within this specialism including the training and development as child abuse investigators. 7. GMP to ensure that there is a clear structure of supervision and monitoring and quality assurance of CSE investigations. 8. Senior Leadership Team to ensure that roles are understood to deliver the Rochdale multi-agency CSE strategy to prevent, protect and prosecute. 9. To develop and implement a toolkit of CSE prevention and disruption activities which can be monitored, evaluated and shared as best practice to ensure continuous improvement. 6.11.8 The following information has been provided by GMP regarding actions taken as a result of the lessons identified in this Review: One of the key issues we have previously encountered was the lack of visibility of CSE within our I.T. systems. We have now upgraded OPUS so that all incidents recorded can have a closing code for CSE and flags have been created for crimes, victims, offenders and intelligence. This will allow us to identify and evaluate large pieces of data thus enabling us to create problem profiles across the force and identify force and divisional needs for resources. The need for better training of all police officers and staff was also identified and this is now being implemented across the force, with call takers, crime desks, safer schools partnerships as well as response, Integrated Neighbourhood Policing Teams and the Public Protection Investigation Unit officers receiving training. RBSCB Overview Report 142 This is an ongoing process and we are also working to further develop the current Specialist Child Abuse Investigation Development Programme to include CSE. GMP has recognised the benefit of co-located safeguarding teams and are implementing teams across most of the divisions to complement existing units such as Protect (Manchester), Sunrise (Rochdale) and Messenger (Oldham). Several other teams are also in the process of co-locating; the Exit team in Bolton and the Phoenix Team at Tameside. A welcome recommendation which is being discussed as part of project Phoenix would be to brand each CSE team as Phoenix to increase awareness to police officers and members of the public who the CSE teams are and what they do. The variety of labels is not conducive to an integrated approach to tackling CSE on a Pan Manchester scale. Different divisional names for CSE teams can paint a confusing picture for officers and members of the public, so a central brand would enhance the joint partnership response in this area. The Detective Chief Superintendent of the Public Protection Division is leading these on-going developments, and is working closely with the Office of the Police and Crime Commissioner, which demonstrates the commitment GMP have in addressing the challenges faced by CSE. 6.12 Pennine Acute NHS Hospital’s Trust Pennine Acute NHS Hospital’s Trust has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared two authors, a paediatrician who had previously worked for PAHT and the Head of Safeguarding for Pennine Acute. The authors have had no operational responsibility in the case or any direct involvement with The Young People and their families and as such met the criteria for independence. The Report was countersigned by the Acting Medical Director for Pennine Acute. The countersigner had no direct knowledge or involvement with the services provided to The Young People and their families 6.12.1. Pennine Acute provided hospital health services, including maternity, gynaecology and Accident and Emergency services to all the Young People subject to this review. 6.12.2. It is apparent that although there was evidence of good clinical care in relation to the young people, there were a significant number of occasions when opportunities were missed to intervene with the RBSCB Overview Report 143 young people, for example as a result of repeated presentations at A&E including for self harm and during the night time. 6.12.3. The key learning identified for Pennine Acute is as follows: Poor recognition and practice regarding social issues, lack of recognition regarding child protection issues in young people particularly within the acute Accident and Emergency setting. Due in part to the high turnover of patients within A&E, professionals may focus only on the immediate issue with which they are presented. Poor sharing of information and communication and a lack of escalation when a clear pattern of concerning behaviour became apparent, but also in poor documentation practices. A pattern seen in doctors notes of overestimating how well they communicated information to the receiving doctor. 6.12.4. The recommendations for action made by Pennine Acute NHS Hospital’s Trust are as follows: 1. Development of documentation proforma and training, prompting assessment of social history. 2. Recognition procedures to be reviewed in A & E, Training and awareness raising within PAHT A/E departments to reinforce responsibilities for 16-18 year olds under the Children Act 1989.5.5.5 No information has been provided regarding any immediate actions taken as a result of the lessons identified in the IMR. 3. Safeguarding education to be designed, developed and piloted that is grounded in non-technical skills and human factors including employment of simulation and observation of error and threshold exercises that are grounded in non-technical skills concepts 6.12.5. Pennine Acute Health Trust has provided the following information in relation to actions already taken arising out of this review. 1. Audit has been completed to provide baseline information re: assessment of social history with particular focus on caring responsibilities. An action plan is being monitored through the Trust Safeguarding children Group. A flow chart has been produced prompting inquiry around assessment of social history to add to the proforma currently present. An audit is planned to assess its use. 2. A baseline audit has been completed that considers specifically issues re: 16 and 17 year olds and the consideration of their vulnerability as children. This is in progress and is not completed as yet. Emphasis to 16 and 17 year olds already given in mandatory training and consent training. Specific work in A&E RBSCB Overview Report 144 setting pending. Second wave of CSE briefings planned for later in the year to include this information. 3. This is a major piece of work which has not yet begun. A meeting is planned with a human factors expert to take this forward. Preliminary discussions have taken place with the skills lab to facilitate this type of training. . 6.13 Pennine Care NHS Foundation Trust Pennine Care NHS Foundation Trust has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Project Lead for Community Commissioning for Quality and Innovation at Pennine Care NHS Foundation Trust. The author has had no operational responsibility in the case or any direct involvement with the Young People or their families and as such met the criteria for independence. The Report was countersigned by the Acting Head of Safeguarding Children. The countersigner had no direct knowledge or involvement with the services provided to the Young People or their families. 6.13.1. Pennine Care provided services to all the young people through the Crisis Intervention Team, which provided sexual health advice; School Health; Health Visiting and the Child and Adolescent Mental Health Services (CAMHS). 6.13.2. All the young people had been known to the School Health Service prior to 2007 due to problems with school attendance and behaviour and support relating to sexual health. There is evidence of concerned and persistent response by practitioners within the school health service, but also that at times they struggled to effect change or to engage other services as well as they would have wished. 6.13.3. The Crisis Intervention team had intermittent contact with all the young people during the time frame. The team first had contact with 11111111111111111111111111111111111111111111111111111. Understanding CIT’s role within the multi-agency partnership has proved more difficult. It was suggested by CITC at the Home Affairs select Committee that the team had made over 100 referrals to Children’s Social Care or the police and nearly 200 “alerts’ regarding these and other young people. This has been considered in more detail in the critical analysis, however the evidence presented to this report is that in relation to these 6 Young People there were a total of 4 referrals to CSC and 2 to Greater Manchester Police during the time period covered by this review. 6.13.4. Pennine Care has openly identified that although the CIT team had begun to recognise CSE before many of the other agencies, there were significant flaws in their understanding of the requirements of safeguarding, their approach to multi-agency working and RBSCB Overview Report 145 information sharing and their willingness to access supervision. As a result the team, whilst having developed a working understanding of CSE did not always contribute well to the multi-agency response and the attempts to safeguard the young people concerned. 6.13.5. Referrals were made to CAMHS for 111 in 2009; 111 in 2005 and again in 2008; 111 in 2011 and 111 in 2008. Information from 6.13.6. Health Visiting services were involved with the children of all the young people except 111 who did not have children. 6.13.7. The analysis of Pennine Care’s involvement is of a good quality and care has been taken to achieve a more nuanced understanding of practice leading to a good depth of learning. 6.13.8. The recommendations for action for Pennine Care NHS Foundation Trust are as follows: 1. CAMHS to review DNA policy in collaboration with key referrers in order to promote positive engagement of potential service users. 2. Crisis Intervention Team: Improvement in safeguarding children practice. All CIT staff to attend Level 3 Safeguarding children training. 3. The Crisis Intervention Team to undertake training in relation to record keeping requirements in respect of safeguarding children and statutory/legal responsibilities. 4. The Crisis Intervention Team, Health Visiting and Safeguarding Children Teams records should comply with record keeping practice in relation to safeguarding children and/or legal/statutory requirements. 5. Structured safeguarding supervision to be implemented within the Crisis Intervention Team. 6. Crisis Intervention Team to be made aware of role and responsibilities of other key children’s services professionals (i.e. HV and SHP) in that they work with. 7. Exploration work with individual practitioners within the Crisis Intervention Team and the team to determine methods of ‘positive’ engagement of subjects involved or vulnerable to CSE. 8. Role of the School Health Practitioner in relation to the contribution to safeguarding children is reviewed. 9. Improve interview skills and techniques for School Health Practitioners involved with victims involved in, or vulnerable to, CSE. 10. Review the effectiveness of the Safeguarding Children Policy. RBSCB Overview Report 146 11. Lessons Learned from the IMR shared with services involved. 6.13.9. Pennine Care have provided the following information regarding actions that have already taken place as a result of this review: 1. All CIT staff have received Level 3 Safeguarding Children Training 2. Record keeping training for CIT staff has been organised and will be delivered by December 2013 3. A record keeping audit of CIT, HV and SHP records has been completed 4. A record keeping audit of CIT records in relation to safeguarding processes is planned for October 2013 5. Structured safeguarding supervision has been implemented within the CIT. A variety of approaches ranging from 1-1 and group supervision is now undertaken 6. School Health Practitioner Safeguarding Pathway is currently under development 6.14 RMBC Homelessness Service/Rochdale Boroughwide Housing Housing Services Rochdale (encompassing two services: RMBC Homelessness Service & Rochdale Boroughwide Housing) has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Director of Services for Neighbourhoods. The author has had no operational responsibility in the case or any direct involvement with The Young People and their families and as such met the criteria for independence. The Report was countersigned by the Chief Executive who had no direct knowledge or involvement of the services provided to The Young People and their families. 6.14.1. Homelessness/RBH had contact with all 6 of the young people as well as some of their wider family members, generally as a result of seeking accommodation through the homelessness service. Various offers of accommodation were made to the young people at different times including through the emergency service, supported housing and independent tenancies. 6.14.2. Both services have acknowledged that its staff had comparatively little knowledge of Child Sexual Exploitation in the early years covered by this review and identified how this is being resolved. It has also identified a gap in the quality of its partnership working with CSE. 6.14.3. Whilst both services have identified learning from this review and used the opportunity to consider further improvements, none of the identified weaknesses in policy and practice had a significant impact on the protection of these young people RBSCB Overview Report 147 6.14.4. The recommendations for action for Housing Services Rochdale are as follows: 1. Establish protocol for dealing with applications from self referring applicants where safeguarding/sexual exploitation issues are presented. 2. Look to allocate Assessment Officers cases so that continuity is maximised. Consider risk Assessing culturally appropriate case distribution. 3. Consider MAPPA style approach to rehousing victims/perpetrators of sexual exploitation 4. Improve relationship with CSC 5. Review how Homelessness Service assesses vulnerability. 6.14.6 The following information has been provided by Housing Services Rochdale regarding immediate actions taken as a result of the lessons identified in the IMR: 1. Recommendation that the allocation of cases to Assessment Officers when homelessness presentations are made, should try to ensure continuity, so that presenting households are ‘followed through’ wherever possible. The Homelessness Manager is trying to co-ordinate this via one to one supervisory meetings and amendments to work practices. 2 The Service Manager has met the YOT Manager who has oversight of those 16/17yr olds referrals presenting from Children’s Services. They have agreed to support the development of an Access service based at their office. This has also been agreed as part of Homelessness Strategy Action plan and will be monitored as a specific action. 3. RBH’s Director of Services for Neighbourhoods has contacted the new lead officer in CSC, with a view to establishing more regular contact at an operational level, to consider how applications for housing from individuals involved either as victims or perpetrators of CSE and child abuse should be dealt with, and to improve relations generally. 6.15 Schools RMBC Support for Learning Service have provided a chronology and Individual Management Review on behalf of Schools for this Serious Case Review. The report has been prepared by a Senior Education Welfare Officer. The author has had no operational responsibility in the case or any direct involvement with the Young People and their families and as such met the criteria for independence. The Report was countersigned by the Senior RBSCB Overview Report 148 School Improvement Manager who had no direct knowledge or involvement of the services provided to The Young People and their families. 6.15.1. Five of the 6 young people attended schools within the Borough during the time period subject to this review. 111 had left SchoolB by the beginning of the time period. SchoolA and SchoolB closed during the time period and failed to archive their files correctly leading in the loss of all of the school files for 11111111111 and some of the files in relation to 111 1111. A comprehensive search for these files was undertaken by the IMR author. 6.15.2. Whilst in the early period it is apparent that school staff had little understanding of CSE, it is equally evident that they recognised that the young people had significant welfare and safeguarding needs and attempted to pursue these. Schools made a number of attempts to refer the young people both to CSC and on to other support services with mixed success. Staff lacked confidence in challenging decisions made by CSC and there was no formal escalation process undertaken at these points. 6.15.3. The schools IMR has clearly identified gaps in practice and areas for learning responding with relevant recommendations. 6.15.4. The recommendations for action for Schools are as follows: 1. Staff in schools need to use the local policies and procedures to challenge decisions made where there are clear differences of opinion in safeguarding concerns and ensure that actions, outcomes and follow up around safeguarding concerns is a priority. The process by which concerns are escalated needs to be clear and concise and shared with schools. (Schools and safeguarding board). 2. Early intervention and other support services are flexible in their approach of where their service can best be delivered to young people taking their needs into consideration. Given that school staff see young people more than any other service, especially if that pupil is on roll and attending well, then the good practice model of services going to the young person should be considered. (Safeguarding Board). 3. The Common Assessment Framework tool needs to be more widely used in schools to address early signs of concerns and vulnerability and that further training, advice and support is made available to education settings in order to fully utilise this early assessment tool. 4. Schools to be issued with new protocols and training as to the expected educational recording standards for pupil files and that this practice is standardised across all schools in the borough. RBSCB Overview Report 149 5. Further analysis of staff understanding and information sharing around CSE will need to be monitored in the future. It will be a long term action to establish CSE within both primary and secondary school curriculum although training on this has already taken place both for designated safeguarding leads and PSHE co-ordinators in schools. 6. A new policy needs to be developed on the archiving of pupil school files which includes timescales for the destruction of pupil education and child protection files. I would appear that there is currently no policy in place advising schools about requirements. 7. With the increasing autonomy of schools there needs to be better links forged between school representation on the LSCB, ensuring that key safeguarding themes, SCR lessons and other relevant safeguarding information is brought directly to the attention of schools. 6.15.5. The following information has been provided by regarding actions already taken as a result of the lessons identified in the IMR 1. Education Safeguarding Lead has met with the council’s corporate Customer and ICT services records manager to look at a secure way of indexing and archiving school files in the future. Currently working on making the corporate council policy available to educational establishments and issuing schools with a separate addendum to the corporate procedures to ensure that all school files are, in future archived with Safe Records Management so that school files can be located and tracked when requested. 2. Meeting organised with the e-CAF co-ordinator for early in the Autumn Term 2013 and plans to re-instate the Schools’ Safeguarding leader Network meetings to ensure that learning points from SCRs are embedded in schools and to look at topical local and national issues, including the use of CAF as an early intervention assessment tool. 3. Education Safeguarding Officer is currently looking at tackling this issue at the first Safeguarding Leaders network meeting to be held in the Autumn term by consulting with and using a combination of best practice from a range of schools 4. All school Safeguarding leads have attended a ½ day ‘train the trainers’ session on CSE for them to roll out across the different staffing groups in the school setting. These sessions took place over the Autumn and Spring Term 2012/13 and were delivered by the Education Safeguarding Lead and the Healthy Schools Programme Manager 5. All the school’s PSHE co-ordinators have attended a session delivered by the Healthy Schools Programme Manager on embedding CSE which is age and stage appropriate into the curriculum. All training returns received by Healthy Schools programme Manager, report written and forwarded on to the RBSCB Overview Report 150 Assistant Director, Early help and Schools and the Safeguarding Board multi agency trainer who is collating evidence on the embedding CSE within the curriculum. 6.16 Youth Service Rochdale Borough Youth Service have provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by a Senior Youth Officer. The author has had no operational responsibility in the case or any direct involvement with The Young People and their families and as such met the criteria for independence. The Report was countersigned by the Head of Schools Service who had no direct knowledge or involvement of the services provided to The Young People and their families. 6.16.1. The Youth Service had some very limited contact with 11111111111111111. These 5 young people all attended open access youth provision, but did not have any individual sessions with staff. The young people’s attendance varied between 13 sessions and 1 session and took place at their local Youth Centre. Given the nature of the provision there was no reason for the Youth Service to have specific knowledge about any of the young people, including whether they were victims of CSE. 6.16.2. Despite their limited involvement, the Youth Service have taken the opportunity as a result of being part of this Review to reflect on their service and in particular to consider how they can improve their understanding of sexual exploitation and their services to young people who might be at risk. 6.16.3. The recommendations for action for Rochdale Youth Service are as follows: 1. Continue to deliver and improve training to all staff 2. Improving information and support to young people 3. Developing the recording of individual concerns by generic practitioners 4. Improving information sharing and communication particularly between generic and targeted teams 5. To develop and improve the effectiveness of gender specific work in universal provision. 6.16.4. The Youth Service has provided the following information regarding actions already taken arising out of this Review: 1 General Safeguarding and CSE courses and briefings are planned and have been delivered to staff and volunteers. RBSCB Overview Report 151 2. The Senior Management Team have requested that appropriate sessions are delivered as a planned part of youth work programmes . These will be checked and monitored. 3. An incident report form has been developed and will be fully embedded in September 4. Work is underway to devise a process and a means of recording improved information sharing. 5 The Senior Management Team have requested that gender specific sessions are delivered as a planned part of youth work programmes . These will be checked and monitored. 6.17 Youth Offending Team (YOT) Rochdale Youth Offending Team have provided a chronology and Individual Management Review for this Serious Case Review.The report has been prepared by the Deputy Manager. The author has had no operational responsibility in the case or any direct involvement with the Young People and their families and as such met the criteria for independence. The Report was countersigned by the Service Manager. The Service Manager was responsible for managing the YOT service and directly responsible for supervising the operational managers. There is therefore some compromise to the independence of the oversight of this IMR. 6.17.1. The YOT team had some limited knowledge of 11111111 having been routinely informed by the police when they committed minor offences, but with direct contact with these two young people. 111, 1111111111 all received statutory orders as a result of offending and were Case Managed by the YOT team. 111 was involved with the YOT between 2005 and 2007 having been made subject to a 3 month referral order and 2 Reparation Orders. . 111 was known to the YOT as a result of a short period of bail support and a three month Referral order during 2006. 111 undertook a Final Warning Programme in 2008 and a period of prevention work in 2008 followed by a 6 month Referral Order and a Reparation Order which she completed in Spring 2010. 6.17.2. The YOT team had no knowledge about CSE in relation 111 until March 2006 and there is an acknowledgement that in relation to 1111 work took place in isolation of other agencies . There is no information as to how the information in 2006, which in fact was about 111 effected the work that was undertaken with her. Information about 111 being a victim of CSE was known from the outset of the YOT involvement as she was at the time subject to a CP Plan. The YOT is critical of others failure to share information 6.17.3. The YOT has shown that it met its statutory obligations and also provided extra services to support some of the young people, for example in relation to diversionary activities. It has acknowledged problems with managerial oversight and supervision including a lack RBSCB Overview Report 152 of clarity as to who was responsible for the supervision of one worker and in relation to a social work student who was case managing 111 as well as inconsistency in assessing risk of vulnerability. 6.17.4. Whilst YOT has identified learning from this Review, the information and analysis would at times have benefitted from a greater degree of precision and detail at times, combined with a more self critical approach. This could have led to more thorough understanding of the practice and what could be learnt from it. For example it is of interest that despite their involvement with 111, the YOT were not able to identify any information about her parents, even though one of the workers had regular contact with 111111. It is also stated that YOT had no knowledge of 111 experiencing CSE, yet their own records state that this information was shared with 111’s worker. 6.17.5. Recommendations whilst not without merit would benefit from more considered thought. For example it has been identified that inconsistency in workers was unhelpful and yet the recommendation is simply to review the effectiveness of multiple workers. Given that the IMR refers to the fact that this led to a recommendation from a previous Serious Case Review, an approach of simply looking at the issue again appears weak. There is a risk for the YOT that as a result there are gaps in their learning from this review and that this has not been addressed despite repeated feedback during the SCR process from panel members and as such could appear a little complacent. 6.17.6. The recommendations for action for the Youth Offending Team are as follows: 1. Re-establish the YOT sexual exploitation group, to link with Sunrise, to monitor screening of CSE ,referrals to CSC and follow up work 2. Review Case Planning Forum process in relation to CSE 3. Establish the Case Planning Forum action tracker 4. Review effectiveness of multiple workers working with young people 5. Review YOT’s use of the CSE screening tool 6. Establish more consistency in quality and frequency of supervision 7. Improve YOT’s links to strategic plans 8. Ensure YOT plans (PTGS and Vulnerability Management Plans) highlight staying safe work 6.17.7. The Youth Offending Team provided the following information in relation to actions already taken arising out of this review: The YOT have a nominated social worker as a virtual member of the Sunrise team. RBSCB Overview Report 153 All young people subject to YOT interventions have a CSE screening tool completed. This is monitored through the intervention check process and through reviews which are conducted in accordance with National Standards. All YOT staff have attendance CSE training and YOT senior staff have contributed to it’s development and delivery. A YOT deputy manager is leading a task and finish group looking at peer on peer abuse and will report back to the safeguarding board. HMIP has made comment following the full joint inspection carried out in July 2013, that there where were clear protocols in place for thresholds relating to child protection and that good communication had been established between the YOT and sunrise. 6.18 Heywood, Middleton and Rochdale clinical commissioning group The Primary Care Trust responsible for commissioning has provided a Health Overview Report encompassing the three individual IMRs. The report has been prepared by the Designated Nurse for Safeguarding Children and Adults. The author has had no operational responsibility in the case or any direct involvement with the Young People and as such met the criteria for independence. The report was signed by the Executive Board Nurse. The countersigner had no direct knowledge or involvement with the services provided to the Young People or their families. The Health Overview Report has made one additional recommendation for action for health commissioners In conjunction with Public Health and health commissioners review health services which provide sexual health services to young people, consider the extent to which safeguarding and child protection are considered as part of sexual health assessments. RBSCB Overview Report 154 Name of SCRP chair assuring quality of overview report Audrey Williamson Date 12th November 2013 1 Endorsement by LSCB Name of LSCB Chair Jane Booth Date of LSCB endorsement of overview report 15th November 2013 Signed on behalf of LSCB: Position: Independent Chair of Rochdale SCB Author: Sian Griffiths BIBLIOGRAPHY Biehal, N (2005): Working with Adolescents: Supporting families, preventing breakdown. Brandon, M et al ( 2008 ), A Biennial Analysis of Serious Case Reviews 2003-05, Department of Children Schools and Families. London. Brandon, M et al (2009), A Biennial Analysis of Serious Case Reviews 2005-07, Department of Children Schools and Families. London. Brandon, M et al (2010) A Biennial Analysis of Serious Case Reviews 2007-09, Department of Children Schools and Families. London. Brandon, M et (2011) A study of recommendations arising from serious case reviews 2009-2010 Brandon, M et al (2012) A Biennial Analysis of Serious Case Reviews 2009-11, Department of Children Schools and Families. London. Calder, M (2009) Sexual Abuse Assessments:Using and Developing Frameworks for Practice Cleaver, H et al (2011) Children’s Needs, Parenting Capacity. CPS (Oct 2013): Guidelines on Prosecuting Cases of Child Sexual Abuse Daniel et al (2010, 2nd Edition: Child Development for Childcare and protection workers. Davies, C and Ward, H (2012): Safeguarding Children Across Services. Messages from Research Department of Health (2009) Information Sharing: Guidance for practioners and managers. Department of Health (et al) 2000: Framework for the Assessment for Children in Need and their families. Finkelhor, D (1986) A Sourcebook on Child Sexual Abuse Gohir, S (2013): Unheard Voices: The Sexual Exploitation of Asian Girls and Young Women. Muslim Women’s Network HM Government (2013): An Overview of Sexual Offending in England and Wales HM Government (2012) Children First:The Child Protection System in England HM Government (2009) Safeguarding Children and Young People from Sexual Exploitation. Supplementary Guidance to Working Together to Safeguard Children HM Government (2010) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London Draft Rochdale SCB Overview Report YP1-6 v4 156 HM Government (2006) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London Klonowski, Anna: Report of the Independent Reviewing Officer in Relation to Child Sexual Exploitation Issues in Rochdale Metropolitan Borough Council during the period 2006-2012 May 2013 Lodrick, Z. (2007) Psychological trauma – what every trauma worker should know. The British Journal of Psychotherapy Integration. Vol. 4(2) Morris, K (2008) Social Work and Multi-agency working Munro, E (2008): Effective Child Protection OFSTED (2011) Ages of Concern: Learning Lessons from Serious Case Reviews. Parliament: Home Affairs Minutes of EvidenceHC68 20.11.2012 NSPCC (2010) Children and young people disclosing sexual abuse: An introduction to the research NWG Network (March 2013) “If you Shine a Light you will probably find it” Pearce, J (2009): Young People and Sexual Exploitation: its not hidden, you just arent looking. Report of a Grass Roots Survey of Health Professionals with Regard to their Experiences in Dealing with Child Sexual Exploitation (Dr Paul Kirtley) Rees, G et al (2011): Adolescent Neglect. Research, Policy and Practice. Rochdale Borough Safeguarding Children Board (Sept 2012) Review of multi-agency responses to the Sexual Exploitation of Children Turney et al (2011) Social Work Assessment of children in need. Messages from Research University of Bedfordshire (2011): What’s Going On? Wilson and James (2007) The Child Protection Handbook Draft Rochdale SCB Overview Report YP1-6 v4 157 Appendix A: Terms of Reference Appendix B: Full Glossary of Codes for Professionals and Family Members Appendix C: Comprehensive Chronology Appendix D: Explanation of processes referred to Draft Rochdale SCB Overview Report YP1-6 v4 158 APPENDIX D: Explanations of terms referred to in the Overview Report A Strategy Meeting/Discussion is required whenever there is reasonable cause to suspect that a child is suffering, or likely to suffer significant harm. This should include CSC, the police, health and any other appropriate body. The meeting should agree on further actions required, for example legal action or further enquiries under the Children Act 1989. An Initial Assessment is a brief assessment undertaken by CSC following any referral where it is necessary to identify if a child is in need or suffering/likely to suffer significant harm as defined in statutory guidance (Working Together). A Core Assessment under S47 of the Children Act 1989 is a detailed assessment undertaken by CSC when it is suspected that a child is suffering, or likely to suffer, significant harm. Section 20 of the Children’s Act: provision for a child in need to be accommodated by the Local Authority with the consent of the parents or others with parental responsibility. An Emergency Protection Order is a short term order made by the courts when a child requires urgent protection either to remove a child to a safe place or to prevent them being removed from a safe place. Looked After Child (LAC) Reviews: statutory reviews of plan for children who are looked after by the local authority The Core Group is the group of family members and key professionals who meet regularly to implement and review the Child Protection Plan Gateway or Legal planning meetings are held when a social worker and manager decide that the circumstances of a child require detailed consideration with legal services and there is a strong prospect that the council is likely to need to seek an application to court for an order. A Referral Order (Criminal Evidence Act 1999) is a court order lasting between 3 months and 12 months during which the young person undertakes reparation work with the victim or community and also an offending behaviour programme. A Reparation Order is a court order which requires the young person to complete a set number of hours undertaking either direct or indirect reparation work. ASSET is an assessment tool used nationally by YOT to assess risk of reoffending, vulnerability and risk of serious harm Draft Rochdale SCB Overview Report YP1-6 v4 159 Achieving Best Evidence: Guidance produced by government regarding video-recorded interviews with vulnerable, intimidated and significant witnesses. (2nd Edition, 2007) School Action is a plan of educational support put in place when there is evidence that a child is not making progress at school and there is a need for action to be taken to meet learning difficulties. School Action Plus is adopted when adequate support is not being achieved by School Action and there is a need for more specialist help LEARNING DISABILITY, LEARNING DIFFICULTIES AND SPECIAL EDUCATIONAL NEEDS Learning disability is the term used by the Department of Health within their policy and practice documents. Valuing People (2001) describes a ‘learning disability’ as a: significantly reduced ability to understand new or complex information, to learn new skills reduced ability to cope independently which starts before adulthood with lasting effects on development. (Department of Health. Valuing People: A New Strategy for Learning Disability for the 21st Century. 2001). Learning difficulty is a term used to describe any one of a number of barriers to learning that a child may experience. It is a broad term that covers a wide range of needs and problems, including dyslexia and behavioural problems, and the full range of ability. Special Educational Needs: The 1996 Education Act defines a child as having Special Educational Needs “if they have a learning difficulty which calls for special educational provision to be made for them”. Children have a learning difficulty if they: a. have a significantly greater difficulty in learning than the majority of children of the same age; OR b. have a disability which prevents or hinders them from making use of educational facilities of a kind generally provided for children of the same age in schools within the area of the local authority; OR c. are under compulsory school age and fall within the definition at a. or b. above or would do so if special educational provision was not made for them. |
NC52695 | Non-accidental injury to the leg of a 1-year-old boy who was identified with significant emerging health needs prior to the injury. He is developmentally delayed and was described as non-mobile. Learning includes: the importance of knowing and understanding the impact of a parents vulnerabilities and history on their parenting; parental substance misuse, mental health, and prescribed pain medication; working with homeless families; exploring and understanding a disabled childs likely and actual lived experience; considering absent parents, even when domestic abuse is alleged; considering what support is required to ensure a lone, non-birthing parent acquires parental responsibility; referring/ transferring a child in need plan across local authority borders; and the need to consider if the parent requires an assessment or support due to their own needs or as a care leaver. Recommendations include: the partnership should request that agencies review their practice in respect of ensuring that the person caring for a child has parental responsibility and provide feedback on what recent progress has been made; the MASH to be asked to consider their expectations and processes regarding transfers from other Local Authorities in respect of children subject to a Child in Need plan; and the partnership to consider how it can promote the responsibilities of partner agencies to care leavers.
| Title: Child safeguarding practice review: learning identified from considering Ted. LSCB: Southampton Safeguarding Children Partnership Author: Nicki Pettitt Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CSPR Ted 1.12.22 1 Child Safeguarding Practice Review Learning identified from considering Ted Contents 1. Introduction page 1 2. Process page 2 3. Learning identified page 2 4. Conclusion and Recommendations page 16 1 Introduction 1.1 The Southampton Safeguarding Children Partnership (SSCP) agreed to undertake a Child Safeguarding Practice Review (CSPR) to identify learning, by considering the engagement of professionals with the family of a child to be known as Ted. 1.2 When Ted was a year old, he had a leg fracture (femur) which is thought to be a non-accidental injury (To be updated after criminal investigation/finding of fact). Ted was identified with significant emerging health needs prior to the injury1. He is developmentally delayed and was described as ‘non-mobile’. His father has recognised vulnerabilities including care experience, mental and physical health issues and is a regular cannabis user. He was a single, young male carer at the time of the incident leading to this review. Ted had not had contact with his mother for over six months. 1.3 Learning has been identified in the following areas: • The importance of knowing and understanding the impact of a parent’s vulnerabilities and history on their parenting • Parental substance misuse, mental health, and prescribed pain medication • Working with homeless families • Exploring and understanding a disabled child’s likely and actual lived experience • Considering absent parents, even when domestic abuse is alleged 1 Evolving cerebral palsy. Ted will have long-term health issues with delayed motor milestones CSPR Ted 1.12.22 2 • Considering what support is required to ensure a lone, non-birthing parent acquires ‘Parental Responsibility’2 • Flexibility in providing on-going support when a family moves temporarily (including across local authority borders) or the case steps up from early help • Referring/ transferring a child in need plan across local authority borders • Emotional support for parents of children with complex and lifelong conditions • The need to consider if the parent requires an assessment or support due to their own needs or as a care leaver 2 The Process 2.1 An independent lead reviewer3 was commissioned to work alongside local professionals to undertake the review. The detailed information provided during the Rapid Review process was considered. It provided a focus for the review and formed the basis for the terms of reference. 2.2 A face-to-face multi-agency meeting with professionals involved in Southampton at the time was held for discussions about the case and the wider system. A panel with an independent chair from within the Partnership worked with the lead reviewer to identify the overall learning and recommendations included in this report. The panel also took responsibility for considering the single agency learning and improvement actions required. Discussions were also held with safeguarding partners in Hampshire. 2.3 The lead reviewer hoped to meet with both parents to identify any learning from their perspective. Ted’s father was spoken to by a professional working with him closely at the time of the review and he was clear he did not wish to engage. He is aware that if he changes his mind, contact will be facilitated. Ted’s mother agreed to meet with the lead reviewer and a plan was made on two occasions, however she did not attend. She will be contacted again prior to publication. 3 Learning identified 3.1 The learning identified for the safeguarding system and partnership is highlighted below, followed by detailed and case specific analysis. Consideration needs to be given to a parent’s vulnerabilities and history when deciding if an assessment is required, when undertaking assessments and making plans for children, to understand if there is or is likely to be an impact on their parenting 3.2 There was little doubt that Ted’s father loved him and was committed to his care. All of those who knew them and worked with them noted a close bond and professionals were committed to helping Father to be a good parent to Ted. There was an understandable view that he was doing his best in a very difficult situation. The responsible community paediatrician told the review that Ted is going 2 Parental Responsibility is defined in the Children Act 1989 as being "all the rights, duties, powers, responsibilities and authority which by law a parent of a child has in relation to the child and his property". In practical terms it means the power to make important decisions in relation to a child. 3 Nicki Pettitt is an independent social work manager and safeguarding consultant. She is an experienced lead reviewer and entirely independent of the SSCP. CSPR Ted 1.12.22 3 to need complex medical support for the rest of his life, and that ‘his father tried his utmost despite his own vulnerabilities, mental health issues and having been in care himself as a child’. 3.3 Father had predisposing vulnerabilities that had an impact and were exacerbated by the pressure of caring full time for a young child with emerging special needs, in insecure housing and with complex relationships with his family who he was relying on to support him. Father had apparently been in care in another part of the country from age 14 -18. His lived experience within the care system was not known to those working with him in respect of Ted, although it was thought that Father had been in care due to a breakdown in his relationship with his parents and concerns about physical and domestic abuse. His own childhood records were not readily available to professionals in Southampton or before that Hampshire, where the pre-birth assessment was undertaken. Father was not receiving care leavers support from the local authority where he had been in care or from Hampshire where he lived as a young adult, and no consideration was given to providing him with support in his own right as a care leaver living in Southampton. The law states that care leavers can be supported up until they are 25 years old. Father was 23 when he moved to Southampton with Ted. There is no evidence that his care leaver status was confirmed or considered in respect of any support he may require. In Southampton, extensive support is available for care leavers but only to those who were in the care of Southampton City Council, not those who were in care in other areas. Father was the responsibility of the local authority where he lived as a child for care leaver support. Health agencies have some responsibility for care leavers but this tends to just involve issuing a health passport.4 3.4 There was the possibility that a Care Act 2014 assessment5 could have been requested due to Father’s own vulnerabilities. While it is possible that he would not have met the requirements for support under the Care Act, there is no evidence that this was considered at the time. This may have been more of an issue if he had been childless and had then requested support and housing in his own right in Southampton, as the requirement to support Ted under the Children Act 1989 met the family’s needs at the time. 3.5 It is known that adverse childhood experiences have an impact on a person’s physical and mental health and on their social outcomes. This includes the likelihood that their own children will be known to safeguarding services. The longer-term negative impact on the mental health of a person who has experienced adversity in their childhood is also well acknowledged. In this case, Father was involved with CAMHS as a child due to a suicide attempt, and he told professionals in Southampton that he had a history of anxiety and depression. Father was spoken to by a worker in the early help hub shortly after he came to Southampton in March 2021 and self-referred to children’s services for help with housing. He was honest about his history. He informed them that Ted was on a child in need plan in Hampshire, that he did not have Parental Responsibility, that he 4 An electronic system that stores health information (appointments, health history, immunisations, prescribed medication etc) in one secure place. 5 A Care Act 2014 assessment is how a local authority decides whether a person needs care and support to help them live their day-to-day life. CSPR Ted 1.12.22 4 had a history of drug use and fluctuating mental health, that he had CSC involvement during his own childhood, that he had been struggling with family bereavements, and that he was on probation for assaulting and racism to a police officer and for possession of cannabis. He described recent difficulties in co-parenting with Ted’s mother and that there had been a lot of arguments resulting in the relationship breakdown. The early help hub worker noted that there were indicators of domestic abuse and the recording from the hub management oversight recorded that it needed to go to locality for a worker within Sure Start to contact the family and discuss the groups available to them, with the expectation that Ted would remain allocated to the social worker in Hampshire. The recording of management oversight states that a referral should be made to the MASH if the family remained in the area. It was not clear at the time that they would stay in Southampton. 3.6 There were clear vulnerabilities for Ted at this point. He was just 13 weeks old, was living with his father as a sole carer without Parental Responsibility, the family were living with family members short-term, and Father had shared his own vulnerabilities that could be a risk to Ted. Southampton MASH received the referral from Hampshire in May 2021. A decision was made in the Southampton MASH that a new social work assessment was not required, and that early help was the appropriate plan for Ted, with an expectation that, should the situation deteriorate, a re-referral would be made to the MASH in the usual way by the early help service. This was not challenged by any professionals in Hampshire or Southampton and there was no record of a request for a threshold review. There is no evidence that Hampshire provided copies of the pre-birth assessment and child in need information, or that they were requested by the Southampton MASH, who did not undertake their own agency checks. Consideration was not given to what information from Hampshire needed to be shared with early help to enable them to better understand the vulnerabilities and risks. This was because Father had engaged with the early help service and appeared to be managing well. The review was told that there have been issues with case transfers when a family moves areas across the wider HIPS area, and this may be reflected in what happened in this case. Practice when a transfer is required needs to be child and vulnerable family centred. A recommendation is made in respect of this. 3.7 A social work assessment on Ted had been completed in Hampshire pre-birth due to Mother’s mental health and learning disability, and Father’s drug use and social care history. They were also homeless at the time and had financial difficulties. Repeated learning from case reviews shows that assessments are often mother focused. The 2021 national CSPR, The Myth of Invisible Men6, states that ‘service design and practice tends to render fathers invisible and generally ‘out of sight’ and that there are ‘deeply engrained roles, stereotypes and expectations about men, women and parenthood in our society.’ This is an issue nationally that needs to be considered and challenged. CSC in Hampshire understandably did not consider at the time how the father would manage as a 6https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1017944/The_myth_of_invisible_men_safeguarding_children_under_1_from_non-accidental_injury_caused_by_male_carers.pdf CSPR Ted 1.12.22 5 single carer, what support he would require and whether there were potential risks to Ted if this were the case. 3.8 There is evidence on the CSC case record in Hampshire that when Ted and his father moved to Southampton there were conversations between the allocated social worker and the Southampton MASH, homeless team and health visitors. This record states that a referral had been made to the Southampton MASH with a request that an assessment was undertaken as Father was living with Ted on his own when they moved. The referral was in writing and stated that the transfer was required for support. At the time Father had been caring for Ted alone for around two months and it is recorded on the Southampton MASH record that he was ‘proving to be able to provide for Ted appropriately with the support of his family,’ and that he had been ‘engaging with early help’. Although at the time the early help worker’s focus was on rehousing rather than parenting support. A decision was made by the Southampton MASH that no further assessment was required and that the on-going provision of early help was the appropriate response. The case was also then closed to children’s social care in Hampshire. 3.9 A further referral to the Southampton MASH was made later in June 2021, as part of a hospital discharge planning meeting that was attended by the hospital paediatrician and coordinated by the safeguarding clinical nurse specialist. The referral shared some low-level concerns about Ted’s care and concerns about Father’s social circumstances and vulnerabilities. The paediatrician requested and offered immediate support with housing, highlighting the inappropriateness of the family sofa-surfing or being in B&B accommodation with Ted’s emerging health needs. At the time Father was working with the early help worker and the MASH felt this was sufficient. 3.10 Early help professionals in Southampton were aware that Ted’s father smoked cannabis and he admitted that he had used cocaine and had ‘an unhealthy relationship with alcohol’ in the past. He was adamant that he only smoked cannabis after Ted was in bed however and that he would go outside and take a baby monitor so that he was able to respond if his son needed him. This was a concern which was discussed with Father by the early help worker but was accepted as it was acknowledged that this alone would not meet the threshold for a safeguarding intervention. The early help worker told the review that they had never smelt cannabis or saw any evidence of cannabis in the property. The health visiting service was not aware of the cannabis use until a child in need meeting was held in Southampton on 1 October 2021. The early help worker told the review that she had hoped to organise an early help meeting of professionals involved with Ted prior to this, which would have included information sharing, but had not been able to achieve this. There was evidence of discussion between the early help worker, housing and the health visiting service, but a date suitable for all was apparently not found. 3.11 As well as his mental health issues, Father had physical health issues with back pain following a historic road accident. He was prescribed pain killers that could also have had an impact on his parenting. The early help service was conscious of this potential risk as they had been told by Father’s new girlfriend that Father would be ‘knocked out’ after taking the medication and he CSPR Ted 1.12.22 6 admitted it made him drowsy. The risk was believed to be heightened because a child with complex needs can wake more readily and often in the night, and there was a concern that Father would not wake. The social work assessment which started in August 2021 recognised that Father suffers from ‘acute and significant pain’ and that this is difficult for him to manage. Father reported that he regularly delayed taking his medication because of the side effects and his wish to be alert when looking after Ted. The assessment acknowledged that the resulting pain could impact on his ‘regulation’ however. This was a significant issue as he was known to have issues with managing his frustration and that this could lead to him being angry and abusive to professionals. The review was told that there was a flag on the police system from 2019 that said that anyone dealing with him ‘should be aware that he can suddenly become very violent without much warning and will spit.’ This information was not widely known by professionals in Southampton and lone visits were often undertaken, for example, by the therapists working with Ted. Father was also involved with probation at the time of his move with Ted to Southampton, having received an 18-month community order in January 2020 for offences against a stranger when he had been drinking alcohol that included common assault and battery, racist abuse, and possession of cannabis. (While the police have a record of a 12-month order, the probation service has confirmed it was 18-months). 3.12 When Ted was on a child protection plan it was clear that Father struggled to contain his temper and to regulate his behaviour with professionals who he experienced as critical of his parenting. Those who have experienced historic trauma are known to find it difficult to regulate their emotions and it is thought that they have a narrow ‘window of tolerance’.7 It is important for those working with parents with a traumatic background to consider this when working with them, and for effective support to be in place to enable insight and the capacity to respond positively when feeling stress or anxiety. 3.13 An assessment completed in September 20218 resulted in a child in need plan for Ted, closely followed by a decision for an Initial Child Protection Conference (ICPC) to be held and then a Child Protection (CP) plan agreed. From October the father’s mental health notedly declined. This was most likely due to a volatile relationship with his then partner and a recent ex-partner, deteriorating relationships with family members who lived locally and who were a known support with Ted, and him feeling overwhelmed with the news of Ted’s special needs and the number of appointments related to this. He voiced his sadness and frustration that Ted was likely to have a disability, which was understandable and not uncommon for parents of children newly diagnosed with a serious health or developmental issue. The emotional impact of having a disabled child needed to be discussed with father, along with an understanding of father’s mental health history and the likely impact on him of the emerging concerns for Ted. The therapists working with the family following the needs emerging provided good practical and emotional support to Father. An invitation to a group 7 The Developing Mind (1999) Dan Siegel. 8 Assessments must be completed in 45 days. CSPR Ted 1.12.22 7 was made to Father and Ted, but Father was anxious about this type of setting and stated he would struggle to attend on public transport. The team recognised the issues and undertook home visits. 3.14 The issue of ongoing pain from his back condition was also evident in agency records from the time. He saw his GP several times and received prescription medication. He also contacted 111 due to the need for assistance in managing his pain. When Father rang for an ambulance prior to the injury being discovered, he told the call handler that he had not slept for five days due to the pain of his back. He had previously reported the practical impact of having a bad back, for example when he had to get Ted’s pushchair up and down the stairs, and when undertaking some of the exercises required in Ted’s physiotherapy. Pain medication has side effects and there is also a risk of dependence and withdrawal. Consideration needed to be given to addiction to prescription medicines as it has been identified as an emerging and potentially significant issue for individuals, and a child safeguarding issue. Prescription drugs are thought to be misused and abused more often than any other drug except cannabis and alcohol. In 2017, Public Health England were commissioned to identify the scale, distribution and causes of prescription drug dependence, and what might be done to address it. The report was published in September 20199 and shows a significant problem that is not always considered or recognised by professionals as a substance misuse problem. 3.15 When it is identified that a parent has a health issue that requires prescribed medication it is important that professionals ask detailed questions about the use of prescribed or over the counter medication, request and share information with other professionals, and consider the impact of any side effects, dependence, and withdrawal on their parenting, particularly if they are a single carer and if they have a young child or a child with special needs. In this case the early help worker was concerned enough on one occasion that she requested help from EDT to clarify if there was an issue with Ted staying alone with his father while he was on his pain medication, as he had reported he felt drowsy and was worried he would not wake for Ted. The early help worker was reassured by EDT (who had spoken to an ‘on-call doctor’ who did not know any of the family members) that there were no concerns about the sort of medication he was taking, with a statement made that it was available over the counter so was not a concern. This was not the case, as while lower levels of the medication prescribed may be available in the pharmacy, the dosage prescribed to Father was prescription only. They could have made him drowsy which may be more of a concern if Father was also using non-prescribed drugs, such as cannabis or alcohol. 3.16 Information from the GP records shared with the review show that Father’s compliance was poor and mainly crisis led. There is no evidence the medications were then reviewed or that this information was shared with the health visitor with responsibility for Ted. Father’s pain medication and management needed to be part of the plan for Ted. There were two liaison meetings between the GP and the health visitor where this family were discussed, in July and September 2021. The GP also emailed the health visitor in November 2021 alerting them to the change of address and 9 https://www.gov.uk/government/publications/prescribed-medicines-review-report CSPR Ted 1.12.22 8 concerns about Ted not being brought to appointments. This was good practice in respect of contact with Ted. GPs also need to engage in and invite communication with health visitors when there is an adult health issue that could impact on parenting, and for consideration to be given to a GP vulnerable person meeting to include the health visitors if a child is living in the household. 3.17 There were few opportunities for professionals in Southampton to explore or consider if Ted’s mother had any vulnerabilities that could impact on her parenting of her child, as there was very little contact with her by any agency and an understandable acceptance that Father was the single carer when the family initially moved to Southampton. CSC in Hampshire shared that a child in need plan had been in place since the child was born because of both parents’ mental health issues, housing and financial issues. Father initially stated that Ted’s mother’s poor mental health had been the main reason why he was now caring for Ted alone and this was partly confirmed by Hampshire CSC. In Southampton, Ted and his father were treated as a family and Father’s explanation for why he was a single carer was largely accepted. Father later told the homelessness team that Mother had been abusive to him and that he was a victim of emotional domestic abuse. It is a legal duty for housing to accept domestic abuse, without question, as a criterion for rehousing. Hampshire Police have no record of any domestic abuse and on one occasion on an unrelated matter in November 2021, Father was asked if there had been domestic abuse in the relationship with Ted’s mother, and he said there was not. There was no consideration given to making an adult safeguarding referral when Father told the homelessness worker that he was the victim of domestic abuse. 3.18 Consideration of a parent who does not live with a child is important, regardless of their gender and whether they are said to be a perpetrator of domestic abuse. There was initially little understanding of why Ted’s mother was not in contact with him and what her views were. This replicated what is often the case when a single mother is caring for her children and there is little professional consideration to involving an absent father. The review was told that the health visiting service in Southampton inadvertently rang Ted’s mother soon after the move to Southampton and she advised that Father had taken Ted but that she accepted the situation due to her own difficulties at the time. When Ted’s mother was spoken to by the social worker as part of an assessment in September 2021, she said that Ted had been ‘abducted’ by his father and that she had felt helpless to do anything about it. When the social work assessment was completed, there was a commitment to involving Ted’s mother which resulted in a very angry response from Ted’s father. She was visited and informed of the child in need then child protection plan and was invited to meetings held virtually. 3.19 In Southampton there is a project that was devised to address the lack of professional focus on fathers and male carers, which Father was referred to by the early help worker. Families First seeks to deliver services to all fathers and men who provide care for children, and they work in collaboration with other agencies across the early help, child in need and child protection levels of intervention. This includes drop-ins, groups, outreach, and one-to-one work. They were involved with Ted’s father at the time of the ICPC and attended the core group held in November 2021. This CSPR Ted 1.12.22 9 case shows the benefit of including these types of voluntary sector agencies as an important part of any team around a child where the parent requires support and a degree of advocacy. When a family is homeless and living temporarily with friends and/or family members, or when they are in temporary accommodation, this can have an impact on the effectiveness of assessments, support and oversight and may require flexibility in the system 3.20 Practice in Ted’s case was impacted due to the family moving from Hampshire to the Southampton area in the spring of 2021, followed by a period of insecure or temporary housing. On arrival Ted and his father were effectively ‘sofa-surfing’ with different family members, two in Southampton and one just over the border in Hampshire. There was a delay in him being accepted as homeless in Southampton as there was a tenancy in his name in his previous town in Hampshire. It was not until he made allegations of domestic abuse from his previous partner (Ted’s mother) that his application was accepted. There was also then a delay in him completing the required forms, although he required and received support from the early help worker and No Limits10 with this task. 3.21 While they were ‘homeless’ and Father was using the addresses of extended family members, this led to difficulties, particularly in registering with a GP and allocation to a consistent health visitor. From the time that Ted and his father moved to Southampton, there were five different GPs involved and four different health visitors. There were also other complications linked to the family’s housing status. After Ted’s significant needs emerged, the Southampton Equipment Store/Service did not provide the required equipment11 for Ted as the family were living in emergency guest house accommodation at the time and not in a permanent residence. This was challenged but it was not until they were housed in more stable temporary accommodation that the delivery was made. The review was assured that this matter is being discussed with the relevant department. 3.22 The review has found systemic difficulties which led to a lack of a consistent health visitor, as would have been good practice for a child who had been on a child in need plan since birth, who was not living with his mother, who had no home, and who had emerging health and developmental needs. Health visitors in the area work geographically and allocation is determined by the address where the family are living. As one of the extended family members lives just over the border in Hampshire, this led to the Southampton health visitors transferring the case back to Hampshire for a short period after Father gave the Hampshire address when Ted was discharged from hospital. This was despite the address only being temporary while the family member was away on holiday and just 5.6 miles from the previous address in Southampton. The review was told that the health visitor was informed by Ted’s father that the move was permanent, which justified the transfer. Other agencies knew this was not the case, however. There is a health visiting record that shows the health visitor spoke to a duty family support worker when the plan to stay at the family member’s 10 No Limits is a charity offering free and confidential information, advice, counselling, advocacy and support to children and young people under the age of 26 in Southampton and Hampshire. 11 For example, a bath seat, positioning mat and specialist baby chair. CSPR Ted 1.12.22 10 address ‘broke down’ after 12 days, to express her concern, although the family support worker was clear during the review that it was only a temporary place for the family to stay. 3.23 The health visiting service has been impacted by vacancies in the 0-19 service and COVID-19. The review was told that at the time there was little to no flexibility in the system to allow a health visitor to remain involved with a child when they move out of the area, even if it is to a temporary address very close by, but that such cases could be discussed in safeguarding supervision to reflect on the child’s specific needs. There was a health visitor specifically for homeless families in Southampton at the time, but the role did not extend to covering a ‘sofa-surfing’ situation out of the city boundaries. There is evidence of good information sharing and some joint working between health visitors from Southampton and Hampshire through joint attendance at Ted’s hospital discharge planning in June 2021. Once the concerns regarding Ted’s developmental delay started emerging in May 2021 there was also good information sharing between the different health visitors allocated to Ted and a shared awareness of the concerns. 3.24 The Southampton early help service recognised the need for the family to have consistency of support and kept up their involvement with Ted and his father even while they were temporarily staying in the other local authority area. This was flexible, child centred practice. 3.25 The review has identified learning about the need for professionals to understand the practical realities of what can be offered to a homeless family like this one. The fact that Father had a tenancy in another local authority area legally limited what the homeless team in Southampton could do. There were reported delays in receiving information from the borough council in Hampshire despite efforts to chase this up. There is a potential lack of ‘ownership’ when a family is not permanently housed in an area, which can increase a child’s vulnerability. This lack of ownership or delay in taking responsibility can impact on multi-agency contributions to assessments and plans. 3.26 There was an issue with the number of social workers involved with Ted and his father. From the start of the Southampton child in need plan in October 2021, until the injuries were identified in December 2021, there were four different social workers involved and a period where Ted had to be temporarily allocated to a practice manager. This was after Ted had been allocated to a new social worker on 18 November who then left on 8 December. He was then allocated to a new social worker on 10 December, who left on 23 December. This experience was largely due to general issues with social work staff leaving and issues with recruitment. For his father, who was known to get frustrated when having to meet new professionals and explain his and Ted’s history, this would have been exceptionally difficult. 3.27 Contacting social workers at this time was a challenge for professionals and examples were shared with the review that included attempts during November 2021 by the health visitor to contact the social worker for an update on the case since the ICPC. She escalated the lack of contact by contacting the MASH. It appears that professionals had not been contacted about a change of social worker. Single agency learning has been identified about the need for CSC to ensure that ‘out of office’ messages are in place with a number to contact in an emergency and that there is a CSPR Ted 1.12.22 11 system in place for messages to be heard and calls to be returned. Further to this, for those involved in core groups to be informed in a timely way about a worker leaving or a change of allocation. There is also learning for community health professionals about accessing safeguarding support both in and out of office hours. Professionals need to explore and understand a child’s likely and actual lived experience 3.28 The importance of professionals having a child centred approach is well recognised in safeguarding work and there is evidence of a commitment to this in Southampton. The referrals and contacts over the summer of 2021 that led to a single assessment and child in need plan focused on the impact on Ted of his father’s disclosed difficulties. The GP surgery showed good information sharing and child centred practice when they contacted the MASH in May 2021 stating that the family’s insecure housing and lack of funds was having an impact on Ted receiving the medical care he needed, as Father had to cancel an appointment with the GP due to not being able to travel to the surgery they had registered at when they were staying with a different family member. 3.29 It is important that all professionals also consider historic information within the parents’ own records and use opportunities to share this with other agencies as appropriate. The review has found that the available information in Father’s GP record was very limited however and would not have indicated that Father’s mental and physical health difficulties may have an impact on his parenting of Ted. There were no recent or consistent flags for mental health or substance misuse from the previous GP12; no multi-agency documents demonstrating Father’s own self-reported care history; or that there had been a CSC pre-birth assessment and plan for Ted. There were references made in the consultation notes about some of Father’s issues and his limited engagement regarding these, but not enough to indicate the level of vulnerability that is now known. 3.30 In August 2021 emergency accommodation was offered when Father reported he could no longer live with family members due to difficult relationships. His housing application was being processed. There is a severe shortage of accommodation locally and the need to use B&Bs for emergency accommodation is reportedly unavoidable. The early help worker shared concerns with CSC about Father’s relationship with his then partner and their view that Father required significant support to provide consistent care to Ted, and that he was relying on his partner who there were concerns about due to her own child not living with her. It was the involvement of this partner in Ted’s care and the early help worker’s concerns about the real threat of the family being evicted from the temporary accommodation that led to the completion of a single assessment in September 2021, followed by child in need planning. 3.31 Towards the end of November 2021 there were concerns for Father’s mental health when he told professionals he had gone to a local notorious suicide spot, with Ted, and had considered ending his life. He stated that his wish to be around for his son had stopped him from going ahead with the plan, but this episode showed the level of his despair at the time. While a child is often a protective 12 The Southampton Named GP is sharing learning about this with their counterpart in Hampshire, so that it can be shared with Father’s previous GP surgery. CSPR Ted 1.12.22 12 factor for a parent with depression, professionals need to ensure that they reframe this to consider the negative impact this can have on the children and that it may be an indicator of emotional abuse. The physiotherapist working with Ted was extremely concerned when Father disclosed this to her and tried to speak to the social worker who was undertaking the single assessment. Attempts were made that day, and the following week, to share the information and be assured that support would be in place for Ted and his father. 3.32 Unknown to the physiotherapist, who was increasingly worried, CSC were aware of the matter as they had been informed in a timely way by No Limits, who Father had also spoken to. A CSC social worker visited Ted the same day to address the matter. Despite this, there is little evidence of liaison with Father’s GP or mental health services. The known issues at the time indicated a need for a mental health assessment to identify what treatment was required. No strategy meeting was held and no S47 investigation was undertaken about this concerning event. Ted was already on a child protection plan at the time; however a strategy meeting may still have been required and a S47 should be completed when there is further concerning information about a child who is already subject to a CP plan. The meeting could also have considered Father’s needs and whether a referral to mental health services was required. A recommendation has been made in regard to ensuring that non-mental health professionals know what they need to do should they be aware of a potentially significant suicide event. 3.33 The impact on Ted of his father’s demeanour was of concern. While there was a perception that Father was doing his best in difficult circumstances, this was not always enough in terms of Ted’s lived experience. The single assessment completed early in October 2021 shows child centred practice by stating that Ted would become ‘wide eyed, watchful and stare’ at his father when he became ‘angry and abusive’. The assessment reflected that it is likely that Ted would experience anxiety and fear during these incidents which would have a negative impact on his longer-term emotional wellbeing. There were triggers for Father’s anger, including when Ted’s mother tried to instigate contact with her child, and when professionals challenged Father about the need for him to facilitate this. It was Father’s anger and emotional dysregulation during the first child in need meeting, along with evidence of his declining mental health, his ongoing cannabis use and the evident impact of his pain medication, that led to the ICPC October, and a unanimous decision was made for Ted to be the subject of child protection planning. 3.34 Ted’s grandmother’s GP made a referral to CSC on 9th December 2021, flagging concerns after a consultation where she shared how concerned she was about Ted. The same day an anonymous referral was received by CSC stating that Father got frustrated with Ted and would ‘shout in his face to shut up’ and handle him roughly. A duty social worker unknown to the family visited the next day and Father told them Ted may need respite care as his relationship with his mother (and main support) remained strained and he was finding things very difficult. There is no evidence that this was pursued further or that the increasing risk to Ted at this time was acknowledged. On the 16th December 2021, the day before Ted was injured, early help visited. There were no concerns CSPR Ted 1.12.22 13 identified during the visit although Father described his frustration that Ted couldn’t do the things that other 1 year old children could do. 3.35 There were examples of good practice in considering the child rather than focusing on the father, despite his own needs and how much support he required. This included monitoring the living conditions and Ted’s physical care. There was flexibility in parts of the system and those involved worked hard to make sure that if an appointment was missed, that it was rearranged with flexibility to ensure that Ted received what was required. For example, the physiotherapy and occupational therapy teams would contact Father and make an appointment for the next day if he did not attend with Ted. The early help worker had very regular contact with father by text message and phone and was responsive to the family needs even when she was not due to visit. The paediatrician shared their concerns about the impact on Ted of the insecure housing situation and the family’s need for support. 3.36 It was established by early help professionals in Southampton that Father did not have Parental Responsibly (PR) for Ted, and that Ted was not having any contact with his mother, who had PR for him. There was uncertainty about whether Ted’s birth had been registered, and whether there was a birth certificate. The early help worker tried to assist by contacting the registry office and it seemed that there may have been a registration for Ted, but no information was shared by the registry office who suggested that the potential certificate was applied and paid for. Father did not prioritise this13. Father would not have been listed on the birth certificate as he was not present when the birth was registered, which is required if a couple are not married. The health visiting service and those providing therapy for Ted were not aware that Father did not have PR for Ted when they started working with him. There is a prompt on the Solent NHS recording system but it appears that an assumption was made that Father had PR rather than the health professionals specifically asking the question. 3.37 A mother automatically has parental responsibility for her child from birth. A father usually has parental responsibility if he’s either married to the child’s mother or is listed on the birth certificate. Neither of this was the case for Ted’s father. To obtain Parental Responsibility, Father would have to have his name registered on the birth certificate (or re- registered if it was not included at initial registration); or by entering into a Parental Responsibility Agreement with the mother; or by obtaining a Parental Responsibility Order from the court; or by being named as the resident parent under a Child Arrangements Order. 3.38 The lack of PR did not hinder the engagement of services or Ted’s health needs being met, but there are potential difficulties when the only person with PR for a child does not care for them and has no contact. Legally, healthcare professionals require the consent of the person with PR to approve treatment, and with hindsight those who were involved at the time recognised that they did not ask for proof of PR and did not consider making an issue of this to ensure that Ted’s needs were met. This legal issue remained the case throughout the period being considered. There was also 13 A birth certificate costs approximately £18 including postage. CSPR Ted 1.12.22 14 reflection about practice in an acute hospital setting regarding how PR for a child is sought during emergency department attendances and admissions and is documented in the medical record. For the ED attendances in this case, it is recorded separately that both Father and Mother had PR, and this was not questioned or discussed with agencies. 3.39 It is recorded by CSC and Early Help that Father was going to apply for PR and for a ‘live with’ order. This was accepted and encouraged, but there was delay in this happening and it was not until November 2021 that it was recorded in a Core Group that Father was going to be attending court for this matter. This issue does not appear to have been followed up with Father and in December he told a duty social worker that he was in the process of applying for PR. Father likely did not prioritise this issue as he had other priorities and also due to the cost involved. There is no evidence that support, either practically or financially, was provided by professionals. This is an unusual circumstance however, and like Father, professionals had more pressing priorities regarding Ted. More focused and timely support with this matter would have been good practice and in Ted’s best interests, however. 3.40 The review has also found that there was a degree of acceptance and lack of challenge when Father stated that Ted was not having contact with his mother, at least until the social work assessment in August 2021. This was partly due to a wish by professionals not to be seen as penalising the father for his gender and being a single male carer, and an acknowledgement that had he been the mother there would have been little challenge about where the father was and why there was no contact. Father stating that there had been domestic abuse also made people cautious about asking too much about Ted’s lack of contact with his mother. It is not often that professionals work with single fathers of young children and this had an impact. When a child is made subject to a child in need or child protection plan, the family should not lose the potential for the type of hands-on and practical support provided by the early help service if this remains a need 3.41 When the family moved to Southampton, the child in need plan that Hampshire had in place was not transferred. An early help assessment had been completed and a worker was allocated to Ted and his father. At the time in Southampton, it was the practice for an early help worker to discontinue their involvement with a family when a social worker became allocated following a child in need or child protection plan being made. In August 2021, following referrals from the GP, the early help worker and Ted’s community paediatrician, a social work assessment was undertaken in Southampton and a child in need plan was made. This meant that a professional who had a good relationship with Father, knew Ted, and held a lot of information, was no longer going to be involved. It was positive that the early help worker was invited to the child protection conference held shortly afterwards however, and that they could share their views and knowledge of the family. There was however a decline in ‘hands on’ support at the time, partly due to the differing roles but also due to staffing issues in the social work team, as described above. While there is evidence of social worker contact with Father at the time, the lack of consistency from social care staff and from CSPR Ted 1.12.22 15 health visitors would have been difficult for Father. Numerous reviews have shown the importance of working with the same practitioners over time; demonstrating that this enables parents and children to gain trust and build better relationships. It equally helps professionals when they understand the family history, the context in which the family live, and the other agencies and professionals involved with the family. There is also the benefit of recognising any deterioration or improvement in the circumstances, the parent’s mental health and the child’s voice. 3.42 The core group held following the ICPC included the community health professionals who attended the ICPC, such as the physiotherapist and occupational therapist involved with Ted and Father to enable him to meet Ted’s needs. There is evidence of good support and flexibility from these professionals, who identified concerns and recognised the pressure that multiple appointments would put on Ted’s father. They devised a plan for home visits in multi-disciplinary pairs to cut down on the demands on Father to take Ted to numerous appointments. At the core group, Father had a new partner who attended. There is no evidence that there was any plan made to undertake checks or assess her. A health visitor met her when visiting Ted and Father and did not record her name or other details. There is often risk to children when a new partner joins a family, as shown most recently in the 2022 national CSPR which considered the learning from the murders of Arthur Labinjo-Hughes and Star Hobson. 3.43 It was towards the end of October 2021 that things began to noticeably deteriorate. Father did not bring Ted to two scheduled appointments with the hospital paediatrician and with neurology in late October14. Housing department staff were trying hard to get Father to complete the paperwork required to ensure he was on the housing waiting list and for his housing benefit to be paid. He did not respond to numerous attempts to rectify the issue. Two homeless workers were invited to the ICPC and a report was provided. The housing department reflected that they would usually undertake home visits to their most vulnerable tenants who were living in temporary accommodation, but at the time the ongoing response to COVID 19 limited them to telephone contact and / or doorstep visits. 3.44 The ICPC was held on 20 October 2021 and Ted was made the subject of a CP plan, with the category of emotional abuse. There was a need for a timely multiagency plan for Ted with the social worker as the lead professional, but also with the active involvement of family support workers, health and housing professionals. Working Together 2018 states that the core group should meet within 10 working days of the ICPC and that the outline child protection plan should be developed by the core group, to ‘set out what needs to change, by how much, and by when, in order for the child to be safe and have their needs met.’ In Ted’s case the core group was delayed, being held 16 days after the conference, and the record of the core group section that lists the child protection plan is blank. As this was a time where the concerns about Father and his care of Ted were high, there needed to be a timely response and plan with a high degree of oversight. 14 The Lead Paediatric Consultant was proactive and contacted the Trust’s Safeguarding Children Team (as per the Was Not Brought policy) when Ted’s appointments were missed, and appropriate actions were taken. CSPR Ted 1.12.22 16 3.45 While there was good practice from several health professionals with Ted and his father, there were also gaps in information sharing and understanding from non-health professionals about who was involved and in communication between different parts of the health systems. A number of reviews nationally have found that there is a common misperception by non-health professionals that by speaking to one health professional, for example the health visitor, they will be aware of all the necessary health information. Non-health professionals are not always aware of the complexity of health provision and there is no guarantee that different health professionals are communicating with each other, or that they have access to all health databases for the children and for the parents. When there are emerging vulnerabilities, comprehensive checks must be undertaken across all relevant health agencies. 4 Conclusion and recommendations 4.1 This CSPR has considered the learning from Ted’s case and has identified learning that will be helpful for the wider system. Like the national CSPR published in 2021, The Myth of Invisible Men, this review considered a father/male carer of an infant to identify learning following an injury that was likely to have been perpetrated by him. The national review points out how important it is for professionals to be aware of the factors that interplay in cases where a child has been harmed. These factors include fathers with a ‘background of abusive, neglectful or inconsistent parenting’, who have ‘histories of impulsive behaviour and low frustration thresholds’, who ‘abuse substances’, who ‘mitigate their difficulties with others through an easy default to violence and controlling and angry behaviour’, and who are experiencing external pressures from homelessness and ‘poor relationships with the mothers of the children’. The review also highlighted how common it was for the father’s they considered to have ‘significant relationship problems, within a spiralling negative cycle of drug abuse, deterioration in mental state and poor decision making, and a lowering of what was for many an already low frustration threshold.’ Similar has been found in this case. The national CSPR states how important it is to identify which father’s require support interventions and for professionals to engage with them. In the case of Ted’s father this happened, largely because he was a single carer, but we have regardless found many examples of positive work undertaken with him in Ted’s best interests. 4.2 In 2021 the SSCP published a thematic serious case review (SCR) concerning the non-accidental injury of three infant children. Some of the reflection and learning is relevant to the case of Ted, particularly in regard to the need to ensure that young parents are assessed and supported to care for their children in a way that recognises their own age and development, the impact of mental health issues, self-harming behaviour and substance misuse15 on parenting capability, the impact of homelessness, anger management and domestic abuse, evidencing the child’s lived experience within the family, and over optimism on the part of professionals as to the parents’ capacity to care for a vulnerable child. 15 The SCR notes that cannabis misuse by parents has become a common feature of the day to day work of social care and health professionals, which can lead to a degree of professional complacency about the impact on children. CSPR Ted 1.12.22 17 4.3 The thematic review makes some recommendations relevant to this review. Firstly, about the need to seek, document and share a parent’s history, and secondly about the need for professionals to consider and understand the impact and risk when a parent misuses substances, including cannabis, on their ability to care for and safeguard their child. 4.4 Single agency learning has been identified during the review and recommendations have been agreed to address the need for improvement actions. There has been excellent cooperation with this review from partner agencies, which was essential in establishing the learning from this case. 4.5 Having considered the learning outlined in this report, the following recommendations are made: Recommendation 1 The SSCP to propose that the HIPS protocol for protecting children who move across local authority borders16 is reissued and widely promoted across the HIPS partnership areas to encourage improved cross border working with vulnerable families Recommendation 2 That the learning from this review is shared with the Southampton Safeguarding Adult Partnership Recommendation 3 That the SSCP seeks assurance from the relevant partner agencies about the quality of core groups17, to include timeliness and the attendance of professionals and family members Recommendation 4 The SSCP to request that agencies review their practice in respect of ensuring that the person caring for a child has PR and provide feedback on what recent progress has been made Recommendation 5 The Southampton MASH to be asked to consider their expectations and processes regarding transfers from other Local Authorities in respect of children subject to a Child in Need plan Recommendation 6 The SSCP to consider how it can promote • the responsibilities of partner agencies to care leavers • the responsibility to make adult safeguarding referrals and/or a referral for a Care Act assessment when a parent is an adult with care and support needs • trauma informed practice with children and their parents • responses to men who allege they are victims of domestic abuse • what non-mental health professionals need to do when they are aware of a significant suicide situation18 16 https://hipsprocedures.org.uk/qkyyol/children-in-specific-circumstances/protecting-children-who-move-across-local-authority-borders 17 held following a child being made subject of a child protection plan 18 This issue could be taken to the HIPS suicide prevention group CSPR Ted 1.12.22 18 Recommendation 7 The SSCP to ask its partner agencies to consider how they can ensure that non-medical professionals understand the systems that provide health services, and that ‘health’ is more than one agency/service |
NC046271 | Death of a 4-month-old girl in December 2012. Child H died of unknown causes and Corner recorded an open verdict. H had a number of injuries thought to be non-accidental. Police investigation found mother not guilty of causing/allowing serious physical harm to Child H. Mother's partner was given a custodial sentence after pleading guilty. Family was known to agencies due to the serious domestic abuse and harassment the mother experienced from her previous partner, the father of Child H and her sibling. Children were not considered at risk of harm, other than in regards to their father, who was thought not to have any contact. Little was known about mother's new partner, who was wrongly believed to be H's father, although there were concerns about his controlling behaviour. Mother had a history of mental health problems, alcohol misuse and abusive relationships. Identifies learning including holding a common assessment framework (CAF) meeting early to help clarify concerns and responsibilities; and professionals should consider the impact of historic experiences of domestic abuse. Uses the Significant Incident Learning Process (SILP) to review the case. Recommendations for the safeguarding board are to share the learning from the review and commission a multi-agency case file audit of children subject to a common assessment framework (CAF) where domestic abuse is an issue.
| Title: Serious case review: Child H: overview report. LSCB: Nottinghamshire Local Safeguarding Children Board Author: Nicki Pettitt Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Version 6. 26.6.14. 1 Serious Case Review Child H OVERVIEW REPORT Version 6. 26.6.14. 2 CONTENTS 1. Introduction to SILP Page 3 2. Introduction to the case Page 4 3. Family Structure Page 4 4. Terms of Reference Page 5 5. The Process Page 5 6. Background prior to the scoped period Page 8 7. Key practice episodes Page 9 8. Analysis by theme Page 28 9. Conclusions and lessons learned Page 46 10. Recommendations Page 50 11. Bibliography Page 53 Version 6. 26.6.14. 3 1 Introduction to the Significant Incident Learning Process (SILP) 1.1 SILP is a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted in a certain way at the time. This way of reviewing is encouraged and supported in the new Working Together to Safeguard Children published in March 2013. 1.2 The SILP model of review adheres to the principles of; • proportionality • learning from good practice • the active engagement of practitioners • engaging with families, and • systems methodology 1.3 It has been generally accepted that over recent years the Serious Case Review agenda had become over-bureaucratic and driven by Ofsted ratings. The practitioners in the case have often been marginalised and their potentially valuable contribution to the learning has been under-valued and under-utilised. 1.4 SILPs are characterised by a large number of practitioners, managers and Safeguarding Leads coming together for a learning event. All agency reports are shared in advance and the perspectives and opinions of all those involved are discussed and valued. The same group then come together again to study and debate the first draft of the overview report, and to make an invaluable contribution to the learning and conclusions of the review. 1.5 Nottinghamshire Safeguarding Children Board (NSCB) has requested that the SILP model of review be used to consider the circumstances surrounding the injuries, and potentially the death of a child known as Child H. Also being considered is a healing rib fracture found on an older sibling during a child protection medical instigated by the death of Child H. This systems review is being undertaken in order to learn lessons about the way that agencies in Nottinghamshire work together to safeguard children. 1.6 Working Together 2013 states that SCRs and other case reviews should be conducted in a way which; Version 6. 26.6.14. 4 • recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. 1.7 This serious case review has been undertaken using the SILP model, which ensures that these principles have been followed and provides a systems review of the case. 2 Introduction to the Case 2.1 The subject of this review is Child H, a 4 month old girl who died in 2012. Child H died of currently unknown causes, but had a number of injuries of varying dates which are thought to be non-accidental. She had one sibling who was 17 months old at the time Child H died. She lived with her Mother, her Mother’s Partner and her sibling throughout her life. 2.2 Mother’s Partner was thought to be the Child H’s father until DNA tests were undertaken after Child H died. All of the professionals involved during Child H’s life were under the impression at the time that Mother’s Partner was the baby’s father. The DNA tests show that her previous partner is actually the father of both children. 2.3 The family had been known to a number of agencies as a result of serious domestic abuse between Mother and her previous partner, the father of the children. There were no reported incidents of domestic abuse between Mother and Mother’s new partner during the period covered by this review. 3 Family Structure 3.1 The subject child is to be referred to as Child H. Her sibling is to be referred to as Sibling or HS. There are no other children in the immediate family. 3.2 The parents of the subject children are referred to in this report as Mother and Father. The man who was living with the family at the time of Child H’s birth until her Version 6. 26.6.14. 5 death will be referred to as Mother’s Partner. Mother and her Partner married shortly after the birth of Child H. Other family members will be referred to by their family title e.g. Father’s father. 3.3 Mother had been married previously but her first husband died before the scope of this review. They had no children together. Mother began a relationship with Father shortly before the death of her first husband. 3.4 Mother’s Partner has an older child, but there was no contact and they are therefore not considered in this review, other than a reference being made as to why there was no contact. 3.5 The children, both parents and Mother’s Partner are white British. 4 Terms of Reference 4.1 The Terms of Reference and Project Plan were drawn up and agreed at the start of the process. The purpose, framework, agency reports that were commissioned and the particular areas for consideration were all described therein. A format template for the agency reports setting out what the agency authors were asked to analyse was provided to each agency involved. 4.2 It was agreed that the scope of this review would be from 10 May 2011, which is the date of the first multi agency risk assessment conference (MARAC) held in regards to Mother and Father, until the date of Child H’s death in December 2012. 5 Process 5.1 The mother of Child H was contacted in order to ensure her views were considered and heard as part of the review. A letter was sent and the author, along with a Nottinghamshire Safeguarding Children Board representative, visited Mother the day before the Learning Event. Mother was cooperative and keen to assist in the review. 5.2 The information provided by Mother and her views have been included throughout this report. Version 6. 26.6.14. 6 5.3 It was agreed after the visit to Mother that Partner should be spoken to as part of the review. He was living with the family from the birth of Child H to the date of her death, and it was thought that he might have information about the professional involvement at the time that would contribute to the learning. However the review was made aware of information about his current circumstances that led to a change in the plan to consult with him at the time that the review was being undertaken (January – March 2014.) However it is planned that after appropriate consultation with any professionals involved with him, Mother’s partner will be contacted before this report is published. 5.4 After consultation with the Police and with Children’s Social Care (CSC) it was agreed that direct contact would not be made with Father, as he had made it clear to CSC after the death of Child H that he did not want to be involved in the care proceedings on HS. It has been agreed however that a letter will be sent to him at the conclusion of this review, and after the criminal investigation has been completed, to inform him of the review and the plan to publish this report. 5.5 The Department for Education (DfE) expects full publication of Serious Case Review overview reports, unless there are particular serious reasons why this would not be appropriate. Working to that requirement, some confidential historical family information will not be disclosed in this report. It is written in the anticipation that it will be published, and contains all of the information that is relevant to the professional responses and contact with Child H and her family. The decision to disclose information has been taken with reasonable caution to prevent the identification of the children concerned and other family members, and to protect the right to an appropriate degree of privacy for the family. 5.6 A meeting for authors of individual agency reports was held on 10 December 2013, where the SILP process and expectations of the agency reports was discussed. A full day learning event took place on 7 February 2014. Most of the agencies involved were represented by both the report author and staff, including managers, who had been involved during the scope period. Absences were accounted for by valid explanations, including certain professionals who were no longer employed and or had moved away. One key professional was on leave at the time of the learning event but attended the recall day. All the agency reports available had been circulated in advance, to ensure all staff attending were able to fully understand the Version 6. 26.6.14. 7 multi-agency information and focus of the review. Two agency reports were outstanding before the learning event but were available to the author before version 1 of the overview report was completed and to other professionals involved before the recall day. 5.7 The recall day was held on 13 March 2013. Participants who had attended the learning event considered the first draft of this report. They were able to feedback on the contents and clarify their role and perspective. All those involved contributed to the conclusions about the learning from this review. The final version of this Overview Report was presented to the Nottinghamshire Safeguarding Children Board on (ADD) 2014. It has been agreed that some additions may be included in this report once the criminal investigation has been completed, and if any further information becomes available during that process. 5.8 The Coroner has investigated the death of Child H. This serious case review ran parallel to the Coroner’s enquiries. The Coroner was informed that this review was being undertaken. An open verdict was made. 5.9 The Police investigation was on-going at the time of the recall day with both Mother and her Partner charged with an offence contrary to Section 5 of the Domestic Violence and Victims Act 2004 - causing/allowing serious physical harm to Child H. Mother was found Not Guilty and her partner received a custodial sentence after pleading guilty. 5.10 The sibling (HS) was the subject of child care proceedings, and is not currently living with either of her parents. 5.11 The reviewer in this case and report author is Nicki Pettitt, an independent child protection social work manager and consultant. She is an experienced chair and author of serious case reviews, and is a SILP associate reviewer. She is entirely independent of NSCB and its partner agencies. 5.12 Working Together 2013 does not require the completion of a health overview report which considers the commissioning of health services and in some circumstances may be helpful in pulling together the related health information. It was agreed with the NSCB that an additional review of this type is not required in this case, as there were no complex health issues that needed to be addressed. Version 6. 26.6.14. 8 5.13 There has been a delay of approximately 10 months in starting this review after the death of child H. This was due to the wish to clarify if the child’s death had been due to suspected abuse or neglect. A number of tests and investigations were undertaken over a period of time, and the post mortem eventually concluded that it was unable to ascertain the cause of death. The NSCB SCR sub-group maintained an overview of the case while the post mortem process was on-going. It was agreed in November 2013 that a serious case review should be undertaken despite the uncertainty of the cause of death. This was a positive decision as the NSCB wished to ensure that any lessons should be learned in regards to the multi-agency work with Child H and her family. 5.14 This process has been effectively administered by the NSCB. 6 The background prior to the scoped period 6.1 Agency authors were asked to consider all of the records held on the subject child, and relevant records on other family members. While they were asked to provide detail and analysis on the period of the scope of this review, they were also asked to provide a summary of information known to them from before the period in question in order to ensure that relevant and pertinent background information was available to the review. 6.2 Mother became pregnant with HS shortly after meeting Father. She told the reviewer that she did not think she could have children, so it was a very welcome surprise that she was expecting a baby. Mother told us she had a happy childhood, and described her family as supportive. Mother had some mental health issues when she was a teenager however, and has suffered with depression on occasion throughout her adult life. She told us she had taken an overdose after the death of her first husband. Mother also told us that she was a ‘regular drinker’, and that she used alcohol to ‘relieve stress’, but didn’t feel she had a ‘problem’. 6.3 The GP report for this review provided helpful information on Mother’s history, including her early history of eating disorders and mental health concerns. It was confirmed she had taken paracetamol overdoses in September and October of 2010. Version 6. 26.6.14. 9 She has received prescriptions for anti-depressant medication on a number of occasions and was referred to psychological services in 2010. 6.4 In September 2010 Mother was arrested for drunk driving, and the Police stated in their first referral for a MARAC the following month that they felt Mother had issues with alcohol use. They also had concerns about her mental health, resulting in them getting a nurse to assess her before they interviewed her for the drunk driving offence. Information was available from the Police that Mother had been in a number of other domestically abusive relationships before she met Father. Mother told us she thinks men recognise that she is vulnerable. In respect of her relationship with Father, the Police informed the review that there were 15 domestic abuse incidents between Mother and Father prior to the first MARAC referral in October 2010. It is not clear why there was a delay in bringing the case to MARAC, and it is outside of the scope of this review to pursue this. 6.5 The first MARAC meeting held on the couple was in May 2011, by which time Mother was pregnant with HS, who was born 2 months later. 6.6 Father is very well known to the Police. He has been in prison a number of times, for assaults on Mother and for other non-related crimes. He was not known to Children’s Social Care (CSC) in his own right. He was in prison from before the scope period of this review until May 2011. He was also issued with a Restraining Order by the court in December 2010. It stated he was not to contact Mother directly or indirectly, and was not to enter the road where she resides. 6.7 Mother’s Partner was known to the Police briefly due to an incident, outside of the scope of this review, where an allegation was made that he had physically assaulted his sister. He was known to CSC due to issues in his own childhood. He had periods of time on the Child Protection Register as it was then, and it has been established that there were concerns about the parenting he received and his exposure to domestic abuse as a child. His school also reportedly arranged for him to have some help with managing his anger. 7 Key Practice Episodes 7.1 There were 3 key practice episodes identified in the scoping period. They were: Version 6. 26.6.14. 10 I. May – July 2011. Mother’s pregnancy with HS. II. July – December 2011. The birth of HS and escalating concerns. III. January – August 2012. The pregnancy with and birth of Child H and limited engagement with services. Key practice episode I – Mothers pregnancy with HS: 7.2 Mother was 20 weeks pregnant with her first child when she first saw the midwife early in 2011. She told the midwife she had not realised she was pregnant until she was in the second trimester. She explained some of her back ground, particularly that her husband had died and that she had been depressed. She appeared to have a supportive partner, who was said to be the father of the child. This was later ruled out when the advanced duration of her pregnancy was determined, and the relationship ended. Father was in prison at this time. The midwife asked a routine question about alcohol consumption, and no issues were identified. On a subsequent home visit by the midwife, after the MARAC (see below), Mother disclosed a high level of alcohol consumption prior to the confirmation of her pregnancy and that she had lost her driver’s licence. However she said she was not drinking anymore. 7.3 The midwife contacted Children’s Social Care (CSC) to make a referral about Mother and the unborn child after the MARAC meeting, which she had received feedback from. The midwife shared the concerns identified at MARAC with the duty social worker. A decision was made by CSC to take no action as there was no suggestion that Mother would reunite with Father, who was not thought to be the father of the baby. The CSC records also listed the support Mother was receiving in relation to the previous domestic abuse and any on-going threat from Father. A letter was sent to Mother to stress the importance of her not having any contact with Father when he was released from prison. It is not recorded that any suggestion was made that a Common Assessment Framework (CAF) piece of work should be considered at this stage, however an assumption may have been made that it would be obvious to professionals that a CAF was suitable in a case where a number of different agencies were providing services. This was not the case however. (See 8.23 below for an explanation of the CAF process.) 7.4 A referral to perinatal psychology was discussed with Mother by the midwife, she initially agreed, but later appears to have changed her mind, stating that she did not Version 6. 26.6.14. 11 require that level of intervention. At the meeting with Mother at the start of this review process, she stated that she was feeling very positive about the birth of her child and did not feel that depression was an issue any longer. 7.5 At this time Mother had a lot of support and involvement from various domestic abuse agencies and professionals. Over the course of the scoped period she had regular contact with a number of specialist workers and various alarms and safety devices were available to her, including a Home Office alarm, a Sky Guard (a handheld personal safety device which sends a message to the Police when triggered by a victim of domestic abuse) and Sanctuary, which provides various safety features being fitted into the house, which may include safety measures such as strong locks and window grilles. 7.6 Father had been the subject of restraining orders and the Integrated Domestic Abuse Programme (IDAP), which is a court ordered group work programme, on a number of occasions. However both when in prison and when he was released from prison he continued to harass Mother, resulting in the agencies who were supporting Mother genuinely fearing for her safety on occasion. 7.7 There was planned pre-birth liaison between the midwife and the health visiting service before the baby was born at 37 weeks gestation. The health visitor and midwife involved work geographically and discuss any cases of concern. They spoke about Mother’s pregnancy in one of their regular meetings. This type of liaison was appropriate and a joint visit would have been justified in this case due to identified issues around maternal mental health and the domestic abuse, and Mother’s information about her previous level of drinking. The early birth of HS meant that a joint visit did not happen in this case. 7.8 When HS was born she had a low birth weight (2nd centile) but had no identified health or development issues. Mother and HS were discharged home the day after she was born. 7.9 This has been identified as a key practice episode as a number of professionals were involved with Mother and were aware of her pregnancy. Despite evidence of serious domestic violence, and concerns about Mother’s alleged use of alcohol and mental health issues, there was no consideration of conducting a CAF at this time, or of CSC opening the case for an assessment. The presenting issue of Father’s release from Version 6. 26.6.14. 12 prison and the MARAC was the main focus, and the belief that Mother would not reconcile with him led to a view that no further assessment or plan was required in regards to the expected baby. 7.10 Key practice episode II - The birth of HS and escalating concerns: 7.11 The health visitor carried out a new birth contact within the home two weeks after the birth. The midwife, who was still involved, visited a week later and she found the door to the flat propped open. Mother told the midwife that it was inconvenient for her to visit as she already had a visitor. The health visitor told the Learning Event that she suspected that Father may have been there, but did not explore this with Mother. A different health visitor visited again six days later when the Family Health Needs Assessment was completed. A decision was made that extra support was required and the family were placed on an enhanced Health Visiting Service – Partnership Plus (Level 3 as it is now known)1. This decision was made due to concerns of reported domestic abuse from Father who was said to be continuing to harass Mother, maternal low mood and anxiety, and Mother’s wish to move house to avoid Father. 7.12 In the month after HS was born there is evidence that the health visitor and the community midwife spoke, and that they shared information in regards to the concerns about domestic abuse and the MARAC meetings. The health visitor then spoke to the health representative on the MARAC (the Domestic Violence Specialist Practitioner), to the Women’s Aid worker involved, with Mother’s permission, and to Fathers probation officer. In light of this liaison the health visitor received copies of the previous MARAC meetings (there had been 3). She noted that there were concerns about Mother’s drinking, with one reference to her being an alcoholic. However the health visitor had very recently completed the health needs assessment with Mother, who had said she had no current issue with alcohol. The health visitor rang drug and alcohol services to see if Mother was known to them. She was not. 1 Universal Partnership Plus provides on going support from the health visiting team plus a range of local services working together and with the family, to deal with more complex issues over a period of time. These include services from Sure Start Children’s Centre, other community services including charities and where appropriate the family care nurse. Version 6. 26.6.14. 13 7.13 The health visitor and a community health assistant practitioner visited Mother on 19 August 2011. Mother was described as very low. She described continued harassment by text and phone from Father, problems with benefits and her home office alarm being removed which made her feel unsafe. She didn’t feel suicidal and was not drinking, but the health visitor was concerned. She spoke to the Domestic Violence Specialist Practitioner and suggested the case return to MARAC. 7.14 In light of this visit and the information gained by the health visitor, she decided to contact CSC with her concerns, which she did that day. She stated that Mother had made 2 previous suicide attempts and during a visit that day had presented as tearful and depressed. An appointment had been made to see the GP whom the health visitor hoped might refer Mother to the crisis team. Mother was described as having some support from family members and had been referred to the Surestart children’s centre. The social worker asked how Mother was coping with the care of the baby and there were no concerns about the baby itself. The DSW consulted with the team manager and they agreed that there was no role for CSC at this time as Mother was receiving a lot of appropriate support. A CAF was suggested. This advice was confirmed in writing to the health visitor. Despite being concerned the health visitor accepted this decision and did not escalate the matter. 7.15 The CAF did not go ahead at this stage however. In Nottinghamshire at this time the take up of CAFs was low, with around 50 being started per month, which was low compared to a much higher number of initial assessments being undertaken by CSC. The review was told that the paperwork for the CAF in this case was evident in September 2011, and that it was ‘registered’ as a CAF, but that the assessment and any subsequent plan and meeting of a team around the child did not go ahead. It was also confirmed that at the time there was not a clear process for notifying and recording the key professional in a CAF. The system and process for CAF was later improved, but this case shows that the system in place at the time was insufficient. At the learning event there was a degree of understanding about why the CAF did not go ahead at this time, it appears that Father being in Prison had an impact and Mother was said to be cooperating with all agencies. At the time in Nottinghamshire there was said to be a degree of anxiety amongst professionals regarding the lead professional role. Again this is said to be much improved in the last year. Version 6. 26.6.14. 14 7.16 The Health Visitor was also clear that she had no concerns about the care of HS. The interaction between Mother and child was said to be positive, the home was well maintained, the physical care of HS was good, she was meeting developmental milestones and although her weight was low, she was maintaining her centile position. Mother appeared to be stable and no attachment or bonding issues were evident. Mother would often cancel appointments without good cause, but this was not felt to be a significant issue. 7.17 Mother saw the GP twice during August 2011. She appeared to be struggling emotionally and reported financial difficulties. Anti-depressants were prescribed. Mother told the GP at the second appointment that she was not taking them consistently however because of the side-effects. There is no evidence that the GP and the health visitor had a conversation about Mother and HS at this time, despite them both recording concerns about Mother’s well-being, and contradictory evidence in regards to the previous statement that Mother’s mental health was stable. 7.18 In August 2011 CSC were contacted by a housing worker to state that they had suspicions that Father had been visiting the family home. When challenged, Mother had told the housing worker that it was her brother. The housing officer stated they would take the case back to MARAC (see 7.19 below). The notes from the MARAC were placed onto the CSC file a week later, with no actions for them. The CSC agency author quite rightly questioned the lack of any further checks by CSC at this time to what would be child protection concerns had the housing officers suspicions been right. 7.19 The MARAC was held on 25 August 2011 and it was recorded that Mother was ‘very frightened, very vulnerable, with deteriorating mental health, financial concerns and under continual harassment from Father’. It was noted she had a Women’s Aid worker and a social worker. It has not been identified who this was referring to as CSC were not involved at this time. It is presumed that the SW mentioned in the recommendations was in fact a Surestart worker. The recommendations were: • Mother to be re-issued with a Sky Guard for a 4 week period. • Issues with neighbours to be looked into. • Discussion with Mother regarding a CAF referral. • SW to encourage Mother to report incidents to the Police. • IDVA to discuss her housing / possible move situation. Version 6. 26.6.14. 15 There was no consideration of CSC getting involved at this stage, despite the continuing concerns about domestic abuse and Mother’s vulnerabilities. 7.20 The Surestart Children’s Centre had became involved around this time. Most of the contact was in Mother’s home, and it proved difficult to get her to attend the centre. Taxis were offered when Mother stated she was afraid of leaving the house in case she ran into Father. These were refused by Mother. The Children’s Centre staff made a huge effort to engage Mother, who they contacted a number of times a week from September 2011. At one stage Mother showed an interest in becoming a Surestart volunteer. This did not happen however, and Mother told the reviewer that her Partner had later stopped her pursuing this opportunity. 7.21 In September 2011 Mother and HS were seen for the baby’s routine 8 week check with the GP. No concerns were identified with the care of HS. It is recorded that Mother explained that her depression was not having an impact on looking after HS. However it was recorded that the health visitor was to keep an eye on the baby’s weight. The health visitor could not confirm if she had a conversation about HS with the GP, but stated it was possible. The poor weight gain was again considered in October 2011, with the GP recording that the baby should be weighed regularly in clinic. As stated in the GP agency report, ‘There is no evidence in the GP record entry that the poor weight gain had been viewed in the context of the household in which there was a clearly documented history of domestic violence’. It has been confirmed that there were numerous domestic abuse notifications evident in the Mother’s records which the GP had access to. 7.22 Systems for communication between GPs and health visitors in the area where Mother lived at this time were not clear, and have not improved significantly since the time of HS’s birth. Health visitors are not GP attached in this area which makes communication more difficult. In the north of the County they have SHARE where GPs can see health visiting records, but not visa versa. This review has requested that the issue of GP and health visitor communications be reviewed, and a recommendation has been made to this effect. 7.23 On 15 September 2011, the Police contacted CSC to inform them that a police officer had visited the home and was concerned about the impact on Mother of the threat from Father, she was said to be physically shaking. She had reported an incident Version 6. 26.6.14. 16 where Father had allegedly been to the house and tried to force his way in, making threats to Mother and saying her ‘baby would be dead'. (13 September) The police officer also shared that Father had been to the house previously (10 September) when Mother had allowed him in resulting in him assaulting her while HS was present. 7.24 The Social Worker telephoned Mother the same day to clarify the support she was receiving. When the CAF was discussed it became evident that it had not been followed through by a CAF meeting and a plan that was understood by all and was being progressed, so was not effective as a plan for the child. However it was recorded that the support available was extensive and understood by Mother. She was made aware that CSC would become involved if she reconciled with Father. There does not appear to have been a challenge about the incident on 10 September when Mother willingly allowed Father into the home however, and no consideration of the threat to kill Mother and HS. (It was also noted that the Police did not specifically respond to the threat to kill which is a criminal offence). The outcome recorded for this contact was that the threshold for CSC was not met as Mother had not reconciled with Father, that she had acted appropriately to safeguard her child and was seeking support from the Police. The social worker recorded that Mother was well supported by family and professionals, and that HS was well cared for. This was an opportunity to undertake an assessment of this 2 month old baby and her Mothers ability to protect herself and her child from on-going domestic abuse and threats from Father. If the assessment had been undertaken it may not have established any risk to the child, however the high number of domestic abuse referrals and the other factors which were likely to have an impact on Mother’s care of the baby were not recorded and explored, with CSC accepting an optimistic view of her coping abilities and the support being accepted. 7.25 In September 2011 Father was arrested, charged and remanded in custody for breaching the restraining order. The Police agency report for this review states that Mother was most concerned during this period and appeared very anxious and frightened of Father. 7.26 Mother saw her GP on 10 October 2011 and she was prescribed anti-depressants. The GP recorded she was ‘postnatal with stress’. Mother told her Surestart worker (a Health and Family Support Worker, to be called the Surestart worker throughout this Version 6. 26.6.14. 17 report) the same day that she did not intend to take the medication as she did not want to become addicted. There is no evidence that this information was shared with the GP or the health visitor. However the Surestart worker spoke to her manager the same day and they agreed a referral should be made to CSC. There is no evidence this happened. This could be because during a conversation later the same day with the Women’s Aid worker the Surestart worker was informed that CSC had closed the case recently as it did not meet the criteria for their services while Father was not living at the home. 7.27 The health visitor visited on 13 October 2011. The purpose of the visit was to weigh HS and support Mother. HS’s weight had dropped from the 2nd to the 0.4 centile, which was of concern. The health visitor was worried that the amount of feed being offered was insufficient and advised Mother that this be increased, and that HS be given 6-8 feeds in a day. She arranged to visit and re-weigh HS in two weeks and asked Mother to make an appointment with the GP. Mother presented as anxious throughout the visit, and as concerns remained about how this and the domestic violence would impact on HS, the health visitor recorded that targeted intervention was to continue. 7.28 The health visitor liaised with the Surestart Worker and asked her to provide feeding support to Mother. When the Surestart worker rang Mother to discuss that Mother was very upset and stated that she felt undermined by the health visitor and that she was fed up of so many professionals being involved in her life. The agency author rightly asks whether this was an attempt by Mother to play one worker off against another. 7.29 Whilst Father was in prison, Mother contacted the Police following alleged threats made against her by Father’s father. They went to the home and during this visit a concern is raised about her mental state and a decision was made to contact CSC Emergency Duty Team (EDT). The planned contact from the Police with EDT happened on 25 October 2011. The Police told the CSC Emergency Duty Team that Mother had contacted them to report that Father had telephoned from prison and threatened her. The Police were concerned for Mother’s mental health. There were no concerns for HS. The EDT social worker noted there was a very young baby in the household, and also made a referral to the Community Mental Health team. Version 6. 26.6.14. 18 7.30 A duty social worker (DSW) from the CSC duty team for the area contacted Mother later that day to inform her of the EDT referral and to see if she required support. She refused the offer of a Domestic Abuse Link Worker2 as she was already receiving support from Women’s Aid. She gave permission for checks to be undertaken, and the DSW spoke to the health visitor to share information, to make health checks on HS and to enquire about the CAF. The DSW recorded that a Women's Aid worker would be the lead professional on the CAF. The health visitor advised that HS’s weight was low but there were no other concerns. She stated that Mother had said she had no intention of returning to Father and had taken steps to protect herself and HS. CSC took no further action, as the CAF was said to be imminent and there was a lot of agency support going into the family. 7.31 The adult mental health worker (AMHW) received the contact from EDT and looked on Frameworki (the CSC database) noting that CSC had been involved but that there was a history of closure and no child protection issues. Mother was telephoned by the AMHW on a number of occasions over the next few weeks and was offered support. The AMHW also undertook a home visit to Mother. Mother spoke mostly of her grief at the death of her husband. She was asked about drinking and Mother said it was not a problem. Mother spoke of her concern that the CAF had been ‘cancelled’, that she was often overwhelmed by the number of professionals involved, and that she had issues with the way she had been treated by the Police. She initially declined counselling, but later agreed. The AMHW contacted CSC to enquire about the ‘cancellation’ of the CAF. The SW said it was still open and appeared confused about what was happening. 7.32 After a number of attempts the AMHW spoke to the GP and they agreed to make an urgent referral for grief counselling to both CRUSE and psychology services. The referral letters were written, but Mother then refused her consent, saying it was not the right time as she felt stressed about Father’s imminent release from prison, and they were not sent. Although she could not come to the learning event or recall day the AMHW spoke to the reviewer and stated that she did not have serious concerns about Mother. She appeared to be coping well with her baby, her home and her self-care, despite the stress of her bereavement and the threats from an abusive ex-partner. She also appeared to have support from professionals and identified 2 A DALW works with or on behalf of children. They were employed at the time by Women’s Aid and would work with families that did not meet the threshold for CSC. Version 6. 26.6.14. 19 members of her family. She thought Mother showed good insight into her situation and was adamant she was not going back to father. The AMHW was not aware of concerns about Mother’s drinking or the drink driving incidents. Having cross-referenced with the CSC agency, it does not appear that this information had been recorded on the Frameworki database by CSC. 7.33 The GP records contain a copy of an urgent referral for psychological therapy, made in November 2011. The issues highlighted in the referral include Mother’s recent bereavement, her overdose attempts, the history of an abusive relationship, that she was caring for a baby and that she had a pending court case for driving whilst under the influence of alcohol. There is no further reference to this referral on the GP files and no evidence that Mother received any assessment or assistance. It seems that Mother withdrew her consent, as stated by the AMHW. The agency report from Nottinghamshire Health Care Trust (NHCT) clarifies that Mother was not known to their adult mental health service. 7.34 A MARAC meeting was held on 27 October 2011. On 1 November 2011, the Police forwarded a domestic violence notification to CSC stating that the MARAC Chair requested that a referral be made to CSC because of the concerns about domestic violence, alcohol, concern about lack of engagement from Mother, and concerns that HS was at risk of both physical and emotional harm due to her parents lifestyle and the domestic abuse. It was recorded that Father was currently remanded in prison for offences against Mother, and that there were concerns that Mother's lifestyle was chaotic and not conducive to the welfare of HS. The CSC agency report author rightly points out that concerns regarding Mother’s lifestyle are a new development, but that the concerns were not supported by the information from the health visitor gained two days before. 7.35 A duty social worker (DSW) again spoke with Mother who claimed to be confused as she felt that nothing had changed, that HS was safe, and that the case had been closed just a few days beforehand. Mother complained that she had not received support in feeling safe from Father, stated that she was due to give evidence against him in court, and that she was going to be starting counselling regarding her bereavement. 7.36 Checks were also undertaken by the DSW with the Sanctuary Worker involved, which was a positive action. They had no concerns about Mother’s parenting but Version 6. 26.6.14. 20 described her as vulnerable in regards to Father and the risk he posed, stating that she had allowed him in to the house in the past despite telling the involved agencies that she would not. The Team Manager with responsibility for the duty service decided that the information received would not be treated as a referral and no further action was taken. It was appropriate that this decision was made by a manager, however the review thought that an assessment should have been undertaken at this time, due to the strongly worded request from the MARAC chair that an assessment be undertaken and the lack of progress of the CAF. The absence of GP checks was also noted. 7.37 In December 2011 Mother told her IDVA that she had a new partner, who worked shifts but often stayed with her. She expressed fear about the threat from Father and stated he might have access to firearms. This allegation does not appear to have been reported to the Police but resulted in the issue of a Sky Guard to Mother. Again this was an opportunity that could have been taken to reconsider the needs of and risks to the child in the family. 7.38 Over the Christmas period 2011 there were a number of incidents reported to the Police by Mother and her partner in respect of threats and harassment from Father. These were listed to the IDVA in the New Year by Mother, who also stated she was concerned at receiving a letter from a prisoner claiming to have met Father in prison and asking for personal information from Mother. The IDVA wrote to the Police Public Protection Unit about the concerns and spoke to the local police officers. She also spoke to a number of other domestic abuse professionals involved with Mother, and while this was a good attempt to both share and receive information, there is a confusing picture of who was involved, why and what extra support they brought to the case. It has been difficult for the reviewer to see who had responsibility for both coordinating and taking action in regards to support for Mother and for the investigation of further allegations. When compiling a map of professional involvement for the review, there were over 10 professionals having regular contact with Mother around this time. 7.39 On one occasion, on 28 December 2011, the police contacted CSC EDT. They reported they had responded to a call from Mother stating that Father was harassing her. The Police were concerned about Mother’s reactions to them and to the incident. They stated she appeared to be very immature and they questioned her capacity to Version 6. 26.6.14. 21 look after a child. The house however was described as comfortable and there were no concerns about how HS presented. They also said Mother’s partner was acting responsibly. The EDT social worker recommended an assessment, particularly in light of the previous concerns. However the day-time duty team manager recorded that the issues were in regards to Mother and there were no concerns for HS. A letter was sent to Mother advising her to see her GP if she felt stressed and ‘unable to cope. No checks were undertaken with other professionals and there was no communication with adult mental health, although it was recorded that Mother was referred to them in the past. 7.40 This is a key practice episode because there were on-going concerns about domestic abuse and harassment, about Mother’s vulnerability and mental health, unexplored concerns about Mother’s drinking, and some unsubstantiated concerns about the extent of Mother and Father’s contact with each other. There is evidence of multi-agency working, and good communication between the health visitor, Surestart and some of the domestic abuse professionals. However there was also some drift in making the CAF a meaningful way of coordinating support for a very young child and in ensuring the matter is kept on the agenda at MARAC. There were missed opportunities for a fuller and coordinated assessment, involving CSC, of Mother’s ability to meet HS’ needs and to keep her safe from Father and from witnessing domestic abuse. 7.41 Key practice episode III. Pregnancy and the birth of Child H, and the gradual withdrawal from support services. 7.42 There was relatively little professional involvement with the family early in 2012. On 25 January 2012, a police notification was received by CSC regarding an incident on 12 January 2012 of verbal abuse from Father to Mother. No action was taken by social care. Although this incident was in relation to verbal abuse, in light of the previous serious domestic abuse incidents that had resulted in Father receiving custodial sentences, and Mother’s high anxiety about any contact with Father, this verbal abuse could be said to be more significant than it might be in other cases. 7.43 The following day Mother reported seeing Father on the street, but was told by the Police that this was not a breach of the restraining order as it was a chance meeting. However on 4 February 2012 Father was again charged with breaching the order and was remanded for Court. Version 6. 26.6.14. 22 7.44 In February 2012 the GP records have a note of a positive pregnancy test. HS would have been 6 months old at this time. At the learning event it was stated that Mother attended all appointments with the midwife but missed 3 separate appointments with the consultant obstetrician. The reasons given were not documented. This was not flagged as a concern at the time. Mother told the reviewer at the start of this process that she had a difficult pregnancy with a lot of sickness. She also stated that her Partner was reluctant for her to meet with professionals when he was not able to be present. He had a particular issue with male professionals, according to Mother. Professionals at the learning event confirmed that they always saw Mother with her Partner there. At the time however he was felt to be a protective factor and all focus was on the risk from Father. 7.45 In March 2012 Mother’s Partner contacted the Police to say his tyres had been slashed and he believed Father was responsible. No evidence was provided of Fathers involvement however, and on reflection the Police agency report author considers that Mother’s Partner may have been exacerbating the situation. There were also allegations made that Father had set the family’s rabbits free, which were unproven. 7.46 On the weekend of the 8 April 2012 Mother reported Father for following her into shops. Her Sky Guard was to be removed from her a week later as she had not been using it. The following day she made a further referral of harassment and threats to her and her partner from Father. She told the IDVA at this time that she didn’t actually use the Sky Guard when the incidents happen. At a cost of around £7000, a Sky Guard is an expensive resource, the allocation of it to someone who is not benefitting from it was therefore questioned. It is not clear why Mother was not using the alarm. 7.47 On 24 April 2012 the IDVA had supervision and the issue of so many people being involved was discussed and recorded, giving Mother the potential to undermine some professionals to others. It was agreed that this should be considered at the MARAC due to be held in May. During April there was good communication between the numerous professionals involved with Mother regarding their growing concerns about Mother’s Partner, who they felt was showing signs of being controlling and manipulative. However there was felt to be little evidence and the professionals were Version 6. 26.6.14. 23 reluctant to rely totally on instinct. Mother also consistently defended her partner to her domestic abuse worker. 7.48 On 26 April 2012 there was liaison between the Children’s Centre and the IDVA and it was recorded that a CAF was still not completed after the previous MARAC, and that Mother had been overwhelmed by all of the agency involvement. It was agreed that a CAF needed to be prioritised. The Children’s Centre agreed to get Mothers permission to go ahead with this. 7.49 The case was again heard at the MARAC on 10 May 2012, it was the 4th MARAC where Mother had been discussed. The recommendations included enquiries to be made into Mother’s partner and any relationships he has with children, that Women’s Aid should assist with an application for re-housing, should instigate the CAF, should raise the concerns with Mother following the MARAC, and that the Police should take the matter back to court and get the breach addresses changed. Professionals at the learning event remembered concerns being discussed at this MARAC about the way that Mother’s Partner spoke to her. The review was told that these concerns were not documented in the body of the MARAC report however. It was clarified at the learning event that checks subsequently undertaken on Mother’s Partner did not raise any issues of concern. The review was provided with the notes from this MARAC meeting. It is clear that there were a number of concerns about the threat that Father continued to pose, however it was also stated by Women’s Aid that Mother was doing everything she could to disassociate from the relationship and was reporting all incidents. It was recorded that Father had made a statement that Mother continued to contact him and wanted contact however. This statement does not appear to have been believed by any of the professionals. 7.50 On 11 May 2012 CSC received a police notification stating that Father had been harassing Mother in the street. It was stated that she was pregnant. The Police provided the evidence to the CPS, who did not pursue it as it was their recorded view that the CCTV footage undermined Mother’s allegations. (This information had been shared at the previous days MARAC). As a result of this notification, a letter was sent to Mother informing her of this latest referral and asking her to contact the department to discuss concerns and what support she was receiving for herself and HS. Mother made contact and said she was being supported by her worker at Sanctuary and had requested a CAF, which she was confident would now happen Version 6. 26.6.14. 24 after the May MARAC. CSC took no further action, and did not make any checks to confirm that professionals were engaged with Mother and HS and that the CAF was an effective tool for meeting the family’s needs. If this were a one off incident this would have been an appropriate reaction to the police notification, but as this was yet another incident, a manager should have been consulted and consideration given to undertaking an assessment. 7.51 Following the MARAC the case was closed to WAIS (Women’s Aid Integrated Services), one of the agencies involved with Mother, as there was on-going involvement from NWA (Notts Women’s Aid) and Outreach. This should have made some difference to Mother having a clear idea of who was providing support in relation to the domestic abuse. However on 20 August 2012 Mother was visited by a new WAIS floating support worker (FSW) and Mother herself voiced her anxiety about having another new worker and having to repeat the history. The FSW explained the changes were a result of recent changes to funding arrangements. At this visit, where partner was present throughout, Mother stated Father was not the father of her child or the baby she was expecting. No further visits took place as the FSW had to rearrange a meeting, and then Mother decided in September that she did not want any further involvement or support. 7.52 During August 2012 a CAF (team around the child) meeting was held. Mother, her partner and his Mother attended, along with the health visitor, the Surestart worker, the Women’s Aid worker, the Sanctuary worker and the Occupational Training and Recruitment worker (OTR). The health visitor showed good challenge when she expressed her concern that HS would be impacted on negatively due to concerns about Mother’s mental health issues, which are exacerbated by the stress of the harassment from Father. It was agreed that the Surestart worker would be the lead professional for HS. However it was noted that she then planned to stop her involvement and close the case 2 weeks later, as there were felt to be enough professionals involved. It was agreed during this review that the CAF meeting was not timely and the impact was not robust. 7.53 Despite concerns about the number of professionals involved, at this time a new domestic abuse professional was introduced, the WAIS Floating Support Worker. When she first visited Mother, as recorded above, she noted that Mother had been anxious about meeting yet another professional and having to repeat her history. Version 6. 26.6.14. 25 7.54 Child H was born prematurely at 32 weeks gestation. Despite her prematurity she needed no breathing support and there were no medical concerns. It is not known why Mother had gone into premature labour. There was no obvious medical reason. Prior to discharge Child H spent three weeks on the neonatal unit. 7.55 In the days after her birth Mother married Partner and he was registered as Child H’s Father on the birth certificate. The community midwife attempted to visit Mother at home, but was turned away at the door, with Mother stating she did not have any issues and did not want to see her. When it was asked during the review how common this sort of response was in the general experience of the health visitors and midwives involved, they stated it was not common. 7.56 No pre-discharge planning meeting was held at the hospital. It was considered by the Safeguarding Nurse, but it was not felt to be needed as the concerns regarding domestic abuse were felt to be historical, there was well documented support in place for the family, and there was also no current CSC involvement. While Child H was in hospital there were no concerns identified in regards to the ‘parents’, who spent most days on the unit and rang during the evenings. They received help and advice in caring for a premature baby before Child H was discharged from hospital. 7.57 On 3 September 2012 Mother’s Partner complained to the Surestart worker that the WAIS Floating Support Worker had asked to see Mother alone, without him there. He said he felt that she was implying that he was controlling Mother. The Surestart worker told her manager that Mother’s Partner appeared to be speaking for Mother as well as himself. 7.58 On 10 October 2012 the health visitor visited at 11.30 am she found Mother, Partner and Child H asleep in bed. HS was not seen, her whereabouts were not noted, and no reference was made to her weight. When Child H was weighed she had a slight drop in the centiles on the growth chart. The health visitor suggested the GP was spoken to and arranged to visit again on 17 October 2012. At the next visit Child H was again weighed by the health visitor, she had gained weight well and there were no concerns regarding her health or development. 7.59 On 8 November 2012 Child H was seen at a paediatric out-patient appointment, presumably arranged due to her prematurity at birth. The baby was weighed and Version 6. 26.6.14. 26 measured. She was said to be healthy, alert, with no developmental concerns and was gaining weight and growing appropriately. 7.60 The Police have a report from November 2012 regarding anti-social behaviour issues between Mother and her neighbours, which allegedly had been going on for a lengthy period, with the Local Authority involved. Mother is described by the police officer involved as vulnerable at this point but feeling positive about an imminent house move. 7.61 On 16 November 2012 a children’s health assistant practitioner (CHP), on behalf of the health visitor, saw Mother, her partner and Child H at the family home. She recorded that the baby had only gained 1 oz in a week and was crossing down a centile. Mother reported that Child H had seen the Paediatrician the week before they were satisfied with the weight gain. The CHP provided advice and reminded parents that Child H’s immunisations were overdue. The groups at the Surestart Children’s Centre were also discussed. Mother had shown interest in attending but had not yet done so. Support to attend was offered and encouragement to get involved. 7.62 The family moved home in November 2012. The move had been supported by a number of professionals due to the concerns from Father. Mother’s Partner contacted the Police and asked them to remove the alarm from the property, stating they would not need it in their new home. The following day Mother stated she wanted to keep the alarm and remained very concerned about the threat from Father. 7.63 On 29 November 2012 a CAF meeting was held. Mother and her Partner did not attend, telephoning in advance of the meeting to say that they were ill. There was a detailed discussion recorded regarding support for the family, and the action plan from the previous meeting was reviewed and it was recorded that it appeared to have been actioned appropriately. A decision was made to close the CAF after one more meeting, which was to be held after the family moved home. The purpose of the final meeting was to confirm all appropriate supports were in place in the new area. It is recorded that the parents had still not accessed the children’s centre groups due to illness and other meetings. 7.64 An invitation to the CAF meeting had been sent to the WAIS Floating Support Worker, but as Mother did not confirm that she wanted her to attend, she did not. She Version 6. 26.6.14. 27 later closed the case to her service as Mother said she no longer required support, and expressed her annoyance that the WAIS Floating Support Worker had implied that her partner was controlling. A letter was sent to Mother to confirm that the case was to be closed and included an open invitation for Mother to make contact should she need to. 7.65 On the same day (29 November 2012) Child H was seen by the GP and they undertook a full undressed physical examination. No concerns were noted. 7.66 Mother was seen by the GP a week later and had a injury to her gums and teeth. She stated she had fallen out of bed. There is no record of whether any question of potential domestic abuse was raised with Mother by the GP, no record was made about the likelihood of this explanation causing the injuries, and information on these injuries was not communicated to the health visitor. 7.67 Child H was seen by the CHP on 3 December 2012. She was weighed and had not maintained an increase in weight. Increased feeds were advised along with an appointment with the GP to be made by Mother. The new health visitor (due to house move) then made a ‘transfer in’ visit on 17 December 2012. Baby was not weighed at this visit due to her being asleep and settled. The learning from this, which was clearly identified in the agency report, is that when there are concerns about weight gain and the HV is seeing the baby it is worth considering that waking the baby up may be necessary in order to weigh, particularly when the baby is premature. It is particularly of interest in this case due to the events of the following day. However at the time the health visitor could not have known that seeing the baby awake and naked for weighing may have been significant. There were no concerns however and the health visitor recorded there was good interaction between the parents and the children’s needs were being met. She had been unable to enquire about domestic abuse, as is the procedure, because Mother’s Partner was present throughout the visit. A follow up appointment was made for four days later. 7.68 The following day an ambulance was called, it arrived in 8 minutes and Child H was taken to hospital. She was pronounced dead 45 minutes after arriving at the hospital. 7.69 This is a key practice episode because the focus of services remained on Father and the risk he posed to Mother and the family. Child H was born two months early, and Mother was looking after 2 very young children with a new husband who appeared to Version 6. 26.6.14. 28 be a protective factor, but who did not encourage Mother to engage with agencies for support and advice, and about whom very little was known. At the time professionals had some concerns about Mother’s Partner and his seemingly controlling nature, but there was no evidence of any domestic abuse and Mother certainly appeared to be coping better. It is significant that at the very time agencies were speaking of closing the CAF and the domestic abuse professionals were withdrawing due to Mother’s lack of engagement, Child H was probably being subjected to physical abuse. 8 Themed Analysis 8.1 The analysis section of the review will consider the information above, which was gained from the Agency Reports and from the staff who had worked with the family and attended the Learning Event, by identifying the key themes and providing thematic analysis. The questions in the terms of reference were considered and answered in the majority of agency reports. The information included in those reports have been considered as part of this analysis. 8.2 The themes that have emerged and will be considered are: • Communication and information sharing • The Common Assessment Framework (CAF) • Domestic abuse and the MARAC • Dominance of Mothers issues, including her mental health • Thresholds for social work assessment and S47 enquiries. 8.3 Communication and information sharing 8.4 The question asked in the terms of reference for this review is ‘from an inter-agency perspective, were processes, communications and information sharing effective? Did services operate in silos rather than being “joined up” with each other? Were any concerns escalated?’ As these issues are often identified in reviews of this kind, it is an important consideration. 8.5 In this case there were examples of good communication between professionals, however this was not the case with all professionals at all times. There was regular good communication between the health visitor and the Surestart worker. There were also examples of good communication from the Surestart worker and the health Version 6. 26.6.14. 29 visitor with domestic abuse professionals. The Surestart worker in particular took it upon herself to ensure that she spoke to the right person and regularly fed back to the health visitor regarding Mother. The GP however did not make contact any other professional, although they provided a good response when contacted by the AMHW. 8.6 There appears to have been some degree of confusion regarding who was providing a lead role with Mother from the complex domestic abuse services who had contact with her during the scope period. This led to the Surestart worker and health visitor having to have a number of conversations with different people in order to establish the latest information. 8.7 Both the midwife and the health visitor made appropriate referrals to CSC in regards to HS. The health visitor and the Surestart worker also appropriately asked for the case to go back to MARAC. 8.8 As well as leading to difficulties in working out who was the right person to speak to, a lot of repetition of information sharing occurred on a number of occasions, for example in July 2011 the health visitor and midwife had a conversation and recognised they did not have the latest MARAC meeting minutes and were not clear who was involved with Mother. It took a number of phone calls to find out about the MARAC meetings and who was working with Mother in regards to her domestic abuse. There was also some confusion regarding who knew what information about the allegations Mother was making about continued harassment from Father. As the picture slowly emerged about Mother not consistently reporting contact from Father and not engaging with services put in place to support her, this lack of clarity of role provided Mother with an opportunity to avoid professionals and to not be totally open about what was going on. The lack of regular meetings where Mother and professionals attended together, as would be the case with an effective CAF or with a child in need plan, allowed Mother to decide what information she wanted to share with the professionals around her. If the CAF meetings had been in place earlier, issues with Mother’s engagement may have been exposed, possibly leading professionals to push for the involvement of CSC. 8.9 The systems of sharing police information with CSC appeared to be working well. The checks made by CSC prior to deciding whether the threshold for their involvement was met were adequate, other than the lack of GP checks, and Version 6. 26.6.14. 30 information was shared appropriately with the DSW. However they focused on the threat from Father as an indicator of risk to the children, without considering the wider concerns about Mother’s vulnerability (which included issues with alcohol and metal health concerns). No assessment of her ability to meet her children’s needs herself and to protect her children from Father or any other inappropriate adult was undertaken. While an assessment was unlikely to have resulted in on-going involvement from CSC, an assessment could have been warranted because of the number of domestic abuse notifications and because of the additional factors of Mother’s anxiety and vulnerabilities. 8.10 Historically communication has been identified as an issue in a number of serious case reviews. In Ofsted’s 2008 report ‘Learning lessons, taking action’ it was concluded that there were clear weaknesses in a large number of reviews in regards to record keeping and communication across universal services, that ‘allowed vulnerable children to be missed by services’. In Learning lessons from serious case reviews 2009–2010, which is Ofsted’s evaluation of serious case reviews undertaken between 1 April 2009 to 31 March 2010 it is stated that in the cases where practice was inadequate, the issues were: • poor communication • failure to include key professionals or agencies • insufficient training or engagement of some professionals • ineffective meetings • incomplete record-keeping • a lack of follow-up of the agreed actions. 8.11 While this case did not highlight many deficiencies in these areas, on some occasions there was a lack of appropriate communication. For example from the GP to the health visitor and/or the Surestart worker and visa versa, particularly regarding Mother’s medication for depression. It has been identified that while health needs were discussed with Mother by the health visitor and Surestart worker, and that she was urged to see the GP with any health issues for the children or her own mental health, it is unclear within the health visiting records if Mother accessed this support. After the birth of HS the GP recorded that the health visitor was to monitor the baby’s weight as a concern had been identified, however there is no evidence that this expectation and the concern about HS’s weight was communicated to the health visitor. Much of the information provided about the GPs advice was self-reported by Version 6. 26.6.14. 31 Mother. It would have been appropriate and good practice in this case for the GP and the health visitor to have a conversation about Mother and whether her issues would have an impact on her parenting capacity. 8.12 A study published by the Department of Education in 2009 ‘The Child, The Family and the GP” found that GPs preferred to consult with Health Visitors and other Health colleagues rather than with CSC where they had concerns. The study found that there was a general reluctance by GPs to approach CSC to make referrals unless there was a clear injury, disclosure or evidence of failure to thrive. The conclusion of the study stressed ‘the important role of the Health Visitor in safeguarding children, and as a key fellow professional for the GP to refer to’. Building relationships between GPs and Health visitors is therefore key. The situation in Nottinghamshire is that health visitors tend to work geographically, but also there are GP link health visitors, who would be the person that the GP could speak to and they would pass on the information to the relevant heath visitor for the family. This does not appear to be straightforward, and it was clear to the reviewer that staff do not like the system. 8.13 In April 2012 the ‘Guidance on Information Sharing and Issuing Alerts to Safeguard Children in Primary Care’ was developed and published by a working group on behalf of the NHS Nottinghamshire and Nottingham City Data Advisory Group. It states that it is ‘intended to safeguard children by supporting GP practices and community health teams to share information relating to vulnerable children’. It helpfully states that the Caldicott review ‘identifies a new Caldicott principle, that the duty to share personal confidential data can be as important as the duty to respect service user confidentiality’. However, if the practical links between professionals are not straightforward, and relationships are not meaningful, the policy will only go part of the way to ensuring information is shared and concerns are communicated. 8.14 There was evidence of effective communication between the MARAC and the safeguarding midwife, and subsequently the community midwife, who also made the first referral to CSC after identifying some potential safeguarding concerns for the new baby. There was regular communication between the community midwife and the health visitor, however it is not clear that all of the information was handed over at transfer between services, with the health visitor not appearing to have all of the information about Mother’s mental health history and vulnerabilities, other than that which was self-reported by Mother. Version 6. 26.6.14. 32 8.15 When Child H was in the neo-natal unit there was good communication with the health visitor regarding her discharge, and good use of the safeguarding lead. 8.16 There was a particular issue identified regarding communication between the primary health providers for HS (other than the GP) and the mental health services. Around October 2011, when Mother was struggling as a single parent to HS and was very stressed due to Father‘s on-going harassment, a social worker from adult mental health (AMHW) got involved briefly. She completed an assessment and concluded that Mother required bereavement counselling. She liaised with the GP regarding this, who referred Mother to psychological services. She also planned to refer to a bereavement charity, however Mother withdrew her consent. There is no evidence that the heath visitor was aware of these referrals or involvements. 8.17 The Police agency report states that there was good communication and following of processes in place regarding safety planning for Mother in respect of the domestic abuse. Referrals regarding the children were made appropriately, however there is no evidence anyone in the Police checked if any action was being taken in respect of safeguarding the children. There is also limited consideration, by the Police, to making a specific referral in regards to the impact on HS (and later Child H) of the concerns the Police had about Mother’s mental health and drinking, although they did contact EDT in October 2011 with concerns about Mother’s mental health after the allegations of harassment from Fathers father. 8.18 Mother clearly did not report all of the incidences of harassment from Father directly to the Police. On occasion she would inform other professionals, such as when she informed the Surestart worker on 8 September 2011. Mother would always be told that she must inform the Police of all incidents, however it was rare for the involved professionals to also report the incidents they had been made aware of directly to the Police, or to check that Mother had made the Police aware of concerning incidents. During the review the professionals involved in this case highlighted a systemic issue in Nottinghamshire in regards to contacting the Police in any specific case. They said that in this case, and others they hold, it was not clear who they should ring if they have questions or concerns about a family and needed to communicate with the police. They agreed that if CAF meetings had been held earlier, and the IDVA had attended, this would have provided a good link into the Police. However the meetings Version 6. 26.6.14. 33 were not held and the IDVA does not appear to have taken an active role in liaising with child care professionals in this case. 8.19 There is no evidence that discussions were held between CSC and the AMHW. CSC staff had access to the AMHW’s records on Frameworki (the local CSC and adult services client database system) and there is evidence that these were considered when CSC were making a decision regarding whether they should open the case for an assessment, and by the AMHW when undertaking her assessment. It would have been good practice to not just rely on the written records however, but to speak to the AMHW both to establish her assessment of Mother’s current state of mind, and also to share information held by CSC and reported to them by other agencies. It is clear however that the AMHW did not have concerns about Mother’s parenting, but arguably this was partly due to noting that CSC did not have any concerns recorded on Frameworki. 8.20 As has been pointed out in a number of the agency reports, an effective process for coordinating and sharing information in regards to the children would have been the CAF. In this case however the CAF did not appear to commence in a timely manner, and regular meetings and reviews did not appear to be held. Despite a number of agencies identifying the lack of action on the proposed CAF, no one escalated their concerns. 8.21 Despite some minor concerns being identified about information sharing and communication in this case, there are also examples of good practice. It can therefore be concluded that there were no major lapses in information sharing and communication. 8.22 The Common Assessment Framework (CAF) 8.23 The Common Assessment Framework is a part of the previous Government’s Every Child Matters: Change for Children agenda. It was developed as a tool for early intervention for practitioners working with children and young people. The CAF was designed to ensure timely and integrated responses to children and young people at risk of not achieving a positive outcome but who may not meet traditional thresholds for statutory or specialist services. A CAF should help in the early identification of needs, ensure the provision of services is coordinated, promote the sharing of Version 6. 26.6.14. 34 information, fully involve the family themselves, and reduce the need for service users to have to keep telling their story to different professionals. 8.24 There was clearly some confusion and uncertainty from the point of view of the professionals involved, and from Mother herself, regarding the CAF in this case. There appears to have been delay in both starting the CAF administrative process and in compiling the assessment, communicating the content of the CAF, and confirming the identity of the lead professional. Mother changed her mind about whether she wanted a CAF to be completed on a number of occasions, and professionals confirmed at the learning event that they did not really see, at the time, what additionality would come from a CAF when so much support was going into the family. 8.25 The health visitor provided some information to the review regarding the CAF process in this case. She stated that professionals were trying to move forward with the CAF for the family. She had records to show that she had chased the Women’s Aid worker who it had been agreed would be completing the CAF in September and October 2011. A meeting had been arranged then cancelled in November 2011. As Father was in prison at this time, it is recorded on the health visitor records that Mother had not wanted to pursue with a CAF. It is not clear how much persuasion had been attempted to convince Mother of the benefits of having a CAF at this stage. The next time that a CAF had been discussed in regards to this family was when it was requested by Mother in May 2012 and Surestart completed the required form. The meeting was then held in August 2012. 8.26 It was identified fairly early on that a more timely and persistent CAF would have been helpful in this case however. The integrated chronology completed to assist in this review makes references to a CAF being needed on at least 33 occasions before a CAF or ‘team around the child’ meeting is actually held to share information and discuss a plan for the children. This delayed the chance of ensuring a joined up approach that considered the needs of the child/ren as its main priority. 8.27 There were opportunities which could have provided the impetus for ensuring that the CAF was completed and a CAF meeting was held. Including; after the early referrals were made to CSC in September and October 2011; when Father had been discharged from prison and Mother was showing signs of being much stressed; and later when Child H was discharged from the neonatal unit at the hospital. Version 6. 26.6.14. 35 8.28 There were some CAF meetings held towards the end of the scope period of this review, and Mother was certainly under the impression that her children were subject to the CAF previous to these meetings, although she was not necessarily sure what this meant. For a CAF to be effective the parents need to cooperate and engage in a meaningful way with professionals. Mother’s lack of meaningful engagement would have been exposed earlier had regular meetings with all of the relevant professionals been held more often. This could have led to a re-referral to CSC for an assessment and the potential for a time limited child in need plan. 8.29 Mother voiced her frustration, when consulted as part of this review, in regards to having to keep repeating her history and information about Father and the domestic abuse time and again. There appears to be a degree of confusion throughout the professional network in relation to the involvement of services that support the victims of domestic abuse, and who was involved at any one time. The existence of a timelier CAF with regular meetings may have helped in regards to these issues. 8.30 It has not been possible at this stage to meet with Mother’s Partner, who was a important person in the lives of both children during the period of the scope of this review. What is clear is that he was spoken to a number of times by a number of agencies at this time. What did not happen was a conversation, by the majority of agencies, with Father. As the threat from him was the main concern throughout this period, it would have been good practice for professionals involved with the children to have spoken to him. Both to clarify expectations about him not contacting Mother and the children, but also to hear his view of the situation. In this case Father was in contact with the police and probation, but was not spoken to by any of the agencies involved with the children or the team around the child. The threat from Father in this case was very evident, but he was absent in the assessments and subsequent work being undertaken. 8.31 It should be stated however, that even if regular CAF meetings had been held, and Mother had not cooperated with the plan, there were probably not grounds for a S47 investigation or to convene a child protection conference, and certainly there were no grounds for care proceedings in respect of the children. It must also be noted that the review found evidence of professionals communicating effectively with each other about the children and Mother in the most part, albeit not in a CAF meeting setting. Version 6. 26.6.14. 36 8.32 All of the professionals who attended the Learning Event spoke of the support Mother and Partner received from extended family, a number of whom had been present on occasions when professionals visited to the family home. 8.33 Conclusion 1: That information sharing and communication between agencies in cases that have a number of professionals involved due to concerns about a child is most effective when the child is subject to a plan which clarifies in writing and through regular meetings what the concerns are, who is involved/responsible and what needs to change. All children who are identified as in need of a plan, (be that a CAF, a child in need plan or a child protection plan) should have parents and professionals working closely together, sharing information, meeting regularly, and working towards stated and shared outcomes. These plans should include extended family members. In this case the information sharing was generally good, but it would have been helpful to the professionals, and to Mother and the children, to have held a CAF meeting earlier. 8.34 Domestic abuse and the MARACs 8.35 The MARAC meetings were a good opportunity to consider the threat posed by Father to Mother and indeed it was agreed at the meetings held that Father posed a high risk a lot of the time. MARACs have been a positive development in recent years in ensuring that the threat of domestic abuse is considered, assessed and shared between key agencies. CAADA (Co-ordinated Action Against Domestic Abuse) is a national charity who promote a strong multi-agency response to domestic abuse. They explain that ‘Multi-Agency Risk Assessment Conferences (MARACs) are regular local meetings where information about high risk domestic abuse victims (those at risk of murder or serious harm) is shared between local agencies. By bringing all agencies together at a MARAC, and ensuring that whenever possible the voice of the victim is represented by the IDVA (Independent Domestic Violence Advisor), and a risk focused and co-ordinated safety plan can be drawn up to support the victim. There are currently over 260 MARACs operating across England, Wales and Northern Ireland managing over 57,000 cases a year’. 8.36 In December 2013 and January 2014 CAADA undertook an inspection of the local MARAC and domestic abuse services in Nottinghamshire. They concluded that Version 6. 26.6.14. 37 practice is good. It was clear to this review that a lot of good work was provided to Mother and her family, and that Mother received some helpful services in relation to the domestic abuse she experienced from Father and positive support in regards to the threat he continued to pose to her and the children. However the large number of domestic abuse professionals involved was questioned by Mother and by other professionals as part of this review. 8.37 How effective the role of the IDVA was in this case has been considered. It is an expectation that each victim referred to the MARAC will be allocated an IDVA, whose role it is to prioritise the safety of the victims assessed as being at high risk of harm. Those attending the learning event and recall day considered their expectations of the IDVA and the MARAC meetings in this case and it was clear that there was a degree of confusion about the roles and the responsibilities of the IDVA and the status of the MARAC plan. Neither the IDVA or their manager attended the meetings held as part of the review, so it has been difficult to include their views on what happened and why. It is not clear how well Mother engaged with the IDVA. What is clear is that it is the role of the IDVA to consider the victim’s safety, not to assess or advocate on behalf of the children. However they would be a helpful part of a team around any child, as they provide a clear link to the MARAC and the Police. 8.38 Although Father was not living with the family at the time of the death of Child H, the focus of the risk for the family was clearly thought to be in regards to him. In fact he has not been implicated in regards to the injuries that Child H was found to have after her death. It was the domestic abuse between him and Mother, and the resulting vulnerability of Mother however that alerted professionals to the children in this family having additional needs. While he was not involved in the care of the children at the time of Child H’s death, he remained an important element of any assessment, if only because of the stress that Mother and her Partner claim they were under due to his harassment and the history of violence to Mother. 8.39 In December 2011 the NSPCC, as part of their research for the ‘All Babies Count’ campaign, analysed their collection of SCRs relating to children aged less than one year. Of the 130 babies in England and Wales who had been the subject of a serious case review from 2008 – 2011 domestic abuse was a factor in at least 60 of these cases, and parental mental health was an issue in at least 34 of the cases. There should be little doubt amongst child care professionals that children who live in Version 6. 26.6.14. 38 families where domestic abuse is an issue are more at risk of physical injury and emotional harm than most other children. 8.40 In a briefing paper published in November 2013 the NSPCC outlined a number of other factors which can increase the risk to children who live in families where domestic abuse is present. They include mental health problems, alcohol, and lack of engagement in the support services being offered. All of these were evident in this case. In regards to Mother’s mental health issues, it is likely that her depression, low self-esteem and anxiety would have impacted on her ability to protect herself and the children from physical harm, and from the impact of domestic abuse inside the home, along with the ongoing and persistent threat of domestic abuse from Father. 8.41 The role of alcohol in problematic relationships is well documented. In ‘Grasping the nettle: alcohol and domestic violence’ (2010) Sarah Galvani states that while alcohol does not cause domestic abuse, in such cases alcohol is often present. As well as considering the perpetrators use of alcohol, the study also looks at the victims drinking, asking two questions; ‘one is whether it increases the risks of victimisation, the other is whether the victim uses alcohol to cope with the domestic violence’. She states that victims of domestic abuse had ‘higher levels of alcohol consumption than non-victims and that the risk of violence increased with increasing levels of drinking’. It is important for professionals to remember that alcohol plays a role in both the suffering and perpetration of domestic violence. In this case Mother admitted to using alcohol to cope with stress. So at the time of the continued harassment from Father, and what with hindsight appears to be her continued relationship with him, it is suspected she was probably drinking heavily. This was not identified at the time however, other than by the Police who were aware that Mother was drinking in the evenings. 8.42 The NSPCC 2013 briefing paper also states that in cases of domestic abuse it is common that Mothers do not take up or disengage with support services, and that social workers may be under the impression that services and support are going in that are not. This can put the children at risk. In this case the belief that a CAF was on-going led CSC to tell the MARAC chair that they felt the family was receiving the required level of support. While there were a number of agencies involved, many of whom were offering high levels and standards of support, it was not as integrated and coordinated as would have been helpful in this case. While CSC were right to be reassured by the activity being undertaken, their colleagues from other agencies Version 6. 26.6.14. 39 were not considering risk and challenging Mother in the way that CSC might have done if they had become involved, even for a short time. 8.43 The above NSPCC report also outlines the triggers for domestic abuse. It lists pregnancy and threats to kill as being high risk, and suggests that a risk assessment is undertaken in these cases. Domestic abuse during pregnancy is also associated with adverse pregnancy outcomes including premature birth and having a low birth weight baby, as was the case with Child H. However, as the risk was all felt to be from Father and he was not living with the family, any additional risk factors in the household were not considered in an assessment of the care and protection being given to the children. The only risk assessment undertaken was in relation to Mother via the MARAC. 8.44 The NSPCC study outlines the learning from the reviews they considered. And many of them are relevant to this review. Firstly there is the need to consider the complex nature of relationships which feature domestic abuse, particularly those characterised by separations and reconciliations. In this case however it was only suspected that Mother may have had some on-going contact with Father. This was only confirmed after the death of Child H and the DNA testing. While there was some challenge of Mother regarding her relationship with both Father and her Partner, on the whole the view was largely that Father was dangerous, that Mother had successfully separated from him, and that her relationship with her Partner was a relatively positive one for her and the children. 8.45 Women who have a history of domestically abusive relationships often get involved in new relationships that are also abusive. Unless they have undertaken a lot of work to understand the nature of their relationships and their own vulnerabilities, they are likely to be the victim of future domestic abuse. In this case Mother had not attended the Freedom Programme3 and had not shown professionals that she had insight into why she had been involved with a number of violent men. The learning event was told that the Freedom programme had been offered to Mother on a number of occasions but that she had not engaged. Professionals should therefore have been 3 The Freedom Programme is a support project for female victims of domestic abuse. The aim is to help them to make sense of and understand what has happened to them. It also explores how children are affected by being exposed to domestic abuse and how their lives are improved when the abuse is removed. Version 6. 26.6.14. 40 alert to the possibility of domestic abuse in her relationship with her Partner. As it was not possible to see Mother alone since her partner had moved in, it was difficult to explore these sensitive issues with Mother. Mother’s Partner being at all the visits and meetings in itself was an indicator that he may be abusive. He would also answer Mother’s phone regularly and tell professionals that Mother was either not available or unwilling to talk to them. A number of professionals felt that Mother’s partner was controlling and potentially abusive, but they did not feel they had any proof. 8.46 At the time of undertaking this review, a previous serious case review undertaken on behalf of the NSCB, but not yet published, was shared with the reviewer. The case of EN12 had domestic abuse in the history and the family was subject of a MARAC. The two cases were actually the subject of MARACs at the same time in 2011 and 2012. The EN12 review highlighted an issue with how and to whom the minutes of MARAC were distributed. The same issue was identified in this case, with the health visitor stating that it took a number of months for the MARAC minutes to reach her. In this case it was not a significant concern as the midwife had the minutes from the MARAC and met with the health visitor. There has been a recommendation made in respect of this issue in the other SCR, also in a recent Domestic Homicide Review undertaken in Nottinghamshire. The NSCB are clear that the MARAC guidance has been revised and there are much clearer expectations in place, so it is not necessary to revisit this recommendation in light of this case. 8.47 Another issue identified in EN12 was the focus of the MARAC on risk to the adult and not the children. It states that ‘the actions address the risks to (the victim) rather than the risks to (the child) and although it is understood that MARAC is a victim focussed system, children are also potential victims and it would be better practice if the MARAC discussions and records included a focus on risks to children’. This review supports the learning and subsequent recommendation within the EN12 SCR. It also recognises the advances made in Nottinghamshire in regards to the effectiveness of the MARAC in these identified areas. 8.48 Conclusion 2: This case shows that the risk to children who live in homes where there is or has been domestic violence are intensified where there are additional risk factors present such as problematic alcohol use or parental mental health issues. Even when the Version 6. 26.6.14. 41 violence is thought to be historic, as in this case, the victim may continue to have issues and their vulnerability can lead to poor choices of future partners and them being targeted by abusive men, which will impact on their children. 8.49 Dominance of Mothers issues, including her mental health 8.50 Mother had a history of mental health concerns in her adolescence and early adulthood. She suffered with depression at various points during her adult life, and had been prescribed anti-depressants. After the death of her first husband, and shortly before she became pregnant with HS, Mother twice attempted suicide. She told a number of professionals that she had also been drinking too much as a way of coping with her feelings. A large amount of the time professionals spent with Mother focused on how she was coping with the harassment from Father, and supporting her with this and her past issues. Her vulnerability was well recognised, and she was clearly very needy. Despite Mother’s needs professionals like the health visitor and the Surestart worker usually recorded how the children presented, noted progress with their development and made observations about their attachment with Mother, and comments on her parenting were recorded. However with Mother’s often overwhelming needs, particularly during practice episode 2, it would have been very hard for the professionals to keep their focus on the children’s needs. CAF meetings would have been a way of ensuring that the children were the focus of the support being provided. 8.51 Considerable attention was paid to Mother’s issues around her past history of domestic abuse and bereavement. There was awareness amongst some of those involved that Mother could be manipulative and was possibly showing disguised compliance however. ‘Disguised compliance’ is a term that can be attributed to Peter Reder, Sylvia Duncan and Moira Gray in ‘Beyond blame: child abuse tragedies revisited’ (1993). It involves a parent or carer giving the appearance of co-operating with agencies to avoid raising suspicions, to allay professional concerns, and ultimately to diffuse professional intervention. Mother’s dominance of professional attention was an effective way of avoiding scrutiny of her parenting, her drinking and her relationship with Partner. There are clear signs of disguised compliance from Mother throughout the period of this review. 8.52 At the learning event there was agreement that Mother’s own needs dominated much of the support provided. The involved professionals also reported having to visit Version 6. 26.6.14. 42 Mother and the children at home because she would not come to the office, clinic or centre. Mother claimed to be too scared of Father to leave the house, but on other occasions cancelled visits because she was going shopping. This appears to have been largely accepted by professionals and was not challenged as forcefully as it might have been. The reason for her not wishing to leave the house was never really pursued with Mother or challenged, it was accepted that she was scared of meeting Father. However it might also have been due to lack of interest, or due to Mother’s low mood and state of mind. Professionals working with Mother allowed her to dominate discussions and for her needs to have priority rather than the children’s, who would have benefited from attending child focused groups at the Children’s Centre, for example. 8.53 Mother’s partner also attempted to manipulate professionals. Mother did not meet with any professional without him being there, and she told the reviewer that he would not allow her to do so. The Midwives told the review of their various attempts to speak to Mother alone, to no avail. 8.54 In April 2011 Ofsted published their fifth report evaluating Serious Case Reviews. Titled ‘the voice of the child: learning lessons from serious case reviews’ it has a single theme, the importance of hearing the voice of the child. One of the themes identified in this report was that practitioners focused on the needs of parents, especially vulnerable parents, and overlooked the implications of the parent’s issues for the child. In this case both children were seen by professionals regularly, but Mothers needs dominated the contact and the threat posed by Father dominated the consideration of risk. Mothers partner, while thought to be somewhat controlling of Mother, did not appear to pose any risk to the children. His care of them was noted to be positive and Mother described him as helpful and a good father. 8.55 Working Together 2013 has legislated to ensure that the ‘voice of the child’ is addressed more fully by professionals working with children and their families. It states that ‘Children should be actively involved in all parts of the process based upon their age, developmental stage and identity. Direct work with the child and family should include observations of the interactions between the child and the parents/care givers’. In this case there is evidence that the children were observed with Mother and Mother’s partner, and that the positive relationships seen were felt to be a protective factor in this case. On occasion however HS was not observed during Version 6. 26.6.14. 43 the visits to Mother and it is not recorded where she was at the time. Recording was dominated by Mother’s issues and concerns about her own state of mind and her fear of Father, but despite this the children were evident within the records. 8.56 The CAF in this case was delayed and was predominantly determined by Mother’s wishes and needs. It included an expectation that Mother take HS (and then Child H) to stay and play and messy play activities at the Children’s Centre, but Mother did not attend and refused all offers of support to get there. Again, Mother’s own needs took precedence over the best interests of her children. However when observed Mother was said to be warm and caring with the girls and no concerns were identified about her care or that of Mother’s Partner. At the learning event the health visitor stated that HS presented as being a healthy child, her development was good and she appeared to have a good bond with Mother with appropriate levels of warmth and love demonstrated. The issues with her weight were not thought to be significant. Mother did not appear to be depressed, and as the health visitor was not aware of the visits to GP regarding her depression, the health visitor did not consider of the additional strain this would put on Mother and the potential impact on her parenting. 8.57 None of the agency reports stated that the family’s background or culture played a significant part in the review. However it should be pointed out that Mother had financial and housing issues around the time of HS’s birth. These matters and the impact of the resulting poverty put an additional strain on her and could have had an impact on HS’s care in the early months. Professionals involved with Mother were clear however that they recognised that the label of ‘mental health’ when being considered in respect of Mother needed to be seen within the context of her being terrified and traumatised by the abuse she had suffered from Father. It should also be pointed out that there was a culture of domestic abuse within the wider families, which was not explored to any degree with Mother or her partner. 8.58 Conclusion 3: It is difficult for staff to remain focused on the needs of the child when parents have complex and demanding needs of their own. As stated in Working Together 2013 ‘Ultimately, effective safeguarding of children can only be achieved by putting children at the centre of the system, and by every individual and agency playing their full part, working together to meet the needs of our most vulnerable children.’ In this Version 6. 26.6.14. 44 case those involved did record their observations of the children and provided services aimed at supporting Mother with the children as well as with her own issues. 8.59 Conclusion 4: All professionals working with children and families need to be trained and supported to ensure the needs of the child remains paramount. This should include the provision of reflective supervision, provided by experienced managers who have additional training in safeguarding children, which enables staff to identify and challenge parents who lack the capacity or motivation to change, or who use manipulation and disguised compliance. In this case Mother received services and support on her own terms. While staff did all they could to ensure she engaged with services, the support was not as coordinated as it might have been and this allowed Mother to appear more cooperative then she actually was. 8.60 Thresholds for social work assessment and S47 enquiries. 8.61 There were opportunities for CSC to open the case and undertake an assessment and give consideration to a time-limited child in need plan, such as after Father had made threats to kill, and after the MARAC chair requested a referral be made to CSC and that an assessment be undertaken. It appears that part of the reason that CSC did not open the case at this time was due to the belief that a CAF was in place and in the belief that Mother was cooperating with the team around the child. In hindsight, both of these were optimistic assumptions, and show a degree of uncertainty among the professionals involved regarding whether a CAF was in place in this case, what a CAF involved, and what support and protection it would bring to the children. When considering the decision made by CSC not to undertake an assessment on this case however, it must be acknowledged that CSC receive a high level of referrals regarding domestic abuse on a daily basis, and they have to make difficult judgements regarding whether each case meets the threshold for their intervention. It is the view of the review that in this case, due to the high number of police notifications and the view of the MARAC chair, CSC should have undertaken an assessment. 8.62 In 2010 the Pathway to Provision Multi-Agency Thresholds Guidance was launched in Nottinghamshire. The document states that the purpose of the handbook is to ‘support practitioners to identify an individual child’s, young person’s and/or family’s Version 6. 26.6.14. 45 level of need and to enable the most appropriate referrals to access provision. It is especially critical that appropriate referrals are made to Children’s Social Care to ensure the safety of children and young people in Nottinghamshire’. A number of versions have been published since, but the threshold level stated in the guidance has remained the same in each version. The guidance includes ‘definitions and indicators for practitioners to assist in the identification of levels of need for children and young people. It also includes guidance on when to commence the Common Assessment Framework process and/or make a referral to the appropriate service within Nottinghamshire’s Pathway to Provision’. 8.63 When considering the definitions and indicators in the document, it is clear that HS was a child in need of targeted services during the key practice episodes 1 and 2, which is what she received. What is not clear is whether HS or Child H would have met the threshold for level 4 specialist services at any stage, with what was known at the time. Level 4 provision could have included an assessment by and support from CSC. The lack of clarity about whether the threshold was met is due to the following factors: • Mother was separated from the perpetrator of domestic abuse, • Mother did not appear to be drinking heavily after the birth of the children, • Mother did not disclose current mental health issues, other than an understandable degree of anxiety, and possibly some depression, which was said to be around the harassment from Father, • Mother was apparently cooperating with professionals most of the time, • the children did not appear to be suffering harm, and certainly not significant harm, and • Mother’s partner appeared to be a stabilising factor, despite some professional concern about his controlling behaviour. 8.64 Despite the above, and despite the MARAC meetings and the proposed CAF, it would have been good practice for CSC to undertake an initial assessment (as it was then) due to the amount of referrals being received. A more comprehensive and multi-agency assessment was never undertaken on the children, or on Mother and Partner’s capacity to parent. The occasion where the MARAC chair requested that the case be opened to CSC would have been a good opportunity to consider the wider issues in the family, rather than continue to see Father as the main issue. Version 6. 26.6.14. 46 8.65 If the assessment had reflected on the impact on the children of Mother’s vulnerabilities and extensive needs, and had explored the new relationship between Mother and her Partner, more information may have been available to consider the needs of the children and any risks. If a well managed and executed time-limited child in need or CAF plan was then put in place it would have been evidence based and outcome focused. It could also have involved the extended family as well as the parents. It would have clarified exactly who was involved with the family, and could have made optimum use of the professional’s time and expertise. 8.66 Undertaking an assessment of this type would have also ensured that the domestic abuse incidents and Mother’s many calls to the Police were not seen in isolation or as one-offs which did not, on their own, meet the threshold for child protection procedures or the involvement of CSC. An assessment would have considered all of the incidents and would have taken into consideration everything that was known about the family across all of the different agencies involved, from the point of view of the children and the parenting they were experiencing or likely to experience, rather than with the domestic abuse focus provided by the MARAC. The CSC agency report points out that at the time the process within that agency was that three contact/referrals in respect of domestic violence would trigger an Initial Assessment. This did not occur in this case. The duty team manager told the agency author that it appears the history was not considered fully when decisions regarding outcomes of contacts/referrals were made. 8.67 There was some evidence of professional curiosity regarding Mother’s partner, as a number of professionals had some concerns about him, mostly based on professional instinct and some limited observations of him speaking to Mother in a way that was felt to be harsh and opinionated. The MARAC requested that police checks be undertaken on Mother’s partner, and a number of professionals made a point of speaking to each other to find out what was known about him. However no assessment was undertaken that would pool the information and find out more about the relationship between Mother and her Partner and his relationship with the children. The MARAC instigated checks raised no concerns about him. 8.68 There is some question about the extent of the assessments undertaken in regards to Mother’s mental health. It is clear she received some sort of assessment at A&E when she came in having taken overdoses after the death of her husband, probably being seen by a psychiatric registrar. Mother was not referred to neonatal or perinatal Version 6. 26.6.14. 47 psychiatry in or after either pregnancy. This could be because she did not meet the criteria, despite the overdoses, or because she did not wish to receive the service. The Midwife identified a history of mental health issues and the GP diagnosed depression and prescribed anti-depressants after the birth of HS. The adult mental health worker undertook an assessment which led to a recommendation that Mother attend bereavement counselling. 8.69 Conclusion 5: It would have been good practice, considering the number of referrals, for an assessment by Children’s Social Care to have taken place in this case. 9 Conclusions and lessons learned 9.1 The following is a summary of the conclusions and learning from the review, as stated within the analysis above. This is followed by a list of the good practice identified, and consideration of whether the death of Child H was predictable and/or preventable. 9.2 Conclusion 1: That information sharing and communication between agencies in cases that have a number of professionals involved due to concerns about a child is most effective when the child is subject to a plan which clarifies in writing and through regular meetings what the concerns are, who is involved/responsible and what needs to change. All children who are identified as in need of a plan, (be that a CAF, a child in need plan or a child protection plan) should have parents and professionals working closely together, sharing information, meeting regularly, and working towards stated and shared outcomes. These plans should include extended family members. In this case the information sharing was generally good, but it would have been helpful to the professionals, and to Mother and the children, to have held a CAF meeting earlier. 9.3 Conclusion 2: This case shows that the risk to children who live in homes where there is or has been domestic violence are intensified where they are additional risk factors present such as problematic alcohol use or parental mental health issues. Even when the violence is thought to be historic, as in this case, the victim may continue to have Version 6. 26.6.14. 48 issues and their vulnerability can lead to poor choices of future partners and them being targeted by abusive men, which will impact on their children. 9.4 Conclusion 3: It is difficult for staff to remain focused on the needs of the child when parents have complex and demanding needs of their own. As stated in Working Together 2013 ‘Ultimately, effective safeguarding of children can only be achieved by putting children at the centre of the system, and by every individual and agency playing their full part, working together to meet the needs of our most vulnerable children.’ In this case those involved did record their observations of the children and provided services aimed at supporting Mother with the children as well as with her own issues. 9.5 Conclusion 4: All professionals working with children and families need to be trained and supported to ensure the needs of the child remains paramount. This should include the provision of reflective supervision, provided by experienced managers who have additional training in safeguarding children, which enables staff to identify and challenge parents who lack the capacity or motivation to change, or who use manipulation and disguised compliance. In this case Mother received services and support on her own terms. While staff did all they could to ensure she engaged with services, the support was not as coordinated as it might have been and this allowed Mother to appear more cooperative then she actually was. 9.6 Conclusion 5: It would have been good practice, considering the number of referrals, for an assessment by Children’s Social Care to have taken place in this case. 9.7 Good practice identified: It should be noted that by ‘good practice’ the author wishes to identify things that agencies did that we would wish them to continue doing. In some instances it would be good practice that went beyond what is expected, in others it would be expected practice in the agency. • It is clear that the professionals involved worked hard to engage Mother and showed an unwavering commitment to her and the children. • The family were offered a comprehensive package of support which was flexible and accommodating to the family’s needs. Version 6. 26.6.14. 49 • There was a degree of challenge evidenced. For example domestic abuse workers spoke to Mother about her partner when they believed he was being controlling. • The plan to protect Mother and the children from Father was timely and the relevant resources were available. • Positive action was taken by Police against Father. This was supported by the CPS. A report published on 27 March 2014 by the HMIC4 criticised police forces in England and Wales for failing the victims of domestic abuse by not prioritising domestic abuse cases. In respect of Father in this case however, the review found that Nottinghamshire Police were effective in prosecuting him as appropriate. • The EDT social worker made a recommendation for further action in the context of the history of referrals and known information about the case. • Consideration was given by the MARAC to Mother’s additional vulnerability when she was pregnant. • Good practice identified between the MARAC liaison, safeguarding and community midwife. Good liaison between the safeguarding nurse advisor and family health visitor. • The Health Visitor undertook checks with drug and alcohol services to see if Mother was known to them. • The concerns were taken to safeguarding supervision by health professionals when advice was needed and most of the advice given was followed. • The MARAC chair arranged for a referral to be made to CSC. • Checks were undertaken on Mother’s partner and established that nothing of significance was known about him across agencies. 9.8 When considering if Child H’s death could have been predicted or prevented, a clear conclusion has been reached by this review that the death could not have been predicted and as such would have been very difficult to prevent. The professionals involved recognised that had Father been in contact with the children they would have been right to be very concerned about the risk that he posed to the children. The reviewer was reassured that had this been the case action would have been taken. Mother, had a more detailed assessment been completed, may have been identified as posing a risk of emotionally neglecting her children due to her own 4 Her Majesty’s Inspectorate of Constabulary - who independently assess police forces and policing. Version 6. 26.6.14. 50 unresolved issues and her drinking. However there was no evidence held by any professional that Mother’s partner would be a risk to children. 9.9 As stated above, there was no assessment, child protection investigation or consideration given to a child protection conference by CSC, as there was no evidence available to professionals, either at the time or with hindsight and with all of the information available to this review, that would lead professionals to believe that Child H would have experienced physical abuse from her carers. These children were not considered at risk of harm at any point in the case history, other than in regards to their Father, who was thought not to have any contact. This was an acceptable conclusion for professionals to come to at the time, and this review recognises that the death and probable abuse of Child H was not predictable. 9.10 This review has identified some points in the work with the family which could have led to an assessment into the family’s situation by CSC. However, even if an assessment had been completed it is unlikely that Child H’s death would have been prevented. 10 Recommendations 10.1 Each agency report submitted to this review has included reflection on its individual learning, and some have made recommendations that are agency specific. The lead reviewer welcomes this and recommends they are followed through and that progress is reported to the NSCB. 10.2 The following changes have been made subsequent to Child H’s death: • Nottinghamshire Police have implemented (February 2014) the Repeat Victim Reduction Plan. This gives Domestic Abuse Investigation Team officers personal responsibility for the management of an individual identified as being a high risk repeat victim. It is expected that it will also ensure that concerns around children in these situations are continually raised, and escalated where necessary. • The date of child safeguarding update training is now checked routinely as part of the annual GP appraisal process across Derbyshire & Nottinghamshire. • The Multi-Agency Safeguarding Hub (MASH) became operational in December 2012 and is staffed by professionals from social care, education, health, police (CAIU and DASU), early help, probation and adult safeguarding. The MASH is Version 6. 26.6.14. 51 the county’s first point of contact for new safeguarding concerns and has significantly improved the sharing of information between agencies, helping to protect children and adults from harm, neglect and abuse. The MASH in Nottinghamshire is one of only a handful of MASHs nationally that handles concerns about both children and vulnerable adults, taking a holistic family approach. • The MASH receives all safeguarding concerns (called MASH enquiries) and for those that meet the threshold for social care involvement, representatives from the different agencies in the MASH and outside will collate information from their respective sources to build up a holistic picture of the circumstances of the case and the associated risks to the child or adult. Timescales for agencies to provide this information are set. A process of ‘social work triage’ takes place whereby systems will be checked and all background information, including previous contacts/referrals/enquiries will be read. All MASH enquiries have oversight from a team manager who will decide upon the outcomes of enquires. • There was significant investment in CSC in 2011 and 2012, and additional social worker and team manager posts were created as it was acknowledged that there was insufficient capacity to respond to demand. Improvements were made, and the duty and assessment service was subsequently judged adequate by Ofsted. • In March 2014, the NSCB and the Children’s Trust partnership introduced the Early Help Assessment Form (EHAF) to replace the CAF documentation. The EHAF is much shorter than the previous Family CAF documentation. The EHAF still uses the Common Assessment Framework to underpin its structure and promotes the involvement of children and families in agreeing what positive change is required. The EHAF aims to provide practitioners across the children's workforce a tool to help them quickly assess need, plan their own interventions and to make onward referral for other services if required. The EHAF has been specifically designed for those practitioners working in universal services such as schools, maternity services and health visiting. The form was consulted on with all partners during November and December 2013. • A review of the step down processes for cases between Children’s Social Care and early help or universal services has been undertaken recently. A new role has been developed, a step down co-ordinator, whose responsibility is to co-ordinate the step down plan. Feedback from front line practitioners in Early Help Services and Children’s Social Care felt that this was a more useful job title than Lead Professional. It is envisaged that these changes will improve the uptake Version 6. 26.6.14. 52 and responses to the early help assessments which have replaced the CAF in Nottinghamshire. • Following a drive to improve inter-professional communication around safeguarding in primary care (health visitor GP communication) a survey was undertaken in June 2013. This identified that in all of the practices contacted, good systems were in place to share significant information with health visitors and to flag children who were subject to safeguarding concerns. The results of this survey were shared with the NSCB in March 2014. It was therefore felt that the issues identified in this case were not necessarily systemic, but were likely to have been due to practice in the specific GP practice. A meeting has therefore been held with the individual GP practice involved with the family to share the lessons learned from this review and to reaffirm the communication systems within the practice. 10.3 The review considered a recommendation in regards to the need to review the Pathway to Provision to provide clear guidance on the criteria for an assessment by CSC in respect of children who are the subject of Police domestic abuse notifications, and about the threshold for the involvement of CSC in MARAC cases. However the processes around responding to domestic abuse have improved in Nottinghamshire recently. The MASH outlined above is now fully operational and referrals relating to domestic violence are more robustly dealt with. This has been strengthened by the co-location of different agencies, and by the clear escalation process which is now in place for cases where referrers feel appropriate action has not been taken. 10.4 Under the current MARAC procedures each meeting is attended by a manager from Children’s Social Care and therefore safeguarding issues are taken back by that manager for further consideration and action. This is significantly different from the previous processes. It was therefore agreed that a further recommendation was not required in either of these areas. 10.5 The recommendations of this overview report are to be monitored by the Serious Incident Review sub-group of the NSCB, along with those made in the agency reports. They are: Recommendation 1: Version 6. 26.6.14. 53 NSCB to share the learning from this review with staff across all partner agencies and with the Safer Nottinghamshire Board for wider dissemination. Recommendation 2: That the NSCB commissions a multi-agency case file audit that focuses on children who are subject of a CAF (or early help plan) where domestic abuse is an issue, to audit whether the needs of the child are sufficiently considered by professionals involved, whether a key professional is identified and is appropriately coordinating services, and whether any issues of disguised compliance or avoidance of services are being challenged and addressed. …………………….. Version 6. 26.6.14. 54 Bibliography Saunders, H. (2004) Twenty-nine child homicides: lessons still to be learnt on domestic violence and child protection. [Bristol]: Women's Aid Federation of England (WAFE). NSPCC briefing (2013) Learning from case reviews where domestic abuse was a key factor. Peter Reder, Sylvia Duncan and Moira Gray (1993) ‘Beyond blame: child abuse tragedies revisited.’ Sarah Galvani. (2010) Grasping the nettle: alcohol and domestic violence. Ofsted (2011) The voice of the child: learning lessons from serious case reviews. |
NC52296 | Death of an adolescent boy due to a fatal stabbing in January 2020. Learning includes: professionals tackling child criminal exploitation need to know and understand the serious youth violence strategy, engage with families, have a comprehensive knowledge of the National Referral Mechanism and be alert to a 'reachable moment' for a child; professionals need to understand the impact of adverse childhood experiences on children and how to deal with these using a trauma informed approach; professionals need to understand what 'place' means to a child and how that influences their lives; preventing school exclusion is a good preventative move because being in education is a safe place for children to be; educate children as to the dangers of knives and being involved in gangs and serious youth violence because this can prevent future exploitation; consider using a 'think family' approach; health agencies have limited occasions to intervene and so should capitalise on them where possible; children who go missing should have a return home interview.
| Title: Local child safeguarding practice review: BSCP 2019-20/02. LSCB: Birmingham Safeguarding Children Partnership Author: Russell Wate Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Local Child Safeguarding Practice Review BSCP 2019-20/02 Lead Reviewer: Dr Russell Wate QPM Published 21st September 2021 2 1. Introduction The subjects of this Child Safeguarding Practice Review (CSPR) are Child A and Child B. Although a number of other young people are involved with them, they will only be referred to contextually within this report to ensure the focus for learning is from Child A and Child B’s lived experiences. In January 2020, Child A and Child B and a third young man (aged 18) all from the Birmingham area, were together in a different area of the country and whilst there were involved in a violent assault. The incident resulted in the fatal stabbing of Child A and serious injury to the 18-year-old, who sustained a stab injury to his torso damaging his liver. Child B was able to get away from the scene of the incident and received no physical injury. All three of these young people were believed to have been involved in an urban street gang from an inner-city neighbourhood in Birmingham. It is strongly suspected by the police from their investigation that the purpose of the young people’s visit concerned the supply of controlled substances in a method that is frequently and now commonly referred to as ‘County Lines’.1 The Police undertook a criminal investigation to establish the circumstances surrounding the incident. Further details of this incident are not detailed within this report other than to identify the extent of the influences that these children appear to have been under at the time of the death of Child A. The perpetrator has been brought to justice, together with three individuals who have been convicted of perverting the course of justice. All four received substantive custodial sentences. The aim of this review is to identify learning improvements that can be made to help safeguard children and to prevent, or reduce the risk of recurrence of, similar incidents. The review team and the author have undertaken an objective analysis of what happened and why, suggesting learning, bearing in mind that the criminal exploitation of children quickly evolves at the hands of organised crime gangs. In supporting the terms of reference and gaining an understanding of the national as well as local perspective, the author has considered the County Lines Exploitation non-statutory guidance for practitioners published by the Ministry of Justice in 2019 and the legislation in respect of modern slavery, in particular the statutory defences. This states that: Child Criminal Exploitation is common in County Lines and occurs where an individual or group takes advantage of an imbalance of power to coerce, control, manipulate or deceive a child or young person under the age of 18. The victim may have been criminally exploited even if the activity appears consensual. Child Criminal Exploitation does not always involve physical contact; it can also occur through the use of technology.” 1 County Lines is defined in the Serious Violence Strategy 2018 as a term used to describe gangs and organised criminal networks involved in exporting illegal drugs into one or more importing areas within the UK, using dedicated mobile phone lines or other form of ‘deal line’. They are likely to exploit children and vulnerable adults to move and store the drugs and money, and they will often use coercion, intimidation, violence (including sexual violence) and weapons. 3 2. Terms of Reference, Contributions and Methodology A Child Safeguarding Practice Review (previously known as a Serious Case Review) is governed by Chapter 4 of Working Together 2018, which states: When a serious incident becomes known to the safeguarding partners, they must consider whether the case meets the criteria for a local review. This includes whether the case: • Highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified. • Highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children. • Highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children. The BSCP Serious Cases Sub-Group agreed that the period to be examined within this review will be from early 2018 up until the incident in early 2020, looking at the extent and impact of agency involvement with Child A and Child B and their families during the last two years leading up to the incident which culminated in the death of Child A. Key Issues to be addressed by the review agreed by the Serious Cases Sub-Group: • Is Birmingham’s current approach to young people involved in ‘County Lines’ working? • Where there is a discontinuance of criminal proceedings (National Referral Mechanism, NRM), what intervention should this trigger? • How effective is the Birmingham Community Safety Partnership ‘One Day One Conversation’ in identifying and managing risk? • What can we learn about the interface between criminal exploitation and young people’s affiliation with gangs and knife crime? Contributors to the review A number of agencies from Birmingham have contributed to this review. The review author was very taken with their knowledge, passion, and commitment to make a difference for the children of Birmingham involved in similar circumstances. The compilation of this report also benefited greatly from the two practitioner events held with individual professionals that had worked with both Child A and Child B. 4 Membership of the Review Team Birmingham Safeguarding Children Partnership commissioned an independent author to carry out the review. The review is supplied by RJW Associates and the lead reviewer is Dr Russell Wate QPM. He is independent of any agency within Birmingham. He is a retired senior police detective, who is very experienced in the investigation of homicide and in particular child death. He has contributed to a number of national reviews, inspections, and inquiries, as well as being nationally experienced in all aspects of safeguarding children. He was one of the reviewers of the National Child Safeguarding Practice Review Panel report ‘It was hard to escape - Safeguarding children at risk from criminal exploitation’ (March 2020). He has carried out a large number of Serious Case Reviews (SCRs) and is also an independent chair of a Safeguarding Children Partnership. Review Team members The review team members were all really experienced and supported the review author greatly in the production of this report and the learning developed. Agency Team Manager, CASS & MASH Education Officer, Birmingham City Council (BCC) Head of Service, Birmingham Children’s Trust (BCT) Deputy Designated Nurse, Birmingham & Solihull CCG Head of Service, Contextual Safeguarding Hub, BCT Assistant Head of Service, Youth Offending Service, BCT Detective Inspector, West Midlands Police Independent Author The review process was also supported by two practitioner learning events (one each for Child A and Child B). The review process was strengthened further by the benchmarking exercise which was held with the Gangs, Violence and Serious Organised Crime Strategic Board. 3. Summary of the case: What happened in the lives of Child A and Child B? Child A: Background Child A was the eldest in his family, and he lived with them in an inner-city neighbourhood in Birmingham. At infant and junior School, he had a fluctuating attendance with a large number of unauthorised absences. Birmingham Children’s Trust (BCT) received a referral that he and his mother presented as homeless following eviction: she had rent arrears and the housing team felt she had deliberately made herself homeless from her previous address. BCT provided temporary bed and breakfast pending permanent accommodation. Mother also had concerns during his primary years that Child A had ADHD and he was taken to the GP who made a CAMHS referral for him. Mother was concerned about his ‘hyperactive’ behaviour, with violent outbursts at school and no sense of danger. He attended CAMHS once after which he ‘was not brought’. 5 Child A attended primary and secondary education provision ending when he was 16 years old. Since that time, he appeared to have been NEET.2 His siblings are all younger and currently of school age. Child A in 2016 started at an engineering academy, albeit his attendance was extremely poor, dropping to a little over 50% by the end of his time there. The school indicated that Child A effectively disengaged from school life. Despite pastoral intervention it was not clear what had motivated this lack of engagement for him. Child A was registered intermittently as requiring Special Educational Needs (SEN) support whilst at school. This support was to require management in school only, with no need to refer to other professionals and was required for his Behavioural, Emotional and Social Difficulty. It is recorded that there were periods where no support was provided at all. Child A was known to several agencies during his life. In summary of his involvement in criminal activity, police records indicate that Child A first became known to the West Midlands Police (WMP) due to the theft of a pedal cycle when aged 13 years old. A pattern of significant and rapidly escalating offending follows, and it is unknown if any referrals were made to other agencies. This continued and he was involved in several incidents where there was evidence of violence and weapons. Those occurrences were in spring 2018 and late summer 2018 although no action was taken against Child A. Early in 2019, Child A was searched following a report made to the police. A large hunting knife and bags of herbal cannabis were discovered in his possession. He failed to make his first court appearance following him being charged with those offences and he was arrested before being further bailed. Child A was subsequently convicted of both offences and received a 12-month referral order and a fine. In Spring 2019, Child A was one of several young people arrested following the pursuit of a stolen vehicle and which was also linked to another violent crime. A large machete was found after they fled the scene. Child A was arrested. He was subject of bail and curfew checks by the police. At the time of his death, the offences remained under investigation and review by the Crown Prosecution Service. From Summer 2019 Child A’s case was managed by the Police Offender Management Team as a ‘Deter Youth Offender’ (DYO) and continued as a DYO from Autumn 2019. This included additional wrap-around management based on his emerging risk around re-offending. He was also referred into ‘One Day One Conversation’ offender management system, which resulted in allocation of the Police Offender Manager working with him and his family alongside the Youth Offending Service Case Manager, Substance Misuse Worker and Youth Offending Service Training and Employment Officer. He was not known to Birmingham Children’s Trust (BCT) but was open to one of the Birmingham Youth Offending Teams and had an appointment scheduled for the day after his tragic murder. 2 Not in Education, Employment or Training 6 In summer 2019, Child A ran off upon seeing police officers, was pursued, and stopped. He was found to be in possession of two ‘joints’ of cannabis. A Community Resolution was administered but subsequently rejected as Child A had been convicted earlier in 2019 of the same offence. This case was then raised for a postal charge, but this action was never taken, and the matter remains outstanding. The common thread of many of those recorded occurrences is that Child A was apparently associating with other males of a similar age to himself and the underlying issues involved violent crime, weapons, and the supply of illegal drugs. These incidents are indicative of potential ‘gang’ involvement although not specifically directly indicative of ‘County Lines’ criminality. Child B: Background Child B is the second child of siblings living with their mother, a single parent. In 2016, the family moved to Birmingham from another local authority area. He had poor school attendance and was excluded for an assault on a teacher. The family came to the UK from a European country and would appear to be currently here illegally, with no right to remain. Whilst living in Birmingham several concerns manifested themselves in respect of neglect, poor hygiene and home conditions and the permanent school exclusion of Child B. There is significant evidence of Child B being involved in ‘County Lines’ with him being located by the police in different regions of the country. This happened on five separate occasions where on each occasion, he was found with a combination of quantities of Class A drugs, money, and offensive weapons. In respect of each of those occasions Child B was missing from home, and it should also be noted that he had never been reported as missing by his family. Early in 2018 Child B (15 years old) was found at an address away from his home area following the execution of a drugs search warrant. As a consequence of a number of safeguarding concerns, a strategy meeting concerning the family was held in Spring 2018 and an Initial Child Protection Conference held where all the children of the family were made subjects of a Child Protection (CP) plan. The mother was reported to be “hostile” to agencies and refused to engage with the plan, as did the eldest sibling. Shortly after the CP plan commenced, Child B went missing from home and on this occasion, was found by the police in another area some distance from his home area in possession of Class A drugs and money. He was charged with a number of offences. The case against him was discontinued in winter 2018 following a positive response to the request for him to be awarded a National Referral Mechanism status (NRM)3. 3 The National Referral Mechanism (NRM) is a framework for identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support. Further information about the NRM is available here: https://www.gov.uk/government/publications/humantrafficking-victims-referral-and-assessment-forms/guidance-on-the-national-referral-mechanism-for-potential-adult-victims-of-modern-slaveryengland-and-wales 7 In summer 2018, Child B was arrested on suspicion of robbery, possession of drugs and possession of an offensive weapon as a passenger in a vehicle, which had been stolen in a car-jacking the previous day when a firearm was used. Child B was found to be in possession of cannabis and a knife. Child B received a youth conditional caution for possession of cannabis and possession of a bladed article in a public place. No further action was taken against him for other offences owing to insufficient evidence. Early in 2019, Child B was arrested in a different area of the country and it was identified that there were concerns he was being exploited and involved in ‘County Lines’ drug dealing. In spring 2019, Child B was arrested in another different area of the country on suspicion of supplying Class A controlled drugs. The information presented suggests that there is unequivocal evidence to show that Child B was immersed in criminality, specifically the supply of Class A controlled drugs. This is indicative of behaviours typically associated with exploitation of children in ‘County Lines.’ Child A and Child B associating together There is some evidence that Child A and Child B associated with each other and this is known to have dated back to winter 2017. On that occasion, they were part of a larger group of males stopped and searched by police officers following a report of a group of teenagers seen with a large knife. It is also apparent that there is commonality in that the two of them were frequently either directly involved in criminality or on the periphery of crime committed by associates. It is not apparent that there was any inference of County Lines influences on either of them at this time in late 2017, but this definitely started to develop for Child B shortly afterwards. It is of note that there was an inference of gang affiliation and influences exercised from a very young age on both Child A and Child B which may be a pre-cursor to the wider coercion and control experienced by them both as they grew older. This applies in particular to Child B, whose immersion within County Lines appears far greater than that of Child A, taking account of the information provided to the review. 4. Analysis of the Terms of Reference Is Birmingham’s current approach to young people involved in ‘County Lines’ working? Birmingham’s current approach is extremely extensive, particularly if you consider it from a strategic perspective. The approach is that Birmingham Children’s Partnership has a strategic responsibility for the coordination and continuing development of the City’s response to 8 contextual safeguarding.4,5 The Chief Executive of the Birmingham Children’s Trust is the strategic lead for the Children Partnership intervention through the Contextual Safeguarding Board which they co-chair with the East Birmingham Area Commander and Children’s lead. The board includes the Birmingham Community Safety Partnership sub-group and the Gangs, Violence and Serious Organised Crime Strategic Board, and work in conjunction with the Youth Offending Service. There is also the Violence Reduction Unit operating across the West Midlands area, which also operates extensively in Birmingham. The Birmingham Safeguarding Children Partnership and the Gangs, Violence and Serious Organised Crime Strategic Board jointly commissioned an independent ‘Deep Dive’ review relating to two ‘County Line’ cases. The review was completed in June 2019 and identified important learning around the death of a young male in Oxford and a second young male who sustained life changing injures. The findings have helped inform the on-going development of the City’s response to knife crime and ‘County Lines’. This review has taken account of the findings of this ‘Deep Dive’ and the action plan that resulted from it. In October 2019, the partnership established a Contextual Safeguarding Hub (now called EMPOWER U Hub) in order to maximise real-time information and intelligence sharing, with the aim to better target inter-agency intervention. Birmingham has also successfully applied to be part of the Department for Education (DfE) ‘Tackling Child Exploitation’ programme, working alongside Research in Practice, The Children’s Society, and the University of Bedfordshire. This work will inform the continued development of the City’s approach to tackling County Lines and Contextual Safeguarding. It is clear to the review author from an operational perspective that a great deal of work and effort went into trying to help the children and the families of both Child A and Child B. The EMPOWER U Hub at the front door of Children’s Services is beginning to make a difference, but more needs to be done to link up with young people. EMPOWER U is the official name of the Exploitation and Missing Hub based within MASH and includes representatives from Birmingham Children’s Trust (Exploitation and Missing Co-Ordinators, Youth Offending Service and Social Care) as well as West Midlands Police, Health, Education, and other agencies such as Barnardo’s, The Children’s Society and Probation. The result of all the effort though was limited in protecting Child B from involvement in ‘County Lines’, as highlighted by one of the professionals at the practitioner event, who suggested that the current approach needs to be more pre-emptive or proactive and procedures need to be clear and robust with more contextual assessment; they are still, in the main, reactive to specific incidents. That said, it must be acknowledged that those endeavours reflect the complexities that are involved in these situations and how crucial it is that a much wider intervention requiring key stakeholders and others, including family and third-party influences, is needed. It is of note that the formation of the EMPOWER U Hub 4 Contextual Safeguarding as a concept was developed by Carlene Firmin at the University of Bedfordshire to inform policy and practice approaches to safeguarding adolescents. It is an approach to understanding and responding to young people’s experiences of significant harm caused from outside their families. 5 As well as threats to the welfare of children from within their families, children may be vulnerable to abuse or exploitation from outside their families (Working together 2018). 9 came towards the end of this review period and if it had been in place earlier, may have made a difference to these two boys, Child A and Child B. In Child A’s case, his offending profile was somewhat different from that of Child B as he was not discovered in other areas of the country like Child B was. Although there is information that they associated with each other, there is little evidence that they were close associates, and their association does appear to be by influence rather than their own design. ‘County Lines’ is a significant national issue and the complexity and organisation behind the criminality involved goes considerably beyond looking at the individual circumstances of Child A and Child B. The review author is fully aware of the issues that Birmingham and the West Midlands face and feels that this should be taken into consideration, as the analysis needs to be balanced, take account of the context that agencies and professionals are working in and must also avoid hindsight bias. A National Crime Agency publication regarding ‘County Lines’ (2019) states: …that currently, the biggest [drug] exportation area outside of the Greater London area, is the West Midlands and there is little doubt that this is influenced by a number of factors which reflect the scale of the population, income deprivation and the ability of the criminals to influence young people quickly and effectively within communities who are vulnerable to the lure and promises of rewards. This is an additional problem to ‘gang’ culture, which although closely allied to drugs and drug supply and adds another layer to the vulnerabilities of young people, County Lines are well-organised and a growing problem. The influences of home life can be critical to assist professionals early on in tackling vulnerabilities within the Child A and Child B age group. For example, there is evidence that Child B’s mother was frequently hostile to professional support and the apparent limits of her parenting ability to safeguard her children are recorded by agencies. This seems likely to have enabled Child B’s associates to further undermine and exploit him and use this to take advantage of these vulnerabilities and become the dominant figures in his life. When the Child Protection plan was made, Birmingham Children's Trust attempted to engage Child B’s mother in the plan by ascertaining her understanding of risk posed to the children, considering all the concerns. In his own mother’s words, Child B was able to “do his own thing”. Critically, this was from a remarkably young age where he would frequently be missing from home without being reported. The suggestion that he was ‘doing his own thing’ may be an example, not only for these two young people but in general, of the parental lack of understanding about the external risks of contextual safeguarding that children are vulnerable to. A key time for professionals to intervene further and more strongly was when Child B’s immersion into being involved in ‘County Lines’ first started, under the influence of other adults. This could have been explored when he was frequently found ‘missing from home’. 10 His mother rarely, if ever, reported him as ‘missing’. This reporting could have helped to target diversionary support and interventions that the police and other agencies could then perhaps have influenced. This might possibly have explored his movements and given an indication of his lifestyle. The numerous occasions that Child B went missing are, on analysis, closely allied to his offending profile and there is no obvious indication that these were of his own volition, but rather a product of his exploitation. The Government approach to youth justice continues to recognise and promote the safeguarding of children as the primary objective. The vision is to see the child first and them as an offender second. On analysis, it is not clear that this has been true in all the incidents involving Child B. It is essential that all the relevant information from areas around the country concerning those children found operating within ‘County Lines’ is fed back to the home area of the young person. This will enable a holistic profile to be formed concerning them, and the incidents must not just be seen as happening elsewhere, where the focus of the individual children’s issues may be overlooked. The review author notes that when Child B was released on bail by the police in early 2019, he was put on a train to Birmingham when his family were, in fact, in a different part of the West Midlands region. There is no indication that any bail checks were made before or following his release on bail. Although, a strategy discussion was held by this area of the West Midlands Children’s Services and Birmingham Children’s Trust, they then only ‘become re-involved’ in respect of Child B’s whereabouts and accommodation needs. It wasn’t until spring 2019 that Birmingham Children’s Trust were confirmed to be responsible for Child B given that he had previously been their Child Looked After. The ‘County Lines’ guidance is clear in that ‘The home area of the child always retains responsibility for the child, wherever they are found.’6 In spring 2019 Youth B was residing in a different area of the West Midlands region in a hotel with his mother. He was also reported as missing. In the summer of 2019 Child B was issued with a Youth Conditional Caution (YCC) and the YOT for the area he was living in agreed to take the case on behalf of Birmingham as it was established Child B was a Birmingham ‘relevant’ child. In respect of Child A, his offending profile is considerably less than that of Child B. Child A’s second possession of drugs (Class B) offence took place less than halfway into the period of his referral order. A referral order requires the individual to attend a youth offender panel which will set a contract that seeks to address the causes of the offending behaviours. It is appropriate to consider that the existence of a referral order issued only five months previously may have enabled the Court and partner agencies to make more informed decisions about Child A. There is an indication that the work with Child A, as records show, was more productive than that of the agency’s experiences with Child B. Child A engaged on four occasions with the Youth Offending Team (YOT) and it is recorded and confirmed by his workers at the practitioner event, that contact was positive and encouraging, suggesting that Child A was 6 County Lines Exploitation practice guidance 2019. 11 working with YOT to prevent re-offending. The negative inference is that Child A may have been showing disguised compliance. The safeguarding ‘traditionally-based’ structures for children are thoroughly established and based on the ‘Working Together’ guidance published in July 2018. ‘County Lines’ seemed to be seen within it as emerging so relatively little was written in ‘Working Together’ in relation to safeguarding those children involved. Consequently, current approaches nationally to safeguarding do not take into specific account the criminality and exploitation ‘explosion’ that has arisen in a comparatively short time, and certainly since the 2018 iteration of ‘Working Together’. Birmingham, though, have implemented robust procedures that they are building on. There will be occasions when children are released under investigation (RUI) for offences aligned to exploitation and ‘County Lines’. It is imperative that safeguarding services are triggered immediately with a full and factual referral and that there is a dynamic approach to maintaining communications with the ‘host’ area. This should happen in Birmingham through its EMPOWER U Hub. In answer to the terms of reference question ‘Is Birmingham’s current approach to young people involved in ‘County Lines’ working?’, the review author feels in relation to Child A and Child B the answer must be no. As of July 2020, over six months after the death of Child A, Child B is still actively involved in ‘County Lines’. In terms of what the author has learned from the partnership, indications are that the current structures are beginning to work, and this will only increase into the future. In support of this view a review team member stated that “Birmingham’s current approach is in its infancy of establishing a robust response and offer to the issues around criminal exploitation”. The individual history goes back many years for both children who would have been assessed and responded to within the traditional safeguarding approach within statutory legislation. It is now recognised that approach is outdated and does not lend itself well to criminal exploitation. The exploitation of Child B is long standing and the behaviour presented is entrenched. More preventative action is needed early on which recognises indicators and engages to prevent behaviours becoming entrenched and reduces the need for reactive responses. Where there is a discontinuance of criminal proceedings (NRM) what intervention should this trigger? The review author considers it may be helpful to summarise here what ‘County Lines’ involves and use of the National Referral Mechanism: In summary terms these are: • County Lines is a major, cross-cutting issue involving drugs, violence (including sexual violence), gangs, safeguarding, criminal and sexual exploitation, modern slavery, and missing persons. The response to tackle it involves the police, the National Crime Agency, a wide range of Government departments, local government agencies, and voluntary and community sector organisations. 12 • Although Class A drug supply underpins County Lines offending, exploitation remains integral to the business model of the organised crime groups who recruit, transport, and exploit children and vulnerable adults to carry out activity including preparing, moving, storing, and dealing illegal drugs. Children in the 15-177 age group are, statistically, more likely to be exploited although the ages of the victims to this vary considerably. • The National Referral Mechanism (NRM) is a framework for identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support. Modern slavery is a complex crime and may involve multiple forms of exploitation and encompasses: - Human trafficking - Slavery, servitude and forced or compulsory labour An individual could have been a victim of human trafficking and/or slavery, servitude and forced or compulsory labour. Victims may not be aware that they are being trafficked or exploited and may have consented to elements of their exploitation or accepted their situation. A potential victim of modern slavery is a potential victim of a crime. NRM referrals should be made by the first responder/frontline worker and referred to the police to consider what crime is to be recorded and what action is to be taken. If the potential victim is under 18, or may be under 18, an NRM referral must be made, and child victims do not have to consent to be referred into the NRM. They must first be safeguarded and then referred into the NRM process. The process involved is that once criminal proceedings have been commenced the NRM will be ‘triggered’ by a referral to the UK Human Trafficking Centre. Any decision to make a discontinuance of charges utilising the Section 45 Modern Slavery Act 2015 defence, will generally be a decision based on a clear judicial direction or decision, a legal defence or a decision made by the Crown Prosecution Service (CPS) to discontinue the case. ‘Ownership’ of the prosecution case will usually be that of the CPS as the prosecuting authority, with the casework led by the respective law enforcement agency which in the case of Child B would appear to be a Constabulary in the South West of the Country. To clarify the legal context, Section 45 states that a defendant, when faced with criminal liability, can raise a defence that they were a victim of trafficking. This does not apply to every criminal offence but drug offences synonymous with ‘County Lines’ have been more prevalent for the raising of this defence in more recent years. For children, less is required for the defence to be raised than adults, primarily based on vulnerabilities, and will succeed if the child can show that: a. They committed an offence as a direct consequence of being a victim of slavery or relevant exploitation; and 7 Ministry of justice 2019. 13 b. A reasonable person in the same situation and having the person’s relevant characteristics (including their age) would have committed the offence. Child B’s case was discontinued by the judge at Crown Court in winter 2018 due to the NRM status, and when a different area Magistrates Court discontinued their proceedings shortly afterwards, Child B therefore went to release with no statutory Youth Offending Service supervision, and he then went to reside in a different area of the West Midlands region. The Birmingham Children’s Trust, who had ‘responsibility’ for him whilst on remand kept his case open. In effect, Child B walked out of custody in winter 2018 and within a very short time frame was swept up into re-offending again as by late winter 2019 he was detained in Northern England selling Class A drugs. When arrested, police officers from the West Midlands Police attended the family home to conduct a search only to discover that the family no longer resided at the address. There was a significant gap in agencies’ knowledge and at that time information does not appear to have been readily shared between the agencies. It does highlight that Youth Offending Services in the respective areas that Child B was being dealt with for criminal offences did not appear to have effective communication with Birmingham Children’s Trust, the Local Authority children services who had responsibility for him. This does appear, on the face of it, to have highlighted gaps in national rather than local practice. The discontinuance under the statutory defence also highlights the complexities of County Lines in that where cases are discontinued, the individual could be at that time at greater risk of re-offending. There is an argument that the success of the defence does, in effect, enable (and almost empower) the criminals to continue the exploitation by further exploitation in the knowledge that the defence can be used to their advantage. In Child B’s case it is less than two months before he is shown to be active again. This emphasises the need for services to be able to take appropriate actions to safeguard the young person. Young people who are being criminally exploited are often referred to the NRM in the expectation that it will give them protection. This is not the case in practice as protection relies on local safeguarding arrangements. Modern slavery, seen as ‘County Lines’ in this case, should also be seen as a child safeguarding issue so a referral into the NRM by a first responder8 does not replace or supersede established child protection processes, which should continue as parallel processes whatever the outcome of criminal proceedings. This will include the processes such as a Section 47 or Section 17 enquiry. The critical part of this is, therefore, that following this NRM decision, the child’s safeguarding must be appropriately embedded into practice through existing and acknowledged safeguarding processes, protocols, and arrangements by the local authority in accordance with the Children’s Act 1989 and Working Together.9 The key for professionals is 8 The list of first responders Includes the Police, Local authority and local authority children’s services. 9 All children, irrespective of their immigration status, are entitled to safeguarding and protection under the law. Where there is reason to believe a victim could be a child, the individual must be given the benefit of the doubt and treated as a child until an assessment is carried out. 14 that this must not be lost sight of at any stage, regardless of the NRM process. In the case of Child B, at the end of 2018 and thereafter, it unfortunately did seem to be. On spring 2019, a West Midlands region Youth Offending Team indicated that they were unable to establish contact with Child B due to an address change and this restricted the delivery of the out of court outcome. Consent to refer to the NRM is not required for children under 18, but it is nevertheless important to explain the process to them (and their parents/carers) and the duty to notify is satisfied by the NRM in all children’s cases. There is no specific timescale for when an NRM referral should be made but it is advisable that it is made as soon as possible to assist in the safeguarding interests of the child. The National Child Safeguarding Practice Review Panel published a report10 in March 2020 into child criminal exploitation. Their thoughts on the NRM which is relevant to this review were: The National Referral Mechanism (NRM) is not well understood and is inconsistently used. Young people who are being criminally exploited are often referred to the NRM in the hope that it will give them protection. The review found that the NRM’s original purpose does not always fit well with the circumstances of this group of children and that understanding and use of the NRM was patchy. Looking specifically at the case of Child B, he was subject to sentencing at the end of 2018 at Crown Court for possession of a class A drug with intent to supply and other offences, which appeared to be related to relevant exploitation. The trial judge had originally adjourned this matter for a pre-sentencing report in autumn 2018. Child B remained in youth custody on remand pending the trial. Child B received a positive grounds decision the end of 2018, with the judge discontinuing the case in accordance with the defence under S45, Modern Day Slavery Act. Child B was released with no court orders or conditions around him. The NRM was therefore closed. The Youth Offending Service, therefore, did not have a statutory role with him, but some liaison did take place with the other area’s YOT as Child B was still to be dealt with for an out-of-court disposal for possession of a knife and cannabis. Child B was released from remand and returned to his mother who was now living in temporary accommodation. Given he was out of the Birmingham area, as well as being released with no controls, restrictions or management of his ongoing risks, the resulting engagement appears to have been voluntary and both he and his mother seem to have been resistant to offers of support. This resistance may be indicative that this continued behaviour was being externally influenced. A little over two months later, in winter 2019, Child B was arrested in the North of England for similar drug-related offences. By this time, the out of court disposal remained incomplete but there was a clear indication that Child B’s offending was continuing, and this should have heightened awareness of his safeguarding needs. 10 The Child Safeguarding Practice Review Panel (March 2020,) It was hard to escape - Safeguarding children at risk from criminal exploitation. 15 At the review team meeting in mid-2020 the members queried what role the Magistrates and Crown Court should play in keeping children safe from criminal exploitation. In the case of Child B, it appeared to be a revolving door as the court clearly felt that, or were not asked to consider, remand in custody was a method of keeping him safe from the influence of ‘County Lines’ and gangs. The judge, by discharging Child B of all offences, unintentionally made it possible for him to continue being exploited. A further comment made in The National Child Safeguarding Practice Review Panel report stated that: An unintended consequence of the application of the NRM was the removal of statutory orders which might have been helping to control the child’s risk-taking behaviour. For example, a tag was removed for a child as a result of a referral to the NRM being successful. The grandmother looking after the child was concerned because she saw the tag as the only thing that was curbing her grandson’s risk-taking behaviour. This does seem to mirror Child B’s circumstances following his acquittal in at the end of 2018. How effective is the Birmingham Community Safety Partnership/West Midlands Police ‘One Day One Conversation’ in identifying and managing risk? Child A was referred into the ‘One Day One Conversation’ (ODOC) offender management process which resulted in allocation of a Police Offender Manager working with him and his family alongside the Youth Offending Service Case Manager, Substance Misuse Worker and Youth Offending Service Training and Employment Officer. Child B has continued since the incident in early 2020 to offend, breach orders and is suspected of being involved in ‘County Lines’. For example, he has subsequently been arrested in a house, supplying controlled drugs in south of England. Child B was discussed and nominated at the ODOC meeting in July 2020. The review author has been supplied with the Pan Birmingham Youth ‘One Day One Conversation’ Operating Standards from June 2020. Obviously, this is post January 2020 but it would appear that it is fundamentally the same as what was in operation during the key time frame period for this review. To inform the review author and to help with the completion of this report, he was invited to attend (remotely) the ODOC meeting in July 2020. This review is also helped as one of its review team members is a co-chair of the ODOC meeting and process. The ODOC is a monthly multi-agency meeting of statutory and voluntary organisations responsible for the effective management of the cohort of children who are considered suitable for an integrated offender management approach. This cohort is either: 16 1) Prolific and Priority Offenders: PPOs are those young people where there is a high likelihood of re-offending and/or serious harm to others, which may be evidenced by the following: - Current statutory intervention - A young person committing a disproportionate amount of crime - An established pattern of offending which requires active multi-agency risk-management strategies to mitigate the risk posed by that young person - Recent intelligence which indicates a high or increasing risk of re-offending and/or harm to others - Further arrests, charges, and convictions whilst subject to statutory supervision - Harm and re-offending factors identified by the Youth Justice Asset Plus assessment or 2) Deter Young Offenders: DYOs are those young people below the age of 18 where there is identified and increasing likelihood of re-offending and/or serious harm to others. It is likely that these young people will continue to commit crime and without targeted resources may become prolific and/or priority offenders (PPOs). These may be evidenced by the following emerging patterns of concern: - Current statutory intervention - An increase in offending, including arrests, charges, and convictions - Intelligence patterns identifying an increasing level of re-offending and/or harm-related behaviour - Identification of emerging patterns of offending and risk via the Youth Justice Asset Plus assessment The ODOC meeting monitors those cases that have been adopted, decides whether to de-select, and then considers new cases. The cases adopted are managed by four strategies: control, change, diversion, and safeguarding. They are then risk assessed at different levels: either red, amber, green, or clear. The ODOC meeting that the review author attended worked exactly as described in the Operating Standards. The review author was extremely impressed and identified several strengths: the chairing of the meeting; the thoroughness of the examination of each individual child during the meeting; the passion and engagement of the multi-agency professionals involved in each of the child’s lives who were discussed; and the actions which were multi-agency and multi-faceted in design. The sharing of information was comprehensive and readily supplied. The review author was also told by the review team and practitioners at the learning events that information-sharing is working effectively between agencies and the EMPOWER U Hub on a daily basis. The review author felt that those practitioners who spoke about the children they were working with were constantly trying to establish moments in the life of the children when they might have been amenable to make changes to their behaviour and lifestyle. Some research calls this a ‘reachable moment’, or in Education a ‘teachable moment’. In the National Child Safeguarding Practice Review Panel’s report on safeguarding children at risk from criminal exploitation (March 2020) it is called a ‘critical moment’. 17 There is a concept in systemic theory literature described as a critical moment which changes social worlds. Systemic therapists promote the importance of acting wisely to identify when the words used at a particular critical moment can have a powerful influence on the direction taken after the conversation has ended. In a similar vein, the notion of the teachable moment is well established in education, youth offending and health sectors. The review author believes that this ‘reachable moment’ for Child A and Child B might have been after their arrests, in particular the first time it happened, and for Child B when arrested in another part of the country and needed to be conveyed back to the West Midlands. Another moment may have been for Child A when he attended the hospital Emergency Department (ED) after being assaulted. The inclusion of Redthread11 in EDs now may help in the future. The review author is not able to state exactly why professionals were not able to capitalise on potential ‘reachable moments’ in Child A and Child B’s lives, and possibly alter the events that followed. It may be that these were not recognised as such by professionals in involved at the time. There may be some possible gaps with the ODOC process. The review author feels that there needs to be a robust process to capture those that are emerging or do not have a current statutory intervention. For example, when Child B had his intervention concluded in at the end of 2018, what could have been put in place to safeguard and manage him? Another example is that not a lot was being learnt by professionals in relation to Child A. At around the same time, his offending profile was either well-hidden or emerging, but this changed when he was adopted by the ODOC meeting. More possibly could have been done earlier to prevent him getting to the stage of being an ODOC nominal. This activity appears to be something that the EMPOWER U Hub would now action out. The EMPOWER U Hub was established in October 2019 by the partnership to provide enough contextual information to the partnership in real time. The review author has been told that the Ofsted visit in February 2020 reported it was an innovative initiative that was a strong and effective addition to front door services. From the information the review author has received the actions from the Hub’s daily meeting would include disruption activity, which includes the young person being considered at a disruption planning meeting ensuring MASH consideration for safeguarding, safety planning using a ‘Think Family approach’, understanding what the police activity is in relation to crimes committed, and making sure information is provided for One Day One Conversations (ODOC), Multi-Agency Child Exploitation (MACE) and Chief Officer Group (COG). The rapid review for Child A states that this approach could be good but must be delivered in practice. This will assist the partnerships in moving forward in respect of “maximising real- 11 A youth work charity aiming to support and enable young people to lead healthy, safe and happy lives. 18 time information and intelligence sharing”, in particular a more consistent and comprehensive completion by professionals of the locally adopted screening tool. What can we learn about the interface between criminal exploitation and young people’s affiliation with gangs and knife crime? There are two main child Urban Street Gangs operating in the relevant inner-city neighbourhood of Birmingham. These two groups are made up of children and young people who are 14 to 19-year-olds. The youth gangs appear to be the testing ground before taking on roles in the adult Urban Street Gang. The ‘B19’ task these two young urban street gangs to carry out street robberies, car theft, burglary, drug dealing and to get them involved in the ‘County Lines’ drug dealing. There are high levels of violence in the offending patterns. Child A had been assessed by the Youth Offending Service as being associated with one of these children gangs. There is no specific mention in the information received by the review of Child B’s involvement in a specific gang. However, a number of agencies, for example school and Youth Offending Service, believed he was a member of a gang, and strategy and mapping exercises were looked at for him. At the practitioner event for Child A, some of the practitioners that worked with him said they found him a nice young person, but because he was from the relevant inner-city neighbourhood in Birmingham and the people in these gangs were his peers and friends who he had grown up with, in their opinion his membership of a gang seemed to be an inevitable consequence. Dr Carlene Firmin, from the University of Bedfordshire and the Contextual Safeguarding Network, often talks about safeguarding organisations needing to tackle ‘Place’ to break young people’s cycle of being harmed through involvement with gangs. 19 For Child A, the ‘Place’ influence was the inner-city neighbourhood in Birmingham where he grew up. Child B was also said to have many friends in this same neighbourhood and visited frequently. There is a history of gang violence (generational) within this area. The community state to professionals working there that they are living in fear and there are also the issues of poverty within this area. Moving victims and families should be considered as a last resort (although this may be necessary in specific circumstances, for instance where there is a threat to life). It is believed to only serve to misplace the family and by the same token can place the victims in a much more vulnerable position by exposing their vulnerabilities and possibly making them retreat to familiarity and fall-back into similar home area networking. The moving of people should only take place after an individual risk assessment. However, in this case this may have helped Child A at the time he was adopted by the ODOC meeting as this might have helped to divert him and protect him from his peers and organised criminal gangs operating in the relevant inner-city neighbourhood in Birmingham. Location based assessments should take place prior to any move. There needs to be a concerted effort to tackle the gangs operating in the relevant inner-city neighbourhood in Birmingham. The work of all agencies on individual cases may be successful but the gangs will just recruit the next young person to take their place unless their network can be successfully disrupted. This is where the crucial work of the Birmingham Community Safety Partnership and the Serious Youth Violence Strategy should, can and will make a difference. Child A moved to a university school academy to break out of the local school environment, but he had attendance issues in education. This was the same for Child B and despite interventions by education and other services, the deterioration of attendance and lack of engagement with the support offered to them made them vulnerable to peer pressure which, in turn, exposed them to criminal gangs who exploit children and young males. Educating children and young people to the dangers of both gangs and ‘County Lines’ needs to be co-ordinated and targeted to those of secondary school age, but with consideration to those in their last years of primary school. It would be prudent for this to be a multi-agency approach which needs to be managed and able to draw on current and emerging themes as the organised crime behind this becomes more sophisticated. This needs to be ‘hard-hitting’ and serve to deter and may best be demonstrated by actual case studies that show the raw realities. The reality is that to criminals the child is purely a commodity and worthless whether or not they have exhausted their usefulness. Educational exclusion may well only have served to increase their exposure to a criminal gang. It is a fact that the networking within organised crime is significant and that like law enforcement agencies, criminals have their own ‘intelligence’ systems targeting young and vulnerable victims. To many this can result in a devastating impact on their lives within a very short time frame having been lured by promises of significant rewards which quickly transpose to threats of assault, intimidation and invariably threats to their family’s lives, with drugs debts building up. Weapons are a common feature of ‘gang culture’; knives or other 20 bladed weapons appear to be the weapon of choice, although access to and the use of firearms is not uncommon. For Child A, his exclusions appear to have happened during times where he was not receiving SEN support for Behavioural, Emotional and Social Difficulty. It is unclear what parental engagement with the schools was like, although the school have shared that parents were hard to contact and failed to attend meetings during 2018. What led to the exclusions of both Child A and Child B and were those decisions made subjectively and in the best interest of them at the time? Were there alternative considerations made in looking at the risks associated with excluding them from mainstream education and their peer group? Being in education is seen as a safe place for children, and any efforts to prevent exclusion where possible would be a good preventative move. Keeping the momentum of changes to the law, for example the amendments to legislation in respect of weapons (Offensive Weapons Act 2019), are key opportunities in working in partnership to ensure that each of the agencies are aware of their powers to deal with offences and make appropriate and timely interventions. Changes included in the offensive weapons legislation (not all provisions are enacted) has created powers to act against individuals in private premises. These are important changes and could have a real-time effect on knife crime. Taking victims out of contact with perpetrators by using legislative opportunities whilst on one hand may be considered as criminalising the individual, but it may also offer diversionary and disruption tactics that will in fact safeguard them and place them at the forefront of statutory responsibilities by agencies. Child A was on bail for offences at the time of his death. The conclusion to the investigations and subsequent prosecutions appears to have been adversely protracted in consideration by the prosecuting agency and appear not to have served the best interest of the child. Safeguarding of the child remains a primary consideration and delays in decision making that adversely affect the safeguarding processes should be escalated to the prosecuting agencies. Another key area to consider is ensuring that partnerships pay appropriate value to the missing persons reports of individuals within the 14-17 age group and that all missing/return home interviews are conducted with due diligence. Although it is recognised that not all parents/carers will report missing episodes (the case of Child B is no exception to this) gaining an immediate indication from the child of where they have been and who they have been associating with at the earliest opportunity is crucial to build up an intelligence picture of these gangs, whilst such opportunities exist for that young person. These opportunities will diminish rapidly as the exploitation into gangs and County Lines takes control. 5.0 Conclusions and Learning Themes The review author has been extremely impressed by the efforts and structures that Birmingham have put in place to tackle child criminal exploitation. There is no doubt that this structure involves a high level of sophistication to the arrangements. This builds in at the same time, a degree of complexity, which has the unintended consequence of creating some duplication but also some gaps. 21 The structure relies on the commitment and strategic leadership of the Birmingham Children’s Partnership and effective collaborative input from key partnerships including the Birmingham Safeguarding Children Partnership, the Community Safety Partnership, their subgroup the Gangs, Violence and Serious Organised Crime Strategic Board, and The Youth Offending Service Management Board. The commitment and input from agencies including Birmingham City Council, Birmingham Children’s Trust, Health commissioners and providers, West Midlands Police, National Crime Agency, Regional Organised Crime Unit, and the Voluntary Sector. The partnership also needs to work closely and in conjunction with the West Midlands Violence Reduction Unit. A key aspect of learning from the death of Child A and the case of Child B is that this sophisticated system needs hierarchical governance which is currently being provided by the Contextual Safeguarding Board which is co-chaired by the Chief Executive of the Children’s Trust and the East Birmingham Area Commander and Children’s lead. This should be maintained and strengthened to provide system leadership, governance, and direction. The Birmingham Gangs, Violence and Serious Organised Crime Strategic Board is in the process of undertaking a separate review of partnership intervention. It will also look at all known nominals in the particular Urban Street Gang involved with Child A and Child B and the gang that is a young faction of this urban street gang. The Youth Offending Service Management Board are undertaking a separate Serious Incident Review into the death of A as prescribed by the Youth Justice Board; the findings will be shared with the Birmingham Safeguarding Children Partnership. The involvement of definitely Child B, and most probably Child A, in ‘County Lines’ drug dealing, was a real issue for professionals attempting to work with them and divert them from criminality. One of the key learning themes from this review is ensuring the engagement and support of a child’s family to assist professionals. In the case of Child A, the practitioner event revealed that both his parents were very guarded and whilst mother appeared to want to help Child A get out of trouble, she was distrustful of the police and youth offending service, and the father wanted the support of services, but remained reluctant to engage. The parents live separately and although they said they wanted to work with services they often didn’t attend booked appointments. In relation to Child B the information received for the purposes of the review was that mother was hostile and resistant to any attempt by professionals to engage positively with him. The practitioner event supports this stating that mother is very resistant in terms of talking to agencies and regarding who is allowed to talk to the children; she wants to be involved in everything. Mother is seen as obstructive, and fearful of cooperating with agencies. An added problem for Child B was that his mother has no access to funds due to probably not having the right to remain in the UK. Child B, it was believed, was involved in crime to support his mother and siblings. His father and an older sibling returned to the European country they had left for the UK from, four years previously, so his father is not present to support Child B, the family and professionals. 22 Consideration also needs to take place in relation to the fear faced by parents. Child B’s mother is a woman with no recourse to public funds or an asylum seeker, who also may have a different view of people in authority due to experiences in her country of origin. Could professionals have used someone from within her own cultural group to support them with engaging her to better understand her experiences and the experiences of the children thereby understanding the behaviour presented? Her hostility is possibly due to fear. A ‘Think Family approach’ may not have helped Child B but might more probably have helped Child A which was also highlighted in the rapid review for him, and this approach could help other current and future children who are getting involved in ‘County Lines’ and criminal exploitation. Another learning point in relation to Child B was that he was constantly going missing from home. He was almost never reported missing by his mother. One of the practitioners advised there has been a continuing concern around his mother not declaring Child B missing when he had missing episodes. When a previous social worker reported Child B missing in mid-2018, his mother was angry saying that if she had not reported him missing, no-one else should. He had been reported missing by his mother only once that particular year. The Department for Education (DfE) ‘Statutory guidance on children who run away or go missing from home or care’ makes it a requirement that when a missing child is found, they must be offered an independent return interview. The review author has seen very little evidence that these return home interviews took place on a regular basis and even if they did take place, what positive action took place following them? The review author’s view is that more importance should be placed on the carrying out of the interviews and the value of completing them for the child themselves and any information they can also offer to safeguard themselves and others. The National Referral Mechanism (NRM) is the appropriate mechanism for ensuring that any discontinuance of a prosecution under Section 45 Modern Slavery Act can be addressed with immediacy by the local authority in order that appropriate safeguarding, other interventions, and agency activity can continue with the child and family. The learning from this review is that professionals should have an unambiguous understanding of the NRM mechanism. They should also ensure there is a link to address child safeguarding and if appropriate, a disruption plan to ensure it is taken following a positive NRM reasonable grounds decision. The review author is of the opinion in respect of Child B and his involvement with the NRM that it was the right thing for professionals to do in his case at that time. The learning arising from his involvement in the NRM process is that a more comprehensive knowledge of the NRM is required by all professionals involved in safeguarding. The review author also feels that there is very relevant learning from the two points raised earlier in this report in relation to NRM that he has included from the Child Safeguarding Practice Review Panel report ‘It was hard to escape’. The One Day One Conversation is a strength for the partnership as is the EMPOWER U Hub. The learning from this review for the partnership is to ensure those young people who are 23 emerging into criminal exploitation or don’t have a current statutory intervention, have a method of being tracked with appropriate interventions actioned. Ensure appropriate use of the County Lines Vulnerability Tracker (CLVT) is being used as a live tracking of the risk that these young people are exposed to. Further learning is that all professionals look out for and understand when there is a ‘reachable moment’ in the young person’s lives. In order to understand this, further learning of Adverse Childhood Experiences12 and a trauma-informed approach may be of assistance. The influence of the two main youth urban street gangs in the relevant inner-city neighbourhood in Birmingham, were too great for Child A to resist. These two groups are made up of young people who are 14 to 19-year-olds. These young people were his peers and school friends that he had grown up with. These two youth gangs appear to be tasked by the adult Urban Street Gang and therefore also involve these children like Child A and Child B in ‘County Lines’ activity. Learning from this review makes it clear that partnership activity, including action to tackle serious youth violence and other activity that also involves agencies that operate outside of the immediate partnership such as the National Crime Agency and the Regional Organised Crime Unit, needs to robustly pursue adult gangs. If not, Child A and Child B will easily be replaced by the next children that the gangs can exploit. The Magistrates and Crown Court should be involved in keeping children safe from criminal exploitation. In the case of Child B, it appeared to be a revolving door as the court clearly felt or were not asked to consider remand in custody as a method of keeping him safe from the influence of ‘County Lines’ and gangs. The judge, by discharging Child B of all offences, just made it possible for him to continue being exploited. The Partnership should try and engage with Magistrates, the Judiciary and CPS through the Local Criminal Justice Board to discover and establish what role they can play in tackling Child Criminal Exploitation. The importance and powerful influence of what Carlene Firmin describes as ‘Place’ for where children live, visit, and grow up is important for professionals to understand in order to try and safeguard them from criminal exploitation and to divert them from getting involved in criminality. The strategic targeting of the ‘Place’, in this case is the relevant inner-city neighbourhood in Birmingham and is important in order to improve the environment for children in that area to safeguard them from CCE. Careful consideration of the moving of children and their families should take place, as just replacing the ‘place’ with another ‘place’ or where the draw of the original one might be too great for the child to resist, so they are continually returning. This was what happened in the case of Child B. It can of course be the best option to safeguard that child and their family for a move to take place. Although the review author fully understands why some exclusions take place with the overarching need to safeguard other pupils and staff from the behaviour of a child, educational exclusions are often a bad thing for that individual child. Other reviews and 12 The term 'Adverse Childhood Experiences ' is credited to Dr Vincent Filletti who carried out a study in the United States of over 17,000 people in the 1980's. His study was the first to identify the relationship between experiences in childhood and problems with health and social integration throughout a lifetime 24 research suggest that those excluded children are even more vulnerable to CCE. Both Child A and Child B were at significant times not in school. Another consideration could be the movement of the child to a school outside of the area, this may help to break friendship and gang groups, and it may also help to ensure that the child is kept in education. However, we also need to recognise the risk involved in this in terms of postcode and other gangs in other areas when you enter into their area could cause further risk. A review team member emphasises this further with a need for legal safeguarding processes to be in place to safeguard children from being excluded from school when there are links to criminal exploitation. So, they are not forced to leave school for behaviour that directly links to the exploitation. Within school there is also a need to recognise the impact of adverse childhood experiences by teachers and understanding of trauma on behaviour. Although not specific learning from the lives of Child A and Child B, it is important that learning from the review emphasises the importance of educating children to the dangers of both gangs and ‘County Lines’ needs to be co-ordinated and targeted to those of secondary school age, but with consideration to those in their last years of primary school. Another key feature of learning is the absence of any meaningful or insightful data from health agencies. This isn’t because the review didn’t look for it; this was because there was very little interaction by these boys with health agencies. The learning must be for health agencies to acknowledge that their time with the majority of children being subjected to criminal exploitation or part of a gang will probably be fleeting. They must ensure staff are aware of the signs of CCE, Gangs and Knife crime and try to intervene in those fleeting moments. That is why initiatives such as ‘Redthread’ are a credit to the partnership. Learning themes • The system to tackle Child Criminal Exploitation (CCE) needs hierarchical governance which is currently being provided by safeguarding children partnership and the community safety partnership through their co-chairing of the Contextual Safeguarding Board. Taking account of the drivers of exploitation and the overlay of Serious Youth Violence there needs a clear and effective strategy and operational response to tackle perpetrators of CCE and Serious Youth Violence. There needs to be agreement that this is then maintained and strengthened to provide system leadership, governance, and direction. • Professionals that work with tackling CCE to also know and understand the Serious Youth Violence strategy. • Keeping children safe from CCE involves engaging with their families to assist professionals to work with them. • The use of a ‘Think Family Approach’ is an important one to consider. • Children who go missing should have a return home interview, especially important in cases that it is suspected involve CCE. The information gained by BCT and the WMP should be shared with partners through the EMPOWER U Hub in a timely manner. • A more comprehensive knowledge of the NRM is required by all professionals involved in safeguarding children from CCE. The NRM decision should be made locally. 25 • The ‘One Day One Conversation’ is a strength for the partnership. Those children that fall outside the criteria for inclusion also need a similar robust process to safeguard them. • Professionals need to be alert to a ‘reachable moment’ for a child involved in CCE. • Professionals need to understand Adverse Childhood Experiences whilst they are still children and how to deal with these in a trauma informed approach. • The partnership and those agencies operating alongside them including regional resources need to ensure pursuit of adult gangs operating in the relevant inner-city area of Birmingham. • Professionals need to understand what ‘Place’ means to a child and how that influences their lives. • Being in education is seen as a safe place for children to be in, and any efforts to prevent exclusion where possible would be a good preventative move. • Educating children as to the dangers of knives and being involved in gangs and serious youth violence can be beneficial to prevent future exploitation. If necessary, this awareness raising to take place in the last years of primary school as well as secondary schools. • The Partnership would benefit from engaging with Magistrates, the Judiciary and Crown Prosecution Services through the Local Criminal Justice Board to discover and establish what role they can play in tackling Child Criminal Exploitation. • Health Agencies will only have limited occasions to intervene, and if possible, should capitalise on them. • The ‘benchmarking exercise’ against the national review it was ‘hard to escape’ findings was important to assess what needs to be done in the short term and long term, with reviews required during the next 12 months to chart progress against the action plan developed and establish the learning further. |
NC52642 | Death of a 4-week-old girl while co-sleeping with her mother. The services provided to Child AK's siblings are included in the scope. Learning themes include: the risks posed by neglect; the impact of neglect on the children's lived experience; family dynamics and the role of the fathers in the lives of children; the impact of domestic abuse on children; understanding the risk of physical harm within a family, especially with regards to 'physical chastisement'; the risks of substance misuse within the family; the impact of Covid-19 restrictions; use of language by services, practitioners and managers. Recommendations for the partnership include: the revised Norfolk graded care profile (GCP) must be used when there are concerns about child neglect and an audit of neglect cases from across the child's journey used to assess how it impacts on planning and interventions within 12 months; babies born into large sibling groups receiving interventions should be recognised as increasingly at risk; to produce and promote sector specific good practice guides on working with fathers and father figures; to write a position statement about 'physical chastisement' and substance misuse and be clear about how to promote and endorse these; professionals should be mindful of the extent of current and historic substance misuse and the impact on the unborn child as well as any existing sibling groups, including financial impact, parental ability to regulate mood and neglectful and/or emotionally abusive parenting.
| Title: Child safeguarding practice review: Child AK. LSCB: Norfolk Safeguarding Children Partnership Author: Bridget Griffin Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 NSCP CSPR AK Final Report January 2023 Norfolk Safeguarding Children Partnership Child Safeguarding Practice Review Child AK January 2023 2 NSCP CSPR AK Final Report January 2023 Introduction Norfolk Safeguarding Children Partnership were notified of the sad death of Child AK. At the point of referral, it was suspected that Child AK died as a result of overlay1 whilst in her mother’s care; mother was allegedly under the influence of drugs and alcohol at the time. The Rapid Review2 that took place following Child AK’s death concluded that the criteria for a Child Safeguarding Practice Review (CSPR) had been met and that a deeper analysis was likely to highlight important learning for the local area. Norfolk Safeguarding Children’s Partnership (NSCP) agreed that a CSPR should commence. At the latter stages of this CSPR, the inquest took place. The coroner recorded an ‘Open Conclusion’3 as to the cause of death. Methodology This CSPR has complied with relevant guidance4; relevant information has been supplied by agencies involved in providing services to Child AK and her family; a panel of agency representatives, who had no direct involvement in the services provided, has met on several occasions; the perspectives of practitioners has been gained, and family members have given their views. An independent lead reviewer has authored this report.5 Scope The scope of this CSPR covers a period of one year which includes mother’s pregnancy until Child AK’s sad death. Agencies were asked to consider significant events prior to this timeline. The services provided to Child AK’s siblings are included in the scope. The circumstances of Child AK’s death Child AK was born at full term with no additional needs. At the time of her birth, and discharge home, national restrictions remained in place as a result of the coronavirus pandemic. Child AK was four weeks of age at the time of her death. Mother had been caring for Child AK during the day and had attended a family celebration when she had consumed alcohol and smoked cannabis before sleeping in the same bed as Child AK that evening. A criminal investigation, commenced at the time of Child AK’s death, concluded that no further action would be taken. The family Child AK was born into a five-member family which included her mother, her two brothers (brothers 1 & 2) and two sisters (sisters 1 & 2). At the time of Child AK’s death, brother 1 was fourteen, sister 1 twelve, brother 2 nine, and sister 2 was six. The children all have different fathers, these five fathers have been variously involved in caring for the children. The two youngest children in the family have additional needs, brother 2 is profoundly deaf, 1 The definition of overlay: something placed on top of something else – in this case it was suspected that mother may have unintentionally laid over Child AK whilst they were asleep 2 After notification of a significant safeguarding incident, local safeguarding children’s partnerships may decide to convene a Rapid Reviews. The core functions of a RR is to; gather the facts about the case, as far as they can be readily established at the time, discuss whether there is any immediate action needed to ensure children's safety, share any learning appropriately and decide whether the criteria for a CSPR is met. 3 An Open Conclusion is given where there is insufficient evidence to prove any other conclusion. 4 Working Together to Safeguard Children. HMG 2018 5 Bridget Griffin CQSW, BA, MA 3 NSCP CSPR AK Final Report January 2023 and sister 2 has significant learning needs. Both have Education, Health and Care Plans (EHCPs).The family are white British, the extended family originate from Norfolk. The family live in an area of relative deprivation. Summary of multi-agency involvement There have been various multi-agency services involved in the lives of the children from a young age. Concerns about neglect in maternal care have been the focus of these concerns. There have been long standing concerns about the misuse of drugs and alcohol by mother, and some of the fathers, alongside concerns about maternal emotional wellbeing, ‘physical chastisement’ and domestic abuse. It was noted in the Rapid Review that these concerns have not altered from the original involvement of services, several of these concerns remain to date. Multi-agency involvement over a period of at least ten years has been considerable and has included: - Extensive pastoral support provided by the primary schools attended by the siblings – the breadth and depth of this support remains in place for brother 2 and sister 2 . - Continuity of teaching assistants for brother 2 through his transition and attendance at a new primary school - Significant support in place for brother 1 & sister 1 at their secondary school - Various periods of involvement by Children’s Services. Child protection or child in need plans have been in place at different times over the children’s lives. Considerable support has been provided by various social workers and intensive family support workers. Children’s services remain involved. - Extensive support provided by teachers for the deaf, audiology and ophthalmology departments. - Intensive speech and language support has been in place for brother 2 and more recently for sister 2 - Brother 2 and sister 2 have Education, Health and Care plans (EHCPs) in place and are provided with significant additional support to assist in their learning and development - Health visitors, midwives and GPs have provided support throughout The family have been in what has been described as immense grief since the death of Child AK. Extensive support has been provided to the family as whole, and to individual members, to support them in coping with this very significant bereavement. Bereavement support became the focus of multi-agency involvement for some time after Child AK’s death. Key Themes The key themes identified in this CSPR are set out using the terms of reference agreed by NSCP. 1.To what extent did the multi-agency network understand, assess, and respond to neglect as a risk to this family, including to a newborn baby? What impact did neglect have on the children’s lived experience? 4 NSCP CSPR AK Final Report January 2023 Cumulative harm is a series or pattern of harmful events and experiences that may be historical, or ongoing, with the strong possibility of the risk factors being multiple, interrelated, and co-existing over critical developmental periods.6 The Rapid Review describes this case as involving chronic neglect over several years and almost without exception, practitioners spoke about this being a family where the children have experienced long term neglect. Reviewing agency records, and speaking to practitioners as part of this CSPR, reveals the absence of a joint multi-agency understanding and approach to this family and little agreement about how to respond to the neglect the children have experienced. At the final stages of this CSPR, a joint multi-agency plan has been agreed. However, during this CSPR the case was progressing through the stages of the professional escalation process to reach an agreement about how to proceed. The reasons for this are varied. During this CSPR, the following factors have been identified as influencing the position that had been reached. 1.1 Neglect is complex: It is not that… neglect is impossible to define, but that it cannot be defined in absolute terms. Like other forms of child maltreatment, neglect needs to be interpreted in context. 7 Nationally, it is well established that identifying, assessing, and responding to neglect remains challenging for multi-agency services. In responding to these challenges, multi-agency safeguarding practitioners have been supported by using an evidenced based practice model, and associated tools, to assess and respond to neglect. The preferred model in use nationally is the Graded Care Profile (GCP).8 The Norfolk safeguarding partnership promoted the use of the GCP in 2015: …the GCP is a tool to complement professional judgment. Used as a multi-agency tool, it will contribute to well informed decision-making based on clearly understood and well articulated concerns across different disciplines.9 The GCP was adopted in Norfolk in 2016. The GCP was not used to assess the neglect in this case, this meant that there was no shared multi-agency model used in responding to the children’s needs. The result was drift, indecision and fragmented multi-agency working. Practitioners who had known the family over many years spoke about the ‘start again syndrome’ being a feature of assessment and decision making. They spoke about being trained in using the GCP but their experience of using the GCP was rare. They said that the GCP was inconsistently used in Norfolk and there were challenges to implementing the tool at the time, including understanding the roles and responsibilities of the multi-agency professional network in terms of who would complete the GCP. It was identified that this may be partly due to the frequent flux/changes in the social work workforce in Norfolk and it was said that these issues remain a barrier to achieving good multi-agency work. In late 2019/early 2020 the Neglect Steering Group10 reviewed use of the GCP and actively sought to learn from the experience of other Safeguarding Children’s Partnerships in implementing this model. Learning from the experience of Hertfordshire, a revised GCP tool was adopted for use. During July – August 2021, 61 practitioners were trained in using the revised tool and a trial commenced. The recent GCP evaluation11 revealed that 20% of the trial cohort had used the GCP and concluded that the inconsistent use of the GCP remained 6 Psychology Developing practice: the child youth and family work journal 2007.P1 L. Bromfield, P. Gillingham, Daryl J. Higgins 7 Child Protection and Introduction. Beckett 2007. 8 The Graded Care Profile is an assessment tool that helps practitioners take a strengths-based approach to measuring the quality of care a child is receiving and supports them to identify neglect. The tool is licenced and promoted by the NSPCC. 9 Barnardo’s/Richardson July 2015. https://www.norfolklscb.org/wp-content/uploads/2016/07/GCP-Version-4.pdf 10 Now known as: The Neglect Strategy Implementation Group (NSIG). 11 Evaluating the Alternative Graded Care Profile trial – June 2022. 5 NSCP CSPR AK Final Report January 2023 a concern. NSCP continues to endorse the use of the GCP when safeguarding children from neglect: The [Partnership] has endorsed the use of the Graded Care Profile (GCP) as the assessment tool to be used in all cases where neglect has been identified. The tool should be used for assessment, planning, intervention and review. During the CSPR workshop involving members of the NSCP Priority Subgroups (Neglect & Protecting Babies), the GCP was discussed. The group recognised that some national challenges remain, particularly in relation to the consistent use of the GCP, but members of this group and the Panel were clear that research shows that it works and the benefits to children of using the GCP far outweigh the challenges. Several benefits of using the GCP were identified including: - a consistent clear view of the family to be maintained which can mitigate the risks of staff turnover - Helps to evidence issues / progress and measure progress. - Helps to show cumulative harm – makes neglect less nebulous - Helps to inform an effective plan and interventions - Supports an understanding of cumulative neglect – maintains a cumulative composite organisational memory without which the view of the harm is compromised by being in the “here and now” – by responding to crisis - Neglect as a word creates noise in system and does not describe a child’s experience of harm – without the GCP - there is an over emphasis on the parental voice and quick wins dominate practice 1.2 Understanding the risks posed by neglect requires the uniqueness of each child to be kept in view Brother 1. Brother 1 attends a local secondary school, he is fifteen. He is described as engaging well with school staff and no significant concerns have been identified. School staff have said that he has often been tearful and seeks support from trusted adults when needed, although he is not happy to share what is on his mind – he has written down that he often feels sick and describes as wanting to kill himself at the thought of coming to school although says he does not feel like this at home. In his history there has been an occasion of deliberate self–harm and concern about his sexual vulnerability. He is described by his school as lacking confidence in his ability. Brother 1 has received extensive support from both his primary and secondary school who have provided consistent and extensive support throughout his childhood. Sister 1. Sister 1 attends a local secondary school, she is thirteen. She is described as engaging well with school staff. Earlier this year there were concerns about Sister 1 wandering out of lessons and punching walls and doors – this behaviour improved over time although recently she has been suspended from school. School staff have been concerned about periods of self-harm. Sister 1 is described as having a close group of friends who try and support her with her mental health needs. She has stayed with her father and his partner on occasions during her childhood. They described her as a quiet unhappy child who struggled to know how to play with her step siblings/family members – preferring to isolate herself in her room. Sister 1 has spoken openly about feeling responsible for Child AK’s death – she described asking mother if she could care for Child AK when her mother attended the family event on the day of her death – she feels she should have made sure this happened. 6 NSCP CSPR AK Final Report January 2023 Brother 2: Brother 2 is ten, he attends a local primary school. Brother 2 is profoundly deaf. He receives extensive support to assist him in his learning and communication and says: I had an operation to have cochlear implants to help me hear. If I take off my cochlear implants, I can’t hear anything, but I can feel noise vibrations. I am shy and always late for school. A multitude of concerns have been expressed by his primary schools throughout his childhood. These concerns primarily relate to the lack of care and attention paid by his birth family to his hearing needs – his cochlear implants have been regularly missing/damaged, and he has persistently not been taken to audiology appointments.12 His mother and father have been repeatedly provided with opportunities to learn British sign language (BSL), but these opportunities have not been taken up - no one at home is able to communicate with brother 2. His development is delayed. Brother 2 has been provided with extensive support by school staff and teachers of the deaf – he is supported at school throughout the day by teaching assistants who have been with him for many years, both communicate with brother 2 using BSL. He regularly describes being hurt at home; this seems to largely relate to the shouting that he says often happens – Brother 2 understands this shouting through the body language he observes. He has tooth decay and head lice – and describes the head lice as spiders in my head. Despite repeated and consistent attempts to support his birth family to successfully treat this infestation – there has been little success. Brother 2 spends most of his time at home in his room playing games/accessing the internet and this has been a concern for the schools. He has described seeing dark shapes in his room and on one occasion described seeing a demon on the roof of the school. Brother 2 has recently started to hide in cupboards at school rather than attend his lessons. Throughout his childhood school staff have regularly raised concerns about the care he receives at home - consistent and persistent support is provided by school staff to meet his needs. Brother 2 describes liking quiet places and needing people to communicate with him by one person talking at a time and by using visual aids – he does not like shouting – loud noises hurt my ears. Sister 2. Sister 2 is eight, she attends the same primary school as brother 2. There have been consistent concerns about her cognitive development including her learning and speech and language and concerns about a chaotic home environment impacting on her emotional wellbeing/development. She is described as functioning two years below her chronological age. Sister 2 enjoys a close relationship with her paternal grandmother and stays with her and her father regularly – the care provided by paternal grandmother is regarded as good. Sister 2 says she wants her mother to get better13 and that she wants to live with her paternal grandmother. 12 School staff have ensured these appointments now happen in school when staff support Brother 2. . 13 Sister 2 and her siblings have often referred to wanting mum to get better – by this they mean for her to stop shouting and be happy. 7 NSCP CSPR AK Final Report January 2023 Child AK. Mother’s pregnancy with Child AK was not planned and there was delayed contact with ante-natal services. During pregnancy, mother presented at hospital with vomiting and dehydration. Child AK’s birth was uncomplicated and there were no concerns about any additional needs at birth. When Child AK and mother returned home, services had limited access to the family home as a result of the Coronavirus Pandemic. Consequently, her lived experiences were largely unknown to professionals. Her father described caring for Child AK at the maternal family home shortly after her birth - he described feeding, bathing and changing her and said he enjoyed undertaking these tasks and spending time with his daughter. Child AK was loved by her mother, father and siblings, who enjoyed having Child AK in the family and helped to care for her. Child AK was four weeks when she sadly died while in the care of her mother. All the children in this family have been described by school staff as ‘lovely’ and ‘delightful.’ Recent national reports14 have set out the pressing need to understand the lived experiences of children. This is relevant to all children and is of particular importance when assessing how neglect may impact on these lived experiences. Throughout the children’s lives, concerns have existed about; maternal emotional wellbeing, substance misuse, the impact of poor school attendance on the children’s learning and development, the lack of parental attendance at professional meetings, children not brought to important appointments relating to their health, wellbeing and development, use of ‘physical chastisement’ and a chaotic home environment (which has included various household visitors and episodes of domestic abuse). It has been, and is, widely acknowledged that the children in this family have a history of adverse life experiences attributable to chronic low-level neglect. It is clear there has been extensive support provided by multi-agency services, in particular schools, to fill the gaps in the parenting they have received at home to meet their needs. The question that has perpetually arisen, and has been the subject of professional disagreement, is: When should a higher threshold of intervention be used to safeguard the children? This question can only be answered by an evidence-based assessment that considers the unique needs of each child in the family and the specific impact of neglect on each child. The impact of neglect on adolescents. There is extensive research15 about the impact of long-term neglect on children which suggests that whilst a child’s experience of neglect may not be serious enough to take statutory action in their childhood’s - the longer-term outcome can manifest in behaviors seen during adolescence, which is shown to include mental health difficulties, poor academic achievements, substance misuse, and can increase the risk of sexual and/or criminal exploitation. The impact of neglect on younger children. Research about the impact of neglect on young children widely accepts that it has the potential to compromise the developing brain and a child’s development across a range of domains.16 It is also widely accepted that with the right kind of support from services, the extent of the impact on a child’s development can be reduced - persistent and consistent support has the potential to build resilience and improve outcomes. However, whilst there are some basic needs that are common to all children, as stated earlier, the unique needs of each child and the impact must be in clear view. Assessments and interventions must consider these unique needs by considering the 14 Such as: Annual Report 2020 Patterns in practice, key messages and 2021 work programme. Child safeguarding practice review panel 2021. The case for change - the independent review of children’s social care. Josh Mc Alister May 2022. 15 Understanding Adolescent Neglect: Troubled Teens A study of the links between parenting and adolescent neglect. November 2016. The Children’s Society. CORE-INFO: Neglect or emotional abuse in teenagers aged 13-18. NSPCC. https://www.norfolklscb.org/wp-content/uploads/2015/05/core-info-neglect-emotional-abuse-teenagers-13-18.pdf. That Difficult Age: Developing a more effective response to risks in adolescence: Evidence Scope (2014). Research in Practice 16 https://learning.nspcc.org.uk/child-health-development/childhood-trauma-brain-development. 8 NSCP CSPR AK Final Report January 2023 age, stage of development, gender, position in the family, any additional needs and how each child uniquely feels the experience of neglect. Brother 2 and sister 2 have significant additional needs. The impact of neglect on their childhood experiences, on short and long-term outcomes, is unique. The impact of neglect on babies. The risks to babies living in a household where neglect is a feature are unique. For older children, with no additional health needs, the risks are predominantly around short and long terms outcomes in health, wellbeing, and development. In households where there is a large sibling group, there is a risk that the unique risks to a baby can be minimised or overlooked. For babies, because of their complete dependency on care givers, the risks of living with neglect can be fatal. 17 Throughout this CSPR practitioners have spoken about the existence of low-level chronic neglect in this family but several struggled to articulate what this meant for each child. Ante-natal and post natal services seemed aware of the neglect and, when the risks of physical harm were discussed during this CSPR, these risks were understood. Parental education about household risks and safe sleeping were often discussed with mother18 but the risk of physical harm (resulting from domestic abuse, chaotic care giving, and a mother who used drugs and alcohol) was not raised within the multi-agency group as a specific concern about the potential of physical harm to a baby. Conclusion: Sadly, this CSPR was commissioned as a result of the death of a baby. Her death has led to a systemic overview of the harm the siblings have experienced and the services provided that may not have happened if a CSPR had not commenced. The pattern of multi-agency responses to the neglect in this case was characterized by responding to incidents of acute concern when they arose. Each period of intervention by Children’s Services appeared to be influenced by the view that this was a family known well and the parenting was seen as not quite good enough but not quite bad enough to lead to higher thresholds of intervention. The risks were not viewed through a lens that considered the changing context and dynamics of the risks within the family as they evolved. The Rapid Review highlighted that the overall pattern/ history of the children’s experiences was not considered in weighing the risks, and there was a repeated syndrome of starting again. As identified in national reports and in relevant CSPRs/Serious Case Reviews,19 this kind of approach to neglect is not specific to Norfolk. This CSPR has highlighted that the lack of an assessment using an evidence-based model/approach was the root cause. Finally, the perspective of parents/carers in these circumstances is critical. The children’s mother experienced many years of service intervention in family life; multiple practitioners were involved, and multiple tasks were set. Without a clear assessment about what needed to happen to achieve long term change; what were the priorities, what were the timescales and what were the consequences, it is perhaps reasonable that change has been difficult to achieve. Mother’s views are that she is thankful for the services that have been provided and that she could not have parented the children without them. However, she also described the multitude of services, practitioners, plans, tasks, and appointments as - overwhelming. A relevant Joint Targeted Area Inspection20 recommends a coordinated and strategic approach across all agencies and that both adult and child focused services need to look holistically at the whole family. At the learning workshop, members of the Protecting Babies subgroups in Norfolk identified that this approach is needed in Norfolk. 17 The Role of Neglect in Child Fatality and Serious Injury. Marian Brandon, Sue Bailey, Pippa Belderson, Birgit Larsson. First published: 27 August 2014. 18 Considerable work has been completed in Norfolk as part of the Protecting Babies Strategy to promote safer sleeping; Just One Norfolk provides easily accessible consistent messages; safer sleeping and the risks of co-sleeping have been made with parents and workforce training provided 19 Such as : Serious Case Review Hakeem. Birmingham Safeguarding Children’s Partnership 2022 20 Growing up neglected: a multi-agency response to older children. Joint Targeted Area Inspection. Ofsted. July 2018 9 NSCP CSPR AK Final Report January 2023 Recommendation 1. The revised Norfolk GCP must be used in cases of neglect with strong multi-agency leadership to ensure effective implementation. This should include agreeing clear roles and responsibilities for completing the Norfolk GCP in any safeguarding/care plan. Audit of neglect cases from across the child’s journey to test effective implementation and assess how it impacts on planning and interventions within 12 months of publication. Recommendation 2. Babies born into large (4+) sibling groups receiving interventions should be recognised as increasingly at risk; this should cover Early Help Assessments, Family Support, Child in Need and Child Protection Plans. This specific risk should be written into the Norfolk Threshold Guide. Risks should be made clear in records and tested through a dip sample audit within 12 months of publication. 2. Was there sufficient understanding of the family dynamics and the role of the fathers in the children’s lives? How well were they engaged and what support did they provide in the care of their own children and the family as a whole? The previous section has outlined how the evolving needs in the family were not considered as part of a dynamic risk assessment that considered the unique needs of the children. It is however important to recognise that a valid challenge to intervening in family life at a high level of threshold intervention in cases of neglect, such as legal proceedings, is that the current options available in state care for improving outcomes for children are poor.21 This poses challenging dilemmas for children’s social care and multi-agency services. However, it is important to move away from considering the options for children in binary terms (such as a child remaining at home with parents or removal into state care) and find flexible and creative solutions with the support of extended family and kinship. Josh MacAlister describes this as unlocking the potential of family networks and building a loving tribe.22 At the start of this CSPR, NSCP were keen to reflect on the local safeguarding landscape in light of the report published by the Child Safeguarding Practice Review Panel23 highlighting the lack of involvement by services with fathers/male care givers in the lives of children. Information was gathered from all agencies involved in this review to understand how much was known about the fathers and how much contact was had with them. It is clear from the information provided that whilst the fathers were known about, there was little information in agency records about the relationship with their children and contact details were rarely documented. During this CSPR, mother has been described as a ‘single mother.’ Describing, and perceiving, mother as a single carer has largely dominated agency records, the narrative of practitioners and discussions in panel. This description has been challenged on the basis that it is widely known that all the children have different fathers, all of whom have had some form of contact with their children. Some of the children have spent significant periods of time in their care, and at least two of the fathers have shown an ability to provide effective care. Four of the fathers were keen to share their perspectives as part of this CSPR. 21 The case for change – independent review of children’s social care, J. MacAlister 2021 22 The case for change – independent review of children’s social care, J. MacAlister 2021 23 “The Myth of Invisible Men” Safeguarding children under 1 from non-accidental injury caused by male carers Child Safeguarding Practice Review Panel. September 2021 10 NSCP CSPR AK Final Report January 2023 In Norfolk, Family Networking is described as an integral component to Signs of Safety24 practice, which involves delivering care and support through extended family networks. We know that young people grow more resilient and are more likely to achieve better outcomes when they have the support of a naturally connected network, yet this is one of the most underdeveloped areas in safeguarding. Family Network training has been provided to the workforce to provide search and engagement tools that both build and strengthen important connections for young people and their networks. In this case, Family Networking has not been successfully used to achieve the involvement of fathers and the extended family. A family group conference has attempted to include the extended maternal family (who mother has described as critical in supporting her care of the children) although this has proved problematic. It is understood that fully involving fathers in these meetings has been complicated to achieve and therefore has not yet been successful. Fathers have spoken about being involved in their children’s lives for many years but of not knowing what services have been involved or the nature of the concerns held. They spoke about not knowing what was expected of them/what they needed to do in order to – in the words of a father – co-parent their child, and how they might be supported to do so. Overall, what has emerged chimes with national findings: Many of the issues explored here reflect deeply engrained roles, stereotypes and expectations about men, women, and parenthood in our society. Notwithstanding major social changes, women continue to be regarded as the prime and sometimes only protective carer for their children…... The report also takes stock of how well safeguarding and other services engage with men. It sets out systemic weaknesses in the way that universal and specialist services operate. Too often, even if unwittingly, they enable men to be absent.25 A cultural shift is needed: Cultural change is never easy to achieve. It means taking an organisation-wide approach to including fathers and working with other agencies and joining up principles; it means starting with a belief that fathers matter too, and engaging them in the early years sector, schools, social services and health services.26 The view of the CSPR Panel is that this statement should read fathers are equally important and that including father’s should be a mantra of safeguarding practice - this is the cultural shift Norfolk is aiming for. The NSCP is responding to the Myth of Invisible Men report with a dedicated project lead to implement a three-year father inclusive strategy across the whole partnership to raise the visibility of fathers and improve the engagement of fathers in Universal, Early Help and Specialist Children’s Services. This strategy is taking a systemic approach using the four-tier model identified in the report to help improve the engagement and assessment of fathers and father figures as well as the support and challenge that is offered to them. Recommendation 3. The NSCP should produce and promote sector specific good practice guides on working with fathers and father figures and good practice in working with them, highlighting the expectations of all partner organisations around professional curiosity, engaging, assessing, recording and information sharing when working with all families. 24 The Signs of Safety® approach is a relationship-grounded, safety-organised approach to child protection practice, created by researching what works for professionals and families in building meaningful safety for vulnerable and at-risk children. 25 “The Myth of Invisible Men” Safeguarding children under 1 from non-accidental injury caused by male carers. The Child Safeguarding Practice Review Panel September 2021. 26 www.fatherhoodinstitute.org- The risks of excluding fathers. 11 NSCP CSPR AK Final Report January 2023 3. Was the history of domestic abuse fully explored and understood in terms of the impact on the sibling group? In the history of this family there have been incidents of domestic abuse. However, according to agency records, these incidents were not frequent. The children have been recognised as victims and provided with regular opportunities to speak about life at home, their testaments show that their experiences are not of frequent domestic abuse but of a volatile household where there are often arguments and ‘shouting.’ When domestic abuse incidents have occurred, these have been responded to by providing services to the children’s mother, and more recently to a father, and safety planning has taken place for the children. Recently, practitioners have identified a suitable specialist service for brother 1 and sister 1 to explore the impact of this domestic abuse and referrals have been made. However, the siblings have not accessed these specialist services. The reasons are multiple including the high level of needs in the family requiring the involvement of multiple services, the difficulty in securing engagement from mother, the ongoing cycle of service response to crisis and the recent death of Child AK. During this CSPR it was clear that practitioners understood the impact of domestic abuse on children and the recent work completed by the family support team and the emotional wellbeing support provided in schools has provided avenues for the children to speak about the impact of their lived experiences. Providing frequent opportunities for children to reach out to adults they trust to speak about their emotional worlds is in line with trauma informed practice. In cases such as this, it is a pragmatic response that fits with evidence-based practice.27 4. How was the risk of physical harm understood in the family? The risk of physical harm to Child AK because of neglect has been discussed previously. According to the records, and to practitioners, the risks to Child AK’s siblings of physical harm stem from the use of ‘physical chastisement.’ There are historical agency records detailing incidents of what has been termed ‘physical chastisement,’ one significant incident reported by brother 1 was concluded to be an incident of ‘physical chastisement’ although was not fully investigated. There have been later disclosures by brother 2 and sister 2 of being slapped and pushed by mother. Services were too quick to conclude these to be incidents of ‘physical chastisement’ with no clear rationale documented to show how these conclusions were reached. It is understood that there continues to be incidents of ‘physical chastisement.’ The reasoning behind the conclusion of ‘physical chastisement’ rather than physical abuse is now clearer, and work has been completed with mother by children’s services to improve her parenting and avoid resorting to ‘physical chastisement’ as a way of disciplining the children. Understanding and responding to the use of ‘physical chastisement’ by carers continues to be an area that presents challenges to the children’s workforce. Knowing how to assess the risks to children and how to respond has been raised in Serious Case Reviews/Child Safeguarding Practice Reviews.28 This confusion is not helped given that it is not completely outlawed under current legislation given that for criminal prosecutions for assault there is a defence of reasonable chastisement. This year Wales joined Scotland and 60 other countries across the world in no longer tolerating any physical violence against children, in the same way they don’t for adults. 27 Trauma-informed responses in relationship-based practice. Danny Taggart 2018. https://www.researchinpractice.org.uk/children/news-views/2018/june/trauma-informed-responses-in-relationship-based-practice. 28 NSPCC Repository. https://learning.nspcc.org.uk/case-reviews. 12 NSCP CSPR AK Final Report January 2023 The argument that England should follow suit has recently strengthened in recognition of the growing research that physical chastisement is linked to increased aggression in children, greater tolerance of violence and compromises a child’s development and wellbeing. Having reviewed 20 years of research on physical punishment, we can unequivocally say that the evidence is clear: physical punishment is harmful to children’s development and wellbeing.29 Recommendation 4. NSCP to write a position statement about ‘physical chastisement’ and substance misuse and be clear about how to promote and endorse these statements in practice. 5. How were the risks around substance misuse understood and addressed with the mother, fathers, and wider family network? Mother is described as ‘open’ when talking about her depression and her drug and alcohol use. In discussion with mother as part of this CSPR she was asked if she has understood what changes she needed to make in the parenting of her children. She was quick to identify that she needed to change her ‘drug habit’ and referred to the good work now being completed by The Matthew Project30 with brother 1 and sister 1. Services have been provided to a father, who is in regular contact with the family, to address drug use and it seems there is now a focus on mother’s drug use. It has been reported that mother has said that this is used to ‘self medicate.’ It has been suggested that mother’s drug use has been exacerbated by the tragic loss of Child AK. Practitioners were all clear that substance misuse has been an issue in the family for some time. However, prior to this point, there seemed to be little attention paid to the extent and impact of substance misuse on the mother, the fathers, the children, the family dynamics, and household functioning. Whilst the question posed by the terms of reference suggests that substance misuse by the wider family was an area of concern, little has been seen to suggest that this has been explored. References made by professionals to mother ‘self medicating’ on class A and B drugs, including her own disclosures, require further thought. Framing drug use in this way can enable open discussions to be had about use and perhaps reduces the shame that can often accompany the use of drugs that can perpetuate the cycle of addiction. This is an understandable and well researched31 way to work with addiction. However, when safeguarding children, of central importance is the need to appreciate the impact of drug misuse on them. This has not received sufficient attention in the past and is illustrated in the substance misuse by mother and sister 2’s father when caring for Child AK prior to her death. As identified earlier, neglect commonly poses a constellation of risks to children which can include living in households where carers are misusing substances. The Panel felt that this is something that can be normalized and rarely something that, in isolation, reaches a threshold for immediate intervention. The pressure on resources and the volume of demand 29 Dr Anja Heilmann, UCL Department of Epidemiology and Public Health https://www.nspcc.org.uk/about-us/news-opinion/2022/equal-protection-wales-england. 30 The Mathew project is a community organisation based in Norfolk that undertakes work with parents and children who are effected by drug use. 31 https://www.nhs.uk/live-well/addiction-support/drug-addiction-getting-help/ The shame of addiction. Owen Flanagan. Department of Philosophy, Duke University, Durham, NC, USA 2013. 13 NSCP CSPR AK Final Report January 2023 placed on safeguarding services can lead to multi-agency services addressing each risk when it emerges as an acute need. Research suggests that children are harmed by the cumulative nature of neglect which can include living in families where there is a chronic misuse of substances. The sheer complexity of assessing and responding to neglect in a system that is set up and proficient in safeguarding a child from immediate harm means that providing a response to the constellation of harm posed to children of chronic low-level neglect can risk being delayed. Conclusion: Children living with carers who misuse substances are likely to live through a continuum of experiences including - an inconsistent response to their needs and/or daily life that features a volatile and neglectful carer whose behavior is erratic, fearful, and difficult to predict. As stated previously, neglect is a constellation of risks - substance misuse may form part of this constellation as it did in this case. To assess the impact on children’s lived experiences, and intervene effectively, an evidenced based assessment framework is needed. The Graded Care Profile assessment framework and associated tools provide an opportunity to provide an effective response. Recommendation 5. Professionals working with pregnant mothers and fathers-to-be should be mindful of the extent of current and historic substance misuse and the impact on the unborn child as well as any existing sibling groups. This should include financial impact, parental ability to regulate mood and neglectful and/or emotionally abusive parenting. The Norfolk GCP should be used in response to these cases to measure impact over time and should be incorporated into the GCP audit. 6. What impact did work under Covid-19 restrictions have on the interventions put in place, the professionals’ ability to risk assess and the mother’s and fathers’ compliance? The scope of this CSPR has covered a period when national restrictions were in place as a result of the coronavirus pandemic. In summary, in August 2020 lockdown was in the process of easing – leisure and recreational facilities were re-opened. In October 2020, a second national lockdown commenced for four weeks – this eased but was followed by tier four restrictions coming into force towards the end of December 2020. This eased over the following months and by July 2021 all restrictions were lifted. Multi- agency services were clearly affected by the pandemic; some services were restricted; schools were only open to children classed as vulnerable, some workers were shielding, and home working was well established. The universal impact of the coronavirus on children and families has now been well documented, and the fact that the pandemic deepened existing inequalities (according to ethnicity, age and economic status) is well known. The family in this case live in an area of relative deprivation. There is no doubt that the pandemic compounded existing economic hardship and restricted access to resources. Inequality, resulting from living in a low-income household, remains a feature of the children’s lived experiences. In terms of service provision, it is clear that all services were flexible and creative in the ways the family were supported and the restrictions in place did not have a discernible impact on the ability of professionals to assess the risks. These risks were well known before the pandemic started. It is clear that professionals often struggled to access the home and the pandemic was often cited by mother as a reason why the children could not attend school, why appointments were not kept or why professionals could not access the home. In this climate, it is 14 NSCP CSPR AK Final Report January 2023 reasonable to assume that these reasons may have been valid - the pandemic was a context within which compliance could not be reliably assessed. For the purposes of this CSPR the key question is how ‘compliance’ was assessed and measured over time. As previously described, fathers were not held in view – their compliance was neither requested nor the subject of assessment. All practitioners have referred to a long history of ‘disguised compliance’ by mother. When practitioners were asked what this meant, it seemed to equate to mother agreeing to plans, decisions, goals and tasks but not following these through. This remains a concern to current practitioners and is given as the prime reason why progress has not been made in time for the children. As identified by members of the NSCP Protecting Babies subgroups, there are risks associated in using terms such as ‘disguised compliance’. The term in itself is felt to be a message to families reinforcing where the power lies in their relationship with services and, without a full assessment of what is getting in the way of services securing the engagement of families, using the term in isolation is of little use. The views of panel members were that using this term has become an accepted part of the safeguarding language; it is a term that is commonly used but conveys little meaning. In this case, there was no meaningful engagement. The view of panel members was that the nature of engagement should be described, and the extent of engagement measured exclusively on the outcomes for children. Language fills the void created in the absence of an effective evidenced based tool.32 Learning Point: Understanding a child’s world - paying attention to the language we use. Realities are socially constructed, constituted through language, and organised and maintained through narrative - Communication is the creation and exchange of meaning.33 The use of language by services, practitioners and managers has been an area identified by the NSCP Protecting Babies subgroup and panel members as requiring attention. It has been highlighted that certain terms or words can frequently be used in safeguarding work and a shared meaning assumed. The examples in this case were the terms ‘physical chastisement’ and ‘disguised compliance’. Another example cited by panel was using the term ‘good/poor attachment’. The importance of understanding a child’s lived experience by describing what is being observed was emphasised – doing so provides an opportunity to get beneath the surface to the heart of a child’s world - this correlates with the findings from national reviews.34 Conclusion This CSPR has identified service changes are needed when safeguarding children from neglect. However, it is important to note that had all these services been in place at the time, there is no guarantee that Child AK would be alive today. 32 Member of the Protecting Babies Subgroup NSCP 33 From the work of M White & D Epston 34 Such as : Child Protection in England. The Child Safeguarding Practice Review Panel 2022 15 NSCP CSPR AK Final Report January 2023 The support provided by services to this family have been immense. Mother has said how thankful she is for the support that has been provided. She is clear that without this support she would not have been able to care for her children. This case is a testament to the incredible work of schools in Norfolk, the work of health professionals, and to the recent services provided by children’s services that have filled the gaps in parental care. Throughout the years of intervention there have been times when there has been multi-agency disagreement about the level of statutory intervention needed to safeguard the children. During this CSPR, these professional differences have been resolved. A great deal of work has been completed to support mother to care for the children at home, some of this work has been successful. However, the lack of an evidenced based assessment at an early point, and throughout service intervention, contributed to a position that was reached which appeared to be binary – either the children should remain at home, or the children should be provided with state care. The positions taken on both sides of the multi-agency split that existed were reasonably informed by research - the outcomes for children in state care are poor and the children’s lived experiences of living with neglect are reasonably predicated to result in poor outcomes. The history shows that opportunities to take a robust approach to safeguard the children from neglect have been lost. This includes the effective assessment of the whole family network and particularly the assessment, support and challenge offered to the fathers. It is therefore perhaps understandable why a binary position was reached. To the credit of the multi-agency group, and use of an innovative multi-agency forum (Joint Agency Group Supervision) in Norfolk,35 creative and flexible approaches have now been negotiated across the multi-agency safeguarding system that fully considers the children’s needs in the short and long term and galvanises the multi-agency network, family, kinship and trusted adults to find a way forward. Learning point – Joint Agency Group Supervision (JAGS) In responding to learning from Serious Case Reviews/CSPRs, NSCP established multi-agency supervision forums known as JAGS. The purpose of JAGS across partner agencies is to provide a mechanism to reflect on cases which are very complex, including – but not exclusive to - cases which feel ‘stuck’, or are drifting. Joint supervision provides a reflective space for joint analysis of assessment information, an opportunity to explore what professionals know about the lived experience of the child and should help strengthen the relationship between professionals who are working together with families to secure the best outcomes for children. These forums are regarded by practitioners as a positive development that strengthens their work together. It was felt important to raise the profile of JAGS in Norfolk so that they continue to underpin multi-agency work and provide an opportunity for other areas to learn from NSCP experiences of developing such an important forum. 35 https://www.norfolklscb.org/about/policies-procedures/3-16-joint-agency-group-supervision-procedure/ 16 NSCP CSPR AK Final Report January 2023 Summary of Recommendations Recommendation 1. The revised Norfolk GCP must be used in cases of neglect with strong multi-agency leadership to ensure effective implementation. This should include agreeing clear roles and responsibilities for completing the Norfolk GCP in any safeguarding/care plan. Audit of neglect cases from across the child’s journey to test effective implementation and assess how it impacts on planning and interventions within 12 months of publication. Recommendation 2. Babies born into large (4+) sibling groups receiving interventions should be recognised as increasingly at risk; this should cover Early Help Assessments, Family Support, Child in Need and Child Protection Plans. This specific risk should be written into the Norfolk Threshold Guide. Risks should be made clear in records and tested through a dip sample audit within 12 months of publication. Recommendation 3. The NSCP should produce and promote sector specific good practice guides on working with fathers and father figures and good practice in working with them, highlighting the expectations of all partner organisations around professional curiosity, engaging, assessing, recording and information sharing when working with all families. Recommendation 4. NSCP to write a position statement about ‘physical chastisement’ and substance misuse and be clear about how to promote and endorse these statements in practice. Recommendation 5. Professionals working with pregnant mothers and fathers-to-be should be mindful of the extent of current and historic substance misuse and the impact on the unborn child as well as any existing sibling groups. This should include financial impact, parental ability to regulate mood and neglectful and/or emotionally abusive parenting. The Norfolk GCP should be used in response to these cases to measure impact over time and should be incorporated into the GCP audit. . |
NC048442 | Death of Baby J aged 4 weeks in summer 2014 owing to head injuries associated with being shaken. Baby J's father, FJ, was later convicted of manslaughter. Baby J's parents had both received support from mental health services prior to and after Baby J's birth. FJ had a history of domestic abuse with a previous partner and increasingly with Baby J's mother. He was the subject of a Non-Molestation Order in relation to his previous partner and their child. Both parents were homeless and living in separate hostels throughout the pregnancy although Baby J's mother moved to her parents after the birth. An initial assessment was carried out November 2012 and although recommended, a pre-birth risk assessment was not carried out. Findings include: no one agency had a full picture of the parents' history of mental health issues and drug and alcohol misuse; risk assessments did not provide the full picture; the risks posed by domestic abuse and coercive control by perpetrators were not understood; written agreements with families need to be monitored. Recommendations for all agencies included improving information sharing, communication and record keeping in relation to domestic abuse and mental health issues, and involving fathers in risk assessments.
| Title: Serious case review: Baby J. LSCB: Hull Safeguarding Children Board Author: Colleen Murphy and Linda Richardson Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Baby J November 2016 Last amendments March 2017 Hull SCR Baby J /Mar 2017 2 Contents 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 2. The circumstances which led to this Serious Case Review (SCR) 3. The approach used 4. Scope and Terms of Reference 5. The family’s perspective 6. Agency involvement with the family 7. Analysis and Findings ASP 1: The extent to which potential risks in this family were assessed and well understood by professionals /agencies ASP 2: The ways in which professionals communicated and worked collaboratively within a multi-agency context. ASP 3: The response of CSC to referrals and contacts from partner agencies ASP 4: The response by agencies in Hull to incidents of domestic abuse1 Appendix 1: The Findings and Issues for Hull Safeguarding Children Board Appendix 2: Actions identified in Agency Learning Reports Appendix 3: Relevant developments in Agencies since the period under review 1 In Hull, the term domestic abuse is preferred to domestic violence. The Review Team therefore made a decision to use this term wherever possible throughout this report. However, the recording and reporting systems in some agencies used the term ‘domestic violence’ at the time and this has necessitated its usage in some parts of this report. Hull SCR Baby J /Mar 2017 3 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 1.1. The main responsibilities of Local Safeguarding Children Boards (LSCBs)2 are to co-ordinate and ensure the effectiveness of the work of member agencies to safeguard children. The statutory guidance3 which accompanies legislation and which underpins the work of LSCBs is very clear in its expectation that LSCBs should maintain a local learning and improvement framework so that good practice can be identified and shared. 1.2. In situations where children die, and where abuse or neglect of the child is known or suspected, LSCBs are required to undertake a rigorous, objective analysis of what happened and why, to see if there are any lessons to be learnt which can be used to improve services in order to reduce the risk of future harm to children. There is an expectation that these processes, known as Serious Case Reviews (SCRs), should be transparent with the findings shared publicly. 2. The circumstances which led to this Serious Case Review (SCR) 2.1. Children’s Social Care (CSC) became involved with MJ (mother) and FJ (father) in spring 2013 when they were expecting their first child and there were concerns about the domestic abuse perpetrated by FJ against a previous partner, SS. CSC remained involved with the family until April 2014 when a decision was taken by CSC to end their involvement. 2.2. The couple’s second child, Baby J, was born to MJ and FJ in summer 2014. Four weeks after the birth, FJ and MJ took Baby J to hospital stating he was unresponsive. Hospital scans revealed significant bleeding inside the brain and eyes and further tests indicated that the baby’s injuries were a result of head trauma, associated with being violently shaken. Baby J died two days after being admitted to hospital. 2.3. Having considered the circumstances surrounding the life and death of Baby J, the Serious Case Review Sub-committee recommended to the Independent Chair of Hull Safeguarding Children Board (HSCB) that the criteria for undertaking a Serious Case Review were met. The Chair agreed with this recommendation and, as soon as the medical opinion about the cause of death was received in May 2015, confirmed that a SCR should be undertaken in respect of Baby J. 2.4. FJ was charged and convicted of manslaughter and received a custodial sentence of 8.5 years in relation to the death of his son. 3. The approach used 3.1. This SCR used a systems methodology to look at not only what happened to Baby J, but also to try and understand some of the factors that influenced why professionals acted as they did or why they did not act at all. Two independent reviewers, both of whom had experience of using a systems methodology, were commissioned to lead the serious case review process. Neither reviewer was employed in any capacity by the agencies involved in the review process, nor did they know the family prior to the review. 2 s14 of the Children Act 2004 3 Working Together to Safeguard Children 2015. HMSO Hull SCR Baby J /Mar 2017 4 3.2. A Review Team of senior professionals representing the agencies that were or had been involved with the family was established. Their role was to provide a source of high-level strategic information about their own agency and their involvement with Baby J’s family through their contributions to the SCR process and through the submission of an agency learning report. The Review Team gathered and analysed data, appraised practice and agreed the content of this report. The Review Team consisted of: Lead Reviewer (Chair) Colleen Murphy Independent Consultant4 Lead Reviewer Linda Richardson Independent Consultant Business Manager HSCB Professional Practice Officer HSCB Child Death Review Coordinator HSCB Senior Probation Officer Humberside, Lincolnshire and North Yorkshire Community Rehabilitation Company (CRC) Victims Manager / Senior Probation Officer National Probation Service Detective Inspector Lead for Child Protection, Humberside Police Named Midwife for Safeguarding/ Supervisor of Midwives Hull & East Yorkshire Hospitals NHS Trust Practice Manager Hostel Accommodation Provider Named Nurse for Safeguarding Children City Health Care Partnership (CHCP) Designated Nurse for Safeguarding Children NHS Hull Clinical Commissioning Group (CCG) Principal Social Worker Children, Young People & Family Services Hull City Council Named GP NHS Hull Clinical Commissioning Group (CCG) Domestic Abuse Services Manager City Safe & Early Intervention 3.3. A Practitioner’s group was also established which consisted of frontline professionals who worked directly with the family or who were known to other adults related to this SCR. Their openness and willingness to reflect on their work with this family contributed to much of the learning which has emerged from this review. The practitioner’s group consisted of: Midwives Hull & East Yorkshire Hospitals NHS Trust Hostel Worker Hostel Accommodation Provider GP Local Surgery Police Officer 1 and 2 Humberside Police Health Visitor City Health Care Partnership (CHCP) Probation Officer 1 National Probation Service Probation Officer 2 Humberside, Lincolnshire and North Yorkshire Community Rehabilitation Company (CRC) Women’s safety worker (Women’s Safety worker for period of review) National Probation Service Social Worker } Children, Young People & Family Services Manager } Hull City Council Family Practitioner } Mental Health Nurse Humber Foundation Trust Manager } Hull City Council Family Practitioner } 4 These consultants were independent of all the agencies involved and had prior experience of undertaking SCRs. Hull SCR Baby J /Mar 2017 5 Mental Health Nurse Humber Foundation Trust 3.4. Both parents, individually, offered their perspectives about their experiences and their views, together with those offered by the maternal grandfather, were welcome contributions to this report. 4. Scope and Terms of Reference 4.1. The Review Team agreed that the SCR would look at what happened between October 2012, when FJ began a new relationship with MJ, and September 2014 when Baby J died. Tentative lines of inquiry were centred on agencies’ understanding of, and responses to, domestic abuse, the extent to which agencies communicated with each other and the challenges for frontline practitioners in working with a mother who denies or is unable to acknowledge the abusive behaviours of her partner. The Review Team was also mindful of previous case and serious case reviews, which had taken place locally and nationally. 5. The family’s perspective FJ 1990 Father of Child SJ and Baby JSS SS (a previous partner of FJ with whom she had a child) MJ 1992 Mother of Child SJ and Baby J SJ 2013 Sibling of Baby J Baby J 2014 SUBJECT d.2014 MGM and MGF (MGPs) Maternal Grandmother and Maternal Grandfather (Maternal Grandparents) The perceptions of FJ 5.1. FJ met with representatives from HSCB who advised him about the SCR and he agreed to meet with the independent reviewers so his views and experiences could be represented in this report. A meeting took place in HMP Hull in June 2016. There were some specific issues highlighted during the conversation, which offer useful insights into work with males suspected or known to be violent towards partners. 5.2. FJ acknowledged the difficulty he had in controlling his emotions, especially his anger and frustration. He felt that police and social workers always saw him as a perpetrator and ‘someone who was violent’ and that because of this he was never given a fair hearing. He believed when he tried to give his version of what had happened between himself and MJ… ‘It was always with MJ, they didn’t bother with me’. FJ said that no one was interested enough to find out more about him or thought to check about whether he was a good father. He said the problem with his ex-partner was directly linked to her refusal to allow him contact with his son and this was the cause of all their arguments. 5.3. There was an acknowledgement by FJ that despite what they told social workers, he and MJ had been living together and not just for the ‘two days a week’ they told social workers. FJ said he didn’t understand why he could stay for two days but not move in and so he and MJ had pretended to go along with the arrangement. FJ also said that on the occasions when social workers called he was often in the bedroom listening to what was being said. He told the reviewers that MJ was struggling Hull SCR Baby J /Mar 2017 6 to cope and he needed to be there to help her look after Child SJ and then later Baby J. He said that he worried about how she looked after the children as ‘she smoked a lot of weed’. 5.4. FJ said the IDAP5 programme (with which he engaged between September 2013 and March 2014) was just ‘OK’ and although he learnt a few things, most of the input was about physical violence towards women and whilst he had used violence in fights with other males, he did not see himself as a man who was violent towards the women with whom he had been involved. FJ said he would have liked more help to understand and control his emotions, which he linked to the violence he had experienced in his childhood. The perceptions of MJ 5.5. MJ told the reviewers that she felt bad because she had not been honest with social workers and police officers about her relationship with FJ. She explained that when they first began seeing each other everything was fine and she had believed that it was the behaviour of SS, his previous partner, which made FJ behave as he did. However, once she became pregnant, she said that FJ began to be more controlling and although he ‘slapped’ her a few times, it was his angry outbursts and threats that she feared most. 5.6. MJ said that FJ became more abusive towards her as their relationship progressed especially when he had been drinking. He took her phone and money and threatened her that he would tell social workers that she was a bad mother and they would remove her children. MJ explained that she was unable to tell social workers what was happening, as she really believed that FJ would harm her or their child. MJ said that she knew of another child who had died following an attack by an abusive ex-partner and this had made her fearful about what FJ could do. 5.7. In response to queries by the reviewers, MJ said she didn’t think social workers could have done much more to help as FJ was always listening to what she said and he told her what to say when police came to the door. Referring to a bruise on her eyebrow seen before she gave birth to Baby J, MJ confirmed that this was caused by FJ but said she wouldn’t have admitted this to the midwife, no matter how sensitively she had been asked about it. She said that although she had different social workers visiting, she wasn’t sure if anything would have helped her talk about FJ and what he was like. 5.8. MGF was present with MJ when she met the reviewers. He expressed his anger that social workers did not do more to help MJ because they ‘knew what he was like’. He said they did not listen to him and his wife when they told them about the arguments. MGF said at first he thought FJ was OK but then he saw him lose his temper with Child SJ when trying to put on his coat and he saw a different side to him. MGF said he believed that FJ could easily dupe people into thinking he was OK and a good father. 5 The Integrated Domestic Abuse Programme (IDAP) is a nationally accredited community-based group work programme designed to reduce re-offending by male domestic abuse offenders. Hull SCR Baby J /Mar 2017 7 6. Agency involvement with the family Background Information 6.1. FJ had a son with SS, but the relationship ended in March 2012 following several domestic abuse incidents, which were reported to police and children’s social care. FJ continued to harass and threaten SS, and she obtained a Non-Molestation Order to prevent contact. FJ told his probation officer and social workers that his actions were solely in relation to SS preventing him having contact with their child. 6.2. In May 2012, FJ was referred by his GP for a mental health assessment. This assessment concluded that FJ needed help in managing and controlling his emotions, especially his anger. FJ had by then, self-referred to the Strength to Change6 programme, but although he was offered appointments, he did not attend or make further contact with the programme co-ordinators. Towards the end of the summer in 2012, following a breach of the court order, FJ was placed in police custody. As there were concerns about his mental state he was seen by the custody nurse who identified what appeared to be a correlation between FJ’s mental health and alcohol use. FJ declined the subsequent offer of a referral to a specialist service, and acknowledged that he had anger issues which he had experienced for most of his life and that he was discussing an ‘anger management programme’ with his probation officer. October 2012 – December 2012 6.3. According to police and probation reports, FJ continued to threaten and harass SS and consequently a DASH7 assessment was undertaken by a DAP8 worker which identified there was a ‘high risk’ 9 to SS from FJ. A referral was consequently made by the same DAP worker to MARAC10 and at a meeting in October 2012, the details of the DASH assessment were shared with the agencies present which included police and CSC. Risk management strategies were agreed to ensure SS and her child would be better protected from future threats or violence from FJ. When it became known that FJ was in a new relationship with MJ and she was pregnant, it was agreed that the DAP representative would make a formal referral to CSC. This action was undertaken and in 6 Strength to Change is a service to males who want to address their abusive behaviours 7 Domestic Abuse, Stalking and Honour based Violence (DASH) is risk assessment tool used by practitioners working with victims of domestic abuse to help them identify those who are at high risk of harm and whose cases should be referred to a Multi-Agency Risk Assessment Conference (MARAC) meeting in order to manage the risk. 8 Domestic Abuse Partnership is a multi-agency team which works to improve the safety of survivors and children in Hull through a coordinated and effective inter-agency response. 9 Risk Assessment Categorisation: Based on the OASys (Offender Assessment System developed by the Prison and Probation Services) Standard: - Current evidence does not indicate likelihood of causing serious harm. Medium: - There are identifiable indicators of risk of serious harm. The offender has the potential to cause serious harm but is unlikely to do so unless there is a change in circumstances, for example, failure to take medication, loss of accommodation, relationship breakdown, drug or alcohol misuse. High - There are identifiable indicators of risk of serious harm. The potential event could happen at any time and the impact would be serious. Risk of serious harm means ‘a risk which is life threatening and/or traumatic, and from which recovery, whether physical or psychological, can be expected to be difficult or impossible’. (Home Office 2002 and OASys 2006): 10 A Multi- Agency Risk Assessment Conference (MARAC) is a local, multi-agency victim-focused meeting where information is shared on the highest risk cases of domestic violence and abuse between statutory and voluntary agencies so victim can be better protected. Hull SCR Baby J /Mar 2017 8 response, CSC took the decision to instigate an initial assessment. At the time MJ and FJ were living in separate hostels. 6.4. The decision by CSC to undertake the initial assessment was based on the information and concerns shared at MARAC - FJ’s domestic abuse, his controlling behaviours and the use of drugs and alcohol which exacerbated feelings of anger towards others. The assessment undertaken by DSW111 included contact with both hostels where MJ and FJ were living, the probation service, DAP, and the midwifery service who confirmed that MJ was pregnant and engaging with antenatal services. MJ was seen on one occasion and a telephone conversation took place with FJ to ascertain his views. 6.5. In November 2012, following another breach of the Non- Molestation Order, FJ was sentenced to a 24 month community order and was required to attend and complete the Integrated Domestic Abuse Programme (IDAP). 6.6. MJ told DSW1 that she was ‘shocked’ at the suggestion that FJ might pose a risk to her or to her unborn child. She acknowledged that he was hostile towards SS but said this was because he was refused access to his child and SS was to blame for this. Both MJ and FJ were described as being excited about the pregnancy and the assessment stated they ‘indicated a willingness to work with services’. DSW1 completed the initial assessment and recommended that a ‘Pre-Birth Assessment’ be undertaken ‘to ensure that FJ is fully committed to the IDAP and safety measures are in place whilst this is completed’. 6.7. As part of the preparations for FJ attending the IDAP programme, MJ was offered the support of a women’s safety worker and a visit was made to MJ in her hostel just before Christmas 2012. At this visit, MJ made it clear that she did not require any support and said that she thought FJ would attend the programme but only ‘to get it over with’. She told the link worker at the visit that she was pregnant but had not had any recent contact with CSC. The women’s safety worker forwarded a report to FJ’s offender manager (OM1) advising her of MJ’s pregnancy and stating that MJ seemed to have limited understanding of domestic abuse and had refused any further support. January – April 2013 6.8. In January 2013, two months after the initial assessment had been completed, the CSC team manager (TM1) transferred the case to a locality team for ‘further assessments’ to be undertaken. This decision was based on FJ not being allowed contact with his child from a previous relationship because of ‘significant domestic violence’ and because both he and MJ were living in hostels with neither having a permanent address. The case was passed onto the locality team, and although a decision was taken not to allocate a named worker, they were ‘supported by visits and contacts’ through the duty arrangements in place at the time. 6.9. In March 2013, staff in the hostel where FJ was living, contacted CSC to report a domestic abuse incident between the couple. CSC responded promptly and DSW2 contacted the caller and was told that FJ had taken MJ’s phone and keys after an argument and would not return them. DSW2 was also told that FJ and MJ were always arguing and there had been complaints by other residents and as a result MJ had left her hostel to return to live with her parents. MJ had asked staff at the hostel 11 There were several duty officers /social workers involved with the family during the period under review. For ease of reference these practitioners are referred to as duty social workers (DSW 1 – 9). Hull SCR Baby J /Mar 2017 9 not to report the incident to CSC, as she was worried they would ‘take her baby’. The response to this referral was a visit to MJ at the home of her parents and later, a telephone call to FJ. Both adults were then invited into the office where it was agreed that FJ should continue to work with IDAP, both adults would attend a parenting course and liaise with health professionals and MJ would continue to live with her parents until suitable accommodation was found. 6.10. The health visitor (HV1) saw MJ in the antenatal clinic in early April 2013, where she attended with her mother. HV1 later made a referral to CSC following information from MJ about FJ’s history. Health visiting records indicate that HV1 was informed by CSC that an assessment was to be undertaken. Information was received from CSC on 1.5.2013 and recorded in midwifery records, that a ‘pre-birth assessment’ had been undertaken following concerns about FJ and his ‘domestic violence’ towards a previous partner and a Child’s Plan had been formulated which confirmed that: When born, Baby J would live with MJ and her parents, there would be no restrictions in respect of FJ and contact with Baby J FJ would attend an IDAP programme Both parents would attend a parenting course. A written agreement specifying the expectations of the local authority would be put in place 6.11. Midwifery services were asked to advise the CSC locality team when Baby SJ was born and discharged with MJ. 6.12. At the end of April 2013, DSW2 and a community support team worker made an unannounced visit to see MJ at her parent’s home. As MJ did not have a named social worker, this duty visit was in line with interim arrangements in place at the time. CSC records indicate that FJ was present and said he and MJ saw each other for around 3 hours on a night and he occasionally stayed over with MJ at her parent’s home. FJ was still waiting for a start date to join the IDAP programme. FJ was told that whilst there were no restrictions in place in terms of contact with the baby when born, the local authority did have expectations about both parents’ engaging with professionals and if this did not happen then CSC would ensure any future contact with the baby would be supervised. 6.13. DSW2 returned the following day and the details of a written agreement were discussed and agreed with MJ, FJ, and the maternal grandparents. The agreement specified that FJ would continue to engage with the Probation Service and the IDAP programme; both parents would attend and engage in a nurturing parenting programme; MJ would engage with the women’s safety worker through IDAP; and, the parents would work with CSC and allow access to their baby following the birth. May – July 2013 6.14. Child SJ was born in May 2013 and discharged to the home of maternal grandparents with MJ, where the baby progressed well and met expected milestones. Visits by duty social workers and practitioners from the community support team were then made on a regular basis, as the case remained unallocated to a named worker. 6.15. Between May and June 2013, there were 4 visits from the health visiting service. As a result of MJ’s postnatal depression, she was offered an enhanced health visiting service, which at the time involved six ‘listening visits’ from the health visitor in addition to seeing the GP for medication if Hull SCR Baby J /Mar 2017 10 needed. MJ declined the offer of this service but accepted advice and support, which were offered by HV2. Due to other family members being present, HV2 was unable to make routine enquiries about domestic abuse until the third visit when she found MJ at home alone and without FJ being present. MJ denied there was a need for any concern and suggested the arguments between FJ and herself were trivial and she was often to blame. MJ confided that she was feeling low and had visited her GP. 6.16. The MGPs did not raise any concerns with social workers or the health visitor about the care of Child SJ, although records indicate they did describe the heated arguments that sometimes took place between the couple and they were left wondering how the couple would manage if they lived together. The MGPs told DSW3 on one occasion that it was sometimes difficult having their daughter living with them as it could be ‘chaos’ but DSW3 stressed the importance of their support for their daughter until she became more confident as a parent. MJ continued to stress that the arguments were just ‘bickering’ over trivial things and were often caused by her ‘mood swings’. 6.17. FJ told his offender manager (OM1) about the same time that the tensions in the home were between MJ and her parents and were ‘nothing to do with him’. HV1 continued to record that Child SJ was well cared for and thriving. The maternal grandparents moved house again about this time and MJ and Child SJ moved with them. FJ later told OM1 that he could not move in with the family. 6.18. Towards the end of July 2013, staff from FJ’s hostel again contacted the CSC locality team, to advise that the CCTV camera had picked up a worrying incident of MJ and FJ having a heated argument outside the hostel in the presence of Child SJ. An off-duty police officer witnessed the same argument and rang 999 to report the incident. According to police records, officers attended and spoke with both FJ and MJ following which MJ returned home with Child SJ, who had been asleep throughout the incident. The attending officers graded the incident as ‘standard risk’ using SPECSS12 risk assessment tool in place at the time and a Domestic Violence Form was completed. In reviewing the incident, the attending officers recorded that there were no previous incidents on record between the couple although they were aware that FJ did have a Non-Molestation Order in place with a ‘previous partner’. The records further stated that FJ told officers that MJ was struggling to cope with being a new mother and trying to find accommodation. He also said that MJ had postnatal depression but would not seek medical treatment. The Domestic Violence form was forwarded to the domestic violence unit and entered onto the records on 1st August 2013. The incident was not subject to a secondary risk assessment13 or shared with partner agencies. 6.19. DSW4 visited the following day, although the context of the duty arrangements meant that the practitioner had not met the family before so the extent of her knowledge about the family background was limited. MJ and Child SJ were seen and MJ again blamed herself for the argument, stating that she had been very snappy and was starting arguments with FJ over ‘silly things’. She told DSW4 that she was having a break from FJ for a few days and FJ ‘was OK with that’. FJ was not seen on this visit or contacted to discuss the incident. 12 SPECSS: Separation (child contact), Pregnancy (new birth), Escalation, Community isolation, Stalking harassment, Sexual abuse 13 Secondary Risk Assessments were introduced so that any incidents attended by police officers and identified as domestic abuse were reviewed by a senior officer taking into account known history and providing an overall risk assessment Hull SCR Baby J /Mar 2017 11 6.20. DSW4 visited MJ a few days later and again discussed the incident which MJ continued to describe as an argument over little things and linked it to her having ‘baby blues’. She confirmed she had an appointment with her GP. A few days later this visit was followed up by DSW3 and MJ repeated her assertion that the arguments between herself and FJ were her fault and said they were ‘alright’ now. Following this conversation, DSW3 consulted with the team manager (TM2) and subsequently made a referral to DAP; it was also confirmed that CSC would not provide a letter of support for the couple to gain a tenancy if MJ moved out of her parent’s home and that the previous plan - that FJ and MJ should not live together until FJ had completed the IDAP programme and a further assessment had been undertaken – would remain in place. 6.21. In response to the referral made by DSW3, DAP contacted police who confirmed that the recent incident had been a verbal argument and had been assessed as ‘standard risk’ and that they had been informed by MJ that the argument was linked to her ‘struggling with a new baby’. DAP, consequently, took no further action. 6.22. In late July, MJ was allocated a new health visitor, HV3. MJ told DSW5 during a visit that she had completed an application for a property with a [named] housing provider and that she knew FJ was not allowed to move in with her. She said relations between herself, FJ and her parents were good, and the maternal grandmother confirmed this to DSW5. FJ had just begun his IDAP programme and DSW5 advised MJ that in some circumstances when men undertook this programme there was an increased risk to their partners and children. MJ was advised she should report any incident to police and CSC. MJ said she did not think this would be an issue. 6.23. At the end of August 2013, FJ was arrested and charged with an affray following an argument with a family member. He was bailed until October and appears to have been dealt with by a conditional discharge, as there is no reference to a further order or other penalty. OM1 contacted FJ’s key worker in the IDAP programme and was informed that FJ was learning from the programme and finding it useful to manage situations more positively. Probation records state that FJ’s personal goal at this time was to be ‘the best parent he could be.’ MJ had not, however, responded to overtures from the women’s safety worker and, consequently, no work was undertaken with her. September – December 2013 6.24. Reports of FJ’s attendance at IDAP during September 2013 continue to suggest he was gaining insights into his behaviour and was making progress. This information was shared with CSC by OM1 at the end of October 2013. 6.25. Between September and October 2013, FJ made several visits to his GP and records and recall by the GP indicate that FJ said he had been in prison for the past year and he described his low mood, his history of domestic violence, and the situation with MJ and his past partner. He also indicated he did not live with MJ and his child. The records indicate that FJ told his GP that his ‘children were his only protective factor’. He was prescribed anti-depressant medication and referred to mental health services but did not keep the appointments offered. 6.26. A named social worker, DSW6 was allocated to the family during this period but only one visit took place with MJ and FJ before the worker took a lengthy period of sick leave, resulting in the family again being supported under duty arrangements. DSW7 visited the family mid-October and FJ self-reported he was making good progress on the IDAP programme. MJ said she had been offered her Hull SCR Baby J /Mar 2017 12 own property. Towards the end of October, MJ moved, with Child SJ, into this property and DSW8 made an unannounced visit the following day when MJ, FJ, and Child SJ were seen. The parents advised DSW8 that they wanted to live together and said that the written agreement did not state this could not happen. They said that FJ was spending two nights at the property and visiting every day to ‘help’. MJ said that FJ had unsupervised access to Child SJ whom he sometimes took to stay at his mother or sister’s house. DSW8 agreed to return to the office and check on details. 6.27. Following this visit, DSW8 referred back to the team manager’s decisions recorded in April 2013 and confirmed with TM2 that, although there were no contact restrictions in place, it was clearly stated that FJ should not move in until the IDAP programme had been completed. The couple had, however, stated that FJ was already staying over for two or three nights each week and FJ occasionally had sole responsibility for Child SJ. DSW8 made contact with HV3 who confirmed that she had no concerns about the care of Child SJ whilst MJ had been living with her parents and had been well supported by them. Contact was also made with OM1 who expressed no concerns and indicated that FJ was ‘progressing’. It is to be assumed that neither practitioner highlighted concerns about the couple’s ‘new’ living arrangements 6.28. In October 2013, MJ was prescribed anti-depressants by her GP and was referred to Single Point of Access14 (SPA) by her GP who was concerned about her weight loss and possible Post Natal Depression (PND). MJ met with a mental health practitioner but denied any problems with coping or depression and insisted the referral was due only to her weight loss. The contradiction between the GP’s referral and MJ’s presentation led the clinician to refer MJ for a mental health assessment, which took place in November 2013. However, the triage15 assessment appears to have focused only on the physical element of weight loss and did not explore any mental health concerns in relation to PND. 6.29. In November 2013, during a supervision session with DSW9, the team manager (TM3) in CSC determined that a core assessment (1) was required for this family, given that MJ was no longer living with her parents and had obtained a tenancy in her own right. DSW9 undertook the core assessment (1) and made a number of visits to the family. The assessment was completed in December 2013 and led to a decision by TM3 that, before CSC could close this case, a multi-agency core group16 should be convened. At this time, FJ had another 2 months before he completed his IDAP programme. January- March 2014 6.30. In January 2014, CSC implemented a new model for the delivery of social work services. The new structure consisted of small social work teams known as ‘Pods’; each led by a consultant social worker (CSW). DSW9 had supervision with CSW1 in January and the supervision records refer to the positive core assessment (1) that had recently been completed and noted that no worries or concerns had been raised by other agencies. The decision to convene a core group was also noted. 14 The Single Point of Access (SPA) service for Humberside provides a first point of contact for people aged 18 and over who have been referred to mental health services. 15 Mental health triage is a process which aims to assess and categorise the urgency of mental health related problems. 16 A core group is a meeting of relevant professionals and family members who come together to ensure that child in need or child protection plans are properly implemented and progress is regularly monitored and reviewed. Hull SCR Baby J /Mar 2017 13 By this time, however, it was known that MJ was pregnant with her second child and CSW1 requested DSW9 to complete a second core assessment (2) in respect of unborn Baby J. 6.31. The first core group meeting was held at the end of January 2014 and was attended by both parents, DSW9 and HV3. Probation had been invited but could not attend. The record of the core group meeting would suggest that the respective GPs and midwifery services were not invited, nor were they asked to contribute to the meeting. There were no concerns identified in relation to Child SJ’s health or development, and MJ’s family were described as being supportive. The only actions to emerge from this meeting were that MJ should continue with health appointments for herself and Child SJ, and FJ should continue with the IDAP programme. 6.32. In early March 2014, a reflective discussion about the family was held in the Pod team, led by CSW2. Drug and alcohol use were noted to be a feature in this family, but the discussion concluded that there was no evidence that these were impacting on family life. A decision was taken that, following further checks with the police and the IDAP programme, a final core group meeting should be held and, if all agencies agreed, CSC would close the case. 6.33. On the same day this discussion took place, police received an abandoned 999 call from the couple’s home address. Police officers attended the address and spoke to MJ and FJ. Both adults were described as being calm, and they confirmed there had been an argument but would not disclose to police what it had been about. The attending officers graded the incident as ‘standard risk’ and a domestic violence form was completed. Consent was provided by the couple for the information to be shared with other agencies. There is no record of whether Child SJ was seen by the officers, but police records indicate that FJ left the property. The domestic violence form was forwarded to the domestic violence unit the same day and entered onto the domestic violence recording system on the following day (5th March 2014). According to Police records, the incident was shared with CSC on the same day but this is not recorded in CSC case files and did not lead to a duty visit. 6.34. When MJ attended an antenatal appointment in March 2014, she advised the midwife that CSC were ‘closing the case’ and the midwife contacted the CSC social worker based at the hospital to confirm this information. She was advised that, although they were aware of MJ’s pregnancy, FJ had completed his IDAP programme, and as there had been no domestic abuse incidents, the case was in the process of being closed to CSC. The risks that FJ posed to others however remained unchanged and were still assessed as ‘medium’. 6.35. The women’s safety worker had attempted again to contact MJ to inform her about FJ’s progress in the IDAP programme and to obtain any feedback but there was no response to her efforts and the case was closed, as per usual practice. 6.36. Information was received by Probation mid-March 2014 that FJ had again been arrested for a breach of the Non-Molestation Order in respect of his previous partner. Later that month, a second core group meeting was held attended by DSW9, the health visitor, and the probation officer. According to the record of the meeting midwifery services were not asked to attend or to contribute to the meeting and, although FJ was present, MJ did not attend but the record of the meeting did not refer to her absence or the reason for it. Child SJ was again reported to be well. The information about FJ’s arrest was shared by OM1 at this meeting and FJ gave his own account Hull SCR Baby J /Mar 2017 14 of the incident, and said this had occurred as a result of a misunderstanding and he was required to attend the police station to explain what had happened. OM1 reported that there had been a ‘stabilisation of FJ’s emotional management’ over the last year and he had now completed the IDAP programme, and although he was required to undertake further work on a one to one basis with OM1 around anger and understanding the emotions of others, OM1 said that on completion of IDAP programmes ‘no-one comes away with no recommendations’. 6.37. The professionals who attended the core group agreed that CSC would close the case, pending the outcome of FJ attending the police station in respect of the reported incident. Those present, apart from FJ, were unaware of the abandoned 999 call and FJ did not share this information. He said that his use of cannabis had subsided and he did not often drink any more. Following this meeting, DSW9 made two further home visits; during the last visit FJ informed her that the police were to take no further action in relation to the incident which had led to his arrest. CSC closed the case on their records at the end of March 2014. 6.38. In April 2014, FJ’s case was transferred as part of a bulk transfer of cases from Humberside Probation Trust to the Community Rehabilitation Company, as the Probation Trust was being spilt into two separate agencies – The National Probation Service and the Community Rehabilitation Company (CRC). The management of FJ was consequently transferred from OM1 to a new offender manager (OM2). 6.39. Police arrested FJ for producing and possessing a controlled drug in May 2014, – this related to a small quantity of cannabis buds and cuttings. FJ admitted to possession of these substances and attended court the following month where he received a fine. 6.40. Two related incidents occurred between MJ and FJ in July 2014. The first was dealt with by two police community support officers who observed a heated argument in the community between the couple and intervened. MJ and FJ eventually agreed to go their separate ways and FJ agreed to take Child SJ and look after him for the evening. A second incident was later captured by CCTV operators during which both adults were again seen to be arguing in the street. Police officers attended the incident; FJ informed officers that he had just returned Child SJ to MJ as he had changed his mind about looking after the child and this had resulted in a further argument. Both adults stated they would stay with their respective families for the evening. 6.41. Both incidents were recorded on one domestic violence form and the form was finalised by the officer dealing with the second incident. The incidents were graded as ‘standard risk’. The record shows that the police were informed that although the parents were in a relationship they lived at separate addresses. The records also show that Child SJ was seen during these incidents and ‘appeared to be well.’ The domestic violence form was forwarded to the domestic violence unit and entered onto police systems on 29th July 2014. The incidents were not subject to a secondary risk assessment or shared with partner agencies. 6.42. On the 28 July 2014, the day before these incidents were recorded on the police system, an incident was reported to the police by a member of the public who stated that a female was shouting inside a property ‘he’s taking my baby’. Police officers attended the address and spoke with both MJ and FJ. Child SJ was noted to be present at the address. There is limited information on the incident log, which recorded the incident as a ‘verbal argument’ between the adults, both of Hull SCR Baby J /Mar 2017 15 whom lived separately. The officers gave advice and graded the incident as ‘standard risk’. A domestic violence form was again completed. The only information recorded on the risk assessment is in relation to Child SJ, which states that the couple have one child who lives with MJ and that she is currently pregnant and due to have her second child in six weeks. The domestic violence form was completed and forwarded to the domestic violence unit and entered onto police systems on 7th August 2014. The incident was not subject to a secondary risk assessment and was not shared with partner agencies. The record shows that a DAP booklet was posted to MJ which she later returned insisting she was ‘not a victim’. 6.43. Baby J was born at the end of August 2014 and discharged to MJ’s care. MW2 visited and noted that Baby J appeared well. After three unsuccessful attempts to visit the family, MW2 eventually gained access to the family again, 3 days later. Child SJ and FJ were present. Baby J woke up and despite crying ‘inconsolably’, FJ picked him up only after being encouraged to do so by the midwife. MW2 was concerned that the family needed support and left a message with the duty health visitor as HV3 was on leave. 6.44. MJ attended for a postnatal check 5 days later and MW3 noticed a bruise to MJ’s left eyebrow. Records indicate that the midwife decided not to ask about the bruise directly as MJ appeared ‘withdrawn and reluctant to talk’ and she thought MJ might be more forthcoming in response to more routine questions about domestic abuse. MJ simply replied ‘No, never’ to the questions asked about possible domestic abuse. She said she was feeling unwell and dizzy and was therefore referred by MW3 to her GP. No concerns were noted in respect of Baby J who appeared well. MJ advised MW3 that she had been taking cannabis the night before and this had left her feeling unwell. MJ did not keep her appointment with the GP and later suggested there was some confusion over the appointment time. 6.45. There were two related incidents reported to the police on 17.9.2014. The first of these was reported by an anonymous caller ringing 999 just after midnight and stating there had been shouting at a flat since 20.30 hours and they had heard a woman shouting – ‘You f… woman beater’. The caller believed that young children were living in the property as they heard crying but they had no details of who the children or occupants were. The caller said this was a regular occurrence and they had reported it to their housing provider who had advised them to keep a diary, which they had done since March 2014. 6.46. Police attended a block of flats about 15 minutes later but had no means of identifying which property within the 3-storey block the caller had been referring to. Although some windows were open in the block there was no sound of shouting or any disturbance. There were no means of the police entering the block of flats other than to force entry or ring individual flats for more information. Neither action was considered appropriate as all was quiet and there were no sounds of a disturbance taking place. 6.47. Completion of the incident log was delayed for welfare enquiries to be undertaken later that morning. However, at 02.30 hrs, police received a call from FJ stating that his girlfriend was shouting and screaming in the street; during the contact, a female could be heard shouting and crying in the background. FJ informed police they had a new-born baby in the house, police officers attended the property and gained access where they spoke with both FJ and MJ. The attending officers graded the incident as ‘standard risk’. The risk assessment records state that the couple Hull SCR Baby J /Mar 2017 16 argued on a regular basis, possibly due to them having two very young children close in age and they were tired from lack of sleep. The records state that the couple had been in a relationship for two years and, whilst there had been no physical assaults, MJ had said she felt angry towards FJ because he was always criticising her for being a bad mother. 6.48. The risk assessment showed that the attending officers saw both children. Child SJ was asleep on the living room settee and Baby J was asleep in the pram in the living room, and although they had been present when both parents were arguing, they were described as being fast asleep when officers arrived and it was concluded that they had been ‘unaffected’ by the arguing. The domestic violence form was forwarded to the domestic violence unit and was recorded on police systems on 24th September 2014. 6.49. On the 23 September 2014, Baby J was found unresponsive by FJ and was taken to hospital. Baby J died two days later. 7. Analysis and Findings 7.1. This analysis is based on discussions in the Review Team and with practitioners, the individual agency contributions to the Review and research information accessed by the lead reviewers. The analysis also takes into account learning from local and national SCRs and the recently published triennial analysis of SCRs. 17 7.2. The examination of single and multi-agency working leading up to the death of Baby J has identified several areas of learning for agencies, together with some reflections about how judgments were applied at key points of interventions. The analysis is structured around four areas of significant practice (ASPs), which lead to the findings and identification of common thematic issues. The ASPs are listed below and further details follow. ASP 1: The extent to which potential risks in this family were assessed and well understood by professionals /agencies ASP 2: The ways in which professionals communicated and worked collaboratively within a multi-agency context. ASP 3: The response of CSC to referrals and contacts from partner agencies ASP 4: The response by agencies in Hull to incidents of domestic abuse 7.3. ASP 1: To what extent were potential risks in this family assessed and understood by professionals /agencies No one agency held the full picture of FJ’s history, or that of MJ, so important information about the parents’ mental health and use of drugs and alcohol was not shared and, consequently, these aspects were not considered alongside concerns about domestic abuse. This left potential risks to the children unexplored. Professionals viewed FJ’s attendance and completion of the IDAP as a significant safety measure and concluded when the programme had been completed that risks were reduced. The prediction of future harm is highly complex and the assessment in this case would have 17 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014: Final report May 2016.Peter Sidebotham, Marian Brandon et al. Hull SCR Baby J /Mar 2017 17 been enhanced by the use of risk assessment tools by the practitioners working with the adults in the family. Had assessments been more robust, the risks associated with FJ’s behaviour and MJ’s minimisation of those risks might have been better understood and the need for safety plans for Baby J recognised and acted upon. Assessing Risk 7.3.1 There is an extensive body of evidence that shows how parental problems such as domestic abuse, substance misuse and mental health problems can undermine parenting capability and increase the likelihood of significant harm to children. Research18 continues to emphasise the importance of understanding and acting on concerns about children’s safety and welfare when they are living in households where these parental problems are present. Although such problems in families do not preclude caring and effective parenting, research suggests that it is where these multiple problems interlock and interact as a ‘toxic trio’ that there is a substantially increased risk that children will be exposed to maltreatment and suffer significant harm. 7.3.2 FJ was referred to in agency records as a perpetrator of domestic abuse. He was discussed at a MARAC meeting which, by definition, identified the risk he posed to SS, his previous partner, as ‘high’. At the time, FJ was also on remand having repeatedly breached a Non-Molestation Order in respect of SS. 7.3.3 Munro (2008) writes the ‘best guide to future behaviour is past behaviour’ and suggests that without evidence of different dynamics or changed behaviour in families, professionals should always consider the likelihood that past behaviours will re-emerge under certain circumstances. The Review Team was told by most practitioners that, as far as they were aware, FJ’s behaviour was changing as a result of the IDAP programme and not only had there been no ‘domestic abuse’ incidents reported between the couple, MJ had also described their arguments as ‘trivial ‘and ‘silly’ and said that abuse was not a factor in their relationship. 7.3.4 Research studies 19 suggest, whilst individuals may change, where domestic abuse is concerned change is probably the exception rather than the rule: it takes time, and in itself is not always easy to recognise or measure. Women may also minimise the risks experienced by themselves in response to threats and coercion from their partner, or as a means of ensuring that their children are not removed from their care by statutory agencies. In its ‘Practice briefing for social workers and family support workers’ in relation to the learning about domestic abuse from serious case reviews, Research in Practice states that: ‘many mothers suffer[ed] cumulative harm that made it difficult for them to disclose the abuse, access services, leave a violent man or protect their children. Assurances that a violent man has changed or does not present a risk to children should be treated with scepticism; violence does not usually stop without intervention’. (2016) 18 Brandon, M., Bailey, S. and Belderson, P. (2010) Building on the learning from serious case reviews: Child abuse: Parental mental illness, learning disability, substance misuse and domestic violence (2011)Cleaver, Unell and Aldgate; 19 Research in Practice is a charity which brings research and practitioner expertise to build the sector’s capacity for evidence- informed practice. Hull SCR Baby J /Mar 2017 18 7.3.5 The Review Team was of the view that FJ’s attendance and completion of the IDAP programme was very much regarded as a ‘safety measure’ and, by default, viewed as a form of ‘intervention’. IDAP is a cognitive-behavioural programme, which challenges convicted offenders’ attitudes and beliefs in order to change their behaviour. Men are referred to the programme on the basis of a pre-sentence report recommendation but the programme is not considered suitable for all those with relevant convictions. An offender manager assesses suitability on the basis of a risk assessment, age, level of drug and/or alcohol dependency, literacy, and crucially, the level of motivation. It is not, however, a programme designed to improve parental capacity. Whilst it touches on issues of responsible parenting, it does not equip offenders with the skills required for safe and responsive parenting. The core group’s assumption that FJ’s compliance with the IDAP programme equated with safety measures for both Child SJ and Baby J obscured and minimised the risks which, had they been known and fully assessed, were evident both before and after the birth of Baby J. 7.3.6 Health and CSC practitioners told the Review Team that they were unfamiliar with IDAP but believed that FJ’s compliance and completion of the programme was a strength within the family. Whilst right to view FJ’s commitment as a strength, the assumption that completion of the course meant FJ was less of a risk to his children was mistaken and was neither tested nor measured. Significantly, no actual ‘work’ or ‘intervention’ was undertaken with the parents during this period so professionals were left with a misplaced confidence that the IDAP programme, together with the (required) separation of the couple, were adequate safety measures to address the perceived risks from FJ. 7.3.7 The emphasis on the parents not living together whilst the IDAP was being undertaken was regarded as an additional safeguard. However, enforced separations do not take into consideration the emotional and psychological aspects of a relationship and without any additional work with parents, such ‘ties’ were left unassessed and the couple, perhaps inevitably, sought ways to be together because they did not understand why they should live apart. The Review Team was of the view that the decision to require the couple to live separately was not a safety measure, but it did provide a degree of reassurance to social workers. In effect, the couple began living together when MJ moved into her own accommodation and both parents admitted independently that they deliberately gave the impression of living separately, but remained puzzled by the fact that CSC said they could not live together as a family yet it was acceptable for FJ to stay over for two or three nights a week. 7.3.8 Munro 20states that making ‘decisions in conditions of uncertainty’ (i.e. risk taking) is a core requirement for professionals working with children. The challenge of assessments, however, is predicting the likelihood of risk where both risk and uncertainty are key features. Given his past history, it should have been predicted that FJ would be ‘more likely than not’ to continue with his abusive behaviour in a new relationship; the extent to which the IDAP would help him to manage his emotions and behave differently was certainly far less predictable, yet this was accepted as a given. Had this issue been raised and explored in any depth, the limitations of this programme as a 20 The Munro Review of Child Protection: Final Report: A child-centred system 2011 DfE Hull SCR Baby J /Mar 2017 19 safety measure might have been better understood. The Review Team was also of the view that, had the core group been more curious about FJ and sought more detailed information from key professionals who knew him, it is highly likely that the emergent chronology would have highlighted incidents and significant patterns of behavior, which would have better informed their subsequent decision-making. 7.3.9 FJ was a known domestic abuse perpetrator; both parents had been referred to mental health services; and both were open about cannabis use. FJ was also known to drink heavily at times which was known to adversely impact on his behaviour. These features are viewed as indicators of increased risk of harm to children and young people but the extent to which all three features were present in this family was not known and this impacted upon the assessment and quality of decision-making. 7.3.10 ‘Healthy scepticism’, ‘professional curiosity’ and ‘respectful uncertainty’ are all phrases associated with good quality child protection work. The absence of any ‘healthy scepticism’ prevented practitioners from seeking out ‘missing’ information to confirm their views or what they had been told by FJ and MJ. Critical and analytical thinking encourages practitioners to process information rigorously and methodically and to question the reliability of both sources and content. This is an essential component of risk assessments but it did not happen in work with this family and the Review Team learnt from practitioners that this view was linked to the parent’s apparent co-operation and the absence of any concerns about Child SJ, together with a pre-conceived view as to what ‘domestic abuse’ looked like. The context, content and concerns of the original referral to CSC through MARAC were lost as professionals worked independently and assessed risk only in terms of their own perspective. Finding 1: Without a clear system for linking MARAC assessments to police call-outs and family work, the risks posed by perpetrators of domestic abuse may not be well understood. Understanding the nature of Domestic Abuse 7.3.11 There are conflicting recorded accounts as to whether FJ was physically violent towards his previous partner and MJ said that FJ had never, and would never, physically assault her. She also insisted to the DAP worker that she ‘was not a victim’. There was, however, evidence of FJ’s controlling and coercive behaviours towards MJ, which research suggests is not only ‘the most common context in which women are abused, it is also the most dangerous.’21 The Review Team found that the absence of any evidence to suggest that FJ was physically violent towards MJ, together with her denial that it occurred, led practitioners who knew about FJ’s background to underestimate the risk of domestic abuse as a factor in their relationship. 7.3.12 Practitioners confirmed in discussions that had MJ presented with bruises and injuries, agency responses might well have been different. Police confirmed that their response would also have been different if signs of physical injuries had been seen and confirmed that at that time, officers handled verbal arguments differently to incidents of physical violence. The probation officer recorded that there was no evidence of physical violence towards previous partners and that FJ demonstrated ‘mainly controlling behaviours within his relationships’. The records also state ‘there 21 Evan Stark (2007),’ Coercive Control. How Men Entrap Women in Personal Life.’ Oxford University Press Hull SCR Baby J /Mar 2017 20 was no domestic violence between FJ and MJ’, a view repeated in CSC assessments which referred to FJ’s past behaviours but which did not take into account MJ’s self- blaming comments or those made by hostel workers which suggested that FJ was controlling and coercive in his relations with MJ. It was not recognised by these professionals at the time that this, in itself, was a form of domestic abuse and without the sharing of information in a multi -agency context the extent, the nature and potential impact of FJ’s behaviour remained unassessed. 7.3.13 New legislation22 now protects victims by criminalising patterns of coercive and controlling behaviour that amounts to psychological and emotional abuse, even where there is no evidence of physical violence. Difficulties, of course, can arise in determining at what point marital arguments and disagreements are classed as abusive, but in terms of safeguarding children, professionals need to broaden their understanding of what constitutes abuse where behaviours are observed to be intimidating and controlling. 7.3.14 It is now more widely recognised that coercive control is a core part of domestic abuse and this recognition has been a significant and influential factor in changing the terminology used from domestic violence to domestic abuse. The Review Team would suggest that certainly more could be done in Hull to encourage greater use of the term ‘domestic abuse’ and eliminate and discourage the term ‘domestic violence’. The Review Team was informed that training and increased awareness is beginning to make a difference as patterns of behaviour and a couple’s history are now assessed in much more detail, placing even more emphasis on the importance of good recording and information sharing and succinct chronologies so emerging patterns can be more easily recognised. Finding 2: Coercive control is subtle, circumstantial, and highly nuanced; professionals are more likely to recognise controlling and coercive behaviours as domestic abuse when they are well trained and where there are good records, succinct chronologies and opportunities to share and analyse information and concerns within a multi-agency context. Drug and Alcohol Issues 7.3.15 The Review Team was unable to evidence any consideration by professionals related to the hidden harm and risks associated with drug and alcohol misuse. Examination of agency records indicates that FJ was a known cannabis user and was convicted for the possession of cannabis in 2014. The Offender Assessment System (OASys23) made reference to FJ previously being in receipt of prescribed anti-depressants and yet, when he self-disclosed taking his mother’s Tramadol tablets, this information was not addressed by his offender manager and neither was it shared with other agencies. FJ was also noted to recognise the relationship between alcohol and his unpredictable behaviours but this did not trigger the need for a further discussion with other agencies. 7.3.16 MJ was also known to have used cannabis since her early teens and remarked to her GP that she ‘liked taking Tramadol’. The Review Team considered it an unlikely coincidence that both parties independently referred to this prescribed drug, but a lack of communication and collaboration between agencies meant the significance of these remarks went unnoticed and information, which may have been significant, was lost. The link, therefore, between substance misuse and potential 22 The Serious Crimes Act 2015 became law in December 2015 23 OASYs Offender Assessment System measures the risks and needs of criminal offenders under their supervision. Hull SCR Baby J /Mar 2017 21 harm was not made or evidenced in any agency records and neither were they considered as risk factors in the CSC assessments or the two core groups, which took place. Mental Health of Parents 7.3.17 FJ made several visits to his GP in relation to feeling ‘low’ for which he was prescribed anti- depressants. He also talked about suicide and told his GP that his children were his ‘protective factor’. He did not, however, engage with mental health services after being referred, although it appears that his GP was unaware of this. When he was taken in to custody in August 2012, FJ was referred to the custody nurse where he was noted to be calm and engaging. Notes from the assessment highlighted naivety and immaturity and a lack of emotional resilience; FJ also scored high on an alcohol assessment and notes suggest that alcohol played a significant part in his violent outbursts. FJ said he had struggled with anger issues all his life, but he declined any further support. FJ had a difficult childhood and was known to have witnessed and experienced significant domestic abuse as a child; this, coupled with a struggle to manage his emotions, left FJ as not only a vulnerable adult but also a very volatile one. In the absence of any contact with his GP, the duty social workers and health visitor were unaware of his mental health issues and the impact that alcohol was known to have on his behaviour. 7.3.18 The mental health assessment carried out in November 2013 for MJ focused just on weight loss and the disparity between the details of the GP referral and MJ’s presentation was not picked up by the mental health practitioner or addressed with the GP. Neither was there any exploration of drug and alcohol use in the assessment, although CSC records suggest MJ had been using cannabis since she was a young teenager. The mental health practitioner reflected on her assessment during the review and acknowledged that it would have been helpful to liaise with other practitioners involved with the family so that important information could be shared and discussed. The Review Team was advised that further work has since been undertaken by that agency and all assessments are now monitored and regularly reviewed. 7.3.19 The decision by the core group to close the case in the early stages of MJ’s pregnancy with Baby J was made on the basis of incomplete and missing information, both in terms of the extent of drug and alcohol use within the family and, importantly, the mental health of both parents. Had information been sought from all the various professionals involved with the family and specifically from their GPs, and hostel staff, the additional risk factors around vulnerabilities may have emerged and the need for a pre-birth assessment considered. The problems of making decisions on the basis of incomplete information are well documented24 and, whilst it cannot be assumed that the decision to close the case would have been different, even had they considered any of the above factors, there would, however, have been far greater evidence to support their professional judgment and subsequent decision-making. The responses of MJ 7.3.20 According to agency records, the bruise seen by MW3 was the only time any injuries were noted on MJ. The bruise, observed by the midwife soon after the birth of Baby J, led her to ask a routine 24 DePanfilis, D. & Girvin, H. (2005) Investigating child maltreatment in out-of- home care: Barriers to good decision-making Hull SCR Baby J /Mar 2017 22 question about domestic abuse to which MJ replied ‘no, never’. Had MW3 been more aware of what was happening in the family, if, for example, midwifery services had been invited to the earlier core group meetings; it might have encouraged her to ask more directly about the bruise. However, MJ told the reviewers that no matter how sensitively she had been asked, she would not have admitted what was happening because she was so fearful of what FJ might do and this fear was greater than the belief that she and her children would be kept safe if she told anyone about FJ’s behaviour. MJ also told reviewers that FJ controlled what she did and where she went and she was frequently told by him that she was a useless parent and could not look after her children. She was threatened with exposure and losing her children if she spoke out about what was happening. 7.3.21 MJ’s experience is mirrored by Stark’s research 25 which illustrates the concept of coercive control in his description of women who live with aggressively controlling men, who would ‘isolate these women, impose restrictions on them, and control many aspects of their lives. The women would behave in ways that highlighted the fear within which they lived, but often would not disclose the abuse they were experiencing from their partners’ 7.3.22 If the context of coercion and control presents significant barriers to women disclosing what is happening in their lives, it also creates particular difficulties for professionals trying to ensure the safety and welfare of children in the family whilst also seeking to support the non-abusing partner, even assuming the woman is ready both psychologically and physically to confront what might be happening. Where there is past or present evidence of domestic abuse, professionals need to approach work with a family with a degree of scepticism if told that that abuse is no longer a feature of that relationship. Whilst the need for challenge to the abusing partner is essential, there is an equal and paramount need for sensitivity in providing repeated and ongoing opportunities for women to disclose so they can be supported and helped to voice their concerns. 7.3.23 There was evidence of a lack of recognition of the ongoing vulnerability of MJ to FJ’s controlling behaviours as professionals who knew FJ’s history believed the risks he posed were being addressed through the behaviour change programme. They were also reassured by MJ’s assertion that he was not an abusive partner. The implications of MJ failing to engage or acknowledge the reasons why FJ was attending the IDAP programme were not addressed by social workers or those who attended the core group. Had the women’s safety worker been invited to attend the core group meetings, this information may have alerted professionals of the need to consider if MJ’s refusal to engage with DAP impacted upon her ability to protect her children and was in any way influenced by FJ. The use of tools to aid professional judgment 7.3.24 In effect, there were a number of risk indicators evident in this family which, had they been known and considered in greater depth, would have alerted professionals to consider the need for more robust safety plans for Child SJ and Baby J. The Review Team found that without the use of any risk assessment tools to inform their professional judgment, together with the lack of a comprehensive multi-agency view, CSC professionals were left to rely upon their professional view to determine risks and the likelihood of harm to children in the family. It is important to acknowledge that a practitioner’s intuitively based feelings and responses have been identified as an important source 25 Stark, E. (2007). Coercive Control: The Entrapment of Women in Personal Life. New York: Oxford University Press Hull SCR Baby J /Mar 2017 23 of data in assessments. However, the dangers of reliance upon intuition, because of its potential as a source of bias, are also well researched and highlight that intuition needs to be tempered with critical and analytic thinking in any assessment process. 26 7.3.25 Where decisions have been based largely on intuition, it is important that professionals consciously check and review their judgments, using objective evidence where possible, in order to detect any errors even if they are confident about the accuracy of their decision.27 There are many tools that can help make reasoning more explicit, informed, and systematic but none of these were used in work with this family. The Review Team was told that the use of such tools is not commonplace in CSC or in other agencies locally and there is little evidence that supervisors or managers encouraged their use. 7.3.26 Research studies28 suggest that ‘without the use of tools to assess risk, professional judgment can too often be flawed, with assessments being ‘only slightly better than guessing’. The assessments undertaken by CSC did not use any specific risk assessment tools, such as the DASH29 assessment, which may have informed the analysis of risk, or tools such as Prochaska and Diclemente’s model30 to ascertain the extent to which both parents were actually able and motivated to change their behaviours to keep their children safe. Even a tool as simple as a multi-agency plan to determine and measure progress was not in evidence. The challenge for professionals, of course, is to know which tools to use and when and this is where guidance from line managers and the safeguarding board becomes essential. Finding 3: The reliability of practitioners’ judgments concerning the assessment of risk and harm; could be significantly improved if information is collected and analysed using integrated chronologies, evidence-based tools and standardised measures to inform structured professional decision- making. Finding 4: A range of safety measures are required to protect children in families where domestic abuse is a concern, but a reliance on the physical separation of family members and/or perpetrator change programmes, in the absence of a wider multi-agency plan, may leave children vulnerable and without effective help. There are also particular challenges for professionals where women deny or are unable to accept the risks posed to their children from their partners and this requires persistent ongoing work in relation to safety planning for all parties. Risk indicators for abusive head trauma 7.3.27 Research undertaken by Ofsted in 201131 summarised some key findings from 482 SCR’s evaluated between April 2007 and March 2011. 35% of children considered by these reviews were under the age of one year and the study found that information sharing between professionals was often inadequate, that parents’ own needs and the fragility and vulnerability of very young infants were 26 Judgements or Assumptions? The Role of Analysis in Assessing Children and Young People's Needs. Helm 2011 British Journal of Social Work. 27 Thinking Fast and Slow Kahneman, 2011; 28 Systemic Review of Models of Analysing Significant Harm DFE RR199 Barlow 29 Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) is a checklist for identifying and assessing risk used by police and partner agencies across the UK. , 30 Prochaska and Diclemente: Stages of Change (2009) 31 Age of Concern. Ofsted 2011 Hull SCR Baby J /Mar 2017 24 underestimated, and that pre-birth assessments were not undertaken or, where they did occur, they were insufficiently detailed or analytical to identify risk and plan support for parents. 7.3.28 Additional research32 highlights how parental stress, anxiety and relationship problems can also impact on a parent’s ability to respond calmly to their babies’ crying, leading to some parents ‘shaking’ their babies and causing head trauma. In the UK, nearly 200 babies suffer from these injuries each year with infants who are under six months old being at greatest risk of non-accidental head injury. Both parents were informed of these risks by midwives and by HV3 but they were not considered in the assessment process. The same research suggests that, whilst there is a growing awareness about the causes of head trauma injuries, it is not only parents who need to be educated about how to respond to a baby’s crying, social work professionals also need to be aware of the triggers which can lead to such injuries in babies and be mindful of these in their work with all families. 7.4. ASP 2: The ways in which professionals communicated and worked collaboratively within a multi-agency context Examining the integrated chronology, it is clear that in work with this family, each agency held pieces of information which, had they been shared with partners, would have contributed to a better understanding of potential risks within this family. The information that was shared was not analysed in any depth and this left individual professionals in contact with parents without access to shared hypotheses or multi-agency plans. The Review Team considered that in relation to Child SJ and Baby J, individual agencies were working independently of each other and so missed opportunities to work collaboratively to ensure the safety and well-being of children within the family. 7.4.1 The importance of an integrated professional group being accountable for safeguarding children rather than confining the responsibility to children’s social care was stressed in Munro’s33 first two reports on the child protection system. A collaborative approach is meant to ensure that not only are parents recognised as having needs in their own right, but also the impact of those needs on their children becomes part of a multi-agency response. National policy and guidance supports these principles and research34 confirms that the value of inter-agency collaboration is widely accepted by professionals, including those working in adult services, who are now more likely to regard themselves as part of the child well-being system. Nevertheless, continued work is required to ensure that these principles are embedded and reflected in local practice. By its very nature, joint working brings together professionals with different roles and responsibilities as well as divergent professional cultures and these differences can act as barriers to effective joint working. Understanding the roles and responsibilities of colleagues from different disciplines and respecting their expertise is critical to the success of joint working. 32 lr Med J. 2010 Apr;103(4):102-5. Medical, social and societal issues in infants with abusive head trauma, Koe S, Price B, May S, Kyne L, Keenan P, McKay M, Nicholson AJ. 33 The Munro Review of Child Protection: Part 1: A Systems Analysis, 2010; Part 2:The Child’s Journey 2011 34 Children’s needs – Parenting capacity Child abuse: Parental mental illness, learning disability, substance misuse and domestic violence DFE 2011 Hull SCR Baby J /Mar 2017 25 7.4.2 During the review process practitioners helpfully explored the question ‘why did we not know ‘ [certain pieces of information]. The Review Team were told that it is not uncommon for professionals from partner agencies to hold the view that social workers ‘must know best’ and it was assumed CSC would automatically share information relating to any risks and issues of concern, as they were the key agency ‘working’ with the family. The fact that no multi-agency meetings were called until early January 2014 was attributed, in the practitioners’ meetings, to CSC decisions that none were needed, yet GPs, probation and the staff from the hostels each had significant bits of information not known to, or asked for, by CSC when undertaking their assessments. 7.4.3 The significance of the combination of factors was, therefore, not recognised by practitioners as they each focused on their own discipline and area of expertise within their respective services. It would, for example, have been helpful for the GP to liaise with CSC; given the knowledge that FJ was a parent, had mental health issues, was struggling with drugs and alcohol, and had a history of domestic abuse. These factors – the toxic trio - are common features in families where harm to children has occurred but the GP was of the view that, as FJ did not live with his family at the time, any risks to the children were minimal. Even if contact with CSC had not taken place, a conversation with HV2 would have been of benefit. Similarly, when MJ was referred to mental health services, a conversation with HV3, given there was a baby in the family, may well have alerted her GP to the vulnerabilities in this family. 7.4.4 The staff at the hostels where MJ and FJ were living held a significant amount of information, not only about FJ but also about the couple’s relationship and MJ’s reluctance to acknowledge FJ’s abusive behaviours towards herself and others. When staff at the hostels contacted CSC, they were informed that they were waiting for the outcome of an assessment and they should call back for updates – this was a missed opportunity for practitioners to learn more about FJ and MJ and how they were coping and highlights a lack of understanding about the work of the hostel and the services provided by that charity. 7.4.5 National guidance emphasises that ‘safeguarding is everybody’s business’ and that effective safeguarding requires the input of all professionals in collaborative multi-agency working. In discussions with both practitioners and the Review Team, it became apparent that professionals’ determination of need and risk were not consistent and were significantly influenced by what is described in research35 as ‘subtle hierarchies’ within the system. This led to information being ‘weighted differently’ dependent upon the source and the perceived ‘expertise’ of that source. The concept of these ‘hierarchies’ also helps to understand the tendency for some practitioners across professions to ‘defer safeguarding responsibility to social workers’ or to assume that ‘social workers, or the police for example, know best’. The concerns held by hostel staff, which they attempted to share with CSC, for example, were not seen by duty social workers as significant, despite their considerable involvement with FJ and MJ and the fact that the hostel workers in question were also qualified social workers. This left hostel staff feeling devalued and that their concerns were not ‘heard’ or well understood. 35 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014: Final report May 2016.Peter Sidebotham, Marian Brandon et al. Hull SCR Baby J /Mar 2017 26 7.4.6 A recent study 36 of health organisations offers useful insights to the broader issues of multi-agency working and, perhaps not surprisingly, concludes that workplace cultures are more influential in shaping such behaviours as opposed to being an inherently human way of working. The research suggests that ‘subtle hierarchies’ are more a result of the structures and entrenched cultures in organisations which, despite the clear need for effective teamwork, can create professional silos and a reluctance or hesitancy to work more collaboratively. Professor Braithwaite, the author of the study, suggested that strengthening inter-professional teamwork would be enabled by paying more attention to the characteristics of the context in which teams operate, and the encouragement of more joint activities, shared decision-making and mutual responsibilities, but this in itself requires ‘effort on the part of managers and leaders, and the [professionals] themselves’. The Review Team were told by practitioners during this review that they would welcome more opportunities for joint training and case discussions with colleagues from other agencies but also stressed that competing demands on their time severely limited such opportunities. 7.4.7 Issues about data protection and sharing information with voluntary organisations were discussed in the practitioners group and, although it was acknowledged that colleagues working in the voluntary and private sectors are partners when safeguarding and child protection issues are explored, the Review Team was told by the hostel manager that he did not feel this to be the case. He expressed frustration that accessing information or attempting to pass on information to CSC was not always easy and, although the charity often held important information, they were too often not regarded as an ‘agency partner’. The point was made in the practitioner’s meetings that many professionals do not know the extent of the services offered by accommodation providers or, in some cases, by partner agencies and especially those who work within adult settings. Certainly, better collaboration and more curiosity between adult services and children’s services may well have highlighted the different perspectives about what might be happening in this family. 7.4.8 CSC did not establish a core group until early 2014, but no agency had identified the need for a multi-agency meeting before then: the issue of FJ’s ‘domestic abuse’, known to all agencies, was located only within his previous relationship and each agency held only their own piece of the ‘jigsaw’. Without creating opportunities to share and analyse information, a holistic picture of the family did not emerge. 7.4.9 Although various studies show that the development of joint protocols and information-sharing procedures support collaborative working between children’s and adults’ services, there was evidence from this review that, in terms of working in families where domestic abuse is a concern, recourse to multi-agency meetings was seen more as an option than a necessity. A process which requires initial multi-agency meetings, so that information can be shared when domestic abuse has been identified, would be a step forward, although the sheer number of reported incidents presents as a not - insignificant barrier to this approach. For unborn babies, that process should always lead to a pre-birth assessment although, even in this family, that process was overlooked, in part because the domestic abuse related to a past partner. 36 BMJ Health services research. The basis of clinical tribalism, hierarchy and stereotyping: a laboratory-controlled teamwork experiment Jeffrey Braithwaite et al 1 Hull SCR Baby J /Mar 2017 27 7.4.10 Time, capacity, and workload pressures were all offered as explanations as to why there was limited recourse to multi-agency working. It was suggested that unless CSC called a multi-agency meeting, it was less likely to happen, partly because of the perceived status of that agency but also because other agencies were not confident that other professionals would attend if they were not invited by CSC. The hostel manager said he had not had much success in trying to call various meetings for those reasons. 7.4.11 In order to make a full and comprehensive risk assessment and subsequent risk management plans, it is important for all agencies to be pro-active in seeking out information when domestic abuse is or has been known to be a feature in a family. As such, it would have been good practice, even without multi-agency meetings, for practitioners working with this family to make regular checks and have regular liaison with other agencies known to be involved with the family. There were many examples of where better communication between agencies would have enhanced professional understanding of this family; between CSC and OM1, between midwifery and health visiting and between GPs and CSC, for example, but clearly the most effective way of supporting good communication are opportunities for professionals to discuss, reflect and challenge views and perceptions within a multi-agency setting. It is well known that joint working results in a more proactive and integrated approach to the delivery of relevant and timely services for families where domestic abuse is a concern but this requires joined-up service provision and specific attention given to creating robust professional links between children’s and adults’ services in both statutory and voluntary sectors. 7.4.12 Effective multi-agency working is a significant challenge - just because it is a good idea does not make it happen naturally- it is time-consuming and can engender tensions and conflict between professionals. In this review each agency had their own source of information relating to FJ and MJ and there was insufficient collaboration so information was not shared in a purposeful way and the need for plans to address risk or secure the safety of the children did not emerge. 7.4.13 The lessons about agency involvement with the parents are not just about risk factors arising from the parents’ background and lifestyle; the lessons are also about the practitioners’ assessment of their parenting capacity. There was limited curiosity or understanding by professionals of the impact of the parents’ own experience of being parented and how this could impact on how they cared for their own children. 7.4.14 Greater priority should also have been given to collaboration and inter-agency working between the organisations providing services for adults (such as domestic violence, substance misuse, and mental illness) and those working with children. The Review Team concluded that the reason this did not happen was linked to the view that the couple were working with agencies and co-operating well and risks were considered minimal. In effect, professionals demonstrated a degree of over-optimism which, together with the couple’s disguised compliance, meant that potential risks in the family remained largely unexplored. As there were no perceived imperatives to collaborate or have recourse to multi-agency meetings, professionals continued to work in ‘silos’ and to their own agendas and the significance of FJ’s mental health and past behaviours, and MJ’s struggle to accept what was happening, were not seen in the context of risk to either Child SJ or to Baby J. Hull SCR Baby J /Mar 2017 28 7.4.15 The evidence provided to the Munro review in 2011 found ‘mixed experiences and absence of consensus about how well professionals understand one another’s roles and work together’ and she argued for ‘thoughtfully designed local agreements between professionals about how best to communicate with each other about their work with a family...’ The Review Team concluded that so much more could have been achieved had there been better collaboration and a clearer understanding of how different agencies were working with both parents. Finding 5: There was insufficient collaboration between agencies, and between children and adults’ services and the expertise of practitioners in specialist services was not used effectively to inform assessments, judgments, and plans. Without information being sought, shared, and analysed, agencies did not have a holistic picture of the family needs and vulnerabilities did not emerge. 7.5. ASP 3: The response of CSC to referrals and contacts from partner agencies There were three assessments undertaken by CSC during the period under review; an Initial Assessment was undertaken in October 2012 but the organisational context of locality duty arrangements meant that contact with the family between January and November 2013 lacked consistency and planning. Although the potential risks to Child SJ were recognised, and practitioners worked to ensure that there was contact with the family and Child SJ was seen on a regular basis, there was no child’s plan and no further assessment until the core assessment (1) in December 2013 for Child SJ, and the core assessment (2) for Baby J. Even though risks had been recognised, neither pregnancy led to a pre-birth assessment and, consequently, the risks posed from the parents’ own needs relating to drug and alcohol misuse, abuse FJ suffered during childhood and being a perpetrator/victim of domestic violence as an adult, were significantly underestimated. There were occasional contacts by CSC with other professionals, particularly the health visitor for Child SJ, but the absence of a multi-agency core group (until Jan 2014) or other framework for involvement meant that multi- agency assessment and planning was limited. 7.5.1. The Initial Assessment undertaken by DSW1 in October 2012, included contact with the hostels where MJ and FJ were living at the time, the probation service, DAP and the midwifery service. MJ was seen on one occasion and a telephone conversation took place with FJ to ascertain his views. The Review Team considered that, given the concerns highlighted by DAP, a meeting with FJ, rather than a telephone call, would have been expected practice, even accepting Initial Assessments were meant to be quick assessments of need. There are significant limitations in making any assessment only on a telephone conversation and there is considerable research, which stresses the importance of working with fathers as well as mothers in families. Whilst the Review Team acknowledged that FJ did occasionally talk with social workers, this was not in response to any specific or purposeful plan and, to this extent, there was no direct work undertaken with FJ to determine or assess his parenting abilities. 7.5.2. Significantly, FJ told the Reviewers that he believed that he wasn’t seen as an individual in his own right and professionals saw him as a potential perpetrator rather than as a parent. Although he admitted that there were occasions when he was hiding in a bedroom when social workers visited, he said this was because the couple were fearful of what would happen if social workers found out he and MJ were actually living together. FJ said that social workers were more interested in MJ … ‘always MJ’ and never discussed with him issues about the care of Child SJ or Baby J. This limited engagement with FJ as a parent was acknowledged by practitioners and was thought to be influenced by the knowledge that he was ‘seen’ regularly by other workers - OM1 and the key worker on the IDAP programme. Hull SCR Baby J /Mar 2017 29 7.5.3. Although DSW1 did not meet FJ as part of the Initial Assessment, she nevertheless concluded that, due to the knowledge about his background and the heightened risk related to MJ’s (first) pregnancy, a ‘full Pre- Birth Assessment’37 was required. Pre-birth assessments differ from Initial Assessments in that key professionals are brought together from the outset so that potential risks can be explored from a multi-agency perspective and plans agreed. CSC procedures at the time stated that the criteria for undertaking pre-birth assessments included concerns about actual or potential domestic violence in the family use of drugs, or any parental issues, which could place an unborn baby at risk. These factors were identified by DSW1 in the initial assessment and the recommendation for a pre- birth assessment was both timely and appropriate. 7.5.4. Although the initial assessment was concluded in November 2012, with the recommendation for a pre-birth assessment, it was not until January 2013 that a decision was taken by the team manager to transfer the case to a locality team. The Review Team was informed that this was due to the volume of work and the organisational structures in place at the time, arrangements that were later replaced when a revised organisational structure was introduced in January 2014. 7.5.5. The decision to pass on the case to the locality team, although out of timescales, was appropriate. However, at the point of transfer, the language significantly shifted from the need for a ‘pre-birth assessment; to ‘further assessments’, and it is not clear from records whether the need for a ‘full pre-birth assessment’ was well understood, but the absence of such a timely assessment was a significant missed opportunity to gather and assess information from a multi-disciplinary perspective, especially in relation to the sharing of background information about FJ. When agencies are able to anticipate safeguarding risks for an unborn baby, such concerns should be addressed through a pre-birth assessment, the aim of which is to make sure that the risks are identified as early as possible, to take any action to protect the baby, and to support parents in caring for the baby safely. 7.5.6. It is important to highlight that midwifery services received notification from the CSC social worker based at the hospital in May 2013, informing them that a pre-birth assessment had been undertaken and providing details of the ‘child’s plan’. Whilst a challenge to not being involved in such a process would have been appropriate, the midwives nevertheless recorded this information on their records. The Review Team were unable to ascertain why the hospital social worker believed a pre-birth assessment had taken place and she was unable to recall the specific conversation or access any records related to it. It is possible that, upon being told about the ‘child’s plan’, the hospital social worker assumed that a pre-birth assessment had been undertaken. The long established systems of informal communication with health staff, which relies on the hospital social worker, appears to have provided the conditions for this misunderstanding, which was exacerbated by the fact that knowledge of the family within children’s social care had been fragmented by the duty social work arrangements. On this basis, the Review Team concluded that there could be benefit in exploring the role as it currently operates within the re-modelled health and social care systems to establish whether the role and function in relation to safeguarding processes and inter-agency communication is effective and well understood. 37 A Pre Birth Risk Assessment is a formal process of multi-disciplinary collation, and analysis of information regarding the circumstances of an unborn child, which will identify the potential risks to the child following the birth Hull SCR Baby J /Mar 2017 30 7.5.7. Further enquiries confirmed that the CSC duty arrangements in place at the time led to the need for a pre-birth assessment being overlooked, highlighting the importance of managerial oversight to check that actions and decisions are followed through, especially in times of transition if families in need are without a named social worker. 7.5.8. At that time, the role of the Central Duty team was to act as a single point of contact for referrals and to make an initial assessment of need only. The system was designed so that the workflow between the two teams was more rapid, with the locality teams having responsibility for the completion of more detailed assessments where these were required. However, the decision to transfer cases for ‘more detailed’ assessments led to a high volume of new cases in locality teams, not all of which could immediately be allocated to a named worker. 7.5.9. In order to manage this system as safely as possible, a management decision was taken to support some families through duty arrangements. In effect, this meant that for some families, visits were planned by a duty co-ordinator and allocated on a rota basis to duty social workers and/or community support team workers who then visited the family and reported on any emerging issues of concern or risk. It was acknowledged that this was not an ideal situation. Practitioners found the arrangements not only challenging, in terms of their impact on the development of meaningful relationships, but also anxiety- provoking, as they were not working to any specific plans or goal-related work. Not all practitioners were qualified social workers, and this added a further layer of challenge in terms of the confidence felt by some practitioners in relation to the complexity of the family’s needs. In terms of this review, there was further impact in that most practitioners had only minimal contact with the family and, without a comprehensive assessment of the family, the purpose of the visits was simply to check all was well and respond to any emerging issues. 7.5.10. Given the challenges of responding to increasingly higher numbers of referrals and significant capacity issues, these arrangements were an attempt by senior managers to safely manage challenges within the authority during a critical period. The Review Team was informed that data (about unallocated cases) was regularly collected and monitored at senior leadership level, but questioned to what extent decisions were informed by a sufficiently thorough analysis of risk given the length of time this family, for example, was without an allocated worker or a multi-agency plan.38. 7.5.11. The organisational context of the duty arrangements, however, meant that contact with the family lacked consistency and planning. Although some of the potential risks to Child SJ were recognised and there were attempts to ensure contact with the family, the absence of any child’s plan or multi-agency core group resulted in social workers visiting the family without any clear goals or multi- agency remit. The use of written agreements 7.5.12. The decision taken in May 2013, that there would be no restrictions on FJ’s contact with his child when born, was in stark contrast to the CSC decision that FJ was not allowed contact with his son from his previous relationship. The Review Team was informed that, in relation to unborn Child SJ, there was no evidence that there was any domestic abuse by FJ towards MJ and she was living with 38 These ‘holding’ arrangements were discontinued in January 2014 when Social Work Pods were created; each led by a Consultant Social Worker who ensured that all cases were allocated to named workers Hull SCR Baby J /Mar 2017 31 her parents who were seen as a supportive and protective influence and all parties had discussed and accepted a written agreement. 7.5.13. There is, however, little to evidence that this agreement was used constructively during any of the visits by duty workers, the only time the agreement was reviewed appears to have been in response to a challenge by both parents about their living arrangements. The agreement did not specify that the couple could not live together although this was the advice given to both adults then and on later visits. The agreement was forwarded appropriately to HV2, probation, and midwifery services but was not forwarded by probation to the women’s safety worker linked to the IDAP programme. This could, perhaps, have made MJ’s cooperation with the support worker more likely. This does highlight the importance of key professionals being kept well informed of the involvement of other agencies working with family members. 7.5.14. Planning and intervention in work with families is a core social work task, requiring a solid grasp about what needs to change and how to know whether progress is being made. The duty arrangements in place at the time, together with the absence of any plan, other than the written agreement, was undoubtedly a challenge for the different workers who visited the family and this clearly made it difficult for visiting workers to undertake any ‘change work’ with either parent. The use of written agreements was described as common practice in Hull at the time and they were used as a means of responding to ‘lower’ levels of concern by clarifying and stipulating the expectations of the local authority. The Review Team considered that the use of these ‘written agreements’ could too easily become practice that protects the agency rather than as part of a working plan aimed to protect children. Research39 suggests that such agreements or letters are ineffective in reducing domestic abuse incidents, may actually increase risks for some victims and, in themselves, do not keep children safe. In addition, more recent research40 suggests that there can be an over reliance on ‘working agreements ‘ and it can also create uncertainty for both parents and professionals if they lack rigour and clarity about what is expected and how this can be achieved. 7.5.15. The Review Team is aware that ‘written agreements’ in CSC were replaced at the end of 2013 by ‘Family Plans’ but are of the view that these are not significantly different from written agreements. The Review Team suggested the use of ‘safety plans’ for children would be more appropriate given these agreements are intended to manage threats to a child’s safety and rely upon a parent’s awareness and acknowledgement of these and their acceptance and willingness for the plan to be implemented. Finding 6: Written agreements or family plans can be valid tools for helping a family to change, to solve problems and, in some cases, to remove the risks that would otherwise make the children unsafe at home. However, without a process by which an agreement is monitored and reviewed as part of a multi-agency plan, these ‘agreements’ do not, in themselves, constitute a plan or keep children safe but may give the impression of doing so. 7.5.16. There was a timely response by CSC to the referral from the hostel in July 2013 but there is no record of any liaison with other agencies or a consideration of a core group meeting, then or later 39 NSPCC Children and Families experiencing Domestic Abuse (2010) 40 Pathways to Harm op cit Hull SCR Baby J /Mar 2017 32 when it became apparent that MJ had moved into her property and FJ was staying over ‘a couple of nights’ every week. The Probation service and the hostel were key agencies in terms of their relationship with FJ, and had knowledge not just of the risks he presented but also about his vulnerabilities but the absence of any multi-agency forum meant that this knowledge was not shared. The Review Team acknowledged the difficulties for the different CSC professionals to have oversight of the complexity of issues and see the family from a holistic viewpoint, but it is here where managerial oversight should have made a difference. The absence of not only multi-agency meetings but also of a working plan meant there was no focus or direction in work with the parents. 7.5.17. Partnership practice with parents and building relationships is an important part of the assessment process, as parents are often experts in what is happening in their family. However, as previously discussed, it is critical that professionals maintain a level of ‘healthy scepticism’ about what they are told. This is an active process of triangulating the information from different sources, and establishing whether there are discrepancies and what those discrepancies might mean for the child. 7.5.18. Fish41 suggests that professionals need to take active steps to work against ‘our human tendency to seek only the information that we wish to find’, and confirms the dangers of a tendency to ‘stick to what we think we know’ and carry on work with a family without question or challenge. She goes on to state ‘one of the most common, problematic tendencies in human cognition ... is our failure to review judgments and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.’ The Review Team concluded that there was evidence of such professional bias in both core assessments and, whilst it is possible that this was a result of the fragmented knowledge of the family due to the duty arrangements, the outcome was influenced by a lack of managerial oversight and challenge. 7.5.19. The decision to undertake the first core assessment in November 2013 was taken by TM3 almost a year after the initial assessment had been completed and was in response to a review/audit of cases as part of the implementation of the ‘pod’ model. The family were allocated a named social worker at the same time. When MJ’s second pregnancy was confirmed, a decision was taken to undertake a second core assessment in relation to unborn Baby J. The Review Team was unable to establish why this was not a pre-birth assessment. 7.5.20. Core assessments are in-depth assessments, which address the central or most important aspects of the needs of a child and the capacity of his or her parents or carers to respond appropriately to these needs within the wider family and community context. The core assessments completed by children’s social care were, therefore, key documents that defined and guided the work of children’s services. As key tools, these should have provided a structured framework for children’s social care to record information gathered from a variety of sources to provide evidence for their professional judgments, facilitate analysis, decision making and safety planning. Although the Review Team were informed that risk issues were discussed in supervision, these were not articulated in either of the core assessments. 41 SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews Hull SCR Baby J /Mar 2017 33 7.5.21. The two assessments were, not surprisingly, similar in content and had a significant degree of repetition. MJ was described as a mature young woman well able to protect her children and this, together with FJ’s attendance at IDAP, were regarded as strengths within the family. The risks of domestic abuse were referenced only in relation to FJ’s previous relationship; there was no reference to drug or alcohol issues or any reference to the mental health of either parent. When Child SJ was born, MJ was living with her parents and was considered to have a significant level of support. Whilst practitioners acknowledged this support in the early months of Child SJ’s life, it was also clearly evident that there were tensions within the family and the grandparents expressed their concern about the couple actually living together but this was not explored at all. 7.5.22. In contrast to the strengths identified, MJ was described as minimising FJ’s previous behaviour, but again this was not explored, nor is there any consideration of the fact that MJ did not engage with the women’s safety worker as part of IDAP, which had been a requirement of the original written agreement. The assessments, in this respect, focussed on the very recent period of involvement by CSC and there was minimal reference to background history or any evidence on which to make a confident assessment of change/risk reduction. 7.5.23. There was no contact with any worker or agency involved with SS, FJ’s previous partner, and no reference to any information which explained why FJ was ‘not allowed’ to see the child of that relationship. Probation records simply stated that CSC would ‘not permit child contact’. The Review Team was curious about why there was not greater effort by CSC to find out more from colleagues in their own agency about what had happened between SS and FJ and why FJ was not permitted any contact with his child from that relationship but no further information or explanations came to light during conversations with practitioners. This suggested evidence of professional ‘availability bias’ in which a decision maker relies upon knowledge that is readily available rather than examine other alternatives or explanations. 7.5.24. Telephone contact was made with the probation service at the end of January 2014 in relation to the assessment. However, that service was not invited to provide a written contribution to the assessment, which would have been good practice given the weight attached to FJ’s engagement in the IDAP programme. The information given by FJ about the outcome of a court appearance in January 2014, following an altercation with his brother in 2013, could have been helpfully discussed with the probation service. FJ received a restraining order and a 24-hour training course in respect of drugs and alcohol, but this issue was also not explored or acknowledged, despite the original referral in October 2012 stating that FJ’s behaviour was thought to be more violent when he was under the influence of drugs. This risk factor should have been considered in depth. 7.5.25. The completion of the first core assessment led to the decision to convene a core group. Whilst acknowledging the importance of multi-agency meetings, the Review Team was of the view that the convening of this meeting appeared to be more in response to the need to close the case rather than an attempt to plan for a child in need. The first core group meeting was held in early February and was attended by DSW9, the parents, and HV3. FJ’s offender manager, although invited, could not attend, yet given the contact this professional had with FJ, her attendance at the meeting was crucial. There is no evidence to suggest any consideration was given to inviting midwifery services or the women’s safety worker who had been trying to engage MJ. Hull SCR Baby J /Mar 2017 34 7.5.26. The GPs for both parents were not invited to the meeting and neither were they asked to contribute any information, yet both had specific information relating to the mental health of the parents and this could have had a bearing on the decision taken to close the case. The Review Team recognised that the timing of such meetings can be problematic for GPs but are of the view that their contributions are immensely important and should always be sought as a matter of good practice. 7.5.27. FJ, DSW9, the health visitor, and the probation officer attended the second core group meeting 6 weeks later. MJ did not attend. Again, neither the GPs nor midwifery services were invited, despite MJ’s current pregnancy. Notes from the meeting indicate that FJ’s engagement with IDAP was positive and there were no concerns about the care and development of Child SJ. An agreement was reached by all agencies that CSC should close the case, pending the outcome of FJ attending the police station in respect of the incident in the street involving his brother’s girlfriend. 7.5.28. It is important to understand the context in which this decision was made. As far as the core group were concerned, there had been no reported incidents of any physical violence between the couple and both parents were considered to be working with agencies as per the written agreement made in May 2013, despite the fact that the ‘agreement’ was not actually used as an ongoing contract. There were no concerns about the care and development of Child SJ who was reported to be progressing well. The core group was not, however, in possession of all the relevant information, partly because, as already outlined, key professionals were not invited to attend or to contribute to the meeting and partly because the core group did not ask themselves whether they were in receipt of enough information to make an informed decision about the level of risk in the family. 7.5.29. Munro’s research suggests that professionals need to take active steps to work against “our human tendency to seek only the information that we wish to find”, and confirms the dangers of a tendency to “stick to what we think we know” and carry on with plans without question or challenge. Munro argues that professionals should always take time to step back and question the assumptions, which underpin actions and decision-making, a form of reflection she describes as ‘double loop learning‘, although creating the ‘space’ for this is easier said than done, and relies upon access to good quality, consistent ‘reflective supervision’ and ‘reflective case discussion’. 7.5.30. The Review Team considered that the ‘reflective discussion’ which took place in CSC in early March would certainly have benefited from a more critical and challenging analysis of the actual and potential risks in this family and a consideration of how the birth of the baby later in the year could impact on relationships in the family. Importantly, although FJ was just completing the IDAP programme, it had been identified that further work was needed and was to be undertaken with the offender manager. 7.5.31. This ‘further’ work is significant and should have been carefully considered when making the decision to withdraw services from the family, especially given that MJ was pregnant. The notes from the core group would suggest a degree of minimisation about the work FJ was required to undertake. It was said, and accepted, that ‘no-one comes away (from IDAP) with no recommendations’. The work was, however, to address three specific areas: Victim awareness: – for FJ to recognise that actions have consequences and to increase his awareness of the impact of these on the individual and the wider community; Victim empathy: look at things from a different perspective, to include looking at the triggers to his behaviour and how he can better respond in Hull SCR Baby J /Mar 2017 35 the future and finally, Victim safety: to develop his understanding of the harm he can cause to others if confronted and the impact this can have on himself and to others around him. There was no discussion in the core group as to whether the assessed need for this additional work had a bearing upon FJ’s role as a father or how it could impact on his relationship with his pregnant partner. 7.5.32. CSC closed the case in early April 2014 without confirming the detail of the incident with police, but relying on FJ self-reporting that the incident was closed. Had contact been made directly with the police, CSC may have been alerted to the abandoned 999 call which came from the couple’s home address earlier that month. According to police records, this was forwarded to CSC via the ‘domestic violence form’ but there was no record of this abandoned call on CSC files and it was not, therefore, considered at the core group meeting held in March 2014. No arrangements were made to ‘step down’ support from CSC to targeted services, which, given that MJ was pregnant, would have been appropriate. The Review Team was informed that the early help services at that time were in the early stages of development and were not at that time being used ‘as expected.’ 7.5.33. The contact by DAP with the Access and Assessment Team on 5th August 2014 was triggered by MJ herself who had attended the DAP offices to ask that all references to her being a victim be removed from records. This information was shared with CSC but was recorded as ‘information sharing’ only. Whilst there was reference to the three reports to the police from neighbours about verbal arguments at the family home, it also indicates that the police had not referred these incidents to DAP under the domestic violence information sharing arrangements. This appears to have influenced the decision that there was no role for CSC, despite MJ’s current pregnancy. Finding 7: Assessments underpinned by good analysis and shared critical thinking support better decision–making, but this requires access to integrated chronologies and full social histories. Without these, professionals are more likely to base their decision-making on ‘here and now’ observations which do not include a thorough analysis of past behaviours and actual/potential capacity for change. 7.6. ASP 4: The response by agencies in Hull to incidents of domestic abuse Hester (2011)42 uses the term ‘planets’ to describe the very different and separate professional and practice worlds of those involved in domestic abuse work. Whilst practitioners from the hostel were highly concerned about FJ’s behaviours, these were not seen in the same light by health and social care professionals or, indeed, by probation and police. Agencies clearly have different priorities shaping their work with families, and when there are a number of agencies involved, careful co-ordination and joined up working is required to ensure that the safety needs of children are being met and risks are being identified and addressed. However, the monitoring of known high risk domestic abuse perpetrators, if they have a history of perpetrating domestic abuse in more than one intimate relationship, is extremely important in terms of understanding patterns of previous behaviour and how this can impact on current risk factors. The approach to domestic abuse in this family was incident based and, consequently, the repeating pattern of coercive control was not recognised. 42 British Journal of Social Work Volume 41 Issue 5. Hull SCR Baby J /Mar 2017 36 7.6.1. Evidence from serious case reviews continues to highlight domestic abuse as a characteristic in families where children die or are subject to a serious incident. Of the many risk factors identified in the backgrounds of parents, the most prominent in these reviews is the ongoing risk posed by situations of domestic abuse and the risks to children under the age of 5 and, particularly, those under one. 7.6.2. Police responded to seven separate ‘domestic abuse incidents’ during the 14 months prior to the death of Baby J. On each occasion, the attending officers completed a risk assessment based on that specific incident, some of which were recorded as a ‘verbal argument’ between the adults. The incident details and the risk assessment were recorded on the Force’s DA form and submitted to the DA unit in line with force policy. All of the incidents were graded as ‘standard’ risk. 7.6.3. Only one of the domestic abuse incidents (March 2014) was shared with CSC prior to the death of Baby J; however, CSC have no record of this incident. The domestic abuse incident in September 2014 was not shared until after the death of Baby J. CSC should have been notified of all of the domestic abuse incidents, due to the age of Child SJ and the fact that MJ was noted at these incidents to be pregnant. The information sharing policy in place at the time required the Police DA team to send a summary and risk assessment via email to CSC for review and appropriate action. 7.6.4. The response of CSC to information from the hostel or the police when informed about these incidents usually led to a visit by a duty officer, but these were also dealt with on an incident-by-incident basis and, therefore, the ongoing controlling nature of FJ’s behaviour was not recognised. This, alongside the absence of any multi-agency working, militated against a more complete, shared understanding of risks being built up over time. 7.6.5. Working within an incident-focused model carries the risk of harm to children continuing unabated for long periods, and ignores the huge damage that will already have been done to victims by the time any action is taken. As Stark (2007) comments, ‘A growing consensus favours intervention in relationships where there is extreme violence, stalking, or an injury to a child. But by the time abuse reaches this point, coercive control is likely to have severely eroded a woman’s personhood from the inside out, the way carpenter ants devour a house.’ Research suggests that assessments can too easily focus on the immediate or presenting issue while failing to consider the case history. Incidents need to be considered in context; concerns need to be connected in order to build up a fuller picture of what might be happening in a child’s life. There was little to evidence in this review that police or CSC, in response to reported domestic abuse incidents, took time to carefully sift through the family’s case history, a process that is integral to any assessment process. 7.6.6. Humberside Police introduced secondary risk assessments following SPECCS and DASH Assessments to support better decision-making around incidents of domestic abuse. These secondary risk assessments were completed by domestic abuse co-ordinators (police officers and/or police staff) who had undertaken additional training in risk assessing in order to undertake the role. The process involved the domestic abuse co-ordinator undertaking a review of the incident that had occurred as well as reviewing any previous domestic abuse history in the relationship and providing an overall risk assessment on the case. 7.6.7. Over time, this process of secondary risk assessing each case created substantial backlogs in the number of domestic abuse cases that, firstly, needed to be implemented onto police systems and Hull SCR Baby J /Mar 2017 37 then, secondly, made subject to a secondary risk assessment. In order to address this backlog, a number of temporary solutions were put in place including the decision not to undertake secondary risk assessments on incidents that had initially been risk assessed by the attending officer as ‘standard’. The outcome of this decision led to cases being entered onto the police system with no overall review of the domestic violence situation, increasing risk levels and the need to share information with partner agencies. To provide some context, there are nearly 16,000 domestic violence incidents per year across the Force area, all of which required manually inputting onto police systems. 7.6.8. The temporary solution described above has, subsequently, been reviewed and additional safeguards and improvements made. All frontline police officers have recently received domestic abuse training and staff inputting cases onto the police systems have received awareness training to enable them to raise any concerns with a domestic abuse coordinator. There is a triage system in place which ensures that all domestic abuse incidents which involve households with children or where there is a pregnant woman, are immediately notified to children’s social care, irrespective of their assessed ‘risk level’. An information sharing agreement is also in place with City Health Care Partnership for those cases where young children are living in the household or the female is pregnant. Secondary risk assessments are still undertaken, and the backlog has reduced, but this process does not delay information sharing. Nevertheless, despite these strengthened arrangements, the Board needs to assure itself that the multi-agency capacity is in place to consider the history, circumstances and nature of the abusive incident, to identify patterns and ensure that current and future risks are not overlooked. 7.6.9. Given the prevalence of domestic abuse in Hull and other cities, it is likely that one of the largest cohorts of children requiring early help will be those experiencing and witnessing domestic abuse. The role and remit of LSCBs has been expanded to ensure the effectiveness of early help for children and the LSCB has been assured that the new Early Help and Safeguarding Hub in Hull will benefit families in these situations by drawing in more elements and facilitating purposeful meetings with significant practitioners/agencies. 7.6.10. The learning from this review, however, highlights the need for a step-change in terms of how professionals, agencies, and society as a whole understand and respond to domestic abuse. There needs to be a move away from incident-based models of intervention to a deeper understanding of the ongoing nature of coercive control and its impact on women and children. Whilst there is substantial research43 to back up such a shift, the challenge should not be underestimated and it remains the responsibility of all agencies to ensure that professionals continue to respond to evidence of domestic abuse and not leave it to potentially vulnerable victims to act for their own or their children’s protection. Finding 8: Clarity of terms and definitions in relation to the recognition and assessment of risk in domestic abuse situations is required to support effective multi-agency safeguarding processes. The language and definitions used around risk in domestic abuse situations can determine processes and outcomes and impact on decisions to act or not to act. This can leave some families without access to effective help. 43 Domestic Abuse and Safeguarding Children: Focus, Response and Intervention. Cathy Humphreys and Caroline Bradbury Jones 2015 ,
Hull SCR Baby J /Mar 2017 38 Finding 9 Where the systems in place for the assessment and reporting of domestic incidents are under such considerable pressure, there are consequent and predictable issues around oversight and consistency and these create increased opportunities for human error. 7.7. Additional Areas of Learning: 7.7.1. The police and CSC were not the only agencies experiencing structural changes during the period under review. In April 2014, FJ’s case was transferred as part of a bulk transfer of cases from Humberside Probation Trust to the Community Rehabilitation Company, as the Probation Trust was being spilt into two separate agencies – The National Probation Service and the Community Rehabilitation Company (CRC). The management of FJ was, consequently, transferred from OM1 to a new offender manager (OM2). At this point, case management responsibilities of FJ transferred between offender managers, a full case handover meeting should have taken place but this did not happen. Such a meeting would have fully appraised the new offender manager of areas of risks including those related to re-offending and safeguarding concerns and would have confirmed the outstanding interventions that needed to be undertaken with FJ. 7.7.2. The Review Team was told that the staffing restructure and subsequent significant caseload reassignment process meant that the need for this handover meeting was overlooked. There is certainly very little evidence to suggest any of the required work with FJ was undertaken after he had completed the IDAP programme; the focus of supervision was on his welfare and social issues. At times of such significant change it is especially important that there is good communication between colleagues in order to fully ensure no issues or actions are overlooked. It would have been useful, for example, in the absence of such a meeting for OM2 to undertake and record an administrative review of the case and risk issues involved. Finding 10: When organisations undergo structural changes, safeguarding agencies need to be alert to the risks that transitions can have on decision-making and professional practice. Without strong managerial oversight, the risks posed to some children and families may be overlooked. Hull SCR Baby J /Mar 2017 39 Appendix 1 Findings and Issues for Hull Safeguarding Children Board The findings from this review have been grouped under 6 themes. Progress and developments since the period under review are included in Appendix 2. Using tools to assess risk and inform quality assessments Finding 3: The reliability of practitioners’ judgments concerning the assessment of risk and harm could be improved. Judgments based on experience and intuitive thinking should be supported but not replaced by information collected and analysed through evidence-based tools and standardised measures to inform structured professional decision- making. Finding 6: Written agreements or family plans can be valid tools for helping a family to change, to solve problems and in some cases to remove the risks that would otherwise make the children unsafe at home. However, without a process by which an agreement is monitored and reviewed and shared with other agencies, these ‘plans’ do not in themselves keep children safe but may give the impression of doing so. Finding 7: Assessments which do not include a full social history and detailed chronologies make it difficult to support critical and analytical thinking, and, consequently, professionals are more likely to base their decision-making on ‘here and now’ observations which do not include a thorough analysis of past behaviours and actual/potential capacity for change. Issues for the Board a) How can the Board address the issue of the use of ‘risk assessment tools’ in relation to domestic abuse to achieve a better understanding of risk and a shared ‘common language’? Which agencies should use which tools? b) How can the Board be assured that practice in the use of ‘family plans’ has been strengthened, so that their use is more effective as a clear, explicit and shared ‘safety plan’ for children, which is monitored and reviewed? Hull SCR Baby J /Mar 2017 40 Recognising and understanding domestic abuse in all its forms Finding 1: Without a clear system for linking MARAC assessments to police call-outs and family work, the risks posed by perpetrators of domestic abuse may not be well understood. Finding 2: Coercive control is subtle, circumstantial, and highly nuanced; professionals are more likely to recognise controlling and coercive behaviours as domestic abuse, where there are good records, succinct chronologies and opportunities to share and analyse information and concerns. Issues for the Board a) How well do practitioners in Hull have a shared understanding about risk and the impact on children and unborn babies in domestic abuse situations? b) How does this understanding extend beyond a recognition of ‘violence’ to an understanding of coercive control? c) How can the Board help to facilitate a better shared understanding about the role and impact of ‘behaviour change’ programmes in reducing the risk to women and children from domestic abuse? Hull SCR Baby J /Mar 2017 41 Working with parents where there are concerns about domestic abuse Finding 4: A range of safety measures are required to protect children in families where domestic abuse is a concern but a reliance on the physical separation of family members or perpetrator change programmes, in the absence of a wider multi agency plan, may leave children vulnerable and without effective help. There are also particular challenges for professionals where women deny or are unable to accept the risks posed to their children from their partners and this requires persistent ongoing work in relation to safety planning for all parties. Issues for the Board a) How are practitioners supported to work effectively with men where domestic abuse is known or suspected? b) Is the Board confident that the strategy for meeting the needs of children living in families where domestic abuse occurs but which fail to meet the threshold for statutory intervention is robust and effective? c) There are a growing number of SCRs published nationally which relate to the death or injury of young babies from abusive head traumas. Has the Board considered how it might address this issue, both in term of prevention and improved understanding by professionals, about the triggers which can lead to such injuries? Hull SCR Baby J /Mar 2017 42 Supervision and Managerial oversight Finding 9 Where the systems in place for the assessment and reporting of domestic incidents are under such considerable pressure, there are consequent and predictable issues around oversight and consistency and increased opportunities for flawed decision-making. Finding 10: When organisations undergo structural changes, safeguarding agencies need to be alert to the risks that transitions can have on decision-making and professional practice. Without strong managerial oversight, the risks posed to some children and families may be overlooked. Issues for the Board a) Within agencies, how do we ensure that opportunities for ‘reflection’ are a consistent feature of work with children and families? b) Is the Board confident that the quality of initial police assessment of domestic abuse reports is improving? c) Are the police systems for ‘triage’ and secondary risk assessment stronger now? d) How is the Board assured that agencies routinely and randomly quality assure the quality of assessments and the learning from this activity is fed back to the Board? Hull SCR Baby J /Mar 2017 43 Working collaboratively in a multi-agency context Finding 5: There was insufficient collaboration between agencies, and between children and adults’ services and the expertise of practitioners in specialist services was not used effectively to inform assessments, judgments, and plans. Without opportunities to share information across agencies, a holistic picture of the family needs and vulnerabilities did not emerge Finding 8: Clarity of terms and definitions in relation to the recognition and assessment of risk in domestic abuse situations is required to support effective multi agency safeguarding processes. The language and definitions used around risk in domestic abuse situations can determine processes and outcomes and impact on decisions to act or not to act. This can leave some families without access to effective help. Issues for the Board a) Is the Board confident that the arrangements for multi-agency consideration of ‘standard’ risk domestic abuse incidents ensure that history and patterns (chronologies) are properly considered? b) How does the Board ensure opportunities for reflection in a multi-agency context? c) Is the Board confident that local systems do not militate against an ‘incident-focused approach’ to domestic abuse? d) Are there any mechanisms the Board can strengthen or put in place to build better teamwork across disciplines so that keeping children safe is always “everyone’s business”? Hull SCR Baby J /Mar 2017 44 Wider Implications Finding 8 Where the systems in place for the assessment and reporting of domestic incidents are under such considerable pressure, there are consequent and predictable issues around oversight and consistency and these create increased opportunities for human error. Finding 9: When organisations undergo structural changes, safeguarding agencies need to be alert to the risks that transitions can have on decision-making and professional practice and without strong managerial oversight, the risks posed to some children and families may be overlooked. Issue for the Board to consider a) Where key agencies are undergoing significant organisational change, how does the Board ensure that risks to existing safeguarding practices and processes have been assessed and are being managed? b) Is the Board confident that Hull’s Domestic Abuse Strategy has emerged following a thorough and deep analysis of both the external environment and the internal capacities of key agencies? c) What actions does the Board take to ensure that the wider issues around domestic abuse are raised beyond the safeguarding community? End/ Hull SCR Baby J /Mar 2017 45 Appendix 2 Actions identified in Agency Learning Reports City Health Care Partnership CIC 1. To ensure all CHCP staff are aware of the importance of sharing information regarding Domestic Abuse. 2. Improvement of the process of record keeping and assessment to be undertaken following receipt of DV 913 forms. Hull Children’s Social Care 1. Working group will be established to review guidance on the use of Family Plans specifically in relation to the work of the Early Help and Safeguarding Hub. 2. Audit of sample of Family Plans will be undertaken between May and July 2016. 3. The views of men are clearly reflected in social care assessments together with analysis of their strengths and any risks identified in relation to their role in family life. 4. The Systemic Leadership Team will clarify next steps /agency policy in relation to current model and practice for individual supervision. 5. Reports to be made available to managers in relation to the proportion of cases subject to Reflective Pod discussions. 6. Review of CSW development programme, to include content on systemic supervision. 7. Review to assess opportunities for the rollout of training session on systemic supervision for all CSWs, Team managers, and other managers. Hull & East Yorkshire Hospital NHS Trust 1. Increase awareness of the referral process to CSC to all midwives and ensure the process is utilized correctly. 2. Midwives to become more confident in having difficult conversations. 3. Postnatal care and record keeping to be consolidated. 4. Routine enquiries guidance will be amended to include information about who attended with woman at appointment. Humber Foundation NHS TRUST 1. All practitioners working with families in MH assessment services to undertake advanced SG Children training in line with intercollegiate document. 2. Safeguarding Supervision model to be rolled out into MH assessment services to ensure staff work in a “think family” way and can access appropriate safeguarding supervision. 3. HFT will deliver the planned 2016/17 refresh ‘Think Family’ campaign across the Trust. 4. Adult MH Caregroup will provide updates on access to anger management programmes. Hull SCR Baby J /Mar 2017 46 5. All staff undertaking mental health assessments within the police custody suite will communicate the relevant findings from the assessment to appropriate partner agency practitioners. 6. In the delivery of the refreshed `Think Family` campaign, a bespoke IG package will be delivered focussed on information sharing. This will reinforce the data-sharing concordat. Humberside Police 1. A pilot has been introduced within Hull for the sharing of domestic violence incidents with health and, if successful, this will be rolled out across the force area. CRC Probation Service 1. A greater inter-agency understanding of the purpose, content, and outcomes (potential and actual) of domestic abuse programmes, and the need for post programme consolidation learning. 2. Improved evidence of liaison and joint working with children’s social care, and improved awareness of and confidence to use the LSCB escalation process. 3. Improved evidence of inter-agency communications and collaborative working. NHS Hull Clinical Commissioning Group (CCG) [GP Practice] No actions identified Hostel 1. To develop strengthened working relationships with other agencies and to make better use of the LSCB escalation process to resolve professional differences. Hull SCR Baby J /Mar 2017 47 Appendix 3 Developments in Agencies since the period under review 1. Children’s Social Care: a) In January 2014, children’s social care implemented a new model for the delivery of social work services in Hull. b) Increase in the staffing of the Access and Assessment Team in recognition of the high volume of contacts made with children’s social care. c) A new children’s social care single assessment was introduced at the same to replace the Initial and Core Assessments referred to in this review. d) There is improved managerial oversight in place following an increase in staffing levels. e) Regular reports of those cases with a child’s plan in place are now available to managers, with the most recent report (April 2017) showing only a very small number of children without a current plan. f) There is an Early Help Hub based in each locality, which works alongside three early help social workers in the Access and Assessment Team, to offer a range of support and interventions to those children and families who do not meet the threshold for referral to children’s social care. g) An Early Help and Safeguarding consultant social worker has been appointed to provide additional safeguarding support and oversight to early help arrangements. h) The ‘Strengthening Families’ approach has been adopted in Hull. This is an inclusive evidence-based parenting programme, designed to promote protective factors which are associated with good parenting and better outcomes for children. i) The Early Help and Safeguarding Hub is due to ‘go live’ in June. This will enhance information sharing at every level, including early help. j) The role of the hospital social worker has been reviewed and is now based within the Access and Assessment Team with clearer arrangements for management support and oversight. k) CSC has commissioned a replacement ICS system (Liquidlogic) which will ‘go live’ before the end of May 2017: this will facilitate better storing, organisation and sharing of information and create a direct information link between CSC and early help. l) Quality audits (as part of the Board’s joint evaluation of cases) have shown mostly good quality social work assessments, which have shown good evidence of direct engagement with men, good joint working and effective core groups. 2. Police Service a) The Force’s policy in relation to the sharing of domestic violence incidents with children’s social care has been updated (May 2015 & July 2015). b) Further work has been undertaken with the local authority in relation to sharing of domestic violence incidents that do not meet a safeguarding threshold but require intervention by early help and a process for these referrals in now in place (July 2015). Hull SCR Baby J /Mar 2017 48 c) A pilot was introduced within Hull for the sharing of domestic violence incidents with the health community. This is now embedded. d) Since February 2015, Humberside Police have provided a further training programme for all front line police staff and supervisors across Communities, Operations and Specialist Commands. ‘Domestic Abuse Matters’ was delivered by external trainers and included a bespoke focus on coercive control. (Humberside Police has subsequently had a successful ‘victimless’ prosecution using the new law on coercive control) e) The current Domestic Violence Form (F913) is in the process of being amended. The new version of the form will ask attending officers to record whether a child has been seen and spoken to, including the demeanour of the child in relation to the incident. f) The Force has introduced a dedicated team within its Incident Handling Centre, led by an Inspector. This team is responsible for reviewing incident logs where a potential safeguarding need is identified. The team undertakes relevant checks of police and partner agency systems, records these within an incident log and so ensures that officers attending incidents have up-to-date safeguarding information to inform their decision-making. g) All domestic abuse incidents are reviewed by a supervisor. This includes 913 forms and the rationale for risk classification made by the attending officer. ‘High’ risk cases are quickly identified and appropriate safeguarding action taken. Cases involving children in households are identified, leading to early notification of partners. h) A recent audit of ‘medium risk’ assessed DA cases showed that the strengthened triage process is now more robust. i) Humberside Police has taken a lead role in developing the EHaSH (Early Help and Safeguarding Hub) in Hull. This is due to ‘go live’ in June 2017. j) The force is one of three taking part in a national pilot of a revised DASH assessment tool. This is being led by the College of Policing and will report in the autumn of 2017. k) The force is implementing a new IT system – CONNECT – in June 2017. This will allow direct inputting of DA incidents and will enable DA specialist staff more time to focus on triage, secondary risk assessment and domestic violence prevention notices. l) The force is making increased use of safeguarding mechanisms (disclosure) under Clare’s Law. m) Improved processes are in place which identify (highlight) any repeat domestic abuse incidents – this allows for better recognition of patterns. 3. CRC Probation Service a) An Integrated Quality Assurance Model (IQAM) has been operating within the CRC since Sept 2014. This has recently been updated and remodelled. Safeguarding is a ‘thread’ that runs throughout the audit tool. The first full audit (using the new model) took place in April 2017 with outcomes expected shortly. IQAM audits will take place quarterly and will inform improvement plans. b) A guidance document has been provided to all staff which includes information on quality indicators across all phases of offender management. c) All Hull-based CRC staff have completed (HSCB) refresher level 1 safeguarding children training within the last 6 months. Hull SCR Baby J /Mar 2017 49 d) An update to BBR (‘Building better relationships’ which has replaced IDAP) post-programme reports will be completed by end June 2017. This includes guidance to programme staff in respect of how success and outcomes are measured. e) Guidance for non-probation practitioners about BBR, what is aims to achieve, how it works, what ‘success’ looks like and what that means in terms of risk management will be completed by end of June 2017. 4. Hull and East Yorkshire Hospitals a) A new electronic referral process (referrals to CSC) in line with the new Strengthening Families approach, commenced in February 2016 and has improved communication between agencies. b) The guideline for ‘Supporting Women with Complex Social Needs’ has been developed (2016) This includes assessment for risk factors and vulnerabilities at booking, during pregnancy at 16 and 32 weeks, and post-natally prior to discharge from maternity services. c) Midwives are using the locally developed ‘vulnerability toolkit’ and the developed pre-birth vulnerability pathway. d) All midwives were informed of the new processes in 2016 and this is reinforced on ‘caring for vulnerable women’ training and other mandatory training. e) Guidelines have been strengthened to ensure that when midwives receive new or changed information this is always reported to the health visitor. f) Systems for regularly updating contact lists have been designed so all staff working with women have easier access to community contacts. This includes improved links with housing and hostels. g) A tracking system is now in place to ensure that midwives have access to key information in maternity records prior to antenatal and postnatal appointments. This also enables midwives to more easily identify women who are not attending during the post-natal period, to better facilitate timely and appropriate follow-up. h) The induction process for new midwives has been strengthened and includes safeguarding session with the Named Midwife, ensuring that new midwives have knowledge of the trust’s safeguarding processes and how to access safeguarding supervision and support. i) Antenatal day unit paperwork has been revised to offer more support to midwives asking routine questions about domestic abuse. The most recent routine enquiry audit showed 95% compliance. j) A new system has also been introduced which offers women the opportunity to alert midwives if they wish to talk about domestic abuse. 5. Humber Foundation NHS Trust a) A process of assessments of the practitioner is now in place. Hull SCR Baby J /Mar 2017 50 b) Progress has been made in ensuring that all practitioners working with families in mental health assessment services undertake advanced safeguarding children training. c) HFT delivered a refresh ‘Think Family’ campaign across the trust in 2016/17. d) Processes are in place to ensure that the findings from mental health assessments in police custody are communicated to appropriate partner agency staff. e) A revised safeguarding supervision model has been rolled out into mental health services to ensure that staff are working to a “think family” model. 6. City Health Care Partnership CIC (CHCP) a) CHCP acts as the ‘single point of contact’ for Police domestic abuse (913) forms for the local health community. This was established on a pilot basis initially and has now been embedded b) An audit of 913 DV213 forms was undertaken and this had led to improved systems for circulating this information to the wider health community. c) A second audit has been completed leading to further improvements. d) The system is now firmly embedded. 913 (domestic abuse) reports are now circulated to all relevant staff in CHCP, as well as GP’s, midwifery services and staff in Humber NHS Trust within 48 hours of receipt. e) In 2016, all family nurse practitioners received DASH training. The training evaluated very well. This has led to referral (using DASH) to MARAC from FNP. f) There is a planned roll-out of DASH training to all health visitors and school nurses. Six dates have been established for this. g) All staff working in (CHCP) children’s services, including minor injuries units and sexual health services, have received ‘routine enquiry’ training, which is refreshed every three years. 7. The Hostel a) These issues have been discussed at staff meetings with an agreement to ensure staff coordinate and work alongside statutory and other agencies to ensure appropriate information is shared and is a two-way process. b) Other agencies have been invited to staff meetings on a regular basis to share information about their respective agencies and to discuss partnership working. The Hostel Manager has also attended a CSC management meeting to give a presentation about the work of the hostel and working in partnership. c) The hostel is now more confident in calling, and in some cases chairing, multi-agency meetings. 8. Hull Safeguarding Children Board a) Held a ‘deep dive’ day for the full Board in July 2016 in order to explore current issues and extent of domestic abuse in Hull and the impact on children. This included consideration of Hull SCR Baby J /Mar 2017 51 the emerging learning from this SCR and others, locally and nationally, an audit of cases involving practitioners and a review of MARAC. b) Revisited ‘domestic abuse’ at the Board day in March 2017 to assess improvement. c) Influenced the establishment of a new cross-partnership strategic steering group on domestic abuse, with a focus on developing new approaches in tackling the issue locally, given the continuing rise in incidence. d) Continues to provide domestic abuse training to all partners, including a two-day course which was provided on nine occasions in 2016/17 and new training on routine enquiry to Children’s Centre staff. e) Developed, launched and implemented a pre-birth vulnerability pathway to strengthen joint work where potential risk is identified to unborn babies. f) Has had continual oversight of the developments in early help and progress towards implementing the Early Help and Safeguarding Hub (now due to ‘go live’ in June 2017. g) Reviewed arrangements at the ‘front door’ (of CSC) and early help at the Board day in November 2016. h) Used domestic abuse as the theme for the joint evaluation (multi-agency audit) of cases between January – March 2017 and provided a summary of learning to the Board in March 2017. i) Has influenced the wider use of DASH across the partnership – FNP have been trained and are using the tool; briefings have been provided for social workers, with more planned; health visitors and school nurses are being trained in 2017. j) Has agreed a ‘whole partnership’ review of domestic abuse training to commence in June 2017. k) Is leading on work across the partnership on ‘engaging men and fathers’ in work with families at all levels and contexts. This includes a focus on engaging men who are known to be violent. |
NC52326 | Developmental delay and obesity of a 4-year-old girl due to neglect over a number of years. Learning: managing long-term neglect can be complex and difficult; medicalisation of weight gain can distract professionals from safeguarding concerns; where a medical diagnosis is offered as an explanation for neglect, all aspects of the child's health and well-being should continue to be considered to avoid diagnostic overshadowing; managers should ensure their staff are able to use agreed multi agency escalation procedures; professionals who attend initial child protection conferences should be confident and able to professionally challenge one another, to avoid over-optimistic thinking or disguised compliance; ensure that information given to parents whose first language is not English is fully understood and that they can meaningfully engage in professional meetings and discussions; translation services should be used when appropriate; when children are not brought to medical appointments follow the family engagement process; the need to assess parental capacity to sustain change; ensure that the voice of the child is heard consider he lived experience of children within the family; ensure the vital role of early years settings in the safeguarding system is understood by all involved. Makes no recommendations but highlights the importance of understanding and assessing the capacity of a parent to sustain change and following the escalation policy where this does not happen.
| Title: Learning review report: Grace. LSCB: Hampshire Safeguarding Children Partnership Author: Hampshire Safeguarding Children Partnership Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Learning Review Report Grace A summary of the case: Grace came to the attention of Hampshire Children’s Services at the age of two, initially due to concerns regarding the family’s housing situation. That year, a referral was made by the health visitor to the Disabled Children’s Team relating to Grace and her sibling. It was noted at this stage that Grace was obese and showing signs of global development delay. Assessments were undertaken and it was agreed that Grace did not meet the criteria for services. The following year further referrals were made by the occupational therapist. Following further review by the Disabled Children’s Team, it was felt that considerable services were being provided to the family by universal services and the case did not progress. It was reported by Grace’s nursery that Grace was not attending the setting as planned, despite funded transport being requested and provided. When Grace was three, she was seen by a consultant paediatrician. It was reported that at age three Grace was 2.5 times the weight of an average three-year-old. She was unable to stand or walk and there was evidence of her airways being obstructed at night-time. Grace was referred to a specialist medical team for further assessments, and a significant number of tests were undertaken to ascertain if there was a medical reason for the weight gain. Later that year Grace was attending a pre-school, where concerns were raised regarding the impact Grace’s weight was having on her. A Child and Family Assessment was completed by Hampshire Children’s Services, and the case was progressed to Child in Need (CIN) planning. During the Child in Need planning, there were concerns raised that numerous appointments with specialist health services had been missed. However, it was being reported that the family were making good progress and sticking to diet plans. Grace’s parents were informed that she needed to lose weight quickly due to the risks associated with being morbidly obese. Grace’s weight continued to increase, and she was admitted to hospital for one month. During this time Grace lost a significant amount of weight and made excellent progress developmentally. Concerns were raised that mother was refusing the use of potentially lifesaving equipment and taking Grace off the ward early. This was shared with the Health Visiting Service. Four months after Grace’s admittance to hospital it was recorded that Grace continued to lose weight. Three months after this point her weight had started to increase again. Grace was observed in this period eating chocolate provided by her mother and had missed numerous health appointments. At this point Grace was on a Child in Need plan. A further referral was made to Children’s Services and an Initial Child Protection Conference was held. At the Child Protection Conference, the consultant paediatrician advised that genetic testing identified that Grace had an underlying obesity disorder and that her weight was due to this 2 metabolic abnormality and her weight gain was not environmental. This was accepted, despite medical tests being inconclusive and evidence being gained whilst she was an in-patient regarding her significant weight reduction whilst on a controlled dietary regime. At the conference, Grace’s parents reported that they were struggling to follow diet plans as their first language was not English. The outcome was unanimous that Grace should not be the subject of a Child Protection Plan. At the age of four, Grace was seen urgently in hospital due to a significant weight gain in a short period of time. Her parents stated they had no idea she had gained this much weight. Parents had not been taking Grace to regular weigh-ins in-between clinic appointments. The parents cited a lack of transport as the reason for missing appointments, despite the health visitor providing clear instructions regarding transport for hospital appointments. Grace’s parents were unable to provide an explanation for the weight gain. At this point it became known that potentially lifesaving equipment that had been provided to Grace’s parents was not being used. A referral was therefore made to Children’s Services and an Interim Care Order was granted. Learning points for managers: • The complexity of managing long-term neglect and the difficulties which professionals can encounter when children and families appear to be compliant. • The medicalisation of Grace’s weight appeared to allow practitioners to become distracted from the safeguarding concerns which were evident during her admission to hospital. • Where there is a medical diagnosis offered as an explanation for the presenting features of neglect, all aspects of the child’s health and well-being should continue to be considered to avoid the potential for diagnostic overshadowing. • Point for managers to ensure their staff are well versed and empowered to use agreed multi agency escalation procedures. Learning points for practitioners: • Professionals who attend Initial Child Protection Conferences should ensure that they are confident and able to professionally challenge one another, to ensure they are not being optimistic in their thinking and have explored the possibility of diagnostic overshadowing and disguised compliance. • When a parent’s first language is not English every effort should be made to ensure that information given to parents is fully understood and that they can meaningfully engage in professional meetings and discussions. Translation services should be used as appropriate. • When children are not brought to medical appointments the Family Engagement process should be followed. Learning points for HSCP: • Working effectively with neglect and in particular assessing parental capacity to sustain change. • Ensuring that the voice of the child is heard and there is careful consideration of the lived experience of children within the family. • Ensuring the vital role of early years settings in the safeguarding system is understood by all involved. 3 Themes in common with other reviews in Hampshire: • The need for ensuring parents whose first language is not English have access to translation services as appropriate. • Parental capacity to sustain change. • Recognising disguised compliance. • Professional challenge and escalation. If you do one thing, take the time to…. Understand and assess the capacity of a parent to sustain change. Where this continues to be an issue and progress is not sustained the Escalation Policy should be followed. How was learning achieved: A multi-agency review was commissioned by the Learning and Inquiry Group of Hampshire Safeguarding Children Partnership. Hampshire agencies provided written reports. These were reviewed by two senior managers, independent of the case and where required, additional information sought from professionals involved in the case. HSCP response: The Learning from this Learning Review Report has been incorporated into HSCP workstreams. This has included multi-agency training, planned audits, scrutiny work, professional guides, and featured newsletter items. Training and resources: • HSCP Training - HSCP offers training on a variety of safeguarding themes. • HSCP Training 2020/21 • HIPS Procedures • HSCP and IOWSCP Neglect Strategy and Toolkit • Neglect training • Child and Family Engagement Guidance for Primary Care • Child and Family Engagement Guidance for Secondary and Tertiary Care • Escalation Policy for the Resolution of Professional Disagreement • Spotlight on Disguised Compliance • Published SCR/LCSPR reports and learning summaries can be found in the Learning and Reviews section of the HSCP website - Published Reviews. Publication Date: 1 February 2022 |
NC043246 | Executive summary of a review into the death of Christine, aged 17 years, on 12th March 2012, at the hand of her sister's ex-boyfriend, Michael. A friend of Christine was also murdered and her sister kidnapped. Michael tried to flee the country but was caught and sentenced to serve a minimum of 34 years. Christine had been known to children's services since 2007 and was living in supported independent living at the time of her death. History of: challenging and risk-taking behaviour; drug and alcohol use; going missing from home; suspected child sexual exploitation (CSE) by older men; and disclosures of domestic abuse made against an ex-boyfriend. Makes single and multi-agency recommendations, including: awareness raising of CSE risks to young people, particularly those over the age of consent; extending the NHS safeguarding supervision to involve staff from GUM clinics who see patients one-to-one; and an action plan for addressing domestic abuse between young people.
| Title: Serious case review executive summary: Christine LSCB: Wakefield and District Safeguarding Children Board Author: Pat Cantrill Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Wakefield and District Safeguarding Children Board Serious Case Review Executive Summary Christine 2 1. Introduction Reasons for the Serious Case Review 1.2 Chapter 8(9) of Working Together to Safeguard Children 2010 requires a Local Safeguarding Children Board to undertake a Serious Case Review whenever a child has died and where abuse or neglect are known or suspected to be a factor in the death. 1.3 The purpose of a Serious Case Review is: • To establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children • To identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • To improve intra- and inter-agency working and better safeguard and promote the welfare of children. Scope and process of the review 1.4 On 14th March 2012, the Independent Chair of the Wakefield and District Safeguarding Children Board (WDSCB) made the decision to hold a Serious Case Review Panel to consider the circumstances of Christine’s death. 1.5 This Serious Case Review Panel met on 11th April 2012 and recommended that the case met the criteria for a Serious Case Review. The Independent Chair of the Wakefield and District Safeguarding Children Board subsequently made the decision to undertake a Serious Case Review. Terms of reference 1.7 The Serious Case Review Panel identified the following specific lines of enquiry: • Was the level of vulnerability and risk to Christine fully understood by the different services within an organisation and effectively communicated between different services and to partner agencies? • Were Michael’s level of vulnerability and the extent of the risk he posed to others fully understood by the different services within agencies and effectively communicated between these different services and to partner agencies? • Was the level of risk to Christine effectively communicated during the transition from children’s services to adult services? • Was the level of risk posed by Michael effectively communicated during the transition from children’s services to adult services? 3 • When Christine or Michael failed to engage fully with services provided were services sufficiently persistent in promoting engagement or were there missed opportunities? • Did the services within agencies have effective procedures to deal with non-engagement or non-attendance and were these procedures followed? • When different services within agencies became involved with Christine or Michael, were their histories sufficiently explored and understood to enable these services to fully understand the vulnerabilities and risks? • When Christine returned to Wakefield in February 2011 from an out of area placement did the Safeguarding and Family Support Directorate effectively share information with partner agencies in health to enable them to provide adequate support? • Did the services effectively communicate with Christine and Michael in a way that they could fully understand? Were there any missed opportunities to communicate more effectively? • Were there any missed opportunities to share information effectively with partner agencies? • Did practitioners use line-managers or supervision to effectively discuss any concerns that they had about Christine or Michael? • Is there any evidence of practitioners being overly-cautious or inhibited due to cultural issues? • Was appropriate action taken in line with West Yorkshire Procedures in relation to any concerns about possible child sexual exploitation? • Is there any evidence that a focus on the issues of possible child sexual exploitation impacted negatively on the identification of other risks? Time Period 1.8 This Serious Case Review has covered the period from 1st January 2011 to the date of Christine’s death. 1.11 The independent author of the Overview Report is Professor Pat Cantrill. Professor Cantrill has led a number of high profile Serious Case Reviews. She has considerable experience in cases of domestic abuse and child sexual exploitation. Professor Cantrill is a Visiting Professor at Sheffield Hallam University and the University of Lethbridge in Canada. 2. Case Summary Christine 2.1 Christine became known to specialist safeguarding services in 2007. At this point, concerns focused on the following issues: 4 • Challenging behaviour within the home • Risk-taking behaviour • Use of alcohol and drugs • Going missing from home • Association with older males and possible Child Sexual Exploitation 2.2 Christine was made subject to a Child Protection Plan in 2007 as a result of these concerns. However despite intervention by professionals, these problems escalated and in December 2007 Christine was accommodated by the Local Authority initially at a local children’s residential unit and then in a foster home. 2.3 Whilst in foster care these concerns lessened and Christine returned home to live with her mother in August 2008 with support from professionals. However in November 2008 the situation deteriorated and Christine was again accommodated by the Local Authority. 2.4 Between August 2008 and February 2010 Christine was placed with foster carers but experienced a number of placement changes as a result of challenging behaviour and concerns relating to risk taking behaviour, going missing and suspected sexual exploitation. In February 2010 the decision was made that it would be in Christine’s best interests to be placed in a therapeutic residential placement outside the Wakefield district. 2.5 A settled period followed however in December 2010 Christine, then aged sixteen, indicated a desire to leave her placement. A decision was subsequently made to support Christine to live independently in a flat in February 2011. 2.6 After this point, concerns about Christine’s welfare again began to increase. She appeared to become increasingly hostile to professionals and had stopped attending college. She disclosed that she had experienced domestic abuse from her ex-boyfriend. 2.7 Christine remained in this placement with support however concerns persisted and in July a local police officer reported concerns about adult males visiting Christine’s flat and possible use of drugs at the property. 2.8 Christine indicated her intention to return to Wakefield in August 2011 stating that she was being harassed by local males. After her return to Wakefield she was placed briefly in bed and breakfast accommodation before moving with her agreement to experienced supported lodgings providers. 2.9 Whilst in supported lodgings, concerns about Christine’s welfare persisted. In particular, these concerns centred around suspected drug and alcohol use, periods of absence from the placement and possible sexual exploitation. 2.10 In December 2011 partly as a result of requests made by Christine herself and partly as a result of concerns about the impact of Christine’s behaviour on other resident young people, the decision was made to support Christine to move from supported lodgings to supported independent living in a flat in central Wakefield. 2.11 Professional support continued after Christine moved to this supported tenancy however despite frequent visits from professionals, concerns remained. There were several complaints from neighbours about noise from Christine’s tenancy and frequent visitors to the property. 5 Professionals continued to hold concerns about drug use and suspected sexual exploitation although Christine denied this. In March the parent of a friend contacted the Local Authority and informed them of concerns about possible sexual exploitation and in addition another young person also raised similar concerns. 2.12 On several occasions, Christine had expressed concern about the welfare of her older sister due to domestic abuse and threats by her older sister’s boyfriend, referred to in this Serious Case review as Michael. Professionals had met with Christine’s older sister on several occasions and offered advice and support in relation to domestic abuse and alternative accommodation. Christine’s older sister subsequently separated from her boyfriend. 2.13 On 12th March 2012 Christine was murdered in her flat by her older sister’s ex-boyfriend. A young female friend of Christine was also murdered. Christine’s older sister was kidnapped and the ex-boyfriend made an attempt to flee the country. 2.14 After Christine’s older sister escaped, she was able to raise the alarm. The adult male referred to as Michael was subsequently arrested. Michael 2.15 Michael first became known to agencies in Wakefield in October 2007. He was an unaccompanied asylum seeker who had fled Afghanistan. 2.16 Although he claimed to be fifteen years old, an age assessment was undertaken in line with guidance and his age was assessed at sixteen years. 2.17 Michael was initially placed in a local hotel however after a suicide attempt, he was placed in a local authority children’s residential unit in November 2007, where it is believed that he first met Christine’s older sister. 2.18 In March 2009 Michael moved from this residential unit to a multiple occupancy supported tenancy, where he received support from the Local Authority. 2.19 The Independent Overview Report provides a detailed account of the services and support provided to Michael until the incident in which Christine and her friend were murdered in March 2012. 2.20 Michael has since been convicted of the murder of Christine and her friend. He has been sentenced to serve a minimum of thirty four years in prison. 3. Conclusions and Learning 3.1 This Serious Case Review has identified a number of areas of good practice including the degree to which some professionals were persistent in attempting to support and guide Christine in an effort to reduce risk. 3.2 The Serious Case Review has also identified missed opportunities to protect both Christine and her older sister and to assess the risk posed by Michael. 3.3 The Independent Overview Report identifies learning for agencies in the following areas: 6 • Working in partnership to identify risk and to safeguard and protect teenagers • Domestic abuse and in particular, abuse within teenage relationships • The provision of services to young people who are placed outside of the local authority area • Identifying and reducing the risk of sexual exploitation • The provision of mental health services to young people in crisis • The provision of accommodation to vulnerable young people and particularly young people who are leaving the care system • The process of age assessment of unaccompanied asylum seeking children and the need for these to be reviewed in the light of new information 3.4 Prior to the completion of this Serious Case Review, changes have already been made in relation to the delivery of services to young people and care leavers. 3.5 These changes include the review of mental health services provision in the district and new systems to support the allocation of independent accommodation to care leavers as well as the development of a local Child Sexual Exploitation Strategy and Action Plan and new multi-agency arrangements to tackle child sexual exploitation in the district. 3.6 Following the completion of this Serious Case Review a detailed action plan has been developed to enable the implementation of the recommendations that have been made for agencies. This action plan will be monitored by the Safeguarding Children Board. 4. Recommendations The Mid Yorkshire Hospitals NHS Trust 4.1 The LSCB member for MYHT will provide the LSCB with an action plan indicating how awareness of the risk factors for child sexual exploitation will be communicated to staff. This will specifically include risks to children of over the age of consent. 4.2 The LSCB member for MYHT will ensure that all staff within the GUM service who work with children and young people in 1:1 situations are included in the Trust Safeguarding Supervision Policy. 4.3 Raise awareness of purpose and function of Looked After Health Team with specific consideration to Increased Vulnerabilities SPECTRUM Community CIC 4.4 To develop a care pathway for Young People accessing Spectrum Community Health Services who misuse substances. 4.5 Educational programme will be extended for CASH outreach nurses to include: mandatory 7 training related to substance misuse and qualification as a non-medical prescriber. 4.6 The Named Professional Safeguarding Children will amend the Safeguarding Supervision Policy (2011) to include that prior to an arranged Safeguarding Supervision session Outreach CaSH nurses will identify which young people are currently open on their caseload at: • Child Protection Level • Child in Need Level • ‘Looked After’ Children • Any case identified by the CaSH outreach nurse has having poor multi-agency working. 4.7 The Executive Lead for Safeguarding (Spectrum) will provide the LSCB with an action plan indicating how awareness of the risk factors for child sexual exploitation will be communicated to staff. This will specifically include risks to children of over the age of consent. South West Yorkshire Partnership Foundation NHS Trust 4.8 The CAMHS referral process should be strengthened • There will be clear criteria with regard to what constitutes an urgent referral • Standards will be developed for responding to urgent referrals • The referral documentation used by agencies should be reviewed to ensure that it elicits the information required to ensure the child or young person gets the right service at the right time. • A clear care pathway should be agreed outlining a Childs journey in CAMHS once a referral is made, (including potential for disengagement) through to effective and safe discharge or transition. 4.9 An examination should take place of how complex cases and cases and multiple repeat referrals are managed and a pathway and process developed to ensure effective outcomes for children and young people. 4.10 The development of a system and process should include multi professional consideration of cases where children and young people are identified as vulnerable or identified at risk. 4.11 That a review and analysis of risk, its assessment and management in the CAMHS service is undertaken, this should include: • What is understood about risk assessment and management in the CAMHS service and in particular what is understood by the different professional groups? • The assessment tools used , including specific tools for specific issues(CSE for example) • The quality of assessments undertaken, including regular reassessment at key points of child’s journey(inclusive of discharge planning) • Are the risks identified translated into the care packages provided to children and their families? This will result in clear recommendations for practice; recommendations will be incorporated into a risk management appendix for the Clinical Risk Assessment and Management Policy for 8 South West Yorkshire Foundation Trust. 4.12 That a targeted programme of learning and development takes place in relation to Child Sexual Exploitation (CSE).This will include identifying and recognising the signs of CSE in young people and training staff to undertake specific risk assessments related to CSE and heighten the awareness of communicating the identified risks. West Yorkshire Police 4.13 West Yorkshire Police to review the process of domestic violence notification to the Police Safeguarding Units with respect to timeliness and management oversight 4.14 West Yorkshire Police to ensure that all cases that meet the criteria for MARAC are referred in a timely manner WDH 4.15 To review the current lease arrangement and working protocol between WDH and Wakefield Council (Vulnerable Adult Services) for the provision of temporary accommodation. CRI Rebound 4.16 To ensure that the background history of young people who access the service, in particular any previous or current safeguarding concerns, is identified and recorded. When a young person indicates that they do not wish information to be shared with their social worker, this must always be explored with them to identify the reasons for this and they must always be advised of the exemptions to confidentiality. 4.17 The working relationship between Rebound and SPECTRUM should be strengthened. WMDC Safeguarding and Family Support Services 4.18 The current review of the organisational structure within Safeguarding and Family support should establish clear lines of accountability and responsibility within the Leaving Care Service, for both management of staff and for service users. The Leaving Care Team should also establish a system to notify partner agencies when a young person eligible for services moves into or returns to the Local Authority area. 4.19 The Strategic Group looking at Domestic Abuse should ensure that it develops an action plan to address Domestic Abuse between young people. In the meantime there should be an exercise to identify the scope and scale of DA between service users within the Leaving Care Service resulting in a clear action plan to address the needs of both the victim and perpetrator. 4.20 The way in which age assessments/risk assessments are conducted in respect of unaccompanied asylum seekers should be considered in line with new national guidance and the local training already commissioned. This should emphasise the expectations that age and risk assessments should be reviewed to ensure currency. 4.21 To develop a new mechanism for the multi-agency discussion of cases where the plans that have been made for an individual young person are not being achieved and where the young person is still at risk. This system should be applicable to any young person including LAC and 9 Care Leavers and should allow for reflection, review and also challenge of the intervention of each agency. WMDC Youth development and Support Service 4.22 The YDSS will ensure that all staff are clear about their responsibilities for undertaking assessments, planning interventions, sharing information and recording all information. 4.23 Changes to be made to YDSS recording practices that include: • All records to be held electronically • Managers to agree the correct assessment and planning tool for each service area and communicate this to relevant staff • Managers to ensure they have access and can use the range of electronic databases used by the staff they supervise. 4.24 Information sharing consent forms that are signed by young people to be updated to ensure they contain clarity on how risk management and safeguarding impact on confidentiality and have an annual review built into them. 4.25 Supervision arrangements to be amended to ensure the following. • The supervision template prompts the manager to: � ensure information sharing consent forms are in place and renewed annually for all open cases. � an assessment and plan is in place for each case � ensure that issues of risk management, safeguarding, inter-agency working and information sharing and wider family concerns are considered in relation to each case where relevant. � ensure that follow-up action previously agreed has been completed. � record whether the interventions discussed have been undertaken within the required standards and policy and practice guidance. � ensure the case recording is of a sufficient standard. • Quality assurance of line manager supervision to take place in line with Family Services policy and Service Manager to follow up deficiencies identified by the audits. 4.26 Targeted Youth Support Services to establish a case planning forum that quality assures the assessment, planning and review of all TYS cases. |
NC049401 | Sexual exploitation of children and adults with needs for care and support in Newcastle between 2007 and 2015. A police-led multi-agency investigation, Operation Sanctuary, was launched in January 2014 to investigate the sexual exploitation of children and vulnerable young adults in Newcastle. A large number of victims were identified and the investigation resulted in the arrest of over 30 men. Eight cases were selected for this joint review to maximise learning, reflect the different circumstances in which victims had suffered sexual exploitation and include factors likely to be present in other cases. Learning includes: understanding the prevalence of sexual exploitation requires assuming it is taking place and adopting a pro-active approach to look for it, recognising that the most reliable source of information is from victims and those targeted; the most effective way to address sexual exploitation and safeguard and promote the welfare of victims is to resource multi-agency teams, co-located in the areas in which sexual exploitation takes place; effective safeguarding is a collective responsibility and requires a culture of robust interagency and professional challenge of practice and strategy; sexual exploitation is not restricted to child victims. Recommendations for the government include: to consider which community services not routinely involved with local safeguarding frameworks have a contribution to make to early identification and prevention of sexual exploitation and make arrangements to ensure that their contribution is made and monitored through regulatory functions or otherwise. Recommendations for the National Health Service England include: to consider establishing a risk information sharing system for sexual health settings.
| Title: Joint serious case review concerning sexual exploitation of children and adults with needs for care and support in Newcastle-upon-Tyne. LSCB: Newcastle Safeguarding Children Board Author: David Spicer Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board Joint Serious Case Review Concerning Sexual Exploitation of Children and Adults with Needs for Care and Support in Newcastle-upon-Tyne Independent Report Author – David Spicer February 2018 2 3 Contents Section Page 1 Introduction 7 1.1 The Decision to Carry out a Joint Serious Case Review 8 1.2 Terminology 9 2 The Review Process and Methodology 11 2.1 Governance 11 2.2 The Victims and the Eight Cases 13 2.3 Participating Services 14 2.4 Timelines and Timeline Reports 18 2.5 The Learning Events 18 2.6 Acting on Learning During the Review 18 2.7 Additional Information 19 2.8 Perpetrators’ Contributions 20 3 Summary of Thematic Findings 21 4 Sexual Exploitation – The Complexity 25 4.1 What is Sexual Exploitation? 25 4.2 Why is Tackling Sexual Exploitation so Difficult? 27 4.3 Modern Life, Attitudes and the Impact of Technology 30 4.4 What is the Impact of Sexual Exploitation? 30 5 The Newcastle Response to Increased Awareness 32 5.1 Operation Sanctuary 32 5.2 Perpetrators’ Families 33 5.3 Paid Police Informant 33 5.4 Disruption 33 5.5 Establishment of the Multi-Agency Sexual Exploitation Hub 36 5.6 Victims’ Mental Health Needs 38 5.7 Impact of Operation Sanctuary and the Multi-Agency Sexual Exploitation Hub 39 5.8 Complex Abuse Meetings held in relation to Sexual Exploitation 40 5.9 Safeguarding Adults 41 5.10 Transition 44 5.11 Understanding, Informing and Mobilising the Communities 46 6 The Perpetrators 50 7 Newcastle in the Context of the National Picture: preparing for, preventing and responding to sexual exploitation 54 7.1 Response to Legislation and Guidance 54 7.2 Overarching Response 59 7.3 Response prior to 2014 59 4 7.4 Why were Perpetrators not Investigated and Prosecuted or otherwise Disrupted Prior to 2014? 61 7.5 Interagency Responses 63 7.6 Interagency Awareness and Preparedness 63 7.7 Regional and National Links 66 7.8 Police and Crime Commissioner 67 7.9 Crown Prosecution Service 68 7.10 Links with the Judiciary 71 7.11 Leadership from the Safeguarding Lead Agency 71 7.12 Interagency Leadership 74 7.13 Resources 74 7.14 Quality Assurance and Audit 74 7.15 Public Sector Commissioning 75 7.16 Other Providers of Services 75 7.17 The Role of Schools and Education Services 77 7.18 Children Missing School Education 78 7.19 Children who Change Schools 80 7.20 Arrangements to Consider Missing Children and Young People 80 7.21 Raising awareness among potential victims 82 8 Consultation with Children and Adults 84 8.1 The SCARPA Squad 85 8.2 Children and Young People Staying Safe in the City Event 86 8.3 Young People in Newcastle and the risk of sexual exploitation: Unicef U-Report August 2017 86 9 Identifying Sexual Exploitation; Protecting Victims 87 9.1 Identifying 87 9.2 Sexual Health Services 88 9.3 School Nursing 95 9.4 Information Sharing and Recording 96 9.5 Children and Adults Who Move Area 97 9.6 Professional Culture 98 9.7 Professional Curiosity 99 9.8 Assessments 100 9.9 Chronologies and Genograms 101 9.10 Neglect 102 9.11 Understanding and Responding to Diversity, Language and Culture 102 9.12 Plans 105 9.13 Working with Families 108 9.14 Safeguarding Procedures: Children Looked After by the Local Authority and Adults subject to Adult Protection Plans 109 9.15 Listening to Victims 110 5 9.16 Lack of Engagement with Services 112 9.17 Team Around the Worker 114 9.18 Capacity and Choice 114 9.19 Mental Health and Learning Disability 115 9.20 Education Services and Learning Disability 118 9.21 Placements 119 9.22 General Practice 123 9.23 Boys and Men 123 10 Professional Awareness, Training and Staff Development 125 10.1 Interagency Training 125 10.2 Agency Training 127 10.3 Personal Professional Responsibility 129 10.4 Staff Welfare 130 11 Challenge, Support and Escalation 132 11.1 Challenge 132 11.2 Supervision 133 12 The Criminal Court Experience and Court Processes 135 13 Supporting Victims and Survivors of Sexual Exploitation 141 13.1 Advocates 141 13.2 Support of Victims during Trials and Beyond 142 13.3 Compensation and Personal Injury Claims 142 14 Concluding Remarks 145 15 Recommendations 147 15.1 Local 147 15.2 National 149 6 7 1. Introduction This is a report of a Thematic Serious Case Review carried out jointly by Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board to consider and learn from sexual exploitation involving children and young adults in Newcastle. It was decided to carry out the Review when there was increased awareness of the prevalence of sexual exploitation that had taken place and was continuing in the Newcastle area. The decision was not taken as a result of any exposure of persistent disregard of whistle blowers’ allegations or public concern which was ignored or any scandals uncovered by investigative journalism1 that drove the need to carry out high profile reviews and inquiries in some other areas. Early in 2013, briefings to the Newcastle Safeguarding Children Board included cases of child sexual exploitation occurring elsewhere, initiatives by the Children’s Commissioner, the local Child Sexual Exploitation Action Plan and arrangements in place for prevention and the management of cases. A local profile of known cases confirmed previous judgments that child sexual exploitation was not a significant problem in Newcastle. Continuing work to review the situation by public authorities and community and voluntary organisations confirmed previous assessments, that while individual cases were identified, there was not an extensive problem. However, over Christmas 2013, a 21-year-old woman who has a learning disability began to speak to her social worker about experiences of sexual exploitation over a long period. With encouragement, support and great courage, in January 2014 she gave a statement to the police in which she detailed her abuse and concerns about other children and young people. She identified places to which she had been taken. This account and other intelligence suggested the extent of sexual exploitation was greater than previously identified and required a strategic, well-resourced, victim focussed multi-agency response. Proposals were taken to the Northumbria Police Chief Officers’ Team and to senior officers in partner agencies. A police-led multi-agency investigation, Operation Sanctuary, was launched in January 2014. Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board provided interagency strategic commitment and there was strong political support. Operation Sanctuary led initially to arrests of over 30 men, accompanied by a publicity campaign. Two 19-year-old women in February 2014 reported to the 1Independent Inquiry into Child Sexual Exploitation in Rotherham 1997-2013: Alexis Jay OBE Rotherham Metropolitan Borough Council. 2014; Report of Inspection of Rotherham Metropolitan Borough Council: Louise Casey CB. House of Commons. 2015; Broken and Betrayed: The true story of the Rotherham abuse scandal by the woman who fought to expose it. Senior. Panmacmillan. 2016 8 police that they were victims of rape, sexual abuse and exploitation by a number of perpetrators over a period of years. Their accounts and subsequent inquiries confirmed that sexual exploitation was occurring in the Newcastle area on a much larger scale than previously recognised. The victims of exploitation were, as in high-profile cases elsewhere, young children but were also children approaching adulthood and adults with vulnerabilities. A picture emerged that suggested that over a period of years some perpetrators had abused hundreds of victims, some over many years during childhood and early adulthood. The extent of targeting of adults with vulnerabilities appeared not to have been identified elsewhere in the country. 1.1 The Decision to Carry out a Joint Serious Case Review In February 2014, Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board established a Joint Case Review Committee, the remit of which included considering from an inter-agency perspective, the progress of investigations and whether the criteria for carrying out statutory Reviews in relation to the child and adult victims were met. The circumstances suggested that lessons would be learnt from examining the experiences of victims, the strategic arrangements and the effectiveness of the responses of agencies over the period that it was becoming apparent exploitation had taken place. The Safeguarding Boards encourage continuous learning and improvement across organisations2 and a number of reviews of cases were carried out. In September 2014, the Joint Case Review Committee recommended that the criteria for carrying out Serious Case Reviews and Safeguarding Adults Reviews were not then met and this was agreed by the Independent Chairs of the two Boards. Ofsted and the Department for Education were notified of the circumstances and regular updates provided. The National Panel of Independent Experts on Serious Case Reviews was also consulted. As investigations progressed, the Committee met on a 3-monthly basis to review the position. The proactive approach of Operation Sanctuary and establishment of a Multi-Agency Sexual Exploitation Hub led to a rise in the number of cases and further clarity of the extent of exploitation. Having regard to the growing body of knowledge nationally, by May 2015, the Joint Case Review Committee concluded that unless the background was examined thoroughly in the context of current arrangements, it could be not be said definitively that there were no concerns about interagency working. While some very effective practice had taken place, some victims experienced exploitation which had not been identified and had received no agency intervention; for others interventions had limited impact. It was likely that the criteria for carrying 2 Chap. 4. Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government. 2015; Para. 14.138. Care and Support Statutory Guidance Issued under the Care Act 2014. Department of Health. 2014 9 out Reviews were met in a number of cases and it was recognised that Boards should consider conducting reviews on cases that did not strictly meet the criteria. The Committee recommended to the Chairs of the Boards that Serious Case Reviews and Safeguarding Adult Reviews should be carried out. The Chairs consulted senior officers in partner agencies and agreed that a more rigorous, comprehensive process of review with an independent element providing an overview of the circumstances should be carried out. There was an opportunity to review evolving knowledge of abuse of older children and vulnerable adults and working arrangements between adults’ and children’s services. A focus on improvements and good practice was likely to build on issues identified in other reviews and contribute to national learning.3 It was clear that carrying out a Serious Case Review would have significant time and resource implications. Advice was taken from Leading Counsel on the appropriate model to adopt to be consistent with statutory obligations and maximise learning. It was not practical to carry out individual reviews in relation to the large number of victims being identified. The process needed to be proportionate to the scale and complexity of the issues and the learning that would be likely to arise. It was important to ensure that if every case was not to be reviewed, this should not suggest that the experiences of victims who were not included were less serious or deserving of consideration. The safety and welfare of all known victims were considered through interagency safeguarding processes. Safeguarding Boards have a discretion within National Guidance4 concerning learning models to be employed. In October 2015, the Chairs decided that the Safeguarding Boards would jointly carry out a thematic Serious Case Review to look beyond specific incidents or individuals and focus on identifying, examining, and recording patterns or themes that are likely to apply in other circumstances. The National Serious Case Review Panel, Ofsted, the Health and Care Quality Commission and National Health Service England were notified of the intention to carry out a Joint Serious Case Review on this basis. 1.2 Terminology Throughout this Report, except where the context requires otherwise, the term: • “the cases” is used to refer to the cases considered during the Review; • “child” is used rather than “young person”. Many teenagers may prefer not to be described as children, but because child sexual exploitation involves the manipulation and gaining total control over those who cannot consent to sex 3 Chap. 4. Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government 2015 4 Chap. 4. Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government 2015; Para. 14. Care and Support Statutory Guidance Issued under the Care Act 2014 Department of Health 2014 10 either by virtue of age or capacity, it is important to refer to anyone under 18 as a child so their status is never overlooked.5 • “community and voluntary sector organisations” is used to refer to agencies and services sometimes referred to as the “Third Sector”; • “Hub” is used to mean the Multiagency Sexual Exploitation Hub; • “Newcastle” is used to mean Newcastle-upon-Tyne; • “Newcastle Children’s Social Care” and “Newcastle Adults Social Care” means the statutory social care services provided for children and adults by Newcastle City Council; • “NSCB” and “NSAB” mean Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board respectively; • “Practitioners” means professionals involved in the cases and who attended the Learning Events; • “the Newcastle Safeguarding Boards”, “the Safeguarding Boards” and “the Boards” means Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board; • “the Panel” means the Joint Serious Case Review Panel. • “the Review” is used to refer to the Joint Serious Case Review; • “sexual exploitation” includes “child sexual exploitation” and “adult sexual exploitation”. • “victim” is used to include “complainant” or “survivor”; • “vulnerable adults” or “adults vulnerable to exploitation” are used, adopting the approach of the Law Commission and High Court, rather than terms used in recent legislation.6 5 Report of Inspection of Rotherham Metropolitan Borough Council: Louise Casey CB. House of Commons 2015. 6 Mental Capacity and Deprivation of Liberty. Law Commission Vulnerable Adults Bill proposal. 13th programme of Law Reform. 2016 11 2. The Review Process and Methodology 2.1 Governance The Safeguarding Boards established a Joint Serious Case Review Panel of representatives of partner agencies to manage, oversee, scrutinise, challenge and quality assure the process. The Panel worked with and supported the Lead Reviewer, contributed to discussions, and ensured compliance with and approved any amendments to the Terms of Reference. It met regularly and reported progress to the Boards. A Lead Officer was appointed to Chair the Panel and manage the process on behalf of the Boards, report to the Chairs and work closely with the Lead Reviewer. The membership of the Panel was: • Service Manager and Principal Social Worker, Children’s Safeguarding Newcastle City Council (Chair and Lead Officer) • Newcastle Safeguarding Adults Board Coordinator • Newcastle Safeguarding Children Board Coordinator • Assistant Director of Children’s Social Care - Newcastle City Council • Assistant Director Adult Social Care – Newcastle City Council • Vulnerable Learners Manager and Safeguarding Lead for Schools • Assistant Director Legal Services - Newcastle City Council • Detective Chief Inspector - Northumbria Police • Service Manager Safeguarding Adults - Newcastle City Council • Executive Director of Nursing, Patient Safety and Quality – NHS Newcastle Gateshead Clinical Commissioning Group • Nursing and Patient Services Director – The Newcastle upon Tyne Hospitals NHS Foundation Trust • Safeguarding and Public Protection Manager - Northumberland Tyne and Wear NHS Foundation Trust • Improvement Manager – Children and Family Court Advisory and Support Service The Panel appointed additional members to represent community and voluntary organisations from: • The Angelou Centre • Newcastle Council for Voluntary Service Guidance7 requires one or more appropriately qualified individuals to be appointed to lead the Review. After a procurement process, taking account of knowledge, skills, competence and availability, I was appointed as Lead Reviewer for the Review. 7 Checklist for Serious Case Reviews: Chap. 4. Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government 2015; Para. 14. Care and Support Statutory Guidance Issued under the Care Act 2014. Department of Health. 2014 12 My name is David Spicer. I am a Barrister and trustee and former chair of the British Association for the Study and Prevention of Child Abuse and Neglect. I am independent of the Safeguarding Boards and the organisations involved in the cases. Until 2009, I managed a legal service for a large local authority, specialising in responsibilities for child and adult welfare, and practised and advocated in public law jurisdictions for over 30 years. Since 2009, I have acted as the Independent Author of more than 30 Serious Case Review Overview Reports, Child Practice Review Reports and Multi-Agency Vulnerable Adult Review Reports in England and Wales and undertaken consultancy and training. The National Panel of Independent Experts was provided with the name of the Lead Reviewer. Due to the scale and complexity, an Independent Review Team was appointed to work with the Lead Reviewer. The five professional members have experience in practice and strategic roles in safeguarding adults and children from police, health, education, and social work perspectives and contributing to review processes. A Joint Serious Case Review Business Group of four Panel members including the Lead Officer had responsibility for planning the Review and ensuring tasks were completed. The Group worked closely with the Lead Reviewer and the Independent Review Team. This Review was carried out in as transparent a manner as possible, balancing areas of public interest.8 To prevent trials being undermined by material reaching the public domain or potential witnesses being influenced, careful attention was given to a court order restricting publicity. National Guidance informed the process9 and advice was taken from the police and Crown Prosecution Service. This Review considered significant amounts of information, all of which cannot be included in a Report. Some sensitive issues if published would inappropriately alert perpetrators and allow them to consider how to avoid measures taken to prevent their offending. Assertions of fact and expressions of opinion in this Report are supported by a clear evidence base which is available to the Safeguarding Boards. I agreed with the Chief Executive and the Director of People of Newcastle City Council that if the Review identified any individual at immediate risk that was not being addressed, I would refer the circumstances to them. There were no circumstances that required this to happen. 8 Chap. 4. Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government 2015 9 Liaison and information exchange when criminal proceedings coincide with Chapter Four Serious Case Reviews or Welsh Child Practice Reviews: A Guide for the Police, Crown Prosecution Service and Local Safeguarding Children Boards; Association of Chief Police Officers and the Crown Prosecution Service. 2014 13 2.2 The Victims and the Eight Cases Arrangements were made to invite contributions to the Review from individuals who have suffered sexual exploitation and their families and friends, if appropriate. Early discussions took place with them to agree how they might be involved and how their expectations could be managed appropriately and sensitively.10 A sheet was printed with information about the Review for professionals to use when speaking to children and adults who might be involved in the Review. Contributions in the form of conversations were made by a number of victims and the mother of one victim. Some victims who gave evidence in criminal proceedings prepared Victim Impact Statements to be considered by the sentencing judge and gave permission for these to be considered within the Review. One victim prepared a short statement in addition. The victims’ contributions included in this report appear in italicised type. “I have sent you a short statement of facts I believe should be reported and would be grateful if you could pass this to the author. If subsequently this is not in the report then at least I have tried to show where things went wrong from my side. It seems the only chance of putting this out so I just needed to do that even though it’s been very difficult to put down.” During the conversations, I thanked the victims for meeting with me and, having included extracts within the Report, I have asked for them to be thanked again for their contributions, which have been invaluable. The feedback on the process from victims has been positive. They have appreciated being able to share their views and have them heard. Agencies were asked to review their involvement in eight cases. These were selected from a large number to maximise learning, reflect the different circumstances in which victims had suffered sexual exploitation and include factors likely to be present in other cases. They included circumstances where: • The sexual exploitation began and ceased when they were children; • The sexual exploitation began when they were children and continued into adulthood; • The sexual exploitation began after they became adults. The cases included six victims who were white and two who were from different Black and Minority Ethnic backgrounds. The time periods for the reviews of the cases were: • For child victims, the start date was when it was known or suspected or is now known that the individual suffered, or was likely to suffer sexual exploitation; • For adult victims, the start date was when they reached their 18th birthday. 10 Chap. 4. Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government 2015; Para. 14. Care and Support Statutory Guidance Issued under the Care Act 2014. Department of Health 2014 14 The end date for child and adult cases was 10 July 2015, when it was decided to carry out a Review. The total period covered 2007 to 2015. Action taken after this period in response to the Review and otherwise and strategic arrangements and national developments before and after this period were also considered. The cases involved different models of sexual exploitation. All the victims suffered extreme, calculated abuse and were very damaged by their experiences. Following the first series of criminal trials Newcastle City Council Chief Executive paid tribute to all the victims, whether or not they were able to give evidence, for their courage in helping to put the people convicted behind bars: “No-one should underestimate the trauma that these young women and children have gone through but undoubtedly they have helped to make our communities safer places by their actions.” 2.3 Participating Services Services Relevant Functions Newcastle Adult Social Care Newcastle City Council services supporting adults with care and support needs; carrying out and coordinating enquiries; taking action to safeguard vulnerable adults. Newcastle Children's Social Care Newcastle City Council services for children in need of services; carrying out and coordinating enquiries, taking action to safeguard children and caring for children looked after by the Council. Newcastle Environmental Health and Pest Control Newcastle City Council services; standards of premises, food hygiene and safety, pest control. Newcastle Housing Advice Centre Newcastle City Council advice, assistance services; housing, housing benefits and homelessness. Newcastle Legal Services Newcastle City Council in-house legal service for the Council and Service Departments; specialist advice representation for safeguarding vulnerable children and adults. Newcastle Schools and Learning Newcastle City Council services; information, advice on education and support for children, young people and their families, school attendance, support and training for school and colleges on safeguarding. Newcastle Youth Offending Team Newcastle City Council service working with representatives from range of services responding to needs of young offenders. Your Homes Newcastle Limited Private company controlled by Newcastle City Council providing, managing council housing and housing services for tenants on behalf of the Council. Durham Children’s Social Care Durham County Council services for children in need; carrying out and coordinating enquiries, taking action to safeguard children; caring for children looked after by the Council. 15 Gateshead Adult Social Care Gateshead Council services supporting adults with care and support needs; carrying out and coordinating enquiries; taking action to safeguard vulnerable adults. Northumberland Children's Social Care and Youth Offending Team Northumberland County Council services for children in need; carrying out and coordinating enquiries, taking action to safeguard children; caring for children looked after by the Council; responding to needs of young offenders. South Tyneside Children's Social Care, South Tyneside Council services for children in need; carrying out and coordinating enquiries, taking action to safeguard children; caring for children looked after by the Council. Stockton-on-Tees Children’s Social Care Stockton-on-Tees Borough Council services for children in need; carrying out and coordinating enquiries, taking action to safeguard children; caring for children looked after by the Council.Statutory social care services provided for children. These local authorities have statutory duties to establish interagency Safeguarding Boards. They must co-operate with and lead partner agencies to take action to safeguard and promote the welfare of children in need of services and adults in need of care and support, who are experiencing, or are at risk of, abuse or neglect from which they are unable to protect themselves. They must carry out all functions having regard to the need to safeguard and promote the welfare of children. NHS Newcastle Gateshead Clinical Commissioning Group Commissions most hospital and community NHS services in Newcastle, including General Practice, and health services to ensure vulnerable children and adults are safeguarded. Northumberland Tyne and Wear NHS Foundation Trust Delivers a range of mental health, learning disability and neurological care services across North East England for children and adults. Newcastle upon Tyne Hospitals NHS Foundation Trust Delivers specialist acute healthcare services and care to patients from across the country; community services including school health; sexual health services and a range of clinics and outreach services. Northumbria Police Force Delivers police services to 1.5 million people from the Scottish border to County Durham and the Pennines to the North East Coast. Responsibilities include prevention and investigation of suspected offences and taking action to safeguard vulnerable children and adults. These agencies are statutory partners of Newcastle City Council. They must11 carry out all functions having regard to the need to safeguard and promote the welfare of children and cooperate with the Council, each other and other partners 11 Children Act 2004; Care Act 2014 16 to safeguard children and adults with needs for care and support and ensure inter-agency safeguarding frameworks operate effectively. CPS North East • Independent Crown Prosecution Service Team for North East Region including Newcastle. Decides on sufficiency of evidence, the public interest and charges in serious/complex cases investigated by police; advises during investigations; prepares and presents cases at court; provides information, assistance, support to victims and prosecution witnesses. The Children and Family Court Advisory and Support Service (Cafcass) Appoints Children’s Guardians to represent children in family courts to ensure their voices are heard and decisions are taken in their best interests. UK Visas and Immigration Part of the Home Office; responsibilities include considering and deciding whether foreign nationals may remain in the UK. Aycliffe Secure Centre Durham County Council secure children's home for children the aged 10 to 18 years. Clare Lodge Secure Children’s Home National provider of secure accommodation for girls aged 10 to 17 years; programmes of intervention and protection. Keys Limted, Highcroft Private company providing children’s homes/schools and support services including therapy, fostering, education, training and development for children and young people. Kyloe House Secure Children’s Home Northumberland County Council secure children's home offering group living. Radical Services Provides family style homes; care programmes for children and young people experiencing family or placement breakdown or other significant interruptions in their lives. Right-Trak Limited Private company providing residential homes in Newcastle for children and young people with emotional and/or behaviour difficulties. St Cuthbert's Care Registered charity providing foster homes and residential homes and services to improve the lives of vulnerable young people aged 7 to 17 years. The establishment and management of residential homes for children is governed by statutory regulation. Only children placed in accommodation registered as secure may have their liberty restricted and the terms of registration may impact on facilities and arrangements. Care and control of individual children are determined by arrangements made with placing authorities. Homes for children are registered, monitored and inspected by Ofsted and, if individuals over 18 years are accommodated, by the Care Quality Commission. Spark of Genius National provider of education, autism services, residential care and community support for children and post 16 young people. Registered with Care Inspectorate, national regulator for care services in Scotland and Education Scotland. 17 SWIIS Foster Care Limited Private company providing foster homes for local authorities and support, training and guidance to foster carers. Team Fostering Independent not for profit fostering agency that recruits, trains, assesses and supports foster carers for children who are looked after by Local Authorities. Agencies providing fostering services are registered, monitored and inspected by Ofsted. BAB Accommodation Ltd Private company providing supported living accommodation for young people 16 years and over. Careline Lifestyles Independent provider of specialist care and support for people with mental health needs, acquired brain injuries and complex learning or physical disabilities. Coquet Trust Registered charity providing support in the home and community for people with learning disabilities. New Key Support, KPW Newkey Ltd Private company providing supported living accommodation for people with physical disabilities, mental health and substance misuse, problems, autism or learning difficulties. These agencies are registered and regulated by the Care Quality Commission. Angelou Centre Registered charity offering holistic services for Black and Minority Ethnic women across the North East. Barnardo’s National registered charity offering services to care for and support vulnerable children and young people. National Youth Advocacy Service (NYAS) National registered charity providing information, advice, advocacy and legal representation for children, young people and vulnerable adults. National Society for the Prevention of Cruelty to Children (NSPCC) National registered charity providing direct services, advice, consultancy, training, research, campaigning for children; statutory power to take court proceedings. Safeguarding Children at Risk, Prevention and Action (SCARPA) Registered charity The Children’s Society Programme of targeted support to young people who go missing or are at risk of sexual exploitation. Streetwise Registered charity offering confidential advice and support for children and young people aged 11-25 years by referral or walk-in. Your Voice Counts Registered charity providing advocacy services; support for self-advocacy and user led groups; runs “drop in” sessions offering help with and awareness raising on a range of issues in local communities. These agencies’ functions are determined by their constitutional documents. They may have specific duties arising from commissioning or grant conditions. 18 Five Newcastle schools, attended by pupils whose cases were considered, participated in the Review. The Governing Bodies have statutory duties12 to ensure that their functions relating to the conduct of the school are exercised with a view to safeguarding and promoting the welfare of pupils. 2.4 Timelines and Timeline Reports Agencies that had involvement with the cases were asked to provide Timelines of their involvement and analytical reports, prepared by senior personnel who had no direct involvement with the cases. Timelines rather than chronologies were provided to emphasise the need not to be drawn into detail that might otherwise be required for a review of a single case. Report authors were encouraged to involve practitioners to clarify uncertainties and assist identifying themes, why events occurred as they did, good practice and lessons that might lead to better outcomes. They were asked to identify changes that have taken place since the cases arose. Forty-three agencies were involved in the Review and 113 reports were produced. 2.5 The Learning Events The report authors were invited to Learning Events to present their information and collectively consider lessons to be taken forward. After victims, the most fertile source of information and opinion is the staff who were involved. Consistent with guidance13 Practitioners involved in each case were invited to Learning Events to collectively review and discuss their involvement, that of other agencies and consider what happened and why and what might have led to better outcomes. Events began with a pen picture of the victim whose case was considered. Reviews that lead to changes in agency behaviours are carried out in a “no blame culture”14 in which participants do not fear being blamed for actions taken in good faith. This Review was intended to be a trusted and safe experience to encourage honesty and transparency to identify key learning and obtain maximum benefit.15 The participants consistently evaluated the Events very positively. 158 professionals from 43 agencies attended 16 Learning Events organised over 12 months. There was widespread interest in and support for the Review. 2.6 Acting on Learning During the Review Victims likely to give evidence were not approached until the criminal trials were completed. Unavoidably some trials were postponed, leading to a long period 12 s175 Education Act 2002; Keeping children safe in education: Statutory guidance for schools and colleges. 13 Chap. 4. Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government 2015; Para. 14. Care and Support Statutory Guidance Issued under the Care Act 2014. Department of Health 2014 14Domestic Violence Fatality Reviews: From a Culture of Blame to a Culture of Safety: Websdale, Town, Johnson. Juvenile and Family Court Journal. 1999 15 Protecting Children in Wales: Child Practice Reviews: Guide for Organising and Facilitating Learning Events. Welsh Government. 2012 19 before the Review could be completed. Measures were put in place to ensure learning, dissemination and improvements were not delayed.16 Progress was monitored centrally and arrangements made to engage with regional and national processes to make them aware of significant issues. Consequently, most of the local changes described in this Report were made either before the Review began or were implemented during the Review or arrangements are in place to implement them. It is unnecessary to make recommendations in respect of all these issues but it is important for the Boards to ensure that changes, whether or not addressed in recommendations, are sustained and have the intended impact. Recommendation 1.1 I recommend that: Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should make arrangements to review the progress and impact of the actions taken and intended to be taken as a result of carrying out the Joint Serious Case Review. The recommendations I have made concern some national issues. The recommendations are set out adjacent to the text from which they arise and are listed in Section 15 with references to the Section and page in which they appear, distinguishing local and national recommendations. 2.7 Additional Information The Review considered what was known and understood about sexual exploitation by agencies and by Safeguarding Boards, the responses, published reviews and relevant research. Agencies were asked to follow up issues and provide information. Meetings were held with agency representatives and staff groups to explore specific areas and agencies arranged meetings of staff, whether or not involved in the cases, to consider what might make a difference. The Review was inclusive. Numerous conversations and a number of meetings took place with agencies or with individuals who had no or limited involvement with the individual cases but, because of legitimate interests, it was important they were aware of the process and had the opportunity to contribute if they wished. These included: • Rt Hon Nick Brown MP • Catherine McKinnell MP • Chi Onwurah MP 16 Checklist for Serious Case Reviews: Chap. 4. Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government 2015; Para. 14. Care and Support Statutory Guidance Issued under the Care Act 2014. Department of Health 2014 20 • Dame Vera Baird QC, Police and Crime Commissioner • Colin Morris, Chair of Newcastle Safeguarding Children Board • Vida Morris, Chair of Newcastle Safeguarding Adults Board • Pat Ritchie, Chief Executive Officer, Newcastle City Council • Ewen Weir, Director of People, Newcastle City Council • Karen Simmons, Assistant Director of Children’s Social Care • Alison McDowell, Assistant Director of Adult Social Care • Councillor Nick Forbes, Leader of Newcastle City Council • Councillor Anita Lower, Leader of Opposition, Newcastle City Council • Councillor Joanne Kingsland, previous Cabinet Member for Children and Young People • Councillor Nora Casey, Cabinet Member for Children and Young People • Councillor Karen Kilgour, Cabinet Member for Adult Care and Health • Councillor Habib Rahman • Councillor Dipu Ahad • A foster and adult carer • Her Honour Judge Rachel Hudson, Designated Family Judge for Northumbria and North Durham • Her Honour Judge Judy Moir, Lead Court of Protection Judge • Her Honour Judge Penelope Moreland, Crown Court Judge Conversations also took place with a representative of The Children’s Society and Chief Officers and senior managers in Streetwise and Changing Lives, both of which provided reports covering a number of specific areas. 2.8 Perpetrators’ Contributions Following conviction and imprisonment, a number of Perpetrators’ were asked through their Offender Managers whether they were prepared to contribute. One agreed but declined when a pre-arranged visit to the prison was made. Another did meet with the Lead Officer and me at the prison in which he is serving a lengthy sentence. His understanding of English was sufficient to have a conversation. He used the time to protest his innocence and maintain that witnesses were paid to lie by the police and the government who with the judge conspired against him. Nevertheless, some attitudes which he shared were relevant to the Review and are included during the discussion about Perpetrators in Section 6.21 3. Summary of Thematic Findings Some findings from the Review confirm national research and lessons from other reviews. Others relate directly to sexual exploitation as it has occurred in Newcastle. In early 2014, when a number of victims with growing understanding chose to speak to the police and other professionals about their suffering and the abuse of others, the interagency response was swift, determined and committed. It led to disruption, prosecution and conviction of significant numbers of perpetrators and lengthy prison sentences. Large numbers of victims have been identified, supported and protected. The high quality of services has attracted independent national recognition. Until early 2014, despite interagency arrangements in place to assess the prevalence of sexual exploitation in Newcastle, this was not fully understood. Prior to 2014 individual cases received committed and persistent interagency attention to support and address behaviour and the safety and welfare needs of victims. Links between suspected cases were identified, but this had limited impact because it did not involve consistent action to investigate, prosecute or disrupt perpetrators. This was because of reliance on requiring complaints from victims who were likely to co-operate and be able to give coherent and clear evidence in criminal trials. There were some weaknesses in practice, familiar from other reviews, and in arrangements for accessing specialist advice and services for victims. While important and relevant for safeguarding generally, if these had been addressed earlier, outcomes for victims would not necessarily have improved unless comprehensive action had also been taken against perpetrators. When addressing victims’ safety and welfare, there is a need to focus on action against perpetrators through effective criminal investigation and prosecution, civil processes and disruption tactics, relying on victims’ testimonies only where this is unavoidable due to lack of other evidence. Despite comprehensive action to disrupt and prosecute perpetrators and the publicity that this has attracted, sexual exploitation continues. Perpetrators show remarkable persistence over long periods in targeting and grooming victims, undeterred by involvement of the police and other agencies.17 The Review was unable to gain a true understanding of the offending through engagement with perpetrators. This requires further local and national attention. Information available about likely profiles of perpetrators and what drives their activities, including the extent to which cultural values and attitudes are relevant is 17Sentencing remarks by HHJ Moreland. Newcastle Crown Court. September 2017 22 very limited. There is an urgent need for guidance to robustly address these issues. Sexual exploitation of boys and men is complex and hidden with different models to those identified with female victims. The low incidence of identified cases is likely to be a significant under-representation of the abuse occurring. In Newcastle, decisions about taking action were not influenced by lack of concern or interest, misplaced fears about political correctness or fear of being seen as racist. Neither was there any evidence of ineffective leadership or inappropriate interference by senior officials or political leaders to prevent action being taken that have been a feature of reviews elsewhere. Nor is there any evidence that any professional, individual, member of the public, politician or agency attempted to alert the authorities or complain about lack of proactivity or attention being given to addressing large scale sexual exploitation. Understanding the prevalence of sexual exploitation requires assuming it is taking place and adopting a pro-active approach to look for it, recognising that the most reliable source of information is from victims and those targeted. The most effective way to address sexual exploitation and safeguard and promote the welfare of victims is to resource multi-agency teams, co-located in the areas in which sexual exploitation takes place, prioritising bespoke victim support and including robust investigation, prosecution and disruption of perpetrators. The successful, flexible, collaborative and innovative working in Newcastle since 2013 has improved morale and commitment beyond the specific area of service. Relationships between professionals, agencies and different areas of service have improved with a corresponding rise in quality of outcomes for victims. Effective safeguarding is a collective responsibility and requires a culture of robust interagency and professional challenge of practice and strategy. Sexual exploitation is not restricted to child victims; vulnerability is not determined by age and it is likely that extensive abuse of vulnerable adults is taking place across the country unrecognised. The national framework of legislation and guidance for safeguarding adults from sexual exploitation requires urgent review to take account of the growing knowledge of sexual exploitation. The early development of collaborative planning and arrangements for joint working between Newcastle City Council Children’s and Adults social care services and engagement of partner agencies developed over the period reviewed and are models of good practice Checklists and tools are helpful to identify actual or potential victims but all children and vulnerable adults are at risk; some will not fit the profile and others will do so 23 but will never be exploited. A particular feature of a number of victims was early history of bereavement or loss which had not been addressed effectively. Thoroughly researching history from wherever information is held is an essential precondition to forming sound judgments and making effective plans. The impact of lack of history must be considered within assessments. All the areas of local practice and interagency working that would have benefited from attention during the Review period had either been addressed before the Review began or have been addressed during the Review or there are clear arrangements in place to ensure they are addressed. The success in Newcastle has depended on flexible and testing interpretations of legislation and processes. Legislation and guidance will never keep up with the changing nature of risks and effective safeguarding depends on adopting an imaginative and creative approach, working closely with proactive, specialist lawyers to explore all options and expose weaknesses. The framework for addressing sexual exploitation has been subject to piecemeal development and reforms. There is a need for a national review and debate on what is required and to ensure reforms are effectively and consistently implemented. The early identification of victims or potential victims or activities of perpetrators depends on alert universal services, in particular education, health and community services. Prevention also depends on awareness and reporting by the public and sophisticated education and awareness programmes which engage with all communities. Victims are very likely to attend sexual health services or walk-in community support services while being groomed and when they are being exploited. The current approach to and principles applied to confidentiality and assessment of capacity to consent to advice and sexual acts means identifying victims or potential victims is extremely difficult. Unless there is a change, which requires a national debate, sexual exploitation is not likely to be prevented and early identification will remain difficult. Sexual exploitation is a traumatic event and therefore the use of a trauma informed approach to recognise and address the impact on victims and their families is critical. Victims require long term support to enable them to recover from trauma and recognise the reality of the abuse they have suffered, acquire the confidence to sever connections with perpetrators, cope with the impact of criminal justice processes and to live a full a life as possible. Child victims are likely to require continuing services during adulthood. 24 Among the matters that require attention is the detrimental impact that sexual exploitation has on the ability to form trusting relationships and to parent children. There are similarities between the development of understanding and the responses to domestic abuse and modern slavery and therefore common areas for learning. Despite comprehensive arrangements to provide support, appearing as a witness in a criminal trial continues to be an abusive and destructive experience for victims which deters potential witnesses from giving evidence. One community voluntary organisation was unable to play a full part in the Review because records had been destroyed. Consequently, the records will not be available to inform responses in individual cases or for individuals who wish to access their records. Interagency procedures and commissioning should address retention of records to include agencies to whom statutory requirements do not apply. Sexual exploitation took place in commercial premises and privately rented premises. Social housing tenants have access to support if concerned about activities of other tenants. Consideration needs to be given as to whether landlords’ awareness and responsibility for what occurs in privately rented premises and support for their tenants can be increased. The processes for obtaining authority to restrict the liberty of suspected child victims is inflexible and costly. Consideration needs to be given to allowing placement in semi-secure accommodation which will satisfy the requirements of Article 5 European Convention on Human Rights and Fundamental Freedoms and, for adults and children, not involving huge costs. The current national scheme providing for compensation to be paid to persons who suffer injuries as victims of violent crime discriminates particularly unfairly against victims of sexual exploitation whose involvement in other criminal activities may be the result of abuse they have suffered but which may disqualify them from receiving compensation for the persistent rapes, serious sexual assaults and ill-treatment they have experienced.25 4. Sexual Exploitation – The Complexity 4.1 What is Sexual Exploitation? In March 2015, the Government indicated the intention for the first time to provide a definition of child sexual exploitation18 and, in February 2017, published Advice including a definition19 emphasising that child sexual exploitation is a complex form of abuse which can be difficult to identify and assess: “Child sexual exploitation is a form of child sexual abuse. It occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if the sexual activity appears consensual. Child sexual exploitation does not always involve physical contact; it can also occur through the use of technology.” This and previous definitions have not described the sexual activity that actually takes place. Practice suffers from a lack of vocabulary to properly describe what needs to be clearly understood if enquiries, investigations and conversations are to be carried out with a common understanding. The Government has asserted that: “There is no culture in which sexual abuse is not a serious crime.” 20 However, what is considered abusive might be affected by cultural and legal issues. Victims, family members, the public, professionals and perpetrators may have different understandings of the terminology used. In some cultures, anything other than vaginal sexual intercourse, for example anal intercourse or oral sex, is not considered to be a sexual act. The age of consent to sexual activity (not universally defined) varies significantly in different countries; in some, there is no lower age for consent to sexual activity; in some, it is permitted to marry a child under 10 years of age. The age of consent to sexual acts varies across European countries.21 In some States of the United States the age below which a child cannot marry with parental or judicial approval is not specified, allowing some children as young 12 years old to be married. Sexual exploitation may involve horrific acts amounting to persistent inhuman and degrading treatment which most people are likely to consider depraved and not 18 Para 48. Tackling Child Sexual Exploitation. HM Government. March 2015 19 Advice, Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. Department for Education. February 2017 20 Changing the Culture of Denial: Page 4. Tackling Child Sexual Exploitation. HM Government. March 2015 21 United Nations Committee on the Elimination of Discrimination against Women and the Committee on the Rights of the Child Recommendations on minimum age of marriage laws around the world. 2013 26 “normal” sexual activity. Victims may be repeatedly raped, forced to have sex, oral and vaginal simultaneously with different men, assaulted while under the influence of drugs or alcohol or while unconscious or asleep and usually contains elements of coercion and control. They may be trafficked locally or to other towns or cities. The arrangements might be well organised or ad hoc sessions at a variety of venues. Much of the detail has only become apparent from accounts given by victims in criminal proceedings. A Report22 in 2013 described the abuse of Muslim girls; “Offending behaviour mostly involved men operating in groups . . . The victim was being passed around and prostituted amongst many other men. Our research also showed that complex grooming ‘hierarchies’ were at play. The physical abuse included oral, anal and vaginal rape; role play; insertion of objects into the vagina; severe beatings; burning with cigarettes; tying down; enacting rape that included ripping clothes off and sexual activity over the webcam.” There is a danger that unless the horror of what is experienced is fully understood, the need to act urgently on suspicions will not be appreciated. “I never had sex when I was sober.” “I saw her raped when she was unconscious.” “I wanted to leave. I was given drink. I kept saying no and fighting them off. I was very tired and fell asleep. When I woke, I had been raped.” “When I was asleep I was raped.” “They gave it to the girls – M-Cat was cheap, makes you like a zombie and wanting to keep going. It’s addictive. It makes it easier for them to get what they want.” “When I was out of it they could do anything they wanted to me.” Early lack of understanding across the country contributed to victims being regarded as promiscuous, choosing to be involved, being described as having a sexual relationship, as being involved in underage sex, having a boyfriend or partner or being seduced and attending parties, all of which inhibited effective safeguarding action. The language used when reporting the outcome of trials often perpetuates misunderstandings. Media reports of the Newcastle trials included reference to victims being given drugs and alcohol “in return for sex”, whereas the drugs were given in order to encourage dependence, incapacitate victims and remove any ability to choose. 22The UK Muslim Women's Network Report on Child Sexual Exploitation. September 2013. Para 11.15. Independent Inquiry into Child Sexual Exploitation in Rotherham (1997 – 2013) August 2014 27 There is no national definition of sexual exploitation of adults in legislation or government guidance or advice. This is likely to contribute to a lack of public understanding, being informed largely by models of child sexual exploitation, and a reluctance of adult victims to speak out because they may think it only happens to children. In 2015, Newcastle Safeguarding Boards worked together to develop a definition, included in their joint Sexual Exploitation Strategy, which states that sexual exploitation can affect people throughout their lives and is: “Someone taking advantage of you sexually, for their own benefit. Through threats, bribes, violence, humiliation, or by telling you that they love you, they will have the power to get you to do sexual things for their own or other people’s benefit or enjoyment (including: touching or kissing private parts, sex or taking sexual photos.)” Training across agencies in Newcastle does make clear the nature of the abusive experiences. 4.2 Why is Tackling Sexual Exploitation So Difficult? Nationally practitioners have been shocked that, despite elaborate safeguarding procedures and processes, some of their clients may well have suffered from unrecognised sexual exploitation. Research and government guidance has highlighted the difficulties in recognising and addressing it. Child and adult protection systems have developed primarily to address abuse and neglect in families23 or caring environments and do not facilitate a timely response in the detection of victims and perpetrators of sexual exploitation.24 In the absence of concerns, there was little scope for proactively looking for abuse, whereas any child, in any community, may be vulnerable to sexual exploitation and all practitioners should be open to the possibility that the children or adults they work with might be affected.25 While abuse of young children was well understood, it was generally thought that vulnerability reduced as children grow older. In 2011 an Ofsted thematic report26 drawing on serious case reviews across the country indicated that in some respects, rather than diminish, the risks increase as young people approach and enter adulthood. 23 Supporting parents of sexually exploited young people: An evidence review. Centre of Expertise on child sexual abuse. September 2017 24 The Brooke Serious Case Review into Child Sexual Exploitation: Bristol Safeguarding Children Board 2016 25 Advice, Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. Department for Education. February 2017 26 Ages of concern: learning lessons from serious case reviews. A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011. Ofsted. October 2011 28 In 2017, Government Advice listed factors that might suggest vulnerability to sexual exploitation but acknowledged that research27 indicates not all children and young people with vulnerabilities will experience child sexual exploitation and it can occur without any apparent vulnerabilities being present.28 This is confirmed by the experience in Newcastle. Tools developed in England and Wales may be less appropriate for boys, younger children and disabled children.29 Sexual exploitation occurs in locations not usually frequented by safeguarding professionals and victims may not attract concerns of welfare agencies for any other reason. Indicators can be mistaken for normal adolescent behaviours. The abuse is hidden. Sophisticated grooming means victims may not recognise they are being abused and believe they are in control, in healthy consensual relationships. Apparent close relationships may develop to involve intimidation, threats and coercion. “I didn’t think what was happening was wrong. I thought they were my friends. They bought me drink and drugs. I thought it was ok because of my family.” “Then it became more sinister. Different. There were parties with men a lot older. 30/40, when previously 20/21.” They knew that they had us”. “They are very skilled at who they target.” “Judges, social workers - get the police involved. They need to know how hard it is to get out of this.” “I did not realise what was happening. The men treated me nicely but not everyone else. Some men were horrible. They left their countries in lorries – they’d done bad things - they have done bad things elsewhere in other countries – they said they had done bad things.” “I didn’t think it was out of the ordinary. We stayed there for days. My Dad used to worry. I said I was just sleeping over. I didn’t think anything bad was going on. I didn’t tell my friends I had been raped. I didn’t think they would believe me. They thought I wanted to go with him. It was on my birthday. I thought no-one would believe me.” Potential victims may not appear vulnerable but something may happen - a change of school, lack of friends, bereavement or difficulties at home that creates vulnerability. 27 Child Sexual Exploitation: Understanding risk and vulnerability. Brown et al. Early Intervention Foundation. London. 2016 28 Advice: Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. Department for Education. February 2017 29 The use of tools and checklists to assess risk of child sexual exploitation. An exploratory study. Brown et al. Coventry University. Centre of expertise on child sexual abuse. October 2017 29 “I had a horrific time at school. I was bullied. I had no help with it. I have had mental illness since I was 11 or 12. Severe depression. If this hadn’t happened I don’t think the exploitation would have happened.” “I had no attention at school and then suddenly I got attention from everyone. Sexual exploitation comes from wanting attention and affection.” “I had not seen my father for a very long time and I had to act as if he was my Dad. I couldn’t. My parents started arguing over anything and everything – all the time.” “I grew up quickly. I looked older than I was and acted older. It’s difficult if you grow up too quickly.” “I suffered a significant early bereavement. I was really down and started drinking a lot of alcohol from when I was 14 years old”. “I was sexually abused as a child and there was domestic abuse at home. I began running away when I was 13 years old.” Victims may have mild cognitive difficulties that do not impact significantly on ability to cope with education or functioning as an adult. However, involvement with perpetrators, use of drugs and alcohol and the abuse itself may increase vulnerability. Perpetrators demand extreme loyalties and create dependence so victims maintain links even after attempts to protect them and resent inquiry by agencies, actively mislead or avoid professional contacts. Victims may, while needing protection themselves, become involved in recruiting other victims and facilitating abuse. They will have been separated from friends and family and peer groups so that offering alternatives that do not leave them isolated may be difficult. The application of the law and professional standards of practice relating to consent, capacity and the right to choose is complicated and uncertain. The presence of some form of exchange or benefit complicates assessments. Working with challenging adolescents and adults requires particular skills. Lack of progress may be frustrating and time limited interventions may not have a significant impact. Progress might be limited to keeping a victim as safe as possible while continuing to be abused. Bad experiences of the criminal justice system deter victims from coming forward or persisting with complaints. Perpetrators will adopt cruel tactics and, being aware of agencies’ processes, become skilled at undermining attempts to safeguard victims. “I was too scared to tell the police and the social worker rang on my behalf.” “I was frightened of being killed and the children being hurt.” 30 Perpetrators display an arrogance and persistence that suggests power. Criminal and civil legislative frameworks have not developed to respond to what is occurring. Managers and practitioners have found that they need to act imaginatively with legal advisers to fit circumstances into complex legal and procedural provisions. 4.3 Modern Life, Attitudes and the Impact of Technology Perpetrators have been empowered by technology which allows for unprecedented and easy access to sexually exploitative materials and provides increased opportunities for sexually exploitative acts or sexual offences.30 Sexual exploitation could not happen on such a scale without mobile phones, the internet, and social media, being used to maintain contact with and control victims and arrange activities. The attitudes of children and young people to sexual relations and what they expect to happen are rapidly changing. Technology offers many positive opportunities for learning and social interaction but it also provides perpetrators with new opportunities and pathways to target potential victims31. Sexual Health Service’s staff commented that now: “Porn is the norm – it encourages normalisation of abusive sex and exploitation. Everything they see is sexualised.” Teachers have highlighted32 that pupils watch pornography to educate themselves, are being coerced into doing things they later regret and the language used is degrading and lacking understanding of consent and mutual respect. 4.4 What is the Impact of Sexual Exploitation? Research indicates that victims of child sexual exploitation, have been diagnosed with borderline personality disorder, psychosis and suffer feelings of trauma, betrayal and stigmatisation. They may blame themselves.33 In 2017, the Government emphasised34 the devastating, long-term consequences, impacting on every part of life and future outcomes – physical, sexual and mental health and well-being, education, training, future employment prospects, family relationships, friends and social relationships and relationships with their own children. 30 National Plan to Prevent the Sexual Abuse and Exploitation of Children developed by the National Coalition to Prevent Child Sexual Abuse and Exploitation. March 2012 31 Report of the Parliamentary Enquiry into the Effectiveness of Legislation within the UK 2014 32 BBC coverage 5 October 2017 33 Para. 77. Child sexual exploitation and the response to localised grooming Child Sexual Exploitation: scale and prevalence. House of Commons Home Affairs Committee. June 2013 34 Advice: Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. Department for Education. February 2017 31 Historically work with adults has focused on sex work and prostitution and the Review found no current research on the impact of sexual exploitation on vulnerable adults. The cases and experience from supporting adult victims in Newcastle indicates that sexual exploitation of adults gives rise to the same devastating consequences as for children. “I suffer from mental health. Personality disorder. It impacts on every part of my life, including my family because of the trauma and abuse that I suffered.” “After the abortion, I got quite depressed. I had no support. I started self-harming.” “I went to the emergency department and said I was suicidal. I did that a few times. I lost control.” “No-one understood what was happening. I had voices in my head. The perpetrators were continually in my head. I was sectioned and detained.” “I keep getting flash backs of the rape.” The sentencing remarks35 made by the judge at the trials in September 2017 included: “…You used drink to facilitate offences… She was at a low point when you targeted her, drinking heavily, and you are responsible for significantly worsening that addiction. She was particularly vulnerable because of her learning disability and other difficulties. She has flashbacks and is unable to sleep. She expects that the consequences of the offending against her will affect her for the rest of her life. She is now suffering from severe depression and anxiety: she can’t sleep for nightmares.… has suicidal thoughts.… has serious mental health problems and has been detained under the mental health act on three occasions in the past year. In her words “I was harmed beyond imagination physically, emotionally and psychologically”.” 35Sentencing remarks by HHJ Moreland, Newcastle Crown Court, September 2017 32 5. The Newcastle Response to Increased Awareness 5.1 Operation Sanctuary Accounts of victims and increasing intelligence led Northumbria Police in January 2014 to launch Operation Sanctuary as the overarching police investigation into sexual exploitation across the Force area, predominately in Newcastle. Large numbers of leaflets were distributed in Newcastle City Centre publicising arrests. More victims came forward and described being taken to sessions involving young women and children at which drugs and alcohol were supplied and at which they and others were raped and abused. Protection of victims and addressing the scale of exploitation required a programme of action against the perpetrators, significant resources and effective strategic and multiagency arrangements. Northumbria Police Chief Officers Team established a dedicated full Gold Command structure - a framework for delivering strategic, tactical and operational responses involving escalation of decision making and clear lines of accountability and responsibility. Senior officers across agencies discussed what resources and services were required. Within weeks, a team, led by a Detective Superintendent, was brought together including experienced officers from the police Protecting Vulnerable People Team, major crime, forensic services, homicide, intelligence and research with skills in conspiracy investigation, covert strategies and enquiries. Dedicated officers focused on undermining the activities of perpetrators. The Operation was supported by an information technology system36 used for the investigation of major incidents. Senior staff and practitioners from Newcastle City Council, the lead agency for safeguarding adults and children, were involved from the outset. Staff from health, education and community and voluntary organisations were brought in. Agencies prioritised Operation Sanctuary victims and identified single points of contact. The collective commitment was to develop a model of best practice accessing advice from the College of Policing, the National Police Child Sexual Exploitation Co-ordinator and the Home Office. Senior police officers and managers from Newcastle City Council Children’s and Adults’ Social Care visited Rochdale and Oxford to learn from their experience of large scale sexual exploitation investigations. An experienced psychotherapist and expert on trauma was commissioned to provide advice. Involvement of and focus on victims improved knowledge of the abuse and prevention. To alert them to the likely impact on criminal justice processes and high costs, discussions were held with the Crown Prosecution Service and Newcastle Crown Court. Trial slots were identified and a trial judge nominated to avoid delay. The 36 Home Office Large Major Enquiry System 33 Crown Prosecution Service allocated resources for early instruction of Leading Prosecuting Counsel, Junior Counsel and a Junior to act on disclosure. Prosecutions were dealt with by the specialist Rape and Serious Sexual Offences Team led by an experienced lawyer and case worker. This Team worked closely with and provided ongoing advice and consultation to the investigation team. 5.2 Perpetrators’ Families During Operation Sanctuary, arrangements were in place to promptly assess the welfare of children in the families of suspected perpetrators and to consider the need for support of adults who had no involvement in abuse. Your Homes Newcastle works closely with the Hub and has a single point of contact to consider re-housing requests related to the Operation. All staff were made aware of the potential for neighbourhood unrest and to be vigilant and report concerns. A multi-agency team involving children’s and adults’ social care teams, tenancy services and the police gathers information on support needs and identifies and manages risks to individuals and the community. 5.3 Paid Police Informant Following the ending of reporting restrictions reports appeared in the press about a paid police informant who was also a convicted child rapist. This was not an issue included within the scope of this Review. The Chief Constable responded robustly to questions about the use of this informant. He acknowledged this carried risks but emphasised that sexual exploitation requires thinking outside the box. Appropriate procedures were undergone and many victims had been protected. It sent a message to perpetrators that people will inform against them. Public comments received were overwhelmingly supportive. During conversations with some victims, they expressed concern that this informant may have abused them and they were reassured there was no evidence of this. 5.4 Disruption The significant issue that prevented interagency working from having the intended impact until 2014 was that perpetrators were insufficiently targeted. “I felt I was being punished. It would be better if the men were dealt with.” “They should have punished the men that were doing it and not me.” “Something should have been done against the men – a lot have not been prosecuted.” “They should have punished the men that were doing it and not me. I was the one in the wrong.” 34 “I was in a care home – but those men were walking about free.” The SCARPA Squad (a group of young people) told the Review that we need to change the people, not the city, by doing something with the perpetrators. Although Complex Abuse Investigation processes brought together experience from different cases, the focus of interventions was on individual cases rather than the wider picture. There was little disruptive action to curtail the activities of actual and potential offenders, which was seen as a police and criminal justice responsibility. Practitioners described their frustration that while trying to influence victims’ behaviour, sometimes through coercive measures, perpetrators continued to abuse. Confidence was lacking in what could or could not be done. The period leading to a criminal trial can be lengthy and perpetrators and people close to them can use it to threaten victims: “I was really scared –…. their family members were sending threats. I was frightened of being killed. I had seen rapes and was too terrified to say anything.” “At the care home, I had a call …. said I would be killed ….” It was a driving principle of Operation Sanctuary that while securing convictions is important, other steps should be taken immediately to interfere with and disrupt the activities of perpetrators without putting responsibility on victims. Resources to identify and carry out effective disruption were made available. Two dedicated intelligence teams developed disruption strategies and tactics are embedded in daily business. Applications for Sexual Harm Prevention Orders and Sexual Risk Orders37 are routinely considered and significant numbers of Child Abduction Warning Notices are issued to prevent contact with children by adults suspected of grooming. Following arrests, bail conditions are carefully considered to have maximum impact. Information on the Police National Database and Police National Computer is interrogated to ensure intelligence held by other Forces is available. Disruption is an inter-agency responsibility and close working relationships have been established across Newcastle City Council departments and with partner agencies that have regulatory and inspection functions, including border agencies, Trading Standards, Licensing, Consumer Services, Environmental Health and the Fire Service. There is close liaison with children and adult safeguarding services. Using overt and covert investigation strategies, activities of perpetrators which can attract action are identified. There are good arrangements in place to ensure that actions taken are proportionate to the risks identified. 37 Anti-Social Behaviour, Crime and Policing Act 2014; replacing Sexual Offences Prevention Orders, Risk of Sexual Harm Orders and Foreign Travel Orders 35 All hotels within Northumbria Police area have been visited and leaflets and posters left at the premises. Officers visit hot spots and local shops licensed to sell alcohol. It is not appropriate in a public document to set out in more detail action which might be considered against actual or potential perpetrators or people associated with them. The arrangements are an excellent example of pro-active disruption and have had a very significant impact. A consistent comment from Practitioners was that the tactics involving partners are well developed and comprehensive. This view was shared by Ofsted in 201738 which found that highly effective intelligence-led disruption and prevention strategies are making children, young people and vulnerable adults in the city safer. This is consistent with the Government’s expectation in 2015 that techniques and resources should be at the same level as for other forms of organised crime. The arrangements go further than the Government suggestions made in 2017.39 The team has attracted a reputation for excellence and a specialist officer advises other Police Forces, speaks at regional conferences and delivers training. Experience identified a weakness in licensing arrangements for individuals who have a licence to operate a taxi removed but may continue as a private operator of larger vehicles. It was also suggested that because of the large number of licensing authorities for different areas a national data base of individuals who have been refused a licence or had one removed should be kept. Recommendation 2.1 I recommend that: The Government should carry out a review of vehicle licensing for driving vehicles that transport members of the public, to include arrangements for private operators of larger vehicles, and taking account of the body of knowledge about sexual exploitation. Newcastle City Council Legal Services’ reviews of the cases included considering action that might be taken in Family Court jurisdictions to interfere with perpetrators’ activities. In 2014 injunctions made in open court 40 in Birmingham restrained a number of defendants from contacting children and attracted publicity. It is uncertain how many other local authorities make such applications as generally proceedings are in private. 38 Newcastle Upon Tyne Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board. Inspection date: 24 April 2017 – 11 May 2017. Ofsted Report. 7 July 2017 39 Tackling Child Sexual Exploitation. HM Government. 2015; Annex B - Guide to Disruption Orders and Legislation: Annexes to “Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation”. Department for Education. 2017 40 BCC v Riaz et al [2014] EWHC 4247 (Fam) 36 Since 2014, doubt has been expressed41 about the availability of injunctions since the advent of Sexual Risk Orders in a case in which a Local Authority made an application in relation to children who were not known and not subject to any family court proceedings. This needs clarification by the Court of Appeal or, as the judge suggested, legislation. Sexual Risk Orders and Sexual Harm Prevention Orders are narrow in their scope. They require acts of a sexual nature to have been committed whereas interference with statutory welfare responsibilities and the likelihood of sexual exploitation may arise before that can be sufficiently established. The Government included considering making applications for injunctions in the Advice published in 201742. If granted, injunctions may contain conditions relating to the welfare of a victim and restrain individuals from interfering with the exercise of statutory functions relating to children and vulnerable adults. Breaches are likely to lead to imprisonment. The Review gave the opportunity to consider a proactive, cooperative approach to disruption arrangements whether action is taken by the police or Newcastle City Council. Training for Newcastle City Council Legal Services staff on the range of powers available has taken place and there are good links with the specialist police officers leading on disruption so that information and evidence can be shared and actions co-ordinated. 5.5 Establishment of the Multi-Agency Sexual Exploitation Hub Early in 2014 assessments confirmed that significant resources were required to sustain Operation Sanctuary. An application for funding to develop multi-agency co-located victim support teams was made to the Home Office Innovation Fund, supported by 16 public, community and voluntary sector and academic agencies in the region. Funding of £3.5M was secured allowing the expansion of the Victim Team to include additional resources and expertise from social care, community and voluntary sector and health agencies. From April 2015, the police operation was enhanced by the establishment in separate premises of a co-located, victim focused Multi-Agency Sexual Exploitation Hub working alongside the Police Victim Team. The staff involved are social work practitioners and managers from lead agencies for safeguarding adults and children in Newcastle City Council, and staff from Barnardo’s, the Children’s Society, Bright Futures, an organisation supporting young people and adults with complex needs, and Changing Lives, a charity that supports vulnerable people to make positive, lasting changes in their lives. A Safeguarding Nurse Advisor (Children’s and Adults) was appointed and supervised by NHS Newcastle Gateshead Clinical Commissioning Group with effect from July 2016. A Safeguarding Adults Manager was immediately appointed to the Hub as a single point of contact for sexual exploitation within Adult Social Care. 41 London Borough of Redbridge v SNA [2015] EWHC 2140 (Fam) 42 Annex B - Guide to Disruption Orders and Legislation: Annexes to “Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation”. Department for Education. February 2017 37 There was a commitment at senior levels across agencies to address sexual exploitation effectively and secure significant resources at a time when all budgets were under pressure. The intention was to embed cultural change, focussing on evidence but with a prime objective for all agencies to support and protect victims and recognise that no evidence of abuse is not evidence of no abuse. Initially based in Newcastle, covering three local authority areas in the North Northumbria Police area, from April 2016 a similar team was based in Sunderland to cover the three local authorities in the South Northumbria Police area. The Hub is located where sexual exploitation is most evident and so attracts confidence from victims. The victim focused approach is helped by the building which is not obviously public service offices or police premises. The rooms for interviews with victims are as close to nicely furnished living rooms as is possible. There is a suite to carry out interviews compliant with guidance requirements43 and a separate complainant interview room and facilities for group work. In Newcastle, all children’s safeguarding concerns are considered and screened by a Multi-Agency Safeguarding Hub. Any suspicion of child sexual exploitation is routinely referred to the Multiagency Sexual Exploitation Hub with which allocated safeguarding children social workers work closely. For adults, proposals for a similar co-located Multi-Agency Safeguarding Hub to receive referrals are being considered by the Newcastle Safeguarding Adults Board. Referrals are currently made through Social Care Direct to the Adults Safeguarding Unit where they are screened and sexual exploitation concerns referred to the Hub with which allocated safeguarding adult social workers work closely. The Hub has developed exceptional team working recognised by the National Policing lead on Child Sexual Exploitation as a unique example to be recommended elsewhere. Victim engagement has been recognised as national best practice. A key strategy is a persistent and patient approach towards a victim through a trusted professional, identified by all agencies within the victim team and other safeguarding agencies. This requires working with the victim at their own pace and capturing evidence in a way that they are comfortable with, understand and want, adapting rather than applying standard responses. The care with which the arrangements have been put in place is very evident. The Team has no backlog of work, and the investigators meet the victim team every week to discuss cases and actions. The developments reflect expectations set out in the College of Policing CSE Action Plan 2014 – 201644. Following evaluation, the Home Office recommended other Forces to adopt similar models. 43 Achieving Best Evidence in Criminal Proceedings Guidance on interviewing victims and witnesses, and guidance on using special measures. Ministry of Justice. 2011 44 Pursue: Disrupting, arresting and prosecuting Child Sexual Exploitation offenders, ensuring a victim centred approach at all times. College of Policing CSE Action Plan 2014 – 2016 38 In 2017 Ofsted45 highlighted the excellence of the provision and will be promoting the Hub in a national resource as an example of good practice. In March 2017, HMIC found46 that victim contact and support is excellent and is bespoke to each victim who receives “a very high standard of service”. During an inspection the Office of the Surveillance Commissioners commented that the proactive and covert investigatory approach is at the forefront of covert policing activity and its use to combat sexual exploitation. The success was recognised nationally in November 2017 when the Team received: The Children and Young People Now Safeguarding Award for “the initiative that has made the biggest contribution to prevent and protect children and young people from abuse and neglect through exceptional team work and multi-agency working” and The Social Worker of the Year Award as Team of the Year – Adult Services for “excelling and making the difference to adult service users” through “outstanding team working in Adult Services”. It was emphasised that: “This team is the first of its kind nationally to address sexual exploitation of adults, and making it of equal relevance to adults as children. This is a national beacon of best practice” Arrangements are in place for an on-going evaluation of the service. 5.6 Victims’ Mental Health Needs Experience in the Hub and consideration of the cases identified difficulty and delay in accessing appropriate assessment and mental health support for victims. Action was taken to address this by the introduction of an interagency Mental Health Triage Meeting which has become known as “The Huddle”. Victims and potential complainants within the scope of Operation Sanctuary are promptly triaged and assessed and fast-tracked to mental health support. Staff have benefited from regular sessions and support, training, advice and guidance on the impact of trauma from an expert independent psychotherapist. Home Office Innovation Fund money was used to pay for these services for 12 months throughout the investigation. Thereafter, Newcastle City Council has continued to fund this support for Children’s and Adult Social Care Services staff. 45 Newcastle Upon Tyne Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board. Inspection date: 24 April 2017 – 11 May 2017. Ofsted Report. 7 July 2017 46 The Report of HMIC’s PEEL: police effectiveness inspection of Northumbria Police Force 2017 39 5.7 Impact of Operation Sanctuary and the Multi-Agency Sexual Exploitation Hub It is difficult to overstate the positive impact on culture and practice and as a consequence improvement in addressing sexual exploitation, improving victims’ welfare and restricting and preventing abusive activities by perpetrators. The success has given more victims confidence to come forward. Success improves morale and commitment. Practitioners consistently remarked on the benefits of a bespoke victim strategy and multi-agency working with flexible, collaborative and innovative working. Relationships between agencies generally have improved and between interagency children’s and adults’ services particularly. Co-location of specialist staff from children’s social care, adult social care, police, community and voluntary organisations and a safeguarding nurse adviser encourages spontaneous sharing of expertise and information and a collective responsibility for promoting victims’ interests and securing their trust and confidence. Links from the Hub to agencies ensure effective access to services for support, welfare and to meet the physical and mental health needs of victims. Lack of pressure of a case load, recognising that progress is in tiny steps and it may take months to encourage a victim to speak to police and sexual health services and that disclosures may occur during routine activities, allows a different way of working. There has been encouragement to think outside the box. If one or two agencies commit resources it has an impact on others and increasing knowledge has led to initiatives across agencies to improve practice. “I have support now – I now know what would happen much better. I could not have better support than Sanctuary. I have support coping with my son’s issues. No-one can do more now.” “The support I have had has been exceptional.” “From court to now has been fabulous.” “The support from the Hub is brilliant.” “I appreciate the support now. Because I have had a bad time. If I had had it then then – the police and others - it would have been good. Later (social worker) came to court. She was my rock.” In 2017 Ofsted47 found “outstanding multi-agency practice” and a highly effective response to sexual exploitation, successful use of court orders disrupting offending behaviour and reducing risks and excellent interagency work by Newcastle City Council and its partners which has resulted in a high number of convictions of perpetrators. 47 Newcastle Upon Tyne Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board. Inspection date: 24 April 2017 – 11 May 2017. Ofsted Report. 7 July 2017 40 During the Review the staff working at the Hub were asked their views on what contributed to the effectiveness of the unit: • Co-location of expertise in a non-police, non-threatening environment • Victim focus • Flexibility and what works approach • Good, comfortable, interview facilities; supporting vulnerable victims • Commitment from key services from statutory and third sector partners to joined up working – not just being in one place • Understanding roles, sharing good practice and different expertise • Robust, effective management oversight and governance • Early information sharing and risk assessment; spontaneous conversations • Weekly meetings look at emerging issues; flexibility of short notice meetings • Tasks fast-tracked - access to services not co-located • Implementing immediate safeguarding plans • Consistency • Joint training • Psychological support for victims and staff welfare • Strong links with community support, missing from home and human trafficking services • Community involvement • Financial savings from reduction in the need to arrange partner meetings Investigations have led to successful prosecutions for sexual assaults, rapes, conspiracy and drug offences. Trials that concluded in September 2017 involved 25 defendants and 22 victims and resulted in substantial terms of imprisonment up to 28 years. The defendants included men aged between 34 and 47 years old. Large numbers of victims have been protected and supported. Across the Northumbria Police Force area approximately 700 victims have been identified of which 108 were linked to Newcastle including those who gave evidence. 5.8 Complex Abuse Meetings held in relation to Sexual Exploitation In 2002, Government Guidance48 addressed undertaking complex abuse investigations that involve one or more abusers and a number of children. The intention was to ensure thoroughness, commission of sufficient resources, working together, sharing information, acting on risks as they emerge and prompt support for victims and their families. The Guidance was most commonly applied in cases involving historical abuse within an institution, and for allegations against staff. In response, Newcastle Safeguarding Children Board developed Complex Abuse Procedures which were applied in relation to child sexual exploitation as far back as 2008, including in a number of the cases considered during the Review. The guidance was also applied to complex investigations of abuse of vulnerable adults. 48 Complex child abuse investigations: inter-agency issues guidance. Home Office. Department of Health. 2002 41 This has been an effective process for multi-agency planning, identifying links between suspected cases and protecting victims using powers and court applications to control their behaviour. However, action against perpetrators did still rely on co-operation and disclosures from victims to satisfy evidential requirements for criminal proceedings. The process was revised and updated in 2014 and since then action is taken to disrupt activities of perpetrators and reliance on victims’ disclosures and co-operation is kept to a minimum. It has also been applied to cases involving forced marriage and organised criminal and drug related activity. There were early examples of adult social care workers attending child centred meetings when suspected victims were approaching adulthood. Now when vulnerability is likely to extend into adulthood or a perpetrator may require adult services, a representative from Newcastle City Council Adult Social Care attends the meetings. Strengthened arrangements ensure consistent attendance of legal advisers at meetings and chairing is limited to senior experienced staff. Any agency can request that a Complex Abuse Investigation meeting be held. An annual overview report on cases when they are large scale, highly sensitive, or linked to a police operation are made to the Safeguarding Boards. Quarterly reports are provided to the Newcastle City Council Chief Executive, the Director of People and the Assistant Director for Children’s Social Care. In the main, only the Police and the Local Authority attend the Gold Command meetings. In view of this it was decided that Operation Sanctuary should in addition be subject to Complex Abuse Investigations processes. This was a positive step and ensures agencies have a forum to facilitate interagency working and robust planning, are kept up to date, information is shared promptly between adults and children’s services and identify and challenge any gaps in services or resources. 5.9 Safeguarding Adults When Operation Sanctuary was launched in 2014 safeguarding adult’s procedures operated within a statutory guidance49 framework dating from 2000 in which powers, duties and authority to act to protect vulnerable adults were uncertain. The main provisions of the Mental Capacity Act 2005, implemented in 2007 and 2009 and the 300-page Code of Practice50 were not directly concerned with safeguarding but had a significant impact on the approach to assessing capacity to make decisions and powers to deprive an individual of their liberty. The definition of vulnerability was prescriptive and did not include adult sexual exploitation as it was being understood in Newcastle. 49 No secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse. Department of Health and Home Office. 2000 50 Mental Capacity Act 2005 Code of Practice. Office of Public Guardian 42 The cases illustrated that during the early period, leading adult protection, Newcastle City Council Adult Social Care adopted a creative and flexible interpretation of criteria to ensure that victims of sexual exploitation were supported. The national adult safeguarding framework was revised significantly by the Care Act 2014, implemented in 2015 when the Care and Support Statutory Guidance was published. Local authorities were required to carry out safeguarding enquiries and establish a Safeguarding Adults Board with a statutory remit. The definition of an Adult at Risk broadened eligibility criteria but the cases illustrated that intervention and continued involvement, consistent support and protection for adult victims continued to require a generous and flexible interpretation of statutory provisions by Newcastle City Council Adult Social Care and partners. This approach required proactively exploring with the Council’s legal staff the options available and testing legislation and court jurisdictions to secure powers to control individuals’ behaviours and where they live. When capacity to make a decision is compromised not because of a disturbance in the functioning of the mind or brain, but because of constraint, coercion or undue influence or for some other reason, the inherent jurisdiction of the High Court51 has been invoked. Funds were provided to access additional specialist legal advice to support this approach, driven by a determination to safeguard when what was happening was clearly abusive, even when assessments might suggest that an individual had the capacity to choose. Conversations during the Review with the Judge leading on Court of Protection processes confirmed her willingness to respond positively to the proactive approach taken in Newcastle. Every application to the Court has been successful. Steps have been taken to ensure the “legal literacy” of social care and legal staff is kept up to date. A Legal Options training course has been launched and is mandatory for all Adult Social Care staff. There is considerable evidence that despite resisting attempts to help, the persistence and availability of support, if and when wanted, and encouragement to see themselves as victims has had a significant impact on a number of the victims whose circumstances were considered. “They were worried about my capacity and went to the Court of Protection for deprivation of liberty. If they had not gone to the Court, I would have ended up dead. Looking back, I know I am much better now. It was the right thing to do but I hated it at the time.” The difficulties in the current legislative provisions arise because there is a significant number of individuals who do not lack capacity for the purposes of the Mental Capacity Act 2005 but are in some way vulnerable to coercion or duress by others and are outside the scope of domestic violence legislation. Local authorities have statutory duties to inquire into the circumstances but it is unclear what steps 51 Lord Justice McFarlane. DL v A Local Authority [2012] EWCA Civ 253 43 can be taken thereafter to secure protection. Court action is expensive and cumbersome and does not cover all situations.52 The state is not permitted without legal authority to intervene to protect adults from making bad choices or forming inappropriate relationships. Human rights issues are engaged. As with children, it was clear that adults at risk were being targeted, groomed and exploited and that perpetrators targeted vulnerability and undermined ability to make choices. But the circumstances that justify or require intervention by a state agency are not well defined. There is a proposal to pass legislation that will clarify the scope of those who should be protected and the basis of and the rationale for intervention in the affairs of those considered vulnerable and the powers of courts and agencies. Safeguarding Adults national guidance and practice advice within the current framework is not as extensive as for safeguarding children. The Newcastle experience confirms that, while there are similarities, adult sexual exploitation requires a different way of working. The vulnerabilities and practice skills required may be different. The Newcastle City Council Safeguarding Adults Manager working in the Hub encourages the police and other agencies to continue to develop their practice. When providing protective services for young adults, adult services experienced the same frustrations as their children’s services colleagues. No effective action was taken against the perpetrators and victims who at the time, because of grooming, threats influence and coercion by perpetrators, resented and resisted intervention in their lives: “I pushed the help away. I knew professionals were trying to see me and I cancelled appointments.” Some cases include individuals who had some cognitive impairment which had not required formal assessment, or who had experienced dysfunctional, difficult childhoods but would have been unlikely to have attracted the attention of adult services without concern about the increase in their vulnerability caused by grooming, abuse, exposure to drugs and alcohol and coercion and threats. In the absence of national guidance for adults, local arrangements were developed, taking into account national children’s safeguarding guidance and the experience of colleagues in children’s services. Existing safeguarding adults policies and procedures were used which provided a framework and information sharing protocol. Information sharing meetings, interagency and adult safeguarding meetings were convened and Core Group Meetings of professionals planned and monitored the delivery of adult protection plans. Difficulties in securing information from health agencies identified by Practitioners at the Learning Events have during the course of the review been addressed through the Newcastle Safeguarding Adults Board by a multi-agency information 52 Mental Capacity and Deprivation of Liberty. Law Commission Vulnerable Adults Bill proposal. 13th programme of Law Reform 2016 44 sharing protocol. Where there might be concerns there are processes in place for protocols and agreements including the need for any alterations to be considered promptly by the Case Review Committee. Newcastle City Council Adult Social Care have arrangements in place whereby the safeguarding adults function and management is independent of Adult Social Care and a Safeguarding Adults Manager, who is independent from operational functions, chairs safeguarding adults’ meetings. Reviewing the cases included checking the consistency of arrangements for ensuring all relevant historical information is available at Safeguarding Adults meetings, relevant professionals are invited and do attend and that Newcastle City Council Legal Services routinely take part. These issues are subject to quarterly audits which are discussed by the Newcastle Safeguarding Adults’ Board. It has been recognised by Newcastle City Council Adult Social Care and Newcastle Safeguarding Adults Board that adults requiring safeguarding services may have lifelong needs. There is little published experience of addressing long-term needs of victims of sexual exploitation. In Newcastle, continuing support is being provided in relation to emotional and mental health needs and dealing with problems associated with the care of their children, some of whom are children of abusers. Established interagency processes including Multi-Agency Public Protection Arrangements and Multi-Agency Risk Assessment Conferences related to domestic abuse have been utilised. This approach is supported by the independent psychotherapist commissioned for training, one to one counselling for workers and group support in relation to specific cases. The conversations with victims illustrated that for some it may be difficult to disengage from services, while others see the commitment to be available if needed as sufficient reassurance: “I know support will always be there for me.” Recommendation 2.2 I recommend that: The Government should urgently issue guidance or advice on addressing sexual exploitation of vulnerable adults. 5.10 Transition A striking feature of the cases involving older teenagers and young adults was the early development of collaborative planning and working between Newcastle City Council Children’s Social Care and Adult Social Care and the engagement of partner agencies. As early as 2007 there were examples of outstanding practice 45 and the application of principles later set out in statutory and practice guidance and legislation from 2011 to 2016.53 These included early assessment of a child's likely needs for care and support when becoming an adult; early planning for adult services; persistence of staff always being there; continuity of staff where possible; tailoring responses to individual needs; identifying a named worker to coordinate care and support and ensuring no young person should be made to feel that they should "leave care" before they are ready. Adult safeguarding staff were involved in planning the responses if it was likely vulnerability of a child would continue into adulthood. Examples of good practice included the involvement of a Barnardo’s high-quality Foster Carer who trained as an adult carer to ensure continuity of care and availability even when the victim was absent for periods. Children’s services worked with adult services until the victim was 25 years of age. In another case ongoing support was provided from the Community Mental Health and 16 Plus Teams in addition to the assistance from support workers who during crises provided support day and night. A protocol now provides for involvement of adult social care in reviews of children looked after by Newcastle City Council from age sixteen. Consideration of a looked after child’s needs as an adult is a standing item on agendas for social workers and Independent Reviewing Officers to consider at each review of a child’s case. The arrangements have been reviewed and refined in the light of the legislation, guidance, and experience. Adult Social Care staff have direct access to Children’s Social Care records. The remit of the Missing and Sexual Exploitation and Trafficking Group operates as a sub group of both the Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board and the Safeguarding Adults Manager attends meetings of the Risk Management Group. As a result of the joint working, definitions of referral pathways have been improved and delays accessing services reduced. Practitioners highlighted the benefits of early assessments and securing historical information for planning adult services which may not previously have been necessary. In 2016, the Newcastle City Council Director for People requested that the Local Government Association undertake a Peer Review of the Council and partners to ascertain the effectiveness of the transition arrangements. The Report54 found that: “Work around sexual exploitation is being used to improve communication, service delivery and outcomes for young people by all partners across the city.” 53 The Children Act 1989 guidance and regulations Volume 3: planning transition to adulthood for care leavers April 2011 Revision date: January 2015; NICE Guideline on Transition from children’s to adults’ services for young people using health or social care services. 2016; Transition for children to adult care and support, etc. ss 58;59 Care Act 2014 54 Local Government Association Adult Safeguarding Peer Challenge Report. March 2016 46 Continuing effectiveness of the arrangements is monitored through regular audits. 5.11 Understanding, Informing and Mobilising the Communities In 2014 The College of Policing55 expected Police Forces would conduct community engagement activities. In 2015, the Government emphasised that communities must help tackle child sexual exploitation rather than assume victims bring it on themselves and in February 2017 stressed that those who do not necessarily work with children also have a contribution to make.56 The public expects to be made aware of risks from perpetrators and how to minimise them. Sexual exploitation may impact on families and individuals who do not come to the attention of safeguarding agencies for any other reason. In Newcastle, prior to 2013 the level of engagement with the public reflected the perceived prevalence of sexual exploitation. As awareness grew the need to involve the community was recognised and acted upon. A central feature of Operation Sanctuary has been communication with communities. The Learning Events highlighted the importance of a continuing strategy, involving potential future victims. Significant investment and a programme to raise local awareness about what to look for and how to report concerns has been overseen by the Safeguarding Boards. This has involved all the features since identified by the Government. Thousands of leaflets were distributed to every hotel, neighbourhood, taxi firm and religious institution, families and to workers including those working during the night and door staff in clubs. The Black and Minority Ethnic Safeguarding Initiative helped to ensure distribution to members of their communities. These initiatives gave confidence to some victims to come forward. Northumbria Police launched a bespoke Vulnerability Training Programme, for staff in the night-time economy, door supervisors and staff in hotels. Recommended nationally as good practice, it has been adopted by the Security Industry Authority and is mandatory door supervisor training. Staff from Safe Newcastle and Newcastle Safeguarding Boards have contributed to the delivery. A growing public health concern is the impact on vulnerable people of changing trends within drug supply, recreational use, and links to exploitation of compounds designed to mimic existing established recreational drugs (Novel Psychoactive Substances - designer drugs, internet drugs, research chemicals, legal highs). Distributing or selling these is a criminal offence but possession is not.57 A range of multi-agency arrangements have been put in place in Newcastle to tackle use and 55 The College of Policing CSE National CSE Action Plan 2014 to 2016 56 Para 4. Tackling Child Sexual Exploitation. HM Government. March 2015; Advice: Educating Communities, and Harnessing the wider community Child Sexual Exploitation Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. February 2017 57 Psychoactive Substances Act 2016. Novel psychoactive substances: a practical approach to dealing with toxicity from legal highs: Dignam and Bigham. Vol. 17 Issue 5 172–177. British Journal of Anaesthesia; Oxford University Press May 2017. Novel psychoactive substances: types, mechanisms of action, and effects: Tracy, Wood and Baumeister. British Medical Journal. January 2017;356:i6848 47 supply. A health needs assessment into the prevalence of children and young people’s drug and alcohol use is being carried out to inform practice, the results of which will be reported to the Safeguarding Boards. In January 2017, the Safeguarding Boards worked with the Black and Minority Ethnic Safeguarding Initiative to organise a conference at a local school. Casey and Jay criticised engagement that restricted communication to older male community leaders.58 In Newcastle, over 100 people, mostly women, attended and were very positive about the event. Interpreters and child care facilities were provided. The Conference included presentations by the Police and Crime Commissioner and the senior investigating officer for Operation Sanctuary, information concerning the Review and group discussions, all of which have fed into the Review. Publicity is provided at significant community events including Northern Pride. In 2017 the HMIC inspection identified strengths in Northumbria Police and other public services in raising public awareness and the Ofsted inspection found that positive engagement with minority ethnic communities is ensuring a focus on under-reporting in these communities and raising awareness. During the Review, conversations took place with members of the Black and Minority Ethnic community who wished to be involved and express personal opinions. When the trials were reported the community was shocked. The abuse was hidden and people were not aware of what was happening. Some people heard things about take-aways and taxis shortly before the launch of Operation Sanctuary but were not aware of the scale. Former school friends were perpetrators. Wives unaware of their husbands’ involvement required help to avoid recrimination and ensure their safety. It was stressed that the community should speak out against the crimes but not be expected to apologise. It should be spoken about but this has yet to take place in religious and social settings. Victims in minority communities are unlikely to disclose due to shame and the impact on themselves and relationships with their families. Adults may not report suspicions, anxious about whether this would be understood during enquiries. The Home Affairs Select Committee59 supported this and Jay criticised the myth that only white girls are victims of Asian or Muslim males which flies in the face of evidence that shows that: “…those who violate children are most likely to target those who are closest to them and most easily accessible.”60 58 Report of Inspection of Rotherham Metropolitan Borough Council. Louise Casey CB. House of Commons 2015; Independent Inquiry into Child Sexual Exploitation in Rotherham 1997-2013 Alexis Jay OBE Rotherham Metropolitan Borough Council. 2014 59 Child sexual exploitation and the response to localised grooming Child Sexual Exploitation: scale and prevalence House of Commons Home Affairs Committee. June 2013 60 Independent Inquiry into Child Sexual Exploitation in Rotherham 1997-2013 Alexis Jay OBE Rotherham Metropolitan Borough Council. 2014 48 Research by The UK Muslim Women’s Network published in September 2013, found Muslim girls were not being made aware of the predatory nature of some men and boys, and the consequences of being lured by them – they are not being adequately warned to safeguard themselves:61 “most victims had not received or been supported by long-term aftercare and when the family became aware of any abuse they re-victimised them, which meant not believing them, blaming them …” Jay recommended that Rotherham Safeguarding Children Board should prioritise under-reporting of exploitation and abuse in minority ethnic communities. The College of Policing62 has expected the police to address under-reporting in BME communities. During the Review one victim spoke about Asian heritage victims in Newcastle: “There were a couple of Asian girls involved.” There is no reason to believe that vulnerable adults in these communities are not at similar risk to children. Northumbria Police has arrangements in place to bring together intelligence and experience to better understand profiles of victims and perpetrators which is being shared with partner agencies. Investigations in the North East have involved a significant number of minority ethnic victims. In Section 6, I discuss the perpetrators within this context. The conversations highlighted the importance of the community being involved in considering the issues, which are about men and power, early education about attitudes to women, some in particular, women’s rights and the lack of open discussion. Concerns are not confined to one minority religious or ethnic community. Some remarks reflected comments by Jay that it was thought for example that some child victims and some perpetrators originated from the Roma Slovak community. In Newcastle action is being taken. It was suggested that there should be a forum to bring together individuals from the community, ordinary people as well as leaders and scholars, and public authorities to talk about these issues. There are some key people. Talks may need to take place separately with men and women, to encourage expression of views. There needs to be very careful consideration of who should be involved and the scope and practical arrangements. Councillor Nick Forbes, Leader of Newcastle City Council will lead on bringing about what should be a very positive development and one which may lead to national recommendations. 61 Unheard Voices: The Sexual Exploitation of Asian Girls and Young Women. The Muslim Women’s Network UK Report: September 2013 62 The College of Policing Action Plan for Child Sexual Exploitation for 2014 – 2016 49 Recommendation 1.2 I recommend that: A report should be made to Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board on the arrangements to take forward the initiative to establish a process for discussion with communities about the issues that have arisen from the Joint Serious Case Review. 50 6. The Perpetrators At the Learning Events, all professionals emphasised the lack of information available about the profile, motivation and driving factors for abusing that prevents looking at how to stop people becoming perpetrators and better protect potential victims. This was contrasted with the PREVENT agenda. The Review was unable to identify any information about work with perpetrators which might help practitioners. In response to questions after the Newcastle trials, the police confirmed that the defendants were mainly not white but came from a diverse range of backgrounds including Pakistani, Bangladeshi, Indian, Iranian, Iraqi, Kurdish, Turkish, Albanian and Eastern European. The sentencing Judge concluded that there was no evidence that the defendants were racially motivated in committing the crimes: “In my view, and speaking in broad terms, these defendants selected their victims not because of their race, but because they were young, impressionable, naïve, and vulnerable.” It has been properly emphasised that there are thousands of white British males on sex offenders’ registers. But with this particular model of abuse, whilst the individual beliefs of the perpetrators are not known, all appear to come from a non-white, predominantly Asian/British Minority Ethnic culture or background. In 2014, Ofsted63 highlighted a particular pattern across the country involving predominantly White British girls as victims and gangs of predominantly Asian heritage men as perpetrators. In Rotherham, by far the majority of perpetrators were described as Asian by victims and in files as Asian males, without precise reference being made to their ethnicity. In 2015 Casey commented on unintended consequences of suppression of these uncomfortable issues which has done a disservice to the Pakistani heritage community as well as the wider community.64 “It has prevented discussion and effective action to tackle the problem. This has allowed perpetrators to remain at large, has let victims down, and perversely, has allowed the far right to try and exploit the situation.” In Oxfordshire65, the perpetrators were predominantly of Pakistani heritage and all the victims were white British girls. The Review recommended that relevant government departments should research why this is the case, in order to guide prevention strategies. 63 The sexual exploitation of children: it couldn’t happen here, could it? Thematic Ofsted inspection to evaluate effectiveness of local authorities’ current response to child sexual exploitation. November 2014 64 Independent Inquiry into Child Sexual Exploitation in Rotherham 1997-2013 Alexis Jay OBE Rotherham Metropolitan Borough Council 2014; Report of Inspection of Rotherham Metropolitan Borough Council. Louise Casey CB. House of Commons. 2015 65 Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F. Oxfordshire Safeguarding Children Board. 2015 51 In Bristol66 the perpetrators were young men in their early 20s with a Somalian background; many were refugees fleeing violent conflict and trauma in their home country. It was not possible to explore the impact of this background and that review found that there is much more to learn from perpetrators’ childhood experiences in order to gain more understanding of risk areas and to identify early warning signs. In 2017 research by the Quilliam Foundation, found that of 264 offenders convicted for grooming offences in the United Kingdom between 2005 and 2017, 84% were of Asian heritage, mostly Pakistani; 8% were black and 7% were white. Asians or British Asians who make up 6.9% of the population, are responsible for 46% per cent of child sexual exploitation crimes.67 The Chief Executive of Quilliam commented that: “Not talking about it doesn’t make the problem go away, and letting bigots hijack the debate creates further division in society. We as a society need to tackle this head on.” This was echoed by Northumbria Chief Constable Steven Ashman following the sentencing in the Newcastle trials: "Why is it that there appears to be a predominance of this type of offending in a particular community? I think that community has to be asked that question ... I think we can take part in that debate, but it's not led by the police, it's a job for society itself..." Some attempts to start a national conversation have not been very successful. In November 2017, it was reported68 that the Chief Inspector of Ofsted has compiled a file of concerning materials found by inspectors in libraries and used for teaching of boys and girls in Islamic maintained schools, independent faith schools and unregistered schools. Out of step with mainstream Muslim thinking, it included examples of discrimination, sexism, and misogynistic material, urging women to be submissive, not to have ambition and never refuse sex to their husbands or leave the house without permission and sanctioning domestic violence by way of correction. Eastern Women were contrasted with internally torn women of the West who attract men and leave home to hang around aimlessly in cinemas and cafés. In 2016 Casey prepared a report for the Government on opportunity and integration and commented that the Department for Education turns a blind eye and hopes that Ofsted will deal with the problem. “It’s all in the too difficult box.” 69 One male perpetrator agreed to contribute to the Review. In prison, he explained that he left his country of origin for a better job, spent 10 years in Turkey, 5 years or so in Greece and some time in Italy and France, before travelling to England on 66 The Brooke Serious Case Review into Child Sexual Exploitation: Bristol Safeguarding Children Board. 2016 67 Research Report, Quilliam Foundation. December 2017 68 Bennett and Sylvester. The Times. 28 November 2017 69 The Casey Review: a review into opportunity and integration: An independent review by Dame Louise Casey into opportunity and integration. Department for Communities and Local Government. December 2016 52 the way to Canada. He was detained by immigration officials who questioned his status and he claimed asylum. Later he was granted indefinite leave to remain in the United Kingdom. He intends to return home at the end of his sentence. During sentencing the judge commented that: “Your intention was to incite these young women (aged 15 years) to prostitution, that is, to encourage them to trust you, and to think of you as their friend, whilst also encouraging their dependency on the drink and drugs you provided so ultimately, they would provide you with sexual services.” “When interviewed you made no comment, except to make remarks which betrayed your complete contempt for the victims of your offending. You described them as “kids” yet your instinct had been, not to protect them because they were children but to exploit them.” Exploring what might have prevented him from offending was not possible. He displayed no regret, claimed he only had sex with girls over 16 years old and that they knew what they were doing. They were responsible and brought drugs onto his premises. One was homeless so what could he do? He was convicted because of a conspiracy by the government, police and the judge who paid the victims. If convicted for rape in his home country, he would be beheaded or buried up to the neck and stoned. He was asked about what he thought about the United Kingdom and influences in his education. He said you can get anything here – any sex, drugs, alcohol. There is no control. He spoke in a derogatory way about lack of morals in British girls and did not go with Muslim girls because there are not many of them. Before his conviction he had been served with a harbouring notice warning that he had no permission to have a 15-year-old in his home but this did not persuade to discontinue his activities. Arrogance and persistence despite authorities clearly investigating is a feature of the cases. Also lack of concealment or care about the arrangements. Sentencing another perpetrator, the judge described how: “Texts show you encouraging young women to frequent your home, attempting to recruit more young women to meet your friends, advertising to your friends when there were girls available at your home, and boasting of your sexual exploits.” It was unfortunate that there were not more opportunities to meet with perpetrators and further attempts, if successful, might lead to greater understanding. Recommendation 1.3 I recommend that: Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should continue to work with relevant partners to try and encourage conversations with perpetrators to better understand the Newcastle context of their offending. 53 The Sexual Violence against Children and Vulnerable People National Group Progress Report and Action Plan published in March 2015 committed the government to: “Develop a stronger evidence base on the motivations for offending and effective interventions.” “The Ministry of Justice and National Offender Management Service will review what we know about child sex offenders and motivations for offending; and identify the feasibility of further research to improve the evidence base including on what approaches are most effective at reducing the risk of offending.” In Section 5.11, I highlight the willingness in Newcastle across communities to have conversations but these issues are bigger than Newcastle and there is an urgent need for them to be addressed robustly at a national level, for reliable research to be undertaken and guidance to be issued. Recommendation 2.3 I recommend that: The Government should arrange for research to be undertaken concerning profiles, motivations and cultural and background influences of perpetrators of sexual exploitation of children and vulnerable adults and publish guidance for strategists and practitioners on the most effective way to reduce offending. 54 7. Newcastle in the Context of the National Picture: preparing for, preventing and responding to sexual exploitation 7.1 Response to Legislation and Guidance Government guidance published in 200070 reflected concern about child prostitution. The title and much of the content focused on children found persistently loitering, soliciting or importuning and in sight and obvious. This had an influence on the steps taken to ascertain prevalence within a particular area. The materials available to the Review indicate that the Newcastle Area Child Protection Committee, established by Newcastle City Council in response to statutory guidance in 199971 provided a good basis for interagency working. In response to the 2000 guidance, the Committee developed a protocol on children involved in prostitution and monitored and reviewed its operation. Significantly, there was a determined interest in understanding local prevalence and in September 2003, the Committee commissioned Barnardo’s to carry out research into Child Sexual Exploitation through Prostitution in Newcastle upon Tyne. In response to growing concern about the lack of framework to protect vulnerable adults from abuse, in 2000 the Government published Guidance72. Definitions of abuse included sexual abuse but no reference to the risk of targeted, organised sexual exploitation or prostitution. Acting on the Guidance, Newcastle City Council established a Multi-Agency Management Committee for Safeguarding Vulnerable Adults which was responsible for developing interagency strategies, policies and procedures. In 2004, revised guidance and procedures on “Safeguarding Children at risk of Sexual Exploitation through Prostitution” were launched in Newcastle. In September 2005 a comprehensive Report73 on reducing the impacts of sexual exploitation, reflecting research and understanding at the time, was published by Newcastle Area Child Protection Committee, Safe Newcastle and Barnardo’s. The research focused on victims known to agencies and identified low numbers, relative to children within the child protection system. It was not unreasonable for the view to be taken that child prostitution was not particularly prevalent in Newcastle. 70 Safeguarding Children Involved in Prostitution: Supplementary Guidance to Working Together to Safeguard Children: Department of Health, Home Office Department for Education and Employment, National Assembly for Wales. 2000 71 Working Together. Department of Health, Home Office, Department for Education and Employment. 1999 72 No secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse. Department of Health and Home Office. 2000 73 Research Report, Reducing the Impacts of Sexual Exploitation. Newcastle Area Child Protection Committee, Safe Newcastle and Barnardo’s. 2005 55 The 2005 Report included a short section on “The needs of older people” but this was restricted to conversations with “adults involved in the sex industry”. The legislative framework for safeguarding adults was weak and there was no significant awareness nationally of the prevalence of sexual exploitation of vulnerable adults. It is not surprising that there were no arrangements at that time to specifically address sexual exploitation of vulnerable adults. In January 2006, in prompt response to legislation and guidance, Newcastle City Council established Newcastle Safeguarding Children Board which replaced the Area Child Protection Committee. Listed partner agencies were required to co-operate with local authorities and proactively ensure that they carry out all their functions having regard to the need to safeguard and promote the welfare of children.74 There was a huge amount of work for the new Local Safeguarding Children Boards to undertake. Within this, the Newcastle Safeguarding Children Board gave priority to the issues addressed and recommendations made in the 2005 Report.75 By Autumn 2006, a Child Sexual Exploitation Strategy and Plan were in place. During 2006, Newcastle City Council also established Newcastle Safeguarding Adults Committee to replace the Multi-Agency Management Committee and formed, within Adult Social Care Services, a Safeguarding Adults Unit, a dedicated team responsible for multi-agency safeguarding procedural advice and to lead on complex safeguarding investigations. In September 2006, the Missing Sexual Exploitation and Trafficking Group involving practitioners and managers in the statutory and voluntary sectors, was set up as a sub-group committee of the Newcastle Safeguarding Children Board. The activities included considering research, sharing information between agencies, identifying hotspots and targeting activity and set the tone for the region. At this time, the view was that, while child sexual exploitation took place, it was not as extensive in Newcastle as was becoming apparent in some other parts of the country. The 2005 Report identified no visible signs of street child prostitution. Incidents involving young gay men appeared to be limited to public toilets and parks. As understanding of child sexual exploitation increased nationally, referring to and treating victims of sexual exploitation as child prostitutes properly became unacceptable, although the terminology persists in definitions of some criminal offences. In a research report published in 2015, the Northern Rock Foundation commented that in 2006 when it began researching sexual exploitation of adults and children in the North East and Cumbria there were few places in the North East where there 74 ss 10;11;13 Children Act 2004; Working Together to Safeguard Children. HM Government. 2006 75 Reducing the Impacts of Sexual Exploitation. Barnardo’s, Newcastle Area Child Protection Committee, Safe Newcastle 2005. 56 was any awareness of Child Sexual Exploitation “with the exception of Newcastle and Middlesbrough.”76 From 2006 to 2008 the approach locally continued to be driven by the national view that teenage victims of sexual exploitation were not victims in the same way as younger children but made choices, may be promiscuous and might be influenced by the offer of money. The multi-agency system was not set up to provide an effective response for adolescents with a complexity of needs, at the time and pace they need it, leaving children with a fragmented and reactive response to different aspects of their behaviour.77 An Ofsted Thematic Report drew on serious case reviews carried out from 2007 to 201178 found that older children were frequently treated as adults, because of confusion about age and legal status. In Newcastle, this changed when a report of a Serious Case Review carried out by Newcastle Safeguarding Children Board in 2008 emphasised that vulnerable adolescent young people are children and their ability to make choices in their best interests can be compromised. Safeguarding duties continue until 18 years old and agencies need to be persistent in delivering services, accepting the difficulties of working with a young person who may not understand the need for a service. The Board published Guidance on Working with Vulnerable Young People in Need and organised multiagency events to reinforce these messages. As early as 2007, cases of sexual exploitation of adults with vulnerabilities were being identified and cases involving older children attracted close working between children and adults’ services as victims’ vulnerabilities were recognised as continuing into adulthood. In 2009, the Government published Guidance which set out the minimum requirements for procedures79 and contained no references to sexually exploited children being prostitutes. It reflected learning from across the country, particularly from events in Rochdale and Rotherham. In Newcastle, the Missing Sexual Exploitation and Trafficking Group considered and addressed the implications of this Guidance. Agencies with responsibilities for safeguarding and promoting the welfare of children, including local and national voluntary child and family support agencies and national voluntary child care organisations with a local presence, were involved in drawing up procedures. Recommendations in the Overview Report of a Serious Case Review carried out by Newcastle Safeguarding Children Board in 2010 sought to strengthen the work with adolescents displaying risk-taking behaviour. 76 Child Sexual Exploitation in the North East and Cumbria. Think. Northern Rock Foundation; Barefoot Research and Evaluation. November 2015 77 The Brooke Serious Case Review into Child Sexual Exploitation: Bristol Safeguarding Children Board. 2016 78 Ages of concern: learning lessons from serious case reviews: A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011. Ofsted. 2011 79 Para. 4.10 Safeguarding Children and Young People from Sexual Exploitation: supplementary guidance to Working Together to Safeguard Children; Department for Children, Schools and Families 2009 57 A multi-agency Risk Management Group was set up in July 2012 to consider young people who were considered to be at high risk of harm including those missing from home and local authority care, involved in drug and alcohol misuse, and offending. A learning review carried out in 2013 endorsed the role and functions of this Group and found that it “has a crucial role in the management of some of the most vulnerable young people”. The Newcastle Safeguarding Adults Board was established in February 2009 and revised Inter-Agency Safeguarding Adults Procedures were published. No government guidance had been issued since 2000 and proposed legislation to address adult safeguarding was still being considered. Consistently with similar arrangements elsewhere there was no specific reference to sexual exploitation but Newcastle Safeguarding Children Board provided both face to face and online child sexual exploitation training from 2009. Lengthy consultation by the Department of Health began on proposed legislation and guidance for an interagency framework for safeguarding of adults with needs for care and support. Newcastle Safeguarding Adults Board and professionals responded to the consultation with representations about the need to recognise and to reflect the growing experience in Newcastle of sexual exploitation of adults which it was thought would be occurring unrecognised elsewhere. They also provided a Case Study example which was included in the Statutory Guidance80 issued in 2015, which includes one other reference to sexual exploitation, emphasising that people who may lack capacity should be helped to understand that they have the right to say “no”. There is no further exploration or guidance or reference to circumstances in which a victim may not want to say “no” but needs protection. Newcastle Safeguarding Adults Board policies and procedures and associated guidance documents and training programmes were revised and launched to coincide with the implementation of the Care Act in April 2015. As the details of high profile cases concerning child sexual exploitation in other parts of the country became available, work continued to understand the likely prevalence in the Newcastle area. In April 2013 a briefing was arranged to inform members of the Newcastle Safeguarding Children Board about Child Sexual Exploitation and the National Context, to review the local situation, and to discuss the local Child Sexual Exploitation Action Plan. It included reports on cases in Derby, Rochdale and Oxford, work being undertaken by the Children’s Commissioner, information on prevention work in Newcastle schools, arrangements for children considering missing from home, and the use of Complex Abuse Procedures to address the management of cases. A presentation included reference to a national Report that suggested “If you Shine a Light you will probably find it”. A Local Problem Profile was given by a senior police officer who reported on what was known and understood about local prevalence 80 Care and Support Statutory Guidance Under the Care Act (2014) Department for Health 2015 Updated 2016/2017 58 which confirmed that although cases were identified and the issue was subject to continuing review, it did not appear that sexual exploitation was occurring on a large scale. Later in 2013, continued profiling suggested that the assessment should not be changed but then accounts of victims, proactive enquiries and intelligence led to a recognition that the extent of sexual exploitation was greater than previously assessed. Operation Sanctuary was launched in January 2014 and the Hub was established. To reflect growing awareness of the vulnerability of adults, in 2014 representation from adult services was included in the Missing Sexual Exploitation and Trafficking Group and it became a sub-group of the Newcastle Safeguarding Adults Board in July 2015. In 2017 the Government81 stressed that all practitioners should work on the basis that sexual exploitation is happening in their area. At the conclusion of trials in August 2017 Newcastle City Council Chief Executive and Northumbria Police Chief Constable emphasised that grooming gangs are active in many, if not all, other areas of the UK: “I think we all need to learn from one another in terms of this happening in different places. What’s different here in Newcastle is that we are going out and looking for it.” “We do not believe that what we have uncovered in Newcastle is unique. Sadly, there is evidence of sexual exploitation in just about every other town and city in the country and anyone who says they do not have it are not looking for it.” The Newcastle experience indicates that this approach must be taken to safeguarding adults and children vulnerable to sexual exploitation. Professionals and agencies in Newcastle have been using regional, national and professional networks to stress the need for greater recognition of the need to proactively look for sexual exploitation of adults, close collaboration between Safeguarding Children and Safeguarding Adults Boards and the need for very early involvement of adult services staff with children’s services as victims or potential victims approach adulthood. The only issue identified by the Review arising from national guidance from 2000 which was not reflected in local arrangements was the expected involvement of the Crown Prosecution Service with the interagency framework in developing procedures and advising on keeping of records to take account of criminal court processes. This would have required national direction to ensure consistency and 81 Advice, Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. Department for Education. February 2017 59 is unlikely to have occurred elsewhere in the country. I discuss this further in Section 7.9. The Newcastle Safeguarding Boards have good arrangements in place to consider the content and impact of newly issued national guidance. Recommendation 1.4 I recommend that: When considering national guidance or advice Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should ensure that expectations for engagement with a national agency that is not a local partner are addressed and kept under review. 7.2 Overarching Response The Review examined carefully the responses of agencies when there was evidence or suspicion of sexual exploitation taking place. There is a stark contrast between the approach before early 2014 when Operation Sanctuary was launched and the Hub established, and the effectiveness of services thereafter. Because of the success of these arrangements, the impression may be gained that prior to 2014 no effective work took place. The Review identified many examples of excellent practice and consistent, committed support for victims where professionals had gone above and beyond what might have been expected and worked outside of thresholds persistently and tenaciously with a creative approach to safeguard victims. Practitioners, however, spoke about their uncertainty about how to manage the risks when they were recognised and their disappointment at the lack of progress with victims and cases feeling ‘” stuck”. There was frustration that the approach and commitment did not achieve the outcomes hoped for. The most significant change that occurred in 2014 was the determination by the police and partners to address more effectively the causes of the exploitation, that is the activities of the perpetrators, through effective investigation and disruption. 7.3 Response prior to 2014 The Review identified many examples of good practice by police officers in relation to immediate victim safety. They responded quickly to requests to locate and return young people missing from the care of the local authority and vulnerable adults who were missing from their placements. If when carrying out other duties, they came across young people drunk or in distress in the company of older men, they acted to take them home to their parents or to their placements. Conversations took place with carers to ensure they were aware of where their children had been found and in whose company. 60 It is not surprising that there were some examples of frustration or reluctance to respond when police officers received frequent, perhaps daily, requests to find and return a victim, when she appeared willingly to go to abusers and was judged to have the capacity to be able to choose. This was addressed quickly and resolved appropriately by agencies through discussions between managers. Some criminal investigations and trials did take place but with variable outcomes. Action lacked consistency and had little impact generally on activities of perpetrators. Perpetrators were not consistently investigated or formally interviewed and background checks were not undertaken. Historical information was not routinely accessed and incidents were treated as separate occurrences with no strategy to pull information together to improve understanding of the whole picture. At the Learning Events, it was felt there was a lack of professional curiosity, thinking beyond the presenting issue, and insight into the actual harm victims were experiencing. There were no effective inquiries about relationships, why girls were with older men to whom they were not related; explanations were accepted, even when a young girl was found in the bedroom of an older man. There was little inquiry into what other victims there may be or the vulnerability of children, young people, and vulnerable adults in the perpetrators’ families and circle of contacts. There was a lack of forensic medical examinations or collection of physical evidence. Suspected offences were discussed at Complex Abuse Investigation Meetings and this did lead to a limited number of applications for harbouring notices and child abduction warning notices but within the Timelines and Agency Review reports there is little reference to activity to disrupt perpetrators’ activities. While perpetrators were not punished or disrupted, attempts to persuade victims to change behaviours and not return to the abusers led to consideration of deterrent punishments of victims for being drunk and disorderly or for making false allegations when accounts were changed. Some victims were placed in secure accommodation. This sent an unhelpful message to perpetrators – they would unlikely to be prosecuted or prevented from continuing to abuse - encouraging an arrogant persistence. It also had a significant impact on victims who learnt that nothing would be done against perpetrators. The absence of criminal processes also led to police officers not consistently attending interagency safeguarding meetings, taking the view that they had little to contribute. This did not recognise the value to the interagency safeguarding arrangements and family court proceedings of police inquiries and intelligence even if no prosecution takes place or a trial leads to a not guilty verdict. Decisions and outcomes of criminal processes have limited value in considering and acting on risks to vulnerable children and adults. All that is ever decided by a not guilty verdict is that on the 61 evidence presented (which may be very limited) the jury was not sure of guilt and “found innocent” is not a verdict known to the law.82 7.4 Why were Perpetrators not Investigated and Prosecuted or otherwise Disrupted Prior to 2014? The Review considered the background thoroughly to better understand the approach by the police over the period reviewed. In Section 7.6, I highlight that reasons identified for lack of action that have been features of reviews carried out elsewhere, including ignoring whistle blowers or members of the public or families, lack of compassion or empathy, misplaced concerns about political correctness or fears of allegations of racism or inappropriate interference by senior official or political leaders, did not occur in Newcastle. Practitioners did feel that early responses had the appearance of blaming the victims for their behaviour and allocating them responsibility for making bad choices and the Reports and discussions identified language in records that reflected this. The perpetrators’ control and influence were not fully understood and uncertainty regarding consent and capacity encouraged the view that some victims chose to be with the perpetrators. This led to frustration that the advice or help offered did not impact on their behaviour. However, while perceptions of responsibility of victims for their own actions complicated identifying an effective response, there is no evidence that this influenced decisions about whether action should be taken or undermined the determination to safeguard victims. The need to be cautious to avoid judgemental and prejudicial language in practice and in recording had already been identified and acted upon in Newcastle before the Review began and is addressed in training on sexual exploitation for frontline staff developed by the Safeguarding Boards. This stresses the possible detrimental impact it may have on evidential accounts. The explanation for the lack of criminal investigation and prosecution of perpetrators is the lack of confidence of police officers, shared by other professionals who accepted their judgments, that there was unlikely to be any realistic prospect of securing convictions. This was influenced by experience of pursuing cases in which there was a lack of co-operation from victims or inconsistency in their accounts, the courts’ historical approach to the evidence of complainants in sexual assault cases, the undermining of victims in court and past advice from and the cautious approach from the Crown Prosecution Service towards approving cases for charge and trial. The House of Commons Home Affairs Committee in 2013 confirmed that in the past, police forces were not taking the right approach towards cases of sexual exploitation 82 Lord Justice Judge Para. 15. R v Cannings [2004] EWCA Crim 01 62 and put this in the context of experience of the criminal justice system, which is widely acknowledged to have failed to adequately protect and support victims. The Director of Public Prosecution acknowledged that the Crown Prosecution Service approach to credibility of victims had been inappropriately cautious and risked leaving them unprotected by the criminal justice system. The standard test for credibility would, if unadjusted, almost always find against a victim.83 Some of the relevant factors were: the insistence on having a complainant who was willing to co-operate and who would be a competent witness; the possibility of inconsistent or confused accounts; damaging material in records that must be disclosed; delay allowing pressure and threats and anxiety to affect willingness to take part; the courts’ traditional approach to consent; victims may be resistant to intervention and maintain links with abusers, even after attempts to help protect them84 and uncertainty about jury members attitudes. Further complications arose if there was any cognitive impairment. In Newcastle, the early application of Complex Abuse Investigation processes reflected a determination to take an overview of the management of criminal investigations and safeguarding but the focus still remained on obtaining reliable disclosures from victims. The Oxfordshire Report85 referred to police saying that if a child did not disclose it was a matter for social services as they “needed to move on to the next job”. Continuing caution regarding these issues in Newcastle led recently to renaming on legal advice a Victim’s Charter as a Complainant’s Charter, to avoid any risk of undermining evidence by implying investigations were not being progressed with an open mind. The Home Affairs Committee reported that the Director of Public Prosecutions had announced new measures to combat the previous failings. There Is no evidence of any reluctance to understand or act upon knowledge of the prevalence of sexual exploitation in Newcastle, but when the prevalence was better understood, it was the catalyst for an immediate change of approach - absence of evidence is not evidence of absence of abuse; safeguarding and support of victims is a priority; prosecution and punishment of perpetrators is part of a range of responses; covert investigative techniques obtain independent evidence to corroborate victims’ accounts; comprehensive tactics for disrupting perpetrators’ activities and minimising reliance on victims’ testimonies. Northumbria Police carried out a rigorous review of a number of previous investigations to consider if there were any missed opportunities or any merit in reinvestigating previous reports. Reconsideration of allegations with the Crown 83Para. 57 Child sexual exploitation and the response to localised grooming House of Commons London: The Stationery Office Limited. June 2013 84 Advice, Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. Department for Education. February 2017 85 Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F. Oxfordshire Safeguarding Children Board. 2015 63 Prosecution Service led to prosecution of perpetrators and facilitators. A number of issues were considered by the Force professional standards department which led to management action against individual officers. Extensive police training has increased the rigour in establishing names, relationships and why people are together when encountered by the police. Improvements in technology allow officers easier access to intelligence through individually issued tablets. 7.5 Interagency Responses Interagency responses focused on the victims and their attitudes and behaviour in order to try and influence them by persuasion and sometimes by control not to associate with their abusers. Very considerable energy and resources were undermined by the continuing influence of the abusers. There is no evidence that the police approach to investigation of perpetrators was challenged by other agencies through interagency procedures. Although there were excellent examples of multi-agency working, Practitioners felt that there were also examples of professionals working in silos and without understanding the full picture. The acceptance that it was very unlikely that there would be successful prosecutions led to police attendance at interagency safeguarding meetings to be inconsistent and they did not routinely receive copies of minutes. Since 2014 this is no longer the case and the attendance at interagency meetings and circulation of minutes is monitored through audit arrangements. 7.6 Interagency Awareness and Preparedness Effective action including resourcing to prepare for and prevent sexual exploitation relies on an understanding of the prevalence or likely prevalence in a particular area. In 2013, the Home Affairs Committee report, citing Oxfordshire, was critical of agencies assuming that it was unlikely to happen in their area. The report of a Thematic Inspection by Ofsted in 201486 rhetorically questioned: “The sexual exploitation of children: it couldn’t happen here, could it?” In 2014, Professor Alexis Jay’s report into the sexual exploitation of children in Rotherham was “a wake-up call for every professional working in the field of child protection.” 87 In Section 7.1 I set out the comprehensive steps taken in Newcastle from 2000 to respond to and implement government guidance and to understand the likely prevalence of child sexual exploitation. Although the launch of Operation Sanctuary was highlighted by all agencies and professionals as a catalyst for substantial change, the Review found no evidence prior to this of any reluctance to understand or act upon knowledge of the prevalence of sexual exploitation. Nor was there evidence of any assumption that it was unlikely 86 The sexual exploitation of children: it couldn’t happen here, could it? Thematic Inspection Report Ofsted 2014 87 Independent Inquiry into Child Sexual Exploitation in Rotherham 1997-2013 Alexis Jay OBE Rotherham Metropolitan Borough Council. 2014 64 to happen in Newcastle. More recently, Ofsted88 found that considerable emphasis has been placed on the collection and sharing of information with partner agencies “resulting in a sophisticated understanding of the extent of sexual exploitation in Newcastle and surrounding areas.” Reports89 in 2014 and 2015 on events in Rotherham referred to unsuccessful attempts by professionals to have sexual exploitation addressed by alerting senior figures. One was a whistle-blower who with The Times investigative reporter, Andrew Norfolk, exposed90 failures of the authorities. In Rochdale and Oxfordshire families and professionals repeatedly attempted to alert police and social care services.91 The Review specifically and as thoroughly as possible considered whether this had occurred in Newcastle. All local MPs, the Police and Crime Commissioner, and key community and voluntary organisations were asked whether they had raised issues or had been approached by any professionals or members of the public. Partner Agencies were asked to check whether such issues were raised through strategic interagency processes, consultation processes or chief officer and senior management meetings or correspondence. Agencies’ complaints and representation records were reviewed to ascertain whether any member of staff or service user had registered discontent. External, independent inspection reports were considered. Press and media coverage of safeguarding and contact with trade unions and professional associations were reviewed. There was no evidence that any professional, individual, member of the public, politician or agency tried to alert the authorities or complain about any lack of proactivity or response in addressing large scale sexual exploitation. The Safeguarding Boards’ multi-agency audits require partner agencies who deliver services to confirm whether they have effective whistle blowing policies and systems in place for professionals and service users, which are compatible with the Boards’ Policies. In 2013, the Home Affairs Committee asserted that Rochdale public servants lacked human compassion and Rotherham Inquiry Reports identified lack of empathy by staff involved. There was no evidence in the material considered during the Review or discussions at the Learning Events that in Newcastle the approach of the police or any other 88 Newcastle Upon Tyne Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board. Inspection date: 24 April 2017 – 11 May 2017. Ofsted Report. 7 July 2017 89 The Independent Inquiry into Child Sexual Exploitation in Rotherham published in 2014 and the Report of Inspection of Rotherham Metropolitan Borough Council published in 2015 90 Broken and Betrayed: The true story of the Rotherham abuse scandal by the woman who fought to expose it. Jayne Senior. Panmacmillan 2016 91 Overview Report of the Serious Case Review in respect of Young People 1,2,3,4,5 & 6. Rochdale Borough Safeguarding Children Board 2013; Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F. Oxfordshire Safeguarding Children Board 2015 65 agency was influenced by disregard for the victims’ welfare and safety. While different responses might have been more effective, in doing what was done, staff were anxious to do their best for the children and adults who were being exploited. Commentators on Rochdale alleged perpetrators were not pursued for fear of being accused of racism.92 In 201593 the Government, citing the Jay Report, declared that in Rotherham misplaced concerns about political correctness stopped any proper action being taken. There was also inappropriate interference by senior officials and political leaders to prevent inquiries being pursued effectively. The Review considered as thoroughly as possible whether anything similar had occurred in Newcastle. There was no evidence that any action or inaction by police or any other staff or officials were motivated or affected by fears of allegations of racism and no evidence of impropriety by any person in a position of authority. Safeguarding vulnerable adults from sexual exploitation has not attracted the national profile of child sexual exploitation and lacks central guidance and advice. There are only passing references to vulnerable adults in the 2017 Report of the HMIC inspection of Northumbria Police94. The HMIC website list of “Our work” highlights “Child abuse and child protection issues” but makes no reference to safeguarding vulnerable adults and no discrete inspections address this area of service. In 201595 the Government warned that child sexual exploitation was not confined to one area and that “any local authority or police force that denies that it has a problem, or thinks that it is only happening elsewhere, is wrong.” This Review has confirmed that this strong statement applies equally to sexual exploitation of vulnerable adults. Some national materials for child sexual exploitation are relevant to adult sexual exploitation. There are arrangements in place in Newcastle City Council Adults Social Care and Newcastle Safeguarding Adults Board to consider and take account of relevant strategic and practice child safeguarding guidance, although the legal framework for services is very different. The sexual exploitation tools used in Newcastle were reviewed jointly when the Safeguarding Boards launched the joint Sexual Exploitation Communication Strategy in 2015. A checklist was developed from work undertaken with victims which Practitioners identified as a very effective tool. Arrangements which include considering the factors in the cases reviewed are in place to evaluate its effectiveness. The Practitioners identified an urgent need to increase awareness of sexual exploitation of vulnerable adults nationally, for government guidance on strategic 92 Times 23 May 2017 93 Tackling Child Sexual Exploitation. HM Government. March 2015 94 Report of HMIC’s PEEL: police effectiveness inspection of Northumbria Police Force March 2017 95 Tackling Child Sexual Exploitation. HM Government. March 2015 66 and practice implications and reform to take account of the weaknesses in the legal framework. In 2017, the Ofsted inspection recognised the excellent interagency work by Newcastle City Council and its partners, highlighting the coordination between the Safeguarding Boards which has effectively supported and overseen the development of “outstanding multi-agency practice in responding to sexual exploitation.” Assessing the impact of consistent responses and preventative action is difficult. More effective identification and raising awareness has led to an increase in numbers of victims. However, some cases involve historical abuse, some involve recent exploitation which indicates that despite action and publicity, perpetrators continue to target victims. In 2016, an independent report96 explained that child sexual exploitation takes place despite a range of preventative, supportive and enforcement measures and that: “The extent of CSE can be mitigated but not eradicated, as a result of the complex array of push factors (which are related to poverty, family relationships and education).” 7.7 Regional and National Links The Review found that there has been a determination to share learning and to learn from increasing knowledge elsewhere. Newcastle City Council Safeguarding Adults Unit have received requests from across the country to provide training, advice and support to authorities looking to embed similar practice in relation to transition and adults at risk of sexual exploitation. Staff at the Hub have given presentations at national conferences and workshops and contribute to national initiatives. Safeguarding Boards and local authorities from across the country visit Newcastle to observe and discuss the good practice in overcoming obstacles to closer working of adults and children's services. Regional meetings of representatives of Local Safeguarding Boards provide opportunities to share information and develop co-operative arrangements. Newcastle representatives stress the urgent need to assume sexual exploitation of adults takes place in all areas. National links include the National Working Group Network (a national charity offering support and advice to staff working with people affected by sexual exploitation, Parents Against Child Sexual Exploitation (a leading national charity working with parents and carers of sexually exploited children) and the Child Sexual Abuse Centre, a Home Office funded centre of expertise on child sexual abuse led by Barnardo’s. 96 Northern Rock Foundation Report on Child Sexual Exploitation in the North East and Cumbria 2016 67 7.8 Police and Crime Commissioner Police and Crime Commissioners replaced police authorities in November 2012 and are broadly responsible for securing efficient and effective policing of a police area. The Police and Crime Commissioner for Northumbria Police Area, Dame Vera Baird, QC, has a national reputation for promoting the interests of victims of domestic violence and sexual assault. She has good relationships with Newcastle City Council and partner agencies and attends and contributes to interagency safeguarding events. She has been kept well informed of developments regarding sexual exploitation in Newcastle and the progress of Operation Sanctuary and was invited to contribute to the Review. She was keen to speak positively of the culture in Northumbria that deals with sexual exploitation and vulnerability as a key issue and gives strong support to the development of Personal, Social, Health and Economic education in schools that addresses sexual violence. She has been a strong supporter of campaigns to ensure that victims can record their evidence for criminal proceedings and need only do so once. The Review gave an opportunity to consider the benefits of more formal links between the interagency safeguarding frameworks and the Commissioner. The Safeguarding Boards routinely send copies of Annual Reports to the Commissioner so that she can fully consider the contents and how she can improve her contribution to safeguarding throughout her organisation and to the joint work of the Boards.97 Arrangements include sending copies of agendas of Safeguarding Boards’ meetings in advance so that she can consider making a contribution. There is a standing invitation for her to request issues to be considered and to attend meetings if appropriate. Representatives of the Newcastle Boards are liaising with other Boards in the region to ensure that there is consistency in this across the Northumbria Police Area. Police and Crime Commissioners have statutory duties under the Children Act 200498 to co-operate with the local authority and to carry out functions having regard to the need to safeguard and promote the welfare of children. They must hold Chief Constables to account for the exercise of their duties under the same provisions.99 As part of its statutory remit, Newcastle Safeguarding Children Board carries out audits with agencies to ascertain how Children Act duties are being met and arrangements have been made to include the Commissioner in these audits. 97 Schedule 2 paragraph 4 (2)(b) Care Act 2014. Paragraph 14.161 Care and Support Statutory Guidance 2014 98 ss 10; 11 Children Act 2004 99 s 1(8)(h) Police Reform and Social Responsibility Act 2011. Para. 18 Chapter 2 Working Together to Safeguard Children. HM Government. 2015 68 In 2017 the Commissioner published an important and influential report100 setting out the results and conclusions from observations by volunteers who attended 30 rape trails at Newcastle Crown Court. In a significant number of cases safeguards for the treatment of victims were not being met. The report included recommendations to courts and the Crown Prosecution Service and the discussions that took place as a result. It is relevant to any work undertaken by agencies supporting victims through criminal processes. 7.9 Crown Prosecution Service The Crown Prosecution Service was requested to take part in the Review but initially declined to do so. The Acting Chief Crown Prosecutor for the CPS North East, was keen to ensure that his Team was not distracted from the job in hand and thought involvement may not have yielded proportionate value to the review. An offer was made to respond to any issues relating to the Crown Prosecution Service that arose. The value of a Serious Case Review is that agencies review their own practice within the context of what was known and done by other agencies. As the Review progressed the failure to deal with perpetrators through the criminal justice system and otherwise was a significant feature of the Learning Events and further representations expressing disappointment that the Crown Prosecution Service was not taking part were made. It was decided that the Crown Prosecution Service would review the cases in which it had involvement. By this time, the interagency review processes were almost complete and the Service reviewer was unable to play any part in the Learning Events or contribute to interagency discussions and it was therefore an isolated piece of work. An Overview Report of a Serious Case Review101 carried out in 2010 included a recommendation, accepted by the Crown Prosecution Service, that it should develop internal arrangements to participate in Serious Case Reviews and the Crown Prosecution Service website appears to reflect a policy favouring involvement. There did not appear to be any established internal processes to contribute to the Review and I had a number of helpful meetings with the reviewer who, although not independent of case work, did apply critical consideration to the process. The final report was the best that might have been produced in the circumstances. It highlighted good practice and included suggestions for improved arrangements, including practical arrangements for witnesses at Court. The CPS North East covers an area within which there are a significant number of Safeguarding Boards and it is reasonable to consider the potential resources required to be involved in reviews. The Newcastle review was likely to be high profile and the action taken against perpetrators is a significant area of public interest. If 100 Seeing is Believing: The Northumbria Court Observers Panel Report on 30 Rape trials 2015-16: Baird, DBE, QC, Northumbria Police and Crime Commissioner. March 2017 101 Overview Report Concerning Children E. Caerphilly Safeguarding Children Board. Neath Port Talbot Safeguarding Children Board. Pembrokeshire Safeguarding Children Board. 2010 69 efficiency of a review is not to be undermined, decisions about participation and arrangements for challenge need to happen quickly. The statutory guidance on child sexual exploitation issued in 2000 and 2009 and safeguarding adults in 2000 and 2014 expected that the Crown Prosecution Service would have links to interagency safeguarding arrangements and with partner agencies. This was so the Service could provide advice on disruption plans, evidential requirements to support criminal offences, what evidence is reliable and can be admitted in proceedings and how non-criminal justice agencies can assist in recording and gathering information in a way that will ensure that it can be admitted as evidence. The lack of action against and disruption of the activities of perpetrators has been a matter for comment in reports considering sexual exploitation across the country and is a feature of the historical approach in Newcastle. Whilst in some local areas the Service has had some links to Safeguarding Boards, there has been no nationally agreed approach or direction and these provisions have not had the intended impact. In correspondence, the Service indicated that it is difficult to provide precise details of the response to the Guidance but as far as can be ascertained the Crown Prosecution Service was not consulted prior to the publication. It was also highlighted that a joint thematic review conducted in 2005 by Inspectorates to assess the effectiveness with which authorities and agencies, including the Crown Prosecution Service, safeguarded children, made a series of recommendations, including “involvement with and attendance (where appropriate)” at Local Safeguarding Children Boards, “which were implemented by the Service”. The framework for interagency safeguarding arrangements has developed significantly since 2005. There has been no involvement the Crown Prosecution Service with the Safeguarding Boards in Newcastle or elsewhere in the North East. While it is not possible to conclude that, had the Service participated as the Guidance expected, action against perpetrators would have been more effective earlier, the participation would have been likely to improve knowledge and understanding across agencies and so inform practice and support for victims. Because of the number of Boards within areas covered by the Crown Prosecution Service, the involvement with Safeguarding Boards requires consistency and national direction. Recommendation 2.4 I recommend that: The Crown Prosecution Service should arrange for guidelines to be developed on involvement of the Service with Safeguarding Boards and other local safeguarding frameworks. 70 Recommendation 2.5 I recommend that: The Government should ensure that when national guidance or advice requires involvement of a national agency or one which is not a statutory local partner with Safeguarding Boards or other local safeguarding frameworks, the documents include confirmation that the agency is aware of and has made arrangements for the expected involvement. In Newcastle there has been contact between staff in the Crown Prosecution Service and the legal services staff in Newcastle City Council to address issues such as disclosure of materials for criminal justice processes. Helpful discussions during the Review identified that more formal arrangements would be benefit both criminal processes and welfare focused processes and legal proceedings. The Crown Prosecution Service can provide feedback on issues arising during criminal processes, explanations for why particular events have occurred, judge’s sentencing remarks, awareness of which may be relevant for Practitioners in addressing victims’ needs, and updating information on developments in law and process. It can also contribute effectively to and benefit from interagency training. The Crown Prosecution Service Review Report recommended the cultivation of working relationships with Local Authority legal teams. In Newcastle, arrangements have been made to identify members of staff in each agency to ensure communication takes place and pending national direction concerning involvement with interagency safeguarding frameworks. Agendas for Board meetings will be sent to the Service and legal staff will also consider whether any issues arising should be communicated. Newcastle staff are arranging for these issues to be raised with colleagues in other areas across the region to ensure consistency of approach. The Director of Public Prosecutions acknowledged, to the Home Affairs Committee in 2013 that the Crown Prosecution Service’s previous approach to credibility of witnesses of sexual exploitation was inappropriately cautious and risked leaving the whole category of victims unprotected. The Committee recorded that the Service had introduced specially trained and accredited rape prosecutors and announced its intention that every Service region would have a dedicated Rape and Serious Sexual Offences Unit. A national policy and guidance for police and Crown Prosecution Service drawn up by the College of Policing were issued and a training package prepared delivering practical advice and guidance to front line police and prosecutors. These arrangements contributed significantly to the successful outcomes of Operation Sanctuary and the associated criminal trials. 71 7.10 Links with the Judiciary During the Review, in order to keep them informed of progress and issues arising, I had a number of conversations with Her Honour Judge Hudson, the Designated Family Judge for Northumbria and North Durham and Her Honour Judge Moir, who is the lead Court of Protection Judge for the region. Whilst Statutory Guidance in 2000102 encouraged involvement with the local judiciary, there is no further national direction and links between strategic interagency processes and local judiciary have been variable across the country. In Newcastle, there were good links with the Family Court Business Committee during the early period reviewed. In 2017, Ofsted103 confirmed that Newcastle City Council has well-established effective relationships with the local family justice board and Cafcass. This ensures efficient and effective progression of legal proceedings, with court timescales among the best locally. Good arrangements are in place to ensure that Newcastle City Council legal services and CAFCASS promptly make Independent Reviewing Officers aware of information and material in family court proceedings. Her Honour Judge Hudson confirmed that when appointed in October 2014, she arranged regular meetings with local authority legal services, Assistant Directors of children’s social care services and with senior solicitors from the 7 local authorities in the region. This is in addition to meetings of the Family Practitioners’ Forum, which involves professional court users, and the Local Family Justice Board. The Judge also corresponds by email with the local authorities, if necessary. These arrangements have proven to work extremely well and Her Honour Judge Moir has also arranged, through Newcastle City Council Legal and Adult Social Care Services for similar meetings to take place with representatives from local authorities in the region to discuss areas of interest concerning vulnerable adults. Arrangements have also been made for copies of agendas for meetings of Newcastle Safeguarding Boards to be sent in advance so that the judges can consider whether they might make a contribution to the issues. There is also a standing invitation for them to request for any issues to be considered and to attend a meeting if appropriate. Representatives of the Newcastle Boards are liaising with other Boards to ensure that there is consistency across the region. 7.11 Leadership from the Safeguarding Lead Agency Newcastle City Council is the lead agency for safeguarding children and vulnerable adults. 102 Safeguarding Children Involved in Prostitution: Supplementary Guidance to Working Together to Safeguard Children. Department of Health, Home Office Department for Education and Employment, National Assembly for Wales. 2000 103 Newcastle Upon Tyne Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board. Inspection date: 24 April 2017 – 11 May 2017. Ofsted Report. 7 July 2017 72 Reports concerning Rochdale and Rotherham included critical comments about lack of leadership104 and press and politicians highlighted that “officials who looked the other way as young lives were all but destroyed have not been brought to account”.105 The Home Affairs Committee in 2013106 asserted that Directors of Children’s Social Care must also take full responsibility for failures of their department as it is their personal responsibility to find out what is taking place. Statutory guidance was issued for local authorities on the roles and responsibilities of the Directors of Children’s Services and Lead Members for Children’s Services107 and in 2015 the Government108 emphasised that “those who fail in their duties to protect children must be held accountable.” The Secretaries of State for the Home Department, Health, Education, Justice, and Communities and Local Government wrote to all Chief Constables, Leaders and Lead Members of Councils, Chief Executives of local authorities and health system leaders and Directors of Children’s Services to reinforce the need for leaders to take responsibility for addressing failures identified by the Jay Report and any other inspections in their area. The Review therefore carefully considered this issue, in relation to strategy and practice in Newcastle and found no evidence to suggest that the approach to addressing sexual exploitation was undermined or adversely affected by any lack of leadership or interest by senior officials. There is currently strong and committed leadership. This view was supported by Ofsted in 2017 which found that the Newcastle City Council leadership, management and governance is “Good”. The senior leadership team and elected members are committed to service improvement and the Lead Member for Children is highly committed and ensures that senior leaders are held to account and can evidence improvements in children’s outcomes. The Ofsted Report described the Council Chief Executive as having demonstrated strong leadership, with effective oversight and accountability. Since coming into post in 2015, she has brought together children’s and adult’s social care into one Directorate. The Director of People has the statutory appointment of Director of Children’s Services and is Director of Adult Social Care Services which reflects “a determination to support children through their life course.” Most local social services authorities do not have this model. In Newcastle City Council, the changes were not driven by economic pressures but to encourage 104 Overview Report of the Serious Case Review in respect of Young People 1,2,3,4,5 & 6. Rochdale Borough Safeguarding Children Board. 2013; Independent Inquiry into Child Sexual Exploitation in Rotherham 1997-2013 Alexis Jay OBE Rotherham Metropolitan Borough Council 2014. Report of Inspection of Rotherham Metropolitan Borough Council. Louise Casey CB. House of Commons. 2015 105 Times 23 May 2017 106 Child sexual exploitation and the response to localised grooming Child Sexual Exploitation: scale and prevalence House of Commons Home Affairs Committee. June 2013 107 Statutory guidance on the roles and responsibilities of the Director of Children’s Services and the Lead Member for Children’s Services For local authorities. Department for Education. April 2013 108 Tackling Child Sexual Exploitation. HM Government. March 2015 73 effective service delivery. In 2016, a Local Government Association Peer Review commissioned by the Director109 reported positively on the single directorate. Focusing on sexual exploitation it found a commitment from service providers to work together to tackle it at whatever age. In conversations, the Assistant Directors of Children’s Services and Adult Services confirmed the benefits for joint working, collaboration and understanding each other’s business, encouraged by co-location with other senior managers. They have strong links with practice and chair panels and oversee decisions regarding individual children and adults. The Review found that over the whole period reviewed there were examples of children’s and adult services excellent working together. The structural arrangements embedded management and operational improvements across services and have impacted positively on partner agencies. The Director has a strong personal commitment to safeguarding and being in touch with frontline practice. The Service Managers for Safeguarding Children and Safeguarding Adults report directly to him. He encourages support from across Council departments and recognises the need for proactive specialist legal services. The Chief Executive is familiar with and supports the objectives of the statutory provisions and guidance under which she is accountable for the effectiveness of safeguarding arrangements. She meets regularly with the Director of People to discuss safeguarding issues and meets with the Newcastle Safeguarding Children Board Chair and holds him to account for achieving statutory objectives. Although the statutory framework does not require it, she has also made arrangements to meet with the Chair of the Newcastle Safeguarding Adults Board on the same basis. As the issues concerning sexual exploitation have developed the Chief Executive and Chief Constable have had regular conversations and she has given frequent high-level briefings on the progress and eventual outcomes of Operation Sanctuary to chief officers of public authorities in the region who attend the Accountable Officers Group and the North East Combined Authority Chief Executives Group. The Newcastle City Council Corporate Safeguarding Group ensures that safeguarding is considered in all aspects of the Council’s business. Good arrangements have been made to ensure elected members of Newcastle City Council have been kept informed through reports to the Scrutiny Committee, which is chaired by the Leader of the Opposition. In conversations with me, the Leader of the Council, previous and current Lead Members for Children’s Services and Adult Services and the Leader of the Opposition spoke highly of the political climate of challenge and extent to which senior officers have ensured that they have been kept well informed over the whole period considered by the Review. 109 Local Government Association Adult Safeguarding Peer Challenge Report. March 2016 74 7.12 Interagency Leadership The Newcastle Safeguarding Boards were established and functioned in accordance with statutory guidance and regulations over the period reviewed. Collaborative arrangements between the two Boards developed early beyond expectations in guidance, and as awareness grew were well-equipped to respond to challenges of child and adult sexual exploitation. In 2017, the Ofsted inspection found the functioning of Newcastle Safeguarding Children Board was “Good,” effectively meeting statutory requirements and supported by constructive relationships between partner managers with strong governance arrangements and board processes with political overview. It highlighted the coordination between the Newcastle Safeguarding Boards which has supported and overseen the development of “outstanding multi-agency practice in responding to sexual exploitation”. 7.13 Resources Agencies have made available significant resources to address sexual exploitation through Operation Sanctuary, the establishment of the Hub and otherwise. The Practitioners and Report Authors emphasised the dramatic impact of the resourcing and expressed anxiety about whether the changes can be maintained once the court cases were over and having regard to austerity measures and increasing demand. They believed that the cases identified through Operation Sanctuary reflect the “tip of the iceberg” evidenced by the lack of male victims or survivors and low numbers from Black and Minority Ethnic communities. It is not necessary to make a recommendation concerning future resourcing. Funding has been agreed until March 2019 from Newcastle City Council for the posts and the accommodation. Conversations with the Council Chief Executive, the Director of People and the Leader of the Council confirmed the intention to provide on-going resources. Careful consideration is being given to ensuring other essential services are not unduly affected. Northumbria Police and the Police and Crime Commissioner are committed to continuing resources and NHS Newcastle Gateshead Clinical Commissioning Group has approved staffing resources for a member of staff to be shared between the two Hubs. 7.14 Quality Assurance and Audit Effective audit is necessary to quality assure practice and the impact of strategic initiatives and training. The Review considered carefully what has been and is in place across children’s and adults services. There has been a history of utilising audit processes, informed by experience and increasing knowledge, to evaluate and inform planning. 75 Audit Groups report multi-agency practice and themed audits to relevant sub groups and the Safeguarding Boards and do not to rely on records and data only but involve practitioners to understand what has happened and why.110 The Risk Management Group Data Group established in 2016 strengthens how data and outcomes are used to target resources and reports to the joint Multi-Agency Sexual Exploitation and Trafficking Group and the Safeguarding Adults Boards. Newcastle City Council Adult and Children’s Social Care operate an internal audit procedure where cases are randomly selected. The arrangements are robust, identify changes or trends and influence development of training. The framework firmly ensures compliance with statutory requirements and that senior managers are well aware of the strengths and weakness of their service.111 7.15 Public Sector Commissioning Newcastle public authorities have a tradition of encouraging and supporting community and voluntary organisations and they provide a necessary and effective contribution to services for the vulnerable, working hard to preserve services and to minimise the impact of austerity with reduced funding streams. Good commissioning arrangements are underpinned by strong partnerships and good consultation with stakeholders, providers and voluntary organisations.112 The processes within Newcastle City Council for commissioning and grant aiding community and voluntary organisations are in accordance with statutory requirements.113 Regular and effective audits take place to monitor compliance. 7.16 Other Providers of Services Preparedness for recognising and responding to sexual exploitation needs to include all services in which professionals might have contact with victims or potential victims, including those who may not usually be involved with safeguarding processes. The Review considered a number of these in Newcastle. Chemists and Pharmacists provide contraceptives, morning after pills, advice, and pregnancy tests. “I went constantly for the morning after pill – to different places.” Professional development is monitored by NHS England. Registered pharmacists are required to undertake professional development relating to safeguarding training which includes sexual exploitation of children and vulnerable adults. If a client is under 16 years they should assess competence according to the Fraser Guidelines, 110 Para. 1.9. The Munro Review of Child Protection: Final Report A child-centred system. Professor Eileen Munro. Department for Education. 2011 111 Newcastle Upon Tyne Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board. Inspection date: 24 April 2017 – 11 May 2017. Ofsted Report. 7 July 2017 112 Para. 83. Ofsted Inspection Report. 7 July 2017 113 s11 Children Act 2004 76 but as with other health professionals, assessment relies on a conversation. If not competent the client should be referred to Contraception and Sexual Health Services. They have available a Referral for Contraceptive Support Sexual Exploitation Risk Assessment Checklist and relevant agency telephone numbers. A summary record of consultations should be kept. In Private Health Provision, General Medical Council and Nursing and Midwifery Council codes apply. The rules of professional conduct relating to safeguarding, capacity, consent to treatment and safeguarding are the same as within public provision - professional first, employee second. Understanding principles for information sharing is particularly important since victims may be taken to private provision to avoid this. Private sector providers are inspected by the Care Quality Commission. Counselling services may be provided privately. NHS Dental practices are responsible for ensuring that they are adequately trained and are overseen by NHS England. Newcastle Gateshead Clinical Commissioning Group has encouraged NHS England to seek assurance that sexual exploitation training is part of reviewing practices; a safeguarding assurance framework has been developed and is being proposed. Early identification and prevention requires awareness by all those professionals who might have contact with a victim or potential victim and clarity of expectations of their responses. Awareness of the potential for vulnerable adult victims is likely to be low. Recommendation 1.5 I recommend that: Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should identify services in the community that are not routinely involved with local safeguarding arrangements and consider how best to engage with them on safeguarding issues. Recommendation 2.6 I recommend that: The Government should consider which community services not routinely involved with local safeguarding frameworks have a contribution to make to early identification and prevention of sexual exploitation and make arrangements to ensure that their contribution is made and monitored through regulatory functions or otherwise. 77 7.17 The Role of Schools and Education Services The cases included victims for whom abuse began during teenage years, but one victim described how: “A man in his twenties waited outside the primary school. We said he was our friend. I was 10/11 years old.” “In the Park, I met R. I was in year 8. He was asking my age and about school and why I was out so late. He took us to his house. There were a huge number of people there … R. asked me for my number to keep in touch and that was the start of the problem.” The Home Affairs Committee in 2013 identified teachers as more likely to see victims on a regular basis than almost any other professional. Recurrent or prolonged absences and significant changes in behaviour are key in identifying children at risk at an early stage and, by raising concerns, they may be able to stop grooming before sexual exploitation has begun. The Committee recommended that all teachers are provided with a list of warning signs.114 Schools can be protective environments and can help to build resilience but only if children attend. “(my parents) didn’t rate education – I didn’t do much at school – different schools and didn’t go much.” But regular attendance and good performance does not mean exploitation is not taking place. Some victims continued to attend school and exploitation was not recognised. One victim aged 12 years met a man at the Park and they: “... got real close. It was good at first. He bought me stuff – he was making up for my parents. Phones, clothes, food. I still went to school.” She had very high attendance and achieved excellent examination results, continuing to higher education. Another said: “At school, I was not naughty and passed all the exams except maths. I did not have any involvement with social services.” The cases also included examples of severely disrupted early school history, a lack of chasing absence or responding to bullying and inadequate responses to bereavement and loss. Staff from schools contributed positively to the Review. With hindsight, they felt that there were early warning signs in the backgrounds of pupils, whom it was later learnt were victims, but schools did not at the time have a sound understanding. 114 Para. 104. Child sexual exploitation and the response to localised grooming Child Sexual Exploitation: scale and prevalence House of Commons Home Affairs Committee June 2013 78 Training and work with the school staff, reinforced by involvement in the Review, has led to a greater understanding and better insight into multi-agency work, especially understanding thresholds. They reported a greater sense of trust, more collaborative work and sharing information with agencies and pastoral staff. Welfare referrals to other agencies have increased as a safety-first approach has been adopted and better monitoring of progress takes place by Deputy Head Teachers when a child is accessing or is referred by staff to specialist agencies or the school nurse. The Safeguarding Boards’ sexual exploitation checklist is available in all Newcastle schools in order to promote more effective practice. The Home Affairs Committee asked the Minister to look, once again, at the relationship between schools and local authorities highlighting concerns about missing children This is a reference to increasing independence of schools from local authorities, which includes responsibility for safeguarding arrangements and the management of budgets for training and development of data systems. Safeguarding training might be commissioned by governing bodies from local authority specialist staff or from other sources. Statutory safeguarding guidance for schools requires governing bodies to quality assure training and recommends that it is consistent with policies, procedures and priorities of Safeguarding Boards. There has been a proliferation of different types of school within the public sector. Draft statutory interagency guidance115 would expect all local safeguarding arrangements to contain explicit reference to how safeguarding partners plan to involve, and give a voice to all local schools and academies in their work. Newcastle City Council education safeguarding lead officer for schools has worked hard to preserve good working relationships with Newcastle schools and provide safeguarding advice. There is a schools sub-group of the Newcastle Safeguarding Children Board and head teacher representation from primary, secondary and special schools. Schools contribute to the Boards safeguarding audits. In all Ofsted inspections of schools safeguarding arrangements are considered. Schools can also access safeguarding training and advice from partnership agencies in Newcastle including The Children’s Society, Barnardo’s, Streetwise, Brighter Futures and specialist staff from Newcastle Safeguarding Children Board partner agencies. 7.18 Children Missing School Education The cases included children whose attendance was erratic, where the victim was said to be registered as receiving education at home or whose expected transfer to another school did not occur or where there was a significant delay because the family moved out of the area, leading to absence from education. 115 Consultation draft Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children April 2018.HM Government. October 2017 79 Newcastle City Council has a statutory responsibility to offer all children, except those registered as being educated at home, a full time offer of education when requested by parents. The Education Service attendance team has developed robust monitoring procedures concerning alternative provision, partial timetables, permanent exclusion and transfers to help state schools to fulfil their statutory duties. There is now greater support and challenge to schools around attendance. In January 2017, the monitoring of children who are electively home educated was brought back in-house within Newcastle City Council, into the same team responsible for children missing education. This ensures information about potentially vulnerable children is recorded consistently and can be cross referenced with other information sources including social care. The monitoring officer works closely with other agencies to assess and address safeguarding concerns. The legislative framework for children not being educated in a school over the period considered by the Review was not helpful. Local Authorities had, and continue to have, no mandate for intervention or monitoring of pupils around safeguarding, despite increased vulnerability. It was suggested at the time of the review that clearer guidelines from the Department for Education and increased powers are required. However, in October 2017, the Department for Education confirmed that there are no government plans to change legislation despite the report of a review in 2009 having made twenty recommendations for reform including improved safeguarding arrangements.116 There is no data kept centrally on children allegedly being home educated for whom there are safeguarding concerns. A Private Members Bill117 introduced into the House of Lords in June 2017 to make provision for local authorities to monitor the educational, physical and emotional development of children receiving elective home education might improve the arrangements, if it successfully passes all Parliamentary stages. Proposed changes for statutory guidance on interagency safeguarding118 would require the Child Safeguarding Practice Review Panel to have regard to significant harm or death of a child educated otherwise than at school when deciding whether a national review should be carried out but there is no indication why this is particularly important. Recommendation 2.7 I recommend that: The Government should arrange for a review of the safeguarding implications for children educated otherwise than at school having regard particularly to the body of knowledge about sexual exploitation, issue guidance on safeguarding children 116 Report to the Secretary of State on the Review of Elective Home Education in England Graham Badman. 2009 117 Home Education (Duty of Local Authorities) Bill (HL) 2017-19 118 Para. 37 Chapter 4: Consultation draft Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children April 2018.HM Government. October 2017 80 Recommendation 1.6 I recommend that: Newcastle Safeguarding Children Board should arrange to carry out an audit of a sufficient number of cases to form a judgment about whether regulatory and guidance expectations concerning pupils who change educational settings are consistently followed. educated otherwise than at school and consider the need for legislation to more effectively regulate this provision. 7.19 Children who Change Schools The cases highlighted that vulnerability can be compounded if the child is at risk of exclusion, is excluded or changes school. It was apparent that there was a need for schools and other agencies to be vigilant so that welfare oversight and continuity of educational opportunities are not disrupted. Educational history and assessments were not readily available to the Review without approaching individual past schools despite statutory duties on governors to ensure transfer of records. Current school staff did not have access to information about whether there had been previous concerns to inform their judgments. There are now improved arrangements to manage a move from one school to another to prevent permanent exclusion. Fair Access procedures in Newcastle should ensure that no situation arises when a pupil is not on roll of a school. The schools involved in the Review felt that, whatever the reason, a move must be managed and all appropriate paperwork completed by the referring schools prior to referrals to the Local Authority and all students should be monitored appropriately. In 2016, the Education service introduced a new service area, Vulnerable Learners, to monitor the safeguarding and attainment of pupils susceptible to a range of vulnerabilities including attendance, disrupted or missed education. This service is developing a robust data set and systems through which to support and challenge school performance and meet local authority and school statutory responsibilities. The school staff reported improved information sharing between schools, including previous concerns, particularly safeguarding. Changes of responsible staff are kept to a minimum and a peer support network of pastoral leads in secondary schools has developed. This provides peer challenge and support around managed moves which fall outside statutory admissions processes. 7.20 Arrangements to Consider Missing Children and Young People The Missing and Sexual Exploitation and Trafficking Group was established as a sub-group of the Newcastle Safeguarding Children Board as early as 2006 and became a sub-group of the Safeguarding Adults Board in 2015. 81 The Risk Management Group considers monthly children facing serious risks, including those who go missing and are at risk of sexual exploitation, considers and interrogates data, monitors patterns and reports to the Boards. It ensures robust planning, allocation of resources and identifies connections between individual children and young people and the potential risks within their networks. This Group includes representatives from Newcastle City Council Children’s and Adults Social Care, Northumbria Police, Your Homes Newcastle (which provides council housing on behalf of Newcastle City Council), Aspire Housing Association, the Youth Offending Team, the Screening and Intervention Programme for Sensible Drinking, the Child and Young Peoples Service, and Newcastle upon Tyne Hospitals NHS Foundation Trust, which also represents General Practitioners. Practitioners identified that the system for carrying out interviews with children who have returned or been found after being reported missing is now more robust. SCARPA undertakes return home interviews with children not receiving a service from Children’s Social Care and, with a specialist City Council social worker, those who are looked after by the Council or otherwise receiving a service. The vast majority of children going missing receive return home interviews. However, learning from the Review and the Ofsted Inspection in 2017 has led the Group to review and update procedures to ensure consistency in individual planning and wider prevention strategies. A designated social worker has been appointed to the Multi-Agency Safeguarding Hub to coordinate missing children and young people issues. In March 2017, HMIC found that a robust review and checking process ensures that all cases are always checked for links to child sexual exploitation.119 The processes are kept under review by monitoring through audit, reported to the Missing and Sexual Exploitation and Trafficking Group. This is more complicated for adults, who, unless known to have a vulnerability, can choose where they will be and if elsewhere than expected this will not necessarily give rise to concerns. Adult safeguarding staff adopt a proactive approach to determine on a case by case basis whether return interviews should take place. When an individual is subject to known or suspected safeguarding concerns, contact between agencies takes place and protection plans address the concerns. All residential and domiciliary care staff caring for someone at risk of sexual exploitation are provided training and guidance on how to respond to missing episodes. Recommendation 1.7 I recommend that: Newcastle Safeguarding Adults Board should carry out an audit of a sufficient number of cases to form a judgment about the effectiveness of arrangements to interview vulnerable adults following a period of missing. 119 PEEL: Police effectiveness 2016 The report of HMIC’s inspection of Northumbria Police. March 2017 82 7.21 Raising awareness among potential victims The Newcastle experience illustrates that potential future victims include children and adults with vulnerabilities. Age is not the determining vulnerability. A joint communications strategy has been developed by the Safeguarding Boards and Northumbria Police have invested significantly to raise awareness in communities. The Newcastle Safeguarding Adults Board has produced a series of generic adult abuse leaflets made available at points across the City. Work is undertaken with Boards in North Tyneside and Northumberland to promote Safeguarding Adults for Everyone; a weeklong series of events and publicity drives to raise awareness amongst victims and the public. Bespoke training and awareness raising sessions are provided for community and service user groups. Positive links with children and young people across Newcastle are provided by a large number of charitable, community and voluntary, faith and public-sector organisations. They deliver a diverse range of activities and support services including assistance with accessing education, employment and training. Newcastle City Council commissions and grant aids services. The Play and Youth Support Team publishes a Directory of Services and provides co-ordination and assistance on safeguarding, identifying additional funding, training, and signposting professionals to services to meet the needs of a particular young person. The 2017 Ofsted inspection found the Voices for choices and Care Leavers Group for Children in Care Council to be strong and visibly actively promoting the voice and experiences of children looked after by Newcastle City Council. Established following the publication of the Care Matters White Paper in 2007, the Group organises events, makes films and DVDs, comments on services locally and regionally, works with Councillors and MPs, advises government on regulation and policy and is involved in staff recruitment. A quarterly newsletter is sent to children looked after by the Council across the City and is published on-line. The Group has direct access to senior managers and members of the corporate parenting advisory committee and provides good communication, consultation and advice on a range of issues including risks to safety and welfare and the likely effectiveness of proposed arrangements. In April 2017, legislation120 required relationships education to be taught in schools in England and relationships and sex education taught in secondary schools from September 2019. Governors and proprietors will be responsible for content and delivery. Newcastle City Council Personal, Social, Health and Economic lead and Healthy Schools team will lead responses to consultation on relationships and sex education and provide support and training to develop the programme. 120 Children and Social Work Act 2017 83 During the time considered by the Review, all state schools in Newcastle delivered Personal, Social, Health and Economic in accordance with non-statutory guidance. Schools taking part reported that awareness of child sexual exploitation is included. Education of children about sexual activity can be controversial in relation to content and age at which it should be delivered, particularly among parents and faith groups. This is a difficult area. Sophisticated grooming by perpetrators is calculated to persuade victims that they are in intimate relationships; interest or excitement may encourage them to try it out. Researchers recently suggested that teaching adolescents about sex and making access to contraceptives easier may have encouraged risky behaviour.121 Other researchers monitoring changing sexual practices of young people since 1990, have commented that sex education programmes need to keep up with experiences of young people. Easy access to internet pornography contributes to moving away from traditional sexual activity and updating sex and relationships education to keep pace with current trends in sexual practices is crucial.122 Newcastle Safeguarding Boards’ Sexual Exploitation Strategy includes reviewing and monitoring the impact of raising awareness. Recommendation 2.8 I recommend that: The Government should arrange for national research to be carried out on the impact on sexual exploitation of Personal, Social, Health and Economic education programmes. 121 Paton and Wright. The Effect of Spending Cuts on Teen Pregnancy. Journal of Health Economics 23 May 2017 ISSN 0167-6296 122 Lewis et al, London School of Hygiene and Tropical Medicine and University College London. Journal of Adolescent Health. November 2017 84 8. Consultation with Children and Adults There have been determined efforts in Newcastle to engage with young people to inform services and the issues arising are being taken forward by agencies and the Safeguarding Boards. Victims who contributed to the Review were asked what might have helped them to avoid becoming involved with exploitation. “I should have been taken away from my family before I was born. For neglect. It took until I was 14 years old.” “I’m not sure anything really. I don’t think anything would have stopped me at the beginning. Except maybe information about it. People are familiar with it now – Coronation Street.” “I needed someone to sit down with me and ask who do you think would do this “ (Who should have sat down with you?) “Trust is a real issue. I didn’t trust anyone at first. I needed one person for me not a big team. If I had had someone to talk to sooner it might have helped but I did not have the words.” “If I had been alerted to sexual exploitation it would have made a difference.” (How could you have been alerted?) “Probably only by Social Media.” “I went to a community support service and they sent me to sexual health services for contraception. There was no mention of sexual exploitation.” “The teachers could not have done anything – they were brilliant teachers. Nobody could have known – I was a bright kid. I knew when someone wanted to know something and I would not have helped them. Some kids from the High School came to help out – that could help. I had a good relationship with one. Some kids do not talk to adults.” “If I had had someone to talk to it might have made a difference. I used to tell them to f-off – but they shouldn’t give up.” “Parents - if the kids are out with friends, check up and see they are ok – put a tracker on the phone. Check their phone bill. Make sure the kids are with who they say they are. Tell them not to get in a car. 85 But I wouldn’t have taken that at the time.” “When you are young and told not to do something you are more likely to do it – it’s tempting. So, it’s important that the police take action when they can. I didn’t have a relationship with anyone.” “It would not have helped if I had been told about grooming. I didn’t have enough school to hear about it.” “The only thing that would have stopped it happening would have been if I was taken into care at birth. It would also have been good if I had been taken away when a teenager or later.” 8.1 The SCARPA Squad The Children’s Society Safeguarding Children At Risk – Prevention and Action Programme (SCARPA) set up the SCARPA Squad, a group of young people, to comment on and inform agencies. The Squad has developed training, produced a DVD highlighting risks of child sexual exploitation and raises awareness in schools and locations where young people are likely to meet. During the Review, a conversation took place with Squad members. They were unaware of sexual exploitation before attending SCARPA and felt it would not be stopped without listening to what young people suggest about tackling it - young people are more likely to listen to other young people than to professionals. They were realistic about expecting too much and thought “friends might not want to betray friends” and would be unlikely to “grass on mates” Young people need to learn how to keep safe and should get the help before it happens Teams need to spot the signs and look beyond the behaviour and ask why? There is a reason behind everything. Young people need to take it seriously. Schools should teach healthy and unhealthy relationships. There should be more films; DVD’s: programs, like Whitney off East Enders, Coronation Street; documentaries; cards and Apps rather than leaflets. The best places are schools, cinema adverts, buses and metros, and public toilets and hotspots where young people congregate, day and night. Staff should be educated. There should be more information in schools. Where are the risks? “Online is massive.” The Squad had good support and information from SCARPA, but were less complimentary about other professionals. They did not feel well treated by the police, and thought social services want to split families up. Most doctors haven’t a clue. Nurses at sexual health services are quite good and ask the right questions and return home interviews 86 are useful because they come to you, and speak to you alone. More mental health services during transition are needed. 8.2 Children and Young People Staying Safe in the City Event In 2017, Newcastle Safeguarding Children Board hosted an event to canvass young peoples’ views about staying safe in Newcastle and to share learning from the Boards. There were presentations from young people, including the SCARPA Squad and Young Carers, activities on themes including Sexual Exploitation and questions and answers with a panel of decision makers from across partner agencies. The issues that arose included: • Mental health services - accessible and responsive to need – waiting lists are unacceptable • Schools - education about sex and sexual exploitation to be compulsory • Awareness – messages about services available for sexual health or sexual exploitation are not getting out to young people - more should be done to raise awareness 8.3 Young People in Newcastle and the risk of sexual exploitation: Unicef U-Report August 2017 Newcastle Safeguarding Children Board rolled out the Unicef U-Report app as part of a consultation exercise with young people about sexual exploitation. The findings included: • 49% had received information on sexual exploitation • School and social media are most significant to help to know when at risk • 76% knew where to go or what to do if they were concerned • 65% thought young people and parents should be involved in strategic and operational work; 31% of whom thought that education and awareness important As a result of these contributions, the Missing Sexually Exploited and Trafficked Group is co-ordinating a more strategic approach to awareness in schools, the community and social media. 87 9. Identifying Sexual Exploitation; Protecting Victims 9.1 Identifying Recognising that grooming is taking place or an individual or individuals are suffering sexual exploitation is the most difficult and most important area in which to make an impact. The skill and sophistication employed by perpetrators and the influence they have on the behaviour and attitude of potential and actual victims inhibits identification. The cases included sexual exploitation of child victims not known about until it had ceased when as adults the victims came forward or were approached by police because other victims identified them. They were “not known to services at significant junctures”. One victim gave a chilling account of what contributed to her decision to go to the police: “I started seeing younger girls there being raped and not realising it. School girls in uniform with their school bags coming from school.” In 2017, the Government stressed that early sharing of information is critical to providing effective help when there are emerging problems123 and repeatedly publishes guidance to encourage more effective sharing but it is not surprising that practitioners remain confused about the principles to apply. Wherever possible practitioners should share confidential personal information with consent but: “where there are concerns that a child is suffering, or is likely to suffer, significant harm, practitioners should be willing to disclose information without consent where the public interest served by protecting the child from harm outweighs the duty of confidentiality.” 124 If suspected, these are the criteria that should trigger child or adult protection referrals. But because of its hidden nature, if the level of concern regarding sexual exploitation satisfies the significant harm test, it is likely that considerable harm will already have been suffered. Guidance issued by the Government in 2006125 and since indicates that multi and interagency work starts as soon as there are: “concerns about a child's welfare, not just when there are questions about possible harm." 123 Advice: Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. Department for Education February 2017 124 Information Sharing: Advice for practitioners providing safeguarding services to children, young people, parents and carers 125 Para. 8.14 Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children. HM Government 2006 88 Effective safeguarding systems are those where all professionals share appropriate information in a timely way and can discuss “any concerns about” an individual child with colleagues and local authority children’s social care.”126 Safeguarding is everyone’s responsibility and: “Any professionals with concerns about a child’s welfare should make a referral to local authority children’s social care.” In 2017 the Government indicated that any practitioner working with a child who: “They think may be at risk of child sexual exploitation should … share this information with local authority children’s social care.” On 25 October 2017, the Department for Education published consultation documents for proposed revisions to Working Together to Safeguard Children.127 The first page of the dedicated website is headed: “CHILD ABUSE. IF YOU THINK IT, REPORT IT.” What is sufficient to indicate “problems” or “concerns” or that sexual exploitation is “likely” or an individual “may be at risk” or to “think” abuse all of which appear to require a lower standard than suspicion of significant harm? Nor is the public interest restricted to safety of an individual child or adult. There is a strong public interest in ensuring that other victims and potential victims are safeguarded. Check lists of potential vulnerability are helpful but not all children and young people with vulnerabilities will experience child sexual exploitation and as the cases considered illustrated, sexual exploitation can also occur without any of these vulnerabilities being present.128 Thorough consideration and assessment of checklist criteria would require sharing and acquiring information. The Practitioners felt that where better sharing of information may have helped form judgments, it did not occur because of lack of triggers. Sharing information was necessary to decide whether information should be shared. 9.2 Sexual Health Services Children and adults attend sexual health service clinics where advice, contraceptive treatment and treatment for sexually transmitted diseases are 126 Working together to safeguard children A guide to inter-agency working to safeguard and promote the welfare of children. March 2015 updated in 2017 127 https://consult.education.gov.uk/child-protection-safeguarding-and-family-law/working-together-to-safeguard-children-revisions-t/ 128 Advice: Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. Department for Education. February 2017 89 provided confidentially. Terminations of pregnancy may be arranged. The same services might be provided by a GP and some by a pharmacist. Children and adults may be referred to sexual health services by public sector agencies or a community and voluntary organisation, such as Streetwise. Pupils may be referred by a school nurse. Individuals can access sexual health services and Streetwise services without referral and without an appointment. Delivering a health service otherwise than for an emergency to an individual without capacity to consent is unlawful. The professional delivering the service must form a judgment about whether a person under 16 years or a person with cognitive impairments has capacity. If not, whoever has parental responsibility or authority to act for an impaired adult should be involved or a referral made to safeguarding agencies. In a majority decision in the House of Lords in 1985129 it was decided that contraceptive advice and treatment could be given to children under 16 years without parents’ consent or knowledge provided strict principles were applied. The Fraser Guidelines/Principles are now referred to and referenced throughout health service literature, materials and guidance and often stated or used as prompts to inform an evidential basis for the formation of the judgment. They are widely applied to circumstances unrelated to contraception. The review identified that the judgment is rarely read by professionals applying the Guidelines. The concern of professionals, which still dominates these issues, was that denying contraceptive advice to girls under 16 might cause some not to seek professional advice at all and expose them to risks of pregnancy and sexually-transmitted diseases. The professional should decide whether a particular patient can reasonably be expected to act upon advice to abstain. A professional must be satisfied that the patient will understand advice, cannot be persuaded to inform her parents or allow them to be informed, is very likely to begin or to continue having sexual intercourse with or without contraceptive treatment, is likely to suffer physical and/or mental ill-health unless she receives contraceptive advice or treatment and her best interests require contraceptive advice, treatment or both without parental consent. In the “overwhelming majority of cases”, the best judges of a child's welfare are the parents and it should be "most unusual" to advise a child without their knowledge and consent. There should be no question of giving advice to a “very young girl.” How can a judgment be reliably formed? Can it be formed on the basis of a conversation without accessing information held by other agencies which might include safeguarding concerns? This is an old case that made no reference to child protection or children in public care. It includes as an example of when advice or treatment would be permitted 129 West Norfolk and Wisbech Area Health Authority and Department of Health and Social Security v Gillick (1985) UKHL 7 90 circumstances in which abstinence from intercourse could not reasonably be expected “because the girl is under the influence of her sexual partner”. There is no reference to the age of any partner. The public interest in safeguarding other children received no consideration. A study by the sexual health service in Newcastle after the launch of Operation Sanctuary, found that approximately 85% of victims of sexual exploitation had received services from sexual health services. “R. and I were in a sexual relationship. It got really bad when I got pregnant. I was 12 years old. He was at university in his early twenties. I went to have an abortion. I did it by myself. I went to a Walk in Centre.” Another victim aged 13 or 14 years received contraceptive advice and treatment and termination of pregnancy at 15 years. A 16-year-old victim who attended the service was found during a criminal trial to have had impaired capacity to consent to sexual acts sufficient to sustain a conviction and long prison sentence. “I went to (a voluntary community service) and they sent me to (sexual health) for contraception. There was no mention of sexual exploitation. They asked about partners and I … gave them a list of names. They said I was high risk for infections. They were aware there were lots of men.” “I used to go to sexual health. I told them my name and age and when I had sex. They could have picked up what was happening.” The Newcastle upon Tyne Hospitals NHS Foundation Trust’s review of the cases found it was not consistently and clearly evidenced that sexual exploitation or the Fraser Principles were considered. This was addressed by the development and introduction of an Under-16 proforma which in 2017 was amended to Under-18, completed when a patient attends. The form addresses the Fraser Principles and “incorporates an assessment of sexual exploitation” using a tool with trigger questions developed in conjunction with NHS Newcastle Gateshead Clinical Commissioning Group for use in emergency departments, Walk in Centres and by General Practitioners. This assessment is confined to considering answers on the form and conversations and is not an assessment as it is understood in any other area of safeguarding practice. An audit involving 150 sets of records has been carried out to consider the use of the Under-18 proforma in clinical practice and an audit tool has been devised to collect data for the number of Young people under 18 years attending for termination of pregnancies. The results were reported to the Trust Safeguarding Committee in January 2017. Patients are told by General Practitioners, school nurses, Streetwise, sexual health services and early pregnancy clinics that information will not be shared with other 91 agencies unless they consent or it is suspected that they are suffering or are likely to suffer significant harm, the referral criteria for safeguarding referrals. “Likely” in this context should not be understood to mean more likely than not, but attracts a lower standard of proof – “a real possibility … that cannot sensibly be ignored having regard to the nature and gravity of the feared harm.”130 It was suggested that current practice is that a child seeking a contraceptive implant (or removal) would be referred to safeguarding agencies if under 13 years old, as sexual intercourse is classed as statutory rape under criminal law, but there have been examples of children aged 12 receiving contraception without a referral being made. A referral on a child of 13 or over would in any event still be dependent on other factors. The Principles applied are similar for adults except that there is a presumption under the Mental Capacity Act 2005 that an adult has the capacity to consent unless it is established otherwise. The proforma is used when it is suspected that an adult has vulnerabilities affecting cognitive functioning but the form currently makes no reference to this. The Review involved helpful discussions with very experienced and committed staff from the sexual health services. They try to persuade young persons that they should not feel compelled to have sex and refer to data suggesting 70% people do not have sex under 16 years and a high proportion of those that did, wish they had not. They see patients alone and question them about their circumstances and relationships. If a patient is judged competent to consent to contraceptive advice and treatment they are assumed to have the capacity to prohibit sharing of information not only with parents but also other professionals. The professional practice was and is consistent with what is expected generally in applying the Fraser Guidelines and acknowledging that it should be the fundamental, working assumption of all frontline staff working with children and young people that sexual relations between an adult and a child under the legal age of consent are non-consensual, unlawful and wrong.131 The staff are not as familiar with an individual and their family as a school nurse or General Practitioner. Sexual health services and Streetwise rely on patient honesty and accurate disclosure of information. They make no inquires of other agencies to verify information about age and identity or ascertain whether there are any concerns, unless they have consent from the patient or they suspect significant harm. Unless patients volunteer information, it is not known whether they are looked after by the local authority or they or people close to them have been subject to child protection or adult protection plans or concerns. 130 In re H (Minors) (Sexual Abuse: Standard of Proof) [1996] AC 563; In the Matter of J (Children) [2013] UKSC 9 131 Child sexual exploitation and the response to localised grooming Child Sexual Exploitation: scale and prevalence House of Commons Home Affairs Committee. June 2013 92 General Practitioners are not always aware of other health interventions. One of the cases concerned a victim who had undergone a termination of pregnancy and her General Practitioner was only informed when complications arose. During the Review, it was suggested that sexual health service staff should routinely ask patients for consent to share information with their General Practitioners, who operate under the same principles of confidentiality. Discussion of these issues has led to arrangements for a representative from The Newcastle upon Tyne Hospitals NHS Foundation Trust to attend meetings of the Risk Management Group at which individual cases involving sexual exploitation are considered. The representative shares the information with Health Visitors, General Practitioners, Public Health School Nurses and sexual health staff. The NHS Newcastle Gateshead Clinical Commissioning Group also has a member of staff working in the Hub. Should sexual health professionals have access to information about which children are looked after by the local authority or be told when a child becomes looked after and have a data system that allows information about young people or adults at risk, dangerous individuals and addresses or locations to be kept for reference? Is consent to medical treatment being confused with capacity to consent to sexual acts and consent to share information? The Home Affairs Committee in 2013 was concerned that children might be taken successively to different sexual health clinics in a region without this being recognised and recommended that: “sexual health services give consideration as to how such information might be shared across the region in order to better identify children at risk.” There are no such arrangements in the North East. Recommendation 2.9 I recommend that: National Health Service England should consider establishing a risk information sharing system for sexual health settings. In March 2015, the Government set out the intention to create a culture where the health service and medical professionals are spotting the signs of child sexual exploitation early and are supported in sharing information with others.132 NHS England has set up The Child Protection - Information Sharing Project which is connecting IT systems so that local authorities and the NHS can share child protection information securely and health and social care staff have a more complete picture of a child's interactions with health and social care services.133 In Newcastle a Trust Task & Finish Group is to be established to 132 Para. 20 Tackling Child Sexual Exploitation. HM Government. March 2015 133 https://digital.nhs.uk/child-protection-information-sharing 93 identify the processes and what is needed to support this initiative and recommendations will be made to the Newcastle Safeguarding Children Board which will include the arrangements in procedures. It does not appear to address similar concerns about vulnerable adults. Recommendation 2.10 I recommend that: The Government should consider whether The Child Protection - Information Sharing Project arrangements should also apply to safeguarding adults systems and procedures. Practitioners questioned what would trigger contact with other professionals? A significant number felt that a 12 or 13-year-old seeking contraception and clearly involved in sexual acts was sufficient in itself to satisfy concerns to generate sharing information – accessing as well as giving information. They felt that most parents would expect that serious operative treatment of a 13, 14 or 15-year-old would require parental consent or local authority consent if the child is in care. There was unease at encouraging children to deceive their parents which did not sit well with parental responsibility. Young teenagers are not considered mature enough to enter into binding legal contracts, to vote, or to marry. Government Advice on Risk and adolescent development emphasises the turmoil of adolescent years.134 An unintended consequence is that if a patient is under the under the influence and control of a perpetrator, who may have brought or encouraged the patient to access the service, unless the processes persuade a patient to disclose this information, the service is unwittingly assisting perpetrators to abuse without risk of pregnancies and disease. The Bristol Review found that: “A confused and confusing stance in national policy about adolescent sexual activity, leaves professionals and managers struggling to recognise and distinguish between sexual abuse, sexual exploitation and/or underage sexual activity; this risks leaving some children at continued risk of exploitation in the mistaken belief they are involved in consensual activity.”135 The Oxfordshire Review recommended that: “Relevant government departments should consider the impact of current guidance on consent to ensure what seems to be the ever-lower age at 134 Annex A: Adolescent Development. Advice, Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. Department for Education February. 2017 135 The Brooke Serious Case Review into Child Sexual Exploitation. Bristol Safeguarding Children Board 2016 94 which a child can be deemed to consent (for example to treatment) and attitudes to underage sex are not making it easier for perpetrators to succeed.”136 Should sexual exploitation be treated differently procedurally from other forms of abuse? There has always been a reluctance to approve arrangements outside established procedures because of the risk of inconsistencies and inappropriate tolerance of abuse. Practitioners thought lower thresholds were now generally being applied for sharing information and contacting other professionals. Waiting until concern met normal thresholds risked the influence of perpetrators, sexual exploitation and serious harm continuing. “Unless you know what others know, it is not possible to know the importance of what you know.” The launch of Operation Sanctuary, the start of the Review and introducing arrangements to improve awareness of sexual exploitation have led to an increase in safeguarding referrals across agencies, although referrals from sexual health and school nursing services have declined. Victims of sexual exploitation are very likely to attend sexual health services or walk-in community support services while being groomed and when they are being exploited. The current approach to and principles applied to confidentiality and assessment of capacity, to consent to treatment and sexual acts means identifying victims or potential victims is extremely difficult and is unlikely to occur. Discussions during the Review have not led to any suggestions about how this might be overcome. Unless there is a change, which appears to require a national debate, sexual exploitation is not likely to be prevented and early identification will remain difficult. Recommendations 1.8 – 1.10 I recommend that: 1.8 The outcome of audits carried out in Newcastle to review the processes of assessment of capacity of patients to receive sexual health services should be reported to Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board. 1.9 Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults’ Board should consider what arrangements can be made to monitor the numbers of patients who are identified as sexual exploitation victims and have received sexual health services. 136 Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F. Oxfordshire Safeguarding Children Board 2015 95 1.10 NHS Newcastle Gateshead Clinical Commissioning Group should arrange a forum for discussion about how potential and actual victims of grooming and sexual exploitation might be more likely to be identified in health settings and report to the Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board. Recommendation 2.11 I recommend that: The Government should urgently arrange for the principles applied to confidentiality and safeguarding in sexual health settings to be reviewed having regard to the body of knowledge about sexual exploitation. 9.3 School Nursing School nurses, located in schools, are not part schools’ staffing establishments. The Review considered circumstances in which a school nurse gave a 13-year-old girl pupil contraceptive advice and referred her to sexual health services without informing her parent. There was good liaison and exchange of information between the sexual health service and the school nurse who gave support within the school. But the General Practitioner and teaching staff were unaware that the pupil was sexually active and were not informed when later, aged just 15 years, she had a termination of pregnancy. Nor was her parent informed. Discussions confirmed that this is not an area in which practice has changed in the light of increasing knowledge about sexual exploitation. School nurses will not without consent pass on information to teaching staff unless significant harm is suspected, in which case interagency processes would be followed. Teachers were concerned that, despite strong pastoral support systems, including full-time counsellors and chaplains, there was no system in place for methodical oversight by a senior staff member of involvement with school nurses or with specialist drug and alcohol services also operating on school premises. They felt school nurses have a role in preparing a child for adult life and safeguarding and promoting welfare rather than just medical responses to a health issues. Recommendation 1.11 I recommend that: Newcastle Safeguarding Children Board should arrange a forum for discussion about collaborative working between the school nursing service and teaching staff. 96 9.4 Information Sharing and Recording The cases highlighted excellent examples of information sharing within agencies and between staff working in different agencies and also some areas for attention for a number of agencies. Practitioners at Learning Events were provided with an overview of the history of the individual victims, the agency responses and family genograms. Consistently they commented that most valuable was seeing the whole picture. Despite considerable professional and interagency activity, responses to events had taken place without the full background and family context being understood. Some were shocked by what victims had experienced and by information known to others. Discussions emphasised that good practice includes: • Proactively considering who needs to know what - making sure the right people have the right information in a timely manner; not assuming other agencies will have shared the information • Acquiring relevant information as well sharing it with others • Good arrangements within an agency as well as for external communication • Acknowledging that case transfer is a critical period and updating information should happen prior to agreed transfer • Providing context and history as well as presenting issues • Providing an indication of the significance of information, particularly when shared outside professional groups • Ensuring early and continuing multi-agency review and information sharing in order to put together a full picture • Being clear about information that should be shared or sought Greater understanding of sexual exploitation has led generally to lower thresholds being applied for sharing information and carrying out checks or enquiries and earlier multi-agency working. All safeguarding children’s referrals are now considered through the Multi-Agency Safeguarding Hub and immediate information sharing by agencies and collection of data helps to identify emerging trends. The effectiveness is monitored through audit processes. The Ofsted inspection in 2017 highlighted the impact of the considerable emphasis now placed on the collection and sharing of information with partner agencies. A consistent frustration felt by Practitioners was the lack of integrated systems to pull together information held by different agencies. This applied particularly to health agency systems which do not operate as a single service. However, safeguarding information should be effectively dealt with for children referred in to the MASH, where the health representative contacts appropriate health providers for example mental health and General Practitioners. The agency reviews and the discussions led to improvements in consistency of recording which should be reviewed during supervision of staff. 97 The cases confirmed the importance of ensuring that arrangements are in place in Children’s Social Care and Adult Social Care to receive and accurately record legal advice and the basis on which it is given. The Council Legal Services have an experienced team of lawyers who provide a specialist service. During the Review discussions took place between legal and social care staff to ensure that the most suitable and effective arrangements are in place. Advice is uploaded onto the social care data system, is easily identifiable and available to social care and legal staff. Periodic reviews take place to ensure these arrangements are operating effectively. 9.5 Children and Adults Who Move Area The cases illustrated the problems that arise when a family giving rise to concerns moves from one local authority area to another, particularly when this is motivated by an intention to undermine or avoid efforts to address safeguarding issues. This issue has arisen in many serious case reviews. Practitioners highlighted the “start again syndrome”, the danger that local authorities and partners re-start involvement, without sufficient account of work undertaken during previous interventions. In the cases, appropriate notices were given to the local authority to whose area a family moved but difficulties and delays occurred in transferring relevant historical information to the new authority and preparations for legal action ceased. “My Mum kept moving to get away – to different authorities. So new social workers that didn’t know it.” Local authority administrative boundaries are intended to encourage more efficient delivery of local services. Statutory duties of local authorities are identical. However, social care information is not routinely transferred. Differing data systems complicate sharing of information. The issue is as relevant for continuity of services for adults as for children, but legislation does allow local authorities to provide services for adults ordinarily resident in another area.137 Newcastle Safeguarding Children Board has raised the issues at regional meetings of representatives of Safeguarding Children Boards and a cross boundary protocol is being developed for the North-East Region to overcome the problems. Where legal staff are preparing to issue proceedings at the time a family moves, they will continue to act until such time as legal staff in the receiving authority have been properly instructed. Newcastle City Council Director of People holds the statutory appointments as Director of Children’s Services and Director of Adult Social Care Services and is a member of the Association of Directors of Children’s Services and the Association of Directors of Adult Social Services. He has made arrangements to raise with the 137 s19 (2) (3) Care Act 2014 98 Associations, nationally and regionally, the need to agree effective arrangements for the transfer of social care records between local authorities. He has also arranged for this to be considered by the Regional Chairs of Safeguarding Boards and Directors. Recommendation 1.12 I recommend that: There should be reports made to Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board on the outcomes of the actions taken to improve information sharing in the region when vulnerable children or adults move administrative areas. While health information should follow an individual, the Review identified difficulties when a child looked after by the Council experiences multiple placements, particularly if some are out of authority, or if an adult with safeguarding needs has a series of different area addresses. One victim had been registered with 16 General Practices. NHS Newcastle Gateshead Clinical Commissioning Group has raised this issue with NHS England to ascertain whether this can be addressed more effectively. Similar problems were identified in relation to the transfer of school records and continuing education for children who move either with their family or as a result of placement changes. During the review The Pupil Referral Unit in Newcastle was reviewing arrangements to try and ensure for pupils who have attended the Unit there is better and more effective sharing of information with neighbouring Local Authorities. Newcastle School Attendance Service has reviewed arrangements to encourage early identification of children moving into the City to ensure a school placement is found in a timely way. Barnardo’s have also reviewed their approach to delivering services when victims’ families frequently move between areas to minimise the disruption that occurs. Recommendation 2.12 I recommend that: The Government should address the need to improve national arrangements for facilitating transfer of data between social care authorities. 9.6 Professional Culture Practitioners commented that “there was a different culture in 2007” and since there has been a huge amount of learning and change. Professional cultures can impact on the response and consideration of child and adult welfare issues. 99 There was a strong emphasis on showing greater respect for children’s views and give greater responsibility to older children and adults with cognitive impairments to make choices about their lives, which impacted on responses. While there is no evidence in Newcastle of an approach identified in Rochdale where girls as young as ten years old were recorded as engaging in consensual sexual activity, there was historically an acceptance that teenage girls would be involved in sexual acts and made life-style choices. This was encouraged by victims who under the influence and control of perpetrators, insisted that they were making choices which they were entitled to make, avoided contact and expressed resentment and opposition to attempts to intervene. In 2011, drawing on lessons from serious case reviews across England, Ofsted highlighted138 that agencies had focused on challenging behaviour, seeing children as hard to reach or rebellious, rather than trying to understand the causes of the behaviour and the need for sustained support. Young people under 18 were treated as adults rather than children, because of confusion about age and legal status. Practitioners did not fully understand the calculated erosion and removal of the ability to choose by perpetrators through grooming, alcohol and drugs, coercion and threats and offering food and shelter. At the Learning Events Practitioners identified the significance of accepting that agreeing did not necessarily satisfy the need for consent and continued contact should not be misinterpreted as informed choice or an indication of absence of harm.139 In Newcastle, while these issues affected the perception of what might be achieved and particularly what action could be taken against perpetrators and complicated the approach, it did not lead to inactivity or lack of effort to influence victims. On the contrary, there were examples of persistent efforts to persuade and offer services as the impact of abuse led to mental health and emotional problems. Better understanding also led to recognition that effective work with victims requires a long-term commitment to support and previous encouragement to carry out time limited interventions was not helpful. 9.7 Professional Curiosity The Government Advice in February 2017 emphasised that responding to sexual exploitation requires knowledge and skills and: “Professional curiosity and an assessment which analyses the risk factors and personal circumstances of individual children to ensure that the signs and symptoms are interpreted correctly and appropriate support is given.” 138 Ages of concern: learning lessons from serious case reviews. A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011. Ofsted. October 2011 139 Advice. Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. Department for Education. February 2017 100 The Climbié Report in 2003 and subsequent reviews140 including of sexual exploitation have emphasised the need for practitioners and supervisors to think beyond the presenting issue and consider the bigger picture. Practitioners highlighted areas that with greater understanding of sexual exploitation would have benefited from exercising curiosity and should inform practice - challenging denials or explanations of victims and perpetrators without assuming victims lack insight into the harm they experience; exploring why victims are with older unrelated men or in particular places; considering ages of men to be significant; taking into account that victims will be unlikely to answer truthfully; following victims; always considering the level of understanding and the influence of drugs and alcohol, inducements, coercion and abuse. The need to exercise professional curiosity supported by examples is included in the Safeguarding Boards’ interagency training and practice guidance and reflection of it in practice is subject to audit. 9.8 Assessments The thoroughness of assessments impacts on developing effective plans and the quality of outcomes for children and vulnerable adults. There are fewer published materials and tools to aid assessments involving adults. The Review found that pressure of persistent crises and constantly changing circumstances led to superficial approaches which tended to focus on single issues, rather than employing a systematic, holistic approach. Delays in collating, assessing and analysing evidence of emerging concerns over an extended period contributed to this. Better understanding of the significance of individual events and the context would have assisted the working of the cases and informed assessments. A recurring weakness identified in research and serious case reviews has been that histories are not researched sufficiently and consequently over-estimating families’ abilities to understand and respond to professional concerns is common.141 An early principle established in the field of child abuse and neglect, also applicable to adults, was that “if you don’t understand someone’s behaviour, you don’t have enough history”.142 If parents are experiencing difficulties in parenting, then knowing the parents’ own family history, assessing their understanding of the impact of what is happening to them and how they parent children, and their capacity to adapt and change 140 See for example Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F. Oxfordshire Safeguarding Children Board. 2015 141 Assessing Parental capacity to Change when Children are on the Edge of Care: an overview of current research evidence. Research Report. Ward and Hyde-Dryden, Centre for Child and Family Research, Loughborough University. Department for Education. June 2014 142 Quoting Brandt F Steele; C. Henry Kempe, University of Colorado School of Medicine in 1980s; The APSAC Handbook on Child Maltreatment, Fourth Edition, Klika and Conte; The American Professional Society on the Abuse of Children. 2017 101 becomes crucial.143 Understanding life experiences informs what might impair or support interventions. A systematic approach to enquiries using a conceptual model is the best way to deliver a comprehensive assessment144 which should include “Family history and functioning.” This requires a forensic approach, identifying what needs to be known, how to acquire necessary information and consideration of the impact of what is known and what is not known. In the cases, weaknesses in researching family histories led to over-optimistic assessments of parenting capacity and repeated reliance on parents to provide a safe environment despite evidence to the contrary. General Practitioners were not consistently involved which led to important patterns and impaired cognition in parents not being sufficiently understood. Learning included that minutes of children’s and adults’ safeguarding meetings must demonstrate fully the risk analyses, risk management requirements, the rationale for decisions and the status of the victim. Local authorities’ children’s and adults’ services are responsible for carrying out safeguarding assessments, but consideration of the quality and analysis and making an appropriate contribution is an interagency responsibility. This requires persistent monitoring because of the pressures of daily work and time constraints for decision making. The Ofsted inspection in 2017 identified continuing weaknesses which are being addressed through an Action Plan, monitoring and auditing. In 2015, the Government wrote to Directors of Children’s Services to ensure that the decision-making tools used to support assessments are properly evidence-based, and used to help thinking, discussion and decision making during supervision.145 Newcastle City Council Children’s and Adults Social Care promptly reviewed the sexual exploitation tool in use, taking account of learning from Operation Sanctuary and practice experience in the Hub. Within adult safeguarding, nationally accredited tools are not available. The Safeguarding Boards therefore worked together to produce materials relevant for safeguarding vulnerable adults and children. 9.9 Chronologies and Genograms Practitioners commented that the Timelines and Genograms prepared for the Review and the analyses improved understanding of the whole picture and context of their involvement. Well prepared, up to date chronologies highlight persistency of concerns and the cyclical nature of interventions. Genograms help understand relationships and highlight areas for further enquiry and understanding. 143 Analysing child deaths and serious injury through abuse and neglect: what can we learn? Department of Children, Schools and Families. 2008 144 Working together to safeguard children A guide to inter-agency working to safeguard and promote the welfare of children. March 2015 145 Tackling Child Sexual Exploitation. 2015 102 Newcastle City Council Children’s Social Care have introduced processes for preparing genograms and recording analytical chronologies and life events which can be updated in live terms to provide a full picture of each case to underpin and inform case planning. Compliance and effectiveness is monitored through reports made to the Senior Management Team. The arrangements for interagency children’s and adult’s safeguarding meetings and processes undertaken at other points of the systems include considering whether the preparation of chronologies and genograms are necessary to assist a full understanding. The Safeguarding Boards have arrangements in place to encourage and review the preparation of chronologies and genograms across agencies. 9.10 Neglect During the early period of the cases, there was less awareness of the impact of long term, persistent neglect and the possible link to sexual exploitation identified in research more recently.146 Disengagement with health agencies and education is significant,147 particularly when victims came from large families. Practitioners’ observations that vulnerable individuals were “lost in the wider family” reflected the research. They confirmed the importance of considering the needs and identities of siblings in large families and the impact on the lives of each child148. During the period reviewed, neglect was addressed more effectively. In 2017, Ofsted confirmed that action taken by senior managers in Newcastle Children’s Social Care in 2015 “led directly to innovation and investment in evidence-based practice”. Practice and services to children and families improved as a result.149 In 2016, there was an ambitious redesign of long-term social work services through the introduction of the Family Insights systemic practice model, funded through the Department for Education Innovation Programme. Independent monitoring and evaluation is being undertaken to explore the impact of this innovation150 on permanent positive change for families. 9.11 Understanding and Responding to Diversity, Language and Culture Culture - the ideas, customs, attitudes and behaviour characteristics of a particular social group or people or society,151 has a significant impact in safeguarding. Within families or communities, cultural attitudes may be determined or encouraged by religion or might develop despite principles under-pinning religion. 146 Hanson, E Exploring the Relationship between Neglect and Child Sexual Exploitation: Evidence Scope 1. Research in Practice: Dartington. 2016 147 Failure to ensure access to health care is feature of statutory definition of neglect and should alert professionals to safeguarding needs. HM Government. 2015 148 Child Visibility in Cases of Chronic Neglect: Implications for Social Work Practice, Howarth, J. and Tarr, S. BJSW 45 (5), 1379-1394. 2015 149 Newcastle Upon Tyne Inspection of services. Ofsted Report. 7 July 2017 150 Newcastle City Council’s Family Insights Innovation Programme: Research Evaluation Report 31 July 2017 151 Oxford English Dictionary 103 It might lead to differences of approach to men and women and to girls and boys and may affect how a child or vulnerable adult feels about themselves and what they can expect from others. It might vary across a geographical area, be strongly influenced by family traditions or affect an individual’s or group’s attitude towards authority, whether advice or stronger expectations will be adhered to and whether departure from what is expected will be acknowledged. It may influence whether concerns are reported. In 2015, the Government asserted that: “There is no culture in which sexual abuse is not a serious crime.” 152 However, what is considered to be abusive might be affected by cultural and legal issues. In any assessment, it is therefore important to ensure that as much relevant information as possible is obtained concerning the attitudes and approach of carers and of perpetrators to child rearing and the care of vulnerable adults. In cases involving people from abroad these issues may be prominent but need to be considered whatever the background. Two of the victims in the cases had family backgrounds from different African States. No enquiries were made about their experiences before they came to the United Kingdom or about the likely cultural attitudes towards the issues that were causing concern. In both, immigration status had affected the families including severely restricting income but no links had been made with the Home Office. One victim discussed cultural issues that she thought had not been understood: “… one night I was late and petrified of going home …. I called the police and they took me to a foster home. When you are black my parents said they assume you have problems and they want to put you in jail. When they took me, I thought they were right.” Later when she was a victim of rape: “They were going to kick me out.” “My parents blamed me. It was a matter of pride …. It is cultural.” “In … there are (very many) ethnic groupings and almost as many languages. Two main languages. But there is no single … culture. It is important to understand what individuals think and believe. My parents believe that children can misbehave because of evil spirits that can be beaten out of them and got support from the church. But not all … believe that. Nobody understood.” 152 Tackling Child Sexual Exploitation.HM Government. March 2015 104 It is difficult if conversations with family members take place in a language no professionals understand. “No one could understand what he was saying. He told me to say I wanted to go home.” The Practitioners accepted that the parents’ deeply ingrained cultural values were not fully understood. They also identified the need to consider the background of the workforce and volunteers, whether they will understand the important issues, or have access to competent advice, whether language inhibits engaging with and understanding communities and perpetrators’ values. It was emphasised that these issues are relevant for other communities including learning disabled and deaf and blind communities. In Newcastle, resources are available to practitioners to assist understanding cultural issues. A section on Abuse Linked to Spiritual and Religious Beliefs is published in the Procedures Manual by the Newcastle Safeguarding Children Board153, and reflects and has links to non-statutory government guidance from 2007, the National Action Plan 2012 and a research report on Possession and Witchcraft 2006. These were not referenced in the Agency Review reports and awareness in practice appeared limited. The involvement of a Home Office representative at Learning Events was described by other participants as “welcome and helpful”. As a result, the Home Office had a better understanding of the potential risks for other children and young people and of a return to the country of origin and how immigration status and inability to work might contribute to vulnerability to sexual exploitation. Arrangements have been made in Newcastle for Home Office representatives to establish links with local authority social care services, attend Safeguarding Conferences to encourage networking and sharing information and contact children’s services regularly for update, to better understand safeguarding issues to feed into immigration decisions. In the cases which had foreign links, no attempt had been made to obtain information from the countries of origin. In 2014, the Government published Advice154 for local authorities, social workers, service managers and children’s services lawyers on working with foreign authorities including Embassies’ contact details to inform judgments about children and families with foreign links and inform courts of the steps taken if proceedings 153 Abuse Linked to Spiritual and Religious Beliefs http://newcastlescb.proceduresonline.com; Safeguarding Children from Abuse Linked to a Belief in Spirit Possession. Department for Education and Skills 2007; Child Abuse linked to Faith or Belief: National Action Plan, Department for Education 2012; Child Abuse Linked to Accusations of “Possession” and “Witchcraft”. Stobart research Report No. 750 Department for Education and Skills. 2006 154 Working with foreign authorities: child protection cases and care orders Departmental advice for local authorities, social workers, service managers and children’s services lawyers Department for Education. July 2014 105 were initiated. A copy of the Advice is on the Newcastle Safeguarding Children Board Website. The need to have regard to and apply the Advice was raised by their manager with Independent Reviewing Officers and Children’s Services Teams in Newcastle City Council and there is evidence of it being used by staff. Further work is being undertaken to embed this in practice. Newcastle City Council legal services specialist staff routinely contact relevant Embassies and report outcomes in court proceedings. Only few responses have been received, even after sending a reminder. In the cases with no response, with agreement of the court, further delay was considered detrimental to the children. There is no national guidance relating to adult safeguarding and contacting Embassies and Foreign Authorities. Newcastle City Council Adult Social Care staff apply the principles in the children’s Advice when working with an adult. Staff have linked with foreign authorities for cases involving forced marriage of people with a learning disability and when working with asylum seekers. A designated staff member who works with asylum seekers and people with no recourse to public funds helps build expertise and knowledge of appropriate contact points for Foreign Authorities. Recommendation 1.13 I recommend that: Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should consider how access for practitioners to advice on cultural attitudes when assessing and managing risks might be improved. 9.12 Plans A survey of over 500 professionals in 2017 found that developing plans related to Harmful Sexual Behaviour was the work area with the lowest level of confidence.155 Safeguarding plans that deliver good outcomes depend on good assessments and analysis. They are more than strategic intentions and should set out measurable operational objectives and how they will be achieved, the “how, who, what and when” to enable the plan to be used as a means of checking whether or not those objectives are being met156. To avoid effecting changes in a crisis, there must be a contingency plan.157 In the cases, the plans focused on the behaviour of the victims and how to persuade or prevent them associating with perpetrators. They did not address the cause of the concern, which was the activities of the perpetrators, and as a result, 155 Workforce perspectives on harmful sexual behaviour: findings from the Local Authorities Research Consortium 7. National Children's Bureau. 2017 156 Richards J.: R (AB and SB) v Nottingham CC (2001) EWHC Admin. 235 157 Munby J.: R v Caerphilly County Borough Council (2005) EWHC 586 106 although they engaged the interagency framework and significant resources and commitment, they did not ensure consistent safety of the victims. Circulating widely actions to be taken against perpetrators is not appropriate but the need to address the issue and who will be involved should be clearly addressed so that effectiveness and impact on other areas of practice can be reviewed. The pressure of repeated crises, victims being missing or frequent changes of placement, inhibited carrying through actions identified as necessary. “Why don’t they do the plans? I was meant to have psychological treatment and so on. Never done. I was told I would not accept support but they said I needed longer for treatment but it didn’t happen. Why don’t they listen to advice? Unclear plans.” The Agency Reports robustly identified persistence with plans that were failing, supported by misguided optimism, uncertainty about how to manage the risks and insufficient overview, so lack of progress was not identified. The cases included victims looked after by the Council and so subject to oversight by Independent Reviewing Officers, and whose welfare was considered by courts and Children’s Guardians. One of the most common, problematic tendencies in human cognition is the failure to review judgements and plans. Once a view is formed, evidence that challenges that picture is often unnoticed or dismissed.158 “Nothing changed.” Before the Review began, overuse of multiple “contracts of expectation” had been identified in multi-agency audits and highlighted in a serious case review. These statements, sometimes repeatedly insisted upon by courts, signed by carers, set out detailed lists of actions for carers and were repeated from one meeting to the next with limited attention to outcomes for individual children. Reference to them has been removed from Newcastle City Council Children’s Social Care Practice Guidance which encourages instead working collaboratively to achieve tightly planned goals and positive outcomes with clear timescales, monitored through audits reported to the Senior Management Team and Newcastle Safeguarding Children Board. Where court proceedings are contemplated, the development of the Public Law Outline includes a requirement that local authorities clearly set out concerns and what is needed to address them and provides an alternative to agreements. Where there was anxiety about lack of progress, legal advice about what options might be available was not always sought promptly. There have been discussions between staff in the respective departments and work undertaken to maximise access to legal expertise. Weekly meetings ensure a consistent effective early 158 SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews. Fish, Munro and Bairstow. 2008 107 contribution and consideration of the soundness of judgments and quality of assessments which reflects court expectations.159 Decisions about accommodating children and initiating proceedings are now considered by the fortnightly Care and Resources Panel, chaired by the Assistant Director of Children’s Social Care and attended by Legal Services to provide robust oversight and up to date legal advice. A fortnightly Legal Proceedings Panel considers and monitors the progress of all cases involving proceedings. The effectiveness of the processes is monitored through performance data and review. That the development of plans was an area in need of improvement was identified by audit and inspection and an Action Plan to address this, including training, was in place before the Review began. It is impossible to know whether, if early plans had included the need to address the perpetrators and failure to achieve better outcomes had been highlighted, the focus on investigating, disrupting and prosecuting perpetrators might have occurred earlier. Newcastle City Council social care services are responsible for ensuring safeguarding plans are in place but the development of and effectiveness of plans is an inter-agency issue. There was no evidence that any other agency commented or complained about the ineffectiveness of or criticised the adequacy of the implementation of plans. In Section 11, I discuss the need for robust collective responsibility and interagency challenge. Taking part in the Review encouraged agencies to consider carefully their internal planning arrangements. Right-Trak Ltd, which manages care homes, developed a model for Missing from Home Safety Plan. This is a robust document setting out boundaries and expectations of residents, curfew times, when and where they should be when attending education, guidance on locating residents should they go missing, known associates that pose a risk and areas of concern and addresses where they could be at risk of harm. The Risk Management Group, set up in 2012 to consider children who were considered to be at high risk of harm, now has a multi-agency membership which includes adult social care. Chaired by a Newcastle City Council Children’s Social Care senior manager, the Group ensures earlier identification and access to multi-agency support and scrutiny at senior level. All children and young people considered medium or high risk following a sexual exploitation risk assessment are referred to the Group. If plans are not achieving objectives this is identified and addressed. 159 Munby P. Darlington Borough Council v M, F, GM, GF and A [2015] EWFC 11 108 9.13 Working with Families The Agency Reports and Practitioners identified that the pressure of recurring crises generated a reactive approach and the persistent and determined efforts to impact on and influence the behaviour of victims detracted from constructive and systemic work with families. The lack of engagement with or involvement of family members was not identified or challenged. It was assumed that sexual exploitation was an issue external to the family and lack of knowledge about family backgrounds led to both inappropriate reliance on the ability or interest to protect and overlooking potential for positive contributions. A mother of a victim commented that she felt that if she had had help with problems in the family, which wore her down physically and emotionally, sexual exploitation might not have happened. She also thought that, although she had been able to express her concerns about her daughter’s placements they were not acted upon. In September 2017, the Centre of Expertise on Child Sexual Abuse published an evidence review160 examining “Supporting parents of sexually exploited young people”. The key messages included are as relevant to cases involving adults: “There is a wealth of evidence pointing to the significance of parents in the lives of young people and the importance of parenting to outcomes, even where parent-child relationships are on the verge of breaking down. It is vital that services support the role of parents in supporting their children.” Many parents will be encountering services and systems for the first time or, if not, the focus is likely to have been quite different. One of the biggest sources of distress for parents is their child not receiving the help they need. Before the Review began the intention to address this area of practice contributed to the decision to introduce the Family Insights Systemic Practice Model of social work into Newcastle City Council Children’s Social Care. Child sexual exploitation cases have been allocated to a specific Unit, the effectiveness of which is closely scrutinised. Outcomes are measured and monthly meetings involving leaders and operational managers explore data, examine the quality of casework and identify lessons which can be shared. A Multisystem Therapy Team provides intensive family and community based collaborative intervention for children aged 11-17 at risk of being removed from home. Service User Satisfaction Surveys were fed into an evaluation through Oxford University. Consultation and support has been provided by Morning Lane, a social enterprise organisation with a proven track record of assisting local authorities improve the skill set within their workforce. Reporting arrangements to oversee ongoing implementation are through a Strategic Board chaired by the Newcastle City Council Director of People. 160 Exploratory study on the use of tools and checklists to assess risk of CSE. Centre of Expertise on Child Sexual Abuse. 2017 109 9.14 Safeguarding Procedures: Children Looked After by the Local Authority and Adults subject to Adult Protection Plans Children may become looked after by the Local Authority because they are known or suspected to be suffering sexual exploitation. The local authority can decide where the child lives and other resources are available, but the behaviour or attitude of the victim is unlikely to immediately change or the risk of abuse diminish by reason only of the change of status. Victims may meet others for whom there are similar concerns. The local authority powers to control or restrain are very restricted unless statutory criteria are satisfied and the child is placed in registered secure accommodation, which involves placement away from agencies who have been working with the child and family. The cases included circumstances in which an agency other than Newcastle City Council was aware that a looked after child was suffering or likely to suffer significant harm but a referral under the interagency Child Protection Procedures was not made and there were therefore no child protection enquiries or conference to consider whether a child protection plan related specifically to safety should be developed. The Procedures do not include any provision excepting their application to children looked after by the local authority; nor are statutory provisions requiring child protection enquiries so limited. A number of the cases included circumstances in which children were not subject to any child protection processes as they approached adulthood despite being victims of unresolved sexual exploitation. Newcastle City Council Adult Social Care while involved during the transition period did invoke adult safeguarding procedures. Statutory regulations and guidance161 address circumstances in which a child subject to a child protection plan becomes a looked after child and provides that the child protection plan should continue unless and until the child is protected from significant harm. Meetings held to review a looked after child’s case have a different function and children mostly want as few people as possible at a review meeting when they are present, whereas a child protection conference is a multi-agency meeting. The regulations and guidance do not address specifically circumstances in which a looked after child suffers significant harm but the argument for child safety focussed processes are strong. There were similar examples when concerns were not shared when a vulnerable adult was subject to an adult protection plan or Newcastle City Council Adult Social Care were already actively involved. It is likely that there was an assumption that the welfare of the victim would be safeguarded by arrangements in place arising from status, including, for looked 161 Paras 2.11 to 2.13 The Children Act 1989 guidance and regulations Volume 2: care planning, placement and review. Department for Education. 2010 updated 2015. The Care Planning, Placement and Case Review (England) Regulations 2010 amended 2013 110 after children, the requirement for a care plan and oversight by an Independent Reviewing Officer. Reports of reviews elsewhere162 and Ofsted163 drawing on reviews across the country have highlighted dangers when professionals do not consistently refer to procedures and assume other agencies will be aware or are responsible for addressing concerns and so make no referral. This issue has been addressed within Newcastle Social Care guidance. Safeguarding Procedures require agencies to make safeguarding referrals or notifications whatever the victims’ status, wherever they live and whatever arrangements are in place, so that full information is collected and consideration given to whether safeguarding enquiries and interagency meetings should take place. When the victim is a looked after child, the Independent Reviewing Officer will consider whether involvement of expertise and independence that arise from convening safeguarding meetings can be achieved through the statutory review of the child’s case or a safeguarding conference should be convened. These arrangements are subject to audits reported to the Safeguarding Boards. 9.15 Listening to Victims In 2015, the Government published164 an intention to generate a culture in which all professionals listen to victims and those at risk and respond to allegations. The cases demonstrated how difficult it is to take account of what victims want to happen, when the perpetrators’ calculated and malign influences ensure that they will be deceitful, misleading and contradictory. Practitioners also commented that: “Often we just go in and expect them to disclose straight away when in fact they need to build trust in people before they can even consider disclosure.” Listening may include challenging and clarifying, being available and waiting until a victim is ready and confident to talk. Victims gave much fuller accounts of their experiences than previously when giving evidence in court. One victim felt strongly that what she had to say about who was responsible for her going missing and being exploited was insufficiently listened to. She thought that she did not have anyone she could trust and talk to and that unavoidable changes of social workers contributed to this. She worried that what had happened to her was not fully understood and despite many conversations never really understood the risks. “People kept saying I was at risk but I didn’t understand. What was CSE?” 162 The Review of Multi-Agency Responses to the Sexual Exploitation of Children in Rochdale; Rochdale Borough Council. 2012 163 Ages of concern: learning lessons from serious case reviews: A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011. Ofsted. 2011 164 Tackling Child Sexual Exploitation HM Government March 2015 111 She and her mother regularly attended meetings and voiced their concerns about where she was placed and the contact she was allowed to have with another victim with whom she was placed. “I told the social worker. The staff … should’ve known that there were restrictions …”. The Review looked carefully at the background to this. What they were saying was clearly understood, considered and recorded but the contributions from victims have helped agencies and practitioners learn, reflect and change practice. While the focus of the extensive work was on protecting the victim from exploitation, the case illustrates how important it is to clearly communicated to the victim and family with explanations for what was happening and why, including any difficulties arising from limited placement options and problems planning when responding to frequent crises. If agreement on proposals cannot be reached, there should be consideration given to how nevertheless victims might be helped not to feel they have been excluded. These contributions illustrate how important it is not just to listen. Listening must be accompanied by clarity over what has been understood and communication of the likely implications, including ensuring all relevant professionals are fully aware. This victim is being helped to access advice and raise concerns about her time in residential care and is being encouraged to work with staff to look at practice. She is very keen to support other children at risk and is helped to do so. Work has been undertaken to encourage focussing on continuity, consistency and communication. In 2017, the Ofsted inspection found that in Newcastle children do have meaningful and consistent relationships with social workers, who know them well and Inspectors saw good examples of direct work helping children understand their histories and experiences. All the other victims maintained that when sexual exploitation began they would not have co-operated with any attempts at persuading them to talk about it, which appeared to be due to lack of understanding about the true nature of the abuse, fear, and threats and coercion they faced. Arrangements to carry out return interviews of individuals who have been missing have been improved and allow that not even partial disclosures might occur without further work being undertaken. Support includes accepting that victims will frequently require time before talking about experiences. All the victims stressed how important continuing support and patience of staff working in the Hub was in gaining their confidence. Newcastle Safeguarding Boards’ interagency training, practice guidance and review and audit processes include care taken to listen to victims. 112 9.16 Lack of Engagement with Services In the cases, there were examples of victims and victims’ families not engaging with services available or offered. This concerned particularly mental health or specialist community services. Agency Reports and Practitioners noted that records often described this as a client’s difficulty in engaging with services or failing to attend or to keep appointments. It was suggested that it is preferable to record that the service was failing to engage with the client as this is more likely to encourage consideration of how the problem could be addressed. The victims’ lives were chaotic, they lacked awareness of their abuse and their priorities were at odds with the professionals whose involvement was resented. “I pushed the help away. I knew professionals were trying to see me and I cancelled appointments. I was scared of being judged.” “I was not eating properly - I was anorexic. The social workers were worried about me. It was difficult to contact me. They did not know why. I was scared to tell anyone – ashamed.” Inevitably, pressure on resources leads to discharges or closure of cases and there may be no benefit from an open case if there is no attendance. There were good examples, including SCARPA, and Newcastle City Council services where files were kept open even though a client was not attending, in case the situation changed. With other agencies repeated failure to attend appointments led to discharge from the service with no or insufficient enquiry to ascertain the reason and without follow up or action. There were examples of correspondence notifying appointments being sent to a recipient who had difficulty reading or sent to an out of date address. “With letters people need to be more understanding about what I can understand.” Practitioners emphasised that discharge should not occur without a family member or local authority employee responsible for ensuring appointments were kept being informed. A child in the care of a local authority should not be considered for discharge from a service without reference to the responsible social worker and consideration by the managers of the authority and the Independent Reviewing Officer. Where attendance is a feature of a safeguarding plan for a child or adult, the issue should be considered within interagency arrangements. “When my mother died. I was offered counselling in school but did not go back. They did not ask why.” “It was fear of the perpetrators and their associates. Also, everyone would know – the embarrassment, humiliation and I was a grass”. 113 “I didn’t tell people about the voices – I don’t know why. I was drinking heavily. there was a lot of chaos.” “I was struggling to get to appointments – it was put down to the drink.” There were no examples of agencies “giving up”, but plans to address this problem were often weak. In 2015, the Government165 commented that it is unacceptable that children who need treatment from Child and Adolescent Mental Health Services cannot access services or should be dropped from services where they are unable to attend an appointment. It undertook to set out in a Child and Young People’s Mental Health Taskforce report an ambition to support and inform the design and delivery of local services to all children and young people, including those sexually exploited. Delivering that ambition “will require local leadership and ownership”. “Mental health support has been a joke. Loads of assessments but nothing comes out from them – what is to be done about it? “I have been detained under the Mental Health Act on 3 occasions. But nothing happened afterwards. “That is until now. I am involved with the Personality Disorder hub – psychologists.” In February 2016 the Department of Health and Department for Education commissioned the Social Care Institute for Excellence to establish an Expert Working Group. In November 2017, the Group published its final report including recommendations on improving mental health support for children and young people.166 Non-engagement with victims was reflected in the Review Learning Logs as requiring immediate attention. The expectation now is that when interagency safeguarding arrangements are in place, availability of provision should not be withdrawn without the issue being considered and a solution agreed or the development of alternative plans. General Practitioners and Newcastle upon Tyne Hospitals NHS Foundation Trust have a protocol to address non-attendance of children at appointments which involves referral to the Trust safeguarding team, which has a monthly operational safeguarding meeting with a social worker in attendance. These arrangements are subject to audits that confirm such referrals are made. Agencies have also reviewed how their service models might include a broader range of methods for engaging children and young people who may be hard to reach or at risk including how to mitigate loss of contact through being placed on a waiting list. 165 Para. 54 Tackling Child Sexual Exploitation HM Government. March 2015 166 Improving mental health support for our children and young people: Expert Working Group. SCIE. November 2017 114 Recommendation 1.14 I recommend that: Northumberland Tyne and Wear NHS Foundation Trust should report to Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board on the arrangements being made for local delivery of the Governments ambition to improve access to Mental Health Services for all children and young people, including those sexually exploited. 9.17 Team Around the Worker The Review included cases in which multiple needs of victims led to involvement of large numbers of agencies which ironically increased the likelihood of non-attendance. For one case 25 agencies provided timelines and reports. The Learning Events highlighted that this was likely to be overwhelming for the service user. It was suggested that a co-ordinator should be appointed through interagency processes to ensure continuity, flexibility and wrap around services and to identify the professionals or services with which a victim feels most comfortable. This would be a challenging role requiring considerable support, hence the reference to a “Team Around the Worker”. These principles have been reflected in the development in children’s services of Early Help and the Team Around the Family which includes an expectation that an appropriate Lead Practitioner will act to co-ordinate services. The framework developed by Newcastle Safeguarding Children Board expects that the co-ordination will identify specific support for members of the Team and is subject to review and monitoring. In Adult Safeguarding arrangements are in place to try and keep the number of professionals involved to a minimum by identifying a single point of contact through the professional who has the best relationship with a victim. 9.18 Capacity and Choice A persistent feature of the cases was uncertainty about whether a suspected victim had the mental capacity to consent to sexual acts and to reject attempts by agencies to prevent abuse and to choose to continue to be involved with perpetrators. In 2011, Ofsted found that in serious case reviews across the country that during 2007 to 2011, there was a failure to understand the impact of coercion by abusers on behaviour and to assess capacity to make informed choices or truly consent to 115 go with their abusers.167 The issue has consistently arisen since, including in Rochdale, Rotherham, Oxfordshire and, in 2017, Somerset.168 As children approach adulthood the impact of the statutory ability to consent to sexual acts after the age of 16 years complicates the issue. In Newcastle, similar uncertainties and the extent to which vulnerabilities undermined capacity also arose in relation to adult victims. Practitioners felt there had not been a clear understanding of the application of Mental Capacity Act principles and the impact of the assumption of capacity. Risky behaviour was interpreted as making unwise decisions by competent individuals rather than possible result of abuse. However, there was no evidence that assumptions were applied to all cases systematically or that having concluded victims had capacity, attempts to influence victims and the choices they made ceased, as appears to have occurred elsewhere. On the contrary, the encouragement to allow children and adults with vulnerabilities autonomy, responsibility and the right to choose influenced judgments about what could be done rather than whether something should be done. As the prevalence and impact of sexual exploitation has become better understood, the criminal courts have been more accepting that the ability to consent and make choices in best interests can be eroded by grooming, coercion, drugs and alcohol. National safeguarding children guidance now stresses the importance of considering these factors. The experience in Newcastle illustrates that the same care must be applied to adults who are vulnerable and targeted. These issues have been robustly addressed by the Safeguarding Boards through interagency training programmes, the joint sexual exploitation strategy and by partner agencies through internal training. Problems are considered by the Multi-Agency Sexual Exploitation Group and individual cases at the Risk Management Group. The effectiveness of arrangements is monitored through audit and reported to the Boards. 9.19 Mental Health and Learning Disability The cases included victims whose cognitive impairment had been identified previously and others in which no impairment had been identified but was suspected by professionals involved in addressing the exploitation. There were also circumstances in which cognitive difficulties of parents and the impact on their ability to protect had not been considered. During the Learning Events discussions identified uncertainty about: 167 Ages of concern: learning lessons from serious case reviews: A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011. Ofsted 2011 168 The Fenestra Serious Case Review into Child Sexual Exploitation: Somerset Safeguarding Children Board November 2017 116 • Differences between learning disability and learning difficulty and relevance • The extent to which either is susceptible to formal diagnosis • Whose responsibility it is to assess • Education services responsibilities • What is the relationship with mental ill-health • The meaning and impact of mild, moderate or severe categories • Skills to work with impaired victims and when victims are unwilling to engage • Handling and distinguishing capacity to decide some things but not others • Impact on capacity of drugs and alcohol, abuse and mild cognitive impairment • When to expect that impairment will have been identified during childhood • Sources of expertise, advice and consultation for practitioners and availability from mental health services or the Community Learning Disability Team This is unsurprising. Uncertainty is widespread. NHS Choices explains that learning disability is not the same as learning difficulty or mental illness but “it can be very confusing as the term "learning difficulties" is used by some to cover the whole range of learning disabilities.”169 There is a difference in the language used in the education, health and social care services. Learning disability is assessed taking account of a combination of IQ and intellectual and social functioning rather than an absolute diagnosis. Terminology might determine eligibility for services and for benefits. Recommendation 1.15 I recommend that: Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should arrange for guidance to be issued to practitioners on the differences between learning disability and learning difficulties and the relevance for safeguarding judgments and services. In one case, practitioners in Children’s and Adults Social Care working with a victim approaching adulthood, who had no history of assessment of cognitive impairment, suspected her ability to make appropriate choices was undermined by cognitive problems. This issue had an impact on the ability to intervene once she became an adult. After seven months of negotiations it was concluded by the provider of mental health services, Northumberland Tyne and Wear NHS Foundation Trust, it would require the victim’s consent to assess capacity and if she was not for any other reason eligible for services, the Trust would not become involved. The same principles would be applied if an assessment of a parent or carer was required. Even if a victim refuses to consent and is not eligible for mental health services, safeguarding practitioners still need advice on the approach to the case and to 169www.nhs.uk/livewell/childrenwithalearningdisability/ 117 support court applications. Newcastle City Council paid privately for an assessment and advice. In some cases, such difficulties have been overcome by the willingness of individual professionals to become involved rather than clarity about the appropriate source for these services. NHS Trusts have statutory duties170 to co-operate with the local authority to safeguard and promote the welfare of children and vulnerable adults and carry out all their functions having regard to the need to safeguard and promote the welfare of children. But the services are commissioned and funded by NHS Clinical Commissioning Groups. There is a determination in Newcastle to address and clarify this issue. NHS Newcastle Gateshead Clinical Commissioning Group is taking the lead in bringing interested parties together to discuss and clarify the need for services and from where they should be accessed. A report will be made to the Safeguarding Boards on the outcome of this initiative. The Review confirmed that there is now a greater awareness of the need for timely recognition that victims may lack capacity, the impact of learning disability on capacity to make decisions and that children and adults with special needs may be at increased risk. Responding to Agency Reports and the Learning Events discussions, training has been delivered and attended by the Council Legal Services, to improve understanding of the Mental Capacity Act 2005, the application to individuals aged 16-18 years, the Deprivation of Liberty Safeguards, the relationship with the Care Act 2014 and other legislation, the jurisdictions of the Court of Protection and High Court and the impact of case law. Northumberland Tyne and Wear NHS Foundation Trust has made improved the organisation of safeguarding arrangements and guidance and training to increase awareness and improve practice in identifying children and young adults who may be at risk. Policies have been updated to encourage a multi-agency approach and include clear criteria and referral processes and the consideration to be given to vulnerability wider than mental health. Staff attend Multi-Agency Risk Management Group meetings and take part in the Huddle, which provides a fast track process for mental health services for victims considered within the Hub. NHS Newcastle Gateshead Clinical Commissioning Group has commissioned, through The Newcastle upon Tyne Hospitals NHS Foundation Trust, Specialist Learning Disability Liaison Nurses within the Safeguarding Adults team, who work across the Trust and provide support to ward staff and community staff. The records of patients with a learning disability are flagged so all services are aware and make reasonable adjustments. The under-18 proforma in Sexual Health Services has been amended to demonstrate consideration of mental capacity and assessment and a specialist learning disability nurse has been appointed. Mental Capacity Act training is 170 Children Act 2004. Care Act 2014 118 provided and there is a Mental Capacity Act Steering Group within the Trust, and Lead member of staff in post. There has been investment in a learning disability service in maternity services and in improving recognition, response and recording in the emergency department. Your Homes Newcastle has arranged training to raise awareness of working with clients with learning difficulties and a specialist mental health social worker advises the Housing Advice Centre. The Missing, Sexually Exploited and Trafficked Group has developed an Action Plan and established a working group to ensure that the learning and recommendations in a report171 on the needs of children with learning disabilities who experience, or are at risk of, sexual exploitation are incorporated on a multi-agency basis into documents, policies and procedures. The Ofsted inspection in 2017 identified that some children in Newcastle are waiting too long for timely access to specialist emotional and mental health support services. Children also criticised delays. Action is being taken to address this and multi-agency policy and procedures are being updated. 9.20 Education Services and Learning Disability The cases included an adult who was at continuing risk of financial and sexual exploitation. There was no record of any assessment of learning disability during childhood but as part of the safeguarding adult’s processes, she was assessed as having a significant learning disability, sufficient to support an application to the Court of Protection for authority to deprive her of her liberty. Practitioners at the Learning Events highlighted an apparent discrepancy between school reports of her doing well and evidence of learning disability and limited capacity as an adult. However, review of her school file indicated that although this was not available to adult practitioners, she had been identified as having special educational needs and undergone continued assessment while at school. With this support, she was able to make satisfactory progress against attainment targets. To place this in context, during the Review a contribution from the Manager of the Educational Psychology Service provided helpful clarification: • Assessments of special educational needs and disabilities operate with a statutory Codes of Practice172 revised from time to time. During the period reviewed, they consistently emphasised the need for a graduated response, with schools being expected to assess and meet needs before involving outside specialists or requesting additional support from the Local Authority. 171 Unprotected, overprotected: meeting the needs of young people with learning disabilities who experience, or are at risk of, sexual exploitation; Franklin et al, Barnardo’s. 2015 172 Special Educational Needs and Disabilities Code of Practice; latest version issued 2015 119 • Education staff refer to learning difficulties - learning takes place within a context and learning difficulties will vary according to environment, teaching methods and a range of social and emotional factors as well as underlying cognitive skills. Access to provision or level of support within Newcastle’s education systems is never determined by an IQ score. • Whether a child has a defined learning disability is not typically a focus for school assessment or intervention. Schools and Educational Psychologists focus on the child within context, investigating possible reasons for any Special Educational Need, planning appropriate interventions and reviewing progress. • From an education perspective, a young person's adaptive behaviour and the protective factors are as important in predicting vulnerability as their IQ. A young person with a low IQ might be less vulnerable than one with a higher IQ depending on their life experiences and environment. • Newcastle City Council funds Educational Psychologists to carry out statutory assessments for the Education, Health and Care Plan process. All other work is funded by schools or other services. The majority of work in schools is planned through priority setting meetings with school staff. • School staff are unlikely to refer children to the Educational Psychology Service if they are settled and happy and making progress at their own level, with or without support. It is therefore not unusual that even though an adult may be assessed as having a severe learning disability, there will not have been and need not have been any cognitive assessment during childhood. Therefore, no assumptions should be made about cognitive impairment and in safeguarding processes appropriate assessments always need to be considered. It was suggested that there is a need to develop protocols between education and social care services to provide for what action social workers should take if concerned a child may have cognitive impairments or a learning disability. While discussions that include consideration of children over school leaving age have been taking place, guidance has been issued by Newcastle Children’s Social Care to social workers clarifying the issues and emphasising the need where assessments are necessary to inform judgments to privately commission them from appropriate services. A report will be made to Newcastle Safeguarding Children Board when a protocol for access by children’s social care services to educational psychological services to inform welfare judgements has been agreed. 9.21 Placements Placing children looked after by the local authority is complex. When for reasons linked to their vulnerability and perhaps coercion, they are determined to leave 120 accommodation and not co-operate with arrangements, the complexity is significantly increased. Resources for children with complex needs are scarce. Victims of sexual exploitation are likely to be placed with other children who have complex needs. In her contribution, one victim illustrated this problem. Providers of accommodation decide who will be admitted and local authorities compete for provision. Residential placements are often at considerable distance from home areas and the professionals working with them. Residents may include victims from their own area and from different parts of the country. “I wanted to get away. P was placed there. We ran away and were picked up by L and a man. The abuse went on.” Another case included a victim who experienced 13 different care placements and 16 moves and, another, 15 placements involving two foster placements, seven residential placements, two independent living placements and four periods in secure accommodation. In these circumstances it is difficult to plan and ensure continuity of health and education provision. Arrangements have since been made to try and ensure health information promptly follows the child and is shared with relevant personnel. Within the constraints, the cases reflected a strong and ongoing commitment by Newcastle City Council Children’s Social Care to identify appropriate placements to protect the victims. This included secure accommodation when it was necessary to restrict the ability of a victim to leave a placement, continued unusually in one case until the victim was 18 years of age to maximise opportunities to influence her behaviour. During the Learning Events the Practitioners expressed unease at the placement of a victim in a secure placement while the perpetrators remained free. All the victims had high regard for the staff who work in secure units but resented having been placed. “I was put in a secure placement with kids with a criminal background. I was a victim – why was I there, I had done nothing wrong.” “I was in a care home – but those men were walking about free.” “The risk assessments also meant that my phone and internet were removed which made me feel isolated. I had no contact with friends who were no risk to me.” One victim spent 10% of her childhood in secure accommodation. Secure placements for children are authorised and kept under review by the Family Court and must end when the statutory criteria allowing the placement are no 121 longer satisfied. Residents can be skilled at complying with requirements and securing release before there has been an opportunity for therapeutic intervention. “It didn’t change me”. The Oxfordshire Review concluded that secure accommodation may solve the problem temporarily but is ineffective beyond, unless groomers are disrupted or removed.173 The Practitioners commented that the placements had two objectives, to save victims from themselves and to save victims from perpetrators. Mostly the first was met but the second was not always met in secure settings, since contact from perpetrators continued and there were no effective measures to deal with them. An evaluation report of a secure unit published in 2016174 commented that for a secure placement to do more than care for a young person for the length of the order, it needs to be part of an integrated long-term plan by the placing authority, incorporating: • Thorough appraisal of needs and assessment • An ongoing relationship with a worker – preferably prior to, during and after • Transition planning from the start of the order • Appropriate residential, foster care and independent living options being available • The start of therapeutic relationships to continue in the community • Transitional support to parents and carers “… this is far more difficult if young people are placed a long distance away.” The circumstances in which this is achievable must be very rare. The impact of current legislation is that a child may either be placed where there is no ability to physically control or in a registered secure placement. There is more flexibility for placements of adults and Newcastle Adults Social Care has effectively used the court to gain authority for making variable arrangements, short of total deprivation of liberty. These still require judicial overview to satisfy Article 5 European Convention on Human Rights and Fundamental Freedoms. “I am in a bungalow for people with disabilities. I am there under a court order. I am to learning to manage. I am not ready to leave yet.” It would be helpful to consider introducing similar flexibility for the placement of children. Article 5 and the courts’ interpretation require the ability to appeal against and continuing judicial review of deprivation of liberty. The current arrangements are 173 Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F. Oxfordshire Safeguarding Children Board 2015 174 Scott, S Aycliffe CSE Innovation Project: Evaluation Report, Department for Education. 2016 122 unwieldy and costly and would benefit from consideration of whether arrangements more suitable for the task might be introduced and be compliant with Article 5 requirements. Recommendation 2.13 I recommend that: The Government should review the arrangements for obtaining authority to control or restrict the liberty of children and vulnerable adults at risk of sexual exploitation with a view to improving flexibility of provision and reducing costs and complexity of judicial overview. In Newcastle, arrangements for planning and commissioning placements have been reviewed. Only 5% of children looked after by Newcastle City Council are in residential care. Decisions about accommodating children and initiating proceedings are considered by the Care and Resources Panel which is attended by Legal Services. Admissions to care are approved by the Assistant Director and consistent with legislation and guidance, decisions to place out of authority and at a distance are taken personally by the Director of People. Local authorities in the region work together to assure quality of placements and, when it is necessary to go outside the local framework, checks are made of relevant Ofsted reports, consultations take place with area local authorities and the social worker visits prospective placements prior to and during placement. Police may be asked to undertake checks to help identify potential risks. As part of an overall strategy, Newcastle City Council is to build a new children’s home for young people who may be harder to place. All the agencies providing residential care that took part in the Review have introduced changes that reflect careful consideration of the issues. These include: • More effective planning of sharing information with residents • Identifying a sexual exploitation champion staff member to lead with the Home Manager on sexual exploitation • Improved arrangements for notifying social workers of safeguarding concerns • Improved partnership working with police • More care considering referrals of previously placed young people and victims who become perpetrators • More focus on multi agency work • Clarity about work to be completed before the end of placement • Prioritising an Impact Risk Assessment and information gathering prior to admission • Child Sexual Exploitation Risk Assessment • Locality Risk Assessment, identifying crime rates and local area hotspots • Developing a Missing from Home Safety Plan • Risk Management Panels • Online safety training; devices to jam Wi-Fi signals 123 9.22 General Practice A feature of serious case reviews is often that General Practitioners have been insufficiently engaging with or contributing to safeguarding. In this Review, however, General Practitioners supported victims and, in the context of what they knew, responded to their needs and acted appropriately in relation to interagency processes. The cases revealed that an assumption by other agencies that General Practitioners are the repository for most health records and details of health engagements was wrong. They may not be informed of involvement by other health agencies, including sexual health services, and safeguarding enquiry processes need to have regard to this. This has been addressed in Newcastle within procedures and practice guidance. Practitioners argued that if confidential relationships extended across the health service rather than with a professional or a unit, a General Practitioner may treat a patient with an understanding of the bigger picture. General Practitioners were not consistently informed about the status of a patient, in particular if they were looked after by the local authority or subject to child protection or adult protection concerns, strategy meetings or conferences. Action has been taken to address this and compliance is included in audit arrangements. NHS Newcastle Gateshead Clinical Commissioning Group has drawn on experience elsewhere and developed a tool to assist General Practitioners to better identify sexual exploitation and flag records. 9.23 Boys and Men There were no boys or young men among the cases considered in the scope of this Review and only one victim suggested their involvement. “There were a lot of girls and boys. Some were beaten up. It was sort of normal.” Although the consensus of opinions is that males are likely to be sexually exploited, they have not been significantly represented in investigations and responses. In the cases that have arisen, different and complex models of exploitation have been involved. It is suggested they have been largely overlooked.175 In 2015, Research on Child Sexual Exploitation in the North East and Cumbria identified a total of 310 female and 41 male victims.176 In 2017 the Government asserted177 that boys are also at risk and during the Review the SCARPA Squad suggested that boys need to be educated in healthy relationships, as they get exploited also. 175 Summary of findings Research on the sexual exploitation of boys and young men: A UK scoping study. Nicholls et al. Barnardo’s. August 2014 176 Child Sexual Exploitation in the North East and Cumbria. Hartworth Northern Rock Foundation November 2015 177 Advice: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation”. Department for Education. February 2017 124 The Newcastle Safeguarding Boards Joint Sexual Exploitation Strategy relates to female and male victims. Tools and the training highlight the importance of proactively engaging with male victims and the barriers to male victims making disclosures and how they may present differently. The local understanding of the prevalence of sexual exploitation of boys and young men is a priority area in the Strategy. The BLAST Project is the UK’s leading male only sexual exploitation service. In June 2017 staff from the Hub, Northumbria Police and the Newcastle Safeguarding Boards attended the BLAST training programme on promoting awareness of sexual exploitation of young men and boys. 125 10. Professional Awareness, Training and Staff Development Up to date training programmes and a knowledgeable and skilled workforce are preconditions to competent responses to sexual exploitation.178 Managers and practitioners need to have confidence in a level of understanding across agencies. 10.1 Interagency Training Training delivered in response to Government Guidance from 2000 was developed in the context of the understanding of the prevalence and nature of sexual exploitation. The staff who attended the Learning Events felt that, during the early period reviewed, training was “patchy” and the general level of awareness was low. There was a lack of experience and expertise to draw upon. Some professionals, particularly General Practitioners, had difficulty committing time. They confirmed that there is now a significantly greater awareness of sexual exploitation encouraged by inter- and intra-agency training over recent years, informed by national and local reviews. The Newcastle Safeguarding Children’s Board has provided face to face training on child sexual exploitation carried out by the Children’s Society since 2009 and online training commissioned through the Virtual College with an increase year on year. In 2014 the Audit Group established a set of minimum standards of knowledge for practitioners within a Sexual Exploitation Capability Framework. Newcastle Safeguarding Children’s Board with the NSPCC provided a seminar to key professionals across agencies on partnership working to protect from child sexual abuse and exploitation. The Safeguarding Boards identified common features of sexual exploitation of children and vulnerable adults and collaborated on strategy, procedural and practice development, but found a lack of national resources and training relating to adults. As a consequence, the Boards developed training materials from scratch, based on local experience and knowledge and a joint training work plan with pathways for all agencies. The Boards have also worked with the Virtual College to develop an e-Learning package which covers both adults and children, the first of its kind available nationally. In 2016, the Boards introduced a joint training programme. Briefings and training events have addressed General Practitioners, Practice Nurses, Paediatricians, Adults Safeguarding Team and Independent Schools and 178 Advice, Child sexual exploitation: Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation. Department for Education. February 2017 126 Newcastle City Council Senior Education Advisor Safeguarding and SCARPA Project Manager have trained Designated Teachers. In February 2016, Newcastle Safeguarding Children’s Board commissioned the drama production of Chelsea’s Choice for schools, linked to the Personal Social, Health and Economic healthy relationship curriculum. Ten schools were involved in this, reaching 1093 pupils. Consideration of the cases and discussions at Learning Events identified a number of areas for training which included: • A need to improve awareness and “legal literacy” amongst professionals of the provisions Mental Capacity Act and the impact of case law. This has been addressed through training which Newcastle City Council Legal Services has delivered, improving the level of knowledge within its own service. • Working with different cultures and faiths. The Practitioners’ Events indicated a need for further training on distinguishing between differences in child rearing and practice skills to address the shame families might feel at having professionals involved. Newcastle City Council Children’s Social Care have included these issues in training provision reflecting the importance of including culture and faith issues as an integral part of all safeguarding. • Managing cases of neglect The cases confirmed research179 that neglected children are vulnerable to sexual exploitation. A background of child neglect also gives rise to risk for adults with vulnerabilities. Neglect training measured through evaluation, feedback and surveys, was launched as a priority by Newcastle Safeguarding Children Board in January 2016. The Ofsted Inspection in 2017 found the identification of neglect as a Board priority has ensured a consistent focus and practice development. • Wider education across agencies on the importance of considering the impact and need for care across the whole life course. The Safeguarding Boards joint training programme on sexual exploitation addresses need for understanding the impact of sexual exploitation throughout life. • Training should be through a variety of methods accommodating for different professional groups. The Review found that there is a range of well-planned training across agencies which includes face to face and on line, taking account of different learning preferences. The Boards’ multi-agency joint training programme is delivered in line with priorities and informed by a range of audits of practice, evaluations and 179 Exploring the Relationship between Neglect and Child Sexual Exploitation: Evidence Scope. Research in Practice: Dartington. Hanson, E. (2016); Howarth, J. and Tarr, S. 2015 Child Visibility in Cases of Chronic Neglect: Implications for Social Work Practice, BJSW 45 (5), 1379-1394 127 research and a Training Evaluation Strategy. Attendance and frontline practitioner’s views and suggestions are reported to the Board. Community and voluntary organisations attend Newcastle Safeguarding Boards’ training and deliver training to other agencies and to the community and to schools. Barnardo’s and the Children’s Society have brought learning from their agencies’ national perspectives. The Angelou Centre provides a link with ethnic minority communities. The Newcastle Council for Voluntary Service disseminates up to date information to the voluntary and community organisations and contributes to training by the Boards and SCARPA. An annual safeguarding check-up about safeguarding for voluntary and community sector organisations is undertaken. Because of Operation Sanctuary, Newcastle has become a centre of excellence and a source of expertise. Success breeds success and attracts and retains staff and has an immeasurable beneficial impact on morale and availability of expertise for training. The Ofsted inspection in 2017 confirmed this positive view of the training arrangements. Recommendation 1.16 I recommend that: When reviewing the training strategy Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should have regard to the issues raised at the Learning Events. 10.2 Agency Training The Safeguarding Boards audit agency training to establish what is provided and by whom and have set minimum standards to ensure consistent learning outcomes. All agencies and Practitioners have reported increased training, including refresher and induction training, for staff on recognising, working with and the impact of sexual exploitation. The expertise and specialism within the Sexual Exploitation Hub has supported practitioners across the workforce. Reviewing the cases, the Newcastle upon Tyne Hospitals NHS Foundation Trust found it was not consistently evidenced that sexual exploitation was considered when individuals attended services, including emergency departments, Walk in Centres, sexual health services and early pregnancy clinics. Action has been taken to raise awareness and the Review reports reflected a confidence that learning has been embedded through training, safeguarding forums and a sexual exploitation awareness day. A package reflects learning from the Review and includes children and young adults. Northumberland Tyne and Wear NHS Foundation Trust identified weaknesses in understanding and recognition during case management and in multi-agency 128 approaches to referrals, assessments, care planning, treatment and support for victims. Every team member now covers all aspects of safeguarding and has received additional training to encourage comprehensive and holistic approaches. Sexual exploitation training has been updated and includes referral processes. All clinical staff undertake Mental Capacity Act, Mental Health Act and deprivation of liberty safeguards training every three years. Extensive training in Northumbria Police meets College of Policing expectations.180 It has been identified through Northumbria Police's Sexual Exploitation Strategy and Action Plan, the Multi-Agency Sexual Exploitation and Trafficking Groups and business managers. A CSE APP provides guidance on relevant legislation and orders. Operation Sanctuary increased understanding of possible responses. A training package was delivered to all operational staff within four months of the launch and refresher training to all officers throughout 2015. In October 2015, a joint conference was attended by 500 professionals from all safeguarding partners in the region. Dealing with victims with complex needs has been addressed and a psychotherapist has improved understanding by all officers, including the Chief Officer Team. Northumbria Police has delivered joint training for leads in primary and secondary schools, for all General Practitioners, health visitors, midwives, Newcastle City Council Elected Members and Adult and Children’s social care. They have worked with the licensing staff in local authorities to train taxi drivers and all taxi drivers now have to attend safeguarding training as a condition of license application and renewal. In order to improve awareness, Your Homes Newcastle has arranged additional training and a lecture from a national expert for support staff, extending an invitation to attend to Board partners and some voluntary organisations. All support staff have had training in Mental Health needs and discussions with Newcastle Safeguarding Children Board have been held to include front line Young Persons Service staff in learning disability training as this has been identified as a multi-agency need. Training for all staff and induction in the Housing Advice Centre Team includes awareness. In Newcastle Children’s Social Care and Adult Social Care sexual exploitation training, underpinned by learning from local and national reviews, is included in all safeguarding children and adults training including induction. Training has been carried out by Barnardo’s for all Children’s Social Care staff and mandatory training is provided for all residential staff and foster parents. Staff have access to a Cultural Competence departmental training course provided by the Coram BAAF Academy. 180 College of Policing CSE Action Plan 2014 to 2016 129 Joint training developed for children’s and adult social care staff covers a range of topics including the Mental Capacity Act, Transitional Arrangements, The Care Act 2014 and responding to sexual exploitation. Newcastle City Council Legal Services has ensured that all legal staff are aware of the range of legal options available to address sexual exploitation and the Mental Capacity Act implications for children and adults. Legal staff have contributed to training including court skills for Adult and Children’s Social Care staff. The Home Affairs Committee181 highlighted the need for awareness of sexual exploitation across Council departments. Newcastle City Council has a Corporate Safeguarding Group chaired by the Director of Operations that brings together senior staff from across departments to address wider training and education within services other than social care and education. Community and voluntary organisations have comprehensive training programmes including awareness and addressing sexual exploitation, taking account of learning from the Newcastle experience. The Safeguarding Boards’ routine audits ask agencies about training on sexual exploitation within the organisation and providers of services they commission. 10.3 Personal Professional Responsibility The government has emphasised that practitioners need to be aware of their personal responsibility to ensure they have the knowledge and skills to competently practice. During consideration of the cases and at the Learning Events, there was extensive evidence that staff worked hard to safeguard and support victims. The Agency Reports included reference to research and national guidance when commenting on practice, but there was little evidence of consideration of these in the working of the cases. National published materials address strategic arrangements but often also include detailed practice guidance. Working Together to Safeguard Children 2015, includes in the answer to “Who is this guidance for?” “All relevant professionals should read and follow this guidance so that they can respond to individual children’s needs appropriately.” A version of the guidance for young people and a separate version suitable for younger children are also available for practitioners to share. Unless aware of the content they clearly cannot decide which children or young people should have a copy. Paragraph 49 of Working Together 2015 provides that: 181 House of Commons Home Affairs Committee Report: Child sexual exploitation and the response to localised grooming House of Commons London: The Stationery Office Limited. June 2013 130 “Social workers and managers should always reflect the latest research on the impact of neglect and abuse and relevant findings from serious case reviews when analysing the level of need and risk faced by the child. This should be reflected in the case recording.” The Government Advice in February 2017, emphasised that practitioners across agencies are responsible for ensuring they fulfil their role and responsibilities in a manner consistent with the statutory duties of their employer. Detailed practice expectations were set out in Annexes. Departmental Advice published in 2014 on Working with foreign authorities, was “primarily for local authority staff working with children and families, frontline social workers, their team managers, service managers, and children’s services lawyers.”182 This issue is as important for safeguarding adults as for safeguarding children. Newcastle partner agencies and the Safeguarding Boards have good arrangements in place to consider new guidance and paraphrase or reflect the content in local guidance and procedures. Links are provided to substantive documents and briefings or additions to training programmes promptly arranged. There will be a delay before local interpretation and dissemination can take place and practitioners need to be able to put the local materials within a national context and be aware of what they can expect of other agencies and professionals. Newcastle Children’s Social Care staff have access to Community Care and Research in Practice which provides up to date guidance on and legislation as well as evidence and learning of best practice across the country. Adult Social Care staff are provided with updates on guidance and legislation through “Community Care Inform”. Audit arrangements and reports to the Safeguarding Boards address whether agencies have in place arrangements to make clear to staff that they have a personal responsibility to be familiar with legislation and guidance that relates to their area of function. 10.4 Staff Welfare Sexual exploitation and the work involved is distressing. The inability often to have a positive impact and addressing the long-term damage is likely to be stressful. Staff may be exposed to violence. The emotional impact may include negative feelings such as anxiety, worry and upset even by those reporting higher levels of knowledge, skills and experience.183 Newcastle City Council Adult Social Care and Children’s Social Care have arranged for external expert support on an ongoing basis for staff in the Hub from a psychotherapist who has provides group and individual sessions for staff, case discussion sessions and oversight of policies and procedures 182 Working with foreign authorities: child protection cases and care orders Departmental advice for local authorities, social workers, service managers and children’s services lawyers Department for Education July 2014 183 Workforce perspectives on harmful sexual behaviour: findings from the Local Authorities Research Consortium 7. National Children's Bureau. 2017 131 New Key Support Ltd have a staff friendly rota system and a staff retention and welfare policy to provide early recognition and intervention of personal and team staff issues. Northumbria Police Force arrangements reflect the College of Policing Action Plan which expects effective welfare procedures for staff investigating child sexual exploitation. The Children and Family Court Advisory and Support Service has a confidential counselling helpline service for staff welfare. Audit arrangements and reports to the Safeguarding Boards address whether agencies have in place arrangements to consider the welfare of staff in the context of carrying out safeguarding responsibilities. 132 11. Challenge, Support and Escalation 11.1 Challenge There was no evidence that any agency challenged the police over their approach to investigations or lack of action against perpetrators prior to 2014 or raised concerns about the adequacy of safeguarding assessments and plans that did not address the perpetrators. There were examples of agencies having anxieties about responses by other agencies but this was not addressed in interagency meetings or escalated to senior managers or through any other processes. The effectiveness of safeguarding arrangements is a collective interagency responsibility and a culture in which challenge is expected, encouraged and welcomed is necessary.184 The tendency of groups to avoid dissension needs to be countered by professionals challenging themselves and encouraging challenge as the most effective corrective to biases, misjudgements or clinging to erroneous beliefs.185 The members of Safeguarding Boards have an individual and shared responsibility for the effective discharge of the Boards’ functions, to contribute to the work of the Boards, to make the assessment of performance as objective as possible and to recommending or decide upon action necessary to put right any problems: “This should take precedence, if necessary, over their role as a representative of their organisation.”186 The Learning Events highlighted lack of familiarity with Newcastle Safeguarding Children Board’s inter-agency Resolving Professional Differences Protocol and it has been relaunched and widely circulated. Audits show that pathways for resolving issues without formal processes are well established. The use of and circumstances leading to the use of the Protocol are monitored and reported to the Board. Practitioners identified the establishment of the Hub and co-location of staff as encouraging collective responsibility, challenge and contribution to judgments made by other professionals, extending beyond the Hub. There is a new openness to critical reflection and challenge which they found supportive. Schools reported that collaborative work was taking place with staff in Children’s Social Care and they have no hesitation in taking up concerns about responses 184 Ages of concern: learning lessons from serious case reviews: A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011. Ofsted .2011 185 Munro: Improving reasoning in supervision. Social Work Now. August 2008. Groupthink: psychological studies of policy decisions and fiascos, Boston, MA: Houghton Mifflin Janis 1982, Reder and Duncan Lost innocents: a follow-up study of fatal child abuse, London: Routledge 1999. Working with child abuse, Corby 1987; Birchall and Hallett; Farmer and Owen. Milton Keynes: Open University Press. 1995 186Paras. 3.58; 3.65 Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government. 2006; Paras. 3.70; 3.85 Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. Department for Schools, Children and Families. 2010 133 with senior managers and would if necessary escalate the issues through the Protocol. Checks and balances to provide for challenge include the role of Independent Reviewing Officers and, during family court proceedings, the Children’s Guardians appointed by the Children and Family Court Advisory and Support Service. In the cases, there were examples of Independent Reviewing Officers acting positively to challenge drift, but others where it was insufficient. Neither service challenged the inadequacy of plans that did not disrupt perpetrators’ activities. In 2017 Ofsted187 commented that Independent Reviewing Officers’ scrutiny of children’s plans and evidence of their challenge and impact is not well recorded and could be stronger. Action has been taken by Newcastle City Council to strengthen the remit and authority of Independent Reviewing Officers and the effectiveness of this role will be subject to continuing review and audit. Audit arrangements and reports to the Safeguarding Boards address whether there is evidence in practice that healthy challenge is a feature of safeguarding work in Newcastle. 11.2 Supervision A recent survey of over 500 professionals working across agencies in six local authority areas found high quality reflective supervision is key to practitioners' ability to work safely, but access to this is patchy. All those working in this area should have access to one-to-one support enabling reflection on and processing the emotional impact of work. Agencies should share practice on effective supervision, to minimise variability.188 Materials available to support supervision in adult safeguarding are limited. The issues that arose are relevant for safeguarding children and vulnerable adults. In reviewing the cases, Newcastle Social Care found there was limited evidence of supervision or reflection on case records. Since, the Social Work supervision policy has been updated and rewritten, providing for greater reflection and challenge. Managers have been trained in the use of reflective supervision. In addition, the process for ensuring supervision is recorded on the child’s record has been reviewed and compliance is subject to overview through regular reporting and audit. The Ofsted inspection confirmed that regular supervision takes place at all levels but recommended that the quality should be improved and case records better demonstrate how staff are supported and able to reflect on practice. An Action Plan to address this includes addressing the skill mix within teams and the importance of supervision and support to unqualified staff. 187 Newcastle Upon Tyne Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board Inspection date: 24 April 2017 – 11 May 2017 Report published: 7 July 2017 188 Workforce perspectives on harmful sexual behaviour: findings from the Local Authorities Research Consortium 7. National Children's Bureau. 2017 134 There were no significant references to supervision in other agencies’ reports or comment on why it did not identify weaknesses in plans and lack of action against perpetrators. Newcastle Safeguarding Children Board’s audits require agencies to confirm whether staff receive regular supervision and appraisals but not the detail and the practice effectiveness - what part experience has in the allocation of cases, how is challenge ensured and the continuity of involvement of professionals.189 “The support I have had has been exceptional. Except mental health support has not been as good. It took a long time to get a CPN. I’ve had 4 and the latest is about to change.” “I had mental health problems. As the trial came up I had CPNs – there were constant changes when the trials were on – a different one every month - no-one for 3 months. I had to rely on the police. They were a good support.” “I never had anyone I could trust and talk to…. workers kept changing.” “ … workers not going on long term sick when they have complex cases. They need more support as it’s obviously having an impact on them.” Recommendation 1.17 I recommend that: Partner agencies should report to Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board on the arrangements for supervision of staff and how they measure the effectiveness and impact on outcomes. 189 The Munro Review of Child Protection: Final Report A child-centred system. Professor Eileen Munro Department for Education. May 2011 135 12. The Criminal Court Experience and Criminal Justice Processes In 2013, The Home Affairs Committee190 highlighted widespread acknowledgement that the criminal justice system has failed to adequately protect and support victims. It criticised reluctance to prosecute and the damaging experience in court which has a detrimental impact on the administration of justice. The court process can compound the damage to victims who suffer with feelings of trauma, betrayal and stigmatisation and blame themselves. The Committee referred191 to a victim who spent 15 days in the witness box, 12 of them under cross-examination by a succession of defence lawyers. In 1989, the Report of the Advisory Group on Video Evidence192 recommended that witnesses eligible for special measures should be allowed to give evidence by video recording. Ten years later, section 28 Criminal Evidence Act 1999 allowed video recorded cross-examination or re-examination but this was not implemented. The Home Affairs Committee and the Lord Chief Justice criticised the Ministry of Justice for failing, after fourteen years, to implement this measure. A pilot scheme at three court centres was then introduced and in summer 2016 the Justice Minister reported that s28 would be rolled out nationally but this depends on whether Courts have facilities available. This was not available for the victims giving evidence in the Sanctuary Trials in Newcastle in 2017. The Crown Prosecution Service Review Report highlighted problems at Newcastle Crown Court with the ability of witnesses to give evidence through a link and not be seen in court. The Service has been proactive in raising this with the Court but the practicalities of arranging this include taping cardboard around the TV monitor. The Home Affairs Committee recommended that each court should have a named individual with the responsibility for ensuring that special measures are being implemented appropriately. Recommendation 1.18 I recommend that: Newcastle Safeguarding Boards, involving the Northumbria Police, the Police and Crime Commissioner and the Crown Prosecution Service, should arrange for discussions to take place with Newcastle Crown Court to consider how practical arrangements at court can be improved to ensure protection of the interests of victims giving evidence. 190 Para. 85 House of Commons Home Affairs Committee Report: Child sexual exploitation and the response to localised grooming House of Commons London: The Stationery Office Limited. June 2013 191 Evidence of Andrew Norfolk, Times. House of Commons Home Affairs Committee Report: Child sexual exploitation and the response to localised grooming House of Commons London: The Stationery Office 2013 192 Report of the Advisory Group on Video Evidence. Judge Thomas Pigot. Home Office. 1989 136 The Home Affairs Committee identified “Myths” that are commonly canvassed in sexual assault trials to undermine victims’ accounts. These are listed on the Crown Prosecution Service Website.193 Returning to abusers is routinely represented as evidence victims consented to and enjoyed the experiences. The Crown Prosecution Service and Trial Judges are expected to correct the myths but defence lawyers continue to exploit them. Cross-examination about sexual history should not take place without permission of the judge who should determine relevance and prevent harassment or bullying of a witness. A Government Report194 in 2014 included eight recommendations on how distress to victims in trials of sexual violence might be reduced. In early 2017, Northumbria Police and Crime Commissioner published a Report195 highlighting that in 30 rape cases heard in Newcastle Crown Court over 12 months the expected protections were not consistently enforced. None of the Sanctuary Trials were included in the work carried out for this survey. A dedicated trial judge was appointed to preside over all the trials and she took care to ensure that proper process was followed and there was no cross examination that went beyond what should be permitted. The Crown Prosecution Service arranged for teams to identify how complainants were coping with the prosecution and other issues in their lives and assist in fast tracking referrals to support agencies. Each complainant was allocated a contact officer. Liaison with social care and mental healthcare professionals assisted in assessing ability to give evidence. All witnesses had comprehensive support through the Hub. The Crown Prosecution Service Report highlighted that the Crown Court has responded positively to requests for early dialogue about forthcoming cases including expediting timetabling of cases to avoid delay and joinder of cases. Nevertheless, despite this care and the support victims received, all victims who gave evidence and contributed to the Review complained about the delays that increased the likelihood of witness intimidation, about how they were treated in cross-examination, the pressure, aggressive questions about their backgrounds and motives and about personal details in records of which they were previously unaware. Court Professionals are familiar with the rules – strangers’ inexperience, anxiety and vulnerability can be easily exploited. It is not difficult to confuse and distress a vulnerable witness. For some it led to lasting serious mental health problems. 193 Rape and Sexual Offences - Chapter 21: Societal Myths. www.cps.gov.uk 194 Report on review of ways to reduce distress of victims in trials of sexual violence. Ministry of Justice March 2014 195 Seeing is Believing: The Northumbria Court Observers Panel Report on 30 Rape trials 2015-16: Baird, DBE, QC, Northumbria Police and Crime Commissioner. March 2017 137 “I waited a long time for a trial date. There were video interviews, statements, identity parades. I gave full evidence at the trial and was cross examined. Court was awful, the worst experience ever – spoken down to – felt I was on trial – the defence. The judge intervened a lot to stop it but it still went on. I was commended for my strength by the police and prosecution. Shortly afterwards, thinking it was over, I was told there was a legal problem with a part of the case, not to do with me or my and evidence. The trial was stopped. A year later I was asked to give evidence again. I couldn’t face reliving it. To stand up in front of all those people -and then told I had to do it again – I had already made statements. If I only had to tell it once that would be brilliant. The Police understood and asked the CPS to consider using evidence from the original trial because of the impact on my mental health. The CPS requested a mental health assessment, which resulted in a brief meeting. I was asked first off to take Diazepam to go through with the trial. The allegations referred to drugs being used for the purposes of rape and I was now being asked to take a drug to help relive it and put up with another full trial. I couldn’t do it and refused. Two days later I was sectioned under the mental health act for risks to my own life, whilst the men despite all the evidence were set free. Why couldn’t that jury have seen my evidence like they saw my original video evidence? They record everything anyway. If this had been allowed I might’ve got justice for what happened to me. They walked free. The impact of the crimes and failed court process to the victim and close family is intolerable.” Material concerning victims in agency records is considered for disclosure to the defence and may be referred to in cross-examination. The Crown Prosecution Service Report stressed the care and planning by the prosecution team to ensure the process maintained the confidence of the Trial Judge and of the defence lawyers. Material was also used positively to highlight patterns of vulnerability. The Report reinforces the importance of considering the material and its likely impact before a decision is taken to charge. The disclosure process is costly. Records are not kept expecting they might be disclosed. Victims are unlikely to be aware of much of the content and are not informed in advance of appearing as a witness for fear of allegations that they have been coached and prepared. 138 The consequence of this is that damaged and vulnerable individuals are knowingly exposed to distressing material without notice and to an experience calculated to confuse, intimidate and cause them further damage and distress. There is a strong argument that this is inhuman and degrading treatment prohibited by the European Convention on Human Rights and Fundamental Freedoms and does not lead to fair administration of justice.196 “I received compensation. I was cross examined about it. In the last trial, I was asked about the compensation – I was startled. I applied after the first trial – I didn’t know anything about it until I was told then. They accused me of knowing and doing it all for the money and lying – including in the case already decided.” “The second time in court the defence lawyer hated me. It was suggested that the previous case was all lies. That I had planned everything – the self-harming was done because I enjoyed self-harming. He said I made it up to get compensation.” “When cross-examined I was called a liar – that it was all untrue. It was hard to put up a fight. I knew the police believed me.” “You should not be questioned about stuff outside the time zone for the case. For me, some of it was years ago. For some it’s new and fresh. You can put it at the back of your mind. I was questioned about a note for school asking for absence when I forged my mother’s signature years before. Afterwards I cried. I was in a catatonic state for a day. I felt that I was on trial. He hated me. Said I preyed on older men (I was 15/16). Said I had done something like this before – i.e. made complaints that were lies. There were not guilty verdicts. It put me off ever giving evidence again. I would not do it.” “It was 3 years and nine months after I went to the police that final sentencing took place. I was prepared for court. But the police did not tell me what they would ask. I was not prepared for that. I was frightened of the perpetrators. Court was horrific. I knew the men there. I was talking about them. I thought I could hear them – sighing and grunting as if I was lying. 196 Article 3; Article 6; European Convention on Human Rights and Fundamental Freedoms 139 It would have been better if I could have talked when they were not in the room. I was told I could not do video. I would have preferred if there was someone else. If someone was sitting with me it might have helped.” “I should not have gone – I was so distressed in my head. They questioned me one after the other for 2/3 days. I was talking about horrible stuff. It was intimidating. I was asked about a very intimate thing which was extremely distressing. It has caused me a lot of stress. I don’t know why they had to ask such a personal question. They brought up personal issues – made me feel unclean. There were screens. I could see the jury. The perpetrators and their family members were there. I had to see the doctor – who said I was not well enough. Then the trial was stopped - I don’t know why. I was told it was politics and to do with the jury. I went back to heavy drinking. Lost control. The perpetrators were continually in my head. I was sectioned and detained.” “I had good support for the criminal court. Good preparation. But it made me angry. I was made out to be a liar and it made me feel low. That came as a surprise – it was dreadful. I wasn’t expecting it. Afterwards I was very upset and couldn’t control myself. I started having dreams and flash backs. I was asked about things in my records that I knew nothing about – my past and I didn’t know why.” Bad experiences are shared and deter other victims coming forward. Only one victim despite her experiences stated that: “I do not regret going to court. I would say to someone else don’t feel ashamed – do it”. At the end of the trials, Newcastle City Council Leader Councillor Nick Forbes praised the victims who had to relive their ordeals in giving evidence and face their perpetrators. Some suffered the trauma of doing it more than once: “I can’t begin to imagine how difficult that must be, but I would like to pay tribute to each and every one of them. They have been brave beyond belief and undoubtedly have made our city safer.” The Crown Prosecution Service Review Report highlighted the difficulties in identifying appropriate criminal offences that address obviously abusive activities. A proactive and imaginative approach was taken to address evidential difficulties 140 including those arising from issues of consent with victims over 16 years old. A range of charges included criminal conspiracies. Victims were surprised by and complained about charges that included incitement to prostitution, fearing this labelled them as prostitutes. Similar inappropriate terminology has been removed from national safeguarding guidance. Staff supporting victims during and after the trials suggested that there should be an updating review of the law relating to sexual exploitation which is informed about the importance of language, the nature and impact of grooming and addresses the growing knowledge of activities of perpetrators. The Sanctuary Trials were a considerable success. Prosecutions have been taking place across the country but defendants represent a fraction of total numbers of perpetrators. Those convicted know who else is involved. A separate offence of having been convicted when it is clear others were involved and failing to identify them might encourage co-operation. It might be known a person was present when abuse took place but there is no direct evidence of involvement in offences because of reluctance or fear or confusion in the victims. In some jurisdictions it is an offence to fail to disclose an arrestable offence to the police197. In England, recent legislation requires some professionals to report abuse. An offence of being present during abuse and not preventing or reporting it, would address this issue. Careful drafting could ensure victims present at abuse of others are appropriately protected. Recommendation 2.14 I recommend that: The Government should arrange for a review of the criminal law to ensure that it provides a range of criminal offences that reflect the body of knowledge about sexual exploitation, more effectively address the behaviour and involvement of perpetrators and does not through terminology cause distress to victims. Recommendation 2.15 I recommend that: In the light of the body of knowledge about sexual exploitation and continuing concerns about the treatment of victims when giving evidence in criminal proceedings and the impact on the fair administration of justice, the Government should arrange for a review of the rules relating to the treatment of victims when giving evidence and the disclosure of records and their use in proceedings, including whether data subjects should be made aware of material disclosed. 197 Criminal Law Act (Northern Ireland) 1967. An examination of local, national and international arrangements for the mandatory reporting of child abuse: the implications for Northern Ireland: Wallace and Bunting. NSPCC. August 2007 141 13. Supporting Victims and Survivors of Sexual Exploitation A guiding philosophy underpinning the establishment of the Hub was that suspected victims should have available continuous, reliable, comprehensive support, whether or not they were able or willing to give evidence in criminal proceedings or able to accept support. Practitioners emphasised that experience shows that additional or targeted resources are likely to be required for care and support over a long period. 13.1 Advocates Victims may find it difficult to engage and articulate or argue on their own behalf. In the cases, there were examples of timely arrangements for appointments of independent advocates funded by Newcastle City Council Children’s and Adults Social Care to help suspected victims to contribute to processes and ensure their opinions were considered. The service is provided for children and adults aged up to 25 by the National Youth Advocacy Service and specifically for adults by Your Voice Counts. In the early period reviewed Advocacy Centre North provided a service for adults. Involvement included advocating wishes and feeling of victims and considering positive male role models during placements in secure accommodation, at reviews of children looked after by the local authority, and at safeguarding adult’s meetings. Support was available during criminal justice and Court of Protection processes. The service brought experience of good practice in cases involving learning disability and impaired mental capacity. Even when processes require independent involvement to assist victims and family members, they may still feel that their views have had little impact and expect more. “I had a solicitor when I was put in secure but they didn’t talk to me about anything except this is what they are saying and did I agree or not.” It may be what a victim wants to say is not relevant to the decision being taken and this is difficult to accept. An Independent person is appointed to assist children at all reviews of secure placements but this victim could not recall this. Nor could she clearly recall the role played by the Children’s Guardian and Independent Reviewing Officer - “no-one listened to me.” Advocacy services and formal representation and complaints processes have been addressed in procedures and written material for children looked after by the Council. The Ofsted inspection report in 2017 suggested this was an area for more attention. There were circumstances in which appointing an advocate was not routinely considered during reviews of children’s cases. Action has been taken to improve support by social workers and Independent Reviewing Officers to access the advocacy service and ensure children are aware 142 of its availability and formal representation and complaints processes. This is being monitored through practice audits. The appointment of an advocate is considered during adult safeguarding processes and if appointed they attend all adult safeguarding meetings. Practice audits include reviewing compliance with this expectation. 13.2 Support of Victims during Trials and Beyond A report198 on Rochdale recommended that Criminal justice organisations should work together to ensure support is provided from reporting the crime, making a statement, preparing for trial and after the trial. In Newcastle, the victim focus of the Hub has included intense support by the whole multi-agency framework to ensure that practical, housing, emotional and health needs are addressed. In one case, when a victim was admitted in a catatonic state, a social worker stayed in the hospital with her. All the victims, while criticising the court process, have consistently commented that the support from the Hub and colleagues in the agencies was excellent and was always there. They continue to be supported since on the same basis with an expectation that for some it may be lifelong support. “The support from the Hub is brilliant.” “I know support will always be there for me.” The Ofsted inspection in 2017 found that: “Wrap-around services provided by a high number of agencies to assist children to recover and move forward with their lives are outstanding. At the core of this practice is targeted work to promote children’s self-esteem and self-confidence in order to reduce future risk and support recovery.” Throughout the trials a confidential helpline was put in place which allowed other victims to make contact, to report abuse or seek advice as a result of publicity about convictions and sentencing. 13.3 Compensation and Personal Injury Claims The Review considered the support provided for victims to pursue applications for compensation under the Criminal Injuries Compensation Scheme199 under which a person may be eligible for an award if they sustain a criminal injury directly attributable to being a direct victim of a crime of violence. Payment can never fully compensate for the injuries suffered, but it is recognition of public sympathy.200 A 198 Review of Multi-Agency Responses to the Sexual Exploitation of Children: Rochdale Borough Safeguarding Children Board. 2012 199 The Criminal Injuries Compensation Scheme Ministry of Justice 2012; Criminal injuries compensation: a guide to applying for compensation under the Criminal Injuries Compensation Scheme Ministry of Justice. March 2014 updated November 2016 200 A guide to the Criminal Injuries Compensation Scheme 2012. Criminal Injuries Compensation Authority. 2013 143 person may be eligible for an award whether or not the incident has resulted in a conviction. Encouragement and help provided by an adult care social worker resulted in a significant payment in one case. Others clearly entitled to apply had not made applications and were unaware of the scheme. In some circumstances the issue was not identified even though the victim was a child looked after by the local authority and had been subject to family court proceedings when Children’s Guardians and advocates were acting. This is a difficult area because of the common practice of defence counsel in criminal trials cross examining victims alleging they are motivated by the possibility of compensation. Understandably, this has led to the issue not being addressed until after a trial is completed which can involve considerable delay. This can give rise to problems because of time limits on applications which can only be extended for exceptional reasons. Also: “The Criminal Injuries Compensation Scheme is a government funded scheme to compensate blameless victims of violent crime.” Awards will be withheld if the applicant has unspent convictions, whether or not related to the crimes and abuse committed against, or where the conduct of the applicant or the applicant’s character makes it inappropriate to make an award.201 One victim gave evidence in a Sanctuary Trial which resulted in the defendant receiving a sentence of 29 years. She had been convicted of an offence and sentenced to a community order for 12 months which attracted a further 12 months rehabilitation period before being spent. Her application for compensation was made before the rehabilitation period expired and she was refused compensation. A delay in applying would have put her application outside time limits. It was irrelevant that the impact of the abuse and exploitation led her into the offending behaviour. The decision letter explained: “I have no discretion to waive this irrespective of the personal circumstances you were in which led to your conviction.” It is not likely that decisions regarding prosecution and sentencing would have considered the likely detrimental impact on her ability to claim compensation for serious abuse. A further difficulty recently highlighted by Barnardo’s and Victim Support202 drew attention to awards being refused on the basis of victims of sexual exploitation having consented to the abuse. 201 A guide to the Criminal Injuries Compensation Scheme 2012. Criminal Injuries Compensation Authority. 2013 202 The Times 18 July 2017 144 These provisions have particularly impact on victims of sexual exploitation. It is it not likely that the draftsmen of the Scheme intended that these victims would be so disadvantaged. These issues illustrate the importance of victims receiving good advice and support that takes account of the detail of the Scheme. The Scheme is also: “intended to be one of last resort. We expect you to try to claim compensation from the person, or persons, who caused your injury or loss. You may also be able to claim from someone who was indirectly responsible for your injury.” 203 Victims may be able to obtain payment of damages directly from an abuser who has assets by pursuing a civil personal injury claim. This is subject to time limits204 and the amount of the amount of damages will depend on how well the case is prepared and argued. Arrangements are now in place for compensation and damages to be considered as a standing item within the statutory review of every case of children looked after by Newcastle City Council and at Safeguarding Adults Meetings. Legal services staff are available to assist with the preparation of applications under the statutory scheme or arrange for victims to be advised and represented by experienced personal injury lawyers. The Council is arranging to work with the police, the Police and Crime Commissioner, the Youth Offending Team, sentencing courts and other relevant partners to raise awareness of the impact of prosecution of victims on their ability to claim compensation. Information will be collected in order to draw the attention of government to the unfairness of these arrangements. Payments made to children or to adults with impaired capacity will need to be managed and a process for accessing the fund established. Some victims may in any event need advice on managing an award or it may be important to delay payment if a victim is subject to inappropriate influence. Although arrangements are in place to identify cases as they arise, there are likely to be some individuals who have been entitled to claim but have not done so. They need to be identified and assisted. Regular reports will be made to the Safeguarding Boards informing members of the effectiveness of these arrangements. 203 A guide to the Criminal Injuries Compensation Scheme 2012. Criminal Injuries Compensation Authority. 2013 204 The Limitation (Childhood Abuse) (Scotland) Act 2017; in Scotland survivors of child abuse no longer face the ‘time-bar’ that requires personal injury actions for civil damages to be made within three years of the related incident 145 14. Concluding Remarks This Joint Serious Case Review into Sexual Exploitation in Newcastle was commissioned in October 2015 by the Newcastle Children and Adult Safeguarding Boards. In 2014, a picture emerged in Newcastle of hundreds of victims of sexual exploitation. There was a proactive approach to protecting victims and dealing with perpetrators and quickly over 30 men were arrested. Despite the length of the Report, it has been difficult to do justice to the large amount of material and the energy and effort that has characterised this ambitious Review which has been carried out in a proportionate and open manner. The large scale of the exploitation is reflected in the thematic methodology used to undertake the Review. It looked beyond individuals and focused on identifying and examining themes to fully understand the circumstances and issues arising from sexual exploitation in Newcastle and provide evidence for findings, conclusions and lessons for future practice. It was agreed that a sufficient number of individual cases should be considered to facilitate consideration of the themes. The eight cases identified fully reflected insofar as possible the different characteristics of the wider cohort of individuals who had been identified as victims. The Review also considered what has been known and understood about sexual exploitation within agencies and by the Safeguarding Boards and the response to this knowledge, other published reviews and relevant research. The contributions from victims have improved significantly understanding of vulnerability, the impact of sexual exploitation and the long-term nature of the support that is required. It is significant that Newcastle is different to other areas where there has been large scale Child Sexual Exploitation. In Newcastle, the exploitation has also involved vulnerable adults. In addition, there is no evidence in Newcastle that decisions about taking action were affected by lack of concern or interest, misplaced fears about political correctness or fear of being seen as racist, ineffective leadership or inappropriate interference by senior official or political leaders to prevent action being taken that have been features of reviews carried out elsewhere. The Review has highlighted the complex nature of Sexual Exploitation - the extreme and long-lasting impact it has on victims; the difficulties in identifying and preventing the exploitation; the intense and lengthy support that is required to gain the trust of victims to help them understand that what they have experienced is exploitation and enable them to talk about their experiences. The primary aim must be to protect victims, prevent further exploitation and help them so far as possible to rebuild positive lives, whether or not prosecutions and 146 convictions are achievable. This approach that has proven to be successful in Newcastle. The material illustrates the calculated and persistent determination of perpetrators over a long period to exploit women and girls through horrific acts of abuse, violence and manipulation, targeting and grooming the most vulnerable with a dismissive disregard for the criminal justice system. The learning from this Review and from Operation Sanctuary has been embedded in Newcastle through enhanced service provision, particularly the development of the Multiagency Sexual Exploitation Hub. But it has also raised awareness and developed understanding of the nature and impact of sexual exploitation. This has impacted positively not only on identification and prevention, but also on how best to support victims and has led to exceptional victim led practice recognised independently and nationally. Tackling sexual exploitation must address the perpetrators – not only preventing their activities but understanding their motivation. A common experience of reviews of this kind has been the lack of meaningful engagement of perpetrators. Often when they do participate it is in order to protest their innocence and derogate the victims. This should not prevent attempting to develop an understanding of what has led them to be involved and what might have helped prevent their offending – this was the strongest message from practitioners at the Learning Events. The learning from this Review does not only apply to Newcastle. It is hoped that it will be used to influence and shape services in other areas of the country and inform the need for national reform. The review has reinforced the message to agencies that if they do not recognise sexual exploitation of children and vulnerable adults in their area, it is because they are not looking hard enough. Developments in Newcastle illustrate that determination and multi-agency victim focused services can make a significant difference. “The future – I take each day as it comes…. I have proved everyone wrong. I am learning to manage. There are people I can get in touch with. I know support will always be there for me.” “I would really like to help other people who get abused. I have been involved with the National Working Group.” 147 15. Recommendations 15.1 Local Number Recommendation Section Page 1.1 Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should make arrangements to review the progress and impact of the actions taken and intended to be taken as a result of carrying out the Joint Serious Case Review. 2.6 19 1.2 A report should be made to Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board on the arrangements to take forward the initiative to establish a process for discussion with communities about the issues that have arisen from the Joint Serious Case Review. 5.11 49 1.3 Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should continue to work with relevant partners to try and encourage conversations with perpetrators to better understand the Newcastle context of their offending. 6 52 1.4 When considering national guidance or advice Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should ensure that expectations for engagement with a national agency that is not a local partner are addressed and kept under review. 7.1 59 1.5 Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should identify services in the community that are not routinely involved with local safeguarding arrangements and consider how best to engage with them on safeguarding issues. 7.16 76 1.6 Newcastle Safeguarding Children Board should arrange to carry out an audit of a sufficient number of cases to form a judgment about whether regulatory and guidance expectations concerning pupils who change educational settings are consistently followed. 7.19 80 1.7 Newcastle Safeguarding Adults Board should carry out an audit of a sufficient number of cases to form a judgment about the effectiveness of arrangements to interview vulnerable adults following a period of missing. 7.20 81 1.8 The outcome of audits carried out in Newcastle to review the processes of assessment of capacity of patients to receive sexual health services should be reported to Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board. 9.2 94 148 1.9 Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults’ Board should consider what arrangements can be made to monitor the numbers of patients who are identified as sexual exploitation victims and have received sexual health services. 9.2 94 1.10 NHS Newcastle Gateshead Clinical Commissioning Group should arrange a forum for discussion about how potential and actual victims of grooming and sexual exploitation might be more likely to be identified in health settings and report to the Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board. 9.2 95 1.11 Newcastle Safeguarding Children Board should arrange a forum for discussion about collaborative working between the school nursing service and teaching staff. 9.3 95 1.12 There should be reports made to Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board on the outcomes of the actions taken to improve information sharing in the region when vulnerable children or adults move administrative areas. 9.5 98 1.13 Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should consider how access for practitioners to advice on cultural attitudes when assessing and managing risks might be improved. 9.11 105 1.14 Northumberland Tyne and Wear NHS Foundation Trust should report to Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board on the arrangements being made for local delivery of the Governments ambition to improve access to Mental Health Services for all children and young people, including those sexually exploited. 9.16 114 1.15 Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should arrange for guidance to be issued to practitioners on the differences between learning disability and learning difficulties and the relevance for safeguarding judgments and services. 9.19 116 1.16 When reviewing the training strategy Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board should have regard to the issues raised at the Learning Events. 10.1 127 1.17 Partner agencies should report to Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board on the arrangements for supervision of staff and how they measure the effectiveness and impact on outcomes. 11.2 134 149 1.18 Newcastle Safeguarding Boards, involving the Northumbria Police, the Police and Crime Commissioner and the Crown Prosecution Service, should arrange for discussions to take place with Newcastle Crown Court to consider how practical arrangements at court can be improved to ensure protection of the interests of victims giving evidence. 12 135 15.2 National Number Recommendation Section Page 2.1 The Government should carry out a review of vehicle licensing for driving vehicles that transport members of the public, to include arrangements for private operators of larger vehicles, and taking account of the body of knowledge about sexual exploitation. 5.4 35 2.2 The Government should urgently issue guidance or advice on addressing sexual exploitation of vulnerable adults. 5.9 44 2.3 The Government should arrange for research to be undertaken concerning profiles, motivations and cultural and background influences of perpetrators of sexual exploitation of children and vulnerable adults and publish guidance for strategists and practitioners on the most effective way to reduce offending. 6 53 2.4 The Crown Prosecution Service should arrange for guidelines to be developed on involvement of the Service with Safeguarding Boards and other local safeguarding frameworks. 7.9 69 2.5 The Government should ensure that when national guidance or advice requires involvement of a national agency or one which is not a statutory local partner with Safeguarding Boards or other local safeguarding frameworks, the documents include confirmation that the agency is aware of and has made arrangements for the expected involvement. 7.9 70 2.6 The Government should consider which community services not routinely involved with local safeguarding frameworks have a contribution to make to early identification and prevention of sexual exploitation and make arrangements to ensure that their contribution is made and monitored through regulatory functions or otherwise. 7.16 76 2.7 The Government should arrange for a review of the safeguarding implications for children educated otherwise than at school having regard particularly to the body of knowledge about sexual exploitation, issue 7.18 79 150 guidance on safeguarding children educated otherwise than at school and consider the need for legislation to more effectively regulate this provision. 2.8 The Government should arrange for national research to be carried out on the impact on sexual exploitation of Personal, Social, Health and Economic education programmes. 7.21 83 2.9 National Health Service England should consider establishing a risk information sharing system for sexual health settings. 9.2 92 2.10 The Government should consider whether The Child Protection - Information Sharing Project arrangements should also apply to safeguarding adults systems and procedures. 9.2 93 2.11 The Government should urgently arrange for the principles applied to confidentiality and safeguarding in sexual health settings to be reviewed having regard to the body of knowledge about sexual exploitation. 9.2 95 2.12 The Government should address the need to improve national arrangements for facilitating transfer of data between social care authorities. 9.5 98 2.13 The Government should review the arrangements for obtaining authority to control or restrict the liberty of children and vulnerable adults at risk of sexual exploitation with a view to improving flexibility of provision and reducing costs and complexity of judicial overview. 9.21 122 2.14 The Government should arrange for a review of the criminal law to ensure that it provides a range of criminal offences that reflect the body of knowledge about sexual exploitation, more effectively address the behaviour and involvement of perpetrators and does not through terminology cause distress to victims. 12 140 2.15 In the light of the body of knowledge about sexual exploitation and continuing concerns about the treatment of victims when giving evidence in criminal proceedings and the impact on the fair administration of justice, the Government should arrange for a review of the rules relating to the treatment of victims when giving evidence and the disclosure of records and their use in proceedings, including whether data subjects should be made aware of material disclosed. 12 140 David Spicer LLB February 2018 Barrister |
NC043736 | Serious and prolonged sexual exploitation of a young person who was looked after under section 20 of the Children Act 1989. The young person had severe learning difficulties, her mother had arranged for her to live with family members and her father was in prison. She attended A&E frequently and often went missing from care. Issues identified include: unqualified staff; inadequate supervision; inadequate assessments; barriers to information sharing; a sense of helplessness by professionals in how to intervene to protect this young person and a lack of understanding about the complex relationships that sometimes exist between perpetrators of child sexual exploitation and their victims. Contains multi-agency and single agency recommendations covering: decision-making in regard to specialist placements for young people with complex needs; reviewing escalation policies; developing knowledge, skills and processes around child sexual exploitation, reviewing procedures to reinforce agencies' responsibilities around 16 and 17 year olds. Review was carried out in parallel to the review in respect of Young People 1,2,3,4,5&6 and this report does not seek to duplicate what was included there.
| Title: The overview report of the serious case review in respect of Young Person 7. LSCB: Rochdale Borough Safeguarding Children Board Author: Sian Griffiths Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. RBSCB YP 7 Publication 20th Dec 2013 This report has been redacted for legal reasons The Overview Report of the Serious Case Review in respect of Young Person 7 This report has been commissioned and prepared on behalf of Rochdale Borough Safeguarding Children Board and is available for publication. 1 Contents Page Glossary 3 1 Introduction 4 1.1 Summary of circumstances leading to the SCR 4 1.2 Terms of Reference 5 1.3 Membership of the Serious Case Review Panel 8 1.4 Timescale for the Serious Case Review 9 1.5 Methodology 9 1.6 Parallel Processes 11 1.7 YP7 Contribution to the Review 12 2 : Factual Information 2.1 Genogram 13 2.2 Composite chronology of significant events 14 2.3 Relevant ethnic, cultural or other equality issues 14 2.4 Contextual Family Information 15 2.5 Information Provided by YP7 16 3. Summary of information known to the agencies during the timescale of the SCR 18 3.1 1111111111111111111111111111111111111111 1 3.2 111111111111111111111111111111111111111111111111 1 3.3 111111111111111111111111111111111111111111111111 1 3.4 111111111111111111111111111111111111111111111111 1 3.5 11111111111111111111111111111111111111111111111111 1 3.6 11111111111111111111111111111111111111111111111111 1 3.7 11111111111111111111111111111111111111111111111111 1 3.8 11111111111111111111111111111111111111111111111111 1 3.9 11111111111111111111111111111111111111111111111111 1 3.10 1111111111111111111111111111111111111111111111111 1 4 Critical Analysis 20 4.1 Introduction 20 4.2 National and local strategic approach to child sexual exploitation during the timeframe 20 4.3 Grounds for intervention by Children’s Social Care 21 4.4 Identification of CSE and resulting multi-agency response 28 4.5 Engagement with YP7 34 4.6 Long term planning and Review 36 4.7 Inter Agency Relationships 38 4.8 Managing Risk of Harm 1111111111111111111 40 4.9 The Impact of and responses to Race, Gender, Disability and Disadvantage 42 4.10 Could the harm to YP7 have been prevented or predicted? 45 2 5. Multi Agency Recommendations 47 6. Individual Agency Reports and Recommendations 48 6.1 CAFCASS 48 6.2 Children’s Social Care (Targeted Services) Rochdale MBC 49 6.3 Children’s Social Care (Safeguarding Children Unit) 51 6.4 Connexions Rochdale (Careers Solutions) 52 6.5 Early Break (Young People’s Drug and Alcohol Service) 53 6.6 GP Services Rochdale 55 6.7 Greater Manchester Police 56 6.8 Pennine Acute NHS Hospitals Trust 58 6.9 Pennine Care NHS Foundation Trust 59 11 11111111111111111111111111111111111 11 6.11 RMBC Strategic Housing Services 62 6.12 Schools (RMBC Children’s Services, Early Help & Schools) 63 11 11111111111111111111111111111111111111111111111 11 6.14 Heywood, Middleton and Rochdale PCT (Commissioning) 65 Endorsement of Rochdale Borough Safeguarding Children Board Chair Bibliography 3 GLOSSARY FAMILY YP7 Subject 1111111111111111111 1111111111111111111 1111111111111111111 1111111111111111111 1111111111111111111 1111111111111111111 1111111111111111111 1111111111111111111 SIGNIFICANT OTHERS An anonymised list of other family members can be found at the end of this report. Other Acronyms: A & E Accident and Emergency ACPO Association of Chief Police Officers CAF Common Assessment Framework CAFCASS Children and Family Court Advisory and Support Service CPS Crown Prosecution Service CSC Children’s Social Care FWIN Force Wide Incident Notice (Police record of incident) GP General Practitioner IMR Independent Management Review LSCB Local Safeguarding Children’s Board OFSTED Office for Standards in Education PCT Primary Care Trust PPIU Police Public Protection Investigation Unit RMN Registered Mental Health Nurse SCR Serious Case Review SCRP Serious Case Review Panel TOR Terms of Reference 4 1. INTRODUCTION This Serious Case Review has been prepared in relation to Young Person 7 who experienced serious and repeated sexual exploitation as a child. The purpose of the Serious Case Review is to identify whether agencies which provided services to this young person acted appropriately and whether lessons can be learned from YP7’s experience. 1.1 Circumstances that led to this Review 1.1 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 1.2 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 1.3 111111111111111111111111111111 referred YP7 to the multi-agency Serious Case Review Screening Panel which met on 13th February 2013. The panel recommended that a Serious Case Review should be undertaken and this decision was formally approved by the Chair of the Board. As was required at the time, OFSTED and the Department for Education were informed of the decision to undertake a Serious Case Review on 20th February 2013. 1.4 The focus of the Serious Case Review was specifically to consider learning arising out of YP7 having been identified as suffering serious harm as a result of experiencing child sexual exploitation. For this reason, the Serious Case Review was undertaken purely in relation to YP7 and not her siblings. 1.5 The Independent Chair and Independent Author who were undertaking the Serious Case Review in relation to YP1-6 also relating to child sexual exploitation, were appointed to undertake the same role for YP7. The Serious Case Review Panel (SCRP) was at that point established to manage the process with representation from the relevant agencies. 5 1.2 The Terms of Reference of the Review 1.2.1 The Terms of Reference for the Serious Case Review, which fully set out the scope and context of the Review are attached as Appendix A. A summary of the Terms of Reference is as follows: 1.2.2 The Terms of Reference were established in line with the requirements of Working Together 20101, which states that a Serious Case Review must: Establish what lessons are to be learned from the case about the way in which local practitioners and organisations work individually and together to safeguard and promote the welfare of children Identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result Improve intra and inter agency working and better safeguard and promote the welfare of children 1.2.3 The Terms of Reference highlighted that: “The prime purpose of a Serious Case Review (SCR) is for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children. The lessons learned should be disseminated effectively, and the recommendations should be implemented in a timely manner so that the changes required result, wherever possible, in children being protected from suffering or being likely to suffer harm in the future. It is essential, to maximise the quality of learning, that the child’s daily life experiences and an understanding of his or her welfare, wishes and feelings are at the centre of the SCR, irrespective of whether the child died or was seriously harmed.” 1.2.4 In addition to the overall Terms of Reference the following Key Lines of Enquiry were identified for specific consideration by the Individual Management Reviews: 1 Working Together 2010, which was the relevant version at this time, is the statutory guidance relating to safeguarding and protection of children. 6 Key Lines of Enquiry 1. Recognition a) Consider whether your organisation recognised that YP7 was a victim of child sexual exploitation and responded to her as such. Comment on the effect of her challenging and 1111111111 behaviour on your agency’s understanding of her needs. b) Comment on your organisation’s ability to recognise child sexual exploitation at an operational level and to proactively intervene to safeguard victims and support their families c) When did your agency first recognise that YP7 was subject to child sexual exploitation; and when did you identify that abuse as organised .What was the agency response following this understanding 2. Intervention a) Consider and comment on the timeliness and quality of intervention, including early intervention services, offered to the subject of this review by your agency. This should specifically include consideration of:- i. CAF process ii. Teenage pregnancy services iii. Children missing from home iv. Children missing from education v. Learning disability services vi. Physical disability services vii. Drug and alcohol support services viii. Mental health services ix. Schemes to divert young people from the criminal justice system. b) Consider and comment on the effectiveness and development of your agency’s strategic approach to CSE during the period of the review. c) Consider and comment on your agency’s ability to effectively provide appropriate services to the subject, which reflected both her welfare and safeguarding needs and also any risks she might pose. d) Consider the effectiveness of any services provided to the subject in relation to her own children, given the history of CSE. This ToR does not seek to review the services provided to the subject’s children directly, but to consider any learning for services regarding the implications of the subject’s’ experience as she moved into parenthood. e) What protocols, policies and procedures nationally were in place that would have informed and guided operational staff when undertaking assessments, interventions and escalation in relation to this case f) Comment on the level and impact of managerial oversight, control and challenge to case work in this case 3. Diversity 7 a) Did assessment and intervention at an operational level fully reflect consideration of ethnicity, culture, equality and diversity raised in this case? 4. Partnership working a) Consider what, if any, barriers existed within the review period to inhibit appropriate information sharing in both inter agency and multi-agency settings and identify the barriers to effective inter-agency and multi-agency working in this case. Identify any good practice examples of interagency work. b) Comment on the interface between yours and any other agencies in determining the operational lead and subsequent actions to safeguard the subject of the review with consideration to the criminal/safeguarding threshold. 5. Context a) Identify whether there were lessons available from contemporary serious case reviews (local and national) which, if learnt, would have better informed practice and decision-making in this case. 6 . Overview Author Specific Terms of Reference: Consider national direction and any relevant frameworks available to strategic leads and practitioners with regard to child sexual exploitation during the review period. 1.2.5 The Terms of Reference (ToR) identified that the time period for consideration by the Serious Case Review should begin at the point when YP7 first became known to the 111111111111111111 System1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. The ToR would finish at the point at which the Leaving Care services which YP7 was entitled to receive from the Local Authority ended, that is, after she reached the age of 21 years. 1.2.6 The agreed timescale was therefore: November 2003 – Summer 2011 1.2.7 IMR authors were however specifically required to consider any relevant contextual historical information pre-dating the ToR that was available to them. This was to be included as appropriate in summary form and used to inform their analysis of the services that had been provided. 8 1.3 Membership of the Review Panel The Serious Case Review Panel was made up as follows: Agency or Organisation Role Audrey Williamson Independent Chair CAFCASS Head of Service, Greater Manchester, CAFCASS Connexions(up to April 2013, when replaced by Positive Steps) Connexions Service Manager until April 2013 Assistant Director, Early Help and Schools, post April 2013 (commissioner) Early Break Chief Executive Early Help and Schools Head of Schools Greater Manchester Police Detective Superintendent, Specialist Protective Services 111111111111111111111111111 11111111111111111111111111111 Heywood, Middleton and Rochdale CCG Designated Nurse for Safeguarding, Heywood, Middleton and Rochdale Heywood, Middleton and Rochdale CCG Designated Doctor for Safeguarding, Heywood, Middleton and Rochdale Rochdale Children’s Services Safeguarding Unit Manager Rochdale Children’s Services Interim Assistant Director RMBC Strategic Housing Services Homelessness Service Manager Pennine Care NHS Foundation Trust Acting Head of Safeguarding Children Pennine Acute Hospital NHS Trust Head of Safeguarding 11111111111111111111 11111111111111111111111 Also in attendance at the Panel meetings were the following: Sian Griffiths, Independent Overview Author Rochdale Borough Safeguarding Children Board Business Manager Rochdale Borough Principal Solicitor or deputy Administrator, Rochdale Safeguarding Children Board Advisor from The National Working Group (Tackling child sexual exploitation), a charitable organisation formed from a UK network of practitioners working on child sexual exploitation. 9 Audrey Williamson is the Independent Chair of this Serious Case Review. Audrey qualified as a social worker in 1981 and is registered with the Health and Care Professions Council. Ms Williamson has worked in Social Care in a number of local authorities in the North West and was a senior manager in both children and adult social care services before becoming independent in 2011. Ms Williamson is the Independent chair of Warrington, Halton, Cheshire West and Chester Safeguarding Children Boards. Sian Griffiths is the Independent Author of the Overview Report. Ms Griffiths works as an Independent Social Worker. She is not employed by any Local Authority or Agency other than for commissioned pieces of work of an independent nature. Ms Griffiths has been a qualified social worker since 1987, working both in the Probation Service as a practitioner and manager and later as a Family Court Advisor in CAFCASS. Ms Griffiths is registered with the Health and Care Professions Council. She has previously authored Overview Reports for Serious Case Reviews for a number of Safeguarding Boards and is accredited by SCIE to undertake Learning Together Reviews adopting a systems learning approach. 1.4 Timescale for undertaking the Review 1.4.1. This Review was commenced whilst a major Serious Case Review regarding child sexual exploitation (SCR YP1-6), was already ongoing. It was agreed that the Review for YP7 should run in parallel to this larger review. A decision was made by the Chair of the LSCB to appoint the same Independent Chair and Author who were undertaking the Review for YP1-6 so that the learning from the two Reviews could be linked most efficiently. Given the complexity of the two Reviews it was agreed that completing this Review within a 6 month period, as normally required for a Serious Case Review was not practically possible. The completion date for this Review was reviewed with the Chair of the Safeguarding Board periodically. A final completion date was set for one month after the presentation of the SCR for YP1-6 to the Safeguarding Children Board. 1.4.2. This Serious Case Review was presented to the Rochdale Safeguarding Children Board on 17th December 2013. 1.5 Methodology of the Review 1.5.1 This Serious Case Review was conducted in line with the requirements of Working Together 2010. The Review Panel was aware of the ongoing redrafting of Working Together and the development of a systems approach to undertaking SCRs. The possibility of adopting such a methodology was considered, but following earlier advice from the 10 Department of Education regarding YP1-6, the Review was undertaken in line with existing statutory guidelines, reflecting the method taken in relation to the SCR YP1-6. 1.5.2 The SCR Panel agreed that the framework for the Review should be that required by Working Together. However, the underlying principles adopted as far as practicable reflected the Systems learning model as outlined in the recently published Munro Report.2 In particular IMR authors were encouraged to reflect with practitioners on the context of their decision making at the time, in order to maximize the learning from this review and to increase the focus on why things happened, not simply what happened and whether it met the required standards. 1.5.3 The Panel was explicit in its view that any early lessons identified during the Review should be responded to in practice without delay where this was possible. Agencies were required to provide the Panel and the Board with updates regarding any early learning during the process including a written update prior to the Overview Report being presented to the Board. Where this was provided it is referenced during Section 5 of the Review. 1.5.4 The Panel requested and received Individual Management Reviews (IMRs) from the following agencies: CAFCASS Early Break GP Services Rochdale Greater Manchester Police 1111111111111111111111111111 Pennine Acute Hospital NHS Trust Pennine Care NHS Foundation Trust (Community and Mental Health Services) Rochdale Borough Housing Rochdale Children’s Social Care (Targeted Services) Rochdale Children’s Social Care (Safeguarding Children Unit) Rochdale Connexions Trust Schools 1111111111111 1.5.5 Additional information was provided to the Review by some of the services involved later in the process when gaps in the information in their IMRs were identified. In particular some significant gaps in information and the detail of contacts were identified in the CSC IMR at a late stage in the process. It was agreed that due to the time constraints at this point, and in order to ensure that independence was 2 Munro (2011) 11 maintained, the IMR author would undertake a limited review of CSC files written and electronic files as a result of which some further information has been included. 1.5.6 Information was sought from the following agencies who confirmed that they had no relevant knowledge of the family during the time period identified: Hopwood Hall College Action For Children Barnardos 1.5.7 A Health Overview Report was commissioned from Heywood, Middleton and Rochdale NHS Primary Care Trust to encompass the IMRs of the two NHS providers listed above. The report was authored by the Designated Nurse who was also a member of the Serious Case Review Panel. 1.5.8 The Serious Case Review Panel met on the following dates: 26 February 2013 (half day meeting) 8th May 2013 (half day meeting) 19th July 2013 (half day meeting) 20th August 2013 (half day meeting) 19th September 2013 (half day meeting) 22nd November 2013 (half day meeting) 6th December 2013 (half day meeting) 1.5.9 A meeting was also held on 12th March 2013 with IMR authors were also provided with individual feedback on their reports. Authors had access to ongoing advice and support from Panel members and the Independent Chair and Author. As a result all the IMRs were resubmitted following first drafts and several of the resubmitted IMRs provided a subsequently improved depth of learning. 1.6 Parallel Processes 1.6.1 Police investigations were ongoing during the period that this report was undertaken, including the possibility that YP7 would as a result become a witness in future court proceedings. 1.6.2 CSC have, prior to and during the course of this Review, undertaken a number of internal proceedings in relation both to managers and front line practitioners. The outcome of these proceedings has included disciplinary action and referral to the Health and Care Professions Council (HCPC), the regulatory body for Social Workers. 12 1.6.3 The other agencies which provided services to YP7 have confirmed that they reviewed the actions of individuals and concluded there was no basis for triggering internal proceedings. 1.6.4 The Local Authority had commissioned a report by an Independent Consultant which was published in May 20133. The primary purpose of this report was: To highlight opportunities which the Council and its partners may take to reduce the risks and ensure the safety of children and young people within the borough of Rochdale. To review the interactions and supporting processes within the Council departments and between the Council and external agencies. 1.7 Young Person 7’s Contribution to the Review 1.7.1 In line with the expectations of Working Together (March 2010) early consideration was given by the panel to seeking a contribution to the Review by Young Person 7. Contributions were also sought from YP7’s parents. 1.7.2 The Chair of the Panel wrote to YP7 to explain that a SCR was taking place. This was followed with a visit to YP7 by the Business Manager of the Safeguarding Board and a 1111111111111111111111111. YP7 indicated that she would like to contribute to the Review and subsequently met with the Independent Overview Report Author and the111111111111111 Manager. 1.7.3 A number of attempts were made to contact YP7’s parents to offer the opportunity for them to contribute their views to the SCR. However, although messages were left for both parents, neither responded to this request. 3 Klonowski, May 2013 13 2.1 Genogram RBSCB YP 7 Publication 20th Dec 2013 2.2 COMPOSITE CHRONOLOGY OF SIGNIFICANT EVENTS A full chronology of significant events was prepared to inform this review. Each individual agency provided a chronology as part of their IMR and also provided brief historical information which whilst outside the timeline provided relevant contextual information for the Review. 2.3 RELEVANT ETHNIC, CULTURAL OR OTHER EQUALITIES ISSUES 2.3.1 In line with the requirements of Working Together, IMR authors and the authors of both the Health Overview and this Serious Case Review Overview Report were directed specifically to consider any particular issues of race, culture, language, religious identity or disability of significance to the family. 2.3.2 Those agencies which recorded information regarding diversity identified the family as white British or white English. 2.3.3 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.3.4 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 15 111111111111111111111111111111111111111111111111111111111111111111111111111111 2.3.5 YP7’s father told her school that YP7 was Roman Catholic, however she was recorded by her GP as Church of England. There is no other information to identify that religion was important in YP7’s life. 2.3.6 It was apparent that YP7 was brought up within a family which lived in economically impoverished areas of the borough where there was significant intergenerational disadvantage. The 2010 Index of Multiple Deprivation results placed Rochdale borough as the 29th most deprived out of 326 districts in England (DCLG website4). 2.3.7 Information about the perpetrators’ race, culture and ethnic background as understood by the Services involved at the time, is limited. There are a number of references to men as “Asian” without specifying what this meant, or indeed why it was considered significant to record it. Within this review the term “Asian” or other references to race or ethnicity, will be used where it was the term used either by Services or by the subjects and their families. Analysis of the use of this term and what it signifies will be included in Section 4 (Critical Analysis). 2.4 Contextual Family Information 2.4.1 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.4.2 Reference has been made by CAMHS to YP7 previously being looked after by another Local Authority, but no information has been identified to confirm this and YP7 herself said that her first involvement with CSC was when she was 1111111 . 2.4.3 There is also reference by a Social Worker in 2007 to a substantial file including several child protection referrals. A file regarding the family predating the timeline for this Review has been identified and reviewed by the Independent Overview Author. The records identify evidence of financial pressures within the family and a number of allegations of domestic violence. There are references to concerns about the children’s care, school attendance and supervision. There were also two referrals regarding injuries, but medical opinion was that these were non-accidental and therefore no further action was taken. 4 https://www.gov.uk/government/organisations/department-for-communities-and-local-government 16 2.5 Information provided by YP7 2.5.1. YP7 met with the Independent Author of this Review in order to provide her views about the services that she had received. 2.5.2. YP7’s experience of being a Looked After Child was not a very positive one. She feels very strongly that she was failed by CSC in particular and that, because of this failure, her later life has been badly affected, not least because her own child has been adopted and 11111111111111111111111111111111. She believes that if CSC had taken proper care of her, she would not be in the position that she is now in. 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. 2.5.3. 1111111111111111111111111111111111111111111111111, YP7 had no recollection of being involved with CSC, although she said that her mother contacted CSC on several occasions when YP7 was younger, due to domestic violence perpetrated by her father. YP7 first remembered having contact with CSC when she was 13 and her mother had left YP7 and her siblings to live with a family friend. YP7 talked about the fact that she wanted to live with her father rather than her mother and that the main reason was that she knew her father would not try to make her go to school. She said that CSC knew about what sort of a person her father was, that he had been violent to her mother and that he had been in prison, and she felt it was wrong for them to place her with him, even though that is what she said she wanted. 2.5.4. YP7’s strongest criticism of CSC was that they had not allowed her to live in residential care when she felt she really needed to. YP7 spoke positively about the Residential Home in 1111111 , where she felt she had done well and where her behaviour had been much better. She remembered the system of gaining privileges for good behaviour, which she thought was good and that there was a therapist who worked with the children. At the end of the 6 month placement she had wanted to stay in the home, but had been returned to her mother in Rochdale. YP7 believed she should have been allowed to stay in 111111111 at that time, but also that when her relationship with her mother broke down CSC should have put her back in residential care. 2.5.5. YP7 describes asking her Social Worker to let her go back to the Home, but says that she was told that she could not go back into residential care as she was now 16 and the funding was not available. This is something she feels really angry about. She now believes that she should have been removed from Rochdale and that she needed to be somewhere safe. 2.5.6. YP7 had limited recall of other services, but did remember some professionals more positively. She felt that the 1111 workers, Early 17 Break and CIT had been good to work with and when asked what it was about these professionals that she had liked, she said it was because they stuck by her. She knew that the 111111111 had been very flexible with her so that she was not taken back to 1111111. She described the CIT team as helpful and said that she could talk to them and that the manager at 1111111111115 was good to her and would give her a second chance. YP7 knew that her behaviour wasn’t always easy and clearly appreciated those professionals who did not give up on her. 2.5.7. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 2.5.8. YP7 did not like going to school. One of the reasons was that she needed to have individual attention rather than being in a classroom which she did not get at school. She contrasted this with help she was given by one of the 111111111111, who spent time working with her alone. She also said that she had enjoyed the few months that she spent at college, but this did not last because of problems that she was experiencing at home which meant that she was homeless again. 2.5.9. YP7 gave a powerful description of her relationship with some of the men who abused her and why she would turn to them rather than to professionals. “I thought they (the men) cared about me…….they (the professionals) go home at night to their families … I had no-one, I was in a kids home…..” 2.5.10. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 18 Replacement for redacted Section 3 3 INFORMATION KNOWN TO AGENCIES DURING THE TIMESCALE OF THE SCR As with all SCRs a comprehensive chronology was prepared and detailed the relevant contact episodes between YP7 and each agency. Each IMR and the Health Overview Report included a full detailed chronology and narrative containing all the information regarding the agencies’ involvement with YP7. The detail cannot be published for legal reasons. This section therefore provides a summary of YP7’s experience during the period under consideration. Section 4 will critically analyse the detail of events and contacts with agencies. 3.1. YP7 became known to Children’s Social Care (CSC) when she was 111111111111 and was living with a family friend. Her mother had moved temporarily to another country returning only for very short periods of time. YP7’s father served a number of custodial sentences and was for most of the period under consideration either unwilling or unable to care for his daughter. 3.2. It was known to the wide range of services that were involved with her that YP7 had very significant problems. 3.3. When the private arrangement with the family friend broke down, YP7 lived for periods with other family members but effectively became homeless and was placed for a short period in a local children’s home. At this point it had become apparent to the agencies that she had been subject to child sexual exploitation by a group of men in Rochdale and elsewhere and within a matter of months was placed in a Secure Children’s Home. No Care Proceedings were taken by CSC who believed that they could meet her needs with the agreement of her parents without applying for a court order which would have given them Parental Responsibility. This approach was not supported by the other agencies. 3.4. In the absence of any family able to care for her, YP7 was placed in a residential children’s home in another county, where she remained for 6 months. This was comparatively successful and she was felt to have responded well. However at the end of the placement, CSC arranged for her to return to live in Rochdale, with her mother, who had moved back to the UK. 3.5. The arrangement for YP7 to live with her mother lasted for a very short period after which YP7 then spent a few weeks in supported accommodation in another county. When this also broke down YP7 returned to Rochdale and for approximately the next two years was effectively homeless, moving repeatedly between friends, temporary accommodation and various hostels. 19 3.6. YP7’s circumstances during this period caused considerable concern for many of the agencies. It was known that she was being abused by a group of men, initially a group of men later by a number of men who were only loosely connected with each other, if at all, that she had met in hostels or elsewhere. 3.7. YP7 became pregnant when she was 1111111111111. A pre-birth assessment was undertaken by CSC and concluded that YP7’s child should be placed in foster care at birth, given the extent of YP7’s difficulties and the impact on her ability to parent her child. 20 4 CRITICAL ANALYSIS 4.1 Introduction 4.1.1. This analysis is based on the individual Agency contributions to the Review, discussions held within the SCR Panel and the author’s own contributions. IMR authors were required to structure their reports using the Key Lines of Enquiry established within the Terms of Reference. The IMRs provided for this Review contain a high level of detail and analysis regarding the actions of individual agencies, which will not be routinely replicated here. However, where there appear to be gaps in individual agency learning these will be identified. 4.1.2. This critical analysis has considered all of the Terms of Reference, including the Key Lines of Enquiry which provided the working hypotheses for consideration within this review. The analysis will begin with a brief summary of the context within Rochdale at that time and then consider in detail a series of decisions by CSC which were crucial in establishing the pattern of intervention for YP7 throughout the period considered by this Review. This is considered to be at heart of the service provided to YP7. It will then consider a number of overlapping themes which have emerged during this review as being key areas for future learning. The analysis will be structured by using illustrative examples to identify these themes. 4.1.3. This Serious Case Review was conducted in parallel with another, larger, Review in relation to child sexual exploitation (YPs1-6). A detailed scrutiny of the services provided to YP7 has been undertaking in order to ensure the SCR panel had a full understanding of YP7’s individual experience. The Critical Analysis for this Review will not routinely repeat the themes and contextual information regarding the approach taken to CSE by the agencies in Rochdale which are fully examined in SCR YP1-6. What is evident from the SCR regarding YPs1-6 is that the young people had remarkably similar experience of the agencies that worked with them, which is reflected once again in relation to YP7 Where issues of concern have been covered in depth by the Review for YP1-6 that Review will provide the prime source of detailed analysis, with this more focussed Review analysing the particular practice that was specific to YP7. 4.2 National and local strategic approach to child sexual exploitation during the timeframe. 4.2.1. The Serious Case Review for YPS 1-6 concluded that there had been significant weaknesses in the strategic leadership provided within Rochdale regarding child sexual exploitation. In summary, there was a lack of effective prioritisation or focus at a strategic level which had a consequent impact on the response at the operational level, both in terms of agency recognition of CSE and of effective intervention. Prior to 2007 there was no evidence of any leadership role taken by the Safeguarding Children Board with regard to CSE and none of the agencies had specific CSE policies. In 2007 the Board set up a 21 Sexual Exploitation Working Group, which led to a decision in 2008 to develop a multi-agency team to respond to CSE in the borough. This eventually became the Sunrise team; however this team did not become operational until 2010, too late to be relevant to the experience of YP7. 4.2.2. It is also important to note that understanding of child sexual exploitation at a national level in the early years covered by this Review was still quite limited. Research and advice regarding CSE was available, although not necessarily easily accessible, and there had been a number of well publicised prosecutions in the North West. However, Statutory Guidance6 referred to ‘child prostitution’ until 2009, language which is evidently reflected in the early stages of involvement with YP7. 4.2.3. In this context it quickly becomes apparent that the same gaps in leadership and understanding evident for YPs1-6 are also equally applicable in relation to YP7. As such many, if not all, of the underlying contributing factors that helped explain why decisions were taken or not taken with regard to YPs1-6, are relevant to the service provided to YP7. 4.3 Grounds for intervention by Children’s Social Care 4.3.1. The history of CSC’s response to YP7 shows a pattern of confused and contradictory decision making. There is a clear failure either to recognise the degree of YP7’s vulnerability and the risks that she was facing, or to accept statutory responsibility for managing her welfare and safety. There were a number of points when there was an adequate, sometimes compelling grounds for statutory intervention which were not pursued, and which could and should have been recognised at the time. Throughout each of these episodes what is most noticeably lacking is any evidence of skilful, consistent supervision which ensured that the primary focus was on the child and that staff were effectively supported. This lack of good quality management provides some insight into why the quality of intervention was so ill conceived. 4.3.2. April 1111: The first involvement of CSC with YP7 during the timeline for this review was in April 1111 when it came to their attention that YP7’s mother had handed over ‘full authority’ for % of her children to a family friend. Initially CSC recognised that there might be a problem as to who had parental responsibility for the children. An Initial Assessment was undertaken but the quality is unknown. What is known is that significant information was available at the time which should have led to questions as to whether YP7, and/or her siblings’ welfare was being properly met in this placement including: School concerns re YP7’s behaviour, 11111111111, history of exclusions and assessment as having severe learning difficulties 6 Working together - ref 22 Allegations that Yp7’s sibling had been assaulted by her sister’s partner YP7’s father serving a prison sentence. No coherent reason as to why MYP7 was in %%%% or evidence that she was prioritising her children’s needs. 4.3.3. There is no evidence of any investigation regarding the allegation of assault on one of YP7’s siblings; no evidence of further enquiries, for example as to how long the mother had been in 1111111111 or why the father was in prison. There is no evidence that the assessing Social Worker spoke to the school, despite the fact that the School Nurse had specifically left messages. There is no evidence that the children were seen on their own as is required. The issue of Parental Responsibility remained unresolved and there appears to have been an acceptance that this was a private fostering arrangement without consideration as to whether this was in the children’s interests. Given the unanswered questions about the arrangements, combined with what is known about YP7’s learning difficulties and her personal presentation a much more detailed assessment was clearly warranted. 4.3.4. The passage of time has made it more difficult to know precisely why this assessment was so limited. However, the SCR for YP1-6 has identified that at this time there appeared to be a number of factors influencing the quality of practice in the assessment team of CSC, including: management oversight; staffing and resource problems, some of which led to problematic organisational responses; the competence of individual workers and a lack of a quality culture in some parts of the service. A particular factor in relation to YP7 may also have been the perception of private fostering arrangements by CSC at the time. 4.3.5. Private fostering had become an increasing cause for concern at a national level, in particular following the death of Victoria Climbie case which highlighted the potential vulnerability of children living within such arrangements. There was also national recognition that many Local Authorities considered that scrutinising private fostering was a low priority7 . New statutory regulations were enacted in July 2005 identifying the responsibilities of Local Authorities; nevertheless there was already in 2004 a requirement on the Authority to check the suitability of such arrangements. In this context it is possible that the assessing Social Worker was reflecting the culture or expectations of the Local Authority in not considering the possible risks within such an arrangement. 7 Dept Of Health (2001) 23 4.3.6. Another opportunity to re-assess the case quickly re-presented itself in that within a matter of weeks the family placement was breaking down and there were further concerns about YP7’s behaviour, specifically that she was aggressive to other children in the family. The Social Worker recorded previous Child Protection referrals, 1111111111111111111111111111111111111111111111111111111111111 and was specifically asked by the family friend to take YP7 into care. Instead of recognising or acknowledging that this was a young person at significant risk and therefore necessitated a Core Assessment, YP7 was allocated to a trainee Social Worker whose role appeared to be to support her move to live with her father on his release from prison. The highly predictable breakdown of this arrangement meant that YP7 soon afterwards had to be found emergency accommodation, instead of a planned approach to her needs having been adopted. 4.3.7. At this point there was no-one effectively exercising Parental Responsibility for this 13 year old girl with complex needs. Neither of her parents was able or willing to look after her, and the family or friends suggested as alternatives were evidently not stable or adequate for her needs. It is therefore of particular concern that the Local Authority did not pursue Care Proceedings which would have allowed them to share Parental Responsibility with the parents, but instead accommodated YP7 under S20 of the Children Act. 4.3.8. Becoming a Looked After Child under S20 requires the consent of those who have Parental Responsibility, generally, as in this case, the parents. This can be withdrawn at any point, which given all the indicators that her parents were failing to care for her meant it was clearly inadequate as a safeguard for YP7. Even were it not withdrawn the fact that neither of her parents was taking an active role in her care should have led to the conclusion that YP7 was a young person experiencing neglect. Again, this mirrors a feature of the SCR for YP1-6 where there was also a failure to recognise neglect in relation to adolescents. There is a body of research evidence to suggest that this is a comparatively widespread problem (Rees et al, 2011; OFSTED 2011) and this has been identified as one of the areas for attention as a result of the SCR for YP1-6. 4.3.9. It is also of note that on at least two occasions it was recorded by the Social Workers that there were discussions with the Police about a possible offence of Child Abandonment by the mother. There is however no information as to what advice was given by the Police to CSC and no evidence of a Strategy Meeting given that this was a potentially serious criminal offence. It is a weakness in the information provided by the police that there is no information about this episode and therefore whether they met their safeguarding responsibilities. For the next few months any intervention by CSC appears reactive and purely short term. 4.3.10. Until this point there does not appear to have been any direct evidence of child sexual exploitation, but it became very clear during 24 YP7’s stay at the children’s home is 111111111111 that she was being abused by older men. Although this was not, as far as is known, specifically understood as sexual exploitation. Given YP7’s age, both chronologically and developmentally, this should have led to a Strategy Meeting and a comprehensive assessment of her welfare. There is no explanation as to why there was no Police or multi-agency investigation at this time and again, Greater Manchester Police have been unable to find any information about this incident. The subsequent decision by CSC simply to close the case at the point when YP7’s Aunt in 1111111111 refused to be assessed as a carer was an unacceptable abdication of responsibility, given all the evidence that suggested YP7 would go missing again and would continue to be at risk. 4.3.11. Judging to what degree the approach taken by CSC was the result of confused decision making by an inexperienced, unsupported worker or a conscious decision at a management level to avoid taking formal proceedings so as to secure her legal position remains unknown. However, given information regarding the management position taken over subsequent months, it is highly likely that the (trainee) Social Worker was following instruction from her managers. Whatever was the immediate reason for the decision, the lack of proper case management which focussed on the needs of this child represented very poor practice. 4.3.12. Minimal evidence has been found at this time as to the routine managerial oversight of this case or that the student social worker receiving regular planned supervision, which would have been vital to ensure accountability and quality of service. After the case was closed there was occasional contact between the Social Worker and YP7’s family and with other agencies. The one recording of supervision identified three actions including a planning meeting – but no reference to this being followed up or reviewed. The approach was primarily to ‘monitor’, an intervention which risks being very passive. Over the following months despite further referrals and sharing of concerning information by other agencies, these did not lead to any child protection investigation. 4.3.13. The CSC IMR has highlighted that the practice of allocating such a complex case to a student social worker without very close supervision and support was unrealistic and has made a recommendation to CSC as a result. Although there is no evidence that would suggest it was understood as a complex case. 4.3.14. April1111 : The second significant episode in relation to CSC began in April 1111 following a particular episode when YP7 was missing from home; she was accommodated by CSC in a local Children’s Home again under S20 of the Children Act. The impression given by the events leading up to this, is that it was ultimately the urgency to find somewhere for YP7 to stay, the only remaining option being a residential children’s home, that led to her becoming accommodated under S20 and therefore a Looked after Child. 25 4.3.15. There was now a growing body of concern regarding sexual exploitation, self-harm, substance misuse, injuries to YP7, difficult and at 111111111111111 by YP7. Irrespective of whether CSE was fully recognised and understood, this was a child who was at serious risk of harm. It was evident that YP7 had no-one in a caring position who could meet her needs and no reason to believe that this would change within any reasonable time frame. Neither was there evident understanding that YP7 was experiencing profound neglect. Finally, there is no record of any discussion as to whether she may have met the threshold for instigating Care Proceedings. 4.3.16. The inaction by CSC at this point was evidently difficult for other agencies to understand. Whilst the CSC IMR tells us that there was regular phone contact with MYP7 in 1111111 there is a lack of any detail as to: the nature of these discussions; how consent to accommodate her was established and what assessment was made of MYP7’s parenting. However, a series of e-mails between SWTM1 and CSCSM/AD has since been seen by the Overview Author and these provide insight into the approach being taken at a senior management level to YP7’s case. It is apparent from the e-mails that the focus at this point was on sending YP7 to live with her mother in 1111111111. 4.3.17. Plans were discussed for commissioning an agency within 111111 to visit and ‘say if it is ok’. The intention appeared simply to be to check the accommodation and there was no evident reference to other factors. What is of significant concern in both this and other internal exchanges is a lack of apparent focus on the risks to or needs of YP7 as an individual, but instead a focus on the organisational priorities and risks. There are inappropriately dismissive references to the legitimate concerns of other agencies and an informality of tone that is surprising and unacceptable when considering the needs of a vulnerable child. 4.3.18. June 11111 : The risk and vulnerability factors already identified were increasingly evident during the following couple of months that YP7 was accommodated in Rochdale. Evidence of sexual exploitation was increasingly alarming and YP7 was routinely missing from the home. Despite this, although there is reference by other agencies to the possibility of a placement out of Borough, there is no evidence from CSC of a fundamental re-appraisal of their approach or of their duty towards YP7. However because of the deteriorating circumstances, a decision was made in June 2005 to seek an order for YP7 to be accommodated in a Secure Unit 4.3.19. What is of further concern is that despite having made an application for a Secure Order, the Local Authority absolutely resisted all suggestions that they should apply for a S31 Care Order. Options that were being considered by CSC were viewed both by other agencies at the time, and by this Review, as inadequate to protect YP7 and considerable pressure had to be exerted before agreement was reached to find a residential placement out of Borough. At the 26 same time the Children’s Guardian, was making a strong case for a Care Order which was dismissed as manipulative. There was also a clear indication by the Judge at the end of the Family Court Proceedings in November 2006 that a Care Order would be necessary if YP7 left the therapeutic placement which had eventually been agreed for her. Nevertheless, once again CSC relied on S20 to enable them to accommodate YP7. 4.3.20. June 111111: After a period of around 6 months in Residential Care out of Borough, a decision was made to return YP7 to her mother’s care. The placement was believed to have been a success and YP7 appeared to have stabilised to some extent. The decision was therefore made to return her to her mother’s care with no statutory involvement from CSC other than providing her with the support she was entitled to as a child leaving care. SW11 explained that both YP7 and her mother had wanted her to be returned and this was always the intention. 4.3.21. Given that YP7’s mother had effectively abandoned YP7 previously and in the absence of any assessment as to how she would be able to meet her child’s needs or keep her safe, this decision was not defensible. What was required was a proper analysis of YP7’s current needs, in what way she had been stabilised, and whether the features that contributed to this improvement could be replicated if she returned to live with her mother in Rochdale. What was absent was any evident understanding of the risks YP7 might face in Rochdale, from which she had been to a great extent protected from whilst she was out of the Borough. This decision is described in the CSC IMR as “almost impossible to understand”. In the context of the clear direction that was being given by senior managers not to pursue care proceedings or a long term placement, the rationale becomes much easier to understand. 4.3.22. Within three months of her return to Rochdale YP7 there were reports that YP7 was being sexually exploited and she had left her mother’s care saying that she had been physically abused by her. Again, this should have triggered a re-assessment as to whether YP7 could be kept safe but also whether her basic physical and psychological needs were being met. However for the next 18 months no statutory safeguarding processes were invoked and instead, YP7 was only provided with support as a care leaver. The growing chaos, damage and distress that YP7 was living with did not lead to a rethink by CSC who appeared to be focussed entirely on attempts to get YP7 to take responsibility for her own welfare and safety 4.3.23. Again, the Review lacks direct information about the process of the Social Workers’ decision making throughout this period. However, what is known is that a very strong direction was being given at a senior management level both regarding possible Care Proceedings and the option of long term residential care level. It is also the case that discussions regarding YP7 at a management level take as their starting point the cost implications, rather than her needs. One 27 comment states that “whilst she needs support to enable her to protect herself, she is also of an age where she carries some of that responsibility”. This fails to recognise not only the dynamics of child sexual exploitation but also YP7’s developmental age and her capacity to manage her life without the support and protection of anyone taking parental responsibility. An e-mail to the team manager from the Service Manager in 2007 states: “she has reached the age where anything other than secure accommodation can equally be made accessible as an eligible or relevant young person”. It is the case that most services could be offered to YP7 if she was considered a ‘care leaver’ rather than a child in care, and she could chose to accept these services or otherwise. However, what this fails to acknowledge is that YP7 was a young person for whom no-one had exercised parental responsibility for several years, who remained vulnerable to abuse and was by no rational analysis at a point where she was ready to move into independence and protect herself. 4.3.24. An issue of considerable concern which was identified in relation to YP1-6 was that priority for intervention at the time was focussed very largely on babies and young children, rather than on adolescents. One of the ways in which this manifested itself was through a CSC policy, ‘Supporting Children and Young People to Remain within Their Family’ which was issued in September 2006 and therefore illustrates senior management thinking in the preceding months. The policy was known colloquially as the ‘non-accommodation’ policy, and gave a very strong steer away from providing long term placements for young people. 4.3.25. There is evidence within this Review that the cost of funding a therapeutic or other long term placement was a very significant feature in the decision making by Senior Managers. YP7 informed the Review that she was specifically told that it was because of funding that she was not able to stay longer in her placement in 1111111111111 or be placed elsewhere. In the internal communications between managers the issue of funding often appears to be the primary consideration for decision making. 4.3.26. Long term therapeutic placements are punishingly expensive for Local Authorities, who may have very limited means to fund such placements. Further it appears to be politically impossible for an authority to acknowledge that an individual child may not receive a placement due to the resource costs. As a result one response is to take a range of other steps to avoid the option of funding long term care, such as attempting to manage the young person’s needs in the community even in the face of considerable evidence that this is unlikely to succeed. There is no information to indicate whether prior to September 2006 there was a multi-agency approach towards decision making regarding placements for young people with complex needs, or any joint commissioning to plan for and fund such placements. 28 4.3.27. It appears therefore that there were a number of significant factors contributing to what can only be judged as inadequate practice. Such factors include: Resource problems leading to organisational needs significantly impacting on case planning for individual young people lack of agency focus on the needs of adolescents Social Worker inexperience, capacity, confidence or skill Poor quality or absent supervision Lack of understanding of the dynamics of child sexual exploitation Unrealistic expectations on family’s capacity or willingness to care for YP7 Unrealistic expectations on Yp7’s capacity to care for herself. 4.3.28. By examining these episodes in detail it is possible to see the primary importance of CSC in contributing to YP7’s experience and in shaping the overall multi-agency approach. However, other aspects of practice played their part, not least the degree to which other agencies played an effective part in challenging, or formally escalating their concerns and the apparent lack of any means to agree a multi-agency approach to the funding of any specialist care that might be required. 4.3.29. Two recommendations have been made as a result of these identified weaknesses: Recommendation 1 and Recommendation 2 4.4 The identification of CSE and resulting multi-agency response 4.4.1. With hindsight we can now identify a number of indicators that YP7 may have been experiencing child sexual exploitation from the outset, including: symptoms of sexually transmitted infections and YP7’s statement that she had had a number of sexual partners at the age of 13. These could not necessarily have been expected to lead to consideration of CSE at the time given the level of awareness across agencies in 2004. Nevertheless that this degree of sexual activity in a 13 year old girl with developmental delay did not raise a greater sense of curiosity or alarm is of concern. One of the important issues for learning arising out of the SCR for YPs1-6 was the need for greater focus on safeguarding in these circumstances, particularly in relation to sexual health services. This is highlighted once again with YP7. 4.4.2. The first specific reference to sexual exploitation is at a professionals’ meeting in April 2005 and from this point on it is a concept that is quite frequently referred to, although it was not known to all the agencies. It appears however that there was little understanding of the nature of CSE including the persistence of the offenders and its impact on victims and the nature of their responses. On a number of occasions references are made to YP7 having been a victim of CSE in the past 29 with an implication that it was now over. What evidence there was for this conclusion is not clear and given what we now know about the nature of CSE was, with hindsight, unrealistic. What was understood by all the agencies was that she continued to be at risk. 4.4.3. There were repeated indicators from 1111111 when YP7 returned to Rochdale that either directly identified or suggested that YP7 was still experiencing the exploitation. In the earlier stages this is most apparent in relation to her involvement with a group of Asian men where there were indicators of a degree of organisation. Later in 2008 and 2009 there is evidence of various men, whose race is not identified, who appear to have exploited her in a more opportunistic way. This was taking place in the context of YP7 believing these individuals were genuinely concerned about her or as being part of a loose group, it seems predominantly male, based 1111111111111. The agency response was typically to try to encourage YP7 to keep herself safe either because her inability to do so as a victim of CSE was not understood, or because agencies were resigned to working with her in the community with little resources, guidance or knowledge as to how they could effectively respond to the exploitation she was experiencing. 4.4.4. The degree to which different agencies recognised and understood the levels of risk varied over time and between agencies. A common feature acknowledged by all three of the health IMRs was a pattern of responding to YP7 in relation to her clinical need without a more holistic approach being taken with regard to her wider welfare needs. There is for example no evidence that GPs at any point considered that YP7’s presenting symptoms might be indicators of sexual abuse or CSE. In attempting to understand why this was the case, the IMR recognises that GPs, along with other professionals had little knowledge about indicators of CSE at this time. 4.4.5. Another reason that GPs may not have questioned YP7’s circumstances or followed up information provided to them by other health professions, was that they were aware she was a looked after child and therefore assumed that this information was known to CSC and there was no need for them to contribute. It should not be concluded that greater involvement of the GP Service would automatically have led to a different outcome. Had, however, the GPs become more proactively involved, this should have led to a better analysis as to what was happening, but could also have introduced a new professional perspective including the potential for another challenge to the position taken by CSC. These underlying explanations for the lack of a proactive approach by GPs have led to recommendations within the IMR. In taking forward these recommendations the Review would particularly underline the importance of not making assumptions about what is or is not known by others and recognising the potential value of GPs as part of a wider team working in a child’s best interests, rather than as individuals dealing with individual clinical need. 30 4.4.6. It is also the case that the hospital held significant information that could have better highlighted the nature of the risks that YP7 was facing. Information was shared with other professionals including CSC, but this was inconsistent and there was little evidence that hospital departments, particularly the Accident and Emergency Department and the wards where YP7 was then treated, recognised that she might be a victim of CSE. The IMR for Pennine Acute Health Trust, clearly identifies opportunities to intervene which were missed to intervene as a result of YP7’s repeated attendance at A&E – 17 occasions in a period of 15 months. Again, recommendations are made for the Trust as a result. 4.4.7. In 2007, there was explicit recognition that YP7 was one of a number of young women experiencing exploitation by a linked group of offenders. This led to three strategy meetings instigated by CSC in 11111111111111 2007 specifically in relation to the multiple abuse of vulnerable young people. These meetings have been described as representing the first step leading to the recognition of the need for a joint approach to CSE and the development of the Sunrise Team in Rochdale. Whilst this is undoubtedly the case, progress in 2007 faltered quite quickly. Although a police investigation was initiated, YP7’s case was not ultimately one of the young people subject to the investigation. The reason for this is recorded by the IMR as being due to YP7’s unwillingness to co-operate. After the three initial meetings, no further strategy meetings were put in place and there was no other structured means for sharing the information. 4.4.8. Whilst these Strategy Meetings had clearly begun to identify the pattern of CSE in the Borough, what was missing was ownership and direction from a senior level in the statutory agencies. In the absence of the involvement of and leadership by senior managers who were able to take decisions about resourcing and who could have ensured that these issues were considered at the Safeguarding Board, the process was fundamentally flawed. In reality the meeting predominantly involved those professionals already directly working with the young people. 4.4.9. Information was shared between agencies during this meeting. However, a barrier arose which had a significant effect both on the police investigation, particularly relating to YP7 but also on the wider approach taken. The Crisis Information Team Co-ordinator was unwilling to share the names of the young people they believed were experiencing CSE at the first meeting. CIT took the view that the victims should remain anonymous or they would be placed at further serious risk of physical assault and intimidation. The investigating Police Officer although clearly frustrated by this did not feel able to challenge what appeared to be the ‘expert’ view of the Crisis Intervention Team. CITC was subsequently informed by senior management within the Trust, including the named nurse for child protection and the Deputy Director for Public Health that the information should be shared, and this is noted within the April meeting. However, the information was then only shared verbally and 31 the list of names returned to CIT at the end of the meeting. The actual e-mail sent by the Deputy Director for Public Health was not as clearly worded as it should have been as to exactly how the information must be shared. However, of more significance is that having taken the unusual step of giving CITC a direction regarding a particular course of action there is no information as to whether any of the relevant managers followed up this direction to satisfy themselves that their instruction had been followed. 4.4.10. It is also evident from the notes of the meeting that CIT were strongly of the view that victims should not be contacted directly at their homes, and that most of the victims would not engage with the police. In effect this meant that CIT was in the position of screening the victims who could be approached. CITC also made it a pre-condition that the police would undertake surveillance. It is noted that CIT considered that “there is a culture of fear or a misconception about the nature of the relationship between the girls and the men, which could make it impossible to break through”. There was some dissension to this rather fatalistic view, including by Early Break and Legal Services, who both suggested other ways to intervene. However, the combination of the position taken the CIT and the view of the Police that a direct complaint was necessary to progress any prosecution effectively created a further obstacle in attempts to intervene. It is now recognised by the Police that this ‘traditional’ model of investigating is not effective in cases such as CSE and requires a much more creative approach and better understanding of how to engage with victims. 4.4.11. It is clear in minutes of the meetings that there was a desire by the police to establish a multi-agency approach to this investigation, and that attempts were made by the Detective Inspector in charge of the PPIU to pursue this, but at this point these attempts were unsuccessful. In the absence of proper resourcing, it was not possible for one investigating officer to effectively pursue such a complex investigation, including the expectation of surveillance, or to take a lead in the development of a multi-agency approach. The failure by the police force at a strategic level to prioritise CSE in the Borough at this time has been considered in detail in the SCR regarding YP1-6 and has been accepted by the police. However, during this Review GMP has also identified that a Serious Case Review (Child A) was published in Manchester in 2007 which specifically identified child sexual exploitation and recommended that this become a strategic priority for the force. GMP’s resulting action plan was: 1. Commission the Force Intelligence Bureau to scope the extent of the problem force-wide. By June 2007. 2. Determine a force wide response to tackling CSE by September 2007 4.4.12. What is now apparent is that little if any progress was made by GMP in relation to these actions and the opportunity to learn from the 32 Serious Case Review in relation to Child A was not pursued. Why this was the case remains fundamentally unexplained, leaving the only conclusion available to this Review that this was not a priority for the force at that time. 4.4.13. Nevertheless, it was also the case that none of the other agencies took action to pursue these strategy meetings or attempted to establish an alternative multi-agency approach. There is no evidence that any of the other agencies sought to challenge the GMP decision not to resource a complex investigation into CSE at this time. Neither was there any evidence that Senior Managers in Health or Social Care, or through the Safeguarding Board, who were aware of these meetings taking place, took any proactive approach as a result. Instead agencies continued to deal with the problems of CSE on an individual case by case basis. 4.4.14. The absence of any multi-agency forum or co-ordinated, strategic approach, meant that opportunities to develop more creative ways to deal with CSE were not available to practitioners during the timeline relevant to YP7, for example; disruption techniques; information sharing; awareness raising; joint approaches to the victims; management of confidential information. 4.4.15. Investigation of CSE as a wider phenomenon in the Borough was unable to progress effectively at this time; however other allegations continued to be made either directly by YP7 or by agencies on her behalf. These often could not be progressed given a lack of information about individual perpetrators. However, there were also a number of occasions in relation to YP7 were information about assaults on YP7 was held by agencies and individuals but not reported to the police or to CSC, meaning that opportunities either to investigate criminal offences or to undertake strategy meetings were lost. Examples included: YP7’s first presentation at 13 years and nine months of age with a disclosure of sexual activity YP7 telling staff at the sexual health clinic (CIT) that she had had unprotected oral and anal sex, sometimes against her wishes and that the men would hit her if she refused. YP7 disclosing to CIT and a Connexions worker that a man had poured petrol on her and threatened to set her alight because she refused to perform oral sex. 4.4.16. Whilst it is not possible given the passage of time to identify absolutely why such individual decisions were made, two factors that are likely to have impacted on decision making can be seen at work. Firstly there appeared to be a sense of helplessness amongst agencies about intervening to protect YP7, as is so clearly evidenced in relation to the 2007 Strategy meetings. It is also the case that practitioners, including the CIT workers and the Connexions worker referred to above, did on other occasions pass on information or make 33 referrals which appeared to lead to little formal action by the statutory agencies. Examples included: 11111111111111111111111111111111111111111 Injuries to YP7’s ear in 2005 Allegations of abuse against YP7’s father. However when these concerns were not responded to with a similar level of concern, this appeared to result in a sense of resignation by agencies. 4.4.17. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. Whilst it is apparent that agencies understood and were concerned for YP7’s wellbeing, there was limited evidence that they felt they were in a position to take action to protect her, given the perception that she placed herself in these settings by choice. One of the agencies, Rochdale Borough Housing has identified that staff working in11111111111111111 , although often very skilled at engaging with residents, have to some degree become desensitised to what risks are viewed as ‘normal’ , seeing them as something that their client group may not be able to avoid. This once again linked with a tendency to refer to YP7’s lifestyle, or making choices, which is a fundamental misunderstanding of the response of victims of sexual exploitation. 4.4.18. That there was a lack of action at a number of key points also needs to be understood in the context of the development of knowledge about CSE. Again this mirrors the learning from the SCR for YP1-6 where more detailed analysis is to be found regarding the developing research and practice knowledge in this field. The degree of control exerted by the perpetrators in now much more widely understood. In particular the research identifies that in order to survive traumatic and potentially life threatening experiences, victims may behave in ways that appear contradictory, for example returning to their abusers.8 For many young people the perpetrators may also be the only people that they have an attachment to, which even though it is damaging and dysfunctional acts as a powerful draw for the young person as YP7 herself described: I thought they (the men) cared about me…….they(the professionals) go home at night to their families … I had no-one, I was in a kids home…..” Breaking this cycle of re-victimisation is likely to require a long term multi-agency approach including in many circumstances the removal of the young person from the perpetrators sphere of influence for a significant period combined with therapeutic intervention. 4.4.19. A further incident necessitates comment, although it was not directly related to child sexual exploitation. YP7 was placed at one point by CSC in private bed and breakfast accommodation and whilst in this accommodation 111111111111111111. That this had not led to any 8 Lodrik (2007) 34 comment or investigation either at that time or within the IMR has been a cause of concern. Despite a specific request from the Overview Author, agreed by the SCR Panel, limited further information has been provided by 111111111, whose IMR noted this incident, as to how this was responded to or what the future implications might be for using this or other private providers. 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.5 Engagement with YP7 4.5.1. Developing positive professional relationships with young people whose behaviour may be 111111111111, abusive, difficult to understand or rejecting, requires significant reserves of skill, empathy and support. There is no doubt that YP7 was a highly complex individual, who presented an often contradictory mixture of assertiveness and vulnerability. This was a young person who had experienced some degree of abuse and neglect as a child, who had been explicitly rejected by her parents, who had developmental delay and had been sexually exploited. Her behaviour and her vulnerability also clearly led to a high level of anxiety and concern on the part of several of those working with her. 4.5.2. Despite this, and to some extent in contrast with the experience of the young people in SCR for YPs1-6, many of the professionals involved showed a considerable degree of concern and empathy for YP7, even though it was more difficult to achieve good outcomes. These included Early Break, CAMHS, the Behaviour Improvement Practitioner, the Manager at 111111 and Connexions. The health visitor for ChildYP7 also showed tenacity in attempting to maintain contact and engage YP7 in order to involve her fully. Many of these professionals offered levels of contact, or prioritised YP7’s needs in a way which was a step beyond expected practice. One of the factors that is identified by the Early Break workers was that they felt supported by their organisation and managers in their work, but otherwise the Review has been provided with limited information as to what enabled these workers to maintain a positive empathetic approach. 4.5.3. Between 1111 when she returned to live in Rochdale and 1111111111111111111111111111111 the two services which had the most significant regular contact with YP7 were the CSC Young People’s Support Team which provided leaving care support and the 111111111111111111111111111111111111111111111111111111111111111111111111111111111 What is evident is that both services provided a very high level of support, sometimes daily or even several times in one day. Much of that support was in providing practical help, particularly relating to her very unstable housing position. What also emerges however is that there was a significant difference in perspective between the two agencies as to the approach to engaging 35 with YP7. It should be acknowledged here that the Review has not been provided with the full detail from the perspective of the Young Person’s Support Team, nevertheless there is enough information to allow some analysis. 4.5.4. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.5.5. What is apparent over a considerable period of time is that this mini team demonstrated a high level of empathy and care towards YP7 and attempted to work with her on a variety of levels, from providing practical help with independent living, to working with her on self-esteem. To some degree they stood in the space where a parent should have been, providing support, attempting to establish boundaries, managing difficult behaviour, encouraging independence, listening to her when she was in distress and attempting to provide her with skills for survival. 4.5.6. It was evidently not easy to maintain this level of support, faced with YP7’s often childlike responses and inability to respond to structure. That they were able to do so appears to have been in part due to the team approach and a willingness to work flexibly. There was evidence also of a willingness to have difficult discussions with YP7 and a capacity not to allow themselves to be thrown off course by YP7’s unsettled and unsettling responses. However, managing this balance was evidently difficult for the practitioners at times. What appears to have been missing was an explicit management or supervisory structure within which their efforts could be reviewed, the impact assessed and alternative approaches considered. In particular strong and thoughtful management could have ensured that the work of this team was more effectively linked with CSC and could have taken a lead in co-ordinating the exit strategy and her transition into adult services. 4.5.7. The approach taken by the Young Person’s Support Team was much more focussed on moving YP7 into independence. There was clearly a high level of activity by the YPST, not least in relation to YP7’s accommodation. What is less apparent is whether there was an understanding or sense of empathy about the complexity of her situation. What is more apparent is an increasing sense of frustration with YP7’s repeating pattern of behaviour and inability to ‘keep herself safe’. 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 36 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. To what degree this mindset was a result of the individual experience, skills and capacity of the workers, or their support and working environment is difficult to assess. There is however, no evidence of management support or challenge and given the prevailing view identified by other workers and, possibly more significantly, senior managers within CSE that YP7 should accept responsibility for herself within a very clear timescale, it may not be surprising that individual workers adopted a similar approach. 4.5.8. Little information has been provided about the commissioning of a package of leaving care support for YP7 in11111111111 . It would appear that at this point the YPST stopped having direct contact with YP7 instead receiving weekly updates from the provider. It had been acknowledged that the numbers of professionals working with YP7 was often counterproductive. The thinking behind this decision to introduce new workers at arm’s length is unknown, but there were inherent risks. There is a well-established body of evidence that children value continuity in their relationships9 (introducing a change in professionals in this way might further impact on the quality of the relationship between YP7 and her worker at YPST. There were of course other inherent risks, particularly in relation to information exchange with other key agencies. 4.5.9. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. 4.5.10. It is apparent that there is a gap in the confidence, skill and knowledge base in working with adolescents, something which was also a feature of the SCR for YP1-6. A consequential recommendation has therefore been made (Recommendation 3) 4.6 Long term planning and Review 4.6.1. At the front line much of the intervention with YP7 appeared to be reactive, for example responding to individual episodes of crisis, clinical need or allegations with no overarching ,shared understanding of what outcome agencies were working towards or how they would be achieved. That this was the case will have been due in no small part to the lack of a comprehensive assessment of her needs from the outset. As has previously been considered interventions were often 9 Munro (2011:32), 37 based on a complete misconception of YP7’s needs and capacity and at the practice level often seemed hard to understand. 4.6.2. YP7’s comparatively successful stay at the residential home in 11111111 could have provided information an important opportunity to understand what interventions might be successful in the future and therefore shape future planning. However, it would appear that there was no sophisticated analysis of what this period meant in terms of the long term needs of YP7. Instead Children’s Services appear to have assumed that because the placement was viewed as ‘successful’ it paved the way for rehabilitation with her mother. Why it was successful, for example the degree to which the level of containment, structure and therapy at the placement were the reason for this success, and whether this could be sustained away from the placement does not appear to have been considered. 4.6.3. However, at a senior level within CSC there was a clear plan identified for YP which was to rehabilitate her to her mother’s care at the age of 16 and from that point the only intention was to respond to her as a care leaver. Research10 has identified the existence of very common patterns in human reasoning, which can lead to poor decision making, particularly when those decisions are being made in highly complex work environments. One of these common patterns is an unwillingness to reconsider our initial judgement about a situation, even in the face of new and contradictory evidence. Recent analysis by Eileen Munro11 and others has applied this approach to understanding decision making within social care. Although it is perhaps most commonly thought of in relation to front line practitioners, the same problematic patterns of human reasoning can be seen in operation by Senior Managers in CSC regarding YP7. These managers reached an early conclusion as to what course of action was required, and even in the face of continuing or new opposing evidence were unwilling or unable to change their minds. A particularly stark example of this can be seen in a letter from a CSC team manager to the CIT co-ordinator which argues, against empirical evidence that YP7 should be returned to her mother’s care: “You raise your views that YP7’s mother has made little attempt to address her vulnerability or to meet her health needs, evidencing her failure to accompany YP7 to a health appointment when she was last home. All of this is of course factually correct …..however it now appears that mother has changed her position and she is finally taking responsibility for YP7” There was nothing to demonstrate that the mother had changed her position, only her assurances, which given the previous history could not be seen as adequate without supporting evidence. This highlights 10 Woods et al (2010), Dekker, S (2006), 10 11 Munro (2008), (2011) 38 that the need for challenge and reflection across all levels of decision making within an organisation, and is not only a requirement for front line practitioners. (see Recommendation 1) 4.6.4. That some agencies frequently struggled to plan effectively should be understood in the context of CSC’s decision not to take decisive action to protect YP7. An example identified by the Homelessness Service was that different agencies had different views about the sort of accommodation YP7 needed, making a challenging situation even more complicated. Without primary safeguarding action by CSC it is difficult to envisage what plans could have been put in place to keep YP7 safe. 4.6.5. Neither was there any clearly established means by which the agencies could co-ordinate their efforts. Groups of professionals at different times organised meetings to consider particular concerns or plans. However, by their nature these did not consider YP7 holistically or have a route by which they could feed in to a more comprehensive planning process. In the absence of one agency taking ultimate responsibility for drawing the threads together, the reality of anything up to 13 different agencies, with changing staff members attempting to work together was likely to have limited success. 4.6.6. Theoretically, even in the absence of a care or Child Protection Plan, CSC could have been expected to take the lead in planning. However, it becomes evident that the 1111111team were in effect the lead role in the day to day work with YP7 and this was at times openly acknowledged by the Young People’s Support Team. However, the 111111 team did not have access to the range of options available to CSC which might have kept YP7 safe or otherwise improved the outcomes for her. In effect partner agencies were required to work with YP7’s complex problems without the tools to keep her safe. 4.7 Inter-agency relationships 4.7.1. The numbers of agencies involved combined with the level of contact many of those agencies had with YP7, meant that comprehensive information sharing would not be a realistic expectation. Nevertheless there was evidence in relation to several of the agencies and key practitioners of a good level of routine information sharing, discussion and joint meetings. It is apparent that several of the agencies worked closely together and within smaller groupings attempted to co-ordinate and plan some of their work. Following YP7’s 1111111111111111111 there is evidence of very well co-ordinated working between 1111111111111111111111111111111111111111111111111111, 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 very good level of liaison between the social worker and 11111111111111 staff in11111. 39 4.7.2. What however is also evident are some significant tensions between several of the agencies and CSC. There were clearly fundamental differences between CSC and other agencies about the approach to working with YP7. None of the other agencies appears to have supported the CSC position and this is particularly illustrated at the professionals’ meeting in April 2005. There was evident frustration from other agencies about what they felt was a lack of progress in safeguarding YP7, frustration which the Social Worker’s manager felt had been unfair to the practitioner. However well these tensions were or were not managed within the meeting, what it reveals is the lack of recognition by the CSC manager that there was a legitimate concern about the direction being taken. The defensiveness of the management position, and the dismissive attitude towards other agencies that is displayed in her subsequent internal communications, was clearly recognised by other workers and acted as a barrier to constructive working, including appropriate professional challenge. 4.7.3. Other evidence of these tensions which can be seen include: Frustrations when professionals not invited to meetings by CSC Criticism by YPST of 111111 approach to their work, including an accusation that the 11111111111 approach was purely designed to “cover their backs”. Disputes as to whether Connexions or YPST should lead on education and training. 111111111 worker implicitly criticising CSC for not properly informing YP7 about the pre-birth process. CAMHS identifying in 11111111 that CSC should take the lead. 4.7.4. It is not in itself entirely unusual, or necessarily problematic, for there to be some tension between the perspectives of CSC and the Guardian within court proceedings. However in this case there was a particular degree of negativity towards the Guardian which was far from conducive to managing legitimate professional disputes in relation to YP7. The Guardian’s view that the Local Authority should take Care Proceedings was, on all the evidence, asserted quite properly, however, internal communication between managers described the Guardian’s actions as manipulative. 4.7.5. The level of concern by the Guardian and her manager about the lack of protective action that had been taken by CSC, was so significant that in 1111111 a decision was made to write to the Head of Child Care Services in his role as Chair of the Area Child Protection Committee12 to request that a Serious Case Review be undertaken. It is understood that at that time there was no sub group whose role it was to make this decision. Instead a decision was made, apparently by the Head of Child Care Services alone that there was no need to undertake a Serious Case Review. A letter was sent to CAFCASS by 12 The Area child Protection Committee (ACPC) was the body responsible for co-ordinating multi-agency child protection work, which pre-dated the creation of Safeguarding Children Boards. 40 the interim service manager on behalf of the Head of Childcare Service stating that this was being considered but asking why this had not been raised previously. Subsequent internal e-mails in October confirm that a decision had been made not to undertake a Serious Case Review. There is no evidence that the CAFCASS manager pursued this any further. 4.7.6. Whether this approach was the most constructive way of achieving change for YP7 merits some consideration given the level of tension that was already evident between the two organisations. Having initiated the process and not it would appear received a satisfactory answer, it is surprising that this was not pursued further. CAFCASS has informed this review that it is standard practice for this approach to be taken, but no further information has been provided. It was clearly legitimate for CAFCASS to escalate their concerns. However whether seeking a Serious Case Review which is intended to provide lessons from past practice to inform future practice as a means to deal with concerns about a young person’s current situation may not be the most effective way of achieving the required outcome. A recommendation has therefore been made by the Overview Report that CAFCASS review the effectiveness of this practice in achieving change. 4.7.7. What does not remain entirely explained is why the Guardian finally accepted the Local Authority’s view that there was no need for Care Proceedings. It is noted that this was due to the return of YP7’s mother to the UK and the fact that she was said to be working constructively with the authority. The IMR concludes that professional standards were met, but in the absence of a more detailed analysis this decision appears inconsistent given the history of MYP7’s parenting and the level of concern that was raised by CAFCASS. 4.7.8. What was significantly absent was effective challenge to CSC or escalation of agency concerns. Evidence from this Review and that of YP1-6 suggests that one of the reasons agencies seemed unable to successfully escalate concerns was their experience of the inappropriately negative attitude taken at quite a high level by CSC. That this sort of approach was taken by CSC is of significant concern both for the wider damage it causes to effective multi-agency partnership working, but also because it can lead to poor decision making in relation to individual cases not being reconsidered at an early stage. Given the potential significance of this issue to the outcome for YP7 2 related recommendations have been made by the Overview Author: Recommendation 1&4. 4.8 Managing Risk of Harm 11111111111111111 4.8.1. The relationship between YP7’s involvement with the 11111111111111111 and the Child Protection system was a significant issue for consideration at the outset of this Serious Case Review and was identified as such within the Terms of Reference. 41 The Review wished to understand the degree to which the two systems worked together and in particular whether there was a proper balance of focus in relation to YP7 as a young person who had offended but also as a young person in need of protection. The SCR Screening panel was aware of wider debates at a national level about the degree to which young people who are victims of child sexual exploitation can become criminalised as a result of that exploitation, and the possibility that victims’ 111111111111 is more visible to agencies than the fact that they are being abused. 4.8.2. It is clear from this Review that agencies whose primary focus was to work with YP7 in relation to her 11111111111, also fully understood that YP7 was a child with complex welfare needs and worked with her on this basis. There is considerable evidence that both the 1111111111111111111111111111111111111111consciously worked as part of the multi-agency child safeguarding partnership and balanced this with their primary focus on 111111111111111. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.8.3. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.8.4. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.8.5. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 42 1111111111111111111111111111111111111111111111111111111111 111111111111111111111111111111111111111111111111111111111111111111111111 1111111111111 1111111111111111111 11111111111111111111111111111111111111111111 1111111111111111111111111111111111 111111111111111111111111111111111111111111111111111 4.8.6. 11111111111111111 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.9 The impact of and responses to Race, Gender, Disability and disadvantage 4.9.1 As has also been found to be the case with YP1-6 a thread that ran through much of the response to YP7 related to the understanding and professional confidence with regard to issues of diversity. YP7 like the other young people faced particular pressures and barriers due to structural disadvantage and personal attributes. 4.9.2 Many of the features that played such a significant part in the understanding of YP1-6’s experience are repeated with regard to YP7. Particular analysis has been provided in the SCR for YP1-6 regarding attitudes both towards the perpetrators and towards what 43 has been frequently described as the young people’s ‘lifestyle’ and are equally relevant to YP7. 4.9.3 As was the case with Yps1-6 there is no evidence to suggest that there was an unwillingness by practitioners or agencies to make referrals about the abuse, because the men were ‘Asian’. However, the regular reference to perpetrators as ‘Asian’ men without any explanation as to what this terminology signified or what it implied, is particularly noticeable in YP7’s case, given that other men’s racial background or country of origin is never referred to. What was absent both in the case of YP7 and of YPs1-6 was any attempt to understand why the fact that many of the men were “Asian” might or might not have been relevant and legitimate for consideration. In particular there is no evidence that practitioners asked questions as to why quite well established social and racial boundaries were being crossed so frequently. This issue has been considered in more detail in the SCR for YP1-6, but in summary what it suggests is a lack of awareness by practitioners and a lack of confidence in articulating and analysing their responses with regard to race. Once again reflecting the young people subject to the related SCR what is clear in relation to YP7 is that whatever the origin of the perpetrators, agencies ultimately seemed unable to intervene to prevent the abuse. 4.9.4 A key feature that in varying degrees was known to or recognised by all the agencies concerned was that YP7 had some form of learning difficulty or developmental delay. Eventually it was assessed that this was very significantly a feature of her social and educational experiences with little evidence to suggest an underlying Learning Disability. Whatever the cause, this highlights the degree to which education systems during YP7’s early years seemed unable to meet YP7’s needs or to access appropriate support for her from an early stage in her school life. It is evident that the school at which YP7 was a pupil during the timeline for this report tried a number of interventions to help YP7, but there is little evidence as to how successful these interventions were. By 11111 the Headteacher stated that a mainstream school was not suitable for her needs. However it is unclear what options for a specialist school were considered, rather than the decision to a move to the Pupil Referral Unit. 4.9.5 Although agencies were aware of her difficulties, there was a mixed approach in the degree to which interventions with YP7 were adapted in order to meet her needs. Practical advice had been provided to agencies following the assessment by CAMHS as to how best to communicate with YP7. Whether this was put into practice is difficult to ascertain. 4.9.6 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 44 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.9.7 One possible explanation for this, may be that as described in the Pennine Care IMR: “On paper YP7’s learning needs did not appear that severe even though, in practice, the combination of difficulties that she had (learning, memory, concentration, managing her emotional responses) disadvantaged her considerably.” More worryingly in relation to the response by the Young People’s Support Team, there is some reason to believe that there was a failure to understand the significance of YP7’s learning difficulties and their complex link with her emotional and family experiences and instead to focus on attempts to change her behaviour, by insisting that she take responsibility for herself. Whether this reflected poor skills and knowledge base is unknown, but once again, there is no evidence of management intervention to question or help improve practice. 4.9.8 111111111111111111.11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.9.9 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 45 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.9.10 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 4.9.11 A question that was raised very significantly in relation to YP1-6 was whether the background and class of the young people affected professionals’ expectations as to their future options and what was normal for them to experience. During the period of more than 4 years that YP7 was living in the community that is considered by this review, the level of harm and abuse she was exposed to is particularly shocking and again raises the same question. Whilst there is much evidence from this Review to suggest that professionals were frequently distressed and worried for YP7, that they did not think what was happening to her was acceptable, ultimately however, there was perhaps a sense that there was little further they could do. If this sense of helplessness in the face of young people living with brutal and traumatising experiences is to change it will need an absolutely clear and consistent message from the highest level of each of the agencies that if that experience is not be acceptable for our own children, it will not be acceptable for any children. 4.10 Could the harm to YP7 have been prevented or predicted? 4.10.1. As was the case with YP1-6, it is evident that the weaknesses in practice identified within this Review reflected not just the agencies’ approach to child sexual exploitation, but also to significant underlying problems within routine safeguarding practice. 4.10.2. There is little doubt that a radically different course of action than was taken in relation to YP7 was required from as early as 2004. Had proper protective action been taken when YP7’s situation was first brought to CSC’s attention, this would have provided: opportunities to better understand what was happening in her life; to identify a placement most suitable for her needs and with the greatest potential for a positive outcome; opportunities to address her significant 46 emotional and developmental difficulties; 11111111111111111111111111111111111111111111111111111 Most crucially it could have provided her with a place of safety. 4.10.3. There could be no absolute guarantees that YP7 could have been kept completely safe nor that the damage caused by her early negative experiences could have been reversed. However, without decisive action it should have been clear that the outcome for YP7 was unlikely to be anything other than a negative one. It was known by 2005 that YP7 was experiencing sexual exploitation and there was no rationale for considering that this would simply stop in the foreseeable future. By 2008 it was painfully evident that YP7 was routinely exposed to significant risk of harm and that that harm could be catastrophic. The corrosive combination of her life experiences clearly could not equip her to live independently, safely or in a way which allowed her basic needs to be met. 4.10.4. There were both strengths and weaknesses in the response of all the agencies. However, the conclusion of this Review must be that CSC, the agency with the primary responsibility for protecting YP7 from serious harm failed to protect her from continuing harm. 47 5 MULTI AGENCY RECOMMENDATIONS 5.1. The individual management reviews for each of the agencies involved in providing services to YP7 have identified relevant recommendations for their own agencies as a result of this review and additional recommendations have also been included arising out of this Overview Report. 5.2. This Serious Case Review was completed within a matter of weeks of the Serious Case Review in relation to YP1-6 who were also subject to child sexual exploitation. A conscious decision has been made within this Review only to produce multi-agency recommendations which focus on the learning particular to YP7’s experience rather than in relation to each identified weakness in service, particularly when these are lessons reflected in the SCR for YP1-6. RBSCB has clearly recognised that the learning from these two reviews needs to be linked together. 5.3. The multi-agency recommendations for Rochdale Borough Safeguarding Children (RBSCB) are therefore as follows: Recommendation 1: RBSCB to use the developing mechanisms for auditing and review of safeguarding practice, in order to identify evidence of improvement in multi-agency working, including the acceptance of the legitimacy and importance of inter-agency challenge. Recommendation 2: RBSCB to assure itself that the role of agencies in decision making regarding specialist placements for young people with complex needs, is properly understood. Further, that commissioning, whether joint or single agency, results in an appropriate range of options being available Recommendation 3: 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 Recommendation 4: The RBSCB to undertake a review of its escalation policy and satisfy itself that that partner agencies have effective escalation policies which are used as intended. Recommendation 5: The RBSCB to request a report from 111, CSC and Rochdale Borough Housing regarding the quality of accommodation available to vulnerable young people. The report to consider whether additional policy and procedures are required in relation to risk assessments being undertaken prior to placements and staff’s responsibility to report and take action on concerns. A further recommendation has been made as identified within the schools IMR for the wider schools network: 48 Recommendation 6: The leadership role of the primary and secondary head teacher representatives on the Safeguarding Board needs to be strengthened in order to effectively deliver key safeguarding messages to all head teachers in the borough through the head teacher network meetings and in liaison with the Education Safeguarding Lead. Detailed responses and action plans with regard to the Multi-Agency Challenges and Recommendations become the responsibility of the Board. 6 INDIVIDUAL AGENCY REPORTS AND RECOMMENDATIONS Each agency through the production of its IMR has identified learning and provided recommendations for that agency. A number of recommendations, relating to relevant areas of learning had already been made by many of the agencies as part of the SCR for YPs1-6 and therefore have predominantly not been repeated here. 6.1 CAFCASS: Children and Family Courts Advisory and Support Service 6.1.1. CAFCASS has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Service Manager, National improvement Service. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family, and as such met the criteria for independence. 6.1.2. The Report was countersigned by the National Child Care Policy Manager who had no direct knowledge or involvement with the services provided to YP7. 6.1.3. CAFCASS provides advice to the courts and make provision for children to be represented family court proceedings. CAFCASS had two periods of involvement with YP7. The first when a Children’s Guardian was allocated to YP7 in relation to the Local Authority’s application for a Secure Accommodation Order. The second was in 2009, when a Children’s Guardian was appointed to represent ChildYP7 in the Care proceedings. 6.1.4. No recommendations have been made by CAFCASS in the light of learning already considered within the related SCR regarding YP1-6. 6.1.5. A recommendation has however been made by the Overview Report Author that: CAFCASS review the effectiveness of its practice in referring cases of current concern for a Serious Case Review in the light of this Review. 49 6.2 Children’s Social Care: Targeted Services 6.2.1. Rochdale CSC has provided a chronology and Individual Management Review for this Serious Case Review. 6.2.2. The report has been prepared by an independent consultant commissioned by Rochdale MBC due to lack of capacity to provide an IMR author internally. 6.2.3. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family, and as such met the criteria for independence. 6.2.4. The Report was countersigned by Assistant Director who had no direct knowledge or involvement with the services provided to YP7. 6.2.5. CSC: Targeted Services provides a range of services to children who are assessed as “in need” or at risk of significant harm, including assessment at the point of referral, services for Looked after Children, after care and family support. 6.2.6. During the later stages of the Review it became apparent that significant information was missing from the CSC IMR. Given the time constraints and the importance of maintaining independence, the Independent Overview Author reviewed relevant CSC files for YP7 in order to ensure that as complete a picture as possible was available for the Overview Report. 6.2.7. The recommendations for action for CSC are as follows: 1. CSC should further introduce measures to ensure that all practitioners working with young people have a good working understanding of the nature and dynamics of child sexual exploitation and are able to improve the quality of risk assessments. 2. CSC should ensure that procedures, processes and review systems are in place to promote effective multi-agency planning in child sexual exploitation cases. 3. There should be a clear mechanism within CSC for the Strategic involvement of Senior Managers in organised child sexual exploitation scenarios. 4. CSC should have clear guidance on the management of extra familial child sexual abuse cases. 5. CSC should undertake regular case audits to ensure that the needs of children are at the core of work undertaken and based on the child’s journey. 50 6. CSC should have very clear standards and guidance about the circumstances, if any, in which non-qualified social care staff undertake qualified social worker tasks. 7. There should be regular auditing of files, with reports to the LSCB, on supervision within CSC. This should encompass the “challenge” role of supervision. 6.2.8 As a result of the learning arising out of this Review for and that of YP1-6 the following actions have been put in place by CSC: The effective and early identification and addressing of child sexual exploitation is a top priority of local authority and is included in the Service Improvement Plan and the CSE Strategy which are report to the Children’s Safeguarding Board. A new quality assurance framework has been developed and is in place. This framework which uses auditing, direct observation and service user feedback to monitor the effectiveness of recognising and includes due regard to the issue of child sexual exploitation. In addition, a constant theme of auditing activity focusses on historical information informing assessments, SMART planning and the extent the ‘voice of the child’ is evident in decision making and planning. A revised supervision policy and guidance was launched in August 2013, which includes a programme of regular auditing activity by middle and senior managers to monitor the quality and effectiveness. A learning workshop has been held for all managers responsible for the chairing of Child Protection Strategy Meetings and a good practice tools distributed. A critical case briefing protocol and guidance has been issued to all managers/staff and implemented. In addition a weekly caseload report is produced for all managers to monitor the workload of staff and ensure remedial action is taken where required. A bespoke learning and development package has been produced for all practitioners and managers in recognition, assessment and response to child sexual exploitation and intra-familiar abuse. Roll out has started and is a part of the mandatory induction programme for all news starters. All children referred to Children’s Social Care are screened for risk for child sexual exploitation. The development of a bespoke placement service for vulnerable young people who are at risk of CSE is being led by the Local Authority Commissioning Manager for Placements. 51 6.3 Children’s Services: Safeguarding Children’s Unit 6.3.1. Rochdale Children’s Social: Safeguarding Children’s Unit Care has provided a chronology and Individual Management Review for this Serious Case Review. 6.3.2. The report has been prepared by an independent consultant commissioned by Rochdale MBC due to lack of capacity to provide an IMR author internally. 6.3.3. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family, and as such met the criteria for independence. 6.3.4. The Report was countersigned by the Head of Safeguarding who had no direct knowledge or involvement with the services provided to Child A, B and C. 6.3.5. The Child Protection Unit Reviewing Service was responsible for providing Chairs for Child Protection and Independent Reviewing Officers for Looked after Child (LAC) Reviews 6.3.6. The recommendations for the Safeguarding Children Unit are as follows: 1. The IROs need clarification of their role and further development of their quality assurance role. 2. The specific role of the Reviewing Officers in “Strategy Meetings” should be clarified. 3. Management arrangements need to be in place to ensure that there is an appropriate escalation within the Reviewing Service, when there are concerns about safeguarding issues. 4. Children who have been or are being sexually exploited should be assessed as children in need or in need of protection and offered services to support them where appropriate. 5. Where there are ongoing child protection issues for looked after children, a CP Plan must be built in to the LAC Planning process and monitored through the Reviewing system. 6.3.7 The Safeguarding Children Unit has identified that within the timeframe of the Review and since, there has been a number of changes at the safeguarding children unit which correspond with recommendations made within the review. A new agenda and template of minutes for conferences provides greater scrutiny of child protection cases and to the wishes and voice of the child or young person. Advocacy service for Rochdale children has been extended to support children who are subject to child protection plans and the advocate has supported children to either attend conference or to have their views clearly stated. Reports from the advocate are produced with recommendations for the senior leadership team. 52 The unit has appointed a quality assurance officer who has introduced a new quality assurance framework to ensure that there is regular feedback from both conferences and from looked after reviews for, children and parents. The reports produced from this feedback are shared at senior management team meetings to ensure that gaps in service are addressed and themes are reviewed again at regular intervals to examine progress. The unit has increased ts capacity with the introduction of a team manager for the IRO and conference review service and three additional IRO’s to ensure that case loads reflect recommendations within the IRO handbook and IRO’s are able to greater develop their quality assurance and challenge role. The unit has introduced an escalation procedure in relation to child protection conferences and has reviewed the dispute policy for looked after children. Monthly reports of the escalations are produced and themes are identified and actions agreed via the senior management team. The unit has carried out a review of its business processes to ensure minutes are distributed within agreed timeframes The new Greater Manchester Safeguarding Procedures have been adopted which clarify the role of the strategy meeting 6.4 Connexions Rochdale (Careers Solutions) 6.4.1. Connexions Rochdale has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Service Manager. The author has had no operational responsibility in the case or any direct involvement with the Young Person and her family and as such met the criteria for independence. 6.4.2. The Report was countersigned by the Head of Targeted Services at Careers Solutions. The countersigner had no knowledge or involvement of the services provided to YP7 or her family. 6.4.3. During the course of this Review, the service provided by Connexions was transferred to Positive Steps. Both companies have made a commitment to share the learning from the Review and the action plan will be taken forward by Positive Steps. 6.4.4. Connexions Rochdale provided Education/Training and Employment advice and support YP7 on a number of occasions. The service included routine careers advice within schools as well as more individualised support. 6.4.5. The recommendations for Connexions/Positive Steps are as follows: 53 1. Client intervention notes and information received from/passed on to other agencies need to be thorough and detailed to ensure other workers conducting future interventions have a clear understanding of clients’ circumstances. Additionally it is vital that time is taken prior to an intervention to read previous contact details. 2. Where Advisers raise concerns about clients with their Line Manager, there needs to be a clear process of follow up of agreed actions being undertaken. 3. The need for an escalation procedure internally and externally which clarifies the process to be followed when liaising with partners. 6.4.6 The following actions have already been taken in relation to the learning from this review: Team Managers conduct verification audits twice a year for each Adviser, which focus on ensuring documentation recording of client interventions are completed to required standards and this will include checking that where information has been received from or passed on to another agency, a key contact from that agency is identified and any agreed actions have been followed up. The client database has in place an ‘alert’ system should there be issues that Advisers need to refer to prior to conducting future interventions. Although all Connexions Advisers received CSE briefings during July/August 2012 , CSE refresher training is being arranged with RMBC for all Advisers during January 2014. Positive Steps has completed a programme entitled Safeguarding Month in which staff from all directorates within Positive Steps had to opt for up to 4 training sessions around safeguarding themes, one of which had to include the mandatory ‘ ensuring client safety’ session. 6.5 Early Break (Young People’s Drug and Alcohol Service) 6.5.1. Early Break has provided a chronology and Individual Management Review for this Serious Case Review. The report has been prepared by the Area Business Manager and Safeguarding Lead for Early Break East Lancashire. The author has had no operational responsibility in the case or any direct involvement with the Young Person and her family and as such met the criteria for independence. 54 6.5.2. The Report was countersigned by the Chief Executive. The countersigner had no knowledge or involvement of the services provided to YP7 or her family. 6.5.3. Early Break provided advice and support regarding alcohol and use to YP7 for three separate periods during the timescale. . 6.5.4. No new recommendations for Early Break have been made as the learning reflects recommendations that were made in the SCR for YP1-6, which were as follows: Recommendation 1: Early Break to establish a formal process for the dissemination of learning from SCR Recommendation 2:Early Break to review its current locality based process for recording and reporting of CSE. These to be recorded in one central place and the workforce to be updated on them. Recommendation 3:Early Break’s workforce to reflect on their own organisational culture and how they also experience other organisational cultures in relation to CSE. Workers to also identify areas of tension and explore these in relevant supportive forums e.g. supervision Recommendation 4:Early Break to establish clear escalation processes for safeguarding issues and complaints about other organisations 6.5.5. Early Break have identified that the following actions have been taken as a result of the learning arising from this Review and that of YP1-6: Recommendation 1: This process has now been established and serious case review information is now formally disseminated throughout service. Recommendation 2: Workforce development undertaken on this and workers discussed locality based CSE processes. These are now recorded in a central place and this is reviewed with the workforce throughout the year. It is part of induction for new workers. Recommendation 3: This will remain an on-going process. Workforce development specifically undertaken on this with a focus on culture and areas of tension and how to resolve these or escalate. 55 6.6 GP Services Rochdale 6.6.1. GP Services Rochdale has provided a chronology and Individual Management Review for this Serious Case Review. 6.6.2. The report has been prepared by a GP Practice Lead for Child Protection. The author has had no operational responsibility in the case or any direct involvement with YP7 or her family and as such met the criteria for independence. 6.6.3. The Report was countersigned by the Clinical Lead for NHS Heywood Middleton and Rochdale Clinical Commissioning Group The countersigner had no direct knowledge or involvement with the services provided to YP& or her family. 6.6.4. GP Services were provided to YP7 for much of the period of this review, however there are some gaps in information as a result of missing records and also for periods while YP7 was living out of the Borough. 6.6.5. Three recommendations for action have been made for GP services in Rochdale as follows: 1: The Pan Manchester Protocol for the management of Sexually Active Young People under the age of 18 years needs to be distributed to all GP surgeries in the borough with audit to be completed after six months to ensure that policy is embedded into practice. 2: Training in CSE and child protection for GPs needs to be reviewed to ensure that key risk indicators are recognised and the role of the GP is emphasised. Recognition of child abuse as a differential diagnosis also needs to be included. Safeguarding training for Gps needs to be audited to ensure that it is changing clinical practice. 3: GPs must receive training in CAF and understand their role to initiate its implementation for children and young people who require additional support. 6.6.6. The following information has been provided regarding actions taken as a result of this Review and that of YP1-6: 1. The Pan Manchester Protocol for management of sexual activity in young people below the age of 18 years has been distributed to all GP services in the borough and has been included in the GP training programme 2. Training for GPs now includes CSE as part of level 3 single agency training 56 6.7 Greater Manchester Police 6.7.1. Greater Manchester Police have provided a chronology and Individual Management Review for this Serious Case Review. 6.7.2. The report has been prepared by a Senior Review Officer. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family and as such met the criteria for independence. 6.7.3. The Report was countersigned by the Head of the Public Protection Division who had no direct knowledge or involvement of the services provided to YP7 and her family. 6.7.4. The IMR concluded that there were no new lessons for the Police arising out of this Review that had not already been recognised in regard to the SCR for YP1-6 and therefore the recommendation remained the same: Recommendation: That the Head of Greater Manchester Police Public Protection Division ensures the continued participation of GMP in Project Phoenix and ensures that all agreed recommendations or directives arising out of the project are implemented by Greater Manchester Police within a realistic time scale. 6.7.5. Subsequent to further reflection, Greater Manchester Police concluded that more detailed recommendations were required in relation both to YP1-6 and YP7 as follows: 1. CSE and safeguarding children to remain as a priority for GMP and included in the Rochdale divisional delivery plan to support the PCC Police and Crime Plan. 2. To ensure all staff are trained to a minimum required standard and are aware of local safeguarding board procedures. 3. Provide all new operational staff working in Rochdale with induction training in CSE and multi-agency safeguarding children procedures. 4. GMP to commit to developing and maintaining the Sunrise Team and to work proactively with the RBSCB to ensure a cohesive approach pending any final agreement and implementation of Phoenix within Rochdale. 5. GMP to re-emphasis the escalation process for the review and professional challenge of CPS decisions. 6. Ensure all officers investigating CSE within the Sunrise team have suitable accreditation within this specialism including the training and development as child abuse investigators. 7. GMP to ensure that there is a clear structure of supervision and monitoring and quality assurance of CSE investigations. 57 8. Senior Leadership Team to ensure that roles are understood to deliver the Rochdale multi-agency CSE strategy to prevent, protect and prosecute. 9. To develop and implement a toolkit of CSE prevention and disruption activities which can be monitored, evaluated and shared as best practice to ensure continuous improvement. 6.7.6. Greater Manchester Police have taken a range of actions as a result of the learning from this and other Reviews. GMP’s Rochdale Divisional Commander chairs the RBSCB child sexual exploitation Sub group whose work includes: Establishing a Cohesion Unit to build confidence and increase awareness within the community including the concept of ‘World Cafes’ which encourages our diverse community to take responsibility to tackle CSE. Includes other initiatives such as Accreditation for Taxi Drivers and designated Safeguarding Officer from the Rochdale Council of Mosques. Implementing Operation Noric, the aim to tackle CSE by proactive means. It involves regular weekday and weekend evening and night time work visiting high risk offenders, hotspot locations and conducting visits to young person's identified as being at significant risk of harm. Both uniformed and plain clothes officers working in conjunction with social workers, housing, fire and licensing enforcement officers, HMRC and VOS. 6.7.7. Other specific actions taken by GMP as a result of the learning identified in this Review include: Training and awareness to all Rochdale police officers, PCSOS and police staff involved in operational policing. Police officers are now fully embedded in the commissioned multi-agency sunrise team. There is a clear structure of supervision, monitoring and quality assurance of CSE investigations. There has been development and implementation of a CSE prevention and disruption toolkit which can be monitored and evaluated and shared as best practice to ensure continuous improvement. The Rochdale Senior leadership team are fully involved in safeguarding and hold key roles in order to support and drive CSE strategy to prevent, protect and prosecute. A monthly performance scorecard has been developed to monitor performance. Police members of the RBSCB are fully involved in the development of Project Phoenix and fully involve the wider partners. 58 6.8 Pennine Acute NHS Hospital’s Trust 6.8.1. Pennine Acute NHS Hospital’s Trust has provided a chronology and Individual Management Review for this Serious Case Review. 6.8.2. The report has been prepared by the Named Doctor for Safeguarding, North Manchester General Hospital. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family and as such met the criteria for independence. 6.8.3. The Report was countersigned by the Head of Safeguarding. The countersigner had no direct knowledge or involvement with the services provided to YP7 and her family. 6.8.4. Services were provided to YP7 by 4 hospital departments: Accident and Emergency, the Children’s Ward, the Medical Emergency Unit and the Obstetric Department. 6.8.5. Three recommendations for action were made by Pennine Acute NHS Hospital’s Trust: 1. Development of documentation proforma and training, prompting assessment of social history 2. Recognition procedures to be reviewed in A & E and MEU, Training and awareness raising within PAHT A/E and MEU departments to reinforce responsibilities for 16-17 year olds under the Children Act 1989. 3. Safeguarding education to be designed, developed and piloted that is grounded in non-technical skills and human factors including employment of simulation and observation of error and threshold exercises that are grounded in non-technical skills concepts 6.6.7. The following actions have already been taken in relation to the learning from this Review: CSE briefings programme extended to include 2 extra dates in Dec. Documentation proforma to prompt assessment of social history has been developed and is being piloted in Rochdale Urgent Care Centre. Following a staff survey the proforma has been amended and the pilot has been extended. Records will be audited in Dec with a view to rolling out the proforma to the rest of the Trust in 2014. Level 2 and Level 3 safeguarding training (children and adults) has been revised to strengthen emphasis on the care and responsibilities towards children and young people. Learning Lessons bulletin has been developed for YP7case. 59 Specific sessions re: YP 7and the learning lessons bulletin will be delivered to all A/E and the UCC depts. during December. A DVD highlighting the story of a pregnant teenager has been developed as a ‘patient story’. The story is in the words of the patient herself and highlights what help and what hindered her journey from childhood to parenthood in extremely difficult and abusive circumstances. . 6.9 PENNINE CARE NHS FOUNDATION TRUST (Community and Mental Health Services) 6.9.1. Pennine Care NHS Foundation Trust (community and mental health services) has provided a chronology and Individual Management Review for this Serious Case Review. 6.9.2. The report has been prepared by an Independent Author with a substantial background in nursing, health visiting and midwifery and 14 years experience as a Named nurse for Safeguarding children. Named Nurse for Safeguarding Children for Oldham Borough for Pennine Care NHS Foundation Trust. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family and as such met the criteria for independence. 6.9.3. The Report was countersigned by the Acting Head Safeguarding Chidren. The countersigner had no direct knowledge or involvement with the services provided to YP7 and her family. 6.9.4. The recommendations for action for Pennine Care NHS Foundation Trust are as follows: 1. A single agency procedure for child sexual exploitation to be developed and ratified in line with any multi-agency procedure and implemented. This should include a clear pathway for referrals and for sharing intelligence with the Sunrise Team. This should be compliant with the Trust policy for electronic transfer of personal identifiable of data. 2. Record keeping training and a records audit of the Crisis Intervention Team records to be undertaken to ensure that they meet statutory, legislative and Trust safeguarding requirements for clinical documentation. 3. That a standard operating procedure be developed, ratified and implemented to ensure prompt transfer of records for Looked After Children. 4. Health visitors to be reminded of their duty of care to mother's, whose babies have been removed into foster-care at birth, with regard to assessing individual cases of the need for parenting support and maternal post-natal mental health and well-being. This should be in line with the local and the National 60 Commissioning Board: Greater Manchester Area Team Health Visiting Service Specification. 5. That the supervision arrangements provided to the Crisis Intervention Team be reviewed and evaluated to include: managerial function; learning and development function; the opportunity to evaluate and reflect on the effectiveness of action being taken in complex cases; the opportunity to resolve professional differences (mediation). 6. The safeguarding children competency framework for all staff identified as level 3 (Royal Colleges of Paediatrics and Child Health Intercollegiate document, 2010) be harmonised across Pennine Care NHS Foundation Trust and implemented. 7. All staff to be reminded to use the Safeguard Incident Reporting system in line with PCFT policy to escalate differences of opinion that cannot be resolved in relation to critical decisions concerning the care of children and young people, as well as their line manager and Named Nurse. 8. Training needs analysis of CIT staff to be undertaken in relation to safeguarding children. 9. CIT staff to demonstrate awareness and understanding of the Trust’s Safeguarding Children Policy and the multi-agency safeguarding children policy.Two further recommendations have been made by the Overview Report Author: 10. Pennine Care NHS Foundation Trust should collate factual information and examples of their concerns about the threshold at which Children’s Social Care take action in cases of sexual abuse. The information to be presented to the Board in order to contribute to work currently being undertaken regarding thresholds. 11. Pennine Care NHS Foundation Trust should review the accessibility and responsiveness of services provided to the survivors of sexual abuse in the light of this report. 6.9.5 The IMR identified that the following actions have already been taken in relation to the learning from this and related reviews: 1. The "Step by Step" guide for children at risk of sexual exploitation (DfE, 2012) has been circulated to all health practitioners. 2. A records audit tool has been developed to ensure the CIT records meet statutory and legislative requirements in relation to safeguarding (audit to be undertaken in December 2013). 3. The Crisis Intervention Team has attended record-keeping training. 61 4. Health visitors have received briefings in respect of their duty of care to mother's, whose babies have been removed into foster-care at birth, with regard to assessing individual cases of the need for parenting support and post-natal mental health and well-being. 5. A single safeguarding children competency framework has been developed and disseminated; staff awareness raising has been completed. 6. All staff have been reminded to use the Safeguard Incident reporting system in line with Pennine Care NHS Foundation Trust policy to escalate differences of opinion that cannot be resolved at practitioner level. 7. The Safeguarding Children’s Team has undertaken a structured appraisal of the safeguarding learning needs of the Crisis Intervention Team staff. 8. Crisis Intervention Team staff have engaged in a safeguarding session with the Safeguarding Children’s Team to review and discuss the Trust’s and multi-agency safeguarding policies and procedures. 6.10 1111111111111111111111111111111111111111 6.10.1. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 6.10.2. 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 6.10.3. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 6.10.4. 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111. 6.10.5. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 6.10.6. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 62 6.11 RMBC Strategic Housing Services 6.11.1. RMBC Strategic Housing Services has provided a chronology and Individual Management Review for this Serious Case Review in relation to the Homelessness Advice and Housing Option Service. 6.11.2. The report has been prepared by An Access Officer at the Homelessness Advice and Housing Options Service. The author has had no operational responsibility in the case or any direct involvement with YP7 or her family and as such met the criteria for independence. 6.11.3. The Report was countersigned by the Homelessness Services Manager. The countersigner had no direct knowledge or involvement with the services provided to YP& or her family. 6.11.4. Advice was offered to YP7 and the services working with her on a number of occasions, including referral to a range of accommodation provision. The RMBC service also provided YP7 with emergency accommodation, in particular by 1111111111 where she lived intermittently for several months. 6.11.5. Three recommendations for action have been made for Rochdale Strategic Housing Service as follows: 1. Improve awareness of safeguarding issues across the service 2. Empower and encourage staff to be confident 3. Improve internal processes 6.11.6 The IMR identified that the following actions have already been taken in relation to the learning from this and related reviews: Recommendation1: CSE Awareness Briefing delivered to a Housing Strategy meeting using the materials provided through RBSCB Lessons Learnt Staff Training Event held Recommendation 2 All staff have been issued with new service standards including standard reporting to colleagues and line managers Recommendation 3 All pregnant customers to be notified to Family Support Worker – this has been embedded as part of our Assessment process. 6.12 Schools (RMBC Children’s Services, Early Help & Schools) 63 6.12.1. RMBC Children’s Services, Early Help & Schools have provided a chronology and Individual Management Review for this Serious Case Review. 6.12.2. The report has been prepared by the Senior Education Welfare Officer Safeguarding. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family and as such met the criteria for independence. 6.12.3. The recommendations made for Schools (RMBC Children’s Services, Early Help & Schools)arising out of this Review are: 1. New protocols and guidance to be written and issued to all schools on the required recording standards for pupil files(all education and child protection) 2. Development of a borough wide protocol for the transfer of relevant information at transition between designated staff within mainstream education and post 16 provision. 3. Ensure that the signs and symptoms of CSE are understood and responded to by staff in school settings. CSE awareness-raising to be incorporated into single agency safeguarding training delivery. 4. The CAF to be embedded as an early intervention assessment tool in all schools. 6.12.4. Information has been provided regarding actions taken as a result of this Review. 1 Briefings have been provided to both Primary and Secondary Headteachers. A regular designated Leads network meeting set up each term with a standing time reminding them of recording standards. Guidance being written to incorporate best practice for recording standards and filing of records.. Safeguarding training now also includes reference to record keeping. 2. Protocol has been made available on the intranet and has been highlighted at the designated leads meetings and briefings. The impact to be assessed through moderation activity and sampling. 3. Safeguarding training packages have been revised to include and reflect CSE. 4. The numbers of CAFs being opened by schools and the quality of CAFs are increasing and are now being monitored for quality and appropriateness. 64 6.13 111111111111111111111 6.14 HEYWOOD, MIDDLETON AND ROCHDALE PCT (COMMISSIONING) 6.14.1. The Primary Care Trust responsible for commissioning has provided a Health Overview Report encompassing the three individual IMRs. 6.14.2. The report has been prepared by the Designated Nurse for Safeguarding Children. The author has had no operational responsibility in the case or any direct involvement with YP7 and her family and as such met the criteria for independence. 6.14.3. The report was signed by the Executive Board Nurse. The countersigner had no direct knowledge or involvement with the services provided to YP7 and her family. 65 6.14.4. No further recommendations for action have been provided for Health Commissioners in the light of relevant recommendations for YP1-6. 66 Name of SCRP chair assuring quality of overview report Audrey Williamson 1 Endorsement by LSCB Name of LSCB Chair Jane Booth Date of LSCB endorsement of overview report 17th Dec 2013 Signed on behalf of LSCB: Position: Independent Chair of Rochdale SCB Author: Sian Griffiths 67 BIBLIOGRAPHY & BACKGROUND READING Brandon, M et al ( 2008 ), A Biennial Analysis of Serious Case Reviews 2003-05, Department of Children Schools and Families. London. Brandon, M et al (2009), A Biennial Analysis of Serious Case Reviews 2005-07, Department of Children Schools and Families. London. Brandon, M et al (2010) A Biennial Analysis of Serious Case Reviews 2007-09, Department of Children Schools and Families. London. Brandon, M et al (2012) A Biennial Analysis of Serious Case Reviews 2009-11, Department of Children Schools and Families. London. Calder, M ed (2009): Sexual Abuse Assessments Dekker, s (2006): The Field Guide to understanding Human Error Department of Health (2001); Private Fostering: A cause for concern. Finkelhor, D (1986) A Sourcebook on Child Sexual Abuse HM Government (2010) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London NICE public health guidance 28 updated April 2013 NSPCC (2010) Children and young people disclosing sexual abuse: An introduction to the research Munro, E (2008): Effective Child Protection Munro, E (2011): The Munro Review of Child Protection (Dept of Education) Ofsted (2008) Learning lessons, taking action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008 Reder,P., Duncan, S. and Gray, M. (1993) Beyond blame: child abuse tragedies revisited Wilson and James (2007) The Child Protection Handbook Woods, D et al (2010) Behind Human Error |
NC52841 | Covers the period Sept 2018 until June 2021 when there was a disclosure of sexual abuse by a girl against her stepfather. The family had been well known to services since 2012. Beta and her siblings had been subject to child protection plans historically and there had been a previous Serious Case Review following the death of a sibling. Learning themes include: the need for conversations around risk, including people's perception of risk, the different risk assessments, and the interface between them; ensuring all partners are informed, and a multi-agency approach taken when a local authority contests a Special Guardianship Order (SGO), or there is a change in circumstances within a family unit; making sure children always remain the focus and are central to processes so that if adults caring for children experience medical issues, grief etc, consideration should always be given to the impact on the children; ensuring all partners are aware of a family being involved in a SCR/CSPR and that records reflect that; building trust, providing opportunities for children to disclose, and asking the right questions at the right time; professional curiosity and considering issue of disguised compliance; where multiple types of abuse are taking place, making sure attention is given to each form of abuse rather than allowing one type of abuse to overshadow the other; and ensuring the voice of the child is heard. Recommendations are embedded in the learning. Highlights examples of good practice.
| Title: Child safeguarding practice review: final report: Beta. LSCB: Staffordshire Safeguarding Children Board Author: Nicki Walker-Hall Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review Final Report BetaReview October 2023 MARCH 202 Nicki Walker-Hall Final Version October 2023 2 | P a g e Table of Contents 1. Introduction 3 2. Summary of learning themes 3 3. Context of Child Safeguarding Practice Reviews 4 4. Succinct summary of case 4 5. Methodology 6 6. Limitations 7 7. Key lines of enquiry 7 8. Engagement with family 8 9. Review team 8 10. Timescales 8 11. Analysis pertaining to the key lines of enquiry 9 12. Examples of good practice 23 Appendix I – Key to acronyms/ abbreviations 25 Final Version October 2023 3 | P a g e 1. Introduction 1.1 This Review has been commissioned by Staffordshire safeguarding partners, following a decision by the Staffordshire Safeguarding Children Board (SSCB) Rapid Review Group that, in Accordance with Working Together 20181, this case met the criteria for a Child Safeguarding Practice Review (CSPR) as abuse or neglect was suspected. Beta had suffered serious harm and there were concerns about the way agencies had worked together to keep her and her siblings safe. 1.2 The family were well known to services in Staffordshire. Beta and her siblings had been subject to Child Protection (CP) plans historically and there had been a previous Serious Case Review following the death of a sibling. 1.3 A CSPR was proposed to, and agreed by, the National Panel. This CSPR will consider the guidance in Working Together and the principles of the systems methodology recommended by the Munro review.2 1.4 Beta, the subject of this review, is of white British heritage. Beta is a young person who is very articulate and artistic. Beta loves Japanese comic style animation and loves to create pictures using technology. Beta likes crystals, loves her sister and is very close and protective. Beta attends the police cadets and would like to become a police officer; she likes 3D dragons which assist with her anxiety. 1.5 The following is a table of all the individuals referred to within the report: Name Relationship to Subject Blood relative to subject Beta Subject Mother Mother Yes Stepfather Mothers ex-partner No Guardian 1 Stepgrandfather No Guardian 2 Stepgrandmother (mother to stepfather) No Sibling 1 Brother (deceased) Yes Sibling 2 Half sister Yes Cousin 1 Stepcousin No Cousin 2 Stepcousin No 2. Summary of Learning Themes 2.1 The following are the main learning themes resulting from this review: • There is a need to have a conversation around risk including, people’s perception of risk, the different risk assessments, and the interface between them. 1 HM Government (2018) Working Together to Safeguard Children https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf 2 The Munro Review of Child Protection: Final Report: A Child Centred System (May 2011). Final Version October 2023 4 | P a g e • When the Local Authority contests an SGO, or there is a change in circumstances within a family unit, all partners should be informed, and a multi-agency approach taken. • Children need to always remain the focus. Children are not currently central to processes and should be. If adults caring for children experience medical issues, grief etc, consideration should always be given to the impact on the children. • How does the SSCB make sure all partners are aware of a family being involved in a SCR / CSPR and ensure that records reflect that? • Building trust, providing opportunities for children to disclose, and asking the right questions at the right time, is imperative to disclosure. There is a need for honesty and for keeping children informed about what a practitioner will be doing next. • Exhibit professional curiosity. Question everything – what if what you’re being told is not true? Is there evidence to the contrary that can be explored? • Where multiple types of abuse are taking place, give attention to each form of abuse rather than allowing one type of abuse to overshadow the other. 3. Context of Child Safeguarding Practice Reviews 3.1 The responsibility for how the system learns the lessons from serious child safeguarding incidents lies at a national level with the Child Safeguarding Practice Review Panel and at local level with the safeguarding partners. The purpose of the review is to identify improvements to be made to safeguard and promote the welfare of children. Locally, safeguarding partners must identify and review serious child safeguarding cases which, in their view, raise issues of importance in relation to their area. Serious child safeguarding cases are those in which: • abuse or neglect of a child is known or suspected and • the child has died or been seriously harmed. 3.2 This review will: • provide a way of looking at and analysing frontline practice as well as organisational structures and learning. • reflect the child’s perspective and the family context. • be proportionate to the circumstances of the case. • focus on potential learning, and • establish and explain the reasons why the events occurred as they did. 4. Succinct summary of case 4.1 Beta was previously known to children safeguarding services and early help (EH) services in Staffordshire from 2012. Beta and her siblings were subject to child protection plans on two occasions spanning 4 years under the category of neglect. Concerns included very poor home conditions, lack of food, domestic violence, adult mental health issues, lack of parental supervision, disguised compliance and non-compliance with professionals and regular presence of persons who present a Final Version October 2023 5 | P a g e risk to children3 (PPRCs) in the home. Beta’s stepfather had a historic conviction for a sexual offence against a male child. Stepfather was 17 at the time of his offences and for that reason he was placed on the sex offenders register for a period of 2.5 years, following which he was removed from the register and classified as an unregistered sex offender. 4.2 Beta’s sibling, sibling 1, died due to neglect. Mother was subsequently found guilty of cruelty to, or neglect of children and stepfather was found guilty of manslaughter by gross negligence and sentenced to 90 months in prison; he was released after 39 months. A Serious Case Review was conducted. 4.3 Beta and her half sibling, sibling 2, were placed with stepgrandfather and stepgrandmother who later applied for a Special Guardianship Order4 (SGO). The reviewer was informed by practitioners that the couple had indicated that securing care of sibling 2 was their primary focus. Children’s Social Care (CSC) following assessment recommended adoption for sibling 2 and a Child Arrangement Order5 for Beta. The Court granted an SGO to stepgrandfather and stepgrandmother (hereafter known as Guardian 1 and Guardian 2) along with a 12-month supervision order; the local authority viability assessment was negative. 4.4 In September 2018 Guardian 2 died. Although a referral was made to CSC at the time of her death, this did not lead to a review of the SGO or re-assessment of Guardian 1 ability to becoming the sole carer for the children. The children remained in sole care of Guardian 1. Guardian 1 was also caring for two other stepchildren (cousin 1 and cousin 2) at that time. Guardian 1 had his own health issues including unresolved Post Traumatic Stress Disorder (PTSD) type symptoms, including a stammer (which increased with anxiety and was a source of frustration), poor physical health, diabetes and depression and was struggling financially. A referral was made to the Early Help Team (EHT) to provide support to him. CSC would have done an EH assessment but whilst the EHT worker was going in the home, Guardian 1 refused the formal assessment. 4.5 The Community Mental Health Nurse was going to look at the impact of trauma therapy and Guardian 1 was re-referred to the GP to increase his anti-depressants. 4.6 A few months later when the referred issues had been addressed the case was closed. No concerns were identified for the children when presented for health appointments. 4.7 Further contacts to CSC were made during 2019 and 2020 with regards to concerns about risky adults visiting the home who were previously known to the children, funding arrangements under the SGO, and concerns from mother’s sister that stepfather was having telephone contact with her daughter cousin 2. Stepfather was still in prison at this point. All of this resulted in the team offering advice only; no further action was taken by the local authority. 4.8 The probation service informed CSC of stepfather’s imminent release. Stepfather was released to approved premises6 in Birmingham with conditions attached to his 3 PPRC – Formerly known as a Schedule One offender – a person convicted of one of the crimes listed in the Children and Young Persons Act 1933. However, the term Schedule One offender has now been replaced with the term ‘person posing a risk to children’. 4 Special Guardianship is an order made by the Family Court that places a child or young person to live with someone other than their parent(s) on a long-term basis. Adoption and Children Act 2002 5 A Child Arrangements Order is a legal order where the court decides either where a child will live or who a child can spend time with and for how long. 6 Approved Premises (APs) are premises approved under Section 13 of the Offender Management Act 2007. They provide intensive supervision for those who present a high or very high risk of serious harm. Final Version October 2023 6 | P a g e licence which meant he had a curfew, had to disclose any new relationships, as well as any contact with children, which would have had to have been pre-approved by the offender manager. It came to light stepfather had been able to have telephone contact with all the children in the household whilst in prison. 4.9 Following his release in March 2021, and with CSC’s knowledge, stepfather resurrected his relationship with the family. He was known to be having video and face to face contact with the children at Guardian 1 home address; Guardian 1 was required to supervise this contact. 4.10 There is some evidence suggesting Guardian 1 might have been deceiving professionals. Stepfather informed probation of a change in Beta, saying she was becoming more distant and appeared to be overwhelmed with the contact, not just with stepfather but with others too. Stepfather agreed to only visit Beta when she asked. Further to Beta’s increasing anxiety, stepfather reported a reduction in visits to every fortnight but later indicated he has not seen the children and was waiting for them to make contact. It appears that stepfather was having contact with many children in the wider family, in part because he started an intimate relationship with his stepbrother’s half-sister. 4.11 Beta disclosed sexual abuse by stepfather, he was recalled back to prison. During her Achieving Best Evidence7 (ABE) interview Beta disclosed that since stepfather resumed contact in March 2021, he had abused her on more than one occasion; she indicated the abuse had started before he went to prison. This was not known during the previous SCR. 5. Methodology 5.1 Following notification of the circumstances of Beta’s case, and agreement by the SSCB partners to undertake a Child Safeguarding Practice Review, the Review Panel was established. A reviewer/chair, Nicki Walker-Hall, was commissioned by SSCB. An initial set up meeting was held, and the following methodology agreed. 5.2 The single agency chronologies provided for the Rapid Review were merged and used to produce an interagency chronology. This was analysed by the reviewer and the panel members who developed hypotheses, to further inform the Key Lines of Enquiry for exploration and consideration. 5.3 Each agency was required to complete a learning summary report focussing on the Key Lines of Enquiry, providing analysis, and identifying single agency learning. It was agreed the review would examine in its entirety the period from 14-09-2018 until the 18-06-2021. 5.4 A summary of any significant incident/s the author deems relevant to the case was to be included, if it was believed that additional learning could be extracted or if the event pertained to the key focus points. 5.5 Key practitioners were identified and asked to attend a practitioner’s event. The event provided an opportunity for the partnership to consider the potential systemic issues identified through the individual agency reports. This event 7 ABE - covers the interview process for child and adult victims and witnesses during a criminal investigation, the pre-trial preparation process and the support available to witnesses in court. The interview guidance set out in ABE includes video-recorded interviews with vulnerable and intimidated witnesses where the recording is intended to be played as evidence-in-chief in court. ABE promotes a strong victim-centred and trauma-informed approach throughout the guidance. https://www.gov.uk/government/publications/achieving-best-evidence-in-criminal-proceedings Final Version October 2023 7 | P a g e focussed on the subject’s journey through the system in order to reflect on and share learning and, to identify opportunities for improved working within and between agencies in the future. 5.6 The 3-hour event involved practitioners from across health and the police and was facilitated by the reviewer. There were no local authority attendees, all SW’s involved in the case either no longer work for the authority or were unavailable. The reviewer has had an opportunity to discuss the case from a SW perspective with the assistant manager in post at the time, and another who knew the case and family well. 5.7 The reviewer spoke with Beta to gain an understanding of her experience of practitioners and the services they provided. 5.8 The reviewer completed a draft report which was analysed by the panel. Partner organisations via the panel were provided an opportunity to agree actions to address the blockages and barriers identified. The panel considered the most appropriate method to share the learning across the workforce in Staffordshire. 5.9 Whilst it is intended learning from the full report will be made available to the public, the decision regarding publication of the full report will be made only following consideration by the partnership. 6. Limitations 6.1 There have been some limitations to the review. Not all invitees attended the practitioner’s event. Not all the young people within the household have been spoken to. One declined involvement due to concentrating on exams, another was felt to be too young. 7. Key Lines of Enquiry 7.1 The following Key Lines of Enquiry were agreed: 1. Examine the quality of decision making and assessment: • regarding the SGO following Guardian 2’s death • within the first response team • around the arrangements for contact with the children following stepfather’s release from prison, along with the on-going assessment of risk given that stepfather 1 has previously admitted adults with PPRC status were entering the home under his supervision. • by the courts at the time the SGO was agreed 2. Consider what led to the lack of exploration of stepfather 1’s motivation throughout, but specifically at the point of his wife’s death and latterly wishing to secure an SGO for Cousin 1 and cousin 2. 3. Explore if/how agencies had no knowledge of the relationship between this child and the adult, all of whom were subject to the previous SCR. 4. Consider how collectively the partners have not been able to prevent stepfather from re-offending, and whether there were missed opportunities to protect Beta at various points prior to Beta disclosing. 5. Consider whether the SGO is a legal failure or an operational/ practice failure? 6. Examine the voice of the child considering Guardian 1 behaviour, and whether this was seen through the eyes of the children. Why was their voice rarely heard, other than by the two schools? Final Version October 2023 8 | P a g e 7. Explore how practitioners formed their view of Guardian 1 and his ability to keep the children safe, both during the time stepfather was in prison where the children should have had no contact, and upon release. Consider how easy it was for stepfather to manipulate others over the phone, and how was this seen, should this have alerted professionals more so because of Covid-19? An additional line of enquiry will be looked at via a separate meeting and will consider: 8. The decision making around the key lines of enquiry used in the previous Serious Case Review. This meeting will concentrate on decision making around PPRC’s. 8. Engagement with family 8.1 The reviewer met with Beta to gain an understanding of her interactions with professionals and her experiences of the services provided. The reviewer is grateful to her for her willingness to help others through her reflections. The reviewer met with Beta on two further occasions, to provide an opportunity for Beta to shape the content of the report and understand the learning to be shared. Beta expressed a wish for the full report to be published to help others. Extensive efforts have been made to include other members of the family in the review unfortunately these have not proved successful. 9. Review team 9.1 The Review Team consisted of the reviewer, Nicki Walker-Hall, and members of the SSCB Review Subgroup, which included senior safeguarding representatives from the following agencies: • CSC • Education • Police • Probation • CCG • MPFT • CAFCASS • SSCB Business Manager Nicki has worked in safeguarding roles for over twenty years. Nicki has an MA in Child Welfare and Protection and an MSc in Forensic Psychology. Nicki is an experienced author of both children and adult safeguarding reviews; she has a background in health. 10. Timescales 10.1 Working Together to Safeguard Children 2018 states that a review should be completed and published within 6 months from the date of the decision to initiate a review. Given that there are other proceedings which have had an impact on publication, for example an ongoing criminal investigation, the safeguarding partners will agree a date for publication once these proceedings have concluded. Final Version October 2023 9 | P a g e Analysis pertaining to the Key Lines of Enquiry 11.1 Partner’s ability to prevent stepfather re-offending, protect Beta and not rely on self-disclosure 11.1.1 Before Beta’s siblings’ death, professionals understood that stepfather had PPRC status relating to a sexual offence but lacked understanding regarding what level of risk he posed. During that time, mother was supervising stepfather’s contact with the children. Stepfather was classed as a medium risk8 and was not allowed any unsupervised contact with the children (stepfather was living with the children at the time). Stepfather was being managed by the Community Rehabilitation Company (CRC). 11.1.2 Stepfather was then convicted for manslaughter and, following his time in prison he was managed by Probation. Probation have rightly identified lots of positive practice taken by practitioners around monitoring and trying to help reduce the likelihood of stepfather offending. However, stepfather was manipulative and non-compliant with restrictions which is not uncommon. Whilst offenders are stringently monitored, probation can’t stop someone from re-offending if that is their intention, but they do recall offenders back to prison immediately if a further offence is suspected or proven. 11.1.3 Following Beta’s siblings’ death stepfather was assessed as a high risk9 to children due to his manslaughter conviction and not because of his historical sexual offences. In part due to stepfather’s young age at the time of the sexual offences he was, by that time, an unregistered sex offender10. This was not widely understood by all agencies and created much confusion. 11.1.4 Stepfather’s PPRC status was accurately communicated to the prison, and he was to have no contact with children (level 1). This was then stepped down whilst stepfather was incarcerated to written contact only (level2); the rationale is not understood and is contrary to the conditions of his sentencing. Under level 2 there should still have been no telephone contact with, or visits from, children. 11.1.5 It later transpired that stepfather had been having some contact with Beta via telephone. Beta indicated she had wanted telephone contact with stepfather as” he was my dad” and had never been, or felt, forced into the contact. As telephone contact had not been agreed stepfather’s telephone calls were not being monitored thus providing an opportunity for stepfather to groom Beta. 11.1.6 Because stepfather was an unregistered sex offender, he was not subject to the same assessment and monitoring as a registered sex offender. Stepfather was not assigned a named police public protection officer to assess his level of risk of recidivism as would be the case for a registered sex offender. As a result of no assessment being required, whilst static risks such as age at first offence, sex of victim, and criminal record were all well known what was not known were any dynamic risk factors as a result of changes in circumstance. This is likely to be the 8 Medium: there are identifiable indicators of serious harm. The offender has the potential to cause. such harm, but is unlikely to do so unless there is a change in circumstances 9 High: identifiable indicators of risk of serious harm. The potential event could occur at any time and would be serious https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1060610/Risk_of_Serious_Harm_Guidance_March_2022.pdf 10 The length of time an individual must remain on the sex offenders register will depend on the offence which they have committed, and the sentence passed. Final Version October 2023 10 | P a g e reason why professionals were consistently seeking clarity on the level of risk he posed. Learning point 1: A lack of understanding by the receiving agency regarding stepfather’s PPRC status and the level of risk he posed in relation to sexual offending, coupled with his non-adherence to conditions of sentencing in relation to his contact with children (which was not shared with or known to the probation service), left Beta and potentially other children vulnerable to grooming whilst stepfather was incarcerated. 11.1.7 Probation, in line with procedure, notified CSC of stepfather’s imminent release. The reviewer learned that the format and content of the PPRC notification form is somewhat limited and does not assist receiving practitioners to understand what they need to do with the information it contains. CSC assured probation that adequate safeguarding was in place through another adult supervising all contact. That assurance was accepted and, in the absence of any conflicting evidence, was not challenged. Because CSC were assured Guardian 1 was able to supervise contact between stepfather and the children, probations notification of release did not lead to a multi-agency meeting (either CP or CIN) to fully explore how the children within the family would be kept safe. 11.1.8 There is no requirement for Probation to inform other services involved with the children of an offender’s release, thus they were not formally made aware. School was made aware by Guardian 1 that stepfather was to be released. Guardian 1 reported he would be supervising all contact; confirmation was sought by school from CSC who corroborated this information. 11.1.9 An anonymous referral regarding another known PPRC visiting the family home resulted in no further action. Guardian 1 was contacted by telephone and indicated that he would strictly supervise all contact if this man was to visit the home again. Practitioners trusted that this was the case however, it is of concern that this man was allowed into the home in the first place, and there does not appear to have been consideration of Guardian 1 lack of judgement regarding this, or wider thinking of whether this affected thinking regarding whether Guardian 1 would be compliant with a request not to have a PPRC back in his home. 11.1.10 When partner agencies contacted CSC, they were informed stepfather presented a low risk of serious harm to children; it is not clear how CSC had come to that conclusion, or what risk assessment tool they had used. However, what is known is that stepfather had advised CSC that he had been having telephone conversations with the children whilst in prison. The fact that he had already been having contact with the children, a lack of clear understanding around the conditions of his sentencing, coupled with Guardian 1 assurance that he would supervise all contact, appears to have lulled CSC practitioners into a false sense of security. There appears to be a lack of understanding, and differences in professional’s interpretation, of direct and indirect contact. It is also possible that professionals were themselves being groomed or deceived. 11.1.11 The SGO gave some practitioners a false sense that everything must be ok. Had sufficient thought been given to Guardian 1 belief that stepfather had served his time and therefore he posed no risk, practitioners might have taken a different view. Final Version October 2023 11 | P a g e 11.1.12 Upon release, stepfather was staying in Approved Premises. These premises are for high-risk offenders; this was not known to practitioners working with the children. Stepfather had a license condition that he was to have no unauthorised contact with children and was to disclose any new relationships. 11.1.13 Stepfather did discuss his contact with the children, giving some information to probation staff regarding the children’s reactions to him, which in retrospect appears highly suspicious. This was not referred to CSC. 11.1.14 Stepfather portrayed himself as a victim and didn’t take responsibility for his offending. He tried to evoke sympathy from professionals; it is possible that the same dynamic occurred between stepfather and Guardian 1. 11.1.15 Although information regarding the children having a stepfather known to have a PPRC status was held within both Beta and sibling 2’s GP records, not everyone had access to this, and for those that did, it was not easily accessible. PPRC status wasn’t highlighted on the children’s records as a cause for concern. The information did not appear on stepfather’s records and was therefore lost. 11.1.16 When Beta disclosed abuse the probation service recalled stepfather back to prison. Learning point 2: Systems and processes around notifications of release and PPRC status are not providing the level of clarity, to those receiving the information, regarding the level of risk posed by offenders. Practitioners need to be curious when they receive information to ensure they understand what they are being told and what is to happen next. There is inconsistency in how agencies have assessed and are recording the risks. There is potential for the PPRC status of those committing offences as young people to be lost. There was some confusion about what ‘medium risk’ looked like for Probation and what was meant by direct and indirect contact as well as confusion about the terms ‘sex offender status’ and ‘PPRC’, and what this meant for managing risk. Lack of understanding regarding PPRC is not a new finding in Staffordshire; this was highlighted in a previous thematic review. The probation service is currently putting together a briefing outlining probations powers and licensing conditions to increase the partnerships understanding. Issues that should have been seen as red flags to practitioners were not given sufficient consideration in the context of what was known of the family. Professional curiosity was not exhibited even though this was a family who were well known to have contact with a number of PPRCs. Considering this it would be reasonable to expect any referral in these circumstances, suggesting on-going contact with a PPRC, should have led to thorough investigation. 11.2 The granting of the Special Guardianship Order (SGO) in relation to Beta and sibling 2 11.2.1 Beta was removed from the care of mother and stepfather following the death of sibling 1. Beta and sibling 2 were placed temporarily with Guardian 1 and Guardian 2. This arrangement became permanent following the court granting an SGO. Prior to this CSC conducted a Full Connected Persons (FCP) assessment11. Concerns were 11 If a Local Authority is responsible for accommodating a child, the child acquires ‘looked after’ status and as such The Care Planning, Placement and Case Review (England) Regulations 2010 require that the Local Authority satisfy itself that any placement into which the child is accommodated is appropriate, safeguards and promotes the child’s welfare and meets the child’s needs. If the Local Authority is proposing to place a Final Version October 2023 12 | P a g e raised about the implications for the placement based on the fact that Guardian 1 and Guardian 2 had no biological relationship with Beta, and Guardian 2 did not duly acknowledge the seriousness of stepfather’s prior sexual offending. The FCP assessment concluded negative with an outcome that Guardian 1 and Guardian 2 would not meet National Minimum Standards (2011) for foster carers and therefore their application for Special Guardianship was not supported by CSC. In addition, the appointed children’s guardian12 did not support the SGO. 11.2.2 The CSC sought a CAO and SO for Beta and adoption for sibling 2 but the court over-ruled this. 11.2.3 The author is aware that whilst the CSC viability assessment was negative, Beta expressed a wish to remain in the care of Guardian 1 and Guardian 2. Guardian 2 was an intervenor in the court proceedings and present throughout; Guardian 1 did not take an active part. The case was heard over a week and was reported to be a very difficult case with a very long judgement. The Family Court, based on all the presented information, granted an SGO in respect of Beta and sibling 2 to remain in the care of Guardian 1 and Guardian 2 and, unusually, made a 12-month Supervision Order.13 The children’s guardian did contest the decision in respect of sibling 2 but not Beta. The judge indicated further review may be needed at the end of this period to consider whether a further period of supervision and support may be required. The author understands that the children’s guardian was not unhappy with the final judgement. Due to lack of engagement by the courts in the CSPR process, it has not been possible to explore the rationale for the decisions further. Despite some movement to facilitate the involvement of the judiciary service in reviews, and the Presidents Guidance regarding Judicial Cooperation with Serious Case Reviews (2017), 14this guidance is now out of date and lack of involvement by the judiciary continues to be a national issue. Learning point 3: Lack of readiness by the judiciary to support and share proportionate information for this Child Safeguarding Practice Review, has been a limiting factor in fully analysing this KLOE. This finding is of national importance. 11.2.4 Partner agencies were unaware of the Supervision Order, and indicated that had they been aware of it, the case would have been managed in CIN. The lack of information sharing around the Supervision Order and subsequent lack of a multi-agency approach was contrary to procedures and a missed opportunity. Learning point 4: Following the court issuing a supervision order in addition to the SGO, all involved agencies should have been made aware, the case discussed in a Supervision Order planning meeting and the SGO support plan reviewed. child in the care of a ‘connected person’, an assessment is required to determine whether that placement is consistent with the requirements of the above Regulations. If the child is ‘looked after’ by the Local Authority full assessment of the ‘connected person’ will need to satisfy the requirements of The Fostering Services Regulations 2002. 12 The role of Cafcass – the role of the Children’s Guardian | Cafcass 13 A Supervision Order imposes a duty on the local authority to 'advise, assist and befriend' the child. 14 https://www.judiciary.uk/wp-content/uploads/2017/05/pfd-guidance-judicial-cooperation-with-scrs.pdf Final Version October 2023 13 | P a g e 11.2.5 When Guardian 2 died Guardian 1 notified CSC’s Family and Friends team the same day. Regulation 1715 requires that where the local authority provides special guardianship support services for a person, it must review the provision of such services if any change in the person’s circumstances which may affect the provision of special guardianship support services comes to their notice. At that time there was no procedure informing staff what to do in such circumstances. 11.2.6 The First Response Team (FRT) contacted the Team Manager of the Family and Friends Team (F&F) who agreed to contact Guardian 1 and explore support. The First Response worker (FRW) updated the Assistant Director (AD) of the plan to close the referral as support would be offered by F&F team. It is documented that the AD had checked with legal services whom the SGO was made to, as if only Guardian 2, there would be matters of parental responsibility to address. It was confirmed that the SGO was made to both Guardian 1 and Guardian 2, therefore Guardian 1 retained parental responsibility for both children. Agreement had been given by managers and the AD for support to be offered via the Early Help Team. A referral was made to the Early Help Service (LST) to provide support to Guardian 1. 11.2.7 Whilst these actions were taken internally there was no formal notification to partner agencies who learned of Guardian 2 death via Guardian 1 in the following weeks. The lack of notification meant that any immediate opportunity to consider the impact of Guardian 2 death on a multi-agency basis was lost. Learning point 5: The lack of a procedure covering the change in circumstance of those awarded an SGO proved problematic. Frontline practitioners rightly sought the advice of their managers. The focus was on support for the family; there was no decision to re assess the SGO made previously. Managers made a specific note that practitioners needed to be mindful of the emotional impact of Guardian 2 death upon the family. The reviewer has considered the draft procedure and suggests the procedure be more explicit regarding the requirement for reassessment in all cases where the Local authority was not supportive of the original order. 11.2.8 Full consideration as to whether Guardian 1 could adequately keep safe and care for all four children in his care was required via an assessment. However, practitioners were impeded as Guardian 1 did not consent to an Early Help Assessment. Consideration should have been given at this point for internal step up to the safeguarding team on the basis that Guardian 1 had refused consent for assessment. This was a missed opportunity to review risks and analyse his care. 11.2.9 Guardian 1 attended the GP at this time, and it was noted he was struggling. A referral was made to CSC. The GP was informed the Early Help Service were visiting him that day and would support him. 11.2.10 Guardian 1 said he would kill himself on two occasions in the weeks following Guardian 2 death. Police officers attended on both occasions, on the first occasion they spoke to the SW directly and on the second, they submitted a Multi-Agency Referral Form and allocated a Local Neighbourhood Officer. No formal written assessment was undertaken from the EHT, nor was the level of Guardian 1 mental health, and the effect of such upon the children, and his ability to care, considered. Of note Guardian 1 mental health is detailed within the SGO assessments from 2017 (deemed negative). The information around his mental health was considered 15 Regulation 17 - Special Guardianship Regulations 2005 Final Version October 2023 14 | P a g e from a position of grief, rather than within the wider context of his caring responsibilities. Learning point 6: Whilst it is entirely appropriate for professionals to be empathetic and supportive of a bereaved guardian, whenever a guardian appointed through an SGO dies a multi-agency response and review of the suitability of their remaining guardian must take place. Guardian 1 was seen as someone doing his best for the children and this appears to have allowed a more relaxed approach when concerns were raised. 11.3 Guardian 1 motivation for wanting to secure an SGO for cousin’s 1 and 2. 11.3.1 Guardian 1 motivation for wanting to secure an SGO for cousin 1 and cousin 2 is not fully known; it appeared to CSC that his motivation may in part be financial. There was much confusion amongst professionals regarding his financial situation. Guardian 1 consistently indicated he had no money to his GP however CSC believed he gave his money to the children. 11.3.2 Beta informed the reviewer that following Guardian 2 death Guardian 1 struggled financially and described the state of the home as going from “modern day to old”. Beta indicated Guardian 1 got “a bit of money from someone” which they used to do the house up. Beta indicated the children received money from their parents which they saved and would choose to give that money to Guardian 1 to help out; “they fixed the house and got a new back garden”. 11.3.3 An assessment undertaken by the safeguarding team in March 2020 when Guardian 1 sought an SGO in respect of cousin 1 and cousin 2 concluded No Further Action (NFA), it does not appear Guardian 1 financial situation was fully explored. CSC were of the opinion that he should seek to obtain a private SGO. Guardian 1 did not agree and indicated he had not received any of the promised help or support over twelve years. 11.3.4 School informed the reviewer that Guardian 1 had indicated he wanted an SGO in place to give him parental responsibility, citing issues in gaining permission to obtain passports for the children. If that was his motivation a Child Arrangement Order (CAO) would have been sufficient. 11.3.5 In July 2020, cousin 1 and cousin 2’s mum indicated she had concerns about stepfather wanting contact with the children upon his release. Because CSC were not involved in the SGO application it is not known whether this was considered as part of the application. 11.3.6 There was an opportunity to consider Guardian 1 motivation to secure an SGO when he attended the GP with sibling 2 in June 2019, and again in December 2020 when it is recorded that Guardian 1 had applied for special guardianship for 2 other children. Guardian 1 was being provided with a sick note during this period due to anxiety and depression therefore a contextual assessment e.g. ‘Think Family’16 at this time may have been identified whether there were any concerns about him being a sole carer for 4 children. 16 Think Family aims to secure better outcomes for adults, children, and families by coordinating the support and delivery of services from all organisations and promoting the importance of a whole-family approach. Final Version October 2023 15 | P a g e Learning point 7: Practitioners concentrated on supporting Guardian 1 and the family. Wider thinking as to whether Guardian 1was capable of looking after all the children, and his motivation for securing an SGO, were never explored but had been viewed by practitioners as coming from a good place. There is no evidence to suggest Guardian 1 motivation in obtaining SGOs for the children was considered untoward or suspicious. 11.4 Explore if/how agencies lacked knowledge of the relationship between Beta and the adults, who were subject to a previous SCR. 11.4.1 Over time not all practitioners or agencies working with the family were aware of the relationship between Beta and stepfather. Stepfather was not Beta’s biological father and due to the way and where information was recorded, the connection to his previous conviction, was lost. When Guardian 2 and Guardian 1 were granted the SGO for Beta, whilst CSC knew, this was not known within all partner agencies; there was nothing on their internal records to indicate any relation to the SCR for Beta’s sibling. Following referrals to CSC it was in the main only Guardian 1 view that was sought; therefore, practitioners were not in receipt of a full picture. 11.4.2 During Guardian 1 conversations with practitioners, he spoke about the family dynamics and specific family members contact with the family unit. He could choose to tell what he wanted, this was his narrative, and no evidence was sought either way to test if what he was saying was true or not. Guardian 1’s narrative was one of poor relationships in particular with mother, but refers to Guardian 2, and others (including a known PPRC), in a positive light. 11.4.3 The lack of assessment following Guardian 2’s death meant that any change in family dynamics or family time was not considered within a wider picture. Practitioners’ perception was that everything was alright. Learning point 8: It is vital that important historical information is recorded within client’s records and professionals apply critical thinking to ensuring the connections are made when children are involved in reviews. At the time this review was commissioned, there was no process across the partnership to ensure that connections to a previous or ongoing review were in place. Had this information been available at the time, when stepfather was released from prison it could have triggered wider, critical thinking from partners as to whether there was the need for an assessment. 11.5 Consider whether the SGO in respect of Beta was a legal failure or an operational/ practice failure. 11.5.1 It should be noted that most SGOs are positive and provide permanency for children however, in this case, particularly when circumstances changed, it was not. 11.5.2 When considering whether the SGO was a legal failure in this case the author was informed that the courts were provided with the assessment completed by CSC. During the hearing Guardian 2 acted as an intervenor within the court. Beta had expressed a wish to remain in the care of Guardian 2 and Guardian 1. Guardian 1 was not present, as sibling 2 was very young and he was taking care of her at home, therefore his views were not heard within court. 11.5.3 The reviewer has not had access to the transcript of the proceedings and is therefore not aware whether the couple’s views on stepfather’s imprisonment for historic Final Version October 2023 16 | P a g e sexual offences were discussed, or whether appropriate guidance was given regarding contact arrangements. The courts in addition to the SGO issued a 12-month supervision order17, suggesting that the court deemed there was a need to have some initial oversight of the children by social services. The reviewer cannot therefore conclude that there was legal failure. 11.5.4 Following the success in obtaining an SGO, there was no formal notification to all the agencies offering a service to the children, and there are various recordings of what this means. Some practitioners have on record that Guardian 1 had parental responsibility, others record that Guardian 2 and Guardian 1 are the parents. 11.5.5 In general, it is not clear whether GPs fully understand the legal association with SGO, and equivalent family arrangements, when care is transferred to other family members. GPs record parental responsibility in many ways. There is the option to apply an SGO code and identify who has parental responsibility on the child’s records but not the adults; there is the option to code the adult as a guardian. There is a place to add some narrative next to a code but there isn’t a facility to connect families on the records. On the most widely used GP system in Staffordshire there is no ability to see family or household relationships. Coding of records is a national issue. Currently the Royal College of GPs and NHS England Safeguarding are conducting a review of coding. 11.5.6 When the SGO was granted, this didn’t mean that all the concerns expressed by CSC were unwarranted, it just meant that having listened to all the presenting arguments it was felt the best option for the children. The practice failure is around what happened next in terms of the supervision order, management of the ongoing concerns and actions taken when new concerns were identified. Following the court issuing a 12-month supervision order there was no formal notification of this to all the agencies offering a service to the children. Beta indicated frequent visits from CSC during this time but was unaware why. MPFT indicated that had they been aware the case would have been managed as CIN. 11.5.7 The SGO seemed to offer a false reassurance to practitioners that everything in the family was and would remain alright. Practitioners have demonstrated a lack of understanding regarding SGO and appear to be under the impression that an SGO brings with it an oversight of the family. Whilst this is true of the supervision order this is not the case with an SGO. There is nothing to prevent a child who lives with a person who has been awarded an SGO also being subject to Child in Need/Child Protection processes if and when concerns arise. 11.5.8 The primary school did contact social services in November 2020 when it had concerns about sibling 2’s cleanliness and presentation. This was a missed opportunity for CSC to conduct an assessment. Learning point 9: There is a general lack of understanding around legal orders; in this case SGOs and supervision orders. There is no robust process for informing partner agencies of a successful application for an SGO at point of issue, or information sharing around what that means in terms of the child’s living arrangement and changes to parental responsibility. There is no agreed format for 17 A supervision order is a legal order, obtained by the local authority through the court, which requires a child to be supervised by social services, while still living in the family home (or placed with a relative), to make sure that the child is well cared for. Final Version October 2023 17 | P a g e recording when legal orders have been made and currently there is no narrative in the GP records when someone is coded as a guardian. 11.6 Voice of the Child - Why were the children’s voices rarely heard. 11.6.1 Very few Agencies/practitioners had any meaningful contact with the children. Following contact with CSC and the Police on two occasions following Guardian 1’s threats to take his own life there was opportunity to talk to the children. No one from CSC front door spoke to the children on the first occasion. However, the children were spoken to by the EHW both when they attended a Teen Aspire Group and when she visited their home. It is recorded that the Police Officer in attendance on the second occasion spoke with the children; the only comment they were said to have made was they were being picked on regarding the death of their brother sibling 1. Beta has no recollection of being spoken to by a police officer at any time. The children were seen by a SW alone once at that time. 11.6.2 Probation had no contact with the children. Despite this, some individuals involved seemed to accept stepfather’s portrayal of himself as concerned and supportive and, assumed there were positives in his relationship with the children without evidence from the children. 11.6.3 Although initial health assessments were completed when Beta first became Looked After in 2016 there is no evidence of any health assessments in the children’s records during the review period. This is likely due to the fact that health assessments are not required once children become subject to an SGO. Health assessments provide a good opportunity for children’s voices to be heard. 11.6.4 There was very little contact with the GP as the children required infrequent visits. GP records for those visits do not demonstrate that their voices have been heard. Guardian 1 contacted the GP regarding cousin 2. Guardian 1 indicated cousin 2 had symptoms suggestive of cystitis for a few days. Whilst this is deemed a common condition, this can also be indicative of sexual activity and an opportunity was afforded for this to be explored further through discussions with the child. Cousin 2 was seen face to face later that day by a female GP, providing a potential opportunity for cousin 2 to say if she was being abused and for the GP to ask. However, it is not clear whether cousin 2 was on her own or accompanied when she was examined, and nothing was identified during examination to suggest any further exploration was required by the GP. 11.6.5 Of note, changes to the way people are accessing health care means there will be less face to face contact which will inhibit GPs abilities to talk to the child directly. 11.6.6 The children were all well supported in school, Beta spoke about sibling 1 and all the children would talk about Guardian 2; they did not openly talk about stepfather or Guardian 1. 11.6.7 Practitioners indicated there was nothing in Beta’s presentation that alerted them to any abuse which raises the question what does an abused child look like? Practitioners need to be mindful not to have a stereotypical view of what an abused child may look like or how they may present. Many resilient children will not give major indicators that they are being abused and many children will do what Beta indicated she had done “boxed off the abuse. “It is therefore imperative that practitioners explore every unusual event/behaviour/piece of information. 11.6.8 Comments made by stepfather indicating he was “no longer sleeping in Beta’s room or giving personal care”, should have triggered further exploration with Guardian 1, stepfather, and Beta. Disclosures by cousin 2 that Guardian 1 was mentally abusing Final Version October 2023 18 | P a g e her and shouting at her all the time, and that he had pulled Beta’s trousers down to smack her bottom, did lead to CSC involvement but Beta was not spoken to regarding cousin 2’s claims. Beta reported that her behaviour did change, she stopped being talkative, became distant and was over dressed, but this was either not noticed or explored by practitioners. 11.6.9 Research on identifying and responding to disclosures of child sexual abuse18 has identified a number of key messages for practitioners: • Children’s disclosures of sexual abuse vary in the mode of communication, intent, spontaneity, and amount of detail that is included. Disclosure is best understood as a process which is influenced by relationships and interactions with others and may extend over a considerable period. • Rates of verbal disclosure are low at the time that abuse occurs in childhood. However, children say they are trying to disclose their abuse when they show signs or act in ways that they hope adults will notice and react to. This is particularly important for disabled children. • Professionals need to keep in mind that any child could be attempting to disclose, but certain children may face additional barriers to disclosure because of their disability, gender, ethnicity and/or sexual orientation. • The act of disclosing sexual abuse can heighten shame and guilt. Others‘ negative reactions to disclosures may compound these impacts. This should not stop professionals from providing opportunities to children to disclose, but it is essential that children and their families receive appropriate support following disclosure. • A range of complex and interacting individual, relational and social barriers may prevent children from disclosing abuse to professionals or anyone else. Teachers are the professionals to whom children will most commonly disclose, but the disclosure process can be helped or hindered by the way in which any professional engages with a child about whom concerns exist. • Children want to be noticed by friendly, approachable, and caring professionals, with whom they have built a trusted relationship. They want to be asked how they are doing and what is going on, so they have an opportunity to have an open dialogue. • Confidentiality is important to children but can be difficult to balance with professionals’ safeguarding responsibilities. Professionals may experience a tension around this in their relationship with the child. If maintaining confidentiality after a disclosure may not be possible, it is important to be open, honest, and transparent with the child. 11.6.10 It is imperative that children are provided the opportunity to speak out and are asked the right questions. Nationally, in training, practitioners have been discouraged from asking children leading questions so as not to impede criminal investigations, this message seems to have inadvertently impacted on practitioner’s confidence to ask any questions. Without some questions being asked, it is unlikely children will speak out. What helps children tell?19 addresses the question of what helps children disclose experiences of child sexual abuse. It established two key dynamics that help children with six associated facilitating factors: • The Need to tell, 18 Centre of Expertise on Child Sexual Abuse (2019) Identifying and Responding to Disclosures of Child Sexual Abuse 19 What Helps Children Tell? A Qualitative Meta‐Analysis of Child Sexual Abuse Disclosure (icmec.org) Final Version October 2023 19 | P a g e o Realising it is not normal o Inability to cope with emotional distress o Wanting something to be done about it • The Opportunity to tell. o Access to someone you can trust o Expecting to be believed o Being asked 11.6.11 When decisions were being made to take no further action or to make onward referrals to Early Help for support, opportunities for Beta to tell were missed as this meant no SW was directed to visit and speak with the children to ascertain their wishes. This is especially significant at the point stepfather was being released from prison. CSC were aware stepfather had been having contact with the children over the telephone; the children’s wishes and feelings regarding this contact could have been explored and should have had a direct influence on what was to happen next. It is possible stepfather was able to groom Beta from prison, what is not known is whether this prompted any change in Beta’s behaviour that might have been detectable by professionals. 11.6.12 Beta is extremely articulate and bright, who given the right circumstances and being asked the right questions may have felt able to disclose earlier. Practitioners need to be mindful that they are not waiting for a verbal disclosure but are ensuring all opportunities to tell are being provided. 11.6.13 Beta in discussion with the reviewer talked about social workers “coming in like seagulls and creeping out like crabs”. Beta indicated they would swoop in with an increase in visits and activity and then their involvement just petered out without Beta understanding why. No one ever asked her whether her situation had improved or whether she felt it was the right time to cease involvement. 11.6.14 Beta felt she had trusted too much before she lost trust. Beta described sharing information with practitioners and then discovering other practitioners had knowledge of what had been discussed. This left her questioning how they had obtained the information. Beta was not asked for permission to share her information or informed how her information was going to be used or shared. This had the impact of reducing her trust in practitioners and she learned over time not to tell anyone anything. 11.6.15 Beta described a marked change in her responsibilities after Guardian 2 died. Beta described a household were she and cousin 2 were responsible for cooking, cleaning, housework as well as caring for sibling 2, whilst Guardian 1 and her male cousin fetched and mended things. Beta described being scared she would be shouted at or told off if she did not do what was expected. Beta and cousin 2 would discuss Guardian 1’s treatment of them comparing it to slavery and calling it abuse amongst themselves. On one occasion Beta and cousin 2 packed their bags and ran away but they did not have the confidence to stay away so returned home without anyone knowing. Beta experienced emotional abuse from Guardian 1. On one occasion Beta recalled Guardian 1 threatening to telephone the SW and ask her to come and take Beta away. Beta recalls wishing the SW would come soon. Beta was treated like a stranger all weekend and fed only leftovers from the family meals. On another occasion, as a punishment, Beta was made to stand at a door for up to 4 hours or would have her electronic devices removed; the longest they were confiscated for was 8 months. Beta indicated she had kept her distress hidden, crying in secret. Final Version October 2023 20 | P a g e 11.6.16 Beta indicated that she felt if a practitioner started to see signs that were suggestive of abuse they should take the child out of the situation, ask questions and be clear that they were there to help the child over the adult. 11.6.17 Beta indicated she felt she was being treated differently in the house. Guardian 1 accused Beta of hurting sibling 2 and told her he had installed cameras to keep an eye on her; Beta indicated she had no privacy. 11.6.18 Beta informed the reviewer that she had experienced bullying in school and indicated she felt it took ages for any actions to be taken and that reports of bullying were not being taken seriously. 11.6.19 Beta indicated her experiences had left her with anxiety. 11.6.20 In discussions with practitioners, it was clear that messages given to practitioners within training to “not ask leading questions” are stopping practitioners from responding to young people when they might be ready to disclose. A clear message was given by police colleagues that leading/probing questions can be asked as long as they can be rationalised and are well documented. There needs to be a human response to the child. Learning point 10: The children’s voices were not being heard for a number of reasons. Either, practitioners were not acting on small but potentially significant pieces of information because of messages received within training not to ask leading or probing questions, there were limited opportunities for contact with health practitioners, or because of decisions to take no further action following referrals and notifications. There is strength in the opportunities the schools provided Beta to talk, however concentration needs to be on the quality of the contact. Considering Beta’s information, in the context of what helps children tell, it can be concluded that decisions to take no further action reduced the number of opportunities Beta had to tell. The impact of information sharing without explaining to Beta that was going to happen, reduced trust. Lack of decisive action following reports of bullying reduced Beta’s sense that she was being believed. Apart from sibling 2, all the children were of an age where they could have contributed to practitioner’s decision making. A lack of wider thinking, and full exploration, of the referred issues with the children has meant opportunities to further understand their lived experiences have been missed. 11.7 Explore how practitioners formed their view of Guardian 1 and his ability to keep the children safe. 11.7.1 Practitioners’ views on Guardian 1 and his ability to keep the children safe are largely based on how he represented himself to them, rather than through formal assessment. 11.7.2 Guardian 1 was viewed as caring who in the face of adversity was willingly taking on board the care of 4 children. These are qualities that were seen in a positive light by practitioners. Guardian 1 also acknowledged that at times he needed support and would seek this support out himself. This was again seen as a positive. In addition, Guardian 1 made timely communication with CSC and the children’s school following the death of his wife. Guardian 1’s communication with school was reported to be generally good; this was particularly evident during Covid-19 lockdown when there was lots of communication and acceptance of home visits. 11.7.3 Because Guardian 1 was seen as someone who was doing his best for the children, wider thinking regarding motivation was barely considered. When issues arose, Final Version October 2023 21 | P a g e these were always seen in context of a Guardian 1 trying to keep the family safe and together. Guardian 1 gave the impression of being open to service involvement and compliant, he was seen as someone who had the best interests of the children at heart. There was no evidence that Guardian 1 couldn’t keep the children safe whilst stepfather was in prison however, practitioners did not know that stepfather had been having telephone contact with the children contrary to the conditions placed on him as part of his sentence. 11.7.4 When school were informed by Guardian 1 that sibling 2 was going to have contact with stepfather, they made an assumption that there would be some oversight, and as they had no safeguarding concerns, they did not see it as necessary to refer to CSC. There was insufficient consideration as to whether Guardian 1 would be capable of keeping the children safe once stepfather was released from prison. The belief that Guardian 1 could supervise the contact led to a lack of assessment by CSC at that time. Consequently, this prevented a clear plan of action being developed; the lack of plan was compounded by Covid-19 which affected practitioners’ ability to have direct contact with the children. Covid-19 and the National lockdown, reduced practitioners contact with the children, the children’s opportunities to disclose, and practitioners’ abilities to monitor the situation. 11.7.5 Guardian 1 was well known to Primary Care due to living with poorly controlled type 2 diabetes and experiencing anxiety and depression with an associated stammer. Guardian 1 also had 2 x historic convictions, one for Actual Bodily Harm (ABH) in the 1990’s and the other for theft in the 1980’s. Whilst Guardian 1’s past offending behaviour would likely have been considered in the early days and triangulated with the SGO, over time this was less likely to have been considered. There is no evidence that practitioners were considering that Guardian 1’s past offending behaviour might remain relevant to the safety of the children. Whilst past offending does give historical context, in the absence of any offending for many years, it becomes understandable that it was not seen as particularly relevant. However, a letter from stepfather to Guardian 1 asking for £30k and for Guardian 1 to ‘keep quiet’, that was intercepted by prison staff and notified to the police provided an opportunity for greater professional curiosity as to whether there were any indicators that Guardian 1 might be involved in criminal activity. This letter has now been lost. 11.7.6 On one occasion, during a home visit, the family HV had confronted Guardian 1 who then displayed aggressive behaviour. Guardian 1 was struggling with media attention and both he and Guardian 2 felt under scrutiny; sibling 2 was present. The HV noted her concern regarding this. Sibling 2 and Guardian 2 were asked some simple questions regarding Guardian 1’s behaviours, both supported Guardian 1. Guardian 1 did not want the HV in the house and made a complaint. Guardian 1 was given a change of health visitor, and when the new HV took over there were no further problems or concerns with Guardian 1. 11.7.7 When Police were attending incidents, as in all cases, stepfather’s PPRC status would not show as a warning marker on the Police National Computer (PNC). Stepfather’s previous convictions would have shown and if he had been a registered sex offender this would have been evident. Risk to children flags are shown on NICHE (police records management system) and ViSOR (Violent and Sexual Offenders Register). 11.7.8 There was a written agreement in place with Guardian 1, regarding supervised contact following stepfather’s release from prison; however, it was not legally Final Version October 2023 22 | P a g e binding. CSC did not explore the nature of stepfather and Guardian 1’s relationship or speak directly to stepfather when making the decision regarding supervised contact. 11.7.9 There was no indication that the GP/ Nurse who completed Guardian 1’s consultations considered him a risk to children. There was consideration of the need to liaise with CSC in order to establish support for him when he presented as not coping in February 2019. This may have been considered a normal response to bereavement; however, Guardian 1 did have physical as well as mental health conditions which would have been a challenge at the time alongside acute emotional stresses. Guardian 1 engaged well with the vaccination programme (influenza and Covid-19) and whilst these occasions presented opportunities to explore his wellbeing further, in reality Guardian 1 rarely engaged in health promotion and so there were limited opportunities for any practitioner to explore anything else with him during Covid-19. 11.7.10 There is no evidence of the GP being aware of stepfather’s release from prison and visiting or staying at Guardian 1’s address. It is unlikely there would be a connection between Guardian 1 and stepfather and the implications of stepfather staying at this address. Learning point 11: It can be difficult for practitioners to remain objective when working with families over a prolonged period of time. Practitioners generally took at face value what Guardian 1 was telling them. Guardian 1 was viewed as a caring grandad doing his best for his grandchildren. Practitioners were not considering whether there might be issues of disguised compliance. A lack of assessment and SGO support, coupled with a lack of professional curiosity and wider thinking regarding motivation, led to a situation where these children’s safety was compromised. 11.8 The decision making that led to PPRC not being included in the key lines of enquiry used in the previous Serious Case Review. 11.8.1 The reviewer learned that stepfather’s PPRC status was discussed at the Child Death meeting. The Health Visitor had expressed concerns that stepfather was taking sibling 2 to clinic unaccompanied whilst classed as medium risk. The GP was not aware of stepfathers PPRC status. Overall, there was a lack of clarity regarding the risk stepfather posed. School was informed by the SW that stepfather was low risk and had permission to collect the children from school. 11.8.2 It was known that stepfather had connections with at least two associates both of whom had PPRC status. Whilst stepfather had committed a number of previous offences, these were of multiple types and the sexual offence conviction was historic. Stepfather was not seen as an active sexual predator. 11.8.3 At that time, whilst stepfather’s offending history was an issue, it was thought not as problematic as the neglect. 11.8.4 There was a lot going on in the family with many neglect issues; these overshadowed everything else. Stepfather was driving whilst disqualified, there were issues of drift, neighbours were reporting concerns and there were concerns over grandparent’s application for an SGO. There was also evidence of multiple domestic abuse incidents. Grandparents did not believe stepfather was guilty of the sexual offence and would strongly refute it. These issues, coupled with a focus on mother’s ability to safeguard and parent, masked the PPRC concerns. What was Final Version October 2023 23 | P a g e also overlooked was that mother was herself a victim of stepfather and others; she was a vulnerable adult. It was reported that she loved the children but lacked the availability to parent / safeguard them. 11.8.5 Had full information been known, the review team should have been clear that stepfather was deemed to be ‘high risk’. However, it is clear that the review team also lacked understand regarding exactly what PPRC status meant in this case. Learning point 12: Issues of neglect overshadowed the issue of stepfather’s PPRC status. Whilst stepfather’s PPRC status was discussed by the panel, lack of understanding regarding the level of risk stepfather posed, compounded by grandparents refuting that stepfather was guilty and a strong belief by Guardian 1 that once a prison term had been served there was nothing to answer for, distracted the review team and thus it was not fully considered as part of the SCR. 12. Examples of Good Practice: • The Cafcass FCA acted within the expectations of the internal policy and the court by interviewing Guardian 1 and offering advice to the court regarding ‘next steps’. Their advice that CSC needed to undertake further assessment of the family was appropriate and ensured that the proceedings could progress in a timely manner. • Probation sought the views of CSC on advisability of contact and permission for contact was delayed until assurances were provided. • Stepfather was accurately assessed by probation as posing a high risk of serious harm to children. • School highlighted the family and offered support making regular home visits during the pandemic. Financial support was offered, and a key worker assigned to the family. • School provided a good level of support to the children who all had excellent friendships with peers and good relationships with school staff. • School completed a swift EHCP in respect of cousin 2 to ensure she would receive support from her secondary school. • An attendance at the minor injuries’ unit highlighted Guardian 1 as the child’s guardian and that she was Looked After. This demonstrated a robust system and good information sharing. • The GP records indicated Guardian 1 was a guardian of 4 children. • The GP/Nurse identified the potential need for support and responded appropriately when Guardian 1 indicated he was struggling. • Police attended on both occasions Guardian 1 expressed a wish to end his life and on one occasion spoke with the children allowing them an opportunity to share their concerns. • The EHW encouraged Guardian 1 to engage and made visits to the home. Both Beta and cousin 2 were seen individually away from the home. The EHW and a SW from the F&F team completed a joint visit. • Supervision offered to EHT worker and management decisions recorded. • Each request for an SGO was responded to and assessed by CSC. • After Guardian 2 died clarification was sought by frontline practitioners within CSC regarding whether the SGO for Beta and sibling 2 was in respect of both Guardian 1 and Guardian 2 and the concerns explored. Decisions Final Version October 2023 24 | P a g e were signed off following advice at Assistant Director level. • There were occasions that the FRT liaised with probation and sought clarity on parts of their information. Final Version October 2023 25 | P a g e Appendix i – key to acronyms/ abbreviations ABE Achieving Best Evidence CAFCASS Children and Family Court Advisory Service CAO Child Arrangement Order CCG Clinical Commissioning Group (as of 1st July 2022 Integrated Care Systems (ICSs) became legally established through the Health and Care Act 2022 and CCG’s were closed down. CIN Child in Need CP Child Protection CSC Children’s Social Care CSPR Child Safeguarding Practice Review CRC Community Rehabilitation Company EH Early Help EHT Early Help Team F&F Family and Friends FCP Full Connected Persons FRT First Response Team FRW First Response Worker GP General Practitioner HV Health Visitor KLOE Key Lines of Enquiry LAC Looked After Children LST Local Support Team MPFT Midlands Partnership Foundation Trust PNC Police National Computer PPRC Person Posing a Risk to Children PTSD Post-Traumatic Stress Disorder SCR Serious Case Review SGO Special Guardianship Order SSCB Staffordshire Safeguarding Children Board SW Social Worker ToR Terms of Reference UTI Urinary Tract Infection |
NC52254 | Concerns that an infant was seriously harmed due to fabricated or induced illness (FII) in 2017. Child V was admitted to hospital for observation. On the day of admission Mother was observed to physically abuse Child V, following which Child V became looked after by the local authority. Child V was the subject of a child in need plan and was subject to multiple medical investigations and treatments. There were a large number of practitioners involved with the family and a high level of multi-agency activity. Concerns around physical abuse and neglect due to presentations of injuries and bruising. Uses the Significant Incident Learning Process (SILP) methodology. Ethnicity or nationality are not stated. Learning includes: the potential for parents to act as conduits for information between professionals, which may become a route for misinformation; where a child has been identified as a 'child in need', a child in need plan should be the overarching planning and review process; professionals should maintain focus on the needs of the child; the need for professional curiosity and scepticism with regard to possible neglect and abuse. Recommendations include: the need to deal with FII as robustly as other forms of abuse and neglect, following local and national guidance; early recognition and action in respect of perplexing presentations; practitioners have a basic understanding of the features of perplexing presentations and FII; when there are unexplained concerns about feeding and weight gain, the parent-child relationship should be considered, as well as possible medical causes.
| Title: Serious case review: Child V. LSCB: West Sussex Safeguarding Children Partnership Author: Adrienne Plunkett Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Child V Independent Reviewer and Author: Adrienne Plunkett Date: September 2020. 2 CONTENTS: Page No. 1. Background to Serious Case Reviews 3 2. Significant Incident Learning Process (SILP) 3 3. Process for the Serious Case Review 3 4. Family Engagement 4 5. Pre-Scoping 5 6. Scoping Period: Key Episodes 5 7. Themed Analysis: Terms of Reference 7 8. Examples of good practice 21 9. Recent developments 22 10. Key learning 23 11. Conclusion 26 12. Recommendations for West Sussex SCP 28 Appendixes: • Appendix A: Glossary • Appendix B: References 3 1. Background to Serious Case Reviews: 1.1. This SCR was undertaken in line with the Local Safeguarding Children Boards Regulations 2006 which outlined that LSCBs should undertake reviews in specified circumstances. 5 (1)(e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. 5 (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.2. Given the timeframe for this Serious Case Review (SCR), it was commenced under the guidance contained in Working Together to Safeguard Children 2015, Chapter 4,1, which emphasised the importance of LSCBs developing a Learning and Improvement Framework and outlines that reviews should be completed in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight; • Is transparent about the way data is collected and analysed; • Makes use of relevant research and case evidence to inform the findings. 1.3. Working Together 2015 encourages LSCBs to use a variety of models for undertaking SCRs, including the systems approach. The Significant Incident Learning Process (SILP) is one such model. 2. Introduction to the Significant Incident Learning Process (SILP) 2.1. The SILP methodology reflects on multi-agency work systemically. It engages frontline staff and their managers in the review, focussing on why those involved acted in a certain way at that time. Importantly it recognises good practice. 2.2. The SILP methodology adheres to the principles of; • Proportionality • Active engagement with practitioners • Involvement of families • Learning from good practice 3. Process for this Serious Case Review: 3.1. In 2018, the Chair of the Local Safeguarding Children Board (LSCB) made the decision to undertake a SCR in respect of Child V. It was agreed that the criteria had been met under Chapter 4, Paragraph 8, Working Together to Safeguard Children 2015. 2 There were concerns that Child V had been seriously harmed due to fabricated or induced illness and 1 Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, HMG, March 2015. 2 HMG, March 2015. 4 there was cause for concern as to the way in which the Local Authority, Board partners and other relevant persons had worked together to safeguard the child. 3.2. Furthermore, a decision was taken that the SCR would be undertaken using the SILP methodology and a Scoping Meeting to discuss the Terms of Reference was held. The Scoping Period was from Mother’s pregnancy with Child V to the child’s admission to hospital in 2018. Relevant agencies were requested to submit an Agency Report and a briefing for Report Authors was held in March 2018. 3.3. Due to parallel processes there was a delay in holding the SILP Learning and Recall Events and an Interim Report was prepared to identify immediate learning and recommendations that the Board could take forward. The Learning and Recall Events took place in January and March 2019. 3.4. The current definition of fabricated and induced illness (FII), used in this SCR, is 3. There are three main ways of the carer fabricating or inducing illness in a child. These are not mutually exclusive and include: • Fabrication of signs and symptoms. This may include fabrication of past medical history; • Fabrication of signs and symptoms and falsification of hospital charts and records, and specimens of bodily fluids. This may also include falsification of letters and documents; • Induction of illness by a variety of means. It can involve reported concerns about both the physical and mental health of the child, such as difficulties in the autism spectrum. 4 3.5. In recognition that there is a spectrum of presentations, the SCR will also refer to ‘perplexing presentations’ or ‘medically unexplained symptoms’ 5. The 2013 RCPCH Child Protection Companion extended FII to embrace ‘the commoner wider range of perplexing presentations or medically unexplained symptoms’, where the clinical information may ‘not add up’, leading paediatricians to consider ‘what’s going on?’ (WGO Syndrome)’. The Companion recognises that the impact on the child is similar whether they are victims of FII or of the wider spectrum of perplexing presentations. 3.6. Working Together to Safeguard Children 2015, defines physical abuse as: A form of abuse which may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child.6 4. Family Engagement: 4.1. Child V’s parents were advised that the Serious Case Review was being undertaken by the LSCB and that they would be invited to contribute to the review when appropriate. 4.2. Recently the parents have been offered the opportunity to meet or speak with the Lead Reviewer, but they have both declined to be involved in the review. 3 Safeguarding children in whom illness is fabricated or induced, Supplementary guidance for Working Together to Safeguard Children, Chapter 1, 1.5. DCSF, 2008 4 Bass and Glaser. Early recognition and management of fabricated or induced illness in children. Lancet 2014, 383, 1412-21. Published Online March 6, 2014. 5 Perplexing Presentations (including FII), Child Protection Companion 2013 (2nd Edition) Royal College of Paediatricians and Child Health. 6 HMG, March 2015. 5 5. Pre-Scoping Period 5.1. Child V lived with biological parents, older sibling and two half-siblings. Mother was a teenager when she had her first child. 5.2. Child V’s Father has older children, one of whom was the subject of a Child Protection Plan in 2008/09 and was made the subject of a Special Guardianship Order. 5.3. Immediately prior to Child V’s birth, Children’s Social Care were involved with the family due to the attempted abduction of Child V’s sibling by a stranger in a public place. This raised concern about the supervision of the children and CSC undertook an assessment. Parents co-operated and it was planned social work involvement would cease before Child V’s birth. 6. Scoping Period: 6.1. Mother presented late 7 in the pregnancy requesting a termination, but this was declined as the request was outside the legal time limit. Child V was born prematurely with the usual health complications of prematurity, requiring a period in the neo-natal unit. The prematurity meant that the counselling offered to women who book late in a pregnancy was not provided, there was no discussion at the multi-agency Ante-Natal Concerns Meeting, convened by the Midwifery Service, and the Health Visitor was unable to complete the ante-natal assessment visit. 6.2. On discharge Child V was progressing well, feeding and breathing without assistance, and no additional care was required. Despite this progress, the parents continued to present Child V with health difficulties, including in relation to apnoea episodes and feeding. Assessment by the Speech & Language Team at Hospital 1 evidenced Child V had a strong sucking mechanism, and bottle feeding was to be encouraged, however, Mother appeared reluctant to persevere with this. 6.3. Hospital 1 referred Child V to Hospital 3 for further investigations, aged three months. Studies undertaken evidenced self-resolving apnoea, related to prematurity, and the administration of oxygen, via nasal cannula, was commenced. This was planned to be a short-term intervention and the condition quickly resolved, but due to communication difficulties between healthcare professionals, the administration of oxygen continued until Child V was placed in foster care, aged two years. 6.4. Hospital 3 referred Child V to Hospital 6 in respect of the reported feeding difficulties and for consideration of insertion of a PEG-J. Hospital 3 made an error in interpreting the referral letter from Hospital 1 and wrongly believed that an abnormal swallow had previously been detected. Hospital 3 was unable to complete a feeding assessment whilst Child V was an inpatient. Hospital 6 planned to undertake further tests, but Mother was keen for the gastrostomy to be inserted and this went ahead, when Child V was aged 7 months, without further investigations. There was a lack of medical reviews and Child V continued to be enterally fed until being placed in foster care, aged two years. 7 Late Booking is defined as presenting for maternity services after 20 weeks. It is always important to remember that unless the woman genuinely has not been aware she is pregnant she has still concealed her pregnancy up until the point she has accessed antenatal care. A booking appointment with a midwife should be around 10 weeks (NICE 2008). A woman who presents to antenatal care late in her pregnancy should continue to be assessed with the reasons for the delay in presentation and associated risks as part of the assessment, even once booked and attending for antenatal care. Concealed Pregnancy, Pan Sussex Child Protection and Safeguarding Procedures. Updated March 2019. 6 6.5. There were some concerns in relation to the neglect of Child V. Early on health staff were concerned about Child V’s care, including poor weight gain, being cold and left on the floor. There were numerous hospital admissions during which there were concerns about the lack of parental visiting, difficulties arranging meetings with medical staff and delayed discharges. These were explained by the challenges of caring for the other children in the family together with financial and transport difficulties. 6.6. Whilst Child V was a baby the family were referred to the Children’s Access Point 8 by the Children’s Community Nursing Service and Hospital 1. An early help plan was recommended, but the parents failed to engage. Concerns continued regarding Child V’s care and welfare, which on occasions were discussed at Hospital 1’s Safeguarding Meetings. 6.7. During the Scoping Period there were three incidents when there were concerns about physical harm to Child V. These related to a fractured femur whilst an inpatient at Hospital 3, a hospital admission with a subdural hematoma with retinal haemorrhages and an admission with high salt and glucose levels, leading to safeguarding concerns about possible salt poisoning. A referral to Children’s Social Care (CSC) was made in respect of the head injury, strategy meetings were held but a Section 47 enquiry was not instigated, nor an Initial Child Protection Conference convened. Referrals were not made in respect of the fractured femur and possible salt poisoning. 6.8. There were occasions when bruising was observed on Child V’s face, the parents’ explanation that these were caused by a toy was accepted. 6.9. The outcome of the medical investigations into the subdural hematoma was that there was a potential diagnosis of a rare life-limiting condition, which could be an explanation for the injury. However, this was not a definitive diagnosis and subsequent testing did not support the diagnosis. The Consultant Neurologist recommended that ‘vigilance’ and close multi-agency working was required to safeguard the child. This information was not shared with all the practitioners involved with the family, including the Police, and a further strategy meeting was not convened to review the outcome of the investigation given the new information. 6.10. A child and family assessment was undertaken by CSC, Child V became the subject of a child in need plan and case responsibility was transferred to the Children with Disabilities Team. Child V continued to be viewed as a child with a life-limiting condition, despite the lack of a confirmed diagnosis, and the family as in need of support. The focus of agencies’ involvement was on providing support services, e.g. home nursing, respite care at the local children’s hospice. 6.11. Mother had reported that Child V had ‘absences’ which, though not observed by clinicians, were investigated. Epilepsy can occur with the life-limiting condition and so, with this potential diagnosis, Child V was commenced on epilepsy medication. There was concern on one occasion when Mother took Child V to the hospice with unnamed syringes containing epilepsy medication four times the prescribed amount and stated that if necessary, she would administer the full amount, contrary to medical advice. This was followed up by the Paediatrician, Hospital 1. 8 Children’s Access Point (CAP): Single point of contact at this time for referrals to Children’s Social Care. 7 6.12. There were early concerns during Child V’s first year about the discrepancy between Mother’s reporting of health conditions and clinical observations. At times Consultants were ‘puzzled’, e.g. when Mother talked of Child V needing a tracheostomy and wondered whether fabricated or induced illness should be considered. It was recognised that there was a need for close working between practitioners and steps were taken to try and co-ordinate Child V’s medical care. 6.13. Concerns about Child V’s care increased during 2017, leading to a Multi-Disciplinary Meeting, Professionals Meeting and discussion at the Perplexing Cases Panel. The Children’s Continuing Care Nurses identified a ‘mismatch’ between Child V’s identified health conditions and treatments and presentation at home. Concerns included poor weight gain and whether there was a need for epilepsy medication, nasal suctioning 9 and a tracheostomy, as reported by Mother. It was agreed Child V should be admitted to hospital for observation. The local child protection procedures and national guidance in relation to the management of cases where there was concern about FII were not consulted or implemented. 6.14. There was a large number of practitioners involved with the family and a high level of multi-agency activity. Multi-disciplinary meetings were held, though Child in Need reviews did not take place. 6.15. Admission for assessment was arranged for Child V at Hospital 4. On the day of admission Mother was observed to physically abuse Child V and immediate steps were taken to safeguard the child. Child V became looked after by the local authority; quickly thrived and was walking and feeding normally, with no evidence of epilepsy or of the need for oxygen or suctioning. 7. Themed Analysis: 7.1. Effectiveness of multi-agency working: Information sharing is essential for effective safeguarding and promoting the welfare of children and young people. It is a key factor identified in many serious case reviews (SCRs), where poor information sharing has resulted in missed opportunities to take action that keeps children and young people safe.10 7.1.1. Agency Report Authors have commented that co-ordinating Child V’s care became increasingly challenging due to the large number of medical practitioners and agencies involved with the family. However, the lack of effective and robust multi-agency processes did not support the co-ordination. The CSC Report Author highlights ‘the lack of comprehensive minutes of meetings, action plans and health chronologies, which would have supported and enhanced the communication between all professionals.’ 9 Suctioning is used to clear retained or excessive lower respiratory tract secretions in patients who are unable to do so effectively themselves. This could be due to the presence of an artificial airway, such as an endotracheal or tracheostomy tube, or in patients who have a poor cough due to a variety of reasons such as excessive sedation or neurological involvement. 10 Information sharing: Advice for practitioners providing safeguarding services to children, young people, parents and carers. DFE, 2018. 8 7.1.2. Despite this, it is very apparent that there was a considerable amount of hard work, liaison and communication between agencies. A plan was put in place when Child V was discharged from the Special Care Baby Unit, involving the Health Visitor undertaking enhanced visiting and the Neo-Natal Outreach Nurse providing support, followed by the involvement of the Children’s Community Nurses (CCNs). Hospitals 3 and 6’s Agency Reports note the good communication between the hospitals and with the CCNs. There was a planned handover between Hospital 6 and the local hospital. Hospital 1’s Report notes evidence of regular communication between the Consultant Paediatrician, Dietician and the Children’s Community Nursing Team to monitor Child V’s progress, weight and health needs. The Social Worker worked hard to arrange multi-disciplinary meetings. 7.1.3. However, local health services, including the referring Hospital and the GP, were not always in receipt of up to date information, e.g. there was no discussion between the Respiratory Clinic, Hospital 3, and Hospital 1 about the plan to refer Child V to the Gastrostomy Clinic at Hospital 6. The Respiratory Consultant had not understood that the CCN service was not provided by Hospital 1 so, whilst liaising with CCNs, had failed to liaise with the Consultant Paediatrician. Some clinic letters from secondary and tertiary hospitals were received in a timely way, others took several months. This becomes an issue as delays leave gaps in communication between health providers that parents can step in and fill. The NHS FT 1’s Author notes that Mother often provided information regarding recent hospital attendances which ‘negated the need for dialogue between the professionals involved in Child V’s care’. It is not uncommon when children have complex health needs that parents can be viewed as experts regarding their own child. However, Davis, Murtagh and Glaser 11 warn that many carers ‘act as conduits for information between professionals and this may become a route for misinformation’. Examples of this have been identified, including Mother reporting that Child V required deep suctioning, Hospital 3 was considering a tracheostomy and informing Hospital 7 Child V was already being investigated for high sodium levels. (Learning point). 7.1.4. There was limited liaison by other agencies, including within Health, with the GP. From birth Child V was under the care of a several hospitals and all medical conditions were diagnosed in secondary care. The family had open access to the children’s ward at the local hospital and could seek advice without needing to go to the GP, which is not unusual for children with complex needs. The GP was informed of Hospital 6’s concerns about the lack of parental visiting by a letter from the Safeguarding Nurse. The CCG Report Author notes that, helpfully, this was summarised in the child’s GP records, making the information easily accessible. However, the information was not added to Mother’s records; if it had been the GP could have prompted a discussion during her next consultation. 7.1.5. The GP was not informed of the Early Help or CIN plan nor that the family were receiving support from CSC at any point, and therefore the GP did not have knowledge of, or a role in, the multi-agency activity. 7.1.6. At the Learning Event there was a discussion about the fact that practitioners’ roles and responsibilities were not clear. There was a general presumption that a professional was taking a lead role, but a lack of clarity about who this was. Some Agency Report Authors, e.g. CSC and NHS FT 1, commented that there is no evidence that there was a key health professional co-ordinating Child V’s care, which would have been helpful. The CSC Report notes that social workers had difficulty arranging meetings, speaking to and getting a response to emails from Consultants and a single point of contact in Health was required. It 11 Davis, Murtagh and Glaser: 40 years of fabricated or induced illness (FII): where next for paediatricians? group.bmj.com. April 2018. 9 is therefore interesting that Hospital 1’s Report notes there was a Lead Consultant Paediatrician in the Acute Trust, and from July 2016 a Community Paediatrician to co-ordinate Child V’s health care. If the Health Visitor, Social Worker and CCN were not aware of these arrangements, there must be a question about the quality of communication and how effectively this lead role was being performed. (Learning Point) 7.1.7. The CSC Agency Report Author highlights that the Team Manager, CDT, considered health professionals were ‘unwilling to address their concerns in an open and transparent way directly with the family’ and were ‘unwilling to stand by their worries in meetings.’ The CSC Author reflects that there was no forum for professionals to have an ‘unfettered discussion’ about concerns and to challenge each other and considers that Professionals Meetings should have been convened to fulfil this purpose, to give practitioners time for reflection. In fact, the most appropriate course of action would have been to follow the FII guidance and convene a child protection strategy meeting which would provide the most effective opportunity for practitioners to openly share concerns and agree a plan of action which would safeguard the child. 7.1.8. There is evidence that Mother was able to ‘split professional. The parents had complained about the care received from Hospital 1 and had requested that Child V’s medical care be transferred. There appeared to be a sympathy for Mother’s perspective from the Health Visitor and the Psychologist, Hospital 3, and the latter discussed with Mother making a complaint. Staff at Hospital 1 were not aware of this. In addition, there were different perspectives between Hospital 1 and CSC about what should be expected of the parents in caring for Child V. These dynamics may well have impacted on the quality of interagency communication and undermined the co-ordination of Child V’s care. It is well recognised that mothers who perpetuate FII are more likely to complain, threaten legal action and attempt to split practitioners in the way that is apparent here. (Learning Point) 7.1.9. The issue of professional status and hierarchy has been considered during the review and this is certainty a factor that needs to be borne in mind by practitioners when there are concerns about perplexing presentation/FII. Children are likely to be referred to specialists at centres of excellence and it is understandable that local practitioners, e.g. community nurses, will feel reluctant to challenge their opinions. Therefore, practitioners will need the support of managers and Safeguarding Leads to do so. (Learning Point) 7.1.10. A number of specific examples have been identified which raise concerns about the effectiveness of multi-agency working including: • Whilst an in-patient at Hospital 3, the administration of oxygen was commenced as a temporary short-term measure to stabilise Child V’s breathing and reduce apnoea episodes. The CCNs were requested to undertake follow-up sleep studies, which gave normal results. Information was sent to Hospital 3, however, this was not received by the Respiratory Consultant and there was no further follow-up by the Consultant or the CCNs. This lack of communication led to Child V being administered oxygen for considerably longer than was necessary. • Concerns were raised by Mother at Hospital 3 about Child V’s feeding difficulties and reflux. Evidence presented indicates that the Speech and Language Team (SALT), Hospital 3, believed that SALT, Hospital 1, had identified an unsafe swallow, which was incorrect. SALT, Hospital 3, undertook a ‘bedside assessment’ which raised concerns about Child V’s swallow and a referral was made to Hospital 6 for the insertion of a PEG-J. Whilst a PEG may have been beneficial in helping to stabilise Child V’s weight at this time, the procedure was undertaken without either hospital undertaking further 10 tests, e.g. a videofluoroscopy swallow study. There is evidence that Mother had shown reluctance towards bottle feeding, which may have been a factor in her keenness for enteral feeding to commence. • It was concluded that the possible explanation for Child V’s subdural haematoma was a rare condition. However, three months later genetic tests were negative. CSC and Hospital 1 were advised that close multi-agency networking and vigilance was necessary. There is no evidence that this information and advice was shared with other agencies, notably the Police. This should have triggered a further Strategy Meeting in order to review the information and reassess the level of risk to Child V. (Learning Point and Recommendation) • There were different perspectives between Health and CSC practitioners over how the family was viewed. During April/May 2016 health practitioners raised concerns about Child V’s poor weight gain and the difficulties in gaining parental agreement to admission for observation. CSC’s view was that the health practitioners did not understand the challenges that the family were facing, i.e. the focus was on the needs of the parents rather than the needs of the child. • Despite Child V being admitted to hospital in a life-threatening condition with suspected salt poisoning, information was not sought from health practitioners working with the family, e.g. CCNs, and the allocated Social Worker was not informed of the safeguarding concerns. Safeguarding information was not easily accessible in the medical records, which is being addressed by the Safeguarding Team, Hospital 1. 7.1.11. Considering the reasons behind these communication difficulties, it is apparent that from early in Child V’s life practitioners were faced with a complex situation, which over time became increasingly complex. This complexity was exacerbated by the interactions between multiple professionals and agencies working with the family. The Triennial Analysis of Serious Case Reviews 2011 – 2014 12 highlights that the complexity and dynamics within the family may be mirrored in the responses of professionals and hence ‘the more complex a case, the more complex the inter-agency working becomes.’ The Analysis suggests that ‘Authoritative practice is an appropriate response to such complexity and manager and service leads have a responsibility to model authoritative practice.’ 7.1.12. Multi-agency meetings: The review has attempted to gain an overview of the planning processes for Child V and develop an understanding of whether this was through the CIN process or the MDT meetings. 7.1.13. Multi-Disciplinary Team Meetings (MDTs): MDT meetings are generally organised by health practitioners when children have complex health needs to review the care plan. However, in this case, some were arranged by Health and others by the Social Worker and there were difficulties in securing attendance, so that the right people were not always present. There are no minutes for any of the MDTs. Health practitioners do not produce minutes; any resulting actions are recorded in the child’s medical notes, which can make it difficult to track progress. GPs are not routinely invited or informed of the outcome. At the SILP Learning Event professionals highlighted that there is confusion about terminologies used, i.e. MDT/Professionals meetings, the purpose of meetings and which meetings parents 12 Pathways to harm, pathways to protection: A Triennial Analysis of SCRs 2011 to 2014. University of Warwick, University of East Anglia, May 2016. 11 should attend. This raises a concern about practitioners’ understanding of the purpose/objectives of meetings 7.1.14. Professionals Meeting: At the MDT meeting in September 2017 serious concerns were raised about Child V’s care, notably in relation to weight gain, the need for deep suctioning and Mother’s wish for a tracheostomy to be inserted, which led to the Professionals’ Meeting in November 2017. There is a question about whether a Strategy Meeting under the FII procedures should have been convened at this point in order escalate the level of concern, gain greater clarity about Child V’s medical conditions and put a plan in place to oversee medical treatment and any further investigations. There is no evidence the local and national guidance were considered. 7.1.15. Child in Need (CIN) Planning: From December 2016, the family received a service from CSC’s Children with Disabilities Team. The basis for the team’s involvement was that Child V had been assessed as a child in need 13, due to the complex medical condition. A CIN plan was drawn up and CIN visits are recorded. However, there is no evidence of CIN meetings being held or of the CIN plan being regularly reviewed in line with procedures, i.e. a minimum of three monthly during the first year. The CSC Report Author has suggested that in view of the challenges of getting professionals together, the MDT meetings were seen as a substitute for CIN meetings. However, there is no evidence they fulfilled the key task of reviewing and updating the CIN plan. Any child receiving a service from CSC should have an up to date plan and it is of concern that one was not in place. The CSC Report Author notes that the CIN Plan focussed very much on Child V’s health and did not address the social and emotional issues for the family. It also lacked timescales and accountability. 14 (Learning Point and Recommendation 2) 7.1.16. Perplexing Cases Group (PCG): It is evident that practitioners’ concerns about the discrepancy between Mother’s reporting and clinicians’ observations were increasing when Child V was discussed at the PCG by the Children’s Continuing Care Nurses in December 2017. It is understood that this is a reflective multi-agency meeting; an anonymous forum where practitioners can bring cases for ‘support and supervision’. Case responsibility lies with the practitioner and advice from the Group is dependent on the information supplied at the time of the discussion. 7.1.17. Notes of the PCG in December are available, the names of attendees are noted but not their role and agency; the same with the two actions agreed, where practitioners are identified by name or initial. Actions do not have a timescale. The Group suggests linking with all the professionals involved in Child V’s care to ensure a coordinated approach. However, information about the discussion and the actions agreed was not shared with practitioners working closely with the family. This is of concern as it may have influenced the response when Child V was admitted to hospital in a life-threatening condition later in December. The role of the Group is to provide support and supervision but is not operational. There may be some confusion here, as supervision implies that its role is operational, when it would appear to be advisory/consultative. (Recommendation 5) 7.1.18. In analysing the effectiveness of multi-agency working, consideration needs to be given to the pressures on all services, notably health and Children’s Social Care. Reduced 13 Section 17 Children Act 1989. A child is ‘in need’ if: S/he is unlikely to achieve or maintain, or have opportunity to do so, a reasonable standard of health or development without provision of services by a local authority, or if Her/his health or development is likely to be significantly impaired or further impaired without such services or S/he is disabled. 14 West Sussex Children’s Services Procedures Manual, Child in Need Plans. 12 resources across public services mean that practitioners and managers are often operating in challenging circumstances, with increased workloads. This reduces the time and space available for reflection, face to face discussions and following up ‘loose ends’, which is crucial when there are developing concerns about a perplexing presentation/FII. Such cases absorb a great deal of professional time and thought. Additionally, as has been identified in many SCRs, there is the continuing issue that electronic patient information systems are not integrated, so that practitioners cannot gain an up-to-date overview. 7.1.19. Summary: Overall, the evidence presented to the SCR suggests that there was a lack of effective information-sharing and multi-agency planning for Child V. It is apparent that there is a need for greater clarity about how the processes in Health and CSC fit together to ensure that there is effective assessment, planning and review for children who are believed to have complex needs. How do Health’s MDT meetings fit with the CIN processes and vice versa? How can it be assured that concerns raised at MDTs are shared with all health practitioners and CSC? There are no minutes of some MDT meetings, which makes it difficult to review a child’s progress and actions agreed. Additionally, if the MDT meetings are used as the planning process does that lead to a greater focus on a child’ health needs, rather than a more holistic approach? 7.1.20. Where a child has been identified as a ‘child in need’, CIN should be the overarching planning and review process to ensure there is a holistic approach to meeting the child’s total needs. CIN plans can also manage risk, as long as it remains safe to do so. (Learning Point and recommendation) 7.2. Assessment of family functioning and level of risk to Child V: 7.2.1. Much of the evidence from Agency Reports strongly suggests that the view of practitioners was that this was a family caring for a child with complex health needs requiring support. It is apparent that this view influenced practitioners’ approach to safeguarding concerns. The CSC Report Author notes that from early on Child V was viewed very much as a child in need with a life-limiting condition, rather than a child in need of protection, the drive was to set up a support plan for Child V to be cared for at home. The role of the Social Worker, CDT, was to co-ordinate services. 7.2.2. However, it should also be noted that there were different perspectives between CSC and Hospital 1 during 2016. Health practitioners were concerned about the family’s lack of engagement in Child V’s care and lack of visiting when an inpatient. The Social Worker was of the view that health colleagues were not understanding of the difficulties the family faced. The CSC Report Author suggests that there was not enough sharing of information and face to face discussion between practitioners to understand the bigger picture. 7.2.3. It is evident that none of the agencies gained a full understanding of the family functioning or of Child V’s position within the family. A chronology of Child V’s health care was not completed, which would have assisted practitioners in understanding involvement with health agencies and helped to identify emerging patterns. 7.2.4. Evidence regarding Child V’s early months raises concern about the quality of the attachment between Mother and child and the impact this may have had. Mother’s presentation in pregnancy was viewed as a late booking 15 and it is known she had requested a termination. There was a lack of opportunity to access counselling for late bookers and for antenatal assessment by the Midwife, as well as for the pre-birth assessment 15 Concealed Pregnancy, Chapter 8.10, Updated February 2018. Sussex Child Protection and Safeguarding Procedures 13 by the Health Visitor. Child V was born prematurely, requiring hospitalisation for eight weeks. There were concerns about the lack of visiting whilst the baby was in hospital and delay in discharges home. There are suggestions that Mother was fearful of caring for Child V and ‘angry’ when the plan was put in place for total bottle feeding. It is understood that this early information had not been shared with the Health Visitor and Neo-Natal Nurse, nor with CSC. 7.2.5. From the records it is difficult to gain a picture of Father’s role in the family. However, practitioners report that there were no indications of domestic abuse in the parents’ relationship and no evidence that father was aggressive or intimidating in his behaviour. When practitioners visited, he tended to ‘take a backseat’ and Mother would provide information and ask questions. 7.2.6. Whilst Child V was an inpatient at Hospital 6 from April to June 2016, there was a significant lack of engagement by the parents and concern about the infrequency of visiting, i.e. no visits for 23 days. Parents were required to complete competencies in feeding Child V through the PEG-J but they failed to do so and there was concern that by not completing the training were intentionally delaying discharge. This was raised as a safeguarding concern; however, the Hospital Social Worker’s view was this would not meet the threshold for a referral to MASH or CSC involvement and this concern was not raised with local agencies. The adverse emotional and psychological impact of prolonged separation upon a young child has been accepted for many decades and the reason parents are encouraged to stay with their child in hospital. This raises a question about whether the emotional harm caused by this neglect was fully recognised by staff at Hospital 6, at the very least it should have prompted a discussion with the local CSC. 7.2.7. It would appear that the focus was very much on the parental difficulties and not on the needs of the baby. Government guidance highlights that in deciding whether to share information with CSC, practitioners ‘must weigh up what might happen if the information is shared against what might happen if it is not and make a decision based on professional judgement’. Practitioners should not only consider the legality and impact of sharing information, but also the impact of not sharing information. 16 They may have the missing piece of a puzzle. Agencies do not have to be 100% certain that a referral will be accepted by MASH before making the referral, direct communication between agencies, i.e. telephone discussion, can clarify this. (Learning Point) 7.2.8. There is a question about whether the relevance of this early history was fully recognised in assessments and work with the family. Bass and Glaser 17 highlight that FII can represent an abnormality in the attachment system between mother and child and attachment theory might be relevant in understanding the dynamics with FII. Certainly, there were indications of difficulties in attachment as highlighted below, but there is no evidence that these factors were pulled together, and importantly their significance recognised. (Learning Point) • Late presentation in pregnancy • Denied request for a termination. • Premature, traumatic, birth and period of hospitalisation post birth. • Mother’s resistance to bottle feeding rather than naso-gastric feeding. • Concern that Mother was depressed and anxious. • Parental lack of visiting and engagement in child’s care during hospital admissions. • Delayed hospital discharges. 16 Information sharing: Guidance for practitioners and managers, HM Government (2008) 17 Bass and Glaser. Published online Lancet, April 2014. 14 • Concerns about neglect; poor weight gain and baby being cold and left unattended. 7.2.9. NHS FT 1’s Agency Report notes that the Health Visitor did not undertake an assessment, in part due to the circumstances of Child V’s birth, and the overarching view was that Mother was doing a ‘fantastic job’ in caring for the children. The concerns about the lack of parental visiting were not considered in detail, the focus was on the difficulties that the parents were experiencing rather than the impact on Child V. Similarly, the CCCN Report Author suggests that there was a ‘complete absence’ of ongoing concern about the events that had happened in Child V’s earlier life, i.e. being extremely unwell at a young age, needing ventilation after discharge, fractured femur, subdural haematoma. All these were ‘dismissed by the diagnoses’ and Mother’s ‘plausible façade’ 7.2.10. The IPEH (now Early Help) Report Author notes that the early help assessment was not robust and the CSC Report Author notes that the Child and Family Assessment (CFA) undertaken in 2016 was delayed, lacked rigour and did not include key information about the family history. The assessment was superficial. There is no reference to the early concerns about the circumstances of Child V’s birth and during the first year, i.e. discrepancies in reported and observed symptoms, parental lack of engagement and hospital visiting. 7.2.11. It is then highly significant that the CFA was not updated by the Assessment and Intervention Team regarding the uncertainty around the diagnosis of a life-limiting condition prior to allocation to a Social Worker in the CWD Team in December 2016. This meant that Child V was viewed by the CWD Service as a child with a life-limiting condition, with a family who needed a high level of support. This established the basis for work with the family for the next year and it was from this viewpoint that further information was considered. For example, the NHS FT 1 Report Author noted that head banging was accepted as ‘a feature of Child V’s presentation’ and an explanation for bruising, but this had not been seen by any professionals or formally reviewed, indicating a lack of professional curiosity. (Learning point) 7.2.12. Risk Assessments: There are four key instances where concerns about the quality of the risk assessment have been identified: 1. Fractured Femur: Whilst an inpatient at Hospital 3, Child V sustained a suspected fractured femur when in the sole care of Mother. Despite this being an injury to a pre-mobile baby, there was no discussion with the Trust’s Safeguarding Lead or with MASH. Mother’s explanation was accepted without challenge. As the x-ray did not evidence a fracture initially this may have lessened concern, despite it being known that a fracture may not become apparent immediately. Information received early in the review indicated that a member of staff had been present when the injury occurred, however, further investigation evidenced that this was not so, and Mother had been alone with the child. It was concerning to note how this incorrect information had been shared with other agencies and over time had become fact. A fractured femur was evidenced in the x-rays undertaken at Hospital 1. However, whilst Hospital 3 had referred Child V for further investigations, there was no follow-up to ascertain the outcome. (Learning point) 2. Subdural haematoma: Evidence would suggest that the cause of Child V’s subdural haematoma was not investigated robustly, and any potential risk not fully understood across the professional network. Three Strategy Meetings were held, but a Section 47 15 enquiry was not instigated. The CSC Report Author notes that there seemed to be a determination to get an ‘absolute truth’ from the Consultant Paediatrician, which was provided with the possible diagnosis of a rare life-limiting condition, cementing the view that the subdural haematoma was medically explained. This then shut down wider discussion and assessment of the family and did not promote ‘a critical and curious stance’. The Health Visitor was informed by the Safeguarding Nurse, Hospital 4, that Child V was likely to have a diagnosis of a rare life-limiting condition and non-accidental safeguarding concerns had been ‘ruled out’ by CSC and medical staff. The SCR has identified that at this stage a life-limiting condition was a possibility and not a definitive diagnosis but had quickly become an established fact. This position was compounded because the Social Worker and Manager ‘do not revisit in any substantial way the possibility that this injury could be non-accidental’ following receipt of the information that Child V had tested negatively for the life-limiting condition some months later. The Team Manager advised the Social Worker in the Assessment and Intervention Team to set up a MDT meeting, but it is not clear whether this was to be a multi-agency strategy discussion or a professionals’ meetings. A MDT meeting was held in November 2016. There are no minutes available, though the Duty Social Worker made notes of the meeting. It appears that the need for vigilance and close multi-agency working was not addressed. This was a missed opportunity to convene a follow-up Strategy Meeting to review earlier decisions in the light of new information. Social Care Institute for Excellence (SCIE) highlights the importance of practitioners being prepared to reconsider an earlier conclusion. and that professionals need to constantly guard against ‘the tendency to cling to original beliefs, searching only for information that supports them and devaluing or reframing new information that counters them.' ‘Sound judgements can only be achieved when a professional revisit their initial assumptions in the light of fresh evidence or a fresh view of the existing evidence.’ In order to achieve this, practitioners, need to employ a reflective approach and recognise that ‘the ability to change their mind is imperative’18. They need to maintain a ‘healthy scepticism’ . (Learning point and Recommendation) There has been consideration as to whether if a Section 47 enquiry 19 had been commenced this may have shifted the focus towards a greater consideration of the potential risks to Child V. There are mixed views as to whether the threshold for a Section 47 enquiry was reached, but given that Child V had a serious unexplained head injury, it took several days for the potential diagnosis of a life-limiting condition to be raised and protective steps were put in place in respect of V’s siblings, on balance there were clear grounds to initiate a Section 47 enquiry. The CSC Report Author notes that the Child and Family Assessment did not provide a reliable starting point for involvement by the CDT. The transfer summary did not include relevant safeguarding information. Additionally, by the time of allocation it was an out of date piece of work. The overarching view of the parents was positive, and this set the tone and direction for future work with the family. The CSC Report Author notes that following Child V testing negative for the life-limiting condition, there 18 When child protection professionals are confronted by new information about cases. Community Care, 18 Sept 2009. 19 Section 47 (1)(b), Children Act 1989. A local authority is under an investigative duty ‘where they have reasonable cause to suspect that a child who lives or is found in their area is suffering or is likely to suffer significant harm. 16 was ‘no analysis of risk or revisiting the CFA to ensure that it had captured and addressed the need for vigilance.’ 3. Preloaded Syringe: Child V attended the Hospice in April 2017 with a pre-loaded, unnamed, syringe of epilepsy medication, four times the prescribed amount. The Hospice sought clarification from the GP and informed the Consultant Paediatrician, who promptly followed this up with the parents. In the course of the SCR, this incident has been looked at more closely. From May to November 2017 the GP prescribed 32 doses of buccal midazolam. This is a significantly high number and raises concerns about the monitoring of the long-term medication. (Recommendation 6) Given the Mother’s statement that she would administer four times the dosage to Child V and the high number of prescriptions issued, it is considered that this required further investigation. The CCG Report Author’s view is that this should have triggered the Significant Incident (SI) process and hence a more robust investigation. 4. High sodium and glucose levels: The lack of a referral by Hospital 7 to MASH and of information sharing with the allocated Social Worker indicates a lack of recognition of the potential serious risks to the child. Child V had presented in a serious life-threatening condition, with high glucose and sodium levels, without a medical cause, and there was concern about intentional salt poisoning. In addition, staff had observed no clinical signs in respect of Child V’s chronic health conditions and had ascertained that Mother had given false information about previous similar episodes being investigated by Hospital 1. The Trust’s view was that there was not conclusive evidence to make a child protection referral in respect of FII, they were not 100% sure. Further that there were no grounds to obtain an Emergency Protection Order to retain Child V in Hospital. However, it appears the Trust made these decisions without discussion with other health practitioners working with the family, e.g. Health Visitor, Children’s Community Nurses and Social Worker. Given Child V’s admission in a life-threatening condition, without a medical explanation, the concerns should have been sufficient to discuss the safeguarding concerns with the allocated Social Worker. In view of the increased concerns about Child V’s care and the possibility of FII at that time, it is highly likely that a Strategy Meeting would have been convened and a Section 47 enquiry commenced. The Local Authority, with legal advice, would have considered whether there were grounds to apply for an emergency protection order. It is the responsibility of the LA to make this decision not health practitioners. There is a question as to whether a child who had presented at hospital with unexplained serious physical injuries, where NAI had been considered, would have been discharged home without a discussion with the local MASH/CSC, which could indicate professional anxiety about raising concerns in respect of FII. Therefore, there is a question about whether this decision was based on a need to be confident that there was conclusive evidence of FII, rather than on Child V’s need for protection. At the Recall Event there was a discussion about the need ‘to believe the unbelievable’. 7.2.13. Summary: There were indications prior to Child V’s birth that Mother was ambivalent towards the pregnancy and in Child V’s early months signs of attachment difficulties and that Mother was experiencing difficulty in meeting Child V’s needs. However, these concerns were not pulled together, analysed and the impact recognised. It would have been 17 important to understand what the meaning of this child was for this Mother, given the complex issues around the birth. 20 It appears little is known about Father’s role in the family and in the care of Child V. There is evidence that safeguarding concerns were not followed up robustly and concluded in three key events, namely the fractured femur, subdural haematoma and raised sodium level. 7.2.14. It is very clear that the overarching view was that this was a family in need of support in caring for a child with complex health needs, although there was some challenge to this by Hospital 1 early in 2016. Thus, the focus appears to have been on the parents’ needs, rather than Child V’s needs, including the need to be kept safe from harm. NHS FT 1’s Agency Report Author’s view is that the child’s voice was not heard and there was a ‘general concentration on the needs of Child V’s parents and an inadequate effort to keep the child at the centre’. ‘When practitioners empathise strongly with parents, the voice of the child can be overtaken by the needs of the parent.’ When practitioners are focussed on supporting a family it is important that they remain alert to signs of possible neglect and abuse, which may require a shift in their thinking as highlighted by SCIE. 21 Overall, there appears to be a lack of professional curiosity and scepticism, which hindered reflection and assessment. (Learning Point) 7.3. Recognition of FII/Perplexing Presentation Paediatricians’ early recognition of perplexing presentations preceding fabricated or induced illness and their management might obviate the development of this disorder. 22 7.3.1. As has already been highlighted, evidence suggests that overall practitioners considered they were caring for a child with complex health needs, a child in need, and working with a family that needed support. It is clear that this view influenced their approach to safeguarding issues. 7.3.2. It is apparent that there were early signs of a perplexing presentation. 23 By the time Child V was just three months medical practitioners at Hospital 1 were becoming ‘puzzled’ by the pattern of discrepancies between how Mother presented Child V’s health needs and clinical observations and results of tests, e.g. feeding and respiratory difficulties. Safeguarding concerns were escalated to the Safeguarding Team and the Named Doctor. Practitioners spoke at the Learning Event of being ‘surprised’ at the level of medical intervention following Child V’s referral to Hospital 3, i.e. administration of oxygen and insertion of a gastrostomy, and thought they must have ‘been missing something’. During admissions to Hospitals 1 and 3 in March and April 2016 whilst some health issues were identified, the symptoms reported by Mother were not always supported by clinical observations. In November 2016, concerns were discussed at Hospital 1’s weekly Safeguarding Meeting. 7.3.3. At the same time the Consultant Paediatric Neurologist, Hospital 4, was also ‘puzzled’. Mother had reported that staff at Hospital 3 were considering a tracheostomy when there were no medical indications for such a procedure. The Consultant Neurologist approached colleagues in Hospitals 1 and 3. The Respiratory Consultant, Hospital 3, was clear that a tracheostomy was not being considered and the possibility of FII was raised. Plans were 20 Reder. Duncan and Gray: Beyond Blame, Child Abuse tragedies revisited, Brunner-Routledge, 1993. 21 When child protection professionals are confronted by new information about cases. Community Care, 18 Sept 2009. 22 Early recognition and management of fabricated or induced illness in children. Bass and Glaser, published online Lancet, March, 2014. 23 Perplexing Presentations (including FII), Child Protection Companion, RCPCH, 2013. 18 being made for Hospital 4 to co-ordinate Child V’s medical care, however, there is no evidence that these concerns were escalated to Safeguarding Leads or shared with other practitioners working with the family, notably the Social Worker and CCNs. 7.3.4. The Royal College of Paediatricians and Child Health’s Child Protection Companion, 2013, 24 highlights that ‘The common starting point for both ‘Perplexing Presentations’ and fabricated or induced illness (FII) is that the child’s clinical presentation is not adequately explained by any confirmed genuine illness, and the situation is impacting upon the child’s health or social wellbeing. There is a spectrum of presentations, with the rarer ‘true’ FII involving deliberate deception of medical services by the carer; which may involve actions to falsify specimens or investigations, or induction of actual illness in the child, and the commoner wider range of ‘perplexing presentations’ or ‘Medically Unexplained Symptoms’ that should be considered in the same way but do not necessarily involve deliberate deception These presentations are primarily verbal accounts and descriptions by the carer.’ Evidence would suggest that by the end of 2016 there was increased evidence of a perplexing presentation, which was being recognised by the Consultants. Therefore, action in line with local and national guidance was required but was not pursued. 7.3.5. The Child Protection Companion refers to perplexing presentations as the What’s Going On (WGO) syndrome? and when dealing with such situations recommends the following good practice: • Following local and RCPCH guidance. • Preparation of a detailed medical chronology. • Paediatricians should avoid iatrogenic harm 25 and only undertake tests or treatment that are clearly indicated – the temptation to keep investigating must be resisted. • Admission to hospital can be helpful in order to differentiate between erroneous and true reports of signs and symptoms. 7.3.6. Similarly, Ball and Glaser 26 stress that to reduce harm to the child, and possibly avoid the development of FII, as soon as doctors feel perplexed, i.e. things do not make sense, they should establish the child’s involvement with health services and what is or not wrong with the child. Responsibility at this stage rests with the paediatric services. This approach may encourage medical professionals to raise concerns earlier, as they do not have to be confident that the concerns have reached the level of FII. Glaser and Davis suggest that early identification of perplexing presentations may help to reduce the potential for iatrogenic harm, help to restore normal functioning and reduce the need for later safeguarding interventions. 27 7.3.7. The Child Protection Companion 28 highlights that in approximately half of all FII cases, a chronic medical condition co-exists with FII. Child V’s prematurity meant that for the first few months of life the child presented with several health concerns, requiring medical treatment and follow up. However, it appears that despite these medical conditions improving or resolving, e.g. need for oxygen, Mother continued to present a child with 24 Perplexing Presentations (including FII), Child Protection Companion, RCPCH, 2013. 25 Definition of iatrogenic: Due to the activity of a physician or therapy. For example, an iatrogenic illness is an illness that is caused by a medication or physician. MedicineNet 26 Ball and Glaser, March 2014. 27 Glaser and David: Forty years of fabricated or induced illness (FII): Where next for paediatricians? Paper 2: Management of perplexing presentations including FII. 4 April 2018. Published by group.bmj.com. 28 Child Protection Companion, RCPCH, 2013. 19 complex health needs and this was how the child continued to be viewed by medical practitioners and hence received unnecessary, invasive, investigations and treatment. This was compounded by the possible, though not definitive, diagnosis of a life-limiting condition. It appears that some of the diagnoses of Child V’s medical conditions were based on parental reporting and there was an over-reliance on Mother’s reporting. The approach taken was very much ‘Mother knows best’. Glaser and Ball warn against this over-reliance. 29 7.3.8. The London Child Protection Procedures, 2.4.3. 30 encourage professionals to concentrate on the interaction of three variables in identifying and recognising fabricated or induced illness: • The state of health of the child, which may vary from being entirely healthy to being sick; • The parental view which at one end is neglectful, and at the other end causes excessive intervention either directly or indirectly; • The medical view, which is equally on a spectrum from being dismissive at one end to performing excessive intervention or treatment at the other. 7.3.9. Dr Danya Glaser 31 suggests that the starting point for FII is ‘carers, usually mothers, who have (s) an underlying need for the child to be recognised and treated as ill/more ill’. The child becomes the vehicle for the mother to fulfil her own needs, including her need for attention, for recognition as a heroic mother, and for financial or material gain. In this case, Child V’s early months in hospital meant that Mother received considerable support and attention, which may have been difficult for her to relinquish. Fathers may support the mother but may also be unaware or absent. In order to have her needs fulfilled the mother engages doctors through erroneous reporting, including exaggeration and inventing, persistent insistence on more investigations/referral and falsification. The doctor becomes involved by examining and (over) investigating the child. Tests may be undertaken to reassure the parent, but also for fear of not treating a child with a serious condition. The RCPCH Child Protection Companion 2013 advises that ‘a parent learns by ‘trial and error’ to fabricate convincingly and that doctors may inadvertently ‘coach’ the parent in the course of taking repeated clinical histories from the parent.’ 32 Davis, Murtagh and Glaser warn doctors of inadvertently taking on the role of ‘co-abuser’ which must be a difficult concept for doctors to contemplate. 33 7.3.10. The behaviour of parents, notably mothers, can be extremely challenging for practitioners in dealing with cases of FII. In the course of the review we have identified that Mother’s reporting of symptoms encouraged practitioners to undertake interventions and treatments. Practitioners have spoken about Mother being ‘eloquent’, ‘plausible’ and ‘knowledgeable’ about Child V’s conditions and that she regularly presented the child at hospitals was viewed as positive. Practitioners found it difficult to get a clear and consistent picture from Mother about Child V’s health, e.g. CCCNs. The Consultant Paediatrician, Hospital 1, acknowledged that the referral to Hospital 3, was due to Mother insistence; locally clinical observations had not evidenced the symptoms Mother was reporting. 29 Ball and Glaser, March 2014. 30 Fabricated or Induced Illness, London Child Protection Procedures, 5th Edition, 2017. 31 Fabricated or Induced Illness (FII): A Wider View and Alternative Approach. BASPCAN Masterclass, November 2017. 32 Perplexing Presentations (including FII), Child Protection Companion, RCPCH, 2013. 33David, Murtagh and Glaser, 40 years of fabricated and induced illness (FII): Where next for paediatricians? Paper 1: Epidemiology and definition of FII. ADC Online, 4 April 2018. 20 7.3.11. There is evidence that Mother’s wish for Child V to be enterally fed was a key factor in the surgical insertion of the PEG-J. From the age of a few months Mother was reporting that Child V had difficulties with feeding, and she demonstrated some resistance to persevering with bottle feeding. It is apparent that Hospital 3 made an error in interpreting the information provided by Hospital 1 regarding whether or not Child V had an abnormal swallow, did not complete a full swallowing assessment and referred Child V to Hospital 6 for the procedure to be undertaken. Hospital 6 anticipated undertaking further tests, but Mother was keen for the procedure to go ahead and it was performed without the planned investigations. Thus, it appears Mother was able to exploit the lack of effective communication between the health professionals. 7.3.12. During the SCR process consideration has been given as to whether there was sufficient evidence to support the decision to continue enteral feeding and insert the PEG-J. It is evident that there are mixed views about this as the swallowing assessments by SALT, Hospital 1, were positive and further testing by Hospitals 3 and 6 was limited. In addition, various factors have been identified. which may have impacted on the quality of the mother/child attachment, and this may have contributed to the reported difficulties as feeding may not have been a nurturing experience. However, Mother consistently reported feeding difficulties and there was concern about Child V’s weight gain, which the insertion of the gastrostomy would help to stabilise. The biennial report of learning from SCRs 2009 – 201134 highlights that ‘it is not helpful to consider poor weight gain for babies as a purely mechanical feeding problem and a contextual understanding of the different reasons why parents appear not to be nurturing the child is very important.’ Therefore, the parent-child relationship and quality of attachment also need to be considered. This has resonance for this review. (Learning Point) 7.3.13. The longer the parental behaviour continues, the greater the challenges posed to effective multi-agency working. The more hospitals and clinicians become involved, the more difficult it becomes to maintain timely communication, as does piecing the picture together and gaining an overview of the child’s condition and treatment. The Named Doctor, Hospital 1, has suggested that indications of FII were possibly obscured by the diagnoses and involvement of the specialist clinics at the tertiary hospitals, which gave them credibility. This indicates the importance of early recognition and management in line with RCPCH guidance, i.e. Responsible Paediatrician to oversee medical care. 35 (Learning Point) 7.3.14. Despite the earlier concerns in 2016, it appears that it was not until the MDT in September 2017, when practitioners were requesting greater clarity about Child V’s medical conditions, that concerns about FII became clearer. Hence the convening of the Professionals’ Meeting in November 2017 and discussion at the Perplexing Cases Group initiated by the CCCNs who considered that there was a mismatch between Child V’s diagnoses and Mother’s reporting. It is significant that the CCCNs brought a ‘fresh pair of eyes’ to the situation, which was valuable. However, this should have been a time for practitioners to reflect on the information available and access the national and local FII guidance, which should have led to a multi-agency Strategy Meeting and a Responsible Paediatric Consultant being identified to oversee Child V’s medical investigations and treatment. The situation was further compounded in December 2017 when Hospital 7 took the decision not to raise safeguarding concerns about possible salt poisoning with the allocated Social Worker because staff were not 100% confident there was evidence of FII. 34 New Learning from serious case reviews: A two-year report for 2009 – 2011. Brandon et al. July 2012. DoE. 35 Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians Royal College of Paediatrics and Child Health, 2009, reviewed 2012. 21 7.3.15. There is no evidence that local or national guidance was accessed by any of the practitioners. It is important to try and understand why there have may been a reluctance to name, highlight concerns and make a referral regarding FII. The reasons may include: • Lack of knowledge and understanding of the indications of perplexing presentation/FII and of its impact on children. • Lack of confidence in knowing what action to take. • Medical practitioners’ fear of getting it wrong and the child has a genuine, rare, medical condition which explains the reported, but not observed, symptoms. • Fear of taking a different approach to members of one’s teams/other medical practitioners. • Fear of parents complaining and/or taking legal action against a member of staff/Trust. Social media has become a mechanism for parents to attack and threaten doctors. This can seriously undermine a practitioner’s confidence. • Will not get a positive response from CSC/MASH unless have sufficient evidence to be 100% confident of FII. • The emotional challenge of facing up to having inadvertently become involved in the abuse of a child, as a ‘co-abuser’36, and causing iatrogenic harm. 7.3.16. Summary: Evidence presented to this SCR would suggest that there were early indications of a perplexing presentation and concerns developed during 2016, which led to discussions between Hospital Consultants about the possibility of FII. However, it was not until November 2017 that the concerns were discussed at a Professionals’ Meeting and December 2017 at the Perplexing Cases Group, and then not all practitioners were aware of this discussion and the outcome. 7.3.17. Worryingly, there is no evidence that the relevant local and national guidance was considered at any point by any of the professionals working with the family. Earlier recognition and action in line with RCPCH guidance may well have prevented the development of Mother’s behaviour, Child V undergoing unnecessary invasive tests and treatment and presenting in a life-threatening condition in December 2017. (Learning Point and Recommendations 4/5) 8. Examples of Good Practice: • GP summarised clinic letters and reports in the child’s records, which is helpful for GPs responding to children with complex needs. • Social Workers strove to bring professionals together in order to understand Child V’s complex needs better and plan services. • Children’s Community Nurse raised early concerns about Child V’s care with the Health Visitor and made a referral to Children’s Access Point (CAP), now MASH. 36 David, Murtagh and Glaser, April 2018. 22 • Hospital 1 made an early referral to CAP expressing concerns about neglect of the baby. • Social Worker and Children’s Community Nurses were proactive in ensuring that Child V received urgent medical attention in December 2017. • The Hospice identified concerns about Child V’s epilepsy rescue medication and raised this appropriately with the GP and Consultant Paediatrician. • The CCCNs identified discrepancies in how Child V’s health needs were viewed and followed this up. • Multi-agency Ante-Natal Concerns meetings enable information to be shared pre-birth and a plan put in place. 9. Recent developments: • West Sussex Safeguarding Children Board: ▪ FII Training Event held in March 2018. ▪ FII guidance is being updated and will be disseminated. This needs to be targeted to key frontline staff and managers. ▪ Pan Sussex Procedures in respect of late bookings and concealed/denied pregnancies are being reviewed and the early findings from this SCR will be considered. The additional vulnerability and psychological needs of women where a request for a termination has been declined are recognised in the procedures. ▪ Pan Sussex Escalation Policy in place. • Children’s Social Care: Children’s Disability Team: March 2019: Policy and guidance supporting the alignment of Children in Need (CIN) work by Children’s Disability Team with Children’s Social Care. Introduces two categories of CIN for children with disabilities: 1. Disability Complex Needs: Under Section 17, Children Act 1989, disabled children are CIN by virtue of their disabilities. Work will follow a visiting regime of minimum 3 monthly, with reviews minimum of 6 monthly. 2. CIN: Where there are additional issues impacting on the child’s welfare and development, e.g. linked to parenting concerns, neglect issues, mental health, substance use, domestic abuse. Under Section 17, Children Act 1989, where the child is unlikely to achieve or maintain a reasonable standard of health or development, or to be impaired or further impaired, without the provision of services from the local authority. CIN will follow the 23 same processes for all CIN open to Children’s Social Care in West Sussex (monthly visiting, with 8 weekly CIN reviews) CIN are worked with in a way that seeks to improve their safety and their lived experiences, with clear outcomes linked to stepping down/escalation. Children with Complex Needs will continue to receive social work support and intervention that is proportionate and delivered in partnership with parents/carers. My Plan is the assessment and planning tool for children within the Lifelong Service; ‘Signs of Safety’ the practice framework to support risk assessment and safety planning. Additionally: • Early learning practice sessions delivered to the CWD teams. • Social Worker from Children with Disabilities service is based in MASH. • Group Manager, Children with Disabilities Service, attends the Reflective Practice Group (Previously Perplexing Cases Group). • Hospital 1: ▪ To reduce silo working and promote co-ordinated approach electronic patient records (EPR Evolve) have been introduced. Dieticians and physiotherapists are using the EPR system and email correspondence is being scanned onto the system. From 2018 safeguarding records are stored electronically for practitioners to access. • Hospital 3: ▪ Increased resources of the Safeguarding Team and availability to attend internal and external meetings. ▪ Safeguarding Team to hold pre-discharge planning meetings for all complex cases. • Hospital 6: • Establishing a pathway for staff to escalate concerns when parents do not visit children who are inpatient. • Parent visiting record to be more visible on wards. 10. Key Learning: • Fabricated or induced Illness is child abuse which results in significant harm to children. It has short-term and long-term physical, emotional and psychological impact on children, which can be life-threatening. FII needs to be dealt with as robustly as other forms of abuse and neglect and in line with local and national guidance. (Recommendation 1) 24 • The importance of following local child protection procedures, as these provide a framework for safeguarding children, but also for managing practitioners’ concerns and uncertainties, particularly where there are concerns about perplexing presentation/FII. (Recommendation 1) • Early recognition, and action, in respect of perplexing presentations (What’s Going On?) is essential. This can help to reduce the development of fabricated or induced illness in children. The longer the behaviour continues the more difficult the task of understanding a child’s conditions and treatment becomes. (Recommendation 1) • All practitioners, including Police, require a basic understanding of the features of perplexing presentations and FIII and key practitioners require a more in-depth knowledge, e.g. Safeguarding Leads, Community Paediatricians, Children’s Community Nurses. (Recommendation 1) • Practitioners should be mindful of the potential risks of an over-reliance on parental reporting and of parents becoming conduits of information between health practitioners, which can lead to a lack of direct contact between practitioners and to misinformation being provided. There is a danger that parental reporting can become fact over time, without an evidential base. Medical practitioners should record how information is obtained, i.e. parental reports, clinical observations and results; in this way a pattern of discrepancies can be identified. (Recommendation 1) • Medical practitioners need to consider whether investigations and treatments are being pursued due to parental reporting and insistence, practitioner’s anxiety or in the best interests of the child. The needs of the child should always be paramount. and the least restrictive care should be provided. Parents should be involved in decision-making, but clinical decisions rests with the medical practitioners. (Recommendation 1) • Value of collating an overview and timeline (Chronology) of the child’s presenting symptoms and diagnoses, investigations and treatment, when there are developing concerns about a perplexing presentation/FII. (Recommendation 1) • All practitioners must maintain a focus on the needs of the child (Think Child), rather than on the day to day difficulties faced by the parents. There is a need to ‘Think the Unthinkable’. (Recommendation 1) • The importance of supervision and support for practitioners dealing with concerns regarding perplexing presentations/FII and of managers being aware of the challenges faced by practitioners, which may require additional support and a co-ordinated approach by the organisation, managed by a senior officer. (Recommendation 1) • The value of the role of Safeguarding Leads in providing advice at an early stage and co-ordinating with other organisations when necessary. (Recommendation 1) 25 • Importance of early concerns about perplexing presentations/FII being shared with all practitioners working with a family and a multi-agency approach being taken, with a Lead Paediatrician being identified to oversee and co-ordinate a child’s medical care and a medical chronology being completed. The focus should be on actively excluding FII. The plan should be communicated to all practitioners working with the child and family, including the child/family’s GP. GPs receive a high volume of letters and reports and any areas of concerns should be highlighted by direct contact. (Recommendation 1) • All practitioners, notably Midwives and Health Visitors, need to be mindful of the potential impact of a late booking, an unwanted pregnancy, a traumatic birth and a baby’s prematurity on the quality of attachment when undertaking assessments. FII can be a manifestation of an abnormality in the attachment system. Midwifes supporting Mothers post-birth should access ante-natal records and ensure that significant information is shared with the Health Visitor. (Pan Sussex Procedures being revised) • When there are unexplained concerns about feeding and weight gain, there should be a dual approach, which investigates possible medical causes, but also considers the parent-child relationship, and quality of attachment, and whether this might be having an impact. (Recommendation 1) • The adverse emotional impact on the child of neglect through a lack of parental engagement/visiting whilst the child is an inpatient should be carefully considered and further enquiries undertaken. The focus should be on the impact on the child, not on parental difficulties. (Developments at Hospitals 4 & 6) • The importance of timely referrals to MASH in respect of children where there are immediate child protection concerns. It is not necessary to be 100% confident that the concerns meet the threshold of child protection, another agency may also have highlighted concerns. Agencies should not be prevented from raising concerns/making a referral by ‘second guessing’ what the response may be. (Recommendation 1) • Where a child has been identified as a ‘child in need’, CIN should be the overarching planning and review process to ensure there is a holistic approach to meeting the child’s needs. With parental agreement, all agencies working with the family should be invited to be involved in the CIN process, including the GP, and provided with copy of CIN plan. CIN plans can manage risk, as long as it remains safe to do so. (Recommendation 2) • Practitioners working with families where a child in need has a disability should remain professionally curious and alert to the possibility of safeguarding concerns. Children with disabilities are at increased risk of abuse and neglect which is not always recognised. There can be a reluctance to challenge parents who are seen to be under considerable stress. 37 (Recommendation 3) 37 Safeguarding Disabled Children, Practice Guidance Department for Children, Schools and Families, 2009. 26 • The role of ‘Professionals Meetings’ should be clarified, including under what guidance/procedures they are being held. They should not be a substitute for strategy meetings convened under the child protection procedures. (Recommendation 4) • All multi-disciplinary/professional meetings should be recorded, noting the type and purpose of the meeting, areas of concern and actions agreed, with timescales and responsibilities identified. The role and agency of attendees and those sending apologies should be noted. Through this a common approach can be achieved and progress monitored. All practitioners actively involved with a family should be invited to meetings and if they cannot attend minutes should be sent, e.g. tertiary hospitals. (Recommendation 4) • There should be greater clarity about the role and function of the Reflective Practice Group (Previously the Perplexing Cases Group) and how this fits with parallel processes. (Recommendation 5) • When a decision in child protection enquiries is based on a medical observation and that observation is subsequently changed, undermining the validity of the earlier decision, all agencies must be informed of that change and should review their original decision-making in the light of the new information, e.g. at a follow-up strategy meeting. There is a need for a reflective approach and practitioners should maintain professional curiosity. (Recommendation 7) • Information sharing is more than just the sharing of information; it is a dynamic process. There needs to be a checking back of what has been shared to ensure a common understanding of the significance of the information, agreement regarding the actions to be taken and by whom, follow-up and timely recording. (Recommendation 8) • The importance of direct communication, i.e. face-to-face meetings/telephone discussions; letters and emails are not a substitute as this helps to build professional relationships. Direct contact/discussion between community services, District General Hospitals and tertiary hospitals leads to better understanding of a child’s medical needs, particularly in situations where there is a discrepancy between parental reporting and clinical observations. There is a need to be mindful of the impact of status and hierarchy which can lead to a reluctance to challenge another’s view and escalate concerns. (Recommendation 10) • Importance of practitioners knowing when and how to escalate concerns within and across agencies, including between health trusts, in line with WSSCB guidance. 38 (Recommendation 9) 11. Conclusion: 11.1. This Serious Case Review related to a very young child and concerns regarding physical abuse, child neglect and fabricated or induced illness. There has been an imperative to 38 WS SCB Escalation guidance 27 understand why a fundamentally well child was viewed as having a life-limiting condition and underwent long-term unnecessary, invasive, investigations and treatments, including being fed enterally, administered oxygen and prescribed medication for epilepsy. Understandably, this impacted significantly on the child’s quality of life, restricting childhood experiences, and limited overall development. The Review has been highly complex, very much reflecting the real challenges for practitioners in dealing with cases where there are concerns about a perplexing presentation/fabricated and induced illness. 11.2. There is evidence of considerable multi-agency activity and communication, and that practitioners were striving to ensure the family were supported and Child V’s health needs met. Several multi-agency processes were operating in parallel, including Child-In-Need Reviews, Multi-Disciplinary Team Meetings and Professionals Meetings. However, the overall picture is very confused, with a lack of co-ordination and effective information sharing, notably between health practitioners in secondary and tertiary care. Inevitably, this undermined the effectiveness of the multi-agency safeguarding network. The increasing number of hospitals and professionals involved with Child V meant that communication between medical practitioners became more challenging, but also more essential. It has been suggested that the high level of multi-agency activity gave an illusion of safety for Child V and the risk of emotional and physical harm was not recognised. 11.3. There was a lack of recognition of the significance of the period pre and post Child V’s birth, and of the impact of this on the quality of the parent/child attachment. Following birth Child V had additional medical needs relating to prematurity, leading to a period of hospitalisation, but on discharge Child V was progressing well and feeding normally; it was anticipated that this progress would continue. However, Mother regularly presented Child V at hospital reporting health concerns. Whilst it is recognised that Child V did have some health difficulties, evidence supports the view that Mother’s reporting led to unnecessary and prolonged medical investigations and interventions, which meant Child V was perceived as a seriously unwell child. It appears that Mother presented as very knowledgeable medically and there was an over-reliance on parental reporting, rather than clinical observations. 11.4. There were instances when there were concerns about serious physical harm to Child V, including a fractured femur, subdural hematoma and salt poisoning, but investigations did not follow procedures, were not sufficiently thorough nor brought to a robust conclusion. From the point of the potential, though not definitive, diagnosis of a life-limiting condition, the approach by agencies was one of support for the parents in caring for a child with complex needs and of meeting Child V’s health needs. This was the lens through which further information about Child V and the family was viewed. There was a lack of professional curiosity and indicators of risk were not recognised and acted upon. 11.5. There were early indications that there was a discrepancy between what Mother was reporting and clinical observations, and doctors were puzzled; what the RCPCH refers to as a perplexing presentation. These concerns came to the fore at various stages during the Scoping Period and increased during 2017. However, at no point did the practitioners reference or consider implementing the national and local Fabricated and Induced Illness guidance, which would have provided a framework through which to oversee and manage the ongoing medical investigations and interventions. Where FII is a factor, it is not uncommon for children to have medical conditions which are exaggerated, and the framework supports practitioners in ensuring medical treatment is appropriate and proportionate. 28 11.6. Evidence presented to the SCR suggests that there was a reluctance by professionals to follow up on indications of perplexing presentation/FII and the review has sought to understand what underpinned this reluctance and hence why such concerns were not acted upon sooner. Concern about FII is one of the most complex and challenging situations that child protection professionals face and it appears that they may experience varying degrees of anxiety, even fear, due to a combination of factors. These include the hierarchical nature of relationships between practitioners, fear of being wrong and they are treating a seriously ill child with a rare condition, the threat of complaint, legal action and adverse publicity on social media platforms and the emotional impact of inadvertently becoming involved in a child’s abuse and causing iatrogenic harm. This highlights the importance of practitioners having support, reflective supervision and access to expert advice, as well as, on occasions, the need for a co-ordinated multi-agency approach, overseen by senior managers. 11.7. Significant learning has been identified for single agencies and for multi-agency working. However, the most important lesson for practitioners is the importance of consulting and adhering to national and local child protection procedures, whether this is in relation to concerns about physical harm, neglect or perplexing presentation/fabricated and induced illness. 11.8. FII should be dealt with as early as possible and in accordance with guidance. It requires effective direct communication and close multi-agency working between practitioners. This may prevent fabricated and induced illness developing, but importantly will provide a framework for managing medical interventions and ensuring that the child does not experience unnecessary medical investigations and treatment. The longer the behaviour continues the more difficult it becomes for practitioners to gain an understanding of the child’s medical conditions and treatment and to work effectively together to safeguard the child. 11.9. Each agency involved in the SCR has an action plan and below are the recommendations for West Sussex Safeguarding Children Partnership (WSSCP). The Partnership will take forward the multi-agency recommendations, monitor the implementation of actions by individual agencies and disseminate the key learning at briefings for practitioners and managers. 13. Recommendations for West Sussex Safeguarding Children Partnership: 1. The Partnership to ensure that the revised fabricated and induced illness guidance reflects the key learning of this SCR, that the FII training has been accessed by key staff across agencies and the guidance is being embedded into practice. Practitioners and front-line managers need to be equipped with sufficient knowledge and understanding to apply the guidance with confidence when dealing with concerns about perplexing presentation/FII. Safeguarding Leads must provide expert advice and guidance to staff dealing with perplexing presentations/FII, to ensure that these concerns are dealt with at an early stage, and senior management should ensure that support is in place for staff dealing with the challenges in managing cases of FII. Evidence that the guidance is embedded across agencies will be gained through staff surveys and multi-agency case file audits. 2. The Partnership to receive the report of the review currently taking place of the new multi-agency planning and review process in place for children with disabilities/complex needs (My Plan). The Board should ensure this addresses 29 concerns about the efficacy of Child in Need (CIN) planning and how this fit with Health’s multi-disciplinary team (MDT) meetings. 3. The Partnership to consider how well-equipped, knowledgeable and confident practitioners working with children with disabilities/complex needs across the multi-agency network are to recognise, assess and manage safeguarding concerns and what additional training and support may be required. The need for professional curiosity and an open mind should be promoted. 4. The Partnership to ensure that there is greater clarity about the type and purpose of multi-agency meetings, notably Professionals Meetings; how they fit with local policies and procedures, e.g. child protection, child in need. They should not be a substitute for Strategy Meetings. It should be clear who is the Lead Professional and how the meetings will be chaired and recorded, and how decisions and actions will be reviewed. 5. The Terms of Reference and governance arrangements for the Reflective Practice Group (Previously Perplexing Cases Group) to be reviewed, importantly considering how this process fits with WSSCP’s structure and child protection procedures. 6. The Clinical Commissioning Group to follow up the lack of monitoring of the prescriptions for epilepsy rescue medication and consider whether any further advice is required for local health services. 7. The Pan Sussex Child Protection and Safeguarding Procedures Manual should be amended to include guidance that when the information on which the decision-making of a previous Strategy Meeting is based changes significantly, a further Strategy Meeting should be convened to review that earlier decision-making. 8. The Partnership should ensure that practitioners understand that information sharing is a dynamic process and that the principles of information-sharing and confidentiality are embedded in training and communications, so practitioners know that when making a decision about sharing information, the wellbeing and safety of the child always takes priority. 9. The Partnership should promote the Pan Sussex Child Protection and Safeguarding Procedures Manual’s Resolution of Professional Disagreements, encouraging respectful challenge and escalation as appropriate. 10. The Partnership should share the learning from the SCR with NHS England (London) as this highlights the need for greater co-ordination and information sharing between primary, secondary and tertiary health services. 30 Glossary: APPENDIX A • CSC: Children’s Social Care • CAP: Children’s Access Point • IPEH: Intervention, Integrated Preventive Earliest Help • CDT: Local Authority Children with Disabilities Service • MASH: Multi-Agency Safeguarding Hub • PCG: Perplexing Cases Group • CCN: Children’s Community Nurse • CCCN: Children’s Continuing Care Nurse 31 References: APPENDIX B • Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, HMG, March 2015. • Safeguarding children in whom illness is fabricated or induced, Supplementary guidance for Working Together to Safeguard Children, DCSF, 2008 • Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians Royal College of Paediatrics and Child Health, 2009, reviewed 2012. • Child Protection Companion 2013 (2nd Edition) Royal College of Paediatricians and Child Health. • Fabricated or Induced Illness, London Child Protection Procedures, 5th Edition, 2017. • Concealed Pregnancy, Chapter 8.10, Updated February 2018. Sussex Child Protection and Safeguarding Procedures • Unexplained injuries to young children, Chapter 8.4., Sussex Child Protection and Safeguarding Procedures. • Information sharing: Guidance for practitioners and managers, HM Government (2008) • Information sharing: Advice for practitioners providing safeguarding services to children, young people, parents and carers. DFE, 2018. • Reder. Duncan and Gray: Beyond Blame, Child Abuse tragedies revisited, Brunner-Routledge, 1993. • When child protection professionals are confronted by new information about cases. Community Care, 18 Sept 2009. • Bass and Glaser. Early recognition and management of fabricated or induced illness in children. Lancet 2014, 383, 1412-21. Published Online March 2014. • Fabricated or Induced Illness (FII): A Wider View and Alternative Approach. BASPCAN Masterclass, November 2017. • Davis, Murtagh and Glaser: 40 years of fabricated or induced illness (FII): where next for paediatricians? group.bmj.com. April 2018. • David, Murtagh and Glaser, 40 years of fabricated and induced illness (FII): Where next for paediatricians? Paper 1: Epidemiology and definition of FII. ADC Online, 4 April 2018. 32 • New Learning from serious case reviews: A two-year report for 2009 – 2011. Brandon et al. July 2012. DoE. |
NC046504 | Serious sexual and physical assault of a 4-year-old girl in August 2013. Child J was presented at hospital with bruising to the trunk and arms, a bite mark and evidence of significant trauma to the genital area. Stepfather was convicted of the offence of sexual assault and sentenced to 17-years imprisonment. Child J moved to the UK from an EU country with mother and older sibling in 2010 and took up temporary residence in a Midlands town. Family returned to the EU country when mother's relationship with her partner, a UK citizen, broke down. Mother married Child J's stepfather in 2012 and family moved again to UK. Child J was presented to GP, and subsequently the hospital, several times in the months prior to the incident. During the final hospital visit before the incident symptoms were identified including a rash to scalp, swelling to eyes and face and bruising on trunk, arms, feet and wrists. Child J was discharged following examination with the conclusion that it was likely that the swelling was due to an acute allergic reaction to antibiotics prescribed for the rash. Child J was taken to hospital in August 2013, where injuries prompting a Section 47 enquiry were identified. Identifies themes in the case, including: the impact of ethnicity, identity and language; mother's history of marriage and relationships falling outside cultural norms; inconsistent identity checks across agencies; professional challenge; professional curiosity and optimism; communication within and between agencies; and missed medical appointments. Identifies best practice examples and findings in relation to professional practice and makes recommendations for Cambridgeshire Safeguarding Children Board. Uses the Significant Incident Learning Process (SILP) methodology.
| Title: Serious case review using the significant incident learning process of the circumstances concerning Child J. LSCB: Cambridgeshire Safeguarding Children Board Author: Brian Atkins Date of publication: [2015] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 CAMBRIDGESHIRE SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW USING THE SIGNIFICANT INCIDENT LEARNING PROCESS OF THE CIRCUMSTANCES CONCERNING CHILD J Final Report INDEPENDENT AUTHOR: Brian Atkins October 2014 2 Topic Page 1. Introduction 3 2. Process 5 3. The Family 6 4. Timeline: Engagement with Services and Key Practice Episodes 8 5. Themed Analysis 15 6. The Mother’s Perspective 22 7. Examples of Good Practice 23 8. Findings 24 9. Recommendations for the Board 26 Appendix 1 Terms of Reference and Project Plan 27 Appendix 2: Agency Recommendations 32 3 Cambridgeshire Safeguarding Children Board Overview Report of a Serious Case Review Subject CHILD J Final Report 1. Introduction 1.1 Introduction to the Case 1.1.1 This is the overview report of the Serious Case Review conducted in respect of Child J who was 4 years old at the time of the serious incident prompting this review. She was the younger child of a family of two children; there was also a six year old male sibling. The family had recently arrived in the UK having previously lived in another EU country. She was presented at hospital in August 2013, suffering from bruising to the arms and trunk, a bite mark and evidence of significant trauma in the genital area. Following the incident, Child J and her sibling were taken into care. Child J is currently the subject of a supervision order and in the care of her mother. Her stepfather was convicted of the offence of sexual assault, and has been sentenced to 17 years imprisonment. 1.1.2 Following a recommendation from the SCR subcommittee on 1st October 2013 the chair of the Cambridgeshire LSCB decided that this case met the criteria for a Serious Case Review, and to undertake this review using the SILP methodology. Review Consulting were commissioned to provide an overview report writer to lead the review (see below). Due to the criminal proceedings in connection with prosecution of the stepfather and a perceived conflict in the methodology and the ongoing criminal proceedings, work on the review was delayed until the end of the court proceedings regarding the assault on the subject child. This delay also meant that the first lead reviewer appointed, Paul Tudor, was unavailable to complete the report and so a new reviewer, Brian Atkins, joined the process in February 2014 as overview author. 1.2 Serious Case Reviews (SCRs) 1.2.1 Local Safeguarding Children Boards are required 1to undertake Serious Case Reviews (SCRs) in every case where abuse or neglect is known or suspected, and either: • a child dies • a child is seriously harmed and there is cause for concern as the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1 This is a requirement under Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 which sets out the function of LSCBs including their duties in relation to Serious Case Reviews 4 1.2.2 The statutory guidance ‘Working Together to Safeguard Children (2013)’ makes clear that a case that meets the criteria must trigger an SCR, and that the LSCB should aim to complete this within 6 months. It should result in a report which is published and readily available. Where the criteria are not met, the LSCB may still wish to review and share instances of good practice. 1.3 The Significant Incident Learning Process (SILP) 1.3.1 SILP is a learning model which engages front-line staff and their managers in reviewing cases, focusing on why those involved acted in a certain way at the time. 1.3.2 The SILP model adheres to the principles of: • Proportionality • Learning from good practice • The active engagement of practitioners • Engaging with families • Systems methodology These principles are confirmed and supported in current government guidance (Working Together to Safeguard Children 2013) 1.3.3 SILPs are characterised by a large number of practitioners, managers and Safeguarding Leads coming together for a day, with all agency reports having been shared in advance in order to discuss the emerging learning from the review. The first Learning Event seeks to enhance the understanding of the experience of those in practice with the child and family under review; the second recall day allows practitioners to come together again to study and debate the first draft of the Overview Report. 1.3.4 Working together 2013 states that SCRs and other case reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did • seeks to understand practice from the viewpoint of individuals and organisations involved at the time rather than using hindsight • is transparent about the way data is collected and analysed • makes use of relevant research and case evidence to inform the findings 1.4 Lead Reviewer and Overview Report Writer 1.4.1 This review, conducted under the SILP methodology, was led by Brian Atkins, and supported by Paul Tudor. Both are accredited SILP lead reviewers. 5 1. 4.2 Brian Atkins BSc. CQSW, MBA is a Registered Social Worker, who has worked for many years as a practitioner, manager and senior manager in local authority Children’s Social Care and Youth Justice Services. Since 2000 he has worked independently as a Children’s Social Care Consultant working with different local authorities and partnerships across England and Wales. He is the author of this overview report. 2. Process 2.1 Terms of Reference The full terms of reference are attached at the appendix to this report 2.2 Scope 2.2.1 The time period covered by the review was determined as: From a date in 2007 (the birth of the elder child) to a date in the summer of 2013 (the discharge of the children from hospital in to foster care). 2.2.2 Agencies were also asked to review and report on any significant events or safeguarding issues in respect of mother and the children prior to February 2013. This material was used primarily to provide a background context and therefore was required to be concise and summarised, highlighting any particular learning points. 2.3 Agency Reports 2.3.1 Agency reports within the scoping period were commissioned from: • Primary Care Services (General Practice) • Cambridge University Hospitals Foundation Trust • Cambridgeshire Children’s Social Care • Cambridgeshire Constabulary • Cambridgeshire Community Services (Universal Services) • The Learning Directorate, Cambridgeshire County Council, covering the school 2.3.2 Relevant information was sought from the equivalent agencies by agencies report authors from a Midlands town and a Northern town, where the family previously lived. 2.4 Learning Events 2.4.1 A full day SILP Learning Event took place in April 2014. All but one of the agencies involved were represented by both the agency report author and staff including managers who had been involved during the period in scope. All of the agency reports had been circulated in advance, to ensure that all staff attending were able to fully understand the multiagency dimension and the focus of the review. 6 2.4.2 At a Recall learning event held in June 2013, participants who had attended the Learning Event considered the first draft of this report. They were able to feedback comments on the contents, add additional information, and clarify the issues. All of those involved contributed to the conclusions and learning from this review. 2.5 Attempts to contact the family Letters were sent by the Chair of the LSCB offering the child’s mother the opportunity of discussion with the Overview author during the preparation of the report, but initially no response was received. A further attempt to contact her in August 2014 resulted in a meeting with the Overview author and the LSCB Board Manager in September 2014. The mother’s views have been incorporated throughout this report, and her perspective summarised in Section 6. 3. The Family 3.1 Family Background and Movements 3.1.1 The family background summarised below is drawn from the agency reports, some of which required considerable research to identify the facts. Key factual information is taken from the Police agency report, supplemented by information from other agencies and the SILP Learning Events. Information from the mother has now been included. It should be recognised that this detailed information was not available to practitioners at the time of their intervention with the family. 3.1.2 The subject child’s mother is from an ethnic minority and she has spent a considerable part of her life in Europe. It is understood that the she moved to an EU country from outside Europe when she was 6 years of age. She became an EU citizen, alongside her family, before settling in a different EU country. 3.1.3 In 2005, she returned to her country of birth in order to be married. Her husband was unable to obtain a visa and consequently remained living in that country whilst she returned to live in the EU country, returning on occasions to her husband, where both the older sibling and the subject child were conceived in 2006 and 2008 respectively. 3.1.4 Both children are reported to have been born in a EU country, although this is not confirmed. During 2008, the mother of Child J separated from her husband, who is the birth father of the subject child and the older sibling. 3.1.5 The family continued to reside in the EU country and the mother and children held that EU country’s nationality. The birth father of Child J was reported by the mother to have died in 2012. The details of the exact date and circumstances of his death have not been ascertained. There is no information concerning his contact with the children in the intervening period between their parents’ divorce and his death, although the living arrangements of the 7 mother and father in different continents suggest that he had little contact with his children. 3.1.6 In 2010, Child J’s mother moved from the EU Country to the United Kingdom and took up temporary residence in a Midlands town. This was as a consequence of her forming a relationship with a new partner who was resident in the UK. The relationship between this man and the subject child’s mother broke down after a relatively short time and she returned to live in the EU country approximately two months later. The subject child and older sibling are understood to have accompanied their mother throughout this time. 3.1.7 Child J’s mother and the subject’s child’s step-father were married in 2012 in the UK 3.1.8 In May 2013, the subject child was temporarily in the care of her Aunt in a northern town for a period of some 3 weeks. The maternal grandparents were caring for the subject child’s sibling for part of this period; he was at school in Cambridgeshire for two of these three weeks. 3.1.9 In June 2013, the family moved to a different residential address in Cambridgeshire. In order to support the rental costs, additional rooms were sub-let to other tenants. In July 2013, the child’s mother, who had been working since April 2013, was unable to continue to work due to her pregnancy and she consequently remained at home. 3.2 Ethnicity and Language 3.2.1 All members of the family, including the extended and reconstituted family members, were originally from outside Europe. The mother, and the 2 children have EU nationality. 3.2.2 Mother, stepfather and other adult family members speak their first language and English. The mother also speaks two other EU languages. The subject children speak an EU language, English and some of the parents first language 3.2.3 The family practice a recognised religion. 4. Timeline: Engagement with Services and Key Practice Episodes This section of the report summarises the timeline of engagement of the family with services, in particular Health and Education. Key practice episodes (KPE) are identified. 4.1 In early February 2013 the family are recorded as living in a Northern town at the address of the Mother’s sister. The family were registered with a GP which generated a visit from a health visitor; a letter had been sent to advise them of this. An unsuccessful visit is recorded in late February, but it is likely that the family had moved to Cambridgeshire by this time as the subject child’s sibling was registered with a school in the area shortly thereafter. 8 4.2 The subject child’s sibling (Sibling 1) was placed on the primary school roll in Cambridgeshire and started the following week in late February. He was ill for the first two days and thereafter his attendance record shows a medical code as the reason for absence, and his attendance was recorded at 79.5% with 14.8% authorised absence. 4.3 Sibling 1 suffered from an unusual, non-contagious skin condition, which is characterised by blistering to the skin. He was seen by the GP surgery in early March, requesting a prescription for the condition, and the surgery was informed that he was being treated by a Midlands Children’s Hospital. 4.4 The school were initially unaware of this skin condition. Staff noticed that he used dressings and sterile needles to manage his own care. Once this was established the school asked the advice of the School Nurse. A meeting was set up with the Nurse and Mother and advice given. The nurse saw the GP notes and talked through a care plan with the mother. April 2013 4.5 At the beginning of April 2013 Child J’s mother was seen by the GP registrar: she was diagnosed as pregnant and feeling unwell. No discussion about the home situation was recorded. A medical report from this visit noted a large scar at the base of the mother’s abdomen, apparently for a skin graft when she was burnt on her leg during the previous marriage. No further questions were asked about this at this point, but it is recorded by the GP registrar that she suspected that the injury may have been due to domestic abuse within that marriage. 4.6 Child J was registered with a GP practice in Cambridge in early April. The GP practice did not send a notification to Child Health Services in this case and so there was no referral to or visit from the Health Visitor. 4.7 Child J was seen by the Practice Nurse in mid-April as her mother was worried that the child could not hold her urine. The Practice Nurse recorded her intention to contact the health visitor to provide tips on this problem, but did not do so. There are electronic systems available for referring to the Health Visitor Service, but these were not used in this case. 4.8 The mother attended her first midwife appointment in mid-April. The Primary Care Services report noted that it is normally part of midwifery care to ask about the home situation and domestic violence, but there is no record that this happened on this occasion. 4.9 At the end of April, Child J’s mother visited the GP practice complaining of lower back pain. This was recorded as a routine consultation. The School Nurse requested previous records as these had not yet been received. 9 May 2013 4.10 In mid-May Child J’s mother attended the surgery for a 16 week appointment with the midwife. On the same day the school nurse met the children’s mother to complete a health assessment for the sibling. She had missed 2 previous appointments. The School Nurse assessment noted there was a warm and appropriate interaction between mother and child. Mother was compliant with treatment and the GP was liaising with the Midlands Hospital about treatment and dressing requirements. 4.11 During mid-May Child J was temporarily in the care of maternal grandparents in the northern town for a period of 3 weeks. They also cared for her sibling for part of the same period. June 2013 4.12 In mid-June Child J was bought by her mother to be seen by the GP. She had been living for a three-week period in the care of her maternal grandparents in the northern town. Child J had returned, according to the mother “happy but subdued”. The mother also said she had noticed significant hair loss over the scalp and one bruise to the anterior chest. On examination, no bruises were seen on the body but some hair loss was noted. The mother was asked by the GP to take Child J to have a blood test, but reported later that she had lost the forms and did not do so. A blood test taken later showed no major abnormalities. 4.13 Later in June mother failed to attend an antenatal appointment. 4.14 In late June the mother bought Child J to the surgery for a minor illness appointment and was seen by the Practice Nurse. The mother stated that the child gets lesions on her skin which look like a bruise. She said that Child J woke that morning complaining of all over body pain. Child J appeared to be alert and happy, and looked well. The mother also discussed Sibling 1's skin condition. No further action was taken. July 2013 4.15 In July 2013 the mother was unable to continue to work through her pregnancy and was feeling unwell. It was reported later that the stepfather took over more of the personal care of the children during this period. 4.16 In early July the School Nurse met The Mother at school 4.17 Blood test results for Child J were returned in July and were normal; no further action was taken. 10 4.18 The following day in July, Child J was taken by her mother to the GP surgery with a history of 4-5 days rash on her scalp. On examination this was thought to be shingles and an antibiotic was prescribed. 4.19 Key Practice Episode 1 (mid-July) In July 2013, Urgent Care Cambridge (UCC, commissioned to provide the out-of-hours GP service) received phone call from Child J’s mother at 11:12 am on a weekend morning. The mother reported that Child J had been prescribed antibiotics, now had a swollen face and that her “eyes and everything” were swollen. A clinician returned her call. The mother said she was worried and thought Child J had bumped into something. 4.20 The doctor explained that this could be an allergic reaction and arranged an appointment at the Primary Care Centre. The mother and Child J attended for a face-to-face assessment at 11:50 am. The doctor recorded this as “an interesting case”, being treated by antibiotics to prevent infection of shingles to her scalp. The assessment identified that the child was complaining of pain in her right thigh and difficulty in weight-bearing although there was no localised tenderness. She had a bruised and swollen face, bruising to trunk both front and back and to her arms, facial swelling and scalp infection. A bloodshot right eye and a high level of allergy white cells were noted from the blood test results in the GP record. 4.21 The doctor advised the mother to take the child to the Emergency Department for further assessment. She did not send her with a letter of referral, and did not telephone the Emergency Department to advise that the mother and child would be attending. 4.22 The doctor from Urgent Care Cambridge had full access to the subject child’s GP records which she reviewed accordingly, and which showed that Child J had been seen by at least two other GPs recently before attending the out of hours service, neither of whom had raised safeguarding concerns. There was nothing of concern on the notes from the GP surgery, school nurses or Children’s Social Care. 4.23 The mother and Child J attended the emergency department at the Hospital later on the same day with a swollen face and bruising. She had started antibiotics 2 days prior. An initial Safeguarding Assessment was completed by hospital staff. The nurse undertaking the assessment recorded that the child did not attend the Emergency Department frequently with injuries and that the history did not give rise to any safeguarding concerns with an arrangement for review at the hospital the following day. 4.24 Child J was fully examined by a doctor at the hospital, in particular the facial swelling around the eyes. Bruises were noted on the child’s feet, wrists, under the eyes and on one cheek. These were drawn onto a body map. Within this examination the doctor confirmed that she had considered child maltreatment 11 using NICE guidance, and wrote that she was not sure if she suspected child maltreatment. 4.25 The case was discussed with the Paediatric Consultant within the hour and a full CT scan of the child’s head was undertaken. Later that evening the eye examination and CT head scan were reported as normal. 4.26 Children’s Social Care Emergency Duty Team (EDT, out of hours social care service) recorded a first contact from the Hospital at 8:49 pm on the same day to ask if Child J was known to social care. The notes were recorded on CSS (electronic record system). 4.27 In this discussion the doctor described the swelling around the child’s eyes and bruising to the arms, which were thought to be an allergic reaction to the prescribed penicillin. The EDT worker confirmed that CSC had no record of this family, but pointed out that ‘this should not matter as for some children there would be a first episode and a child with no involvement with social care should not be prevented from being kept safe’. 4.28 Another doctor later completed a discharge summary stating that a discussion with social services EDT had taken place due to the bruising. Detail and time of the discussion are not recorded other than “no concerns” on the typed discharge summary to the GP. No written referral was made to Children’s Social Care which prevented the usual pathway of concern being flagged to the hospital safeguarding team. 4.29 Based on information about the CT head scan result, eye examination result and “no concerns” in the discharge note, and the discussion with Children’s Social Care EDT, a decision was made to allow the child home with her mother on the same evening, with a plan for the same paediatric consultant to review her on the ward the following day. 4.30 A hospital nurse present through this episode later expressed her concern that she had had misgivings about the safeguarding actions but felt that staff with more experience would have better judgement 4.31 The child was brought back by mother to the hospital for review as arranged. She was seen by a different Paediatric Registrar. The Consultant Paediatrician checked the child’s mouth, chest, abdomen and genital area for the evidence of trauma and concluded that it was likely that the child‘s eye swelling was due to an acute reaction to the antibiotic. Mother consented to photographs being taken by the medical photography unit and attended the same day. 4.32 There is no evidence that the child was spoken to separately from the mother throughout this process. 12 4.33 Children’s Social Care Integrated Access Team followed up the work of the EDT the previous weekend night, and completed a threshold document2 during the working day. They made phone calls to the hospital, the school (to get mother’s telephone number), and the child’s mother, who was contacted by telephone on her way to the paediatric appointment. The consultant paediatrician was consulted, who said that she was certain that this was not non-accidental injury (NAI), and believed that the injuries were as a result of reaction to penicillin. Children’s Social Care assessed this as Level 1 on the Model of Staged Intervention (MOSI) and decided that it did not meet the threshold for Social Care intervention. CSC later contacted the mother to inform her of this decision, and the view that the swelling and bruising was as a reaction to medication. The mother said that she was relieved and said that she would never hurt her child. This follow up from the overnight episode was part of the ongoing case management process. 4.34 Child J was discharged home and a letter sent to the GP asking for follow-up in one week. Information was given in the letter that Children’s Social Care had been contacted and the GP was asked to note that child is now allergic to the antibiotic Flucloxacillin. The main diagnosis was an allergic reaction. Details of bruising were provided to the GP. 4.35 In the same week in July the GP received the hospital discharge letter saying that Child J had been seen in the Emergency Department with swollen eyes and bruising. The letter said that her case had been discussed with Children’s Social Care at the time due to additional bruising on the arms and feet. A CT scan was normal and the swelling was thought to be due to an allergic reaction. There was no reference to the pain in her right thigh and difficulty weight-bearing. The GP thought that the diagnosis of an allergy did not seem plausible but no challenge was made to hospital colleagues. The Doctor added the code “Child protection report submitted” so that this would be visible to other clinicians using SystmOne. (A Health Service Information System) August 2013 4.36 Key Practice Episode 2: In early August Child J was seen at the surgery by a trainee GP registrar in the afternoon. This was following a call in the morning from the mother that had been ‘triaged’ by the GP surgery that morning to say that Child J had blood in her urine and a mild fever. She was seen with her mother who stated that Child J woke up that morning in a “pool of clots and blood”. She had not been able to open her bowels or urinate since then. Child J told her mother she had fallen out of bed. A history was taken from the mother as Child J was said to speak only an EU language. Child J was reported as quiet and shy. She had scratches around the neck, a bruise on her face and with a red left eye. Abrasions were noticed on her left buttock and thigh and a bruise was present on her left knee. 2 A document used by IAT team in Cambridgeshire to record whether the threshold criteria for social care intervention are met, and the evidence and reasons for making this decision. 13 Vaginal bleeding was evident with fresh blood. The case was discussed immediately with a more senior doctor who suggested a referral to the on-call Paediatric SHO in view of safeguarding concerns. No contact was made with Children’s Social Care or the Police at that time. 4.37 The mother was given a GP referral letter and asked to go to the Paediatric Emergency Department at the hospital, where she arrived at 7 pm, after an interval of several hours. During this time it is now known that she had met up with the stepfather before taking Child J to the hospital. The content of any discussion is unknown. 4.38 The initial nursing assessment at the hospital was linked to the earlier report in July where safeguarding concerns had been considered. The mother advised the nurse that the child had been to hospital with spontaneous bruising before and that she wanted answers this time. 4.39 A second nurse became involved later and spoke directly to Child J. Contrary to what the mother had said, Child J could speak and understand English to a level which the nurse described as “understandable”. The child stated that her sibling had told her not to tell her mother about it (her bleeding). This was documented and the nurse in charge was advised. 4.40 At 9.45 pm EDT received a phone call from a paediatric consultant to the effect that Child J was in hospital with bruising to legs and arms and cheek, following a presentation to the GP earlier in the day regarding blood in her urine. The consultant said that the bruises were different to those present in the previous presentation in July. A further phone call from the hospital was received by EDT later to say that Child J had an adult bite mark on her back. EDT arranged a Strategy Discussion with Police. 4.41 During the phone calls to EDT, hospital nurses became concerned about the safety of Child J’s sibling, as the initial response from social care had been to review this child the next working day. 4.42 At 0.15 am on the following day a Strategy Discussion was held between Police and Children’s Social Care EDT. A decision was made that the threshold for a Section 47 enquiry was met, and that Police Protection would be used in respect of the sibling who would be brought to the hospital as a ‘Place of Safety’. The discussion did not include the construction of a plan of action to guide the investigation, or clarify the role of staff in looking after the children whilst in hospital. Information continued to be gathered overnight. 4 .43 The sibling was subsequently was bought to the hospital by police as a ‘Place of Safety’ under Police Protection. He was examined and admitted. His whereabouts in hospital was kept confidential from his mother and step-father and a pseudonym used. 4.44 Child J remained on the ward throughout the following day for further investigations. The child played with staff and had her mother in attendance. 14 The stepfather was permitted to visit without restriction. The child was calm and appeared to enjoy her stay on the ward. 4.45 Hospital nursing staff directly involved in the care of the children were unsure about what information they were able to give the mother about Child J, especially at the time of the forensic medical examination of the child under anaesthetic, as this was not clarified by any party in the Strategy Discussion. There were also not clear about the information they could give regarding the sibling. They did reassure the mother that he was being cared for and was not distressed. Staff witnessed several heated discussions by telephone or face-to-face with mother’s husband. These took place in their own language and were not understood by staff. 4.46 During the day, Child J had further investigations, an eye examination, interviews with the police and social care and an examination under anaesthetic late in the afternoon, some 24 hours after admission. These examinations confirmed evidence of a very serious sexual assault. 4.47 Both parents were arrested on the ward on the basis of evidence from the examination under aesthetic. Police later arrested lodgers at the family home and took forensic samples. 4.48 A foster care placement was found for the children with carers who spoke the same EU language, and Agreement for Accommodation and legal Proceedings was given by the Head of Social Work the same day. The children were placed together in the same placement. 4.49 Two days after Child J was admitted in August, Looked After Children paperwork was completed by Children’s Social Care. Requests for information were made to Children’s Services in the relevant Midlands and Northern towns. Patient records and a paediatric consultant report were received. An Emergency protection Order was granted. 15 5.0 Themed Analysis The analysis section of this review considers the information documented above, which was obtained from the Agency reports and from the staff who worked with Child J and her family, and who attended the Learning Event. Further information came from discussion at the Recall SILP event, when Agencies were able to consider the implications of the first draft of this overview report. 5.1 The impact of Ethnicity, Identity and Language Ethnicity, Religion and background 5.1.1 All members of the family, including the extended and reconstituted family members, are originally from outside Europe. Although clearly stating that they adhered to their religion, the mother described herself as “Modern” in respect of her religion. 5.1.2 In the interview with the mother she described being modern as not being religiously conservative, thus offering an explanation of some of her actions as being outside the norm. Ability of family members to communicate in English 5.1.3 Analysis of agency reports suggests that the mother could speak four languages. The stepfather could speak his own first language only. The sibling was quite fluent in English and could also speak the EU language and the first language. Child J could speak English at least to a limited extent at the time of the incident. In her interview with the author, the mother had said that at the time she thought that Child J could speak the EU language and a little of her first language, but only a little English. It may be that Child J learned some English to the mother, as she was described by hospital ward staff as having understandable English. 5.1.4 While at the hospital the parents conversed in their first language between themselves. However, when interviewed by Children’s Social Care the couple opted out of using an interpreter and were able to speak in English. 5.1.5 It is important for both universal and specialist services to clarify with the family and children at an early stage what languages are spoken, and to what extent they are spoken within the family. This will help to clarify areas where interpreters are needed, and where direct verbal communication with children can take place. 16 5.2 Marriage and Relationships 5.2.1 The mother’s history of marriage and relationships appear to fall outside normal cultural boundaries. The Mother states that she raised the children in the EU country as a single parent. 5.3 Identity Checks and Background Records 5.3.1 The agency reports show that different names and spellings were used by agencies for the mother and both children in this case. The mother says that she showed the birth certificates for the children, issued by the EU country, to the NHS (General Practice), but that they recorded the name of Child J incorrectly. Requiring formal documentation as part of the registration process with agencies was not a key issue in this case as family members were clearly identified. However it does raise a more general issue about proof of identity which may be a factor in other cases and deserves some discussion by the LSCB. 5.3.2 A Unique Pupil Number (UPN) is allocated to children when they register at a school, which will follow them if they move to different schools. In this case it was assumed that there was no previous school, or if there had been it would have been in the EU countries for which no records were realistically available. However, according to the mother, the children attended nursery or school in these countries from the age of 3 to 4 years old . 5.4 Health Visitor Involvement 5.4.1 Neither the GP or the Practice Nurse referred the family to Universal Child Health Services (Health Visiting) although she intended to do so. This demonstrated a lack of communication between General Practice and Universal Services and was a missed opportunity to engage the mother to discuss any concerns she may have had with a health professional specialising in family issues. 5.5 Support for the sibling 5.5.1 The sibling had a poor attendance record at school (80%), the majority of which was authorised by the parent. The Education Service has confirmed that this would have been investigated in more detail had he returned for a further term, but given his skin condition they were less concerned than might be the case for another child. 5.5.2 School staff and the school nurse provided positive support for sibling and his mother in managing his skin condition within the school setting, including the construction of a care plan. When his skin condition was under control he was an active boy, played happily with friends and presented well. The condition is known to flare up with stress, and may have been an indicator of what was happening in the family. It may be relevant to note that the Foster Carer with 17 which he was eventually placed was a nurse, and that the skin condition improved when in this placement. 5.6 The voice of the child 5.6.1 Throughout early agency involvement with this family there was an assumption, thought to have originated from the mother, that the subject child could not speak English. There were many opportunities for professionals to talk directly to the child, but this was not done until after her admission to hospital. It is not unreasonable of staff to believe what the mother told them, or alternatively to attempt to engage directly with the child. 5.6.2 Examples of this are documented in the timeline of engagement: 17.6.13: GP did not attempt to speak to the child 26.6.13: The Practice Nurse did not speak directly to the child 14.7.13: The child was not spoken to directly during the medical examination 5.8.13: A ward nurse at the hospital became involved in the care of the subject child during the medical examinations and spoke directly to her. This was documented and the child’s English described as “understandable”. 5.6.3 In all potential child protection and safeguarding situations, the role of professionals hearing the voice of the child is critical. The perceived language barrier may have prevented this, but as emphasised in most safeguarding training there are other ways apart from formal language for communicating with young children. Attempts at communicating in other ways may have led to direct communication in English, or the need to engage an interpreter. This lack of direct communication does represent a missed opportunity for agencies and organisations, particularly within the health service, to understand what may have been happening with respect to Child J. The LSCB should seek assurance from member Agencies that their processes for engaging with children and families clearly identify the languages spoken by adults and children, and identify where interpreters are needed for effective communication. 5.7 Multi-disciplinary assessment / diagnosis of child maltreatment, and professional challenge 5.7.1 A key finding from Serious Case Reviews nationally is that identification and diagnosis of maltreatment should be undertaken on a multiagency basis, and that the view of one professional should not override others. Professional challenge in these circumstances is seen as healthy and productive in securing safe judgement. In this case the view of the consultant paediatrician was accepted within the health service and by Children’s Social Care EDT in their threshold judgement. Evidence of this is contained within the key practice episode from July below: 18 5.7.2 The view given by the consultant paediatrician that this was “not NAI” was accepted by other parties, and was not challenged either by staff within the hospital or by Children’s Social Care, despite reports of bruising on arms and trunk. This is not to say that the Doctor’s view was incorrect, but a professional and respectful discussion would have helped clarify the reasons for this view, and supported multidisciplinary agreement on the risks and the way forward. 5.7.3 This view formed part of the Children’s Social Care judgement by EDT when it was decided that the case did not meet the Social Care threshold. The case was followed up by the CSC Integrated Access Team the following day to obtain more information, which has been noted as an example of thorough practice. This information was considered and assessed as level 1 (least risk or need) using Cambridgeshire’s threshold criteria, the Model Of Staged Intervention (MOSI), when the view of the consultant paediatrician was known i.e. it was decided that the case did not meet the social care threshold. 5.7.4 The hospital discharge letter was received by the GP surgery. The GP thought that the diagnosis described in the letter of an allergy did not seem plausible and discussed concerns with colleagues in the medical practice. The GP’s lack of confidence in the diagnosis was demonstrated by adding the code “child protection report submitted” to the record so this would be visible to other clinicians using the computer system. 5.7.5 However, no direct discussion was held with hospital colleagues to clarify the issues. In their subsequent review the medical team were reminded that such a discussion or challenge could have been routed through the Designated Doctor. 5.8 Communication between and within Agencies In this case, the prevalent means of communication within and between agencies is written through notes, email or fax. In some cases direct conversations take place between and within agencies, either by telephone or face-to-face discussion, which can help improve understanding through dialogue. The means of communication are identified in the sections below. 5.8.1 Communication between the Hospital and Children’s Social Care EDT Initial contact between the Hospital and Children’s Social Care EDT team in July took the form of a telephone call which did not identify any safeguarding concerns, and was recorded by EDT as a ‘contact’ 5.8.2 The discussion with Children’s Social Care EDT team did not result in a referral to Children’s Social Care, and information was not transmitted to the hospital safeguarding team who consequently could not undertake follow-up action. New electronic systems in the hospital are being introduced in October 2014 to ensure that the safeguarding team is notified of concerns whether or not Children’s Social Care is contacted. 19 5.8.4 The later contact in August between the Hospital and Children’s Social Care was characterised by generally good communications and effective joint working, together with the police, to safeguard the children in the family and undertake the necessary investigations with the adults concerned. This is demonstrated in KPE2 (August) when EDT were involved, and a Strategy Discussion organised for later in the day. Unfortunately, information available to the strategy discussion was limited as the emergency department nurse, who had some key information regarding the abuse from direct discussions with the child, was not on duty at the time of the discussion. Despite this appropriate action was taken to secure the safety of the children and take the police investigative action. 5.8.5 Communication between General Practice and Children’s Social Care The lack of contact from General Practice to Children’s Social Care in August, when essential safeguarding information was not shared, may be in part explained by the experience of a previous safeguarding case at the surgery, when staff were criticised for not emphasising medical needs over safeguarding needs. The surgery now accepts that both elements are of equal importance and is making changes to practice. 5.8.6 Communication between the hospital and the GP surgery Following discharge from the hospital in July, a letter was sent to the GP asking for a follow-up in one week. Information was given that Children’s Social Care had been consulted. The main diagnosis was an allergic reaction and details of the bruising were provided. The GP Agency report suggests that more direct communication between the hospital and the surgery would have been helpful. 5.9 Ensuring attendance at essential medical appointments On five occasions over the period, the mother was advised by health organisations to bring her daughter for further medical examination, some of which had clear safeguarding implications . No follow-up mechanisms were put in place to ensure that she did attend. 5.9.1 On the first occasion, following a medical examination at the GP surgery when Child J returned from relatives in the northern town, the mother was asked by the GP to take her daughter for a blood test, but lost the forms and did not do so. 5.9.2 On the second occasion the mother was advised by UCC following a telephone consultation to bring her for a face-to-face assessment at the primary care centre. The mother did as she was asked, but there was no mechanism in place to ensure that she did so. 5.9.3 Following this assessment the mother was advised to take the child from UCC to the hospital emergency department for further assessment. This was not 20 followed up to ensure that she had attended the appointment. Mother did attend later that day with the child. Following this appointment she was asked to bring the child back to the hospital the following day for a review by the same consultant. 5.9.4 The mother brought the child back to the hospital for review the next day as arranged with the hospital. The review was planned to be undertaken by the same paediatric consultant, but in the event was undertaken by a different registrar. There is no evidence that any process was in place to ensure that the mother attended this appointment. 5.9.5 When Child J’s mother took her to the surgery in August she was seen by the GP, and safeguarding concerns were very evident, including bruising, trauma and vaginal bleeding. Despite this she was given a GP referral letter and asked to take the child to the Emergency Paediatric Department at the hospital herself, where she was seen at 7pm. The revised report from the GP surgery states that the doctor phoned the on-call paediatric registrar before sending the mother and child to the Emergency Department. This was not made clear in the original Agency report. Neither the Police nor Children’s Social Care were notified by the GP surgery. 5.9.6 On each of these occasions there was the opportunity for the mother not to co-operate with the request to attend medical appointments. There were no clear mechanisms in place to ensure that she did attend. The episode in August in particular provided significant safeguarding risks to the child, where the mother had the opportunity to discuss issues with the stepfather, and to leave the Cambridge area. 5.10 Care of the Children in Hospital as a Place of Safety. 5.10.1 During the period of intense activity in August when Child J was admitted to hospital, arrangements were made to bring her sibling to the hospital as a place of safety and accommodated on a ward anonymously. During this period hospital nursing staff had the task of looking after the children. There was a significant lack of clarity about the role of the staff and what could be said to the parents about their children. This issue should have been addressed by participants in the strategy discussion as part of their action planning. 5.10.2 Mother and stepfather were allowed unrestricted access to Child J, the subject of the enquiry, but not to her sibling. The nursing staff were given no clear instructions as to their role. In the event they carried out an exceptional job in looking after the children, but in circumstances of considerable anxiety about not knowing their appropriate role in the circumstances. Their actions clearly helped the children to settle in these traumatic circumstances. 5.10.3 To help provide a safe service and reduce anxiety for staff, the Hospital, Police and CSC should ensure that such practice issues are discussed and 21 agreed at the Strategy Discussion, as part of the plan of enquiry and safeguarding. 5.11 Professional Curiosity, undue optimism / false reassurance There are a number of occasions during the review period when professionals demonstrated a lack of professional curiosity when presented with potentially worrying but unclear information. Examples of this are summarised below. 5.11.1 There was lack of curiosity when Child J returned from a stay with relatives in the Northern town, and was seen by the GP. Child J appeared subdued, and the mother said that she thought she had been bruised. It is good practice to routinely ask about the domestic situation in such circumstances, and follow-up the mother’s concerns in more detailed discussion. 5.11.2 Similarly there was a lack of curiosity from the school about periods of absence, although in this case the sibling was absent for only one week of the three-week period. The Agency report advises that schools need to be more curious about periods of absence of families, if they are new or unknown to them. 5.11.3 The mother frequently presented Child J to the GP surgery in May and June for a variety of issues. There is no evidence to suggest that the GP and nurses were not concerned by the frequency of presentation and the child was not spoken to directly. There was no health visitor involvement with the family, which may have helped identify any concerns. 5.11.4 An example of these presentations took place in late June when the mother bought the child to surgery for a minor illness appointment, saying that the child had lesions on her skin which looked like a bruise. She said that the child woke that morning complaining of all over body pain, despite looking well, alert and happy. More than one doctor had been involved in seeing Child J and her mother, and sharing information and consulting with each other may have been beneficial in identifying any possible patterns in the symptoms. 5.11.5 In Mid-July the child was taken to UCC and seen by a doctor. She was described as an “interesting case”. Raised levels of white blood cells associated with allergy from the blood samples were confirmed in the GP records. It may be reasonable to conclude that other causes of the bruising to trunk and arms, and the facial swelling should have been explored, and possible safeguarding concerns considered. The doctor concerned, who had undertaken level 4 safeguarding training, has concluded that with hindsight she could have been more suspicious and made a subsequent referral to social care. 22 5.12 Agency actions to secure the safety of the children once maltreatment was identified There is significant evidence from Agency reports that Agencies worked together very effectively to secure the safety of the children once maltreatment was clearly suspected. Police and Children’s Social Care worked effectively with hospital staff. Strategy discussions formulated a plan for effective interagency intervention. Nurses in the hospital provided good care of the children in a very difficult situation. CSC worked effectively to immediately secure a foster placement with the appropriate language, and also a carer with a nursing background. 6.0 The Mother’s Perspective 6.1 The mother of the subject child, Child J, was interviewed at her new address in the Northern town in September 2014 by the Overview Author and the Cambridgeshire LSCB Board Manager. She presented as an intelligent and articulate woman, who demonstrated good and relaxed care of her youngest child who was present during the interview. The interview took place after the overview report had already been drafted; her comments have been incorporated into the main report as appropriate, and the key issues she raised are summarised below. It should be noted that some of her comments are not consistent with Agency reports of her reaction to events. 6.2 The mother felt that had the GP being more actively involved the abuse to her child could have been stopped. She said that she had taken Child J to the GP surgery on several occasions, but received no adequate explanation as to what could be happening. She was concerned about the continued bruising, but thought there was a medical explanation. Child J had several tests but nothing happened. She had no idea that someone was hurting her child. She felt that the GP should have been more alert, and checked previous notes, and that they should have followed her up following the discharge from hospital in July. She said that doctors should be trained to report concerns to Social Services. 6.3 She also felt that Children’s Social Care should have visited her in person when they had concerns, and not just communicated through telephone calls. She described the call from CSC on the Monday morning to the effect that the hospital had referred Child J to them and that they were going to look into the matter. Mother attended hospital and subsequently received a further telephone call from CSC to say that they would not be taking any further action and that the file would be closed. She said that if they had visited to discuss concerns with her in person she would have welcomed this and accept any help offered. 6.4 The mother has reported that when in the hospital she felt discriminated against. Staff did not ask her any direct questions (which may have been connected with gathering evidence), but that not having her questions answered was the worst thing for her. When she was asked to take the child 23 to hospital on 5th of August she did so, but was not told about any type of abuse being suspected. When in hospital she became more and more anxious, and was feeling tired, pregnant and the need to have a wash. She could not understand why Child J had to go for a blood test when she was bleeding, and was concerned when she was put into a private room with a closed door. She felt that Child J was well looked after by staff but as a parent felt left out of the process. When she was arrested by police she states that she was still not told why she was being arrested. 6.5 She said that professionals have never looked into her husband’s past. She thought it would be hard for people who had never had children to adopt another child. She felt that whatever he did there must be some explanation; possibly mental illness. She would have liked to have had some explanation of this but these questions remain unanswered. She has no had no contact at all with her husband and would find it helpful even now to help her understand why things had happened. 6.6 She said that after August, Children’s Social Care, and in particular her last social worker in Cambridgeshire were very helpful, supportive and understanding of her feelings and the impact of what had happened to her. She said that the school was also very helpful and supportive. 7. Examples of Good Practice There have been a number of examples of good practice from partner Agency staff emerging through this review. A summary of these follows below, and more detail can be found in the timeline and Key Practice Episodes. 7.1 Children’s Social Care Good practice by Children’s Social Care was shown by the day service (IAT) following up the EDT contact with the hospital on 15th July to discuss with staff, undertake further enquires and ensure completeness of the record. From 5th August 2013 when maltreatment of the subject child was established, there was good and effective working with both police and hospital staff, and the sourcing of well matched, EU language speaking foster carers, one of whom was a trained nurse and who could look after both children in this family. 7.2 The Hospital 7.2.1 There was caring and sensitive practice by nursing staff in looking after the children when they had been admitted to the hospital as a place of safety despite difficulties and uncertainties concerning the role. The nurses spoke directly to the child and obtained information about the abuse from the child’s perspective. There is no doubt that they significantly contributed to the well-being of the children in these circumstances. 24 7.2.2 The hospital records were very comprehensive in recording what had happened, and proved very helpful to the police investigation and the subsequent court process. 7.2.3 Following the admission of Child J to the ward, hospital staff expressed concern and challenged about the safety of her sibling, subsequently leading to the police exercising their powers of protection, and bringing him to the hospital. 7.3 Cambridgeshire Constabulary 7.3.1 An exceptionally thorough agency report significantly enhanced the review’s understanding of the background of this family 7.4 The Cambridgeshire Learning Directorate 7.4.1 School staff proactively identified the need for support for the sibling to manage his treatment and medication for his skin condition. This included the school nurse making contact with the hospital, and discussing a care plan with the mother. The mother felt well supported by the school. 7.4.2 The school also identified the sibling’s educational and language needs, and ensure that effective interventions were in place, including the provision of additional support for a child with English as an Additional Language. 7.5 Community Services NHS trust The school nurse undertook research to understand the nature of the sibling’s medical condition, and helped the mother to develop a care plan 8. Findings 8.1 This is a tragic case of a very serious sexual assault on a four-year-old girl. There is no clear evidence that it could have been prevented, although with hindsight it is likely that deliberate harm was a factor in the mid July presentations to hospital, which would have justified some challenge and an assessment of potential risks. There were no evident systemic failures within the multiagency safeguarding process. 8.2 There was one potential opportunity in mid July 2013 to identify the risks to the subject but these were missed. There were other occasions when professionals could have been more curious as noted below: 8.2.1 The lack of follow-up by the GP and the practice nurse to involve Primary Care (Health Visiting). This may have been a missed opportunity for the Health Visitor to get to know the family well, which may have enabled the mother to express any concerns she had about the child. 25 8.2.2 Medical professionals not talking directly to the child due to a perceived (and incorrect) language barrier. This review has identified the need for all professional Agencies to identify the language spoken by families, including children, as part of the service uptake process. Lack of direct communication at the surgery, at UCC, and the hospital were other missed opportunities to engage directly, and potentially understand the family situation better 8.2.3 Lack of pro-active curiosity is understandable in the context of busy professionals working in services under pressure to achieve tasks and activities within prescribed timescales. Routine tasks are undertaken and targets met in this way, but skilled and trained professionals should be encourage keep their minds open to exploring the unusual and seeking to understand uncertainty, particularly in the context of their duty to safeguard children. This would be in addition to following required procedures, and can help to clarify the thinking and evidence which inform important professional decisions. 8.3 There were also some professional practice issues which potentially impact on safeguarding, and may have put the child at additional risk. These include: 8.3.1 A reluctance to challenge other professionals, particularly within the medical profession. This is understandable in the context of status differentials within the medical profession, and between the medical profession and other Agencies. A preferred culture would be one of respectful discussion between junior and senior professionals, where it is seen as part of the learning experience to seek clarification, and the reasons for the professional judgements of more senior staff. The importance of the Cambridgeshire LSCB’s Escalation Policy – Resolution of Professional Disagreements in Safeguarding Work should be emphasised. 8.3.2 The prevalent means of communication within and between Agencies is written, through notes, email or fax. Some of the Agency report authors have identified the benefits of more direct verbal communication, in person or by phone which can help clarify any areas of debate or uncertainty. A key message must be for professionals to talk to each other when uncertain about what they are seeing rather than relying on electronic communication. 8.3.3 The undue level of trust placed in the mother to take her child to medical appointments was potentially dangerous, and may have exposed the child to the risk of the mother not complying and potentially taking her out of the area. This practice was evident even when serious abuse could have been suspected. It appears likely that medical professionals did not recognise the potential safeguarding issues until the incident in August, but still did not take the necessary steps. In such circumstances it is necessary for all professionals to make arrangements to ensure that children do get to 26 appointments, and that systems are set up to ensure that Agencies are quickly alerted in the event of this not happening. 8.4 There were also some key areas of good practice shown by all Agencies involved as documented in section 7 of this report. Throughout the SILP process, partner agencies have become aware of shortfalls in their practice, and have taken steps to address them, without waiting for the conclusion of this review. They were thoroughly engaged in discussions with their partner agencies and professional colleagues at both of the learning events, were not defensive about their practice, and were, without exception, anxious to make immediate improvements where necessary. It is understood that improvements to practice in primary care services are taking place outside of this process. 8.5 Areas of good practice which should be reinforced A number of issues have emerged from this Serious Case Review which the Board may wish to disseminate and manage through the LSCB Learning and Improvement Framework. In particular: 8.5.1 The focus on the care of the children involved while investigations are proceeding which was amply demonstrated in this case. Remembering the welfare of the child(ren) while complex investigations are taking place is important at the time, and to help the children feel safe and able to cooperate with professionals from caring agencies in the future. Areas where continual reinforcement is required 8.5.2 The need to clearly ascertain the languages spoken within families, particularly those families which have recently migrated to the UK health language spoken by the children. This will help ensure that there are no barriers to direct communications and talking to children, and will help identify where an interpreter is required. 9. Recommendations for the Board 9.1 The Board should seek assurance that hospital staff working out of hours and those in Emergency Departments are familiar with the process of making contact with Children’s Social Care, and what and what does not constitute a referral, following existing guidance. 9.2 The Board should seek assurance that medical practices are aware of the need to ensure the notification to Child Health services of families with young children living in their area, particularly Health Visiting, and promote awareness of Universal Services which could provide support. 27 9.3 The Board should seek assurance that member agencies have procedures which emphasise the need to ensure follow up appointments in the safeguarding context. GPs should follow LSCB procedures in relation to making referrals to Children’s Social Care and the Police, and ensure that missed appointments where there are safeguarding concerns are followed up and escalated as appropriate. Brian Atkins SILP Lead Reviewer 10.11.14 |
NC042538 | Report from the Metropolitan Police Service (MPS) and the NSPCC, detailing the work of Operation Yewtree, the police investigation into allegations of sexual abuse made against Jimmy Savile and others. Key figures include: 600 people came forward with information, 450 relating to Jimmy Savile; 214 criminal offences have been recorded against 28 police forces; of his victims, 73% were children under 18. Key outcomes include: a significant rise in the level of reporting of past sexual abuse of children, increasing awareness about the importance of support for victims, collaboration between charities including NSPCC, NAPAC and CEOP, offering opportunities to develop further understanding and best joint working practices when dealing with victims of child sexual exploitation.
| G ivi n gVicti msa Vo i ceJoi n t rep o rt i n to sexu alal l egati o n s mad e ag ai n stJi mmy S avi l e A u t h o r sD a v i d G r a yD e t e c t i v e S u p e r i n t e n d e n tM P SP e t e r Wa t tN S P C C 1 ‘Giving Victims a Voice’ A joint MPS and NSPCC report into allegations of sexual abuse made against Jimmy Savile under Operation Yewtree January 2013 2 ‘Giving Victims a Voice’ Index 1. Introduction 2. Executive Summary 3. Overview 4. Police and other agencies 5. Background - Savile 6. Background - Investigation 7. Summary of victim accounts 8. Support for victims 9. General points on Savile’s offending 10. Learning and outcomes 11. Conclusion Appendix A Operation Yewtree Terms of Reference Appendix B Operation Yewtree Gold Group Terms of Reference Appendix C Operation Yewtree Stakeholder Meeting Terms of Reference Appendix D Definition of Child Sexual Exploitation. Appendix E Child Abuse Investigation in the MPS Appendix F Child Protection and Sexual Offences Legislation Appendix G Hospitals (and hospice) where Savile is reported to have offended 31. Introduction 1.1 An ITV programme broadcast on 3 October 2012 featured five women who recounted being abused by the late television presenter and charity fund-raiser Jimmy Savile during the 1970s. 1.2 At the request of the Association of Chief Police Officers (ACPO), the Metropolitan Police Service (MPS) took the lead in assessing and scoping the claims made in the programme and in the days and weeks following the broadcast hundreds of people came forward to say they had also been abused by Savile and others. 1.3 Co-ordination has been extensive and police have been working in partnership with the National Society for the Prevention of Cruelty to Children (NSPCC) and the National Association for People Abused in Childhood (NAPAC). 1.4 The MPS investigation - given the operational name ‘Yewtree’ - brought together officers with paedophile and serious crime investigation experience and has collated all the allegations against Savile, irrespective of where the offences took place. The MPS is grateful for all the assistance provided by police colleagues from across the UK in contacting victims, taking statements and making appropriate referrals. 1.5 A number of reviews relating to Savile’s reported offending at various institutions and whether earlier opportunities to arrest and prosecute him were missed are also underway. These matters have not been investigated by Operation Yewtree and do not form part of this report. 1.6 An issue that has understandably been raised is that as Jimmy Savile is dead there can be no criminal prosecutions against him and the testimony of his victims cannot be challenged in the courts. 1.7 However it is this lack of criminal proceedings - and justice for victims - that has contributed to the MPS and NSPCC view that the information contained in our joint report should be put into the public domain. 1.8 Account should also be taken of the substantial rise in the reporting of non-recent sexual abuse since Operation Yewtree began and the beneficial impact of this in apprehending other potential sex offenders. 1.9 Not all the victims who have come forward have been interviewed by police. However the patterns and similarities of the offences and behaviours that have come to light so far have given police and NSPCC staff an informed view that most people have provided compelling accounts of what happened to them. It should be recognised that others will also have experienced abuse but have chosen not to speak out. 1.10 We therefore consider it pragmatic to present this report in as factual a way as possible given that the information provided has not been corroborated. Further investigation seeking corroboration of individual allegations, the majority dating back many years, is considered disproportionate when there is no prospect of criminal proceedings. 4 1.11 This is why the report is entitled Giving Victims a Voice - we hope that those who suffered as a result of Jimmy Savile’s actions can take some comfort that information based on their accounts is being published. We also hope that the data and information will be useful to the organisations concerned as they take steps to ensure that similar offending to that reported is not currently happening or wouldn’t go unnoticed or unchallenged in the future. 2. Executive Summary 2.1 Operation Yewtree is being led by the MPS Child Abuse Investigation Command. There is currently a team of 30 detectives involved in the three strands of the investigation. These are defined as ‘Savile’, ‘Savile plus others’ and ‘others’. This report is concerned only with allegations relating to Jimmy Savile. 2.2 The first strand is offences believed to have been committed by Jimmy Savile on his own; the second is where victims have said there were other people around Savile who they believe were involved in offending; the third strand involves accounts from people who have come forward as a result of the publicity about Jimmy Savile but who have said they were sexually assaulted by people unconnected to him. 2.3 Costs are estimated at £450,000 so far. This is the cost of diverting officers from other investigations and other expenses such as overtime that have been incurred by the three strands of Yewtree. 2.4 The volume of the allegations that have been made, most of them dating back many years, has made this an unusual and complex inquiry. On the whole victims are not known to each-other and taken together their accounts paint a compelling picture of widespread sexual abuse by a predatory sex offender. We are therefore referring to them as ‘victims’ rather than ‘complainants’ and are not presenting the evidence they have provided as unproven allegations. 2.5 It is not proposed to issue a further narrative on Operation Yewtree although the data given here may be updated in the future if other victims come forward or further information comes to light. 2.6 The information gathered by the separate reviews connected to Jimmy Savile will be shared between the various parties involved although details that would identify individual victims will only be exchanged with their permission. 2.7 Since Operation Yewtree began on the 5 of October 2012 approximately 600 people have come forward to provide information to the investigative team. The total number of these relating to Savile is expected to be about 450, mainly alleging sexual abuse. 2.8 Most but not all victims have been interviewed and to date 214 criminal offences have been formally recorded across 28 force areas in which Savile is a suspect. 2.9 Whilst the NSPCC Helpline was contacted by some people who had previously reported their concerns and wished to alert the authorities again, the majority of 5people had never spoken about their experiences to the authorities until now. The reasons cited for this were varied and included the fear of not being believed and a lack of trust in statutory agencies or feeling that the justice system would be ineffective in prosecuting the offender. 2.10 The earliest reported incident was in 1955 in Manchester, the final reported offence was in 2009. The location of alleged offending was predominately in Leeds and London - Savile’s home town and his main work location. 2.11 There are reports of offences from when Savile worked at the BBC between 1965 and 2006, at the final recording of Top of the Pops. At Leeds General Infirmary, where he was a porter, offending was reported between 1965 and 1995. At Stoke Mandeville Hospital, where he was also a porter, reported offending took place between 1965 and 1988. At Duncroft School there are allegations of offences between 1970 and 1978 when he was a regular visitor. 2.12 The peak offending that’s been reported was between 1966 and 1976 when Savile was between 40 and 50 years old. 2.13 According to victims’ accounts, offences were mainly opportunistic sexual assaults - many in situations manipulated by Savile - but there are others where an element of grooming or planning is said to have occurred. Within the recorded crimes there are 126 indecent acts and 34 rape / penetration offences. 2.14 Of reported offending by Savile, 73% was against those aged under 18 years. The total victim age range of those who have come forward was between eight and 47 years old (at the time of abuse). Of those, 82% were female and most were in the 13 to 16 age group. 2.15 There is no clear evidence of Savile operating within a paedophile ring although whether he was part of an informal network is part of the continuing investigation and it’s not therefore appropriate to comment further on this. 2.16 Most victims did not come forward at the time of the alleged offences although records show that some allegations about Savile were made to police in the past. These did not proceed for a number of reasons such as victims and witnesses not wishing to take matters further and Her Majesty’s Inspectorate of Constabulary (HMIC) is currently looking at these interactions to see whether any opportunities were missed. 2.17 It is also worth noting that the reported peak offending period was between 1966 and 1976, a time when police investigation of such crimes was more basic and lacked the specialist skills, knowledge and the collaborative approach of later years. (See appendix E for the background of child abuse investigation in the MPS). It was more than a decade before the Children Act 1989 for England and Wales, the most comprehensive piece of legislation concerning child protection to be passed by parliament. (Child protection and sexual offences legislation is detailed in appendix F). 2.18 A significant number of suspects other than Savile have been identified to police during this investigation, probably as a result of the media coverage of 6Operation Yewtree and - it’s hoped - increased public confidence in the safeguarding authorities that victims will be listened to and when possible action will be taken. 2.19 We recognise that there may be people who read this report who have been victims of sexual abuse but have chosen to remain silent, possibly for many years. We are therefore taking this opportunity to again publicise the NSPCC Helpline which offers advice, support and guidance - 0808 800 5000 or [email protected] 3. Overview 3.1 Operation Yewtree was launched in response to the broadcast of ITV’s Exposure programme on the 3 October 2012. Former police officer and investigative journalist Mark Williams-Thomas detailed five women’s accounts of being sexually abused by the late Jimmy Savile at Duncroft School in Staines and in relation to the filming of BBC programmes. All said they had been abused during the 1970s, two in relation to Duncroft School and three on BBC premises. 3.2 Based upon the available information after broadcast, Savile was initially suspected of having abused about 20 to 25 victims and the police response was set up accordingly. The Metropolitan Police Service took the role of lead force and utilised experienced officers from within its Paedophile Unit, Serious Case Team and Major Incident Teams. 3.3 There was sustained media interest and coverage in the days and weeks following the broadcast and as further reports continued to come in the actual extent of Savile’s likely offending began to emerge. 3.4 This report is designed to provide a detailed analysis of Jimmy Savile’s offending profile, based on the accounts provided, as well as ‘giving victims a voice’ and responding to the justified public interest in a television personality who is now believed to have preyed on scores of people, many of them vulnerable and most of them women and children. 3.5 By drawing on the experiences of victims we can begin to explore how police and other bodies can learn to be more effective in the resolution and prevention of serious crime relating to predatory abusive behaviour. 3.6 Central to the many questions being posed by both his victims and others are why did it happen and why was it not noticed and stopped by police, health, education or social services professionals, people at the BBC or other media, parents or carers, politicians or even ‘society in general’? 3.7 It is now clear that Savile was hiding in plain sight and using his celebrity status and fundraising activity to gain uncontrolled access to vulnerable people across six decades. For a variety of reasons the vast majority of his victims did not feel they could speak out and it’s apparent that some of the small number who did had their accounts dismissed by those in authority including parents and carers. 3.8 Some people have questioned why police resources are being deployed on an investigation when the suspect is dead, cannot defend himself or be criminally prosecuted. This is understandable but does not take account of the need for 7hundreds of victims to have official recognition of the serious crimes they have suffered and to know they have been taken seriously. It must also be emphasised that Operation Yewtree has received information alleging serious sexual abuse by other people, unconnected to Jimmy Savile, which police have a duty to investigate and, where there is evidence, prosecute those responsible. 4. Police and other agencies 4.1 The ACPO national lead for Child Protection asked the MPS to take the lead role and to conduct an assessment and scoping of the allegations made in the television programme. 4.2 Senior officers met with the ITV production team and it became apparent that in addition to the five women who had agreed to appear on the programme, a further 15 may have been victims. It was agreed that a dedicated Serious Case Team, proportionate to the number of potential victims, would be formed within the MPS Paedophile Unit which has expertise in non-recent child abuse. 4.3 Contact was made at a senior level within the organisations where many of the offences were reported and assistance was provided to the inquiry team. There was engagement with police forces from across the UK and through the media, NSPCC, the National Association for People Abused in Childhood (NAPAC) and other agencies, as a consequence further victims came forward. 4.4 The Terms of Reference were set for Operation Yewtree (see appendix A) and governance for the operation was provided through a Gold Group chaired by the MPS Head of Specialist Crime Investigation (Terms of Reference at appendix B).The group included representatives of the police investigative team, the NSPCC, the Crown Prosecution Service (CPS), the Child Exploitation and Online Protection centre (CEOP) and representatives from the MPS Directorate of Media and Communication and Legal Services department. A stakeholders group was also formed which included representatives from NAPAC and individuals from some of the other non-police review and investigative teams. (Terms of Reference at appendix C). 8 5. Background - Savile 5.1 James Wilson Vincent Savile was born on 31 October 1926 in Leeds, the youngest of seven children. He went on to become a radio disc jockey, television presenter, media personality and charity fundraiser. He hosted the BBC television show Jim'll Fix It and was the first presenter of the BBC music chart show Top of the Pops. He presented many episodes of Top of the Pops and was also present on the last ever broadcast in 2006. He was awarded an OBE in 1971, was knighted in 1990 and received a Papal Knighthood in 1990. He died on 29 October 2011 aged 84. 5.2 During the Second World War Savile was conscripted to work in the coal mines. He later began a career in dance halls, first playing records and then moving on to manage them, including the Mecca Ballroom in Manchester. He began working as a DJ at Radio Luxembourg in 1958 and on Tyne Tees Television in 1960. In 1964 he presented the first edition of Top of the Pops and from 1968 worked on BBC Radio 1. Between 1975 and 1994 he presented Jim'll Fix It. As well as his television and radio work he supported charities and hospitals, in particular Stoke Mandeville Hospital in Aylesbury, Leeds General Infirmary and Broadmoor Hospital in Berkshire. 5.3 During Savile's lifetime there were some rumours connecting him with child abuse but these only became more widely publicised after his death. Savile claimed the key to his success on Jim'll Fix It had been that he disliked children, although he’s later said to have admitted that this was to deflect scrutiny of his personal life. He’s quoted as saying that he did not own a computer as he did not want anybody to think he was downloading child pornography (UTV interview 2006). 5.4 In a 1990 interview for The Independent on Sunday, journalist Lynn Barber asked him about rumours that he liked young girls. Savile's reply was that, as he worked in the pop music business, ‘the young girls in question don't gather round me because of me – it's because I know the people they love, the stars, I am of no interest to them.’ 5.5 In April 2000, in a television documentary by Louis Theroux, Savile acknowledged that rumours about whether he was a paedophile had been raised by some media. He denied that he was although the way he controlled and deflected the questioning takes on a sinister aspect when the interview is re-viewed in the knowledge of what has now been recounted by those who have come forward. 5.6 In 2009, Savile was interviewed under caution by Surrey Police investigating an allegation of indecent assault at Duncroft Approved School for Girls near Staines, Surrey, in the 1970s where he had been a regular visitor. The CPS advised that there was insufficient evidence to take any further action and no charges were brought. 5.7 In March 2008, Savile started legal proceedings against a newspaper which had linked him in several articles to child abuse at the Jersey children's home Haut de la Garenne. Savile denied visiting Haut de la Garenne but later admitted that he had following the publication of a photograph showing him at the home surrounded by children. The States of Jersey Police said that an allegation of an indecent assault by Savile at the home in the 1970s had been investigated, but there had been insufficient evidence to proceed. 95.8 In 2009, Savile publicly defended the convicted paedophile Gary Glitter, saying: ‘He just watched a few dodgy films and was only vilified because he was a celebrity, it was for his own gratification. Whether it was right or wrong is up to him as a person.’ 6. Background - Investigations 6.1 There are two distinct categories of investigations / reviews: • previous investigations (prior to the commencement of Operation Yewtree) and • current investigations as a result of publicity about Savile’s reported offending (including Operation Yewtree). 6.2 Previous Investigations. Police records indicate a number of previous police interactions connected to Savile although most victims who have come forward have told the investigative team that they did not report allegations or incidents at the time. The reasons for this are listed in paragraph 8.13 of the report. At the request of the Home Secretary the HMIC is now examining the previous allegations that were made about Savile to identify any potential failings by police. Date Investigating Force Brief details 1980s MPS It’s understood that a female reported that she had been assaulted in Savile’s camper van in a BBC car-park. No trace of a police file has been found despite extensive efforts and the investigating officer has since died. 2003 MPS A victim attended a West London police station to report she had been touched inappropriately by Savile on Top of the Pops in 1973. A crime report was created but she did not wish to proceed at that time unless there were other victims who had reported similar issues. At that time no trace of other victims was found and at her request the matter was left on file. 2007-2009 Surrey Police Investigation into two alleged offences at Duncroft School concerning two victims and a witness, and a further victim who alleged she was assaulted at Stoke Mandeville Hospital. 2008 Sussex Police Investigation into victim who said that in 1970 she was assaulted by Savile in his caravan in Sussex. The victim was reluctant to support a prosecution. 2008 States of Jersey Police Savile was considered as part of the Haut de la Garenne investigation in to child 10abuse. He denied ever having been there and no evidence was found to proceed. Photographs were published subsequently that strongly indicate he had visited the location. 6.3 Current Investigations. In total 14 inquiries or reviews have been launched since the television broadcast on 3 October. Organisation Scope HMIC Investigation into the quality of police actions relating to past claims about Savile and whether opportunities were missed. MPS Operation Yewtree - criminal investigation into sexual abuse claims against Savile and others. Director of Public Prosecutions Review of CPS decisions not to prosecute Savile in 2009. North Wales Police supported by the National Crime Agency / Serious and Organised Crime Agency Operational Pallial, the investigation into North Wales children’s homes. Greater Manchester Police A review of allegations made against the late MP Cyril Smith. MPS Operation Fairbank, a review of issues raised by Tom Watson MP. Surrey Police Operation Outreach - review of various matters relating to Duncroft School. BBC Investigation led by former Sky News chief Nick Pollard whether there were management failures in relation to Newsnight not broadcasting its report about Savile. (Now completed). BBC Independent investigation led by former Appeal Court judge Dame Janet Smith into the corporation's current and previous culture and practices in relation to child protection and the reporting of wrongdoing. BBC Investigation led by Dinah Rose QC into the handling of past sexual harassment claims. BBC Investigation by the Head of BBC Scotland into a Newsnight report claiming the involvement of a former Government figure in claims of abuse at children’s homes in North Wales. Department of Health Broadmoor Hospital review (Oversight by Kate Lampard). 11Department of Health Leeds General Infirmary review (Oversight by Kate Lampard). Department of Health Stoke Mandeville Hospital review (Oversight by Kate Lampard). 7. Summary of victims’ accounts 7.1 On the whole victims are not known to each other and taken together their accounts paint a compelling picture of widespread sexual abuse by one offender. We are therefore referring to them as ‘victims’ rather than ‘complainants’ and are not presenting the evidence they have provided as unproven allegations. 7.2 Information from victims came to the investigative team through the following 12 ‘pathways’: • The NSPCC helpline • The NAPAC helpline • The CEOP centre • ITV programme makers • BBC Investigation Services • Dame Janet Smith’s BBC investigation • Direct to the MPS incident room • Other police forces • The NHS • The MPS website • Contacting the media • Members of Parliament 7.3 Since Operation Yewtree began on 5 October 2012 approximately 600 people have come forward to provide information to the investigative team. The total number of these relating to Savile is estimated to be about 450, mainly alleging sexual abuse. Most but not all victims have been interviewed and to date 214 formal crimes have been recorded across 28 force areas in which Savile is a suspect.* * The significant difference between the number of crime reports and the number of people who have come forward is due to factors such as some people wishing to remain anonymous and others who don’t wish the matter to be reported as a crime or are unable to remember sufficient detail. There may also be changes in the categorisation of some crime data in the future as further details become known and / or further victims come forward. 7.4 Those with experience in this specialist field believe there are likely to be further victims who do not feel able to come forward at this time and we respect their desire for privacy. 7.5 The accounts of victims have been collated, analysed and summarised. The earliest recorded incident is in 1955 in Manchester. The final recorded offence was in 2009. The peak offending was between 1966 and 1976 when Savile was between 40 and 50 years old. In some cases, although the victim has provided information to the investigative team, they have not been willing or able to make a formal recorded report. 127.6 The charts used in this report are based on formal crime reports but the broader findings have taken account of the wider data available to investigators i.e. accounts from victims that have not resulted in formal crime reports. 7.7 Each recorded crime is being referred to the police force covering the geographic area where it occurred for recording purposes. 7.8 The location of offending is predominately in Leeds and London, Savile’s home town and his main work location. There are 57 allegations where hospital premises (this includes hospices) have been identified, 33 identifying television or radio studios and 14 relating to schools. 7.9 There are allegations of offences at the BBC from 1959 until 2006, at the final recording of Top of the Pops. At Leeds General Infirmary, where he was a porter, offending was reported between 1965 and 1995. At Stoke Mandeville Hospital, where he was also a porter, reported offending took place between 1965 and 1988. At Duncroft School, where he was a regular visitor, there are allegations of offences between 1970 and 1978. 7.10 Of reported offending by Savile, 73% is against those aged under 18 years. The total victim age range of those who have come forward was between eight and 47 years old (at the time of abuse). Of those, 82% are female and the majority was in the 13 to16 age group. 7.11 Victims’ accounts show that offences were normally opportunistic sexual assaults but there are others where an element of grooming is said to have occurred. Within the recorded crimes there are 126 indecent acts and 34 rape / penetration offences. Of the rape / penetration offences 26 victims were female and eight male. 7.12 There is no clear evidence of Savile operating within a paedophile ring although whether he was part of an informal network is part of the continuing investigation and it’s not therefore appropriate to comment further on this at this time. 7.13 The following are some of the main premises linked to Savile: Location Details BBC Television Centre Savile had access to Television Centre and associated property in the BBC's control. Broadmoor Hospital Savile’s positions included membership of a management taskforce. He had an office and flat outside the main building and keys to the hospital. Duncroft School The building has now been redeveloped. In the 1970s it was subject to oversight by the Home Office and was visited by Savile. The Gorge Glencoe Savile’s holiday cottage in Glencoe in the Scottish Highlands. 13Leeds General Infirmary Savile was a fundraiser and porter at Leeds General and had his own office in the main building. Stoke Mandeville Hospital Savile was a main fundraiser and volunteer at Stoke Mandeville Hospital. He had an office in the main building and a flat on site. Figure 1 - The footprint of offending is based on allegations that have resulted in recorded crimes and is spread over a wide area of the British Isles. The boxes indicate the police force areas where the offences are reported to have taken place. 14 7.14 Offences by Police Force Areas: 15 Figure 2 - Female victims by age. 18236317521Under 1010 to 1313 to 1616 to 18Over 18UK Figure 3 - Male victims by age. 1015105Under 1010 to 1313 to 16Over 18 16 Figure 4 - Victims by offence type. Current offence classification breakdown by age of complainant0510152025303540Under 1010 to 1313 to 1616 to 18Over 18UnknownAge categoryNo. of allegationsNo CrimeCrime Related IncidentCommon AssaultExposureSexual AssaultAssault by PenetrationRapeTransferred to other Force (classificationunknown) Figure 5 - Chronology of offending. Timeline of allegations (including notable locations)02468101214161955195719591961196319651967196919711973197519771979198119831985198719891991199319951997199920012003200520072009YearNo. of allegationsOtherDuncroft School for GirlsLeeds - General InfirmaryLondon - BBC CentreStoke Mandeville Hospital 17 7.15 Figure 5 shows peak offending between 1965 and 1978. Each bar is split to give an indication of where offences were committed. Between 1970 and 1978 he was offending at the BBC, Duncroft School, Stoke Mandeville Hospital and Leeds General Infirmary. There was also an offence at Broadmoor hospital during this period. (For reference, legislation relating to child protection issues can be found at appendix F). Figure 6 - NSPCC data shows an increase in calls and other contacts in October and November following media coverage about the investigation. 7.16 Example victim accounts of sexual abuse by Jimmy Savile (now recorded as crimes): • 1960. A 10-year-old boy saw Savile outside a hotel and asked for his autograph. They went into the hotel reception where he was seriously sexually assaulted. (Classified as assault by penetration). • 1965. A 14-year-old girl met Savile in a nightclub. She later visited his home and was raped. (Classified as rape). • 1972. A 12-year-old boy and two female friends attended a recording of Top of the Pops. During a break in filming Savile groped his genitals and the breasts of his two friends. (Classified as sexual assault). • 1973. A 16-year-old female hospital patient was befriended by Savile. He led her to an office where he kissed her, touched her inappropriately and then subjected her to a sexual assault. (Classified as sexual assault). • 1974. Savile took a 14-year-old schoolgirl for a drive in his car and seriously sexually assaulted her. (Classified as assault by penetration). 18• 2009. A 43-year-old woman was sexually assaulted by Savile when he put his hand up her skirt while talking to her on a train journey between Leeds and London. (Classified as sexual assault). 8. Support for the victims 8.1 The NSPCC, with NAPAC, have been supporting and advising police during the investigation. The NSPCC is the leading UK children’s charity dedicated to the prevention of child abuse. NAPAC is the National Association for People Abused in Childhood and provides support for those who have suffered any type of abuse in childhood. 8.2 NAPAC’s figures show a large increase in survivors of abuse contacting them by telephone in October and November 2012, following the launch of Operation Yewtree. They also reported a fourfold increase in email contact. Month Connected Calls May 355 June 339 July 323 August 340 September 255 October 803 November 507 Total 2922 8.3 Operation Yewtree has greatly benefited from the NSPCC’s country-wide Helpline which provides a freephone and online 24/7 accessible service for the public and professionals seeking advice about the welfare of children believed to be at risk of ill-treatment or abuse. The Helpline is staffed by a range of child care professionals, including child protection social workers, counsellors, teachers and health workers. It responds to over 40,000 contacts a year, generating more than 24,000 child protection referrals to statutory agencies. 8.4 Since the Helpline was established in 1991 the service has had significant experience of being commissioned by both police and local authority children’s services across the UK to provide specialist helpline services to support major child protection enquiries. These commissions are mainly established to offer advice and information to members of the public who may be affected by the enquiry. The commissioned helpline becomes a single point of contact for those wishing to provide information. 8.5 Additionally the Helpline is also commissioned by other organisations in the event that they experience an incident that raises concerns about child welfare. They therefore work with the NSPCC to ensure that there is an independent source of advice and information for both employees and the public. 8.6 Delays in alerting police and children’s services to abusive behaviour towards children have a detrimental impact on the progression of any criminal investigation. It also undermines the protection of known child victims as well as others who may be at risk, and the prevention of further abuse. Seeking to minimise delay and encouraging victims and witnesses to come forward to report abusive behaviour or 19alert the authorities to adults potentially presenting a risk to children are paramount to the effective prevention and detection of crime and safeguarding of children. Perpetrators are reliant upon victims and witnesses of abuse not speaking out. Thus improving and extending opportunities to inform statutory agencies of abuse can be a significant deterrent. 8.7 Recognising this, ACPO contacted the programme makers prior to broadcast to ensure that the NSPCC Helpline service would be available for viewers to contact when it was aired, for the public generally to provide information that might assist police and to offer initial support to adult victims of non-recent childhood abuse. 8.8 The NSPCC Helpline service provided a flexible response with both telephone and online access and the opportunity for those making contact to remain anonymous. This approach was critical to enabling public contact and to empowering people to overcome their reluctance to speak out. This led to an efficient and open information flow to the police and effective intelligence gathering of alleged abuse incidents. It also ensured action was taken with minimal delay and linked victims with appropriate support services. 8.9 The effectiveness of the NSPCC Helpline was enhanced by the public’s perception of and confidence in the NSPCC as an independent child protection agency. Where there has been some public concern expressed in the historical management of allegations relating to Jimmy Savile and others by police and children’ services, the confidence in those and other agencies is likely to have been enhanced by the partnerships established with the NSPCC. 8.10 The NSPCC Helpline responded to 97% of all contacts made to the service for Operation Yewtree, in excess of the NSPCC’s service target for response to contacts of 95%. Those few who were unable to access a practitioner immediately were offered a call back. As expected the greatest demand on the service occurred in the first week of the initiative. Greater demand was placed on the service following television and radio promotion of the Helpline number. 8.11 From the period 3 October to 21 November 2012 a total of 233 referrals to the police were generated specifically in relation to Jimmy Savile. In addition, a number of referrals to the police were made in relation to other high profile figures. A further 274 adults who contacted the NSPCC Helpline said they did so because they were prompted by media coverage; they went on to discuss their own experiences of being abused as children resulting in the NSPCC Helpline making 83 additional child protection referrals to police and other agencies not related to Operation Yewtree. 20 8.12 Of those contacts that resulted in referrals, 79% were made by phone and 21% online, mainly by email. Of those callers to the service, 67% were female, 33% male. Callers who raised issues that led to referrals came from the following regions in the UK: Region % East Midlands 7.6 Eastern 14.7 North East & Cumbria 4.6 North London 9.7 North West 9.7 Northern Ireland 0.4 Scotland 3.4 South East 12.2 South London 4.6 South West 14.3 Wales 2.5 West Midlands 4.6 Yorkshire and the Humber 11.8 8.13 The NSPCC Helpline was contacted by many people who had previously reported their concerns and wished to alert the authorities again. However the largest proportion had never spoken about their experiences before. Many of the latter had kept their abusive experiences a secret for several decades. The reasons offered for not speaking out previously included: • fear of not being believed or taken seriously; • shame being brought on one’s self or the family; • a perception that they were responsible; • a lack of trust in statutory agencies and feeling the justice system; was ineffective in prosecuting the offender; • a fear of getting themselves or the perpetrator into trouble; • a perception that the abusive behaviour was ‘normal’; • the perpetrator used threats and coercion to silence them. 8.14 It is also worth noting that many of these reasons are the same ones cited by adults who were told by children at the time that they were being abused, as to why they did not speak out themselves at the time. 8.15 The service offered by the NSPCC Helpline was victim-led, with child protection practitioners emphasising and reassuring callers that information provided by them would be taken seriously and would be shared with and assessed by the police. Some callers expressed greater confidence that the information they gave would now be acted upon and those who previously gave information to agencies historically were keen to report their concerns again, despite it being decades later. 21Many said they were encouraged to come forward because of what they had seen and heard in the media about others starting to speak out. For some, the time now ‘felt right’ to be heard. 8.16 The Helpline categorised users seeking support for the abuse they had experienced into two groups: (1) those who were seeking support to address the impact of non-recent abuse and had no dependants but the abuse affected their relationships with other adults; and (2) those who were seeking support to address the impact of non-recent abuse, who had child-dependant responsibilities and their abuse was influencing their patterns of child care. 8.17 While all received a service, shared their concerns and discussed future coping options, the first group was provided with details of other agencies to contact for further support. The latter group was given direct support from the Helpline. The NSPCC Helpline is aware that those additional supportive agencies for adults survivors of abuse are few in number and many are not located close to callers. 8.18 Many callers made a range of allegations not related to Jimmy Savile. The challenge the NSPCC Helpline had was determining which referrals should be made to Operation Yewtree and which should be referred to other police forces. Whilst the Helpline did not wish to refer inappropriately and overload the police enquiry team with unrelated referrals it also did not wish to exclude potentially important information. As a result most referrals of sexual abuse involving allegations relating to ‘prominent’ individuals or in organisations were made to Operation Yewtree officers. 8.19 To assist in the management of these initial referrals, in the first week of the operation a NSPCC Helpline senior practitioner worked in the Operation Yewtree headquarters with police officers on Helpline referrals and assisting in the contact with adult victims. 8.20 As a result of the media interest in allegations against Jimmy Savile the NSPCC Helpline received a number of unrelated contacts making allegations of current sexual abuse against children. Raising public awareness of sexual abuse will inevitably increase demand and agencies’ ability to support victims of both present day and non-recent abuse. 8.21 The NSPCC Helpline continues to provide support to Operation Yewtree and will do so until the completion of those enquiries or at the request of the Metropolitan Police. 8.22 Example quotes about / from callers to the NSPCC Helpline in relation to Operation Yewtree.(NSPCC note to editors: please include the following disclaimer when using these quotes - all quotes are from real people contacting the NSPCC but they have been edited to remove any potentially identifying factors and to increase clarity). 22• ‘The whole thing (the Jimmy Savile story) has brought child abuse to the fore, and people are questioning and reassessing the part they can play in protecting children. Lots more people who get in touch are now using words like, ‘duty’, ‘responsibility’ and ‘obligation’ when we ask them why they are talking to us, and are saying that seeing others speaking out about past abuse has motivated them to take action. Seeing people who are adults now talking about how nobody spoke up for them in the past, is a powerful motivator to speak up for children in the present,’ NSPCC Helpline Supervising Senior Practitioner • A neighbour called the NSPCC about suspected abuse of a baby, prompted by the Jimmy Savile story: ‘The mother is verbally abusive to the children, and a while ago I heard an almighty slap, then the baby stopped crying. The slap was hard enough that I heard it through the open window. Do you know, if it wasn’t for this Jimmy Savile thing, maybe I would have still been trying to turn a deaf ear to what’s going on. It’s really made me feel bad that I didn’t report it earlier.’ • A woman called to report abuse she experienced in the past: ‘I was watching TV this morning and they said if you know something and you don't do anything, you're allowing it to continue…with all these people coming forward about Jimmy Savile, I want to take action. I was in this dance group...at the time I didn't know what was happening but now that I am older, I know what it is called. He 'groomed' me, then it stepped up to more. The thing that worries me most is that he is still running the group - I don't want to feel guilty any more about not saying anything.’ 9. General points on Savile’s reported offending 9.1 Police believe that Jimmy Savile used his celebrity status to offend although he had committed sex crimes before he became famous. The bulk of the reported offending appears aligned to his rising public profile and increased access to children, particularly between the ages of 40 and 50, in the 1970s and 1980s. Of his victims, 27% were adults. Victims’ accounts show that some of the offences took the form of opportunistic touching over or under clothing but many others included coercion, violence and rape. 9.2 The victims tell us that at Duncroft School Savile was given unsupervised access and preyed upon girls by offering ‘favours’ such as trips in his car and cigarettes in return for sexual activity. 9.3 At Leeds General Infirmary, Broadmoor Hospital and Stoke Mandeville Hospital he was taken at face value as a volunteer and fundraiser, probably because of his growing celebrity status. Having been accepted at these institutions he gained access to vulnerable children and adults. 9.4 Operation Yewtree took into account previous investigations at two of the key locations. At Stoke Mandeville Hospital in 1990 a doctor was found guilty of sexually assaulting children but no link to Savile has subsequently been established. At the BBC in 1971 a newspaper reported on sexual favours being offered to influence decision making, again no link to Savile has subsequently been found. 239.5 Accounts from victims have left police and NSPCC staff with the unambiguous view that Savile’s behaviour was that of a predatory sex offender who opportunely abused people. It’s believed that he manipulated some of those around him to access potential victims and by real or implied threats used his status and position to prevent his activities being made public. His actions would today be categorised as ‘child sexual exploitation’. (See definition of child sexual exploitation at appendix D). 10. Learning and outcomes 10.1 The circumstances of Savile’s status and activities are unique. He is dead and there is no prospect of criminal proceedings. Hundreds of people have now given accounts of being abused by him and police have police taken the unusual step of presenting their uncorroborated accounts, when taken together, as compelling evidence of similar facts. This is a potential watershed - a growing number of victims of non-recent sexual abuse now have confidence that that they will be taken seriously by the authorities when in the past they did not. 10.2 A considerable amount of information has been amassed that will inform future decision-making about the prevention of sexual exploitation of children and assist the related reviews and investigations that are currently underway. Key outcomes to date are: 10.3 A formal record of the type and scope of offending by Savile based on the accounts of victims who have had the courage to come forward and share their experience of abuse. 10.4 A significant rise in the level of reporting of past sexual abuse of children. This is believed to be the result of media coverage about Jimmy Savile and victims’ increased confidence that they will be listened to by the authorities. 10.5 A better understanding of the reluctance to confront abusive behaviour, particularly that of dominant figures in positions of authority or influence. 10.6 Reinforcement of the need for organisations and institutions to operate rigorous safeguarding and vetting procedures. 10.7 Corroboration of the benefits of the integrated approach taken by police, the NSPCC, NAPAC and CEOP and the opportunity to develop further understanding and best joint working practices when dealing with victims of child sexual exploitation. 10.8 Increasing awareness about the importance of support for victims and the vital roles played by charities in this field. A practical example of this is the collaboration between the NSPCC and NAPAC. NAPAC is a small charity with limited means and prior to the exposure of Jimmy Savile’s activities was only able to offer a limited service to people wishing to contact them by telephone. As a result of the two charities’ collaboration through Operation Yewtree, the NSPCC Helpline has enabled NAPAC to provide a 24-hour service to callers. 2411. Concluding remarks 11.1 From the information provided by the hundreds of people who have come forward to Operation Yewtree, police and the NSPCC have concluded that Jimmy Savile was one of the UK’s most prolific known sexual predators. Indeed the formal recording of allegations of crime on this scale is, to the best of our knowledge, unprecedented in the UK. 11.2 The details provided by the victims of his abuse paint the picture of a mainly opportunistic individual who used his celebrity status as a powerful tool to coerce or control them, preying on the vulnerable or star-struck for his sexual gratification. Sadly, this type of behaviour is not uncommon in any society - sexual abuse, whether in street gangs, though trafficking or within families and institutions, often involves the use of powerful coercion, intimidation and manipulation to exploit the vulnerable. 11.3 It would be naive to view this case as the isolated behaviour of an individual rogue celebrity. We do, however, need to recognise the context of the 1960s and 1970s (the peak offending period). It was an age of different social attitudes and the workings of the criminal justice system at the time would have reflected this, even though the abuse committed was as illegal then as it is now. Thankfully attitudes have changed considerably in a relatively short period of time. 11.4 The increased confidence of victims is manifested in the significant increase in the reporting of non-recent abuse as a direct result of the exposure of Jimmy Savile. This does not mean there is any room for complacency though - more work still needs to be done to ensure that the vulnerable feel that the scales of justice have been rebalanced and their confidence in the criminal justice system enhanced. 11.5 The questions asked by victims were how was Savile able to offend over so many years, why wasn’t he stopped and could it ever happen again? The accounts victims have provided, showing the pattern of his behaviour and the protection from public exposure his celebrity status appears to have afforded, go some way to answering the first two questions. 11.6 Institutions and agencies that may have missed past opportunities to stop Savile’s activities - and organisations where similar sexual abuse could be going on undetected - must now do all they can to make their procedures for safeguarding children and vulnerable adults as robust and rigorous as possible. Only then can the victims who have come forward be reassured that it is unlikely to happen again. 11.7 Perhaps the most important learning from this appalling case is in relation to the children and adults who spoke out about Jimmy Savile at the time. Too often they were not taken seriously. We must not allow this to happen again - those who come forward must be given a voice and swift action taken to verify accounts of abuse. Detective Superintendent David Gray MPS Paedophile Unit Peter Watt Director of Child Protection Advice & Awareness NSPCC 25Appendix A Operation Yewtree Terms of Reference - initial assessment and also used for subsequent investigation. 1. To provide a proportional and consistent policing response, putting the victims or potential victims at the heart of our work. To enable victims to find assistance and possible closure through the appropriate referral or partner agencies and third-sector support networks. 2. To ensure the ethical recording of criminal offences emanating from victim accounts or third parties. 3. To secure and preserve evidence in relation to criminal offences involving persons who can be subject of further investigation. 4. To reassure the wider community that the MPS is achieving its objective of proportionality and consistency, whilst bringing to justice those suspected of committing offences. 5. To enable other organisations to learn lessons and draw conclusions from the facts established within this assessment. 26Appendix B Operation Yewtree Gold Group Terms of Reference Aim - To provide strategic oversight for Operation Yewtree through the co-ordination of a multi agency response. Objectives - - To ensure public and victim confidence is maintained. - To support and enable the Senior Investigating Officer to deliver a proportionate policing response through his strategic intentions. 27Appendix C Operation Yewtree Stakeholder Meeting Terms of Reference Aim - To share information between agencies and co-ordinate a multi-agency response. Objectives - - To ensure public and victim confidence is maintained - To support and enable the SIO to deliver a proportionate policing response through his strategic intentions Governance and Membership Chair MPS - Commander Spindler Senior Investigating Officer - MPS Detective Superintendent David Gray MPS Directorate of Media and Communication MPS Directorate of Legal Services CPS CEOP BBC Internal Investigations Solicitors for Dame Janet Smith Review NSPCC NAPAC Department of Health Member of Kate Lampard’s Oversight Team 28A ppendix D The National Working Group for Sexually Exploited Children and Young People developed the definition of child sexual exploitation which is now used by government and other organisations: Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. Child sexual exploitation can occur through the use of technology without the child’s immediate recognition; for example being persuaded to post sexual images on the Internet/mobile phones without immediate payment or gain. In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person’s limited availability of choice resulting from their social/economic and/or emotional vulnerability. 29Appendix E A brief history of child abuse investigation in the Metropolitan Police Service In the mid 1980s, a joint MPS and Social Services project in the London Borough of Bexley, known as ‘The Bexley Project’, supported by the Home Office, established early benefits in applying joint investigation teams. In 1988, following the presentation of the findings of The Bexley Project, the MPS introduced regionally supervised Child Protection Teams (as they were then known) dedicated to investigating child abuse across London. In response to the death of Victoria Climbié in February 2000, a public inquiry was launched in May 2001, chaired by Lord Laming. His final report was published in January 2003. This report made 108 recommendations to improve safeguarding measures for children and young people. Following Victoria's Climbie’s death, the MPS formed a central command in July 2000 to coordinate the Child Protection Teams (now called Child Abuse Investigation Teams) and to implement the recommendations from Lord Laming's report. In 2002, the command (then SO5) moved from Specialist Operations to become part of the Specialist Crime Directorate, renamed as SCD5. In 2009, Her Majesty's Inspectorate of Constabulary (HMIC) conducted an inspection of SCD5 following the investigation and trial into the death of Peter Connelly (Baby P). They identified 28 areas for improvement. As a consequence, the command set up the SCD5 Modernisation Programme to implement these and other necessary changes. The success of the programme led to a 20% growth in staff, an increase in resources and an improvement to procedures. This included the introduction of the Child Risk Assessment Model (CRAM) - a risk assessment process that uses intelligence research as the basis for making decisions concerning the welfare of vulnerable children. The command is now part of Specialist Crime and Operations (SC&O) and is the world's largest dedicated team of child abuse investigators. We continue to strive for excellence in delivering a corporate approach to investigating child abuse. We have developed robust standard operating procedures, ensuring that all our officers are equipped to conduct effective, high quality investigations. We have also improved intelligence sharing protocols, within the MPS and with partner agencies, to safeguard children and promote their welfare. The command also contains specialist units including the Paedophile Unit, Serious Case Team and High-Tech Crime Unit. It provides the MPS response to; Female Genital Mutilation - Project Azure, Sudden Unexpected Death in Infancy - Project Indigo, Safeguarding children from abuse linked to a belief in spirit possession - Project Violet, Enhanced protection for the most vulnerable children - Project Topaz. 30Appendix F This timeline mainly details child protection legislation and gives a brief overview of sexual offences legislation. Source: NSPCC Information Service A history of child protection legislation 1889 - The Prevention of Cruelty to, and Protection of, Children Act 1889 was the first statute of many to impose criminal penalties to deter mistreatment of children. 1894 – Prevention of Cruelty to Children (Amendment) Act 1894 extended the definition of cruelty to children to include “injury to mental health”. 1894 – Prevention of Cruelty to Children Act 1894 consolidated the 1889 and 1894 (Amendment) Acts. 1904 – Prevention of Cruelty to Children Act 1904 enabled NSPCC Inspectors to remove children for abusive or neglectful family homes, provided they had the consent of a JP. 1908 – Children Act 1908 set up the first juvenile court and introduced the registration of foster parents 1908 – Punishment of Incest Act 1908 – made sexual abuse within families a matter for state jurisdiction rather than intervention by the clergy. 1926 – Adoption of Children Act 1926 – Provided adoption for the first time as an alternative to guardianship or institutional care in orphanages. 1932- The Children and Young Persons Act 1932 broadened the powers of juvenile courts and introduced supervision orders for children at risk. 1933- The Children and Young Persons Act 1933 consolidated existing child protection legislation into one act. Includes a list of offences against children, which are referred to as Schedule One offences. 1938 - Children and Young Persons Act 1938 sought to improve the care of juvenile offenders. 1948- The Children Act 1948 followed the death in 1945 of a 13 year old boy, Dennis O’Neill, as a consequence of the neglect and beatings of his foster father. Focused on children in the care of the state and living apart from their families. Established a children's committee and a children's officer to take responsibility for looked after children in each local authority. 1963 – The Children and Young Persons Act 1963 introduced a mandatory duty to require local authorities to “make available such advice, guidance and assistance as may promote the welfare of children by diminishing the need to receive children into or keep them in care under the 1948 Children Act”. 311969 – The Children and Young Persons Act 1969 introduced more compulsory measures for local authorities to take over the parental rights of children; and allowed children committing criminal acts to be made subject to care orders. 1970 - The Local Authority Social Services Act 1970 legislated for social services departments, bringing together councils’ social work services and care provisions for children, disabled adults and older people. 1974 - The inquiry into the death of Maria Cowell at the hands of her stepfather highlighted a serious lack of coordination among services responsible for child welfare. Its report led to the development of area child protection committees (ACPCs) in England and Wales, which coordinate local efforts to safeguard children at risk. 1975 – The Children Act 1975 introduced time limits before children could be considered for non-consensual adoption. 1978 – The Protection of Children Act 1978 legislated against child pornography. 1989 - The Children Act 1989 for England and Wales is the most comprehensive piece of legislation concerning children which had ever passed through parliament. It was far reaching, and sought to provide to clarify the many different pieces of legislation which came before it. It gave children the right to be protected from abuse and defined key elements of the child protection system – including serious harm, the paramountcy principle and parental responsibility. 1991- Working Together under the Children Act is published in England. This requires ACPCs (Area Child Protection Committees) to conduct a review when child abuse is suspected to have played a role in a child’s death. 1991- The United Kingdom ratifies the UNCRC (Convention on the Rights of a Child). This enshrines the basic human rights of all children in the law. 1993 - The murder of James Bulger and the subsequent media coverage and trial of his killers caused debate and promoted reform of the juvenile criminal justice system. 1995 - The Children (Scotland) Act 1995 is passed into law. The Act incorporates three fundamental principles from the UNCRC into Scottish Law. These were non discrimination, a child’s welfare being a primary consideration and listening to the views of children. 1995 - The Children (Northern Ireland) Order 1995 is passed into law in Northern Ireland which sets out the responsibilities of the authorities to provide services to children in need and their families, to provide for and support looked-after children, to investigate children at risk and take appropriate action. 321995 – The Department of Health published ‘Child Protection: Messages from Research’ which presented evidence which criticised the child protection system in the United Kingdom. It encouraged a greater focus on the impact of neglect, and the use of family support.1 1996 – The Family Law Act 1996 in England and Wales amended the Children Act 1989 by providing protection for victims of domestic violence and their children by requiring a suspected abuser removed from a family home, with the child remaining. 1997 – The Sex Offenders Act 1997 (UK wide) created the sex offenders register through a series of monitoring and reporting requirements. 1998 – The Human Rights Act 1998 enshrined in UK law the principles of the European Convention of Human Rights. Despite not explicitly referring to the protection of children, the act recognises that children are classed as persons in the eyes of the law and should therefore be afforded the same protection as adults. 1999 - The Protection of Children Act 1999 aimed to prevent sex offenders from working with children. It required childcare organisations in England and Wales to inform the Secretary of State for Health about anyone known to them who is unsuitable to work with children. The Protection of Children (Scotland) Act was passed in 2003 which also required the relevant minister to record individuals who were not suitable to work with children. 1999 – The Department of Health publishes Working Together to Safeguard Children which set out guidelines for professionals working in child protection in England. 2000 – Eight year old Sarah Payne was murdered by convicted sex offender Roy Whiting. Her death led to calls for ‘Sarah’s Law’ to be introduced, similar to Megan’s Law in the United States which allows members of the public to access data relating to sex offenders living in their area. 2001 – Peter Clarke is appointed as the first Children’s commissioner for Wales. 2001 – Cafcass (Children and Family Court Advisory and Support Service) is set up in England and Wales to safeguard and promote the welfare of children involved in family court proceedings. 2002 - Section 120 of the Adoption and Children Act 2002 in England and Wales amends the Children Act 1989 by expanding the definition of "harm" to include witnessing domestic violence. 2002 – The National Assembly for Wales published Too Serious a Thing by Lord Carlile– a review into the safeguards for children and young people treated and cared for by the NHS in Wales. 1 Corby, Brian, ‘Child Abuse: Towards a Knowledge Base’,2006, p. 99-97 332003- In January, Lord Laming published his report into the death of child abuse victim Victoria Climbié, which found that health, police and social services missed 12 opportunities to save her. 2003 – As a result of the Laming Report , a government green paper, Every Child Matters is published, which proposed significant changes to the child protection system in England. This recommended the amalgamation health, education and social services; a children's director to oversee local services; statutory local safeguarding children boards (LSCBs) to replace ACPCs; and a children's commissioner for England. 2003 - The Sexual Offences Act 2003 was introduced to update the legislation relating to offences against children. It includes the offences of grooming, abuse of position of trust, trafficking, and covers offences committed by UK citizens whilst abroad. Similar offences were introduced into other parts of the UK by the Sexual Offences (Scotland) Act 2009 and the Sexual Offences (NI) Order 2008. 2003 – The Scottish Executive published their Review of Child Protection in Scotland, which was prompted by the death of 3 year old Kennedy MacFarlane in 2000. 2003 – Protection of Children (Scotland) Act 2003 was brought into law in Scotland in order to improve safeguards and to prevent unsuitable adults working with children. 2003 – Nigel Williams is appointed as the first Commissioner for Children and Young People in Northern Ireland. 2003 - The Protection of Children and Vulnerable Adults (Northern Ireland) Order 2003 (POCVA) came into force in Northern Ireland in order to improve safeguards in preventing unsuitable adults working with children. 2003 – Co-operating to Safeguard Children is published in Northern Ireland which provides guidance to safeguard children at risk of significant harm. 2003 – Northern Ireland introduce Case Management Reviews (CMRs) which are undertaken if a child dies and abuse is suspected to have played a part. 2004 – The Scottish government publishes Protecting Children and Young People: the Charter. This document set out what young people need and should expect in order to protect them from harm. 2004 – Sir Michael Bichard publishes his Inquiry Report into child protection measures in Humberside and Cambridgeshire following the deaths of Jessica Chapman and Holly Wells in 2002. 2004 – The Children Act 2004 is passed for England and Wales which creates the post of Children's Commissioner for England, new Local Safeguarding Children Boards, and a duty of care for many agencies. Section 58 amends the law on physical punishment. 34 2004 - Domestic Violence, Crime and Victims Act 2004 created a new offence of "causing or allowing the death of a child or vulnerable adult" to address the situations where previously the police were unable to prosecute parents or carers over a child's death because they could not prove which one of them had actually dealt the fatal blow. 2004 – Kathleen Marshall is appointed as the first Children’s Commissioner for Scotland. 2005 – Professor Al Aynsley Green is appointed as the first Children’s Commissioner for England. 2005 – Northern Ireland publishes Regional child protection policy and procedures which sets out the local procedures and processes for agencies to comply with the 2003 Co-operating to Safeguard Children guidance. 2006 – The Safeguarding Vulnerable Groups Act 2006 is passed, which establishes the Independent Safeguarding Authority which works to prevent unsuitable adults working with children in England, Wales and Northern Ireland. 2006 – The Northern Ireland executive published a ten year Strategy for Children to 2016, which outlined their pledge to protect and support children. 2006 – The Child Exploitation and Online Protection Centre (CEOP) is formed. CEOP works to tackle online child abuse across the UK. 2006 –Working Together to Safeguard Children is published in England, superseding the 1999 publication. 2007 - The Safeguarding Vulnerable Groups (Northern Ireland) Order 2007 is passed, replacing the Protection of Children and Vulnerable Adults (Northern Ireland) Order 2003. 2008 – Standards for child protection services, applicable to all public bodies, organisations, professionals and other persons who provide statutory services to children in Northern Ireland is published. 2008 - The Home Office launches the Child Sex Offender Disclosure scheme in England and Wales, which would allow members of the public to request information about a named individual to ascertain if they posed a threat to children. 2008 - The Sexual Offences (Northern Ireland) Order 2008 brings sexual offences legislation in Northern Ireland in line with that in England and Wales. 2009 – Lord Laming publishes his review of child protection in England, following the death of Peter Connelly in 2007. 352010 – Professor Eileen Munro is commissioned by the coalition government to conduct a review into child protection in England. 2010 - Updated guidance entitled ‘Working Together to Safeguard Children’ is published in England, superseding the 2006 guidance. 2010 – Children, Schools and Families Act 2010 contains provisions about: effective information sharing in LSCBs; strengthened the evaluation of Serious Case Reviews; and greater media reporting of family court proceedings. 2010-12 ACPO Child Protection Delivery Plan. 2011 – The Scottish Government introduce the Protecting Vulnerable Groups (PVG) scheme to ensure that those who have regular contact with children do not have a known history of harmful behaviour. Sexual offences legislation 1885 – Age of consent for heterosexual activities raised from 13 to 16 in England, Scotland and Wales. 1908 – Punishment of Incest Act 1908 made sexual abuse within families a matter for state jurisdiction rather than intervention by the clergy. 1956 – Sexual Offences Act 1956. Under this law men under the age of 24 could use the defence that they had “reasonable cause” to believe a girl was over 16. 1960 – Indecency with Children Act 1960. 1967 – Sexual Offences Act 1967 – sets age of consent for homosexual activities at 21 in England and Wales (same age brought in in Scotland in 1980 and Northern Ireland in 1982). 1976 – Sexual Offences (Amendment) Act 1976. 1985 – Sexual Offences Act 1985 1991 – Criminal Justice Act 1991, s.31(1) includes a formal list of sexual offences in England and Wales 1992 – Sexual Offences (Amendment) Act 1992 1993 – Sexual Offences Act 1993 1994 – Criminal Justice and Public Order Act 1994 lowered age of consent for homosexual activities to 18 in all parts of the UK. 1996 – Sexual Offences (Conspiracy and Incitement) Act 1996 361997 – Sexual Offences (Protected Material) Act 1997. 1997 – Sex Offenders Act 1997 introduced the sex offender register, includes a list of which offenders might find themselves having to register 2000 – Sexual Offences (Amendment) Act 2000. Lowered age of consent for homosexual activity to sixteen (came into force January 2001 in England, Wales and Scotland). Also introduced the offence of “abuse of trust” to prevent sexual relations between workers with the care of young people and the young people in their care, even if the young person if over 16. 2003 – Sexual Offences Act 2003 - Comprehensive reform of law on sexual offences, including the strengthening of the registration requirements for sexual offenders. Repealed the right of men under the age of 24 to use the defence that they had “reasonable cause” to believe a girl was over 16. 2008 - In June 2008 the House of Lords passed the Sexual Offences (Northern Ireland) Order 2008, which lowered the age of consent in Northern Ireland from 17 to 16 (came into force on February 2 2009). 2010 - ACPO Child Protection and Abuse Investigation (CPAI) produced a comprehensive Child Protection Delivery Plan (CPDP) in 2010 that cut across the entire range of child protection issues, not just those traditionally related to child abuse investigation. The plan examined areas where practice was in need of development and made 35 recommendations at a national, regional and local level to make a tangible difference to this area of policing. The recommendations have been completed and a new CPDP is under construction and will be released later in 2013. ACPO has also developed an action plan in regards to child sexual exploitation to enhance and support work already ongoing within forces and nationally. That plan covers seven key areas for progress which it expects to report on at the end of July 2013. 37Appendix G List of hospitals and hospices where Jimmy Savile is reported to have offended (recorded crimes). Savile’s role as a fundraiser and volunteer gave him a high level of access at Leeds General Infirmary, Stoke Mandeville and Broadmoor hospitals. No information has been received that suggests he had similar access at the other premises listed here. NHS Leeds General Infirmary - 16 offences 1965-95 Stoke Mandeville Hospital - 22 offences 1965-88 Broadmoor Hospital - one offence 1991 St James Teaching Hospital, Leeds (same trust as Leeds General Infirmary) – one offence 1962 High Royds Psychiatric Hospital (closed 2003 services into Leeds community services) – one offence 1989 Dewsbury Hospital (now part of Mid Yorkshire NHS Trust) – one offence 1969 Wycombe General Hospital (now part of Buckinghamshire Healthcare NHS Trust) – one offence Great Ormond Street Hospital NHS Foundation Trust – one offence 1971 Ashworth Hospital NHS High Secure Unit – one offence 1971 Exeter Hospital (part of Royal Devon & Exeter Hospital NHS Foundation Trust) – one offence 1970 Portsmouth Royal Hospital (now closed and facilities part of Portsmouth Hospitals NHS Trust) - one offence 1968 St Catherine’s Hospital, Birkenhead, part of Wirral Community NHS Trust - one offence 1964 Saxondale Mental Health Hospital, Notts (closed 1988) - one offence 1971 Non-NHS Wheatfield hospice, Leeds (part of Sue Ryder) - one offence 1977 38 |
NC043708 | Serious injuries of a 3-week-old baby girl in October 2012. Mother admitted shaking and hitting Child D and was subsequently arrested; she was remanded in custody until a Hospital Order was made under Section 37 of the Mental Health Act 1983. Mother had been known to a wide number of agencies since her infancy; she experienced abuse and neglect as a child and entered local authority care four months before her 17th birthday. Mother had a history of mental health problems including anxiety and depression. Identifies themes, missed opportunities and lessons learned, including: inadequate assessment of mother's learning difficulties leading to the withdrawal of support services; lack of agency lead in response to mother's multiple, overlapping needs; agency assumption that father was a protective factor to Child D, despite lack of supporting evidence; and underestimation of mother's support needs as she often presented to agencies as more capable than was the case. Identifies service improvements made by agencies and makes various recommendations focusing on multi-agency working.
| Serious Case Review No: 2014/C5019 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. CHILD D A SERIOUS CASE REVIEW Page 1 of 69 TABLE OF CONTENTS TABLE OF CONTENTS ............................................................................... 2 1. INTRODUCTION ...................................................................................... 4 2. FAMILY COMPOSITION.......................................................................... 4 3. SERIOUS CASE REVIEW PROCESS ..................................................... 5 3.1 Arrangements for the Serious Case Review.......................................... 5 4. METHODOLOGY USED TO DRAW UP THIS REPORT ......................... 6 5. NARRATIVE CHRONOLOGY ................................................................. 8 5.1 Introduction .............................................................................................. 8 5.2 Background .............................................................................................. 8 5.3 Events before the birth of Child D .......................................................... 8 5.4 Events after the birth of Child D ........................................................... 11 6. THE FAMILY .......................................................................................... 12 6.1 Ms E ........................................................................................................ 12 6.2 Mr F ......................................................................................................... 13 7. THE AGENCIES .................................................................................... 14 7.1 Introduction ............................................................................................ 14 7.2 The General Practitioners ..................................................................... 14 7.3 The Community Learning Disability Team........................................... 15 7.4 Maternity Services ................................................................................. 18 7.5 Mental Health Services .......................................................................... 21 7.6 Children and Families Services ............................................................ 25 7.7 Health Visiting Services ........................................................................ 30 7.8 Adults’ Services ..................................................................................... 32 7.9 Dietetic, Accident & Emergency and Acute Paediatric Services ....... 34 7.10 Educational Psychology and Special Educational Needs Services - report for information .................................................................................. 35 7.11 Housing Services – report for information ....................................... 35 7.12 Ambulance Service NHS Trust –report for information. ................... 36 7.13 Specialist child hospital –report for information ............................. 36 7.14 Police – report for information ............................................................ 36 7.15 Health Overview Report ...................................................................... 37 8. ISSUES SPECIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW ..................................................................................................... 38 8.1 Introduction ............................................................................................ 38 8.2 During the pregnancy, could more have been done to assess the mother’s needs and provide her with support? ........................................ 38 8.3 Were the mother’s problems appropriately assessed and addressed across agencies, both recently and when she was in care and a care leaver? .......................................................................................................... 39 8.4 How did assessments and interventions seek to understand and address issues of diversity, including those of ethnicity and disability in particular? .................................................................................................... 40 8.5 Did assessments take into account the mother’s relationships, support networks and their impact on her parenting? ............................. 41 8.6 Did the local authority’s triage arrangements have any bearing on how agencies responded to concerns? What form of triage should have been triggered once concerns were notified? .......................................... 41 Page 2 of 69 8.7 Were assessments appropriately child focussed? ............................. 42 8.8 During Child D’s life before the incident, were communication, support and the assessment of risk effective? ......................................... 43 8.9 On the day Child D sustained the injuries, and subsequently, were there any communication problems between agencies? ......................... 43 8.10 How well did all the agencies involved work together - was there good mutual understanding and communication? ................................... 44 8.11 How effective was management oversight both before and after Child D’s birth? Were concerns escalated when that was appropriate? 45 8.12 What issues are there of support relating to learning disability and mental health concerns in this review? ..................................................... 46 8.13 Are local services appropriately using best practice models for safeguarding unborn and very young babies? ......................................... 47 8.14 Were there any organisational difficulties within or between agencies? ..................................................................................................... 48 8.15 What LSCB quality assurance processes could provide timely overview of services to vulnerable children and parents? ...................... 48 8.16 Where can we identify good practice in this case? .......................... 49 8.17 What outcomes are envisaged from the recommendations from this review? ......................................................................................................... 49 8.18 How can the LSCB ensure that recommendations have an impact? Are there implications for training – single agency and multi agency? . 50 9. SERIOUS CASE REVIEW PROCESS ................................................... 50 10. CONCLUSIONS: THEMES, MISSED OPPORTUNITIES AND LESSONS LEARNED ................................................................................ 52 11. SERVICE IMPROVEMENTS MADE BY THE AGENCIES .................. 55 12. RECOMMENDATIONS FROM THIS OVERVIEW REPORT ............... 60 12.1 Introduction .......................................................................................... 60 12.2 Key theme – working together for the child ...................................... 60 12.3 Key theme - Improving the quality of casework and managing risk to the child. ................................................................................................... 61 12.4 Key theme - Developing good systems that keep children safe. ..... 61 APPENDIX A: brief autobiographical details of the author of this report. .......................................................... Error! Bookmark not defined. APPENDIX B: anonymised Terms of Reference for the SCR ............... 64 APPENDIX C: SCR Panel ......................................................................... 68 APPENDIX D: References ........................................................................ 69 Page 3 of 69 1. INTRODUCTION 1.1 Child D, who was just under three weeks old, was admitted to hospital with multiple serious injuries in October 2012. Medical advice was that these injuries had been inflicted. Child D’s mother, Ms E, a woman in her early twenties, was arrested. 1.2 Ms E was known to adults’ and children’s social care services and to a range of health services, before and during her pregnancy and following the birth of Child D. 1.3 On 08.11.12 the Independent Chair of the Local Safeguarding Children Board confirmed that a Serious Case Review (SCR) should be carried out. This decision was based on the following considerations: • Child D had sustained serious, apparently inflicted injuries. • There were indications of weaknesses in the way that agencies had worked together to safeguard Child D. 1.4 The purposes of SCRs are set out in “Working Together to Safeguard Children1” (Para 8.5). They are to • establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • improve intra- and inter-agency working and better safeguard and promote the welfare of children. 2. FAMILY COMPOSITION 2.1 Ms E lived alone before her baby was born. Her mother and sister lived nearby. The putative father, Mr F, did not live locally but had some contact with Ms E during the pregnancy. 1 Working Together to Safeguard Children (2010) – referred to in this report as “Working Together” – was the government’s statutory guidance on how organisations and individuals should work together to safeguard and promote the welfare of children and young people in accordance with the Children Act 1989 and the Children Act 2004. It has been revised while this review has been in process and replaced by Working Together to Safeguard Children (2013). Agencies drew up their reports before Working Together 2013 was in place. This Overview Report has taken account of changes in the revised guidance. Page 4 of 69 3. SERIOUS CASE REVIEW PROCESS 3.1 Arrangements for the Serious Case Review 3.1.1 Fuller details of the SCR process are set out in Appendix A. It was determined that the following agencies should contribute to the Review. Those agencies with substantial and / or recent contact were required to submit full Individual Management Reviews (IMR) whereas agencies with less or less recent involvement provided reports for background information. AGENCY NATURE OF CONTRIBUTION Children & Families Services Individual Management Review (IMR) General Practitioners IMR NHS IMR / Health Overview Report 2 Maternity Services IMR Health visiting services IMR Dietetic services, Accident and Emergency Services IMR Mental Health services IMR Learning Disability services3 IMR Adult Social Care services IMR Ambulance Service Information report Housing Services Information report Police Information report NHS Foundation Trust Information report Education Services Information report 2 Working Together 2010 (Paragraph 8.30) required that in every SCR the appropriate Primary Care Trust (as was) should draw up a health overview report focusing on how health organisations have interacted together, which will also constitute the IMR for the PCTs as commissioners. This is no longer a requirement. 3 Mental Health Service manages this service now, and has therefore supplied this IMR, but did not do so during the period under review – see Paragraph 7.3.12 below Page 5 of 69 3.1.2 The anonymised Terms of Reference for this SCR are attached at Appendix B. When they were drawn up the key issues for consideration specific to this case were judged to be: • difficulties in Ms E’s early life and her family background, as well as current medical and social problems, and the extent to which agencies understood and took account of these issues. • the nature and quality of the services provided during Ms E’s pregnancy and subsequently. • the quality of the specialised learning disability and mental health services provided particularly in relation to safeguarding of children. • the agencies’ response to the requirement to protect unborn and very young babies. • the quality and effectiveness of joint working across the agencies involved. 3.1.3 The review considered in detail the period from just before the conception of Child D to just beyond the date of the injuries. All agencies were also asked to provide a summary of any previous involvement from the point at which the mother came into the care of the local authority when she was a young person. 4. METHODOLOGY USED TO DRAW UP THIS REPORT 4.1 This Overview Report is based principally on the agency IMRs, background information submitted and subsequent Panel discussions and dialogue with IMR authors. Family involvement is discussed at section 6 below. 4.2 The report consists of • A factual context and chronology. • Commentary on the family situation and their input to the SCR. • Analysis of the part played by of each agency, and of their IMR. • Closer analysis of the specific issues identified in the Terms of Reference. • An outline of service improvements made by the agencies in response to these events and more generally. • Conclusions and recommendations. 4.3 The conduct of the review has not been determined by any particular theoretical model but the review has been carried out in a way that is in keeping with the underlying principles of the statutory guidance, set out in Working Together 2013. The review • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Page 6 of 69 • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight4; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings5. 4.3 The government has introduced arrangements for the publication in full of Overview Reports from Serious Case Reviews, unless there are particular reasons why this would be inappropriate. This has implications for the extent to which certain matters, including some sensitive personal information, can be included in this Overview Report. This report is written in the anticipation that it will be published and has been drawn up so as to preserve confidentiality wherever that is necessary. 4 This review does not rely on hindsight, and tries not to use hindsight in a way that is unfair. It does use hindsight where that promotes a fuller understanding of the events and their causation. 5 Working Together (2013) Page 7 of 69 5. NARRATIVE CHRONOLOGY 5.1 Introduction 5.1.1 This section of the report briefly describes Ms E’s family circumstances and summarises her contact with the agencies involved in this review. Further factual detail is then provided as necessary throughout the report. 5.2 Background 5.2.1 Ms E was known from her infancy to some of the agencies involved in this review, or their predecessor organisations. There is evidence that her childhood was often unhappy and troubled, and that she was abused and neglected. From her earliest days at school it was identified that she also had a number of educational problems. When she was 11 years old a statutory assessment of her special educational needs found her IQ to be within the “moderate learning difficulties” range. 5.2.2 From that age she attended a special school. She made progress there but her situation deteriorated further during her teenage years. Her behaviour became very “out of control” and risky, and she came into the care of the local authority four months before her 17th birthday. 5.2.3 While living in a semi-independent unit managed by a voluntary organisation Ms E became involved in an inappropriate relationship with a senior member of staff, Mr F. This relationship came to light and Mr F resigned in the course of a disciplinary investigation. Ms E was now over 18 years old and no criminal charges were preferred. Contact between Ms E and Mr F continued and he was to become the father of Child D. 5.2.4 The local authority’s Leaving Care Service continued to support Ms E until she was in her early twenties and was living independently. Contact with the local authority then ceased. No onward referral was made to any other agency. 5.3 Events before the birth of Child D 5.3.1 In October 2011 Ms E was referred by her GP to local Learning Disabilities Psychiatry Team (LDPT). She had approached the GP because she had been experiencing anxiety and panic attacks, and had harmed herself. The referral described her as having a “mild learning disability”. She was seen in late November by a psychiatrist (Dr L) who tentatively diagnosed that she had a generalised anxiety disorder, panic disorder and concurred that she had a “mild learning disability”. She was referred on to psychologists within the LDPT for assessment of her cognitive skills. The referral noted that “Her cognitive abilities need to be assessed properly as she looks more capable of doing many things”. Page 8 of 69 5.3.2 A nurse, N1, from the LDPT became involved in supporting Ms E and continued to do so until tests were carried out by a psychologist, P1. From these tests P1 concluded that Ms E’s IQ was “low average to average” and that she therefore did not have a learning disability. The tests were not carried out till late April 2012 – some 6 months after she had been referred - and N1 had a good deal of continuing contact with her during that time. However, on the basis of the IQ tests Ms E was found to be ineligible for services from the LDPT and contact with that team was terminated in May 2012. 5.3.3 In February 2012 Ms E had seen her GP who confirmed that she was in the early stages of pregnancy. A swift referral from the GP to ante-natal services gave details of the difficulties in her childhood, referred to her having “learning difficulties” and noted that she was being seen at the LDPT. The GP and Dr L discussed the situation and decided together that anti-depressant medication (Prozac), which she had taken in the past, should be prescribed for Ms E. 5.3.4 Maternity services responded promptly and continued to provide a high level of direct contact to Ms E throughout her pregnancy. An early referral was made from midwives to their service’s Safeguarding Team. After discussion by the Safeguarding Team, Ms E was categorised by maternity services as “medium risk”. 5.3.5 Ms E contacted the LDPT in April complaining of feeling low. She was seen by N1, who recorded that she was not taking her anti-depressant medication and was “very down”. At this time Ms E said she was looking after the child of her sister who was having another baby. 5.3.6 In mid May Ms E presented to A&E services at a non-local hospital feeling very low and wanting to talk to someone. She was seen by the Crisis Assessment & Treatment Team who were concerned by her presentation but found her mentally stable. She denied any thoughts of self harm or any delusional beliefs about the baby. She described good social support, contact with a community midwife and her GPs, and continuing contact with the father of the unborn baby. She was discharged with notifications made to a range of health services and children’s social care services local to her address. 5.3.7 This attendance prompted correspondence between a range of professionals and services. Dr L, the GP, the Named Nurse for Safeguarding at the NHS Trust and the Named Midwife had discussions about the concerns arising from this contact. Referrals were made to the local authority, the Community Mental Health Team and the Perinatal Mental Health Service (although the latter was not accepted on the basis that it was too early in the pregnancy). 5.3.8 As part of their response the GPs made a referral to the local authority’s adult social care services. Adult Services liaised with various agencies and saw Ms E before concluding that she was not eligible for the services they provided. Page 9 of 69 5.3.9 During May police were contacted by Ms E who reported persistent noise nuisance from neighbours. Appropriate advice about sources of assistance was given. Police were to have no further significant contact before the injuries to Child D came to light. 5.3.10 A Health Visitor, HV1, from the service that would be supporting Ms E after the birth of her child, had picked up the concerns arising from the presentation at the non-local hospital in May. In mid-June she called to see Ms E and was concerned about her presentation and her capacity to care for a child. She also contacted C&F (Children’s & Families Services). 5.3.11 In response to these various referrals C&F now carried out a Core Assessment6 led by a social worker, SW1. SW1 visited once in mid-June – a month after receiving the referral from the hospital and apparently prompted by the referral from HV1. The social worker judged that Ms E’s presentation raised no serious concerns and that there was a strong professional network around her. The outcome of the assessment was that no further action was taken by C&F during the pregnancy. 5.3.12 In June Ms E had her first contact with psychiatric services, as a result of her presentation at hospital in May. A psychiatrist, Dr S, assessed her and concluded that she was not mentally ill but, particularly in view of her pregnancy, decided to see her again in three months’ time. 5.3.13 Between July and September Ms E had continuing frequent contact with maternity services and complied fully with ante-natal care. There were no major problems with her pregnancy but she described “unbearable panic attacks”. It was noted by midwives that she was taking her anti-depressant medication sporadically but there was no contact from maternity services to mental health services or the GPs about this. Throughout the pregnancy Ms D kept in close contact with her GPs. 5.3.14 Ms E was reviewed by Dr S in September. This did not lead to any action other than a further appointment offered in two months’ time. In October Ms E told a midwife that she had not taken any anti-depressant medication since June. The midwife did not take any action in response to this. A week later Child D was born, a Caesarean delivery. 6 Part of the national framework of guidance, a core assessment should be undertaken when an in-depth multi-agency assessment is necessary to understand a child's developmental or welfare needs and circumstances and the parents' capacity to respond to those needs, including the parents' capacity to ensure that the child is safe from harm now and in the future. Page 10 of 69 5.4 Events after the birth of Child D 5.4.1 Immediately after the birth maternity services made a referral to C&F, expressing concern about Ms E’s ability to care for the child. After liaison between health services HV1 made a similar referral, as did a GP. There were a number of discussions between health services and C&F. 5.4.2 Initially C&F were going to conduct a further assessment but then decided that it was not necessary to do so because their Core Assessment, completed only three months previously, did not raise any safeguarding concerns. They decided that the most appropriate response to the current concerns was to make a referral to their Early Intervention Service (EIS). This service would help Ms E develop parenting skills, and would establish a “Team around the Child” (TAC)7. 5.4.3 Ms E and her baby were discharged from hospital three days after the birth and received standard follow up from the midwifery service. Midwives reported no concerns about the care of the baby who was putting on weight, nor about Ms E’s health or presentation or the condition of the home. 5.4.4 Six days after discharge from hospital Ms E took the baby to the GP (GP3), concerned that the baby was constipated, and was given advice. The GP was concerned about Ms E’s ability to cope with the demands of a young baby and, two days later, wrote to the health visitors to that effect. 5.4.5 Two days after that Ms E again went to the GP stating that the child was not sleeping. The GP (GP4) felt that Ms E was not coping well but was reassured when Ms E said that the child’s father would be staying with them that night. 5.4.6 The following day a New Birth Visit was carried out by a Health Visitor (HV2). The Health Visitor’s assessment was similar to that of the midwives – that Ms E was coping adequately with the care of the child, who appeared well. There was subsequently a discussion between HV2 and GP4, in which HV2 advised that she had no immediate concerns from the New Birth Visit. Nonetheless GP4 contacted C&F, learned that the EIS was visiting in three days time and was satisfied with that. 5.4.7 Meanwhile Ms E and the baby attended a group held at a local Children’s Centre at the suggestion of one of the midwives. Staff at the meeting had no concerns for the presentation of mother or child. 5.4.8 The following day, the Friday of that week, Ms E took the baby to the GPs. They were seen by GP5 who noted that the child had a severe nappy rash. The GP was concerned about Ms E’s ability to care adequately for the 7 A multi-disciplinary team of practitioners established on a case-by-case basis to support a child, young person or family. Page 11 of 69 child and contacted HV2. They discussed the situation and the Health Visitor, decided not to take any action that day but to assess the situation at her next visit, which was scheduled for Monday, her next working day. 5.4.9 On the same day, Friday, C&F were making their first post-natal contact with Ms E, through the EIS service. The allocated member of staff, EIS1, spent a long time with Ms E and the baby. She felt that Ms E appeared to be coping. She was observed to cuddle and sing to her baby, though she told EIS1 that she found night times extremely challenging because of the baby crying. EIS1 made a detailed plan for continuing contact with the family. 5.4.10 GP5 remained concerned after the discussion with HV2 and contacted C&F, at the same time that EIS1 was carrying out her visit. On returning from her visit EIS1 responded to a message left by GP5. EIS1 explained that she felt that Ms E was managing adequately. The GP said that she still had concerns and would make a referral to C&F via their designated referral number8. EIS1 advised her manager of this. 5.4.11 GP5 telephoned the designated referral number and was asked to put her concerns in writing (which she did, later that day, after C&F services had closed for the weekend). There was a discussion between teams within C&F about the fact that the GP had used the designated referral number, when a C&F team – the EIS - was already involved, but no further action was taken by C&F that day. 5.4.12 Two days later – the Sunday - an ambulance attended Ms E’s home in response to a 999 call. Child D was taken immediately to hospital and found to have a number of very serious injuries. Ms E told members of staff that she had shaken and hit the baby on the Friday as she would not stop crying. 5.4.13 Police attended. Ms E repeated her admissions and, in due course, faced criminal charges. She was remanded in custody until her case was concluded when a Hospital Order9 was made. Child D is now the subject of a Care Order to the local authority and has limited contact with each parent. 6. THE FAMILY 6.1 Ms E 6.1.1 The extent of Ms E’s vulnerability is captured in the Health Overview Report: “Ms E was a vulnerable woman in her own right. She had been subject to a difficult childhood where she had suffered (multiple forms of abuse). She had been a looked after child. She had a difficult relationship with her mother and was largely unsupported. She had a number of mental health issues including a history of self-harm, bulimia, anxiety attacks and drug abuse. She had a 8 In early 2012 the local authority introduced one direct number for people to call for advice, support or information on a range of services for children and families, and for professionals to make referrals. 9 Section 37, Mental Health Act, 1983 Page 12 of 69 relationship with an older man at a young age… She had some learning disability which left her unable always to understand what people said and with limited reading and writing skills. In every way she was an adult who would need professionals to understand her situation and … help her achieve the best outcome…”. 6.1.2 Ms E presented as a woman who wanted her child and engaged with everybody but agencies did not see the extent of the limitations of her ability to be a parent - each only saw a compartmentalised picture. She was apparently articulate and the extent of her mental health and learning needs was misjudged. 6.1.3 The author of this report and a Panel member visited Ms E in hospital but she refused to see us. Hospital staff reported that she had initially rejected their support and assistance because she believed she should have remained in prison. She was now compliant with medication and recovering. Her mother and sister visited her regularly. 6.2 Mr F 6.2.1 Mr F did not respond to an invitation to meet the author of this report. Page 13 of 69 7. THE AGENCIES 7.1 Introduction 7.1.1 This section of the report examines the involvement of each of the agencies which have contributed to this review, with reference to their IMR. In doing so it deals with a number of the “headline” issues detailed in the Terms of Reference for the review. The final part of this section also summarises the content of the reports received for information from those agencies which did not have recent or substantial contact. The agencies are considered in the order in which they appear in the brief chronology above. 7.1.2 This review has raised concerns about the practice and performance of some individual professionals. These matters are all being addressed through the relevant organisations’ procedures and are not detailed in this report. 7.2 The General Practitioners 7.2.1 During the period under review Ms E and her baby are recorded as having some contact with fourteen GPs, indicating the size of the large practice with which they were registered. Many of these contacts were not significant for the purposes of this report and usually the practice ensured that she was seen by a small number of doctors –in fact on seventeen of her attendances she saw the same doctor. She had confidence in her GPs and used them appropriately. 7.2.2 The Health Overview Report identifies a lack of productive liaison between the GPs and Maternity Services throughout the pregnancy. Despite the GPs making a very full initial referral, there was no continuing liaison. This is discussed further below, in relation to Maternity Services, but the GPs did not follow up the lack of response to their referral. This was a missed opportunity and the Health Overview Report concludes that “there is not a strong pathway for communication between GP practices and the Midwifery Service”. 7.2.3 No concerns arise from the GPs’ direct involvement with the family. Their liaison with mental health and learning disability services was thorough. GP5 persevered with a referral to C&F on the day that the baby was injured, despite the reassurances in the views of the other professionals directly involved. One of the GPs saw Ms E frequently for counselling. The IMR judges that all of the GPs “followed (GMC) guidance and demonstrated a high standard of professionalism”. 7.2.4 The GPs made an appropriate referral to the perinatal mental health service. That was rejected on the basis that it had been made too early in the pregnancy. The GPs might have diarised the need to re-refer when the appropriate time was reached although the mental health services concede that Page 14 of 69 “The way that (our response) was phrased may not have reassured the GP that they were open to a re-referral”. Nonetheless, one would not expect the GPs to be deterred by that. 7.2.5 GP5’s level of concern, when she spoke with EIS1, was sufficient for her to persevere in calling the designated referral number, which was commendable. However the GPs were well placed to challenge the need for more robust safeguarding input from C&F, and the other agencies, from a much earlier point. 7.2.6 There are some similarities with findings from other SCRs: “Some GPs, who were often one of the first points of contact for families, were uncertain about the levels of concern that should have prompted a referral”10. In this case the uncertainty was more about process and how to deal with an inadequate response to a referral. This is a very common finding in Serious Case Reviews. The Board should satisfy itself both that there are well understood arrangements for escalation of difficulties between services to more senior managers and that agencies are regularly reminded of those arrangements. 7.2.7 It is a reality of child protection work – and many other sorts of multi-agency work – that a degree of determination is needed to ensure that partner agencies “pull their weight” and play an appropriate part in joint arrangements. Procedural agreements often do not automatically swing into action. There were increasing numbers of agencies involved here and a clear need for those agencies to get round a table and talk about this situation. The GPs had the best overview of all the services involved, were best placed to demand a more coherent response and had the professional authority to do so. 7.2.8 Lessons learned from this review have been incorporated into training arrangements in local primary care provision. The IMR author has advised that “GPs will be urged to make their language very clear and realise that they are dealing with professionals who often do not have their understanding of medical issues and who will need to have the exact cause of their concerns spelt out both clearly (and) robustly”. During the past year the Designated Doctor and Named GP have sought “Section 11 audits”11 from GP practices in the borough. 7.3 Community Learning Disability Team 7.3.1 Ms E was first seen by the LDPT in November 2011. She was assessed by a Specialist Registrar in the Psychiatry of Learning Disability, Dr L. Dr L’s assessment was thorough except that it did not go so far as to include any subsequent enquiries with other agencies about Ms E’s childhood experiences. It concluded in a diagnosis of generalised anxiety disorder and 10 Learning lessons from serious case reviews 2009-10 (Ofsted) 11 Section11 of the Children Act 2004 places duties on a range of organisations and individuals to ensure their functions – and any services that they contract out to others – are discharged having regard to the need to safeguard and promote the welfare of children. Page 15 of 69 panic disorder, with a request for the service’s psychologists to assess whether Ms E did have a learning disability. 7.3.2 She was next seen by the service for a routine follow up three months later. At this consultation a nurse, N1, was also present as a chaperone. This nurse was to become closely involved in supporting Ms E, seeing her 13 times, supporting her in attending appointments and generally liaising with other professionals. Dr L and N1 demonstrated a continuing commitment and concern for Ms E throughout their involvement. 7.3.3 By now Ms E was pregnant and the GP had as a result ceased to prescribe Prozac. Dr L, in conjunction with the GP, decided to re-start this medication as it was felt that there was a high risk that she might become depressed again. She mentioned that she was receiving counselling from one of the GPs and Dr L ensured that the psychologists were aware of this. 7.3.4 A psychologist, P1, saw Ms E in April, 5 months after Dr L’s referral, and assessed her. The service did not have target timescales but 5 months was clearly an unacceptable delay, compounded by the fact that it then took the psychologists a further six months to produce a written report of that assessment. No explanation for these delays has been provided. The assessment concluded that Ms E did not have a learning disability. 7.3.5 This was fed back verbally to Dr L and subsequently to Ms E herself some days after the assessment. Soon after that Ms E presented at A&E, which led to a number of referrals and communications between services. Among those was the referral by Dr L to mental health services. The LDPT remained involved, principally through the supportive role of N1, until Ms E had her first contact with the mental health services in June. The service then withdrew. 7.3.6 The first issue arising from this account is the determination of whether Ms E was eligible for services from the LDPT. The review has established that the assessment tool used by P1 had been devised many years ago and that the British Psychological Society has described it as “dubious”. In particular the IMR suggests that it can lead to an inflated assessment of IQ, by as much as 20 points. “The worldwide accepted tool is the Wechsler Intelligence Scale (WAIS 1V)… The WAIS is seen as the “gold standard” assessment tool and should have been used”. 7.3.7 The consequences of this flawed assessment were very serious. The IMR in respect of the mental health service comments “If she had been diagnosed then a Multi Disciplinary Team approach including, psychology, psychiatry, care manager and allocation of a support worker would have been instigated… they would continue to support Ms E attending antenatal clinic appointments, arrange a visit to the unit with the safeguarding midwife, be present at the birth and consider whether a Mother and Baby Unit may be appropriate to assess her ability to parent”. Page 16 of 69 Ms E lost that support, and the support from other services to which it might have led, on the basis of that assessment. 7.3.8 There is no reference to social care services, either children’s or adults’ services, in the list quoted in the previous paragraph. In fact it seems that the psychologist had proactively advised C&F in May of the outcome of the assessment and had highlighted Ms E’s vulnerabilities. It was appropriate to share the information about a vulnerable and pregnant young woman but it is unclear exactly what the psychologist expected or intended to happen as a result of this notification. 7.3.9 This account raises concern, not just about P1 using the “wrong” test and that this was not identified within the agency (which has confirmed that use of this testing method has been discontinued). More broadly it is of concern that service arrangements are allowed to turn on that one factor. One cannot be reassured from the IMR that this might not happen again – so that if a service user now just failed to meet the required “score”, even using an appropriate assessment model, this could still lead to a withdrawal of services. 7.3.10 In that respect the locality is not unusual and this problem could have arisen in other localities. The Panel was told that the same arrangements apply in all learning disability services across the region. But this is out of line with an underpinning principle of the national arrangements for the provision of health and social care services – that a “person centred” approach should be used in which assessments should be led by the needs of the service user not by the way services are arranged. 7.3.11 Other concerns are raised by another comment in the IMR: “Team dynamics within the LDPT are reported to have been difficult over the last decade; this was described as a power struggle between psychiatry and psychology”. 7.3.12 That discord will not have been diffused by repeated changes in the management arrangements for health services. The LDPT had been initially managed by the local Primary Care Trust. Management was transferred to the Health Trust in April 2011. In 2012 (after the injuries to Child D), management was transferred to the mental health service. “The service went out to tender half way through the financial year 2011-2012 and the Mental Health Service was awarded the contract. The staff were facing their third transfer in less than 18 months with all the associated new reporting and management lines”. 7.3.13 Despite the commitment of the doctor and nurse involved, concerns arise about the overall management and quality of this service. The IMR indicates the need for a more searching and far reaching review of the way this service operates and that is echoed in this report. The work carried out should include arrangements to address the issues arising from this review, namely: Page 17 of 69 • Assessments which do not result in a comprehensive, multi-agency approach, particularly where children may be involved. • A lack of clarity about roles and what “support” really means. • Arrangements for psychological assessment and responding to the outcomes of these assessments. • Overall management of the service with particular reference to how well disciplines work together. The SCR Panel was told that these issues are accepted and addressed in the Action Plan arising from this review. 7.4 Maternity Services 7.4.1 “Throughout her pregnancy Ms E engaged well with maternity services and never missed an appointment”. That comment from this agency’s IMR captures the extent to which maternity services at the local hospital, like many of the services involved in this review, failed to differentiate between engagement and purposeful engagement. This IMR also draws out an absence of professional curiosity by the midwifery service – which recognised Ms E’s vulnerability and increased its own involvement without pressing for the involvement of other services, from both health and social care. 7.4.2 Ms E’s pregnancy was identified at an early stage, and the response of the two agencies involved was good: “She went to her GP at five weeks gestation and was booked at almost 8 weeks gestation. This is an example of good practice as the GP had flagged up that she was vulnerable and the service responded well by providing an early booking appointment to ensure appropriate referrals and support could be put in place”. 7.4.3 Ms E was always entirely open about her involvement with other services. At her first appointment she spoke of having a “Support Nurse” – the Learning Disability Nurse who subsequently accompanied her to maternity appointments until the LD service withdrew – but this did not prompt the midwives to liaise with that service or even enquire as to who they were. 7.4.4 This insularity characterises the input from maternity services. They recognised Ms E’s vulnerability at once and, unusually, decided to see her every week (when a standard level of contact would be 10 visits over 40 weeks for a first time mother). However they did not see the opportunity, or necessity, to involve other services. At this early point the midwives could have used the Common Assessment Framework12 (CAF) as the most 12 The CAF was established by the former Department for Children, Schools and Families. It is described as “a standardised approach to conducting assessments of children's additional needs and deciding how these should be met…The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development”. Page 18 of 69 appropriate way of drawing together a multi-agency approach to the situation but this was not apparently considered. 7.4.5 There was a referral by the booking midwife to the service’s “Vulnerable Women and Safeguarding Team”. The review team heard that this meeting can provide a useful screening function, as it considers a large number of potentially vulnerable women. However the referral here led only to a discussion at a poorly attended meeting, reviewing a number of cases. From that meeting the Safeguarding Midwife was to liaise with mental health services but her liaison was ineffective: “the Safeguarding Lead Midwife reports that she spoke to someone in mental health who knew about Ms E but was unable to clarify the position that Ms E was in”. In fact, at this point Ms E was not yet in contact with mental health services. 7.4.6 In any event this meeting made a fundamental error in deciding that Ms E was not classified as a “high risk” case. By doing so the pattern and content of her ante-natal care was altered. This also gave an inappropriate message of reassurance to the midwives who were supporting her on a weekly basis. The Health Overview Report confirms that weaknesses around the Vulnerable Women’s Team are not restricted to the events under review here: “the … role, referral criteria or membership (of the team)… has not been clarified. It is uncertain how well this team integrates with the clinical team managing the case and how they access the records particularly if they are working from community bases”. 7.4.7 A picture of confusion in this service is demonstrated in the service’s own analysis of these events: “The Safeguarding Lead Midwife also referred Ms E back to Community Midwifery care with no further actions... The midwives however, were unaware of this referral back to them, although they received a document that suggested they should ask about her mental health at every visit which they were doing and did not understand what this document was or take any further significance from it”. 7.4.8 The midwives displayed a lack of thoroughness in their approach to Ms E’s use of medication throughout the pregnancy. They recognised that she was taking it only sporadically, if at all, but this was not followed up. “It was an omission on the midwives’ part not to discuss this directly with the GP, the Safeguarding Lead Midwife or the psychiatrist for a more robust multidisciplinary plan of care”. 7.4.9 The IMR identifies a reactive and unimaginative approach, even in response to quite worrying presentations: “when Ms E reports that her panic attacks are unbearable the midwife advised her to speak to her GP as she had an appointment in 2 days’ time … and the GP could assess if she required urgent referral. Ms L had (already) … reported regular liaison with the mental health team. This was a missed opportunity for the midwife to liaise personally …with both the GP and the mental health team (or to liaise directly) with the Named Midwife for Safeguarding”. Page 19 of 69 7.4.10 There are worrying indications of a disorganised approach which lacked management “grip”: “two midwives believe they have imparted information about this case by communicating in a corridor or via the telephone to the Safeguarding Lead Midwife while the recipient of the information was busy with something else”. 7.4.11 The IMR identifies but does not explain what appears to be a fundamental error in the midwives’ routine contact with Ms E. Although they were aware of her contact with mental health services, they failed to ask the “Whooley questions13” at each visit. In fact the dynamic seems to have been that the midwives believed that because a more specialist service was involved they were excused from asking questions and playing their part in a joint approach. 7.4.12 When the baby was born the reality of the problems Ms E was going to experience finally seemed to have been recognised by health agencies. There was considerable liaison between community health and social care services and the Safeguarding Lead Midwife registered her concerns by submitting a CAF form. 7.4.13 Many agencies have recognised that it was not easy to assess Ms E, whose presentation did not fall neatly into any “bracket”, and who certainly did present at times as more coping and capable than may have been the case. The midwives did not register any particular concerns in their post-natal contact: “The midwives reported that Ms E was doing well and caring for her baby appropriately. The home was reported as being relatively clean and tidy, the baby was clean and fresh looking, appropriately dressed for the weather”. 7.4.14 By that time however a fixed view of Ms E’s capacity, and the roles of other agencies, seems to have led the midwives’ approach to the case. This was a significant failure. The midwives had the greatest and most regular contact with Ms E and were best placed to anticipate the problems which would arise. However there is no sense, particularly during the ante-natal period, of the midwifery service understanding that they were operating in a multi-agency system. 7.4.15 It is difficult to gauge from the IMR the extent to which these problems indicate underlying weaknesses in the quality of the service. However there is little to suggest that they are not deep-lying and might not recur. The fact that some of the weaknesses are directly linked to the role of the professional who ought to be best placed to identify them – the safeguarding lead – is a particular cause for concern. Equally however there seems to be an inappropriate expectation that other members of staff are excused from safeguarding responsibilities because this role exists. Moreover it is not clear that this role is adequately resourced and managerially supported. 13 A common method of screening for post-natal depression using standard questions. Page 20 of 69 7.4.16 These findings are echoed in the Health Overview Report. They are serious and are said to be entrenched. It is not clear that those problems have been recognised and well understood by the service. They may also be found in the area of a neighbouring local authority which is also covered by this service. 7.4.17 The SCR Panel was particularly concerned about this service. While there were weaknesses in the involvement of all key agencies, the reports from the other agencies responded more purposefully than was the case for maternity services. Panel members reported that they were not aware of any indication of maternity services responding positively to the issues arising from this case. In fact the LSCB Manager and the Designated Nurse for Child Protection specifically reviewed14 maternity services at the local hospital in June 2013, in the light of the emerging lessons from this review, and felt that there was still clear evidence of cause for concern. These concerns have been highlighted to the most senior staff at the hospital and to the relevant Clinical Commissioning Group, and are reflected in the recommendations from this report. 7.5 Mental Health Services 7.5.1 This agency has submitted an incisive IMR which identifies and addresses serious weaknesses in their service to Ms E. 7.5.2 Her first contact was with the Increased Access to Psychological Therapies (IAPT) service as a result of a referral from her GP in August 2011. The IMR explains that this service is “part of the NHS national strategy to improve access to psychological therapies for people with depression and anxiety disorders …and… delivers evidence based interventions defined by the National Institute for Clinical Excellence (NICE) as effective for these conditions, especially cognitive behavioural therapy”. 7.5.3 She was accepted by the IAPT service and placed on the treatment waiting list on 17/10/ 2011. On 21/3/12 it was decided that “Step 3 IAPT” intervention, an intensive service, was appropriate. It is not clear how the service took five months to decide that intensive input was necessary. There were then some unavoidable delays in making contact with her, before she was seen by an experienced psychologist in May 2012. 7.5.4 After that one contact she was discharged from the service because other services, including mental health services, had now become involved. That may have been an appropriate decision although it is not clear what communication there was between services, if any, before the decision was reached, nor what information, if any, was shared with other services such as 14 This was part of a statutory “Section 11 audit” - Section 11 of the Children Act 2004 places a statutory duty on key persons and bodies to make arrangements to ensure that in discharging its functions, they have regard to the need to safeguard and promote the welfare of children. Page 21 of 69 C&F. Overall the delay in response rendered this an entirely ineffectual intervention. 7.5.5 Ms E was referred to the Community Mental Health Team (CMHT) by the Learning Disability service as an urgent case on 17/5/12 following her presentation at A&E. She was offered an appointment on 21/6/12. This is again an unacceptable delay in response to an urgent referral. A Clinical Director at the Trust has advised that she would have expected the service to respond, at latest, before the end of the working week in which the referral was received. 7.5.6 Ms E did attend that appointment and saw a psychiatrist, Dr S. He took the view that she had no active mental health problems. He was aware of her troubled background but “had no concerns that these contextual issues had a possible negative impact on her mental state or ability to cope with a baby”. No treatment was judged necessary but Dr S offered another appointment in three months time. 7.5.7 Dr S shared this information with his Consultant Psychiatrist, Dr P, but there was no formal supervision in which the decision or the overall response was considered. Ms E attended the next appointment, from which the only outcome was the offer of a third appointment in two months. By that time Ms E was in custody. 7.5.8 The IMR identifies the range of weaknesses in this intervention. There is no indication that the following matters were considered. • Social isolation and its possible impact on her pregnancy and capacity to parent her baby. • Recent presentations to A&E and risk of self harm. • The possible need to involve adult social care services or C&F. • An appropriate medication regime, taking account of her recognised non-compliance. 7.5.9 Furthermore there was no • in depth history taking as part of the formulation of problems. • risk assessment (on the electronic record or the case file). • overall assessment looking at areas of functioning and social network. • history noted on the electronic record. • evidence that the contact with A&E that led to an urgent referral had been considered. • evidence of consideration of discussion with maternity services, the Safeguarding Midwife or the Perinatal Mental Health Service. 7.5.10 The IMR notes that the psychiatrist’s mental state examination “does not mention a learning disability. Nor does it identify Ms E as vulnerable in terms of her history of self harm, social isolation in the context of pregnancy. The psycho-social issues were not robustly recorded during the first assessment although he was aware and considered them. The emphasis Page 22 of 69 and responsibility was placed on Ms E to tell services, when she delivered her baby, that she was known to mental health services”. 7.5.11 The key weakness in this psychiatrist’s assessment was the failure to recognise the complex nature of Ms E’s situation and the consequent need for a multi-disciplinary approach. That would have been provided by the Care Programme Approach (CPA), the national arrangements for responding to complex mental health needs, which provide for a well-structured multi-disciplinary approach. If needs are less complex services are delivered by the Lead Professional Care (LPC) system where a single professional manages the patient’s care. 7.5.12 In this case the clinician judged that the LPC system was appropriate. The failure to implement CPA arrangements is concerning. It seems that the psychiatrist conflated a finding of “no active mental health problems” with a view that no other actions or services were necessary. That was a serious weakness in the doctor’s assessment. 7.5.13 As discussed above Ms E had also been referred by her GP to the Perinatal Mental Health service. That referral was rejected because she was only nineteen weeks pregnant whereas the eligibility criteria for the service require that a pregnancy has at least reached twenty-eight weeks. The response was not unhelpful – it appropriately suggested a pre-birth planning meeting which the Perinatal Mental Health service would attend and was copied to C&F and the Mental Health Service. However it left the onus to re-refer on the GP or those other services. That reactive approach to service delivery could be improved, as the IMR suggests, by arrangements to keep referrals “pending” and regularly review them. The service has already made changes to do so. 7.5.14 The report also refers to problems identified in arrangements for recording, saying that it had been “a challenge to understand how teams worked … The Trust expectation is that all notes: letters, referrals and progress notes are uploaded and written on JADE (electronic recording system). It would appear that, prior to June 2012, the doctors in the service did not regularly update JADE directly. Rather progress notes would be written and scanned or there was a separate case file created”. The Trust’s action plan from this review addresses this issue. 7.5.15 In trying to understand the factors leading to this weak assessment the IMR draws out key issues. Underpinning the overall weakness of the psychiatrist’s assessment and follow up were • an over-reliance on medical diagnosis to guide further action. • a failure to appreciate the need for collaboration with other services. • a failure to think beyond the individual patient and see her in the context of family and community. 7.5.16 Insufficient thought was given, in particular, to the pregnancy, its consequences for the general pressures Ms E felt under and even the Page 23 of 69 potential consequences of the pregnancy for medical diagnosis and treatment: “In July 2009, Social Care Institute for Excellence (SCIE) published a guide entitled “Think child, think parent, think family: a guide to parental mental health and child welfare” to help services improve their response to parents with mental health problems and their families. This document was updated in 2012. There would be an expectation that clinicians would be able to identify the need for additional support or assessment for parents”. 7.5.17 The IMR puts these difficulties in context, explaining the consequences of yet another major reorganisation of services and their management between 2011 and June 2012. This made significant changes to some employees’ life at work and met with some resistance and unrest. There may have been some consequences for the management of this individual case: “The assessment and feedback meeting had ceased for a period during this change so there was no formal opportunity outside of supervision or informal contact for cases such as this to be discussed. A structure to discuss cases and request a care co-ordinator to support a service user is now part of the way that the Recovery Teams deliver services”. 7.5.18 The report relies on the restructuring and revised management arrangements to tackle the problems which it very clearly identifies, detailing changes to line management and professional supervision, training and communications. The IMR makes appropriate recommendations but the Board will need to be reassured of their effectiveness. Page 24 of 69 7.6 Children and Families Services 7.6.1 This service was significantly involved with Ms E from infancy. It is hard to imagine a more difficult and unhappy upbringing, which was marred by parental rejection, depression and multiple forms of abuse. “By the time Ms E was 9 years of age she had stopped eating, had intermittent enuresis, and was described as exhibiting ‘odd’ behaviour although articulate of speech”. The reference to her being “articulate of speech” is important. It indicates that, from an early age, there were features of Ms E’s presentation which might give a misleading impression of her abilities – and that this information would have been available from a thorough reading of the records. 7.6.2 Throughout her childhood there was substantial but disjointed input from C&F. “Case files make reference to approximately 20 referrals being made to C&F between 1988 and 2001. During this time the case was open to C&F for long periods”. As she grew older the situation deteriorated: “In 2004 the family situation was in crisis, Ms E refused any support or to engage in any mental health assessment ... She was placing herself at serious risk by running away and establishing damaging relationships where others would abuse her…(she) was aware that people were taking advantage of her (but)… she stated that this was what she wanted”. 7.6.3 When she was in her late teens she came into the care of the local authority by agreement. At first there was a pattern of apparent improvement in the situation, with her seeming more happy and settled, followed by deterioration where she would “abscond, neglect her self-care; speak of suicide and again present as vulnerable”. However, the stability and support offered by C&F and other services gradually seemed to take effect and, by the time she was 18, it was judged that she was “positive, honest, open, polite, mature and happy”. 7.6.4 She moved at age 18 to live in a semi-independent setting with limited support, commissioned by the local authority from a voluntary agency. That support was led by Mr F who, as described above, had a sexual relationship with her. Case records indicate that Ms E was very upset when this came to light and she spoke of missing Mr F. There was evidence of self-harm. Educational and employment placements failed. 7.6.5 However in 2009 she secured her own tenancy and it was felt that the situation had improved: “The social worker at the time reported that Ms E had settled well into her home and had good independent living skills and the necessary support in place”. The “support” mentioned appears to have been the support offered by her family and in particular her mother. It is not clear what if anything, professionals knew of her continuing relationship with Mr F. Page 25 of 69 7.6.6 C&F became involved again eventually as a result of Ms E’s presentation at A&E in May 2012. This was soon after they were sent the letter detailing the outcome of the psychological assessment. This letter had not led to any action within C&F. C&F were notified of the A&E attendance by a direct referral from the hospital on 14/5/12. Also, on 24/5/12, a referral made by GP2 to the council’s adult safeguarding service was copied on to C&F. A social worker, SW1, was allocated to carry out a Core Assessment15. On 13/6/12 a Health Visitor who had proactively responded to notification of the hospital attendance contacted that social worker, who had not yet been to see Ms E. 7.6.7 The very fact that she had made contact immediately after her visit indicates that the Health Visitor had concerns about the situation and we know now that she did indeed have what is described as a “gut concern”. However she may not have communicated that sufficiently clearly. Certainly the eventual assessment by SW1 seems to have focussed on the more encouraging aspects of the contact. The IMR reports from C&F records that “The health visitor reported that she had no concerns about the home environment and Ms E showed no signs of depression during her visit” but does not refer to the lingering concern which had prompted the Health Visitor to initiate the contact. 7.6.8 SW1 visited Ms E the day after being contacted by the Health Visitor. This was a month after the presentation at hospital and subsequent referral to C&F. This was not an urgent matter, in that it was a pre-birth referral, but there is no indication of why there was a delay of a month before any action was taken. There is no indication that the social worker was liaising with other agencies, or exploring the history of the case, in preparation for the visit, and it was not a visit by appointment. It appears that the social worker was prompted to visit by the Health Visitor’s contact – the visit was arranged by telephoning Ms E after the discussion with HV. SW1 based the content of the assessment on that one visit and speaking to GP1 – who knew Ms E particularly well and had been seeing her individually. 7.6.9 Ms E told the social worker about her depression and recent suicidal thoughts. She described noise nuisance and general difficulties she had with her neighbours. The GP expressed concern about her depression and the fact that she was not taking prescribed medication. The analysis in the Core Assessment also reflected what was judged to be a poor relationship between Ms E and her mother. 7.6.10 Nonetheless the assessment concluded that there was no need for continuing involvement by C&F, emphasising that a strong professional network would support Ms E and commenting on her “excitement, commitment and understanding of the skills needed to care for the baby”. The Panel heard that it was around this time that the Early Intervention Service (EIS) was being established and a referral to that service might have 15 A detailed assessment carried out under the Framework for the Assessment of Children in Need – statutory guidance now superseded by Working Together to Safeguard Children (2013) Page 26 of 69 been appropriate at that point. However the case was closed by C&F and there was now no significant involvement from them until the birth of Child D three months later. 7.6.11 After the birth midwives, doctors and health visitors all expressed concerns about Ms E’s capacity to care for the baby and wanted C&F to become involved. C&F initially agreed to assess the situation. Then, taking account of what they regarded as a recent Core Assessment, there was a decision that there was no need for a further social work assessment but that there should be input from the EIS. This service would support Ms E in developing parenting skills. “An email …from C&F to the health visitor outlines that Ms E is likely to need robust support from all agencies and that this would be achieved through a multi agency Team around the Child plan devised by the EIS”. 7.6.12 The IMR is thorough in identifying weaknesses in the way in which C&F dealt with this case and the lessons arising from that. The problems stemmed principally from the inadequacy of the Core Assessment conducted in May / June. The fact that C&F had chosen to carry out a Core Assessment was significant – they could have undertaken a less exhaustive Initial Assessment16, or suggested to referring agencies that an assessment under Common Assessment Framework17 arrangements was appropriate in the first instance. Yet the service chose – appropriately - to carry out a Core Assessment, theoretically the most “in depth” intervention, indicating that they were alert to the fact that agencies’ concerns were high. 7.6.13 The evidence base for the subsequent assessment was insufficient – one visit, discussions with a Health Visitor who had seen Ms E once, and then a GP – both of whom expressed concerns about the situation. It is not clear what reference, if any, was made to records of previous C&F contact. The social worker appears to have significantly misjudged Ms E’s own capacity and to have under-estimated the difficulties facing any new parent. 7.6.14 The assessment itself was, as summarised in the IMR, “optimistic and did not fully appreciate the significant history and complexities relating to the family dynamics”. This was Ms E’s first pregnancy. She had a personal history which should have raised concerns for any professional. There was recent evidence of mental fragility in Ms E herself and wider problems, including child care concerns in relation to other family members. 16 A brief assessment of a child referred to children’s social care services to determine whether the child is “In Need”, the nature of any services required, and whether a more detailed Core Assessment should be undertaken. 17 The CAF was established by the former Department for Children, Schools and Families. It is described as “a standardised approach to conducting assessments of children's additional needs and deciding how these should be met…The CAF promotes more effective, earlier identification of additional needs, particularly in universal services”. Page 27 of 69 7.6.15 SW1 seems to have given insufficient weight to Ms E’s troubled childhood and the extensive contact with services but to have based the assessment on • a false and unevidenced optimism about her capacity to care for a baby for the first time • an assumption, made without adequate investigation, that other services were significantly involved in supporting Ms E. In sum the assessment failed to meet the fundamental requirements of such an assessment, as described in the local Child Protection Procedures: “The core assessment must provide a rigorous analysis of the child’s needs and the capacity of the child’s parents to meet these needs within their family and environment. Based on this analysis the key questions to be answered are: • What is likely to happen if nothing changes in the child’s current situation? • What are the likely consequences for the child? ” 7.6.16 An issue emerging repeatedly from SCRs is the failure of services to take adequate account of historical factors. In this case those factors were relatively recent and clear. It is also of concern that such a weak assessment should have been judged adequate by this social worker’s manager. The local Child Protection Procedures require that “A local authority children’s social care manager must approve the outcomes of a core assessment”. The basis for the unquestioning management decision in this case is not explained. 7.6.17 The significance of this misjudgment is compounded because it became the basis for the decision by C&F not to become involved immediately after Child D was born, despite the concerns expressed by other professionals. Whatever SW1 and his manager may have thought about Ms E’s potential parenting capacity three months previously, this was a new situation and should, without question, have prompted a re-assessment. 7.6.18 It is not clear why C&F managers took this view. They had the discretion to decide to re-assess. A “common sense” approach would suggest that the easiest thing to do, as well as the most appropriate, would be to go and see the family. Any process of management overview of the decision not to re-assess was clearly ineffective. 7.6.19 The IMR notes organisational factors which provide a context for understanding the dynamics of this decision-making: “in October 2012 there were some organisational issues (including)… an increased work load and it is evident that there was some lack of confidence in decision making. The EIS was a relatively new service and it appears that during the implementation of this new model there was a lack of clarity in respect of thresholds”. However there is no evidence that this specific decision was particularly linked to high levels of demand and workload pressures at that time. Page 28 of 69 7.6.20 The failure to re-assess or to give adequate weight to the concerns of health professionals led C&F in the wrong direction. Assuming that Ms E was going to be able to manage, their response lost urgency. It was not until mother and baby had been at home for two weeks that the EIS saw them. Like many other professionals, most of whom were more experienced and better professionally qualified than she was, EIS1 misjudged Ms E’s capacity to care for the baby. That misjudgement turned partly on Ms E’s presentation – we know that in some ways she presented as more capable than was the case. EIS1 may also have been reassured by the very fact that her service was dealing with the case – as they were not a “high end” child protection service, there may have been a degree of self-fulfilling prophesy; she may not have expected to be faced with a parent who was going to find it unusually difficult to manage a new baby. 7.6.21 This situation might have been avoided if EIS managers had more carefully evaluated the referral from their colleagues. This should have identified that the level of need indicated that this was not an appropriate referral for them to manage as the primary case holders. It would have been more appropriate for the EIS to work alongside a qualified and experienced colleague, who would be principally responsible for overseeing any child protection concerns. 7.6.22 By its own lights the contact from EIS1 was thorough: “The initial assessment undertaken by the EIS worker …was very child focussed and covered various aspects and factors from practical topics and advice such as the importance of registering the birth, Ms E’s pet being kept away from the baby, discussion about tummy time, face to face talking with baby, how to stimulate a new born and attachment. The EIS worker also discussed and offered strategies around the sleep difficulties and what different baby cries mean”. 7.6.23 However this assessment and immediate advice, despite its strengths, was being offered in a vacuum, without adequate reference to the history or to the input from other agencies. Two weeks after the birth was too long to wait before Ms E and the baby were seen by C&F although that time had offered an opportunity for agencies to co-ordinate their interventions. It would have been appropriate for C&F to have responded to the concerns of other agencies by taking a lead role and organising a meeting of the various professionals involved but they did not recognise the need to do so. 7.6.24 The final involvement of C&F, prior to the injuries to the baby, was the response to the GP’s contact via the designated referral number. The response itself from the Children’s Access Team (CAT) was inadequate – effectively making a record and asking the GP to submit a written request. Instead, as the local Child Protection Procedures indicate, at the end of the discussion both parties - the referring agency and C&F - should be clear about proposed actions, who will be responsible for those actions and when they will be carried out. C&F services appear to have become sidetracked into an issue about the process of making and receiving referrals and whether or Page 29 of 69 not the designated referral number should be used, rather than analysing sufficiently clearly the content of the referral. 7.6.25 A more proactive approach at an earlier point that day could have avoided these difficulties. EIS1 had made her manager aware of the GP’s concerns and that the GP intended to make contact via the designated referral number. Knowing that the GP had continuing concerns the manager might have contacted a colleague in the CAT to agree how C&F services overall could best respond to the GP’s continuing concerns, and might then have contacted the GP directly so as to pre-empt a new referral via the designated referral number. 7.6.26 The SCR Panel closely examined the arrangements for the designated referral number. The local authority introduced this system to make the process of referral simpler and swifter. The Panel heard from some agencies that there had been problems of slow response times from the designated referral number. In this case issues relating to the designated referral number were not significant - the key problem was not the “front door” but that agencies did not escalate their continuing concerns to more senior officers in C&F. During the extended period it has taken to complete this review the local authority reports having made substantial improvements to this service. Nonetheless it is right to reflect the concerns raised and the Board will wish to be reassured that the designated referral number arrangements are providing a reliable and efficient “front door” to the service for both public and professionals. 7.7 Health Visiting Services 7.7.1 The Health Visiting service’s first contact was ante-natal when a health visitor, HV1, proactively visited upon receiving notification of Ms E’s presentation at A&E in May. “HV1 reported that on the surface Ms E seemed to have everything under control (but) she had a gut instinct that Ms E was not as capable as she seemed”. HV1 had planned to liaise with the GPs and midwives after her visit but did not do so. 7.7.2 It was good practice by HV1 to make this contact although, as the IMR points out, she should not have needed to rely on “gut instinct” in respect of a young woman who “was known to have depression, to self- harm, suffer from anxiety and learning difficulties… and had been feeling suicidal”. 7.7.3 Moreover, although Ms E spoke about her contact with mental health services, HV1“did not observe any signs of depression when she visited her (so) she did not consider her depressed and therefore appeared to dismiss any concerns in this area”. The concerns raised by this are heightened because we know that Ms E told HV1 that she had not been taking her prescribed anti-depressant medication but HV1 took no action. This was a proactive visit by HV1 but the failure to analyse and respond to her concerns and then to liaise fully with other services undermined its value. Although the subsequent Core Assessment by Page 30 of 69 C&F was inadequate, the referral from HV1 could have been more specific and clear in the concerns raised. 7.7.4 A few days after Child D was born HV1 was informed of the birth by another Health Visitor, HV3. HV3 had been the Health Visitor for Ms E’s family when she, Ms E, was a child and knew the family well. HV3 told HV1 that she was gravely concerned about Ms E having responsibility for a baby. HV3 liaised with C&F and made a referral to them. It is unclear why and how HV3 became aware of the situation. The “proper” route should have been a formal handover from the midwives but the Health Overview Report tells us that: “There is no evidence that the Health Visitor received a comprehensive handover of all the concerns from either the Maternity Service or the GP which should have occurred in all cases but particularly when there are so many vulnerabilities”. 7.7.5 When Child D was two weeks old another Health Visitor, HV2, carried out the New Birth Visit18. The home was clean and tidy. Ms E spoke openly about her involvement with other services. The baby appeared relaxed and calm and Ms E was seen to be smiling and making eye contact. HV2 gave routine advice and confirmed that Ms E knew where to get help if things became difficult at any time. 7.7.6 HV2 did not ask to see the baby undressed. The IMR notes that this was in line with current practice locally where the responsibility for that aspect of the overall assessment lay with the midwives. The IMR suggests that this should be a key part of the Health Visitor’s New Birth Visit: “Seeing the baby naked not only allows the HV to have a base line on the child’s skin condition, it allows them to observe how parents handle their babies and comfort them as they undress and dress them”. This change has already been implemented by the service. 7.7.7 The Health Visiting service therefore had only one direct contact with Ms E and Child D post-natally. However the IMR points out that “There were a series of assumptions made by HV2 during her home visit which resulted in an inaccurate assessment of Ms E’s and her baby’s needs; and an inadequate risk assessment for Child D”. HV2 assumed that • Child D’s father was supportive. • Ms E was physically well – though she was recovering from a caesarean section. • Ms E was caring for herself and eating regularly – though the HV did not physically check whether there was food in the home. • Ms E was less intellectually disabled than was in fact the case – a common error identified in this review. • Ms E had other family supports. • Ms E was well organised and managing a demanding set of arrangements for contact with a range of services. 18 A universal service to all newly born children in the UK, where advice is provided on, for example, feeding, weaning and general care. Page 31 of 69 The IMR points out the lack of evidence on which to base these assumptions and makes the point that there was no “assessment of Ms E’s emotional resilience and how she would cope with a newborn baby whose cry could be piercing and relentless”. 7.7.8 This reflects a continuing theme of professionals taking an over-optimistic view of Ms E’s abilities in the face of compelling evidence to the contrary. HV2 acknowledges that she should have ensured that she was more fully informed about Ms E’s background and vulnerabilities, although it is clear that she had been briefed on this by HV1. 7.8 Adults’ Services 7.8.1 This report deals initially with Ms E’s contact in 2006/7 with the man who was to become the father of Child D. That exploitative relationship further confirms the vulnerability of Ms E. 7.8.2 For the purposes of this review Adult Services’ involvement started from a written referral from her GP in May 2012. That referral arose from her presentation at the non-local A&E earlier in the month, which led to a flurry of activity across all agencies. The GP’s referral was addressed to “Safeguarding Adults” and describes her as a vulnerable pregnant woman in need of additional support. The response to the referral came from the Adult Services Reablement Team. 7.8.3 The Reablement Service “provides planned, short term, intensive help. The service is designed to help a person restore their independence, to help them to do as much as you can for themselves, rather than someone doing things for them. Reablement workers spend anything between one and six weeks supporting each individual to re-learn lost skills following a period of illness, disability or a time when a person may have lost some confidence”. In this authority, the Reablement Team serves as the first point of assessment for all Adult Social Care Services with the exception of mental health. 7.8.4 The service did not contact the GP but initially treated the referral, effectively, as a request for practical, household support – one of the principal functions of the Reablement Service. The following day the officer dealing with this was contacted by the psychiatrist from the Learning Disability service, who said that he was concerned about Ms E having suicidal thoughts and an eating disorder. The IMR reports that “He was seeking a Safeguarding Adults’ referral, again in the context of self neglect / harming behaviours”. 7.8.5 After further consideration the Reablement Service decided to copy the GP’s referral to C&F and pass the substantive referral to the Adult Services “Long Term” team. Here it was considered by a manager who decided that this was not a safeguarding referral and passed the referral to a colleague “to undertake a Section 47 NHS and Community Care Act Assessment as both doctors were requesting practical support for Ms E”. Page 32 of 69 7.8.6 That assessment was carried out very swiftly and concluded that Ms E was sufficiently independent that she did not meet the criteria for the provision of services and that no further action should be taken. The assessing officer had recorded that the two “main risk areas” were “deliberate self harm” (“medium”) and “suicidal thoughts” (“high”). There was no feedback to the GP or psychiatrist, and no direct liaison with C&F. The assessment appears to have been based on the immediate situation. What might happen in future and particularly any risk to the baby do not appear to have been considered. 7.8.7 The IMR notes that the lack of direct liaison with other agencies was a weakness but judges that the overall service response was otherwise appropriate because Ms E’s “described behaviours fell outside adult safeguarding arrangements and that she did not appear to be eligible under the Fair Access to Care Services (FACS19) criteria for support under community care provision”. 7.8.8 This account raises a number of issues. The most straightforward, which it recognises, is the lack of any direct liaison from Adult Services with any other professional, either to clarify what was wanted or to feed back on what had or had not been provided. This illustrates the lack of alertness to the fact that Ms E was pregnant and to the needs of her baby. There was an assumption that these matters had been addressed by copying a referral to C&F. 7.8.9 The account illustrates the way in which needs and demands can get re-interpreted to meet what a service provides rather than what is requested or required. The Reablement Service provides practical help and concluded that “She only wanted practical assistance with household tasks”. The Community Care assessment “concluded that Ms E was independent in all aspects of personal care and domestic chores with some support from her mother who visited weekly. She had no physical disabilities, was able to go out, use public transport independently, managed her own finances… and was negotiating a house move with a Housing Officer”. 7.8.10 The report explains why this was “not an adults’ safeguarding matter” because • no other party was causing Ms A significant harm. • matters of self neglect and self harm fall outside the remit of the most relevant guidance, the adult safeguarding procedures20. Those procedures state that “Self-neglect does not come under the scope of these procedures – which relate to circumstances where there is a person or agent, other than the adult at risk, who is causing significant harm. 19 FACs (Fair Access to Care services) is as system for deciding how much support people with social care needs can expect, to help them cope and keep them fit and well. It applies to all the local authorities in England. Its aim is to help social care workers make fair and consistent decisions about the level of support needed, and whether the local council should pay for this. 20 Adult Safeguarding Procedures Page 33 of 69 Practitioners should refer to other procedures relating to handling self-neglect”. 7.8.11 Research by SCIE21 sets out the complexities of reaching a definition of self-neglect, and the wide variance, internationally, in how this is defined and understood. A key distinction is exemplified in the difference between the approach to self-neglect in the USA and the approach in this country. In the USA self-neglect is “officially” categorised as a form of abuse, while in the UK this is not the case and there is no statutory requirement to report and respond to self-neglect. 7.8.12 In any case there was, as the Community Care assessment demonstrated, now no indication that Ms E was neglecting or harming herself. The real concerns were that she was unwell, pregnant, vulnerable and might not be adequately supported. 7.8.13 The overall response from Adults’ Services lacked professional curiosity. The assessment was prompt and, within its limits, thorough. But, like the learning disability assessment, it was a service led assessment, not one led by the needs of the service user. It was not sufficiently alert to the need for a multi-disciplinary approach to the provision of services to vulnerable families. 7.8.14 This SCR has already led to some improvements in communications and liaison between the two services, including involvement in the Multi Agency Safeguarding Hub (MASH), “shadowing” arrangements for staff and further consideration of how historic information in children’s records can be made more easily accessible to Adult Services if necessary. This Overview Report suggests that there should be further specified arrangements within the local authority which enable Adults’ and Children’s Services to work together more effectively when vulnerable people become parents. That approach should not be restricted by an approach to service provision which is led purely by nationally defined eligibility criteria. 7.9 Dietetic, Accident & Emergency and Acute Paediatric Services 7.9.1 Acute paediatric services at this hospital were only involved from the point when Child D was brought to hospital with inflicted injuries. At that time Child D received appropriate treatment before transfer to a specialist child hospital. 7.9.2 During her pregnancy Ms E received dietetic advice, which appears to have been appropriate: “The dietician obtained a good history from Ms E and shared this information appropriately with the GP and midwife”. 7.9.3 Ms E attended A&E at this hospital on one occasion during her pregnancy, in April. On that occasion the service did not demonstrate alertness to safeguarding issues. Despite knowing that she was pregnant and 21 Self neglect and adult safeguarding: findings from research (SCIE September 2011) Page 34 of 69 diagnosed with depression A&E staff did not investigate more fully or carry out any assessment of risk. No notification was made to midwifery / health visiting services. Ms E “should have been referred to the local Liaison Health Visiting Service who would have facilitated communication and information sharing with GP, HV and midwife”. 7.9.4 The IMR does not explore this further or indicate whether this is a familiar weakness in the service. There is an implication that this may be a continuing problem, in the report’s comment that “Identifying vulnerable adults with children or vulnerable pregnant women in A&E remains a challenge”. Moreover notifications following the injuries to Child D did not follow local protocols and there was some delay in information being shared with designated and community health lead professionals. 7.10 Educational Psychology and Special Educational Needs Services - report for information 7.10.1 This brief report confirms that Ms E was known to specialist education services throughout her time at school. A Statement of Special Educational Needs was issued when she was eleven years old and she attended a special school. “Her word reading and spelling skills were two years behind her age, her reading comprehension was three years behind her age and she showed significant learning difficulties in mathematics”. 7.10.2 The report’s summary is telling: “Ms E was a young person with moderate learning difficulties, with a tendency towards anxiety, who had difficulties with social communication and in forming social relationships … She had experienced being bullied. Although she developed some independence skills she was emotionally vulnerable and became less secure when she moved away from … a small group teaching and learning environment...” 7.11 Housing Services – report for information 7.11.1 This report sets out details of the contact between Ms E and her landlords, the local authority. The report confirms that there were a number of problems arising from the conduct of neighbours – noise nuisance and anti-social behaviour. It is clear that these matters were at times very unsettling for Ms E and will have contributed to the pressures she was attempting to manage. The difficulties were eventually dealt with, to Ms E’s satisfaction, by a specialist Anti- Social Behaviour officer. 7.11.2 Otherwise the report is in keeping with a number of other submissions to this review, which have commented on Ms E’s open and “chatty” presentation and the difficulties that may have concealed: “the Housing Officer offered the opinion that Ms E could be described as a model tenant”. Page 35 of 69 7.12 Ambulance Service – report for information. 7.12.1 The only involvement of the Ambulance Service was their response when alerted to Child D’s injuries. This was prompt and appropriate and no matters arise. 7.13 Specialist child hospital –report for information 7.13.1 This agency was only involved after the injuries to Child D. They have submitted a report describing the very serious injuries sustained and their treatment. Child D has responded well to that treatment but the injuries have had life-changing consequences. 7.14 Police – report for information 7.14.1 The Police had no significant contact with this family and have submitted a brief report to that effect. Page 36 of 69 7.15 Health Overview Report 7.15.1 The purpose of the Health Overview Report (HOR) is to provide a particular focus on how health organisations have worked together. It also serves as the report which draws together issues relating to the commissioning of health services. 7.15.2 The HOR identifies “many missed opportunities” to work with Ms E, and the ways in which her presentation as an open, pleasant young woman led agencies to misunderstand and under-estimate how needy she was: “The fact that services such as Maternity left Ms E to liaise with the GP about her anxiety attacks highlights a complete lack of empathy for her position and no understanding of her vulnerability”. 7.15.3 The report’s concerns about safeguarding arrangements in the maternity service are prominent. This service had the greatest continuing contact with Ms E throughout the pregnancy but failed to respond to the evidence of cause for concern. 7.15.4 Apart from the fact that children are central to their work, maternity services are also unusual in that they can plan more accurately than many other health services when their involvement should start and finish. In that context the report appropriately questions “why a referral (was made to C&F) after the birth of baby D … by the Midwifery Service when she had been under their care for several months”. 7.15.5 These were not individual errors. The report highlights the failure of the service to take appropriate corporate responsibility for safeguarding. “Safeguarding is everyone’s business and the Safeguarding Midwife is there to provide support and supervision but it is unsafe to believe that one person can carry sole responsibility for safeguarding”. 7.15.6 This report also confirms the serious concerns about Ms E’s contact with mental health services “failure to complete a comprehensive assessment, failure to take into account social isolation, failure to understand the recent presentation at [ ] Hospital, the need to refer to Social Care and the Safeguarding Midwife and the need for follow up with [the Perinatal Mental Health Service]. There is failure to mention any learning disability or identify vulnerability. There was no exploration of non-compliance with her anti-depressants or her anxiety about her pregnancy”. 7.15.7 Overall, the HOR picks up the same concerns identified throughout this report – poor use of medical and social histories, a lack of liaison and communication between agencies and professionals, an absence of any overall lead in planning and providing services. In sum “different areas of the health services continued to work in isolation, did not share pertinent information and keep each other updated, and made assumptions about each other’s roles and responsibilities, often failing to clarify very basic facts and trusting a very vulnerable young woman to provide a full history”. Page 37 of 69 8. ISSUES SPECIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW 8.1 Introduction 8.1.1 Many of the issues raised under these specific terms of reference have been considered in previous sections of this report and, where appropriate, are summarised and cross-referenced here. 8.2 During the pregnancy, could more have been done to assess the mother’s needs and provide her with support? 8.2.1 Maternity services recognised Ms E’s vulnerabilities and gave her additional support. However they largely did so without reference to any other agency. They appropriately made an early referral to their Safeguarding Team but, when that did not lead to any further intervention, their concerns appear to have lapsed. The midwives were in the best position to form a view about Ms E’s capacity for parenting and one would have expected that they would keep the need for safeguarding input under review. 8.2.2 The Core Assessment conducted by C&F was of a poor standard and led to an inappropriate management decision to close the case, without reference to all key agencies. The assessment assumed that the services with which Ms E was in touch were having a beneficial effect, when that may not have been the case. It would have been most appropriate for C&F to have maintained some contact with Ms E through the pregnancy or, at least, to ensure that key agencies were ready to re-refer as necessary. SW1 failed to liaise directly with mental health services, noting only that she was engaged in “counselling” and did not make any contact with maternity services. Then the response of C&F when the case was referred after the birth was inadequate - but those making the decision not to re-assess would have been misled by the content of the Core Assessment. 8.2.3 As set out above, the psychological assessment carried out by the Learning Disability service was seriously flawed. This led to the withdrawal of the Learning Disability service from the case, so that Ms E lost the support of the Learning Disability Nurse and the psychiatrist. 8.2.4 Adult Services’ assessments were service led rather than needs led. They were sound by their own lights but did not demonstrate a sufficient alertness to the complexity of the situation and the ways in which individual needs challenge the structures of services and relationships between services. 8.2.5 The rejection of the referral by the perinatal mental health service was a significant development. That was the best opportunity during the ante-natal period for a well-informed, multi-agency assessment which had a real focus on Ms E’s parenting capacity and the safety of the child. The overwhelming case for the involvement of that service is set out in the IMR: Page 38 of 69 “A young person who has been a Looked After Child is at higher risk of mental health problems, Ms E had a clear history of self harm and substance misuse. She lived alone and the support networks were not checked out at the point of assessment. A young woman who is pregnant is going through a change physically and psychologically that can be difficult to cope with; these contextual issues would have made pregnancy an additional consideration to her mental state”. 8.2.6 The psychiatric assessment was weak in many ways. It did not lead to a robust set of arrangements to support this very fragile and vulnerable young woman through her pregnancy and beyond. 8.2.7 The only professionals, whose pre-birth involvement was significant but does not in itself give rise to any direct cause for concern, were the GPs. As suggested above they too have some responsibility for the corporate failure of all the agencies to talk to each other in an effective way. 8.2.8 A common thread running through all the agencies’ involvement was the failure to take adequate account of Ms E’s history and family background. Some of the agencies did not make themselves aware of it. Others did not research it fully. An explicit, shared chronology would have helped the agencies to respond in a more informed way. 8.3 Were the mother’s problems appropriately assessed and addressed across agencies, both recently and when she was in care and a care leaver? 8.3.1 The agencies’ responses to Ms E’s mental health problems and learning difficulties, during her pregnancy and subsequently, have been covered above in sections 7.3 and 7.5. 8.3.2 We do not have a detailed account of all the services provided and the work carried out with Ms E while in care and when she was a care leaver. In any case the more important consideration is that she was in her late teens by the time she came into care. She had already experienced significant harm throughout her childhood. 8.3.3 The only agency in a position to comment on her experiences in care and as a care leaver is C&F. Her time in care was not easy: “Ms E’s behaviour would greatly improve and she would report being happy and settled in placement, education placements would be identified and commenced. By the next review a regression would be reported where she would abscond, neglect her self-care; speak of suicide and again present as vulnerable”. 8.3.4 In May 2005, in response to attempted suicides, “a mental health assessment was undertaken the outcome being that there were no mental health issues”. Page 39 of 69 So, several years before the birth of Child D, Ms E’s presentation was causing significant alarm but she was failing to fit neatly into the ways in which services were organised. 8.3.5 It is not clear if any support was offered and / or accepted by Ms E when it came to light that she was being sexually exploited by a person in a position of trust. 8.4 How did assessments and interventions seek to understand and address issues of diversity, including those of ethnicity and disability in particular? 8.4.1 Agencies struggled to understand Ms E’s disability and this is a key issue in understanding their responses to her. Even if they had not been misled by the flawed psychological assessment, it is clear that Ms E’s presentation was not straightforward and a number of professionals concluded that she might be more competent than was the case. There are references to her “engaging” personality and to some extent this may have disarmed those professionals who were concerned. However every professional with whom she had contact did recognise a degree of vulnerability. 8.4.2 The Health Visitors’ IMR appropriately identifies a significant additional pressure for Ms E – her own health and well-being following the birth of Child D: “the experience of the delivery of her baby would have been a more painful one than most. She then had the aftermath of a caesarean section to cope with”. 8.4.3 Ms E’s ethnicity is described in one of the IMRs as “mixed British, Irish, Indian heritage”. The local authority area is an extremely diverse locality. Public data tells us that the ethnicity of fewer than half the population is White British. None of the IMRs finds any evidence that there are any significant issues of identity / heritage to be taken into account in this case. 8.4.4 The SCR Panel expressed some concerns about the extent to which ethnicity had been considered in the delivery of services to Ms E but also in the IMRs themselves. The Panel felt that this indicated a failure to give adequate weight to issues of diversity and to understand that such issues can have a significant impact on how people engage with and make use of services. Page 40 of 69 8.5 Did assessments take into account the mother’s relationships, support networks and their impact on her parenting? 8.5.1 The input from all agencies seems to have lacked any real effort to understand the nature of Ms E’s relationships with her baby’s father, or with her own family. They were all seen as supportive when there was no evidence that this was the case, or that any support offered was useful to Ms E. No professional spoke to her mother, her sister or Mr F at any time during the period under review. The evidence, some of which was known to all professionals, that she had been abused in her own family and exploited by Mr F, seems to have been given little weight. 8.5.2 The reality was that Ms E was very much alone. The accounts she has given of the circumstances in which the injuries were caused clearly indicate that she felt isolated and unsupported at that time – a Friday evening with what must have felt like a long and difficult weekend ahead of her. 8.6 Did the local authority’s triage arrangements have any bearing on how agencies responded to concerns? What form of triage should have been triggered once concerns were notified? 8.6.1 “Triage”, usually used in medical settings, refers to a process of prioritising responses against need. For the local authority this had to be done twice – in response to the referral following Ms E’s attendance at A&E in May, and then in response to the referrals received when Child D was born and subsequently. 8.6.2 The C&F IMR describes a methodical process which, in June, initially led to an evaluation of the urgency of the referral as medium. That was appropriate at the time for C&F, whose principal priority would be the unborn child. However there was then a weak follow-up to that assessment. It does not seem that the “history” of the case – the previous involvement of Ms E with C&F services – was adequately researched. So, although SW1 had some knowledge of the background, it is not clear that the assessment was fully informed. The IMR states that “there was a missed opportunity at this point as considering the history and any likely impact on Ms E’s ability to care for her child would inform planning, future intervention and (would have) provided a more robust Core Assessment”. 8.6.3 In September 2012 the LSCB launched a local protocol providing guidance to staff involved in pre-birth assessments such as this. The Board will need to evaluate how far and how effectively that protocol continues to be embedded in the agencies’ practice. 8.6.4 When the case was re-referred following the birth of Child D the response by C&F was not methodical. Initially C&F agreed to carry out a further assessment. Then that decision was overturned, on the basis of the previous Core Assessment – an inappropriate decision which was not based on a clear evaluation of the situation. It seems patently unwise to decide not Page 41 of 69 to re-assess a new mother, with all the problems Ms E had experienced, in the face of re-referrals from several medical and nursing professionals. 8.6.5 The IMR from C&F refers to the establishment of the Multi Agency Safeguarding Hub (MASH) – a service development being implemented in many localities, where professionals from the key agencies – C&F, police, health and adult social care – are co-located and jointly evaluate and prioritise referrals. These arrangements might have ensured more effective communications between all the agencies in dealing with the presentation in May - although health services, and adult social care services were not at that time part of the MASH in the council. 8.7 Were assessments appropriately child focussed? 8.7.1 Following the birth maternity services give a good account of monitoring the child’s physical well-being: “The baby was closely assessed. The baby was weighed three times. The mother demonstrated clear understanding of feeding and the baby was putting on weight. When the baby had a Guthrie test the mother showed concern by comforting (the baby) … (The) midwife had very clearly documented this. The baby had been seen three times naked while being weighed. There were no untoward markings noted on the baby and mild nappy rash reported at the last visit. Ms E was advised to treat with sudo-cream and if no improvement to go to GP for further advice”. 8.7.2 The Core Assessment carried out by SW1 did not drill down into the detail of how Ms E would be able to manage the demands of looking after a new baby. An over-optimistic view was taken, a factor frequently identified in SCRs: “The rule of optimism rationalises evidence that contradicts progress - so even where the facts show that risk is ongoing or increasing, professionals tell themselves that the opposite is true”22. As discussed above the decision not to carry out a re-assessment by social workers once the child was born suggests a lack of focus on the new baby. The one face to face contact between the EIS service and the family was thorough and reflects the strength of that service, and of the individual officer involved. 8.7.3 The assessments by mental health services lacked any focus on the child. The IMR describes how “there is no evidence of ‘Think Family23’ in the context of her potential for self harm, access to support in the community or her past history. There was no liaison between the psychiatrist with the ante natal services or with Children’s Social Care”. 8.7.4 The involvement of health visiting services is a more mixed picture. “Once Baby D was born, HV3’s statement clearly highlighted her concern for the newborn and HV1’s CAF referral was similarly focussed on the child”. However “HV2 who undertook the first visit did not adequately assess the risk to the baby and was more focussed on support for mother”. 22 Haringey LSCB – Key Messages 23 Think child, think parent, think family – SCIE, March 2012 Page 42 of 69 8.7.5 These accounts again illustrate the difficulty posed to agencies by Ms E’s presentation. The most serious failure was that agencies did not collaborate in a joint assessment to form the fullest, best-informed picture of her capabilities, and the degree of support she would need. This is particularly worrying given that she was compliant and receptive to help and support. 8.8 During Child D’s life before the incident, were communication, support and the assessment of risk effective? 8.8.1 As described in the previous section of this report the assessment of risk by all agencies was not sufficiently well-informed or thorough. The issue of inter-agency communications is considered below. Some of the support provided and the interventions of some individual professionals were of a good standard but, based as they were on an inadequate understanding of the overall situation, could only have a limited effect. 8.9 On the day Child D sustained the injuries, and subsequently, were there any communication problems between agencies? 8.9.1 Child D was injured on a Friday. During that day: • Ms E took the child to the GP because of severe nappy rash. • The GP prescribed cream to treat the nappy rash and asked that the baby be brought back on Monday. • The GP and HV2 discussed the situation: HV2 was already planning to visit on the Monday and felt that it was not necessary to bring that visit forward. • EIS1 carried out her scheduled initial assessment. Ms E confirmed that she had not been taking her prescribed anti-depressant medication. • The GP and EIS1 shared information about their contacts with the family that day. The GP decided to make a referral via the designated referral number. EIS1 said she would make her manager aware of the GP’s continuing concerns. • EIS1 spoke to her manager. The manager has not made a note of any advice given to EIS1. • The GP contacted C&F via the designated referral number and was asked to submit her concerns in writing. • There was a conversation between the manager for EIS1 and the manager for the C&F designated referral number service. That manager advised that EIS1 should have taken the information from the GP and shared it with colleagues within C&F, rather than suggesting the GP should contact the designated referral number. • No further action was taken that day within C&F. • After “office hours” the GP submitted a written note of the information she had already passed on. • Some time later that day Ms E inflicted the injuries which have led to this SCR Page 43 of 69 8.9.2 Despite its tragic conclusion, in many ways the communications on that day were better than at other times during the period under review. The GP, HV and EIS1 shared information promptly and appropriately. On the basis of how the case had been handled thus far they reached a reasonable set of agreements about how the matter should be taken forward. EIS1 shared the GP’s concerns appropriately with a manager. 8.9.3 I would not have expected any agency to take further action directly with the family that day. Although Child D now had a severe nappy rash, and the GP’s concerns were appropriately growing, there was no indication that an “emergency” response was needed. The key errors had been made months previously, when agencies commenced their involvement in Ms E’s pregnancy, failed to assess the reality of the risks to mother and child and failed to put in place arrangements to communicate and work together to manage those risks. 8.9.4 There is some room for improvement in the agencies’ actions that day. The manager for EIS1, in what was a high risk situation, should certainly have made a written record of her involvement and advice. The GP should have been given a clear message about what C&F would do in response to her referral. 8.9.5 There were weaknesses in communications after the injuries came to light. The Health Visitors note that they were not contacted by the hospital to which the baby had initially been admitted and only discovered what had happened as a result of a routine police 24 notification. The Named Midwife was not informed by the hospital or by the Named Professionals in the hospital. It is not clear why communications were insufficient after a serious incident but the Board is asked to clarify its guidance to and expectations of key professionals in such circumstances. 8.10 How well did all the agencies involved work together - was there good mutual understanding and communication? 8.10.1 This was largely not a situation where agencies were in dispute. As discussed in the next section of this report the absence of dispute and challenge between agencies is a more concerning feature. However it cannot be said that there was “good mutual understanding and communication”. 8.10.2 C&F misjudged the situation and did not identify that there was a need for more structured liaison and planning. That might have been evident almost without seeing Ms E, purely on the basis of her history and the nature of the agencies already involved. Instead there was an assumption, based on insufficient evidence, that the involvement of other agencies excused C&F from drawing those agencies together. As the lead child protection agency that is what they should have done. 24 These are the routine notifications to social care and health by the Police Service of children coming to their notice Page 44 of 69 8.10.3 Some good work was undermined by the lack of liaison with other agencies. HV1 proactively visited Ms E during the pregnancy and spoke to SW1 but did not liaise with midwives or the GP. “Good practice would have dictated that the HV liaised with her own health colleagues to ensure they were updated on the latest developments rather than to allow a third party (especially one that was not a health practitioner) to do it for her. If she had done this, she would have discovered that the midwives were not visiting her and she may have elicited a more meaningful history about Ms E from the GPs”. 8.10.4 Some liaison was rendered less effective because of a lack of process. “N1 provided support to Ms E and accompanied her to numerous appointments and follow-ups. N1 liaised with Children and Families, the CMHT and the Safeguarding Leads for Health Visiting and Midwifery. However, it is not clear what information was shared and …N1 had made an assumption that the Mental Health Team would be taking over the case when they closed it”. 8.10.5 The mental health services’ IMR makes a similar point: “The assessment and support plan for Ms E should have highlighted that this was a case involving the level of complexity requiring it to be initially managed under the Care Programme Approach. Ms E clearly needed social support and a pre-birth planning meeting would have explored this with other agencies”. 8.10.6 Adult Services note that communications might have been improved had they been more direct and sustained: “As with the involvement of the Reablement team, there may have been different outcomes, in respect of contacting Children’s Services again, if discussions had been undertaken with the GP and with Dr L following the conclusions of the assessment”. 8.10.7 Communication between agencies and individuals is fundamental to all effective safeguarding. The need for professionals to be talking to each other here was evident if only because of the number of agencies involved. One would expect the cause for concern to be recognised by all the agencies which had a continuing involvement – perhaps particularly by the GPs and maternity services, where there was very regular contact and therefore a regular reminder that a child was involved. Instead there was little evidence of any inter-agency liaison. 8.11 How effective was management oversight both before and after Child D’s birth? Were concerns escalated when that was appropriate? 8.11.1 The weakness of the Core Assessment by C&F was not picked up by management processes within C&F. It appears to have been signed off by a manager without any question or challenge, despite being fundamentally flawed in not tackling key issues and the fact that not all of the other agencies involved had been contacted. That is of particular concern when the decision by C&F to take no further action relied on input from those other agencies. Page 45 of 69 8.11.2 That input was principally to be provided by mental health services but there were also problems of management oversight within that service. As set out above the mental health assessment carried out was weak and there was no adequate process for quality assuring the work of the psychiatrists. 8.11.3 Similarly, in the Learning Disability service, “During the time that the case was with the LD service there is no evidence to suggest that there was any management oversight”. 8.11.4 The lack of purpose and direction in the maternity services’ involvement is amply evidenced and was not questioned by any other service. 8.11.5 Professional escalation processes – that is, the arrangements for involving more senior officers when professionals cannot reach agreement – let Ms E down mainly after the birth of Child D. Before that the greatest systemic weakness was the overall absence of communications and the consequent failure by professionals to identify that there were weaknesses in the response of other agencies. 8.11.6 After Child D was born health visitors and the GPs were dissatisfied with the decision by C&F not to become involved but did not challenge that by talking to managers. The GPs’ contact with the designated referral number was well-intentioned but a more appropriate response, given the previous history, would have been for the GP to speak directly to a more senior officer within C&F. 8.11.7 There are escalation processes in place locally and the local Child Protection Procedures also provide guidance on this. Nonetheless it is an operational reality that professionals need to be routinely and regularly reminded that these arrangements are in place and should be used. 8.12 What issues are there of support relating to learning disability and mental health concerns in this review? 8.12.1 These matters have been addressed principally in the sections above, 7.3 and 7.5, which deal with the lead agencies for those services. Generally there seems to have been little well-informed understanding across other services of the diverse nature of learning disability and mental ill health. The extent to which agencies operate without reference to each other, and view aspects of need narrowly from the viewpoint of their own discipline is a common feature in Serious Case Reviews, and is manifest throughout the events under review here. Page 46 of 69 8.13 Are local services appropriately using best practice models for safeguarding unborn and very young babies? 8.13.1 The simple answer to this question is, from the evidence of this case, that they are not. Unlike many safeguarding situations the antenatal period gives an opportunity for professionals (and families) to work together to plan how the parent(s) and new baby can be best supported. Agencies can assess the situation, identify risks, evaluate the capacity of parent(s) to safeguard the baby, work together and share information so as to ensure the best planned and co-ordinated arrangements for supporting the new situation. This was a very significant missed opportunity in this case, particularly as this was not a non-compliant parent, but someone who demonstrated a willingness to be involved with agencies. 8.13.2 Research by Ofsted25, evaluating over 400 Serious Case Reviews, found that babies less than one year old had been the subject of a high proportion (35%) of those reviews. Each one of the headline findings of that research has a correspondence with this case: • “there were shortcomings in the timeliness and quality of pre-birth assessments • the risks resulting from the parents’ own needs were underestimated, particularly given the vulnerability of babies • there had been insufficient support for young parents • the role of the fathers had been marginalised • there was a need for improved assessment of, and support for, parenting capacity • there were particular lessons for both commissioning and provider health agencies, whose practitioners are often the main, or the only, agencies involved with the family in the early months • practitioners underestimated the fragility of the baby”. 8.13.3 It is particularly disappointing to learn that the local authority does have some targeted arrangements for these vulnerable children: “(A) model of best practice is provided through a comprehensive “Parenting Programme when working with mothers of unborn and very young babies”. It appears that no professional considered that this service could have been of benefit during Ms E’s pregnancy. 8.13.4 Although there was no local protocol in place at the relevant time the local Child Protection Procedures very clearly set out arrangements for protecting unborn children. They stress the need for early intervention, which could certainly have happened here: “concerns should be addressed as early as possible before the birth” These procedures are straightforward and helpful. They were clearly relevant in this situation. It is of concern that no agency appears even to have considered their implementation. As suggested above awareness and use of the local protocol and this guidance will now need to be tested. 25 Ages of concern: learning lessons from Serious Case Reviews Page 47 of 69 8.14 Were there any organisational difficulties within or between agencies? 8.14.1 The review has identified that: • There had been significant large-scale reorganisations which have affected some of the health services involved in this case. • There had been a large-scale reorganisation in the C&F service which was continuing to affect services during the period under review. • There is an apparently unresolved history of discord between professional groups within the Learning Disability service. • The psychologists in the Learning Disability service took far too long to assess Ms E’s IQ and even longer to make a record of that assessment, without any target timescales. • Supervision arrangements in a number of services were unsatisfactory. • There was uncertainty among services about the role and functioning of the designated referral number arrangement. • The perinatal service was operating an inflexible arrangement for dealing with “early” referrals. 8.15 What LSCB quality assurance processes could provide timely overview of services to vulnerable children and parents? 8.15.1 The Board will want to avoid “re-inventing the wheel”. There is a huge amount of research and guidance already developed in this area. The guidance is increasingly focussed on real “well-being outcomes” – whether and how children are actually safer as a result of what the Board and its constituent agencies do. Ways of gathering evidence about the quality and quantity of services and the outcomes of those services are being continuously improved. 8.15.2 Agencies are developing ways of breaking down the overall task into categories, perhaps using this approach which draws on the work of the local Safeguarding Children Board: • Practice - issues such as priority services, specific risk issues or vulnerable groups • Practitioner - issues such as relationships, workforce development, supervision and organisational culture. • Environment / Context - issues such as poverty, housing and social deprivation 8.15.3 Within those areas various combinations of techniques and methods – external peer review, “deep dive” analysis of identified priority areas, staff audits, service user feedback arrangements – can be programmed to provide diverse and well-informed information. The LSCB’s Business Plan will already have identified local priorities to be taken into account. Page 48 of 69 8.15.4 Serious Case Reviews will obviously form an important part of these arrangements – and Boards are now26 encouraged to apply similar approaches to cases which have not met the statutory criteria for a SCR. While acknowledging that SCRs are usually only about one case, they do allow for a very intensive examination of multi-agency professional practice within that case. They are exercises which require significant resources and the best use needs to be made of what they produce. 8.15.5 SCRs have been criticised for repeatedly identifying the same lessons to be learned. Clearly we should not be complacent about that, and this report does not in any way seek to excuse basic failures in professional practice and organisational rigour. But it is a reality that safeguarding children and vulnerable adults is complex and challenging, and there are many ways in which things can go wrong. It would be a significant error to assume that the “same old mistakes” will not recur. The challenge lies in devising the most robust and reliable arrangements for anticipating and identifying those weaknesses within and between local services. The dissemination to local agencies and their key staff of the “lessons learned” from this SCR should serve as a reminder of how basic some of those service weaknesses can be. 8.16 Where can we identify good practice in this case? 8.16.1 Under previous arrangements for evaluating SCRs Ofsted27 suggested that the “best” reviews would identify “Good practice… with… potential for wider implementation”. Some agencies and individuals – principally GPs and the Learning Disability professionals - demonstrated a continuing commitment to Ms E. Some agencies have responded promptly and vigorously to issues arising from the review – Health Visitors are ensuring that they always see a baby undressed at visits, the perinatal mental health service has adopted a more proactive approach to early referrals. However the review has not identified any examples of innovative practice which could be flagged up for implementation elsewhere. 8.17 What outcomes are envisaged from the recommendations from this review? 8.17.1 The key outcomes are probably those which SCRs repeatedly seek to promote: • Early support arrangements for children and families which respond flexibly to their needs and which focus on the child. • A better understanding of the enduring effects of abuse and neglect in childhood and their consequences for parenting. • Assessments which recognise the complexity of family situations, including the position of “absent” fathers. • Agencies taking a more open approach to their responsibilities and displaying a real commitment to working together. 26 Working Together 2013 27 OFSTED SCR Descriptors January 2009 Page 49 of 69 • More thorough and reliable work by individual professionals. • More consistent and productive communications between agencies and professionals, and a better understanding of other agencies’ responsibilities, especially between adults’ and children’s services. • An understanding of when and how to escalate concerns about other agencies’ practice. 8.18 How can the LSCB ensure that recommendations have an impact? Are there implications for training – single agency and multi agency? 8.18.1 The national biennial report28 on SCRs considers the issue of recommendations in depth, reflecting mixed opinions: “Some respondents indicated that the analysis of outcomes of recommendations and action plans is the only way of knowing the impact on practice; others were concerned that emphasising recommendations and action plans was too simplistic, casting doubt on the fact that the impact on practice was necessarily measurable”. 8.18.2 The biennial report recognises the stultifying effect of a proliferation of recommendations, while accepting that there will, by the very nature of this process, be situations where recommendations are necessary and inevitable. Nonetheless it concludes that “LSCBs should be less reliant on recommendations being the central plank of the learning process in serious case reviews”. 8.18.3 Some recommendations from this review are unavoidable: it would be inappropriate for the Board not to require some changes in aspects of practice demonstrated here. Where recommendations are made they should be supported by a continuing and robust process of monitoring, measuring and responding, supported by targeted training, staff development initiatives and user feedback. 9. SERIOUS CASE REVIEW PROCESS 9.1 Some of the agencies involved in this review failed to meet timescale targets during the review process. The Review was initiated in December 2012 and it was not possible to bring a report to Board until January 2014. Although a relatively large number of agencies had been involved, across both children’s and adult’s services, for most of those agencies their involvement had been limited and their final reports were not lengthy documents. 9.2 Working Together requires that SCRs should normally be completed in six months unless they are particularly complex. That complexity often arises when several localities are involved, or the review needs to consider more than one child. There were no such factors in this case. There were no delays in producing this Overview Report other than those caused by the agencies. The SCR Panel reviewed the compliance with timescales of all agencies and found a number of explanatory factors. These included pressures on 28 Building on the learning from SCRs 2007-2009 Page 50 of 69 resources and capacity, illness of key members of staff, failure to follow the Terms of Reference or, for some health services, to consult appropriately with the Designated Professional, so that reports had to be re-drafted - and a simple failure to give the exercise an adequate priority. 9.3 Agencies have not awaited the conclusion of this review before addressing the issues which arise from it. Their action plans demonstrate work already in progress and completed. Nonetheless it is important that reviews and similar exercises are completed without undue delay and there is consequently a recommendation to the Safeguarding Board. Page 51 of 69 10. CONCLUSIONS: THEMES, MISSED OPPORTUNITIES AND LESSONS LEARNED 10.1 The review has identified a range of individual, agency and inter-agency weaknesses in the overall response to Ms E during her pregnancy and subsequently. Many of those weaknesses are often identified as causative factors in Serious Case Reviews. The Board will need to be reassured that agencies have accepted that the findings of this review indicate a need for significant improvements in the way they work with pregnant and vulnerable women. 10.2 Agencies had a great deal of information about Ms E. There were numerous indications that she would find it difficult to cope with the responsibilities of being a new parent. Those signs can be found in her childhood, when she had been abused and exploited, her mental health, her learning disability and her continuing isolation and lack of reliable support. Her presentation could be deceptive, so that she sometimes appeared more capable than was the case – but even that presentational issue had been identified and documented when she was a child. Despite this background agencies missed or under-estimated the consequent need to safeguard Child D. 10.3 Ms E did not always take the medication prescribed for her depression because, we believe, she experienced difficult side-effects. Otherwise she did not seek to conceal her contact with the various agencies and was entirely compliant with what those agencies required of her. She was not someone who was “hard to reach”. It is likely that a continuing supportive and educational relationship with an appropriate professional during the pregnancy – as was provided by the Early Intervention Service after the baby was born – would have enabled agencies to form a clear and early view of her parenting capacity, and the support she would need post-natally. 10.4 There was little professional interest in the father of Child D – who he was and how he might be able to support Ms E and the baby. He was seen as a protective factor without any attempt to understand the nature of the relationship between him and Ms E, and in the face of evidence that the roots of their relationship lay in the exploitation of a vulnerable young woman. 10.5 The fundamental failing was that agencies did not work together. Despite the number of services involved there was never any inter-agency meeting. Such a meeting could have been set up under a number of working arrangements – CAF, CPA or child protection procedures – but opportunities to do so were repeatedly missed. Any of the agencies could have initiated such a meeting but there was no attempt to do so. No agency used escalation arrangements to challenge the response of another agency. 10.6 The Panel has tried to understand how there could have been such a disconnected response to someone who clearly had multiple, overlapping problems. Key factors identified were that Page 52 of 69 • Ms E had so many difficulties that it was too easy to conclude that somebody else must be taking a lead. • Some services – particularly maternity and mental health – generally operated without adequate reference to other agencies. • Relationships between children’s and adults’ services were not well developed. • The Panel advised that local agencies historically and in general had not given sufficient priority to safeguarding. 10.7 Some key agencies – maternity, children’s and mental health services – seriously misjudged the situation in their assessments. These were failings of individual practitioners and their managers or supervisors as well as failures in working practices and systems within those agencies. Some of those mistakes were elementary – such as failing to consult adequately or at all with colleagues in other agencies. All the assessments relied on an unevidenced optimism about Ms E’s capacity to care for a baby. 10.8 Maternity services had the greatest amount of direct contact with Ms E but made little positive use of that contact. During the pregnancy there was no proactive liaison with other services. It is extraordinary that the maternity services should make safeguarding referrals to the local authority once the child was born when they had seen the mother frequently throughout the pregnancy. There was nothing unusual or unpredictable about the child to prompt a referral at that stage. The Review found insufficient evidence of alertness to safeguarding issues in this service. Local members of the SCR Panel described these problems in the service as “entrenched” and the review provided little reassurance that they might not recur. 10.9 The local authority needs to ensure that its arrangements for supervision and review are more reliable than is evidenced in this case. Although the Core Assessment was weak in its process and conclusions, it was still agreed without challenge or comment by a manager. After the child was born, although a manager had taken a counter-intuitive decision not to re-evaluate an assessment, that decision was not challenged or questioned. 10.10 Some agencies feel that the designated referral number arrangements were not working well at the time of these events. That is highlighted here, not because it was significant in this case, but because it should be a keystone of local safeguarding arrangements. The agencies need to be confident that the service is adequately resourced and that its purpose is clear. 10.11 The issue of whether or not Ms E had a learning disability was given too much weight in the agencies’ overall response to her. The consequences of her IQ assessment being of poor quality and reaching the wrong conclusion were far-reaching. But an even greater concern is the priority given to this part of the overall assessment. It symbolises the way in which Ms E was seen as a passive recipient of services rather than an individual user of services. Then, because she did not fit neatly into the way that services are configured and delivered, no service “owned” her and no agency gave adequate weight to the implications of her pregnancy. The consequences of this in this case were Page 53 of 69 extreme but it will not be unusual that vulnerable young people fall between various sets of eligibility criteria. This needs to be factored in to the commissioning of services generally. 10.12 In recent years a number of key services in this review have been through one or more major reorganisation and / or transfer of responsibility between “parent” agencies. Some of the agencies have specifically identified lack of organisational stability as a factor in these events. Issues of conflict between teams and services have been identified. 10.13 The review has tried hard not to allow judgments to be over-informed by hindsight. The Panel felt that there were clear indications throughout the period under consideration of a need for a robust, collaborative approach to protecting Child D and supporting Ms E, and of the potential risks in not taking such an approach. Page 54 of 69 11. SERVICE IMPROVEMENTS MADE BY THE AGENCIES 11.1 All agencies have accepted the major concerns arising from this review. Because it is being finalised over a year after the injuries to Child D agencies have already taken many steps to improve their services in response to the matters identified in this report. More than 200 staff have attended training sessions based around the lessons to be learned from this review. 11.2 Those agencies most significantly involved in the case were asked to provide a summary of the major service improvements made and planned, and they have provided the information set out below. The Action Plan in response to the specific recommendations from this Review is provided separately. LOCAL SAFEGUARDING CHILDREN BOARD Multi agency feedback seminars on learning from this SCR began during the summer and continue. There was a seminar for all staff on working with fathers in December 2013. Networking meetings have been further developed by the LSCB to include health and education staff meeting with social care workers. In October 2013 there was a networking event for those who work with adults and those across the partnership who work with children, to look at joint protocols. The LSCB published multi agency guidance on thresholds for intervention in January 2013 and there are regular LSCB multi agency audits which review this. GENERAL PRACTICE Training is taking place for all GPs on key issues arising from the Review. Delivered by the Named GP for Safeguarding and the Designated Health Professionals, that training addresses information sharing, quality of referrals to Children’s and Adults’ Services, and understanding of roles and responsibilities. All surgeries are being encouraged to identify lead GPs for vulnerable families and for case files to be flagged. NHS FOUNDATION TRUST Mental Health The perinatal service now works to a new NHS England specification for Mother and Baby Units. The service now admits women much earlier in their pregnancies and proactively follows up women who are referred before admission is appropriate. The service is working on an action plan that will allow for them to be registered through the Royal College of Psychiatry. A system of shadowing between mental health services and children’s social care staff is now in place. A review of systems in place in the county has taken place to ensure clinicians are making full entries into electronic records and that paper records cease; this will be audited. An audit of safeguarding training attended by psychiatrists is planned. Page 55 of 69 Learning Disability The practices of the local Learning Disability Team have been reviewed and will be audited. The LD team now has a weekly documented professionals / clinical meeting to discuss new cases, consider how a lead professional is identified and a coordinated approach for the client is best provided. Consideration has been given to the team moving to one site. Training is being reviewed this autumn and gaps identified and filled. The team is now using an evidence-based assessment tool (the WAIS Assessment Tool) when undertaking eligibility assessments. Those cases assessed with the previous inaccurate tool have been audited and liaison with Children’s Services has been initiated as necessary. Eligibility assessments are completed within two weeks of referral. Feedback on the assessment can be given within 48 hours and a written report is provided within 4 weeks. This has been audited on 20 assessments. The team has reviewed how the voice of the person is addressed and captured in assessments so that records can demonstrate this. Patient satisfaction surveys have been completed. All senior professionals now have formal peer support or supervision in place. An audit has taken place of the supervision schedules since April 2013. HEALTH VISITING SERVICE Health visitors ensure they are seeing new babies undressed in new birth visits and babies are being weighed unclothed. Work is ongoing to review pathways of communication at intra and inter-agency level. Health visiting links with GPs are now in place to improve the flow of information. Record keeping training was delivered to health visitors and school nurses on 18/3/13 to ensure only one set of electronic records is being kept, family members’ records are linked, relevant male adults are registered and linked to families, and all correspondence and CAFs are uploaded onto the electronic file. Guidance has been given that all alerts on Rio (an electronic patient record system) are turned on appropriately and removed when no longer relevant, and that all liaisons with other practitioners are followed up in writing in a secure manner. The Named Nurse for Safeguarding has written a template of prompts for reports for writing records, which has been circulated to staff. A Safeguarding Supervision Policy has come into immediate effect, so that all practitioners bring concerns about any vulnerable children to supervision, not only those subject to child protection plans. Safeguarding children is to be an item on the Senior Management Team agenda, and representatives from Adult Services attend Safeguarding Children Meetings at least quarterly. Page 56 of 69 NHS TRUST Paediatrics A safeguarding problem list and action plan is to be incorporated in existing discharge templates for the paediatric ward and postnatal unit. Work is ongoing to strengthen the information sharing pathway between hospital and community, ensuring comprehensive discharge summary letters to GPs, appropriate use of the Liaison Health Visiting Service, and efficient and timely communication between acute and community Named Professionals. The child protection medical assessment and report template should be used for every child protection case to ensure adequate assessment / documentation, and distribution of report to relevant professionals within health, social care, police and named professionals in the community. Child protection reports should be typed and send out by the Child Protection Office. There is an ongoing implementation of the safeguarding protocol in A&E to identify and safeguard vulnerable adults with children via on going staff training and awareness. Maternity Services Midwifery training has been reviewed and will be audited in January 2014 in regard to roles and responsibilities, multi agency escalations, and communication. Whooley’s questions (a tool for screening for depression) are now incorporated into notes for completion at every visit and ante-natal appointment; this will be reviewed in September 2013 and audited in January 2014. CAF training and awareness has been given to all midwives. Guidance is in place for shared documentation to encourage inter-professional documentation so that all agencies write in the maternity hand held notes or place a photocopy of their record in the notes to facilitate communication. An internal review has begun into the role of the Vulnerable Women’s Team seeking to strengthen the role of the safeguarding lead midwife and team, and implement the SCR’s recommendations, overseen by the Director of Nursing. Risk assessments have been strengthened to include hospital records to be available at bookings, documents of fathers, and family support networks, and ensuring all professional details are included in files. Psychosocial meetings have been strengthened, with cases being brought for discussion. Psychosocial meetings now have an action log to be reviewed at the next meeting, minutes are disseminated and discussed, and multi agency attendance has been strengthened. Midwives have committed to undertaking joint home visits with social workers. Page 57 of 69 Regular quarterly midwives’ safeguarding supervision is in place, including group supervision; this will be audited in January 2014. Accident and Emergency Services A safeguarding problem list and action plan is incorporated into existing discharge templates on the paediatric ward and postnatal unit. The information sharing pathways between the hospital and the community are being strengthened, ensuring comprehensive discharge summary letters to the GP and use of the Liaison Health Visiting Service. The child protection medical assessment and report template should be used for every child protection case. Child protection reports should be typed and sent out by the child protection office. A safeguarding protocol in A&E to identify vulnerable adults with children is being implemented. All these initiatives are to be audited in January 2014. LOCAL AUTHORITY Children’s Services Arrangements between agencies for working together on concerns arising before a child is born have been clarified and improved. A pre-birth “tool kit” has been circulated to enhance the LSCB pre-birth protocol. One of the Child Protection Chairs29 is the nominated pre-birth lead for the children’s workforce, providing advice to social workers undertaking pre-birth assessments and liaising with midwifery services. Children’s Services now attend psychosocial meetings at hospitals for pre-birth referrals and weekly meetings at the children’s ward. There has been a very significant investment in staffing with an increase of 24 extra social workers. The “front door”, the first point of contact with the public and other agencies, has been redesigned so as to involve professionals from other disciplines – teaching, health visiting and early years provision. Multi Agency Safeguarding Hub (MASH) screening meetings have been further developed involving an increasing number of local agencies. The functioning of the designated telephone number into Children’s Social Care is under review and there is an improvement in the management of calls. There has been significant investment in improved arrangements to deliver better informed assessments, including a specific focus on the management skills needed to drive up the quality of those assessments. Assessments are allocated to social workers who will then keep the case where it requires longer term work, providing better consistency. Work is ongoing in Children’s Services to recruit and retain a skilled workforce and support has been given to encourage good quality core assessments, 29 An officer with specialist expertise in child protection Page 58 of 69 including analysis, understanding of risk factors, understanding the role of fathers and men in families and households, and planning. The supervision of staff has been a key service improvement target with enhanced arrangements for individual staff, including managers, and across whole teams. Working arrangements between agencies have been further improved by a programme of staff secondments and regular inter-agency meetings of managers and specialist staff. Joint work with adult services is being progressed following a positive workshop between Probation and Children’s Services and the development of working protocols. The role of the EIS and the links between the EIS and other services have been enhanced so that this service is better integrated with other children’s services. EIS now have an escalation protocol and a nominated Child Protection Chair to help develop their risk assessment and safeguarding awareness. The service is being supported by a specialist consultancy and staff have undertaken training in a range of key areas. The local authority is beginning to draw together performance data arising from these new arrangements and has evidenced improvements across the service, particularly in relation to revised inter-agency arrangements for thresholds for intervention. The number of assessments has increased by over 50% from 2011-12 to 2012-13, and applications for court orders also increased by 50%. This combined with a decrease in re-referral rate and numbers of children subject to a child protection plan for more than 2 years demonstrates a change in the approach to thresholds for intervention. Adults’ Social Care An agreement regarding information access has been reached between Children’s Services and Adults’ Services. Amendments have been made to the electronic record system and guidance on information sharing has been issued to relevant staff. Shadowing arrangements for staff between Adults Services and Children’s Services are being promoted. A guidance note was issued to all relevant staff and managers in Adult Social Care to ensure that staff provide feedback to referrers, and referrers are then clear about any actions to be taken. The LSCB “Escalation and Resolution of Concerns” protocol has been issued to all relevant managers and staff and discussed at team meetings. The file audit process now ensures that at least one case in every round of independent file audits includes a household known to Children’s Services. A “Think Family” best practice forum was held for 60 Adult Services’ staff members and managers in September 2013, including training on joint protocols relating to disability, mental health problems or substance misuse concerns, and learning from this SCR. Page 59 of 69 12. RECOMMENDATIONS FROM THIS OVERVIEW REPORT 12.1 Introduction 12.1.1 These recommendations arise from this Overview Report which reflects the views of the SCR Panel and the independent Overview Report author. They are all directed to the Local Safeguarding Children Board and have been endorsed by that Board. 12.1.2 In her reviews of child protection arrangements Professor Eileen Munro has referred to “the child’s journey30” – the journey from needing help to being protected. The LSCB and local agencies have adopted key themes from that work to drive forward service improvement and these recommendations are grouped around relevant themes. 12.2 Key theme – working together for the child Recommendation1 The Board should require those agencies which have provided IMRs to this review to demonstrate that • The need to work with other agencies is routinely considered when providing services to families and individuals, and staff are familiar with the relevant arrangements for doing so. • Referrals between agencies are specific and adequately evidenced. • Arrangements for escalating problems to more senior officers are understood and appropriately used. Background to this recommendation: this review has found evidence of fundamental failures in agencies’ understanding and application of routine arrangements for working with partner agencies. Referrals between agencies were not always made or were not clear enough in the concerns they sought to express. Recommendation 2 The Board should develop multi-agency guidance to promote ways of helping vulnerable young people who may not meet the eligibility criteria of individual agencies and services. Background to this recommendation: There are young people whose vulnerabilities will not “match” the standard ways in which needs are assessed and the criteria for providing services. A flexible and integrated approach to this is needed. 30 Munro review of child protection: interim report - The Child’s Journey Page 60 of 69 12.3 Key theme - Improving the quality of casework and managing risk to the child. Recommendation 3 The Board should require those agencies which have provided IMRs to this review to demonstrate that their assessments are robust, well evidenced (including appropriate use of historical information and liaison with other agencies), carried out without delay and routinely reviewed. Assessments should be structured so as to respond to individual needs rather than to overarching eligibility criteria or to the way in which services are configured. Background to this recommendation: the weaknesses in the overall approach to this case were clearly linked to assessments which were based on insufficient evidence, lacked analytical rigour or were not in keeping with current professional standards. Recommendation 4 The Board should require the local Clinical Commissioning Group and the local NHS Trust to develop and agree a detailed and measurable action plan, (which will also be monitored by this Board), in response to the concerns about maternity services arising from this review. This may also have implications for other localities and the Board should bring this Serious Case Review to the notice of a neighbouring Local Safeguarding Children Board. Background to this recommendation: the Review Panel was particularly concerned about the weaknesses evidenced in the involvement of maternity services in this case. There was a fundamental lack of alertness to safeguarding concerns and safeguarding arrangements. 12.4 Key theme - Developing good systems that keep children safe. Recommendation 5 The Board should require the local authority to review the designated referral number service to ensure that it provides a swift and reliable way of registering concerns about children who may be in need of protection. Background to this recommendation: the review was informed of concerns about the effectiveness of the local authority’s designated referral service, which provides the “front door” to safeguarding services. Recommendation 6 The Board should ensure that this Serious Case Review is brought to the attention of the “Chief Executives’ Group”, a regular meeting of senior local decision makers. The Chief Executives’ Group should be made particularly aware of the consequences for the safeguarding of children of recent service reorganisations, and how these might be identified and mitigated. Page 61 of 69 Background to this recommendation: the Review heard reports of concerns from a number of agencies about the destabilising effects of serial reorganisations and changes to management arrangements in some local services. There was no direct evidence that this was a significant factor in this case, and agencies generally reported that new service management arrangements were now settling in. Nonetheless the Board will wish to remain watchful. Recommendation 7 The Board should, by dissemination to agencies of the findings of this review, emphasise the need to complete case reviews and similar exercises thoroughly and within target timescales. The Board should encourage agencies to develop further understanding of issues of diversity and equality. Background to this recommendation: this has been the first Serious Case Review conducted in the borough for some years and there were some difficulties in the process of the review. Some agency reports did not meet deadlines. Most agency reports failed to address issues of diversity despite being asked specifically to do so. Recommendation 8 The Board should ensure that there are reliable arrangements between agencies for sharing information after serious incidents. Background to this recommendation: the Health Visitors were not made aware of Child D’s injuries by any other agency.Page 62 of 69 Page 63 of 69 APPENDIX B: anonymised Terms of Reference for the SCR These Terms of Reference have been modified and anonymised so that they can be published as an appendix to the Overview Report. Decision to conduct the SCR Child D, aged 3 weeks, was admitted to hospital with head injuries, suffered seemingly through shaking. Child D’s mother was known to adults and children’s services and health services before and during the pregnancy and following the birth. It was decided that a SCR was necessary because: The child has sustained a potentially life threatening injury and serious and permanent impairment of physical health and development through abuse; (8.11 Working Together 2010) The child was seriously harmed following a violent assault perpetrated by an adult, and her chances of surviving without long term impairment are low; (8.11 WT) One of more agency felt that concerns about a child’s welfare were not taken sufficiently seriously, or acted upon appropriately by another agency. (8.12 WT) Notifications of this decision were made to the Department for Education and to Ofsted in November 2012. Existing Learning In October 2011, Ofsted published a report31 considering 482 serious case reviews carried out between April 2007 and March 2011. A large proportion of cases concerned babies less than one year. The key findings were: Shortcomings in the timeliness and quality of pre-birth assessments; Risks resulting from the parents’ own needs were underestimated; Insufficient support for young parents; Role of fathers had been marginalised; There was a need for improved assessment of, and support for, parenting capacity; There were particular lessons for commissioning and provider health agencies, whose practitioners are often the main, or the only, agencies involved with the family in the early months; Practitioners underestimated the fragility of the baby. National lessons from previous SCRs point to babies under a year being especially vulnerable. However, many of these reviews point to prevention having been possible. The LSCB would wish this review to move beyond the findings which are found commonly in these SCRs, and suggest achievable best practice models 31 Ofsted - Ages of Concern October 2011 Page 64 of 69 for safeguarding babies and unborn babies in the borough and would wish to challenge those agencies working with these most vulnerable children and their parents to adopt those best practices, if they are not already using them. Key issues and questions this case raises The purpose of this SCR is to understand this case and consider whether professionals could have taken any other steps to support the mother and avoid the injury to the child. The purpose of this review is to establish what lessons can be learned from the case in which local professionals worked individually and together to safeguard and promote the welfare of children. It is essential to maximise learning that the child’s daily life experiences and welfare are at the centre of the review. The SCR will identify how the learning will be acted upon by agencies and within which timescales, in order to improve safeguarding practice locally and provide learning particularly for work with vulnerable babies and parents. The following questions are pertinent: 1. During the pregnancy, could more have been done to assess the mother’s needs and provide her with support? 2. Were the mother’s problems appropriately assessed and addressed across agencies, both recently and when she was in care and a care leaver? 3. How did assessments and interventions seek to understand and address issues of diversity, including those of ethnicity and disability in particular? 4. Did assessments take into account the mother’s relationships, support networks and their impact on her parenting? 5. Did the local authority’s triage arrangements have any bearing on how agencies responded to concerns? What form of triage should have been triggered once the referral concerns regarding the mother were received? 6. Were assessments appropriately child focussed? 7. During Child D’s life before the incident, were communication, support and the assessment of risk effective? 8. On the day Child D sustained her injuries, and subsequently, were there any communication issues between agencies? 9. How well did all the agencies involved work together – was there good mutual understanding and communication? 10. How effective was management oversight both before and after Child D’s birth? Were concerns escalated when that was appropriate? 11. What issues are there of support relating to learning disability and mental health concerns in this review? 12. Are local services appropriately using best practice models for safeguarding unborn and very young babies? 13. Were there any organisational difficulties being experienced within or between agencies? 14. What LSCB quality assurance processes could provide timely overview of services to vulnerable children and parents? 15. Where can we identify good practice in this case? Page 65 of 69 16. What outcomes are envisaged from the recommendations from this review? 17. How can the LSCB ensure that recommendations have an impact? Are there implications for training – single agency and multi agency? Period under review Enquiries and chronologies will cover the period from approximate conception to just beyond the key incident. This ensures focus on the baby and preparations for the birth and initial parenting, as well as interventions following the birth and communication between agencies following the key incident. However, all agencies will construct a narrative summary from 2004, when the mother became looked after, to the period of the detailed SCR chronology, highlighting any salient issues which should be addressed under the SCR Terms of Reference. Organisations to be involved in the SCR Health Services Learning Disability Services, Mental Health Trust. Hospital – Maternity Services Hospital - Paediatrics, Acute Team and Accident and Emergency General Practitioners Ambulance Health Visiting services Other services Children’s Services (Targeted Services, Early Intervention Services and Children’s Centre) Adults Services and Housing Services Police Conduct of the review Agencies will construct a comprehensive chronology of involvement by their organisation and an analysis of involvement. Agencies will consider the events which occurred and which were omitted, to understand the decisions and judgements made. This will be from an individual practitioner’s perspective as well as the organisation they represent and the community of professionals they were involved with. Interviews with staff members can be undertaken. The overview report will be written with a view to publication of the open document without redactions. The independent Overview Report author, assisted as appropriate by a member of the SCR Panel will be directly involved in any contact with the family. Parallel processes Page 66 of 69 The Police Service (Child Abuse Investigation Team) will liaise with the Coroner’s Office and Crown Prosecution Service as required. Media interest The Police Service will take the media lead until criminal proceedings are determined. LSCB will then assume lead responsibility for any media issues. Independent Chair and Author The Independent Chair of the SCR Panel will be LSCB Independent Chair. The Independent Overview Author has considerable experience in conducting Serious Case Reviews. The LSCB Board Manager will be the link person for the Independent Chair and Author and will coordinate this review. Page 67 of 69 APPENDIX C: SCR Panel Name / Designation Organisation Role Independent Independent Chair Designated Nurse Clinical Commissioning Group Panel member Designated Doctor Clinical Commissioning Group Panel member School Governor Board Member LSCB Panel member Divisional Director, Early Intervention Services Children’s Services Panel member Divisional Director, Targeted Services Children’s Services Panel member Service Manager, Quality Assurance Children’s Services Panel member Assistant Chief Executive NHS Foundation Trust Panel member Head of Service Adult Services Panel member Senior Lawyer Legal Services, Social Care and Education Panel Member Independent Overview Report author In attendance Board Manager LSCB In attendance Administration Assistant LSCB In attendance Page 68 of 69 APPENDIX D: References Footnotes have been used to indicate specific quotations from or references to research, practice guidance and other documentation. This Overview Report has been generally informed by the following publications • Working Together to Safeguard Children,(HM Government 2010) • The Victoria Climbie Inquiry (Lord Laming 2003) • The Protection of Children in England: A Progress Report ( Lord Laming 2009) • Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008 • Analysing child deaths and serious injury through abuse and neglect: what can we learn – A biennial analysis of serious case reviews 2003-2005 • Understanding Serious Case Reviews and their Impact - a Biennial Analysis of Serious Case Reviews 2005-07 DCSF 2009 • Local Safeguarding Children Board – SCR Toolkit (2010) • Review of the involvement and action taken by Health Bodies in relation to the case of Baby P ( Care Quality Commission (2009). • Learning together to safeguard children: developing a multiagency systems approach for case reviews. ( SCIE 2009) • The Munro Review of Child Protection: Final Report (HMSO May 2011) • The Munro Review of Child Protection: Interim Report (HMSO February 2011) • Publication of Serious Case Review Overview Reports: Letter from Parliamentary Under Secretary of State for Children and Families 10th June 2010 • Working Together to Safeguard Children (2010) • Working Together to Safeguard Children (2013) • Adult Protection Procedures • Self neglect and adult safeguarding (SCIE 2011) • Multi agency working and information sharing project (Home Office 2013) Page 69 of 69 |
NC044106 | Executive summary of a review into the death of an 8-week-old baby boy in March 2012 from a significant head injury. Post mortem examination revealed blunt trauma injuries to head, abdomen, back and limbs and rib fractures of differing ages. Both parents were arrested on suspicion of murder. Both parents had troubled childhoods, characterised by: offending, aggressive and violent behaviour, school absence, and contact with adolescent mental health services. Mother was sexually abused as a child and father spent time on the child protection register for emotional and physical abuse. Issues identified include: midwives' practice of not accessing fathers' medical records due to a misunderstanding of data protection laws; midwives' overreliance on information volunteered by parents; insufficient consideration of the impact of parents' traumatic childhoods on their parenting capacity; Responsible Paediatrician's failure to identify significant child abuse injuries; and inability of the police Lead Investigator to challenge the Responsible Paediatrician. Makes recommendations covering health and police services.
| Title: The executive summary of the overview report into a serious case review of the circumstances concerning Child I. LSCB: Northamptonshire Safeguarding Children Board Author: John Fox Date of publication: [2014] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Northamptonshire Safeguarding Children Board The Executive Summary of the Overview Report into a Serious Case Review of the Circumstances Concerning Child I Independent Author John Fox MSc, PhD November 2012 Child I Serious Case Review – Executive Summary 1 CONTENTS PAGE 1. Introduction and summary of circumstances 1 2. Process of the Review 3 3. The lessons learnt from the case 5 4. Recommendations for the LSCB 8 1. Introduction 1.1 What is a Serious Case Review? 1.1.1 A Serious Case Review is held when a child has died, sustained a potentially life threatening injury, or been seriously harmed as a result of being subjected to sexual abuse, and the case gives rise to concern about the way in which local professionals and services worked together to safeguard and promote the welfare of children. 1.1.2 A Serious Case Review examines the ways in which the agencies involved with the family and child worked together and individually to support them. The aim of analysing these cases is to learn how services could be improved in the future to reduce the risk of other children suffering in the same way. 1.1.3 The Government provides advice and guidance on how to conduct a Serious Case Review. These are contained in “Working Together to Safeguard Children 2010” which states that: 1.1.4 The purpose of serious case reviews carried out under this guidance is to: • establish what lessons are to be learnt from the case about the way in which local professionals and organisations work Child I Serious Case Review – Executive Summary 2individually and together to safeguard and promote the welfare of children • identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • improve intra- and inter-agency working and better safeguard and promote the welfare of children. 1.1.5 Serious case reviews are not inquiries into who is culpable for the harm to a child. 1.2 Summary of Circumstances Leading to the Review 1.2.1 The subject of the Serious Case Review is a child who died at 8 weeks old. 1.2.2 At about 6.25 on the morning of Saturday 17th March 2012, an ambulance was called to the home because the child was reported to have been found cold and unresponsive in a cot by the parents. The paramedics attempted resuscitation and transported the child to the Accident and Emergency Department at Hospital where, despite further attempts at resuscitation, the child was pronounced dead at 7.09am. 1.2.3 It was noted by medical staff that the child had bruising on abdomen and on both knees. This bruising was confirmed as being present prior to resuscitation attempts. The parents were asked about the origin of the bruising and they claimed that they had already taken the child to their GP who had given an opinion that they were abnormal blood vessels. This explanation, or another medical cause, was considered likely by a doctor at the hospital but he also suggested that a non accidental cause remained a possibility. 1.2.4 Post mortem X Rays and examination of the child by Forensic and Paediatric Pathologists later revealed the presence of recent blunt trauma injuries to his head, abdomen, back and limbs. Internal examination revealed a significant head injury caused no more than 5 hours before his death, rib fractures of differing age and blunt force injuries to all four of his limbs. The pathologist suggested that the head injury was the likely cause of death. Child I Serious Case Review – Executive Summary 31.2.5 During the period when the child was being treated in the Accident and Emergency Department, the police were called and a Detective Sergeant attended as the lead investigator. There was some tension and a breakdown in communication between the police and medical professionals during the 'rapid response' phase and a significant gap in time between the death being confirmed and X Rays being undertaken to reveal the full extent of the child injuries. It soon became apparent that the GP denied ever seeing any bruising on the child or diagnosing abnormal blood vessels. 1.2.6 The parents were later arrested by the police on suspicion of murder. A Serious Case Review is not concerned with establishing culpability but the analysis in the full Overview Report is underpinned by a belief that the child injuries were deliberately inflicted by someone within the household responsible for his care. 1.2.7 The Independent Overview Report Author concludes that no individual or agency had information which could reasonably have led them to predict the events which triggered this review. However, the full Report also describes a failure to take into account the troubled background of the parents when providing universal services, difficulties in respect of inter-agency communication and challenge, a lack of professional judgement and under-resourcing in respect of key medical diagnostic services which led to a failure to quickly identify and respond to significant injuries suffered by the child. 1.2.8 The Overview Report also identifies some good practice by agencies and professionals and offers recommendations for action to improve the services offered to children and families. 2. Process of the Review 2.1 Independence 2.1.1 In his document Protection of Children in England: A Progress Report Lord Laming (2009) expressed the view that in carrying out a Serious Case Review, it is important that the chairing and writing arrangements offer adequate scrutiny and challenge to all the agencies in a local area. For this reason, the chair of a Serious Case Review Panel and the author of the Overview Report must be independent of all of those local agencies that were, or potentially could have been, involved in the case. Child I Serious Case Review – Executive Summary 42.1.2 To ensure transparency, and to enhance public and family confidence in the process, The Chair of the Northamptonshire Safeguarding Children Board appointed two independent people to lead the Serious Case Review. Mr Kevin Harrington – Independent SCR Panel Chair 2.1.3 Mr Harrington was appointed to chair the Serious Case Review Panel formed to oversee and manage the review process in this case. He was the lead person for ensuring a robust and transparent review was carried out within each relevant agency, and for ensuring that the project management plan was effective. Mr John Fox – Independent Overview Report Author 2.1.4 John Fox was responsible for drawing together all elements of the individual agency reviews. He was responsible for analysing the professional practice of professionals and organisations, writing a full Overview Report and making recommendations to the LSCB for further action to better safeguard children. 2.1.5 Neither of these Independent People has had any involvement directly nor indirectly with the child or any members of the family concerned or the services delivered by any of the agencies. 2.2 Individual Management Reviews 2.2.1 The following agencies and organisations contributed to the learning by this Review. Individual Management Report provided by: Northampton General Hospital NHS Trust Northamptonshire Healthcare NHS Foundation Trust - Primary Care GP Northamptonshire Police NHS Northamptonshire (Health Overview Report) Child I Serious Case Review – Executive Summary 5 Factual Report provided by: East Midlands Ambulance Service Connexions Northamptonshire Education Housing Services Northamptonshire Probation 2.3 SCR Panel 2.3.1 A dedicated Serious Case Review Panel of senior managers from the following agencies was set up to assist with the management of the review and to ensure the maximum amount of learning. Panel membership was as follows: Kevin Harrington Independent Chair of Serious Case Review Panel Children’s Services Manager, NSPCC Detective Chief Inspector, Northamptonshire Police Designated Nurse for Safeguarding Children, NHS Northamptonshire Head of Integrated Safeguarding and Quality Assurance Services Standards, Research and Development Manager, LSCBN 3. Conclusions and key lessons learnt from the case 3.0.1 There was a considerable body of information in health and education records which indicated that the child’s parents had both suffered a traumatic childhood. Whether this may have impacted upon their parenting capacity was not considered by those providing a service to the child, and it would appear that in any case most of this potentially relevant information remained in archives and was not Child I Serious Case Review – Executive Summary 6actually accessed by those working with the family, in particular the midwife at the ante-natal and immediate post birth stage. 3.0.2 The childhood background of the parents, whilst worrying in many respects, was not so remarkable as to be highly indicative of a likelihood that they would inevitably fail to care for the child. However, it is reasonable to suggest that had it been accessed the information held in agency files about the parents own troubled background should have triggered a more intensive assessment of their parenting capacity and possibly enquiries under the Common Assessment Framework 3.0.3 The reason for midwives not accessing relevant information about the child’s parents held by the GP was that without prior safeguarding concerns this would not be routinely done. This is something of a chicken and egg situation because it was only by accessing the GP records that they could have discovered information which may have caused them to conduct further enquiries about the mother’s parenting capacity. 3.0.4 Little was known by professionals about the child’s father and it was revealed during the SCR that paternal medical records are not accessed by community midwives as it is considered that the community midwifes only have the professional/client relationship with the expectant mother and the unborn child. It is also perceived to be a breach of the Data Protection Act to access a father’s medical records. This latter point is wrong because there is a legitimate interest in a group of health professionals working with a particular family sharing information to better ensure that the potential vulnerability of a child is properly assessed. In respect of the professional/client relationship, it is also reasonable to expect that each parent with an ongoing primary care-giving responsibility should be considered as a ‘client’ of the relevant health professionals. 3.0.5 The primary health professional working directly with the family was a Student Health Visitor who had been assessed by her HV Mentor as competent to undertake home visits alone. Whilst no evidence was found to suggest that the work carried out by this Student HV was anything other than satisfactory, there were concerns about the process by which she was allocated this family and also a lack of adequate supervision. Had it been accessed, there was sufficient information available to suggest that this was not a suitable family for a Student Health Visitor to have been allocated. Child I Serious Case Review – Executive Summary 7 3.0.6 In the hours following the child’s death a significant breakdown in inter-agency working occurred which might, if not addressed, have a future impact on other vulnerable children with Northamptonshire. The breakdown occurred between the police Lead Investigator and the Responsible Paediatrician and may have been partly caused by the fact that the first police officer did not arrive at A&E until an hour and a half after the child had been pronounced dead. This, in turn may have been partly due to a delay in informing the police that the child had collapsed at home and died. 3.0.7 The Responsible Paediatrician has specific responsibilities under the LSCBN childhood death protocol (CDRA) which in this case were not entirely fulfilled. In essence, the paediatrician failed to cooperate in a reasonable and professional way with the police and failed to lead a multi agency investigation into how and why the child died. 3.0.8 The Review also revealed an apparent failure to identify significant child abuse injuries by the Responsible Paediatrician involved in the case after the child had died, and therefore there appears to be a gap in the training of doctors within NGH. In addition, there is a gap in service provision at NGH because it was not possible to carry out a full skeletal X-Ray on Kieran during the weekend he had been admitted to A&E. 3.0.9 The SCR identified concerns relating to the ability of the police Lead Investigator to challenge the diagnosis by the Responsible Paediatrician, and also concerns that despite a considerable body of other evidence, the police felt that only a clear conclusion by the Consultant Paediatrician could give them ‘reasonable suspicion’ that a crime had been committed. It is evident that Northamptonshire Police does not comply with guidance issued by the Association of Chief Police Officers to the effect that a Detective Inspector should be deployed as the Lead Investigator in cases of unexpected childhood death. Had such an officer been so deployed it is possible that a better evidential assessment would have been made and in particular that a Forensic Pathologist would have been asked to review photographs 3 days before this actually took place. 3.0.10 However, this SCR did not identify serious failures by agencies or professionals which might clearly have had a bearing on the outcome for the child, and there is little evidence to suggest that any agency providing the child with a service failed to fulfil their Child I Serious Case Review – Executive Summary 8responsibilities, statutory or otherwise, to safeguard and promote the child’s welfare. 3.1 What Happens Next? 3.1.1 Recommendations from this Review form the basis of an action plan, which is regularly monitored by the LSCBN Serious Case Review Committee to ensure that the recommendations are completed. In addition to the recommendation contained below, some agencies have drawn up individual recommendations, and each of these each agencies has agreed to implement an action plan to implement the learning in this case. 8 Recommendations for LSCB These recommendations should be read in conjunction with the Action Plan which provides detail about methods of implementation and timescales. Recommendation 1 It is recommended that the Chair of LSCBN seeks reassurance from the Clinical Director for Paediatrics at NGH that the safeguarding training for Consultant Paediatricians who are expected to perform the role of Responsible Paediatrician under CDRA protocol has been reviewed in light of this case and is fit for purpose, and that no doctor will be asked to perform that role without such training. Recommendation 2 It is unacceptable that there is no facility within Northampton to carry out a full skeletal survey on children at weekends. It is recommended that the LSCB Chair writes to the Director of Nursing for NHS Northamptonshire asking for reassurance that in the LSCB area, radiology, as a diagnostic tool, would be made available for children whenever it was required. Recommendation 3 The LSCB Chair should ensure that the two constituent agencies, East Midlands Ambulance Service Trust and Northamptonshire Police, Child I Serious Case Review – Executive Summary 9report to the LSCB on the feasibility of an arrangement whereby in all cases when an ambulance is despatched to an actual or suspected sudden and unexpected childhood death, immediate communication is instigated between their respective control rooms, thereby reducing the response time for police attendance at A&E. Recommendation 4 LSCBN should be concerned about a perception by NGHT staff that they cannot access relevant notes of the father of a child due to data protection laws. It is recommended that after a review of the legal position is undertaken, the LSCB Chair writes to the Chief Executive of the Trust to seek reassurance that the fathers in potentially vulnerable families will be subject to the same level of enquiry as mothers. Recommendation 5 The LSCB Chair should write to the Department of Health inviting them to note the perception revealed by this Serious Case Review that information about fathers cannot routinely be accessed or shared between health professionals, and that Midwives only consider the mother of a child to be their ‘client’. The Department of Health should be asked to explore whether its own guidance contributes to this perception or does enough to dispel it. Recommendation 6 The general lack of engagement in this Review by the Named GP for Child Protection was of considerable concern to the SCR Panel and LSCBN should investigate why this occurred and ensure that any future SCR’s are not disadvantaged by such a lack of engagement by a key service provider. |
NC046478 | Serious, non-accidental injury of a 4 1/2-week-old child in November 2012. Child X was admitted to hospital with injuries including: up to eight rib fractures, retinal haemorrhages, traumatic subdural haematoma, and leg and foot fractures. Mother and father were convicted in relation to the injuries. Bruises and haemorrhages were seen by a number of professionals in the days prior to the incident including: hospital staff, during two separate admissions; GP; and health visitor. Mother was 18-years-old when Child X was born; maternal grandmother reported that mother had witnessed sexual abuse against her sister by her father and was physically abused by her father as a young child. Identifies issues including: insufficient knowledge of parental history; administrative weaknesses including the loss of papers regarding the targeted status of the family in transit between health visitors and delayed transfer of information between hospital and community health services; insufficiently robust assessments; inadequate recording of injuries; failure to follow procedures in relation to bruises in non-mobile children; optimistic thinking, failure to revise judgments and insufficient professional challenge; invisible fathers; and failure to undertake multiagency discussions. Makes recommendations covering Surrey Safeguarding Children Board, health services and children's services.
| Title: Overview report on the serious case review relating to Child X. LSCB: Surrey Safeguarding Children Board Author: Alan Bedford Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Overview report on the SERIOUS CASE REVIEW relating to Child X Independent Author: Alan Bedford October 2013 Update November 2014 2 INDEX Section Page SUMMARY 4 1 INTRODUCTION 7 1.1 Rationale for a Serious Case Review (SCR) 7 1.2 Anonymity 8 1.3 Family Details 8 1.4 Summary of circumstances leading to the SCR 9 1.5 Terms of Reference 10 1.6 SCR Process 10 1.7 Individual Management Reviews 11 1.9 Methodology 12 1.10 Publication 12 1.11 Family Involvement with Review 12 1.12 Surrey Safeguarding Children Board Approval 13 2 THE FACTS 14 2.2 Up to the birth of Child X 14 2.3 After Child X’s birth to the major injuries 16 2.4 The hospitalisation that lead to the diagnosis of traumatic injury 24 2.5 Diagnosis 26 3 ANALYSIS and APPRAISAL 28 3.3 Was there sufficient information about either parent by the time of pregnancy that might have affected the supervision of, or help provided to, the family? 28 3.4 Health visiting in the antenatal period 30 3.5 Birth 30 3.6 Midwifery care post birth 30 3.7 Guidance on Bruising 32 3.8 Hospitalisation Days 10-14 34 3.9 Health Visiting Services 34 3.10 GP Involvement 37 3.11 Hospital attendance Day 21 38 3 Section Page 3.12 Communications with community health services 40 3.13 Summary up to admission on Day 30 40 3.14 The admission of the seriously unwell X on Day 30 to ASPH 41 3.15 The transfer to St George’s 43 3.16 Race, religion, language, culture 45 3.17 Capacity and Climate 45 3.18 Fathers 45 3.19 Involved relative 45 3.20 Diagnosis of fractures 46 3.21 Summary 47 4 WHY DID THIS SEQUENCE OF EVENTS OCCUR? 49 4.2 Administrative weaknesses 49 4.3 Interagency referrals 49 4.4 Why bruising was not taken more seriously, and an assessment of real risk not made sooner 50 4.5 Why there were no multiagency meetings 53 5 CONCLUSION 54 6 RECOMMENDATIONS 55 APPENDICES App 1 Recommendations from IMRs 58 App 2 Appraisal of IMRs 61 App 3 Key dates 62 App 4 Bruising in Children who are Not Independently Mobile: multi agency guidance 63 App 5 Terms of Reference 66 App 6 Acronyms 69 4 SUMMARY i. This Report is the overview of the Serious Case Review (SCR) which was commissioned by the Surrey Safeguarding Children Board (SSCB) as statutorily required when a child has suffered a serious injury, and there is concern about the way agencies worked together. The Report and recommendations were accepted by the SSCB on 26.09.13. In this case, a four and a half week old baby, born to young parents, was admitted to hospital and eventually found to have brain haemorrhages, several leg and foot fractures, and multiple rib fractures – all of which are thought to have been caused by abuse. In the previous 3 weeks several bruises and eye haemorrhages had been seen but none had been deemed to be from abuse. It is likely that some of the marks were seen after fractures had started. Both parents were convicted in relation to the injuries. ii. Despite the SSCB having a policy in place (see appendix 4) that says that any bruise to a baby who is non-mobile of its own accord must be referred to social care and then referred on for paediatric examination, five different disciplines did not follow that policy. Midwives and health visitors knew of the policy but accepted parental explanation and did not refer on, nor did they discuss it as potential abuse with their managers/advisers. The local hospital (nurses and doctors) similarly accepted explanations, or assumed wrongly that there was “easy bruising”. Paediatricians did not think the policy applied to them, and that they could use their clinical judgement as to whether it was abuse or not before any referral to social care. The GP was unaware of the policy and the GP’s clinical assessment concluded that the marks seen did not constitute abuse. iii. This failure to follow the bruising policy may have been related to the fact that the general SSCB policy about referral of injuries to social care did allow a judgement to be made on the likelihood of abuse before a referral is required. Recommendations in this Review ask the SSCB to explore why professionals did not follow the bruising policy, and to make any necessary adjustments to the policy, provide associated training, and monitor through case audit the compliance with guidance on the reporting of bruising and injuries. iv. Throughout the case – over the baby’s life of less than five weeks – there were numerous examples of poor recording and communications. Midwives and health visitors did not record drawings of bruises, making comparison over time difficult. The first injury seen was recorded as being seen five days earlier than it was actually seen, and other agencies in good faith repeated this record on their own notes. Communications from the local hospital were inconsistent and sometimes incorrect, and often delayed. A GP for example examined the baby with a bruise, having not yet been told by the hospital of two prior A&E attendances, or a four day admission which had ended six days earlier – and thus had no knowledge that many professionals had already seen the bruise. Information about A&E attendances that community health services glean from A&E records and then forward to appropriate community staff 5 sometimes took weeks to arrive. Key information between health visitors was either not sent, or not received. v. This Review has made recommendations in relation to all suspicious marks being drawn on body maps, tardy communication processes being reviewed and improved, SSCB auditing case files to monitor improvements in recording and communication following this review, and emphasising just how important are accurate records. There are recommendations for the community health services to ensure health visitors always discuss suspicious marks with more senior staff, and for the SSCB to be assured about GP compliance with safeguarding training requirements. vi. There were four home visits by midwives – each by a different midwife. The Review makes a number of recommendations about community midwifery to the NHS Trust concerned, including a review of continuity of care, and making arrangements so that midwives are informed of any A&E attendances of babies they are visiting. vii. There were no obvious warning factors prior to birth, but midwives did refer the pregnant mother to social care, concerned about her vulnerability after having to leave her then home. Had social care explored all old records they would have identified that the mother herself had experienced abuse in her own family, which might have added to the assessment of vulnerability. There was lack of clarity about what the midwife referral was actually for, and this probably contributed to social care taking no further action. The Review recommends that the SSCB should ensure there are effective processes in place so that the purpose of referrals is clear. viii. It took some time for the fractures and head injuries to be identified after admission. The local hospital did not locate records of the baby’s prior attendances on the first day of admission and so the records of three prior bruises seen as an inpatient and outpatient were not known. Nor was any professional outside the hospital contacted for background information. This contributed to there being no record of suspicion of abuse, and a working hypothesis of overwhelming infection was the focus, even when blood was found in the spinal fluid. When the history was identified the next day, a chest x-ray and the MRI scan were thought to be clear, although a CT scan may have been a better test. ix. When the baby was so ill that a transfer to a specialist hospital was required, the receiving hospital was given no information about prior bruising, and knew that tests had been ‘clear’, so continued to focus on a medical rather than traumatic cause. Again there were no discussions with anyone outside the hospital. It was only when their specialists re-examined the local hospital tests that rib fractures and brain haemorrhages were seen, and abuse diagnosed. Sight of those tests was delayed as admin reasons prevented them being available quickly. A later full body x ray identified further leg and foot fractures. x. There are recommendations for the local hospital about reviewing its arrangements for ensuring rare or unusual images can be assessed by doctors with sufficient expertise, and for the specialist hospital about ensuring that test results transferred from referring hospitals can be more promptly seen. 6 xi. Throughout this case, until the injuries were diagnosed, there were no multiagency meetings to pool thoughts about the growing number of concerns. This was because no one thought abuse was occurring, but this was often in the absence of knowing what other people knew. The purpose of the policy about babies who are not independently mobile is to ensure that staff do not makes decisions on their own, but this is what often happened. xii. The Review explores why bruising was not taken more seriously, and fuller assessments of risk not undertaken. The answer lies in dynamics within and between professional staff which are seen in SCR after SCR, and which will often occur if there is not the strongest system of management, supervision and training in place to mitigate the risks involved. The first is a rule of optimism, where there is an innate hope for the best that can overtake any evidence to the contrary. Reasons why something might not be abuse are given stronger weight than sceptical inquiry. xiii. Secondly, there is another human tendency which is not to change one’s mind having reached an initial conclusion – again in face of evidence. An example was the local hospital believing that a propensity to bruise easily was the key explanation, with no consideration that a baby might for example bruise easily and be abused. The view, not backed by any incontrovertible evidence, was so strong that even when the old bruises were eventually recalled after the baby’s admission and when the baby was seriously unwell, abuse was never really considered as a cause, and the hospital that the baby was then referred on to was told nothing about previous marks. xiv. The SSCB is asked to ensure that the human tendency towards optimism and unchanging views is addressed in training, and that its member agencies examine their processes to ensure management and supervision arrangements are robust enough to assist staff with these tendencies. xv. The third and related dynamic is a lack of challenge – either to parents or to professional colleagues. Sometimes staff feel that ‘challenge’ is too confrontational, rather than seeing it to be simply requiring good answers. In this case, with the exception of one junior doctor, staff did not challenge each other as no one thought abuse likely. However by not discussing bruises with managers or safeguarding advisers they were denied the challenge that such more distant and objective staff might have made. Nevertheless, it is surprising that only one of the numerous doctors, nurses or midwives formed a more sceptical view and acted in a way that would challenge the thinking about what might be going on. The Review asks the SSCB to review whether it thinks there is a sufficient culture of challenge in Surrey, and that challenge is seen as a highly valued professional activity. xvi. It is important to recognise that, with so many staff making what look in hindsight to be errors, it is unlikely to be just a simple matter of individual responsibility. Whilst agencies may form a view about individual performance, the answer to improvement is much more likely to be found in addressing the systematic issues described. Improving administrative processes and commitment to them, clarity about the expectations of the bruising policy, and in ensuring that systems support staff with any 7 tendency to optimism, unchanging views and reluctance to challenge, is the heart of improvements for the local health and social care community. xvii. It cannot be concluded that the major injuries could definitely have been prevented, although best practice may well have done so. The Review identifies: many failures to follow agreed policy; missed opportunities to have shared concerns with other agencies, more senior staff and safeguarding advisers; a lack of any process that would have weighed up the whole picture. Had this been done much better, there may well have been more monitoring, more support for the family, and more professional scepticism and query about what was happening. Unless the baby had been removed from home after one or other of the bruises – which may not have happened – the more serious injuries could still have occurred. However, had there been an x-ray when the baby was seen in hospital with the bruises, then it is possible that rib fractures would have been evident –in which case intervention could have prevented subsequent injuries. xviii. Whether the injuries were preventable or not, there is very significant learning from this review which should help babies in a similar position in future. 1. INTRODUCTION 1.1. Rationale for serious case reviews (SCR). 1.1.1. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases in accordance with procedures set out in chapter 8 of ‘Working Together to Safeguard Children’ (HM Government, 2010), referred to here as WT2010. The SCR was commenced several months before the publication of the 2013 version of Working Together (WT2013), and was concluded using the WT2010 guidance. 1.1.2. When a child dies or is seriously hurt, and abuse or neglect is known or suspected to be a factor, the LSCB should conduct a Serious Case Review (SCR) into the involvement that organisations and professionals had with that child and their family. The purpose of an SCR as defined by ‘Working Together’ is to: establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result; and as a consequence, improve inter-agency working, and better safeguard and promote the welfare of children 1.1.3. The Surrey Safeguarding Children Board (SSCB) Chair, having heard the advice of the Strategic Case Review Group, decided in December 2012 to 8 commission an SCR because the child had suffered a serious injury and the case gave cause for concern about the way professionals and services worked together. 1.2. Anonymity: 1.2.1. The details relating to the family and individuals are anonymised. Specific dates, and dates of birth, are omitted to aid anonymity 1.3. Family Details 1.3.1. All are white British Mother: Mother of Child X aged 18 at X’s birth Father : Father of Child X aged 20 at X’s birth Child X Their baby born autumn 2012 Maternal grandmother Maternal grandfather Paternal grandmother A The aunt of X and younger sister of the mother The family structure is set out in the genogram below, referring only to those family members mentioned in this report 9 FAMILY TREE 1.4 Summary of Circumstances leading to the Serious Case Review 1.4.1 Child X was admitted to hospital at 30 days old and was eventually diagnosed with up to 8 fractured ribs, retinal haemorrhages, traumatic subdural haematoma (bleeding in the brain) and several leg and foot fractures. In the SSCB’s early consideration of the case, information emerged about the vulnerability of the young mother, and about a number of bruises and other symptoms prior to the major injuries – which may have indicated prior abuse. In addition, the baby was hospitalised for several days for apparently medical reasons. 1.4.2 Child X was seen at hospital at 5 days old for constipation/blood in stool. An abdominal bruise was seen by a midwife at 10 days old, and X was later hospitalised from 10-14 days old after symptoms including blood stained vomit, and the bruise were seen. A facial bruise was seen by the GP, and then the health visitor at 20 days old, along with an old linear abdominal bruise. The facial bruise was also seen, with an additional thigh bruise, on a hospital visit at 21 days old. At 27 days old the health visitor noticed haemorrhages in both eyes. The admission which led to the identification of the major injuries was at day 30. Female Male Enduring relationship e.g. marriage or cohabitation Divorced Paternal Grand-father Paternal Grand mother Mother’s Step - Father Maternal Grand Mother Paternal Grand-father Deceased Father Mother A Sister Baby X Separated 10 1.4.3 The matter was investigated by Surrey Police and both parents were charged and later convicted in relation to the injuries 1.5 Terms of Reference (TOR) 1.5.1 The full TOR are contained in appendix 5. These contain more specific questions to be answered in addition to overall aims which are as in 1.1.2 above. 1.5.2 The timeframe of the review is from pregnancy to the Strategy Meeting after the injuries were diagnosed, although historical information that may have informed professional assessments and decisions during the time frame could be considered. 1.6 The SCR Process 1.6.1 The LSCB appointed Fergus Smith as the independent chair of the SCR Panel. He is an independent consultant and director of Children Act Enterprises Ltd, and has no connection with the agencies in this Review. Alan Bedford was appointed as the independent overview author. He has a background both as a child protection social worker and manager, and many years as a CEO in the NHS. He had 4 years’ experience as an LSCB chair, has written overview reports, and is an accredited SCIE systems reviewer (although the SCIE methodology is not used here). He has no connection with agencies in Surrey. 1.6.2 The process was set up under the national guidance: Working Together to Safeguard Children 2010 (WT2010) but influenced later by the 2013 successor version. Under WT2010 an SCR Panel was set up to oversee the process. This consisted of: Post Organisation Independent Chair CAE Ltd DI Central Referrals Unit Surrey Police Designated Nurse Child Protection Guildford & Waverley CCG Area Head of Children’s Social Care NW Surrey County Council Safeguarding Advisor Adult Services Surrey County Council Group Manager: Team Lawyer Surrey County Council Independent Safeguarding Adviser Alan Bedford Consulting Quality Assurance Officer Surrey Safeguarding Children Board. Serious Case Review Administrator Surrey Safeguarding Children Board. 11 The panel was convened under Working Together 2010 and this report is in line with that guidance. The publication of Working Together 2013 has since removed the requirement for an SCR panel. 1.6.3 The Panel met on 7 occasions, including on one occasion with the IMR writers from the involved agencies. The IMR writers also had their own briefing session. 1.7 Individual Management Reviews 1.7.1 IMRs were produced by the following agencies, plus brief statements from Elmbridge Council, Surrey Education, and SE Coast Ambulance NHS Foundation Trust Ashford and St Peter’s Hospitals NHS Foundation Trust (A&E, Paediatrics, Maternity) – referred to in this report as ASPH St George’s Healthcare NHS Trust (Paediatric Intensive Care) Surrey County Council Children’s Social Care (Children’s Social Care) Surrey Police Virgin Care Services Ltd (Health visiting, School nursing) General Practice (IMR led by the Surrey Named Safeguarding GP) Guildford and Waveney CCG – a Health Overview Report 1.8 IMRs were produced by each agency by someone not involved in the case and signed off by a senior manager. Ongoing dialogue between the Panel, overview author, and the IMR writers ensured that issues the Panel needed to understand, some of which emerged during the process, were fully addressed. There is a brief appraisal of each IMR at appendix 2 IMR Authors Post Organisation Named Nurse for Safeguarding Children Virgin Care Services Ltd Deputy Chief Nurse Named Nurse Ashford & St Peter’s Hospitals NHS Foundation Trust CAMHS Service Development Manager Surrey County Council - Children’s Services Review Investigator, Major Crime Review Team Surrey Police Named Nurse for Safeguarding Children St George’s Healthcare NHS Trust Named GP for Safeguarding Children, Surrey Guildford & Waverley CCG (for the GP Practice) Designated Nurse Child Protection Guildford & Waverley CCG (The Health Overview) 12 1.9 Methodology 1.9.1 The methodology was as described in WT2010: LSCB Chair approved terms of reference, IMRs provided by involved agencies, a Panel of uninvolved agency representatives overseeing the process, and an independent Panel Chair and Overview Author. In addition, the overview author met the paternal grandmother, the lead GP at the involved Practice (with the IMR author), and the named doctor and midwife at ASPH. 1.9.2 Towards the end of the Review the Court made available to the SCR the Finding of Fact made by the Judge in the care proceedings. This is referred to in this report as the ‘Judgement’. These findings, which are made on the balance of probabilities, are incorporated into this report where relevant. This is mainly in relation to the extent, cause, and age of injuries. In the criminal proceedings, a higher standard of proof (beyond reasonable doubt) was used. 1.9.3 The SCR Panel accepted the level of detail used in this Review as necessary to maximise learning about compliance with procedures, opportunities for better practice, and to show how much knowledge can be available but not brought together. 1.10 Publication: 1.10.1 Both before and after WT2013 was published, there is an expectation that the reports of SCRs will be published, unless to do so would harm any children involved. This is so that the professional community can see the lessons that emerge for their work, and so that the public can see that the LSCB and agencies have looked closely at the case and taken responsibility for the findings. The emphasis is primarily on learning, so SCRs are produced in a way that anonymises child and family identity, and individual staff identity, wherever possible. Care is taken to include only information that is relevant to the terms of reference. Publication of the approved report was not possible until the criminal process had been concluded 1.11 Family Involvement 1.11.1 Both parents were approached separately through their representatives to invite them to contribute to the review. It was made clear that the discussion would be about services they had received, not matters of culpability but neither parent accepted the invitation. Through his legal representative, the father declined to be seen. Both through solicitors, and directly, the mother was offered the opportunity to give her views to the SCR but the invitation was not accepted. The paternal grandmother did agree to discuss her views about how the case was managed, and this is described in the report. After the convictions and before publication, family members were offered the opportunity to hear about the SCR findings. The author met the paternal grandmother, and the LSCB Chair and Partnership Support Manager met the father. The mother did not accept the invitation. 13 1.12 Surrey Safeguarding Children Board Approval 1.12.1 This SCR Report and its recommendations were accepted by the SSCB at its meeting on 26.09.13. 14 2. THE FACTS 2.1. Background 2.1.1. This section describes what happened in the case, and includes events or knowledge that was or may have been relevant to looking at whether what happened might have been prevented, and to looking at the quality of services to the family. 2.1.2. The facts are deliberately described in some detail as they demonstrate what was known to whom, and how complicated the story became without any central coordination or assessment to pull it together. The period from birth to diagnosis of the injuries was just 5 weeks. The picture described below was put together with some difficulty given the problems with the accuracy, timeliness and consistency of records. No apology is given for the complexity below as it helps to illustrate how unclear the professional picture was at the time, and the difficulty caused by the lack of any collective view that might have led to different conclusions. 2.1.3. Headline dates are charted in appendix 3 2.2. Up to the birth of Child X This section covers events up until the birth in hospital of Child X. 2.2.1. There is not a great deal known about the mother-to-be’s childhood, but when she was 5 her birth father (now deceased) was imprisoned for sexual offences against one of her sisters. Records of a 2009 Children’s Service assessment quote the maternal grandmother as saying her daughter – the mother-to-be in this case – witnessed the offences, and that all her daughters were abused. There is also a suggestion that the mother-to-be was hit by her father, Child X’s maternal grandfather. The maternal grandmother remarried. There is only some knowledge of schooling, where the mother to be was noted as having some learning and social difficulties and, for a period up to 17 months before the baby’s birth, was being supervised by the school nurse for safeguarding concerns. The SCR has sought, but not obtained, the reason for this. 2.2.2. It is also unclear why a school nurse was involved, as Education informed the SCR that the mother-to-be’s schooling ended in 2010. Surrey Children’s Social Care was aware of the mother as her sister A has been looked after since 2009 as a result of challenging behaviour and a breakdown of relationships in the home. Some aggression from the mother to be to her sister A was noted. Social work assessments at that time suggested a rather chaotic and unstable home life, but the initial assessment of the mother to be concluded there were no issues for her. Prior to Child X’s birth the mother to be had two jobs in nurseries: one ended 3 months before the birth, and she was on maternity leave from the other. Little is known about the father (age 15 20 at Child X’s birth). There are records indicating that at school he had some learning difficulties, and Children’s Social Care have a record of some minor involvement with the police as a teenager (no convictions) in relation to alcohol or being a potential victim of links with older drinkers. This was not known to professionals working with him as a prospective / new parent. The father’s name appeared in obstetric records, but was then crossed out. 2.2.3. The mother-to-be (hereafter described as ‘mother’ unless referring to pre pregnancy) became pregnant in late 2011 and was referred early in 2012 by the GP to maternity services, which are part of Ashford and St Peters NHS FT (ASPH). Both parents were seen in the following month by the community midwife and no concerns were noted. As it was a teenage pregnancy (the mother was 18) she was offered, but refused, parent education, and the opportunity for an assessment under the Common Assessment Framework. She was noted as having housing and financial problems, and not being known to Children’s Social Care. (She was actually known, as an initial assessment had been done on her in 2009). Two months before the birth she again refused teenage parenting classes. Routine antenatal appointments when she was in Surrey were kept. Ante-natally she saw (at least once) two of the midwives who later visited her at home post-natally, plus other midwives. She attended A&E and the labour ward on two occasions in the early stages of pregnancy with sickness and inability to tolerate food and drink. On the second occasion she was admitted overnight. 2.2.4. In mid-summer, the mother reported being ejected from her own parental home. Housing had been arranged in Hounslow. The midwife suggested booking into Wexham Park Hospital for the delivery. The midwife, on the advice of her team leader, notified Children’s Social Care in Surrey of the mother’s problems, although it is unclear what was expected from the communication. The midwife (MW1) told Children’s Social Care that there had been no previous problems and that she was advising for information only. The Virgin Care IMR describes the midwife contact with social care as ‘escalation’. No further action was taken. There is no indication, in the notes of the referral, that Children’s Social Care made the link with A or the information about the then mother-to-be in A’s assessment and from her Looked After records about the childhood abuse. The IT audit system shows the record was accessed that day, but it does not show which elements were looked at. The school nursing service would have known that the mother-to-be was on a ‘targeted’ list by the school nurse only a year before because of concerns about her well-being at home. The midwifery service knew none of this. The mother told midwifery a few weeks later that she was returning to Weybridge. 2.2.5. The same month the maternal grandmother told Children’s Social Care (visiting in relation to a sister) about the physical abuse her daughters had experienced from their late father when they were very young. The sister’s social worker was not aware of the midwife’s ‘referral’ about the mother. 16 2.2.6. The SCR has been supplied with no information about antenatal care in the two months mother lived elsewhere. On her return, a health visitor from one part of the county (HV1) called to make an antenatal visit at the maternal grandmother’s home but was told she had now moved. This visit was under the policy to provide targeted antenatal health visitor support for mothers with additional needs. Health visitors could have seen from community nursing electronic records, had they looked, that the mother to be had been a school nurse safeguarding concern. Although the original health visiting team say the targeted status was passed on, the new team say nothing was received and, in not being aware of it, the case was allocated to a bank health visitor (HV2) rather than a regular staff member. There was no discussion between the two areas about transferring a targeted case between them. No antenatal visit was made by a health visitor. 2.2.7. A month before the birth, the mother referred herself to maternity at St Peter’s with reduced foetal movement. (In this report “St Peter’s” is used rather than ‘ASPH’ if it refers to something specific that happened there, as opposed to corporate Trust issues where ‘ASPH’ is used). She was reassured and discharged. She saw the GP for an ante-natal check 4 days before giving birth. This was the second of two antenatal GP contacts described by the Practice as ‘unremarkable’. (She had only registered with the GP 7 weeks before she gave birth). She referred herself to hospital for reduced foetal movement 2 days before birth, but was seen as normal, and she was discharged to come back the next day, was admitted and Child X was born with father present. The care proceedings Judgement determined that no injuries later seen were caused in the birth process. Mother and baby were discharged at 9pm on the day of birth, although the hospital discharge summary says the discharge was the following day. No problems were identified with Child X. A maternity record says that the mother had experienced one prior neonatal death (death within 28 days of birth) but this does not appear to be correct. 2.3. After Child X’s birth to the major injuries This section covers the events from Child X’s arrival home after birth to admission to hospital in November with what proved to be life threatening injuries. The events are described chronologically as they show the growing number of opportunities for concerns to be formed. These are analysed in Section 3 ‘Analysis’. The baby’s age in days is given, with 0 being the day of birth. Day 1 A midwife (MW2) visit was unsuccessful. The paternal grandmother says it is very hard for people in the flat to hear visitors. The mobile number the midwife had was wrong. The correct number was obtained, and the mother was called and she said all was well. No visit was made. The paternal grandmother says that on the day after birth her son told her about hearing a click in the baby’s leg when changing her, and advised they tell the midwife. There is no record that they did. When relating 17 the click story to a paediatrician, after the last injuries, it was described as a ‘massive crack’ but the Judgement said this day predated the earliest time fractures were thought to have occurred. Day 2 A midwife (MW3) visited, and the ASPH chronology says ‘no concerns’ were noted. The Judgement said that this was likely to be the very earliest date the rib fractures which were discovered later could have occurred. Day 5 The paternal grandmother took the baby with both parents to St Peter’s A&E at 2.26am for constipation and blood in the stool. The A&E record said only father attended. No concerns were noted by the Paediatric Registrar or nursing staff. Health visitors were unaware of this attendance until Day 20 as the paediatric liaison nurse did not see the attendance record until Day 10 and the forwarding by internal mail took until Day 20. There is no record at the GP Practice of A&E notifying the GP of this attendance, and the first time it was mentioned was in a letter on another matter received on Day 20. Later on Day 5 another midwife (MW4) did a home visit and there were no concerns. She was aware from the parents that Child X had been taken to A&E earlier that day. The Strategy meeting after the injuries were diagnosed was told the parents declined this visit as they were going out, but this appears not to have been the case. See also Day 10 below, as much of what happened then was recorded as happening on Day 5. Day 8 There is no record of the following, nor of any action in response in hospital records, but on this day the paternal grandmother says she saw a left, linear abdominal bruise which she said the parents had found on waking. The parents indicated this may have been caused by a car baby-seat belt when Child X was being transported by a relative. The Review was told that the mother tried to call the community midwife but did not succeed, so the paternal grandmother says she called the maternity ward and other numbers at the hospital to see if they could get the community midwife to call. The reason given was because of the bruise. The paternal grandmother says that maternity said they could not do this and to ‘keep trying’. She had expected the hospital to locate the community midwife or ask to see the baby. As the baby seemed well, and as they perceived they were getting no help, they decided to wait for the next midwife visit which they knew would be in the next day or so. No ASPH record has been found of these calls, to confirm the information provided to the SCR. 18 Day 10 Possibly the previous night, the Judgement said the parents had given evidence of a cut lip on X and a high pitched scream. When MW2 visited, her first home visit to the family, father was waiting outside and told her about a left abdominal bruise, saying it was caused by too tight a car seat belt. It is not mentioned in the mother’s notes, but in the baby’s notes the midwife record of the visit says there was a bruise on the left side. The notes do not describe or draw it, or specify where on the left side it was. It was later, after the major injuries were identified, described as round, brown, and of 1cm diameter – in an unspecified place. The midwife later told a hospital doctor she reviewed the seat and found the story acceptable. Advice was given about doing up the belt. The baby was said to have been wearing thick clothes which had made the strap tight. No drawing was made. No medical examination was sought. The bruise was not reported to the midwifery supervisor or to the named safeguarding midwife. A medical note by a hospital doctor about a Day 13 phone call with MW3 says the midwife indicated the parents had been trying to contact her about the bruise before her visit, but that is not in midwifery notes. The description of the bruise is quite different from that described by the paternal grandmother two days earlier, or by the hospital the next day. The mother’s hand held midwifery record written by MW2, which mother later showed hospital staff, showed this incident happening on Day 5. The SCR pursued this and identified that the ‘Day 5’ had been changed to the ‘Day 10’ only after the injuries and the midwife looked at the records for the IMR. Day 10 is likely to be the correct date as a different midwife went on Day 5. The paternal grandmother recalls the mother saying the midwife was not worried about the bruise and was ready to ‘sign her off’. Later on Day 10, in the afternoon at 14.52, Child X was taken to St Peter’s A&E by parents and paternal grandmother with blood-stained vomit and being unsettled. There is no mention of the abdominal bruise on the A&E record or in the summary sent to the GP, although the paternal grandmother says it was discussed while the baby was still in A&E. The hospital was unaware that a midwife had seen a bruise earlier that day. The paternal grandmother says that she was concerned there might be a link between the bruise and the blood stained vomit, and suggested to a doctor there ought to be an X ray to rule out a traumatic cause (although not thinking it might be NAI). She says the reply was that the baby was too well for that to be justified. There is no hospital record of this exchange. Child X was admitted to a ward as her white cell count was raised. A blood test gave a preliminary indication that clotting was normal. The paediatric liaison nurse (who links the hospital and community nursing services) saw the A&E record on Day 14 19 and it was received by health visitors on Day 31. The hospital nursing assessment made no reference to the bruise. The GP was not sent a notification of this Day 10 A&E attendance until Day 26. The notification was dated Day 12 and said that the presenting complaint was that the baby had vomited blood. Midwifery notes, but not in the ASPH IMR, show a message left by mother at 6pm to report the baby’s attendance at A&E and subsequent admission. The Judgement in the care proceedings found that the car seat belt was not the cause of the linear bruise seen by the midwife and hospital. The Judge concluded that the bruise was associated with the squeezing which led to the rib fractures. The Judgement also concluded that blood in X’s throat and mouth was associated with the squeezing that was so hard the ribs fractured. Day 11 On the second day in hospital, a consultant led ward round identified an infection of the umbilicus and a staphylococcus infection and intravenous antibiotics were administered. A junior doctor identified the bruise (which it was said was not unlike a birth mark), and was to contact the health visitor and midwife. In that doctor’s statement for the IMR, the mark was described as on the chest and on the right, although there are many records of it being on the left and on the abdomen. This appears to be an erroneous recollection. It is possible that the ‘bruise’ seen by the doctor was different from that seen by the midwife the day before as the midwife saw a very small round bruise, while the St Peter’s drawing shows something larger, more linear with some small marks around it. The IMR says the health visitor was contacted, and the doctor discussed the bruise with the parents. An SHO (a senior house officer) recorded that ‘we cannot be certain that (the bruise) is not NAI’. (Non-accidental injury) The doctor called midwifery. The midwife who had seen the bruise was not available, and the colleague spoken to would not have known about the bruise seen the day before as it was only recorded on notes held by the mother. They told the doctor that there was no record of social concerns or incidents documented on the visit sheet at the office. Her colleague reported that on the Day 10, Child X’s skin was intact. Day 12 The ASPH IMR suggests a midwife visited the ward, but the SCR was later told this did not happen. 20 Day 13 MW2, unavailable on Day 11, returned the hospital doctor’s calls, and said she was aware of the bruise and described the car seat story. She told the doctor that the parents had tried to contact her as soon as they saw the bruise. The hospital notes about this discussion refer to the bruise being from Day 5 as that is what it said on the parent held record, but the midwife knew it to be Day 10. It is possible neither doctor nor midwife mentioned the date and assumed they were discussing the same date. Day 14 At a ward round, consultant 2 considered the bruise and considered it likely to have been caused by friction in the way explained. The junior doctor told midwifery. No inquiry was made of the GP by the hospital during this admission. Child X was discharged but the wrong discharge letter was sent to the GP. It arrived on Day 20. It was the right name but the wrong patient’s details. Midwifery was informed of the discharge. The health visitors (who had not yet started visiting) received the discharge summary Day 17. This would probably have been the wrong one. The incorrect, and then a correct, discharge letter were faxed to the GP six days later on Day 20. Day 15 A midwife (MW5) visited the day after Child X left hospital and discharged the baby from midwifery care. Nothing of concern was noted. Day 16 The Judgement concludes this was the last point at which the rib fractures could have happened. Day 17 The health visitors received the hospital discharge summary from Child X’s birth. Day 19 The ASPH named nurse for safeguarding contacted a health visitor (HV3) after liaison with the midwife regarding the bruise. On the same day, HV3 met MW2. This was not planned, and is described as an informal meeting when the midwife dropped in. HV3 was told that midwifery had discharged the baby, and that there had been a bruise on the right abdomen on Day 2. This does not match the ASPH IMR (and any other reference) which says the bruise was on the left on Day 10 (although it was also erroneously recorded by a midwife as occurring on Day 5). The midwife was concerned in case the health visitors were not aware of the bruise. The midwife also reported the hospital 21 attendances, and that she had spoken to the hospital about the bruise. HV3 also phoned the Paediatric liaison nurse about Child X’s hospital attendances. No written handover was done by midwifery. Day 20 The GP saw Child X in the morning (for the only time) as mother wanted Child X checked before stopping antibiotics. The morning appointment was before the hospital discharge letters arrived later in the day. The GP notes record the Day 10-14 hospital stay from mother’s self-report, and the GP saw a linear purple mark on the abdomen – ‘could be a pinch mark from car seat as stated by father. Observe’. The GP, who has forensic experience, examined the mark carefully with the baby undressed, and also handled the baby to assess if there was any discomfort – there was not. The GP did not see it as a typical bruise, and was not sufficiently concerned to refer the matter on. The GP was not aware of the LSCB policy requiring any bruise on a non-mobile baby to be referred. The GP also saw a mark on the baby’s face which he said he would not describe as a bruise, but a small mark of undetermined origin. St Peter’s sent a discharge letter from the Day 10-14 admission later that morning, but realised that the contents were wrong so the GP was called by a junior doctor. The GP was told about the car seat bruise. He was asked not to exclude non accidental injury (NAI), and to refer to A&E if ‘any new bruising/suspected injuries/possible signs of NAI’. The hospital doctor asked if Children’s Social Care were involved but the GP was not aware of this. The ASPH IMR says the GP said he had seen the baby with no evidence of ‘further bruising’. By this he meant nothing further to the abdominal bruise. This appears inconsistent with the health visiting notes which record the GP telling her, after her visit described below, that he was aware of the facial bruise – but as noted above the GP did not see it as a ‘bruise’. The junior doctor noted on the medical file, ‘how do we check whether known to social services now?’ A bank (not permanently employed) health visitor (HV2) visited the home to make a new birth assessment within the target 21 days, but the formal Family Needs Assessment was not started as per policy. Weight was satisfactory. There was a ‘bruise’ on Child X’s right cheek. There was also an area of flaky skin above the umbilicus and a 5cm linear bruise on the abdomen ‘still visible’. The bruises were discussed with mother by the health visitor who said Child X had sensitive skin and bruised easily. She was advised to draw the bruise to the paediatrician’s attention at the hospital appointment the next day. The health visitor did not alert the paediatrician to this or make any follow up to ensure that happened. No drawing of the bruising on a body map was done. The family was invited to the drop in baby clinic or call the health visitor as needed. The next visit was scheduled for Day 41. The facial bruise was not discussed by HV2 with her supervisor or the named safeguarding nurse, but was recorded. The HV2 did discuss the visit with the 22 GP, who had seen the baby earlier that day for an antibiotic review. The health visitor says the GP was aware of the facial bruise. The ASPH named nurse, who was curious about the case, and the registrar – who saw the baby on Day 10 and was to see her again on Day 21 – discussed the case. The note of this discussion in the medical notes says the bruise and story were consistent, but does not mention ‘easy bruising’. It said the named nurse should be contacted when the family arrived the next day (by bleep as she would be on leave). Virgin Care received notification of Child X’s Day 5 A&E attendance. At the end of the day, at 17.37, the corrected discharge letter arrived at the GP Practice, confirming what had been said about the body bruise and any further bruising in the earlier phone call from the hospital. The GP saw it the following day. The GP did not refer the new bruise to A&E as requested by the hospital (not seeing it as a bruise). Day 21 Child X was taken to the paediatric day ward at St Peter’s for a follow up, and a paediatric registrar was called. Two new bruises were identified, additional to the abdominal bruise seen before. The cheek bruise, and a small discoloured area on the right thigh. They were recorded as unexplained, with the parents accompanied by the paternal grandmother saying Child X had a habit of pushing a finger into her cheek, and the thigh marking came from a nappy edge. The linear abdominal bruise was now faint. The skin lesions from the infection had gone. The registrar’s statement says that mother said that the facial bruise had been present at her hospital admission over a week before, but there is no record of that. The paternal grandmother who worked at the hospital said that Child X bruised easily as she did. She also said she had done safeguarding training and had no concerns about the mother. Her views on her son were not recorded. A haematologist was consulted who suggested that the staphylococcal infection which Child X had earlier can lead to easier bruising. The registrar considered that Child X had bruised easily when blood was taken for a clotting study, and considered the bruising at that site something she had not seen before in her practice. She said in a later statement that the child had bruised where the doctor’s finger had pressed against her. The baby was discharged shortly afterwards, so there is no evidence of how permanent was any mark. Full clotting studies take several weeks, and in due course these all came back as normal. The ASPH IMR says the registrar discussed with the on-call consultant 3, who was not at the hospital, who suggested talking to the named safeguarding nurse. There was a discussion. The named nurse did not refer the baby as per the bruising policy for babies who are not independently mobile. Child X was discharged home by the registrar without a formal conclusion, or any referral to Children’s Social Care or discussion with outside professionals. Child X was not seen by a consultant. 23 The medical record says, ‘Letter to GP’ but the GP did not receive one. The GP was therefore unaware of the hospital’s thoughts about the facial bruise, or the existence of the thigh bruise. The same day, the paternal grandmother called the health visiting office to speak to bank health visitor, and spoke to HV3. The paternal grandmother was annoyed at what had happened at the hospital (i.e. the querying of the bruises). HV3 said she would ask HV 2 to discuss the concerns with the parents, and that she could not discuss confidential patient details with the grandmother Day 22 The GP notes record a notification that mother called the GP out of hours service Harmoni as Child X was crying continually. The paternal grandmother said this was early afternoon and was because the mother was worried that Child X was not feeding. Harmoni advised Child X be taken to A&E. The Harmoni nurse recorded ‘mother non-committal, asking if it can wait until tomorrow’. The nurse reiterated the advice. Day 24 The registrar emailed the ASPH named safeguarding nurse ‘as the health visitor was talking to you about the bruising’. The email reported that the registrar and a consultant had been ‘happy’ with the car seat explanation of the first bruise. It explained about the mother and paternal grandmother talking about easy bruising and her own observations about redness when she held the baby’s arm. It says the mother said that one of her health visitors had seen the baby push her finger into her cheek. The mother had only ever seen one health visitor, the day before, so there was some confusion between midwives and health visitors in her comment. Day 26 The GP received the notification from A&E of the baby’s attendance there on Day 10 Day 27 Child X was taken to the health visitor drop in clinic. The IMR says the weight had increased 131 grams in a week. Health visitors at these clinics do not have access to prior records, but HV3 who knew about the bruising seen to date was there. Weight gain was about 5 ounces compared to the expected 7. HV3 saw from the parental hand held record that the weight was being monitored by the hospital. Child X also had a right conjunctival haemorrhage the parents said had been there a week, and a left one said to have been a few days old. The health visitor suggested the baby was taken to the GP for an assessment. No check was made to see if an appointment was made or kept. The baby’s GP record shows no such appointment was made. The paternal grandmother, who had also seen a ‘blood shot eye’, confirmed that the mother told her the health visitor advised going to see the GP. 24 HV3 knew from paternal grandmother about the bruising seen in hospital on Day 21. She was also aware of the abdominal bruise from the midwife handover. The health visitor did not consider the sequence of bruises and eye haemorrhages as a safeguarding issue and did not record or discuss them as such. Health visitors had no concerns about any parental handling of Child X that they had witnessed. Day 28 HV3 returned a call to the paternal grandmother who had left a message, very annoyed about the contents of the baby’s discharge letter from the Day10-14 admission which the heath visiting team told her they did not receive. The health visitor said she could not discuss any detail with her and advised that her son should raise issues with HV2. This discharge letter refers to the car seat bruise being seen on Day 5, and neither the mother nor paternal grandmother pointed out this date was wrong. The discharge letter does not mention NAI and is tactfully written, only saying that if there were more bruises Child X should be brought to A&E for assessment. 2.4. The hospitalisation that led to the diagnosis of traumatic injury This looks at what happened from Child X’s arrival at St Peter’s A&E when Child X was 30 days old until the multiagency strategy meeting held to discuss the diagnosis 4 days later. Day 30 The baby’s father called the ambulance service at 00.12 on the advice of the paternal grandmother after he had found her pale and floppy, jerking, with a twitching hand and face. The baby arrived at A&E at 00.44. The ambulance service had no concerns about NAI and their working assumption was epilepsy. No bruising was noted at A&E. Full testing for sepsis (a life threatening condition where the body over reacts to infection) was undertaken and intravenous antibiotics commenced. She had a high pitched scream and her eyes looked a little red. Cerebral spinal fluid was blood stained. A chest X ray for a heart murmur was ordered. The mother told consultant 4 that both her sisters had epilepsy. There was no recorded evidence that NAI was considered as a possibility and on that first day medical records, which would have shown a history of at least 3 bruises and eye haemorrhages, were not located. Bruising was though referred to on the electronic inpatient list which was accessible. Day 31 The case was handed over to consultant 5 the next day, Day 31, with a working diagnosis of infection e.g. meningitis. A junior doctor at the ward round identified the history of bruising and querying of NAI, and also the prior retinal haemorrhages. Consultant 5 discussed with Consultant 4 a brain CT scan to exclude subdural haematoma (bleeding in the brain that can indicate trauma). Consultant 5 declined the CT on the grounds of radiation risk to a neonate and an MRI was ordered. The 25 chest X ray which was looked at for heart irregularities, and the MRI came back as ‘normal’. On this day the health visiting service received information about Child X’s Day 10 attendance at St Peter’s. Day 32 Consultant 6, who is the named doctor for safeguarding, contacted consultant 5 to see if any social concerns had been identified and to ensure that a subdural haematoma had been excluded. She was advised there were no safeguarding concerns. The nursing assessment record made no reference to prior bruising. Nursing records for the Day 10 admission, and this one, are described as fairly minimal and ineffective with no nursing care plans in place, and no social history. St Peter’s doctors were becoming very concerned about Child X’s well-being and started discussions with St George’s Hospital, a specialist tertiary hospital about a transfer. She was transferred in the afternoon to St George’s Paediatric ICU. No reference to any prior bruising or NAI suspicion in the information transferred verbally or in writing from St Peter’s to St George’s. The transfer letter was written by a SHO. The focus of transfer information was on the management of her fitting. During her stay at St Peter’s, no inquiries were made by the hospital with midwifery, health visitors, or the GP. At St George’s: The baby was ventilated and sedated. St George’s doctors tried to access the chest X ray and MRI taken at ASPH but although sent they had not been uploaded, and the relevant office was closed delaying the neurological review until the next day. There is no record that trauma or NAI was being considered as a possible cause, but St George’s’ doctors say that it was. Day 33 The next morning at St George’s, their medical staff were able to examine the X-ray and MRI taken at St Peter’s. Although the parents identified no trauma, the MRI was seen to evidence subdural haemorrhages. The paediatric neurologist spoke to the parents who identified the red eyes a week before admission. An ophthalmology review was also requested, as the eyes can display evidence of head trauma. A clotting test was ordered – unaware that St Peter’s had done a negative test three weeks before, or that St Peter’s knew about bruising. A consultant paediatric intensivist then saw the parents and specifically asked about trauma which was denied. After this, the intensivist noted that a radiologist, looking at the St Peter’s chest X-ray had found a rib fracture and after further examination 4 rib fractures at least a week old had been diagnosed. On this day, the father and HV 2 spoke on the phone. He told her about Child X being in hospital. She had heard this from neither St Peter’s nor St George’s. She said she had tried to contact the St George’s named nurse but had been unable to 26 speak to her. The named nurse was on leave, but the deputy was available and no message has been traced. Due to the almost certain indications of trauma, consideration was given at St George’s to referring the matter to Children’s Social Care or the Police that evening, but it was decided to wait until the following day when the diagnostic information to raise with the parents would be more detailed. No inquiries had been made from St George’s to the GP, midwife or health visitor for background information which may have aided a diagnosis. Day 34 The paediatric intensivist informed the parents of the acute and chronic subdural haemorrhages and four fractured ribs, told them he would tell Surrey Children’s Social Care and the Police and what further tests would be done. Later that day the ophthalmologists confirmed retinal haemorrhages to both eyes. A Strategy Meeting, which is a preliminary multiagency meeting to assess the evidence and plan immediate steps, was called for that afternoon. The Strategy Meeting was attended by staff from the hospital, Surrey Children’s Social Care and the Police. Background information was exchanged, a definitive diagnosis was given, and various actions and inquiries were agreed. Parental access to the child was to be supervised, to which the parents agreed in writing. Children Social Care say the notes of the meeting were circulated, but not all present saw them. For example, they refer to shoulder bruising and the professional said to have reported this has told the SCR that this was not said, and no evidence for such bruising has been found. Also other inaccuracies were reported when they were re-circulated for an accuracy check at the request of the SCR Panel. The outcome of the meeting was not recorded in the medical notes. 2.5. Diagnosis Child X was transferred out of the intensive care unit on Day 35 with the following diagnoses Traumatic subdural haematoma Retinal haemorrhages Bi-lateral rib fractures Refractory seizures, query cause 2.5.1. Subsequent to the original diagnosis as above, further X rays and re-X rays at St. George’s identified further rib fractures, a femur fracture two tibia fractures 27 foot fracture. Dating fractures is a not a precise exercise, but the Judgement concluded the following: 2.5.2. The Judge at the care proceedings concluded that the injuries were non-accidental in origin, with none related to birth or any bone deficiency. The injuries listed in the Judgement and the conclusions on dates were as follows. They are in this report as they put professional decisions during the baby’s life into the context of what the baby may have been suffering. The SCR was concluded before the criminal trial. Injury Approximate date of causation 8 rib fractures Day 2-16 Metaphyseal fractures*: femur and 2x tibia Day 11-25. Unlikely, but possibly after Metatarsal fracture ? but from Day 1 Retinal haemorrhages From Day 28 Brain haemorrhages Possibly Day 24-28 , Probably day 29 Face bruise On or before Day 15 Abdominal bruise On or before Day 10 Thigh bruise On or before Day 21 Cut lip Sometime around Day 10 * changes to the ends of long bones typically caused by pulling or swinging 28 3. ANALYSIS AND APPRAISAL 3.1 This section analyses the events that occurred up to diagnosis of non-accidental injuries, and looks at why actions or decisions were made, trying to identify when practice strayed from what was expected, or was significantly good. It is always easy in hindsight to say what might have happened, and where anything looks inexplicable evidence of what staff thought processes were at the time is sought. Although this SCR will appraise practice, the overall purpose is to identify areas of practice that can be improved or from which others can learn. The analysis is done chronologically, where practical, as that is the easiest way to consider whether a difference could have been made in this case, although each of the questions in the TOR is borne in mind during the analysis. Showing areas of concern in the context of the actual case story, demonstrates real risks and not just theoretical learning points. Recommendations from this SCR overview are in bold italics 3.2 In section 4 the key issues are summarised and where possible errors are noted, the SCR looks at ‘why’ this happened and any systems issues which impacted on professional performance. 3.3 Was there information about either parent by the time of the pregnancy that might have affected the supervision of, of help provided to, the family? The SCR found it hard to piece together historical information about the parental background, and so it was likely that identifying what information existed was hard for professionals at the time. 3.3.1 ‘Referral’ to Children’s Social Care by Midwifery: About 3 months before the baby was due, the midwife, concerned about the mother being ejected from her home, and moving to another area with housing and financial worries, called Surrey Children’s Social Care. This incident has raised issues which will need more thought if in future such conversations are to be more clearly understood by both sides. 3.3.2 Despite the mother being a teenager, there is no reference in the ASPH IMR to ASPH midwifery making any contact with the area to which she was to move. She was asked to make all the arrangements herself, even though she was such a young mother, and there was enough concern to call Children’s Social Care. Maternity services should clarify the circumstances in which a handover should be given to the area where a vulnerable client has moved, and checks made that a vulnerable client has indeed locked into services after moving. The ASPH IMR also concludes that the midwifery documentation was insufficiently detailed about the social factors, and that the risk factors were not sufficiently acted upon. 3.3.3 The ASPH IMR expressed concern that midwifery did not follow up with Children’s Social Care to find out the outcome of the ‘referral’. Children’s Social Care understood the call from the midwife to be for information only ‘as the community midwifery services were monitoring mother and would refer if 29 appropriate’. The Children’s Social Care IMR says it is unclear what were the expectations of the midwife, especially as the midwife said there were no prior problems before the pregnancy was booked in. Children’s Social Care said to the SCR that they receive large numbers of ‘information only’ calls and further checks are only made if the referrer indicates specific risks. If not, the ‘referrals’ are recorded with a no further action (NFA) conclusion. Their IMR said this happened in this case. The risks are clear: social work time is taken up dealing with information that is simply noted, when there are higher priorities getting less time, or, there is ‘no further action’ on cases which might really have more needs but are hidden by ‘information only’. The SSCB should ensure that there are effective processes in place to ensure that the purpose of referrals (and this does not just apply to referrals to social work) is clear. The Children’s Social Care IMR says that recent work had been done on the multiagency referral form to make the expectation clearer and this is about to be implemented. Its success will need to be monitored. 3.3.4 There are also lessons to be learned from how Children’s Social Care handled the call. Although there is evidence that old records were accessed there is no evidence from the write up of the referral that a link was discovered with the mother’s Looked After sister or the initial assessment on the mother to be in 2009 (or if it was, that it was perceived to have any relevance). Had this connection been made (the midwife was unaware) information would have been identified about mother’s earlier years where she is said to have been a witness to a sexual offence against her sister by her now late father, leading to his imprisonment 14 years ago. It would also have said that the mother was physically abused as a young child by her father. It would have given some indication of her social difficulties. The sister’s social worker was unaware of the midwife’s concerns. The importance of this is shown by the Children’s Social Care IMR conclusion that had the information been known, it should have led at least to an initial assessment to see if further assessment or support was needed. 3.3.5 This emphasises the importance of the quality of the exchange between referrer and referred to. The Children’s Social Care IMR concludes that their Contact Centre who received the call should have initiated further checks about mother’s background, and recommends that the Centre reviews how it checks and shares information with area teams who are working with close relatives. The IMR concludes that whilst this would be good practice, it does not mean that if it had been done at the time the later tragic events would necessarily have been avoided. This event is a good example of how a system issue affects decisions. 3.3.6 The Health Overview wonders if the knowledge that the mother worked in a nursery, and presumably had been CRB checked, may have led to a view that she could not be a risk to a baby. The paternal grandmother also wondered if the mother overestimated her abilities as she had an NVQ child care qualification. 30 3.4 Health visiting in the antenatal period 3.4.1 In the summer of 2012 HV1 attempted an antenatal visit, but the maternal grandmother said her daughter had moved. In the IMR process, that health visitor could not recall why the case was targeted (only targeted cases get an antenatal visit). The new health visiting team reported that they never received the targeted antenatal forms from HV1 although their transmission was recorded, and as a result the case was allocated to a non-permanent member of staff. The Virgin Care IMR describes this as an opportunity lost, and there was never an antenatal assessment. It suggests that a verbal handover is a protection against lost records. The IMR rightly recommends that the process of midwife to health visitor communications, and health visiting team to team communications be reviewed to create a more robust process. There is no guarantee that had there been an antenatal assessment, and a greater understanding of the family’s status as targeted, that the later injuries would have been prevented, but there would have been a higher chance that later signs might have been taken a little more seriously. 3.4.2 The Virgin Care IMR is justifiably recommending that the criteria for antenatal visits are reviewed and rolled out effectively to staff. 3.5 Birth 3.5.1 There were no obvious lessons from the mother’s self- referral up to maternity services before birth with apparent reduced foetal movement, or the birth process, and mother had father’s support at the birth itself. The mother and baby’s discharge home at 9pm on the day of birth does not seem unusual these days, but the paternal grandmother said she did not think it was appropriate and that it reflected the intense pressure in the hospital that day. 3.6 Midwifery care post birth 3.6.1 The ASPH IMR indicates that baby was visited at home on Days 2, 5, 10, and 15. The baby was in hospital on Days 10-14. The visit on Day 2 was unsuccessful but later phone contact was made to hear progress. The case was handed over to HV3 informally on day 19 (see above) and the HV2 visited on Day 20. The final midwife visit was on Day 15. 3.6.2 The IMR appraises the midwifery work and says that there should have been a risk assessment to assess the risk level, but this was not done. 3.6.3 The ASPH IMR found the quality of midwifery notes and assessment not of sufficient standard. It said they were ‘not completed appropriately, were scant and minimal with many omissions’ and makes three recommendations: To audit and improve documentation, to ensure there is a proper record of social history, and to develop a risk assessment process to ensure high risk mothers are identified and appropriate action is taken. 31 3.6.4 The author of this report found midwifery records hard to grasp – with at least a parent held mother’s file, a parent held child’s file, and another file held at the office. There can be a lack of consistency between them, and as seen in this case the office file did not contain a record of a bruise when the hospital called, even though a midwife had seen one. The fact that the internally written ASPH IMR originally made a number of factual errors from reading the notes suggests there is indeed an issue. ASPH should review midwifery record keeping systems to ensure a tighter arrangement with key events known at the office and not just patient held records 3.6.5 The midwife was unaware of the A&E attendance which happened when Child X was 5 days old, and although the attendance is not deemed to have any safeguarding implications, it would seem sensible that midwives are informed when a baby, who is being visited by them at home regularly, attends A&E. She was aware of the admission on day 10 as her team was contacted by the hospital. Although a health visitor eventually heard about the A&E attendance of a baby in their care, it seems that midwives are not routinely told, even in the early days when only a midwife would be visiting at home. ASPH should consider when and how their midwives are informed about the attendance at A&E of a baby under their care. 3.6.6 It is of concern that the phone call to the hospital maternity ward about a bruise on an 8 day old baby appears to have led to nothing more than being told to keep trying to contact the community midwife. Leaving it solely to a relative to take appropriate action was not appropriate – even had it turned out to have had a benign cause. Any call received which describes bruising to a baby, especially a non-mobile one, should have been recorded and passed on to a relevant colleague. 3.6.7 The Day 10 bruise seen by MW2 was the first occasion when the baby was seen to be marked by staff allocated to her. There is no indication in records that the midwife was aware her service had been told about the bruise 2 days earlier. The fact that the events of Day 10 were recorded in the maternity notes as happening on Day 5 when they must have been written on Day 10 is inexplicable, and this led the hospital to believe that was indeed when the seatbelt incident was noted. The GP was also given the ‘Day 5’ date in Child X’s hospital discharge note. The Day 34 Strategy Meeting Minutes also recorded the bruise as happening on the day 5, and even after the minutes were re-circulated for an accuracy check in May 2013 the revised minutes still said the car seat bruise was on day 5. 3.6.8 There is also the issue of recording injuries fully. As no drawing was made by the midwife of the ‘small round’ bruise she saw on Day 10, such as on a body map, there was no record of its exact location or appearance, and it cannot therefore be compared with the drawing made at ASPH two days later, or what HV2 saw as ‘still visible’ on day 20 – a 5cm linear bruise. Was it even the same bruise? Whilst not suggesting that pursuing a very small bruise with 32 a clear explanation is necessarily easy, the standard of service in these episodes was not acceptable, and the ASPH IMR recommendations (see App3) on non-mobile bruising are supported by the SCR. 3.6.9 The significance of the procedure on bruising not being followed on Day 10 is that, according the Judgement in the care proceedings, the rib fractures had been caused the previous day and that the bruise was caused in that squeezing incident. One cannot, of course, be sure of what would have happened, but at the very least had the procedure have been followed, the parents would have known the family was under scrutiny. 3.6.10 There must be a question about continuity of care. On the 4 occasions the baby was seen at home, the visit was undertaken by a different midwife. The midwife who visited on the Day 15 would have seen the hand held records saying the car seat bruise was on Day 5, and may or may not have known it was actually the Day 10. (She might have done if she had spotted there was another quite different entry for day 10.) It is recommended that ASPH review continuity of care in community midwifery, especially for potentially vulnerable families. 3.6.11 The handover to health visiting is also an issue. The HV said this was informal rather than formal (although there was the benefit of it being face to face). There was no written material, eg information about the bruise. This would have been good, not least because HV3 recorded the handover as describing a right sided bruise. The midwife told the health visitor she had discharged Child X. There were 5 days between the last midwife visit and the first health visitor visit despite the bruise incident. ASPH and VCSL should set out clear expectations on the nature of midwife to health visitor handover. 3.6.12 The ASPH IMR also suggests that the knowledge that mother had turned down special support, such as parenting education classes should have been highlighted to the community team to ensure ‘more support was available such as daily visits by the community midwifery team’. 3.6.13 The GP says that there is a very positive relationship with the midwife who is the formal link with the Practice. However, given that a number of different midwives might see one baby, the GP view was that the relationship with midwifery beyond the formal link is poor, with GPs ‘kept at arm’s length’ and less information shared. 3.7 Guidance on Bruising 3.7.1 The handling of the abdominal bruise, and the later bruises, is a significant issue for the SCR. The LSCB guidance says that “Children can have accidental bruising, but the following must be considered as non-accidental unless there is evidence or an adequate explanation provided….. Any bruising to a pre-crawling or pre-walking baby”. The midwife who saw them 33 could be said therefore not to have been in breach of procedures in not treating it as NAI as she accepted the story. There is no guidance in the SSCB Safeguarding Procedures Manual which requires a medical examination of bruising in a non-mobile baby. However, there is a separate Feb 2012 policy (Bruising in Children who are Not Independently mobile–Multi agency Guidance- see appendix 5) that is on the SSCB web site – but in a not immediately obvious place – which says “Bruising in a child not independently mobile (any child who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently: Includes all children under 6 months even if they are rolling, or children with significant disabilities resulting in immobility) should raise suspicion of maltreatment and should result in an immediate referral to Children’s Social Care”. The ASPH IMR concluded that this guidance is not well known, and has a plan to circulate to all relevant professional staff. 3.7.2 This means that there is contradictory guidance: one saying there is discretion in judging something non accidental, and the other mandating a referral to Children’s Social Care for any bruise in a non-mobile baby. 3.7.3 The bruising guidance regarding babies who are not independently mobile also says “wherever possible discussion of the case with a senior colleague is expected”. This did not happen with community nursing/midwifery re the abdominal bruise seen on Day 10 or the facial bruise on the Day 20 and only in a limited way by the hospital re the face and thigh bruises on Day 21. Regardless of the guidance, the judgement to accept the parental explanation (a judgement repeated at consultant level later) is questionable. The car seat was seen, but (and this is not a hindsight view, and would have been the author’s view if no other incident happened) it is hard to believe how a car seat strap could cause a small round bruise, or the longer one – whichever it was – through thick clothes and against a soft tummy. Indeed, if despite the clothes etc, the belt was so tight as to bruise a baby one would be questioning parental judgement anyway. The level of suspicion should have been much higher. 3.7.4 Even if the story was believed, and no action taken immediately, or even if it had proved true, the whole point of the guidance to talk to someone else about it is so that there is a chance for another objective view to be involved. This is crucial as it is hard for even experienced professionals to raise such a fundamental issue with parents as possible deliberate injury. Abusing families can be very manipulative in trying to get concern played down. Also, as no one else was told about the ‘seat belt’ bruise, Children’s Social Care would not have known had they been referred the family on another matter, and the GP and health visitor did not know until they heard from different routes on Days 19 and 20. The Judgement concluded that the car seat story was not the explanation and quotes a parent as accepting this. 3.7.5 Recommendations about the bruising policy are at 3.12.3 below 34 3.8 Hospitalisation days 10-14 3.8.1 The importance of sharing information can be seen when Child X was taken to St Peter’s A&E later on the day the midwife saw the bruise. The presenting issue was blood stained vomit. The A&E card makes no reference to the bruise, so the child was either not fully examined, or if the bruise was seen it was regarded as of no consequence, or it was seen and not recorded. Given that the baby was only 10 days old this is of concern. She was admitted, and the next day the bruise was seen by a junior doctor. A drawing was made which was good practice. The midwife did return a call to say she was aware of the bruise. The IMR suggests it took 3 days (days 11-14) until consultant 2 considered the bruise, and the consultant considered it to be friction (accepting the parental story as plausible). Child X was discharged. 3.8.2 It is possible that a paediatric doctor did in fact see the bruise in A&E but this was only recorded in paediatric notes. This would not be appropriate as should there have been a future A&E attendance the A&E notes would not have indicated that any bruise was seen at that attendance. 3.8.3 Consultants and junior colleagues also failed to follow the bruising guidance, by not referring to Children’s Social Care. ASPH’s planned action on ensuring all relevant staff are clear on the guidance is described above. The GP being sent a discharge letter on the wrong baby did not help. Positively, the junior doctor did the right thing in making inquiries of the midwife and health visitor. The hospital re-did the letter and spoke to the GP on day 20 to find that the GP said he had seen the baby, well, with no evidence of any more bruises. 3.8.4 It is interesting that the corrected discharge letter describes the abdominal bruise as one of two ‘presenting’ complaints when the bruise was, according to what is recorded, not noticed until the second day in hospital. 3.8.5 In 3.12.2 below it is described how the paediatric departments apparently thought the non-mobile bruising policy did not apply to the Hospital. 3.8.6 The significance of not following the bruising policy can be seen by the Court conclusion that the rib fractures had been done before the baby’s admission, and that the abdomen bruise was caused in the same incident. Had there been an X ray because the bruise was viewed with more suspicion (perhaps along with the blood stained vomit) injuries might have been seen. 3.9 Health Visiting services 3.9.1 Having made one attempt to visit ante-natally, as the case was ‘targeted’, the loss of this status in transit to another part of Surrey meant that no visit was made before birth. The new birth visit at 20 days was within the 21 day target. The required Family Needs Assessment was not started at this visit 35 made by a bank health visitor. As above, had the health visitors realised earlier concerns, a regular member of staff would have handled the case. There were no medical concerns but a bruise was seen on Child X’s cheek, in addition to the old abdomen bruise seen on the left, and two small areas of flaky skin by the umbilicus. 3.9.2 The day 20 facial bruise: Despite being aware of the guidance on bruising on non-mobile babies, the health visitor made the same error of judgement as midwifery and hospital in not making a referral. This time there was not even an explanation, other than easy bruising, and a check with ASPH would have shown at least a preliminary normal clotting test. There had been a suggestion that the skin infection diagnosed on day 10 when Child X was in hospital could cause easier bruising but it is unlikely the health visitor knew that when she took no action on the facial bruise. The fact that the parents were asked to ask a hospital doctor about the bruise the next day, with no alert to ASPH, or follow up check, compounded the situation. There must have been at least some concern (or why else say show the hospital tomorrow?). No professional should ever assume, when there is some possibility of NAI, that parents will do what they are advised, or that other staff will jump into child protection mode unless they are alerted to concerns. The health visitor thought that as she was not concerned about NAI she did not have to do anything else. No drawing was made on a body map. No supervisor was consulted. Virgin Care should ensure that any possible NAI or bruising in non-mobile babies seen by health visitors is shared with a manager or the named nurse. 3.9.3 As this was the fifth consecutive profession (Midwifery, hospital nursing, hospital doctor, GP and health visiting) which did not follow guidance, it is beyond coincidence that this relates just to individual competence. The likely explanation is a systemic one – that staff are just not clear about the guidance, or find it too hard to implement as written or, for example, referral of minor bruising in the past has been dismissed. (see recommendations at 3.12.3) 3.9.4 It is also relevant that the mother was a child care worker herself, and told the health visitor that she was therefore aware of safeguarding issues. The Virgin Care IMR makes reference to the lack of robust challenge being a feature of many SCRs, and the mother’s work, plus the suggestion of easy bruising and sensitive skin was allowed to deflect focus. It is of note that had there been a check with ASPH they had a record of preliminary clotting tests being normal. 3.9.5 Despite the bruise being the second bruise the health visitor was aware of on a non-mobile baby, no further visit was planned until Day 41. The Day 27 clinic attendance was a ‘drop in’. There seems to have been an assumption that, as the baby was being followed up in hospital, it would be looked at there, but this was not checked. It is not possible to conclude that if the health visitor had referred on the bruises on the non-mobile baby, the baby would have been protected. This is because the hospital to which she would 36 have referred the baby did itself not refer the bruises when seeing the baby the following day. However had Child X been referred in the context of possible abuse it is probable she would have been seen by a consultant, and maybe an X ray would have been done. Social Care would have been told and their outside perspective may have highlighted potential risks. 3.9.6 When Child X was taken to the health visiting drop in clinic on Day 27 her weight had increased, but not by as much as hoped. A right conjunctival haemorrhage was seen which the parents said had been there a week, and a left one for a few days. Such haemorrhages can be indicative of head injury, but even with an abdomen bruise, facial bruise and thigh bruise (the health visitor may have known of the thigh from the paternal grandmother) there was still no concern that the cumulative picture was one of possible concern. The health visitor also asked the parents to consult the GP about the eyes, but did not alert the GP and no appointment was made. This is risky in safeguarding, but the Clinic did not see it in that context so never considered that risk. It is also important, in analysing this episode, that the health visitor knew on day 21 from the paternal grandmother that there had been hospital questions about possible deliberate harm after the face and thigh bruising, but the retinal haemorrhages still did not trigger any alarm bells. A further paternal grandmother call to the health visitor on Day 28 did not lead to any inquiry about what other agencies might be conveying to the family. 3.9.7 IMR writers were asked to report on capacity or climate issues which might affect performance. The health visiting team concerned had a safeguarding caseload on a par with the rest of Surrey. However team functioning was of concern with vacancies and long term sickness. HV3 was one of only 2 qualified staff in the team at the end of October 2012. The staffing of the wider locality within which the team as based had been on the risk register since 2011, and was 21% under establishment in the summer 2012. The team have to submit breach forms when mandatory visits or missed or recording behind, and in October 2012 the return showed 4 targeted antenatal visits, 3 new birth visits, a one year developmental check, and 129 incidents of record keeping not to timescale. These breaches were not reviewed that month. The Virgin IMR reported that additional staff were redeployed to the team pending the arrival in January 2013 of a permanent 1wte health visitor. 3.9.8 It is clear the team was under pressure, and that can lead to hurried work or insufficient attention per case. However, as other professionals also failed to follow LSCB procedure on bruising in non-mobile babies there is likely to be another cause. It is possible that their work pressure made it easier for health visitors’ knowledge that the baby had been seen at length in hospital, and was being followed up, to allow them to think nothing could be wrong and not to intensify visits. 3.9.9 The IMR reported that work had started on updating the database which monitors the training and supervision of bank (ie non-permanent) staff, and that the database is to be monitored by team managers. The health needs 37 assessment guidelines are being updated to reflect lessons from SCRs. Also that 0-19 guidelines and record keeping standards are being updated, and work is in hand to improve communications between midwives and health visitors. 3.9.10 The GP reported the working relationship with health visitors (who are, unusually these days, co-located with the Practice) as excellent with good information sharing. 3.10 GP Involvement 3.10.1 The baby was only seen by the Practice on one occasion – when the mother requested a review of the baby’s antibiotics. This was on day 20 and at that point the GP had no record of the A&E attendance on day 5, nor the A&E attendance on day 10, nor the hospital admission from days 10-14. The GP therefore learned any history from the mother who told him about the abdominal bruise being seen during the day10-14 admission. The GP appropriately undressed the baby to examine the mark and also handled the baby to see if there was any sign of discomfort which might therefore indicate a deeper injury. The GP concluded that it seemed superficial, that the explanation was possible, and that the action was just to observe. The GP was not aware of the policy that all bruises on non-mobile babies should be referred, and like the hospital, considered it normal practice to form a conclusion about a bruise before deciding if a referral was necessary. The rib fractures had almost certainly happened before this examination, and possibly the leg fractures too. 3.10.2 The call from the hospital doctor later in the day to explain about the wrong discharge letter being sent did not change the GP’s plan. The hospital doctor asking that NAI not be ruled out was not recorded by the GP, who accepted in hindsight that it should have been. The GP told the hospital that no bruising, further to the abdominal bruise, and did not mention the facial mark as he did not see it as a bruise. This raises as an interesting issue about terminology as the health visitor described it as a bruise later that day as did the hospital the next day. 3.10.3 It was appropriate that the health visitor who had seen the bruises earlier on day 20 discussed them with the GP – something made easier by co-location. However, neither saw a need to refer on to children’s care. They both knew the baby would be seen in the paediatric department of St Peter’s the next day, and this is likely to have reduced any concern they had. Neither spoke to paediatrics to make sure the marks were considered (the appointment was a routine follow up to the recent 5 day admission). 3.10.4 The GP IMR expresses concerns about ‘a lack of reliability’ regarding information from St Peter’s to the GP Practice, and its author (the Named GP for Safeguarding) commits to exploring this through the Health Subgroup of the SSCB and identifying improvements. 38 3.10.5 The Practice did not have a ‘lead GP’ for safeguarding as was the policy of the PCT. It was argued that there are too many special issues for which a ‘lead GP’ is demanded. Whilst it is not obvious that the lack of a lead GP made a difference in this case, it might have been more likely that the February 2012 policy about how to respond to bruising in non-mobile babies had been known about or understood. The GP says that, in any case, having to trawl through numerous policies on web sites to locate the one needed in relation to a patient in front of the GP is an unrealistic expectation and he recommended there was a one page summary of key principles that GPs could have easily available. 3.10.6 The IMR author regards the GP suggestion as a useful one, and she has committed to working with the designated nurse to draft such headline guidance, for consideration by the local named professionals and SSCB Health Subgroup. 3.10.7 The GPs at the Practice had had no recent update training on safeguarding. In fact the GP could not remember ever being offered training. 3.10.8 However subsequent to the GP IMR interview, the Surrey Named GP for safeguarding reports that this practice has identified a safeguarding lead, and that all Practices in the local CCG area now have safeguarding leads. The Practice is now clear about local and national training requirements, and all Practices have been made aware of dates for level 3 training. It is recommended that the SSCB receives on-going reports from the relevant NHS body on compliance with required training for GPs. 3.11 Hospital attendance on day 21 3.11.1 Child X was taken for review at the day ward at ASPH and was seen by a paediatric registrar. The cheek bruise was seen, plus a thigh bruise. The paternal grandmother, who is a health professional, said Child X bruised easily as she did, and was upset at the potential accusation. The Registrar sensibly consulted a haematologist who said that the infection at the Day 10 admission can lead to easier bruising. Despite the concern, and lack of definitive explanation, Child X was discharged home without specific consultant approval, partly because on call arrangements were either unclear or not followed. It is good practice for a consultant to confirm the discharge when NAI has been considered. By this day, at least three separate bruises had been identified in a non-mobile baby who had just reached 16 days old. It is likely from estimates made on fractures that Child X had suffered the rib fractures before this appointment, so had an X ray been done that day there might have been sufficient evidence for intervention. The ASPH IMR has recommended review of safeguarding arrangements on the day ward to ensure consultant leadership of safeguarding issues and this is supported by the SCR. 39 3.11.2 This was another illustration of the non-mobile bruising procedure not being followed as Children’s Social Care were not involved as required. In this instance there were two causes. Firstly, the ease by which the ‘easy bruising’ possibility became almost the conventional wisdom. The combination of what mother said, what the professional paternal grandmother said, and what the registrar saw when taking blood became so strongly held as to stop any serious consideration of anything else – and certainly no consideration of referral to Children’s Social Care. In a submission to the hospital IMR, the registrar said she was ‘convinced that the child did bruise easily’. The full clotting studies later came back normal, and even if they had not, a child who bruises easily could also be the victim of abuse. Throughout the treatment of Child X, there seems to have been no consideration that a child, if she did bruise easily, might also have been abused. What had become the, actually unproven, conventional wisdom may also have been behind why the hospital did not mention any prior bruising when transferring Child X to St George’s. 3.11.3 Secondly, the policy might not be seen as practical by hospital doctors, and one senior doctor speaking to the SCR suggested that the hospital did not think the mandatory referral rule applied there. This is because, for example, an A&E would see many bruises on non-mobile babies and to refer all might be deemed impractical. Instead, judgement is used to form a view of the likelihood of something being NAI and then a decision is made about referral. (As seen above, this is how midwives and health visitors operated too). It is clearly a risk if the policy says something and professionals implement it differently, and in doing so undermine its purpose. The SCR strongly recommends that the SSCB facilitates discussions with a wide range of professionals about the implementation of guidance on bruising to children who are not independently mobile to understand why it has been so poorly implemented, and to make any adjustments and training necessary. 3.11.4 Also that the SSCB should monitor the circulation and take up of any revised guidance on bruising, and undertake case audits with partners to ensure that guidance is followed and recording of injuries is as expected. 3.11.5 Thirdly that the SSCB should review its web site and how procedures are linked to ensure there is a much simpler way of staff identifying what guidance they must follow. 3.11.6 The Cambridgeshire Safeguarding Board has a very useful line in its 2012 policy on non-mobile babies. It says “This protocol is necessarily directive. While it recognises that professional judgment and responsibility have to be exercised at all times, it errs on the side of safety by requiring that all pre-mobile babies with bruising be referred to Children’s Social Care and for a senior paediatric opinion where there is no obvious medical cause.” This could be added to the Surrey policy as it would remove any doubt about its mandatory nature. 40 3.11.7 This SCR has been made aware that another Surrey SCR on child ‘S’ has also made a recommendation about bruising to babies who are not independently mobile, after two different professionals did not report injuries and accepted parental explanation. Even though the Feb 2012 policy in appendix 4 was not then in place, the other Review believed that the injuries should have been reported/actioned, and it makes a recommendation similar to the first one in 3.11.2 above. The fact that this issue had been highlighted in two local SCRs only emphasizes the importance of these recommendations. 3.12 Communications with community health services 3.12.1 Paediatric liaison services are highly valued as a link between acute and community services, and as a potential to break down barriers to information sharing. In this case communications did not work effectively given the delay in information reaching community staff. The A&E report of Child X’s attendance when she was 5 days old was not collected by the paediatric liaison nurse until 10 days later, and was not sent on to health visitors for a further 7 days – by internal post as no safeguarding concerns. It arrived 3 days after that. The same process after the day 10 A&E attendance arrived on day 31, after Child X’s injuries. Neither form made any reference to bruising (as noted above, A&E did not see the abdominal bruise on day 10). 3.12.2 The Virgin Care IMR recommends the production of a flow chart describing the flow of information from hospital to community staff dealing with children and young people. This is supported and it is recommended that ASPH and community health care organisations review information flows and processes to ensure that community staff are informed as quickly as necessary about events happening to children under their care. 3.12.3 It is also concerning that when Child X was discharged from the 4 day admission at which the thigh bruise was seen the discharge letter to the GP was not sent for 6 days, even when GP cooperation in case of further bruising was sought, and the Day 10 A&E attendance notification was not sent for 16 days after that attendance. 3.13 Summary up to admission on day 30 3.13.1 Prior to admission at least 3 bruises had been seen on a non-mobile baby, plus haemorrhages in both eyes. The parents were young and first time parents, with the mother having experienced some abuse herself. None of the hospital or community staff, be they hospital doctors, GP, nurses or midwives had referred any of bruises to Children’s Social Care. Parental explanation was accepted, and where there was no explanation, a propensity to “easy bruising” was assumed to be the cause – despite no recorded evidence of this. As no one had any significant concern about the bruises there were no multiagency meetings where information could be pooled and 41 an overview could be formed. There was no central pool where all the information could be found, and no one agency or individual was taking responsibility for the baby’s safety. Some information that might not have been critical but which would have improved the overall picture took a very long time to be transferred. 3.13.2 There had been no full medical examination including X-rays as no one’s concern had reached that level. Had there more scepticism about the, by then, several marks on the baby’s body and the eye haemorrhages, they might have been seen in the context of prior marks and a worrying pattern recognised. It is likely that by the time the baby was last seen in the community on Day 27 the rib fractures would have occurred, the leg fractures may well have occurred, and only the foot fractures were yet to come. When the child was last seen in hospital on Day 21 the rib fractures at least would have occurred. 3.13.3 As no one saw the bruises in the context of abuse; there was no referral to social care nor for a formal child protection examination. This made it easier for parental explanations to be accepted and non-explanations seen insufficiently seriously. 3.14 The admission of the seriously unwell Child X on day 30 to ASPH 3.14.1 The analysis of this admission takes into account what was subsequently found at St George’s Hospital. There are issues at ASPH about missed diagnosis, but it is unlikely that this made any significant difference to X medically as her life saving treatment would have been similar. It did however mean the parents had full access to the baby as they were not under any suspicion. 3.14.2 Child X was taken to ASPH A&E by the parents after becoming very unwell, floppy, twitching, and with a high pitched cry. Although the ASPH IMR author was told verbally that trauma/NAI was considered there is no recorded evidence that this was the case, and all tests seem to be to identify a medical cause such as infection or epilepsy. Although blood was found in the spinal fluid (which can have several causes) no one at this stage on the first day had knowledge of prior bruising or retinal haemorrhages, as prior records were not located and no one who would have known was contacted (e.g. health visitor). As on previous visits, the child protection part of the A&E record was not completed. The prior abdominal bruise was available electronically on the ‘inpatient list’, but this was probably not looked at. This SCR strongly supports the ASPH IMR intention to review the current process, improve it and ensure discharge letters are available. Consultant 4, who spoke to the parents on admission day, was aware the baby had been admitted before. 3.14.3 A chest X-ray was ordered, not to look for trauma, but in relation to a heart murmur, and no skeletal survey was done as NAI was not suspected. It was reported as normal. St George’s identified 4 rib fractures from the same x-ray; although it should be pointed out their radiologists say they are not easy 42 to spot. The ASPH IMR rightly proposes that the protocol on when to do skeletal surveys of non-mobile babies should be reviewed and clarified. 3.14.4 The next day, at a ward round, a junior doctor documented the history of prior bruising and alludes to query NAI. ASPH reports that the on call consultant 7 giving advice on managing Child X’s seizures was unable to contact the attending consultant 5 that morning for a detailed handover. Later, after consultant 5’s arrival, the consultant spoke to consultant 4 who suggested the spinal blood might relate to a brain bleed and suggested a CT scan to exclude a subdural haematoma. The junior doctor also reported the eye haemorrhages to consultant 5. He spoke to radiologists who suggested a CT scan but this recommendation was declined by consultant 5. The ASPH IMR says that was because Child X’s seizures were epileptic in nature, there being some family history of epilepsy – although the chronology says the argument was about radiation risk. An MRI was done instead and was reported as normal by two radiologists. When the same MRI scan was examined at St George’s subdural haemorrhages were identified. The ASPH IMR concludes that the advice to do a CT scan should have been considered as it was most likely this would have identified the intra- cranial bleeding and NAI. 3.14.5 In considering why ASPH radiologists failed to see the brain bleeding, the ASPH IMR points out that the radiologists see very few brain scans on children that age, adding that a second opinion of a neuro-radiologist was suggested but did not happen. This illustrates a risk for babies at a general hospital like St Peter’s. Although the delayed diagnosis is unlikely to have harmed this baby, on another occasion there might be other children at risk in the family where a delayed diagnosis might delay their protection. Taken together with the missed rib fractures, ASPH should review arrangements for reporting on rare or unusual scans, and be satisfied that there is access to appropriate specialist/subspecialist advice. In this digital age such access should be possible to arrange even at a distance. The ASPH IMR proposes developing an on-site radiology and orthopaedic expertise in reading paediatric x rays and scans 3.14.6 No indication has been provided to this review that, whilst Child X was at St Peters on her last admission there, any outside professionals such as GP, former midwife, and health visitors were called to see if they could throw any light on what was still a medical mystery. By the end of the second day the hospital was aware of previous bruising, had seen an eye haemorrhage, was aware of blood in spinal fluid, but still did not seek further information from clinical colleagues, a skeletal X-ray or check with Children’s Social Care. On the third day in hospital, day 32, the named nurse and doctor were aware and the named doctor (consultant 6) asked consultant 5 if there were any safeguarding concerns. He advised there were not. 3.14.7 The Health Overview notes that it is a junior doctor rather than consultants who raises the possibility of NAI. It also points out that given the concerns being of a medical nature, there are references to discussions with the named nurse rather than doctor, or the designated doctor in the named doctor’s 43 absence. The thought processes which limit the range of options being considered will be discussed in 4. 3.15 The transfer to St George’s 3.15.1 On Day 32 Child X’s condition was worsening with increased fitting, discussions commenced with St George’s Hospital in London about a transfer to a paediatric intensive care unit (PICU). In the course of preliminary discussions, practical arrangements, and more formal handover, at no time was any reference made to previous bruising, or any prior querying of NAI. The X-ray and MRI were described as normal. The notes of a third NHS Trust which handled the baby’s transfer did not mention anything to do with NAI. The St George’s IMR says that there is no written record at St George’s of the discussions between the two hospitals which preceded the transfer. A number of transfer documents were identified. None mention safeguarding. This meant that St George’s clinicians had no idea that earlier bruising had been identified, nor retinal haemorrhages (by the health visitors), nor that ASPH had actually considered NAI twice – at an earlier admission and a ward attendance. It also meant, as at ASPH, that the parents had full access to the baby. This was not a major risk as in PICU nurse monitoring is very intensiv). The parents did not report any trauma or old injuries when the history was taken. 3.15.2 St George’s reports that the form which is used to record information from other healthcare settings has already been redesigned to include safeguarding information and the name/designation of the person recording the information. The St George’s IMR has an action in place to ensure transfer discussions are summarised in the records as soon as possible after the child’s arrival. 3.15.3 The medical staff were put at a disadvantage by the ASPH MRI scan being said to be normal, which effectively ruled out brain trauma. The IMR had verbal reports that trauma/NAI was being considered, but there is nothing in the records to confirm this was considered on the first day at St George’s. The staff did want however to review the ASPH X-ray and MRI Scan, but were unable to do so because although sent from ASPH they had not been uploaded and the technical office which could have done this was closed. The IMR points out that access to specialist opinion on children’s brain scans is often delayed to the following day when such a specialist is unavailable. St George’s should have a system in place to ensure important test results are always available, and that access to specialist advice can be reaches in urgent situations. 3.15.4 They were able to review them the next day, and the subdural haemorrhages were identified. This triggered appropriate action such as further discussion with the parents, when on this occasion mother reported the ‘red eyes’ seen by the clinic on day 27. The hospital also realised the significance of this not being volunteered before. Eye examinations for retinal haemorrhages, 44 clotting studies, and a skeletal survey were appropriately ordered and NAI became a prime focus. Later the rib fractures were seen. 3.15.5 Although the medical team was now rigorously exploring an NAI diagnosis, the St George’s IMR describes how no inquiries were made of any professionals outside the hospital, when this would be good practice when a baby is admitted to PICU with an uncertain diagnosis. The IMR rightly has planned to ensure such early contact, by earlier completion of the nursing assessment tool, improving the system of access to contact details and PICU teams to emphasise to staff the importance of these discussions. 3.15.6 Although by early evening on the second day the brain bleeding had been identified, and some of the fractures had been found (and so NAI was most likely) the medical staff decided not to inform Children’s Social Care until the next day when the test results would have been more formally reported, and this could be better discussed with the parents. The IMR debates at length, without coming to a conclusion, the benefits of early referral against the risks that diagnosis might be premature and relationship with the parents could have been compromised, also pointing out that Children’s Social Care would probably not have acted that evening. The view of this SCR is that it would have been better to report it and an agreement reached about handling, rather than deny Children’s Service (or indeed the police) any input until the next day. With subdural haematoma and fractures, the chance of it not being NAI was by then very slim. Also Children’s Social Care may have had important information or views. No one knew that they didn’t. 3.15.7 Having said that, the following morning, Day 34, all appropriate internal and external notifications were made and by the afternoon a multiagency Strategy Meeting had been convened and held, and a plan of action reached on the, by then, definitive diagnosis. There are however issues with that meeting in that although the extensive notes are reported as being circulated (not all seem to have received them), errors in them were only identified when queried by this SCR and the notes were re-sent for an accuracy check in 2013. There was a limited response to this which led to the SCR Chair writing again to attendees. The attendance list did not show which agency any of the ten attendees came from, and in five instances not even what role they held. This may be related to the electronic template used. Surrey Children’s Social Care should review the Strategy Meeting record so the proper designation and agency of each attendee is clear. The SSCB must require agencies to read minutes carefully and submit corrections promptly. 45 3.16 Race, religion, language, culture 3.16.1 No issues on this in relation to the family have been identified. 3.17 Capacity and Climate 3.17.1 Each agency was asked to review whether there were organisational issues such as staffing, resources, infrastructure, and organisational climate which may have affected this case. Other than the report on health visiting staffing and capacity, agencies reported there were no such issues. 3.18 Fathers 3.18.1 This section has been deliberately left to the end of the analysis as it will be clear by this point in the SCR overview that there is almost nothing in it about the father. There is hardly any reference to him in IMRs, it is not even clear whether the couple were together throughout the period, nor any view of him as a parent. Other SCRs have found a similar ‘shadowy’ understanding of fathers who have then shown themselves to be a risk to their child. Fathers could also be a protective factor. IMRs noted that neither the midwifery or health visiting assessments (which may have looked at the father) were completed or to time. On the other hand, the vast majority of parents cope well with their babies and fathers are often not assessed, indeed they may hardly ever be seen, if at all, by community staff. However, in this case where the parents were young, where at least one had experienced abuse themselves, and where injuries started to appear, the justification for looking at the father is more obvious. The problem is that there was, rightly or wrongly, hardly any concern in a safeguarding context (and parental handling seen appeared satisfactory). Also in this case the influential presence of his professional mother must have made it even more difficult to focus on him. 3.19 Involved Relative 3.19.1 In this case, the paternal grandmother was active in supporting the baby and parents, and clearly took her responsibilities as grandparent seriously. As noted above, she had a professional background and staff found her comments and questions, which often were on technical matters, difficult and intrusive, something which in hindsight she understands. However, she would have thought it negligent had she not used her professional knowledge in providing support to the family, and in querying what might be happening in hospital. This was not an easy dynamic for either grandmother or staff. 3.19.2 Whilst she did, when interviewed, think there was abuse, she told the Review that when staff asked questions about that being a possibility she would rather they had been more up front about it and done standard tests for injuries e.g. X-rays………‘if you are going to do safeguarding, do it properly’ was her opinion. She said the family would have found it easier if the possibility of NAI had been tested to the hilt to conclude one way or another, 46 rather than leaving it open and vague by raising issues and no conclusion being formed – which they found difficult. This has some resonance with this SCR’s conclusions about insufficient steps being taken when there were injuries. 3.19.3 There is no recommendation on this but staff might consider the possibility that acting more robustly might not always lead to a negative family reaction. 3.19.4 No relative, regardless of professional standing, other than the parents has any right to know anything about a child patient regardless of professional standing (unless parental permission is given). 3.20 Diagnosis of Fractures 3.20.1 Outside the time period of the SCR, learning has been identified in relation to the arrangements for diagnosing and dating fractures. NAI had been identified by Day 34, but during the Review it was identified that a week after this further and more extensive X rays had taken place and further injuries found. There was some uncertainty whether what everything which might have been a fracture was indeed so, and a repeat X ray two weeks later would have shown more evidence of the bone healing which indicates the fracture. Exploration by the St George’s IMR author found that the discharge plan requiring the repeat X-ray was not followed up, and the appropriate appointments not made. The IMR author also identified that there was insufficient reference in the clinical notes about this plan. It was not for a month after the first skeletal survey that the error was identified, and it was done two days later – but at a much less helpful interval. 3.20.2 The IMR has identified that there was a lack of clarity of role in relation to ordering the follow up test between the consultant responsible for the safeguarding aspects of the case, and the consultant who handled the baby’s discharge. St George’s have clarified to paediatricians that it is the consultant responsible for actually discharging the child who must ensure subsequent required appointments are identified and made. 3.21 Summary 3.21.1 There is no way of knowing if the serious injuries found on Child X would have been prevented by different assessments and decisions in this case. It is probable that at least some might have been incurred before the clinic visit on Day 27 or even the hospital visit in Day 21. Unless there had been enough evidence to remove the baby she would still have been in her parents’ care and the injuries might still have happened. However, the above analysis/appraisal, shows that a sequence of events and decisions across several professions and agencies were handled in a less than optimal way, and that if handled differently there might have been either more intensive supervision, more multiagency discussion of risk, more awareness of risk, and possible protective action. These opportunities are listed below, and it is 47 their cumulative impact, rather than any single action which shows that there was an opportunity to make more of an intervention: There might have been a more robust assessment of the risks with this young mother if links with her Looked After sister had been made when the midwife referred Attention to the family might have been greater had the targeted status of the family not been lost in transit between health visitor teams, and antenatal visit/s done, and the health visitors had seen the recent concern of their school nurse colleagues The assessment of the family might have been robust had midwifery and health visiting done the required formal assessments If any of the numerous professionals who saw bruises on days 10-14, 20, 21 and 27 had followed procedures and informed Children’s Social Care there might have been a fuller assessment If the bruises seen by midwives and health visitors had been discussed with managers or safeguarding experts as would be expected, it may have led to more thorough assessment or multiagency discussion If there had been more professional curiosity about the car seat story, or the absence of explanations for the later bruises, it may have led to referral and multiagency discussion If when eye haemorrhages appeared on day 27, they had been added to the 3-4 previous bruises and the picture seen as of concern, there might have been an immediate NAI focussed medical examination If “easy bruising” had remained just a possibility, rather than becoming so firmly ingrained as likely, there would have been a more open mind and referrals to Children’s Social Care may have been made Had the pattern of marks raised enough concern for a skeletal X-ray it is possible at least some of the injuries would have been seen and later ones avoided The points below could not have prevented the injuries Had old records been available when Child X arrived at ASPH, it is probable that NAI would have been much more of a focus, as prior bruising was known, and especially when blood was seen in the spinal fluid. Had the ASPH X ray and scan been seen by doctors of greater subspecialty expertise the trauma would have been diagnosed before the transfer to St George’s. Had there been a more open mind at St Peter’s on the last admission about possible causes (the ‘clear’ X-ray and MRI scan, which later proved not to be clear, did focus attention away from NAI) and had contact been made with GP, health visitor or midwife for background information as the diagnosis was still unclear, then it would have been much more likely that NAI would have been a consideration, and the whole picture might finally have been put together. 48 At St George’s similarly – had professionals who knew the family been contacted there would have been information to balance the transfer information from ASPH that made no mention of possible NAI, or at least brought forward the eventual diagnosis. 3.22 There were many opportunities which might have led to a different outcome. The other conclusion is that, while individual errors were made, the cumulative picture involves so many professionals who either did not follow recommended practice or were insufficiently curious, that one has to look at the systemic context to understand the case enough to make improvements. 49 4. WHY DID THIS SEQUENCE OF EVENTS OCCUR? 4.1. There is no single reason, and this section looks at some key issues that bring together thoughts on why. They are grouped to show they are system wide issues, cannot be just left with individual agencies, and need Safeguarding Board oversight. 4.2. Administrative weaknesses 4.2.1. There are some events such as the loss of papers in transit, or delayed transfer of information from hospital to the community, or a wrong discharge letter being sent, which are just down to poor, or ill thought through, processes. Absence of prior medical records when a child arrives in an emergency can be another example. Agencies will have already given thought to these things, and will have added impetus to do so when they see how such practice made a contribution in this case to risks emerging too slowly. Getting these things right is not just a managerial responsibility, but front line professionals who share in or experience these processes must also take responsibility for ensuring they are not just accepted as normal, but press for resolution. The number of illustrations across agencies suggests that there could be a sharpening of the approach to ensuring administration works well, rather than an assumption that it will, or pessimism about change. There needs to be a commitment that these things matter. 4.2.2. Record keeping in safeguarding work is crucial, and in this case one can see how poor recording affected the work of others and compounded problems. Some IMRs are critical of the recording standards in files they saw. One wrong date of a midwife visiting and seeing the first injury was subsequently recorded in other agency records as a fact, and the absence of drawings of injuries by midwives and health visitors means even now there is no clarity of the number of injuries, and if what one worker saw was the same as next worker what saw. The SSCB should reiterate for all agencies that any suspicious marks must be recorded on a body map in order that there is a permanent record, and one which can help build a picture over time. 4.2.3. The SSCB, through the promulgation of findings from this SCR should emphasise the importance of administration processes and record keeping, and through case audits monitor their quality. 4.3. Interagency Referrals 4.3.1. There is a more fundamental issue about referrals to Children’s Social Care, which applies to any interagency referral. Although it was not a major turning point in this case, the need for both parties to be clear about the purpose of the conversation is very important. Children’s Social Care can find themselves in receipt of numerous pieces of information where it is not clear what is wanted from them, or which on receipt do not identify any obvious action. Whilst there is an important place for Children’s Social Care to 50 provide advice on handling of cases that do not seem to meet their threshold, exchanges without a clear purpose can end up not being looked at as thoroughly as they might be, and referring agencies can step back because they think that something will be done. Alternatively it can also make agencies reluctant to refer as if they do not get what they expect – even if they were not clear what was wanted. The midwifery – Children’s Social Care ‘referral’ illustrates some of these risks. 4.3.2. Children’s Social Care concluded that there was enough information available to have justified an initial assessment, and why this did not happen was for a combination of the reasons which conspired to create an atmosphere where limited checks were deemed necessary. A recommendation was made above which is aimed at the SSCB as this is a general theme which needs county wide oversight and monitoring. 4.4. Why bruising was not taken more seriously, and an assessment of real risk not made sooner 4.4.1. This is at the heart of this SCR. Although individuals did not follow guidance on bruising in young babies, the individuals were many and from different employers and professions, so there is a general not individual cause (although of course individuals can vary in how good they are at their role). The possible confusion about the bruising policy about babies who cannot move themselves has already been discussed and the SSCB will need to understand how that came to be and put it right. Some people may not have been very aware of it, but some who were aware still did not follow it. This points to 3 dynamics which the SSCB, and its member agencies must assess and address, through their collective work. They are not new issues to SCRs, but their continued relevance in subsequent SCRs shows how powerful they are and how organisations should assume their presence when designing training, supervision and audit. 4.4.2. There are three related dynamics between professionals and clients, which professionals have as human beings. A rule of optimism (described in Brandon et al, 20121, as a ‘common and previously identified theme’ in their biennial review of learning from SCRs). Failure to revise judgements. (Fish, Munro and Bairstow, 20092, say that ‘One of the most common, problematic tendencies in human cognition … is our failure to review judgements and plans – once we have formed a 1 DFE Research Report DFE-RR226: Marian Brandon, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson (2012) ‘New learning from serious case reviews: a two year report for 2009-2011’ 2Fish, S., Munro, E. and Bairstow, S. (2008) ‘Learning together to safeguard children: developing a multi-agency systems approach for case reviews’, London: Social Care Institute for Excellence. 51 view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture’). Lack of challenge- of parents and fellow professionals (Brandon et al, 20123, describe numerous lessons from lack of challenge and critical thinking in SCRs). 4.4.3. The rule of optimism is where professionals wrongly assume positive outcomes for children. It rationalises evidence that contradicts progress – so even where the facts show that risk is on-going or increasing, professionals tell themselves that the opposite is true. It is more likely to exist when staff feel under pressure, or when staff find it hard to face up to potentially life changing decisions. In this case, not just one mark of unproven origin was seen not to demonstrate risk, but at least 3 plus eye haemorrhages and not one professional thought it of enough concern to alert Children’s Social Care. The “easy bruising” theory was just that, and there was a natural reaction to accept it and not see the parents as a threat. 4.4.4. The on-going evidence did indeed contradict progress, as by that time there were at least 3 bruises, and retinal haemorrhages, and although there are one or two records of the ‘let’s keep an eye on things’ type no one had any serious concern. In hindsight, it all seems alarming, but because of the innate tendency to want to believe the best, without the strongest systems of training support and supervision, and multiagency review, the optimistic stance can continue. 4.4.5. A feature of this is what E. Munro (‘Improving reasoning in supervision’, Social Work Now, 40, 6) describes: “The single most pervasive bias in human reasoning is that people like to hold on to their beliefs”. This leads to a failure to revise judgements whatever the evidence. This was illustrated at St Peter’s when the “easy bruising” theory, once thought to be the explanation, was so strongly ingrained that bruising was not mentioned at all when the baby was transferred for more specialist care at St George’s. Also, to look at it in a different way, once the assessment of the very ill Child X started at St Peter’s without knowledge of prior bruising, and working diagnosis of epilepsy or infection was pursued, NAI was never seriously considered, even when some knowledge of prior bruising emerged. This in turn influenced the initial approach at St George’s, and as described earlier, the sort of outside checks which a hospital would make to help recognise risks were not made. 4.4.6. This is not an issue just for the hospitals in this case. The author of this Report reviewed a very similar case where very considerably more injuries were not seen by the first general hospital nor immediately found by the specialist hospital, as a hypothesis of a medical illness was the overwhelming focus. 3 op.cit 52 4.4.7. A feature of these dynamics is a lack of challenge – both professional to parent and professional to professional. A dictionary definition of challenge includes ‘summons to engage in a contest’ and ‘demand an explanation’. Often it can be the fear of coming over as engaging in a contest that stops professionals demanding explanations. This can apply to work with families (like not challenging parents too much in case it lessens their motivation or impacts on relationships with staff). Also, it can be hard for workers to challenge parents, when certain of their answers might lead to life changing decisions about the family such as the removal of a child, and the consequential pain for parents. In this case parents were asked for explanations, but even vague ones were accepted as the number of incidents grew. Also, in this case, the regular presence of the professional paternal grandmother made challenge even harder, as she gave strong views apparently from an informed perspective. The SCR saw in IMRs how some staff felt intimidated by this, and this can weaken challenge. 4.4.8. Another way this applied was that even though clinical staff did ask questions, none made it possible for those trained in investigation to meet the parents as no referrals to agencies with statutory powers were made. 4.4.9. There was little challenge evident between professionals. In part, this was because some staff, eg the midwives and health visitors seeing the bruises on day 10, day 20 and haemorrhages on day 27, did not tell anyone such as a supervisor or named professional who might have taken a challenging stance. Although this was because they did not think there was abuse to report, the agencies concerned should review managerial arrangements to see if there is any inhibition to reporting concerns upwards or to advisers. 4.4.10. There may have been opportunities for health visiting to be more challenging of the car seat story they inherited, or for the GP and community staff to engage in more robust discussions about whether explanations were really believable. There were opportunities for doctors to be more challenging of each other. In the sense that challenge is seeking an explanation, it is about ensuring minds stay open. 4.4.11. The SSCB and its member agencies should consider the degree to which ‘challenge’ is encouraged as an important part of professional work, and valued as something in the interests of children. 4.4.12. The SSCB should ensure that the human tendency to optimism in the face of evidence and reluctance to change judgements are understood in training, and that member agencies examine their processes to be sure that there are appropriate management and supervisory structures in place to minimise the impact of such tendencies. SCR after SCR shows that even though these issues are known they continue to apply and affect cases, so there should be no easy assumption that everything is all right. 53 4.5. Why there were no multiagency discussions 4.5.1. There is a simple answer. No one ever triggered one. No one referred any bruise to Children’s Social Care so no assessment was done which might pull together the views of a range of agencies. No one thought that there had been abuse so no strategy meeting was held. There was not even an informal get together to ask what was happening by the time there had been at least 3 bruises plus the eye haemorrhages in the baby’s first 4 weeks. And neither St Peter’s nor St George’s called other agencies when dealing with life threatening, unexplained illness. 4.5.2. This was the consequence of staff and even teams being affected by the rule of optimism, not revising judgements and the lack of challenge – so much so that no one thought it worth invoking child protection processes before the final diagnosis. This just emphasises the importance of agencies singly and collectively having arrangements in place where staff are supported to be more curious, challenging, and helped to ward off the underlying human tendency to hope for the best-despite growing evidence to the contrary. 54 5. CONCLUSION 5.1. This conclusion needs to be seen in the context that unless Child X had been removed from home the major injuries may still have occurred. Even if the family had been placed under close supervision as marks appeared, they could still have happened. After at least 3 bruises to a non-mobile baby were seen between days 10 and 21 it could be argued that an X–ray would have been justified and some of the fractures may well have been present. This would almost certainly have triggered protective action. 5.2. The sequence of events described in this SCR, summarised at 3.21, suggests that, had so many things been done better and had there been stronger checks and balances in place to guard against undue optimism and fixed views, there were indeed opportunities to have made a difference. The illustrations of slow or non-communication, absent or inaccurately/poorly completed records, failure to follow SSCB procedure, insufficient curiosity or challenge, and the fact that at no stage was there any multiagency consideration of what was developing, are all of concern and will provide considerable food for thought for the SSCB and member agencies. 5.3. Although there were examples of individual poor practice, it is too easy to say that individual performance was the root cause. This SCR has shown clearly how many people in a number of agencies acted in a similar way. Also, individual performance can often reflect the support arrangements in their organisation, the priorities of agencies, and the degree to which agencies and or the SSCB monitor the effectiveness of local arrangements. For these reasons many of the recommendations are for those responsible for the effectiveness of the whole system, and not just for single agencies. 55 6. RECOMMENDATIONS 6.1. There are two sets of recommendations. Firstly, those made by the agencies who have written individual management reviews. These reflect the conclusions reached by involved agencies when they looked at their own performance for the SCR. These recommendations are in Appendix 1. Each agency has an action plan, which will be monitored by the SSCB, containing their own actions, and any below stemming from this SCR. 6.2. Secondly, there are those additional recommendations which are made from the conclusions of this SCR. They are supported by the SSCB’s SCR Panel. The paragraph in which the recommendations appear is stated. Surrey Safeguarding Children Board 1. The SSCB should ensure that there are effective processes in place to ensure that the purpose of referrals (and this does not just apply to referrals to social work) is clear (3.3.3) 2. The SSCB should facilitate discussions with a wide range of professionals about the implementation of guidance on bruising to children who are not independently mobile to understand why it has been so poorly implemented, and to make any adjustments and training necessary (3.11.3) 3. The SSCB should monitor the circulation and take up of any revised guidance on bruising, and undertake case audits with partners to ensure that guidance is followed and recording of injuries is as expected (3.11.3) 4. The SSCB should review its web site and how procedures are linked to ensure there is a much simpler way of staff identifying what guidance they must follow (3.11.3) 5. The SSCB should reiterate for all agencies that any suspicious marks must be recorded on a body map in order that there is a permanent record, and one which can help build a picture over time (4.2.2) 6. The SSCB should receive on-going reports from the relevant NHS body on compliance with required training for GPs (3.10.8) 7. The SSCB, through the promulgation of findings from this SCR should emphasise the importance of admin processes and record keeping, and through case audits monitor their quality (4.2.3) 8. The SSCB and its member agencies should consider the degree to which ‘challenge’ is encouraged as an important part of professional work, and valued as something in the interests of children (4.4.11) 56 9. The SSCB should ensure that the human tendency to optimism in the face of evidence and reluctance to change judgements are understood in training, and that member agencies examine their processes to be sure that there are appropriate management and supervisory structures in place to minimise the impact of such tendencies. (4.4.12) Ashford St Peter’s Hospitals’ NHS FT 10. ASPH should clarify the circumstances in which a handover should be given to the area where a targeted midwifery client has moved, and checks made that a vulnerable client has indeed locked into services after moving. (3.3.2) 11. ASPH should review midwifery record keeping systems to ensure a tighter arrangement with key events known at the office and not just patient held records (3.6.4) 12. ASPH should consider when and how their midwives are informed about the attendance at A&E of a baby under their care (3.6.5) 13. ASPH should review continuity of care in community midwifery, especially for potentially vulnerable families (3.6.10) 14. ASPH should review arrangements for reporting on rare or unusual scans, and be satisfied that there is sufficiently quick access to appropriate specialist/subspecialist advice (3.14.5) Ashford St Peter’s NHS FT and Virgin Care Services Ltd 15. ASPH and Virgin Care should set out clear expectations on the nature of midwife to health visitor handover (3.6.11 16. ASPH (midwifery) services and Virgin Care (health visiting) should review managerial arrangements to see if there is any inhibition to reporting concerns upwards or to advisers. (4.4.9) Ashford St Peter’s Hospitals NHS FT and Community Health providers 17. ASPH and community health care organisations review information flows and processes to ensure that community staff are informed as quickly as necessary about events happening to children under their care (3.12.2) 57 Virgin Care Services Ltd 18. Virgin Care should ensure that any possible NAI, or bruising in non-mobile babies, seen by health visitors is shared with a manager or the named nurse (3.9.2) St George’s Hospital NHS Trust 19. St George’s should have a system in place to ensure important test results are always available, and that access to specialist advice can be reached in urgent situations (3.15.3) Surrey County Council Children’s Services 20. Surrey Children’s Social Care should review the Strategy Meeting record so the proper designation and agency of each attendee is clear. The SSCB must require agencies to read the minutes carefully and submit corrections promptly (3.15.7) AB Sep 2013 58 Appendix 1 Recommendations from Individual Management Reviews The following are the recommendations as they appear in the IMRs submitted to the SCR. The Surrey Safeguarding Children Board will monitor the progress of the associated action plans Ashford and St Peter’s NHS FT Recommendations 1. Staff receive an appropriate level of safeguarding training that will assist them in analysis of information when making decisions about bruising in non-mobile children, and to support good recording practice and working with family members, having difficult conversations 2. Staff to have access to all relevant information in a timely way to support decision-making, including policy guidance and information to support the above in a timely fashion e.g. NICE guidance on bruising and immobile babies, hospital pathways and Working Together and local multi-agency guidance. 3. Staff to have access to patient documentation to support decision-making. Staff are trained to ensure this documentation is fit for purpose, for sharing and accessible at time required. 4. A review of the safeguarding structure and capacity within the Trust, to ensure safeguarding leads are available to all staff. 5. Safeguarding supervision to be available to all staff in accordance with hospital policy and safeguarding supervision to challenge the current culture of the organisation regarding responsibilities to safeguarding. 6. A directory of guidance on the management of specific medical conditions where there is no access to expertise within the department, available to all levels of staff. GP IMR (this IMR identified issues mainly for GPs in general rather than the Practice concerned). It recommended that: 1. The Named GP raises with the health sub-group of the SSCB, the issue of robust communication and information sharing between the hospital and GP practices (and vice versa where necessary). 2. An update regarding the GP-specific level 3 training programme, with the 2013-14 dates, is circulated immediately. 3. Guidance is drafted in conjunction with the designated nurse for Surrey for consideration by the named professionals group and SSCB Health sub group59 Health Overview Report (on behalf of Guildford and Waverley CCG) Recommendations for Action: Each Health Provider has made their own recommendations which are endorsed. In addition the following recommendations are made: 1. G&W CCG as lead commissioner for safeguarding needs to ensure that lessons from this review and provider action plans developed in response to this review are monitored by the appropriate CCG to ensure that lessons are being embedded into practice 2. G&W CCG as lead commissioner for safeguarding needs to assure themselves that the named doctor capacity is sufficient and that there are robust cover arrangements to ensure safeguarding advice at times when the presentation is of a medical arrangement 3. G&W CCG as lead commissioner for safeguarding needs to review education provision across the health economy including GP Practices to ensure the protocol for bruising in pre-mobile babies is embedded in practice. St George’s Healthcare NHS Trust Learning for St George’s Healthcare NHS Trust 1. Information shared between St George’s professionals and other healthcare providers prior to transfer should be recorded and this then should be available in the child’s records. 2. Early contact to be made with community professionals such as health visitors, school nurses, GP’s or midwives for all children who are admitted to PICU to inform of the admission and to also seek information. 3. Paediatric Consultants and teams to be reminded that the Consultant and team actually discharging the child on the day are responsible for arranging follow up of the child’s health needs as well as the safeguarding aspects of the child’s care. Surrey Police No recommendations Surrey County Council Children’s Services Recommendations for Action 1. Point 6.10.2 to be brought to the attention of the Contact Centre to consider how they appropriately check and share relevant information with SCS area teams where there is active involvement by the area teams with other close family members. 60 2. To further the work with agencies referring to Children’s Services with regard to their establishing greater clarity of their purpose for referring i.e. whether it is for information sharing, consultation or action and that all identified risks and concerns are clearly stated and recorded. Virgin Care Services Ltd 1. Review the effectiveness of the joint SMART action plan which was created with St Peter’s Hospital as part of this review. 2. Upgrade the database which monitors training and supervision for the Bank 0-19 practitioner’s, and implement monitoring by the team line manager and service manager for action breaches. 3. Investigate the options to improve the flow of timely information from the acute hospitals into the Virgin Care community. 4. Update the 0-19 team’s guidelines to clearly define “targeted ante-natal criteria”, and specify the documentation to be written on RIO (electronic health records). 5. Update all relevant 0-19 team’s guidelines and record keeping standards to mandate that the practitioners obtain a history of the client, including filtering from first contact on RIO, and retrieving any old child/family health records if there is a concern highlighted by outside agencies or seen on RIO. 6. Recommend that the communication procedures between the midwives and the 0-19 team are updated to ensure that a robust system is put in place. 7. Recommend that the Paediatric Liaison criteria and standards be reviewed and updated. 8. Health needs assessment guidelines and tools be updated to reflect lessons learnt from SCR’s, and be communicated to 0-19 practitioners’ so they are aware of the guidelines and timelines for completion. 9. Implement a more robust system to confirm transfer of records internally, and include the use of nhs.net team accounts to alert teams of transfers within the organisation. 10. Provide additional training for Health Visitors to improve skills when assessing parenting and include specific training for the 0-19 team on the RIO system. 61 Appendix 2: Appraisal of Individual Management Reviews 1. Ashford and St Peter’s NHS FT This IMR required considerable re analysis and revision. A number of key facts proved to be incorrect, or presented in a misleading way, around midwifery. It is hard to tell the degree that this was due to insufficient rigour in the original IMR, or was due to poor and confusing recording by front line staff which would make it hard for any reviewer. There were also some additional facts around the hospital service that the SCR later identified. When the SCR raised many queries about the SCR the Trust cooperated well in clarifying the detail. The analysis, although a little hampered by the confusion over some facts, was generally sound. The detailed action plan, developed after they had conducted a serious untoward incident review is quite comprehensive. 2. General Practice This was relatively short as the family were new to the Practice and only saw the baby once. It was clearly written, contained all the key facts, and identified the issues – with actions which were progressed immediately. 3. St George’s Healthcare NHS FT This was a well written IMR, with good detail and analysis. 4. Surrey Police This was a very brief IMR as most police knowledge came after the event. Prior knowledge of the relevant family members was appropriately identified. 5. Surrey County Council Children’s Services The difficulty in being clear who could have known what was reflected in the redrafts of the IMR. However, going through this process clarified for CSC the learning points about access to historical information which are well set out. 6. Virgin Care Services Ltd A well written IMR with the facts set out, a robust analysis and a good, well referenced learning section. 7. South East Coast Ambulance Service NHS FT Not an IMR but the information was not received until the review was near complete. A December 2012 request from the SSCB to the Service led to a response that the case could not be identified. In May 2013 the records were easily found. It seems the Service can only track through an accurate not partial address, and not for example a patient name. However a correct address is believed to have been given so the original ‘no discovery’ seems inexplicable. It would appear that better search facilities would be useful. 62 Appendix 3: Key dates DAY 0 Baby born 1 Abortive midwife visits 2 Midwife home visit 5 A&E attendance for constipation, blood in stool Midwife home visit 8 Parents see abdominal bruise and paternal grandmother reports this to midwifery 10 Midwife home visit. Abdominal bruise seen by midwife A&E attendance for blood in vomit, and admitted with infection. A&E records do not refer to bruise, but it is seen on ward the next day 14 Baby discharged home 15 Midwife visits home and discharges mother and baby 20 GP sees abdominal bruise, and mark on face Health visitor makes first home visit and sees both 21 Baby taken to paediatric ward for follow up appointment. Facial and thigh bruising seen 22 Mother speaks to out of hours GP service as baby very distressed 27 Baby taken to drop in health visitor clinic. Eye haemorrhages seen 30 Baby admitted to local hospital via ambulance in small hours 32 Transferred to tertiary hospital with no diagnosis of injury or mention of prior bruising 33 Local hospital tests are reviewed at the tertiary hospital and fractures and traumatic brain haemorrhages found 63 Appendix 4: Bruising in Children who are Not Independently Mobile: Multi Agency Guidance 1. Introduction This Guidance provides all professionals with a knowledge base and awareness for the management of children who are Not Independently Mobile (NIM) who present with bruising or otherwise suspicious marks. Children with disabilities who are not mobile should also be considered within this guidance. 2. Definition Bruising is the commonest presenting feature of physical abuse in children. The younger the child, the greater the risk that bruising is non-accidental. Any bruising or mark that might be bruising, in a child of any age, should be taken as a matter for inquiry and concern. Bruising in a child not independently mobile (any child who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently: Includes all children under 6 months even if they are rolling, or children with significant disabilities resulting in immobility) should raise suspicion of maltreatment and should result in an immediate referral to Children's Services. It is the responsibility of the examining paediatrician to decide whether bruising is consistent with an innocent cause or not, even if a plausible explanation is given by the carer. 3. Immediate response Any child who is found to be seriously ill or injured, or in need of urgent treatment, should be referred immediately to hospital before referral to Children’s Services. All other cases should be first referred to social care. 4. Making a referral Where a decision to refer to social care is made, it is the responsibility of the first professional to learn of, or observe the bruising, to ensure that a referral is made to social care. Wherever possible, discussion of the case with a senior colleague is recommended. Children should not be medically examined by any professional other than a medical practitioner. Referrals should be made via Contact Centre for Children’s Services and/or via the main Police Switch board for Police (Telephone referral). All telephone referrals to social care via Contact Centre should be followed up within 48 hours, with a written referral using the appropriate interagency referral form. Social care and Police will follow SSCB 64 procedures in making a referral to locality Paediatric Teams for medical examination (Managing individual cases). 5. Medical Examination: (Only to be undertaken by a suitably trained Paediatrician) A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social care history, developmental stage and explanation given. The examining medical practitioner should obtain relevant information from all available sources e.g.: health visitor, GP, hospital records, social services nursery etc. which helps in informed decision making. A full clinical examination of the whole body of the child or young person should be undertaken. Haematological and biochemical studies including a clotting screen should be done to exclude possible medical causes resulting in bruising. Any child under 2 years presenting with unexplained bruising should have full skeletal survey, including a CT Brain scan (see guidelines for requesting, repeating and reporting on skeletal surveys). Retinal examination by an experienced ophthalmologist is essential to exclude eye injury including retinal haemorrhages. 6. Recording The importance of signed, timed, dated, accurate, comprehensive and contemporaneous records cannot be overemphasised. The completed medical examination record form should be circulated within the ‘Gold’ standard time scales to GP, HV, and other involved professionals (refer to Multi agency guidelines to follow when a child is referred for medical examination). 7. Contact details Contact Centre (0800 -1800) 0300 200 100 6 EDT (out of hours 1700 – 0900) 01483 517898 Police: 101 For medical advice Weekdays 09:00 to 17:00 – Community Paediatric Team Surrey Community Health (Except Epsom area covered by Epsom General Hospital) Surrey Community Health North West 01483 728201 South West 01483 783211 East 01737 768511 After working hours, weekends and Bank holidays – On call paediatrician at nearest hospital 65 ASPH 01932 872000 East Surrey Hospital 01737 768511 Royal Surrey County Hospital 01483 571122 Epsom & St Heliers Hospital 01372 735735 Frimley Park Hospital 01276 604604 February 2012 66 Appendix 5: Terms of Reference Scope and Terms of reference for the Serious Case Review (SCR) in relation to child X aged 5 weeks when injuries identified Date Independent Chair agreed to hold SCR December 2012 1. Terms of reference of the SCR Terms of reference relating to the overall purpose of the SCR 1.1 to establish what lessons are to be learned from the case about the way in which professionals and organisations work individually and together to safeguard and promote the welfare of children 1.2. to identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and improve intra-agency and inter-agency working and better safeguard and promote the welfare of children. Specific issues that should be considered arising from the review of information available to the SCR Panel 1. The level and extent of agency engagement and intervention and whether this was appropriate to the assessment of the parents’ ability to provide adequate care and supervision of Child X 2. The recognition of safeguarding issues by all agencies and how these were addressed. Was sufficient consideration given to the fact that this was a pre mobile baby? How were concern and or issues communicated between professionals within each agency or team and between agencies? Were concerns discussed with supervisors and safeguarding advisors 3. The quality of assessments on which decisions and actions were taken 4. The existence of any mental health issues or issues of substance which may have impacted on parenting capacity. 5. Whether there are any factors in the history of any adults that indicated that they may pose a risk to children. What was known to agencies about either parents prior to the birth of Child X and whether there were any indications there could be an impact on their parenting ability? 6. Whether race, religion, language, or culture was a factor in this case and had been considered fully 7. The extent and quality of partnership working between and among key agencies. 8. The effectiveness of working arrangements (including information sharing and communication) between all professionals 9. The existence of any factors relating to the “capacity and climate” within agencies which may have impacted on practice in this case. 10. The degree to which the admitting hospital considered the possibility that the child’s injuries were caused deliberately and in particular how the injuries later diagnosed at a Specialist hospital were not seen in the X-rays and scans which were undertaken at the admitting hospital. 67 11. In addition to the above the review should consider learning both for the individual agency and for how agencies work together through the LSCB Authors of individual management reviews, SCR panel members and the author of the overview report should also bring to the attention of the SCR panel chair any other matters falling within the scope of the review if they think that there are lessons to be learnt either for an individual agency or for the LSCB. Authors of individual management reviews who identify other significant issues not falling within the scope of the review should bring them to the attention of a senior manager within the agency. These are provisional terms of reference, which may be amended if new information comes to light. 2. Time period for review 1. The principal focus of the serious case review will be from the booking of the pregnancy to the Strategy meeting after NAI was identified. 2. The review will invite all agencies to provide family history outside the specific scope and timescale which may have had an impact on parenting capacity or family functioning 3. Parental and family involvement in the review The SCR panel will seek to involve the parents (and other family members where this is identified as relevant) in the review in order to obtain their perspective on the services offered. The mother and father of Child X will be notified about the decision to hold the review in an appropriate way and at an early point, via legal representatives if appropriate. The SCR panel will seek to involve the parents and other family members as fully as possible. In view of the current criminal investigation all contacts with family members will take place within a framework to be agreed by the SCR panel based on legal advice and advice from Surrey Police. 4. SCR panel membership The SCR panel will be chaired by Fergus Smith The following agencies will be asked to provide a senior manager with expertise in relevant aspects of children’s safeguarding to sit as a member of the SCR panel: Surrey Police Surrey Children’s Services Surrey NHS - Designated Nurse Adult Social Care 5. Agencies currently believed to be involved within Surrey The following agencies are known to have been involved at this point and will be asked to contribute Internal Management Reviews Surrey Children’s Service 68 Virgin Care Services Ltd GP/ Guildford and Waveney CCG Ashford and St Peter’s Hospitals NHS FT Surrey Police Agencies currently believed to be involved outside Surrey St George’s Hospital NHS Trust If other agencies are identified they will be asked to contribute as appropriate. 6. Managing public, family and media interest Family interest in the review will be considered by the SCR and the panel chair in keeping with the approach set out in section on parental involvement above. Media and other public interest in the review will be managed in line with the SSCB press / media strategy. The children and other family members will not be identified by the SSCB and all agencies will take whatever steps are appropriate to reduce the likelihood of identification in criminal proceedings if these occur. ------------------------------ 69 Appendix 6: ACRONYMS ASPH Ashford and St Peter’s NHS Foundation Trust CEO Chief Executive Officer GP General Practitioner HV Health Visitor IMR Individual Management Review LSCB Local Safeguarding Children Board MW Midwife NAI Non Accidental Injury PICU Paediatric Intensive Care Unit SCR Serious Case Review SSCB Surrey Safeguarding Children Board TOR Terms of Reference WT 2010 Working Together to Safeguard Children 2010 WT 2013 Working Together to Safeguard Children 2013 |
NC52216 | Serious and potentially life-threatening incident to a 4-year-old boy in July 2019. Child O was taken to hospital after accidentally swallowing Gamma-ButryoLactone (GBL) he found in his mother's handbag. Child O lived with extended family under a Special Guardianship Order (SGO). Child O was alone with Mother when the incident happened, contrary to the SGO agreement. Concerns raised about neglect due to parents' misuse of drugs. A Child Protection Plan was made for Child O but was unsuccessful in reducing risks. Father was convicted of child neglect in 2015 when he was found in-charge of Child O under the influence of drugs. Child O was accommodated under section 20 of the Children Act 1989 and placed with his grandmother. A police investigation was underway but not concluded. Care proceedings were initiated for Child O and sibling which concluded in 2020. Ethnicity and nationality not stated. Learning looks at: the support offered to the family under the SGO and the quality of the support plan; robustness of the communication between local authorities (LAs) including how safeguarding referrals were raised; adult mental health; domestic abuse and MARAC involvement; issues arising from management oversight and supervision information. Recommendations include: review training programs about the legislations, governing and meaning of different types of placements such as SGOs, Children Looked After (CLA) and adoptive placements that are open to LAs when considering the future of children who are unable to live with their birth parents; oversee a multi-agency review of current arrangements for Children in Need that are also subject to SGOs.
| Title: Child O – local child safeguarding practice review. LSCB: Bexley SHIELD Author: Jane Doherty Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child O – Local Child Safeguarding Practice Review (Bexley S.H.I.E.L.D.) Reviewer – Jane Doherty – Independent Social Work Consultant March 2021 1 Introduction 1.1 This review was commissioned by Bexley SHIELD (Safeguarding Partnership for Children and Young People in Bexley) after a serious and potentially life threatening incident to a four year old boy (referred to in the report as Child O). 1.2 In July 2019, Child O was taken to hospital after accidentally ingesting the drug Gamma-ButyroLactone (GBL)1 he found in his mother’s handbag whilst his mother was visiting him. Child O lived with his extended family on a Special Guardianship Order (SGO)2 and contact with his mother was arranged between the family members. When the incident happened Child O was alone with his mother which was contrary to the agreement under the SGO where it was agreed that contact should be supervised. 1.3 After the incident, a Rapid Review meeting took place and it was agreed that a Child Safeguarding Practice Review (CSPR) should be undertaken to examine the circumstances in which the incident occurred. Child O has made a complete recovery but the Partnership considered that there were lessons to be learnt, as early in the enquiries there were indications that Child O’s living arrangements were subject of concern. The placing Local Authority, which was Lambeth, were invited to join the process to enable them to review their own practice. 1.4 At the time of writing the review a police investigation was underway but not yet concluded. Care proceedings were initiated in respect of Child O and his sibling which concluded in 2020. 1 GBL is a Class C drug, sold as a colourless oily liquid that has a euphoric effect. It converts to GHB in the body and is highly addictive. 2 A Special Guardianship Order (SGO) is a court order made by a judge in the family court about where a child should live and who has parental responsibility for them. 2 2 Terms of Reference 2.1 The Terms of Reference are attached at Appendix 1. Agencies involved with the family were asked to analyse their involvement via a brief written submission. The timeframe for the review is from July 2018 to August 2019. NB This time period was extended for Lambeth Children’s Social Care (CSC) and CAFCASS so that they could provide the relevant background information, prior to Child O being placed in Bexley. 2.2 The Terms of Reference were agreed with the Panel overseeing the review. The broad areas that the Panel agreed were the most important to look at were; The quality of the Special Guardianship Assessment including the capacity of the potential carers to look after two small children, their health needs (mental as well as physical) and their ability to place the children’s needs first The support offered to the family under the SGO and the quality of the support plan The robustness of the communication between Lambeth Children’s Services and Bexley Children Services when the children were being placed in Bexley under a SGO Were safeguarding referrals raised appropriately and directed to the correct agency/local authority? If not what were the barriers to these? Were issues of mental health in the adults known about, understood and assessed appropriately? Were issues of domestic abuse known about, understood and dealt with appropriately? How effective was management supervision and oversight in this case? How has this case demonstrated good practice? How was the voice of the child represented by agencies 3 Review Process 3.1 The report is based on the agencies’ submissions (referenced above) and a practitioner event with key staff that had worked with the family and knew them well. The report author had access to other documents relating specifically to the family such as assessments and minutes of relevant meetings held with the family. 3.2 In order to provide context to the working practices at the time of the review, the author also read a number of contemporary policies and procedures. In addition early responses to some of the issues raised by the case were made available. These are referenced in relevant sections. 3 4 Agencies involved in the review Bexley Children’s Social Care Bromley Healthcare 2 local nursery provisions (Bexley) CAFCASS CAMHS Dartford and Gravesham NHS Trust Lambeth Children's Social Care Lambeth Probation Services Metropolitan Police Service Oxleas NHS Foundation Trust SOLACE Lewisham and Greenwich NHS Trust 5 Summary of professional contact with the family Family Members Age at the time of the incident Child O 4 years Sibling (known as Child P) 3 years Mother 31 years Father to Child O 33 years Maternal Grandmother (SGO Carer) 54 years Maternal Aunt (SGO Carer) 34 years Maternal relative 19 years Cousin 5 years Cousin 2 years Half sibling (same father) to Child O (living in Bexley) 2 years Half sibling (same father) to Child O (Living in Bexley) 1 year 4 5.1 Agency submissions to the review have been co-ordinated into a combined chronology, summarised here. Key events leading up to the period under review have been added here for context. Further factual information is provided in subsequent sections to add perspective where relevant. Background information from Lambeth Children’s Services (2015/16) 5.2 Lambeth CSC became involved with Child O in 2015 (when Child O was 3 months old) after concerns were raised about neglect due to his parents’ misuse of drugs. A Child Protection Plan (CPP) was made in respect of Child O but was unsuccessful in reducing the risks. In June 2015 Father was convicted of Child Neglect, when he was found in charge of Child O, under the influence of illicit substances. 5.3 Child O was accommodated under s20 (Children Act 1989)3 and placed with his Maternal Grandmother (MGM) in Bexley. Mother revealed at this time that she was expecting another child (Child P) and had had no antenatal care. Planning for this child was joined to Child O, which had entered the Public Law Outline (PLO)4 as a precursor to issuing care proceedings. When Child P was born in the spring of 2016, he was placed in a Mother and Baby foster placement with his mother. 5.4 This arrangement did not go well and Mother left the placement (without Child P) on at least three occasions. Lambeth CSC issued care proceedings in 2016. At the conclusion of these, a successful application was made for both children to be placed on an SGO in the care of their MGM, her partner and their Maternal Aunt (MA). With the making of the SGO in November 2016, the household consisted of two adults (MGM and MA), three children aged three or under, and another relative who was 16. MA was also pregnant with her youngest child who was born in March 2017. 5.5 Lambeth CSC continued to support the family financially but ended their social work involvement in May 2017 as the children were no longer in their area. The issues surrounding the making of the order are discussed throughout the report but suffice to say at this point that Bexley CSC were unaware of the placement in their area. Agencies continued to liaise with Lambeth, including referring concerns to Lambeth CSC rather than Bexley CSC. 5.6 Contact arrangements (agreed at court by all parties) with their Mother and Father, was facilitated and supervised by the family. Child O had weekly contact with his Mother and weekend contact with his PGM. Father’s contact was supervised through this arrangement. 3 S20 of the Children Act 1989 allows children to be placed into the care of the local authority with parental agreement 4 The Public Law Outline is a mechanism used by local authorities to advise parents of their intention to issue care proceedings if matters of harm and neglect to their children are not addressed. It allows parents to be legally represented and receive support to help them achieve what they need to do to avoid the local authority going to court. 5 5.7 In addition to his maternal cousins living in the family home alongside him, Child O also has two half siblings on his father’s side. These children were born in 2016 and 2017 respectively and also reside in Bexley. Key Events in 2017 – Children begin to display behavioural difficulties 5.8 MA had her youngest child in March 2017. It is not clear if Lambeth CSC knew that she had had a baby when the family were closed to them in May of that year. 5.9 In May 2017, Child O’s nursery arranged with MGM and MA that, providing they had permission, Mother could collect to Child O from nursery unsupervised. Unbeknown to the nursery, this was in direct contradiction to the supervised contact the SGO had set out. 5.10 At the end of May 2017, Bexley CSC received a contact from Queen Elizabeth Hospital (QEH) in relation to MGM having taken an overdose. There was a request for information from Lambeth CSC, but the contact did not progress to a referral because MA confirmed that MGM was not the sole carer for the children. 5.11 In September 2017, the family were experiencing difficulties with Child O (aged 2 and half) and Child P (aged 18 months). MA requested (from health visitor) a review of Child O’s behaviour as she described him as being violent towards other children and he was difficult to manage. His younger sibling was referred by the health visitor to the paediatrician, also due to concerns about his behaviour. Key events in 2018 – concerns grow about how the carers are coping 5.12 The children’s behavioural difficulties continued into 2018. In late summer, the Health Visitor made a number of visits to the family, as she was concerned for their welfare. The Health Visitor suggested a number of options to try and support them but the family was slow to take them up. NB at this point there were 4 children aged four or under living in the household. MA reported that she had contacted Lambeth CSC for support in the past, but she was informed they do not support SGOs and she should contact Bexley CSC. She had however not done so. After appropriate consultation, the Health Visitor made a referral to Child and Adolescent Mental Health Services (CAMHS) for Child O. 5.13 Amid some growing concerns about how the family needing extra support, the Health Visitor telephoned Bexley CSC and discussed with a duty social worker the fact that children were under an SGO. They advised that if there were concerns and a Special Guardian required support, the Health Visitor would need to complete a referral to Early Help services. In the meantime, the CAMHS referral had been accepted and Health Visitor thought that this was a more appropriate service. 6 5.14 At this time Child O’s nursery also had concerns about his behaviour. The staff reported to Lambeth CSC that Child O ‘had said some things at nursery and needed to make social services aware’. Information gleaned through this process revealed that Child O disclosed that when he was younger, he had fallen into a fire and his mother had ‘kicked him in the head’. It is not clear if the specific information was communicated to them but Lambeth’s response was that the case was not open to them and the children did not reside in their area. They did not however, redirect the nursery to Bexley CSC. 5.15 Child O’s behaviour did not improve and MA attended an initial appointment at CAMHS in late 2018. At the appointment she gave very clear descriptions of his behaviour which included aggression, difficulty regulating his emotions and night terrors associated with being abandoned. Some behaviours were also related to contact (or lack of it) with his mother. Throughout the following few months a number of appointments were missed by the family. When appointments were attended, work focused on management of Child O’s behaviour and exploration of his emotional needs in terms of safety and security. He was reported to be particularly distressed on realising that his father had other children. 5.16 Bexley Portage Service was also involved at this time as it was felt that Child P needed some extra input in terms of his development and behaviour. Although the service was directed at Child P rather than Child O, the worker visited fortnightly and engaged all the children in the household, including the older of the cousins. 5.17 Late in 2018, Probation Services confronted Father when asking about his drug use. Father reported that he saw his son (Child O) every weekend but that he did not use drugs in front of him. The Offender Manager (OM) challenged him in view of his previous conviction for neglect. The OM notified him that they would complete a safeguarding referral in light of this disclosure. There is no evidence on file that this referral was completed. Key Events in 2019 – MGM experiences some mental health difficulties. 5.18 In January 2019 MGM was taken to hospital (QEH) having taken an overdose of paracetamol and other medication. She disclosed that she was having problems in her relationship with her then partner, and with her daughter who she described as ‘a drug addict’. Following the doctor’s assessment, he recommended for her to be admitted and that a referral to children’s social care should be made. During her treatment over the following few weeks MGM also mentioned domestic abuse associated with her other daughter. No referral to Bexley CSC was made. 7 5.19 In February, Bexley CSC received a notification of an incident from the Police, as MA had been the victim of domestic abuse from her children’s father. The outcome of the contact was to refer to Bexley Women’s Aid who referred to the Multi Agency Risk Assessment Conference (MARAC). Bexley CSC did not assess any of the children in the household as this was not their practice at that time. This is discussed further in Section 6 Paragraph 42 5.20 Later in February there was an exchange of information between Lambeth CSC and Bexley CSC about Father. This was after the concern (noted in paragraph 5.17) was raised from Probation (to Lambeth) about Father’s contact with Child O whilst under the influence of drugs. Lambeth provided Bexley with information which included some history i.e. Father’s conviction for neglect, the CPP in Lambeth and the eventual removal of the children. The information gave detail about the SGO with MGM and contact arrangements for Father to see Child O by way of a supervised contact with PGM. The information shared does not indicate that the children were residing in Bexley and Bexley CSC’s records do not show what their response was. 5.21 In April 2019, the family was discussed at MARAC in relation to the domestic abuse MA had suffered from her ex partner. It would appear that MARAC attendees were unaware of Child O and Child P in the household. Risks in relation to their cousins were discussed and safety planning went ahead, in relation to MA’s children only. The MARAC referral led to allocation to an Independent Domestic Abuse Advocate (IDVA) who discussed options with MA and supported her with safety planning. Later in May the MARAC discussion was followed up by the Health Visitor who also discussed safety measures and encouraged MA to liaise with the IDVA. 5.22 In July 2019 the events that led to this CSPR unfolded. 6 Findings 6.1 The following section seeks to explore the questions identified in the Terms of Reference. This analysis is drawn from the written submissions from individual agencies, discussions with the panel and incorporates the feedback from practitioners who took part in the review process. The quality of the Special Guardianship Assessment including the capacity of the potential carers to look after three small children, their health needs (mental as well as physical) and their ability to place the children’s needs first Information from the review 6.2 Lambeth CSC contributed to the review in a very open and frank manner. They acknowledged the limitations in practice surrounding the making of the SGO, 8 whilst also recognising the difficult circumstances in which they were operating at that time. 5 Lambeth CSC conducted their own learning process to enhance the information that contributed to this process. A number of practice issues had already been addressed as part of their on going improvement plan and further learning emerged for them as a result. The following summarises a review of the assessment at that time. 6.3 There were multiple occasions when notifications and checks from Lambeth CSC to Bexley CSC were required and should have been carried out. For example as far back as 2016 when Child O was placed with MGM, Bexley CSC were unaware that a child subject to a Child Protection Plan was in their area. This would have enabled Bexley CSC to add him to their temporary register. The same applied when he became s20 and when the SGO for both children was made. 6.4 The decision to assess MGM and MA as prospective guardians for Child O was taken in the context of them as close family members. They were relatives who were known to both children for all their (albeit short) lives and likely to be able to maintain close links with Mother and Father. This is all in keeping with the principles behind the making of SGOs for families where children are not able to live with their parents i.e. preference should be given to extended members of the family. 6.5 Within the SGO assessment presented to court, there were deficits in the analysis of the family dynamics. This was particularly about how the family would manage the inevitable tension between Mother’s drug dependency and contact with her children. At the start of the SGO assessment, Mother was living in the same household and was asked to move due to the tensions this was bringing. The family seemed to grasp the contact arrangements and were certainly aware of how important it was for the children to maintain their relationship. This was a fine balance to assess as contact took place in the home both pre and post the order with the potential to be increased (with MGM still supervising) if all went well. 6.6 From information gleaned from the review it is clear that the contact arrangements were not adhered to and that Mother played a large role in the family’s life post the making of the order. At times, this included staying within the household for half of the week, being unsupervised with the children during that time and picking Child O up from nursery. 6.7 The assessment did not take into account what the family would look like over the coming years. MA was a young woman in her early twenties at the time of the assessment with a young child of her own (and another on the way). Analysis of the impact of having 3 (and later 4) very young children to care for 5 Lambeth Children’s Services received a judgment of inadequate from OFSTED in February 2015 9 on the family as a whole did not take place. Child O was a child who had suffered early childhood physical and emotional neglect and the assessment does not explore the resilience of the family to deal with the potential repercussions of that. Further, the placement with both children was not tested prior to the order being made and Child P only joined the household after the court case was concluded. A report recently produced by the judiciary6 makes this (and other issues also pertinent to this review) a strong recommendation e.g. for potential matches where children are not currently residing with the carers, that final orders should be delayed in order to test a placement. 6.8 The SGO was granted within the court arena. Information gained, as part of this process would indicate that the Guardian appointed to act on behalf of the children was not robust in her analysis of the assessment. Challenge by the Guardian on matters of the family’s understanding of risk, how they would manage the contact arrangements and the procurement of statutory checks would have been beneficial. The CAFCASS records are not sufficient to fully understand the reasons why these were not done but their written submission acknowledges that this practice falls below expected standards. Learning and Implications for wider practice 6.9 As a result of learning from this review, Lambeth CSC have undertaken an extensive piece of work around notifications to other boroughs. This has included a review of cases from 2017 to present, to ensure correct notifications had been made. The same exercise has been completed for more historic cases i.e. those made prior to 2017. Lambeth CSC have been engaged in a ‘future proofing’ exercise to ensure that similar issues do not arise in the future. A work step is being built in the electronic data system to ensure that out of borough alerts are completed when necessary for CIN, CP, CLA and SGO cases. This is projected to go live in the autumn of 2020. 6.10 At the time the SGO was made Lambeth CSC acknowledged that quality assurance of the assessments submitted to court was not in place. Further, that their records do not provide an audit trail to fully understand what happened. Since that time practice has changed considerably and improved as part of their overall improvement plan. This includes; A dedicated SGO team established in 2018 (previously part of the fostering service) Extensive training has been completed and more is planned, particularly about ‘future proofing’ placements and understanding a family’s capacity (or not) to deal with changing need 6 Recommendations to achieve best practice in the child protection and family justice systems: Special Guardianship Orders 10 Increased monitoring of the progress of the assessment at key stages – Initial meeting, mid way review and a final meeting before a final recommendation is made A quality assurance process in relation to the assessment from the SGO manager and the SW Manager, Increased use of group supervision for complex cases Increased scrutiny of the care plan via the Independent Reviewing Officer (IRO) at the final Legal Planning Meeting (LPM) along with the presiding solicitor. 6.11 Since the time covered in the review Lambeth CSC have put in place a number of measures to improve practice which are covered in the following paragraphs. 6.12 Within the new SGO team the Team Manager offers regular individual supervision and fortnightly group supervision for reflective case discussions including learning from reviews. Once the order is in place staff from both services meet together which helps to consider and embed any longer term issues. 6.13 Strategically, Lambeth CSC have also set up a permanence and adoption board which track permanency and updated the Support Plan format. There is further ongoing work to develop the guidance attached to the plan to ensure that areas are not overlooked e.g. transition planning for children not already in placement and out of borough notifications. There are also on going changes to their electronic data system to support some of the changes. 6.14 In addition to these changes, written agreements about levels and frequency of parental contact will be in the support plan. Cases will remain open to the SW team until these have been completed, signed off and uploaded. 6.15 It is clear that the Guardian’s independent scrutiny on behalf of the children did not work in this case. CAFCASS failed to make an independent assessment of the children, the family and the proposed placement. The Guardian did not see the children as part of the assessment and did not adhere to the statutory requirements around DBS checks. 6.16 In response to this, CAFCASS have advised that it is their expectation that practitioners see all children unless there is a reason why this is not appropriate. CAFCASS have introduced a new system which will track and monitor visits to children. This came into force at the end of April 2020. 6.17 CAFCASS’s expectations are that Guardians robustly review SGO assessments including health and DBS checks. Audits undertaken by the National Improvement Service and more local service manager audits should 11 reinforce this and the standards should be upheld for all children. The support offered to the family under the SGO and the quality of the support plan Information from the review 6.18 Child O had been placed with MGM for a number of months prior to the official making of the SGO. His younger sibling joined him soon after the order was made but he had never lived with his sibling or MGM. This meant that the arrangement (at this point 3 adults, 1 young person and 3 very young children) of them living together was never tested during care proceedings. Further, the burden of this fell to MA as it has transpired through the course of this review that the arrangement was for her to do the majority of the day-to-day caring for the children without the support of the MGM. The reason for this is not clear and these arrangements are not set out in the plan that was agreed at court. 6.19 The SGO support plan was mainly focused on financial support and contact arrangements for the family. Lambeth have acknowledged that it should have been tailored more specifically to Child O and the needs of both carer’s. The author and panel would concur with this view and a recommendation is made to ensure that Lambeth do some development work about support plans that accompany SGOs. 6.20 The support plan lacked a multi agency perspective. Given that these children had moved into a new borough with a different set of resources on offer, there were no multi agency meetings to provide a Team around the Child (TAC). This is something that was overlooked and would have been beneficial to co-ordinate the work needed to support the placement. When the issues surrounding this CPSR came to light, in consulting with practitioners, it became clear that Child O’s nursery, health visitor, portage worker and other services were largely unaware of the extent of the early neglect he had suffered. There was no official handover to services in Bexley when Lambeth closed the case in 2017 and they (Bexley CSC) were never notified. Further confusion was caused for those working with Child O in Bexley because Lambeth continued to fund the nursery place. Thus, when concerns arose they reported concerns to Lambeth but were not re-directed to Bexley to assist. Learning and Implications for wider practice 6.21 The benefits of a TAC approach can be viewed as it being the opportunity for agencies to share information and have a more structured multi-agency response to supporting the placement. They would also have been more knowledgeable about the intentions behind the contact arrangements i.e. that they were to be at restricted times and supervised by the family. 12 6.22 A more detailed and specific plan may have been borne out of such a process tailored to the family’s needs. Given the early neglect Child O had suffered it should have been anticipated in the assessment process that he (and his sibling) might well have some additional needs, especially whilst making the transition to MGM and MA’s care. Such needs, arising from neglect and the separation from his mother, (his most significant attachment figure) were likely to result in emotional and behavioural difficulties for Child O. 6.23 It is a familiar theme in Serious Case Reviews that those children, who move from one borough to another, do not always receive a seamless service. This is the case here and a vehicle to assist this may have been by more provision in the SGO support plan to handover to agencies in Bexley, while a Team around the Child was established. This would have supported a smoother transition between boroughs and provided clarity for the network in relation to Child O’s needs. The London Child Protection Procedures7 provide some guidance on transferring children who are subject to Child in Need plans. Section 6.3.4 states; Although there is no formal requirement to hold a meeting to discuss the transfer of a child in need plan, it would be good practice for the receiving authority to hold such a meeting, especially where the family situation is complex or the children have previously been the subject of a protection plan. 6.24 Consideration could have been given to this but it is likely to have been overlooked as the practitioners from Lambeth CSC continued to work with the family (albeit from a distance) after the children had been placed. From a statutory perspective Lambeth also retained case responsibility for the family as the placing authority for the SGO, so were obliged to continue to support the placement. It is good practice to afford children who are subject to an SGO, Child in Need (or Early Help) status. In this case it would have created the opportunity to handover services and plan to support the family across the range of agencies that were involved. 6.25 On reviewing Bexley’s offer in relation to Early Help it is clear that at times in the review period the family were struggling and would have benefitted from more structured help under Bexley’s threshold document ‘Effective support for Children, Young People and Families in Bexley’. Towards the end of 2018, there were a number of agencies working with the family (Nursery, Health Visiting, Portage Service and CAMHS) but they were not co-ordinated. This was a missed opportunity to offer a more effective multi agency approach with a designated Lead Professional. The learning needs to embed the benefits of working with families in this way. 7 http://www.londoncp.co.uk/chapters/chi_fam_bound.html#cin 13 The robustness of the communication between Lambeth Children’s Services and Bexley Children Services including how safeguarding referrals were raised and dealt with Information from the review 6.26 The review has established that the communication by the placing borough (Lambeth) to the host borough (Bexley) was extremely poor. No notifications were made by Lambeth to Bexley about the children’s residence in their area, despite multiple opportunities for this to happen. More importantly, no background checks were made between Lambeth and Bexley to establish if there were any concerns about the family in terms of the children being placed there. 6.27 Further, when approaches were made to Lambeth CSC from agencies wishing to make referrals or pass on information that was of concern, those agencies were not redirected to Bexley CSC as the children’s place of residence. 6.28 The information sharing by Lambeth CSC falls short of expected standards throughout the period under review. It has not been possible to completely identify from the case records in Lambeth exactly why this was. They have speculated that it was either a lack of compliance or a training need in relation to what would be expected. It further appears to be down to several areas of practice which are outlined as follows: A lack of scrutiny of the completeness of the SGO assessment in Lambeth to ensure established statutory processes were adhered to A lack of scrutiny of statutory processes i.e. background checks regarding SGOs within the court arena by the Guardian and the Judge. Due to the above there was a lack of clarity that Child O and Child P were residing in Bexley, so when Lambeth CSC shared information about the children it was not obvious that they were in their area and likely to be Children in Need. There was perhaps a lack of curiosity in Bexley CSC about why the information was shared by Lambeth CSC in January and May 2017 and February 2019 and exactly which children the information was about. This is likely to have been because of confusion about the various sets of children (i.e. Child O’s half siblings on his fathers side and his cousins on his MA’s side). Without the relationships between each of these adults being spelt out, it is likely that the existence of Child O and child P in the household in Bexley was (understandably) overlooked. A lack of management oversight about the referrals that were received from Probation Services and Child O’s nursery led to the information not being re-directed to Bexley CSC. Learning and Implications for wider practice 6.29 The importance of information sharing to support children and families is a well 14 rehearsed theme from Serious Case Reviews and now CSPRs. This case is no exception. Lambeth CSC recognised the lack of information sharing as a wider systemic issue at that time due to the deficits in practice identified at the OFSTED inspection around this time. This has however improved since then. Their written submission demonstrates some of the improvements they have made (cited in paragraph 6.8). These were confirmed by their recent monitoring visit which concentrated on the quality of local authority’s permanence planning. 6.30 Similarly CAFCASS have struggled to understand why this was not noted and challenged by their service. This issue needs be highlighted to their staff through their Learning and Development Bulletin and Quarterly Serious Incident Bulletin as described in their contribution to the review. Were issues of mental health in the adults known about, understood and assessed appropriately? Information from the review 6.31 There is some very brief information in the SGO assessment conducted in Lambeth about MGM’s mental health but this was never clarified with health professionals in Bexley. Lambeth CSC have acknowledged that these issues were not addressed adequately within the assessment. There was also a lack of contact between Lambeth CSC and Adult Mental Health services in Bexley, which would have demonstrated best practice. 6.32 After the SGO had been made there were two periods of concern about MGM’s mental health. In May 2017 MGM took an overdose and was referred to Bexley CSC, as the hospital staff were aware that there were children in her household. The referral was dealt with swiftly on establishing that MGM was not the sole carer for the children. The referral was in relation to Child O’s cousins and this was dealt with appropriately, given the information held by Bexley CSC at that time. It does reinforce the fact that many professionals (including Bexley CSC) were unaware of Child O and his sibling in the household and so equally unaware of their SGO status. 6.33 In January 2019, MGM was admitted to hospital following an acute episode of mental health issues. She was assessed on the medical ward and she was subsequently transferred to a more specialist mental health unit. She remained on the mental health ward for another two weeks. Community outreach services became involved (over the next nine months) and services were focused on managing her mental health, providing coping strategies and build her self esteem. MGM’s GP practice were aware of the overdoses but made no connection between that and the fact that she was caring for children. 6.34 Staff in the hospital became aware of MGM’s living situation during the assessment period in early January when she disclosed to them that she was one of two guardians to her grandchildren. She mentioned that there were four children 15 living in the household. The assessing doctor recommended that a referral to CSC should be made. This was however overlooked and there was no contact between Adult Mental Health services and Bexley CSC. Services continued to work with MGM and whilst there was some consideration of how her home situation may have impacted on her mental health, there was no assessment of the effect of her poor mental health on the stability of the household or the children’s wellbeing. Learning and Implications for wider practice 6.35 Oxleas involvement in the review has allowed them to reflect on the importance of a ‘think family’ approach when dealing with clients experiencing mental health difficulties. The lack of referral to Bexley CSC by either the hospital or community mental health services meant that the impact of MGM’s mental distress was not assessed in terms of her capacity to continue caring for the children. Her hospitalisation presumably meant MA was left caring for all the children on her own which would have been a demanding task. Further, the impact of the change of circumstances within the family home from the children’s perspective was never assessed. The emerging picture from the review is that by 2019, the family were experiencing challenges with the children’s behaviour and that domestic abuse was featuring in their lives. More is said about the domestic abuse in the next section. 6.36 Good practice would indicate that where a parent (or someone in a parenting capacity) has a mental health problem that assessment should be made as a result of collaboration between children’s social workers and adult mental health practitioners. This is to assess any risk but also to ensure that services are provided to support the family. 6.37 The children were registered at the same GP practice as MGM, but little connection was made between them, and the GP practice had limited knowledge of the children’s status or their placement with MGM. When details of MGMs overdose became apparent to them, they displayed no curiosity in ensuring that the children’s needs were met at that time. The Practice noted in their information submitted to the review that they needed to be clearer about what was meant by an SGO and to display more curiosity when the adults and children presented to the surgery. Were issues of domestic abuse known about, understood and dealt with appropriately including the involvement of MARAC? Information from the review 6.38 Early in 2019, Bexley CSC received two notifications (in January and February) from the police regarding MA being the victim of domestic abuse. The former took the shape of unwanted messages over social media from MA’s ex partner. The second took place in the family home shared by MA, MGM and the children that resulted in MA being assaulted by her ex partner. 16 6.39 Bexley CSC initially dealt with this as a contact and a manager spoke to MA who advised that she lived with her mother, who had an SGO for two nephews. It is not clear if she mentioned that they all lived together and that the SGO was in fact held jointly between her and her mother. The record of this conversation further states that the nephews were not known on Bexley’s CSC database. The outcome of this contact was to refer to Bexley Women’s Aid (this service was handed over to Bexley Support and Advocacy Service on the 1 April 2019) who in turn referred to MARAC. The family was presented there in early April 2019. MA was allocated an Independent Domestic Violence Advocate (IDVA) to provide support in relation to the domestic abuse. 6.40 In relation to MA, the IDVA offered an ongoing service for the following three months which MA largely accepted. Safety planning and risk assessment was undertaken and advice offered in relation to legal options and practical measures such as a fireproof letterbox. Within the risk assessment undertaken by Solace, they identified a number of risk factors in relation to MA, which would have impacted on all the family including all four of the children. These were: Prior physical violence from her ex partner towards MA, witnessed by her daughter Conflict over the children’s contact with their father following the separation Threats to kill MA by her ex partner Previous use of weapons towards MA and her family– including being threatened with a hammer and a brick in the home High levels of fear – MA stated she was particularly concerned that her ex partner would try to take the children as he had threatened to do so. Learning and Implications for wider practice 6.41 What we know from research is that abuse is more likely to escalate after separation and therefore this would have been a risky time for both MA and all the children in her care. 6.42 Despite these risk factors Bexley CSC did not assess the children. In their written submission, the reasons Bexley CSC cites for this were that the level of concern was not at the threshold to assess because between the referral and the MARAC meeting, no further concern or referral had been expressed. It is difficult to understand the reasoning behind this decision given the information from the police and the risk assessment via SOLACE, which identified MA as high risk not least because of her recent separation. It was not custom and practice to assess every family with children that were presented to MARAC at that time. It was felt that as well as there having been no other incidents, MA was engaging with support offered from Solace and there was no role for statutory intervention. This practice was revised prior to the events in this review and all children of families discussed at MARAC do now have an assessment. 17 6.43 It has not been possible to ascertain from the review process how the risks to the children were considered at MARAC, as the minutes of the meeting did not give sufficient detail. There was very little contact between the IDVA and CSC. The lack of any formal intervention from CSC at that time meant other agencies were unaware of the issues of domestic abuse within the family or the presence of the other children. Involvement from CSC at this stage would have alerted them to the presence of Child O and Child P in the household and the challenges that they were presenting their carers with. Issues arising from Management Oversight and Supervision Information from the review 6.44 The review has identified a number of occasions when supervision, management oversight and wider quality assurance systems within organisations was not robust enough. With the exception of Lambeth CSC there were limited opportunities for supervision and management oversight in many of the agencies due to their limited involvement with the family but there are some key exceptions. Learning and Implications for wider practice 6.45 Lambeth CSC have acknowledged the lack of management oversight and reflection within their practice. More importantly Lambeth practitioners were hampered by the lack of a wider organisational perspective with appropriate checks and balances, which support individual management decisions. As we have seen through many case reviews, management oversight needs to be proactive in helping practitioners anticipate risks and needs as children develop and change and there was a lack of curiosity in this case. 6.46 CAFCASS employ a number of practitioners who are ‘self-regulating’. To achieve this status, practitioners are required to achieve a consistent level of good or outstanding grades through regular quality assurance. Attaining this allows practitioners to ‘self-file’ reports and ‘self-close’ cases. This does not change the level of supervision afforded the practitioner otherwise. All practitioners are required to advise their managers of significant safeguarding issues and all practitioners have 2 case file audits per quarter which are randomly selected and recorded. This information pulls through to the supervision system for discussion in supervision. In this case, this was not done until after the care proceedings had concluded and practice was found to be poor. This was addressed with the practitioner but not until after the event and so there was no opportunity to influence the direction of the case. A more thorough piece of work by the appointed Guardian may well have resulted in the placement being challenged. A lack of scrutiny in this case i.e. where a significant issue had not been escalated is important process learning for CAFCASS. 6.47 The health visitor in Bexley did good work in trying to assist the family and she 18 was aware of the children’s SGO status. At that time the supervision policy for Bromley Healthcare did not require children who are subject to an SGO to be taken to supervision. The health visitor did not consider that they were at the level that they needed to be discussed with a manager. In particular, although there were issues of behaviour management, there were no concerns about the care that the children were receiving and both carers were said to be doing their best. Bromley Healthcare have reconsidered this policy as a result of their learning from this review and have added children on SGOs to their list of children to be brought up for supervision. This is a positive move as it is likely that the majority of children subject to an SGO will have some level of additional need. How was the voice of the child represented by agencies? 6.48 There is little doubt that Child O was loved very much by his carers. Caring for very young children however is a particularly hard task. As demonstrated earlier in the narrative, little attention was paid to this at the time of the SGO assessment or thought about how this may pan out in the future. 6.49 Child O’s earlier lived experience is well documented in the information provided by Lambeth CSC. The information provides a picture of poor early parenting and attachment, and a sometimes harmful environment that placed him at risk. 6.50 Child O’s life with his aunt and MGM is less well documented. Available information suggests that, although he was very likeable, he could be aggressive, withdrawn and event violent towards other children and adults. This behaviour is likely to be as a result of his inner distress and he communicated it in the only way he knew how. The effects of early neglect, the effects of domestic violence and the subsequent abandonment he felt by his parents should not be underestimated, especially at such a tender age. These issues were noted by CAMHS and attempts to work with the carers to support him to feel safer had very limited success due their lack of insight. 6.51 It is not clear how Child O understood his circumstances about why he went to live with his aunt and MGM. At the time of the SGO, Child O would have been about 18 months old, so it would have been difficult to carry out any preparatory work but some words and pictures may have assisted. It is significant that the support plan did not contain recommendations about future Life Story Work or other therapeutic interventions, designed to help him come to terms with his circumstances, as he grew older. The plan was not child centred and mainly contained details of financial support. Of particular concern should have been how the family would manage contact arrangements and the importance of these being regular, sustained, safe and a positive experience for all. As it turned out, contact with his parents (or the lack of it) was a source of great distress for Child O. As this area did not feature strongly in the SGO assessment, it is unsurprising that it was not included in the plan. 19 6.52 More thought needed to be given about the damaging effects of Child O’s experience of neglect and therefore anticipating difficulties which may occur later on in life. As we have seen, there was no handover between boroughs and no provision in the plan to provide a Team around the Child. In addition there was no forethought for any support for any members of the family. There is learning for Lambeth CS about how SGO placements are supported, particularly when they are in another local authority. The report references a number of initiatives currently being undertaken by Lambeth CS to address these systemic difficulties. 6.53 Later, individual agencies such as the Health Visitor, nursery and Portage Services did recognise his needs and the referral to CAMHS was timely and appropriate. Having a multi agency co-ordinated plan would have strengthened the approach these agencies took to provide support to Child O and his family. 7 Family Contribution. 7.1 Consultations with key family members are a very important aspect of any review and the author and Bexley SHIELD are very grateful that two sides of Child O’s family felt able to contribute. The information they shared is contained in this section in the following paragraphs. Contribution from Paternal Grandmother (PGM) 7.2 The Overview Author had a telephone consultation with PGM towards the end of the CSPR process. Unfortunately, a face to face meeting was not possible due to the national restrictions imposed as a response to the Covid 19 pandemic in the autumn of 2020. At this time the care proceedings arising from this incident had concluded, and Child O was placed with her (an SGO by Bexley, placed in Lambeth). PGM was open, honest and helpful in her comments. It was disappointing to hear that she felt as though she had not been supported with Child O at the point him being placed with her in the summer of 2020. At the time of writing, she was awaiting a service from CAMHS for Child O, help with contact arrangements and ‘Life Story’ work to help him make sense of his circumstances. PGM had hoped to be able to continue the work that had started by CAMHS in Bexley, but this was not possible and so has created a gap in the service Child O received. She does have good support from Child O’s school and his previous foster carer. 7.3 In relation to the first set of care proceedings, she said that there were a number of things that could have gone better. For example, she recalled a number of meetings where the social worker was not able to attend. The person who came in their place was not familiar with the family and so was not able to be helpful. She also recalled social workers meeting in restaurants and discussing important and confidential information, which she did not think as very professional. 20 7.4 PGM stated that she had been happy with her contact arrangements under the original and she had Child O to stay every weekend. He did not display any behavioural difficulties whilst with her and she feels that this was because of the one to one attention she could give. At MGMs house, there were 3 other very young children and they were not able to give the same degree of attention. She was therefore acutely aware of the difficulties that MGM was having and felt pleased to be able to offer Child O the level of contact that she did. PGM was also able to facilitate some contact between Child O and his father. 7.5 PGM was aware that the contact arrangements for Child O’s mother were not clear and she believes that this caused confusion. She believes that MGM needed more details about how the contact arrangements should work and the lack of them contributed to the incident where Mother was alone with Child O. 7.6 PGM did not really understand why Child O was not placed with her in the original set of proceedings as (particularly with hindsight), she understood how difficult it could be for MGM and MA to have all four children. She had understood at the time it was because maternal grandmothers’ ‘take precedence’ over the paternal side of the family. At the time she had accepted this explanation but now realises that this is not correct. PGM was also aware that MGM had barely met Child P when he was placed with her. She found it difficult to understand why she (MGM) had not been able to have contact with him and then was placed straight away after the care proceedings had ended. 7.7 PGM also reflected on the parents’ drug use and wondered if they had been addicted to a more serious drug such as heroin whether they would have been referred to social care earlier. She felt as though their drug use was initially not taken as seriously as it should have been. This led to the children and especially Child O to have very negative early experiences. Contribution from Maternal Grandmother (MGM) and Maternal Aunt (MA) 7.8 Just prior to publication of the report, the Overview Author had a telephone consultation with MGM and MA. They were both able to be candid about their experience and how the contact with services had been for them. 7.9 Both MGM and MA were aware of the difficulties that the children’s mother was undergoing and had supported Lambeth in the original Child Protection Plan and subsequent care proceedings. They attended meetings, made themselves available for assessments and appeared in court when necessary. They live in a big property and although they were very busy, they were happy with the outcome when the children were placed with them. They enjoyed their family unit even though there were very small children to care for. They recalled that professionals who came to the house would comment that it was ‘like a nursery’. The children all had their own rooms and there was lots of space for them to play. 21 7.10 Their experience of Lambeth Children’s Services, however, was not a good one. They recalled trying to contact the allocated social worker by telephone and email and this not being successful. They were frustrated and felt as though they were in the dark much of the time. For example, they were not clear about any support plan that may have been agreed at court, especially in relation to ensuring that Child O had access to therapeutic help. Similarly, the contact arrangements with their mother were explained as ‘it is up to you to manage’. They were aware that contact should be time limited, but they thought that after so many years those stipulations could be relaxed. They were also confused as Lambeth had closed their case, but still making the SGO payments. They did not realise therefore that they could have accessed services from Bexley, as this was not explained. 7.11 When Child O began to display behavioural difficulties and distress, their best resource was the health visitor who they recalled as being extremely helpful. They also got help from the Portage Service and the nursery were always very understanding about Child O’s difficulties. They were very aware that Child O’s struggles were often linked to contact with his mother, especially if this did not take place when it should. He was very bright and knew exactly when she should be visiting. His behaviour became distressed and aggressive if she did not arrive which often happened. They were grateful to the health visitor for getting them a service from CAMHS for him and were disappointed when this could not continue after he moved from theirs. 7.12 MGM and MA were very upset when the children were removed from their care by Bexley CSC, two weeks after the incident leading to this review. MGM was aware that she had not divulged her own mental health problems but had not wanted to disclose this to people she did not know. She considered that she had had enough treatment and help at the time for it not to be an issue. She feels that a better way forward would have been to have discussed it with her first and then Bexley CSC may have realised that it was no longer an issue. She also felt that the presence of MA and her other (adult) child would mitigate against any risks that she posed and that workers arriving and removing them was extremely harsh. Both MGM and MA found this deeply upsetting. In thinking about what other help would have made a difference, they thought that having somebody to be available to talk to would have benefited them both. 8 Summary of Lessons 8.1 There is a significant lesson arising from this review for all the organisations involved, in relation to the importance of thorough background checks when conducting SGO assessments. Triangulating information provided by potential carers is essential to maintain rigour in the assessment process. Child protection systems, which aim to ensure placements are safe and are made in the best interests of children, require a system of checks and balances to support the work 22 of the practitioner. 8.2 During the course of the review Lambeth CSC have acknowledged that their SGO assessments did not receive sufficient independent scrutiny via their care planning processes. In this case it meant the assessment was not scrutinised by the organisation and was not fit for purpose. There was evidence within the review that this was not peculiar to this case but was a systemic issue that needed to be addressed. Since that time, Lambeth CSC have put numerous measures in place to reduce the risk of these systemic failures reoccurring. 8.3 Formal scrutiny via the court system and the children’s guardian (who represents the child in court) also failed to provide the further checks and balances designed to ensure that children’s best interests are served. 8.4 The review has underlined the importance of ensuring that SGO placements are supported by a robust support plan that is tailored to the individual needs of the children. This includes any children who are existing members of the household and their potential carers. This is especially important (as in this case) when placing a child ‘out of borough’ so that the receiving authority and local services can step in to assist in supporting the placement. 8.5 Children who are subject to SGOs are likely to have additional needs. Best practice in supporting both the placement and any transition would be to develop a network around the child. This network can then work as a team to ensure that the family are linked into to local services that can help them. A formal handover between local authorities with an exchange of relevant information would be optimum practice to confirm this is in place. It was also apparent during the review that many practitioners (including key staff such as the health visitor) working with the family were either unaware of the SGO or unaware of the specific arrangements for contact. Some practitioners were aware of its existence but were unsure of its meaning. 8.6 There was a lack of consideration of the future needs of the children in this family placement and a lack of recognition of the level of chronic neglect Child O experienced in his formative years. Therefore there was no provision made to address this once Child O was in placement. There is learning for practitioners from both authorities in how best to identify and address this. The lack of a formal handover mentioned above meant that services in Bexley were unaware of the extent of Child O’s needs. Again Lambeth CSC have taken this learning point on board and have made some headway in tackling the issue. 8.7 The review illustrates the importance of a ‘Think Family’ approach and joint working between children and adult services. Communication by mental health services to Bexley CSC was poor. This meant that the children’s’ needs arising from their carer’s own vulnerabilities were never assessed. 23 9 Recommendations 9.1 Lambeth Safeguarding Children Partnership to assure themselves that Children’s Social Care in Lambeth have made sufficient progress in the quality of SGO assessments and associated support plans. Further that there are now robust quality assurance measures in place. This will ensure that assessments have been undertaken with sufficient rigour, and that associated support plans are targeted to meet the identified physical and emotional needs of the child/ren placed on a permanent basis with their guardian/s. 9.2 Both Lambeth and Bexley Safeguarding Children Partnerships to review their training programs to ensure that there are briefings, information and/or training available for frontline services on; The legislation governing, and the meaning of different types of placements such as SGOs, CLA, adoptive placements etc. that are open to LA’s when considering the future of children who are unable to live with their birth parents 9.3 Both Lambeth and Bexley Safeguarding Children Partnerships to oversee a multi agency review of current arrangements for Children In Need that are also subject to SGOs. This is to ensure that the needs of children in SGO placements are met wherever they are placed. 9.4 In line with the above Lambeth and Bexley Safeguarding Children Partnerships to ensure that for children who are subject to SGOs and placed in another borough, practitioners are aware of the need to transfer these with an appropriate support plan and that they are transferred as Children In Need. 9.5 Lambeth and Bexley Safeguarding Children Partnerships to adopt the practice guidance issued by the Family Justice Council (2020), particularly in relation to; Enhanced support/training for potential SG carers The focus in the guidance on the relationship between the carer and the child; i.e. the assessment process may be extended to ensure that there is a robust understanding of the relationship between the child and the carer and to test the strength of the placement before the making of the final order Quality of support plans 9.6 Bexley Social Care should seek assurances about their own special guardianship assessments, planning processes and support packages in the light of the lessons from this review. This should be overseen and scrutinised by the Partnership. 9.7 Bexley SHIELD to encourage and promote the use of genograms as a tool to understanding family dynamics, when assessing all families but particularly where the make up of a family is complex. 24 9.8 The lessons from this review should be shared with members of the Safeguarding Adult Board in Bexley. There should be some joint consideration of the lessons from this review about the need to ‘Think Family’ between Bexley Children’s Partnership and The Safeguarding Adult Board. This is to include establishing a joint approach between CS and Adult Mental Health when working with carers with mental health difficulties Jane Doherty Independent Social Work Consultant March 2021 |
NC52399 | Injuries to a 4-week-old infant in 2016. Civil court found that the injuries were caused by Father and that Mother failed to protect Child N. A criminal investigation in respect of Mother, Father and Paternal Uncle concluded with no further action in 2020. Child N lived with their mother, father and older sibling, Sibling 2. Both siblings were subject of a Child in Need plan at the time of the injuries. Another older sibling, Sibling 1, died when aged 5-months-old. Mother was a teenage parent with a history of self-harm, mental health problems and personality disorder, and substance misuse. Father had experienced a difficult childhood and had anger control issues. Ethnicity or nationality not stated. Learning includes: when one parent has mental health issues affecting their ability to care for the children, the assessment and plan needs to consider the impact on the other parent/carer; supervision for professionals needs to ensure they are focused on the child and not on the parent's histories and situations; professionals should seek to understand the nature of parenting relationships from the point of view of both parents/adults and the child, and not focus only on the mother. Uses the Significant Incident Learning Process (SILP) methodology. Recommendations include: confirm if formal pre-birth assessments are being undertaken in cases where a new baby will be the subject of a child in need or child protection plan at birth; consider the benefits and practicalities of requesting that the information that a child is on a child in need plan is shared with all professionals working with the family.
| Serious Case Review No: 2020/C8475 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Serious Case Review Child N September 2020 2 CONTENTS 1. Summary of the learning Page 2 2. The case Page 3 3. Process Page 3 4. Background prior to the scoped period Page 4 5. Key episodes Page 6 6. Analysis by theme Page 10 7. Conclusions Page 23 8. Recommendations Page 24 1 Summary of the learning from this review 1.1 This Serious Case Review (SCR) is in respect of a 4-week-old child with unexplained injuries. The baby was known to a number of different agencies prior to the injuries being identified, and was on a child in need plan. 1.2 A number of learning points have been identified for the agencies involved and for the Safeguarding Children Board. Some of the learning requires improvement action and a number of recommendations have been made in section 11 of this report. Learning was found in the following areas, the detail of which is included in the analysis section of this report: • The impact on the child/ren, parent, other parent/carer and the professionals involved when a parent has a mental health issue. • The need for information sharing, assessment and services where there are parental anger control issues. • The importance of considering history when assessing presenting problems. • Maintaining a focus on the child/ren and their lived experience, including unborn-children. • The importance of re-assessing parenting capacity and evaluating risk when a new baby is due. • Identification of superficial or avoidant parental cooperation with agencies. • The need to assess and provide services regardless of the gender of the parent/carer. • Greater consideration of non-accidental injury as a differential diagnosis when children present at hospital with certain health issues. 2.1 The LSCB agreed that this Serious Case Review (SCR) would be undertaken using the SILP methodology1, which engages frontline staff and their managers in reviewing cases and focuses on why those involved acted as they did at the time2. 1 The Chair of the LSCB agreed the SCR, the lead reviewer was appointed, the terms of reference were agreed, agency reports and a chronology were requested, and two events were held to engage with staff in July and September 2018. The lead reviewer is Nicki Pettitt, an independent social work manager and safeguarding consultant. She is an experienced chair and author of SCRs and a SILP associate reviewer. She is independent of the LSCB and its partner agencies. 2 Agency reports are completed where agencies have the opportunity to consider and analyse their practice and any systemic issues. They provide details of the learning from the case within their agency. Then practitioners, managers and agency safeguarding leads come together for a learning event. All agency reports are shared in advance and the perspectives and opinions of all those involved at the time are discussed and valued at the event. The same group then comes together again to study and debate the first draft of the SCR report. Later drafts are also commented on by all of those involved and they make an invaluable contribution to the learning 3 2 The case 2.1 Child N lived with their mother, father and older sibling to be known as Sibling 2. Child N suffered what were thought to be non-accidental injuries3 when 4 weeks old. Child N and the sibling were the subject of a Child in Need plan at the time. Mother was known to mental health services and the family had been in temporary housing for much of the timeframe of this review. 2.2 Another older sibling died when aged 5 months old and this child will be known as Sibling 1. This report will not specify the genders of the children to protect their identities. 2.3 The children share the same mother. Sibling 1 had a different father. This report will refer to the adults caring for the children during the time that is being considered as Mother and Father. Any other family members will be described by their relationship to Child N e.g. Paternal Grandmother. 2.4 The couple originally met in a hostel for homeless young people. They were unemployed and in receipt of benefits. 3 Process 3.1 It was agreed that the scope of this review would be from November 2014 when the child in need began, until 4 May 2016 when the parents were removed from the hospital as a safeguarding measure in respect of Child N. Relevant information prior to these dates was also considered as required, particularly any agency involvement with an older sibling of Child N, who died in 2014 of natural causes. 3.2 Early family engagement is required as part of the SILP model of review. The Police were not willing for the lead reviewer to meet with the family prior to the conclusion of the criminal investigation. Both parents were spoken to separately by the lead reviewer prior to publication of this report. It is acknowledged that this was four years after the injuries to Child N. Their views are included in the report as relevant. 3.3 The Department for Education (DfE) expects full publication of SCR overview reports, unless there are particular serious reasons why this would not be appropriate. Working to that requirement, some confidential historical family information and case detail will not be disclosed in this report. It is written in the anticipation that it will be published, and contains the information that is relevant to the learning established during this review. The decision was made by prior to publication that the review would be published by the NSPCC anonymously due to concerns about the vulnerabilities of the adults in this case. 6.6 There were on-going parallel proceedings to this review, including care proceedings on Child N and Sibling 2 and a criminal investigation in respect of Mother, Father and Paternal Uncle - who was staying with the family at the time the injuries may have been sustained. A finding was made in the civil courts in December 2016 that the injuries were caused by Father and that Mother failed to protect Child N. The police investigation was completed in 2020 and no further action was taken. 7. The background prior to the scoped period 7.1 The father of Sibling 2 and Child N was known to children’s social care (CSC) as a child initially due to concerns about the parenting he received, and later due to his behaviour, and conclusions of the review and analysed; and makes use of relevant research and case evidence to inform the findings. This review has achieved these objectives. 3 The injuries included intracranial haemorrhages, retinal haemorrhaging, two fractured ribs (historic)3 and two fractured femurs (historic). 4 including anti-social behaviour, drug use and criminal behaviour leading to contact with the youth offending service. He was in homeless young person’s accommodation from age 16 - 19. 7.2 Mother’s early years were thought to be neglectful and abusive, due to serious parental drug misuse and domestic abuse. Mother did not live with her birth family from the age of around six years old. It is believed she lived with a family friend in a private fostering arrangement that became a Residence Order4 when Mother was aged eight. She remained there until the placement broke down when Mother was around 16 years old. 7.3 Prior to the birth of Sibling 1, when Mother was 18 years old, she was in a violent relationship with the baby’s father and in temporary housing. Early in the pregnancy Mother was admitted to a psychiatric hospital, which resulted in a diagnosis of Emotionally Unstable Personality Disorder and Mental and Behavioural Disorder. The latter was thought to be due to multiple drug use. She has been supported by the Mental Health Recovery Team5 ever since. 7.4 An Initial Assessment followed by a Core Assessment6 was undertaken by Children’s Social Care (CSC) prior to the birth of Sibling 1 (although the recommendation of the Children’s Access Point had been for a pre-birth assessment). As Mother’s mental health was then stable, she had separated from the baby’s father and there was no evidence of on-going drug use, it was agreed that the baby’s needs would be met if the child were subject to a Child in Need Plan7 from birth. This involved the allocation of a social worker, a high level of support from the health visitor, an agreed plan and regular meetings between professionals and Mother, including Mother’s mental health worker. Communication between professionals at the time was good. This did not include the GP as they were not contacted. Mother engaged with the plan and was felt to be providing good care to Sibling 1 and the attachment was described as positive. The main focus of the child in need plan was housing, planning contact for Sibling 1 with the child’s birth father, and supporting Mother with her parenting. A referral was made to an independent service that supports people affected by domestic abuse by the allocated social worker but Mother did not engage with the services they offered. Health and social care professionals reported observing a positive and appropriate attachment between Mother and Sibling 1. 7.6 Sibling 1 died at five months old. The death was from natural causes, the result of an infection that Mother had probably contracted during her pregnancy, and which Sibling 1 had contracted antenatally8. Following the baby’s death Mother’s engagement with professionals declined and she refused counseling. She had a further period of housing instability and was misusing drugs and alcohol for what was described by her mental health worker as a ‘short time’. 8. Key Episodes 8.1 The time under review has been divided into 4 Key Episodes, which are periods of intervention that are judged to be significant to understanding the work undertaken with a child and their families. They are key from a practice perspective rather than to the history 4 S8 Children Act 1989 5 This involved the support of an allocated care coordinator for emotional and social support and access to medication reviews as required. 6 At the time children’s social workers undertook these assessments of children in need. Initial Assessments would take place within 10 working days of a referral and Core Assessments within 35 working days. 7 Where an assessment by CSC has concluded that a package of family support is required to meet the child's needs under Section 17 of the Children Act 1989. 8 The death of Sibling 1 was fully examined and investigated at the time. 5 of the child. They do not form a complete history of the case but summarise the key activities that occurred, and include the information that is thought to be most helpful in informing the review. 8.2 The key episodes in this review are: 1. Pregnancy and birth of Sibling 2. 2. CFIS9 involvement and the pregnancy with Child N. 3. Birth of Child N and the continued child in need plan. 4. Child N in hospital and suspected non-accidental injuries identified. Key Episode 1: (Pregnancy and birth of Sibling 2. October 2014 until May 2015.) 8.3 Housing initially alerted CSC to Mother’s pregnancy with Sibling 2. No action was taken at the time, as it was early in the pregnancy and the recording of the contact made no reference to Sibling 1. Mother’s midwife made a later referral to the health visiting service as they noted that concerns previously identified for Sibling 1 remained at the time of the pregnancy with Sibling 2, and that these concerns were exacerbated by Mother’s recent bereavement. The referral also referred to Mother and Father sharing that they were using cannabis regularly. The health visitor made a referral to CSC, which included the information shared by the midwife. 8.4 The information known at this time was that Mother had relapsed into drug and alcohol misuse following Sibling 1’s death, but claimed she had stopped using drugs, including cannabis, due to her pregnancy. Mother and Father had known each other for a while, but their relationship was new and it was known that the police had been called due to their arguments. Mother was living in unsuitable temporary accommodation and was facing eviction. Following assessment CSC agreed with Mother that at birth Sibling 2 would be subject to a child in need plan, to support her with the practical issues she faced. These included housing, benefits, isolation and parenting. Both parents were thought to have stopped using drugs and Father was advised to seek help from his GP regarding his anger. Both parents said they were keen to receive the help and support to be provided by the child in need plan. 8.5 There is evidence that Father attended his GP surgery in both December 2014 and then May 2015, firstly seeing the practice nurse in December and then a GP in both January and May 2015. He shared his anger issues, stating he had issues since childhood and wanted help now he was a father. He stated he was not a drug user but that he had been injecting steroids until recently. A blood test was undertaken and it showed high levels of testosterone. Father was referred for anger management by the GP, but the referral was not successful as there was no commissioned service. The GP was advised that he could speak to CSC if there were safeguarding concerns. There is no evidence that this happened or that the GP spoke to Father again about his anger or his use of steroids. The mental health service that the GP referred father to for anger management did not link this information to Mother’s case. 8.6 Child in need meetings were held, starting prior to the birth of Sibling 2 in January 2015. Information sharing took place, and concerns were shared and discussed. For example after her visit in April 2015 the health visitor noted Mother’s high Edinburgh postnatal 9 Child and Family Intervention Service, which is targeted at the most challenging families with multiple needs. They support families using a formal support plan and intensive key working. 6 depression score10 and the information was shared with the GP, mental health services and the social worker, along with the concern that mother’s mental health appeared to be impacting on her ability to provide ’emotional care’ to Sibling 2. Key Episode 2: (CFIS involvement and the pregnancy with Child N. June 2015 until March 2016.) 8.7 Mother and Sibling 2 initially lived in bed and breakfast accommodation, they then moved to temporary housing prior to a move to a permanent tenancy in June 2015. Father was officially not living with the family, although he was effectively permanently staying with them. The housing moves had an impact on the provision of both health visiting and GP services for Mother and Sibling 2, because of their geographical bases. Positive systems to handover between health visitors at the time were reported however. Shortly after the birth of Sibling 2 the health visitor and GP liaised with mental health services to ensure Mother received her medication as she had stopped taking them during her pregnancy. 8.8 The professionals involved identified factors regarding the impact of Mother's own attachment issues, her bereavement, and the impact on her parenting of and bonding with Sibling 2. A referral was made to the Child and Family Intervention Service (CFIS) in May 2015 to address this. The intensive work undertaken led to concerns about how well Mother was coping and the CFIS staff were concerned about Mother’s relationship with Sibling 2. Mother herself also shared her concerns about the difficulties of bonding with her child. 8.9 Father appears to have undertaken the majority of the childcare for Sibling 2. He was included in the child in need plan and the work being undertaken by CFIS, but was reluctant to become involved. Mother reported to her mental health worker that due to episodes of anxiety she could sometimes not leave the house. Her medication also had an impact on her ability to provide 24 hour care to children. Father was thought to be supportive and to have a good relationship with Sibling 2. The focus of the work was on Mother. Father often attended but in the role of supporting his partner. Mother reported to the social worker in August 2015 that Sibling 2 had staying contact with Parental Grandmother, but she was not contacted at the time to provide information about the children and her role or to engage her in the child in need plan. The parents were asked to provide details of family members so that a family network meeting could be held, but the parents choose not to engage with this process. 8.10 Police information was available in July 2015. They had attended following concerns from neighbours that Mother was shouting at Sibling 2 and that there was cannabis use in the home. Further police information was available in September 2015 when it was reported that Father was outside the premises shouting and banging at the door. Again the officers smelt cannabis and raised this with Mother who alleged Father had smoked it. Both incidents were notified to CSC. The concerns were discussed with the parents at meetings but they denied using cannabis in the home. Mother has since told the lead reviewer that they did smoke occasionally, and that she used cannabis to manage her anxiety at this time. 8.11 Due to the on-going concerns, a meeting was held in August 2015 between CFIS, the social worker and relevant managers and the decision was made to have a strategy discussion with the police and to recommend an initial child protection conference (ICPC). The police agreed with the plan but the conference did not happen and it was agreed after Section 10 The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item questionnaire that was developed to identify women who have postpartum depression. 7 4711 enquires were completed that a continued child in need was the best response to the issues identified. The extent of the S47 was limited however as the GP was not consulted. The change of plan appears to be because Mother’s mental health diagnosis had previously been thought to be bi-polar disorder and when it was confirmed that this was not the case the threshold for a child protection response was no longer thought to be met. This decision was made by the social work team, with both the team manager and service manager involved in this decision. Neither CFIS nor any other agency challenged the decision. When Mother’s pregnancy with Child N was confirmed the following month, this decision was not reconsidered. 8.12 The child in need plan for Sibling 2 continued throughout Mother’s pregnancy with Child N. Mother had some pregnancy related health issues. When she visited on the 15 October 2015 the health visitor noted a smell of cannabis in the property. Mother disputed this but the information was shared with the social worker. Mother also appeared to have less support at this time from mental health team as she had cancelled a number of appointments and had difficulties with her mobile phone reception. This led to some difficulties in managing her medication. A newly allocated social worker noted that Sibling 2 spent a lot of time in a chair or car seat, and that mother was reluctant to let the child play on the floor. The health visitor had shared that there was no developmental delay so the social worker did not feel it was problematic. Key Episode 3: (Birth of Child N and the continued child in need plan. March – April 2016.) 8.13 Prior to the birth of Child N, following a child and family assessment (not a specific pre-birth assessment) by the social worker, it was agreed that Child N would also be subject of a child in need plan at birth. Mother was also referred to a peri-natal mental health consultant. When Child N was born Mother showed continuing signs of anxiety relating to the death of Sibling 1 and the safeguarding lead at the hospital shared concerns with the health visitor that Mother was struggling to bond with Child N. The social worker reported during this review that they were aware that S47 enquiries had been completed by the previous social worker in August 2015 and thought that the decision to maintain supporting the family on a child in need basis was the mandate she was required to continue. The family continued to state their need for support and willingness to engage with the plan, so no consideration was given to this being an issue that required a child protection response. 8.14 Child N returned to hospital a week after birth having been referred by the GP due to an infected umbilicus. Father stayed with Child N on the ward. There was no record of Mother visiting and it was noted that Father reported that his partner found it difficult being on the ward. When Child N was 3 weeks old (20 April 2016) they were again referred to the hospital by the GP following ‘multiple presentations in the days before with projectile vomiting, weight loss, crying/unsettled and general concern about the vulnerability of the family.’12 Colic was diagnosed and Child N was discharged the next day. Key Episode 4: (Child N in hospital and suspected non-accidental injuries identified. 25 April to 4 May 2016.) 8.15 On 25 April 2016 Child N was admitted to hospital, having been taken there by Father who reported that Child N had a 'floppy episode' at home. Child N was at the time correctly 11 Section 47 of the Children Act 1989 places a duty on Local Authorities to investigate and make inquiries into the circumstances of children considered to be at risk of ‘significant harm’ and to decide what action it may need to take to safeguard and promote the child’s welfare. 12 Primary Care agency report. 8 treated for a presumed infection and gastro-oesophageal reflux on the ward. During the admission it was observed that the head circumference had increased which led to further investigations which showed intracranial bleeding and retinal haemorrhages. As a result of this scan the child was transferred to a specialist neuro-surgical centre for on-going medical and surgical treatment. Whilst at this hospital further x-rays and scans discovered healing rib fractures, healing leg fractures and 2 types of brain haemorrhage (bleeding). 8.16 It was recorded by ward staff on 29 April 2016 that Child N woke for a feed and was crying. Father was offered help and the nurse ‘witnessed dad raising his voice at Child N and swearing telling Child N “It’s too early”. He declined the help offered.’ 8.17 The Police were informed on 1 May 2016 about the child’s injuries and a strategy meeting13 was held that day. Contact between Child N and the parents was discussed and a medical of Sibling 2 was agreed and undertaken the same day. No safeguarding concerns were identified. Sibling 2 was placed with a family member. 8.18 It was established that Father’s brother had been staying with the family for a period of time prior to Child N’s injuries. Both the health visitor and midwife were told he was staying to support the family for 2 weeks following Child N’s birth, and that he had done the same when Sibling 2 was born. Professionals at the learning events stated that it is not unusual for family members to be present at this time. Very little was known about Paternal Uncle prior to Child N’s admission to hospital. It has since been established that he had been in prison and has a history of drug misuse. 9 Analysis by Theme 9.1 From the information deduced from the agency reports, from the discussions at the learning events, and from the meeting with the family, several key themes have emerged. These can be summarised as: • Mental health • Substance misuse and domestic abuse • ‘Care’ history of Mother • Homelessness/temporary housing • Assessment • Child in Need planning • Parental engagement and focus • Gender • Response to Child N’s injury 9.2 Each theme will be considered below, with any learning clearly identified. Mental health: 9.3 Mother was diagnosed with Emotionally Unstable Personality Disorder (EUPD). Mother’s history of childhood neglect, self-harm and drug misuse were typical of those with this mental health condition. Working with patients diagnosed with EUPD can be a challenge for professionals. The best outcomes are achieved when there has been the opportunity to build consistent relationships with service providers and the availability of psychological therapy. Mother’s immaturity, life-style and the stress of being a mother did not enable the 13 Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer Significant Harm, there should be a Strategy Discussion/Meeting involving Children's Social Care, the Police, Health and other professional as appropriate. 9 required help to be provided consistently and Mother’s symptoms were largely managed by medication. The mental health team providing a service to her did remain involved throughout the time frame of this review however, and she saw her psychiatrist periodically for reviews of medication. There were a number of staff changes of support worker, but handovers took place. 9.4 Mother was prescribed with anti-depressants, diazepam and sleeping tablets. As the pregnancies were unplanned there were some issues with what drugs she was able to take which complicated the consistency of her medication regime. Mother reported being very confused at the time regarding what prescribed drugs it was safe to take during her pregnancy. Some inconsistent advice was also given to Mother by the mental health professionals involved at the time. Mother’s frequent changes of address meant that she was not able to build a relationship with her GP surgery and GP’s were often having to see her without her notes, as these can take time to be transferred from one surgery to another. In a complex case this systemic delay can be problematic. 9.5 There were a number of mistakes regarding the recording of Mother’s mental health issues in agency records, probably due to professionals taking Mother’s word on what her diagnosis was and not checking with mental health professionals. Mother appears to have misrepresented her diagnosis on occasion. It is not clear if this was due to her own confusion, or if she was intentionally not telling the truth. She had stated she had schizophrenia and this was recorded in the health visitor and midwifery notes. The CSC records stated she was bi-polar. Neither is correct. It is the symptoms rather than the diagnosis that was important in this case however, particularly when considering the impact of Mother’s mental health on her parenting. When the decision was made to hold an ICPC in this case, when Sibling 2 was around 6 months old, the discovery that mother was not bi-polar but had EUPD led to a change in the plan and it was decided not to hold an initial child protection conference. This appears to have been agreed without due consideration of the impact of Mother’s behaviour on her care of Sibling 2. There was no risk assessment completed in regards to the impact of her anxiety and lack of bonding with Sibling 2, and no discussion with other agencies. 9.6 It was clear to those working with her that Mother presented as a person with a complex trauma. Mother reported to her Midwife after the birth of Child N that she felt the children did not respond to her in the way that they did to their father, and she had shared similar feelings with CFIS. They believed at the time that this had an impact on her care of her children and her ability to build a positive relationship with them. She was willing to work on practical parenting skills with the CFIS team but was very reluctant to consider the emotional impact of either her childhood experiences or the death of Sibling 1. CFIS shared their concerns with the professionals involved and the family at child in need meetings. However the children were always said to be clean, well dressed, and cared for physically. The mental health workers who were involved prior to the birth of Sibling 2 had no concerns about Mother’s parenting and this reassured the CFIS staff and the social worker. Mother appeared to be up-front and honest and she shared her concerns that she would be unable to bond with Sibling 2 due to her experience of losing Sibling 1. Mother was said to be more positive prior to the birth of Child N due to the child being a different gender to the older siblings. But it was noted that she did not visit the baby in hospital when they were admitted with the umbilical infection when one week old. 9.7 Father, at the request of the child in need meeting, attended his GP to ask for anger control help. He had been able to acknowledge he needed some help and was referred on to 10 mental health services. There appears to have been a gap in services however as no suitable anger control groups or one to one work was being commissioned at the time. Those present at the SCR meetings felt that there is a demand for these services but no current local resource is available to meet the need. This issue was not pursued with Father at later child in need meetings, as an assumption was made that the wait for support is often many months, and the unmet need was not identified. 9.8 Father admitted at the time that he found Mother’s mental health issues difficult to deal with. He asked professionals not to speak to Mother about the death of Sibling 1 as it made her so upset. On occasion she would be disabled by her anxiety and grief and he was effectively a carer for her as well and the children. This was acknowledged at the time, and Father was offered support but he refused help. As Father was effectively the primary carer for the children, the need to ensure he received support with his anger and with the strain of caring for Mother needed to be included in the children’s plans. 9.9 There is little doubt that the shock and pain of losing her first baby had an impact on Mother’s mental health and her relationship with Sibling 2 and Child N. To suffer such bereavement is devastating for the most capable, supported and emotionally stable parents. Mother, who was so vulnerable and young, was inevitably going to struggle to cope with the loss. The professionals involved during the timeframe being considered by this review understood the effect of the loss on Mother and on her ability to parent her children, but on occasion. The same can also be said for Father, who preferred to avoid discussion of Sibling 1’s death to ensure Mother didn’t get upset. It is difficult for professionals to make demands on a young woman who appears to be doing her best and who struggles due to her difficult history and a recent bereavement. The so-called ‘human factors’14 which effect professional practice came into play here and had an impact on the management of the case following the birth of Sibling 2. The professionals involved at the time had sympathy with Mother and while they tried hard to gain her engagement, this was not successful. Without the clear mandate that a child protection plan brings, professionals can often feel unable to push parents to partake in the work they know is required. As this was a case that was seen as ‘child in need’ without the identified risk present when a child is on a child protection plan, there was no final push for further engagement with the services offered by the likes of CFIS. 9.10 Sibling 2 was the same gender as Sibling 1 and was born just a year after Sibling 1 died. Mother had not received support with the bereavement and probably held some guilt that Sibling 1 had died from a condition Mother had passed on during child birth. Bowlby15 states that parents who have experienced the death of a child are often consumed with feelings of anger, guilt and self-blame. Mother was offered bereavement support a number of times but always refused it. Father was not the parent of Sibling 1 and this could have been a complicating factor in their relationship and in his understanding on the impact on Mother. Without work being undertaken to look at these issues, it would have been hard to understand the impact on Sibling 2 and Child N. Mother told the lead reviewer that she was very anxious about passing an infection to Sibling 2 and that this had an impact on her ability to bond with the baby, but that when she was told the baby was infection free, she was able to bond appropriately. Learning: 14 Serious Case Review Quality Markers. 2016. (SCIE / NSPCC.) 15 John Bowlby. Loss, Sadness and Depression. 1980. 11 • When considering the impact of a mental health issue on parenting, it is the symptoms and impact of the treatment of the condition, and not the diagnosis itself that should be considered when assessing the needs of/risk to a child. • When one parent has mental health issues which affect their ability to care for the children, the assessment and plan needs to consider this and the impact on the other parent/carer. • The impact on professionals of working with parents with complex and emotionally powerful issues needs to be acknowledged in supervision and when professionals discuss the case. Those involved with the family softened their approach to Mother which had an impact on decision making and professional judgments. • A service for parents with anger control issues needs to be available in the area. • There is a need for consistent practice on the use of prescribed mental health medication during pregnancy. The decisions made about medication, with the rational, need to be communicated to the health professionals involved and the service user. Substance misuse and domestic abuse: 9.11 Mother seriously misused both drugs and alcohol immediately prior to her pregnancies with both Sibling 1 and Sibling 2. She was also previously in at least two domestically abusive relationships. During her pregnancies she was reportedly able to give up her use of drugs and alcohol, and she successfully separated from her abusive partner while pregnant with Sibling 1. 9.12 Domestic abuse was not believed to be an issue in her relationship with Father, although the police had attended their home on a number of occasions due to verbal arguments. The significance of these events was not thoroughly explored with either parent, and it appears Mother minimised them when incidents were discussed, describing them as one-off verbal altercations. 9.13 There is limited evidence but it seems that that both parents may have continued to use cannabis while caring for the children. The health visitor for Sibling 2 noted the smell of cannabis in the home on one occasion, and both parents had admitted to smoking cannabis during the early pregnancy with Sibling 2. Police notifications also reported the smell of cannabis in the home. Mother confirmed to the lead reviewer that there had been on-going cannabis use. 9.14 Father approached his GP both in 2012 and in 2015 and shared the information that he had misused steroids. There is evidence that this can have a negative impact on anger control, with people reportedly acting aggressively when injecting anabolic steroids regularly16. Father told this review that he had anger issues prior to this behaviour however. Adult mental health services were aware of Father’s reported misuse of steroids, but as they did not link his records with Mother’s they did not consider if there was an issue for Mother or the children. The GP was told by Father that he had a child, but there was no attempt to share the information with other professionals such as the health visitor. It appears Father was seen in isolation and that there was a lack of professional curiosity. Learning: • Consideration should be given to the potential misuse of steroids by parents who report anger control issues, as this may be a safeguarding concern. 16 https://www.drugabuse.gov/publications/drugfacts/anabolic-steroids 12 • Professionals must understand that service users will not always disclose domestic abuse or coercion/control in their relationships while it is happening. • It is important that when families move or new professionals become involved with a family, that the questions about drug and alcohol use and domestic abuse should be asked regularly. ‘Care’ history of Mother: 9.15 As far as Mother was concerned she had been in foster care as a child and believed she was a care leaver. She was happy to share this information with professionals. She presented as a ‘care leaver’ to those involved, who had no reason to dispute Mother’s stated history. It appears that the placement with her ‘foster mother’ was an informal placement made by the family and the Local Authority had no role in Mother’s life or in the placement at the time. This made Mother particularly vulnerable as she did not have any of the support or supervision that should be available when a child is in the care system. At the time in the area (around 15 years ago), as well as elsewhere in the UK, there was not always an adequate awareness of private fostering. Those privately fostering children and other agencies such as schools did not always respond to their legal responsibility to alert the local authority to such situations17. Private fostering is when a child or young person under 16 years old (or 18 if they are registered disabled) is cared for and provided with accommodation for 28 days or more by someone who is not a close relative. All councils are legally required to make sure children who are privately fostered are being cared for by a suitable carer in an appropriate environment, and an assessment is undertaken by a social worker in such instances. 9.16 Despite the informal and unclear status of the placement, Mother had a degree of on-going support from her ‘foster mother’ throughout the timeframe of this review, which shows that their relationship did not just end when Mother moved out. There was very little confirmation however of Mother’s reported history, despite this being important in order to understand the impact of her own experiences on her parenting. 9.17 What was known was that Mother became a parent when she was little more than a child herself, that she had reported a traumatic childhood history, and that she had not lived with her birth family from a young age. The foster mother stated she had taken Mother in when she was young due to concerns of poor care from her mother. There is little evidence that this was checked out and explored in detail by those working with Mother regarding concerns about her own children. There is a current view that she may have lived in another Local Authority, but there was no attempt at any point prior to the injuries on Child N to establish the precise details of her history. 9.18 The most recent social worker was clear at the learning events that she had tried to read the files available about Father as a child, but that the historic files were hard to understand and capacity issues had made it impossible to complete the task. As she had worked in a previous role with both parents in a hostel for homeless young people, she often relied on her previous knowledge of them when considering their histories. While this was helpful information, it was not as comprehensive as was required in this case. It is difficult for professionals who knew parents as children or young adults to have the required focus on their children when they become parents. There is a need for supervision to provide reflection on this issue to ensure that there is no bias or issues with professional judgements. Learning: 17 The Children (Private Arrangements for Fostering) Regulations 2005. 13 • In order to ensure that a thorough assessment is undertaken, knowledge of a parent’s own experiences in childhood is essential. Any information self-reported by parents should be checked, historic records should be sought and read, and the relevant information should be shared with other professionals and considered when reflecting on the risks this may pose for the children. • Supervision for professionals needs to challenge those working with families to ensure they are focused on the child and not distracted and swayed by the parent’s histories and situations. This is particularly crucial where the parents are young, have a care history, and /or require a lot of personal support. Homelessness/temporary housing: 9.19 To quote the Primary Care agency report, ‘with the benefit of hindsight it would seem that the disruption from moving areas just after the birth of Sibling 2 was quite significant’. This would have been an extremely difficult time for Mother and Father. There were concerns about delays in Mother’s medication being restarted after the birth, her anxiety that the new baby looked very much like the baby who had died, her expressed difficulties in bonding with Sibling 2, and her move to an area away from where she wanted to be and away from the support she had from her ‘foster mother’ and from Father’s relatives. Father was not officially living with Mother and the baby, which could have provided additional stress when he was living with them ‘unofficially’. Father had to adjust to being a parent for the first time, with a partner who was grieving for her first child and who was on medication that effected her functioning, and without help to manage his anger. 9.20 While they made time to try to get to know Mother, despite initially working without the records being transferred in the case of the GP, professionals needed to quickly understand a lot of background history and consider the impact on the current situation. It is noted that when complicated high risk patients move areas, it increases the vulnerability and risk for the children. It is at this time that good information sharing is crucial. In this case there was good practice identified with the GP contacting the mental health team, and the health visitors undertaking a handover visit. Also the previous mental health team and social work team remained involved. 9.21 Father’s brother not known to local agencies and those working with the family. As Child N and Sibling 2 were ‘children in need’ there would not have been the same degree of scrutiny regarding who was living in the house as there would have been if the children were on a child protection plan. It is not known how long Father’s brother had been staying with the family and what impact this had on the children and on the parents. Learning: • Robust information sharing and the swift transfer of records is essential when a child in need and their family move home. It should also be acknowledged that there is likely to be an increased risk at this time due to changes of professionals involved in services that work geographically. Assessment: 9.22 Prior to the birth of Sibling 1, Sibling 2, and Child N, both Initial and Core Assessments18 were undertaken, but not a formal Pre-birth Assessment. When the referral for Sibling 2 was accepted by CSC the manager on duty stated it required a Pre-birth Assessment. This would 18 An Initial assessment of a child’s needs is undertaken following a referral and is completed within a maximum of 7 working days. A Core Assessment is a more in depth assessment and should be completed within a maximum of 35 working days. (Framework for Assessment of Children in Need and their Families (2000). 14 have established both the child’s needs and the risk of harm in view of the impact on Mother’s parenting capacity of; her background history; her mental health difficulties; her history of substance misuse; her own experience of being ‘parented’; her unsettled lifestyle; and her recent bereavement. Limited information was available about the fathers of the children at the time, and the assessments needed to thoroughly consider their role and histories too. 9.23 It appears that there was confusion at the time in the area about what cases required a Pre-birth Assessment, with a misunderstanding that they were to be used specifically for children who were likely to be subject to a CP plan prior at birth. The early arrival of Sibling 2, the amount of time spent trying to assist Mother with getting rehoused, the allocation in a busy assessment team, and Mother’s agreement to engage, also had an impact on the type of assessment undertaken. It was acknowledged during the learning events that the pathway for pre-birth assessment work remains unclear, but that a lot of work is underway to improve processes and practice. 9.24 The Ofsted report: ‘Ages of concern: learning lessons from serious case reviews’ provides a thematic analysis of 482 serious case reviews that Ofsted evaluated between 1 April 2007 and 31 March 2011. They found that improving practice in pre-birth assessment was a key area for improvement. Developing an effective and evidence-based approach to pre-birth assessments is considered a critical element of this work. Many of the headline findings of the Ages of Concern research has a correspondence with this case: • There were shortcomings in the timeliness and quality of pre-birth assessments • The risks resulting from the parents’ own needs were underestimated • There had been insufficient support for young parents • The role of the fathers had been marginalised • There was a need for improved assessment of, and support for, parenting capacity • Practitioners underestimated the fragility of the baby 9.25 The local procedures for pre-birth assessments state that the overall aim of the pre-birth assessment is to identify and understand: • Parental and family history; • Life style and support networks and their likely impact on the child's welfare; • Risk factors; • Parental needs; • Strengths in the family environment; • Factors likely to change and why; • Factors that might change, how and why; • Factors that will not change and why. This would have been a helpful assessment prior to the birth of all the children, considering the circumstances that were known at the time. 9.26 Professionals need to be aware of and understand the enduring impact of abuse and neglect in childhood on parenting. While there was some understanding of the parent’s backgrounds, this was largely self-reported and limited by lack of evidence. A full consideration of the significance was not considered at key times, such as the decision making about the type of assessment undertaken and whether an ICPC was required 15 following the S47 prior to the pregnancy with Child N. Information has become available during the later involvement with the family and during this review that it would have been helpful to know when undertaking the assessments both pre and post the birth of the three children in the family. 9.27 Part of the pre-birth assessment for Child N should have included information (not just from the parents themselves) about their backgrounds. There was also a need for a consideration of Sibling 1’s attachment to the parents, particularly after the difficulties Mother had bonding with Sibling 2 following the death of Sibling 1. It was recorded that Mother struggled to bond with Sibling 2 who looked so much like Sibling 1, and that Mother would not hold Child N on the day they were born. Information sharing was evident regarding attachment issues between Mother and Sibling 2, and this needed full consideration due to the probability that the same would be the case for Child N. 9.28 It has been established that there was no re-assessment19 undertaken by social workers following the birth of Child N, which suggests either a lack of focus on the new baby or a decline in concerns about Mother’s ability to cope and an improvement in her feelings towards Sibling 2. At the learning events professionals involved at the time stated that they did believe there had been an improvement prior to the birth of Child N and that consideration was being given to closing the case after the baby was born. This optimism would have led to less focus on the case and on the event of Child N’s birth. 9.29 The child in need plan was on-going and review meetings were being held regularly and within expected timescales. The local authority with the support of partner agencies were using a signs of safety mapping tool at this time and they were completed at the child in need reviews in January and March 2016. The mapping tool includes a ‘harm box’ which lists any risks and should demonstrate that the likelihood of harm was addressed. They were empty in this case. It appears this was due to the view that the box should be used to list actual harm rather than risk factors that may lead to harm. There was also a lack of experience in regards to both professionals and managers in completing the forms at the time. 9.30 CFIS planned to undertake direct work with the family, with a view to improving the relationship between Mother and Sibling 2. They used VIG (Video Interactive Guidance), a method which uses video recordings of interaction between parents and children to encourage positive relationships and improve attachment and bonding. Like a lot of younger women, Mother was reluctant to see herself on film and told the review this was too much pressure for her. Mother cancelled a number of appointments with CFIS. She was pregnant for some of the time and had some health issues, she also made a point of cancelling then rearranging appointments, giving the impression she was actively engaged in the process and willing to work on the issues identified. She only attended five appointments in a seven month period, with Father attending fewer than Mother. 9.31 The attachment issues evident between Mother and Sibling 2 were well known at the time. NICE published attachment guidance in November 2015 titled ‘Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care’. It summarises why a solid attachment is so important for children and why the stakes were high in this case, even without any evidence of a risk of physical harm 19 The children and families assessments (what was previously a core assessment) should be updated on a regular basis, and following any changes of circumstances, for example a new baby or a move of accommodation. 16 to the children at the time20. The professionals in the CFIS team were aware of this and voiced their concerns about Sibling 2 when they requested a child protection response in Key Episode 2. The decision making following the meeting did not sufficiently consider the impact on Sibling 2 of the limitations in the emotional care they were receiving. Learning: • Clarity is required regarding the need for a Pre-birth Assessment in cases where there is a child in need and parental risk factors which may impact on the care of the child they are expecting. Child in Need planning: 9.32 There were clearly recorded plans for the children in this case, with an identified team of professionals who were aware of the plan and who attended meetings. Both parents regularly attended meetings, most of which were held in their home. The plan consisted of clear tasks for the professionals involved and the family, for example that Mother would attend her local family centre and that Father would approach his GP regarding his anger. Some aspects of the plans were weak; they were not outcome focused, they did not state what needed to be achieved before the plan could stop, and they did not include a contingency plan. 9.33 Part of the learning from this review is in regards to children who are on child in need plans not always being seen as in need of risk assessments like children on child protection plans. It has been stated that some of the professionals thought of the children in this case as ‘only’ being child in need. Learning from serious case reviews nationally shows that children who die or are seriously harmed are usually well known to professionals but not the subject of a child protection plan. The assessment process and rigour of a child in need plan can therefore be as important to those who are seen as in need as to those who have already been established as suffering or at risk of significant harm21. In this case the CSC agency report author found that ‘given their CIN status and the lack of any obvious overt crisis or deterioration, the situation was not questioned. The impact of this kind of thinking has been to limit any kind of wider evaluative thinking and analysis of the children’s situation’. Due to the limited use of the signs of safety tool the risk factors were not articulated and acknowledged in Key Episode 3. 9.34 In the area there have been concerns identified about the quality of child in need plans and it has been acknowledged that there is a need to ensure that they are more effective, multi-agency, and that drift and delay is avoided. In November 2015 a request was made for an Advanced Practitioner to review this case and the case note of this review says; “Record checked, child seen in a timely manner. No safeguarding issues identified”. It is the view of the CSC agency report author that ‘this indicates a superficial review and does not evidence that any substantial quality assurance of the situation for the child was achieved’. An OFSTED inspection undertaken at the time noted the expectation that the Advanced Practitioners would improve the quality of child in need work, but that this was not yet 20 The reports states ‘children whose caregivers respond sensitively to the child's needs at times of distress and fear in infancy and early childhood develop secure attachments to their primary caregivers. These children can also use their caregivers as a secure base from which to explore their environment. They have better outcomes than non-securely attached children in social and emotional development, educational achievement and mental health. Early attachment relations are thought to be crucial for later social relationships and for the development of capacities for emotional and stress regulation, self-control and mentalisation. Children and young people who have experienced insecure attachments are more likely to struggle in these areas and to experience emotional and behavioural difficulties.’ Nice Guidance: Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care. 2015. 21 The child protection plan threshold. 17 embedded at the time being considered by this review. It is noted that a recommendation from OFSTED report was that agencies should strengthen the quality of planning for children in need of protection, children looked after and care leavers so that plans are clear about intended outcomes and timescales and clear about who is responsible for actions and have agreed contingency plans. The plan for the Advanced Practitioners to robustly and thoroughly review child in need cases needs to be more effective than was seen on this case. 9.35 At the time that Child N was born and then went into hospital professionals felt that Mother had been making good progress with Sibling 2. Those involved at the time stated they felt the case was moving in the right direction and that Mother and Father looked as though they would be able to parent the children without the need for a child in need plan. This understanding at the time would have led to less focus on the case and less challenge to the parents across agencies, and there was no specific assessment undertaken at this time that considered the impact of another baby on Sibling 2’s care. Learning: • When a new baby is expected and a sibling is on a child in need plan, there needs to be an assessment in regards to the new baby, but also a reassessment of the older child to consider the impact of a new baby on that child. The plans should reflect the new information. Parental engagement and focus: 9.36 Mother and Father were not always entirely open about their issues with the agencies involved with them. They would often give partial information rather than sharing the whole picture. For example Mother told her GP, after the death of Sibling 1, that she had been drinking heavily and had considered returning to drug use, but had not. Other professionals were aware Mother had been using drugs at this time. Father accepted he had some anger control issues but did not tell those involved in the child in need plan that he had been injecting anabolic steroids. Without agencies sharing all of the information known to them, no one agency had the whole picture. 9.37 The Victoria Climbe enquiry22 highlighted that professionals must maintain a ‘healthy scepticism’ and ‘respectful uncertainty’ in order to see beyond what is often being presented by parents. A process of ‘checking back’ with professional colleagues may provide opportunities to detect hidden issues and provide mutual support in challenging parents and in protecting children. This is particularly important where the self-report is not in the professional’s area of expertise (e.g. adult mental health or substance misuse). 9.38 It requires skill and experience to keep a healthy scepticism regarding parents while still building and maintaining a trusting relationship. Parents are not necessarily dishonest or deliberately hide what is really happening at home, however professionals need to maintain their professional curiosity and scepticism in all cases, not just those where there are very apparent concerns. These parents were not angry, aggressive or challenging to professionals and both stated regularly that they accepted they needed help. As a consequence workers did not appear to adequately consider the impact on the children of the lack of cooperation and engagement with much of the planned work. Father told the lead reviewer that both he and Mother would lie to professionals. He added that they also lied to themselves as they knew deep down that they were not managing as parents. 22 Laming, Lord (2003) The Victoria Climbié inquiry. Report of an inquiry by Lord Laming. 18 9.39 The parents were seen as being co-operative by all of the professionals involved. Mother had a pattern of frequently re-arranging appointments rather than simply cancelling them or not attending. This practice, along with a high degree of empathy for Mother due to her anxiety, her bereavement, her challenging housing needs, and her ill-health during pregnancy led to professionals not sufficiently challenging missed appointments. The inconsistent attendance had an influence on the work and interventions provided for the children. As stated in the CSC agency report ‘the local Child Protection Procedures refer to this kind of behaviour which is described as avoidant and a kind of uncooperativeness. Had this been recognised the focus could have remained more clearly on the children’. 9.40 While the parents appeared to be cooperative with the child in need plans and the services offered, such as the CFIS work, they were insistent they would not give permission for a family network meeting, stating that they wished to be independent and that their families had issues of their own to contend with. The social worker was persistent with this issue and they eventually agreed but then avoided providing the contact details required. 9.41 The parents did not always follow advice in regards to certain practices, such the need to let Sibling 2 have more time out of their bouncy chair and on the floor. Both parents needed both practical and emotional help, what is not clear is if consideration was given to how likely it was that they would meaningfully engage. It has been acknowledged however that the family had a lot of appointments to attend due to the work being undertaken with their insecure housing, the involvement with mental health services and on-going health issues. It may have been helpful to coordinate contacts with the family to limit the demands on them and potentially increase their engagement. 9.42 Service delivery in this case became focused on the parents and their needs, particularly Mother. Assessments, the child in need plans, and subsequent interventions were based around Mother’s needs and difficulties. There was limited consideration of the way that her behaviour would impact on the children’s development in the future. Examples of the focus on Mother include the lack of challenge regarding her reluctance to engage with the CFIS work, the decision not to hold an ICPC in order to give Mother more time to engage with the child in need plan (without a full consideration of the children’s timescales) and the professional network’s understanding of how Mother’s grief for Sibling 1 made it hard for her to hold her babies, despite their needs. The CFIS worker told the learning event that it was acknowledged that professionals had to tread carefully with Mother due to her bereavement issues. All of the professionals stated it was like they were walking on egg-shells. 9.43 This sensitive and mother-focused approach was over optimistic about Mother’s potential for engagement and therefore potential to change given her mental health issues, her own negative childhood experiences, and her enduring reaction to Sibling 1’s death. This also led to the children’s voices not being heard as much as would be required to aid the planning and interventions required. It is stated in the NICE attachment guidance (2015) that the window for a child to gain a secure attachment is very small, and in the case of Sibling 2 this was a significant issue. The CSC agency report author’s analysis is that ‘Mother’s openness about her own difficulties drew the CSC workers in to her world, and although her issues were thought of in relation to how this would impact on her ability to parent the children, the children did not remain the priority. This situation led to drift for the children.’ Learning: 19 • Professionals need to identify when parental cooperation with a plan for assessment and support is superficial. Consideration then needs to be given to the impact of this limited engagement on the child/ren. Gender: 9.44 There is evidence that the focus of the work in this case was on Mother. This was over and above the children and sometimes excluded Father. It was hard to ensure that this SCR did not mirror this, as there were no services specifically involved with Father and few professionals who got to know him well. The general focus on Mother was because she was seen as the person with the issues that were most likely to impact negatively on the care of the children. Father was known to be primary carer to the children much of the time, but despite this he appears to have been on the periphery of the work being undertaken. Very little was actually known about Father and about the children’s routines in the home and which parent was responsible for them. Father confirmed to the lead reviewer that this was the case. 9.45 Mothers are often seen as the ‘key’ parent for children. Serious case reviews have shown that professionals often fail to identify, and frequently discount or ignore the men in a child’s life. The ‘invisible male’ is a key theme in a large number of reviews. In this case, Father was known, involved, and engaged with to a certain degree, but there were exceptions such as his address not being recorded in health visitor records and clarity about his contact with his wider family not fully pursued. Research23 shows that professionals often struggle to engage with fathers and that there are limited expectations of fathers. When looking at plans to support or protect children it is often assumed by professionals, and the parents themselves, that ‘parent’ really means ‘mother’. 9.46 The Family Rights Group research argues that social workers tend to see men in a family as either ‘a risk or a resource’ rather than an as equal parent who needs to be assessed, supported and challenged along with the mother. They add that ‘even a father who displays risk factors, such as violence, may display some protective factors. The challenge is to identify interventions that bring forward those protective factors while keeping the risk under control.’ In this case Father undertook a lot of the practical care of the children when Mother was unable to do so. He showed a commitment to the children and their Mother and was said to have a good bond with Sibling 2 and Child N. Despite an initial reluctance to engage with social workers he requested help for his family when the impact of Mother’s anxiety was evident. He appeared to be committed to the care of his children and he had a right to be fully involved in any plans to improve the children’s care. 9.47 CFIS acknowledged that they focused their interventions on Mother, and specifically on working with Mother on improving her bond to Sibling 2. The learning for them from this case is that father’s should be offered their own sessions in cases like this. They were not alone in recognising that services can be focused on women and do not necessarily give appropriate consideration to the importance of the men who are involved in children’s lives. 9.48 The University of Worcester, in collaboration with the Fatherhood Institute, undertook an evaluation of a training programme and toolkit to assist health visitors and community practitioners to engage with fathers as part of the Healthy Child Initiative in 201424. They found that ‘there is little evidence that the importance of engaging with fathers is reflected 23 Family Rights Group, Fatherhood Institute, Daryl Dugdale (Bristol university), Professor Brigid Featherstone (Open University) 2012 24 http://www.fatherhoodinstitute.org/wp-content/uploads/2014/10/Burdett-Report-Final-Version-June-18-2014.pdf 20 in Health Visitor training or, indeed, that family services are making progress in father-inclusive practice’. This was due to the culture of organisations and training, the recording and information systems used, attitudes and preconceived ideas about fathers’ parenting abilities and skills and time constraints. Learning: • Professionals undertaking assessments should seek to understand the nature of parenting relationships from the point of view of both parents/adults and the child. It is not enough to simply focus on the parenting capacity of the child’s mother. • All agencies need to ensure that their systems (including recording templates), procedures, practice, ensure engagement with, consideration of and inclusion of, both parents /adults in a family regardless of their gender.25 • Professionals need to challenge their own practice and their organisational cultures to ensure that service provision considers the child’s day to day experience and that the gender of the care giver/s does not exclude them from receiving the required assessments, support and plans. Response to Child N’s injuries: 9.50 When Child N was taken to hospital by Father there was initially no documented suspicion of non-accidental injuries. No referral was initially made to the Police or CSC as there were no child protection concerns at this stage. S47 enquiries were not undertaken until the suspected non-accidental injuries were identified and Child N moved to the specialist hospital around five days after admittance to the local hospital. The move of hospitals was on a Friday and when the matter became a child protection issue it was the weekend. This meant that the S47 enquiries and strategy discussion happened outside of office hours and in a hospital a considerable distance away from local agencies. Despite this there was good attendance at the strategy meeting, which is positive practice. 9.51 In the meantime both parents had been having unlimited contact with Child N on the ward, despite the possibility of the concerns being non-accidental injuries. A differential diagnosis should have been considered by health professionals after Child N was first seen, while still ensuring the child’s medical needs take precedence. Contact was not stopped and then fully supervised until after the parents were arrested by the Police at the second hospital. 9.51 There was a view at the time that the hospital was a place of safety for the baby. However at one stage when Child N was still in the local hospital, Father was heard speaking crossly to Child N, who could have been at risk even within the hospital environment. A hospital is not a safe place for a child having contact with an adult who may have harmed them as nursing staff cannot provide 24 hours supervision. If there had been an earlier strategy meeting, prior to the move of hospital, the issue of contact could have been discussed and a plan made. Learning: • Non-accidental injury should be considered as part of a differential diagnosis of vomiting, irritability/colic, apparent life threatening events (ALTE) and floppy episodes, which could have led to an earlier strategy meeting in this case including professionals who knew the family and while the child was in the local hospital. 25 A previous SCR led to changes in the booking form used by midwives in the area; they were not fully embedded at the time being considered by this review however. 21 10 Conclusions 10.1. Mother was a teenage parent with a history of self-harm, mental health crises and personality disorder, drug and alcohol misuse, a poor experience of being parented and living ‘in care.’ She was challenged by insecure housing, domestically abusive relationships, a major bereavement and a new relationship with a man who had a difficult childhood himself and a reported anger control issue. Mother and Father both engaged to a degree with the agencies providing support, but one of the children living with them received what are thought to be non-accidental injuries in circumstances that are unknown, when just 4-weeks-old. 10.2. As stated in the 2016 Triennial Analysis of SCRs, for many of the children considered in an SCR, ‘the harms they suffered occurred not because of, but in spite of, all the work that professionals were doing to support and protect them.’ This was true for Child N.26 This SCR has, however, been able to identify learning which is relevant both to this case and to the wider system. It includes clear statements of learning which were developed from the themes considered above, and recommendations. 10.3. Individual agency learning is significant and the LSCB has ensured that a robust consideration of the concerns identified has been undertaken by each agency involved in this matter. A number of single agency recommendations have been made which will improve systems and practice in regards to the learning identified in this overview report. 10.4. It is important to learn from the good practice identified during the course of this review. Good practice across a number of agencies has been acknowledged throughout the report, and includes the following: • The GP surgery Mother registered with shortly after the death of Sibling 1 flagged the following details on Mother’s records. ‘Double appointments always. Sudden death of 4 month old baby. Vulnerable adult with mental health problems’. • GPs referred Child N twice to acute paediatrics and asked for a same day appointment. • Good relationships were evident and reported between agencies in this case. For example between the children’s social work team and the mental health team. • A joint handover visit was completed between two health visitors after Mother and child moved. The health visitor involved when Sibling 2 was born was also contacted. • There was conscientious social work practice in this case, although insufficient focus on risk. • There were numerous examples of good information sharing between agencies. • Father was involved in much of the work. A health visitor made an additional appointment to visit when Father would be in to get his consent for a referral to CSC. • The CSC and police response following the confirmation of that Child N had suffered non-accidental injuries were thorough and followed practice expectations. • The transfer of Child N to a tertiary hospital for further tests was entirely appropriate and in line with the neurosurgical pathway. 10.5. There has been a high degree of cooperation and engagement from agencies with the SCR process. There have also been a number of changes within the partner agencies of the LSCB, which the response to this SCR will outline. 26 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/533826/Triennial_Analysis_of_SCRs_2011-2014_-__Pathways_to_harm_and_protection.pdf 22 11 Recommendations 11.1. It is recognised that actions have already been taken in relation to some of the individual agencies’ identified learning. The agency reports have recommendations which will have largely been completed by the conclusion of the SCR. Some of the learning identified within this overview report will have been addressed by the single agency actions plans. 11.2. The purpose of providing additional recommendations is to ensure that the LSCB and its partner agencies are confident that any areas identified as being of particular concern, and not included in the single agency plan, or which require an interagency or Board action are addressed. Recommendation 1: The LSCB to request that Children’s Social Care undertake a specific quality assurance piece of work to confirm if formal pre-birth assessments, including the use of risk assessment tools, are being undertaken in all cases where it is agreed that a new baby will be the subject of a Child and Family Plan (child in need) plan or child protection plan at birth. CSC should report the result of this piece of work to the LSCB, and provide reassurance of actions to be taken if any issues are identified. Recommendation 2: The LSCB to consider the benefits and practicalities of requesting that the information that a child is on a child in need plan is shared (with consent) with all professionals working with the family, including the child’s GP and the GP for all adults living in the home. Recommendation 3: The LSCB should be assured that the multi-agency partnership is delivering robust child in need plans. This should include a multi-agency case file audit on unborn babies and pre-school children on a child in need plan. To include whether the potential risks/likelihood of harm to the child have been identified and addressed. Recommendation 4: The LSCB should assure itself that services are available and commissioned to meet the need for anger control support for those who require it across the area. Recommendation 5: That the LSCB requests a review by all partner agencies of their forms and information recording and sharing systems to ensure they expect professionals to include and involve fathers/adults present in the household. Recommendation 6: The LSCB to request a review of what advice and support is provided to all new parents regarding coping with babies. This is often delivered alongside safe sleeping advice during the antenatal period27. Recommendation 7: When assessing housing needs, any issues in relation to children subject to a plan should always be taken into consideration by the housing authority, which has a clear responsibility for safeguarding. Those working with children on a plan should ensure that the relevant housing professionals are aware of the plan and who is involved. 27 https://www.nspcc.org.uk/services-and-resources/services-for-children-and-families/coping-with-crying |
NC52233 | Death of a 16-year-old child from natural causes whilst in custody at a Young Offender Institution. Review does not consider the circumstances of Child I's death. Child I lived with his mother, father and older sibling. For much of his childhood there were no known concerns but after transition to secondary school difficulties rapidly emerged. History of school exclusions, violence, theft, carrying weapons; arrested several times in possession of Class A drugs. Child I was placed in foster care and later entered Local Authority care under a voluntary section 20 agreement. At the time of his death, Child I was on remand for murder. Child I was a Black child. Learning includes: practitioners need to recognise 'subtle moments' that might present clear opportunities to help and protect a child; where children are identified as needing early help, it is important that parents and carers fully understand what this involves in respect of a coordinated, multi-agency approach to help and protection. Recommendations include: ensure that policy, procedure and practice relating to critical moments (both well established and those less obvious) is sufficiently robust to ensure effective safety planning; work with schools to ensure that they are able to identify children who show persistent behavioural difficulties; ensure that a multi-agency response to the persistent disruptive behaviour of children is sufficiently described in threshold tools; explore with primary and secondary schools how multi-agency involvement could be improved both prior to and at the point decisions are being made about permanent exclusions.
| Title: Serious case review: Child I. LSCB: City and Hackney Safeguarding Children Partnership Author: Rory McCallum Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case ReviewChild IJuly 2021Rory McCallum, Senior Professional Advisor, CHSCPContents1. Introduction22. Key Circumstances, Background & Context43. Views of the Family84. Findings & Recommendations1111.Introduction1.1This Serious Case Review (SCR) was commissioned following the death of Child Ifrom natural causes whilst in custody at a Young Offender Institution (YOI). At thetime of his death, Child I was 16 years old and on remand for murder. He had aknown history of carrying weapons and had been arrested several times inpossession of Class A drugs.Over what was a relatively short period of time,Child I’s offending escalated significantly. It was entrenched, serious and harmful.1.2Exactly how and why Child I became involved in such a spiral of criminal activityremains largely unknown.However, it is reasonable to assume that despitehaving ‘agency’1, he was unlikely to have chosen this path for himself. At variouspoints in his life, there would have been a range of factors at play that ultimatelydetermined the actions he took. It is highly likely that one such factor was criminalexploitation.1.3That said, the SCR neither seeks to excuse Child I’s behaviour nor dilute theimpact it had upon many, not least his victims and without doubt, his own family. Itdoes, however, recognise that for many children, the boundary between ‘victim’and ‘offender’ will often be blurred. Front-line professionals need to recognise thistoo and give sufficient priority to both areas as part of their practice. Put simply,when offending is driven by exploitation, one won’t be addressed without the other.1.4Whilst the SCR noted some positive work that was undertaken with Child I, hisstory reinforces a number of important lessons for practice. The SCR highlightsthe need for practitioners to be alert to a broader range of ‘critical moments’ thatcan arise in the lives of children.It also underscores the need for practice tocapitalise on the strengths of multi-agency partnerships when risk is predictablygoing to increase.1.5The need for ‘early help’ to be explained by professionals in such a way that it isunderstood by families is a simple, yet important, lesson identified by the review.The SCR also points to whether the offer of early help is early enough.Thesignificance of this latter point cannot be overstated.We know that diverting1 the capacity of individuals to act independently and to make their own free choices.2children from criminal activity and protecting them from harm becomes morechallenging the older they get.Once groomed and engaged, the pull-factors forchildren can simply be too overwhelming.Just as Child I was unlikely to havechosen his path, it was equally unlikely he had much choice to leave it.‘Having worked with good and decent young people who have been drawn into atwisted perception of reality by their gang elders – a world of enemies, honour andartificial territorialism that seems utterly alien to those outside the sphere of control– I’ve seen how lost they can become to reason. However hard their parents try totalk sense into them (and I’ve seen them try incredibly hard), gang elders exert farstronger control.’21.6When looking at Child I’s life in the context of criminal activity, serious youthviolence and exploitation, a number of themes are present that are neither uniquenor unknown.In this respect, the SCR has not sought to repeat many of thosefindings that have already been established from a range of comprehensivereviews3 4 5, rather it focuses on a limited number of areas upon which the SCRbelieves the local partnership should apply focus.Finding1:Practitionersnotonlyneedtorecogniseandrespondtowell-established ‘critical moments’, but ‘subtle moments’ too; moments that mightpresent clear opportunities to help and protect a child.Finding 2:We know much about the circumstances in which risk relating toexploitation, criminality and serious youth violence is predictably going to increase.Despite this knowledge, practice does not always accrue the benefits of a coherentmulti-agency approach.Finding 3: Where children are identified as needing early help, it is important thatparents and carers fully understand what this involves in respect of a coordinated,5 Serious Youth Violence – Thematic Serious Case Review – Buckinghamshire Safeguarding Children Partnership4 Vulnerable Adolescents Thematic Review – Croydon Safeguarding Children Board 20193 It was hard to escape – Child Safeguarding Practice Review Panel 20202 Young perpetrators of knife crime are victims too – Anonymous April 2018, The Guardian3multi-agency approach to help and protection.Without this understanding, theymay be hindered in their ability to provide informed consent.1.7The SCR has not considered the circumstances of Child I’s death at the YOI.These have been reviewed by the Prison and Probation Ombudsman (PPO) andwill be reported following the completion of Child I’s Inquest.2.Key Circumstances, Background & Context2.1Child I was a Black child who lived with his mother, father and older sibling. Formuch of his childhood, there were no known concerns and his primary schoolyears appeared largely uneventful.This changed following Child I’s transfer tosecondary school. After a year of being relatively settled, a number of difficultiesrapidly emerged.2.2In 2015, Child I (aged 13) came to the attention of Children’s Social Care (CSC)when he was reported to have stolen around £2k from his father. Throughout thisyear and later into 2016, there was a noted deterioration in Child I’s behaviour atboth home and school.There were serious incidents where Child I would bullyother pupils for money, many of whom were vulnerable.2.3As a consequence, Child I received a number of exclusions.In an attempt toaddress his worsening behaviour, the school provided weekly sessions ofindividual and group support via the Pastoral Team. Believing more was needed,attempts were made to engage Child I’s family in early help services.Recordsindicate that this offer was not taken accepted by Child I’s parents and that theyfelt the existing support in place was sufficient. Child I’s parents, however, recall adifferent version of events.They state that they never withheld their consent forhelp and given the difficulties they were experiencing with their son, they wouldhave willingly accepted any additional support being offered.2.4In early 2017, an incident took place at home during which Child I damaged hismother’s hearing aid. The Police were called, and Child I was arrested. Whilst incustody, Child I’s mother informed the Police that she had found a large knife in a4bag at home. Child I was bailed to return to the Police station with conditions notto contact his parents.He was placed in foster care and subsequently chargedwith common assault and criminal damage.2.5Child I returned home in late March 2017. Case records from the time show thatmother felt uncomfortable and sometimes fearful when Child I was at home. Shesaid that her son was very rude to her and had no respect. She described him aswanting to do as he pleased and not responding to any rules or boundaries.2.6Both parents were extremely worried for their son’s welfare and his peerassociations.They believed he would be best placed in secure accommodationfor his own safety.2.7In February 2017, Child I was permanently excluded (PEX) following six previousexclusions for disruptive behaviour. Child I was subsequently engaged at a localPupil Referral Unit (PRU), where he remained from early February 2017 until July2017.2.8In May 2017, Child I went missing during the school half-term. Nine days later, hereturned in the early hours of the morning with no explanation as to where he hadbeen.When spoken to, Child I said he went missing as he believed his motherwould lock him in the house over the holiday period. His mother believed he wasrunning ‘county lines’. Around the same time, the PRU reported similar concernsto the Police that Child I was involved in gang activity.2.9In June 2017, Child I was arrested on suspicion of Grievous Bodily Harm (GBH)relating to an incident which had occurred in April 2017. Neither his parents norother family members felt able to continue to look after Child I and he enteredLocal Authority care under a voluntary section 20 agreement6.2.10After coming into care, Child I remained in his first placement for only three daysand was subsequently missing for several weeks. When located, in Brighton, hewas with a known drug user, with a knife, a large sum of money and crackcocaine. Child I was detained in a YOI on six charges including one of false6 Section 20 Children Act 19895imprisonment.Bail (with conditions) was granted, and Child I was moved to aresidential placement in London.2.11At the time, Child I’s parents thought it would be best for Child I to be placedoutside of London.Records indicate that discussions were held with the familyabout the availability of local support. They also show that CSC staff were alert tothe fact that such action does not always mitigate risk, particularly in the long-term.2.12In October 2017, Child I received a 12-month Referral Order for three of theoffences committed in Brighton.Later that month, staff at his residentialplacement called Police to report that they had found a large knife in Child I’sbedroom. An appointment was made by the Police to attend and seize the knife.Child I was not seen or spoken to by officers.2.13Also in October 2017, Child I was arrested in Reading for Affray and possession ofcannabis. This incident was not progressed to charge after he was held overnightand questioned by the Police.2.14Over a period of ten days in late November 2017, Child I was ‘Absent’7 from hisplacement on five occasions. On 28 November 2017, Child I was again arrestedin Reading. This time he had 80 - 100 wraps of crack cocaine. He was held inPolice custody for two nights and then appeared in court. Child I pleaded guilty.2.15In December 2017, Child I started at a new school. He was described as beingacademically able, although he was not always well focused and was fallingbehind.Initially, Child I was polite to all members of staff.He followedinstructions, cooperated with his peers and had been performing well in lessons.2.16In January 2018, he became subject to an Intensive Supervision and SurveillanceOrder (ISS) and was required to wear an electronic tag.7 Police definitions - A person is ‘absent’ when they are not at a place where they are expected or required to be. A person is ‘missing’ when theirwhereabouts cannot be established and where the circumstances are out of character, or the context suggests the person may be subject ofcrime or at risk of harm to themselves or another. Note: The Metropolitan Police Service no longer use the definition of ‘absent’ in their responseto missing children.62.17Two months after being at this new school, Child I’s behaviour and attitudechanged.He was reported to respond to male staff members but ignore and bedisrespectful to female staff.There was also a concern about the re-emergenceof his bullying behaviour, with Child I appearing to target one of the quieter pupils.2.18By April 2018, despite work via a Family Learning Intervention Programme, Child I’sfamily didn’t feel he could return home.However, they remained supportive andfully engaged with the range of practitioners trying to keep Child I safe.2.19In June 2018, Child I was arrested at his placement after staff found a whitesubstance on his bedside table which they believed to be Class A drugs.Nofurther action was taken. Child I stated that it was sugar that he had placed thereas a prank. A cannabis grinder was seized from his room.2.20In October 2018, Child I was arrested in the company of another male after he hadbeen seen on CCTV to place a large knife in a bush. He returned to retrieve theknife, unaware that the Police had seized it.He was arrested on suspicion ofpossession of an offensive weapon. He denied any wrongdoing and was releasedunder investigation. No further action was taken.2.21In January 2019, Child I was arrested again, this time for intent to supply a Class Adrug. He was scheduled to answer bail but did not attend. Child I’s parents informedthe review that this was on the advice of his solicitor. No further action followed.2.22In March 2019, Child I was arrested in relation to an allegation of rape. During asearch of his room, a machete was found underneath his mattress. He was bailedto appear at a London Police station. He did not attend. Again, Child I’s parentstold the review that this was due to the legal advice given to their son.2.23In May 2019, Child I was arrested in relation to suspicion of murder. He was bailedto appear at a London Police station in June 2019. The placement where Child Ihad been for two years served notice due to the significant nature of his recentarrests.72.24As a result, Child I moved to another placement. Here, he did not adhere to hiscurfew, often returning at 1 or 2am in the morning. This was noted as not beingunusual. Whilst Child I reportedly kept in regular contact with placement staff, henever disclosed his whereabouts.2.25In June 2019, Child I was re-interviewed by the Police and charged in relation tothe offence of murder. He was remanded into a YOI.2.26In late June 2019, Child I became unwell, and he was found unresponsive by YOIstaff on his cell floor. Paramedics were called and took him to hospital, from whichhe was transferred to another hospital for specialist care. Child I did not respondto treatment and subsequently died.3.Views of the Family3.1The independent reviewer met with Child I’s parents to better understand theirexperiences and to capture any views on how well professionals worked with thefamily.The CHSCP is grateful for their input.Both were fully supportive of theSCR, recognising that ‘whilst we can’t go back, we can only change what is aheadfor others’. ●Child I was described by his parents as an intelligent boy, with this beingevident from an early age. His parents also acknowledged that Child I appearedto have two sides to his personality, for example they experienced that Child Icould be very kind but were also aware that he could bully other children. ●Child I had a trusted mentor in secondary school with whom he had a goodrelationship. He was noted by his parents to listen to this mentor and was seento be doing well at this point in his life. However, his mentor left at short notice,and this affected Child I.He was upset and was reported to have helped thementor pack her things when leaving her office. ●Child I was also noted as getting on well with a subsequent mentor, althoughthis was time limited support.Despite attempts by Child I’s mother, she wasunsuccessful in her requests to keep this arrangement continuing.8●As concerns escalated in respect of Child I’s behaviour, his parents tried toemphasise these to professionals.For example, Child I was taking a differentroute home from school and was increasingly staying out later. They feltprofessionals were not thinking about what Child I was doing when he wasgoing missing and that the police did not care. They believe that Child I was justbeing seen as belonging to a group and not as an individual child at potentialrisk. ●Child I’s mother felt she was repeatedly asking professionals to listen to her,saying ‘[Child I] is not showing it but he is scared. Please get [Child I] out ofLondon and get him help. The response was for [Child I] to stay andprofessionals to work with him here. I wanted my son to be safe and get properhelp. They didn't listen to me or Child I’s father’. ●Child I’s parents felt frustration in that they were asking for help for issuesarising outside of their family, but they did not receive this. Child I came from aloving home, and they felt professionals would have intervened sooner had theconcerns come from within the family home. ●When Child I stole money from his father, his parents believed he did this tolook ‘cool’ amongst his peer group. When challenged by his parents about theconsequences of theft, Child I’s response was ambivalent and somewhatdismissive.It was as if experiencing prison would be seen as ‘a badge ofhonour’.●Child I’s parents recall recognising a point in time when the seriousness of therisk their son was facing became starkly apparent. This was when Child I toldhis mother that she couldn’t walk to the shops with him and that she should justmeet him there.Child I’s parents believe this was his way of protecting hismother from a risk of violence that Child I knew he was exposed to.●Whilst Child I’s parents would talk extensively to their son, it was clear to themthat he was telling them what they wanted to hear and that he was beingmanipulated / threatened by gang elders. ●Child I reportedly said that the Police told him to call his parents whenever hewent missing and confirm “he was okay and just late”.This was believed tohave been said as ‘advice’ to Child I so as to lessen the urgency / veracity ofany police response. Child I’s parents said their son used this strategy severaltimes.9●Whilst research shows that removing Child I from the local area may not havebeen effective, his mother queried whether other options to keep Child I safehad been fully explored. For example, some interventions appeared to beworking whilst Child I wore a tag.Child I would hurry to get home and wasactually arriving on time. ●Child I told his father (and another family member) that he left the family homethrough his own choice and had no regrets about doing so3.2Child I’s parents also highlighted some key messages for professionals:●Professionals should see children as individuals rather as a group. What worksfor one child may not fit another.●Listening to parents can help professionals help children as individuals; parentsknow their children best. ●Professionals need to reflect on the language used when engaging parents andexplaining the support that might be available. Around the time Child I wasbeing reported to the police, if someone had offered help they would have‘grabbed it with both hands’.●Father particularly noted raising concerns and that these issues could havebeen ‘shut down’ earlier. Both parents were adamant that they never withheldtheir consent for help and support. ●Professionals need to engage parents at the outset to check whether emergingissues align with the parental perception of their child.●Rather than focusing on labelling children, professionals need to focus onfinding out the underlying reasons about why a child is displaying disruptivebehaviours. ●Professionals need to spot early when something is wrong. Child I’s father gavethe analogy of a tooth decay. ‘First, you make sure you’re doing the basics suchas brushing your teeth properly. If there’s a problem, you see a dentist as soonas possible. If you wait too long, the tooth will need to be taken out’. ●Professionals need to be aware of the risk that children can be exposed to bysimply going to school by themselves. Criminal gangs are aware of thesechildren and will engage them on route. ●Child I’s mother felt that all children in Year Five and Six should have access totraining around criminal exploitation as part of the curriculum.103.3Whilst no specific recommendations are made in respect of the key messagessuggested by Child I’s parents, all of these issues will be formally considered by theSafeguarding Adolescent Working Groups in operation in both the City of Londonand Hackney. Any actions deemed necessary will form part of the action plans forthese groups respectively.4.Findings & Recommendations4.1In the four years preceding Child I’s death, his life was characterised by a patternof escalating risk, deteriorating behaviour and increased criminal activity. Thiscomplexity and the challenges faced by those trying to help Child I, including hisfamily, are fully recognised by the SCR.4.2Finding 1:Practitioners not only need to recognise and respond towell-established ‘critical moments’, but ‘subtle moments’ too; moments thatmight present clear opportunities to help and protect a child.4.3Much has been written on the concept of ‘critical’ or ‘teachable’ moments. Theseare described as ‘critical moments in children’s lives when a decisive response isnecessary to make a difference to their long-term outcomes.’8They include thepoint at which children are excluded from school, physically injured or when theyare arrested.4.4The thinking behind such moments is that they present opportunities where childrenare more likely to be receptive to help. In Child I’s case, there was limited evidencethat professionals capitalised on these moments or used them to pause and plan inthe context of risk.4.5This can be seen in Child I’s permanent exclusion from school and his entry intocare a few months later. Both were critical moments. In a relatively short period oftime, there was less oversight of Child I by those that knew him well and given his8 It was hard to escape Page 3, CSPRP 202011known history, risk over this period was arguably predictable. Despite these factors,neither event resulted in any focussed work with Child I about the dangers he mightbe facing. They were missed opportunities.4.6This ultimately meant that there were no real barriers to those who were likely to bemanipulating Child I. A strong hypothesis is that gang elders took full advantage ofhim being ‘less visible’.After his exclusion and entry to care, it was now time forChild I to become a more important part of their ‘family’ and he was quickly taskedwith more criminal activity beyond Hackney’s borders.4.7The arrests that followed Child I’s sharp increase in criminal behaviour were alsocritical moments.Most can similarly be characterised as missed opportunities.Despite the known indicators, there was little evidence that practice by the policewas being driven by a ‘safeguarding first’ philosophy and a need to protect Child I.Actions were largely reactive and based on a criminal justice response to hisoffending.These are seen by the SCR as largely correlating with the concept of‘Adultification’.4.8As described by Davis and Marsh 20209, ‘adultification’ is a term ‘used to describehow preconceptions of children (specifically Black children) may lead to them beingtreated and perceived as being more adult-like (Goff et al, 201410). If Black childrenare seen as less vulnerable and more adult-like, services may overlook their needsand disregard their legal rights to be protected, supported and safeguarded.’ Whilsta relevant learning point, the SCR is aware that Adultification is an acknowledgedissuethattheCHSCPisrespondingtolocally.Assuch,no particularrecommendation is made in this regard.4.9Although Child I’s potential vulnerability was noted as being recognised after hisarrest in Reading, this didn’t appear to result in any escalated response by thepolice. For example, the SCR found no evidence of any disruption activity aimed atidentifying who Child I’s exploiters actually were.10 Goff, P.A., Jackson, M., Di Leone, B., Culotta, C. and Ditomasso, N. (2014) The essence of innocence: consequences of dehumanizing blackchildren, Journal of Personality and Social Psychology, 106(4): 526–545.9 Davis, J. and Marsh, N. (2020) Boys to men: the cost of ‘adultification’ in safeguarding responses to Black boys, Critical and Radical SocialWork, vol 8, no 2, 255–259, DOI: 10.1332/204986020X15945756023543124.10Whilst recognising that a number of local initiatives have been implemented tobetter respond to critical moments (such as specialist youth workers being locatedin hospital Emergency Departments), this is an important aspect of practice toreinforce.A critical moment needs a critical response.Practice in this respectneeds to be timely, systematic and underpinned by a coherent partnershipresponse. This should prioritise safety planning, mitigate risk and create pathwaysfor children to engage.4.11There also needs to be much greater emphasis placed on the disruption of thosewho are exploiting children.Whilst also a role for the wider partnership, the keypowers in this context rest with the police. Without downplaying the complexity ofthis task, such actions should always be a feature within the multi-agency responseto children who are being exploited or at risk of exploitation.This aspect shouldalso form a clear thread of any strategic approach by safeguarding partners, withthe fundamental aim of making it more difficult for exploiters to operate andultimately abuse children.4.12Of equal relevance is the recognition that critical moments won’t necessarily bedefined by a clear set of circumstances or specific events.They might relate towhat a child says or how they act. In this respect, the need for trusted relationshipswith children are essential, as is the need for practitioners to know the children theyare working with.Good relationships and effective communication can make amassive difference to children and their safety.4.13In Child I’s case, one such moment arose whilst in residential care.He told staffthat he didn’t want his electronic tag to be removed. Not much weight was affordedto this comment at the time. In hindsight, this could have been a cry for help or aserious suggestion from Child I about how he might be kept safe. This could havebeen his only excuse not to leave his placement and be criminally exploited. Thiscould have been a strategy to escape his exploiters (even if only temporarily),without being seen as the one making that choice.‘Once a child is part of a county lines gang their loyalty and commitment will betested. The gang will begin to trap the child by making them feel powerless to leave.This might include threats of violence if they leave, making the child feel like they13are betraying their new ‘family’, or telling the child they will get in trouble if they seekhelp because they have committed a criminal offence.’ (Children’s Society, 2019).Recommendation 1:Safeguarding partners should seek reassurance that policy,procedure and practice relating to critical moments (both well established and thoseless obvious) is sufficient robust to ensure effective safety planning.Recommendation 2:Safeguarding partners should seek reassurance from thePolice about the sufficiency or otherwise of local disruption activity targeting thosewho are criminally exploiting children.4.14Finding 2:We know much about the circumstances in which risk relating toexploitation, criminality and serious youth violence is predictably going toincrease.Despite this knowledge, practice does not always accrue thebenefits of a coherent multi-agency approach.4.15The safeguarding sector has a substantial evidence base on which to develop itsresponse to exploitation, criminality and serious youth violence.This has beenamassed through front-line experience, research, the Child Safeguarding PracticeReview Panel and from local safeguarding arrangements that have undertakenreviews concerning vulnerable adolescents.4.16Whilst accepting that intervention in this context is never easy, we do have a goodidea of what the early indicators of risk look like and the circumstances where thethreat of harm is predictably going to increase. One such indicator is wherechildren are displaying signs of challenging behaviour.4.17Whilst acknowledging that there will be numerous reasons why a child’s behaviourcan deteriorate, the SCR believes a much more nuanced approach is needed totackle it. A single agency acting in isolation is unlikely to ever get to grips with theroot causes of such behaviour, and neither will it be capable of mitigating futureconsequences, particularly in the context of risk. This latter point is key. Figurespublished by the Government for 2018-19, show that persistent disruptivebehaviour is the most common reason for both permanent exclusions (35%) and14fixed period exclusions (31%)11.When we know that exclusions (particularlypermanent exclusions) can significantly exacerbate risk for a child, it follows thatpersistent disruptive behaviour should perhaps be better framed as a coresafeguarding issue.4.18This does not mean that all such cases require a statutory social work response,but they do require early coordination of support across a range of differentagencies, and they need to be seen beyond just a disciplinary matter for theschool. A ‘Safeguarding First’ approach should apply, with practice being attunedto reflecting on the past and using this knowledge to focus on future risk. As onepractitioner said at the Child I’s SCR workshop: ‘Due to the numerous incidents,professionals were reviewing what had occurred rather than looking forward’.’4.19In Child I’s case, he made the transition to secondary school without any immediateproblems. One year into his new school, he received his first exclusion. 12 monthslater, he was permanently excluded.Over this period, the response to Child I’sbehaviour was characterised by school staff (and some other professionals) workinghard in collaboration with Child I’s parents.This was positive, but the school wasacting without the full engagement of other agencies that might have been able toprovide additional support. The school recognised this and attempted to facilitate areferral to early help services, but there was no consent from the family to progressthis further (see Finding 3).4.20The overall result was that whilst practice involved more than one agency, it wasn’tmulti-agency.There was limited presence of health services, with information onthe GP records (a conduit for all health-related information) being scant and nosignificant involvement from school nursing.4.21Early intervention with Child I appears to have been largely focused on hisbehaviour at school by the school. Improved coordination of this work with a widerset of agencies (and the family) might have helped more effectively addressed thecauses of Child I’s behaviour.11 Academic Year 2018/19 Permanent and fixed-period exclusions in England. Gov.15Recommendation 3:Safeguarding partners should work with primary andsecondary schools to ensure that they are able to identify children who showpersistent behavioural difficulties.On identification, the partnership’s early helpresponse should be robust and seek to mitigate known or possible safeguardingthreats.Recommendation 4:Safeguarding partners should ensure that a multi-agencyresponse to the persistent disruptive behaviour of children is sufficiently describedin the threshold tools of both Hackney and the City of London.4.22Commenting further on the issue of exclusions, the SCR does not criticise theindividual decisions of Child I’s school in this regard.Based on existingframework, the school acted entirely appropriately, particularly in the context of thesignificant efforts undertaken to help Child I. However, the SCR believes there is awider systems issue that exposes the inherent flaws in how exclusions arecurrently governed.4.23The SCR recognises that discipline is a key issue for schools, as is theirresponsibility to ensure all pupils are safe and have the opportunity to learnwithout disruption. Having said that, permanent exclusion is a known mechanismthat can exacerbate risk. It can inadvertently create more danger for children andas such, this should place this issue firmly under the umbrella of safeguarding.4.24In the opinion of the SCR, the current exclusion process fails to accrue thebenefits of multi-agency working, which as we know, is the most effective way tohelp and protect the young and vulnerable.4.25This does not necessarily mean that the overall accountability for decision makingneeds to change, but the SCR holds a strong view that no child should ever beexcluded without a process that engages the wider partnership.This should bedone for two reasons. Firstly, to leverage the maximum support available to keepchildren within mainstream school and secondly, if this isn’t possible, to begin earlyplanning for mitigating the predictable risk that will arise for some.16Recommendation 5: Operating within the current law and guidance concerningexclusions,SafeguardingPartnersshouldexplorewithbothprimaryandsecondary schools how multi-agency involvement could be improved both prior toand at the point decisions are being made about permanent exclusions.4.26Of equal relevance to this finding are the questions raised about why formal childprotection procedures were never initiated to safeguard Child I.4.27Prior to Child I’s permanent exclusion and entry into care, a number of risk factorswere clearly evident to the professional network. As early as 2016, Child I’s fatherwas reporting that things were deteriorating. He told professionals that Child I hadbeen seen with a knife in Brixton and two knives had been found in his bedroom athome.He was said to be climbing out of his window in the evening to leave thehouse and was not returning from school until very late at night. He had also beentalking on his phone until the early hours. At this time, Child I had also told schoolstaff he had been spending a great deal of time ‘hanging about his local area’ oftenlate into the evening.4.28These incidents, alongside those of Child I stealing from his father in 2015, thebullying for money and his defiant attitude were all potential signs that Child I wasbeing criminally exploited.4.29In this respect, there was a strong argument that Child I was at risk of sufferingsignificantharm.Despitethis,therewasnopartnershipresponse thatunambiguously placed intervention with Child I on a child protection footing. Therewas no strategy discussion, no child protection enquiry and no consideration as towhether a child protection plan was required at any stage of involvement withChild I and his family.4.30Some practitioners believed that had these concerns being dealt with under a childprotection framework, then this might have helped the professional network betterrecognise Child I’s vulnerability and better develop a plan of intervention to makehim safer.174.31The SCR acknowledges the variability that exists across many local areas in theiruse of child protection procedures when responding to extra-familial risk. It is alsoalert to the ongoing debate that is seeking to clarify how this work might better bedefined within relevant legislation and statutory guidance.124.32That said, learning from this SCR is clear.Whatever the source of risk(intra-familial or extra-familial), multi-agency practice should always be undertakenwithin the parameters of clear thresholds and clear procedures. These are key tomaking sure that children receive a service commensurate to their needs and thatthe multi-agency partnership acts as one.As it was, practice involving Child Ilacked this coherence and fell short in developing an agreed multi-agency plan tomitigate risk.4.33Whilst accepting that the existing child protection procedures might not cover thenuances of extra-familial harm, practitioners need to guard against this beinginterpreted that no multi-agency framework is required. In line with the HackneyChild Wellbeing Framework (and depending upon presenting risk), the processessupporting early help, child in need and child protection responses are all availableandshouldbeused.Whilstanimportantissue,theSCRmakesnorecommendation on this issue given it coverage as part of a previous Local ChildSafeguarding Practice Review undertaken by the City & Hackney SafeguardingChildren Partnership.4.34Finding 3:Where children are identified as needing early help, it isimportant that parents and carers fully understand what this involves inrespect of a coordinated, multi-agency approach to help and protection.Without this understanding, they may be hindered in their ability to provideinformed consent.4.35Whilst there is no debate that the school attempted to involve early help services,there are differing opinions as to why the family were never engaged. Some caserecords suggest that a lack of consent stalled the partnership’s ability tomeaningfully engage Child I at a critical moment in his life.The parents’12 The legal and policy framework for Contextual Safeguarding approaches (2020) Firmin and Knowles18recollection is different, and they are categoric in their view they would never haverefused help if offered.4.36The SCR deals with both scenarios as learning points.Firstly, an absence ofconsent for help is not a new issue for safeguarding professionals.There willalways be families who decide that they don’t want professionals involved in theirlives.Depending on the needs of the child and potential risks, some of thesedecisions will be justified, others won’t be. How practitioners react when consentis refused (and the level of professional curiosity and challenge they show) is animportant finding of the SCR.4.37It is established good practice to seek consent from families for help and support,unless doing so might place a child at a risk of significant harm.However, ifrefused, practitioners shouldn’t just end the conversations there. They should beprofessionally curious about the reasons why this is being refused and challengethose reasons where a child’s welfare might be compromised.4.38For any case involving similar issues as seen with Child I, these need to beapproached with a significant degree of rigour.These should be a firm focus onmitigating future risk and robust conversations with parents / carers that explainthe seriousness of what might happen if coordinated support isn’t provided andisn’t provided early.4.39The SCR is already alert to work being undertaken in Hackney to strengthen theapproach of practitioners seeking consent prior to referrals being made toChildren’s Social Care. This work is fully supported by local safeguarding partnersand aligns with statutory guidance. This SCR reinforces the need for the issue ofconsent to be a key focus for the partnership going forward, not only in how this isroutinely sought, but the response by practitioners when consent might not begiven.Recommendation 6:Safeguarding partners should ensure that local thresholdtools, associated guidance and multi-agency training set out clear practiceexpectations about seeking consent. These should include guidance for staff on19how to respond when consent is not given in circumstances where there areconcerns about actual or potential risk.4.40In conversation with Child I’s parents, it was clear that their understanding of whatan early help response might have involved significantly differed to that of theindependent reviewer.Neither parent understood this to involve the level ofmulti-agency coordination that would ideally follow in such circumstances.4.41In this respect, the issue of whether consent was given or not may be somewhatof a red herring.Focussing on this issue alone detracts from a simple learningpoint about how well the offer of early help is set out in Hackney and how this isconveyed to parents and carers. If not done in a way that fully explains how thisworks and motivates the parents or carers to see the difference it can make fortheir child(ren), they may see little point in engaging. To this end, the SCR makesthe following recommendation.Recommendation 7: Safeguarding partners should ensure that the multi-agencyarrangements for early help are underpinned by a defined strategy, clearprocesses and communication material to help practitioners explain the offeravailable to families in Hackney.20 |
NC52711 | Death of 10-year-old girl in April 2020, found in bed with a ligature around her neck. Her father was in prison following a violent assault on the mother. Learning themes include: the lived experience of domestic abuse for a child; vulnerable children remaining the focus of agency concern when they move areas; parental alcohol abuse; cultural and language considerations; signs and triggers of emotional distress in children; and online safety and the dangers of children viewing age-inappropriate content. Recommendations to the Partnership include: all guidance should emphasise the importance of understanding the lived experience of the child; re-emphasise the message that domestic abuse is always harmful to children; proactively offer support to those families who are transitioning from refuge into independent living; review training needs to ensure professionals have a better understanding of the complexity of parental alcohol misuse and include training on interpretation and understanding of hair strand samples; continue to emphasise the dangers of children viewing age-inappropriate content; ensure processes are in place so that when children on a Child Protection Plan move areas, they are not removed from systems automatically and their information is reviewed; ensure schools display the appropriate level of professional curiosity and proactively seek information for new pupils transferred in; ensure that third sector organisations such as refuges share information so that partner agencies have clarity about their role in safeguarding existing and previous residents; ask the 'Victim Care' service to consider reviewing the current arrangements governing the sharing of information regarding the prison release of perpetrators within the family.
| Title: Child safeguarding practice review concerning Child QDS 20. LSCB: Derby and Derbyshire Safeguarding Children Partnership Author: Russell Wate Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page | 1 Final Child Safeguarding Practice Review concerning Child QDS 20 Independent Author: Dr Russell Wate QPM Page | 2 Final 1.0 Introduction and Background to this Child Safeguarding Practice Review In April 2020, a 10-year-old child (QDS) was tragically found in bed with a ligature around their neck. The East Midlands Ambulance Service attended the home and declared the child to be deceased. The child lived with their mother (MQDS) and a younger sibling (SQDS) in private accommodation. The father (FQDS) was in prison following a violent assault on the mother. In May 2019, the family moved from Warwickshire to live in a refuge in the Derbyshire area. The child’s death took place during the first lockdown period of Covid-19 and QDS was not in school as they didn’t fit the criteria the government had set at that time for a child to be classed as vulnerable. This was for those children who were open to children social services or subject of an education health care plan. QDS had been on a Child Protection (CP) plan in Warwickshire. The plan was still in place when the child moved to Derbyshire, with Warwickshire retaining ownership of the plan. The plan had however ended several months before the child’s death. The CP plan concerns were in relation to domestic abuse and mother’s misuse of alcohol. The family are not originally from the UK, but their culture and heritage was from another part of Europe. Although QDS was born outside the UK, she moved to the UK as a young toddler. The family’s first language was not English. Following the death of QDS, Derbyshire Children’s Social Care Services made a Serious Incident Notification to the National Child Safeguarding Practice Review Panel. The Derby and Derbyshire Safeguarding Children Partnership (DDSCP) completed a rapid review which led to the Safeguarding Partnership’s Independent chair agreeing to commission a local child safeguarding practice review (LCSPR) in accordance with Working Together to Safeguard Children (2018) and the Child Safeguarding Practice Review Panel: practice guidance (2019). Terms of reference for the review were agreed and can be seen in full at appendix A. A LCSPR panel was established by the DDSCP to assist with the review and report progress to the DDSCP through its Chair. Membership included representatives from key agencies who had been involved with QDS. The agreed time period for the review covers the period from April 2019 to April 2020. The Partnership also appointed an Independent lead reviewer Dr Russell Wate QPM to assist with the review and to produce a report on the DDSCPs behalf. A learning event was held with front line practitioners involved in the case. This included practitioners from the previous Local Authority, local agencies including schools and a member from the refuge. This learning event was supplemented by a managers learning event. Both the practitioner and managers events were extremely helpful to the author in developing the learning and to compile this report. The review author has also had a conversation with MQDS and he has benefited greatly from her insight into the life for QDS and the family. Page | 3 Final 2.0 Analysis of Learning Themes The rapid review process and the LCPR panel who confirmed the Terms of Reference identified several learning themes arising from the tragic death of QDS. These themes were discussed at the practitioner and managers event, where other key themes for learning were also identified. The themes are articulated and analysed in turn in the below sections of the report. Domestic Abuse The lived experience of domestic abuse for QDS, are that in 2015 a referral was made by the Police highlighting allegations of domestic abuse between parents, this led to QDS becoming subject to at this time a Child in Need Plan. Over the subsequent two-year period there were reports that both the mother and father consumed alcohol to excess. The result was that direct work by a Social Worker (SW) was undertaken with QDS, and MQDS, they received support through the Domestic Abuse Counselling Services in Warwickshire until the case was closed in 2017. In March 2019 there was a significant domestic abuse incident during which FQDS strangled MQDS causing her to lose consciousness. He also kicked and punched MQDS, breaking her nose and damaging her kidneys, which resulted in her being admitted into hospital. When the Police attend this incident, they found that they both had been consuming vodka and SQDS who had witnessed the assault, was covered in her mother’s blood. The Police acted promptly and the following day, FQDS was charged with criminal offences relating to the assault on MQDS and he was remanded to prison and was subsequently sentenced at Crown Court to 33 months imprisonment. QDS and SQDS were moved into a foster placement under a section 20 agreement with MQDS’s consent. Warwickshire Local Authority were prompt in their actions to protect QDS and her sibling and when MQDS was fit to leave hospital arranged for her and the children to be protected in a refuge. The Warwickshire SW at this time worked closely and well with MQDS and her children as well as the refuge, which was situated some distance away in Derbyshire. The refuge carried out support work with MQDS and the refuge Children Young Police worker did do a significant amount of direct work with both QDS and SQDS whilst they were in refuge, this took place in group sessions and one to one around the domestic abuse, boundaries, wishes and feelings, emotions etc. A few days before QDS died, MQDS received a letter from Victim Care that her ex-partner, FQDS would be eligible for release on electronic tag, in October 2020. It is not known what the emotional impact that this may have had on QDS as it is felt that the child would most certainly have read the letter and may have translated it for MQDS. When MQDS spoke to the review author she was adamant that QDS would not have seen the letter, so in her view there was no impact on QDS. MQDS had previously been contacted when her address was obtained through her DA contact worker and Victim Care wrote to her outlining the sentence dates. When MQDS and the children moved into their own accommodation they were sent another letter, with a request for contact if she wanted any additional licence conditions. MQDS made no response, so the Victim Care team as is their usual practice made the case dormant at that time. Page | 4 Final A learning theme for services here is in relation to sending letters like this with sensitive information to victims of DA. The victim service needs to take account of the emotional impact that the letter contents may contain to their victims and also is in an accessible format for them for example in this case written in their first language. The Adoption and Children Act 2002 extended the definition of ‘Harm’ from the Children Act 1989 to include ‘impairment suffered from seeing or hearing the ill treatment of another’. Prolonged or regular exposure to domestic violence can have a serious impact on a child’s development and emotional well-being. QDS lived in this type of household environment. The Department for Education published in March 2020 ‘Complexity and challenge: a triennial analysis of SCRs 2014-2017.’ As can be clearly seen from the table (Table 13 in the report) domestic violence is a major factor featuring in death and serious harm to children. Alcohol Abuse Parental abuse of alcohol is a major feature of this case. Almost all the parental neglect of QDS and SQDS stems from this abuse of alcohol. History of alcohol abuse is a feature in the mother and father’s past. In 2015 Warwickshire Police and Children Social Care (CSC) first got involved with the family this was due to a suicide attempt by FQDS and issues of DA and excess alcohol use were noted by both agencies. As a result of these issues a CIN plan for QDS commenced. Over the subsequent two-year period there were reports of both parents consuming alcohol to excess. In May 2019 as part of the Warwickshire children social care parenting assessment an investigation of MQDS alcohol abuse and dependency was undertaken. The results of the hair strand test taken as part of the assessment showed significant and chronic alcohol use. Warwickshire children services SW advised MQDS to seek support from alcohol services, which she didn’t do due to her imminent move. The family subsequently moved into the refuge in Derbyshire in 2019. The refuge completed a report for the rapid review process and when they attended the practitioner event, they stated that other than when she first arrived at the refuge, where a bottle of cider was found in her belongings, the refuge found no sign of her drinking. Page | 5 Final A practitioner at the event who is not an expert, but offered an opinion that a person who is dependent on alcohol will not have just stopped drinking like that, and she would have become very good at disguised compliance of their alcohol consumption. The refuge representative at the event though was clear that there was no sign of drinking during her time with them. Which could suggest that whilst in the refuge MQDS felt very safe and secure and did not need to depend on alcohol until her circumstances changed. This safe and secure environment changed when MQDS left the refuge and went to live by herself. During the Warwickshire SWs visit to the refuge, alcohol was discussed and was a factor in trying to encourage mum to seek support for triggers etc. However, professionals involved with working with her at that time did not highlight any evidence or concern around mum using/misusing alcohol. In support of this QDSs school at this period never suspected MQDS of being intoxicated or smelt alcohol on her breath. MQDS in her conversation with the review author was adamant that she didn’t drink alcohol whilst at the refuge. A few days after leaving the refuge in October 2019 MQDS sent a text message to her former SW in Warwickshire to say they were now in their own property and happy they were grateful for the support the SW had provided. MQDS was also grateful to refuge's consistent support. The refuge offers up to four "move on" visits when someone leaves refuge to help them settle into their new accommodation and support them to set up their tenancy. MQDS engaged with three of these before stating she didn't feel she needed support anymore. MQDS was then offered "outreach" which is an additional 12 sessions with a different team, however mum declined. This surprised the professionals that knew her from Warwickshire, that MQDS did not take the refuge up on their offer of the out-reach support team. MQDS when speaking to the review author re-iterated her thanks to her Warwickshire SW and the staff at the refuge. It is not until February 2020, which is the first time since June 2019, that MQDS and alcohol is mentioned by any of the professionals in the case. The main agency involved in this period was QDS’s school who did not notice anything unusual. SQDS though was under the care of a HV who also made no previous observations of any concerns. A referral was made in relation to MQDS by the refuge regarding mum's alcohol use. The information had come to them from one of their current residents who had visited MQDS in her home. There is no record of this referral being received by Derbyshire Children Social Services; this is subject to comment in a later section of this report. MQDS told professionals immediately following QDSs death that on the 28th of April 2020 she started drinking before midday and drank vodka to the same amount as she usually does. She described how she finished drinking by approximately 9pm that night. The review author has been told that QDS was not found by their mother until the early afternoon on the 29th of April. This led to questions about why MQDS had not checked on QDS in the morning, but it is now understood that QDS regularly did not get up until midday. This brought further concerns to the review author about neglect of QDS. The Police informed the rapid review process that the attending police officers to the death were concerned about the home conditions, as there was evidence of significant alcohol consumption and vomit evident over the downstairs of the property. No alcohol bottles were seen on the first visit, however on the second visit, 11x1 litre empty bottles of vodka were found under the sink in the kitchen. Page | 6 Final MQDS told the professionals from the Police and Health immediately following the death of QDS, that she previously drank a lot of alcohol. MQDS reported that this was historic misuse of alcohol and only happened at the times when her partner FQDS was drinking heavily. She explained that at around that time Warwickshire children social care did some work with her with regards to her alcohol intake. She told the professionals that she still drinks alcohol and will drink vodka. She explained that her usual drinking pattern would be to start before midday and to drink approximately half a bottle of vodka over the course of the day. She explained that drinking alcohol makes her feel nice, relaxed, in a better mood and that time passes better. MQDS stated shortly after the death of QDS that she has suffered from schizophrenia. There is no agency record of this, and the SWs from Warwickshire had not known of it before it was mentioned at the practitioner event. MQDS felt a deterioration of her mental health around February 2020 which led to her drinking. MQDS did not tell anyone or seek any professional support. MQDS told the review author that she was diagnosed 15 years ago in her home country with schizophrenia. She never sought help in the UK for this and there will be no record that she did. She used alcohol and staying in her bed as her method to cope with it. There was a comment posed at the practitioner event about whether social workers have training relating to substance misuse. SWs have experience in supporting families with drugs and alcohol problems and a large volume of their day-to-day work and case load includes this vulnerability. In this case, the SWs Review Child Protection Conference report, accurately reflected the assessment of risk associated with the uncertainty of MQDS alcohol use and the report also recommended an ongoing CP Plan and a repeat hair strand test. The fact that this was raised does suggest further learning is required for all practitioners of the extreme risks of parental alcohol dependency and misuse. A lot of the de-escalation of risk was put down to the fact that the family did feel safe knowing that father was in prison and mum had taken significant steps as part of the CP plan to move and safeguard the children and there was no evidence of drinking. Her parenting of the children during this time was noted by the professionals at the refuge and the SW as positive. To support the findings of this learning theme being highlighted in this review report of the risk to QDS and SQDS of parental alcohol abuse, the below table taken from the Department for Education’s March 2020 publication, ‘Complexity and challenge: a triennial analysis of SCRs 2014-2017.’1 It states that over a third of children who either died or were seriously harmed had parental alcohol misuse in their home circumstances. This is entirely relevant to the lived experience for QDS and SQDS. 1 Brandon M et al (2020) ‘Complexity and challenge: a triennial analysis of SCRs 2014-2017’ Department for Education. Reference: DfE-00027-2020 Page | 7 Final Cultural and language considerations It would appear that MQDS and her children were isolated from their own community including friends and family members from the area where they used to live in Warwickshire. The main reason stated by MQDS for this, was because FQDS was well known in their community. He had family and a network, that MQDS was worried would let him know where they were living, when he came out of prison. This she said frightened her, so she steered clear of associating with them. MQDS told the review author that she was quite happy with this situation and was content with her use of Facebook to keep her connected with those members of her community that she wanted to. The review report author was under the impression that MQDS only spoke or understood very little English. The rapid review also thought that QDS acted as a translator for her. Hence the concern that QDS would have translated the letter from Victim Care articulating that FQDS would be released from prison in a few months’ time. This would have undoubtably caused unnecessary worry to QDS for their family safety. The contents of the letter may have also been the trigger for MQDS’s increased alcohol consumption. However, at the practitioner event there was a divergence of opinion on whether MQDS could speak and understand English. Those practitioners that knew her well, found that her English was good, in particular her spoken English, but, probably less so for written English. Those that knew her less well thought she understood a lot less than she seemingly did. MQDS told the review author that she felt that she spoke, but also could read English really well. One of the reasons for this conflicting understanding of the level of English comprehension was because, MQDS told professionals that FQDS did not like her speaking in English so she feigned that she could not speak English so as not to annoy him. An example that as well as inflicting physical DA, FQDS also made use of coercive controlling behaviour in his relationship with MQDS. Page | 8 Final A Department for Education funded project ‘Safeguarding and community inclusion’ looked at several of the issues raised in this section and supports the view that MQDS would not reveal her level of knowledge of English and local systems and processes until she had developed a trusted relationship. ‘There is a high level of anxiety and low levels of trust and confidence within eastern European communities about the services that are provided locally. Migrant families are not receiving all the information that they need to make informed choices about using services. There is a lack of knowledge within the community regarding UK legislation relating to safeguarding children.’2 Child perceived herself as a young carer. There is no suggestion that any professional regarded QDS as a young carer either for her younger sibling (less than three years old) or her mother. However, there were numerous signs and comments made by MQDS that she did overly rely on her to help with caring for SQDS. QDS also mentioned to others including her Warwickshire social worker that they felt they needed to support and help their mother. A good example of this is after MQDS was severely assaulted by FQDS in March 2019, it was clear that QDS told professionals that they felt guilty that they were not at home to prevent the assault and to protect their mother. It was said by the professionals involved at the time that QDS felt that they were able to calm the father down and if they had been present it would not have happened. This must have put an emotional burden on QDS with their mother in hospital and father in prison. In 2017 the Department for Education published a report ‘The lives of young carers in England Omnibus survey report Research report3’. The below citation is important to consider for the life of QDS and other children in similar situations. ‘It is clear that young carers in this survey are taking on much higher levels of responsibility in the home than their peers who do not have to provide care. In some instances, the effects of caring on children’s physical and mental health and well-being are considerable and, without formal identification, assessment and support - including early help prevention-based interventions - these could have profound long-term effects on children’s lives.’ MQDS stated to professionals shortly after the death of QDS, that QDS helped her by checking on her and helped with looking after the sibling. She stated that this was especially the case, when MQDS had thoughts in February 2020, that she had a brain tumour and was drinking heavily. Following the death when police asked mum for clothes and nappies for SQDS, MQDS said that she did not know where they were as QDS did that. This evidences further the carer responsibilities taken on by QDS. In contrast to this MQDS did though tell the review author that in her view QDS had no caring responsibilities for her or SQDS. 2 Final-Report-Innovations-Project.pdf (safeguardingcambspeterborough.org.uk) 3 Sarah Cheesbrough et al (2017) ‘The lives of young carers in England Omnibus survey report Research report. Department for Education. Page | 9 Final Signs and triggers of emotional distress in children The purpose of this report is not to make a recommendation in relation to whether QDS intended to take their life or not, that is the role of the Coroner in this case. At the inquest the Coroner made a narrative conclusion. ‘On the evidence QDS must have deliberately tied a scarf around her neck in the fashion of a ligature, but given her young age it is not possible to find that she fully understood that her death would result from that.’ MQDS was absolutely adamant when talking to the review author that this was a very tragic accident. However, it is important to consider for professional learning, what were the signs of the emotional distress that were occurring for QDS’s in their life. An important consideration here is whether QDS was suffering from any adverse childhood experiences (ACEs). The term 'Adverse Childhood Experiences ' is credited to Dr Vincent Filletti who carried out a study in the United States of over 17,000 people in the 1980's. His study was the first to identify the relationship between experiences in childhood and problems with health and social integration throughout a lifetime. His ten identified ACEs are: A number of these ACEs were experienced by QDS for example they had grown up in a household where serious DA, parental substance misuse, maternal mental health and neglect, were a frequent lived experience for them with the associated emotional impact a major factor in their life. FQDS incarceration for the serious assault on MQDS, which caused parental separation. MQDS substance misuse was another ACE experienced by QDS. Practitioners are aware of ACEs but helping children with similar experiences to QDS will need a trauma informed approach taken by professionals. Page | 10 Final At birth QDS was diagnosed with a myelomeningocele4 of the thoracic spine and she was also diagnosed with a congenital hydrocephalus (increased build-up of fluid on the brain). QDS had surgery within 24 hours of birth. This surgery involved repairing the myelomeningocele on her back and inserting a ventriculoperitoneal shunt5 at the same time. There have been no complications from this early childhood medical history or apparent impact on QDS’s physical development. There is information that QDS’s attainment scores when younger were significantly below expected and that they were well below average for their age. At the time of death though QDS’s development seems to have improved. QDS’s death occurred during the period of the first lockdown for Covid-19. QDS was not at school and the school had not been informed of her and the family’s history so was not deemed as one of their vulnerable cohort of children. This period of lockdown would have increased the isolation for not only QDs but for the whole family. Online-Safety QDS had her own mobile phone which they had had for a couple of years. The phone was examined following their death and there was nothing untoward found on it. The family laptop that QDS used on a regular basis had within its search engine history, sites that were not age appropriate. Pinned to the search bar was a site that involved sexual activity that involved asphyxiation. This site was readily accessible and available for viewing by QDS. MQDS agreed that QDS did view the laptop, including sometimes in her bedroom at night. The problem with QDS accessing age-inappropriate material on the internet was not a recent issue. The accessing of this content by her was of concern when QDS was in Warwickshire. They did extensive work in relation to this with both QDS and their mother. The Warwickshire SW had no knowledge of the extent of the content being accessed, until the practitioner event when the police officer outlined what was found on the laptop. It would appear that the material being viewed, agreed by MQDS, was an extreme escalation of the age-inappropriate content. The referral from the refuge in March 2020 also mentioned watching a horror movie that was felt by the family from the refuge providing the information to be totally inappropriate. The evening before QDS died, MQDS and QDS watched a horror movie rated 18 certificate and completely inappropriate for QDS to watch. This movie had graphic violent scenes including killing on the movie including images of being grabbed around the neck and strangulation. MQDS reported that she herself liked watching horror movies and QDS would join her watching them together. At the practitioner event, health professionals were really shocked by QDS accessing this level of internet content and they expressed a professional view that they were very worried about what could have amounted to long-standing neurological damage to QDS. Information Sharing 4 Myelomeningocele is a birth defect in which the backbone and spinal canal do not close before birth. The condition is a type of spina bifida. 5 A ventriculoperitoneal (VP) shunt is a medical device that relieves pressure on the brain caused by fluid accumulation. Page | 11 Final During the period that this review is focussing on, there was some good information sharing between Warwickshire Local Authority and the refuge. At the practitioner learning event both the SWs and the refuge commented on how excellent communication and information sharing had been between them. The review has been informed that the school which QDS attended in Warwickshire sent all educational information to the new school in Derbyshire. This information contained all the previous history. This information the review understands was not received by the first school that QDS attended. The Head of the school was though aware of QDS being on a CP plan, as they liaised with SWs and sent information to update the CP core group. It is important that schools are proactive in finding out information about new pupils, who may have a number of vulnerabilities, that they need to take account of. If Schools do not receive the information that they require in order to understand their pupils risks, they should escalate this absence of information sharing to the child’s SW if they have one or to either the local authority education department or the regulator in exceptional cases. The agreed process for Warwickshire Local Authority is to notify a local authority when a child is transferred into their area who is on a child protection plan from Warwickshire. This happened in this case. Due to the fact QDS and their family were in a refuge, this was considered by Derbyshire Local Authority as temporary accommodation and therefore Derbyshire did not receive the case as a transfer in. On the 8th May 2019 Warwickshire children’s social care services notified Derbyshire children’s social care services, via a telephone conversation, of the family’s move to the refuge and that the two children were subject to Child Protection Plans. Derbyshire Children’s Services were informed that Warwickshire would maintain case responsibility and there was no request from Warwickshire for a transfer of Child Protection Plan conference or a request for service. Following this telephone conversation, Derbyshire’s Child Protection Office sent a letter to Warwickshire to confirm that the children had been added to Derbyshire’s list of Children subject to another Local Authority Child Protection Plan. The letter further noted that Warwickshire would continue to have case responsibility for the children. The letter goes on to add that; ‘If we have received no further update 3 months after the date of this letter, we will remove child/ren from our List of Children Subject to Another Local Authority Child Protection Plan.’ In July 2019, the Warwickshire review CP conference for the two children decided to end the CP plan. The conference members had been informed that FQDS had been sentenced to 33 months imprisonment and his risk to the family had now ceased and that the family had settled in well at the refuge. The SW had recommended that the plan be continued so repeat hair strand tests could be carried out in view of the results of the previous ones and to ensure a transfer over to Derbyshire Children social care. This was also in line with recommendations from the parenting assessment. There was a level of over optimism from the other professionals at the meeting who didn’t agree with the recommendation for a continued plan, so it was agreed for it to end. The chair of the conference who attended the practitioner event now feels in hindsight that a step down to CiN might have been more appropriate but wanted it borne in mind this was his hindsight reflection. The plan ended in September 2019 for QDS and SQDS. Page | 12 Final QDS and their family left the refuge at the end of October 2019 and moved into their new home within the Derbyshire area. QDS transferred schools starting after the half term holiday at the beginning of November. The new school at the practitioner event stated that they had no information shared with them by the previous school about any concerns in relation to the family. Within a week of starting there, the school recorded a concern about QDS. The concern was that they were presenting as being unclean with dirty unkempt hair and with dirty hands, nails, neck, wrist, and ears. A member of staff spoke with QDS about their personal hygiene. The remaining four days of that week, QDS did not attend school, when QDS did return to school there were no further concerns raised regarding QDS’s hygiene and QDS continued to present as clean and tidy. The schools only other concern were about QDS’s attendance and after MQDS was spoken to, the attendance improved greatly. The neglect concerns were not shared by the school, as they felt they were low level and having spoken to QDS they improved. Taken in isolation this is seen by the review author as a legitimate view. However, the school stated at the practitioner event had they been aware of the previous CP concerns, they would have formed a different view and have shared their concerns with Starting Point (Derbyshire's contact and referral service for children's services). In March 2020, as already stated in this report a referral was made from the refuge regarding mum's alcohol use and the inappropriate use of the internet by QDS. The information was provided to the refuge from one of their then current residents who had visited MQDS and children in their home. There is no record of this referral being received by Derbyshire Children social care services and the refuge have established that a call was made on the 6th of March 2020, but can’t confirm this was definitely about QDS, as they have no record of who exactly this was to, or who was spoken to. The review panel have enquired further into this and there is no record of any call being received in Starting Point. There is no facility to make a direct call into Starting Point this happens through ‘Call Derbyshire’. The review panel have made further enquiries with ‘Call Derbyshire’ and there is again no record of a call having been received about QDS. On the 27th of April 2020, an anonymous referral was received by Starting Point. This referral corresponded with another referral that was received by Starting Point a short while later on the same day, which came from QDS’s Primary School. The school made the referral as they had been provided with information from one of QDS’s neighbours, who had become concerned because of what they had heard. The information provided in the referral detailed that ‘mother could be heard crying, screaming and vomiting at home and that there was a two-year-old child in the home who was often heard upset.’ In their referral the Primary School further advised that there were some previous concerns about QDS’s attendance and that they had held meetings with the mother about this and QDS mainly interpreted for her. On the same date, the contact record was screened by a Starting Point Team Manager and a screening decision was made that the Child in Need Plan threshold had been met. On the 29th April 2020, a triage of the case commenced, and three attempts were made in the morning to contact MQDS. One of the calls was answered by a young child (it is assumed that would have been SQDS) but professionals were still not able to speak with MQDS. Later Page | 13 Final the same day at 15:40 hrs, Derbyshire Children’s Services received notification from Derbyshire Police that they had attended an emergency at the family home and that QDS had been found deceased. On reflection and with analysis when QDS transferred to the refuge in Derbyshire, Warwickshire children services complied with their agreed process and demonstrated continuing and consistent care to the family. The letter response from Derbyshire children social care seems a bureaucratic process that might need to have a professional view taken on each case rather than a standard automated procedure. Taking full account that the chair of the review conference said that his was a hindsight view, the review author and panel are of a view that the CP plan should at the very worst have been stepped down to a CiN plan. This should have been the case until it was seen how MQDS coped when not a resident in a safe place like the refuge. In particular because the Warwickshire SW who worked with the family and knew them felt the CP plan itself should have continued. This could have then involved local Derbyshire agencies and supported the neglect concerns seen by the school only two weeks after they left the refuge. A Child Protection Transfer conference should also have been considered to enable partner agencies to understand the vulnerability of the children in the family and make an informed decision of their needs. This would have enabled at the time consideration of the need for a CIN plan to enable a safe transition from the refuge. The referral by the refuge in March is a key piece of missing information that may have involved crucial involvement with the family. It is at this time that MQDS told professionals after the death of QDS that she was drinking heavily and felt although she didn’t seek medical assistance that she had a brain tumour and stayed in bed trying to recover. This in turn would hopefully have meant that there could have been local professional involvement and then the opportunity for the school during the first Covid-19 lockdown to have kept QDS in school as a vulnerable child fitting in with the government guidance at the time or at least had this in mind when they had their regular virtual contact with QDS and MQDS. This could have also alerted SQDS’s HV and the families GP. 3.0 Conclusion In summary, QDS’s lived experience was one where they had early medical issues that were resolved but did require follow up a few years after arriving in the UK. QDS and SQDS lived in a very violent DA household, resulting in their father receiving a substantial period of imprisonment for assaulting their mother. In this household both parents drank alcohol to excess, this continued when MQDS was the lone carer of QDS and SQDS. QDS also had a level of self-appointed caring responsibilities for MQDS and SQDS. This was a missed opportunity for professionals to provide extra support for QDS. There is no information seen by the review author or panel that would suggest that QDS intended to take their own life. As already mentioned earlier in this report QDS had suffered Page | 14 Final several adverse childhood experiences. There is evidence that QDS viewed on a regular basis very age-inappropriate internet content that included asphyxiation. The voice of QDS has not always been sought or strongly heard as often as it could have been. The family were isolated from their own community it is thought by the review panel by the mother for safety reasons. MQDS had, until October 2019, a consistent circle of a professional network but no personal or family support. When living alone this support had finished leaving MQDS and family isolated in particular when the first Covid-19 lockdown occurred and QDS was not in school. The offer of offsite support from the refuge was not accepted by MQDS. The perceptions by some practitioners that MQDS only spoke or understood very little English would appear not to be true. What is now clear to the review author and panel is that MQDS only spoke English freely with someone who they trusted. The key learning is for professionals to understand why this reluctance may exist and to consider strategies to overcome any cultural and language barrier. The level of viewing age-inappropriate internet content by QDS was thought by professionals at the practitioner event to be a major emotional experience for QDS that they would have found it hard to neurologically process. The review author highlights that though it is difficult to know the impact on QDS, their alleged level of familiarity with this sort of content is highly inappropriate. The work the Warwickshire SWs and the refuge did with MQDS to keep her safe and provide a period of stability is seen as good practice. As was the work of the Derbyshire Health Visitor who attended and worked with the family diligently during the time at the refuge. A good level of information sharing did take place at times but could be improved for example in relation to the referral in March 2020. This report has already outlined what has been ascertained in relation to this referral, the learning though relates to professionals ensuring that they record who they spoke to. The refuge has already put this learning in to practice. On reflection and with hindsight the ending of the CP plan would appear to have been premature and the process to just close cases of notification of residents with a CP plan in another Local Authority area could do with refinement. The sending of the letter by ‘Victim Care’ in relation to the release of FQDS was felt by professionals at the practitioner event a trigger of concern for QDS and MQDS. News like this to vulnerable victims should be if possible be conveyed through a SW if one is in place or other local multi-agency agencies or voluntary support services. 4.0 Recommendations This CSPR has identified learning and made some recommendations, as detailed below, and the implementation of these will assist the DDSCP to deal more effectively with similar circumstances in the future, resulting in the improved safety and welfare of children. These recommendations are also of importance to Warwickshire Safeguarding Children Partnership and should be considered by them accordingly. Page | 15 Final Recommendation 1 a) The Derby and Derbyshire Safeguarding Children Partnership (DDSCP) should seek assurance that all practice guidance and learning material they produce emphasise the importance of understanding the lived experience of the child. b) The DDSCP should review the current awareness raising, training and development of staff across the partnership around ACEs and look to see how this learning could be enhanced. Recommendation 2 a) The DDSCP must re-emphasise, to ensure the message that Domestic Abuse is always harmful to children living in households that DA is occurring. The DDSCP should combine this learning message with action plans arising from two local domestic homicide reviews. b) The DDSCP should seek assurance that support is proactively offered to those families who are transitioning from refuge into independent living and are isolated with a number of risk and vulnerability’s which may impact upon parenting ability. Recommendation 3 The DDSCP need to be assured that professionals have a better understanding of the implications and risks associated with the complexity of parental alcohol misuse and how this is harmful and neglectful to children. This will include a review of the training needs of professionals to help them understand the vulnerability of adults who abuse alcohol and the impact of that abuse on children and include training on interpretation and understanding of hair stand samples, as the results are a very key indicator of current and future risks that need to be acted upon. Recommendation 4 The DDSCP should continue to provide the resources they have on online safety, which includes the message of the extreme dangers of children viewing age-inappropriate content. This is with an intended outcome to raise professional and parental confidence to reduce the viewing of children’s of age inappropriate content. (The DDSCP already has in place several online safety resources for professionals to use. The resources can be readily accessed on the safeguarding children partnership website. The information also includes guidance for parents and carers in relation to protecting their children from age-inappropriate content.) Recommendation 5 a) The DDSCP should be assured that processes are in place for children that are temporarily in the area that are on a Child Protection Plan in another area, are not removed from their systems automatically and the information relating to the child is reviewed. This will ensure that all agencies put in place child centred arrangements and are aware of their continuing role in safeguarding children who have been at risk of significant harm in another area to Page | 16 Final Derbyshire and what information should be shared to enable the child and family to start and continue to live in their new home with secure arrangements in place. b) The DDSCP should seek assurance that schools within their area display the appropriate level of professional curiosity and are proactive in seeking information for new pupils transferred into their schools. c) The DDSCP should share this review with Warwickshire Safeguarding Children Partnership inviting them to ask for assurance in relation to cases involving Domestic Abuse where the victim and family is in a refuge and the step-down to no plan whilst they are residing in the safety of the refuge. d) The DDSCP should seek assurance that ensuring that robust safeguarding arrangements are in place and that information is shared with partner agencies by third sector organisations such as refuges, so that they have clarity about their role in safeguarding existing and previous residents. This should include services commissioned by community safety departments. Recommendation 6 The DDSCP should ask the ‘Victim Care’ service to consider reviewing the arrangements that are currently in place governing the sharing of information regarding the prison release of perpetrators within the family. This will hopefully bring about an understanding how vulnerable families that are victims of DA are informed of planned release of offenders and how the emotional impact on these vulnerable families might be managed better for the victims through effective multi-agency support. Recommendation 7 The DDSCP should seek assurance from its partnership agencies that cultural competence training is taking place which highlights awareness raising about the impact of cultural difference and how these are being taken account of in practice? This will help to raise the level and knowledge, confidence, and skill within the local workforce. Page | 17 Final Appendix A Derby and Derbyshire Safeguarding Children Partnership Terms of Reference Terms of reference for Serious Case Review QDS 20 1 Introduction This Child Safeguarding Practice Review is being commissioned by the Derby and Derbyshire safeguarding Children Partnership (DDSCP) in accordance with Working Together to Safeguard Children (2018) and the Child Safeguarding Practice Review Panel: practice guidance (2019). A multi-agency panel established by the DDSCP will conduct the review and report progress to the Partnership through its Chair. Membership will include representatives from key agencies with involvement. The review will consider the lived experience of a young person (primary school age) who died at home because of hanging by a ligature. The purpose of the review is to draw out learning arising from the young person’s individual experiences and identify improvement measures that should be taken to address systemic practice improvement. The review will consider the learning arising about the services provided to: Page | 18 Final Code QDS Subject Child SQDS Sibling MQDS Mother FQDS Father The review will: • Explore all areas of potential learning about the way in which local professionals and agencies work together to safeguard children including seeking the views of professionals involved in the cases; • Determine the extent to which decisions and actions taken were child focussed and considered the children’s lived experience; • Seek contributions to the review from appropriate family members and keep them informed of key aspects and progress; • Identify any actions required by the DDSCP to promote learning to support and improve systems and practice. Methodology The review will be completed in a proportionate way that enables the partnership to learn from the experiences of the family, practitioners involved in the case and relevant managers and promote a positive learning culture. The detail of the methodology will be linked to the key theme and explained below. • Learning events will be held with front line practitioners involved in the case including and include practitioners from the school. • Learning events will be held with managers involved in the cases and strategic managers as needed. • At the learning events a series of exploratory questions linked to the themes below. • The parent will be invited to participate in the review and be interviewed by the overview author. • Reports may be commissioned from agencies to provide specific additional information not included in the Rapid Review. The specific requests for information may be identified Page | 19 Final following the practitioners’ meeting. There may be generic points for clarification and specific requests for individual agencies. A child safeguarding practice review report will be completed to provide: • A brief overview of what happened and the key circumstances of the lived experience for the child and their sibling in a way that does not identify them and is sufficient to understand the context for the learning and recommendations. • A critique of how agencies worked together and analysis of good practice and systemic areas for development. • Analysis of what would need to be done differently to prevent harm occurring to a child in similar circumstances; and, • What needs to happen to ensure that agencies learn from this case. 2 The key themes and questions that the review seeks to answer. These themes incorporate the areas identified in the rapid review and are presented thematically together as below: • Understanding how systemic improvements could be made to ensure that vulnerable children remain the focus of agency concern when they move to live in another area. A review of the policies and procedures governing the transfer of children from one Local Authority to another will be undertaken to ensure that safeguarding arrangements are transferred seamlessly, and that information is shared in a complete and timely manner. This will ensure that all agencies are aware of their continuing role in safeguarding children who have been at risk of significant harm in another area and what information should be shared to enable them to start and continue to live in their new home with secure arrangements in place. • Exploring signs and triggers that can help parents and professionals be alert them to emotional distress in children and promote learning from this case and additional national research that will assist in strengthening responses. • Identifying how to improve the professional analysis of the impact of parental substance misuse on the welfare of children and clarify the actions necessary to address that impact to secure the safety of children. This will include a review of the training needs of practitioners Page | 20 Final to help them understand the vulnerability of adults who abuse alcohol and the impact of that abuse on children. • Understanding how vulnerable families are informed of planned release of offenders and how the emotional impact on vulnerable families might be managed through effective multi-agency support. This would involve reviewing the arrangements that are currently in place governing the sharing of information regarding the prison release of perpetrators within the family and role of victim care in this process. • Understanding how systematic improvements can be made so that agencies, such as refuges, have clarity about their role in ensuring that robust safeguarding arrangements are in place and that information is shared with partner agencies to ensure on-going support is in place post transition from the service. • Understanding whether features in the case lead to wider learning will additionally be explored within the review. These include: the role QDS may have had caring for their younger sibling; the impact of the extreme horror film (and any others) watched in the household; and whether there is learning to support members of the community who may have concerns about their neighbours. • The review will consider whether there is learning emerging from the analysis of the individual experiences of the children and their parent in respect of their race, ethnicity, gender, age, religion, or disability. The parent did not speak English and QDS translated for her. Understanding the impact on QDS and access to appropriate services will be a specific feature of the review. Whilst there were no specific early learning features arising from the impact of restrictions arising from Covid19 this will be considered during the learning events. Additional features emerging after the Rapid Review include: • Understanding the impact of the medical condition “precocious puberty” on QDS development and identify relevant systemic learning for primary school, social care, and health staff to ensure that the needs of other children experiencing the medical condition are understood and addressed. Page | 21 Final The review will establish an understanding of the causal or contributing factors that affected “why things were done well” or “why there were gaps in practice” to draw out the learning that is most likely to be effective and lead to future improvement. Timeframe for the review The review will cover the period of April 2019 to April 2020. Any significant incident relevant to the case but prior to the start of the period may be included in the analysis completed by each agency. The review is undertaken by one reviewer appointed by the Review Panel. They will have responsibility for examining how the statutory duties of all relevant agencies were fulfilled and reporting on this to the Review Panel and the DDSCP. Review Panel members: • Derbyshire Children’s Social Care • Warwickshire Children’s Social Care • Derbyshire Police • Named GP • Designated Doctor • Designated Nurse • Hospitals – Chesterfield Royal Hospital • Health Services – Derbyshire Healthcare Foundation Trust, Derbyshire Community Health Services Trust, • Education – • Derbyshire Primary School’s • The (Domestic Abuse) Refuge 3 Specific tasks of the Review Panel • Identify and commission a reviewer to work with the review panel in accordance with guidance for concise and extended reviews. • Plan with agencies involved in the review for the completion of key tasks as required Page | 22 Final • Plan with the reviewer a learning event for practitioners and separately their managers (if directly involved in the case), to include identifying attendees and arrangements for preparing and supporting them pre- and post-event, and arrangements for feedback. • Plan with the reviewer/s contact arrangements with the children and family members prior to the event. o Contact arrangements will be agreed with the Senior Investigating Officer and will occur following the conclusion of interviews carried out with family members. • Receive and consider the draft overview report to ensure that the terms of reference have been met, the initial hypotheses addressed, and any additional learning is identified and included in the final report. • Agree conclusions from the review and an outline action plan and make arrangements for presentation to the DDSCP for consideration and agreement. • Plan arrangements to give feedback to family members and share the contents of the report following the conclusion of the review and before publication. 4 Tasks of the DDSCP • Consider and agree any learning points to be incorporated into the final report or the action plan. • Ensure the Review Panel complete the report and action plan. • Confirm arrangements for the management of the multi-agency action plan by the Review Panel subgroup, including how anticipated service improvements will be identified, monitored, and reviewed. • Plan publication on DDSCP website. • Agree dissemination to agencies, relevant services, and professionals. |
NC044162 | Physical, emotional and developmental neglect of a 3-year-old-girl and her siblings. Abigail presented to hospital with serious concerns about her health and development in November 2012. Parents were charged with criminal neglect and Abigail and her siblings were placed in foster care. Family were well known to a number of agencies and there was a history of professional concerns relating to abuse and neglect. Both parents had significant physical and mental health problems requiring a high level of contact with health professionals. Identifies learning in relation to five key themes, including: limitations of an incident led approach to child neglect; need for professionals to feel valued and listened to and need for professional challenge; and the impact of professionals feeling overwhelmed or desensitised and the challenge of disguised compliance. Makes recommendations including Gloucestershire Safeguarding Children Board to undertake an audit of assessments and child in need and child protection plans to ensure that the child's voice is heard and taken into account. Review was undertaken using the Significant Incident Learning Process (SILP).
| Title: Serious case review: subjects: Abigail and her siblings Bobbie, Charlie and Daisy. LSCB: Gloucestershire Safeguarding Children Board Author: Nicki Pettitt Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 GLOUCESTERSHIRE SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW SUBJECTS Abigail and her siblings Bobbie, Charlie and Daisy 1: SILP Overview Report 2: Additional Section following Criminal Proceedings PUBLISHED: 20th August 2014 2 SUBJECTS Abigail and her siblings Bobbie, Charlie and Daisy OVERVIEW REPORT 2 March 2014 CONTENTS 1. Introduction to SILP Page 3 2. Introduction to the case Page 4 3. Family Structure Page 4 4. Terms of Reference Page 5 5. The Process Page 5 6. A brief background prior to the scoped period Page 6 7. Key practice episodes Page 11 8. Analysis by theme Page 23 9. Conclusions and lessons learned Page 40 10. Findings/recommendations Page 46 11. Bibliography Page 48 Appendices 1. Terms of Reference and Project Plan 2. Agency Report pro-forma 3 1 Introduction to the Significant Incident Learning Process (SILP) 1.1 SILP is a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted in a certain way at the time. This way of reviewing is encouraged and supported in the new Working Together to Safeguard Children published in March 2013. 1.2 The SILP model of review adheres to the principles of; proportionality learning from good practice the active engagement of practitioners engaging with families, and systems methodology. 1.3 It has been generally accepted that over recent years the Serious Case Review (SCR) agenda had become over-bureaucratic and driven by Ofsted ratings. The practitioners in the case have often been marginalised and their potentially valuable contribution to the learning has often been under-valued and under-utilised. 1.4 SILPs are characterised by a large number of practitioners, managers and Safeguarding Leads coming together for a learning event. All agency reports are shared in advance and the perspectives and opinions of all those involved are discussed and valued. The same group then come together again to study and debate the first draft of the Overview Report. 1.5 Gloucestershire Safeguarding Children Board have requested that the SILP model of review be used to consider the circumstances of child Abigail and a number of her siblings, in order to learn lessons about the way that agencies in Gloucestershire work together to safeguard children. 1.6 Working Together 2013 states that SCRs and other case reviews should be conducted in a way which; recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did 4 what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 1.7 This review has been undertaken in a way that ensures these principles have been followed. 2 Introduction to the Case 2.1. Abigail was admitted to hospital in November 2012 due to serious concerns about her health and development. Despite being nearly 3 years old Abigail was unable to walk and was having a number of other problems caused by physical, emotional and developmental neglect. These included severe nappy rash, anaemia, malnutrition, head lice infestation and decreased bone mineralisation (i.e. weak bones). 2.2 Both parents have been charged by Gloucestershire Police for criminal neglect. All of the younger children in the family are now in foster care or are placed with family members who are able to meet their needs, with the appropriate long-term and permanent court orders in place. 3 Family Structure 3.1 The subject children: Abigail - age 3 Bobbie – of primary school age Charlie – of primary school age Daisy – of primary school age 3.2 The youngest child was admitted to hospital due to the impact of experiencing serious neglect from the parents. The other children are included in this review due to them having similar issues and experiences. 3.3 There are a number of other older half siblings to Abigail. 5 3.4 The parents of the 4 subject children are referred to in this report as: Mother (of all the children) Father (to Abigail, Bobbie and Charlie, step–father to Daisy) The parents have been together since approximately 2007, and are married. 4 Terms of Reference 4.1 The detailed Terms of Reference and Project Plan appear at Appendix 1. The purpose, framework, agency reports to be commissioned and the particular areas for consideration are all described there. What the agency authors were asked to analyse and the format of the agency report appears at Appendix 2. 4.2 It was agreed that the scope of this review would be from 5 August 2010 when a strategy meeting was held due to concerns about the children, until 23 November 2012 when Abigail was admitted to hospital. 5 Process 5.1 A number of family members were contacted in order to ensure their views were considered and heard as part of the review. Neither Mother nor Father agreed to meet with the Independent Reviewers. Three telephone conversations were held with them, and although a number of appointments were made they were subsequently cancelled by the parents. 5.2 The Reviewers met with the oldest sibling, who is now living independently of the family, on 4 July 2013. The Overview Author and the Named Nurse Safeguarding Children, Gloucestershire Care Services NHS Trust, visited the children’s Grandmother on 2 October 2013. This visit was arranged later as the Learning Event had determined how significant she had been during the period being considered by this review. The sibling and the Grandmothers views and information have been considered and will be referred to in this report. 6 5.3 A meeting for authors of individual agency reports was held on 17 May 2013, where the SILP process and expectations of the agency reports was discussed. A full day Learning Event took place on 9 September 2013. Most of the agencies involved were represented by both the report author and staff, including managers, who had been involved during the scope period. All the agency reports had been circulated in advance. 5.4 The GP surgery used the completion of their agency report as a learning tool for all staff, holding a meeting to look at the TOR and the report format, and considering as a team what happened and why. While not requested this was a positive way to learn lessons from the process. 5.5 At a recall session on 10 October 2013 participants who had attended the Learning Event considered the first draft of this report. They were able to feedback on the contents and clarify their role and perspective. All those involved contributed to the conclusions about the learning from this review. The final version of this Overview Report was presented to the GSCB Serious Case Review sub-group on 22 October 2013, the Executive Committee on 4 February 2014 and the GSCB on 20 February 2014. 5.6 The review has been chaired by Donna Ohdedar, an independent safeguarding consultant with no links to Gloucestershire Safeguarding Children Board (GSCB) or any of its partner agencies. This report has been written by Nicki Pettitt an independent child protection social work manager and consultant, who is also independent of GSCB and its partner agencies. 5.7 The process has been efficiently administered by Tahidul Alam of the GSCB. 6 The background prior to the scoped period 6.1 The family has been known to a number of different agencies for over 16 years. Both of the parents had physical and mental health issues requiring a high level of contact with health practitioners. Over the 27 month period specified as in scope for this review there were 127 recorded contacts noted with Primary Health Care alone. 7 6.2 It is clear that poor home conditions have been an issue throughout the years of involvement with services. When Mother had her first child, it was noted on the primary visit from the Health Visitor that there was ‘a dead mouse under the cot, with fleas visible on the furniture’. The Agency Report for community health states that ‘regularly the house was noted to be dirty, untidy and smelling of faeces’. There were concerns about all of the children not reaching their developmental milestones at times, and that outstanding immunisations and other health issues were not always addressed by the parents. 6.3 On occasion other concerns also emerged. In 1999 the Police were involved when Mother alleged that her then husband had physically assaulted and injured their 3 year old child. This resulted in him receiving a Police caution. The Police Officers involved also commented on the children and home being unkempt and smelly. 6.4 In 2006 Mother’s next husband was convicted of sexually abusing two of the children. At this time neglect was again raised as an issue with the children and the home being described as ‘filthy’ and overcrowded by the Police Officers involved. 6.5 In 2007 an Initial Child Protection Conference was held due to concerns about the state of the home and the physical neglect of the children. The decision about whether the children should be made subject to a Child Protection Plan (or placed onto the Child Protection Register as it was then) was ‘deferred’ as there had been improvements. As this improvement was assessed to have been maintained by the time of the Child Protection Conference Review, it was cancelled. 6.6 This improvement was not maintained in the longer term however, and there continued to be concerns about the children. These were exacerbated by Mother marrying the younger children’s Father in around 2007 and then going on to have more children. Father is known to have potentially significant issues of his own. There were a number of contacts and communications made to Children’s Social Care (CSC) but the children were mostly the subject of short term assessment and interventions, including under a CAF (Common Assessment Framework - an early help model.) This approach 8 relied on the parents to work in partnership with professionals and them recognising they needed to improve. 6.7 In 2009 Education Welfare became involved due to the poor attendance at school of some of the children. 6.8 Abigail was born in 2009. The midwife recorded that mother had previous psychological problems, post-natal depression, prior contact with psychiatry services and a chronic pain problem. When attending after the birth of the child the midwife describes chaos, with rubbish and clutter everywhere, dog faeces seen on the bath mat, and a smoky atmosphere. She referred to CSC citing her concerns about parental capacity, including information that the older children were young carers. The midwife also identified that parents were co-sleeping with Abigail and were not taking professional advice on the risks involved with this. 6.9 An initial assessment was undertaken by CSC in response to the midwife’s referral, and a multi-agency meeting was held attended by the Health Visitor, nursery nurse and school nurse, along with the parents. The parents agreed to improve the state of the home and the meeting concluded that the nursery nurse and Health Visitor would monitor the situation. The parents agreed to a CAF and this was completed and managed by Homestart, a voluntary agency that undertakes community based family support work with under 5’s. 6.10 It is clear from the history available to the review through the Agency Reports, and from discussion at the Learning Event, that a number of the older siblings also had similar issues to those now identified in respect of the younger children. These historic issues included very poor home conditions, severe head lice and nappy rash, missed appointments, poor attendance, and professional concerns about inappropriate diet and the over reliance on cow’s milk. There was ongoing evidence that the parents often avoided professionals and that Mother prioritised her own needs. Early in 2010 a Safeguarding Nurse wrote to the CSC Referral and Assessment team to state that the on-going neglect was having a wider impact, with the children ‘showing signs of distress as a result of the neglect they were experiencing’. 9 6.10 Doctors at the family’s GP practice know the family well and have been involved with the family since 1997. The information shared with this review provides valuable background information. This includes concerns during 2010 that the family would often refuse entry to and turn away health professionals. The GP also provided helpful information about the mental and physical health needs of both parent. The most significant being; Father’s mental health issues, including a history of suicide gestures, Mother’s history of depression, Father’s tendencies to miss his own health appointments, leading to physical health problems, Mother’s mobility and health issues, some of which have not been investigated due to lack of engagement, and are therefore unexplained. 6.11 The GP also provided a history of poor home conditions, and a view that the eldest sibling and their partner provided a lot of care to the younger children and helped to look after the home. 6.12 The older children’s schools had a number of concerns during this period. There is evidence of letters being sent to CSC, not all of which were recorded or available on the social care records. The secondary school attended by one of the siblings (not a subject of this review) had written a number of letters explaining their concerns for the child. They included a strongly worded letter on 8 June 2010, copied to a senior manager, expressing clearly the level of concern the school had for the children and their frustration that Parents were not engaging in the CAF process. The report author for Children’s Social Care could not find any response to this letter, or any others sent by the school. 6.13 The information shared with CSC about this sibling is relevant to this review, as the school Agency Report for this review states that the sibling was very small for their age, had very poor hygiene, head lice, a huge appetite in school and was ridiculed by their peers and increasingly isolated. This description does lead us to question why something wasn’t done at the time. 6.14 During 2010 Bobbie and Charlie were referred to the hospital doctor due to concerns about poor physical and developmental progression. They had also 10 missed all but one of their immunisations, despite the parents signing a consent form for them all. Charlie was seen by the paediatrician at 22 months old in June 2010. Charlie was not walking and had friction burns and pressure marks from crawling. A heavy scalp infestation of head lice was also noticed. Despite this, there was reportedly some improvement seen, and the children were discharged from the hospital doctor’s care after the family did not attend follow-up appointments during 2011. 6.15 The safeguarding nurse wrote to a team manager in CSC on the 19 March 2010 outlining some of the concerns about the children. It ended with ‘I have grave concerns about the immediate risks to the children and the long term implications for this family and I would welcome a response from you as to whether a strategy meeting could be called or a meeting take place between ourselves which would initiate the resolution policy.’ The review was informed that no response was received to this letter, and that CSC does not have the letter in their records. However on 29 October 2013 the CSC agency report author informed the overview author that this letter has in fact been found and that CSC undertook an initial assessment and decided that no further action was required. What is not clear is the author’s view of the content, the quality or the conclusions of this assessment. As it was not within the scope of this review, it has been agreed that further details will not be pursued. It does however raise issues about both record keeping and the ability to source historical information on children. 6.16 It is also not clear whether the safeguarding nurse took any action to follow-up her intention to initiate the resolution policy, there does not appear to have been any further contact until a further letter was sent on 21 May 2010 stating that the safeguarding nurse had been asked to chair a meeting between health and education regarding the family, and requested that CSC send a member of their team to update on an incident involving one of the older siblings. The meeting went ahead, but CSC did not attend. This was because the children were seen as a CAF (early help) matter, and they did not wish to attend a meeting without the parents being invited. 11 7 Key Practice Episodes 7.1 This review will now focus on the key practice issues during the period that this review will concentrate on. There were 4 key practice episodes before 23 November 2012. They were: August 2010 to January 2011 - strategy meeting leading to a core assessment January 2011 to May 2011 – emerging concerns about Abigail June to July 2011 – continuing concerns From February 2012 – escalation of concerns leading to a professionals meeting August 2010 – January 2011 Strategy meeting leading to a Core Assessment 7.2 A strategy meeting was held in August 2010, after a local Children’s Centre had informed the Children’s Social Care Referral and Assessment team that a young man was living with the family who may pose a risk to children. There were also a number of concerns reported to CSC from Daisy and an older sibling’s schools about their appearance and presentation, including persistent poor hygiene. 7.3 It has been discussed during this review whether the meeting was held because of the concerns about the man’s presence in the house, or because of the on-going neglect concerns. It appears that the other agencies attending and the CSC manager responding to the contact in May from the Nurse Consultant were under the impression that it was held because of neglect. 7.4 The meeting acknowledged that there was a CAF in place and that it did not meet the needs of the children. The content and subsequent outcome of the meeting appeared to focus predominantly on whether the young man posed a risk, rather than the neglect issues. It was agreed that the threshold for a child protection conference was not met, but that a social worker should complete a core assessment, to be undertaken under section 17 of the Children Act 1989 (child in need). This required both the permission and cooperation of the parents. 12 7.5 A delay followed, with the assessment starting in October 2010, and completed in January 2011. The assessment was undertaken by an experienced Family Support Worker (FSW) rather than a qualified social worker, as was acceptable practice at the time. (See below for improvements in practice since 2011.) The issues identified were poor hygiene, limited diet, lack of interaction with and stimulation of the children by the parents, some developmental delay, anaemia, delays in immunising the children, and chronic head lice. Both parents had alleged chronic physical health issues which limited their mobility and ability to keep the house clean, with the older siblings appearing to assist with the cleaning up that did take place. The assessment concluded however that the risk was reduced due to the warmth and love the Mother showed to her children. This is questioned by the CSC Agency Author who is concerned about how this conclusion was drawn, considering Abigail was rarely seen at home visits or was left in her seat for the duration of the visit. 7.6 The parents were not willing for the assessment to be shared with key agencies, including the schools. As the assessment was undertaken on a child in need basis, this request had to be respected. There were three schools and a Children’s Centre involved at the time, and staff there were not updated on the outcome of the assessment or involved in plans for future work with the family. The Agency Report submitted by CSC reflects that because the level of risk was judged to be at S17 (child in need) this gave the parents ‘a lot of say about who was involved’. This meant that information which would provide detail on the impact that long-term neglect was having on the older children was not adequately considered in the core assessment. As the CSC Agency Author points out, the assessment did not assess the parent’s capacity or motivation to change. 7.7 The Health Visitor received a copy of the assessment and wrote to the FSW to clarify her concerns about poor nutrition, lack of immunisations and the parents’ refusal to allow Abigail to be seen by a Paediatrician due to concerns about growth. The Health Visitor had professional supervision at this time, which concluded that the parents were unwilling to acknowledge the long-term impact on the children of their parenting deficiencies. However this 13 supervision did not result in any progression of the concerns or any formal request for the issues to be considered a child protection matter. 7.8 In January 2011 a dentist was concerned about the level of decay seen in an older sibling. The dentist stated it was due to neglect and he said that it was one of the worst cases he had seen, with the child also smelling strongly of urine. 7.9 In January 2011 Abigail was in hospital for 2 days with a chest infection. It was recognised that Abigail had not had all of her immunisations. No other concerns are recorded. There is no evidence in the hospital notes that CSC were informed of the child being admitted, although it was open to the FSW at the time. 7.10 This key practice episode was significant as the numerous concerns about the care of the children had been shared, albeit not always as forcefully as would have been hoped, and the opportunity to undertake a core assessment was taken. There was an unacceptable delay in the commencement of the core assessment, which was undertaken by an experienced but unqualified member of CSC staff. 7.11 The assessment did identify and acknowledge the key physical neglect issues but did not appear to reflect on the impact these would have on the children in the long term, instead appearing to focus on the parents’ needs and the view of the FSW that the impact was minimised by the belief that the children were loved and experienced warmth from their mother. Significantly the Core Assessment did not include any evidence that the children had been seen or spoken to. 7.12 Key professionals, including those who had concerns about the children, were not involved in undertaking the assessment as the parents refused to allow them to be contacted or for the result of the assessment to be shared with them. This included the children’s schools, which held a substantial amount of both current and historical information about the family. This was not challenged as the decision had been made to work with the family under Section 17 (Children Act 1989) as a child in need issue. This effectively empowered the family to pick and choose who they would and would not work 14 with. There does not appear to have been any consideration of the appropriateness of this at the time, or any revisit of the decision not to undertake a child protection investigation or hold a child protection conference in light of this insistence by the family to avoid the involvement of key professionals. This was a missed opportunity. 7.13 The information from the dentist about the older sibling was shared with CSC, and should have been considered in its own right as a child protection concern. For a dentist to make a referral and for them to state it is one of the worst cases they had ever seen should have been taken very seriously. Research into child neglect suggests poor dental health is a clear indicator of neglect. The dentist’s referral follows the NICE Guidance 2009 written for health professionals who do not work primarily in child protection fields to help them identify the early signs of neglect. The dentist was right to make the referral, and the lack of follow-up was a missed opportunity. The GSCB have explained that training of dentists in recognising and referring child protection concerns was a recommendation of a previous review, which appears to have had a positive impact. 7.14 From the children’s perspective nothing had changed, as there is no evidence that the children were seen or spoken to in this key practice episode. It is unlikely they would have been aware of the core assessments being completed. At the time the older children would have been old enough to have contributed in a meaningful way in the assessment and any plan that would follow. February 2011 – May 2011 Emerging concerns about Abigail 7.15 In February 2011 the Health Visitor asked the hospital doctor to see Abigail as there were concerns about Abigail’s weight, which was moving down the centiles on the growth chart. Three appointments were offered but all were declined or not attended. The hospital doctor communicated to the Health Visitor and GP that there might need to be a meeting about these ’compliance issues.’ This shows good interagency communication and use of the DNA policy. After a conversation with the GP, the Hospital Doctor agreed that another appointment would be offered and a strategy meeting would not be requested. The GP explained at the Learning Event that the pattern that had 15 evolved at the surgery, when responding to the family missing appointments, was to offer as many appointments as was required to ensure they were seen. 7.16 The Health Visitor shared her concern with CSC that Abigail’s weight was ‘falling through the centiles’. On a visit undertaken by the FSW jointly with the Health Visitor Mother was described as defensive and dismissive of concerns, openly disagreeing with the Health Visitor. A child in need (CIN) plan (S17) was completed and shared with the family on 25 February 2011. It was to be reviewed in 6 weeks. The plan included the home being cleaned and maintained, Abigail to see the paediatrician, children to attend the dentist, daily baths/washes, head lice to be treated and for the pre-school age older siblings of Abigail to attend the Children’s Centre. It is of note that this plan did not include measures to improve the children’s weight, diet or developmental delay. 7.17 The infant school Daisy and an older sibling attended reportedly had had serious concerns about the children for some time. They had contact with the allocated FSW, including copying in her manager when writing to her, on six occasions during February and March 2011, including requesting a multi-agency meeting on 28 March 2011. Their concerns focused on on-going physical neglect and Mother’s hostility to the school. 7.18 Meetings were held to review the CIN plan on 24 March and on 13 May 2011. The meetings were attended by the Health Visitor and the parents, and were chaired by the Assistant Team Manager, who supervised the FSW. There was thought to be an improvement in the hygiene of the children and the home. The medical and dental appointments had not been kept however, and there was no record of an update on the children’s development or growth. There was no record of the older children being spoken to and their wishes and feelings considered. There does not appear to be any consideration of involving extended family in the CIN plan. 7.19 At the Learning Event as part of this process, the Health Visitor was clear that she had been assertive about the fact that Abigail’s weight continued to be an issue. The Chair of the meetings clarified that the meeting was aware that a 16 paediatrician was involved, and that this was thought to be sufficient to address the concerns. However, in light of the history and on-going concerns about the older children who regularly missed health and hospital appointments, this was optimistic. 7.20 A further joint home visit was undertaken by the FSW and HV in May 2011. Mother was observed to be playing with the children, the professionals noted with hindsight, that the conversation would always return to the parents own health needs. The parents stated they no longer wanted Children’s Social Care involved, so it was agreed that the Health Visitor would continue to monitor the children and the case would be closed to the FSW. This was despite the ongoing concerns about the children’s health and developmental needs not being met. 7.21 In summary, this key practice episode was a missed opportunity to ensure the needs of the children were thoroughly assessed and that the deficiencies were consistently addressed. When the family did not cooperate in regards to the key issues, such as attending the paediatrician, ensuring the children’s dietary needs were met, and engaging with all of the relevant professionals including the schools, the need for a child protection conference should have been considered. The improvements were at best partial and significant gaps in the children’s care and the wider assessment were evident. 7.22 From the children’s perspective they are unlikely to have been aware of the child in need plan, as there is no evidence of them being involved. It is unclear if they were aware of the efforts that key professionals, particularly their schools and Health Visitor were making to secure suitable services for them. June 2011 – July 2011 Continuing concerns 7.23 On 8 June 2011 the Children’s Centre informed CSC that the older pre-school children had not been attending day care as expected. They were told the case was closed to CSC. The infant school continued to be concerned about the children who attended their school. They believe they had made a further referral, but this does not appear to have been made through the Helpdesk, as is the procedure. They also reflected at the Learning Event that they did 17 not always refer all of their concerns as they recognised that nothing had changed and the parents continued to show animosity to them. They believed that as the situation was chronic, and CSC had assessed before and the threshold was not met, they did not believe anything would change if they continued to refer the same on-going concerns. 7.24 On 13 June 2011 the FSW received an email, copied to them, from the paediatrician about concerns that Abigail had not been brought to appointments. They stated they were following the DNA policy and outlining their concerns about safeguarding issues in the family. On 22 June 2011 the school of an older sibling informed the FSW that the sibling’s hygiene had deteriorated significantly. Neither contact resulted in the case being reopened to CSC. It is not clear if the FSW forwarded the information to the duty team to be seen as a new referral, or if the paediatrician and the school thought they were in fact making a referral. The school shared that they are now aware that they should always complete a MARF (Multi-Agency Service Request Form) rather than email a particular worker. However it is evident that they had not been informed that the case was now closed. Both the Paediatrician and the school were justified, however, in expecting that some action would be considered by CSC in light of the concerns being expressed. 7.25 As well as contacting CSC the Paediatrician also spoke to the GP, who appears to have reassured the hospital doctor that the concerns were not at a severe level. It was agreed between them to give the family another chance of attending, and a further appointment was therefore offered to the family at the hospital. 7.26 The same month the Health Visitor made a home visit after becoming aware that Abigail had missed three scheduled appointments with the Paediatrician. At the visit she noted that Abigail was not yet crawling or walking, and that no significant amount of weight had been gained. Advice was again given about nutrition and stimulation. A further visit was undertaken shortly afterwards and Abigail was said to be asleep. The parents reported that Abigail was now crawling and weight bearing. It is significant to note here that the interview undertaken recently with the older sibling provided information that the parents would put the children to bed when they were expecting a visit from the Health Visitor. This is likely to have been one of the occasions when this 18 happened. It certainly allowed mother to provide information about her child’s progress that was later found to be untrue. At the Learning Event the Health Visitor clarified that she would attempt to time her visits at different times of the day in the hope of seeing Abigail awake, and to try and see the children at meal time, which did not happen. 7.27 On 29 July 2011, six weeks after the decision to offer another appointment, Abigail was assessed by the hospital doctor, but was not physically examined as Abigail was reluctant to leave mother’s lap. The information noted by the hospital doctor is mostly as reported by the parents. There is no evidence that the specific issues raised by the Health Visitor were considered. The child was discharged to the care of primary health services. (GP and Health Visitor.) 7.28 No significant issues emerged during the next 6 months. 7.29 This key practice episode is significant because further concerning information was being noted and raised about the children, none of which led to a referral formally requesting the intervention of CSC. There are also signs that the professionals working with the children were becoming increasingly demoralised about both the family and the likelihood of the matter being seen as a safeguarding issue by CSC. This was not identified at the time however. 7.30 Again, there is little or no evidence of the children being spoken to or directly observed during this key practice episode. From February 2012 Escalation of concerns leading to a professional’s meeting 7.31 During 2012 Bobbie missed 4 out of 5 appointments with the hospital ophthalmology team. This is despite the parents being sent information that explained that the child’s sight could be affected long-term without appropriate interventions. 7.32 In February 2012 there was a change of Health Visitor. The new worker took the opportunity of discussing the family with the GP. The GP said they were not concerned that Abigail was walking late, as they were following the pattern of an older sibling who also walked late. The Health Visitor did 19 establish that both parents suffered with depression and that father was addicted to a prescription pain killer and to Diazepam. After a number of attempts the Health Visitor was able to undertake a developmental review of Abigail. The locomotor skills were that of a 15 month old (Abigail was 28 months old at the time). The weight remained on the 2nd centile. The Health Visitor wrote to the GP and the Paediatrician with her concerns. The Agency Report from the hospital points out that a request for an appointment was not made, and that the Health Visitor may have been under the impression that Abigail was still under consultant appointment follow-up, which she was not. A further appointment was not offered by the Paediatrician. 7.33 The Health Visitor took her concern to her safeguarding supervision and the plan was to ‘liaise’ with other professionals and to monitor Abigail’s development. On reflection, this could raise concerns about the effectiveness of this supervision. Information obtained at the learning event highlighted that paper records were kept with plans from supervision, however they were not available at this time. This meant that previous interventions were unknown, and the resulting lack of consistency was exacerbated by a new professional becoming involved. 7.34 Bobbie and Charlie were both supposed to be attending the Children’s Centre nursery at this time, but their attendance was just 12 – 15%. In September 2012 the Children’s Centre worker visited the family and was concerned about Abigail. She appeared unwell and they were told she had bad nappy rash. Father later told them that cream had been prescribed and that she was getting better. The Children’s Centre expressed their concerns to the Health Visitor. 7.35 Health professionals were increasingly concerned about Abigail from around July 2012 when the nappy rash was identified as problematic. There had also been concerns about failure to thrive identified in a letter from a Paediatrician to the family, copied to the GP, who had stated that there was a potential safeguarding issue. The GPs also spoke to the parents about their concerns, and had weekly contact with the family over the next few months, as well as liaison with the Health Visitor. There was no contact with CSC until 17 October 2012. 20 7.36 The GPs had requested that a hospital admission be considered by parents in respect of the nappy rash, but the parents refused, insisting that there was an improvement in the matter. The GP involved at the time accepted the parents’ report of improvement, and made the decision not to force hospital admittance. This decision was made without seeing the child. In hindsight this was a missed opportunity to intervene in the children’s lives a little earlier. 7.37 The reviewers spoke to the eldest sibling of Abigail as part of this review. The sibling was living at home when Abigail had severe nappy rash. The reviewers were told that the parents did not use the prescribed medication to treat the nappy rash. The sibling reported that Mother had ensured that the cream be thrown away, so that when the Health Visitor visited and checked the medication it looked like it was being used. No one appears to have spoken to the teenager to gain their view of the situation at home. While they may not have made this disclosure, there is a possibility this information may have been shared at the time. 7.38 In this key practice episode the Health Visitor made many attempts to see the family and particularly Abigail. Most of the visits were missed by the family, and on the rare occasions access was granted, the Health Visitor continued to have concerns about the child’s weight, unsteady walking, and persistent head lice. The Health Visitor was also informed by the GP of the concerns of a receptionist at the surgery, who had seen Abigail and father in the waiting area, and that Abigail kept saying ‘sorry’ to father. The receptionist had been very concerned. During this phone call the GP also stated that both parents were addicted to analgesics, and that father had issues with the use of both cannabis and alcohol. 7.39 No new referral was made to Children’s Social Care until 17 October 2012 when a referral was made by the Health Visitor using the Multi-Agency Service Request Form. This was after a further safeguarding supervision session where the Health Visitor reflected on a further number of visits to review the nappy rash which were refused or missed by the family. The referral included information about the severe and chronically infected nappy rash being suffered by Abigail, a severe infestation of head lice in the children, and the parents’ lack of ability to prioritise the children’s care over 21 their own needs. In light of this referral and a joint visit between the Health Visitor and a duty Social Worker on 31 October 2012, it was agreed that a strategy meeting should be arranged. 7.40 It was clarified in December 2013 that the referral to Children’s Social Care made by the Health Visitor on 17 October was initially closed in error, but the mistake was discovered and rectified on 22 October, when the child’s case was opened for assessment. A letter arranging a visit was sent to the family on 26 October, they were spoken to on the 29 October, and visited on 31 October. When questioned why the referral was not treated more urgently, it was explained by the agency that as a number of professionals were actively involved, and the nappy rash had been an issue since June, it was not thought to be urgent at the time. 7.41 CSC and Police had a strategy discussion on 6 November 2012, and it was agreed to undertake S47 enquiries that included completing a core assessment. This happened in agreed timescales, with some of the older children being observed by the Social Worker on 19 and 20 November. The core assessment included information from key professionals. For the children there was no action taken to change their situation however until after 21 November when a further meeting was held. During these additional weeks Abigail would have experienced further damaging neglect. 7.42 On 30 October 2012 the GP spoke with the newly allocated duty Social Worker. The GP voiced his frustration by stating he just wanted the family to be made to attend all the appointments that had been offered. When reviewing Abigail and the nappy rash over the next few weeks the GP noted that the situation was much the same. 7.43 During October and November 2012 a professional who was not a child or adult services worker spent a significant amount of time in the family home, on an entirely unrelated remit. They contacted Children Social Care on 19 November 2012, stating they were ‘shocked and upset’ about the state of the home and the children. They provided particular details about Abigail who they described as still in nappies with nappy rash, that Abigail looked neglected and dehydrated, was grubby and seemed to be underweight. They 22 were told that the family were to be the subject of a child protection meeting due to a referral received previously. 7.44 A ‘professional’s meeting’ was held on 21 November 2012. It was described as a professional’s meeting rather than a strategy meeting as the Police were unable to attend. All of the other key agencies were present however and there was a high level of concern about the children, particularly the parent’s failure to respond to Abigail’s health needs. It was decided to progress to Initial Child Protection Conference. 7.45 Abigail was admitted to hospital on 23 November 2012, not to return home. 7.46 A later further strategy meeting was held on 27 November 2012 which was attended by the Police. This meeting appears to have been called to consider the severe neglect of Abigail and plan the investigation that was required. 7.47 This key practice episode was dominated by drift and the lack of action to address the needs of the children. One of the contributory factors for this was the fact that the parents were successfully avoiding professionals and the children were subjected to further neglect and harm. While the Health Visitor was most persistent in her attempts to access the family, and the GP made efforts to ensure the nappy rash was treated, the acceptance of the seriousness of the situation by all agencies was delayed and the parents reluctance to engage and blatant avoidance of professionals was allowed to go on for too long. 7.48 The older children watched as their youngest sibling became ill and, in the words of the Grandmother ‘was fading away’. Again there is no evidence that any of the older children were spoken to, and the parental lack of cooperation led to limited opportunities for the younger children to be seen and assessed. Until the final decisive action was taken to remove the children from the care of their parents after the hospital admission on 23 November 2012, the children could not have had any faith that professionals were going to respond to their continuingly poor care. 7.49 In addition to the significant incidents listed above, it is of interest to note that during the review period Police attended the family home on 6 occasions in 23 regards to non child protections matters, mostly complaints of criminal damage or theft and neighbourhood disputes. On no occasion were concerns about the state of the home identified or reported by the Police Officers attending. When interviewed for the review, two of the Officers remembered that the house was untidy, unclean and smelly. However they did not have any concerns for the children at the time. 7.50 It needs to be pointed out that the practice outlined above is, at the time of reviewing this case, at least 12 months old. Those involved in the review have been given information about the improvements made across all relevant areas since the time of the incidents being considered. The improvements made are outlined in detail below, and are significant and positive. It has been accepted that there may be further lessons to be learned or certainly that the learning is reinforced, and this report will now outline these lessons as part of the analysis of what happened in this case and why these children suffered significant harm despite the involvement of a number of professionals. 8 Themed Analysis 8.1 The analysis section of the review will consider the information above, which was gained from the Agency Reports and the Learning Event, thematically. All of them lead to lessons that need to be learned from this review. The themes to be addressed here are: A. Listening to children and seeing the child’s world B. Levels of need and the limitations of an incident led approach to child neglect C. The impact of professionals feeling overwhelmed or desensitised, and the challenge of working with parents who are manipulative or show disguised compliance D. Professionals not feeling valued and listened to, and the lack of a culture of resolving professional disagreements E. Understanding neglect At the end of each section of analysis the lesson learned will be stated, along with a recommendation as required. These will be reiterated in the specific sections towards the end of the report. 24 A. Listening to children and seeing the child’s world 8.2 In April 2011 Ofsted published their fifth report evaluating Serious Case Reviews. Titled ‘the voice of the child: learning lessons from serious case reviews’ it has a single theme, the importance of hearing the voice of the child. The report has identified five key issues which ran through many of the cases considered: I. the child was not seen frequently enough by the professionals involved, or was not asked about their views and feelings II. agencies did not listen to adults who tried to speak on behalf of the child and who had important information to contribute III. professionals were prevented from seeing and listening to children by parents and carers IV. practitioners focused too much on the needs of parents, especially vulnerable parents, and overlooked the implications for the child V. agencies did not interpret their findings well enough to protect the child. 8.3 Working Together 2013 has legislated to ensure that this issue is addressed more fully by professionals working with children and their families. It states ‘Children should be seen and listened to and included throughout the assessment process. Their ways of communicating should be understood in the context of their family and community as well as their behaviour and developmental stage. Children should be actively involved in all parts of the process based upon their age, developmental stage and identity. Direct work with the child and family should include observations of the interactions between the child and the parents/care givers’. 8.4 There is very little evidence that the ‘voice of the child’ was heard by a number of the professionals involved in this case, particularly those undertaking assessments. The school were clear about the needs of the older children and showed a good understanding of the children’s difficult circumstances and knew the older children well. They should be applauded for this. Letters were sent from the secondary school to CSC, cataloguing concerns. Few received a response. It is easy to see why the school was frustrated. It was clear at the Learning Event that they had been very distressed over a number of years about their inability to effect positive change for these children. 25 8.5 The core assessment did not evidence that the children had been seen or spoken to, and other professionals recorded positive updates on the children that were reports from Mother, rather than observed themselves. Having to witness the neglect of their younger brothers and sisters must have been very distressing for the older siblings. The eldest child told the review that Mother would lie to professionals constantly. It has been a regular finding from Serious Case Reviews that professionals should be checking what they are told by observing children directly, and speaking to children if that is age-appropriate. Hearing the voice of the child and considering what their life is like needs to be a key part of any assessment and work with a family, with the information gained influencing plans and actions. 8.6 In 2012 Brown, Ward and Westlake of Loughborough University considered the obstacles to focussing on the child when undertaking child in need and safeguarding work. They listed them as follows: Preservation of the family The partnership principle Empowerment, fairness and their limitations Parents’ rights All of these were obstacles in this case. Consideration of the need to work with the parents in order to help the children, Mother’s fierce stating of her rights, and the principle of needing parental permission to see the children and work with other agencies under S17/Child in need, lead to a failure to see the children in this case, both literally and metaphorically. 8.7 The review acknowledged that the older children in this family may have been young carers, and asked if this issue was considered by the agencies involved. The core assessment in 2010 – 11 commented on the fact that both parents had chronic physical health issues which limited their mobility and ability to keep the house clean, with the older siblings appearing to undertake some household chores. The schools reported that the older sibling was responsible for taking the children to school and collecting them. 8.8 The Core Assessment did not highlight that the older children were taking on a significant amount of the household or child care responsibility. However it 26 is not clear if it was explored with the children or the family. There does not appear to be any evidence that the older children’s potential role as young carers was considered by any agency. 8.9 Learning Lessons from Serious Case Reviews 2008 - 2009 stated that ‘young carers who may be caring for a disabled parent are not always receiving the assessments of needs to which they are entitled and as a consequence do not receive services which meet their needs.’ Assessing the older children as potential young carers in this case may have made a difference to those children, and enabled them to receive the support they needed. Grandmother informed us that the eldest sibling ‘did not have a childhood’. It is acknowledged however that in large families where the parents have significant needs of their own, the older children will often play a part in the running of the household. 8.10 Lesson 1: Professionals in the agencies involved in this case had difficulties in keeping a clear focus on the needs of the children, due to the need to negotiate the many demands and difficulties of the parents. Supervision needs to play a clear role in ensuring that assessments, plans and interventions listen to the child’s voice and consider this information when taking actions. To quote Working Together 2013 ‘Ultimately, effective safeguarding of children can only be achieved by putting children at the centre of the system, and by every individual and agency playing their full part, working together to meet the needs of our most vulnerable children.’ Lesson 2: The child’s experiences should be at the heart of all plans. Robust, time bound and outcome focused plans need to be in place for all children where there are concerns about the capacity or motivation of the parents to improve the children’s circumstances. These plans should include extended family members. Recommendation 1: GSCB to undertake an audit of assessments of child in need and child protection plans to ensure that the child’s voice has been heard and is taken into account in the conclusion of the assessment and throughout the plan. 27 B. Levels of need and the limitations of an incident approach to child neglect 8.11 At times during the history of this matter, both before and during the scope period of this review, the decision was made for the children to be seen as in need of early help or universal services, or as children in need, rather than as children in need of protection. At no stage since the deferred conference in 2007 was the care of the children considered a child protection matter. This was despite communications with CSC regarding the condition of the home, concerns about the hygiene and development of the children, and issues with the parents not cooperating with services offered, including important medical appointments. 8.12 Despite brief periods where some improvement was noted in the state of the home and in the presentation of the children, there were numerous concerns about these children, which intensified during the period being considered by this review. The assessments undertaken in relation to the younger children did not take into consideration either the experiences of the older children, which were well documented in a number of agencies, or the extensive information held across agencies about both the parents and the children. When considering the information known to professionals at the time, if a more thorough assessment had been undertaken, including an analysis of all agency information and a thorough chronology compiled including all the information available since the birth of the oldest sibling, it should have been quite clear that the children were at risk of significant harm. 8.13 The failure of the agencies to pull together historical information, covering all of the children, appears to have led to an incident led approach and ‘start-again syndrome’, a term described in the Biennial Analysis of Serious Case Reviews 2003-2005. In these situations the parents’ histories are not considered sufficiently and the focus was on the current circumstances. This led to a lack of systematic analysis of parenting capacity, including their motivation to change, and no acknowledgement of the lack of sustained progress. The children’s experience of harm over a long period was being ignored. 28 8.14 As stated in the Police Agency Report ‘‘there is evidence from the records that each strategy meeting has perhaps concentrated on specific issues and has not looked at wider themes or taken a more holistic view which may have resulted in issues like neglect having been identified earlier”. Individual concerns and incidents did not appear to meet the threshold being used at the time for a child protection response in their own right, including the decision to call a conference. A child protection conference would have allowed all the professionals involved to share the history of the family and the current concerns in a setting chaired by an independent person, where the parents could not have decided who was involved and who was not. 8.15 Even without a child protection response to the children, the child in need plan and S17 response to the neglect was inadequate. The review saw no evidence of a clear, time-limited and outcome focused plan for these children, which involved the extended family as well as the parents. Grandmother states that despite her having regular contact with the family, she was never contacted by professionals either for information or to request her help and involvement in any support plan. She acknowledged that despite her own concerns she did not contact any agency. This was due to her fear that Mother would refuse to let her have on-going contact with the children. 8.16 The timeliness of responses by professionals to issues raised was part of the terms of reference for this review. The Agency Reports and the professionals around the table at the learning event acknowledged that decisive action was not taken in relation to the on-going chronic issues they were aware of. Delays were evident in the provision of appointments at the hospital; the start and completion of the Core Assessment; and in the holding of key meetings, including the meeting that resulted in Abigail being taken into hospital and removed from the parents care. For Abigail these delays probably led to prolonged suffering. 8.17 Lesson 3 The following issues remain of concern and require a clear message to all agencies: 29 - The need for clarity regarding sharing information on children and their siblings and parents, when they are not identified as a ‘child protection case’. - The need for clarity about the option of holding professionals meetings without the parents attending, which may have been useful in this case. - The need for clarity regarding the ability of all agencies to request a strategy meeting. Lesson 4 It is the robustness of the plan, which must include a contingency plan and the involvement of all agencies and the family, which will ensure the needs of the children are assessed and met. Not the status of that plan. In this case it is clear that the plan should have made it clear that if the parents did not cooperate fully with what was required to ensure the children’s needs were met, that legal advice would be sought. Lesson 5 All assessments of risk should consider and analyse the historical information held across agencies. Recommendation 2 The GSCB should support a framework of meetings which allow professionals involved in particular cases to meet and reflect on professional dynamics and disagreements without the presence of children and families. C. The impact of professionals feeling overwhelmed or desensitised, and the challenge of working with parents who are manipulative and show disguised compliance. 8.18 It was clear at the Learning Event that the majority of professionals who had known the family over the years felt both confused and overwhelmed by the complexity of the needs of the parents and children in this family. The GP also stated that the primary health team became desensitised to the family’s way of living. They provided GP appointments on demand, and this led to a degree of collusion with the parents. In the Agency Report the GP states ‘Primary Care took the view that keeping the family on-side and making the system easily accessible was the most practical way of handling the situation’. 30 8.19 The Health Visitor said that it was hard to be child focussed when the parent’s needs were so overwhelming. Mother’s health always appeared to dominate the conversation. The school agreed that this was also their experience when trying to engage with the parents. The professionals at the Learning Event agreed that this family ‘exhausted people’. Serious case reviews have often commented on the difficulty, in child neglect cases, for professionals to decide when ‘enough is enough’ and that when staff feel helpless and sometimes fearful of families, this leads to avoidance and drift. 8.20 Grandmother told us that she would only criticise the parents so much, because Mother would tell her to stay away. Instead Grandmother would try and compensate for the poor parenting she recognised the children were getting by regularly having one or two of the children to stay, or going over on her day off and attempting to do some cleaning or laundry. This threat also stopped Grandmother contacting CSC. 8.21 The challenge of working with parents who are manipulative and/or show disguised compliance was a key theme when reviewing this case. The majority of staff who were involved in this case felt that professionals require more support, supervision and training when it comes to working with families who are dishonest, avoidant or won’t engage. In this case the parent’s dominance of the attention of professionals, to the detriment of their children, was an effective way of avoiding scrutiny of their parenting. Mother was particularly difficult to work with. 8.22 Without a robust multiagency plan that is clearly communicated to the parents, with clear contingency planning, that does not drift or get hijacked by the parents needs, the children’s needs were not assessed or met. 8.23 Grandmother stated that Mother is manipulative and aggressive. She felt intimidated by Mother herself and believes that professionals would have felt the same way. She described Mother as very controlling of her husbands, the children and wider family. She believes Mother would also have wanted the power and control in any relationship with a professional. She said Mother had the potential to ‘eat them alive’. 31 8.24 The GP Agency Report states that Mother ‘was well known to all agencies to be manipulative and at times hostile. She was skilled at playing off one agency against the other’. The school Agency Report stated that Mother knew how systems worked and was described as ‘calling the shots’. 8.25 Schools reported at the Learning Event that Mother could be aggressive, and that on occasion she swore at teachers if she felt challenged. Indeed her refusal to work with the schools in the first key episode of this review did not lead to a reconsideration of the need for a child protection response, but to a collusive agreement that these key professionals could be avoided if Mother agreed to work with the Health Visitor. While this might have been agreed in the spirit of partnership, the needs of the children were not prioritised over their Mother’s unsubstantiated concerns. 8.26 ‘Disguised compliance’ is a term that can be attributed to Peter Reder, Sylvia Duncan and Moira Gray in ‘Beyond blame: child abuse tragedies revisited’ (1993). It involves a parent or carer giving the appearance of co-operating with agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention. There was no doubt at the Learning Event that both parents had adopted this stance as a way of avoiding the agencies who had voiced concerns about the children. They were successful for many years. 8.27 On occasion it is clear that there was over-optimism both about the relationship between Mother and her children (her being described by the FSW as loving the children) and regarding improvements in the children’s development, hygiene and attendance at appointments. 8.28 Both Mother and Father had health and psychological problems of their own, which demanded a lot of professional attention. Grandmother described Mother as attention seeking. Grandmother also informed us that Mother loved being pregnant and having new babies, as she got attention. Grandmother said that after each baby was a few months old, Mother lost interest and started to plan her next child. 32 8.29 The health professionals in particular had the dilemma of how to build a relationship with the parents, in order to see the children and progress their work with the family, without angering Mother and isolating themselves as a help to the children. Mother would often talk about her ‘rights’, and a number of the professionals felt they had to carefully negotiate their position to avoid losing any opportunity they had to engage with the family. Again, without a robust plan to support their role, they did not feel they could push too much. 8.30 Lesson 6 All professionals working with children and families need to be trained and supported, to include the provision of reflective supervision, in the identification and challenge of parents who use manipulation and disguised compliance, to ensure the needs of the child remain the priority. Recommendation 3 That the GSCB review its model of reflective supervision, to ensure that it is fit for purpose in assisting professionals to gain confidence in working with parents who are manipulative and show disguised compliance. Consideration is to be given to using this model with more complex Child in Need cases, as well as those subject to a Child Protection plan. D. Professionals need to feel valued and listened to, and the lack of a culture of resolving professional disagreements. 8.31 It was clear at the Learning Event that at the time a number of professionals struggled to make themselves heard, particularly by Children’s Social Care, who it was felt had to make the decision about what to do to help the children. The Health Visitor involved at the earlier stages expressed her frustration that she was unhappy with the progress the children were making, but felt ‘impotent’ as she was told it did not meet the threshold for child protection. She felt that it did, but that she was the lone voice. 8.32 On the 17 October 2012 the second Health Visitor made the important referral about the nappy rash, the head lice and the parent’s failure to meet the children’s needs, which resulted in an initial assessment being undertaken. However staff present at the Learning Event fed back that it appeared that it was not until the referral was made to a senior manager in CSC, by the 33 person spending time in the family home in an unrelated professional capacity a month later, that the strategy meeting was finally held. This was clearly a coincidence, as this was not the case. The Learning Event acknowledged that it is understandable that the professionals involved felt demoralized and not listened to in regards to their concerns about this family. It must be made clear however that the case had been allocated and CSC were responding to the health visitors referral, not the telephone call to a senior manager that was received later. 8.33 The secondary school records show that they did not feel that front line staff in CSC took their concerns seriously, feeling that they had to copy in senior managers to get any response. Even this had a limited impact. The infant school felt that relations with CSC were good in this case once the case was allocated. The issues were when the referral was made and it wasn’t thought to meet the threshold, then relations were often strained. 8.34 At the Learning Event schools stated that they do not feel valued as professionals by CSC. The head of one of the schools stated that she felt undervalued and that in her previous local authority she had a better relationship with CSC and felt more on an equal footing with them. This viewpoint requires exploration by both CSC and the GSCB. 8.35 Good relationships were reported between the school and health professionals, particularly with the Health Visitors and Paediatrician. The review acknowledges the hard work that school staff and Health Visitors put into this family, and the attempts they made to communicate concerns, even when parents had refused permission for the child in need plan to be fully communicated and then continued. 8.36 There was positive communication from the Health Visitors to the GP, particularly during the 4th key episode. A study published by the Dept of Education in 2009 called the ‘The Child, The Family and the GP” found that GPs preferred to consult with Health Visitors and other Health colleagues rather than with Children’s Social Care where they had concerns that were not clear cut’. The study found that there was a general reluctance by GPs to approach Children’s Social Care to make referrals unless there was a clear injury, disclosure or evidence of failure to thrive. ‘The important role of the 34 Health Visitor in safeguarding children, and as a key fellow professional for the GP to refer to, was confirmed in this study.” 8.37 There were a number of opportunities for concerns about what was perceived as a lack of decisive action in respect of these children by CSC, to be escalated via the Resolution of Professional Disagreements policy. On one occasion they were, with the Safeguarding Nurse formally escalating the Health Visitors concerns at the beginning of the period being considered by this SCR. On other occasions, while information and concerns were being sent to CSC, the resolution policy was not used. The Head of the Secondary School could have made use of the policy, and Children’s Social Care could have directed him in the direction of the policy in response to the letters being copied to senior managers. 8.38 It was acknowledged during the Learning Event that different agencies have different cultures when it comes to the sending and receiving of letters. The use of formal letters in health and education as a way of keeping other professionals informed and updated is common, this is not the culture in Children’s Social Care. 8.39 In 2010 GSCB undertook a major communication drive and road show in respect of a serious case review. This included the publication of an information poster for professionals. The poster shares the lessons learned, and was designed for a wide audience. The first four lessons are as pertinent to this case as they clearly were in relation to that SCR: Advocate on behalf of your children - don’t drop the ball. Stay responsible for the child even after referring to a different agency - always push for the response you know is needed to fully meet the child’s needs. Ensure referrals are of the highest quality. Use the professional disagreements policy if you are not satisfied with the response you receive. Sharing Information. Include all relevant information held by your agency when making a referral, including information on all adults and children, especially previous concerns – missing information could make all the difference. Be Child Focused. Always view your work through the eyes and experience of the children and young people in the family (and always consider the experiences of any children when working with adults). 35 Quality of Assessments. Be challenging and rigorous in your assessment of risk – be aware of being too parent focussed, taking things at face value. Determine what is happening to the child and ensure change is taking place. 8.40 The poster is available on the GSCB website, but this case shows that there are still barriers to implementing and reinforcing learning, as the lack of use of the professional disagreements policy in this case proves. The school Agency Report states that the schools believed that no resolution policy was available at the time, which was not the case. 8.41 The majority of agencies reflected on a problem they had all experienced when sending referrals to CSC at the time. They stated that they couldn’t tell if a referral had been accepted or not, often having to send repeat referrals in order to try and get a response. It must be noted that agencies around the table at the Learning Event reported that things have improved since the introduction of the ‘request for service’ system. School also stated that are now aware of the Resolution of Professional Disagreements Policy, and feel this is useful. 8.42 While very hard working during 2012 and trying all she can to get help for Abigail, the Health Visitor was not specific in her letters to the hospital Paediatrician that she wanted the child seen again. The letters seemed to be for information, rather than requesting a service. Neither the hospital doctor nor the Health Visitor clarified what was required or was being requested. As well as being clear with CSC about what is required for a child or family, all staff should be clear in all communications of the purpose of the information being shared and their expectations about what needs to happen next. 8.43 Lesson 7 All agencies need to have the confidence to challenge or question decisions taken by other professionals in partner agencies. Clear guidelines and training, supported by supervision, needs to give professionals the confidence to challenge each other and to escalate any concerns they have via the resolution policy. The review has heard that agencies defer to Social Care when it comes to decisions about the need for services to be provided to children in need and in need of protection. GSCB need to ensure that they 36 advertise the message, including in training, that professional disagreement is a positive sign of a healthy safeguarding system. Recommendation 4 That the GSCB’s new Levels of Intervention model includes a clear link to the professional challenge policy, and is clear that requests for explanations of why decision have been made should be sought as applicable. E. Understanding neglect 8.44 One of the most concerning issues in this case is the apparent lack of understanding, at the time, of neglect and its impact by a number of the key professionals working with this family. This suggests a need to test whether this demonstrates a wider lack of understanding of the impact of neglect across the county. 8.45 Neglect is defined as ‘the persistent failure to meet a child's basic physical and or psychological needs, likely to result in the serious impairment of the child's health or development’. In this case Abigail and a number of the siblings have experienced severe neglect that will have long-term implications for them. As stated by Daniel et al (2011) ‘Apart from being potentially fatal, neglect causes great distress to children and is believed to lead to poor outcomes in the short and long-term. Possible consequences include an array of health and mental health problems, difficulties in maintaining relationships, lower educational achievements, an increased risk of substance misuse, greater vulnerability to other abuse as well as difficulties in assuming parenting responsibilities later on in life’. Grandmother informed us of her deep sadness that all of the children would have to live with the effects of what they experienced for the rest of their lives. 8.46 A recent SCIE systems review into another matter, and the OFSTED inspection of 2011, both found that neglect was seen as less serious than other types of abuse in Gloucestershire. Managers around the table at the learning event were open with the reviewers that at the time professional practice in regards to neglect was not good enough. 8.47 In their report ‘The state of child neglect in the UK’ (2013) Action for Children remind us that ‘neglect is the most common reason that children are made 37 subject to a child protection plan, with neglect featuring in 60 per cent of all Serious Case Reviews’. In August 2013 547 children in Gloucestershire were subject of a CP Plan, of which 195 have neglect as the main category of abuse. 8.48 All of the signs were there, and had been for many years, that these children were suffering or likely to suffer significant harm due to neglect. At the time there were clear difficulties in ensuring that all of the information on all of the children was available to be considered and drawn together in order to ensure a complete picture. If this had been done, the list of concerns would have looked like this: Tooth decay. Empirical evidence suggests that there is a high level of agreement among different professional groups that poor dental health is an early indicator of neglect. A number of the children had tooth decay and lack of attendance at dental appointments. Severe and persistent head lice. Both the children and the parents had head lice most of the time. The GP Agency report states that ‘No members of the Primary Care team assessed this as a neglect issue on its own’. The 2009 NICE quick reference guide to neglect highlights severe, persistent and untreated infestations of head lice as an indicator of child neglect. The Paediatrician who saw Bobbie in 2012 stated that the child had open sores on the scalp due to untreated head lice. Poor growth and weight gain. Most of the children were small and this was felt to be linked, as they grew, to inadequate diet with an over-reliance on cow’s milk. The parents did not follow professional advice, despite the fact that the children were clearly failing to thrive on the diet they were receiving at home. At least one of the children had rickets. Delayed development. Walking and talking were both areas where professionals were concerned about the delay in the development of the younger 4 children, who are the subject of this review. No information was available to the review on the older children but the schools have noted concerns. Anaemia. It was the view of the paediatrician that both Bobbie and Charlie were suffering from severe non organic anaemia due to malnutrition in 2010- 11. The review heard that is a very serious condition for young children, which could lead to cardiac arrest. 38 Missed health appointments. It was reported that the Parents always gave plausible excuses for the failure to bring the children to appointments, but there was no assessment of the impact on the children’s health and well-being of the parents not taking them to appointments. Failure to immunise. It is not a statutory obligation to immunise children, with many parents opting out. In this case the parents had agreed to the immunisations and attended some appointments, but the course was rarely completed. This potentially left the children vulnerable. Failure to use prescribed medication. The GP has stated that there were issues of compliance with prescribed medication in regards to a number of the children. Severe nappy rash. Most of the children, but specifically Abigail, suffered with chronic and painful nappy rash, which was not appropriately or consistently treated by parents. Professional advice was not sought or responded to with regards to this issue. 6 weeks before the admission, there was an opportunity for Abigail to be taken into hospital with the severe nappy rash. Father told the GP he would agree to Abigail going into hospital for the nappy rash to be treated, however Mother blocked this. The GP, with the support of the Health Visitor, pursued this, but believed the parents report that things had improved and did not push for hospital admittance. This decision was made without seeing the child. This was a missed opportunity to intervene a little earlier in the children’s lives. Poor hygiene and dirty clothes. Was an on-going issue for all the children. This led to them being socially isolated and stigmatised. Poor attendance at nursery and school. Again, this was an issue for a number of the children, and most recently for Bobbie, Charlie and Daisy in relation to the nursery provided at the Children’s Centre. The older children had the involvement of Education Welfare on a number of occasions due to poor attendance. Non-compliance with advice from health professionals. This was the case in relation to the children’s diet, dealing with health issues, and co-sleeping with babies. It is recorded that the parents refused to listen to advice about the dangers of co-sleeping when parents are smokers. This was a risk, particularly as Father was alleged to drink and use cannabis. There was a concern raised in 2012 that Mother may be using her own medication to drug the children. This has never been proven. 39 8.49 The strategy meeting held in August 2010 did not fully acknowledge the neglect issues which had been identified over many years, appearing to focus on the more tangible risk the person staying in the home may bring. This raises the concern that the CSC professionals, including the chair of the strategy meeting, did not at that time have the knowledge and experience to recognise all aspects of the risks for these children. A contributory factor was that the staff were working within a system that, at the time, did not recognise the serious risk that physical and emotional neglect poses to children. The schools were not at the meeting as it was held in the summer holidays. 8.50 The GP Agency Report states that there was a pattern of delaying responses in this case, for example the delay in pulling together meetings, even as late as the meeting held just days before Abigail was admitted to hospital. ‘This appears to be because of the feeling, with this family, that the concerns at the time were just more of the same.’ 8.51 The Hospital Agency Report author points out that the Health Visitor was signalling indicators of severe failure to thrive, but that Abigail did not get the hospital assessment required due to the GP giving the hospital doctor reassurance about Abigail’s well-being. 8.52 All schools felt there needed to be more clarity about the thresholds for neglect. They acknowledged however that recently there has been a Levels of Intervention document shared which helps, and neglect workshops run throughout the county. (See below.) 8.53 CSC reports that at the time of the first two key practice episodes, the culture that existed about neglect in the organisation was unhelpful for these children. Understanding about the serious long-term effects of neglect were not clear, and it was very difficult to get neglect cases into legal proceedings. As recently as November 2012 it took the critical incident, of Abigail’s nappy rash and severe malnourishment, to ensure her removal from the family. 8.54 Lesson 8 Staff across all agencies must have a shared understanding of neglect and its impact on the safety, wellbeing and development of children. All professionals 40 working with children should be trained and supported in regards to recognising child neglect, and be provided with the tools to work effectively with children and families where there are concerns about neglect. This includes a focus on building a shared understanding of the children’s history by incorporating all of the information held on the family across the agencies involved. Recommendation 5 That GSCB review their neglect training to ensure that it has improved the shared understanding of neglect across agencies. This review should include a request that all agencies review professional training and qualification courses locally to ensure they include training on child development and the impact of neglect. 9 Conclusions and lessons learned 9.1 As stated by the author of the Hospital Agency Report ‘the child subjects of this report experienced chronic neglect of basic nutrition, of developmental/learning opportunity, and of emotional development whilst living within the family home in the responsible care of their parents’. 9.2 The study ‘Working with Neglected Children and their Families: Linking Interventions With Long-term Outcomes’ (Farmer and Lutman 2012) considers the processes that are likely to affect the longer-term management of families where there are neglect issues. They are: • Becoming de-sensitised to children’s difficulties through habituation when undertaking medium- to long-term work • Normalising and minimising abuse and neglect • Downgrading the importance of referrals about abuse or neglect from neighbours or relatives • Over-identification with parents • Developing a fixed view of cases which discounts contrary information. • Viewing each incident of neglect or abuse in isolation and not recognising their cumulative impact The majority of these factors influenced the on-going work with the family. It is in many ways a classic neglect case. However the family were provided with 41 preventative interventions and early help strategies for a number of years, rather than working with them under a clear, robust and time bound plan that recognised and met the children’s needs, and used a child protection remit as required. 9.3 Children’s services in Gloucestershire have had to improve their safeguarding services after concerns were identified during an Ofsted inspection in 2011, which was when the serious concerns about Abigail were emerging. A follow up inspection in March 2012 found improvements had been made. The review was provided with information to show the relevant improvements. They include: GSCB provided a Neglect Workshop for partner agencies in March-April 2013. It was attended by staff from schools and colleges, early years, children centres, all health providers, Police, Probation, children’s social care, as well as a number of voluntary sector providers. CSC devised and published their ‘Standards with Timeline for children in need from the point of transfer to the Child and Families Teams’ in 2013. The aim is to ensure more robust work with and oversight of child in need plans. CSC appointed an independent child protection consultant to provide a neglect presentation and a neglect findings report in 2013. Each team also received a neglect research papers file to supplement the presentation. GSCB has overseen the rolling out of multi-agency professional reflective meetings from April 2013, which take place when a child has been subject to a CP Plan for over 12 months. Although it would not have assisted in this case, it should assist in the development of good practice across agencies. The awareness of and benefit of this model will be explored with partner agencies in the Section 11 audit that Gloucestershire are undertaking in the autumn of 2013. 9.4 Two recent ‘Learning Together’ reviews have been undertaken in Gloucestershire using the SCIE systems model, firstly in 2012 and then in March 2013. This review has heard that a number of the issues identified in that review have also been noted here. The findings from the 2012 review included: 42 - Managers to use Safeguarding Practice Reflection. This should be used for all staff working with families across all setting. - Keep Chronologies for children and young people. Record the significant events for your families and include any actions taken and outcomes. Multi-agency chronologies can easily be collated, they also assist with identifying needs, patterns and clear working strategies. Chronologies should be brought to multi-agency meetings to help inform interventions and assessments. The findings in the second review included: - A pattern of significant professional activity but little collaboration or challenge across agencies raises questions about what working together actually means in Gloucestershire. - In Gloucestershire there is a pattern of focussing on the tool (e.g. the Plan for the child) rather than the impact that the content has had on the child’s journey. 9.5 The CSC Agency Report provided helpful information in respect of progress in their systems and auditing in response this child’s case, and others identified during the OFSTED inspections and other reviews undertaken. These include improving children’s assessments and plans by implementing a Framework for Thinking. There remains work to do, but they are committed to embed the system across all teams. There are also improved auditing schedules, both single and multi-agency. 9.6 In January 2014, Ofsted undertook a thematic inspection of Early Help in Gloucestershire. It found that within the early help cases, children’s voices were heard and the professionals know the children well. As a result of well coordinated early help work by professionals, the children and families were well engaged. There was positive feedback to Referral & Assessment teams for the advice they give to partners. Inspectors cited some specific good practice in coordinated services for children needing early help, including the Journey into Positive Parenting (JIPP) programme, Targeted Support Teams and Integrated Youth Services. This shows there have been positive improvements since the children in this case were referred into the system. 43 9.7 The reason for undertaking this review is to learn lessons. The Reviewers have been impressed by the commitment to this process shown by the staff of the partner agencies of the GSCB. In the Agency reports the terms of reference have been addressed, and the lessons for the agency have been identified, and recommendations made. 9.8 The lessons learned for the GSCB and inter-agency practice have been identified in the analysis above, they are : Lesson 1 Professionals in the agencies involved in this case had difficulties in keeping a clear focus on the needs of the children, due to the need to negotiate the many demands and difficulties of the parents. Supervision needs to play a clear role in ensuring that assessments, plans and interventions listen to the child’s voice and consider this information when taking actions. To quote Working Together 2013 ‘Ultimately, effective safeguarding of children can only be achieved by putting children at the centre of the system, and by every individual and agency playing their full part, working together to meet the needs of our most vulnerable children.’ Lesson 2 The child’s experiences should be at the heart of all plans. Robust, time bound and outcome focused plans need to be in place for all children where there are concerns about the capacity or motivation of the parents to improve the children’s circumstances. These plans should include extended family members. Lesson 3 The following issues remain of concern and require a clear message to all agencies: - The need for clarity regarding sharing information on children and their siblings and parents, when they are not identified as a ‘child protection case’. - The need for clarity about the option of holding professionals meetings without the parents attending, which may have been useful in this case. - The need for clarity regarding the ability of all agencies to request a strategy meeting. 44 Lesson 4 It is the robustness of the plan, which must include a contingency plan and the involvement of all agencies and the family, which will ensure the needs of the children are assessed and met. Not the status of that plan. In this case it is clear that the plan should have made it clear that if the parents did not cooperate fully with what was required to ensure the children’s needs were met, that legal advice would be sought. Lesson 5 All assessments of risk should consider and analyse the historical information held across agencies. Lesson 6 All professionals working with children and families need to be trained and supported, to include the provision of reflective supervision, in the identification and challenge of parents who use manipulation and disguised compliance, to ensure the needs of the child remain the priority. Lesson 7 All agencies need to have the confidence to challenge or question decisions taken by other professionals in partner agencies. Clear guidelines and training, supported by supervision, needs to give professionals the confidence to challenge each other and to escalate any concerns they have via the resolution policy. The review has heard that agencies defer to Social Care when it comes to decisions about the need for services to be provided to children in need and in need of protection. GSCB need to ensure that they advertise the message, including in training, that professional disagreement is a positive sign of a healthy safeguarding system. Lesson 8 Staff across all agencies must have a shared understanding of neglect and its impact on the safety, wellbeing and development of children. All professionals working with children should be trained and supported in regards to recognising child neglect, and be provided with the tools to work effectively with children and families where there are concerns about neglect. This includes a focus on building a shared understanding of the children’s history 45 by incorporating all of the information held on the family across the agencies involved. Good Practice and systems that worked well 9.9 It was clear that a number of professionals provided the children and family with a high level of support and assistance. This should not be lost in the analysis of why things went wrong. The family had good consistency of care from health and education professionals, who provided extra support and services to the family for many years, this included the Children’s Centre, the Health Visitors, the GP and the schools. All undertook regular home visits. Both Health Visitors showed persistence in getting access to the house when appointments were regularly missed. 9.10 There were examples of CSC visiting with other professionals, particularly the Health Visitors, in both the first and last key practice episodes. 9.11 When meetings were held, they were very well attended. Whatever the status of the meeting, those that were invited attended. This reflects the amount of concern in the professional network, but also the strong commitment to the children. 9.12 Professional challenge was evident from the schools and the Health Visitors in particular, but also from doctors in primary and secondary care. 9.13 The three schools talked to each other regularly. Information on the children was transferred appropriately at transition and there was a good understanding of the challenges the children faced from their peers due to their problems. 9.14 Since the children were removed from their parents care the Local Authority has been proactive in placing them and getting appropriate orders to ensure their future. The children are reported to be settling well in their current placements, and are receiving help to recover both physically and emotionally from the significant harm they have endured. 46 10 Recommendations 10.1 Each agency report submitted to this review has included reflection on its individual learning, and made recommendations that are agency specific. The lead reviewers welcome this and recommend they are followed through and that progress is reported to the GSCB. 10.2 Listed below are the recommendations from this overview report. Recommendation 1: GSCB to undertake an audit of assessments and of child in need and child protection plans to ensure that the child’s voice has been heard and is taken into account in the conclusion of the assessment and throughout the plan. Recommendation 2: The GSCB should support a framework of meetings which allow professionals involved in particular cases to meet and reflect on professional dynamics and disagreements without the presence of children and families. Recommendation 3: That the GSCB review its model of reflective supervision, to ensure that it is fit for purpose in assisting professionals to gain confidence in working with parents who are manipulative and show disguised compliance. Consideration is to be given to using this model with more complex Child in Need cases, as well as those subject to a Child Protection plan. Recommendation 4: That the GSCB’s new Levels of Intervention model includes a clear link to the professional challenge policy, and is clear that requests for explanations of why decision have been made should be sought as applicable. Recommendation 5: That GSCB review their neglect training to ensure that it has improved the shared understanding of neglect across agencies. This review should include a request that all agencies review professional training and qualification courses locally to ensure they include training on child development and the impact of neglect. 47 ……………………….. 48 Bibliography Ofsted Learning lessons from serious case reviews, year 2 October 2009 Ofsted The voice of the child: learning lessons from serious case reviews April 2011 Ward, H, Brown, R, Westlake, D Safeguarding Babies and Very Young Children from Abuse and Neglect 2012 Action for Children State of child neglect in the UK 2013 Farmer, E, and Lutman, E Working with Neglected Children and their Families: Linking Interventions With Long-term Outcomes 2012 Brandon M et al The Biennial Analysis of Serious Case Reviews 2003-2005 DCFS 2008 49 Appendix 1 – Terms of Reference and Project Plan SCOPE The subject child and where appropriate her three other siblings, during the period between August 2010 (strategy discussion) to 23rd November 2012 (admission to hospital). FRAMEWORK Serious Case Reviews and other case reviews should be conducted in a way in which : Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings (Working Together para 10, March 2013) AGENCY REPORTS TO BE COMMISSIONED 1. GP 2. School Nurse and Health Visiting 3. Education/Early Years/Children’s Centre 4. Children’s Social Care 5. Police 6. Hospitals Trust Gloucestershire (Midwifery and Paediatrics) TERMS OF REFERENCE Individual agency reports need to consider 1. The quality of risk assessment and how the levels of need / harm were assessed by individual agencies. 2. The individual agency reports need to encompass a view as to how an analysis of historical information was used to inform assessment and decision making and evidence of use of a chronology of key events. 3. The culture and approach of each agency (collective if more than one team / school involved) and individual within the agencies towards neglect. 4. Whether professional differences occurred and if so how they were responded to. 50 5. The level and quality of partnership working when the lead professional role was held in the community. 6. The level and quality of partnership working when social care were the lead agency. 7. The timeliness of responses by professionals (internal and external to the agency report) to issues raised. 8. To identify and include areas of good practice within each agency A TEMPLATE FOR AGENCY REPORTS Attached TIMETABLE Scoping / terms of reference 23 April Commissioning letters 3 May Authors Briefing 17 May Distribution of material to all attendees 9 August Learning Event 9 September Drafting 1st report and distribution 3 October Recall Day 10 October Revising Report 17 October Presentation to LSCB/SCR Sub group 23 October Meetings with Family/Significant Others Explanation of Process 10 May Feedback re: experience of services 10 June Discussion of final report 23 October Appendix 2 – Template for Agency Report 51 AGENCY REPORT (name of agency) SIGNIFICANT INCIDENT LEARNING PROCESS SUBJECT : BORN : Name of author Job title Date INTRODUCTION 52 PURPOSE Previous statutory guidance suggests the purpose of a serious case review is : To establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children To identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and Improve intra- and inter-agency working and better safeguard and promote the welfare of children (Working Together para 8.5, March 2010) FRAMEWORK Serious Case Reviews and other case reviews should be conducted in a way in which: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisation involved at the time rather than using hindsight; Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings (Working Together para 10, March 2013) SCOPE 53 The subject child and where appropriate her three other siblings, during the period between August 2010 (strategy discussion) to 23rd November 2012 (admission to hospital). Section 1 – Summary of Facts a. Summarise in narrative form the key information relating to W from your agency/service. b. Summarise the services offered and / or provided to her and/or the decisions reached. Section 2 – Other Relevant Information a. Report any significant information prior to December 2010 which you consider to be relevant to the learning. Section 3 – Analysis a. Critically analyse and evaluate the events that occurred, the decisions made and the actions taken or not. b. Where judgements were made or actions taken which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why. c. Demonstrate whether your agency/service heard and responded to X’s views, wishes and feelings. d. Identify and explain if your agency/service believes that other agencies/services should have been sought and /or provided. You may find the 12 trigger questions from previous statutory guidance (para 8.39 of Working Together 2010) helpful in framing your response. However, it is not expected that you methodically answer every question. Use it as a guide. These questions are attached as appendix 1. Section 4 – Terms of Reference Individual agency reports need to consider 1. The quality of risk assessment and how the levels of need / harm were assessed by individual agencies. 54 2. The individual agency reports need to encompass a view as to how an analysis of historical information was used to inform assessment and decision making and evidence of use of a chronology of key events. 3. The culture and approach of each agency (collective if more than one team / school involved) and individual within the agencies towards neglect. 4. Whether professional differences occurred and if so how they were responded to. 5. The level and quality of partnership working when the lead professional role was held in the community. 6. The level and quality of partnership working when social care were the lead agency. 7. The timeliness of responses by professionals (internal and external to the agency report) to issues raised. 8. To identify and include areas of good practice within each agency Section 5 – Conclusions and Recommendations In your conclusion please consider learning for your agency and multi agency learning as separate issues. Highlight strengths as well as weaknesses. Consider how you will recommend improvements may be made to services, ie What action should be taken by whom and when? What outcomes should these actions bring, and in what timescales, and How will the organisation evaluate whether they have been achieved? Single agency recommendations should be brought into the overview report and Questions here should be more positive to promote good practice e.g. where was good practice identified? APPENDIX 1 a. Were practitioners aware of and sensitive to the needs of the children in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? b. When, and in what way, were the child(ren)’s wishes and feelings ascertained and taken account of when making decisions about the provision of children’s services? Was this information recorded? c. Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare? 55 d. What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way? e. Did actions accord with assessments and decisions made? Were appropriate services offered/provided, or relevant enquiries made, in the light of assessments? f. Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? g. Where relevant, were appropriate child protection or care plans in place, and child protection and/or looked after reviewing processes complied with? h. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded? i. Were senior managers or other organisations and professionals involved at points in the case where they should have been? j. Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? k. Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? l. Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? m. Was there sufficient management accountability for decision making? 56 GLOUCESTERSHIRE SAFEGUARDING CHILDREN BOARD SUBJECTS Abigail and her siblings Bobbie, Charlie and Daisy Overview Report – Additional Section Author: Janice Waters MSc Registered Nurse Specialist Nurse Safeguarding 12th August 2014 57 CONTENTS Section Topic Page 1 Introduction and rationale for the report 58 2 Methodology 59 3 The new information 61 4 Summary of sentencing comments 62 4a Peaks and Troughs 62 4b Not a case of deliberate behaviour 62 4c Physical disabilities 63 5 Summary of Psychotherapist’s feedback 63 5a Powerful personality disorder 64 5b Professional splitting 64 5c Systemic paralysis 65 5d Challenges 66 6 Summary of further information from Housing 66 6a Record keeping 66 6b Accessing the home 67 6c Challenges 67 7 Summary of the Practitioner Learning Event 68-70 8 Conclusion 71 References 72 Appendix 73 58 1. Introduction Working Together 2013 (Department for Education 2013) states that serious case reviews (SCR) of incidents involving children should be conducted in a way that Recognises the complex circumstances in which professionals work together to safeguard children. Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. Is transparent about the way data is collected and analysed. Uses relevant research and case evidence to inform the findings. With this in mind, a serious case review was undertaken through a SILP review process. Following the court proceedings, further work has been undertaken in a way that ensures these principles have been followed, including a multi agency Practitioners Learning Event. This additional section records the findings of this further work. Rationale for the report As was anticipated, other significant information about the family came to light during the court process in respect of the parents of Abigail and her siblings Bobbie, Charlie and Daisy. The additional information has emerged from 3 sources The sentencing remarks during the criminal proceedings (16th June 2014) The report of the Psychotherapist (30th June 2014) Additional views sought from Stroud District Housing (2nd July 2014) In keeping with the SILP report, and the methodology of this additional section, a follow up Practitioner Learning Event was held on the 4th July 2014 to uncover any new learning from the new information. Abigail’s parents declined the offer to take part in any discussion at this time. The PLE was found to be especially powerful in supporting practitioners to effectively collaborate in the process of learning and analysis and to this end Gloucestershire Safeguarding Children Board (GSCB) would like to thank those taking part for their timely and effective contribution to the process. 59 This additional review does make further recommendations; the additional Practitioner Learning Event (PLE) has confirmed support for the recommendations made. Professionals felt the value of their additional discussions would be best reflected by identifying the key issues that the safeguarding board should consider. It is for this reason that this additional section will pose a series of challenges to the Gloucestershire Safeguarding Children Board (GSCB) rather than the setting out of specific recommendations. This is in line with serious case reviews produced nationally using the systems methodology that has also informed this case review. This section will therefore Focus on practitioner reflections at the learning event of the new information that emerged as a result of the court process. Take the opportunity for further reflection on practice in the 6 months leading up to the parents’ arrest on 24th Jan 2013. Reflect on what has changed since that time. 2. Methodology The methodology for this additional work is taken from ‘Systems analysis of clinical incidents: The London protocol’ (Taylor-Adams et al. 2004). This system is based upon James Reason’s ‘Swiss Cheese model’ of accident causation used in risk analysis and management in systems such as aviation, engineering and healthcare (Reason 2000). The model likens human systems to multiple slices of Swiss cheese stacked side by side and is sometimes called the cumulative act effect. The Swiss cheese model of accident causation illustrates that although many layers of defence lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident or incident to occur Taylor-Adams’ and Vincent’s protocol provides a structured, systems approach to the process of learning from incidents in health care settings, providing a “window on the system”. Examples of their work have been adapted in various ways to support investigations outside healthcare, for example by the Social Care Institute for Excellence (SCIE). The purpose of the protocol is to ensure both a comprehensive and a thoughtful investigation of an incident and to move practitioners beyond the identification of fault and blame. Thus, a structured approach to the use of practitioner reflection has been found to be successful in utilising clinical experience and expertise to its fullest extent. 60 This approach is reported by Taylor-Adams and Vincent to assist the reflective investigation process, because: ‘While it is sometimes straightforward to identify a particular action or omission as the immediate cause of an incident, closer analysis usually reveals a series of events leading up to adverse outcome. The identification of an obvious departure from good practice is usually only the first step of an investigation’. ‘A structured and systematic approach means that the ground to be covered in any investigation is, to a significant extent, already mapped out. This guide can help to ensure a comprehensive investigation and facilitate the production of formal reports when needed’. ‘If a consistent approach to investigation is used, members of staff who are interviewed will find the process less threatening than traditional unstructured approaches.’ ‘The methods used are designed to promote a greater climate of openness and to move away from finger pointing and the routine assignation of blame.’ (The London Protocol) This methodology supports the inclusion of ‘contributory factors’ adapted from the London Protocol, using the notion of holes or weaknesses identified in James Reason’s ‘Swiss cheese’ model. Contributory factors are deemed to be features that reveal examples of either good practice or practice that could be improved. Contributory Factors Child or family factors; examples of which may include; Complexity of the problem(s) Personality and social factors Manner of presentation, language and communication – relationship with professional(s) - seeking help, hostility, disguised compliance, impact on professionals and how they worked together 61 Task and technology factors; examples of which may include; Understanding nature of task – e.g. waiting for serious incident, or gathering a cumulative picture? Decision making aids utilised (or not) Availability and use of protocols Frontline Professional factors; examples of which may include; Knowledge, skills, competence Human reasoning Communication/Information sharing Managerial support/Supervision Clarity of roles between professionals Attention (what were the professionals focussing on, the same, or different things?) Culture of dealing with disagreement – was it explicit or covert? Organisational and management factors; examples of which may include; Organisational priorities, structures, cultures – either single, or multi-agency Thresholds, application of local policy & procedures Availability of or gaps in services e.g. expert assessment on personality/capacity to change? National level factors; examples of which may include; Statutory policy e.g. on information sharing, is this a help or hindrance? Tools: assessment, risk management Links with external organisations An interaction matrix is available in the appendix and offers a visual interpretation of the contributory factors drawn out at the Practitioner Learning Event (Appendix 1). 3. The new information This section will consider in turn, the summaries of The sentencing remarks 62 The Psychotherapist’s feedback The housing information Within each summary, consideration will be given to the influencing contributory factors, the response of the practitioners at the learning event to the new information and any learning and challenges which were highlighted. 4. Summary of the sentencing remarks The main points that professionals reflected on in relation to sentencing remarks relate to ‘Peaks and Troughs’ in episodes of neglect throughout the years Reference to this not being a case of ‘deliberate behaviour’ The presence of physical disabilities for both parents. 4a: Peaks and Troughs (Child and family factor) Peaks and troughs in episodes of neglect were highlighted in the sentencing remarks. Whilst there were undoubtedly times when care of the children appeared to improve, the phrase ‘peaks and troughs’ used by the Judge was reflected on by professionals who worked with the family in the context of ‘Disguised Compliance’. This means a situation which poses difficulties for professionals working with families and involves the parent or carer giving the impression of co-operating with services in order to diffuse professional intervention. The term, disguised compliance is attributed to Reder, Duncan and Gray in ‘Beyond blame: child abuse tragedies revisited’ (Reder P et al. 1993). The effect of disguised compliance is to neutralise the authority of the professional, examples of which occur in this case in the sporadic attempts at increased school attendance, attending medical appointments, engagement with professionals for a limited time or the cleaning of the home prior to visits by professionals. 4b: Not a case of deliberate behaviour (Child and family factor) Sentencing highlighted that this was not a case of deliberate behaviour but stated that the parents were ‘inadequate, stupid, stubborn, incompetent but not wicked’. 63 Practitioners at the learning event reflected on the parents’ stubbornness in not responding to professional advice and felt that, on occasions, they exhibited disguised compliance. Examples of this were cited as when the prescribed cream for Abigail’s nappy rash had been squeezed out so as to appear that it had been used and another occasion when it was hidden from view during a professional visit. On other occasions, the cream was used to reinforce a sense of compliance with professionals in an aim to reassure them that the nappy rash was being treated. Professionals at the learning event were clear that Abigail’s mother was resistant to following advice given by them. 4c: Physical disabilities (child and family factor) The physical disabilities of both parents were referred to in the sentencing remarks. The children’s parents both had health and psychological problems of their own, which demanded a lot of professional attention. Practitioners at the learning event confirmed that there was no clear evidence of physical disabilities being the reason for neglect of the children, but rather a case of the parents placing of their own needs above those of the children. This led the PLE to reflect further on incidents where parents appeared to prioritise their own needs; One example includes the number of GP appointments that the parents attended; a total of 100 appointments are recorded during the period for the parents whereas there are just 40 for children despite the number of children involved, the nappy rash, a diagnosis of anaemia and the hospital admissions. Further examples of parental need above that of the children includes the parents taking a holiday which was longer than had originally been planned and stating that they had taken the nappy rash cream with them, but in fact did not. Practitioners at the learning event reported that Abigail’s mother had told them they had never had a honeymoon and that it was their right to do so. 5. Summary of the Psychotherapist’s feedback The main points to be discussed within the Psychotherapist feedback relate to Powerful personality disorder Professional splitting Systemic Paralysis 64 5a: Powerful personality disorder (Child or family factor) The Psychotherapist and her colleagues, working in a separate capacity with a member of the family, made contact with the review team as a result of the family court case. The Psychotherapist recognised within Abigail’s mother a ‘diagnosable and powerful personality disturbance’. She reports a very clear view about the power of Abigail’s mother as a personality who continually interrupted the interview process with her daughter and who could not prioritise her children’s needs above her own. An example given was an incident where the older daughter understood that her baby’s nappy needed changing but appeared to wait for her mother to give her permission to do so. Abigail’s mother was reported to be open and confident in revealing to the Psychotherapist and others that she had been advised to admit Abigail to hospital but had gone against this advice. She described herself as a busy mother who loved her children very much. This confidence was further evidenced by not hiding the nappy rash from the visitors in the house, professionals at the learning event queried whether this was an opportunistic or purposeful act. Abigail’s Grandmother was reported to have been wary of upsetting her daughter for fear of being excluded from the care of the children. 5b: Professional Splitting (Frontline professional factor) The powerful personality displayed by Abigail’s mother appeared to give her the opportunity to divide professional opinion between the Psychotherapist and her colleagues. This was described as a case of ‘professional splitting’ (Melia et al. 1999). Melia et al described professional splitting as the ability to divide loyalties amongst professionals by comparing and complaining about one with another. Abigail’s mother was reported to have the ability to ‘literally fill the room’ and that by doing so was able to divide opinions amongst the Psychotherapist and colleagues, thereby ‘splitting the group’. This resulted in one half of the group reporting that the state of the home and the presentation of the child was ‘none of the their business’ and the other half reporting that ‘serious risk issues were being identified’. Practitioners at the learning event reflected on this additional information from the Psychotherapist and discussed the comments about ‘professional splitting’ in the context of their own experience of the parent’s complaints about one organisation to another. Abigail’s mother was described as being able to influence others, for example the children’s 65 hairdresser who was persuaded to write a letter to health services to say that the children didn’t have head lice when evidence pointed otherwise. Child protection thresholds were viewed as having been reached by some professional groups but not all. This allowed the parents to split professional opinion and resulted on one occasion in Abigail not being admitted to hospital for treatment of her nappy rash. Recognition of ‘professional splitting’ is an example of good practice and could be improved through the sharing of information that recognises the difficulties faced by professionals when dealing with families who criticise professionals and organisations. 5c: Systemic Paralysis (Frontline professional and organisational contributory factor) The Psychotherapist revealed discussions held with colleagues about the filthy state of Abigail’s home and describes the smell emanating from the family and the malnourished appearance of Abigail, who at 3 years old was still in nappies. These were described as serious safeguarding concerns by some, but not all of her colleagues. In light of her concerns, the Psychotherapist reports that she made numerous attempts to contact Children’s Social Care (CSC) but was not able to speak with a social worker for a couple of weeks due to a number of missed attempts at contact by both parties. She questions that in her opinion, whether a ‘systemic paralysis’ was in evidence. By this time CSC were conducting their own investigations and did not view this information as warranting immediate, additional action. Systemic paralysis is described as the act of professionals unconsciously colluding with a parent’s denial of a given situation and themselves becoming at risk of using the same defensive processes as the parents. Practitioners at the learning event reflected upon this statement but did not agree with the Psychotherapists findings. Practitioners at the learning event questioned why the Psychotherapist did not follow up their concerns with a letter or escalate to the manager of the team is there was no response from the social worker. The Team Manager of the team was not aware that this professional had been unable to speak with the social worker so had not been in a position to intervene. The social worker in question was not part of the review as they no longer work for the local authority. 66 5d: Challenges The following reflections and challenges for local services are provided in relation to the information above and placed within the context of systems learning. Should further training be developed for professionals to enable them to remain focused on the purpose of a home visit and take the lead in the conversation rather than following the lead of the parents or carers? Is there sufficient understanding of the concept of ‘professional splitting’ across partners? Are professionals across the child protection system able to recognise when systemic paralysis may be occurring? Should training be made available to assist professionals to recognise the symptoms of professional splitting and systemic paralysis? 6. Summary of further information from Housing The main points from the Housing related to Record keeping Access to the home The feedback from the Housing Department at Stroud District Council (SDC) informed the further PLE that they were not aware of any concerns from a housing perspective, apart from the use of a wood burning fire in the property, which is not an issue related to the neglect of children. Reassurance has been given that all staff members undertake training in safeguarding and are aware of the need to report concerns with to the lead safeguarding officer. It is good practice that staff are all trained in safeguarding, but another perspective on the family might have been gained if they had been more involved at the time. 6a: Record keeping (Frontline professional factor and organisational factor) The family was noted to be difficult to contact and records suggest that, therefore correspondence tended to be by letter. The housing officer involved at the time of the issues raised by the SCR is reported to be no longer employed at SDC and therefore clarity is being sought by them as to whether or not contact was made with the family but not entered into the case notes. If so, an individual management review will be recommended. 67 6b: Accessing the home (Task and frontline professional factor) Factors relating to the child and family are apparent in the difficulty experienced by the housing officer in accessing the house. The difficulties experienced by other professionals, for example hostility and a lack of cooperation may have also been experienced by the officer working with this family. Opportunities to engage with other professionals were unfortunately not identified and may therefore have been missed. Right of entry could have aided this case, for example during gas and heating boiler checks. This may have assisted housing officers in accessing the home perhaps in conjunction with other professionals and therefore represents a missed opportunity to intervene in the welfare of the children. The photographs picturing ivy in one of the children’s bedroom were used by the police during the court case to convey the state of the house and were reflected upon during the practitioner learning event. It was confirmed that these were taken 2 months after the children had left the home and did not represent how workers saw the home while the children were actually living in it. 6c: Challenges Is the importance of the role of housing recognised in child protection work locally? How do we ensure there is a better understanding of ‘right of access’ in respect of the condition of homes owned by LAs or social landlords? How do we enhance the understanding of housing professionals of the impact of housing conditions on families e.g. on a child’s education? How can we progress collaborative working with Housing professionals and should the model of basing family support staff within Housing agencies operating within Families First be replicated? 68 7. Practitioner Learning Event: What we are doing differently As the majority of the responses to the new information are contained within each of the preceding sections, this section highlights the remaining areas of conversation during the practice learning event and highlights what Gloucestershire are already doing differently. A: Healthy challenge involves checking, clarification, being inquisitive and asking the question why. The safeguarding system does not exist without healthy challenge. Healthy challenge has taught us to be aware that just because parents say something it doesn’t mean that it is happening. Some professionals and individual agencies felt that they don’t always have the information to be able to challenge because parents or carers don’t always wish to share information and as a result do not give consent to do so. School practitioners reported that they were not always able to exercise healthy challenge at the level of ‘child in need’ section 17 Children Act 1989 enquiries (s.17) as experienced in this case where Abigail’s mother did not consent for the school to receive the report. A better understanding across agencies now exists of when the threshold of child protection is met and a strategy discussion needed as opposed to when a multi-agency meeting is required. B: At the time of the case, agencies felt although they might share information they would not always get something back. Working with neglect requires proper information sharing across agencies which is less straightforward than it might appear. When working with a Child in Need under section 17 of the Children Act, parental consent to share information is vital. This meant professionals working with Abigail were not necessarily free to gather information from all professionals to identify whether this revealed persistent neglect, as the parents withheld consent for information to be shared between all agencies. Social Workers in the case were particularly mindful of the judicial risks of escalating enquiries to child protection level and the full sharing of information without enough supporting evidence to do so. This is an area under scrutiny by the GSCB as part of the MASH (Multi-agency Safeguarding Hub). Social care reflected that it is rare that a parent refuses consent to share information and when they do their parental rights are respected, but the reasons why they might be withholding consent need to be robustly considered. 69 C: Professionals agreed that the assessment under the Common Assessment Framework (CAF) was not robust in that it wasn’t child focussed, was inadequately monitored and wasn’t multi-agency. Professionals discussed the robustness of the plan and recognised that this is what is important. The level of the plan, whether it is a CAF (Common Assessment Framework), CiN (Child in Need) or CPP (Child Protection Plan) isn’t what makes the plan ‘right’. It is about the plan being able to meet the needs and hearing the voice of the child. This ‘culture of practice’ has moved on and professionals now consider more closely the impact of the plan for the child with a clear contingency plan in place. Plans are tighter and time limited. Police will be involved in the process sooner. D: There was recognition of the fear of family disengagement within the group and a discussion of how organisations made attempts to keep children safe. For example, schools report achieving this by placing importance on being able to see children at school on a daily basis. E: Frustration amongst practitioners was evident in the response to Children’s Social Care who they felt had not always responded adequately to the situation of children in this family historically. CSC confirmed that they had made unannounced visits to the family which did not raise concerns for them and at times what was observed in the family home appeared to invalidate the concerns about neglect that were being reported by professionals. F: In this case the parents were difficult to work with. Professionals were trying to work with them and not allow a breakdown of the professional relationship due to the fear of family disengagement and not being able to keep the children safe is very powerful. Abigail’s mother was discussed as being extremely manipulative with the ability to isolate professionals. Practitioners at the learning event discussed how practice has improved and they would now have a better understanding of the history of the families they are working with. G: Practitioners at the learning event reported that sometimes their experience is that the rights of the parent seem paramount to the rights of the child and at the time of this case, this was thought to be so. Of course this will always be an area where a balance needs to be maintained. There is now an emphasis on seeing children as individuals in their own right who are encouraged to express their opinions, wishes and desires. 70 H: Agency drop off was discussed and described as the experience of Children’s Social Care (CSC). This means that once a referral has been accepted by CSC then other agencies expect them to take the lead whilst the continued involvement and engagement from key professionals is vital to protect children. Agencies were encouraged to maintain their involvement. Challenges Should the GSCB provide more information and training on how to deal with families who employ disguised compliance? Peaks and troughs were observed in this case, a better understanding of the long term impact of neglect demands a long term perspective in understanding whether families are able to make sustained improvements. How can the GSCB promote good planning and clear milestones? Are professionals now better able to balance conflicting needs within families so that parents needs do not take priority over the needs of the children? Are we confident that practitioners respect each other’s views regarding thresholds and avoid unintentionally colluding with challenging families? 71 Conclusion The new information that has now become available in this case suggests that the contributory factors are predominantly associated with the child and family (Appendix 1). It is likely that these factors caused problems for frontline professionals who felt the full force of the difficulties associated with working with this family. Systemic paralysis, if indeed it exists, in combination with a lack of robust planning, feature as organisational contributory factors. Professionals at the learning event were able to confidently identify areas of improvement and ‘moving on’ in order to give reassurance for future practice. Training on the importance of neglect has been rolled out across the partnership. Relationships are reported to have improved and there is increased evidence of ‘joined up’ working. Children are seen individually and their voices are heard and recorded. Practitioners reported that it is good to be challenged, it is welcomed and that we are working in an environment where we need to keep the children at the forefront. The GSCB will receive the systems learning points, recommendations and challenge issues set out in the SILP report and the additional section in order to produce a robust Response Plan which will be monitored until completion of all agreed actions. Janice Waters 72 References Department for Education. 2013. Working together to safeguard children [Online]. Available at: http://www.education.gov.uk/aboutdfe/statutory/g00213160/working-together-to-safeguard-children [Accessed: 12.07.2014]. Melia, P. et al. 1999. Triumvirate nursing for personality disordered patients: crossing the boundaries safely. Journal of psychiatric and mental health nursing 6, pp. 15-20. Reason, J. 2000. Human error: models and management. Bmj 320(7237), pp. 768-770. Reder P et al. 1993. In: Routledge ed. Beyong blame: Child abuse tragedies revisited. pp. 106-107. Taylor-Adams, S. et al. 2004. Systems analysis of clinical incidents: the London protocol. Clinical Risk 10(6), pp. 211-220. 73 Appendix 1 Interaction matrix to reveal where contributory factors impacted on the case Child or family factors Task Factors Frontline professional factors Organisational factors National factors Judge’s sentencing comments Peaks and Troughs Not a case of deliberate behaviour Physical disabilities Psychotherapist’s feedback Powerful personality disorder Professional Splitting Systemic paralysis Systemic Paralysis Housing feedback Failure to access the home Lack of record keeping Failure to access the home Lack of record keeping Practitioner Learning Event Lack of healthy challenge Fear of family disengagement Parents difficult to work with Rights of the parents over the children Lack of response by CSC Lack of information sharing Agency drop off Lack of robust plans |
NC51774 | Death of a 15-year old boy in May 2018. Archie was fatally stabbed by another young person. Archie arrived in the UK in 2014 with his mother and lived with his adult sister and three older siblings until mother's return in 2015. Enrolled in a different school to siblings' due to lack of places. Death of adult sister in a house fire had a traumatic impact on Archie. His behaviour in school began to deteriorate and moves to new schools were unsuccessful, resulting in periods where Archie was home educated. Detained for shop lifting; other offending quickly escalated. Frequent episodes of missing from home; involved in gang culture, controlled and exploited by older associates; known to the criminal justice system and youth justice; subject to a Child Protection Plan. Archie was of African Caribbean heritage. Learning is embedded in the recommendations but also includes: impact of bereavement must not be underestimated. Recommendations include: when a parent elects to home educate their child, the local authority should seek reassurances that the child is receiving a balanced education, including a home visit for an assessment by a trained professional; local authority must develop and communicate a clear escalation process for children not on school roll; ensure there are structures in place to assess, refer and intervene with vulnerable people who may be exploited by gangs and organised crime groups; clear referral route for vulnerable young offenders; implement Child Protection conferences that assess risk and develop plans in line with increased understanding of contextual safeguarding.
| Title: Serious case review: Archie: final report. LSCB: Sheffield Safeguarding Children Board Author: Mike Cane Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Archie Final report Independent Author: Mike Cane Published: February 2020 2 His mum’s memory of her child…. My son was a cheerful, energetic and happy child! His powerful voice of laughter filled the rooms in our home with joy. His big eyes could penetrate and know when something was wrong. His football coach remembered him as a hardworking, passionate and reliable football player. He loved going to Sunday school and was an active participant in helping out. He had a big heart and a giving spirit that was expressed in so many ways to his family and friends. He was my calm! Forever missing his presence and innocent attitude. Forever missing his hugs and kisses. Forever missing his immeasurable smile. Forever missing the Happy Go Lucky Child who lived his life fearless! Gone, but not forgotten, Loved forever 3 Contents: 1. Introduction 2. Methodology and Terms of Reference 3. Brief Synopsis 4. Family Involvement 5. Analysis 5.1 General Comments 5.2 An understanding of the educational arrangements in place and the support offered to Archie and his mother 5.3 The involvement in and influence of gangs including any evidence of criminal exploitation 5.4 An understanding of Archie’s offending behaviour and attempts to tackle or address this 5.5 Specific Agency Issues 5.6 Responses to episodes of ‘missing’ 5.7 Support Archie received in relation to the bereavement of his sister 5.8 An analysis of the Child Protection Plan and its effectiveness 5.9 Support offered to his mother (for example housing, police, health, education, courts, social care) 6. Findings and Recommendations 7. Glossary 4 1. Introduction 1.1 In May 2018 a young man was fatally stabbed in Sheffield. He was taken by ambulance to hospital but, despite the efforts of medical staff, he sadly died an hour later. Archie 1 was aged 15 at the time of his death. 1.2 The death of any child is a tragedy. Sheffield Safeguarding Children Board and all organisations involved in this review offer their sincere condolences to Archie’s family. 1.3 Chapter 4 of Working Together to Safeguard Children 2015 states that Serious Case Reviews and other case reviews should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children. Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. Is transparent about the way data is collected and analysed. Makes use of relevant research and case evidence to inform the findings. Following consideration by Sheffield Safeguarding Children Board it was recommended that this case met the criteria for a Serious Case Review and this decision was endorsed by the Independent Chair of the Board in June 2018. 1.4 Sheffield Safeguarding Children Board appointed an Independent Author for the review. Mike Cane is a retired senior police officer. During his career he led homicide enquiries and investigations involving the deaths of children. As the Head of a ‘Protecting Vulnerable People’ department he was the police representative on a Local Safeguarding Children Board and Child Death Overview Panel in the North East. Since leaving the police service, Mr Cane has completed a number of Serious Case Reviews and Domestic Homicide Reviews as both an Independent Chair and an Independent Author. He has no connection to Sheffield and has never been employed by any of the organisations involved in this review. 1.5 A Serious Case Review Panel was established to oversee the review with representatives from; Children Young People and Families, Sheffield City Council Sheffield Housing and Neighbourhood Services Youth Justice Service, Sheffield City Council Commissioning, Inclusion & Learning, Sheffield City Council 1 ‘Archie’ has been used as the pseudonym for the subject of this review, with the agreement of his family 5 South Yorkshire Police Sheffield Clinical Commissioning Group (CCG) Sheffield Children Hospital NHS Foundation Trust (Acute Services) Sheffield Children Hospital NHS Foundation Trust (Community Services) Sheffield Futures 1.6 The Independent Author, Mike Cane, attended all panel meetings. 2. Methodology and Terms of Reference 2.1 The Review Panel agreed that the review should consider a period from September 2015 through to the date of Archie’s death on 24th May 2018. Agencies that had been involved with Archie between those dates were asked to provide chronologies and brief reports of their involvement including any relevant background information which pre-dated this time period. 2.2 In carrying out this review the Overview Author held a ‘Learning Event’ to which frontline staff and their managers were invited. This helped to gain a greater understanding of the context in which practitioners worked with the family and the reasons for the decisions they made and the actions they took. Another principle is that families should be invited to contribute to reviews. The Overview Author met with Archie’s mother as part of this review. Information she provided is included throughout the report where it informs the learning 2.3 The specific areas of focus identified by the panel were: An understanding of the educational arrangements in place and the support offered to Archie and his mother. The involvement in and influence of gangs, including any evidence of criminal exploitation. An understanding of Archie’s offending behaviour and attempts to tackle or address this. Responses to episodes of ‘missing.’ An analysis of the Child Protection Plan and its effectiveness. Support Archie received in relation to the bereavement of his sister. Support offered to his mother 6 3. Brief Synopsis 3.1 Archie aged 11 arrived in the United Kingdom with his mother in summer 2014, initially living with his adult sister and three older siblings when his mother returned home, before his family moved to the UK later that year. Archie’s mother was fleeing an abusive relationship. 3.2 On arrival in Sheffield, he was enrolled by his elder sister into a local school where he started in December 2014. This was not the same school as his older siblings or Archie’s mother’s or sister’s preferred choice but there were no places available at this school in his year group. 3.3 Archie’s adult sister died in a house fire in September 2015. This had a traumatic impact on Archie’s life. His mother became frustrated with agencies and reluctantly elected to ‘home educate’ her son. This was not her preference, but she felt she had no option to avoid his isolation while awaiting a choice of new school. Archie began to miss significant amounts of education. His behaviour and attendance deteriorated. 3.4 In December 2016, Archie was detained, along with a male of a similar age, at a department store. They had a concealed an item of clothing before attempting to leave. Police were called and both boys admitted to the offence of shoplifting. Restorative Justice was applied which included a condition to engage with the Community Youth Team when requested. This was Archie’s first direct contact with the criminal justice system. 3.5 In the following months, there was a rapid and significant increase in the level of offending involving Archie. The offences were serious and involved use of violence and carrying knives. He was frequently reported ‘missing from home’. 3.6 Archie began to associate with older boys and young men. He described these as his new ‘FAM’2. He became involved in gang culture. 3.7 In November 2017 an Initial Child Protection Conference was convened and Archie was made subject to a Child Protection Plan under the category of physical abuse. He was still subject to a Child Protection Plan at the time of his death. 3.8 In May 2018, Archie was taken by ambulance to the Hospital Emergency Department with two stab wounds to his chest and sadly died as a result of his injuries. 4. Family Involvement 4.1 Archie’s family have been involved in this review. The Independent Author met with Archie’s mother to discuss her experiences and note her concerns and the contents of 2 Street slang for ‘family’. 7 this report have been shared with her. Her views and opinions have informed the report findings. His mother’s memories of him are shared at the beginning of this report. 4.2 Archie and his mother came to the UK around September 2014. His mother was very keen to get him and his siblings into school and tried to enrol them as soon as possible. After a few weeks his mother had to return to their home country to arrange a number of matters and she left Archie in the care of his adult sister. She recalls her adult daughter would send her photographs. These showed he was happy, but she does remember that some pictures showed holes in his uniform and she believed he had been getting into fights. 4.3 His mother returned to the UK on a permanent basis around March 2015. She was disappointed that Archie had not been given a place at her preferred choice of school where his siblings attended but he did not seem to be having any major issues at that time with his education. He struggled a little with some English lessons but was good at Mathematics. She agrees with professionals’ observations of him at that time as ‘a very polite and respectful boy’. 4.4 Her older daughter died in a house fire in September 2015. As well as the emotional loss, Archie’s mum had also relied heavily on practical support from her daughter. She acknowledges she ‘locked myself in my room and was not there for my children’. She did not feel able to give Archie any support and later apologised to him that she hadn’t been there for him during that difficult time. 4.5 His mother believes the bereavement he suffered at the loss of his sister (to whom he, in particular, was very close) affected his behaviour and he started to get into trouble. She accepts he had been disruptive but she was disappointed when the school placed him into ‘isolation’ just two days after his sister had died. The relationship between his mother and the school deteriorated and she removed him from the school roll to home educate. Archie began to miss a lot of school education, but his mum bought him books and other equipment. The lack of school attendance also impacted on him playing for a local football team which had close links to the school. She believes that inevitably ‘he began to hang around on the streets and go missing’. 4.6 On several occasions she went out searching for her son and found him with older boys or young men. She remembers he would usher her away and she believes he was trying to protect her. 4.7 He began to get into trouble and his mother describes the situation as ‘something happening every day’. She recalls lots of different workers from Youth Justice, Social Care or Youth Work were trying to get him involved with different activities; but it was a bit like a ‘merry-go-round’ of different people arriving and then leaving. She thinks this impacted on him as he felt no one wanted to bother with him. He was disappointed that the ‘man who was going to take him boxing’ did not come back. His mother notes 8 that when they were in their home country, he had been on a programme called ‘Big Brother’ which supported him but he didn’t receive that sort of service in the UK. 4.8 He got into trouble on an almost daily basis and then didn’t attend his ‘probation’ appointments. His mother believes he soon realised he could get away with anything and that ‘nothing ever came of his actions.’ (Matters took so long to get to court that he just assumed he had ‘got away with it’.) She accepts his criminal behaviour rapidly escalated. She comments that ‘There were older boys out there on the streets getting him to do things for them’. 4.9 His mother had to give up work as it was difficult to leave him as he was at home all day and not in school. She was also suffering poor physical and mental health. His poor behaviour began to impact on his relationship with his siblings. 4.10 His mum concluded with the comment ‘I saw him change right before my eyes’. 5. Analysis 5.1 General Comments 5.1.1 Before considering each term of reference in detail, it is important to set the context for two areas of this review. These relate to the increase in deaths involving knives across the UK and the relatively new concept of ‘contextual safeguarding’. 5.1.2 The Office for National Statistics (ONS) provides data across the public sector. Their data illustrates that in the year to June 2018 there was an 8% increase in homicides within the UK. (30% of all homicides involved the use of a knife or sharp instrument) and that there has been a 38% increase in crimes involving the use of knives in just 3 years. Data provided by the NHS shows that the number of under 16s treated at hospital for ‘stab’ wounds has increased by 93% in five years. 5.1.3 These figures from the ONS and NHS set the context of a national issue which is disproportionately affecting young people and in particular young black men and boys. Work is now being undertaken at a government level to deal with the surge in knife crime. This review will focus on the detail relating to Archie’s experiences, but it is important that this detail is reviewed against this national context. 5.1.4 The second area to note is the development of contextual safeguarding. Again, details of specifics relating to Archie and Sheffield will be reviewed but this relatively new concept challenges all agencies in their approach to keeping children and young people safe within the child protection process, which are traditionally focussed on the home environment and working with families to improve lives. For teenagers there are additional challenges. Carlene Firmin (2017) provides a national perspective: 9 Contextual Safeguarding is an approach to understanding, and responding to, young people’s experiences of significant harm beyond their families. It recognises that the different relationships that young people form in their neighbourhoods, schools and online can feature violence and abuse. Parents and carers have little influence over these contexts, and young people’s experience of extra-familial abuse can undermine parent-child relationships. Therefore children’s social care practitioners need to engage with individuals and sectors who do have influence over/within extra-familial contexts, and recognise that assessment of, and intervention with, these spaces are a critical part of safeguarding practices. 5.2 An understanding of the educational arrangements in place and the support offered to Archie and his mother 5.2.1 On arrival in the UK Archie was registered with a school (B) in Sheffield. The preferred choice was that family members attended the same school but there were no places available at this school (A) in his year group. As new to the school system in the UK and new to Sheffield it would have been beneficial in settling Archie into mainstream schooling to be in the same school as his siblings. Although registration took place in the summer of 2014 Archie did not start at school B until December 2014, missing three months of his education. The review has not been able to determine the reason for the delay or whether Archie’s mother was provided information about appeal processes. 5.2.2 There were some minor discipline issues during his first two terms in school B but nothing that warranted a permanent exclusion. As a young person arriving from overseas it is not clear from records what, if any, assessment was made in relation to his language skills, educational ability or other factors that might assist or inhibit his integration. Staff in attendance at the practitioner’s event informed the review that no formal assessment was completed. He was said to have had a limited vocabulary but was described by staff as ‘a very polite, respectful boy.’ 5.2.3 In September 2015, Archie’s adult sister, who had also been his carer for his first period in the UK, died in a house fire. This had a major impact on him and his school experience. 5.2.4 The second application for a place at school C for Archie was accepted on 10th July 2016 but he did not start immediately and again it has been difficult to verify the reasons for this, although the headteacher of this school was of the view that Archie should have remained in his first school (B). The opportunity to start at a new school just before the end of summer term (and potentially setting him some work or targets within the holidays) was lost. He had by now missed seven months of education. 5.2.5 Archie started at this second school 3 weeks into the September term in 2016 losing opportunities to integrate with his classmates and pick up on his learning. It is also unclear if any assessment of his individual needs was carried out. He was placed in a mainstream class and not a support unit. His behaviour and attendance were poor from 10 the start. Having missed the majority of the previous academic year, Archie may have struggled to study alongside his peers and this may have been one reason for his poor behaviour. In addition, at the same time the family had re-located to another area of the city meaning that Archie was crossing the city on public transport (a significant and lengthy journey of around 90 minutes) to get to school. His school attendance was poor and within a matter of weeks he was not attending school. 5.2.6 During the first term of the new school year in 2015, Archie’s behaviour deteriorated significantly. He had received two separate one-day exclusions and a large number of ‘yellow slips’ (these are linked to poor behaviour and are an indicator that he was repeatedly disruptive). 5.2.7 In early December 2015 his mother decided she would home educate him. This is her right as a parent: Section 175(1) Education Act 1996: “Responsibility for a child’s education rests with their parents. In England, education is compulsory, school is not”. The education provision should be ‘efficient’ and ‘suitable’ but these are not defined in the Act. Local Authorities are ‘encouraged’ to provide support to parents who decide on elective home education. However, Section 436A Education Act 1996 (as amended by Education and Inspections Act 2006) states: ‘Local Authorities have a statutory duty to make arrangements to establish the identities of children in their area who are not receiving a suitable education’. 5.2.8 Several weeks later his mother received a warning about his poor attendance. When she contacted the school, she was informed that because her email had not been signed her decision to home educate could not be accepted as an acceptable form of notification. Following this she wrote to the Local Authority by letter and received a standard reply relating to her obligations around her son’s education. During the term the school had recorded Archie’s absence as including ‘authorised leave’, ‘education off site’ and a ‘managed move’ to another school (which was not completed). 5.2.9 The standard response to her ‘intention to home educate’ did not take into account her particular needs and was not an adequate response to the complex situation of this family. As a result of a long-term absence of a key member of staff in the Education Department at that time the matter was not given appropriate oversight and Archie was left with no education provision in place. His mother did not start to apply for a school place again until April 2016. By then, he had been out of any education setting for four months. She applied for a place at a new school with support from a MAST worker. 5.2.10 Although it is a right of parents to elect to home educate their children, there are national concerns about this choice of education. In February 2019, the Children’s Commissioner outlined her concerns on national television (Channel 4 ‘Dispatches’ programme broadcast 4.2.19). There are now over 60,000 children being home 11 educated within the UK. This figure has more than doubled in the last five years. Although in many instances, home education is a planned choice by parents, in the majority of cases home education starts after a dispute between the school and a parent. In particular, data shows that 22% of children who are home educated have Special Educational Needs. Figures provided from the Association of Directors of Children’s Services indicate between 11% and 51% (depending on Local Authority area) of children being home educated are already known to Children’s Social Care. 5.2.11 The Children’s Commissioner expressed her concerns at a trend of schools agreeing to parent’s requests for home education as an alternative to school exclusion. Electing home education does not provide the same level of support to a pupil who has been excluded from school. 5.2.12 A series of e-mails were exchanged between the Head Teacher and the Home Education Officer and although Archie remained on the school roll until February 2017 he never attended the school from late October 2016. He had only attended for a maximum of twelve days in the six months he was on their roll. 5.2.13 There are no records showing what support provision was available for a challenging young person within the school. There is no record of an ‘Attendance Officer’ home visit during that time. There is nothing to show if any professional at the school knew or did anything about the bereavement he had suffered. Nor does anything indicate what education provision was made for the three weeks he was recorded as Code B (educated off site). His offending behaviour, and with it his first contact with the criminal justice agencies, started in December 2016. Prior to that although he was a disruptive and difficult pupil he had not been involved in crime. 5.2.14 His experience within the mainstream school system in Sheffield can only be regarded as poor. 5.2.15 In contrast to the previous year, this time there was coordinated action from the Education Department at the Local Authority. The complex case manager raised Archie’s case at the fortnightly ‘Every child in education every day’ meeting. One action from the meeting was to write to School C to inform them that Archie should remain on their roll. 5.2.16 In February 2017, the complex case manager and attendance and inclusion officer carried out a home visit with Archie and his mother as they were concerned that he was not accessing any education provision. Another school was identified as a possible school for him. His education placement was also now the responsibility of the Youth Justice Service. Since his arrest and subsequent caution for a burglary offence, it was one of his conditions that he accessed education. 5.2.17 At a ‘Fair Access Panel’ in March 2017, Archie was allocated a school place at another school. Despite this he was never added to their roll and indeed never attended. With a 12 legal responsibility for the school to add a pupil to their roll on the day they are notified, or for the school to make representations within 5 days or appeal to the School’s Adjudicator within 15 days, (the Education -pupil registration- regulations 2006), the actions of this school are a concern. In May, at another Fair Access Panel, the Head Teacher stated Archie was not suited to mainstream education, but the original decision remained in place. The Head Teacher of a large secondary school has a responsibility to educate pupils on their roll, but they also have a responsibility for the safety and welfare of other students and of their staff. The ‘stand-off’ between the Education Department and the school did nothing to help Archie. Other options such as a Pupil Referral Unit were not considered as he had never been excluded from mainstream education. 5.2.18 In September, Archie and his mother attended a meeting with the ‘Children Missing from Education’ (CME) officer to explore alternatives. The officer reports Archie did not engage well at the meeting. The practitioner contacted the ‘Extended Curriculum Team’ (now re designated the ‘Progression Team’) who advised a risk assessment was necessary before any provision could be arranged. They were also going to make a referral to the ‘gang panel’. 5.2.19 In October during a meeting between several agencies, the decision was to make to request for a Child Protection Conference. One key issue highlighted was that ‘Archie had now been missing from any education provision for 18 months’. 5.2.20 Between November 2017 and March 2018 further interventions were attempted by education professionals. These included offering possible alternative placements. Archie did not attend these placements. He was visited at home and discussed the ‘Not School’ provision and a computer was left. However, the family did not have an internet connection, so this was not feasible and the computer was returned. There was also a referral within the Youth Justice Service from the case manager to the education professional within Youth Justice. None of these were successful in re-engaging him. In May, an education professional met with Archie and agreed a way forward with an Education Welfare Officer looking at suitable placements and for the education professional to personally start work on Maths and English skills. The placements proved difficult to find. By this point there were so many other pressures within his life that any placement was unlikely to succeed. However, it should be recognised that there were determined efforts made by several committed education professionals. 5.2.21 In understanding the educational arrangements in place for Archie and the support on offer we can summarise: There were delays from the very start in him accessing education. Even though his mother registered him in July 2014, he did not start at school until December 2014 and missed the first full term. There are no records of any assessments undertaken when he started school. He had recently arrived in the UK from overseas and we understand that there had been some behaviour difficulties prior to his arrival in the UK. An assessment of his 13 educational ability and his welfare and emotional needs would have been useful in planning a way forward. It does not appear a SENCO at the school was consulted. Cultural issues were not considered (Archie was a teenage Afro-Caribbean boy) or specific arrangements made to support him (e.g. through NASSEA - Northern Association of Support Services for Equality and Achievement). Specialist services can provide advice around harder to reach BAME students in gaining access to quality education. The bereavement of his sister was recognised by a pastoral lead at his first school. This was good practice and shows a level of connection with Archie. However, the subsequent response was not effective and this matter was never fully addressed. Such an event on a young person already exhibiting signs of poor behaviour was bound to have a negative impact. His mother must share some responsibility in her inconsistency of stating she wanted to home educate him and then changing her mind. However, the Local Authority and the schools are the professionals and they needed to be more constructive and dynamic in their approach at a much earlier stage. Through a mixture of bureaucracy and staff absence, matters quickly deteriorated and Archie began to miss a significant period of his education. It was too easy for schools to acquiesce to his mother’s decision to home educate. Her decision had been made in frustration and there were insufficient services in place to support an effective home education. There is a sense almost of a ‘stand-off’ between the Local Authority and the schools over alternative placements for him. This led to further delays and Archie missing even more education. Whilst accepting schools have a duty to protect other pupils and their staff they also have a legal responsibility to educate a child on their school roll. There is insufficient evidence of effective home – school links. The role of a pastoral professional from school staff, reporting back directly to the school would have paid real dividends in understanding his situation. There was a MAST (early intervention) worker supporting the family but their role was wider and education was only one factor in their work with the family. There is evidence of some very committed practitioners working in education within Sheffield who explored several options to get him back into education. It is to the credit of several education professionals that they never ‘gave up’ on Archie. However, these efforts were too late in stopping what had clearly become a downward spiral with him beginning to offend and becoming increasing drawn into a ‘gang culture’, in part due to his repeated absences from school. 14 5.3 The involvement in and influence of gangs including any evidence of criminal exploitation 5.3.1 HM Government’s ‘Serious Violence Strategy’ (April 2018) sets out the government’s intention on how to tackle the increase in violent crime within the United Kingdom. A key element of the strategy is the work around ‘gangs’ and the implementation of the ‘Ending Gang Violence and Exploitation (EGVE) programme. The strategy also explains the plans in relation to ‘County Lines.’ 5.3.2 County Lines is a major cross-cutting issue involving drugs, violence, gangs, criminal exploitation and missing persons. It can also include sexual exploitation and modern slavery. Criminal exploitation of children (and vulnerable adults) is a widespread form of harm that is a typical feature of ‘county lines’ activity. 5.3.3 Child criminal exploitation occurs where an individual or group takes advantage of an imbalance of power to coerce, control, manipulate or deceive a child or young person. The victim may have been criminally exploited even if the activity appears consensual. Factors that can increase a young person’s vulnerability include lack of a safe/stable home environment, social isolation, connections with other people in gangs, mental health issues and being excluded from mainstream education. 5.3.4 Recent research (2018) by OFSTED, HMICFRS and HMI Probation found that although much has been done by local partnerships across the UK to deal with Child Sexual Exploitation, agencies do not fully understand the scale or level of risk to children from other forms of criminal exploitation such as gangs, drugs or violence. 5.3.5 We know that much of Archie’s contact with professionals related to his association with older people. In January 2017, aged 13, he was in company with three other males, one of whom was 17 years old. The group stopped another young male and engaged him in conversation before threatening him with a knife and stealing his neck chain. In February 2017, whilst reported as ‘missing’ from home he was caught by police running from the scene of a burglary. He had committed the offence at 6.00am while in the company of a 20-year-old male. When he was searched by police he was found with a quantity of cannabis. In May 2017 he was stopped while in the company of an 18-year-old male and a 17-year-old female. Whilst the police submitted a child referral to Children’s Social Care in relation to the 17-year-old girl they did not do so in respect of Archie, who was only 14 years old, perhaps an indication of agencies not always recognising the risks of exploitation with teenage boys. 5.3.6 In April 2017 a meeting was convened to discuss the findings of a ‘speech and language’ assessment for Archie. It is a positive development that one of the findings of the assessment identified that he was ‘vulnerable to exploitation’. However, this does not seem to have evolved into action to protect him from that exploitation. 15 5.3.7 During a Social Care assessment in the summer of 2017, Archie was assessed as ‘involved in gang type issues’ but also assessed that he was ‘not at risk of significant harm’. With the other issues affecting his life, he was clearly open to exploitation by Organised Crime Groups (OCGs) and the assessment was therefore not sufficiently robust. Again, this is most likely due to professional’s lack of understanding of the exploitation associated with gang activity. 5.3.8 We know that an educational placement which had been arranged for Archie at a football club was cancelled by the club as their policy does not accept those ‘involved in gang culture’. Although it is understandable how a professional organisation does not want to attract crime and anti-social behaviour, the existence of the policy demonstrates how the assumption is one of criminality rather than exploitation. 5.3.9 Archie’s escalating involvement in crime shows how closely associated he was to gang activity within Sheffield. In addition to the drug dealing already mentioned, he: threatened to stab opponents; he was involved in a large fight with a group carrying weapons; he was in the company of several other males who chased teenagers into a car showroom and threatened the adults with a knife; he was part of a group (with older males) who entered a house, threatened the occupants, assaulted a female inside and stole the occupant’s drugs; he was involved in a ‘drive-by shooting’ when he was in company with four other males (including a 19 year old and a 17 year old) and shots were fired at an address he was staying in. 5.3.10 Agencies did gather this information leading to interventions beginning. His Youth Justice case manager made a referral to the gang panel plus during a home visit a Social Worker stated their intention to refer to the ‘gang matrix’. It is unclear from records if these referrals took place, but Archie was never discussed at a gang panel and the review established at that time there was no direct route for professionals to refer directly to a ‘gang panel’ in Sheffield. The initial work of ‘scoring’ against a matrix was conducted by an analyst within the Police. This appears not to have been fully understood by practitioners who may have referenced a referral but the existing systems at that time did not facilitate a referral by this route. 5.3.11 The police twice served ‘abduction notices’ on older associates of Archie, which was good practice. However, the officers realised these would be difficult to enforce, given his reluctance to stay away from his older associates and his mother’s apparent lack of control over him. The abduction notices needed to part of a wider concerted effort to safeguard him. 5.3.12 Archie often referred to his ‘FAM’ being ‘on the street’; an indication that family dynamics were not working and he was choosing to base himself with others outside the family home – many of whom were several years older than him. Lack of a stable home environment is a recognised factor in determining vulnerability to exploitation by gangs and criminal networks. 16 5.3.13 In summary there were indicators that he was being exploited. His involvement became more entrenched, placing him at greater risk of harm. There are several comments made by professionals of Archie expressing no regard for his own safety. When considering his carrying of knives, taking drugs from rival ‘dealers’, shooting incidents, assaults and threats to stab others it is clear he was at risk of ongoing significant harm. 5.4 An understanding of Archie’s offending behaviour and attempts to tackle or address this. 5.4.1 The government set out its aims for tackling youth offending in its Ministry of Justice publication ‘Review of the Youth Justice System in England and Wales 2016’: It advocates a societal shift so that from youth justice we see the child first and the offender second: “Almost all the causes of the child reoffending lie beyond the reach of the youth justice system. It is vital that health, education, social care and other services form an integrated multi-agency response to a child’s offending, but it is more desirable that these same services intervene with ‘at risk’ children and their families before their problems manifest themselves in offending.” 5.4.2 In just under a decade the numbers of young people entering the criminal justice system either by way of a caution or by a conviction has reduced by 79%. In 2007, 225,000 young people were dealt with by one of these sanctions. By 2015 the figure had reduced to 47,000. 5.4.3 The creation of Youth Offender Teams (YOT) in 1998 was in response to a growing sense that youth offending was not being dealt with in a systematic way. The strength of the youth justice system is in a locally based multi-disciplinary service. 5.4.4 The Youth Justice Service in Sheffield is a multi-disciplinary team comprising of a number of ‘case managers’ and other specialists within the team such as education professionals, CAMHS practitioners, a speech and language therapist, a health nurse, a housing officer and a substance misuse worker. 5.4.5 Although there had been a long-term issue with Archie’s regular school attendance this did not manifest itself in criminal offending until December 2016. He committed a shoplifting offence and subsequently received a ‘restorative justice’ sanction. This included a condition to engage with the Youth Justice Service when requested. This was the correct, proportionate response. It would keep him out of the criminal justice system but hold a sanction for him to think about his offence and the impact on others. 5.4.6 However, only two weeks later, Archie, then aged 13, was in the city centre at 10.30pm with three others including a 17-year-old when they threatened another youth with a knife and took his neck chain. The other three were arrested for robbery. Archie was not arrested as he was on the periphery but clearly associating with others which would 17 most likely get him involved in further offending. There were no referrals to Children’s Social Care regarding this incident or entries on police records to suggest his mother was contacted or advised about him being in the city centre late at night. 5.4.7 In February 2017, Archie had been reported ‘missing from home’. Whilst missing overnight he was in the company of a 20-year-old male. They committed a burglary and were detained by police. When searched he was also found to be in possession of a small amount of cannabis. For this offence he received a conditional caution and, following an assessment by the Youth Justice Service, was required to undertake the following: address his offending behaviour and substance misuse, reintegrate with his education provision and enhance his victim awareness. The work is recorded by the Youth Justice Service as ‘completed’ with the caveat that his education placement was ‘pending’. Given that he had missed so much education already this was a premature closure of the case and it should have remained open until the provision was secured and underway. Although there were early signs of his vulnerabilities; with the exception of the education provision, the response and management of Archie’s case at that stage was an appropriate intervention plan which addressed the presenting issues. 5.4.8 The Community Youth Team received a referral in January (in response to his minor shoplifting offence). They carried out a home visit with Archie and his mother. After an assessment, he was deemed to require a ‘mini’ intervention although the Prevention worker was proactive in recording that this was a ’borderline’ case which could have warranted a ‘full’ intervention. The home visit went well, and he seemed fully engaged in the process. However, when the Prevention worker returned in February he was not at home. Nevertheless, the worker completed forms for referrals to specialist services and left details of positive activities available. The worker also proactively contacted the ‘missing’ team to enquire on his whereabouts. This is good practice. 5.4.9 The Prevention worker returned to Archie’s home later that month but by this time, he had been arrested for a burglary so local protocols meant that the Community Youth Team would no longer work with him. The Prevention worker explained to Archie and his mother that his case would be taken up by the Youth Justice Service. This process requires further review. If behaviour is escalating and there is a need for positive or diversionary activities it is difficult to rationalise why a professional would be withdrawn when they have already started to make a connection with a young person. Ending the involvement of the Community Youth Team was a negative step when trying to divert him away from offending. 5.4.10 In March 2017, Archie met with his Youth Justice case manager. He disclosed his associates (most of who were known to the Youth Justice Service). He discussed how he carried a knife, had held a gun and had witnessed a violent incident. It is positive that the case manager was able to gain a rapport with him so that he revealed these aspects of his life. Indeed, it is a very good way of ‘seeing life through his eyes’. The issue is what was done with this information. We can see now that the violence, knives, weapons and involvement with criminal associates was starting to become an ever- 18 present part of his life. This was an opportunity to make a referral to Children’s Social Care for an assessment if the case manager believed he was at risk of significant harm. 5.4.11 Due to police concerns about his mother’s ability to exercise control over him, the police arranged a meeting with Children’s Social Care in June together with representatives from the Youth Justice Service, MAST, Archie and his mother. The Social Worker did not attend and so the meeting did not progress. This was not the right message to send to him or his mother and no doubt added to his sense of operating ‘on the street’ out of mainstream norms and also to his mother’s frustration. 5.4.12 Over the next six months, he was repeatedly involved in offending with the offences becoming more frequent and more serious. We should also consider these are ‘reported’ incidents. Given police statistics and the national crime survey we know that much crime goes unreported and of course there may well be more offending that he was involved in but was not named or identified. Clearly, offending behaviour was now a major part of his life. 5.4.13 All agencies should work together to prevent offending by children and young people. Within the scope of this review, we consider the actions of four key agencies in tackling or addressing youth offending: Police, the Youth Justice Service, Community Youth Teams and Sheffield Youth Court. 5.5 Specific Agency Issues The Police 5.5.1 The police deal with protecting the vulnerable, preventing crime, gathering intelligence, conducting investigations and gathering evidence to put before the courts. Archie’s activities fell into all of these categories. In some instances, this is purely ‘intelligence’, in others there is evidence against him. The police have a duty of care to the public, the victim of a crime, the witnesses and also to the perpetrator. This is especially so with a young offender. In many of the reported crimes involving Archie, the police take swift and positive action. He is arrested, interviewed and in cases where the evidential threshold is met, he is charged with an offence and put before the Youth Court. In a minority of cases the police could have taken more robust action. 5.5.2 For example, when he was seen by a Police Community Support Officer with a knife, although the PCSO does not have a power of arrest a swifter response by officers may have detained him with the evidence. Or in March 2015 when the police were called by his mother as he had ‘smashed the house up’ and although his mother did not wish to make a formal complaint and therefore a charge was unlikely, he could have been arrested to investigate further. 5.5.3 On other occasions positive action was taken by the police; in February he was arrested after threatening patrolling officers he would “Smash their face in.” In March when he 19 was involved in damaging a car he was arrested and interviewed about the incident. No charges were likely, but the investigation followed a logical course. This was essential at this stage as he was repeatedly coming to the notice of many agencies. Positive police action was a way of setting boundaries and introducing consequences for his behaviour. 5.5.4 The police did refer to Children’s Social Care but the approach was not always consistent. There are instances where police had been involved with him but this interaction was not always shared with Children’s Social Care or the Youth Justice Service. 5.5.5 Breaches of his bail were dealt with well by the police and he was repeatedly arrested for the breaches and put back before the Youth Court. 5.5.6 One problem was that so many different police officers dealt with Archie. It is pleasing to see South Yorkshire Police has now reintroduced Neighbourhood Policing Teams who can get to know their local communities and this includes young people involved in crime and at risk of exploitation. The Youth Justice Service 5.5.7 The Youth Justice Service is a multi-disciplinary team; comprising professionals who both manage cases involving young offenders and also deliver activity and interventions that divert young people away from the criminal justice system. 5.5.8 Following a referral by police in January 2017, the Youth Justice Service completed an assessment and developed a comprehensive plan including , engagement in offending behaviour sessions, a substance misuse referral, a speech and language assessment, victim awareness work and work to reengage him in education. All work was recorded as completed with the exception of his education placement which was shown as ‘pending.’ This may have been a premature closure, given that he had missed so much of his education. There is no doubt that the Youth Justice Service case manager was proactive in trying to obtain a placement for him, but this appeared to cause confusion to which agency was trying to pursue this. 5.5.9 There was also some confusion on the role of the Youth Justice Service as they were also completing ‘return’ interviews with him following his episodes of ‘missing’ together with their role addressing his offending. It does appear that his mother found this confusing and sometimes did not know who to contact. 5.5.10 Comment has already been made regarding the good rapport established between Archie and his case manager. 5.5.11 In later incidents, when he was repeatedly offending, a decision was taken by the case manager to put all matters before the court in one appearance. Due to his continual 20 offending, this meant a significant delay in obtaining any form of sanction. However, the decision was made in the best interests of Archie and the case manager did not have the benefit of hindsight. 5.5.12 There were delays in completing bail assessments and this is identified by the Youth Justice Service as a systemic issue that requires addressing. 5.5.13 When he did appear at Youth Court, he received either bail support packages or Referral Orders. His repeated reluctance to engage with services meant these were difficult to progress but there is ample evidence that the case manager pursued this despite the challenging circumstances. 5.5.14 The case manager was tenacious in ensuring contact was initiated and maintained with Children’s Social Care, especially as their assessment showed he was at risk of exploitation. They also referred him to a gang panel, but it appears he was not heard at the panel nor mapped as a gang member. 5.5.15 Archie’s case was taken to a ‘Multi Agency Risk Panel’ in April 2018. In itself, this was good practice, but it is difficult to see how this operated in conjunction with the existing Child Protection Plan. All efforts should have been directed through a single pathway. Sheffield Futures (Community Youth Teams) 5.5.16 Sheffield Futures is a large charity which delivers the Youth Crime Prevention Service in the city. These services include the Community Youth Team who employ professionals that support young offenders and deliver activity and interventions which divert young people away from the criminal justice system. 5.5.17 Their initial involvement is already documented. An assessment and engagement with Archie in early 2017 was abruptly cut short due to his repeated and escalating offending. It was a mistake to withdraw the service at that time. The Community Youth Team is commissioned to deliver a pre court service. After that stage, responsibility passes to the Youth Justice Service. These agreed thresholds for intervention between the two services form part of the recommendations within this overview report. 5.5.18 Even though the decision was made to withdraw Sheffield Futures’ services they were re- contacted nine months later in an attempt to introduce some positive activities for Archie. They sent a letter to his mother in November 2017. This was a positive step. However, only nine days later, Sheffield Futures withdrew their involvement as he had again reoffended. This process as earlier stated requires review, if the aim is to divert away from offending, why is the assignment of a professional youth service withdrawn? 21 Sheffield Youth Court 5.5.19 HM Courts and Tribunal Service are not part of this review. However, the Youth Court is referred to on several occasions by agencies. 5.5.20 Following his involvement in crime (together with evidence he was also being exploited) he was arrested and charged many times. As with all young people he appeared at the Youth Court. 5.5.21 Data has already been provided of the significant reduction in young people now receiving either a formal caution or conviction (c 80% reduction in less than a decade). The Youth Justice Board notes in its 2017-2018 annual report that due to the huge reduction in numbers in the system, those cases remaining are particularly challenging: ‘Many of the children remaining within this smaller cohort have complex needs. Reoffending rates and serious violence within the secure estate are high.’ 5.5.22 No one wants to see children and young people held in secure custody unless for the most grievous crimes. But with criminal exploitation of young people this can be a difficult arena. 5.5.23 We know of Archie’s home circumstances; his disengagement from his own family, his mother’s inability to control him, his finding a new ‘FAM’ on the streets and his association with older boys and young men. The challenge is how this exploitation and risk of significant harm is articulated to the courts. 5.5.24 The Youth Justice Board has both a ‘vision’ and a ‘mission.’ The vision is: ‘Every child lives a safe and crime free life and makes a positive contribution to society.’ 5.5.25 The ‘mission’ puts ‘Preventing offending by children’ at its core and then also illustrates how it will achieve this – by monitoring the youth justice system, advising ministers, identifying good practice and commissioning research. The mission does not mention ‘safeguarding’ and this omission should be revisited. 5.5.26 Archie appeared before Sheffield Youth Court many times. On each occasion he was released on bail. Initially there were no conditions attached. At later hearings there was imposition of a curfew (without electronic tagging) and then further curfews (with electronic tagging). On several occasions he was arrested for breaching his bail conditions only to appear back at court to be released again with the same conditions. Each time, he was released he went ‘missing’, breached his bail conditions or became involved in further crime. There is a suggestion from the Crown Prosecutor that during his last court appearance, the prosecutor was considering seeking a remand in custody. However, he declined to do so when he reviewed the content of the Youth Justice Service report. We do not know if the lack of detail on the report contributed to this as 22 the prosecutor is speaking hypothetically and the ultimate decision would be one for the Court. 5.5.27 The main reasons a court can refuse to grant bail to a defendant are: They will abscond They will commit further offences on bail They will interfere with witnesses (Bail Act 1976) 5.5.28 Archie repeatedly absconded and committed further offences. As a young person, any remand in custody must be an absolute last resort. But the Bail Act also lists an additional important reason that bail can be denied: ‘For the defendant’s own protection’. The court is reliant on the quality of evidence and the quality of reports for it to make an informed decision. The exploitation of a young person and their risk of being at significant harm when their ‘FAM’ is ‘on the streets’ should be taken into consideration. 5.5.29 There does not appear to have been consideration by the Youth Court to remand Archie to secure custody or to Local Authority care for his own protection. All indications were that his mother could not control his behaviour and that he was ‘missing’ in breach of his curfew. The ‘breaches’ placed him at further risk of significant harm. His mother had expressed her frustrations about his offending and asked for him to be taken into custody instead of being released back to their home address. 5.6 Responses to episodes of ‘missing’ 5.6.1 Being ‘missing from home’ was a regular feature of Archie’s life and linked to other concerns of him being at risk of harm, exploited, exposed to ‘gang’ culture and involved in crime. Best practice for dealing effectively with episodes of ‘missing’ is contained in the document ‘Statutory guidance on children who run away or go missing from home (2014)’. Section 13 of the Children Act 2004 requires: ‘Local Authorities and other named statutory partners to make arrangements to ensure that their functions are discharged with a view to safeguarding and promoting the welfare of children. This includes planning to prevent children from going missing and to protect them when they do so.’ 5.6.2 The statutory guidance also recognises that children who go missing are at risk of sexual exploitation, gang exploitation, violent crime and drug abuse. As part of this framework, Local Authorities and the police should have an RMFHC protocol (Running and Missing from Home and Care). 23 5.6.3 The first episode of Archie being reported missing was in January 2017. He was found by police sleeping in a fast food restaurant in the city centre. The Social Care Emergency Duty Team was notified. 5.6.4 Regular episodes of ‘missing’ followed. This included in June 2017 when he was missing for 13 days. When police officers visited his mother, they realised she had very little control of her son and submitted a referral to Children’s Social Care which triggered a strategy meeting. 5.6.5 Records from the Police indicate that he was reported missing a total of 12 times between January 2017 and January 2018. The duration of him being missing varied from a few hours through to 13 days. Each time he returned (sometimes of his own volition, sometimes when found by the police) he refused to say where he had been and only that he had been with ‘friends’. 5.6.6 It is important to note that several agencies realised that his mother did not always report him as ‘missing’ and so we can reasonably assume he was actually ‘missing’ on many more occasions. Indeed, during the last few months of his life it appears he was missing from home almost on a daily basis with his mother having little idea of where he was. 5.6.7 All children who go missing are at risk. This risk is increased when other vulnerabilities exist such as an unstable home life or associating in a gang culture. The police tactics will be determined by their risk assessment. This in turn is influenced by their ‘APP’ (Authorised Professional Practice). Guidance is that all children (as opposed to adults) should be a ‘medium’ or ‘high’ risk. 5.6.8 All of the incidents of missing relating to Archie were assessed by the police as ‘medium’ risk. He was never assessed as high risk. 5.6.9 High risk is defined in their APP and other guidance as: The risk posed is immediate and there are substantial grounds for believing that the child is in danger through their own vulnerability, or The child may have been the victim of a serious crime, or The risk posed is immediate and there are substantial grounds for believing that the public is in danger. 5.6.10 By declaring a missing episode as ‘high risk’, the police will commit substantial resources and equipment, together with putting command structures in place in order to find the missing child quickly and safely. Most police ‘high risk’ missing episodes relating to children are when they are either very young and are in immediate danger from the 24 elements, motor vehicles etc. or when there are concerns they have been abducted or trafficked. 5.6.11 Archie was identified as part of gang culture; often on the periphery though being drawn further into that culture as time progressed. Some episodes of missing extended into significant periods – in some cases a week, in one instance for 13 days – then police should actively re-assess these cases. The assessed risk at the outset of the episode may not be correct as time passes and especially if intelligence is received that he is involved in crime or is being exploited. 5.6.12 Often when he was reported ‘missing’ he was engaged in criminal activity. This can be seen in January 2017 when he was reported missing and was detained for committing a burglary. Another example was in September 2017 he was reported missing when he carried out an assault. 5.6.13 The statutory guidance on RMFHC protocols includes advice around return interviews when a child is found or returns home. The guidance states ‘When a child is found they must be offered an independent return interview. This is to provide an opportunity to uncover information that can help protect children from the risk of going missing again. Interviews should be carried out within 72 hours of the child returning home and carried out by an independent person who has been trained to carry out such interviews.’ 5.6.14 In Sheffield, at that time the return interviews were carried out by the Youth Justice Service or the police. Initial ‘safe and well’ checks were carried out by the police. The Youth Justice Service carried out three return interviews with Archie; in June 2017, in September 2017 and in October 2017. (He declined to participate in an interview following his lengthy absence in January 2018). The police often found him when he was missing or attended his home to speak with him when he had returned. Whichever organisation is conducting the interview, it should link in to wider planning around safeguarding. As already noted, the police initiated a meeting after one missing episode and the Youth Justice Service notes the June 2017 episode triggered a strategy meeting and on others they notified the Social Worker. 5.6.15 There is an example of some confusion over where responsibilities lay regarding missing episodes. In October 2017 his mother reported to the Youth Justice Service case manager that she had been advised by the Social Worker to contact the Youth Justice Service after she had reported to the Social Worker that she was worried he was being drawn into gangs and that she could not keep him safe. At that particular point, the case manager had to in turn advise his mother that the Youth Justice Service were only involved with him for his return from missing interviews. This must have been a source of frustration and confusion for his mother. 25 5.6.16 The ‘missing’ episodes themselves were dealt with effectively. The interviews were conducted and this was fed into wider strategy meetings for consideration. The weakness is that once ‘missing’ was identified as a factor, it did not then inform the risk assessment, especially when the Child Protection Plan was in operation. 5.7 Support Archie received in relation to the bereavement of his sister 5.7.1 Archie’s older sister died in a house fire in September 2015, when Archie was aged 12. She had been his carer for the first period of his time in the UK. The sudden and unexpected death of a close family relative would have a significant impact on any young person. 5.7.2 The first record of an agency acknowledging the impact of the death on the family was with Sheffield Housing and Neighbourhood Services when a Housing Officer contacted Children’s Social Care. This was not treated as a referral by Children’s Social Care and no further action was taken. Although they were not formally involved with the family at that time, they could have signposted the family for additional support. 5.7.3 Later the same day an education support officer recorded that Archie had disclosed his sister had died and that he felt guilty as she used to be his main carer and he hadn’t seen her for six months. Three days later the safeguarding lead at the school contacted his mother, who said that she was happy for her son to be supported in school, but she did express a wish for her son to move school to be with his siblings. 5.7.4 A subsequent referral was received at MAST (early intervention service) in October and MAST record the referral was from Archie’s school to support the family after the loss of his sister. Unfortunately, due to his mother not responding to phone calls, messages or letters plus some staff absence within the MAST service there was a delay in MAST carrying out their first home visit, which didn’t take place until two months after the death. 5.7.5 The MAST worker assessed that the whole family were struggling with the loss. As well as bereavement, there were other practical issues. To their credit, the support worker from MAST became involved in advising Archie’s mother on issues such as finance, housing, benefits and in particular mother’s concern about Archie’s education. The support worker also noted that he did not have a bed and so slept on the sofa. These were very real issues for the family. However, this meant the MAST role became blurred and the original reason for the referral became lost. It is unclear if the referral for bereavement was made directly to the MAST service by the school or via a third party. 5.7.6 As well as the issues around finance and housing, the MAST support worker became increasingly involved in trying to access education for Archie (this was his mother’s primary concern). There were over 70 contacts from MAST in their period of involvement; the vast majority of these in trying to establish a school place. 26 5.7.7 The family were served notice by the private landlord to leave their accommodation. His mother registered with Sheffield City Council and began bidding for properties and in June they started a new tenancy. This led to a move to a different part of the city and would have meant a change in the MAST team allocation. The worker asked Archie’s mother if she still wanted support, this was declined and MAST closed the case in August as the family moved home. 5.7.8 Meanwhile, Archie had started at a new school, but it was not a successful placement and he was repeatedly absent for a variety of reasons already documented. There are no records of any handover between the schools indicating that he may be suffering from bereavement. 5.7.9 In December, Archie accompanied his mother to an appointment with his GP. After discussing concerns, the doctor made a referral to the Child Adolescent Mental Health Service (CAMHS), indicating that the GP believed Archie required further support. However, the referral states the concerns are for his ‘anger management.’ It does not specifically mention bereavement. It is worth pausing at this point to give some context to this period in his life: 5.7.10 After repeated issues in school, his mother had again started to home educate him, but he was not accessing any form of formal education provision. 5.7.11 He had been removed from the school roll. 5.7.12 Four days before the GP appointment he had committed his first criminal offence 5.7.13 During the following fortnight (Christmas and New Year holidays), access to any non-emergency services was difficult 5.7.14 In January he was reported ‘missing’ by his mother and found sleeping in a fast food restaurant 5.7.15 By February, he had become involved in more serious offending when; in the company of a group of older boys they had threatened and robbed another teenager. 5.7.16 The next reference to support is in January 2017 when the CAMHS team met with MAST to discuss the GP’s referral. The decision at the meeting was for MAST support and there was no further involvement by CAMHS. The GP referral did not specifically mention bereavement and the meeting used their existing protocols to assign what they believed to be the most appropriate service; in this case MAST. 5.7.17 Later that month a Community Youth Team Prevention worker carried out a home visit. The service was to try to engage him in positive activities. As part of the assessment the Prevention Worker documented a referral for ‘counselling support’. Clearly the 27 professional had identified an issue, but their referral also did not specifically mention bereavement. Any subsequent checks on progress were lost when the service was withdrawn two weeks later as Archie had reoffended. 5.7.18 Following the GP referral, in March, MAST reopened their case file. This is a delay from the referral nearly three months earlier. The role of MAST was to explore parenting strategies with his mother, conduct ‘wishes and feelings’ work, seek counselling for Archie and achieve stability around his education. There were no timescales to the work and once again the lack of focus in their role meant the MAST worker was drawn into assisting his mother and repeatedly trying to get him education provision. There are no documents showing referrals to bereavement counselling. 5.7.19 Due to his repeated offending he was now also supported by the Youth Justice Service. During a meeting in June 2017, he agreed to a referral to an ‘Interchange’ counsellor. The meeting with ‘Interchange’ was facilitated by Youth Justice and took place in October. There had been delays with both a waiting list and Archie’s lack of cooperation. 5.7.20 His life was now chaotic with little voluntary engagement with services. This made his situation very difficult for professionals to make progress. In April 2018 at a ‘Multi Agency Risk Panel’ (convened by the Youth Justice Service) one action was for CAMHS to liaise with the Interchange counsellor. A subsequent informal meeting took place when Archie happened to be in the building and was introduced to the counsellor, but further meetings were difficult due to Archie’s refusal to engage. 5.7.21 Archie received no formal psychological support for his bereavement issues. 5.8 An analysis of the Child Protection Plan and its effectiveness 5.8.1 At the time of his death Archie was the subject of a Child Protection Plan. To consider the effectiveness of the plan we need to explore several aspects: the assessment leading to the decision to convene an Initial Child Protection Conference the decisions made and actions agreed at the Initial Child Protection Conference the engagement of Archie and his mother the engagement of agencies in making progress to protect him within the plan the attendances and information shared at Child Protection Conferences and Core Groups. 5.8.2 Regulatory guidelines are for a Review Child Protection Conference to be held within 90 working days of the Initial Child Protection Conference and for there to be Core Groups held every 20 working days following the first core group that takes place within 10 days of the Initial Child Protection Conference. 28 5.8.3 Working Together to Safeguard Children 2018 provides specific advice relating to Initial Child Protection Conferences and Child Protection Plans: ‘The purpose of an ICPC is to bring together and analyse, in an inter-agency setting, all relevant information and plan how to best safeguard and promote the welfare of the child. It is the responsibility of the conference to make recommendations on how organisations and agencies work together to safeguard the child in future.’ 5.8.4 Due to a number of presenting and escalating concerns within Archie’s life, an assessment (under section 47 Children Act 1989) was undertaken which concluded in August 2017. It identified he was not in education, employment or training, had repeated episodes of ‘missing’, was involved in gang offending areas and there were concerns around maternal mental ill health. However, the assessment initially concluded that he was not at risk of significant harm. The assessment was reviewed by the Children’s Social Care manager who re-assessed this conclusion and as a result the case proceeded to an Initial Child Protection Conference. This demonstrates that the poor assessment was an individual performance issue; not a systemic one. The intervention by the manager in Children’s Social Care was the right outcome. 5.8.5 The Initial Child Protection Conference took place in November 2017 (10 days outside the agreed statutory timescales). It was chaired by a safeguarding officer employed within Children’s Social Care but independent of any line management of the social workers assigned to this case. Information was shared by all attending agencies. An advocate represented the views of Archie which was identified as good practice. Due to the information shared, the scaling score (a strengths-based approach was being used in child protection conferences at this point) was 1. This is a low score (with 0 being the most ‘unsafe’ to 10 being ‘safe.’) The unanimous decision of the conference was to make Archie the subject of a Child Protection Plan under the category of ‘physical abuse’. Archie himself did not attend and had been reported missing earlier that day. His mother was not in the meeting but later informed the social worker that she had attended as requested but was left in the main reception area and not brought into the conference suite. This was unfortunate and a missed opportunity for her to inform the child protection plan. 5.8.6 The majority of agencies were represented at the Initial Child Protection Conference but the allocated social worker was absent due to sick leave and their line manager was not present. A duty social worker attended in their place. The safeguarding officer recorded in their notes ‘My concern is that the level of risk is such that a Child Protection Plan is likely to have very little impact’. It is not clear from Children’s Social Care records how the decision and the recommendations of the conference were accessed by the allocated Social Worker on their return. 5.8.7 The day after the conference the safeguarding officer raised a challenge stating that the report by Children’s Social Care had been inadequate and missing key information, for example the death of the older sibling. The social worker in attendance was a duty (agency) worker and was not the same social worker who had written the report for conference. 29 5.8.8 Recommendations made by the conference were for Archie to engage in education, other positive activity placements to be sought, ‘Interchange counselling’ to be offered and to include bereavement issues and for him to be seen fortnightly by the social worker. Even though the social worker’s assessment did not refer to bereavement, it is positive that the conference deliberated this issue anyway. 5.8.9 There is no evidence of a core group meeting taking place within 10 days and therefore the outline child protection plan drawn up in the Initial Child Protection Conference did not become a more detailed plan. The core group is the vehicle to drive the progress of the plan and if it does not convene then progress cannot be measured. 5.8.10 Whilst subject to a Child Protection Plan matters continued to escalate significantly as previously outlined and Archie became involved in several concerning incidents. 5.8.11 Matters were escalating so rapidly that decisive action was necessary. In January Children’s Social Care arranged a strategy meeting involving several professionals. It was agreed that the police would gather more information and the meeting would reconvene later that month. However, there was no consideration of the need to escalate the concerns to the Senior Leadership Team using the ‘High Risk Tracker’, a tracker which had been recently introduced for those children or young people identified as at the most serious imminent risk to provide high level scrutiny. 5.8.12 In February the Review Child Protection Conference was held within statutory timescales. The safeguarding officer was the same professional who had chaired the Initial Child Protection Conference in November. The allocated social worker remained absent from work and an agency social worker attended the conference. The conference record notes; ‘No progress since initial conference, an escalation in concern because of a serious incident in January.’ The record also notes; ‘There have been times when Archie has not been at home.’ This comment does not reflect the escalation, the frequency and length of the missing episodes suggesting he was rarely at home during that time. When linking these episodes of ‘missing’ with the serious criminality he was now engaged in, then, clearly, he remained at risk of significant harm. There were concerns raised that the sharing of the police intelligence was not always timely. The police information sent to the Review Conference contained only one incident, though it was apparent from the multi-agency strategy meeting held in January that more information was already known to agencies by other routes. The police must ensure that all information is shared through the agreed channels so that nothing is missed. 5.8.13 The Child Protection Conference Grid lists concerns: ‘same as before, disobeys his mother, missing from home for longer periods, serious violence incident - Archie involved’. Under the section on the grid ‘what is going well’, the comment is ‘Mum had 30 reported him missing’. Although his mother had done so on several occasions it was evident this was no longer the case and she had stopped reporting him missing from mid-January onwards even though he was now frequently missing. The Review Conference scaled at ‘0’ indicating that attendees believed Archie to be unsafe and the conference attendees stated that Archie was at risk of ‘killing or being killed’. As a result of the scaling and the comments made in the conference there should have been a rapid and significant intervention to try to remove him from harm and the concerns escalated. The child protection plan focussed around the home where he had tensions with his siblings who felt he was bringing trouble to the home and his mother could not control him when the actual risks were ‘on the streets’ with what Archie described as his new ‘FAM’. 5.8.14 Care proceedings or secure accommodation on ‘welfare grounds’ (section 53 Children Act 1989) could have been considered as options. It is very rare to place a young person in secure accommodation without a criminal conviction but in this case, it may have been the only option that would keep him safe. A way to highlight to the Executive Director and other members of the Senior Leadership Team would have been through the ‘High Risk Tracker’. 5.8.15 From the comments recorded, it is clear that attendees considered Archie to be at risk, there is acknowledgement that since the Initial Child Protection Plan no progress had been made, that he remained at risk of significant harm and that the High Risk Tracker should to be used to escalate matters to the highest levels of management within Children’s Social Care, with the secure welfare placement to be considered. The actions that were required immediately were identified in the Review Conference but then not actioned. 5.8.16 In March a Core Group was convened to consider the progress of the Child Protection Plan. It was a poorly attended meeting. Given the serious nature of the case it was vital that all invitees attended. No actions were set during the meeting but without high level intervention the plan was clearly not going to work. Again, the High Risk Tracker is not mentioned. Core group meetings did not take place with the required frequency and were not a driver for progression of the child protection plan. 5.8.17 Throughout March, Archie continued to be arrested either for new criminal offences or for repeatedly failing to attend court to answer existing charges. He did not engage in any education or other provision. His mother had stopped reporting him missing even though it was clear he was rarely at home. 5.8.18 In April, the Children’s Social Care Team Manager made an entry in the case recording for the social worker to take the case to ‘RAPP’. RAPP is the ‘Resource Allocation or Placement Panel’, chaired by an Assistant Director. The case record also asks for a risk matrix assessment to be undertaken to get on to the High Risk Tracker. Neither of these tasks was actioned. 31 5.8.19 As Archie’s offending increased in severity and frequency, the Core Groups did not have sufficient rigour and did not contribute to the child protection plan. Although the Review Child Protection Conference was held within timescales it offered nothing new. This was when intervention was necessary. The ‘High Risk Tracker’ was mentioned and documented several times but was never actioned. 5.8.20 The Child Protection Plan and its management through the Initial Child Protection Conference, Review Conference and Core Group was ineffective. The plan should have been based on the notion of ‘contextual safeguarding’ and not around the home environment. It was clearly right to identify that Archie was at risk of significant harm but the main risk was not located in the home but on the streets. 5.8.21 The plan needed to match those assessed risks and consider the context of the identified risks (The definition of contextual safeguarding is provided at the beginning of this analysis). Sheffield shares the same problems as many other Local Authorities when trying to manage a Child Protection Plan with a teenager who is at risk on the streets rather than in the home. 5.8.22 As individuals move from their early childhoods and into their teenage years, most will spend an increasing amount of time away from the home. In Archie’s case this became the norm as he no longer readily identified with his own family. His ‘FAM’ was his new associates, most of whom were involved in offending and several of whom were much older than he was. 5.8.23 Sheffield has recognised that traditional child protection methods, where change within the family is used to safeguard the child, are not always appropriate and are unlikely to be effective for young people where the risk of harm is not located within the family setting. Such risks might be present in the young person’s community; whether this is a physical, social or an online community and as such these risks have to be identified and addressed. Sheffield (along with other Local Authorities) need to work differently with young people where contextual safeguarding is the issue, by assessing and intervening where that young person is deemed to be at risk. It is important for all partner agencies to fully embrace this new approach as Children’s Social Care cannot tackle this alone. 5.9 Support offered to his mother (for example housing, police, health, education, courts, social care) 5.9.1 All agencies involved in this review had contact with Archie’s mother. Some professionals described her as ‘struggling’, others as ‘cooperative’ and others as ‘inconsistent.’ The MAST worker who worked very closely with her described her as ‘a very proud woman. She would not ask for help until she reached rock bottom.’ 5.9.2 There is no doubt that as a mother with five children having fled domestic abuse, she needed support. The sudden and tragic loss of her adult daughter caused further distress within the family and affected family members in different ways. 32 5.9.3 After the bereavement and following the referral from school for support to the family, there was a delay of six weeks before the first home visit by MAST. It is accepted that Archie’s mother was often difficult to contact and did not return telephone calls or reply to letters, however, agencies needed to be more creative in attempting to contact her. 5.9.4 The first interaction with Sheffield Housing and Neighbourhood services appears positive and after making several bids she took up a tenancy with them in June 2016. 5.9.5 The practitioners with the most regular contact with her were the support workers within MAST. They carried out extensive supporting roles in areas where she required help and advice. The service ended its involvement in August 2016 after the family had moved to another area of the city. Although it was her choice to end the support as she believed it was no longer required, the withdrawal may have been premature as the family issues were not fully resolved. The more important issue was that their role was often ill-defined. 5.9.6 Archie’s mother had poor experiences with the education system. She was concerned to receive notifications about his poor attendance or behaviour and this resulted in her electing to home educate him on at least two occasions. The schools could have done more to communicate with her. The bureaucracy within the Education Department during her earlier exchanges meant that Archie missed significant amounts of his education. However, subsequently the efforts of the education professionals were commendable in trying to secure alternative provision for him. 5.9.7 An assessment was carried out by a social worker in Children’s Social Care over a two month period in the summer of 2017. The assessment included a reference to ‘the mother’s mental health problems’ but does not give details of what these are nor any strategies for intervention. 5.9.8 The assessment concluded that Archie was ‘not at risk of significant harm’ despite clear evidence that he was. The assessment was reviewed by a manager in Social Care who recognised the concerns and the matter was escalated to the Child Protection arena shortly afterwards. But this delayed services being introduced which could have supported him and his mother. 5.9.9 The police had regular contact with the family due to Archie’s repeated offending and almost constant episodes of going ‘missing’. They attended the home on a couple of occasions when he was allegedly ‘smashing the house up’. Each time his mother stated she did not want him to be prosecuted. Although there could be a view that his detention may have set some boundaries for him; from his mother’s perspective the police respected her wishes. There is one instance when she rang the police because he would not get up and go to school. The police declined to attend which is expected, as it is not their role. However, by that stage, they had significant information at their disposal about his offending, his exposure to gang culture and his vulnerability to exploitation. By assisting his mother in getting him to an education provision it may 33 have helped her (and meant fewer calls to the police about his being ‘missing’ or committing crime). With the exception of that incident, the police maintained a reasonable relationship with his mother which would not have been easy when considering they were frequently detaining her son for criminal offences. 5.9.10 In November 2017, Archie’s mum attended the GP for an appointment. Following the consultation, the doctor described her as ‘vulnerable’ and gave her safety advice and spoke to her about Archie’s behavioural problems. This resulted in a second visit a couple of weeks later accompanied by her son. Archie did not want to engage but the doctor persisted and told him he could see a professional alone if he wished to do so. This is good practice with Archie more likely to reveal his concerns without his mother present and the GP did the right thing by making the attempt. His mother was diagnosed with ‘low mood’ and was signposted for IAPT services. Given her chaotic lifestyle, it would have been more effective to refer to IAPT rather than ‘signpost’. 5.9.11 When his mother applied to be rehoused this was progressed by Housing and Neighbourhood Services. At this first instance, the Housing Officer tried to progress, but matters moved forward slowly as Archie’s mother frequently did not respond to telephone calls or messages. The Housing Officer, recognising her chaotic lifestyle, arranged a joint home visit with the MAST worker which meant the housing application could move forward. They had tailored their approach to match her needs. 5.9.12 In March 2018, Archie was appearing in court. Initially his mother refused to take him back home as she said she could not keep him safe. She was only persuaded to take him after the Youth Justice Service manager rang Children’s Social Care who agreed a social worker would attend that afternoon to establish what support could be provided. At a subsequent court appearance nine days later, the case manager enquired but was told that nothing had yet been put in place. This type of reassurance which was not followed with action will have added greater pressure to Archie’s mother’s circumstances and a mistrust of agencies. 5.9.13 The biggest single concern with agencies’ contacts with Archie’s mother is her constant and repeated message that she could not control her son; he was exposed to gangs and violence and she could not protect him. She was right: it was clear he was no longer living with his family and any attempts to plan care for him around the ‘family’ was most likely to fail. 6 Findings and Recommendations. 6.1 His experience of mainstream education was poor. From the time he arrived in the UK, there was no assessment of his needs carried out. Professionals knew little about his background, early life experiences, his exposure to domestic abuse or his academic ability or prior learning. 34 6.2 Early contact with the Education Department was bureaucratic. He was left with no provision and spent an increasing amount of time ‘on the streets’ associating with older boys and young men. 6.3 Every child has a right to education. Recommendation 1: Every child arriving from outside the UK and taking a place in the education system should receive an assessment in the school by a trained professional to assess their academic ability, level of attainment and other vulnerabilities that may impact on their learning. This assessment should be recorded and should be available to influence future interventions by all agencies. Recommendation 2: It is the responsibility of all agencies to ensure every child in Sheffield is in an appropriate educational setting every day and that their policies and procedures work to support this. Where agencies do not have a role in education but failing to attend school or an appropriate educational setting is identified, they should have procedures in place to ensure this is referred to the relevant agency. Sheffield Safeguarding Children Board to seek assurance from agencies that their work meets this responsibility. Recommendation 3: When a parent elects to home educate their child, the Local Authority should seek reassurances that the child is receiving a balanced education which means they are not disadvantaged from children in other education settings. This should include a home visit for an assessment by a trained professional to ensure suitable learning is taking place. It is acknowledged that no specific powers exist, and parents may not wish to comply, but the Local Authority has a duty (section 436 Education Act 1996) to make arrangements to establish (so far as is possible to do so) the identities of children in their area who are not registered pupils and are not receiving suitable education otherwise than at a school. If a parent did not comply then established routes for escalation could be considered. Recommendation 4: The Local Authority must develop and communicate a clear escalation process for children not on school roll. Recommendation 5: All schools within the City of Sheffield should be reminded of their legal obligations to place a child on their school roll on the day they are notified. 35 6.4 Archie was involved in gang related activity. He was initially on the periphery but became more involved and was later identified as making threats of violence and carrying weapons. He was controlled by older associates and thus exploited. The vulnerabilities of his young age, an unstable home life and lack of education provision all contributed to his exploitation through gang culture. 6.5 Despite several records noting a referral to a gang matrix or gang panel, no such panel ever convened to discuss his case and therefore no plans were made to intervene and remove him from this culture. Recommendation 6: Sheffield Safeguarding Children Board must be assured that there is an ongoing commitment to maintain and build on the multi-agency response to addressing child criminal exploitation and reducing youth violence in Sheffield. Recommendation 7: Sheffield Safeguarding Children Board and the Community Safety Partnership should ensure there are structures in place to assess, refer and intervene with vulnerable people who may be exploited by gangs and Organised Crime Groups operating in the city. The referral pathway should be promoted to all agencies. The launch of the Child Criminal Exploitation team (Sheffield’s partnership approach to dealing with serious violence and organised criminality) should be assessed to confirm it identifies and intervenes with young people at risk of exploitation. 6.6 From Archie’s involvement in a minor offence in December 2016, there was a rapid escalation in his offending behaviour and agencies struggled to keep pace with these developments. By the time plans were made to intervene, he had already escalated to more serious offences. 6.7 Early positive steps with youth engagement were abruptly ended when he reoffended. This manifested itself in yet further offending which was both frequent and serious. 6.8 There were blurred lines for areas of responsibility between agencies. This was particularly evident between the Youth Justice Service, Children’s Social Care and the Community Youth Team. Recommendation 8: There must be a clear referral route for vulnerable young people who engage in offending. Services should be commissioned to ensure that once a service is engaged with a young person; a lead professional is identified providing a key point of contact for the young person and their family. Irrespective of further offending, the intervention should continue as appropriate. This will require a review of current commissioning arrangements. 36 6.9 Episodes of being reported ‘missing’ were frequent. There was confusion both with the family and professionals regarding who was responsible for conducting ‘return’ interviews. These are a vital component in keeping a young person safe. Recommendation 9: A review of the arrangements for ‘missing’ should be undertaken and assurance provided to Sheffield Safeguarding Children Board of the appropriateness of these arrangements in keeping children safe. All practitioners should be aware of the policy and process. 6.10 Police recorded Archie as a ‘medium’ risk when he was reported missing. However, this is the minimum risk level for all missing children and young people. He was never escalated to ‘high risk’ even when in one episode he was missing for 13 days and during several instances when he was clearly involved in violent criminality. His bereavement following the sudden and tragic death of his sister was never fully addressed. He never accessed a professional counselling service. Recommendation 10: The current Missing Young People protocol should be revised to ensure that all risks are identified at the point of reporting and all levels of risk, responses and actions are reviewed regularly throughout the missing episode. Senior managers and officers should approve and oversee the development of a multi-agency safety plan for all high risk missing young people. 6.11 The role of the MAST (early intervention) team was ill defined. Individual workers developed a good rapport and understanding with the family, but they became absorbed within the daily problems and therefore were not able to focus on the bereavement. Recommendation 11: A clear pathway should be developed for children and families to access support following the bereavement of a close family member. This should include a mapping of services for children’s emotional and mental well-being. Recommendation 12: The deployment of resources from MAST is a vital early intervention service. To ensure maximum benefit to the family, their role should be clearly defined with a written plan agreed with the referring agency to include key targets and regular reviews. 6.12 Archie’s mother exhibited a number of vulnerabilities. These included mental health issues, low income, fleeing domestic violence and being a single parent in an unfamiliar country. There were several individual errors in contacts with her which will have added to her frustrations. However, she did receive support from many committed and dedicated professionals across many agencies. 37 6.13 The Child Protection Plan was not effective and the Core Groups were either poorly attended or did not take place at the required frequency. The Review Conference noted the increase in his exposure to violent offending and being reported missing on an almost continual basis. It recorded actions to progress to a ‘high risk tracker’ to alert senior management as it had reached the highest possible level of risk and required immediate intervention. Yet it failed to implement the actions to deal effectively with the assessed risk. 6.14 The Child Protection Plan was not working and the family home was not the right environment in which to base the plan. The danger was on the streets rather than in the home environment. Recommendation 13: Sheffield Safeguarding Children Board must put mechanisms in place to ensure agencies involved in the safeguarding of children and young people commit to both the sharing of information in a timely manner and their agency’s attendance at Child Protection Conferences. Recommendation 14: Sheffield Safeguarding Children Board must put mechanisms in place to check agencies identified as having a role in the Child Protection Plan must ensure they send representatives to the Core Groups to ensure the plan is implemented and developed. Recommendation 15: Sheffield Safeguarding Children Board must ensure that there are clear lines of responsibility on who delivers actions against the Child Protection Plan. This is especially important when escalation to senior management is required. Recommendation 16: When a young person is subject to a Child Protection Plan, this must be the forum that takes primacy over all other forums. The Youth Justice Service Multi Agency Risk Panel or the ‘gang matrix’ have important roles to fulfil but they must be incorporated into the Child Protection Plan to prevent duplication and ensure a focus of effort to keep the young person safe. Recommendation 17: Sheffield Safeguarding Children Board to research, develop and assist with the implementation of Child Protection Conferences that assess risk and develop plans in line with our increasing understanding of contextual safeguarding. Recommendation 18: Sheffield Safeguarding Children Board should commission workforce development for delivery to all front line professionals on the issues of contextual safeguarding. This training should include recognising the risks of criminal exploitation and sexual exploitation. 38 Recommendation 19: Contextual Safeguarding should be embedded in all agencies’ considerations, planning and processes linked to safeguarding of children and young people. 39 6. Glossary APP Authorised Professional Practice CAMHS Child and Adolescent Mental Health Services CME Children Missing from Education County Lines Cross cutting issue involving drugs, gangs and exploitation Core Group Forum responsible for developing and implementing the Child Protection Plan CPP Child Protection Plan CSC Children’s Social Care CYT Community Youth Team EDT Emergency Duty Team EGVE Ending Gang Violence and Exploitation FAM Street slang for ‘family.’ GP General Practitioner HMICFRS Her Majesty’s Inspectorate of Constabulary, Fire and Rescue Services IAPT Improving Access to Psychological Therapies ICPC Initial Child Protection Conference Interchange Counselling service IMR Individual Management Review HM government Her Majesty’s Government MARP Multi Agency Risk Panel (Youth Justice Service) MAST Multi Agency Support Team NASSEA Northern Association of Support Services for Equality and Achievement OFSTED Office for Standards in Education, Children’s Services and skills PCSO Police Community Support Officer RAPP Resource Allocation or Placement Panel RMFHC Running and Missing from Home and Care S. 47 enquiries Assessment of whether a child is likely to be at risk of significant harm SOS Signs of Safety (Grid used by Children’s Social Care) YJS Youth Justice Service |
NC52355 | Death of a 16-year-9 month-old girl. Emma was staying with a relative at the time of her death; the relative's partner was convicted of Emma's murder and sentenced to life imprisonment. Findings include: Emma's positive presentation may have resulted in professional over optimism and disguised her ongoing vulnerability; when an adolescent is on a child in need plan the supporting professional network needs to consider the parent's ability to support the child; when children are linked to exploitation it should be established if the parent is able to understand the risk posed by contextual safeguarding issues; practitioners outside of children's social care do not always clearly record the voice of the child. Recommendations include: encourage practitioners to operate a reflective mind-set with their case work, being aware of over optimism and ensuring continuing practice of professional curiosity; practitioners understand expectations regarding recording standards, including how the 'child's voice' is recorded; education settings should ensure that child protection records are transferred in a timely fashion at points of transition; practitioners question the language used to describe a child, their presentation and context in assessments and other recording; practitioners know how to respond when unreported domestic abuse is raised by a child service user; the local safeguarding partnership conduct a multi-agency audit of adolescents known to agencies due to risk of harm following neglect.
| Title: Emma learning review report. LSCB: Hampshire Safeguarding Children Partnership Author: Jon Chapman Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Emma Learning Review Report The purpose of reviews of serious child safeguarding cases, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children. Locally, safeguarding partners must make arrangements to identify and review serious child safeguarding cases which, in their view, raise issues of importance in relation to their area. They must commission and oversee the review of those cases, where they consider it appropriate for a review to be undertaken. 1 This review was co-authored by representatives from Children Social Care and Hampshire Constabulary who had no involvement in the case. The Safeguarding Partnership formed a case review group to oversee the review process. In selecting the reviewers for this case, the review group was cognisant of the requirements of Working Together 2018, that they possessed: - • Professional knowledge, understanding and practice relevant to local child safeguarding practice reviews, including the ability to engage both with practitioners and children and families. • Knowledge and understanding of research relevant to children’s safeguarding issues. • Ability to recognise the complex circumstances in which practitioners work together to safeguard children. • Ability to understand practice from the viewpoint of the individuals, organisations or agencies involved at the time rather than using hindsight. In order that the review maintained an independent focus the safeguarding partnership commissioned an independent review author to have oversight over the review process. I Independently chair a review group in another area, and I have undertaken previous safeguarding reviews for children and adults, as well as Domestic Homicide and Multi Agency Public Protection Arrangements (MAPPA) reviews. As the independent reviewer I have in this case: - • Been involved in the review set up and formation of the terms of reference. • Had access to the various agencies review information and reports as requested. • Been involved in the case review group meetings. • Been involved in the reviewer’s discussions and development of the report. 1 Working Together 2018 - HMG I have been able to provide oversight, scrutiny and challenge to the reviewers. I have found that the process was approached by the case review group and in particular the reviewers with transparency and a desire to achieve child centred learning and improvement for the partnership. Jon Chapman Independent Scrutineer Emma was 16yrs and 9 months when she died. She lived primarily with her mother but also at times, particularly in her teenage years, stayed with other adults, family members or close friends. She was staying with a relative at the time of her death. The relative’s partner was charged and convicted of Emma’s murder in 2020 and was subsequently sentenced to imprisonment for life. The community in which Emma lived, is one in which many of her extended family members lived and the practice in this community, as in many others, is for people to 'take in' and offer support to extended family and friends. It is very common for 16/17 year olds to be staying with people other than their immediate parent/s. Emma was known to both universal and statutory services throughout her life with periods of concern relating to domestic abuse and neglect. At the time of her death a Children and Families Assessment was being undertaken as Emma had moved from one extended family member’s home to another and was considered at risk of homelessness. The perpetrator has been described as having learning difficulties. He had apparently not been in employment for some time. His partner/wife seemed to be a support/carer to him. There were no known or previous concerns relating to the perpetrator. To identify learning from this case the Local Child Safeguarding Practice Review (LCSPR) was tasked to consider the following areas of focus. 1. The voice of the child – what was life like for Emma over the last 18 months of her life? Were her voice and views clearly articulated and captured in agency records and by those who worked with her? 2. The transition from school to college and in particular the significant drop in her attendance after starting college. 3. The impact of the reported rape by a peer the previous summer, and the news that no further action was going to be taken by the Police. 4. What was professionals understanding of the cumulative impact of her earlier life experiences and prior events on the current risks to Emma? 5. Was anything known about the alleged perpetrator that may have indicated a risk? 6. Learning identified from any of the areas highlighted above that may benefit other young people in a similar position or at a similar transition point in their life. Individual agency reports and chronologies were provided to inform the LCSPR and supported the identification of the below findings and recommendations. Finding 1: The Hampshire Safeguarding Children Partnership Escalation Policy was not used effectively. Schools and other partners should have the confidence to utilise the policy to ensure that any concerns are robustly addressed enabling the effective safeguarding of a child. In order to do this, there needs to be an understanding of the potential barriers that prohibit the effective use of this policy. Recommendation 1: Hampshire Safeguarding Children Partnership develop guidance and an associated training package for the HSCP Escalation Policy and process and ensure it is widely promulgated across all agencies. Finding 2: The positive description of Emma by professionals does present a potential dichotomy; whilst it is acknowledged that Emma presented in such a positive way during this time, it is plausible that this was creating over optimism and disguised Emma’s ongoing vulnerability or her ability to effectively utilise the support put in place. Recommendation 2: The Hampshire Safeguarding Children Partnership via their current extensive training programme, proactively encourage practitioners to operate a reflective mind-set with their case work and via supervision, being cognisant of professional over optimism and ensuring continuing practice of professional curiosity. Finding 3: a) For adolescents on a Child in Need Plan, thorough consideration by the supporting professional network needs to be given to the parent’s ability to consistently support the child. Where applicable professionals working with the family need to understand the details of the parenting capacity assessment and what this means in practice. b) For cases of children linked to exploitation this information should be utilised to establish if the parent is able to understand the risk posed by contextual safeguarding issues, has the ability or emotional resource to put in place protective measures suggested for their child, and is empowered to access the relevant pathway of support should they struggle to sustain being a protective parent. Recommendation 3: a) The respective partners of the Hampshire Safeguarding Children Partnership to remind practitioners of their role in contributing towards assessments of parenting, that no one agency will have all of the information and that by contributing, all partners will have a better understanding of the assessed needs. b) The Hampshire Safeguarding Partnership exploitation sub-group to scope what pathways of support are available for parents of children at risk of harm due to exploitation and consider whether engagement with parents and carers is sufficiently reflected in the HIPs Exploitation Strategy and its work streams. Finding 4: Practitioners outside of children’s social care do not always clearly record the voice of the child or differentiate the child’s voice from the parent’s. There are strengths in the CSD ‘voice of the child’ approach that could be utilised by other agencies. Recommendation 4: Hampshire Safeguarding Children Partnership ask the respective partner agencies to review their recording standards and ensure that expectations regarding the quality of recording, including how the ‘child’s voice’ is recorded, is made clear to practitioners. Each agency should ensure that it is meaningful, understood and embedded within training and practice. Finding 5: Disengagement with (professionals and) education increases vulnerability. The college applied its standard procedures in relation to deteriorating attendance and non-engagement. Adjustments to the standard procedure in acknowledgement of the safeguarding context and additional vulnerabilities may have been beneficial and led to more frequent contact with education professionals. Additionally, the timely transfer of child protection records across education settings is imperative in order that education professionals swiftly have a full picture and history of child protection issues and concerns; this was not the case. Recommendation 5: a) Standard operating procedures – for example the procedure for non-attendance in an education setting – should acknowledge and respond to contextual safeguarding, recognising that variation in procedure may be needed to address increased levels of vulnerability for some children b) Education settings should ensure that child protection records are transferred in a timely fashion at points of transition, in accordance with Keeping Children Safe in Education (KCSiE) statutory guidance. Finding 6: The transition from school to college was a very challenging period in Emma’s life and could even be described as a ‘critical moment’. Emma had gone from a child who would readily engage with professionals, to disengaging at college and no longer accessing the support offered. With the Child in Need plan drawing to an end, there is limited information to suggest that there was a continued strong collaborative multi-agency approach and her prior network of support had dissipated. Recommendation 6: Partner agencies of the Hampshire Safeguarding Childrens Partnership should be reminded of the existing guidance which explains when it is appropriate to convene a professionals meeting. This should reflect a commitment to ensuring a co-ordinated approach to children that are not in receipt of statutory support. Finding 7: The impact of a ‘no further action’ decision cannot be underestimated, therefore when a victim of rape or serious sexual assault is given details of the investigation outcome, wherever feasible, and in agreement with the victim, this would be better done in a supportive, face to face environment with the relevant supporting professional present. Other relevant agencies involved with the young person should also be appropriately informed, in order that the necessary support can be given. The impact of Covid on this case should be acknowledged. Recommendation 7: Hampshire Constabulary review its process when providing victims of rape and serious sexual assault with an investigative outcome and put in place a mechanism to ensure that wherever possible this is done so in conjunction with a supporting person or professional present. Finding 8: Professionals must be mindful of the language they use when recording interactions with children. The way in which professionals quantify and record these statements is essential to get right to ensure that the next professional has a good understanding of the provenance. Conversations should take place with individual practitioners in safeguarding supervision, as well as agencies being encouraged to question each other in multi-agency settings, so that assumptions can be questioned, and clarity reached as to what commonly used terms really mean. Recommendation 8: Partners should emphasise that it is incumbent upon practitioners in all agencies to question the language that is used to describe a child, their presentation and context in assessments, reports, plans and general recording. Finding 9: When domestic abuse is not being reported to the police it is important that other supporting agencies, where possible, undertake the relevant domestic abuse (DA) risk assessments. This should be combined with a good understanding of the impact of domestic abuse on children, including older (teenage) children, ensuring that DA is routinely considered though the lens of child protection and the S47 threshold of ‘risk of significant harm’. Recommendation 9: Partner agencies of the Hampshire Safeguarding Children Partnership to ensure practitioners know how to respond when unreported domestic abuse is raised by a child service user or by a parent of a child service user. Practitioners should be encouraged to proactively ask about the presence of domestic abuse in a safe and supportive way. Agencies should encourage a multi-agency approach to the management of risk. Recommendation 10: Hampshire Safeguarding Childrens Partnership conduct a multi-agency audit of a cohort of adolescents known to children’s social care, police and health due to risk of harm following neglect. This audit should enable the HSCP to identify any continued learning for professionals and identify positive practice. |
NC52640 | Death of a 15-year-old-boy in August 2021 from complications due to multiple, non-accidental rib fractures. Learning includes: the need for all professionals to understand the challenges of being a new arrival to the UK; the importance of understanding relationships in families and a full background history where new arrivals are concerned; the need for professional curiosity and allowing practitioners the freedom and space to exercise it; concerns around domestic abuse in families over lockdown during the coronavirus pandemic, and whether they may be under pressure not to report. Recommendations include: ensure that practitioners have the training to be able to understand the challenges for a new arrival into the UK, including how to access health, education, and support services; ensure that practitioners can access information from originating countries to assist in the care of children arriving in the UK; ensure that support is being provided to practitioners to provide resilience within the workforce; ensure the workforce have been given the tools and training to support children and young people coming out of the pandemic to aid their recovery; ensure that where professionals have identified risks within families that the risk is thoroughly assessed and recorded; ensure multi-agency assessments of risk are taking place on which plans of action are based; the National Panel are to engage with the border force to explore the processes in place when a child or young person enters the UK and gain clarity on how safeguarding concerns are identified and communicated to the relevant local authority.
| Title: Local child safeguarding practice review: Paul – Child Q. LSCB: Kirklees Safeguarding Children Partnership Author: Matt Brayford Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 LOCAL CHILD SAFEGUARDING PRACTICE REVIEW PAUL - CHILD Q Author: Matt Brayford Publication: 4 April 2023 2 Contents 1 Introduction and Context 3 2 Arrangements for the Child Safeguarding Practice Review 4 3 Methodology 6 4 Family Composition 7 5 The incident of concern 8 6 Background and Previous involvement 9 7 Key Practice Episodes and Analysis 12 8 Comparator Cases 16 9 Practitioner Learning Event Capture 17 10 Learning & Recommendations 19 11 Next steps to embed learning 22 12 Appendices Appendix 1 - Kirklees Locala Procedural document 2020 Appendix 2 - Domestic Homicide Reviews within Polish nationals living in the United Kingdom - Matejci Matusiak Appendix 3 – Child Mortality Database -Covid deaths in children: (How has the pandemic impacted child mortality?) Appendix 4 – Ofsted Annual Report 2021 23 3 1.Introduction and Context About the author The author comes from primarily an education background with experience of Senior Leadership (including the role of Designated Safeguarding Lead) at the secondary phase. Previous roles and relationships included partnership working with the Home Office, Counter Terrorism Police and Social Services. The author is familiar with Local Government services, functions and has used this information to support the writing of this review. 1.1. This is an overview report from a Local Child Safeguarding Practice Review (CSPR) conducted by Kirklees Safeguarding Children Partnership (KSCP). The matter which has led to the review is fatality of a child aged 15, who had been living in the UK for a period of less than 12 months when the incident occurred on August 13th, 2021. The exact circumstances surrounding the injuries to the child are not clear, but at the time that it occurred, the child was at home and it was mothers’ partner who made the 999 call. 1.2. A rapid review of the case was held in accordance with the criteria set out in Working Together 2018 and highlighted several issues to explore: ➢ The fatality of a child under the aged of 15, who had been in the UK for a period of less than 12 months ➢ The support offered to children and young people who are new to the UK even when parents have been resident for a period of time prior to their arrival ➢ Considerations of safeguarding young people new to the UK ➢ The impact of the Covid-19 global pandemic on child deaths in the UK ➢ The role of agencies in noticing issues of concern and communication with partners 1.3 Completion of this Review includes consideration of children new to the UK and access to Universal and International new arrival services. It uses some comparator cases to consider common factors and the implications for practice regarding Domestic Abuse in the family home specifically linked to Polish families. 1.4 The work in completing this review also considers the significance of criminality in the history of the parents/carers. With a consideration of how this is shared with schools and wider services. 4 2. Arrangements for a Child Safeguarding Practice Review 2.1 The aim of a Local Child Safeguarding Practice Review is for individuals and agencies to learn lessons about the way in which they work both individually and collectively to safeguard and promote the welfare of children. It draws on the criteria set out in Working Together 2018 and at its core, seeks to identify learning to support the local system to improve safeguarding practice. 2.2 It is not about apportioning blame for what occurred, but about learning how the system could improve its response. For these reasons, this review was conducted in such a way that it: ➢ Recognises the complex circumstances in which professionals work together to safeguard children. ➢ Seeks to understand key practice episodes, where it may have been possible to intervene differently. ➢ Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. ➢ Makes use of some comparator cases to consider themes that might further develop the service offered to families of varying backgrounds and origins ➢ Considers relevant research and case evidence from regional and national sources to inform the findings. 2.3 A panel representing partner agencies of the Kirklees Safeguarding Children Partnership developed the terms of reference in line with Working Together to Safeguard Children (2018), and West Yorkshire Safeguarding Children Procedures, Chapter 10.1 (8.20). 2.4 The following agencies, identified as having been involved with the child and family, were asked to contribute, and supply information to the process including some analysis of significant events. Agencies were also requested to identify some comparator cases involving children from Polish backgrounds and domestic abuse. An analysis of the comparator cases is highlighted at section 6. The agencies invited to participate and submit information to support this review were as follows: ➢ Mid Yorkshire Health Trust ➢ West Yorkshire Police ➢ Education via the school ➢ The GP ➢ Locala: Health Visitor Service / School Nurse ➢ MAST Health Practitioner ➢ Immigration Enforcement - National Command and Control Unit 5 2.6 The methodology followed to complete this review is a local proportionate response. The child was unknown to statutory agencies and wider support services prior to the incident of concern. Accordingly, this review has been compiled following the gathering of information from agencies and case discussion with key practitioners. The gathered information has been reviewed, screened and challenged externally by the Independent Scrutineer and forms the considerations and learning discussed within. 6 3. Methodology 3.1 This report has been prepared following a Rapid Review and submission of documentation by engaged agencies. It has considered additional information submitted on request and has also had the benefit of considering learning collated by the NSPCC and from other Safeguarding Practice Reviews and particularly those involving a history of Domestic Abuse in Polish families. 3.2 The review has been conducted and written with the benefit of hindsight and it is recognised that this often distorts the view of the predictability of events, which may not have been evident at the time. It is important to be aware as Munro (2011) states, just how much hindsight distorts our judgement about the predictability of an adverse outcome. Once an outcome is known we can look back and believe we can see where practice, actions or assessments were critical in leading to that outcome. This is not necessarily the case and information can often become much clearer after an event has occurred. This review is therefore sensitive to this ‘bias’. 3.3 The review is also sensitive to pressures on agencies and the demands of the work. The completion of this review also coincides with the challenges agencies and schools have felt in responding to the Covid Pandemic which has drawn on capacity and has impacted upon participation. In completing a proportionate report, it has therefore been essential to recognise those demands and to highlight learning, which can be disseminated with some reflection on how the lessons can help change practice rather than apportion blame to agencies or individuals. 7 4. Family Composition 4.1 The family composition in this case is drawn from records provided by agencies. It includes those reported as living at the address at the time when the incident was reported to have occurred and biological father (Steve) who resides in Eastern Europe. Throughout this process Steve has been supported and regularly updated with the progress of this investigation and the review process by the Police Family Liaison Officer. To protect the identity of those involved pseudonyms have been used, see below-: Subject Child Paul Mother of Subject Child Marie Mother’s Partner Mark Father of Subject Child Steve 8 5. Incident of Concern 5.1 On August 13th, 2021, the emergency service team responded to a 999 call at 10:55am regarding Paul who was not breathing in the bathroom. The call was made by Mark who was the biological mother’s partner. It is unclear if mother (Marie) was present in the family home at the time of the incident. The ambulance arrived at 11:01am. The Patient Care Record reports Paul was in cardiac arrest. It was also documented that the family told the ambulance crew Paul had previously experienced physical and emotional abuse by his biological father, Steve. Paul was transported to Huddersfield Royal Infirmary. 5.2 Police records state at 11:00 am hours on Friday 13th August 2021 a call was received from an ambulance reporting a 15-year-old male was in cardiac arrest at an address in Huddersfield. The male was located unresponsive at the property. Life was pronounced extinct at 11:34 am hours and the scene secured. Two people linked to the address were arrested and charged on suspicion of murder. 5.3 There were no additional siblings or linked family members requiring Local authority intervention. 5.4. The Forensic Pathologist in completing the post-mortem report said that there were a significant number of fractures at various stages of healing, indicating several non-accidental injuries on different days. Four of the fractures may be as a result of resuscitation and four fractures that were healing were infected with pus. The initial cause of death had been noted as complications due to multiple rib fractures and the infection caused by those. Paul’s blood results indicated an infection, and he was also noted to have fluid on his lungs. It is the overall pathologist’s opinion that Paul’s injuries were a result of numerous non-accidental injuries. 5.5 The injuries that have been identified as multiple rib fractures are considered as the cause of death as without the fractures, the infection would not have been able to take hold and develop. Some of the injuries would have been extremely painful and would have changed how Paul walked or sat. Some of the noted injuries were fresher and some which were scabbing over. 9 6. Background and Previous Involvement including chronology of events 6.1 Marie and Mark resided in the UK for a number of years prior to Paul`s arrival on October 4th, 2020. Criminal activities have been logged for both subjects between May 2012 and November 2020. Concerns regarding criminal behaviour included robbery, handling stolen goods, burglary, possession of illegal drugs, assault, and public order offences. Predominantly these offences resulted in cautions and warnings however, Mark was sentenced to imprisonment in 2012 relating to an assault and robbery. The drugs matter involving Mark related to possession of Cannabis where he was stopped alone in his vehicle. This resulted in him receiving a Community order which he complied with and was in line with guidance. Mark and Marie were unknown to support services at this time. Police involvement with the adults was very limited and there were no safeguarding concerns in relation to the criminal activity. 6.2 In addition to Police involvement prior to Paul`s arrival in the UK Marie and Mark had presented at Mid Yorkshire Hospital trust with a variety of injuries. Mark on separate occasions reporting neck pain following a road traffic accident and head injuries following fighting. Mark had not been registered with a GP since 2015. Marie has one case referred for abdominal pain and pelvic bleeding (where pregnancy was not an issue). 6.3 Paul arrived in the UK on October 4th, 2020. It is understood that Paul entered the UK accompanied by Marie and Mark. This was confirmed by the border agency. 6.4 Paul was registered at a Kirklees school on October 19th, 2020. Marie was given access to the My Ed system for school to home communication. In this case, Marie had made use of the system to communicate with school on a number of occasions. Paul had what would be considered an appropriate attendance level (94%), and any absences did not follow a pattern or cause concern. Paul’s character statement can be seen in appendix 5. 6.5 Records show in October 2020 Paul had email correspondence with school regarding online learning tasks and activities. School report there was some supportive communication from members of staff with instructions and additional information pertaining to learning. Communication from Paul at this time was largely around seeking clarification on activities and points of learning; several of them are in response to questions/tasks. School report Google translate was used in some communication and some of the emails from Paul supported a limited understanding and use of English. On one communication soon after registering with the school Paul indicated he wasn’t feeling well, it is unclear if any follow up was carried out by school as to why Paul was unwell. School reported that Paul was not flagged as vulnerable and had a good attendance record. School maintains there was evidence of engaging in learning with a consistent flow of communication between Paul and members of staff. School state as a student with limited English, Paul was being supported by the “English as an Additional Language” department in 10 school. Information from school indicates Paul had an attendance of 94% with only 14 sessions having been missed for illness or lateness in the academic year 2020/21. Paul`s school report reads of a well-behaved child who engaged with school life and interacted with peers and staff. The school dates below are important to understand the time Paul would have spent in school and at home (including the government lock down period) -: Autumn term started – 14/09/20 Paul started school – 19/10/20* October Half term – 26-30/10/20 Autumn term end – 17/12/20 Spring Term started – 05/01/21 Government lockdown – 05/01/21 – 10/03/21 – Remote learning Spring term ends – 26/03/21 Easter holiday – 29/03/21 – 09/04/21 Summer term starts – 12/04/21 May half term – 31/05/21 – 04/06/21 Summer term end – 23/07/21 School Holidays 26/07/21 – 3/09/21 – Incident date 13/8/21 *Because Paul commenced after the beginning of the academic year he would not have been included in the movement in list from education to Child Health. 6.6 On April 7th, 2021, Paul registered at a local GP Practice. According to NHS standards - Children under 16 should be registered by their parent(s), but don't have to register with the same GP as the rest the family. From GP records and following a conversation with the GP practice it still remains unclear who attended with Paul to register. New patient assessments are offered to all patients, and they are encouraged to book this with the Health Care Assistants as part of their registration. It is reported from the GP records there was no evidence that Paul or his family booked an initial health care assessment. 6.7. In April 2021 Locala sent out a letter to the family introducing the Thriving Kirklees 0-19 Team. A leaflet regarding the School Nursing service was also enclosed, which included advice to register Paul with a GP, dentist, and contact the GP for information regarding childhood immunisations. Information was included indicating if any assistance with communication was needed to get in contact using a number supplied. The information sent out to the family was written in English. School report that Marie had an operational level of understanding of English. 6.8 When reviewing information in April 2021, the Health Practitioner deemed that no further action was required at this time due to information about the 0-19 service having been sent out, and records indicated that Paul had an identified school. It was reported that on examination of the records, there were no details regarding school, and this had been recorded in error. However, as there were no known clinical concerns, no further action was 11 reported and was in line with current practice guidance outlined in the Kirklees 0-19 Procedural Document 2020 (Appendix 1). 6.9 A Meningitis immunisation was scheduled on July 15th, 2021, following correspondence via mobile phone with the family. This appointment was cancelled by the GP practice. School-aged children who are due inoculations would be picked up within scheduled vaccinations by the school nurse. If appointments are missed in the Autumn term school can arrange catch up appointments. A review of research shared with the Home Office ‘Domestic Homicide Reviews within Polish Nationals living in the United Kingdom’ authored by Maciej Matusiak a frontline service Police officer in Merseyside Police is of particular interest here (Appendix 2). The report cites ‘Polish culture’, language and cultural barriers alongside reporting as potential barriers to engaging with local area services and reporting domestic abuse. 6.10 August 13th, 2021, emergency services were called to the family home in response to a child being unconscious in the bathroom not breathing. Paul was transported to Huddersfield Royal infirmary; Paul was pronounced dead in the Emergency Care Facility. The Police enquiry was handed to the Homicide and Major Enquiry Team (HMET) who arrested Marie and Mark on suspicion of murder. 6.11 After the event of Pauls death schools CPOMs, (Safeguarding recording tool) record indicates an entry dated September 9th, 2021.The date of the CPOMS entry has been confirmed as the date the information was shared with school by the pupil and is not a retrospective entry. The entry stated, that Paul was ‘frightened’ of his mother. The child disclosing stated they had witnessed this outside the school gates on October 19th, 2020. Marie was seen to berate and shout aggressively at Paul in view of other learners. It is sadly noted that this was not shared by learners with school pastoral staff at the time. This could also be a subtle link to Maciej Matusiak’s research briefly discussed earlier where communities new to the UK find it increasingly difficult to reach out and accept support from services and professionals. 12 7. Key Practice Episodes and Analysis 7.1 In considering this case several key issues and themes arise, that are worthy of some consideration. These would include the support offered to children and families that are new arrivals to the UK. This support should lead to careful screening and checks of parents and carers including background issues linked to criminality and ultimately safeguarding. It is also important to consider when young people are registered with a GP that Initial health screening should be carried out on all new patients and any concerns flagged with essential services. Processes were identified that support the notification of children registered with a GP Practice to Child Health. 7.2 It is important to note though that in day-to-day presentation the health and wellbeing of Paul did not present concerns to professionals. This is important because in the absence of a safeguarding concern regarding Paul it was increasingly difficult to predict the events of August 13th, 2021. However, there are some areas that merit some further discussion. A) The Importance of children new to the UK being identified and supported. From the information gathered whilst compiling this review it has become apparent that Paul was unknown to the Kirklees International New Arrivals Team (INAT) that sits within the Education Safeguarding Service. The service offers a variety of support to families new to Kirklees including housing support, signposting, and support in accessing health and education and language/communication support. In the case of Paul, he perhaps was not logged with the INAT team because Marie and Mark were residing within the country for approximately 10 plus years prior to Paul`s arrival in the UK. There should be an emphasis when schools or admissions register a new learner to mark the child as new to the country. When considering the previously mentioned research around Polish families and engagement this highlights an area of future sign posting through safeguarding training and updates to all Kirklees education/health care settings. There must be strong guidance to notify the INAT when a child born outside the UK registers at their school regardless of the length of time spent in the UK by parents or carers. This would allow for support of the family and give the opportunity as required to conduct a family assessment and flag any potential safeguarding concerns. In the sad case of Paul this could have considered a full background history and could have indicated potential risks and would have allowed for appropriate escalation. 13 B) The safeguarding support and challenge of education settings Schools in Kirklees have several visits conducted by Kirklees Learning Partners (KLP) throughout the academic year and are required to complete a Section 175 safeguarding audit. These visits and audits challenge the schools safeguarding policies and execution of policy in practice. Schools also must have Designated Safeguarding Leads (DSL) that are required to complete specific training and refreshers to be compliant in the role. It is through this partnership working and forum that schools can receive appropriate support in meeting the requirements set out in Keeping Children Safe in Education (2021, KCSIE) guidance. When considering the case of Paul how aware were the school of the support available through the Kirklees INAT team, Early Support Services and Family Support and the benefits it could bring. Is there a robust understanding of the risks associated with certain cultures regarding domestic abuse and engaging with services? It is a view that through partnership working with appropriate challenge and support can be developed further to safeguard all children. C) The role of health services in raising concern Paul was registered as a new patient on April 7th, 2021, at a local GP practice. This presents a very large gap between arrival in the UK and registration for health care. It is unclear if this was with the presence of Marie or Mark. It has been confirmed that Paul did not have a routine health care screening that should be in place for a new patient joining a practice. A health screening should take place and any concerns escalated and communicated to service and partners. It is worth considering if it was clear to Paul ‘how things work in the UK’ in terms of raising and sharing concerns he may have had, and or the way health services work such as Accident and Emergency and safeguarding. There is also an element of understanding family medical history this would be especially important for children born outside the UK. In the case of Paul, Marie and Mark reported previous physical and mental abuse to Paul by Steve. These allegations are largely unproven, if declared in advance of August 13th, 2021, further investigations could have taken place. D) Professional curiosity Professional curiosity is the capacity and communication skill to explore and understand what is happening in a family rather than making assumptions or accepting things at face value. There were several opportunities in understanding this family, from the chronology that may have given a greater insight into the day to day lived experience of Paul • Marie`s and Mark`s background history appears not to have been explored or considered. • The issues relating to health screening and vaccination appointments and the importance of communication between services. 14 • Reports of Marie in June 2021 of suffering with shortness of breath and only being able to walk short distance, leading to a neurology referral following GP consultation. What impact this could have on the family home and directly to Paul? There is a strong possibility that if Marie was struggling at home additional pressures could have been placed on Paul in terms of self-care and day to day responsibility. There is also a consideration of the impact of Mark and the outcomes of this in the home. • The consideration of children being notified to 0-19 services with limited past health information and being new to the country and whether this would be a factor to offer more than an information letter. • Based on post-mortem information there is a clear indication that Paul would have been in significant pain in the weeks leading up to the events on August 13th, 2021, and there would have been biomechanical changes in walking/sitting. This must be considered given Paul was present in school for 19 out of 20 sessions in the last 2 weeks of term and it would seem as there were no observations made regarding behaviour, welfare or difficulty sitting or walking. • For example, prior to the summer holidays commencing Paul had been struck to the bottom on a couple of occasions with a wooden slat. • The abuse Paul suffered significantly increased as did the ferocity of the assaults including whipping with a cable flex once Paul had finished school for the summer. Curious professionals will spend time engaging with families. They will ask questions and seek clarity on the situation for children, to better understand risk. It is well known that children find it hard to talk about their lived experience when it involves abuse or neglect. When they do ‘tell’ it can be through behaviour or comments that are explored sensitively. This was not evident for Paul who presented as ‘a good’ learner. In the case of Paul many barriers existed to disclosure of neglect or abuse if abuse in the home was taking place before August 13th, 2021. These included cultural barriers, language and engagement with services/professionals as previously considered through research (Appendix 2) E) The global pandemic and remote learning It would be wholly remiss not to consider the impact of the global pandemic when considering learning around this sad case. Based on research the National Child Mortality Database indicate the number of children in England who died fell to 3,067 between April 2020 and March 2021. This is 356 fewer deaths than were recorded in the preceding 12 months (Appendix 3). Police statistics show that domestic homicides have not increased during the pandemic and have largely remained at the same level as the year previous. However, its agreed that there is still a prevalence that the number recorded is significantly high. Data may not present a raised concern as a result of the global pandemic. However, its entirely fair to suggest children and young people suffered because of bubble closures, local lockdowns and schools’ closures. These concerns are flagged in the Ofsted Annual report published December 7th, 2021 (Appendix 4). The report discusses barriers children faced 15 during the lockdown periods in accessing online material, progress that was lost and that ‘many vulnerable children disappeared from teachers’ line of sight’. The report talks about children with known vulnerabilities who had been encouraged by government to attend school throughout the ‘closure’ period, and that relatively few did. Approximately 33% of learners classed at vulnerable attended Paul`s school during the lockdown period January 1st, 2021 to April 12th, 2021. It is reported by school that contact remained in place with Paul during this period. With an acknowledgment that children who were not permitted to attend, there was often no way to spot signs that something was going wrong at home. This is concerning, given the general context of the high numbers of domestic abuse. The learning to consider from this for services and education providers would be what constitutes a vulnerability in child or family that requires regular and significant welfare checks. Welfare checks are also another point to consider when deciding what constitutes ‘suitable’. What training is given to staff conducting visits regarding spotting signs or neglect and identifying ‘tells’ as a call for help? School confirmed that in the case of Paul welfare checks were carried out. The long-term impact of the pandemic on children is yet to be fully realised however, from early data there is clear indication of increased mental health issues, behavioural issues, and significantly reduced progress. There is also an increase in school anxiety that has led to an increase nationally of 38% in children being electively home educated. This is a significant point to consider when trying to understand possible domestic abuse and its impact on the family dynamic and vulnerability in families. 16 8. Comparator Cases 8.1 In considering the case of Paul several other cases were considered. These cases involved three children in total. These were cases where Domestic Abuse was a feature and involved families living in England from where England was not the country of origin. A brief synopsis of each case is highlighted below • Case 1(Child D) concerns the death of a 7-week-old English/Polish child in January 2014, as the result of a severe head injury and multiple other injuries. Mother, mother's boyfriend, and another adult male were arrested on suspicion of murder. Mother was known to Police following several allegations of assault and domestic harassment. Insufficient professional curiosity was identified in this case as Mother was able to conceal her pregnancy from professionals. • Case 2 (SOT14) concerns the death of a 6-year-old girl and her 1-year-old sister. Children were murdered by their mother who then took her own life. Family was of Polish origin, but children were both born in England. Children had recently been given “child in need” status although the case had not been allocated at the time of their deaths. Mother had been anxious about the elder daughter's health although health professionals had assured her that there were no serious concerns. Mother reported low mood and thoughts of harming herself and her children to her GP. 8.2 The difference in the comparator cases was that in those cases the families had been known to services and had reported concerns regarding mental health to professionals or had actively avoided medical support and intervention. 8.3 Research was also considered that was presented to the Home Office by Matejci Matusiak a frontline service Police officer in Merseyside Police titled ‘Domestic Homicide Reviews within Polish nationals living in the United Kingdom’, 2019, this research highlights the barriers that can exist with communities and the issues around engaging with services and accepting support (Appendix 2) 8.4 Research was also considered using the National Child Mortality Database, Police Crime figures and Ofsted Annual Review 2021. Around the impact of the global pandemic on child mortality, domestic homicide, and the overall impact of the pandemic on educational settings and children (Appendices 3 and 4) 17 8.5 Ofsted’s Annual Report published on December 7th, 2021, was also reviewed when considering the impact of the global pandemic on children’s welfare, mental health and school progress. 9. Practitioner Learning Event Capture A practitioner event was held on January 26th, 2022, with 57 active frontline staff contributing to the discussions and learning captured below. Attendees at Practitioner learning event for Child Q • West Yorkshire Police • Children’s Social care • Youth Justice Service • Kirklees Neighbourhood Housing • Early Support Services • Education Safeguarding • The school • Youth Engagement Service • Locala • South West Yorkshire Partnership Foundation Trust • Kirklees Corporate Safeguarding Partnership • Clinical Commissioning Group Key discussion Points included-: Not every school in Kirklees will be in the same position as in this case. This school works a lot with International New Arrivals Team (INAT) due to having quite a transient population – there can be approximately 40-50 students arriving and leaving school within one academic year. As soon as a family comes to them, they will link with the team. They probably have more awareness than other schools that will have less need for the service. With new arrivals from outside the EU, INAT will notify school about them before they arrive. With arrivals from within the EU, they might not be flagged straight away – INAT doesn’t know about them until the paperwork comes from the Home Office. If a family was struggling, school would refer back the other way, but that would be more unusual. In terms of Paul’s level of English language, the level was low initially but had picked up quickly. 0-19 Services will be looking at strengthening the process for children new to the UK or other children where they don’t have any information. 18 A missed opportunity was discussed – the health practitioner assessed no intervention required because there were no concerns, but that was because there was no information about him. Consideration of how to strengthen that professional curiosity and getting learning out to colleagues and make improvements. Learning point that no information does not translate to no concerns – it means professionals may need to be more curious. Cultural awareness training would be very useful for Locala colleagues. They will also explore whether they can send the texts in other languages. It’s important that not only parents but children have access to physical resources to read about abuse. There may be trauma uncovered as part of asking the question regarding the child’s background and reasons for coming to the UK, but how else can schools get support for that? It’s important to hear the child’s voice regarding their journey to the UK. As part of this, what is the wraparound support if school start having trauma-informed conversations? Over the years, midwifery have increased their questions about domestic abuse. Could an equivalent be done through services to give children an opportunity to ask questions? How can services enable the culture where it is OK to talk and OK to disclose? Can this be done through the curriculum, via assemblies, etc? This would enable young person to realise they may not be the only one going through this. How can we support schools and partners to develop cultures where young people feel it is OK to disclose? What are the barriers to engagement for specific cultures? People may have certain views of social care and what might happen when they ask for help. The format of the learning event was recognised as having been very useful in terms of learning and information sharing. 19 10. Learning This is an extremely upsetting case in which a 15-year-old boy lost his life. There is nothing to suggest that the events that transpired on August 13th, 2021, were entirely preventable or predictable. Professionals could not have known what was going to occur that morning. There had been no presentation of concern raised relating to safeguarding regarding Paul in the months leading to this incident. The case does remind us though, of the importance of understanding the role of agencies in supporting children born outside the UK and carefully screening their health (physical and mental) and communicating any concerns with partner agencies. Learning point 1: All professionals need to understand the challenges of being a new arrival to the UK and the requirements and opportunities to access health, education, and support services including INAT. Recommendation 1: The Local Safeguarding Children Partnership to ensure that practitioners have the training to be able to understand the challenges of being a new arrival into the UK. This training needs to include information on how to access health, education, and support services. Learning point 2: It is important for professionals to understand relationships in families and understand a full background history of where new arrivals are concerned. Recommendation 2: The Local Safeguarding Children Partnership to ensure that practitioners have access to tools to assist in accessing information from originating countries to assist in making decisions in relation to the care of children arriving in the UK. Learning point 3: 20 Professional curiosity cannot be overlooked or discounted and should be promoted through training and challenge. When talking about the need for professional curiosity, services have to give practitioners the freedom and space to do that – it takes longer to exercise professional curiosity. If services are serious about this, they have to consider allowing staff to work towards outcome rather than outputs which will require a significant programme of organisation and training. Recommendation 3: The Local Safeguarding Children Partnership to receive assurance that professionals ask questions to obtain a full picture of the family and the familial relationships and to ensure this is evidenced in records. Learning point 4: Significant time needs to be spent understanding the impact of the global pandemic nationally and locally and how locally the systems and processes applied by services and settings work. The impact of Covid-19 on professionals needs to be recognised and that the workforce are feeling the pressure of this. Work needs to be done to support resilience in the workforce. Recommendation 4: The Local Safeguarding Children Partnership to receive assurance that support is being provided to practitioners to provide resilience within the workforce. Learning point 5: Consideration around the recovery phase especially for children coming out of a pandemic and the support that can be sought to aid that recovery. Recommendation 5: The Local Safeguarding Children Partnership to receive assurance that the workforce have been given the tools and training to support children and young people coming out of the pandemic to aid their recovery. Learning point 6: The statistics note that domestic abuse in families has not been increasing over lockdown, but from anecdotal evidence, a lot of families were really struggling in lockdown – maybe the statistics do not show the whole picture. They may be under pressure not to report, so cases may just be staying under the radar. Recommendation 6: 21 The Local Safeguarding Children Partnership to receive assurance that where professionals have identified risks within families that the risk is thoroughly assessed and recorded on records. Learning point 7: Consideration should be given to how and when we share information to support families and young people, to be aware of services and how to access them, be that health or wider services. Also, to ensure that they are tailored to meet the individual needs of that family. Recommendation 7: The Local Safeguarding Children Partnership to receive assurance on how separate assessments of risk are being brought together to provide a clear multi-agency assessment of risk on which plans of action are based. Learning point 8: Work is ongoing on the Corporate Safeguarding Strategy that sets out the role of all individuals who might come across children, families, adults and how they might recognise concerns and what to do about those concerns. Recommendation 8: The Local Safeguarding Children Partnership to receive assurance that all staff have a basic awareness of child abuse and neglect hand have the knowledge of how to report this. Learning Point 9: What understanding is there of the Border Force Safeguarding processes when a child or young person enters the UK whether accompanied or not by a family member/other adult? Recommendation 9: The National Panel to engage with the Border force to explore the processes in place when a child or young person enters the UK and gain clarity on how safeguarding concerns are identified and communicated in a timely manner to the relevant Local authority 22 11. Next Steps: Embed Learning This report will be shared widely, and the key messages disseminated by the Safeguarding Children Partnership and practice learning events. Also shared with the National panel, NSPCC and the learning summary will be placed on the Kirklees Safeguarding partnership website. 23 12. Appendices Appendix 1 - Thriving Kirklees 0-19 Clinical Procedural Document V1.1.pdf Appendix 2 - MJ DHR Forward.pdf Appendix 3 Covid deaths in children: How has the pandemic impacted child mortality? (ncmd.info) Appendix 4 The Annual Report of Her Majesty’s Chief Inspector of Education, Children’s Services and Skills 2020/21 - GOV.UK (www.gov.uk) 24 Appendix 5 • Home Office Child Safeguarding Update - September 2022.pdf Appendix 6 - Paul Character statement.pdf |
NC52432 | Death of a 9-week-old girl in January 2018. Following the conclusion of the inquest it was confirmed that Child A died from unknown causes following unsafe sleeping environments at her home. Learning includes: children's social care assessments should ensure historical concerns including home conditions and suitable sleeping arrangements for children are explored during re-assessment; risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services as this may indicate an ongoing, abusive relationship; retractions of statements regarding domestic abuse may be indicative of ongoing contact between the victim, the perpetrator and their children; social workers should speak directly to children being 'programmed' by their parents, without the presence of their parents, to explore their wishes and feelings; perpetrators of domestic abuse should be directly spoken to about the impact of their abusive behaviour on children and included in the assessment process or safety plan for children; consideration should be given to de-escalating to a team around the family plan if low level concerns still need to be addressed when child in need plan is closed; written agreements are not effective tools for managing risk and their use should be avoided; managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information. Recommendations are embedded in the learning. Please note that this report was written in October 2020 but was published in 2022.
| Title: Safeguarding practice review: Child A: version 5 October 2020. LSCB: Kirklees Safeguarding Children Partnership Author: Kirklees Safeguarding Children Partnership Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SAFEGUARDING PRACTICE REVIEW CHILD A Version 5 October 2020 Independent Person from KSCP Partnership Review Author i Table of Contents GLOSSARY ___________________________________________________________________ 1 1. INTRODUCTION ___________________________________________________ 3 2. REVIEW PROCESS _________________________________________________ 4 TIMESCALE FOR THE REVIEW _____________________________________________________________ 4 3. OVERVIEW OF AGENCY INVOLVEMENT WITH THE FAMILY _________ 5 FAMILY COMPOSITION __________________________________________________________________ 5 SYNOPSIS OF AGENCY INVOLVEMENT _____________________________________________________ 5 4. KEY PRACTICE EPISODES _________________________________________ 10 KPE 1: CLOSURE OF CHILD IN NEED PLAN – JANUARY 2016 ________________________________ 10 KPE 2: SUPPORT FOR SIBLING 2 _______________________________________________________ 12 KPE 3: MULTI-AGENCY RESPONSE TO HIGH RISK DOMESTIC INCIDENT ________________________ 16 KPE 4: HOME CONDITIONS ____________________________________________________________ 24 KPE 5: PREGNANCY WITH CHILD A – MAR 2017 TO NOV 2017 _____________________________ 26 KPE 6: POLICE CALLOUT 01:00 ON 01/01/18 ___________________________________________ 29 5. CONTRIBUTION OF FAMILY _______________________________________ 30 CONTRIBUTION OF SIBLINGS ___________________________________________________________ 30 6. ANALYSIS ________________________________________________________ 30 IMPACT OF DOMESTIC ABUSE ON CHILDREN _______________________________________________ 31 SUFFICIENT FOCUS ON FATHER __________________________________________________________ 33 TO WHAT EXTENT WERE AGENCIES AWARE OF THE HISTORY OF NEGLECT OF THE CHILDREN AND DOMESTIC ABUSE WITHIN THIS FAMILY? __________________________________________________ 34 EVIDENCE OF ONGOING NEGLECT OR DOMESTIC ABUSE WITHIN THE FAMILY ____________________ 35 WAS FAMILY HISTORY GIVEN APPROPRIATE CONSIDERATION DURING DECISION-MAKING? _______ 38 QUALITY OF ASSESSMENTS AND DECISION-MAKING DURING THE SPECIFIED PERIOD – SPECIFICALLY RELATING TO FAMILY ENGAGEMENT? _____________________________________________________ 39 WAS CONSIDERATION GIVEN TO WHETHER OR NOT A PRE-BIRTH ASSESSMENT WAS INDICATED PRIOR TO CHILD AS BIRTH? __________________________________________________________________ 44 7. CONCLUDING REMARKS __________________________________________ 44 8. REFERENCES _____________________________________________________ 45 9. BIBLIOGRAPHY __________________________________________________ 46 APPENDIX ONE: FULL TERMS OF REFERENCE ________________________________________ 2 ii APPENDIX THREE: LIST OF LEARNING POINTS ______________________________________ 6 1 Glossary Common Assessment Framework The Common Assessment Framework (CAF) was the standardised approach to conducting assessments of children’s' additional needs and deciding how they should be met. It has been replaced in Kirklees by the Single Assessment framework. Child in Need (CiN) Defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Contact Agreement Written agreement signed with parents to clarify expectations by social care for child contact. It is not legally binding. Contract of Expectations Written agreement signed with parents to clarify expectations by social care. It is not legally binding. Domestic abuse Home Office definition: Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological; physical; sexual; financial; emotional Controlling behaviour is a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour. Coercive behaviour is a continuing act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim. Multi Agency Risk Assessment Conference (MARAC) A meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists from the statutory and voluntary sectors. A victim/survivor should be referred to the relevant MARAC if they are an adult (16+) who resides in the area and are at high risk of domestic violence from their adult (16+) partner, ex-partner or family member, regardless of gender or sexuality Neglect Defined in Working Together as “The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: • provide adequate food, clothing and shelter (including exclusion from home or abandonment). • protect a child from physical and emotional harm or danger. • ensure adequate supervision (including the use of inadequate caregivers); or 2 • ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs”. Residence Order Replaced by ‘Child Arrangement Orders’ in 2014. Stipulations where children are to reside and in whose care. Section 47 Children Act enquiry Children’s Social Care must carry out an investigation when they have “reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer significant harm”. The enquiry will involve an assessment of a child’s needs and those caring for the child to meet them. CAMHS Child and Adolescent Mental Health Services ADHD Attention deficit hyperactivity disorder Single Assessment The Single Assessment replaces the EHA (Early Help Assessment), the Initial Assessment and the Core Assessment. It is intended to assess a child who appears to have additional needs and/or require extra help to support them in the following areas: • The child's developmental needs. • The parents' or caregivers' capacity to respond appropriately to those needs; and • The wider family and environmental factors Victim Personal Statement The Victim Personal Statement (VPS) gives victims a voice in the criminal justice process by helping others to understand how a crime has affected the victim. Multi-Agency Safeguarding Hub Is now referred to as the Duty and advice Team. The ‘front door’ to children’s services in Kirklees Council. Strategy Discussion A Strategy Discussion (sometimes referred to as a Strategy Meeting) is normally held following an Assessment which indicates that a child has suffered or is likely to suffer Significant Harm. The purpose of a Strategy Meeting is to determine whether there are grounds for a Section 47 Enquiry. Non-molestation Order A non-molestation order is, in English law, a type of injunction that may be sought by a victim of domestic abuse against their abuser. PDVG Pennine Domestic Violence Group KNH Kirklees Neighbourhood Housing 3 1. Introduction 1.1. Local Child Safeguarding Practice Reviews are commissioned by Kirklees Safeguarding Children Partnership (KSCP) when partner agencies identify cases that raise issues of importance for safeguarding children in the area. 1.2. This Review was triggered by the death of Child A, who was nearly nine weeks old when she was found lifeless in her parent’s bed. Following the conclusion of the inquest it was confirmed that Child A died from unknown causes following unsafe sleeping environments at her home. Following the post-mortem, mother was convicted of four offences of cruelty to person under 16 years and sentenced to a Community Order. 1.3. Child A’s family were previously known to local statutory agencies for incidents of domestic abuse between parents and neglect of older siblings. As a result, the KSCP took the decision to conduct a Local Child Safeguarding Practice Review to identify learning for local agencies. 1.4. This Child Safeguarding Practice Review has not identified any actions that may have been taken by professionals to prevent Child A’s death. It is therefore not intended to hold individuals to account for their practice, as there are other processes that may be used for that purpose if required (such as disciplinary procedures, professional regulation, and in exceptional cases, criminal proceedings). Rather, this review provides an opportunity to reflect on professional practice to gain an understanding of what happened and why, and identify lessons that can improve the response to children and families in Kirklees. 1.5. This report provides: • An overview of the process for conducting the review. • A brief synopsis of local agency records on the family from 2012 onwards. This includes information recorded about Mother and Father’s own childhoods. • An overview of agency involvement with the family during the review period. • A detailed analysis of six Key Practice Episodes, identified by the independent reviewer as those incidents and/or recurring issues that had a significant bearing on how the case developed and was handled by local agencies. • An analysis of key issues identified by the KSCP in the terms of reference; and • A summary of lessons learned during the review process, to enable the KSCP to work with local partners to improve local safeguarding practice. 1.6. This report has been prepared by an independent member of staff from a KSCP partner agency, with support from staff within the KSCP. The KSCP consider this person to be sufficiently independent of this case and the agencies that were directly involved in supporting the family. 4 2. Review Process 2.1. In light of changes to the statutory guidance that sets out the rules for conducting Child Safeguarding Practice Reviews (formerly referred to as Serious Case Reviews)1, the KSCP developed a new approach to streamline the process for conducting reviews and maximise opportunities for learning lessons in a timely way. 2.2. This approach includes: • Asking partner agencies to complete an initial information gathering tool to enable the KSCP to make an informed decision about whether to conduct a review, and to establish clear terms of reference for the conduct of the review. • Asking those agencies that had a significant involvement with the family during the review period to compile their records into a comprehensive chronology. • Seeking an independent reviewer from within existing partner agency staff that is sufficiently independent of the case and the agencies that were directly involved in supporting the family. • Conducting a practice learning event with professionals that worked directly with the family to provide an opportunity for the reviewer to clarify any inaccuracies or inconsistencies in agency records and understand the context of decision-making during the review period. • Meeting with managers of involved agencies to discuss learning that emerged from the practice learning event and identify early opportunities to implement improvements. • Drafting a review report that considers professional practice in this case; highlights relevant research and best practice; and identifies learning points for the KSCP, and its partner agencies, to determine how best to translate this learning into tangible improvements in safeguarding practice; and • Presenting the review report to the Serious Case Review Workstream for external challenge and scrutiny. 2.3. The review author identified some learning for the KSCP in using this approach for conducting CPSRs and for individual agencies about improving the quality of their contribution to the review process. This has been provided in a separate report to the Board. Timescale for the review 2.4. The review considers agencies’ involvement with this family from 01/01/2016 until the death of Child A on 01/01/2018. Agencies were asked to provide a chronology and analysis of significant events between these dates, and a summary of significant interventions prior to 01/01/2016. 1Working Together to Safeguard Children is the statutory guidance, it was open for consultation during the period when this review was conducted and published on 5 July 2018 5 3. Overview of agency involvement with the family Family composition Synopsis of Agency Involvement Prior to the Review Period (before 01/01/2016) 3.1. Father does not appear to have significant contact with statutory agencies as a child/young person. Records indicate that he was exposed to parental domestic abuse and parental substance misuse as a child. 3.2. Mother similarly does not appear to have significant contact with statutory agencies as a child/young person. Records indicate that she was subject to a custody battle between her parents, and she reported to agencies that she was asked to leave her mother’s address when she was about 13 years old. When she became pregnant with her first child at 15, she reported that Maternal Grandfather asked her to leave the property as he did not approve of the pregnancy and the house was already overcrowded. 3.3. It is not clear from the records when Father’s relationship with Mother began, but we do know that he was 19, and she was 16, when their first child was born. 3.4. Local agencies recognised indicators of low-level neglect from when the eldest child, referred to in this report as Sibling 1, was three months old. Low level domestic incidents were also reported to police in the first year of Sibling 1’s life. Mother and Father had another baby, Sibling 2, when Sibling 1 was 10 months old. 3.5. The family were referred to Children’s Social Care when Sibling 2 was around six months old. There were concerns about leaving children unattended and poor home conditions. The case was assessed as reaching the threshold for Child in Need and professionals noted significant improvements under the Child in Need plan. The case was then de-escalated to a Common Assessment Framework (CAF) and managed by a Multi-Agency Support Team (MAST). 3.6. In the first six months of 2012 there were four low-medium level domestic incidents. Father was noted to be under the influence of alcohol and/or other drugs in two of these incidents. 3.7. In August 2012, Father assaulted Mother causing visible injury. The assault included being thrown across the room, being grabbed around the throat and being hit across the head with an object. The MAST also raised concerns with social care about neglect of the children. As a result, social care undertook an assessment which noted poor home conditions including the state of the children’s bedroom. The children were placed under a Child Protection Plan under the category of neglect. Father signed a contact agreement, which stipulated that contact with the children must be supervised by his grandmother. Mother DOB 1993Sibling 1DOB 2010Sibling 2DOB 2011Sibling 3DOB 2014Child ADOB 2017Father DOB 1991 6 3.8. Following six months on the CP plan, the case was de-escalated to Child in Need as the risk was considered to have been reduced and the family were working with professionals. Mother reported that she wanted to resume the relationship and let Father have more contact with the children. Work was done with Mother to highlight the impact of domestic abuse on children and the case was subsequently closed to social care. 3.9. In August 2013, Mother was charged with an assault on Sibling 1, who was three years old, after she lowered the child out of an upstairs window onto a flat roof. The children were subsequently placed with maternal great grandparents. Following a positive risk assessment undertaken by social care, Mother was granted unsupervised contact with the children. Mother signed a Contract of Expectations to confirm that Father was not allowed to be at the home address. 3.10. Mother was pregnant with twins at this time, and, given the recent concerns identified by professionals, a pre-birth assessment was completed by social care. Sadly, Mother was advised that one of the twins had died and Sibling 3 was born following an emergency caesarean section in February 2014. Sibling 3 was discharged to the home address in his mother’s care. 3.11. Due to ongoing concerns that Mother was still in a relationship with Father, an Interim Supervision Order was imposed in June 2014. A non-molestation order was also granted during this period. The Supervision Order was de-escalated to a Child in Need in June 2015. In November 2015, professionals noted that Mother was living independently (she had been living with Maternal Great Grandmother) and although engagement with professionals had been intermittent, significant improvements had been made and Mother appeared to have addressed concerns around behaviour management and routines. 7 Key Incidents/Interventions (April 2010 – December 2015) Year/ period Child Born Notification to CSC/ request for advice Referral to CSC Early Help Child in Need Plan Child Protection Plan Interim Supervision Order Orders 2 0 1 0 Apr-Jun Sibling 1 Jul-Sep HV request for advice Oct-Dec DV incident 2 0 1 1 Jan-Mar Apr-Jun Sibling 2 Jul-Sep Oct-Dec Poor home conditions 2 0 1 2 Jan-Mar DV incident Apr-Jun DV incident Escalated by MAST Jul-Sep DV incident, significant assault Father - supervised contact order Oct-Dec 2 0 1 3 Jan-Mar Apr-Jun Jul-Sep Assault on child Mother – contract of expectations Oct-Dec Pregnancy/ pre-birth assessment 2 0 1 4 Jan-Mar Sibling 3 PLO letter issued Apr-Jun 3 x DV incidents Non-molestation order issued Jul-Sep Oct-Dec 2 0 1 5 Jan-Mar Apr-Jun Jul-Sep Oct-Dec Agency involvement during review period (Jan 2016- Jan 2018) 3.12. At a Child in Need meeting in January 2016, there was a unanimous decision to close the Child in Need plan that had been in place since June 2015. Mother was recorded to have made significant progress and was meeting children’s needs, although her engagement with agencies was sporadic. She agreed to make an appointment for sibling 2 to attend the GP. Father’s contact with children continued to be supervised, and professionals agreed that concerns would be raised if it appeared that relationship resumed. (KPE1) 3.13. Mother took Sibling 2 to the GP a few days later with concerns about developmental delay, challenging behaviour and self-harm. As a result of this visit, Sibling 2 was referred to a paediatrician to determine if there was a medical cause for his behaviour. 3.14. At a routine screening in April 2016, a school nurse noted concerns regarding Sibling 2’s appearance and referred the case to social care. From the health record, it would appear that social care conducted a home visit and identified no concerns with Mother’s care of the children (although there is no corresponding record from social care). 8 3.15. At their appointment with Sibling 2 in May 2016, the paediatrician reported that the physical screening detected no abnormalities and provided some advice to Mother around behaviour management. In June, September and October 2016, Mother took Sibling 2 back to the GP as she was continuing to struggle with managing his behaviour and wanted medication to help him sleep. In December 2016, Mother requested to speak with school about Sibling 2’s behaviour, reporting that he had been diagnosed with autism and ADHD. (KPE2) 3.16. In September 2016, Mother reported to Police that Father had verbally abused her; woken Sibling 1 and told her that her mother was a ‘slag’ and ‘didn’t care about her’; grabbed Mother by her hair, ragged her to the floor and stamped on her head and back as she lay on the ground. As a result of this incident, the case was discussed at the Multi-Agency Risk Assessment Conference (for high risk victims of domestic abuse) and there was a child protection enquiry, which concluded that the family could be supported via Child in Need. This offer of support under a Child in Need plan was declined. (KPE3) 3.17. Poor home conditions were noted prior to the review period and again as part of social work assessment in September 2016. In early November 2016, KNH had commenced an anti-social behaviour case for condition of the garden. By mid-December 2016, a legal notice was served on Mother to address the rubbish in the garden. By the end of February, Mother had cleared the rubbish and the ASB case was closed. (KPE4) 3.18. In March 2017 Mother attended hospital and a pregnancy was confirmed. She had an antenatal booking appointment in June, where she advised the midwife that the pregnancy was the result of a one-night stand and the father would not be involved. She denied that there was any domestic abuse in her relationship with the father. 3.19. In June 2017, Sibling 2 was seen again in Paediatric Clinic as Mother was still concerned about his behaviour and reported that it was worse than before. 3.20. Father was arrested for failing to provide a specimen for a roadside breath test in July 2017, and subsequently sentenced to a12-month Community Order, supervised by Probation CRC. Probation contacted social care to determine if Father had contact with his children, and was advised that they had previously been involved with the children due to concerns about parental domestic abuse and substance misuse, but the children were no longer subject to child protection. 3.21. Mother attended hospital a number of times in September and October, reporting that she had spontaneous rupture of membranes, reduced foetal movements and pelvic pain. All scans, tests and observations returned normal. She was asked about mood and anxiety and referred to Single Point of Access for support with managing her anxieties. However, she did not keep her appointment and was discharged from the service. (KPE5) 3.22. In September 2017, Kirklees Neighbourhood Housing attempted to access the property to service gas appliances. By the end of October, following a comprehensive process, KNH made a final attempt to service gas appliances. At this point the gas was capped at Mother’s request and there was no gas supply to the address from this point onwards. 3.23. Child A was born at the end of October by a planned caesarean section. Mother and baby were discharged home and there were a number of home visits conducted by the midwife and the health visitor. 3.24. Police were called to a domestic incident at 01:00 am on 01/01/18 after Father reported that his brother was in drink and refusing to leave the property. Officers responded quickly and determined that no offences had been committed and removed Father’s brother. Attending officers were not aware of the domestic history between Mother and Father. (KPE6) 9 3.25. Police records note that an ambulance was called to Mother’s address at 5:58am on the morning of 01/01/18. Child A was found lifeless by father in mother’s bed and taken to hospital via ambulance. Child A was pronounced dead in hospital shortly afterwards. Key Incidents/Interventions January 2016 – December 2017 Year/ period Child Born CSC notification or request for advice Referral to CSC Assessment S47 enquiry Child in Need Order 2 0 1 6 Jan CiN closed Feb Mar Apr Referral by school nurse Assessment, NFA May Jun Jul Referral, no clear source Assessment, not able to complete Aug Sept High risk DV incident S47 enquiry Oct S47 downgraded to single assessment Offer of CiN, Mother declined Nov ASB process for state of garden Dec DV incident 2 0 1 7 Jan Feb Garden cleared and ASB case closed Mar April May Jun Jul Probation check with CSC if Father has children Aug Sept Oct Child A Gas service to property capped, no gas supply from this point on Nov Dec DV incident 10 4. Key Practice Episodes 4.1. Key Practice Episodes (KPE) are identified during the review process to capture key incidents and/or ongoing issues that warrant further analysis. These episodes are usually times when an incident triggers the involvement of a number of professionals; there is an event that is significant to understanding the way that the case developed and/or was handled; and/or there is a recurring issue for the family. 4.2. In this case, the independent reviewer identified seven key practice episodes that warranted further exploration: 1. Closure of the Child in Need plan – January 2016. 2. Support for Sibling 2 – January 2016 to June 2017. 3. Multi-agency response to domestic abuse incidents – September to October 2016; December 2016; December 2017 4. Home conditions – September 2016 to February 2017; and January 2018. 5. Pregnancy with Child A – March to October 2017. 6. Police incident at 1:00am on 01/01/18. KPE 1: Closure of Child in Need plan – January 2016 4.3. Child A’s three elder siblings were subject to a Child in Need Plan when the review period commenced in January 2016. The plan had been in place since an Interim Supervision Order ceased in June 2015. 4.4. There were no domestic incidents between Mother and Father reported to Police and no recorded concerns about the children from other agencies whilst the Child in Need plan was in place (from June 2015 to January 2016). Professionals noted that while Mother’s engagement with professionals and services had been intermittent, she had addressed concerns regarding behaviour management and routines whilst living with her grandmother and appeared to have more insight into potential risk and concerns for her children. Professionals noted that Mother was continuing to meet the children’s needs following her move to her own accommodation in October 2015. 4.5. A Child in Need meeting was held on 08/01/16. The meeting was attended by Mother, the health visitor, social worker, family support worker and vice principal of the children’s current school. School professionals note that the children had moved to the school on 16/12/2015 and therefore had only attended for eight days prior to the meeting. At that time the school had not received the children’s records from their previous school but had phone contact with the previous school and advised the meeting that they felt they knew all they needed to know. There was no representative from Kirklees Neighbourhood Housing at the meeting. 4.6. Mother reported that she felt she had ‘come a long way’ and felt a lot better in herself, reporting that she ‘felt like an eight’ (on a scale of one to ten – with ten being the best). She commented on using positive praise and incentives to encourage good behaviour with Sibling 2, when she used to just shout at him. The social worker reported positively that this meeting was the first time that Mother had been able to identify professionals that she could turn to if she needed support. 11 4.7. The CiN closure summary notes that there had been a significant amount of domestic violence perpetrated by Father, and, although it was agreed that he should have a risk assessment prior to having unsupervised contact with his children, he failed to engage with social care to undertake the assessment. 4.8. At the meeting, a unanimous decision was taken to close the Child in Need plan. All professionals agreed that concerns would be raised if Mother recommenced a relationship with Father and social care were clear that they would become involved if there were any further incidents of domestic abuse. 4.9. Notes from this meeting suggest that Father’s contact with the children would continue to be supervised by family members (but not Mother) due to concerns around domestic abuse. Mother was advised that she would receive information about supervised contact arrangements in the post. Mother was to register the children with a dentist and make an appointment with the GP to discuss Sibling 2’s behaviour. Analysis 4.10. The decision to close the Child in Need plan may have been appropriate, given the stability that the family had achieved. Mother appears to have demonstrated to professionals that her relationship with Father was over, and that she recognised the impact of domestic abuse on her children. Furthermore, professionals at the meeting noted marked improvements in behaviour management and establishing consistent routines. 4.11. However, it may have been prudent to either invite the previous school to the meeting or keep the Plan open until the current school had received relevant records from the previous school and had time to get to know the children and consider their behaviour in the context of their history. It is also unfortunate that no one from Kirklees Neighbourhood Housing was invited to attend the meeting, despite requests from the allocated Stronger Families Consultant to be involved in any multi-agency meetings around the family. Learning Point 1: If children have recently moved schools, the previous school should be invited to multi-agency discussions around safeguarding children. Learning Point 2: Relevant housing providers should be routinely invited to multi-agency discussions around safeguarding children. 4.12. Attendees noted that there continued to be some concern around Sibling 2’s behaviour and suggested that Mother discuss this with her GP. It is not clear what the rationale for this advice was. The concerns that are recorded in the subsequent GP visit relate to developmental delay, self-harm and challenging behaviour, all of which could be attributed to early exposure to domestic abuse and lack of consistent boundaries and routines. 4.13. Furthermore, these issues could have been managed by the professionals attending the Child in Need meeting (i.e. the health visitor) via referrals to appropriate services. Given Mother’s later insistence on securing a diagnosis for ADHD and/or autism (see Key Practice Episode 2), advising Mother to approach the GP, which suggests an underlying medical cause for his behaviour, may have been problematic in that it potentially provided Mother with an alternative to good, consistent parenting. 4.14. The social worker noted that Mother was engaging well with services and could, for the first time, identify professionals that may assist her if she needed support. It may have been prudent to keep the Plan open or de-escalate to a Team Around the Family (TAF) plan to 12 ensure that this engagement with agencies was sustained. This is particularly relevant in light of the ongoing concerns regarding Sibling 2. Learning Point 3: Consideration should be given to de-escalating to a Team Around the Family plan if low level concerns still need to be addressed when a decision is made to close a Child in Need plan 4.15. It appears professionals at the Child in Need meeting clearly communicated that Father was to continue to have supervised contact with his children. Professionals attending the meeting agreed that social care would conduct a further assessment if Mother recommenced a relationship with Father or if there were any further incidents of domestic abuse. There did not appear to be a discussion about how professionals should flag this on their records and/or advise social care if they had any concerns that the relationship had resumed. There was no reference to previous written agreements (Father’s contact agreement in 2012; Mother’s contract of expectations in 2013) that parents had signed in respect to expectations about Father’s contact with children, so it is not clear if these agreements were still in force. 4.16. The multi-agency chronology of professional involvement with this family shows some ambiguity about contact arrangements (see analysis at s6.24 to 6.28 for further detail about this ambiguity), and not all practitioners at the practitioners’ forum were aware that Father was only supposed to have supervised contact with his children and/or the appropriate way to report any breaches. Social Care Managers confirmed that there is no current process for flagging the relevant children’s file to ensure that concerns of this nature can be responded to appropriately; all concerns are referred via the normal referral route to social care and assessed in light of the information provided by agencies and relevant history. Learning Point 4: Children’s social care should explore how their expectations around child contact should be communicated to parents and professionals. This should include clear consequences for failure to adhere to agreed contact arrangements, recommendations for professionals in other agencies to record/flag the arrangements for supervised contact; and a clear process for reporting breaches to agreed contact arrangements. KPE 2: Support for Sibling 2 4.17. Throughout the review period, Mother expressed concern about Sibling 2 and the difficulties she had in managing his behaviour. She primarily sought support via her GP, but also sought support from other agencies for his behavioural problems. Contact with Health Services to secure a diagnosis for Autism and Attention Deficit Hyperactivity Disorder (ADHD) 4.18. At a Child in Need meeting in January 2016, Mother was advised to take Sibling 2 to the GP. They attended the GP three days later with concerns about challenging behaviour, self-harm and developmental delay. As a result of this visit, Sibling 2 was referred to a paediatrician. 4.19. Sibling 2 was seen by the paediatrician in May 2016. The paediatrician reported that the physical screening detected no abnormalities and provided some advice around behaviour management. In June, September and October 2016, Mother took Sibling 2 back to the GP as she was continuing to struggle with managing his behaviour and wanted medication to help him sleep. In December 2016, Mother requested to speak with school about Sibling 2’s behaviour, reporting that he had been diagnosed with autism and Attention Deficit 13 Hyperactivity Disorder (ADHD). The following year, Mother attended the GP requesting a letter to confirm Sibling 2’s diagnosis and seeking a further prescription to help him sleep. 4.20. In June 2017, Sibling 2 was seen again in Paediatric Clinic as Mother was still concerned about his behaviour and reported that it is worse than before. The GP record of this appointment notes that Mother was advised that school should refer Sibling 2 for an ADHD assessment; and Sibling 2 was also referred to the Children’s Emotional Wellbeing Service. The GP record also notes that Sibling 2 was seeing Father more frequently. 4.21. Following this appointment, School considered making a referral to CAMHS for an ADHD assessment of Sibling 2, but had previously been advised that CAMHS would not consider this assessment for a child that has been exposed to domestic abuse in the last two years. The rationale for this is believed to be that children exposed to domestic abuse may display behavioural and emotional problems that are not caused by an underlying medical illness, which can make diagnosis difficult. 4.22. Following a high-risk domestic incident in September 2016 (further detail provided in KPE3), a s47 assessment undertaken by social care noted that Sibling 2 was alleged to have ADHD and Autism and was observed to struggle with verbal interaction. The assessment went on to note that Sibling 2 refused to speak to the social worker. The assessment later states that all children were seen and spoken to together because of their ages and learning needs. This assessment also notes that Mother spoke to Sibling 2 ‘differently’, and that this was the strategy she had been given to manage his diagnosis within the autistic spectrum. She advised that social worker that she was attending a group for the parents of autistic spectrum children, and she particularly liked it as the parents swap advice. Analysis 4.23. Professionals at the practitioner forum agreed that Sibling 2 did not have ADHD and/or autism. This was explored by the paediatrician, who was initially quite clear that Sibling 2’s difficulties were behavioural and provided advice around clear, consistent boundaries. 4.24. Mother was given advice regarding behaviour management from the paediatrician, health visitor, GP and school and it would appear that this advice was not followed. Sibling 2 was also referred to the Children's Emotional Wellbeing Service, but there is no evidence that any appointments were attended. Instead, Mother was intent on securing a diagnosis for Sibling 2 and a medical remedy for his behavioural problems. 4.25. Parents usually find it difficult to accept a diagnosis of autismi. Accordingly, Mother’s persistence in obtaining a diagnosis should have triggered some professional curiosity about what motivated this persistence i.e. did Mother perceive there to be some benefit to a medical diagnosis or was she seeking an easier alternative to good, consistent parenting? It may also be that this focus on a medical cause for Sibling 2’s behaviour sought to distract professionals from other issues in the family and/or potential causes for his behaviour. The Triennial Analysis of Serious Case Reviews identified a case where “[The mother’s] insistence on a specific medical diagnosis for the children’s difficulties seems to have served in many ways to dissipate any consideration of other family and environmental features of their lives – in particular the quality of the parenting they received.”ii Learning Point 5: some parents may be intent on securing a medical diagnosis for a child’s behavioural problems and consequently ignore advice from professionals about behaviour management. A consistent, multi-agency response should be given to parents in these cases to ensure that children receive an appropriate, authoritative parenting approach. 14 4.26. It is also not clear if professionals considered the impact of Mother’s behaviour on Sibling 2 – he was taken to a variety of appointments and treated differently to his siblings due to Mother’s understanding of the causes of his behaviour. However, it is considered likely that singling Sibling 2 out will have compounded his behavioural difficulties. 4.27. A social worker noted that Mother used a more authoritarian style of parenting with Sibling 2 and, when questioned about this, Mother reported that she treated him differently due to this Autism/ADHD, and she was not challenged on the appropriateness of using an authoritarian parenting style to manage his behaviour. Research suggests that authoritarian parenting, which is characterised as low in warmth and nurturance, is likely to exacerbate behavioural problems in children.iii Learning Point 6: An authoritarian parenting style is likely to exacerbate behavioural problems in children 4.28. It is not clear if professionals understood and clearly communicated to Mother that Sibling 2’s difficulties were likely to be the result of early exposure to domestic violence and inconsistent parenting. Children exposed to domestic violence demonstrate greater behavioural and emotional problemsiv, learning problemsv and less secure attachments to their caregiversvi. This is largely because children depend on cues from caregivers to regulate distress and, if caregivers are absent and threatening or being threatened during times of acute distress, it can affect the way children regulate emotions, respond to fearful stimuli, and develop trusting relationships with othersvii. Accordingly, Sibling 2’s difficulties in managing his temper, self-harming and difficulties in sleeping are likely to stem from earlier experiences of living in a volatile environment, feeling frightened and not having a consistent source of support to help him manage his distress. Learning Point 7: exposure to domestic abuse may cause behavioural and emotional problems in children. Professionals should clear about the research that supports this and evidence the work done with parents to increase their understanding of the impact of domestic abuse on their children. 4.29. It is not clear from agency records if the process for obtaining a diagnosis of autism was clearly understood by professionals and/or clearly communicated to Mother. The independent reviewer understands that, since the period under review, there has been concerted efforts by the Child and Adolescent Mental Health Services to raise awareness about ‘ASK CAMHS’, the initial point of contact for those who have concerns about a child or young person’s emotional or mental health. This should assist professionals in providing clear, consistent advice to parents about obtaining appropriate support for children. Learning Point 8: ‘ASK CAMHS’, the initial point of contact for those who have concerns about a child or young person’s emotional or mental health, should assist professionals in in providing clear, consistent advice to parents about obtaining appropriate support for children Offers of Support from Early Help 4.30. At a routine screening in April 2016, a school nurse noted that Sibling 2’s clothes and ears were dirty, and Sibling 2 advised that he had not eaten breakfast and there was no food in the house. The school nurse had worked with the family when they were subject to a Child in Need plan and, given historic concerns regarding neglect, contacted school to discuss her concerns and referred the family to social care. The school nurse recorded that the case had 15 been allocated to a social worker. It does not appear that Mother was advised that a referral was being made. 4.31. There is no record from social care about this referral or subsequent assessment, but health records indicate that Mother attended school angry that a social worker had visited her home and wanted to know if school had referred. From the health notes, it would appear that the school safeguarding lead advised Mother that social care was contacted by health as a result of what Sibling 2 had said during the routine check. 4.32. From the health record, the social worker advised the school nurse that the social worker, and the family support worker that had been involved with the family during the Child in Need plan, attempted a joint visit with Mother but she had refused access. Two weeks later, the social worker advised the school nurse that they visited the home address and saw the children. The social worker noted that the children appeared unkempt but there were no concerns. There are no further entries on the health record (and no corresponding entries from school or social care) so it would appear that the case was closed at this point. 4.33. There appears to be a further referral to social care in July 2016, although there is no record this in the social care chronology. The health record notes that a family support worker contacted the family’s health visitor/school nurse as part of a single assessment, as Mother was finding it difficult to manage Sibling 2’s behaviour. Two weeks later, the family support worker advised the school nurse that Mother no longer wanted a single assessment. Given that single assessments are a voluntary agreement between professionals and families, the family support worker could not proceed without Mother’s consent. Analysis 4.34. The analysis of offers of support from early help is difficult in the absence of appropriate records from children’s social care. The independent reviewer is aware that record keeping is a key part of the improvement plan that is being currently being undertaken by social care, and new Family Support and Child Protection Practice Standards (introduced in February 2018) provide explicit guidance about record keeping. 4.35. Mother appeared to be struggling to support Sibling 2 and, in times of crisis and/or when Sibling 2’s behaviour was particularly challenging, she did reach out to professionals for support. However, all offers of support were subsequently declined. Professional curiosity about why Mother did not want to engage with the support on offer, particularly in light of the previous domestic abuse and subsequent Supervision Order, should have prompted further challenge about why Mother did not want to engage with support. This is particularly significant when Mother previously reported that she found professional support helpful in providing positive strategies to help manage Sibling 2’s behaviour (see 4.6 above). Learning Point 9: Risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their current partner and/or father of their unborn child. This may be indicative of an ongoing, abusive relationship. 4.36. Mother was reported to have been angry about social care involvement with the family in April 2016. This may have been partially mitigated if the school nurse had advised Mother that they would be making a referral, explained the reasons for her concerns and sought Mother’s consent for someone from children’s social care to contact her and offer support. Learning Point 10: professionals should advise parents of any concerns regarding their children and/or gain parents’ consent for someone from children’s social care to contact and offer support (unless doing so would put the child at risk) 16 KPE 3: Multi-agency response to high risk domestic incident 4.37. In early September 2016, Mother rang Police at 7:00am to report that Father had been drinking all night and had just left her address with their 18-month-old child (Sibling 3) in the car. Mother reported that Father was not allowed to have unsupervised contact with the children. Sibling 3 was subsequently returned to the property safe and well, and further investigation by Police determined that Father was not under the influence of alcohol when he left the address with Sibling 3 in the car. 4.38. When Police attended the address to gather further information about this incident, Mother disclosed that Father had assaulted her in the early hours of the morning. Mother reported that Father had verbally abused her; woken Sibling 1 and told her that her mother was a ‘slag’ and ‘didn’t care about her’; grabbed Mother by her hair, ragged her to the floor and stamped on her head and back as she lay on the ground. Mother also reported that Father threatened to return to the property and stab her if he were arrested. 4.39. During this account, Mother also disclosed a domestic history which she described as mostly verbal but included two assaults – one where he poured bleach on her and another where he punched her, pulled her hair and strangled her. Mother also reported that he went to prison in 2014 for assaulting her, and, despite their separation, he continued to control who she could see and where she could go. 4.40. The Police record notes that Sibling 2 was not present during the assault, as he was staying with a grandparent. Sibling 1 was recorded to have been present and witnessed the incident – officers noted that she was very quiet and clearly upset when they arrived. However, as Sibling 1 got used to officers, she became chatty and was getting ready for school when they left. Sibling 3 was described as being fit and well, seemed happy and smiling. Officers noted that the house was in good order, with appropriate food, toys and clothing. They did not identify any concerns about the children during the visit. 4.41. Mother reported that she was very scared and wanted as much support as possible. She requested a panic alarm in the event he came back to the property. Police requested an alarm for Mother and made a referral to Pennine Domestic Violence Group for support. 4.42. Father was arrested on suspicion of section 47 assault and damage. Information sharing between partner agencies 4.43. Police records indicate that details of the assault were shared with social care and child health at 15:13 on the same day (Friday) as the incident. However, the Police record does not show that information about Father leaving the property with Sibling 3 in the car was shared. Health and Social Care records indicate that information about the assault was received the following Monday. About a month after the incident, the school nurse advised the school safeguarding lead about the incident and that a social worker was undertaking a single assessment. The School Safeguarding Lead confirmed that they would contact the social worker as needed. 4.44. There is no record in either the social care or Locala chronologies to suggest that either agency was aware that Father left the address with Sibling 3 in the car. Analysis 4.45. When Father took Sibling 3 from his Mother’s property and set off with him in the car, Father breached an agreement with Social Care not to have any contact with his children unsupervised. 17 4.46. As this agreement was implemented prior to the review period, it has not been seen by the independent reviewer and it is not clear if the agreement was made with both parents (or only Mother) and/or had an end date. It is also not clear if Children’s Social Care advised Police that this agreement, which was made with Mother, was in place. However, Mother did advise Police that Father was not allowed to have unsupervised contact with the children (see 4.36 above). It is recognised that written agreements are not legal documentsviii and Father could not have been charged with any offence over a breach. 4.47. It is considered likely that Mother only contacted the Police because Father had left the property with Sibling 3 in the car, and she was anxious about Sibling 3s safety. As professionals in health and social care were not aware of this incident, those professionals focussed on safeguarding children made a judgement about Mother’s capacity to act protectively without being aware of what her motivations for reporting the incident may have been. Furthermore, Sibling 1 witnessed the removal of Sibling 3 from the property, which is likely to have been distressing. It would have been useful if this information about this incident was shared, so children’s social care could have had the opportunity to explore it as part of their risk assessment. 4.48. The Police information that was shared with health and social care included information about the home conditions and the presentation of each child, which is considered to be good practice in assisting social care with their decision making. Mother’s subsequent withdrawal from agency support 4.49. The morning after the incident, Mother did not attend her appointment with Police to provide further evidence of the assault. When Police contacted her to arrange a subsequent appointment, she declined to have her injuries photographed; declined to let Police see her phone; and declined to provide a Victim Personal Statement. 4.50. Police contacted Mother again a few days later and she declined any further support, reporting that she felt safe and did not need any further assistance. 4.51. Records from the Pennine Domestic Violence Group indicate that Police referred Mother to their service for support 11 days after the incident. There is no corresponding record in the Police chronology so there is no explanation for the delay in making this referral. A worker from PDVG contacted Mother and explained how the service could help to add extra security to her property and/or apply for court orders to prevent him from contacting her. Mother advised that she did not feel she needed any support. PDVG closed her case and advised Police that she declined their support. Analysis 4.52. Mother very quickly retracted her statement to the police, and it is considered unlikely that this is due to any fault of police or other agencies offering to support her. Victims of domestic abuse are most likely to retract their complaints within 5 days of a violent episodeix. In this case Mother retracted her statement one day after the assault. She may have been fearful of the consequences of her disclosure, as she had reported that Father threatened to stab her if she reported him to Police. Retracting her statement may have been Mother’s attempt to mitigate the risk to her and her children. While this may seem at odds with what professionals might expect Mother to do to keep her children safe, it is understandable given her report of ongoing coercive control, the fact that her relationship with Father began when she was a teenager, and the previous involvement of agencies that could not manage the risk that Father presented to her. 18 4.53. Research also suggests that a majority of victims withdraw or retract their complaints because they are still in love with the perpetratorx. Practitioners working with domestic abuse cases should be mindful of ongoing feelings for the perpetrator and alert to indications that the relationship is continuing, or, at the very least, that the victim and perpetrator are in regular contact. The Department for Education notes that disguised compliance is a common factor in families living with domestic abuse and a number of serious case reviews identify victims falsely telling agencies that they are no longer in touch with their perpetrator.xi Learning Point 11: Victims may retract statements or disclosures regarding domestic abuse. The reasons for this are varied and complex, but fear of the consequence of disclosure and ongoing feelings for the perpetrator are likely to be contributory factors. Retractions should not be seen as evidence that abuse has not occurred and may be indicative of ongoing contact between the victim, the perpetrator and their children. Police investigation 4.54. Police attended Mother’s address promptly at 10:00am on the morning that the assault took place to obtain a witness statement. The following day, Mother declined to provide further evidence of the assault (as per 4.49 above). 4.55. The following Monday, the Crown Prosecution Service requested that Father be bailed as there was insufficient evidence to charge Father with the assault. The CPS requested that further evidence be gathered, including statements from anyone who may have visited the address and could confirm that the damage was not pre-existing; photographs of injuries; and a download of abusive messages on Mother’s phone. The officer noted that only limited further evidence would be provided given that Mother was no longer supporting prosecution. 4.56. The following day, the officer contacted Mother again to obtain further evidence as requested by the CPS. The victim declined to provide any supporting information and declined any further assistance from Police. 4.57. Given that Mother retracted her statement and Police could not complete any further enquiries, no further action could be taken. Police contacted Mother to update her that the police investigation would be closed and recorded that she was happy with that decision. Assessment undertaken by Children’s Social Care 4.58. Social Care records reflect the information held by Police about the assault on Mother. There is no record in the social care chronology to indicate that Social Care were aware of Father’s removal of Sibling 3 from the property. 4.59. The Contact Record created by social care includes a summary of social care involvement provided in the closing summary of the Child in Need plan, which notes the ‘significant’ involvement of social care dating back to 2010, the high number of domestic violence logs with Father as the perpetrator and Mother as the victim, and that all children have witnessed domestic violence on various occasions. The record recommends that the case to be progressed to referral to enable further information to be obtained. 4.60. There are chronology entries from Police and Health to indicate that a Strategy Discussion took place two days later and relevant checks were done with these agencies. 4.61. The social care assessment record also notes that a social worker visited Mother and the children as part of a s47 enquiry on the same day as the Strategy Discussion. Mother did not 19 want children to be spoken to as she did not want them to be upset, so she sent them to their bedrooms to prevent the social worker from speaking to them. She refused to allow the social worker to contact the children at school. 4.62. During the social worker’s discussion with Mother, the children kept coming downstairs and standing in the hallway, presumably to overhear what was being said. The social worker encouraged them to come into the room and noted that all children thought the social worker was there to remove them from their mother’s care. 4.63. The social worker noted that the youngest child (Sibling 3, then aged 2½ years) had very limited verbal interaction and that Sibling 2, who was alleged to have ADHD and Autism, was observed to struggle with verbal interaction. As a result, all children were spoken to together. It is not clear if Mother was present when the children were spoken to, but this is considered likely given Mother’s earlier reticence for children to be spoken to at all. The subsequent single assessment noted that Mother appeared to have anticipated social care attending and it was felt that the children had been prepared for the visit. It further noted that ‘it was clear that Mother did not want social care intervention’ and had ‘programmed the children not to speak to’ the social worker. 4.64. The s47 assessment notes that the children were not at home when the assault took place; that the children confirmed that they were not at home when the incident happened; and that the police report of the incident states that the children were not present. This is contradicted later in the assessment record, which in notes that a subsequent conversation with Police confirmed that two children were at the address at the time of the incident. 4.65. Mother advised the social worker that she had been away with friends and, on her return, her ex-partner had broken into her home, assaulted her and tried to steal her passport. The assessment notes that Police contradicted this account, advising social care that Mother had let Father into the property. The assessment also notes that Police advised that CPS did not have enough evidence to charge Father, and Mother had retracted her complaint and refused to provide any further information. On this basis, the assessment concludes that Police advised that the assault did not take place. 4.66. The analysis of information gathered in the s47 assessment notes that Father would want regular contact with his children and Mother was likely to be ‘at further risk of harm’ if she did not comply. The assessment also concluded that Mother was not truthful in her account of the incident and retracted her statement to police. The social worker notes that ‘Police state that there is no evidence that supported that Mother had been assaulted’. The Manager also adds that there was no evidence that Mother allowed Father into the family home or that they continued to be in a relationship. 4.67. The social worker concluded that the family could be supported via a Child in Need plan, but noted (incorrectly) that the family had been subject to a Child in Need plan that closed in July 2016 (the plan actually closed in January). The assessment notes that Mother had only just ‘got rid of social services’ and could not identify any further support needs. 4.68. At the 10-day review, the Team Manager noted that the s47 concluded that the information that led to the referral was incorrect, and that this had been substantiated by Police. 4.69. A single assessment commenced as the s47 was being concluded. The single assessment noted three home visits, two of which were conducted with the health visitor. It notes that Father was still controlling and demanding of Mother, especially when things do not go his way or to plan. However, they found no evidence that the children were at risk when having contact with Father and noted that Mother did not think Father would ever hurt the children. The Single Assessment incorrectly notes that Sibling 3 (rather than Sibling 2) was not present during the incident. 20 4.70. Nearly a month after the incident, Mother advised the social worker that she had now put a plan in place to manage child contact via paternal grandfather, and that this arrangement was working quite well. 4.71. The single assessment concluded that it was unlikely that Mother could have anticipated that Father would attend her home and challenge her aggressively; and that two of the children were at home asleep and did not witness the altercation (although concedes that Sibling 1 indicated to Police that she heard the arguing as it woke her up). The assessment concludes that Mother acted appropriately to safeguard herself and her children and subsequently put measures in place to supervise contact between Father and his children. 4.72. Health records indicate that the social worker advised the health visitor that the case would be closed with no further involvement from social care before the school nurse advised school that the domestic incident took place. From this, it would appear that the children’s school was not contacted as part of the social worker’s assessment. There is information in the single assessment about school attendance and a reference to Sibling 2 having an Educational Health Care Plan, but it is not clear where this information was obtained from. Analysis 4.73. Given that the single assessment noted that Mother appeared to have anticipated social care attending and it appeared that Mother had ‘programmed’ the children’s responses to the social worker, there should have been more challenge to Mother about her ongoing relationship with Father and why children had been prepared for social care’s visit. Learning Point 12: Social workers should challenge parent’s ‘programming’ children’s responses to social workers questions and explore the reasons behind this with parents Learning Point 13: Children being ‘programmed’ by their parents should warrant further exploration and social workers should speak directly to the children, without the presence of their parents, to explore their wishes and feelings. 4.74. The single assessment noted that Father was still controlling and demanding of Mother, especially when things don’t go his way or to plan; but were reassured because Mother did not think Father would ever hurt the children. Given the impact of coercive controlling behaviour on victims, it is unlikely Mother would say anything else. Furthermore, its places an on over reliance on mother’s capacity to assess risk and safeguard her children, particularly in light of the historic risks around domestic abuse and both parents’ struggle to prioritise the care and safety of their children. Ofsted notes that ‘agencies place an inappropriate attribution of responsibly on the victim to safeguard children’.xii Learning Point 14: coercive control has a detrimental impact on victims and may affect their capacity to assess risk and appropriately safeguard their children. Victims should not be expected to take sole responsibility for keeping their children safe from perpetrators, particularly when perpetrators have parental responsibility for their children. 4.75. The social care assessment notes that Police could not confirm that an assault took place and, as such, appeared to undertake the assessment on the basis that no assault occurred. This is despite Mother’s own account of an assault directly to the social worker, and the initial report 21 from Police describing Mother’s report of the assault, damage to the property, and the swelling to her eye. 4.76. It would be worrying if social care took the position that, if the police evidential test is not met, they should work on the basis that an assault has not taken place. The evidential threshold in criminal proceedings is significantly higher than in family law proceedings; and child protection enquiries do not have to establish each element of an offence beyond a reasonable doubtxiii. Furthermore, research into false allegations of domestic abuse demonstrates that false allegations are ‘extremely rare’ – a study by the CPS showed that in a period where there were 111,891 prosecutions for domestic violence, there were 35 prosecutions for making false allegations. The report showed that these cases generally involved young, often vulnerable people and, in some cases, the person alleged to have made the false report had undoubtedly been the victim of some kind of offence, even if not the one which he or she had reported.xiv 4.77. This study pertains to prosecution and not to initial reports, so there may be some variation in the proportion of inaccurate initial reports. However, given the overwhelming number of prosecutions for domestic offences in comparison to prosecutions for making false allegations, professionals should work on the basis that initial reports of domestic abuse are likely to be accurate and subsequent retractions or statements that the abuse did not occur are likely to be false. Learning Point 15: Social care should not use the police evidential test as a basis for determining whether or not an assault took place. Learning Point 16: Professionals should be mindful that an initial report of domestic abuse is likely to be accurate, and subsequent retractions are likely to be false 4.78. The assessment concluded that Mother acted appropriately to safeguard herself and her children. The assessment incorrectly noted that Mother had put measures into place to ensure contact between Father and his children would be supervised by his father (this arrangement was already in place from the closure of the Child in Need plan in January 2016). Father is largely missing from the assessment, except a reference to Police information that Father was ‘difficult to engage’. Ofsted notes that a lack of focus on perpetrators can lead to a short-term view of risks, where swift action is taken to secure the immediate safety of the victim and children without any focus on the perpetrator’s behaviour. In these circumstances, professionals resolve the immediate incident, but can lose sight of the greater risks posed in future.xv Learning Point 17: Perpetrators of domestic abuse, particularly those with parental responsibility for their children, should be directly spoken to about the impact of their abusive behaviour children and included in the assessment process/safety plan for children Domestic Incident in Leeds – August 2016 4.79. One week after the strategy discussion and visit with mother undertaken by the social worker, Police shared information regarding a low-level incident that occurred between Mother and Father the previous month in Leeds. 4.80. The information provided by Police indicates that Mother and Father were visiting the Paternal Grandmother with a view to the children staying there for the night. There was an argument between Mother and Father over a difference of parenting styles, which spilled out into the 22 street, and resulted in Mother leaving with the children and returning home. Father was reported to be in drink and remained in Leeds with his mother. 4.81. This incident was screened by a social worker and police officer in Leeds (as this is where the offence occurred) and emailed to Kirklees (as that is where the victim and children usually reside) nearly two weeks after the incident. Information about this incident was also shared by local (Kirklees) Police to Kirklees social care at the same time, nearly two weeks after Father assaulted Mother and while the social care assessment being undertaken. Analysis 4.82. The information from Leeds should have alerted social care and the police that Mother was having more contact with Father than she reported. Given that they were visiting Paternal Grandmother together, as a family, in violation of an earlier written agreement that all Father’s contact should be supervised by a family member (rather than Mother), it would have been reasonable for agencies to assume that the relationship was ongoing. 4.83. It is not clear whether this information affected the ongoing assessment being undertaken by social care. Given that information about the incident was shared by two different sources, it is reasonable to assume that the information was received by social care. However, it is not reflected in their chronology or assessment record, so it is unclear how this information was acted upon. Learning Point 18: social work assessments should respond to new and emerging information, even when new information contradicts what was previously known or believed to be true. Managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information. MARAC Meeting 4.84. The Police referred the case to the MARAC four days after the assault that occurred in Mother’s address in September. By this time, Mother had retracted her statement and declined any safeguarding interventions, so despite initially consenting to the Police sharing information with partner agencies, her consent for the MARAC had been withdrawn. As a result, the referral was made without Mother’s consent. Police considered the incident to be sufficiently high risk so Mother’s consent could be overridden to safeguard her and the children. 4.85. The MARAC referral provided a summary of the incident and noted that Mother had swelling above her right eye. It did not include details of Father taking Sibling 3 in the car. Police also advised the MARAC that Mother did not support a prosecution. 4.86. Information shared by agencies correctly notes that the case was open to a social worker for an assessment and that Mother had declined PDVG support. As a result, the MARAC recommended that the social worker discuss improving security in the family home with Mother. Social care subsequently advised the MARAC that this action had been completed. Analysis 4.87. The MARAC provides an opportunity for professionals from different agencies to share information about high-risk domestic abuse cases and develop a safety plan to mitigate identified risks to victims and/or their children. It also provides an opportunity for professionals to challenge an agency’s response to domestic abuse incidents and assumptions about risks to victims and/or their children. 23 4.88. It would have been helpful for agencies at the MARAC to have been aware of Father removing Sibling 3 from the property after the assault. Learning regarding this point is identified above in 4.47. 4.89. There is no information in the social care chronology or the assessment record to suggest that the social worker discussed improving security in the family home with Mother. Learning Point 19: MARAC provides an opportunity for information regarding the assessment and management of risk to be shared. Agencies in attendance must ensure that information shared at MARAC is appropriately acted upon. 4.90. Previous serious case reviews have identified improvements for the MARAC process in quality assuring the information that is submitted by individual agencies, and a number of improvements have been implemented since the MARAC in which this case was discussed in 2016. However, the onus is on participating agencies to undertake the actions that have been agreed by the MARAC and provide an update as necessary. Subsequent DV incidents Christmas Day 2016 4.91. On Christmas day in 2016, Mother made a 999 call at 11:44pm, which ended abruptly after what sounded to be a fight. When Police were able to get Mother on the phone again, she reported that her ex-partner was at the house smashing her property up. She was then heard to shout “get off me” before the call dropped again. 4.92. When Police attended the property at 11:50pm, Mother reported that there had been no assaults, no damage and no complaints. She stated that when she said "get off me", the suspect has tried to grab the phone, but had not assaulted her. A physical check was made of the house and there was no damage to any property and no signs of any disturbance. Officers noted that there were no visible injuries to anyone. Father was arrested to prevent a breach of the peace. He was reported to have attended Mother’s address heavily in drink. The DASH report states that Mother would not engage with officers therefore no witness evidence to substantiate further action. Sibling 2 was awake when officers attended and reported to be clean and happy. 4.93. Details of the incident were shared with Health and Social Care (although social care have no corresponding record of the incident). The Duty Health Visitor determined that no further action was required. The reason for this decision is not documented. December 2017 4.94. Mother reported a further domestic incident a week before Christmas in 2017. She reported to Police that her ex-partner was at her address, intoxicated and being verbally abusive. She requested that Police attend the address and remove him. The Police record notes that all children were present and that, apart from the house being messy, the children appeared nourished and happy when officers saw them. They did not seem distressed. 4.95. The Police shared information about this incident with Health and Social Care. The following day, the health visitor spoke to Mother about incident. Mother reported that she and Father had separated, he attended the property and did not leave the property when he was asked to so Mother called the police to prevent escalation. 24 Analysis 4.96. It is not clear what action children’ social care took in response to these incidents, but it would appear that Father was not spoken to about the impact of his behaviour on his children. See: Learning point 17: Perpetrators of domestic abuse, particularly those with parental responsibility for their children, should be directly spoken to about the impact of their abusive behaviour children and included in the assessment process/safety plan for children 4.97. When Mother rang Police in December 2016, she would have been flagged as a MARAC victim. At that time, this incident would not have been classed as a MARAC repeat because no crime was recorded and, accordingly, did not warrant a referral back to MARAC for further discussion. KPE 4: Home conditions September 2016 to February 2017 4.98. Poor home conditions were frequently noted by professionals during their involvement with the family. From November 2010 to January 2018, Health records noted 14 occasions when the home conditions were not considered to be satisfactory. The records note that when improvements were made, they were not sustained. 4.99. Mother moved into a Kirklees Neighbourhood Housing (KNH) property in September 2015. A number of professionals noted the poor state of garden in September 2016. KNH had an opportunistic conversation with Mother about the poor condition of the garden during an estate visits inspection. Also, in September 2016, following the domestic incident (discussed in more detail in KPE3), the social worker advised the health visitor that the home conditions were barely acceptable. Following this conversation, a nursery nurse noted that the garden was ‘unkempt with plates of leftover food, empty beer cans/bottle and broken toys. 4.100. When challenged about the home conditions, Mother reported that she had been unaware of the social worker’s visit and had not had time to tidy up. 4.101. In early October 2016, health records indicate that the social worker who conducted a joint visit with the health visitor was happy with the conditions of the home environment. The single assessment completed by the social worker reports that there was some rubbish in the garden but also notes that Mother had made arrangements for this to be cleaned up. It is not clear from the record if the children’s bedrooms were seen as part of this visit. 4.102. At a quarterly inspection at the end of October 2016, KNH noted the poor condition of the garden. By early November, KNH had commenced an anti-social behaviour case for the rubbish in the garden. At this time, a Stronger Families Consultant working from KNH contacted social care requesting information about their involvement with the family and were advised that social care had closed the case. KNH queried whether there were any arrangements in place to de-escalate the case following social care’s involvement and were advised there was no lead professional for the family in place and that school were the only service involved. At this point, the Stronger Families Consultant made a number of attempts to liaise with school but were unable to speak to anyone about their concerns. 4.103. By mid-December 2016, a legal notice was served on Mother to address the garden condition. Early in the New Year, an enforcement officer visited and spoke to Mother about the rubbish in her garden. Mother explained that does not drive; that she could not afford the local tip due to the amount of waste; that she has three children aged 6, 5 and 2, and her 5 year old has ADHD and autism; and that her grandparents normally help her but had recently been ill and 25 unable to help. The enforcement officer advised that there was a significant amount of waste, and she would need to address it or potentially face a fine. The enforcement officer advised Mother to bag up all the rubbish, recycle more efficiently, and offered some advice around local services that may be able to assist. By the end of February 2017, Mother had cleared the rubbish and the ASB case was closed. Analysis 4.104. It is unclear from the record to what extent Mother prepared for professional visits to the home. Opportunistic visits, as opposed to pre-arranged appointments, appeared to identify issues with home conditions, indicating that the ‘usual’ standard was probably below what professionals would expect. Mother also indicated that home conditions were poor during an unannounced visit because she didn’t have time to tidy up. 4.105. It is recognised that different professionals will have different standards regarding home conditions as this is a subjective assessment. This is apparent when, in October 2016, health and social care professionals were reported to be happy with the home conditions (including the garden), even though KNH were in the process of pursuing anti-social behaviour proceedings for the poor condition of the garden. Staff at the practitioner forum indicated that it may be useful to establish a benchmark to enable professionals to share a collective understanding of acceptable home conditions. Learning Point 20: The use of a visual home conditions assessment tool may be useful to enable professionals to share a collective, objective understanding of what constitutes acceptable home conditions Capping the gas supply 4.106. It would not appear that any professionals made any further home visits until September 2017, when KNH were attempting to access the property to service gas appliances. In mid-September, Mother told the engineer she had no gas on and this was the 3rd occasion where she advised she would be ringing up to set a suitable date. However, there was no subsequent call to property services. By the end of October, following a lengthy process involving Gateway to Care, KNH made a final attempt to service gas appliances with attendance from Noise and Pollution Team. The gas was capped at Mother’s request and there was no gas supply to the address from this point onwards. 4.107. As a result of this case, KNH identified some issues with spin capping and have implemented new processes to ensure professionals seek advice before spin capping properties where there are children and/or vulnerable adults; and monitor all spin capped properties on a monthly basis. Sleeping arrangements 4.108. In November 2017, the midwifery and health visiting teams attended the home address on a number of occasions following the birth of Child A. Unfortunately, the notes of the midwifery visits have been lost, so no information about the home conditions have been recorded. The health visiting records note that the living room was cluttered and needed hoovering, and that there was rubbish in the garden. However, there is nothing in the notes to indicate that the house was particularly cold or without hot water. It is not clear if any professional saw the children’s bedrooms or sleeping arrangements during any of these visits. 4.109. A number of professionals that accessed the property after Child As death described the sleeping arrangements for all the children as inappropriate, in the case of Child A, unsafe. 26 4.110. Mother and Father confirmed that it was normal practice for Child A to sleep in between them, and that they were aware of the risks associated with co-sleeping. The post-mortem identified the following risk factors in relation to co-sleeping: • a soft mattress and inappropriately heavy bedding. • both mother and father had been drinking alcohol; and • Child A had been sleeping in between them. Analysis 4.111. Previous child protection concerns (prior to the period under review) had identified issues with home conditions and lack of appropriate bedding/sleeping arrangements for children. However, there is no evidence that anybody checked any of the children’s’ bedrooms during the review period. This is particularly relevant in light of the s47 assessment undertaken by social care, as it would be prudent for any subsequent assessment to ensure that historic concerns had not re-emerged. Learning Point 21: Children’s Social Care assessments should consider the history of the case and ensure that any historical concerns i.e. home conditions, suitable sleeping arrangements for children etc are explored during any re-assessment process 4.112. Both the health visiting and midwifery records are clear that safe sleeping advice was provided to Mother during each pregnancy and following the arrival of each of her children. From this, it would appear that Mother was provided with safe sleeping advice on at least eight occasions prior to the death of Child A. 4.113. The author is aware that a concurrent CPSR in Kirklees, with regards to Child E, has identified learning with regards to safe sleeping. In this case, the safe sleeping advice, given consistently to mother, was not effective in reducing the risks to Child E. This review points to emerging research that indicates that, whilst the safe sleeping message appears to have effectively reduced deaths in the general population, it appears to be less effective with parents with complex needs. Learning in regard to this finding will be addressed in the CPSR regarding Child E and, accordingly, will not be duplicated here. KPE 5: Pregnancy with Child A – Mar 2017 to Nov 2017 4.114. Mother presented at the local hospital emergency department in March 2017 with bleeding and queried whether she might be pregnant. The pregnancy test in the Emergency Department was positive and scan in the Early Pregnancy Unit suggested a potential pregnancy. A rescan conducted nearly two weeks later confirmed a 6-week viable pregnancy. Mother was encouraged to make an appointment to book her pregnancy with the midwifery department. 4.115. When Mother was approximately 15 weeks pregnant she attended her GP with symptoms of morning sickness. GP queried hyperemesis gravidarum and noted that Mother reported having three children and feeling unable to cope. 4.116. In June 2017, Mother had her antenatal booking appointment at 24 weeks. The booking notes that Mother was previously known to Children’s Social Care and had some mental health issues when she was a teenager. The midwife made a routine enquiry around domestic abuse and noted that Mother declined to provide information about the father of the unborn. Mother informed the midwife that she had a new partner, he was unlikely to be involved with the baby 27 and she had no concerns about domestic abuse. The dating scan confirmed that Mother was due to have the baby in mid-November 2017. 4.117. There is a record in the social care chronology that Mother attended a clinic for a termination in July, but then changed her mind. The clinic advised that this information was also shared with the GP and midwifery service, but there is no corresponding entry in either the GP or midwifery record. 4.118. Mother attended hospital a number of times in September, reporting that she had spontaneous rupture of membranes, reduced foetal movements and pelvic pain. All scans, tests and observations returned normal and Mother was advised to return home, rest and come back to hospital if she had any further concerns. At one appointment she requested an early delivery as she was struggling to cope without any social support. 4.119. In early October Mother attended a further appointment and again reported reduced foetal movements – she was immediately sent for monitoring and assured that the baby was well. She was asked about mood and anxiety and signposted to Single Point of Access for support with managing her anxieties. She divulged that she did not want to see her community midwife anymore, as she brought back memories of her previous pregnancy loss. The information is passed to the community midwifery manager and different midwives were assigned to Mother’s care. 4.120. A referral was made to Single Point of Access on Mother’s behalf. Mother discussed her anxieties over the phone and agreed to a referral to ‘talking therapies’. However, she did not keep her appointment and was discharged from the service. 4.121. Child A was born at the end of October by a planned caesarean section. Children’s Social Care have a record of a low-level domestic incident that occurred on the day of the birth. This is believed to be incorrect, as it is not reflected in the Police or Health record, and Health representatives at the Practice Learning Event were certain that no domestic incident occurred on the day of the birth. 4.122. Mother and baby were discharged home the following day. The midwife conducted a home visit the following day and made a further three home visits during November. Unfortunately, the notes of these visits are not available as Mother lost her notes. The health visitor also conducted a visit in November. The health visitor discussed safe sleeping arrangements, discussed Mother’s social support arrangements, and talked about Mother’s anxieties during her pregnancy. Mother reported that she was emotionally well and did not require any further support at this time. Analysis 4.123. It is clear that Mother was asked about domestic abuse in her relationship as part of a routine enquiry. Given her history of domestic abuse in her previous relationship, it may have been helpful for this routine enquiry to be more targeted and explore the risk posed by her ex-partner i.e. was he aware of the new pregnancy? How did he/ how did Mother think he would react to the news? Learning Point 22: Several agencies now employ routine enquiry in relation to domestic abuse. If the case history and/or responses to the enquiry indicate historic domestic abuse, the current risk posed by violent partners/ex-partners should be explored. 4.124. Mother was routinely asked to identify who the Father of her baby was and if there was any risk of domestic abuse in her relationship. She consistently declined to provide details of the 28 father and denied any domestic abuse in her relationship. Given that Father was the father to her other three children, their relationship commenced when Mother was under 16, and her previous involvement with services due to domestic abuse, it was a reasonable assumption that he was also Father to the unborn. The reviewer is aware of the difficulties in proceeding with any form of assessment without evidence that Mother was in an abusive relationship. However, given the risk involved in domestic abuse cases and the impact of coercive control on victims, perhaps it would be beneficial to consider a different approach to risk assessment in these cases. For example, professionals could consider working with multiple hypotheses – what if the former abusive partner is the father? What if it is somebody else? See: Learning point 9: Risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their current partner and/or father of their unborn child. This may be indicative of an ongoing, abusive relationship. 4.125. Mother was clearly very anxious throughout her pregnancy and it would appear that appropriate offers of support were made. Mother also reported a number of difficulties during her pregnancy – in addition to her reported sickness, anxiety and pelvic discomfort, she was struggling to manage Sibling 2s behaviour and having financial difficulties (not having sufficient credit on her gas account and subsequent gas capping). Mother reported on a number of occasions that she was not sure how she would cope with the new baby. It is recognised that professionals tried to support her and signpost her to appropriate services. It is not clear if Mother was asked what help she needed or what would make life easier for her and her children; Mother may have interpreted offers of support as a criticism of her parenting or an expectation that she needed to do more at a time when she was struggling. This reluctance to engage with services may have also been a further indication that Mother was in an abusive relationship and/or did not otherwise want professional scrutiny of the daily experiences of her children. Learning Point 23: How can we improve the offer of support to pregnant women who are struggling to cope but keep agencies at arm’s length? 4.126. There are some gaps in information following the birth of Child A as the maternity notes were misplaced by Mother. Accordingly, it would appear that there is no electronic or duplicate copies of the notes, which would make it difficult for the midwifery service to share information with other professionals working with the family. Learning Point 24: MYHT may wish to explore electronic and/or duplicate copies of mothers’ maternity notes Father subject to Probation Supervision 4.127. In August 2017, Father was arrested for failing to provide a specimen for a roadside breath test. In September 2017, he is found guilty and sentenced to a 12-month Community Order, to be supervised by Probation CRC. 4.128. His Probation Officer contacted Children’s Social Care to check if Father had any contact with his children. Social care records suggest that there were no concerns for the welfare of the children or to suggest their needs are unmet, and that this was shared with the referrer. Probation records state that a social worker rang to advise that the children were no longer subject to child protection; that the case had been closed in November 2016; and that they had previously been involved due to concerns about domestic abuse and substance misuse. There is no record of a disclosure around a contact agreement or arrangements for Father to have supervised contact with his children. 29 Analysis 4.129. The Probation Officer was proactive in seeking information about Father’s contact with his children. If information about the necessity for supervised contact had been shared, there may have been an opportunity for Probation to explore this with Father and do some digging around his relationship with Mother. See Learning point 4: Children’s social care should explore how their expectations around child contact should be communicated to parents and professionals. This should include clear consequences for failure to adhere to agreed contact arrangements, recommendations for professionals in other agencies to record/flag the arrangements for supervised contact; and a clear process for reporting breaches to contact arrangements. KPE 6: Police callout 01:00 on 01/01/18 4.130. Police were called to a disturbance between Father and his brother at Mother’s address in the early hours of 01/01/18. Father stated that his brother had too much to drink and was getting very aggressive; Father had booked his brother several taxis but his brother would not leave so Father requested Police assistance to remove him from the property. Father reported that his children were present and that his partner was trying to get rid of his brother as he phoned police. Father reported that he was not in fear of violence or distressed. 4.131. Officers responded quickly and determined that there had been no verbal argument and no substantive offences were recorded. Father reported that his brother was intoxicated and did not want to leave, even when Father reported that he had to put his children to bed. Officers saw Sibling 1 from the doorway and she appeared safe and well. Father did not appear to be intoxicated. Officers removed Father’s brother from the property and dropped him at the taxi rank so he could get himself home. 4.132. Responding officers were not aware of the domestic history between Mother and Father or that any arrangement existed to ensure that Father had supervised contact with his children. Analysis 4.133. Police responded quickly to the incident and took appropriate action to remove Father’s brother from the property. 4.134. Given Father’s earlier report that children were present and partner was trying to get rid of his brother, it may have been prudent to speak to his partner and ensure that she and the children were not harmed/distressed and/or in need of support. It is acknowledged that one of the children was seen and appeared to be safe and well. Learning Point 25: Police should consider how to ensure responding officers check on the safety and welfare of children when they are called to an incident 4.135. This incident was not flagged as a domestic and, accordingly, would not have routinely been shared with Children’s Social Care. As already stated, it is unlikely that Police had flagged that there was an arrangement in place to ensure that all contact between Father and his children was supervised. 4.136. Responding officers were not aware of the history of domestic abuse between Mother and Father. Although this was not a domestic incident, it did occur at Mother’s address. There 30 may have been an opportunity for responding officers to consider their response to the incident in light of the domestic history. Learning Point 26: Police to explore what information/history can be shared with responding officers before they attend an incident 5. Contribution of family 5.1. Family members may be invited to contribute to this review following the conclusion of all concurrent enquiries. Specifically, key family members may be asked to comment on the services and support provided by various agencies and whether this was appropriate to their needs. Family members may also be asked to comment on issues associated with the publication of the full overview report. 5.2. The independent reviewer will liaise with the KSCP to contact family members when all concurrent processes have been concluded. Contacts with family members will be handled sensitively and, where possible, via a professional already known to the family. Contribution of siblings 5.3. Child A’s siblings have not been directly spoken to and given their age, are possibly not aware that a CPSR is being undertaken. 5.4. The independent reviewer and CPSR coordinator for the KSCP met with the social worker that is currently working with the children to determine if it would be appropriate to speak directly to the children. We agreed that it would be disruptive and potentially distressing for the children if we spoke to them directly; and they may not share much information about their interaction with professionals prior to Child A’s death. However, the social worker provided valuable insights into the children’s daily experiences, their relationship with their parents, and the relationship between Mother and Father. Where possible and appropriate, these insights have been reflected in the analysis section of the report. 6. Analysis 6.1. This section of the report provides an analysis of work undertaken with the family during the review period. 6.2. The terms of reference for the CPSR set out specific key issues to be considered as part of this review, and these issues provide the headings in this analysis. It is important to note that this report has already highlighted a number of areas of learning, and the aim of this section of the report is to consolidate and build on these learning points. 6.3. It is clear from the story of how this case unfolded that Child A was born into a household marked by domestic abuse and low-level neglect. While there a number of factors that may have contributed to parental neglect of the children – for example, the parents experienced parental rejection and were exposed to parental domestic abuse and substance misuse as young people – this analysis will focus largely on domestic abuse as the principal presenting risk factor in this case. This is considered to be appropriate given that Mother and Father were 31 subject to MARAC during the review period (indicative of high risk of serious injury or death to the victim); and that the children were historically subject to an Interim Supervision Order due to ongoing concerns that the relationship between Mother and Father was continuing despite concerns raised by professionals that domestic abuse posed a risk of significant harm to the children. Impact of domestic abuse on children 6.4. Domestic abuse has been identified by the NPSCCxvi, Ofstedxvii and the Department for Educationxviii as the most common characteristic of situations where children are at risk of serious harm, and the most common reason for children to be assessed by children’s social care services. 6.5. Extensive research points to the impact of witnessing physical incidents of domestic violence on children, including direct physical harm, greater behavioural and emotional problems, neurological differencesxix, more disordered attachmentsxx and learning problemsxxi. There is also a significant overlap between domestic and other forms of harm – the NSPCC reports that a third of children affected by domestic abuse also experience other forms of abusexxii. 6.6. Crucially, caregivers in abusive relationships are often absent when their children are most in need of buffers from distress. Children depend on cues from caregivers to regulate distress and, if caregivers are absent, threatening or being threatened during times of acute distress, it can affect the way children regulate emotions, respond to fearful stimuli, and develop trusting relationships with othersxxiii. 6.7. More recent research highlights the effects of non-physical forms of domestic abuse on children (see Ofsted 2017, Department for Education 2016 and Katz 2016) and that a focus on physical acts of violence fails to appreciate the ongoing, cumulative impact of coercive control. Accordingly, professionals focused on physical acts of violence may fail to understand the daily lived experience of victims and children, how it is affecting them, and the level of risk posed by perpetrators.xxiv 6.8. Current models of intervention that wait until there is extreme violence, stalking, or an injury to a child are problematic in that, by the time abuse reaches this point, coercive control is likely to have severely eroded a victim’s personhood from the inside out, “the way carpenter ants devour a house”.xxv The impact of coercive control 6.9. Women’s Aid define coercive control as “a deliberate and calculated pattern of behaviour and psychological abuse designed to isolate, manipulate and terrorise a victim into complete fearful obedience”. Research indicates that there are similarities between coercive control and tactics used to control hostages, POWs and concentration camp inmates. The negative impact of psychological abuse and coercive control is reported to be more difficult to recover from than physical violence.xxvi 6.10. Katz suggested that children experience behavioural and emotional difficulties as a result of coercive control, as the children in her study expressed similar difficulties whether there was severe physical violence in the relationship or not. These children reported feeling isolated within the home because the perpetrator monopolised the victim’s time; exhibited language and developmental delay due to lack of stimulus and opportunities for play; and broader isolation as victims were prevented from spending time with family members, having visitors to the home or attending appointments. Her research found that children’s freedom to say 32 and do things was narrowed both by perpetrators, and by themselves as a means to avoid further abuse.xxvii 6.11. In addition to direct effects on children, the impact of coercive control on victims can affect their capacity to provide effective care for their children. As perpetrators control everyday behaviours, victims have no freedom to meet their own needs (or those of their children) without worry or fear, diminishing their options, choices and ability to make decisions for themselves.xxviii Abuse can also directly undermine victim’s parenting by humiliating or belittling victims in front of their children and thus undermining their authority. 6.12. Professionals should also be aware that the presence of coercive control in a relationship can be an effective indicator of the likelihood of serious violence resulting in death of victims. Victims of domestic homicide that do not have a history of previous physical abuse are likely to have been victims of extreme forms of coercive control.xxix Learning Point 27: Children’s social care to ensure assessments of risk to children include a thorough exploration of the risk presented by perpetrators of coercive control; and the ongoing, cumulative impact of coercive control on victims and children Increased risks associated with separation 6.13. Research has pointed to shortcomings with current interventions that focus on separation from the abusing partner as the means to protect childrenxxx. 6.14. Professionals should always be cautious about victim’s assurances that an abusive relationship has ended. Victims may advise agencies that a relationship has ended as a means to avoid further professional attention on the family. They may minimise risks posed by an abusive partner in response to threats and coercion, or as a means of minimising the harm their children may suffer. xxxi 6.15. Furthermore, this approach underestimates that ongoing risk of harm to children in the post-separation periodxxxii. Research indicates that, in 50% of cases, domestic abuse continues even after parental separation, often during child contact visits. xxxiii 6.16. Separation and the post-separation period are considered to greatly increase risk for victims and children, sometimes resulting in deathxxxiv. The triennial review of serious case reviews also highlights difficulties with separation and child contact as a trigger for a fatal incident in a number of cases.xxxv Furthermore, 75% of domestic homicides occur within 12 months of separationxxxvi. 6.17. Child contact, which occurs in this context, can become a pivotal part of continuing abuse of victim, and children may be more likely to witness more severe abuse post-separation. Research has demonstrated that more than half of victims with post-separation child contact arrangements with an abusive ex-partner continued to have serious, ongoing problems with this contact.xxxvii Learning Point 28: Key frontline professionals should continue to assess risk, and provide support for victims and children, post-separation in recognition of the increased risk posed by perpetrators during this period 33 Sufficient focus on Father 6.18. This report has identified that Father was largely missing from assessments of risk to Mother and the children (see 4.78), despite being recognised as a perpetrator of domestic abuse that should not have had unsupervised contact with his children without further assessment. 6.19. Research has highlighted that professionals often focus almost exclusively on the quality of care children receive from their mothers and female carers.xxxviii, despite the crucial role fathers play in their children’s lives and the extensive influence they have on children in their care. 6.20. This is particularly important in domestic abuse cases. Despite the increasing recognition of male victims and increased reporting to professionals, women still comprise the majority of victim reports to agencies and are more likely to be physically harmed, report greater levels of fear and are more likely to be murdered or seriously harmed than male victims.xxxix 6.21. Safeguarding agencies often focus on the victim’s role (and often perceived inability) to protect children from domestic abuse and ignore the responsibility of perpetrators to keep their children safe from domestic abuse. xl 6.22. It is also important that fathers can be seen as both a risk and a resource for children and try to avoid narrow and stereotypical approaches that perceive fathers as one or the other. The reality is perpetrators of domestic abuse are often socially marginalised and have their own personal histories that contribute to their abusive behaviour. Interventions to safeguard children should respond to that reality.xli 6.23. This review highlights the following learning points in relation to professional focus on fathers: Learning point 14: coercive control has a detrimental impact on victims and may affect their capacity to assess risk and appropriately safeguard their children. Victims should not be expected to take sole responsibility for keeping their children safe from perpetrators, particularly when perpetrators have parental responsibility for their children. Learning point 17: Perpetrators of domestic abuse, particularly those with parental responsibility for their children, should be directly spoken to about the impact of their abusive behaviour children and included in the assessment process/safety plan for children Contact Arrangements 6.24. Prior to the review period, there were two written agreements (Father’s contact agreement in 2012; Mother’s contract of expectations in 2013) stipulating that Father’s contact with the children should be supervised by a family member. These arrangements appear to have been put in place as a direct result of the domestic abuse that Father perpetrated against Mother. The effectiveness of these agreements is discussed in s6.30 – 6.32 below. 6.25. In January 2016, professionals attending a Child in Need meeting clearly communicated that Father was to continue to have supervised contact with his children, and agreed that, if the relationship resumed and/or there were any further incidents of domestic abuse, social care would conduct a further assessment. 6.26. However, it is unclear if subsequent assessments and professional contact with the family actively explored Father’s contact with his children. At an appointment with the paediatrician in June 2017, the GP record indicated that Sibling 2 was spending more time with Father. The GP may not have been aware that all contact between Father and his children was supposed to be supervised. Accordingly, it does not appear that the nature of this contact was explored, and or that this disclosure was shared with other professionals. 34 6.27. Furthermore, when Probation proactively sought to determine if Father was allowed unsupervised contact with his children, they were advised only that there was no current social care involvement. 6.28. With the benefit of hindsight and following discussion with the children’s current social worker, it is clear that Father essentially lived in the family home with Mother and the children. This report has identified learning for children’s social care in communicating their expectations around child contact, captured in the learning point below: Learning Point 4 Children’s social care should explore how their expectations around child contact should be communicated to parents and professionals. This should include clear consequences for failure to adhere to agreed contact arrangements, recommendations for professionals in other agencies to record/flag the arrangements for supervised contact; and a clear process for reporting breaches to contact arrangements. Written agreements 6.29. This report has identified that there were two written agreements, signed in 2012 and 2013 respectively, that were presumably still in force during the review period. 6.30. At the CiN closure meeting, social care was clear that concerns would be raised if Mother resumed a relationship with Father, and that any incidences of domestic violence would trigger another assessment. There is no reference to the contract of expectations that Mother signed in 2013 to confirm that Father was not allowed to be at the home address; or to the Contact Agreement that Father signed in 2012. 6.31. Ofstedxlii is critical of the effectiveness of written agreements, given that they are often made with the victim and not the perpetrator who is the source of the abuse and therefore the risk. Furthermore, written agreements have no legal status and consequently will have limited meaning or value to professionals in other agencies; and are unlikely to be monitored after social care have ceased their involvement with a family. Learning Point 29: written agreements are not effective tools for managing risk and their use should be avoided. Where considered necessary, written agreements should, at a minimum, be clear about the duration that they are in force; the ways in which agreement will be monitored; and the consequence of breaking the agreement. Any written agreement should be shared with all parties with parental responsibility and shared with universal services that are likely to remain in contact with the family after children’s social care withdrawn their intervention To what extent were agencies aware of the history of neglect of the children and domestic abuse within this family? 6.32. It would appear from the chronology that all agencies involved with the family during the review period were aware of the history of neglect and domestic abuse within the family. When the review period commenced in 2016, the family were still subject to a Child in Need plan due to historic issues of domestic abuse and neglect. Children’s social care, Locala and the children’s school were represented at the final Child in Need meeting. Kirklees Neighbourhood Housing were aware of the plan as they wished to attend the meeting, but it is not clear if information regarding domestic abuse and neglect had been shared with them. WY Police had records of domestic incidents and of Mother’s assault on Sibling 1 in 2013. MYHT, who provided maternity care for all of Mother’s pregnancies, were also aware of the previous supervision order and concerns regarding domestic abuse and neglect. Probation CRC were 35 advised that social care had previously been involved due to issues with domestic abuse and substance misuse. 6.33. It would appear that most professionals had access to this information in their ongoing work with the family. The Probation Officer was not aware that Father’s contact with the children was to be supervised by a relative. Similarly, the Police that responded to the incident between Father and his brother on 01/01/18 were not aware of the history of the domestic abuse or that Father was not supposed to have unsupervised contact with his children. This has been addressed in: Learning Point 4 Children’s social care should explore how their expectations around child contact should be communicated to parents and professionals. This should include clear consequences for failure to adhere to agreed contact arrangements, recommendations for professionals in other agencies to record/flag the arrangements for supervised contact; and a clear process for reporting breaches to contact arrangements. Evidence of ongoing neglect or domestic abuse within the family 6.34. This review has highlighted a number of indicators of ongoing neglect and domestic abuse. It is recognised that a number of these indicators, taken individually, may not be indicative of significant risk. However, with the opportunity to consider these indicators collectively, and with the benefit of hindsight, there are valuable lessons to support our understanding of risk in similar cases. • Neglect – o referral to social care due to children appearing unkempt and hungry; and o poor home conditions. • Domestic abuse – o Mother’s report of assault and coercive controlling behaviour. o Mother declined to provide information about identity of father to Child A; and o Mother reluctant to engage with services. Neglect 6.35. The NSPCC provides indicators of neglect under the following broad headings: • Poor appearance and hygiene (smelly/dirty, unwashed clothes, inadequate clothing, hungry, attending school without breakfast); • Health and development problems (untreated injuries, recurring illnesses, missed appointments, rashes, thin, anaemic, tired, faltering weight/growth, poor communication skills); and • Housing and family issues (unsuitable home conditions i.e. mess or no heating, left alone for a long time, taking on role of carer) 6.36. In April 2016, the School Nurse appropriately recognised Sibling 2’s presentation at school without breakfast and appearing unkempt as indicators of neglect. Various professionals 36 noted concerns with home conditions, including dangerous levels of rubbish in the home and garden. The need for a shared visual description of neglect was identified in: Learning point 20: The use of a visual home conditions assessment tool may be useful to enable professionals to share a collective, objective understanding of what constitutes acceptable home conditions 6.37. It is important to note that all children were believed to have a very good school attendance record (as per the s47/single assessment carried out by social care in September 2016); and all social care assessments concluded that there were no concerns about the children, which indicates that neglect was of a low level and Mother was assessed as being able to provide adequate care for the children. Domestic Abuse Mother’s report of assault and coercive controlling behaviour 6.38. During the review period, there were three occasions where Police were called to Mother’s address for domestic incidents in which Mother was the victim. This is not a significant number of domestic incidents, but indicative of ongoing abuse (as it is likely that not all incidents were reported). 6.39. Significantly, in September 2016, Mother contacted Police and reported that Father assaulted her and that she was a victim of coercive controlling behaviour. The assault triggered a social care assessment, a number of offers of support for Mother, and a multi-agency risk assessment. This review has already highlighted learning for professionals responding to domestic abuse victims in sections 6.4 to 6.17 above. However, it is worth reiterating that professional focus on a seemingly isolated assault ignored a potential daily lived experience and cumulative impact of ongoing domestic abuse on both Mother and her children. 6.40. Mother’s own report of a domestic assault and being the victim of coercive control were the strongest evidence of domestic abuse during the review period. Declining to provide information to professionals 6.41. Throughout her pregnancy, Mother declined to provide details of the father of her child to health professionals. This report has already identified difficulties in proceeding with any form of assessment without evidence that Father was having regular, unsupervised contact with the family. However, given the risk involved in domestic abuse cases and the impact of coercive control on victims, perhaps it would be beneficial to consider a different approach to risk assessment in these cases. 6.42. This is highlighted in: Learning point 9: Risk assessment undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their partner/father of the unborn child. This may be indicative of an ongoing, abusive relationship. Reluctance to engage with services 6.43. During review period, Mother indicated that she was struggling to cope and wanted support, particularly with managing Sibling 2’s behaviour. However, all subsequent offers of support were declined or appointments were not kept. 37 6.44. Mother had twice requested support from agencies in managing Sibling 2’s behaviour, and subsequently declined to engage with the family support worker to complete a single assessment. The Single Assessment Guidance Notes stipulate that “Where consent is withheld it is the role of the practitioner to explain the assessment process in a way that enables the family to understand the benefits of sharing information and working in partnership with other agencies they should also explain what not sharing information will mean for them. In some cases refusal may be judged to indicate “deliberate avoidance” and this in itself may raise safeguarding concerns. There needs to be careful analysis and monitoring of refusals to engage so that an informed assessment of the level of risk can be made.” Given the limited information available to the independent reviewer about these assessments, no analysis about whether this guidance was followed can be provided. 6.45. Sibling 2 was referred to the Children’s Emotional Wellbeing Service, but no appointments were ever made. Mother also reported domestic abuse to Police, then declined to provide any evidence to support a prosecution and declined any support around domestic abuse. She requested support with managing her anxieties in her pregnancy, then failed to attend her appointment. 6.46. It is recognised that these records are held by different agencies so this multi-agency pattern of non-engagement may not have been apparent to frontline professionals trying to support the family. However, during the review period there were two opportunities for professionals to collate multi-agency information to conduct a risk assessment – the assessment undertaken by social care; and the MARAC, both of which were held in September 2016. These processes should have identified Mother’s reluctance to engage with services. 6.47. These points are addressed in: Learning point 9: Risk assessment undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their partner/father of the unborn child. This may be indicative of an ongoing, abusive relationship. Learning point 18: social work assessments should respond to new and emerging information, even when new information contradicts what was previously known or believed to be true. Managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information. Learning point 19: MARAC provides an opportunity for information regarding the assessment and management of risk to be shared. Agencies in attendance must ensure that information shared at MARAC is appropriately acted upon. Rejecting professional advice 6.48. Mother was provided with advice around behaviour management for Sibling 2, and also advised that he did not have an underlying medical cause for his behaviour. However, Mother was eager to secure a medical diagnosis for his difficulties rather than implement the advice offered by professionals. It would appear that she was seeking an easier alternative to good, consistent parenting; and may have been attempting to distract professionals from other issues in the family home. 6.49. This is addressed in: Learning Point 5: some parents may be intent on securing a medical diagnosis for a child’s behavioural problems and consequently ignore advice from health and other professionals about behaviour management. A consistent, multi-agency response should be given to 38 parents in these cases to ensure that children receive an appropriate, authoritative parenting approach. Implications for professional practice 6.50. The indicators of neglect and ongoing domestic abuse highlighted in this section of the report highlight the need for greater professional curiosity in cases where low level concerns are identified and families are reluctant to engage with services. 6.51. Greater professional persistence and challenge are needed to support families to engage with services. In this case, Mother had previously reported that professionals had helped her to establish a more positive relationship with her child and she felt better within herself. It is not clear from the record that there was any challenge to Mother about accepting support, particularly for Sibling 2, when she had previously found it so helpful. With the benefit of hindsight, it would appear that Mother deliberately kept professionals at arm’s length because of her ongoing relationship with Father. Her reluctance to engage with agencies, in the context of her historical abusive relationship, should have piqued professional curiosity about the daily lived experience for Mother and her children. Was family history given appropriate consideration during decision-making? 6.52. Given that the history of neglect and domestic abuse was known to agencies working with the family, and there were indications of ongoing safeguarding concerns, this section of the report considers whether family history was given appropriate consideration during decision making. 6.53. Specifically, this will focus on: • routine checking of the bedrooms; and • The use of routine enquiry when exploring issues of domestic abuse. Routine checking of the bedrooms 6.54. Previous child protection concerns (prior to the period under review) had identified issues with home conditions and lack of appropriate bedding/sleeping arrangements for children. Learning in regard to how this history may inform social care assessments of families has already been identified in the following learning point: Learning point 21: Children’s Social Care assessments should consider the history of the case and ensure that any historical concerns i.e. home conditions, suitable sleeping arrangements for children etc are explored during any re-assessment process 6.55. There were at least 12 visits to the home address by professionals from a number of agencies, but it is not clear from agency records if any professional viewed the children’s sleeping arrangements during the review period. This may be particularly relevant in light of historic concerns regarding the children’s sleeping arrangements, and also given how professionals found these arrangements following the death of Child A. 6.56. The author is aware that the relevant hospital trust is developing guidance for midwifery staff to consider inspecting the sleeping arrangements during post-natal home visits. It may be prudent for other agencies to consider their role in supporting parents to provide appropriate sleeping arrangements for their children. 39 Learning point 30: in light of historic concerns regarding suitable sleeping arrangements for children, all agencies should consider how they can support families to ensure that children have appropriate sleeping arrangements in place. Routine enquiry in historic domestic abuse cases 6.57. Mother was asked about domestic abuse in her relationship as part of a routine enquiry. Given her history of domestic abuse in her (previous) relationship, it may have been helpful for this routine enquiry to be more targeted and explore the risk posed by her ex-partner i.e. was he aware of the new pregnancy? How did he/ how did Mother think he would react to the news? 6.58. This is addressed through the following learning point: Learning point 21: Several agencies now employ routine enquiry in relation to domestic abuse. If the case history and/or responses to the enquiry indicate historic domestic abuse, the current risk posed by violent partners/ex-partners should be explored. Quality of assessments and decision-making during the specified period – specifically relating to family engagement? 6.59. During the review period, there were three assessments initiated by children’s social care: 1. In April 2016, a health professional referred the family to social care when concerns about neglect of Sibling 2 were identified in a routine screening undertaken by a school nurse. It would appear that a social worker conducted a home visit and identified no concerns so no further action was taken. 2. In July 2016, there appears to be a referral to social care but it is not clear who made the referral (there is no record in the social care chronology). A family support worker advised the school nurse that they were conducting a single assessment as Mother was finding it difficult to manage Sibling 2’s behaviour. Two weeks later, the family support worker advised the school nurse that she had been unable to see Mother to complete a single assessment, and that Mother had subsequently advised that she no longer wanted it. 3. In September 2016, Mother reported her child missing. When Police attended the address to investigate, she disclosed that Father had assaulted her. This assault was significant enough to trigger a s47 assessment by Children’s Social Care. 6.60. This section will focus on the quality of the assessment in September 2016 triggered by the assault. This is largely because it was the only assessment that was successfully completed, but also because the social work records of the other assessments have not been made available to the independent reviewer. 6.61. There are a number of shortcomings in the assessment. There is a lack of appropriate focus on the voice of the children; does not adequately assess risk to the children; lacks sufficient challenge to Mother’s assertions about the care of her children; and places an inappropriate responsibility on Mother to be solely responsible for safeguarding the children. These points are addressed in more detail below. Voice of the Children 6.62. The children were seen as part of a s47 assessment in September 2016. However, they were not seen alone and incorrectly advised the social worker that they were not at home at the 40 time of the assault. The subsequent Single Assessment noted that the children ‘appeared to have been coached’ in their responses. However, there was no subsequent visit with the children to explore these discrepancies, invite them to comment on the conclusions reached in the assessment or ask them if they agreed with the outcome. 6.63. Kirklees Council Children’s Services procedures stipulate that: The child must always be seen and communicated with alone in the course of a Section 47 Enquiry by the Lead Social Worker, unless it is contrary to his or her interests to do so.xliii 6.64. In the s47 assessment record, the social worker states that the children were spoken to together because of ‘age and cognitive abilities’. It is not clear, but considered likely, that the children were spoken to in the presence of their mother. At the time of the assessment, Sibling 3 was only 2½, and the social worker noted that Sibling 2 was ‘alleged to have ADHD and autism’ and was ‘observed to struggle with verbal interaction’. There is no suggestion of additional support for Sibling 2 to enable him to contribute to the assessment process. Working Together 2018 provides for professionals to ensure that children’s voices are heard and provide appropriate support to enable this to happen where a child has special communication needs.xliv 6.65. The assessment notes that Sibling 1 was six years old and spoke to the social worker. The assessment notes that the children were anxious that the social worker was there to take them into care, and ‘confirmed they were not at home’ during the assault. 6.66. In the Single Assessment record (which was completed after the s47) noted that the children appeared to have been ‘coached’ in their responses to questions. There is no reference in the Single Assessment to Sibling 1’s incorrect assertion that they were not at home when the assault occurred. 6.67. The Single Assessment notes that three home visits were completed as part of the assessment but there is no indication that the children were spoken to more than once. It is disappointing that the Manager’s Decisions concludes that Mother declined social care intervention “which is there [sic] prerogative”, but there does not appear to have been any discussion with the children about what they might want. 6.68. The social worker could have tapped into existing professional networks around the children (i.e. school and health staff) to facilitate a direct conversation with the children without the presence of their mother. Work with children using any of the recognised tools for information gathering (i.e. ‘three houses’) could have elicited more useful information about their daily lived experience than was obtained through an informal, apparently circular and contradictory, conversation with the children in front of their mother. 6.69. This is addressed in the following learning points: Learning point 12: Social workers should challenge parent’s ‘programming’ children’s responses to social workers questions and explore the reasons behind this with parents Learning point 13: Children being ‘programmed’ by their parents should warrant further exploration and social workers should speak directly to the children, without the presence of their parents, to explore their wishes and feelings. 6.70. This analysis has yielded a further learning point: Learning point 30: Children’s Social Care ensure that children subject to social work assessments: are spoken to alone; are given the opportunity to comment on the assessment 41 completed by social workers; and are asked if they agree with the outcome of the assessment. Information gathering 6.71. The assessment had already commenced when information was provided by Leeds social care to indicate that Mother was having more contact with Father than she reported. It would appear that this information did not affect the ongoing assessment being undertaken by social care. Given that information about the incident was shared by two different sources, it is reasonable to assume that the information was received by social care. However, it is not reflected in their chronology or assessment record, so it is unclear how this information was acted upon. 6.72. This is addressed in the following learning point: Learning point 18: social work assessments should respond to new and emerging information, even when new information contradicts what was previously known or believed to be true. Managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information. 6.73. Similarly, the information shared at MARAC would have highlighted that Mother was not supporting police action or engaging with agencies for support. Furthermore, there is no information in the social care chronology or the assessment record to suggest that the social worker discussed improving security in the family home with Mother, which was an action agreed by the MARAC. 6.74. This is addressed in the following learning point: Learning point 19: MARAC provides an opportunity for information regarding the assessment and management of risk to be shared. Agencies in attendance must ensure that information shared at MARAC is appropriately acted upon. Lack of appropriate challenge 6.75. Mother made a number of assertions about her children, and her care of them, that were not challenged during the assessment process. The s47 assessment includes an observation that Mother’s parenting style with Sibling 2 was between authoritarian and authoritative, and different to her approach to other children. Mother reported that this was the strategy she had been given to manage his diagnosis within the Autistic spectrum. It is recognised that the social worker may have been giving Mother the benefit of the doubt regarding his diagnosis, but even if he did have autism and/or ADHD, authoritarian parenting is not an appropriate approach to managing his behaviour. 6.76. This is addressed in: Learning Point 6: An authoritarian parenting style is likely to exacerbate behavioural problems in children 6.77. In October 2016, Mother advised social care that she had put a new arrangement in place for Father’s contact with children to be supervised by a family member and that this appeared to be working well. This was reported to be in response to the domestic incident in September 2016. However, this arrangement for contact to be supervised by a family member (and not Mother) was put in place during the Child in Need plan, which closed in January 2016. As 42 such, it was not a new arrangement and, in either case, would not (and did not) prevent Father from presenting at her address. Mother could have applied for a legal order to prevent him from attending her address (and previously had one) but did not engage with agencies that could assist her to get such an order in place. Assessment of risk 6.78. The s47 and subsequent single assessment conclude that: • Father is still controlling of Mother. • It was likely that Father would want regular contact with his children and if Mother does not comply then this will put her at further risk. • Mother was not truthful in her account of the incident; and • The children were ‘programmed’ in their responses to social worker’s questions. 6.79. Given the presence of these risk factors, and that Mother had declined to support police action or accept support for managing risk associated with domestic abuse, the case warranted further exploration and monitoring from social care. Inappropriate responsibility on Mother to safeguard 6.80. As part of the assessment process, Mother was asked if she thought that Father would ever hurt the children, and she replied that she did not think that he would. This is discussed in section 4.69, and resulted in the following learning point: Learning point 14: coercive control has a detrimental impact on victims and may affect their capacity to assess risk and appropriately safeguard their children. Victims should not be expected to take sole responsibility for keeping their children safe from perpetrators, particularly when perpetrators have parental responsibility for their children. 6.81. It is also important to note that the Department for Education has highlighted that, while victims may be correct in believing that their partner would not physically harm their children, this does not acknowledge the severe emotional harm suffered by the children from living in a household where controlling behaviour is the norm, or the potential risks where a controlling partner does not get their own way.xlv 6.82. This is addressed in the following learning point: Learning point 27: Children’s social care to ensure assessments of risk to children include a thorough exploration of the risk presented by perpetrators of coercive control; and the ongoing, cumulative impact of coercive control on victims and children Contingency Planning 6.83. Kirklees Children’s Services procedures stipulate that Contingency Planning is essential particularly when working with potential crisis situations and as part of Transfer and Closing Summaries, as professionals and families need to be aware when certain situations will lead to major concerns. 43 6.84. This is considered to be particularly relevant in domestic abuse cases. The Department for Education notes that professionals need to acknowledge how difficult it is to achieve change in these contexts, and that ongoing monitoring and support will be needed.xlvi 6.85. This is addressed in: Learning point 7: Consideration should be given to de-escalating to a Team Around the Family plan if low level concerns still need to be addressed when a decision is made to close a Child in Need plan Management oversight 6.86. The decision to offer the family support via child in need appeared to have been reached following the initial assessment home visit, and on the basis that Mother acted appropriately by calling the Police, and that the children were not present. Further information yielded during the assessment process did not appear to affect this early conclusion. 6.87. It is disappointing that management oversight did not highlight where the assessment would have benefited from clarity. Specifically: • there was some discrepancy about whether Mother let Father into the house or he forced his way in. • on the balance of probability, we can conclude that the assault did take place. • Sibling 1 witnessed and was drawn into the abuse of her mother; and • Sibling 2 did not struggle with verbal interaction, as he was observed speaking to his siblings. 6.88. Analytical supervision may also have teased out some of the issues identified above relating to the voice of the child, lack of appropriate challenge, assessment of risk, inappropriate responsibility on Mother to safeguard and contingency planning. 6.89. Crucially, the social worker should have been supported to include Father in the assessment process. Furthermore, persistent attempts to engage Mother in support should have been made. Rather than accept Mother’s assertion that “what else can you offer that I have not already done”, she could have been supported to obtain relevant legal orders to keep Father away from the property; attended a Liberty Programme; attended parenting programmes to assist with managing home conditions and children’s behaviour; and Children’s Emotional Wellbeing Service could have provided some support for Sibling 2. 6.90. The Independent Reviewer is aware that, since the period under review, the Kirklees Children’s 10 Point Improvement Plan refresh: Creating the conditions for success has agreed an action to: • Strengthen appraisal, supervision and management oversight embedding the 3 obsessions of assessment, planning and recording. Observation of supervisions and feedback conversations will ensure opportunities for development and training are identified 6.91. As part of this action, a new supervision policy has been launched and is supported by briefings for managers and new templates have been developed and rolled out across the service. These changes were implemented in 2018 so the effects may not yet be evident in practice, but the service will continue to monitor the implementation through the improvement plan. 44 Was consideration given to whether or not a pre-birth assessment was indicated prior to Child As birth? 6.92. Professionals that attended the practitioner event were clear that, if they had any evidence that Father was father to the unborn, they would have referred the case to children’s social care for an assessment. 6.93. However, despite being routinely asked to identify who the Father of her baby was and if there was any risk of domestic abuse in her relationship, Mother consistently declined to provide details of the father and denied any domestic abuse in her relationship. The reviewer is aware of the difficulties in proceeding with any form of assessment without evidence that Mother had resumed her abusive relationship. However, given the risk involved in domestic abuse cases and the impact of coercive control on victims, perhaps it may be beneficial to consider a different approach to risk assessment in these cases. 6.94. This is addressed in: Learning point 9: Risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their current partner and/or father of their unborn child. This may be indicative of an ongoing, abusive relationship. 7. Concluding remarks 7.1. The independent reviewer is conscious that any review of any case, regardless of the outcome, will reveal areas where professional practice can be improved. It is considered unlikely that that the events described in this report directly caused Child A’s death, or that the improvements identified in this report may have prevented Child A's death. However, child practice safeguarding reviews do provide us with an opportunity to analyse professional practice and use the lessons to improve our response to children. 7.2. In preparing this report, the author has had the luxury of access to records held by a number of agencies, and the opportunity to spend a lot of time discussing this case with professionals that were directly involved with the family, their managers, and members of the KSCP. The level of analysis provided in this report, and the opportunity to reflect on professional practice in line with current research and best practice, is not possible in day to day decision making in the context of competing priorities, pressing deadlines and heavy caseloads. It is important to note that the conclusions drawn in this report are provided with the benefit of hindsight, time to reflect, and with an objective distance from the family and those professionals that were working directly with them. 7.3. The value of this exercise, in reflecting on how one case can highlight important learning across services, is indicative of the value of reflective activities that are built into professional development but not always prioritised amidst increasing volume and demanding caseloads – reflective supervision, training and peer support networks. The independent reviewer found the opportunity to discuss this case with professionals in other agencies invaluable and would hope that future assessments will demonstrate greater multi-agency input to decision making. 7.4. The author of this report also has the luxury of experience focussing exclusively on domestic abuse cases, and a good grasp of coercive control and its impact on victims. Training in this area is increasingly available, but it may also be beneficial to have named, designated officers within agencies who can provide oversight and support in domestic abuse cases. 45 8. References i Nishi Tripathi, 2015 ii Peter Sidebottom et al, 2016 iii Lindsey Hutchinson et al, 2016 iv CAADA, 2014 v Karen Evans, 2018 vi A Jenney, 2012 vii A Jenney, 2012 viii Kirklees Council procedures: written agreements ix Katy Barrow-Grint, 2016 x Katy Barrow-Grint, 2016 xi NSPCC xii Ofsted, 2017 xiii Ananda Hall, 2007 xiv Crown Prosecution Service xv Ofsted, 2017 xvi Ravi K Thiara and Aisha K Gill, 2012 xvii Ofsted, 2017 xviii Triennial SCRs xix CAADA, 2014 xx A Jenney, 2012 xxi Karen Evans, 2018 xxii NSPCC xxiii A Jenney, 2012 xxiv Katz 2016 xxv Peter Sidebottom et al, 2016 xxvi Women’s Aid, 2016 xxvii Katz 2016 xxviii Katz 2016 xxix Women’s Aid, 2016 xxx Rachel Robbins, 2017 xxxi Peter Sidebottom et al, 2016ysis xxxii Cathy Humphreys, Caroline Bradbury-Jones, 2015 xxxiii CAADA, 2014 xxxiv Ravi K Thiara and Aisha K Gill, 2012 xxxv Peter Sidebottom et al, 2016 xxxvi Carolyn Rebecca Block, 2003 xxxvii Ravi K Thiara and Aisha K Gill, 2012 xxxviii NSPCC, 2018 46 xxxix Heather Coady, 2012 xl CAADA, 2014 xli Scourfield, 2006 xlii Ofsted, 2017 xliii Kirklees Children’s Services Procedures: Section 47 enquiries xliv Working Together 2018 xlv Peter Sidebottom et al, 2016 xlvi Peter Sidebottom et al, 2016 9. Bibliography Amanda Hall. (2007) Related Family and Criminal Proceedings A Good Practice Guide. The Law Society. https://www.judiciary.uk/wp-content/uploads/JCO/Documents/FJC/Publications/RelatedFamCrimPro.pdf Angelique Jenney, 2012. The impact of domestic violence on infants and young children. Infant Mental Health Promotion, the Hospital for Sick Children, 2012. http://www.imhpromotion.ca/portals/0/IMHP%20PDFs/Domestic%20Violence%20Brief.pdf CAADA (2014). In plain sight: The evidence from children exposed to domestic abuse. CAADA Research Report, February 2014. http://www.safelives.org.uk/sites/default/files/resources/In_plain_sight_the_evidence_from_children_exposed_to_domestic_abuse.pdf Carolyn Rebecca Block (2003). How Can Practitioners Help an Abused Woman Lower Her Risk of Death? National Institute of Justice Journal Issue No. 250. Accessed from https://www.ncjrs.gov/pdffiles1/jr000250.pdf Cathy Humphreys, Caroline Bradbury-Jones. (2015) Domestic Abuse and Safeguarding Children: Focus, Response and Intervention. Child Abuse Review Vol. 24: 231–234 (2015) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/car.2410 Emma Katz. Beyond the Physical Incident Model: How Children Living with Domestic Violence are Harmed by and Resist Regimes of Coercive Control. Child Abuse Review Vol. 25: 46–59 (2016). Published online 24 November 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/car.2422 Crown Prosecution Service. False Allegations of Rape and/or Domestic Abuse, see: Guidance for Charging Perverting the Course of Justice and Wasting Police Time in Cases involving Allegedly False Allegations of Rape and/or Domestic Abuse. https://www.cps.gov.uk/legal-guidance/false-allegations-rape-andor-domestic-abuse-see-guidance-charging-perverting-course Heather Coady (2012), Parenting in the context of domestic abuse. Parenting across Scotland. http://www.parentingacrossscotland.org/publications/essays-about-parenting/parenting-under-pressure/parenting-in-the-context-of-domestic-abuse/ Karen Evans (2018). I am looking for information regarding trauma and language development in young children. The Informed Speech-Language Pathologists. https://www.theinformedslp.com/qa_trauma.html 1 Katy Barrow-Grint, 2016 Attrition Rates in Domestic Abuse: Time for a Change? An Application of Temporal Sequencing Theory. Policing: A Journal of Policy and Practice, Volume 10, Issue 3, 1 September 2016, Pages 250–263, https://doi.org/10.1093/police/pav054 Kirklees Council, Kirklees Children's Social Care online procedures. 1.2.5 Written Agreements with Families. http://kirkleeschildcare.proceduresonline.com/chapters/p_written_agree_fam.html Lindsey Hutchison, L, Feder, M, Abar, B, Winsler, A (2016). Relations between Parenting Stress, Parenting Style, and Child Executive Functioning for Children with ADHD or Autism. Journal of Child and Family Studies (2016) 25:3644–3656. http://winslerlab.gmu.edu/pubs/HutchisonParStress2016 Nishi Tripathi. Parenting Style and Parents’ Level of Stress having Children with Autistic Spectrum Disorder (CWASD): A Study based on Northern India. Neuropsychiatry (London) (2015). http://www.jneuropsychiatry.org/peer-review/parenting-style-and-parents-level-of-stress-having-children-with-autistic-spectrum-disorder-cwasd-a-study-based-on-north.pdf NSPCC. Domestic abuse: Facts and statistics. Accessed from https://www.nspcc.org.uk/preventing-abuse/child-abuse-and-neglect/domestic-abuse/domestic-abuse-facts-statistics/ NSPCC (2018). Hidden men: learning from case reviews. Accessed from: https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/hidden-men/ Ofsted, Care Quality Commission, HMI Constabulary and Fire & Rescue Services, and HMI Probation (2017): The multi-agency response to children living with domestic abuse – prevent, protect and repair. Ofsted, 19 September 2017. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/680671/JTAI_domestic_abuse_18_Sept_2017.pdf Peter Sidebotham, Marian Brandon, Sue Bailey, Pippa Belderson, Jane Dodsworth, Jo Garstang, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen (2016); Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report. Department for Education, May 2016. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/533826/Triennial_Analysis_of_SCRs_2011-2014_-__Pathways_to_harm_and_protection.pdf Rachel Robbins, Kate Cook; ‘Don’t Even Get Us Started on Social Workers’: Domestic Violence, Social Work and Trust—An Anecdote from Research, The British Journal of Social Work, , bcx125, https://doi.org/10.1093/bjsw/bcx125. Accessed from https://academic.oup.com/bjsw/advance-article/doi/10.1093/bjsw/bcx125/4616221 Ravi K. Thiara and Aisha K. Gill. (2012) Domestic violence, child contact, post-separation violence: Issues for South Asian and African-Caribbean women and children. NSPCC. Accessed from : https://www.nspcc.org.uk/services-and-resources/research-and-resources/pre-2013/domestic-violence-child-contact-post-separation-violence/ Scourfield, J. (2006) The challenge of engaging fathers in the child protection process. Critical Social Policy, special issue on gender and child welfare, 26, 2: 440-449. Accessed from: https://orca.cf.ac.uk/44771/2/Engaging%20fathers%20for%20CSP%20Scourfield.pdf Women’s Aid – Federation Norther Ireland. Coercive Control Consultation Brief. Accessed from: https://www.womensaidni.org/assets/uploads/2016/07/Coercive-control-consultation-brief-FINAL-15-March-2016.pdf 2 Appendix One: Full Terms of Reference A panel representing partner agencies of the Kirklees Safeguarding Children Board identified these terms of reference for a Local Child Safeguarding Practice Review concerning child A (DOB 31/10/2017–Date of death: 01/01/2018). The terms of reference were developed in line with Working Together to Safeguard Children (2015 and 2018), and West Yorkshire Safeguarding Children Procedures, Chapter 10.1 (8.20). Any amendments to these terms of reference as a result of new and emerging information will be agreed by the KSCP Chair. Decision to conduct Local Child Safeguarding Practice Review This case is concerning the death of an almost 9-week-old baby, Child A, who was found lifeless by her father in the parents’ bed. Although at the present time it is suspect that the death was due to overlay the outcome of the post mortem has not yet received. The family are well known to local services and were subject to a Child in Need Plan the previous year. Local Child Safeguarding Practice Learning Event Key issues are to be explored during a full day Practice Learning Event. Senior Managers will be asked to nominate relevant managers and practitioners, to attend. Agencies required to provide representation are as follows: • Children’s Social Care • West Yorkshire Police • North Kirklees Clinical Commissioning Group • Mid Yorkshire Hospital Trust • Locala • South West Yorkshire Partnership Foundation Trust • Community Rehabilitation Company • Kirklees Neighbourhood Housing • School -Orchard Primary Academy In this case, the Practice Learning Event will be made up of the following: • Reviewer • Facilitator / The Local Child Safeguarding Practice Review Coordinator for the KSCP • Practitioners/Managers who worked with the family from the above agencies Aim of Local Child Safeguarding Practice Review This Local Child Safeguarding Practice Review will enable individuals and agencies to learn lessons about the way in which they work both individually and collectively to safeguard and promote the welfare of children. As far as possible, this review will be conducted in such a way that the process is a learning exercise for everyone that has been involved in the case. 3 Determining the scope and terms The review will consider the following people, although others may be included in information gathering if this is considered appropriate: Individual / Relationship Year of birth Mother 1993 Father 1991 Sibling 1 2010 Sibling 2 2011 Sibling 3 2014 The Local Child Safeguarding Practice Review should be conducted in a way that: • Recognises the complex circumstances in which professionals work together to safeguard children. • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. • Is transparent about the way data is collected and analysed; and • Makes use of relevant research and case evidence to inform the findings • Considers how and what contribution may be sought from family members in respect of service delivery. • Specifically considers ethnicity, religion, diversity or equalities issues that may be required; and • Is able to develop a multi-agency action plan in light of the findings. Specific Issues to be considered The key themes for learning have been identified under six broad headings as follows: • The quality of assessments and decision-making during your involvement with the family during the specified period – specifically relating to family engagement? • Was the family history given appropriate consideration during decision-making? • Is your service responsible for assessing home conditions and does this include routine checking of the bedrooms? • To what extent was your agency aware of the history of neglect of the children and domestic abuse within this family? • Was there any evidence of ongoing neglect or domestic abuse within the family e.g. children not being taken to school and/or appointments? • Was consideration given to whether or not a pre-birth assessment was indicated prior to Child A’s birth? 4 Some of these issues may be revisited by the Child Safeguarding Practice Workstream as the review progresses and new information emerges. Timescale to be considered for the Review The timeframe identified for the purposes of collating detailed information covers the period from 01.01.16 to 01.01.18 (changed from 01.01.17 to 01.01.16) Agencies are expected to provide a chronology and analysis of significant events between these dates. They will also be required to review records and provide a summary of significant interventions prior to 01.01.16. Family Involvement Family members will be given the opportunity to contribute to the Local Child Safeguarding Practice Review process by considering the services and support provided by various agencies and whether this was appropriate to their needs. Family members may also be asked to comment on issues associated with the publication of the full overview report. It is recognised that contacts with family members should be handled sensitively and, where possible, via a professional already known to the family. Review Process The review is to be carried out using a systems methodology process, which involves frontline practitioners who worked with the family. Each of the agencies known to have had involvement with the family will be required to identify both practitioner and manager representatives to attend and participate in a full day Practice Learning Event. Agencies to Contribute Agencies have confirmed knowledge of key personnel and have provided information via a combination of the following: • A summary of historical interventions. • A chronology of significant events occurring within the identified timeframe; and • An analysis of key decisions made. The following agencies have provided information, but are not at this stage considered as likely to be able to add anything further to the learning from this Local Child Safeguarding Practice Review: Pennine Domestic Violence Group The Child Safeguarding Practice Review Workstream may require information from other sources as its work progresses. Timescale for Completing the Local Child Safeguarding Practice Review It is the aim of the Child Safeguarding Practice Review Workstream to undertake the review over a three-month period from the date of the appointment of a Reviewer. The author/reviewer will provide progress reports to the Child Safeguarding Practice Review Workstream; and the KSCP business unit will update the Department for Education, Ofsted and the National Panel of Independent Experts as appropriate. Staff Affected by the Review The Child Safeguarding Practice Review Workstream acknowledges the potential for the process to cause distress for some practitioners. Guidance will be provided to those involved explaining the process and its purpose, and the SCR Coordinator will liaise with any agency where difficulties arise. 5 Role of the Reviewer The Reviewer is to be an individual with relevant experience and expertise that is independent of all local agencies and professionals involved in the Local Child Safeguarding Practice Review, the Child Safeguarding Practice Review Workstream and the Kirklees Safeguarding Children Board. Outside Experts The Child Safeguarding Practice Review Workstream will consider if any aspect of the review requires expert advice to assist with understanding crucial aspects of the case and commission independent professionals as required. Parallel Investigations, Other Reviews, Coroner’s Inquiry and Criminal Investigations The review will ensure that findings from other relevant processes are incorporated into the Local Child Safeguarding Practice Review report. The panel will consider the impact of such processes on timescales for completing the review. Should the case give rise to other parallel investigations of practice, the Child Safeguarding Practice Review Workstream will liaise with the appropriate agencies to develop a coordinated review process to ensure the timely sharing of information. The Child Safeguarding Practice Review Workstream will liaise with relevant agencies to consider these terms of reference in light of other similar types of review, including internal agency reviews, to enable timely sharing of information. The Child Safeguarding Practice Review Workstream will liaise with relevant officers undertaking any criminal investigations to ensure that relevant information can be shared without compromising any aspect of a criminal or coronial process and/or incurring significant delay in the review process. Relevant Research The Local Child Safeguarding Practice Review will consider relevant research, including lessons from Local Child Safeguarding Practice Review’s previously undertaken in the area, and the implications for this Local Child Safeguarding Practice Review. Publication of Reports and Media Interest The completed reports will be submitted to the Kirklees Safeguarding Children Board for their oversight and agreement. Following this, and in accordance with Working Together 2018, the Local Child Safeguarding Practice Review and Action Plan will be provided to the National Panel of Independent Experts 7 working days in advance of publication. The presumption in Working Together 2018 is that all reports will be published. It states that Local Child Safeguarding Practice Review reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case; however, it also states that LSCBs should have regard to the advice of the National Panel when considering publication. Reports will be published on the KSCP website. Names and other identifying elements will be removed in the interests of maintaining anonymity. Kirklees Safeguarding Children Board legal advisers, acting as advisors to the Child Safeguarding Practice Review Workstream, will undertake scrutiny of the Review and Action Plan prior to publication to ensure no contravention of Human Rights legislation or relevant Court Orders pertaining to the case The Child Safeguarding Practice Review Workstream will consult with media contacts in relevant agencies to develop an appropriate media strategy for this Local Child Safeguarding Practice Review if it becomes necessary. 6 Appendix Three: List of Learning Points The Kirklees Safeguarding Children Board will be responsible for ensuring that the learning points identified in this report are translated into tangible improvements in services for children. A list of all learning points identified in this report are provided below to assist this work. Learning Point 1: If children have recently moved schools, the previous school should be invited to multi-agency discussions around safeguarding children. Learning Point 2: Relevant housing providers should be routinely invited to multi-agency discussions around safeguarding children. Learning Point 3: Consideration should be given to de-escalating to a Team Around the Family plan if low level concerns still need to be addressed when a decision is made to close a Child in Need plan Learning Point 4: Children’s social care should explore how their expectations around child contact should be communicated to parents and professionals. This should include clear consequences for failure to adhere to agreed contact arrangements, recommendations for professionals in other agencies to record/flag the arrangements for supervised contact; and a clear process for reporting breaches to agreed contact arrangements. Learning Point 5: Some parents may be intent on securing a medical diagnosis for a child’s behavioural problems and consequently ignore advice from professionals about behaviour management. A consistent, multi-agency response should be given to parents in these cases to ensure that children receive an appropriate, authoritative parenting approach. Learning Point 6: An authoritarian parenting style is likely to exacerbate behavioural problems in children Learning Point 7: Exposure to domestic abuse may cause behavioural and emotional problems in children. Professionals should clear about the research that supports this and evidence the work done with parents to increase their understanding of the impact of Learning Point 8: ‘ASK CAMHS’, the initial point of contact for those who have concerns about a child or young person’s emotional or mental health, should assist professionals in in providing clear, consistent advice to parents about obtaining appropriate support for children Learning Point 9: Risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their current partner and/or father of their unborn child. This may be indicative of an ongoing, abusive relationship. Learning Point 10: Professionals should advise parents of any concerns regarding their children and/or gain parents’ consent for someone from children’s social care to contact and offer support (unless doing so would put the child at risk) Learning Point 11: Victims may retract statements or disclosures regarding domestic abuse. The reasons for this are varied and complex, but fear of the consequence of disclosure and ongoing feelings for the perpetrator are likely to be contributory factors. Retractions should not be seen as evidence that abuse has not occurred 7 and may be indicative of ongoing contact between the victim, the perpetrator and their children. Learning Point 12: Social workers should challenge parent’s ‘programming’ children’s responses to social workers questions and explore the reasons behind this with parents Learning Point 13: Children being ‘programmed’ by their parents should warrant further exploration and social workers should speak directly to the children, without the presence of their parents, to explore their wishes and feelings. Learning Point 14: Coercive control has a detrimental impact on victims and may affect their capacity to assess risk and appropriately safeguard their children. Victims should not be expected to take sole responsibility for keeping their children safe from perpetrators, particularly when perpetrators have parental responsibility for their children. Learning Point 15: Social care should not use the police evidential test as a basis for determining whether or not an assault took place. Learning Point 16: Professionals should be mindful that an initial report of domestic abuse is likely to be accurate, and subsequent retractions are likely to be false Learning Point 17: Perpetrators of domestic abuse, particularly those with parental responsibility for their children, should be directly spoken to about the impact of their abusive behaviour children and included in the assessment process/safety plan for children Learning Point 18: Social work assessments should respond to new and emerging information, even when new information contradicts what was previously known or believed to be true. Managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information. Learning Point 19: MARAC provides an opportunity for information regarding the assessment and management of risk to be shared. Agencies in attendance must ensure that information shared at MARAC is appropriately acted upon. Learning Point 20: The use of a visual home conditions assessment tool may be useful to enable professionals to share a collective, objective understanding of what constitutes acceptable home conditions Learning Point 21: Children’s Social Care assessments should consider the history of the case and ensure that any historical concerns i.e. home conditions, suitable sleeping arrangements for children etc are explored during any re-assessment process Learning Point 22: Several agencies now employ routine enquiry in relation to domestic abuse. If the case history and/or responses to the enquiry indicate historic domestic abuse, the current risk posed by violent partners/ex-partners should be explored. Learning Point 23: How can we improve the offer of support to pregnant women who are struggling to cope but keep agencies at arm’s length? Learning Point 24: MYHT may wish to explore electronic and/or duplicate copies of mothers’ maternity notes Learning Point 25: Police should consider how to ensure responding officers check on the safety and welfare of children when they are called to an incident 8 Learning Point 26: Police to explore what information/history can be shared with responding officers before they attend an incident Learning Point 27: Children’s social care to ensure assessments of risk to children include a thorough exploration of the risk presented by perpetrators of coercive control; and the ongoing, cumulative impact of coercive control on victims and children Learning Point 28: Key frontline professionals should continue to assess risk, and provide support for victims and children, post-separation in recognition of the increased risk posed by perpetrators during this period Learning Point 29: Written agreements are not effective tools for managing risk and their use should be avoided. Where considered necessary, written agreements should, at a minimum, be clear about the duration that they are in force; the ways in which agreement will be monitored; and the consequence of breaking the agreement. Any written agreement should be shared with all parties with parental responsibility and shared with universal services that are likely to remain in contact with the family after children’s social care withdrawn their intervention Learning Point 30: in light of historic concerns regarding suitable sleeping arrangements for children, all agencies should consider how they can support families to ensure that children have appropriate sleeping arrangements in place. Learning Point 31: Children’s Social Care ensure that children subject to social work assessments: are spoken to alone; are given the opportunity to comment on the assessment completed by social workers; and are asked if they agree with the outcome of the assessment.. |
NC52463 | Non-accidental injury to an infant boy in 2019 including eye injury, cracked ribs, and a fractured leg. Learning includes: a need to assess the impact of parental mental health on parenting capacity; a need to identify potential safeguarding concerns to a new-born baby following a family dispute; a need for information held on early help systems to be held on childrens social care systems; a need for a pre-birth assessment by childrens social care which could have informed part of the court proceedings; and a need to ensure GDPR guidelines are correctly applied by childrens social care. Recommendations include: information sharing policy, between the multi-agency safeguarding hub (MASH) and partners, should not allow GDPR to act as a barrier to sharing information when there are safeguarding concerns; the quality of recording and decision making based on effective triage in the MASH needs to continue to be improved and monitored for consistency so that information, risks and vulnerabilities can be connected; the sharing of information between early help and children social care systems needs to be strengthened so that there is a stronger interface between them; there needs to be assurance, from childrens services and midwifery, that the threshold for initiating the pre-birth protocol is being applied appropriately; and any agency that identifies that parental mental health needs are impacting on parenting capacity needs to share that with other partner agencies working with the family so that information can be triangulated and an appropriate response agreed.
| Title: Child Dominik: practice learning review. LSCB: Tameside Safeguarding Children Partnership Author: Tameside Safeguarding Children Partnership Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. December 2022 1 of 12 Child Dominik Practice Learning Review December 2022 2 of 12 The Incident In the summer of 2019 Dominik was taken by his Mother to the GP for his immunisations and the medical practitioner noticed a haemorrhage on their eye. The medical practitioner was concerned due to the fact that the mother could not give any suitable explanation as to how it occurred. The mother had suggested that the baby had rolled onto his dummy but at 10 weeks old this would not be possible and a dummy would not create such an injury. A referral was put through for a Child Protection Medical and the child was later admitted to Tameside and Glossop Hospital. Dominik had a skeletal scan that showed 3 broken ribs and also a fracture to the top of right tibia. The Doctor performing the medical stated that these injuries were non-accidental injuries. The likely cause of the broken ribs were either being squeezed or held too tight and the tibia fracture was likely as a result of a twist of some description. The Doctor estimated the rib breaks being caused within 1 – 3 weeks and the tibia break being within 2 weeks. Dominik has no apparent bone deficiencies or medical issues that would go some way to explaining the cause of the breaks. Tameside Safeguarding Children Partnership was notified of the serious incident and in accordance with statutory guidance under ‘Working Together to Safeguard Children’ 2018 convened a Rapid Review meeting. Members of the Rapid Review Panel all agreed that the criteria for a Local Child Safeguarding Practice Review was met. Statutory partners in Tameside along with the National Panel subsequently agreed with the recommendation. The Review The objective of this review is to establish the learning from the local child safeguarding practice review and consider what needs to change to improve future safeguarding practice. Tameside used a case discussion tool piloted by Salford Safeguarding Children Partnership as their methodology for the review. Salford’s Head of Quality Assurance and Safeguarding kindly agreed to facilitate a learning review with senior representatives of all relevant partner agencies which are listed in the table below. In preparation for the learning review a combined chronology of all relevant agency involvement had been compiled and all agencies had submitted single agency summaries of their involvement with the family. Both of these were shared with panel members in advance of the learning review. An overview of the single agency information and involvement is provided below. Post Agency 1. Service Unit Manager for Child Protection and Child in Need Tameside Children’s Social Care, Children’s Services 2. Improvement Manager CAFCASS 3. Detective Constable Investigations and Safeguarding Review Unit, Greater Manchester Police 4. Safeguarding Specialist Nurse Tameside Pennine Care Foundation Trust 5. Lead Designated Nurse Safeguarding Tameside and Glossop Clinical Commissioning Group December 2022 3 of 12 6. Designated Doctor Tameside and Glossop Clinical Commissioning Group 7. Designated Nurse for Looked After Children (LAC) Tameside and Glossop Clinical Commissioning Group 8. Specialist Children’s Safeguarding Advisor Tameside General Hospital 9. Head of Service – Early Help Tameside Families Together, Children’s Services 10. Service Manager – Early Help Tameside Families Together, Children’s Service 11. Modern Matron/Named Midwife Safeguarding Manchester Foundation Trust 12. Performance Improvement Manager Tameside Children’s Social Care, Children’s Services 13. Senior Solicitor Childcare Tameside Legal Services At the time of writing this report it has not been possible to involve either of Dominik’s parents due to an ongoing criminal investigation. A case reviewer met with the father and mother of this review and shared the final report with the family since criminal proceedings were completed. The father of the review has stated that the family wish to make no further comment and are happy for the review to be published. Agency Involvement and Information CAFCASS Single Agency Summary completed by Improvement Manager Dominik’s older sibling, referred to herein as Daw, had lived with their maternal grandmother since September 2018 when they would have been 10 months old. This was initially an informal arrangement but became a formal child arrangement order granted by the court in early 2019 and with the consent of Daw’s Mother and maternal grandparents. CAFCASS were involved with the family from late 2018 following the application for a Child Arrangement Order. Their intervention was limited to the service provided by Work to First Hearing (WTFH) and as part of that intervention CAFCASS are directed to conduct initial safeguarding checks with the relevant Local Authorities and the Police National Computer; and, where possible, to conduct telephone risk identification interviews with the adult parties. Work to First Hearing (WTFH) does not require any direct contact with the child or children subject to the application. CAFCASS completed telephone interviews with Daw’s Mother and Maternal Grandparents. Contact details were not available for Daw’s Father but CAFCASS did advise the Court to consider a Department for Work and Pensions enquiry to locate him. Information from Tameside Children’s Services, provided by telephone in November 2018, advised of one referral on 06/08/2018 from Daw’s maternal great grandmother regarding his weight. Health Visitors had reviewed this, no concerns were identified and the family were referred to Home- Start. During that sharing of information the Family Court Advisor was advised that Tameside Children’s Services were aware of the unborn child. The Family Court Advisor spoke to the mother alone to ensure confidentiality and to allow her the opportunity to express her views without the risk of compromise. During her interview she advised that she was five months pregnant, suffered from severe anxiety which was heightened December 2022 4 of 12 during pregnancy, high blood pressure and dizziness. She considered that these factors impacted upon her ability to care for her Son. He had lived with his grandparents since September 2018, her view was that Daw should continue to live with his grandparents and return to her and her partners care after she gave birth. The mother was able to exercise Parental Responsibility, was spending significant time with her Son, was actively engaged in his care and attended medical appointments. Daw’s maternal grandparents indicated that they wanted to support Daw and his mother, but it was difficult for them to envisage him being able to return to his mother’s care immediately after she gave birth. Further safeguarding checks with Manchester Children’s Services revealed that the family were not known to them. Additional information from Tameside Children’s Services was provided to CAFCASS stating that in August 2018 Daw was having contact with a registered sex offender. The outcome was to present the case to the Early Help Panel for support who agreed a referral to Home- Start. In February 2019 Daw’s Maternal Grandparents attended the final court hearing. Neither of Daw’s parents were present and the Mothers contact with Daw was reported to have reduced and his grandparents advised that her mental health was unstable. The court found in favour of a Child Arrangement Order (CAO) -live with as the final outcome. CAFCASS advised Tameside Children’s Services that the court had granted a Child Arrangement Order (CAO) -Live with in favour of Daw’s maternal grandparents due to his mother’s poor mental health. Tameside Children’s Services indicated that they were unaware of this and had no knowledge of the unborn child. Accordingly, a Multi- Agency referral was made to Tameside Children’s Services advising that Daw was living with his grandparents due to his mother’s poor mental health impacting upon her ability to care for him. Concerns were shared regarding her ability to care for the unborn child. The referral suggested that a pre-birth assessment be considered. In March 2019 Tameside Children’s Services advised that a pre-birth assessment would be undertaken, later that day CAFCASS were informed that further enquiries had been made, the initial decision had been reversed and there would be no further action. Children’s Social Care Single Agency Summary completed by Service Manager for Child Protection and Children in Need Children’s Social Cares first contact with the family was in August 2018 due to the Great Grandmother of Daw contacting the Local Authority stating that he was not appropriately cared for by his Mother. Screening checks were undertaken by the Local Authority. The Police had visited and raised no concerns a few days prior and also the Health Visitor reported completing a health check which again raised no issues or concerns. The matter was closed at this point. A few days later a police referral was received and raised concerns that a known sex offender was potentially having contact with Daw. Daw’s mother gave assurance that the individual had no sole care or unsupervised contact. Daw was observed by the Social Worker to be well presented and raised no concerns. The Mother agreed to support from Early Help Services. The Early Help Panel referred the family to Home-Start in August 2018. Between August and October they made several attempts to contact and engage the Mother without success of consistent engagement and subsequently referred the case back to the Early Help Panel in October. December 2022 5 of 12 In September 2018 the maternal grandmother of Daw contacted Children’s Social Care regarding his welfare. She reported she had care of Daw for the previous 9 days and had been informed by the G.P. he was underweight. Records do not indicate what was done with this information or whether it was shared with Early Help Services. The Early Help Panel, held in October 2018, indicates that the family had refused Home-Start but the Panel note and action the concerns relating to Mum’s mental health, the fact that she was pregnant and already has a 1 year old and appears to be moving around. It was agreed that Health would see if Mum was accessing Midwifery and if the 1 year old had attended his 12 month check-up. It was noted by the Early Help Panel the following week that Health had not got access to the family on 3 previous occasions that month. The mother, maternal grandmother and child were subsequently seen and there were no immediate concerns. According to the Early Help Panel records for the case remained open to Home-Start and they were advised to escalate if the risk escalated. However, Home-Start involvement ceased at this point and their records indicate that Tameside Families Together would pick up the case, thereby contradicting the Early Help Panel records. No closure form was completed by Home- Start. Children’s Social Care recorded the request for information from CAFCASS in January 2019 and indicated the information is provided at this point. However, CAFCASS records highlight a telephone conversation with Tameside Children’s Social Care in November 2019 where this information was shared. This telephone conversation and subsequent sharing of information is not recorded by Children’s Social Care. Children’s Social Care recorded that in February 2019 maternal grandparents have made a private law application to the court for a Child Arrangement Order due to mother’s poor mental health and inability to care for him. This was highlighted as a concern in respect of whether she will be able to care for the unborn baby once it arrives and CAFCASS advised that a pre-birth assessment was needed. Support was offered from the mental health midwife and the contact was closed to universal service. No pre-birth assessment was completed. Manchester University NHS Foundation Trust Single Agency Summary completed by Head of Nursing & Named Midwife Safeguarding Dominik’s mother booked for care in October 2018 at 12 weeks gestation. She disclosed current anxiety and previous overdose aged 16 years, due to emotional abuse from her own mother, with whom she said she now had limited contact with. A referral was made to the specialist midwives for Mental Health support with consent. The mother attended the specialist Perinatal Mental Health Clinic in December 2018. She disclosed that her anxiety had increased and she was having daily panic attacks. She said she was worried about being able to look after her Son whilst it was happening and that she was currently living with her mother for support. She also states that she is receiving daily on-line therapy for support but would prefer face to face. A referral to Healthy Minds, Tameside for Talking Therapy was made. In February 2019 the Safeguarding Midwives received a phone call from Tameside Children’s Social Care to inform them that CAFCASS were seeking a Special Guardianship Order on behalf of maternal grandparents due to their concerns regarding mother’s mental and health and her care of Daw. December 2022 6 of 12 The Specialist Midwife for Mental Health was contacted in March 2019 by Children’s Social Care to inform them they believed there were no significant risks to Daw or the unborn child and that a pre-birth assessment was not required. A few days later in April the Safeguarding Midwives telephoned Children’s Social Care as they were concerned that the plan had gone from a CAFA/pre-birth assessment to case closure and to confirm what the extent of the Multi-Agency Safeguarding Hub (MASH) enquiry had been. They were informed that the information could not be shared due to GDPR regulations, despite there being potential concerns about the welfare of a child. The Safeguarding Midwives said they would re-refer and escalate if there were any further concerns. No re-referral or escalation was made by the Safeguarding Midwives. Tameside General Hospital (Health Visiting) Single Agency Summary completed by Specialist Children’s Safeguarding Advisor Dominik was open to the health visiting service from birth until he was removed and placed into foster care. Contact was in line with the visiting schedule as per The Healthy Child Programme. At the new birth visit the Mother’s mental health was discussed and she disclosed that she was on anti-depressant medication. As a result a follow up contact was completed where she informed the Health Visitor that her intention was for her older son to return to the family home and that he was currently living with Grandparents. Further explanation for this was not explored at this visit. Positive interaction was noted between the Mother and Dominik and the Mother is described as being affectionate. The next scheduled visit took place at 6-8 weeks and showed Dominik was delayed in 2 of the 5 areas assessed, in the areas of communication and personal social. During this visit it was noted that the Father was giving cuddles to Dominik. The Mother reported she was under stress due to her older child still being with Grandparents. The Mother’s mood and mental health was assessed using the recognised tool, PHQ-4. She scored 1 suggesting her mood and mental health was manageable and under control. The health visitor offered advice to parents on how they could address this ongoing issue and encouraged them to access specialist advice via a solicitor. Parents did attend an appointment with Royal Manchester Children’s Hospital regarding a review of Dominik’s spine. They responded appropriately in ensuring his needs were met. A further visit was undertaken to review Dominik’s development due to previous identification of his delay in two areas. His development was noted to be age appropriate and no longer a concern. The Mother was observed to handle Dominik with affection and to be speaking to him. The Mother’s mental health and wellbeing was discussed again and the Health Visitor checked she was still on her medication. There were some concerns noted regarding Dominik’s weight. This was followed up appropriately by the Health Visitor to ensure Dominik was not at risk of failing to thrive. Pennine Care NHS Foundation Trust Single Agency Summary completed by Safeguarding Families Specialist Nurse Healthy Minds received a referral from the Mother’s G.P. and completed an ‘Opt In’ suitability assessment over the phone in May 2018. Following case supervision it was agreed that she would be put forward for low intensity Cognitive Behaviour Therapy (CBT) treatment as perinatal priority. This would take the form of 1-1 treatment appointments, conducted over the phone and was December 2022 7 of 12 scheduled for June 2018. The mother did not attend/answer the first telephone treatment appointment. She was therefore discharged as per service policy and a letter was sent to her G.P. advising of discharge. In December 2018 a further ‘Opt in’ suitability assessment was conducted following a referral from the Health Visitor. The referral outlined concerns regarding the Mother’s anxiety and low mood and she was 16 weeks pregnant with her second child at this point. The Mother shared that Daw was living with her Mum due to her poor health – she was suffering with pre-eclampsia. No risks were identified or disclosed in relation to self, risk from and to others, neglect and safeguarding. She noted that her partner, and father, to new born was ‘away for much of the time’. The Mother was offered the option of the Post-Natal Well Being Group, however she declined this as she felt unable to attend due to her poor health at that point. She expressed a wish to engage in the computer based treatment ACT (Acceptance and Commitment Therapy – a self-help programme intended to help with anxiety management techniques) as she could do this from home. In January 2019 the mother indicated that she had found the programme OK, and that she had completed the first two modules but that she would like to access 1-1 support now instead of the computerised programme. She was added to the list and offered a short notice appointment which she accepted. She missed the first and second appointment and was therefore discharged from the service in line with the services policy. A discharge letter was sent to the G.P. Greater Manchester Police Single Agency Summary completed by a Detective Constable Greater Manchester Police recorded a standard risk domestic incident between the Mother and her Mother in 2011. Another incident is recorded in 2013 with the Mother saying that her Mother is constantly calling her names and putting her down, this is again mentioned in a report from Dominik’s Mother in August 2018. In an incident in 2016 with her then partner’s family she advises the Police that she suffers with anxiety and panic attacks and states it stems from an abusive family life which is why she has moved to this address. There are 3 family disputes recorded as incidents by Greater Manchester Police in 2018 which relate to the quality and suitability of the mother’s parenting being questioned. 2 of these incidents are reported in August 2018 in a day of each other. One of the incidents is from Dominik’s mother indicating that she is worried that her mother is going to apply for a court order to take Daw away from her. The other is from Daws great grandmother alleging that Daw is being allowed to have contact with a registered sex offender. A family dispute in also recorded in April 2019 when Daws mother and partner have gone to her Mother’s house, where Daw, is residing under the child arrangement order, to try to get her Son back. Daw’s mother was ‘thrown out of the house’ by her stepfather and she is then refused entry. The log notes that the order was put in place to keep her son safe from her ex-partner while she was recovering from illness after pregnancy and the family have been told by CAFCASS that Mother's mental health has to be assessed first and then consideration can be given to handing the child back. The incident was closed with the appropriate Domestic Abuse closing code and a PPI (record) created, and a Domestic Abuse, Stalking and Honour Based Violence (DASH) assessment completed that was finalised as a standard risk. The PPI (record) details that Daws mother has just had a 2nd child with her current partner and the child is days old. Advice was given to both parties regarding further contact and it was advised this should be arranged through solicitors. There was no onward referral to any partner agency at this point and the case was closed December 2022 8 of 12 Manchester Women’s Aid Single Agency Summary completed by Senior Advocate A referral was made to Manchester Women’s Aid in 2017 by the Midwifery Service at University Hospital South Manchester when the Mother was pregnant with her first child. The Mother had disclosed emotional abuse perpetrated by her mother and step father, with whom she was residing. Upon assessment the Mother disclosed that she had suffered ‘mainly emotional abuse’ perpetrated by her mother her whole life. She agreed to 3 sessions of Living Life to the Full (LLTTF) whilst waiting for counselling. She attended the first appointment but no others and, after further attempts to contact her, the case was closed. She does not seem to have engaged with Manchester Women’s Aid counselling service. Analysis Tree: Cause and Effect- factors that may have influenced the incident and individual or / and agency practice Focal Point The focal point in this case was the non-accidental injuries to the child. They include an eye injury, cracked ribs, and a fractured leg. Cause & Effect Cause Effect The Mother was discharged from mental health service provision due to non-attendance at appointments The mothers mental health was reported to have deteriorated at the final court hearing but this had not been assessed at the time The impact of the mothers mental health on her parenting capacity was not assessed GMP did not identify potential safeguarding concerns to a new born baby following a family dispute A referral was not made to Children’s Social Care and there was subsequently no assessment of needs, risks and vulnerabilities Children’s Social Care did not record information about the Mother being pregnant at the time that it was reported to them by CAFCASS Children’s Social Care did not connect information that was freely disclosed by Dominik’s Mother which was that she did not feel, at that time, that she could care for her 1st born child due to her anxiety to any potential risk to an unborn child The pre-birth protocol was not triggered Information held on Early Help systems was not held on Children’s Social Care systems Children’s Social Care were not immediately aware that the mother was pregnant with a 2nd child and that her 1st child was living with her mother due to her mental health difficulties The pre-birth protocol was not triggered It was deemed appropriate for the case to be managed at an Early Help level rather than it potentially being escalated to Child in Need or Child Protection A pre-birth assessment was not undertaken by Children’s Social Care which could have informed part of the court Health providers were not asked to share information about the family Health providers were unaware of the application for a Child Arrangement Order December 2022 9 of 12 proceedings (Work to 1st hearing) Had Health Providers known an application had been made for a court order they might have sought to explore the impact of the mothers mental health on her parenting capacity in more depth An enhanced package of maternity support was not deemed to be necessary and was not offered GDPR guidelines were incorrectly applied by Children’s Social Care Safeguarding Midwives did not feel able to escalate their concerns once they were alerted to the court order because they could not find out what enquiries had already been undertaken by Children’s Social Care. The pre-birth protocol was not triggered The Safeguarding Team at St Mary’s do not have an Information Sharing Agreement with Child Health Information Department/teams’ at Tameside, Stockport and Bolton Safeguarding Midwives at St Mary’s were told they were unable to share their safeguarding concerns with the Child Health Department The Health Visiting Team at Tameside were unaware of the safeguarding concerns The pre-birth protocol was not triggered What are we worried about? At the point that CAFCASS first made contact with Children’s Social Care the recording of information on Children’s Social Care Systems was not robust enough and meant that important connections that might have triggered the pre-birth protocol were not made. The consistency of recording in Children’s Social Care is still a risk due to pressures of the current system and workload. Health checks are limited due to some health providers still keeping paper records. There is no Mental Health representative in the Multi-Agency Safeguarding Hub (MASH) and although there is a virtual link, and information is accessible, the current set up is not as effective as it could be if there was co-location. The pre-birth protocol was not applied in this case and could have been at two different points. It wasn’t applied early on in the case because Children Social Care didn’t record and connect all of the information that CAFCASS had provided. It wasn’t applied when it was later requested by CAFCASS because Children Social Care made enquiries with Midwifery Services and judged there to be no immediate risk because a specialist midwife was providing support in relation to the Mothers mental health needs. Midwifery Services asked Children’s Social Care why a pre-birth assessment was not being completed but did not escalate the case any further in line with the Greater Manchester procedures due to the fact that they had no safeguarding concerns themselves. In the absence of a pre-birth assessment professionals could still have explored the reasons why Daw was living with his Grandparents instead of his parents. This could have resulted in an enhanced offer of support from professionals. Information reported to, and recorded by, Greater Manchester Police in April 2019 was not shared with Children’s Social Care. Had a referral been made to partners, including December 2022 10 of 12 Children’s Social Care and Health providers, the living arrangements for a 17 month old child, the mother’s mental health issues and the potential impact of those on her parenting capacity could have been explored. Information sharing between 2 parts of the same system, early help and children’s social care, are not fully joined up and means that important information can be held by Early Help that Children’s Social Care don’t know about unless the case is escalated. Early Help Services were unable to engage with the Mother and no assessment was ever completed. Although the initial concerns still remained and they discovered that the Mother was pregnant with a second child the case was closed rather than escalated to Children’s Social Care as per the advice from the Early Help Panel. The decision to close the case was not known or recorded by the Early Help Panel. GDPR is still being seen, and used, as a barrier to sharing information even when there are safeguarding concerns. The Safeguarding Team at St Mary’s do not have an Information Sharing Agreement with Child Health Information Department/teams’ at Tameside, Stockport and Bolton. There is no free legal advice or support available to parents or carers after a court order has been granted. In this case the Mother had the right to go back to court at any point and ask for her child back. However, it does not appear that the Mother understood her rights or how to exercise her parental responsibility. What has worked well? The G.P. who picked up on the haemorrhage to the eye during a routine appointment and, following an unsatisfactory explanation from the Mother, requested a full section 47 medical assessment did a fantastic job. The G.P. had attended a safeguarding briefing the day before and it was felt that regular safeguarding updates help practitioners to stay up to date with current issues and alert to the signs of abuse and procedures to follow. The safeguarding procedures and practice that followed from that initial request for a medical examination are a good demonstration of the child protection system and services working well together and they did protect the child from further harm. All reported incidents up to and including 2018 are appropriately followed up by GMP before being closed. The correct procedure was followed in relation to the child sex offender disclosure scheme and the correct referral was made to partner agencies regarding the concerns expressed for Daw, with an immediate welfare check being carried out. When Children’s Social Care received an anonymous referral claiming that the Mother was allowing a known sex offender to have contact with her child they asked her to attend a meeting at the Children Social Care offices. This meant that the Social Worker could properly explain the potential risks and determine whether the Mother was providing December 2022 11 of 12 adequate care and supervision for Daw. The Mother explained that her child did not have unsupervised contact with the person in question and the Social Worker was satisfied with her response. This showed a good degree of professional curiosity and also allowed the Social Worker an opportunity to see Daw and to observe the Mother’s interactions with her Son. The fact that the case came into the Early Help Panel and wasn’t just NFA’d (closed – no further action) by Children’s Social Care was a good decision based on the presenting information at that time. The case was then appropriately allocated to an Early Help Service and that service brought it back to the Early Help Panel after they couldn’t engage with the Mother. The Early Help Panel maintained good oversight of the case, put in place appropriate checks and advised that it be escalated back up to Children’s Social Care if risks escalated. There are some good systems already in place that just need tweaking to make them work better. For example the addition of an Early Help Module to ICS will mean the Early Help and Children Social Care parts of the system are joined up. The Midwifery Service were tenacious in referring to Mental Health services, they followed up on issues across border and asked questions. Learning from this case has already been identified by individual services in the single agency summaries that have been submitted in preparation for the Learning Event. That shows transparency, critical analysis and a willingness to learn and improve. Recommendations 1. The Information sharing policy between the Multi-Agency Safeguarding Hub (MASH) and partners should not allow GDPR to act as a barrier to sharing information when there are safeguarding concerns. 2. The 7 minute briefing on Information Sharing should be revised and re-circulated to all partner agencies to reflect any changes to information policies and to remind them of the escalation policy when there is professional disagreement. 3. The quality of recording and decision making based on effective triage in the MASH needs to continue to be improved and monitored for consistency so that information, risks and vulnerabilities can be connected 4. The Early Help Panel should demonstrate how actions agreed at the panel are communicated to individual case managers. They should also provide assurance that actions/decisions are re-visited by the Early Help Panel, closed with a clear rationale and signed off so that there is no opportunity for those actions to drift or for cases to be closed without their knowledge. 5. The sharing of information between Early Help and Children Social Care systems needs to be strengthened so that there is a stronger interface between them. This will enable both services to make decisions regarding the appropriate application of thresholds based on the same information. December 2022 12 of 12 6. Tameside Safeguarding Children Partnership should consider the development of regular forums to create routine opportunities for the sharing of professional expertise in relation to safeguarding cases. 7. There needs to be assurance, from Children’s Services and Midwifery, that the threshold for initiating the pre-birth protocol is being applied appropriately. All partners would benefit from a refresh on the triggers for a pre-birth assessment so that they can initiate their own early help assessment, make a referral to Children Social Care and/or be in a better position to professionally challenge decisions. 8. Any agency that identifies that parental mental health needs are impacting on parenting capacity needs to share that with other partner agencies working with the family so that information can be triangulated and an appropriate response agreed. 9. The DNA (Discharge) protocol for perinatal clients should be reviewed to determine whether there should be an alternative offer of engagement or support. 10. St Mary’s Hospital Manchester to review information sharing agreements with Child health. |
NC50694 | Death of a 6-week-six-day-old girl found unresponsive on the couch next to her mother in November 2016. Baby A was born prematurely at 36-weeks' gestation. Mother sought help for her infant's feeding difficulties, vomiting and general unsettledness. At the time of her death, both parents had been drinking alcohol and were significantly intoxicated. Baby A's mother had a complex health and social history; substance misuse began when she was 12-years-old; her emotional and mental health challenges dated back to 2005 and in 2011 she was diagnosed with borderline personality disorder. Between 2009 and 2016 children's social care logged at least 13 contacts; a child protection referral was made by a consultant psychiatrist just before the birth of Baby A but the referral box was not ticked so was de-escalated to early help under midwifery and health visiting services. Ethnicity or nationality of Child A is not stated. Learning: practitioners should be aware that pregnancy and post-delivery is a critical time for women to experience deterioration in their mental health; monitoring and assessing growth of new born, premature infants should be in line with expected practice standards; all relevant multi-agency professionals should be contacted for a core assessment; all agencies should contribute to effective information sharing. Recommendations: to ensure all early help guidance addresses the issues identified in this review; to seek assurance that 'Did Not Attend' policies contain clear guidance on the actions to be taken when adults with caring responsibilities fail to engage with services dealing with health issues that can adversely impact on parenting capacity.
| Title: Serious case review: Baby A. LSCB: St. Helens Safeguarding Children Board Author: Jane Carwardine and Melanie Hartley Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW BABY A 20th November 2017 Page 2 of 52 CONTENT PAGE SECTION CONTENT PAGE Content page 2 Abbreviations used 3 Section 1 Executive summary 4 Section 2 Introduction to the review 7 Section 3 The review: a narrative 12 3.1 A portrait of Baby A 12 3.2 Family functioning 13 3.3 Significant historic safeguarding events and emerging themes between 2005 – 2014 17 3.4 Significant safeguarding events and emerging themes between February 2014 and November 2016 21 Section 4 Baby A: an analysis 29 4.1 Was relevant historic information about family/parental functioning known and considered in multi-agency risk assessment, planning and decision-making in the pre-birth and neonatal period? 29 4.2 Was the multi-agency planning robust, appropriate, effectively implemented, monitored and adequately reviewed in the pre-birth and neonatal period to reduce the risk of harm to the infant? 30 4.3 To what degree did agencies challenge each other regarding the effectiveness of the risk management, planning and decision making? 32 4.4 Were the respective statutory duties of agencies working with the infant, parents and family fulfilled? 34 4.5 Were there organisational, contextual obstacles or difficulties in this case that prevented agencies from fulfilling their duties? 41 Section 5 Conclusion 45 Section 6 Recommendations 48 Appendix 1 Collated learning points and good practice 49 Appendix 2 Bibliography 52 Page 3 of 52 ABBREVIATIONS ABBREVIATION/TERM DESCRIPTION ANCC Antenatal Cause for Concern BEP Bleeding in Early Pregnancy BPD Borderline Personality Disorder CAF Common Assessment Framework CAFCASS Family Court Advisory and Support Services CDOP Child Death Overview Panel CIP Critical Incident Panel CPA Care Programme Approach CRP Case Review Panel CSC Children’s Social Care DBT Dialectic Behaviour Therapy DNA Did Not Attend EHAT Early Help Assessment Tool EPDS Edinburgh Post Natal Depression Scoring Tool GP General Practitioner HV Health Visitor/Visiting Home Treatment Team Home Treatment Team LSCB Local Safeguarding Children Board MARAC Multi-Agency Risk Assessment Conference PMH Midwife Perinatal Mental Health Midwife SCR Serious Case Review SIDS Sudden Infant Death Syndrome STR Worker Support, Time and Recovery Worker SUDIC Sudden and Unexpected Death in Infancy and Childhood Page 4 of 52 SECTION 1: EXECUTIVE SUMMARY Keywords: Pre-Birth Assessment Of Risk, Pre-Birth Early Help, Pre-Birth Social Work Assessment (Section 47), Maternity Cause For Concern Processes, Borderline Personality Disorder, Assessment And Intervention With Parental Substance Misuse (Alcohol, Cannabis And Cocaine), Domestic Abuse, Managing Parental Non-Compliance With Mental Health Intervention, Assessing Parental Capacity, Silo Working, Multi-Agency Assessment, Thresholds Of Concern, Effective Communication, Impacts Of Organisational Transformation, Alignment And Adoption Of Multi-Agency Practice Guidance, Assessment Of Parental Capacity, Understanding History And Assessing Capacity For Change. 1. In November 2016, early one morning, Baby A was found un-responsive on the couch by her mother. Her mother called the Ambulance Service and commenced resuscitation. Resuscitation continued when the paramedics arrived and Baby A was transferred to a local NHS Emergency Department, where it was confirmed she had sadly died. The history given at the time of the event by her parents was that both parents had been drinking alcohol during the night of Baby A’s death. Her father went to bed at 00.45hrs and her mother continued to drink vodka until 02.00hrs. Baby A’s mother fed her baby, who fell asleep in her arms. Mother and baby then fell asleep on the couch. Mother advised she had drunk around 22 units of vodka. Toxicology blood tests confirmed both parents were significantly intoxicated (alcohol) at the time of her death and her father had the higher alcohol reading. 2. Baby A was the youngest of the sibling group, all of whom were of primary school age. She lived with her sister, their mother and father. Her paternal half-brother and maternal half-sister stayed regularly at the family home, subject to agreements made through shared care arrangements. It was difficult during the review period to gain a picture of how the siblings experienced their daily life, especially during periods of instability. Extended family members provided some support. However, there was evidence of conflict within the maternal family and substance misuse by some extended family members. The ex-partners of both the mother and father were fully involved in their children’s lives and there is evidence the adults with parental responsibility worked together in times of crisis to keep the children safe. Occasional conflict was evidenced when Children and Family Court Advisory and Support Services (hereinafter known as CAFCASS) or Children’s Social Care within Peoples Services (hereinafter known as CSC) mediated a resolution. 3. There was limited historic or recent information related to father except, he worked full time on a self-employed basis as a contracted painter and decorator. Practitioners advised, he could be supportive of Baby A’s mother and provided care and activities for the children. There was evidence Baby A’s mother had a complex health and social history. It was unclear the level of parenting she provided her children on a consistent basis. Practitioners advised she interacted positively with her children when well and able to do so. Baby A’s mother life was settled at times but could quickly become chaotic. At 12 years of age, she began to use cannabis and her substance misuse behaviours (cannabis, alcohol, cocaine) escalated after that point. There was no evidence of meaningful intervention by Substance Misuse Services. Whilst there was evidence General Practitioner Services asked about alcohol intake, other professional groups tended to “normalise” her alcohol behaviours and there was no significant evidence of professional inquisitiveness. Her alcohol usage was not accurately understood by front-line practitioners involved in providing ante-natal and postnatal care, despite an expert risk assessment by a Consultant Psychiatrist in 2016. 4. In 2011, mother was diagnosed with a borderline personality disorder 1 (hereinafter known as BPD) following a long history of emotional/mental health challenges, dating back to 2005. She presented with 1 An emotionally unstable personality disorder is also referred to as a borderline personality disorder. It is a disorder of mood and how a person interacts with others. A person with this disorder will differ from an average person in terms of how she thinks, perceives, feels or relates to others. The symptoms fall into 4 main categories; emotional instability, disturbed patterns of thinking, impulsive behaviour, intense but unstable relationships. Downloaded www.nhs.uk 23.8.2017. Page 5 of 52 mental health behaviours on a continuum of low to medium severity, as was her presentation of BPD. A range of behaviours were described including; social anxiety, self-harm (cutting and overdose), suicide attempts (overdose), obsessive compulsive disorder, anxiety and depression. She developed positive relationships with practitioners, but overall did not engage with intervention, therapy or medication to sustain stability and improvement in her condition. She was regularly referred to Mental Health Services for assessment and frequently her case would be closed due to non-compliance. Between 2010-2014 she was a victim of domestic abuse on at least eight occasions, perpetrated by differing partners. These incidents were assessed at different levels of severity and her children were present on many occasions. Her case was subject to the local multi-agency risk assessment conference process (hereinafter known as the MARAC) 2 and she worked effectively with multi-agency practitioners to help her manage the risk. There was no significant evidence of violence within her current relationship, although some practitioners documented she had historically described that she had felt emotionally abused by him. 5. Between 2009 and 2016, at least thirteen contacts were logged by CSC. Four of these proceeded to an initial assessment and two core assessments were completed. Ten contacts proceeded to no further action. In September 2016, 11 days before the birth of Baby A, a child protection referral/contact was made to CSC by a Consultant Psychiatrist. The referral technically was not logged as a child protection referral as the drop box indicating it was a referral, hadn’t been ticked. The referral/contact indicated the need for a statutory pre-birth social work assessment, due to the high risk of mother relapsing in the post-natal period. The concern was this would lead to increased anxiety, self-harm and substance misuse therefore impacting negatively on the care she could provide to Baby A. The referral/contact was screened but not assessed as requiring an immediate response. The referral was de-escalated the day after Baby A’s birth to be managed by Mental Health, Midwifery and Health Visiting Services under the framework of early help. This was a missed opportunity to complete a formal social work assessment or to support understanding of the complex interrelating issues to manage the risk for the infant. The communication systems between Health Services were not effective in ensuring front-line practitioners with the responsibility of co-ordinating early help provision were aware of the plans. 6. At the time, front-line Social Workers assessing contacts/referrals were struggling to process the high numbers of contacts. This could have resulted in the pre-birth assessment taking only a narrow risk management approach. The de-escalation process was not managed effectively by multi-agency partners, communication was ineffective, a “Think Family” 3 approach was not developed and a lead professional role was not established. Practitioners did not understand the risks nor have access to historic information that may have supported their risk assessment and subsequent interventions. Practitioners with ongoing responsibility for the provision of services were not made aware of the recent child protection referral/contact or the plan to work the case through early help. Practitioners’ motivation to provide high quality care was evident but they were working very much in their own agency silos, with only their own agency information. A more co-ordinated multi-agency statutory response was indicated when considering the known history, parental risk factors and the expert opinion which hypothesised the risks to the new-born infant in the post-natal period. 7. At the time there was no LSCB multi-agency pre-birth guidance to guide the multi-agency arrangements. This is now in place, but its focus is the pre-birth statutory intervention process. It does not include guidance for early help in the pre-birth period and should be strengthened to support multi-agency practice. There are confusing ethical dilemmas regarding the rights of an unborn infant and the reluctance of statutory agencies to become involved before the 24th week of pregnancy due to abortion 2 Multi-agency Risk Assessment Conference (MARAC) is a meeting where information is shared on the highest risk domestic abuse cases between Police, Health, Child Protection, Housing, Independent Domestic Violence Advisors and other specialists from statutory and voluntary sectors to coordinate a plan to safeguard the victim. 3 Think Family is an approach to support agencies to work together to meet the assessed needs of children and families. The local arrangements are supported by guidance and policy. Page 6 of 52 legislation. However national guidance 4 5 provides a clear expectation of universal agencies (Primary Care, Mental Health, Maternity Services). Their function is not only identifying pregnant mothers with complex health and social needs who may require additional support, it is also about their role in working with pregnant mothers to achieve the optimum outcomes for the infant through early help processes. Baby A’s mother was vulnerable, identified as having complex needs but universal agencies did not have their own early pre-birth practice guidance or services in place to support practice. There was no evidence universal agencies assessed the risk on an ongoing basis, assessed parental behaviours to sustain change or planned early intervention to maximise the parental capacity for positive parenting. Crucially there was no significant evidence of safety planning in respect of parental alcohol or mental health behaviours to manage the risk of a relapse. Following Baby A’s death, it is positive that mother received a comprehensive package of support, including a Mental Health Care Co-ordinator, through the care programme approach (hereinafter known as CPA) 6 to monitor her mental health progress and care delivery. This would have been a positive approach in the ante-natal period. 4 HM Government (2013) Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children. 5 HM Government (2015) Working Together to Safeguard Children- a guide to inter-agency working to safeguard and promote the welfare of Children. Crown Copyright. 6 Care Programme Approach (CPA) is a system used to plan many people’s mental health care. The approach appoints a Care Coordinator to work with the adult with complex mental health issues and complete a care plan that details how the NHS will support the adult. Page 7 of 52 SECTION 2: INTRODUCTION TO THE REVIEW 8. Copyright This serious case review (hereinafter known as SCR) has been jointly chaired and authored by Jane Carwardine and Melanie Hartley as Independent Reviewers. Its content has been quality assured by the Safeguarding Children Board (hereinafter known as the LSCB) and the Case Review Panel (hereinafter known as the CRP). It is owned by and copyright remains with the LSCB. Permission should be gained from the LSCB prior to sharing the content of this review either in paper form or electronically with any organisation or individual. 9. Thanks The Independent Reviewers would like to thank practitioners, managers, multi-agency and provider organisations who openly and honestly reflected on and shared their experiences whilst working on the case. Their contributions were extremely advantageous, enabling enhanced learning and the identification of good practice. The motivation and passion of front-line practitioners, to make a difference to the life of Baby A and the family was evident throughout the process. 10. Anonymity The review has been written to protect the identity of Baby A, the family and practitioners. The emerging themes, key lines of enquiry and significant events have been discussed in a style which minimises the risk that either child or family’s identity will be unintentionally revealed. Multi-agency employees will be described in respect to their job role to protect their anonymity. This approach is taken to encourage open and honest reflection of safeguarding practice. 11. The Decision In November 2016, the case was notified to the LSCB Critical Incident Panel (hereinafter known as CIP) by a CSC Safeguarding Manager. In November 2016, early one morning, Baby A was found un-responsive by her mother. Baby A was transferred urgently to hospital where it was confirmed she had died. Both parents admitted to drinking alcohol the preceding evening. Father went to bed at 00.45hrs and mother continued to drink vodka until 02.00hrs. Mother reported she fed her baby, who fell asleep in her arms and they went to sleep on the couch. Mother advised she had drunk what equated to around 562mls of vodka prior to going to sleep. Toxicology blood tests confirmed both parents were significantly intoxicated (alcohol) around the time of her death. On the 6.12.16 the CIP reviewed the case and concluded the criteria for a SCR as defined in Working Together 2015 7 was met and this decision was agreed by the LSCB’s Independent Chair. The initial review of multi-agency information highlighted there was concern on how board partners worked together to safeguard Baby A in the pre-birth and post-natal period. The CIP developed the SCR research question and terms of reference. A case review panel was convened, and two Independent Reviewers were commissioned to undertake the review process with the panel. 12. The Case Review Panel Independent Safeguarding Reviewers (chair and author). LSCB: Business Manager, Business Administrator, Quality Assurance Coordinator, Lay Member. Police: Detective Inspector. Local Authority: Assistant Director of Safeguarding, Senior Assistant Director-Schools Services, Assistant Director of Social Work. Legal Services: Principal Solicitor. CCG: Designated Nurse, Safeguarding Children. 7 HM Government (2015) Working Together to Safeguard Children- a guide to inter-agency working to safeguard and promote the welfare of children. Crown Copyright. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews. Page 8 of 52 CCG: Named General Practitioner. 13. The Serious Case Review A comprehensive SCR was commissioned; a hybrid methodology was used to complete the review, combining several theoretical models and techniques.8 9 10 These methodologies are regularly used to undertake safeguarding reviews. The format ensures key events, lines of enquiry and themes relating to safeguarding practice are critically analysed, with practitioner and service user involvement. It was felt this approach would provide a greater understanding of Baby A’s experience. A combined inter-agency chronology was developed, and further information was sought as gaps in data appeared. A timeline of significant events was developed in preparation for two practitioner events. Single agencies produced learning summaries including analysis of specific incidents and themes. All agencies/services were requested to share information relating to single agency incident reviews undertaken in respect to the case. 14. Participation The CRP considered the participation of the family in the process. Baby A’s parents were informed of the review process in writing through their Solicitor. At the time of the review’s completion their participation had not been secured due to parallel criminal investigations. Their participation will be an ongoing consideration for the LSCB. Multi-agency services were mostly provided by agencies working within the responsible Local Authority area. Some of the services also worked across geographical boundaries and in other Local Authority areas. Multi-agency organisational and practitioner participation was encouraged to enrich the information within the chronology. An initial short introductory practitioner event was attended by twenty-five multi-agency practitioners and their managers, to ensure they were fully briefed on the process. This was followed by a practitioner only event with eleven practitioners in attendance. Positive feedback was received in respect of both these events. The practitioner events improved understanding of the significant events, key lines of enquiry and emerging themes. Additional verbal and email conversations were convened when necessary. The content of the review has been shared with practitioners involved. Practitioners from the following agencies participated in the process; People’s Services: Independent Reviewing Officer, Team Manager, Social Worker. Maternity Services: Community and Hospital Midwives, Community Midwife Manager, Specialist Midwife. Community Nursing Services: Health Visitor, Matron for Quality, Named Nurse. NHS Mental Health Services: Consultant Psychiatrist, Nurse Practitioner, Recovery Team. Primary Education: Headteacher, Pastoral Care Lead. Police. Primary Care Services: Named General Practitioner (hereinafter Known as GP), Practice Manager. Sudden and Unexpected Death in Infancy and Childhood (hereinafter known as SUDIC)11 Service. Safeguarding Specialist Nurse. 15. Timeline, Research Question and Terms of Reference All records to be reviewed in depth for 2 years prior to the death of Baby A in November 2016. Relevant historical information relating to domestic abuse, child concern, parental/carers substance misuse and mental health to be provided by all agencies. 8 Welsh Government (2012) Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Model. 9 SCIE Learning Together to Safeguard Children: A Systems Model for Serious Case Reviews. 10 HM Government (2015) Working Together to Safeguard Children- A Guide to Inter-Agency Working to Safeguard and Promote the Welfare of Children. Crown Copyright. 11 SUDIC service responds to sudden and unexpected deaths in childhood and infancy to support the investigation at the time of the death. The NHS service works with multi-agency practitioners and families. Page 9 of 52 16. Research Question “Is the LSCB assured that multi-agency partnerships work cohesively and effectively with infants, children and their families to provide early help and protection where there is a history of a parental personality disorder/mental health issues and parental substance misuse?” 17. Terms of Reference No. Issue 1 Was relevant historic information about family/parental functioning known and considered in multi-agency risk assessment, planning and decision-making in the pre-birth and neonatal period? 2 Was the multi-agency planning robust, appropriate, effectively implemented, monitored and adequately reviewed in the pre-birth and neonatal period to reduce the risk of harm to the infant? 3 To what degree did agencies challenge each other regarding the effectiveness of the risk management, planning and decision making? 4 Were the respective statutory duties of agencies working with the infant, parents and family fulfilled? 5 Were there organisational, contextual obstacles or difficulties in this case that prevented agencies from fulfilling their duties? 18. Considerations of Parallel Investigations The Coronial Inquest was not concluded at the completion of this review; therefore, the verdict is not available. The case had been presented to the Child Death Overview Panel however the findings of its investigation will not be completed until the SCR is finalised. The criminal investigation is complete, and the evidential bundle has been presented by the Police to the Crown Prosecution Service. A decision regarding possible charges or prosecution in respect of the death of Baby A is awaited. Agencies were asked to identify their agency critical incident reviews in respect of the case. There have been no disclosures of incident reviews undertaken in respect of this case. 19. Equality and Diversity Considerations There is a growing body of evidence to demonstrate that very young babies are extremely vulnerable to abuse either intentionally or unintentionally.12 Working with parents and families to assess the risk and plan intervention in the antenatal period can reduce the risk of harm to an infant. This intervention can be offered under the framework of early help (also known as the EHAT) or through the statutory social work pre-birth assessment process. Nationally there are many Local Authority/LSCBs that have multi-agency pre-birth guidance to manage the continuum of safeguarding need from early help through to statutory intervention; however these systems are frequently not as well embedded as safeguarding children processes. There are complex ethical dilemmas when considering interventions in pregnancy with parents who have complex social or health support needs and are engaged in behaviours that might cause harm to the unborn infant. A significant dilemma is that the statutory pre-birth assessment is complex partly because the foetus has no legal status. In addition, early intervention in the United Kingdom can be problematic as a pregnant mother can seek a termination of pregnancy up to the 24th week of pregnancy under the Abortion Act (1967). As a result, in practice there may be conflicts between the pre-birth procedure for intervention and the legal power to intervene which is not a legal requirement 12 Ofsted (2011) Messages from Serious Case Reviews. Page 10 of 52 until birth. There is also limited focus on the pre-birth assessment in research which only forms a small part of the literature assessment base in safeguarding and protection work.13 14 20. Protected Characteristics There is gradual but increasing recognition in society, that parents with mental health issues have the right to family life and the right to become parents, with the outcome that the infant/child remains a part of family life. However, to be successful in this outcome and ensure the risk is managed for the infant, these parents may need reasonable adjustments in the provision of services. They are entitled to these adjustments under legislation (Equality Act 2010). There are examples when practitioners made reasonable adjustments in their intervention with Baby A’s mother. The Midwifery Service allocated a Specialist Midwife, who maintained an overview of the case and in the post-natal period there were increased contacts documented in recognition of the need to monitor Baby A and her mother’s wellbeing. Mother’s mental health was unstable resulting in her presenting with social anxiety, so her in-patient experience in a ward with other mothers following the birth would have added to her stressors. She identified her dilemma and the Midwifery Service tried but could not meet her request for a single room. There is no evidence the Midwifery Service understood the complexity of her mental health condition or how her behaviours would respond in certain situations. Maternity Services should ensure that they strengthen their approach to women with protected characteristics under equality legislation. The use of a healthcare passport could have supported professional understanding and communication and is at the heart of equality and diversity work with women who have protected characteristics. Learning Point 1: Pregnancy and post-delivery is a critical time when at least 1:5 women will experience a deterioration in their mental health. Women with a history of mental ill-health are at significant risk of a deterioration therefore practitioners delivering care should be aware of how individual women may present and the triggers to activate a deterioration. The use of healthcare passports 15 is a way of enhancing understanding and communication between the woman, her family and practitioners/services. 21. The Independent Safeguarding Reviewers Jane Carwardine has worked as an Independent Safeguarding Consultant since April 2015 and has completed several case reviews. She holds an MA in Child Care Law and Practice (Keele) and a BA Honours in Health Studies (Bolton). Her professional background is in nursing (Nurse, Health Visitor and Midwife). Jane has undertaken a range of strategic, provider and commissioning management roles. She has had 15 years dedicated safeguarding experience in a variety of leadership roles including; senior and line management, Named Nurse, Designated Nurse for Safeguarding (adults and children) and Head of Safeguarding. Examples of her safeguarding activities includes; supporting the completion and quality assurance of SCRs, leading on multi-agency safeguarding learning and development, assuring the quality effectiveness of safeguarding activity, complex case management, development of multi-agency teams, developing and facilitating supervision systems, developing and leading safeguarding advisory services, membership on safeguarding boards and providing advice to a range of strategic boards. Jane has been directly involved in the completion of more than twenty serious case and multi-agency learning reviews. She has worked intensively to improve the quality effectiveness of the case review process and has recently represented the Royal College of Nursing on the Royal College of Paediatrics and Child Health Child Protection Committee. She has not been employed by any organisation aligned to this review. 13 Hodson A., (2012) How Research on Pre-Birth Assessments Should Affect Practice. Community Care 30.8.2012. Downloaded comunitycare.co.uk 27.8.17. 14 Calder M., Hackett., Et Al (2013) Assessment in Child Care –- Using and Developing Frameworks for Practice. 2nd Ed, Russell House Publishing. 15 A healthcare passport is a communication/information leaflet designed originally to facilitate and improve work with adults with learning difficulties in a NHS setting. Its scope can be extended for service users in other situations. Page 11 of 52 Melanie Hartley has recently retired from the NHS after 41 years of service, to undertake the role of Independent Safeguarding Reviewer. She holds an MA in Child Welfare and Protection (Huddersfield) and firmly believes that effective multi-agency working is vital if vulnerable children are to be adequately safeguarded. The case review process is a key component in this work. It ensures that multi-agency lessons are learnt and that actions are implemented leading to improvements in multi-agency safeguarding practice. Melanie’s professional background is also in nursing (Nurse, Health Visitor), including 20 years’ frontline experience as a Health Visitor, working with complex and vulnerable families and 10 years’ specialist safeguarding experience (Named Nurse Safeguarding Children, Designated Nurse for Safeguarding Children/Children Looked After and the Head of Safeguarding). These roles required the development of expert skills and knowledge in all areas of multi-agency operational and strategic safeguarding work. Melanie has been involved in the production and quality assurance process for numerous single and multi-agency case reviews. She has significant experience of leading and chairing a LSCB’s case review panel which enhanced her experience in case review methodologies and practitioner involvement. This is her third review as an Independent Reviewer. In preparation, Melanie has undertaken relevant training and fully participated in and shadowed a SCR process. She has not been employed by any organisation aligned to this review. Page 12 of 52 SECTION 3: THE REVIEW: A NARRATIVE 3.1 A PORTRAIT OF BABY A 22. The first six weeks of a baby’s life is developmentally exciting. The infant is beginning to settle into family life, may begin to smile, start to follow sound, fix onto her mother’s gaze, communicate through gurgling and settled through cuddling by mother and/or father. It has not been possible to develop a comprehensive pen-portrait of Baby A from her parents’ perspective due to ongoing criminal investigations. The portrait of Baby A has been built from the information reviewed and practitioner conversations undertaken. 23. In October 2016, Baby A was born prematurely at 36 weeks gestation. Her delivery was normal, and she weighed 2.64kg (just above the 50th centile which is the average for an infant). It is positive she remained with her mother on the hospital ward for 6 days due to her prematurity and did not require admission to the Special Care Baby Unit. Her extended stay in hospital was due to her prematurity, for the assessment and treatment of sepsis and to manage her jaundice. She was discharged to the family home under the care of her mother and father. 24. At the age of 11 days, Baby A was weighed and was maintaining her growth. The Community Midwife discussed safe sleep and observed the infant’s sleeping arrangements which were in line with expected guidance. Midwifery Services undertook six visits and documented that Baby A had continued to gain weight until her discharge at 27 days post-delivery. Midwifery Services did not record her growth on the centile chart although assessed her growth not to be of concern. Further conversations with Midwifery Services have highlighted it is not a current expectation of practice to plot centile charts. This practice should be strengthened to meet the requirements of national guidance.16 The expectation is that when an infant is weighed the growth should be plotted to ensure accurate interpretation of the data. Baby A was due to be weighed and assessed on the day prior to her death but did not attend the GP appointment. Baby A’s mother told the Health Visitor (hereinafter known as HV) “mother was asleep and had missed the appointment.” Learning Point 2: Monitoring and assessing growth of new-born, pre-term infants is a core activity to ensure optimal growth. There is an expectation that all new-born infants are weighed, and the weight is then plotted on a growth chart which enables accurate interpretation of the data. All infants have growth charts in their parent held Child Health records, to support growth monitoring processes. Maternity and HV Services should ensure that growth assessment and monitoring are in line with the expected practice standards. 25. When Health Practitioners visited the home, they observed Baby A being cuddled by her mother and advised mother to infant attachment was good. On some occasions, the infant was sleeping in her moses basket. Her mother described her as a fractious, unsettled baby, however practitioner observations were Baby A was settled and normally asleep when they visited. At the age of 4 weeks, Baby A attended the GP for the treatment of “sticky eyes” and “infantile colic”. The outcome of the treatment is unclear. The information in respect of her feeding patterns indicates she was initially breast fed, although this was through expressed milk via the bottle. Her feeds were supplemented with infant formula. Prior to her death she was completely bottle fed. Maternity and HV Services had no concerns about her feeding patterns. At the age of 5 weeks, Baby A attended the GP and was reported to have been vomiting all her feeds back since her birth. The GP had no concerns at that point and documented baby A was “thriving” although noted that there was no Child Health parent held records. The information demonstrated inconsistencies with practitioners in regular contact assessing Baby A as a settled, content and thriving baby. However, her mother’s perspective differed, and she sought help due to her infant’s feeding difficulties, vomiting and general unsettledness. 16 RCPCH (2009) Using the new UK-World Health Organization 0-4 years growth charts. DoH. Page 13 of 52 26. At the age of 6 weeks and 6 days, Baby A was found by her mother at 06.00hrs, underneath her arm, on the couch not breathing. Her mother called the Emergency Services and commenced resuscitation. The paramedics arrived within 6 minutes of the initial call and as they got to the address her mother carried Baby A to the Ambulance. The baby was noted to be pale, cyanosed but was warm to touch. There were no signs of life or no recordable observations. Resuscitation continued enroute to the Emergency Department. Sadly, Baby A did not respond to resuscitation attempts either in the Emergency Department or in the Ambulance and was pronounced dead at 07.15hrs. The father to Baby A was present throughout the process. The SUDIC response to the death was robust and in line with expected practice. 3.2 FAMILY FUNCTIONING 27. Family Dynamics Mother Gender Relationship Residence Female Mother to Baby A, Child M and N Co-habiting with father. Father Male Father to Baby A, Child M and O Co-habiting with mother. Birth-Mother (EFR) Female Mother to Child O Shared care arrangements with father in respect of Child O Birth-Father (EL) Male Father to Child N Shared care arrangements with mother in respect of Child N Boyfriend 1 (NE) Mothers ex-boyfriend Boyfriend 2 (TL) Mothers ex-boyfriend Boyfriend 3 (KT) Mothers ex-boyfriend Baby A** Female aged 6 weeks. Daughter of mother and father. Lived with mother and father. Child O Male Son of father. Shared care between father and birth-mother (EFR). Child M Female. Daughter of mother and father. Lived with mother and father. Child N Female Daughter of mother. Shared care between mother and birth-father (EL). ** denotes subject of the SCR. 28. The Nuclear Family At the time of her death Baby A lived at the family home, with her mother, father and full-sister Child M. Her mother and father’s relationship was long-standing but at some point, in 2008 following Child M’s birth they separated. Father remained in contact with Child M and in 2012 became a father again, when Child O was born into a new relationship. Around December 2013, mother and father’s relationship re-kindled although they appear not to have co-habited as during 2014 she was homeless. In October 2016, Baby A was born and at that point mother and father were co-habiting. Baby A had regular contact with her maternal half-sister Child N and her paternal half-brother Child O who regularly stayed at the family home. The family appeared to have positive support by extended family members including grandparents, step-grandparents and aunts on both the maternal and paternal sides, this contact was viewed as a strength by practitioners. There is historic evidence that mother’s relationships with her own mother and other family members was variable, it could be difficult and unsupportive with some evidence of family violence and substance misuse. During practitioner conversations some Page 14 of 52 practitioners assessed her relationship with Baby A’s father to be supportive and positive, whereas other practitioners had not met Baby A’s father. This will be discussed later in the review. 29. Baby A’s Mother Historic information identified Baby A’s mother had significant social and health challenges as a young person which continued into her adult life. In 2000, at the age of 12 years, it was documented she used cannabis. Her substance misuse behaviours escalated with further evidence of alcohol, cocaine and cannabis use in her adult years. She was regularly assessed to be a “heavy drinker” by GP Services. In 2013, she was arrested for shoplifting alcohol from a supermarket for which she received a restorative justice disposal order (a civil remedy for shoplifting). There was additional evidence of attendances at urgent care due to excessive alcohol intake. This issue will be analysed later in this review. 30. In 2003, at the age of 15 years, mother began to present with unstable mental/emotional health. Many presentations were documented between 2003 and 2016 e.g. obsessive-compulsive disorder, anxiety state, low mood and depression. Mother also had long history of self-harming behaviours (overdose and cutting). In 2009, when Child M was two months of age, an initial suicide attempt (tablets) was documented, which became a repeating pattern of behaviour. General Practice and Mental Health Services offered support and medication. Mental Health Services were regularly involved in assessing and managing her care, following which she would be discharged, as was the expectation in practice. Her engagement and adherence to treatment was inconsistent which was one of the reasons for her case being closed. It is clear from practitioner conversations she formed positive relationships with workers who were supporting her. There is evidence that she would seek support when in crisis and frequently accessed Urgent Care, Mental Health or GP Services. 31. In 2005, at the age of 17 years, she became a teenage mother after giving birth to Child N. Over the following years there were regular concerns documented for her well-being and her ability to provide a suitable environment for her children. Homelessness and poor household hygiene were documented to be an early feature of family life. 32. From 2010, on at least 8 occasions mother was a victim of domestic abuse, perpetrated by differing partners. There was no evidence presented in respect of domestic violence between Baby A’s parents. Mother worked with a range of multi-agency services to manage the risks, resulting in a de-escalation of recorded incidents after 2014. This will be analysed later in the review. Despite these challenges practitioners advised when her presentation was stable she made significant attempts to provide good enough care for her children and there was no significant evidence of neglectful outcomes on her children. Her children were reported to be attached to her. Education advised they did not have any concerns about either Child N and Child M in the school environment at the time of Baby A’s death. Assessment of her parenting capacity and outcomes on the children will be discussed later in the review. 33. In 2011, she was diagnosed with BPD and in 2016 was offered dialectical behaviour therapy (hereinafter known as DBT)17 to be provided by a Psychological Therapist. It was hard for mother to engage in this work and she only attended on an ad-hoc basis, so the therapy was discontinued. She developed a social anxiety problem which can be one of the manifestations of this condition, resulting in her finding it difficult to leave the home. This impacted on her ability to attend events at her children’s school and may have contributed to her non-compliance behaviours. The Independent Reviewers were advised that her mental health presentation did not meet the threshold for care co-ordination through the CPA pathway. Her mental health presentation was low to medium in severity as was her presentation in respect of BPD. 17 Dialectical behaviour therapy is a type of talking treatment based on cognitive behavioural therapy. It is used to treat problems associated with a border line personality disorder and more recently has been used to treat other mental health problems. Downloaded mind.org.uk 23.8.2017. Page 15 of 52 34. Baby A’s Father: The review has not been able to gain an in-depth profile of Baby A’s father. The only information known is some practitioners perceived him to be very supportive of Baby A’s mother, who rang him regularly for support during his working day. He was noted during the practitioner conversations to interact positively with the children, doing the school runs, taking them to activities and was documented to be keen to engage in the care of Baby A. He worked full-time on a self-employed basis. His family were documented to be a positive support network, although practitioners also expressed concerns that his sister, who was a regular supporter, had known challenges regarding alcohol use. Education Practitioners highlighted that Baby A’s paternal grandmother did the school run every day with Child M. It was documented father consumed alcohol, but this was at a manageable level. The toxicology results from the blood samples taken after Baby A’s death highlighted he had higher levels of alcohol than Baby A’s mother at the time of the death. The professionals’ perspective was that the re-established relationship between Baby A’s parents was positive and generally supportive. Practitioners did not appear to have had much if any direct contact with Baby A’s father. The issue of the professional assessment of the father will be analysed later in this review. 35. Child N – Baby A’s Maternal Half-Sister. Child N lived with mother and her birth-father (EL) until their relationship broke down when she was a toddler. EL continued to have regular contact. In 2012, there were concerns about Child N’s school attendance and arrangements were made for her to be transported to school by an Education Welfare Officer, who collected Child N from her mother’s house. In 2013, a Residency Order was pursued by her EL through the Family Courts. In February 2013, an agreement was reached that Child N would live with her mother during the week. In April 2013, mother was evicted from her home and Child N went to live with EL. There is evidence that Child N continued to have shared care arrangements. CAFCASS and CSC mediated these arrangements at times. In September 2016, Child N’s mother approached CSC’s First Response Team for support. She was concerned that Child N was seeing inappropriate peers and being left in “risky situations”. She was provided with legal advice re her contact arrangements. EL had been assessed to be a protective factor and was advised to only allow maternal contact if he was assured Child N would be appropriately cared for. It is documented he was supportive of the contact arrangements with Child N’s mother and Baby A’s father and there appeared to be minimal conflict. 36. At the commencement of this review, Education Services advised Child N had no contact with her mother, although there was contrary evidence that Child N remained in contact with her mother. The school in response to the information request stated they had no concerns; “attendance is excellent 98% and she is a lovely, polite, clever, sensible girl and we have no worries or concerns regarding her." The information states she was obviously upset after the death but came into school as normal and support was in place if she needed it "but she was fine". 37. Child M – Baby A’s Sister. Following Child M’s birth there is evidence she lived with her mother and had regular contact and overnight stays with her father. She would live for periods of time with her father when her mother was in crisis. Her parents had a positive relationship and appeared to manage the shared care arrangements positively during their period of separation. There is evidence that Child M was present when her mother was subject to domestic abuse by three different partners. 38. In September 2014, Child M had seen her mother cutting her legs with razor blades which required suturing. Her mother disclosed to Accident and Emergency Practitioners that Child M’s father had woken her up to see the incident. There is no evidence this was referred as a child protection referral due to the risks of emotional harm and there was no paediatric liaison to inform other agencies. Two days later, co-incidentally, Child O became subject to a child protection referral. He had returned to his birth-mothers home with bruising, following a visit to his father’s. This investigation progressed to a core assessment but there is no evidence that the self-harming incident was taken into consideration as there had been no paediatric liaison or child protection referral undertaken. The mother refused treatment by the Accident and Emergency Doctor and approached her GP to treat the injuries. The GP was not involved in the core assessment, therefore could not contribute the information. The outcome of the safeguarding assessment was no further action as the family could support the situation when Page 16 of 52 mother’s mental health deteriorated, and mother was assessed to be able to “manage her mental health most of the time”. The information gathered for this review does not corroborate this perspective as her mother was having significant challenges in stabilising her mental health during this period. In October 2014, Child M began to exhibit difficult behaviour at home and school which the school offered to support her mother to manage. However, mother felt it difficult to work with school on this issue due to the challenges she faced with her social anxiety behaviours. 39. In November 2014, the Primary School made a safeguarding contact/referral to CSC. Child M was “sitting on carpet trying to stick a drawing pin in her inner left thigh”. The school made a child concern contact/referral to the Local Authority and over the next 10 days had at least 3 contacts with the First Response Service in respect of the referral. School were advised to follow this up with the Contact Centre, but there is no evidence as to whether this action was completed. The case was closed with no further action. The school could not secure engagement with Child M’s parents and there is no evidence of a plan to support the child or consideration of a referral for an assessment by Child and Adolescent Mental Health Services. 40. In September 2015, the Primary School had concerns as Child M seemed “very distant, not listening to instructions and her mind elsewhere”. The school worked with paternal grandma and spoke to Child M who reported her mother and father had been arguing as mother had been sick. Father had taken Child M for a walk and mother wasn’t there when they returned. Child M didn’t know where mother was or when she was coming back. Following the death of Baby, A, it is positive that nurture intervention and timetable was put into place to provide support. A special memory book was set up for Child M. 41. Child O – Baby A’s Paternal Half-Brother. From birth Child O lived with his birth-mother (EFR) and Baby A’s father. The HV Service advised his first year of life was difficult as he struggled with feeding. He was under the care of his GP and Paediatric Services. Parental engagement with all services was good and in February 2013 he was discharged from Paediatric Services. His mother regularly requested and accessed advice from the HV Service in respect of Child O for tonsillitis, biomechanics18, feeding and behavioural issues. 42. In December 2013, his parents separated, and Child O continued to have contact with his father through joint care arrangements. There is documentation that he stayed at least one night a week and that he lived with his father for at least one period. These arrangements were mediated at times by CAFCASS due to parental conflict. 43. In September 2014, a Section 47 19enquiry was initiated by his birth-mother. She had found bruising on her child on his return home from visiting his father. Following a child protection medical and a core assessment the case was closed with no further action, the bruising was advised to be non-specific, felt to be accidental and no further safeguarding action was taken. 44. In December 2015, Child O was assessed by Speech and Language Therapy Services due to a stutter. His birth-mother (EFR) was provided with verbal and written strategies to manage the stutter. The first follow-up appointment was cancelled by the service as Child O had chickenpox and he did not attend the second appointment. In April 2016, his case was closed to the service as per policy. 45. In December 2016, following the death of his baby sister, Child O exhibited signs of distress and began bedwetting. His birth-mother sought support and advice from the School Nursing Service who 18 Biomechanics are services that assess the way lower limbs function, checking for abnormalities and possible causes of pain in the foot, ankle, knee and back and advise on orthotics, made to measure insoles and exercise to improve strength and flexibility. 19 A Section 47 (Children Act 1989) enquiry means that Children’s Social Care must investigate if they have “reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm. The enquiry will include information from multi-agency partners and communication with the child and family. The aim is to determine what action should be taken to safeguard the child. Downloaded scie.org.uk Downloaded 21.09.17. Page 17 of 52 approached Winston’s Wish 20 for expert advice and undertook home visits to support Child O. At the time of Baby A’s death Child O had only been in school for 2 months. The school were not aware of any safeguarding issues and reported he was always “punctual and well presented.” Good Practice 3: Education and the School Nursing Service were very responsive following the death of Baby A in providing Child M and Child O with bereavement support, in seeking expert help and ensuring follow up. 3.3 SIGNIFICANT HISTORIC SAFEGUARDING EVENTS AND THEMES BETWEEN 2005 – 2014 46. This section will not replicate the multi-agency chronology but will provide a narrative in respect of the most relevant historical family history that may have informed the pre-birth assessment process and supported the assessment of the capacity to sustain positive change in parenting capacity. 47. Early Patterns Identifying Challenges for Practitioners in Securing Maternal Engagement In November 2005, Baby A’s mother was in her mid to late teens when her first daughter Child N was born prematurely at 31 weeks gestation. Her condition at birth was good and she was discharged home to her mother’s care after 5-days care in the Special Care Baby Unit. The initial weeks were challenging as the HV Service could not secure mother’s engagement. Child N was not taken to the GP for her routine 6-week assessment. However, her mother would attend Urgent Care Services for advice and support and there were no professional concerns for Child N’s wellbeing. The HV Service consulted with the Named Nurse for Child Protection and the concerns regarding non-engagement were documented as a significant event. In November 2005, the day following the consultation between the Named Nurse and the HV, Child N (aged 11 weeks) was admitted to hospital for nine days for intensive care, due to bronchiolitis. Following this event Child N did not attend for paediatric follow-up. This was followed up by the HV Service and a third appointment was sent, when she was taken by her birth-father. This was documented as a further significant event in the child’s records. The early indicators of parental engagement patterns were beginning to emerge. 48. Early Intervention In June 2006, during an opportunistic contact with the HV Service mother disclosed she was “struggling” and finding parenting Child N difficult. The HV had no concerns about her care of Child N and mother said she had some support from her family at the weekends. Early indicators of maternal instability in her mental health were evidenced. She was “anxious”, “felt down” and disclosed self-harming behaviours related to overdose of tablets. She was assessed using the Edinburgh Post Natal Depression Scoring tool (hereinafter known as EPDS) 21 and scored high indicating the need for further assessment of her emotional/mental health. Single agency early intervention planning for mother and Child N was evident, but there was no evidence of referral for specialist mental health support until 2007. The Teenage Pregnancy Worker began outreach work and in July 2006 expressed further concerns to the HV Service that mother’s mental health was deteriorating, the hygiene conditions in the home were poor, she was isolated and unsupported. It is positive now that in practice young teenage mothers under the age of 19 years are supported antenatally and up to the child’s second birthday through the Family Nurse Partnership Service. The service provides an intensive and voluntary home visiting programme. 20 Winston’s Wish is the United Kingdom’s childhood bereavement charity. It provides professional therapeutic help in individual, group and residential settings. It is one of the only specialist provider of support for children bereaved through homicide, suicide and because of a loss in a military family. Downloaded winstonswish.org.uk Downloaded 21.09.17. 21 The Edinburgh Post Natal Depression scale (EPDS) is a 10-item questionnaire that was developed in 1987 to identify women who have post -delivery depression. Items on the scale correspond to various clinical depression symptoms. It can be used in the ante-natal period but generally is used within 8 weeks of delivery. It is a widely used tool which has been adapted and validated in many languages. Downloaded en.wikpedia.org 23.8.17 Page 18 of 52 49. In May 2007, the HV Service made a child protection referral. Following a disclosure earlier in the month, mother had overdosed following an argument with her boyfriend (Child N’s father). The HV Service had attempted to engage mother with Mental Health Services. She was about to move to a new house which was causing her stress and her relationship had broken down with both her boyfriend and her own mother. Mother refused to be referred for a psychiatric assessment but agreed to be seen by the Primary Care Mental Health Team. The HV Service was concerned about her use of alcohol and it is positive they advised her about the risk of alcohol exacerbating her depressive illness. Mother sought further help from the HV Service 16 days later when she was in crisis and her mental health had significantly deteriorated. Further referrals were made for crisis intervention to Mental Health Services and for child protection concerns to CSC. The child protection referral was not accepted as Child N was not deemed to be at risk because she was with her father. The HV Service made further requests for support and services from CSC under child in need arrangements (Section 17 Children Act) 22 and then positively instigated the Common Assessment Framework to enhance multi-agency planning through early intervention. It is not clear what action was taken by the HV Service to escalate their concerns to CSC or whether further expert supervision was secured to support the case management. This incident was outside of the timeline for information gathering in respect of this review. However, in this period, the evidence reviewed demonstrated that there was evidence of early intervention, planning and communication between agencies which was in line with expected practice at the time. This period also reflects the challenges in understanding the thresholds of concerns as the HV Service attempted to secure intervention with CSC. There was a recognition of the risks for Child N and significant attempts made to support her teenage mother who was isolated, at times struggling to manage to everyday tasks of motherhood, beginning to present with self-harming behaviours, emotional distress and early indicators of alcohol misuse. Good Practice 4: In 2006/07, whilst there was evidence of the challenges in managing the thresholds of child concern between multi-agency partners, there was positive evidence that the common assessment framework was being implemented in practice. It is positive that at that time the HV Service used this process to plan and provide a range of services to support mother and Child N. 50. The review has not received any information regarding the birth of Child M or the status of mother’s relationship with Child M’s father at that time. It is known that they separated although Child M’s father continued to have contact with his child including overnight stays. In December 2009, CSC received a contact regarding concerns that mother was abusing drugs and that this was impacting negatively upon her care of her children, the outcome documented was “no further action.”23 51. Domestic Abuse In September 2010, an initial domestic violence incident was recorded. Baby A’s mother had rung the Police for help, when her boyfriend (NE), threatened to assault her. She took Child N and Child M to a next-door neighbour to protect them, but he continued to intimidate them at the neighbour’s home. During the investigation mother, disclosed her boyfriend (NE) had been violent on many occasions during their short relationship and Helena Partnership 24, expressed concerns having observed mother with bruising and knew of several violent incidents observed by the children. Following the event mother minimised the incident and the risks to the children. A referral was forwarded to CSC, an initial assessment was undertaken, and the case closed as mother had responded appropriately. Mother was 22 Section 17 of the Children Act 1989 provides a definition of a child in need. The Local Authority is obliged to offer the following specific services/support for children in need in their area: advice, guidance and counselling, occupational, social, cultural and recreational activities, home help (including laundry facility), facilities or assistance with travel to and from any services provided under the Act or similar service, assistance to enable the child and the family to have a holiday. Downloaded from protectingchildren.org.uk 24.11.15. 23 This was documented in the original SCR referral made to the LSCB. This incident was not subject to further scrutiny as the date pre-dated the timeline of the review. 24 Helena Partnership is one of the largest housing associations in the North West and is based in the local area. Their role is to build and manage homes, regenerate communities, create opportunities and improve people’s lives. Page 19 of 52 subject to the MARAC process and worked with practitioners. She is reported to have ended the relationship after this event. 52. In March 2011, Education referred their concerns to CSC regarding the emotional impact on Child N and Child M of mother’s allegations against the children’s father. They had separated and were involved in legal proceedings regarding contact. There was no information available as to provide clarity into the allegations. 53. Between May 2011 and September 2011 there were four domestic violence incidents logged. In May 2011, the Police attended an incident when mother had called due to an argument with her new boyfriend (KT). Child M was in bed, KT was advised to leave but refused so mother locked herself in the bathroom whilst her child was in bed. KT was removed from the house. Another similar event was logged twelve days later, and Child M was in bed again. Both parties were “drunk;” KT had attended her home drunk and was banging and kicking the door. He had left when the Police arrived. This incident was documented in Community Health records. In July 2011, the Police attended a similar incident between mother and KT, again both adults were “drunk” and arguing. They had separated, and KT was outside the home. Child M was in bed. Mother was concerned that KT would be violent towards her. He was arrested, and it is documented she decided to pursue a complaint against him. The impacts of domestic abuse on her children were discussed with mother by the Police but she declined further support. This was documented as a significant event in Community Health records. In September 2011, Police attended mother’s home. She was at home with her sister (age 13) and Child M and Child N. KT had been banging and kicking her door having had thirteen cans of alcohol. He left the home and the Domestic Violence Project offered support. In November 2011, the Police attended mother’s home as mother and KT had recently separated and he wanted to resume the relationship. He was banging on the window and mother reported he had been violent previously. 54. In July 2012, a domestic abuse incident was recorded as a contact by CSC, involving Mother and an ex-boyfriend (KT). This event occurred at her parents’ home and the maternal grandmother, maternal step-grandfather sustained minor injuries. The adults didn’t want to make a complaint. The event was witnessed by children present and one of the children was pushed to the ground. The children were reported to be distressed. An initial assessment was completed. No further action was taken as mother had ended her relationship and was pursuing a complaint against him. However, in November 2012 Child N disclosed to her birth-father EL that she had witnessed domestic abuse between her mother and KT. An initial assessment was completed, and no further action taken as mother reported she had ended her relationship with KT and school will monitor the situation and refer additional concerns. The child was distressed but there is no evidence of work undertaken to support the children or build their resilience. 55. On the 1st February 2013, CSC received information Child M and Child N were at home with their mother and her ex-partner (KT) when 3 men entered and assaulted both adults. The incident was not reported for 2 days. Criminal proceedings did not progress, and the incident was thought to be linked to her ex-boyfriend’s (KT) criminal behaviour. A child protection referral was made by the Police and an initial assessment was initiated by CSC with no further action to be taken. 56. Around the 18th February 2013, mother was in a new relationship with a boyfriend (TL), who had a history of psychosis, but did not take the prescribed medication. The HV Service documented a domestic violence incident when Child M had witnessed her mother being assaulted by her boyfriend (TL), who had held a screwdriver to mother’s neck. This information was referred to CSC. An initial assessment was initiated, and the plan was to close the case. On further review of the information the case progressed to a core assessment. In April 2013, the core assessment was completed including all adults with child care responsibilities. Child N and Child M at this point were living with their respective fathers, an arrangement which would continue until mother had more secure accommodation arrangements. During the core assessment process family members expressed concern that the children remained in contact with their mother’s boyfriend (TL) who was abusive. Page 20 of 52 However, CSC perspective was that he did not pose a risk to the children, following checks with the Probation Service. The case was closed with advice given in relation to family law and residency arrangements. On the 20th April 2013, 2 days after the case was closed to CSC, mother was detained by the Constabulary due to shoplifting alcohol from a local supermarket. She was handed down a restorative justice order, a civil remedy used for shoplifting. 57. Escalating Mental Health Issues In August 2013, a referral was made to Secondary Mental Health Services (Assessment Team) by GP Services due to concerns about mother’s mental health. She was thought to be a risk to herself and was struggling to manage her emotions. Her risks were assessed to be mild-moderate, complicated by social and continued drug use. She was advised regarding prescribed medication and continued support was offered by the Home Treatment Team (hereinafter known as Home Treatment Team) 25. She disengaged with the team, was non-compliant with medication and therefore discharged back to her GP in September 2013. During this period of intervention, she attended a local NHS Emergency Department following an episode of self-harm (razor lacerations to left wrist and hip), she absconded from the department and was returned by Security Services and the Police. It is positive that details of her children’s whereabouts were documented and that there was liaison with the Mental Health Services involved providing care. 58. In September 2013, CSC initiated an initial assessment following a contact from school expressing concerns that Child N had disclosed “her father (EL) and his partner are not nice to her”. There is no information available regarding the outcome of this assessment. 59. In October 2013, 5 weeks after the previous episode of self-harm Baby A’s mother attended the same NHS Emergency Department, having taken an intentional overdose and “wanted to die”. She had also sustained a laceration to her head after a fall whilst intoxicated with alcohol. She was re-referred to Mental Health Services for a re-assessment and treatment. Mental Health Services made a referral to CSC as mother disclosed her relationship with her partner was verbally abusive and she had moved out of the family home to live with her own mother. It was documented that mother was requesting an injunction against her partner, due to reports of domestic abuse by her partner (TL), who had bitten her. Mother alleged her own mother had been aggressive toward her and recently assaulted her, so it was her intention to move into a refuge. No further action was taken by CSC as the children were being cared for by their respective fathers, however it was documented a core assessment was required. There was positive evidence of information sharing between NHS agencies and CSC. Her case was closed the same month. 60. Domestic Abuse In November 2013, the mother’s case was referred by the Refuge and discussed within the MARAC process. Mother openly discussed the regular and sustained violence she had experienced whilst in a relationship with her ex-boyfriend (TL). She couldn’t remember all the incidents as there had been so many but described being; “spat at…stabbed in the neck with a screwdriver…kicked in the head…punched in the ribs”. The incident that precipitated her leaving was he had bitten her. The conference was well attended by multi-agency practitioners. A safety plan and a plan of care for mother was initiated. This included referrals to Addaction,26 the Freedom Project and the Chrysalis Centre.27 CSC agreed to undertake a core assessment. The core assessment progressed to provision and coordination of services under Section 17 Children Act and a child in need plan was enacted. The 25 The Home Treatment Team provides intensive home treatment for people who have mental health needs, that are best supported by Secondary Mental Health Services and provides services 365 days a year from 8am to 8pm. 26 Addaction is a service that helps people change their behaviour to become the very best they can be. It supports people with drug, alcohol and mental health challenges to make lasting changes in their lives. 27 The Freedom and Chrysalis Centre is an established women’s mental health charity and offers a range of services to women including; counselling, drop-in, CBT for depression, stress and anxiety management courses, domestic abuse support, confidence and assertion classes, creative therapy. Page 21 of 52 practitioners involved were from the Refuge, the Domestic Violence Project and the Primary School. During this period, it was documented Child M had returned to her mother’s care and further concerns were expressed by an ex-partner. In January 2014, the case was closed to CSC. There was no evidence of Community Health, Mental Health or Primary Care practitioners’ involvement which would have strengthened the planning and intervention. There was evidence that mother continued to have contact with Child N during this period as she attended a Minor Injuries Unit with the child. Good Practice 5: In 2013, there was a cohesive response by the Police and multi-agency partners to the incidents of domestic abuse which included safety planning and the use of specialist domestic abuse services for mother. Learning Point 6: There is a practice expectation that all relevant multi-agency professionals are contacted for information during a core assessment however in this instance key professionals were not involved. This should be embedded in practice and is not a recent expectation. The Local Authority should lead work on ensuring this area of practice is strengthened. 61. In December 2013, Child O’s mother reported to the HV Service that Baby A’s mother and father re-kindled their relationship. It is not known at what point they began to co-habit. 3.4 SIGNIFICANT SAFEGUARDING EVENTS AND EMERGING THEMES FEBRUARY 2014 - NOVEMBER 2016 62. The Timeline Preceding the Pregnancy In February 2014, another referral was made to Mental Health Services by the GP following a consultation with mother who had expressed a wish to return to work. The reason for the referral was unclear except for a review of mother’s mental health and that she had re-commenced her medication. She did not attend on two occasions, so her case was closed in March 2014. This was despite a further deterioration in her mental health as she began to suffer with anxiety and depression. At the beginning of June 2014, the GP documented that mother was “really struggling” with anxiety and depression, not taking medication and “had a Social Worker supporting her”. It has not been possible to clarify that she was being supported at this point by a Social Worker as the case was closed to CSC. 63. At the end of June 2014, mother attended the NHS Emergency Department with a history of vomiting and had a headache following a 3-day history of drinking excessive alcohol. She was appropriately treated clinically and discharged. There was no further enquiry or referral for specialist support regarding alcohol misuse which was a missed opportunity. Despite enquiry about her children there was no paediatric liaison completed to Community Nursing Services. Her GP was informed about this attendance. In July 2014, an appointment was made for mother to attend Addaction, but she failed to attend 2 appointments. Following a referral, Mental Health Services invited Baby A’s mother to attend a consultation with a Psychiatrist on the 15th July 2014, which she did not attend as she was feeling well on the day. 64. On the 23rd September 2014, mother attended the NHS Emergency Department following an episode of self-harm and suicidal thoughts. She had lacerations to her legs sustained with a razor blade and reported that father had woken up the children to show them what mother had done to herself. Mental Health Services documented that the Ambulance Service had advised CSC of the issue. Their argument could be heard on the emergency telephone call. There is no evidence of this contact. Baby A’s mother was homeless, living between her own mother and Baby A’s father’s homes. She took her own discharge, refused treatment and referral to Psychiatric Services. Again, there was no paediatric liaison. It is positive she attended the GP for treatment and for follow up. Two days after this incident Child O became subject to a child protection referral. He had returned from his father’s to his birth-mother’s care with bruising. An assessment was completed, a Section 47 investigation agreed, and a strategy meeting completed. The concerns were not substantiated, and the case was closed. There is no evidence that these two incidents were linked as children belonging to the same sibling group. Page 22 of 52 Learning Point 7: In complex family units, it is crucial the safeguarding investigation undertaken by CSC gathers information in respect of all the children in the nuclear and extended sibling group to build a jigsaw in respect of the impact of an event on all the children involved. All agencies should contribute to effective information sharing to enable CSC to effectively lead the investigation. All agencies should be assured their role in this process is robust. 65. In October 2014, the Primary School reported concerns to CSC that Child M had attempted to deliberately hurt herself with a drawing pin. The school was advised to discuss the issues with the parents. The outcome of the assessment was no further action as all adults with parental or child care responsibilities worked together to support and provide stable care for the children when mothers mental health declines. Whilst this assessment was positive and evidenced information gathering from multi-agency partners, there were some inconsistencies. It detailed that mother managed her mental health well which isn’t demonstrated in the evidence reviewed, it didn’t acknowledge the maternal substance misuse issues or provide understanding into the allegation that the children were awoken to observe mother’s injuries. There is no evidence of professional consideration that the child’s behaviour could have been a possible outcome of observing her mother’s self-harming behaviour/deterioration in mental health and could have been an indicator of emotional harm. 66. On the 20th October 2014, Mother attended a consultation with an Assessment Team Consultant Psychiatrist and disclosed she had not taken her medication for 2 months. A meeting was held with the Recovery Team 28 for psychological therapy. She was discharged as she did not attend a subsequent appointment. In November 2014, Mother was referred to the Mental Health Assessment Team after she had attended an appointment with Open Minds 29 when she expressed difficulty in managing her emotions, impaired motivation, erratic sleep, and ruminating thoughts over a 3-month period. 67. In December 2014, CSC received a contact from the Hospital as mother had self-harmed and was under the influence of alcohol. A decision was taken to complete an assessment although there is no evidence to the outcome of this work. Between December 2014 and May 2015, she presented at both her GP and Accident and Emergency Department with a range of health problems including backpain, depression, asthma, eczema and feeling generally unwell. In July 2015, she asked her GP to support her via a letter to the housing association and later that month she had a miscarriage. 68. In August 2015, the Hospital Accident and Emergency Department referred concerns to CSC as the maternal grandmother, who was considered a positive support to Baby A’s mother had taken an overdose and disclosed she misused alcohol and cannabis daily. It was considered there was no role for CSC and the contact closed. This information was crucial in understanding the family strengths and weaknesses. During practitioner conversations, it was clarified that this information would not routinely become part of the information held in respect of the children in the family. The information system does not link information of extended family members. 69. A Summary of GP Involvement During 2014/15 mother attended the same GP on at least 14 occasions. The records identify the GP Practice was aware of mother’s social and health challenges. There were recordings made in respect of her experience of domestic abuse, child care responsibilities, Social Worker, mental health challenges and substance misuse issues. The consultations were primarily recorded under the heading of anxiety and depression and it was known there were periods of non-compliance with medication as well as non-attendance at mental health appointments. It is positive there was evidence of direct communication with mother to encourage her uptake of Mental Health Services. It was noted she 28 Recovery Team is a NHS multi-agency mental health that provides a recovery focussed approach for people who have secondary mental health needs. It offers treatment based on hope, control and opportunity. 29 Open Minds provides information, advice and access to local mental health services in the area for any one over the age of 16years. Page 23 of 52 tended to consume large amounts of alcohol in a binge type pattern and letters received from the Mental Health Services confirmed that she reported drinking up to a bottle of vodka and 6 to 10 pints of lager during any 1 session. 70. The GP Practice made a referral to Mental Health Services on the 4th November 2015 due to maternal increasing low mood, risk of self-harming and increased alcohol consumption. She was assessed 13 days later, and a short crisis hospital admission was arranged for 5 days on a voluntary basis as she expressed concerns regarding her safety and the effect of her current mental state on her children. In November 2015, during this period of admission Mental Health Services made telephone contact with CSC to discuss the concerns and this is logged as a safeguarding referral in the GP records. There is no evidence of this contact/referral in the CSC information system. 71. During this period, there was positive communication between the GP Practice and Mental Health Services. However, whilst GP Practice understood the safeguarding issues there did not appear to be any communication between the GP Practice and CSC, Community Nursing (School Nursing), Midwifery or Education or vice-versa. The role of GP Practices in multi-agency safeguarding work is clearly documented in guidance.30 Learning Point 8: GP Practices have ongoing responsibility for the health and wellbeing of their practice population; they have the potential to be a hub of information. Currently the review was informed that practices do not receive information directly from CSC, Midwifery or Education. Therefore, the information they hold on families is incomplete. There has been local work to strengthen their role in multi-agency safeguarding arrangements but improved information sharing needs to be a continual focus to ensure the full participation of GP practices in safeguarding arrangements. Recommendation 6: The LSCB to consider how General Practitioner Practices can be supported in increasing their involvement within multi-agency safeguarding work. 72. The Antenatal Period Non-attendance for maternity care was a feature in this case. Mother did not attend 5 appointments within the ante natal period. In addition, there was limited opportunity for the Perinatal Mental Health Midwife (hereinafter known as PMH Midwife)31 to adequately assess any ongoing issues and inform the maternity plan of care as mother did not attend the appointments offered. The records do not reflect any consideration relating to the impact of missed appointments, particularly in relation to mental health which should have been considered in the context of impact on the unborn and maternal parenting capacity. There is no evidence of safeguarding supervision or of management oversight of the case which would be an expectation given the combination for health and social concerns. The Maternity Learning Summary has reviewed this issue and has made suggestions to strengthen practice. 73. The First Trimester Weeks up to 12 Weeks Gestation Between February to April 2016, mother attended 4 sessions of 1:1 DBT. This is the therapy of choice for adults who have a diagnosis of BPD, who have a history of suicide or serious self-harm as a poor coping strategy, a desire to develop and maintain healthy relationships and are trying to find new ways of understanding and coping with emotions. She was also reviewed by the Team Psychiatrist in March 2016 when she was 6 weeks pregnant. Mother’s engagement with therapy was poor and following several unattended sessions, a decision was made to discharge her back to the care of her GP. The Team Psychologist notified the Perinatal Midwifery Team and the GP by letter informing of the discharge plan and provided advice regarding further support by Secondary Services should her condition deteriorate. 30 RCGP (2011) Safeguarding Children & Young People a Toolkit for General Practice. 31 Perinatal Mental Health Midwife (PMH Midwife) is a specialist Midwife who specialises in maternal mental health at a senior level, the role described in RCM (2015) Specialist Mental Health Midwives downloaded 19.9.17 rcm.org.uk Page 24 of 52 74. On the 26th February 2016, mother attended the GP, she was 3 weeks pregnant with Baby A. At that time, she had stopped taking medication, but was in regular contact with the Mental Health Clinic held at the GP Practice. There was evidence she was trying to stop smoking, as her GP prescribed a nicotine patch. The ante-natal care pathway was quickly instigated. However, it was an anxious time as she had had a recent miscarriage and begun to bleed early in this pregnancy. She attended the BEP clinic32 for assessment. During this time, she attended the GP regularly for treatment of her eczema. After non-attendance at the initial antenatal appointment she booked in the 12th week of pregnancy at the local NHS hospital for maternity care. She was referred to stop smoking services. 75. Mother disclosed an alcohol intake of 30 units weekly, a history of substance misuse and her mental health challenges which triggered a referral to the PMH Midwife and an antenatal cause for concern form (hereinafter known as ANCC form) was generated due to the “requirement for her unborn to be safeguarded”. This form is used to inform key practitioners involved in the provision care to mother and baby. It included details of mother’s mental health history but not her alcohol disclosure. Therefore, key practitioners (Community Midwifery and HV) were not alerted to mother’s alcohol history. Midwifery Services do not have a single record, this meant that the Community Midwifery Service did not have access to the information regarding mother’s alcohol history. Maternity Services should strengthen this issue to enable all Midwives involved in the provision of care to have access to the full information. The HV Service received the ANCC form but the family HV did not so did not have insight into the maternal mental health issue. The system has been improved to prevent a re-occurrence of this issue in HV Services. Learning Point 9: The maternity ANCC form is used to share information between Health Practitioners when there are safeguarding concerns. It is a system that has been in place for many years and has recently (July 2017) been reviewed as a part of the standard operating process. It could be used to trigger the early help assessment tool (hereinafter known as the EHAT) in the pre-birth period. Early assessment, planning and intervention could then be used to inform the statutory social work assessment in either pre-birth or neo-natal period. 76. The Antenatal Period: 2nd Trimester up to 27 Weeks Gestation This was a difficult time as mother experienced several pregnancy related ailments including repeated headaches, abdominal pain, pelvic instability, as well as asthma and eczema. There was some evidence of Maternity Services having challenges in securing mother’s engagement to planned appointments. However, she regularly sought support by Maternity and GP services for advice and treatment, when she felt it necessary. 77. In her 15th week of pregnancy, mother was re-referred into Mental Health Services for an assessment by Maternity and GP Services. A request was made for a review of her mental health due to low mood and anxiety. In her 16th week of pregnancy she was seen by the Assessment Team Psychiatrist who commenced her on medication to assist with her depression. She did not want to engage in psychological therapy work and was discharged back into the care of the PMH Midwife and GP Services. She did not attend for follow-up by the Midwife in the 18th week of pregnancy, there is no evidence that this non-attendance was followed up by Maternity Services. 78. In her 22nd week of pregnancy she attended for antenatal care and was urgently referred to the PMH Midwife. She presented with relapsing mental health symptoms, was tearful, having racing thoughts and feeling low. Mother reported feeling worried about how her mood would impact on her partner. She had thoughts of self-harm but denied any level of intent to do so. She was offered a joint appointment with the Perinatal Team Consultant Psychiatrist and a Senior Nurse Practitioner to review her level of 32 The Bleeding in Early Pregnancy (BEP) Clinic is a Maternity Service offered to support and assess women in early pregnancy when there are concerns about the viability of the pregnancy. Page 25 of 52 need and offer appropriate intervention. The following day, mother made telephone contact with the Antenatal Ward. She had recognised further deterioration in her mental health and could not wait the 3 days for the appointment with the Home Treatment Team. It is good practice that the Midwifery Service expedited the appointment. She was seen the same day for an assessment and medication review. The Home Treatment Team remained involved for a period of 5 weeks before her case was transferred to the Recovery Team. Mother reported she felt “well supported” during the period of more regular intervention by the Home Treatment Team. There was a 6-week gap in intervention before the Recovery Team commenced their assessment in her 33rd week of pregnancy. Good Practice 10: The Midwifery Service was proactive and person-centred in recognising mother’s deterioration and expediting her appointment to the same day, for review and assessment by Home Treatment Team Mental Health Services. 79. The Antenatal Period: 3rd Trimester from 28 Weeks Gestation to Delivery Mother’s pregnancy related symptoms continued to cause her anxiety and Maternity Services continued to provide care alongside GP services, although there remained challenges in securing mother’s engagement. 80. At 33 weeks gestation, mother was offered an appointment to meet with the Recovery Team to assess her needs and plan appropriate intervention. Unfortunately, she did not attend this appointment due to pregnancy related difficulties, requiring attendance at hospital. The Support, Time and Recovery Worker (hereinafter known as the STR worker) 33 assertively followed up this non-attendance and a detailed contingency plan was developed to ensure robust communication was available within Mental Health and Midwifery Services. The STR Worker undertook a home visit 3 days later, when mother reported her pregnancy symptoms were making her mental health much worse. She was not taking her medication, had no thoughts of self-harm and felt supported by her family. She agreed for the STR Worker to visit weekly and agreed to attend the next appointment with the Recovery Team Consultant Psychiatrist. There was evidence of good communication between the STR Worker and Midwifery Services. 81. Around this time, mother attended CSC as she was concerned about Child N, her eldest child. She was concerned that; her birth-father was allowing her to have contact with inappropriate persons and her contact arrangements with Child N. She was offered advice and no further action was taken. The CSC learning summary makes reflections on this issue documenting the decision was in line with expected practice. A more proactive approach could be possible but the pressures in the First Response Team at the time made a more proactive response a challenge due to the volume of contacts. The learning summary advised; “The only thing that may have benefited the situation would be for First Response to contact Dad, advise them of mother’s attendance and discuss with him what the concerns were to see if he give any context. Where possible, both parents should be contacted.” 82. In the 34th week of pregnancy, mother attended a consultation with the Recovery Team Psychiatrist, who undertook a reflective discussion in respect of her history, previous service involvement and her difficulties in engaging with treatment and services. Her professional concerns were shared with mother. She was advised that a referral to CSC would be made to request an assessment of her support needs. Mother was unhappy and left the appointment abruptly. The Consultant Psychiatrist ensured the mother was followed up and thought she had made a child protection referral to the Contact Centre. There was confusion whether the referral was for a statutory assessment under child protection arrangements or whether it was a referral asking for support. During the practitioner conversations, it was highlighted the referrer had not ticked the box indicating this was a child 33 A support, time and recovery (STR) Worker provides practical support to adults and young people who have mental health issues or learning disabilities with a range of social issues, including their health. There are no set entry requirements however employers may ask for a health care qualification. Page 26 of 52 protection referral. The referral was screened the same day, but not prioritised for immediate assessment. The referral clearly highlighted the risks to the unborn infant and that there was a high possibility this mother’s condition would relapse in the post-natal period. The hypothesis made was this could exacerbate her risk-taking behaviours including substance misuse. The Consultant Psychiatrist advised that a pre-birth statutory assessment was indicated. Three days later it was recorded the case would be closed. The decision to close the case was documented as “Mother has a history of mental health issues, however reports to be currently well and settled. Mother gave birth yesterday and Midwifery report no concerns”. The rationale for closing the case was that it would be de-escalated to be managed by Maternity, HV and Mental Health Services at Level 2 of the Continuum of Need. 83. The Birth: At 36 weeks gestation, eight days after the referral to CSC, Baby A was born by normal delivery prematurely and weighed 2.640kg. She had septic screen on Special Care Baby Unit, commenced on intravenous antibiotics and commenced 4 hourly observations due to the risk of sepsis. Baby A then returned to mother and was admitted to post-natal ward following delivery with her mother. Baby A made very satisfactory progress, initially having breast milk expressed into a bottle and then feeding on formula fully. She was treated for jaundice, a little sleepy at times and was given antibiotics as a precautionary measure. Baby A was well enough to be discharged home after six days. Baby A’s health, feeding and well-being patterns during her short life is described previously in this report (Section 3.1: a portrait of Baby A). 84. The Post Natal Period and Discharge Planning: Mother was seen on the ward by the PMH Midwife, who reported her to be emotionally stable and confirmed the Community Mental Health Care Coordinator was aware of the admission and planning to visit the following day. Mother had requested a single room as she found it difficult to socialise, but no single rooms were available. This issue has been discussed within the review (pp 20). There were no significant concerns expressed about mother’s presentation except on occasions she was thought to be anxious and stressed about her baby. 85. Mental Health Services documented professional communication between the STR Worker, the PMH Midwife and the Social Worker. The Social Worker advised following their assessment, they did not have any concerns and would place baby on Level 2 on the Continuum of Safeguarding Need. There were two plans documented in Maternity Services. A plan was documented on the paediatric liaison form for the Community Midwife and HV service to monitor and a meeting was to be co-ordinated by the Social Worker. This was inaccurate as during a conversation with the Social Worker, the agreed plan was the meeting would be coordinated by universal services. This was documented in a second plan. 86. Prior to discharge, mother was seen by the PMH Midwife and it was documented no pre-discharge meeting was required. This would have been an ideal opportunity to co-ordinate the plan. It was also noted mother’s case would be managed under Level 2 of the Continuum of Need, a plan of care was in place following discharge and the Safeguarding Midwife was aware of this second plan. The Community Midwife providing post-natal care was not aware of either plan. Midwifery Service’s information systems are not easily accessible for practitioners as a single record. This issue was raised during practitioner conversations. The PMH Midwife contacted CSC to discuss the referral made by the Community Psychiatrist. The second plan, as below, was different from the plan on the paediatric liaison form and was clearly documented within Maternity Service’s records by the PMH Midwife; Mother and baby to remain under Community Midwifery care until twenty-eight days post-delivery. Daily visits if discharged over weekend then twice weekly visits after, the Community Psychiatric Nurse to visit weekly. Monthly review by Consultant Psychiatrist. Social Care requested the coordination of a multi-disciplinary meeting at mother’s home to be attended by; Midwifery, HV Services and the Community Psychiatric Nurse to share information and any relevant concerns. Page 27 of 52 The HV Service was messaged to contact the Maternity Unit, but never received the message therefore there was no further communication in respect of planning service intervention. 87. Communication between multi-agency practitioners was evidenced but interpretation and understanding of communication differed significantly resulting in no effective multi-agency response, planning or coordination. Crucially the key practitioners (HV and Midwife) allocated to provide the care for the mother and baby disclosed during the practitioner conversations they were not fully aware of the plans. The dissemination of the plans was not robust. There is no evidence the information was shared with the Community Midwife. Additionally, the STR Worker was allocated to encourage mother’s engagement through outreach work rather than a qualified Community Psychiatric Nurse to overview the case. The STR Worker is an unqualified support worker and developed a positive relationship with mother, but this case was more complex requiring overview by a qualified and experienced Mental Health Worker. The Mental Health and Midwifery learning summaries have made recommendations to strengthen these areas of practice. Learning Point 11: The effective dissemination of safeguarding care plans to front line practitioners involved in the provision of care to new born infants and their mothers is crucial if infants are to be safeguarded. Frontline practitioners did not hold crucial information to support their intervention. The information cascade system failed in this case. All multi-agency workers including unqualified Mental Health Workers should have access to supervision and case monitoring processes. 88. Alcohol Use in the Post Natal Period The day after discharge (7th post-natal day) she was visited by the STR Worker who recorded mother was happy to be home and looked and reported feeling well. Mother had not arranged collection of her prescription from the Pharmacy but confirmed Baby A’s father would be picking up the prescription that day. Mother was open in her discussion and advised she had consumed alcohol the previous evening on discharge from the Hospital and her partner had agreed to care for the baby through the night. This was a significant issue and whilst the worker had asked for assurance that Baby A had been cared for by her father whilst mother had a drink of alcohol it was an indication that the mother may be relapsing into negative alcohol behaviours. The limitations in inter-agency communications and coordination meant this crucial information was not shared with other practitioners. On the 13th postnatal day a second event was documented by the Community Midwife that Baby A’s mother disclosed she had had a drink of alcohol for her birthday whilst Baby A was looked after by her father. It was her birthday the day after the Community Midwives visit. 89. These were two significant events in the post-natal period that could have alerted practitioners that Baby A’s mother was at risk of relapsing into the use of alcohol. However, the practitioners delivering care were not aware of Baby A’s mother’s alcohol misuse history and did not assess the disclosures to be of concern. They provided advice regarding the use of alcohol. During conversations, practitioners advised had they been fully aware of the maternal alcohol history this may have prompted further multi-agency communications and planning to assess and manage the risk. 90. Maternal Emotional and Mental Health Baby A’s mother’s emotional and mental health in the post-natal period was not stable. There were a significant number of written entries detailing her unstable emotional presentation. Whilst she was in hospital it was identified she was anxious and this was mostly considered as a normal reaction following the birth of a premature baby, her anxieties may well have escalated due to her mental health behaviours. She suffered from “social anxiety” so to remain in a ward with other women must have been a significant challenge for her and would have increased her anxiety levels. She was receiving her medication in hospital and was seen by Mental Health Services, so this would have helped her manage her emotions to some extent. Page 28 of 52 91. On the 10th post-natal day it is positive mother rang the STR Worker as she was experiencing symptoms suggestive of panic and sobbing constantly. She had support from her own mother and sister at the time of call, but her prescription still had not been collected. She therefore most likely had not been taking her medication. The worker stressed the importance of the medication to help with anxiety and sleep and her mother agreed to collect the prescription. The STR Worker made a follow-up telephone call and mother reported she was feeling better. Mother shared her challenges at a visit the day after with the Community Midwife. 92. On the 16th post-natal day during a home visit by the STR Worker, Baby A’s mother reported feeling extremely tired as baby was sleeping all day and awake at night. She felt irritable and concerned that she may experience further deterioration to her mental health. The worker reiterated the importance of medication compliance as mother had not yet obtained her medication. There was confusion at the pharmacy in relation to her prescription which the worker resolved and the medication was collected the following day. 93. On the 22nd post-natal day mother was asleep, and her sister was minding the baby when the STR Worker visited, so the visit was rescheduled for 12 days later. The HV visited on the 23rd post-natal day and had concerns about mother’s emotional presentation. It was an unusual presentation in the HV’s professional experience as mother was always in her “pyjamas and yawning” during the HV contacts. The HV had some challenges in securing communication with Mental Health Services via telephone but eventually following an email to the STR Worker a plan was put in place for the worker to consult with the Consultant Psychiatrist. Mother already had a pre-planned appointment with the Consultant for 4 weeks later. This meant that the unqualified worker was left very much unsupported in her decision making regarding escalation of the case for earlier assessment. Unfortunately, the re-scheduled visit by the STR Worker was then cancelled due to competing commitments for the worker. The Community Midwife also documented on the discharge visit (27th post-natal day) that mother was “feeling anxious and obsessive-compulsive disorder was worse”. The Midwife had thought that mother was being visited by the Mental Health Service’s Home Treatment Team although there is no evidence that this provision was in place. The STR visited 9 days after discharge by the Community Midwife when it was noted mother “felt well in her mental health” although was physically unwell due to respiratory issues. Mum said she “had enjoyed time out walking the baby with her partner and was planning further trips out”. Clearly this period was difficult for Baby A’s mother with no consistent evidence that her mental health was consistently stable. 94. Her presentation (non-compliance with medication, presentation of OCD, excessive tiredness and anxiety), disclosures of alcohol intake were all indicators of an impending relapse. It would have been advantageous for this case to have been supported by a qualified Community Psychiatric Nurse which was a missing link. The Mental Health Services learning summary has made recommendations in respect of this. In addition, the only documented communication in this period between the front-line practitioners was by the HV to the STR Worker. More sharing of information at the time would have been supportive but the case had been assessed as uncomplicated therefore was not subject to any formal planning safeguarding arrangements. Page 29 of 52 SECTION 4: BABY A: AN ANALYSIS 4.1 WAS RELEVANT HISTORIC INFORMATION ABOUT THE FAMILY/PARENTAL FUNCTIONING KNOWN AND CONSIDERED IN THE MULTI-AGENCY RISK ASSESSMENT, PLANNING AND DECISION-MAKING DURING THE PRE-BIRTH AND NEONATAL PERIOD? 95. Baby A’s mother had a complex family, relationship, health and social history up to the time of Baby A’s birth, which is documented in the review’s narrative. A pattern of behaviours and issues emerged resulting in significant periods of social and health instability for mother and her children. Mother presented with escalating mental health challenges which led to a diagnosis of BPD. She exhibited risk taking behaviours including serious self-harm, attempted suicide, developed depression, anxiety and obsessive-compulsive disorder, had challenges in controlling her substance misuse behaviours, was homeless and became a victim of domestic abuse by numerous partners. She had some extended family support although these relationships were also documented on occasions as violent and unsupportive. Agencies could not secure mother’s engagement consistently in a planned way, although mother would seek support and care when in crisis for both herself and her children. There was some evidence mother’s engagement improved when she had outreach support. Mother also had a positive awareness of the needs of her children. When her situation was stable she was thought to be able to offer her children “good enough parenting” through shared care arrangements, with her children’s birth fathers. Following Baby A’s birth, mother appeared to have resumed full responsibility for the care of her baby and children with some support from her partner and extended family. 96. The review has been able to secure historic information from multi-agency partners which whilst not complete provides early insight into the maternal/family functioning following the birth of Child N in 2005. The information gathered following the death of Baby A, forms the multi-agency chronology used in this review. All agencies involved in this review held information in respect of significant factors relevant to the assessment of family functioning and parental capacity. This information when combined into the multi-agency chronology of significant events provided a good information base of the family’s history, patterns of behaviour, agency interventions and parental history. There was evidence of good levels of information sharing, risk management, planning and intervention through the MARAC process and again in recognising the need for early help through the Common Assessment Framework (hereinafter known as the CAF) around 2007. The information provided a narrative without analysis or understanding of the impact of safeguarding interventions for her or her children. The historic information was adult focussed and did not always provide a picture of how children experienced their daily lives, especially when their mother’s health was unstable and their social situation chaotic. Learning Point 12: The historic information was mainly documented in a narrative form and little information was identified pertaining to the needs of the children, impacts on them or any effective analysis of the outcomes of intervention on the children. Can the LSCB and its partner agencies be assured that practice has improved and the outcomes of intervention with families in crisis are documented to support future intervention?. 97. The sharing of information between multi-agency partners is crucial in safeguarding work. A chronology of significant events is a central part of historic information sharing. It helps to: build a continuous assessment of parenting capacity; understand the impacts on the children in the family; assess a parent’s motivation to sustain change; develop a greater understanding of the strengths within a family; and identify the risk factors that may trigger a crisis. It has been an expectation of safeguarding practice for many years, that agencies maintain chronologies of significant events for families when the main carer has social and health challenges as seen in this case and that this supports front line safeguarding practice. 98. The review process is not assured that multi-agency organisations had access to the range of historic information in the pre-birth and neonatal period that should have informed their risk assessment and enabled focussed safety planning/intervention. There was evidence that some agencies/services did Page 30 of 52 not keep an effective chronology of significant events which was documented in the Primary School’s learning summary. This has been strengthened in practice within that service. In Maternity Services, differing service areas did not have access to all the information as a single record, resulting in a Community Midwife providing high levels of care without knowledge of mother’s mental health or substance misuse challenges. This also leads to a hypothesis that the use of accessible chronologies is not used on a regular basis in front-line maternity care. Learning Point 13: The development of chronologies of significant events should be embedded in practice. This is an expectation of safeguarding practice, but the evidence reviewed does not demonstrate their use in supporting the assessment of parenting capacity and parental motivation to change. The use of safeguarding chronologies should be strengthened in single and multi-agency practice to more accurately understand the history. Recommendation 7: The LSCB should seek assurance that all partner agencies have recording practice standards in place which include the use of both robust chronologies and impact analysis. 99. These deficits in information sharing and the lack of a robust chronology of significant events led to front-line practitioners engaging with Baby A’s mother with no significant knowledge of historic information to contribute to their understanding of her parenting capacity or her motivation to sustain change and provide effective and safe parenting. 4.2 WAS THE MULTI-AGENCY PLANNING ROBUST, APPROPRIATE, EFFECTIVELY IMPLEMENTED, MONITORED AND ADEQUATELY REVIEWED IN THE PRE-BIRTH AND NEONATAL PERIOD TO REDUCE THE RISK OF HARM TO THE INFANT? 100. Prior to the Consultant Psychiatrist making the referral to CSC towards the end of September 2016, support had been provided to the mother by the General Practice, Maternity and Mental Health Services. The services were working largely in isolation. Whilst there was some evidence of information sharing during this time, it was largely written information which included the ANCC form and the provision of formal feedback letters by Mental Health Services. There was limited direct communication between professionals addressing the issues of safeguarding. The direct communication was mainly, to meet the mother’s clinical needs. This included when the PMH Midwife contacted Mental Health Services in the ante-natal period to obtain a prompt assessment when her mental health had deteriorated, and mother couldn’t wait for an arranged appointment as she felt so poorly. 101. The information collated for this review indicates there were earlier opportunities for taking further action. At the point that mother’s pregnancy was confirmed, the GP Practice and Mental Health Services were aware that she had recently been admitted due to a deterioration in her mental health. Following discharge, mother was under the care of the Home Treatment Team. This team requested the Recovery Team should offer psychological therapies. Specialist treatment DBT was offered and she attended 4 sessions between February and April 2016. She was reviewed by a Recovery Team Psychiatrist at the beginning of March 2016, when she was known to be 6 weeks pregnant. However, her engagement with the therapy was poor and she was discharged back to the care of the GP and the Perinatal Midwifery Team in the middle of April 2016. In mid-May 2016, Baby A’s mother (16 weeks pregnant) was re-referred by the GP due to reported recent low mood and anxiety. She was assessed by an Assessment Team Psychiatrist who prescribed medication to assist with reported symptoms of depression. She did not want to engage with psychological therapies and a risk assessment indicated she did not pose a risk of harm to herself. She was discharged again back to the care of her GP and the Perinatal Midwifery Team. Direct communication to collate information held by both services and determine whether further action was needed to protect the unborn infant did not take place. This was a missed opportunity. 102. In March 2016, Mother’s attendance at the antenatal booking clinic clearly raised concerns which prompted the development of the ANCC form. In addition, Mother’s disclosure of her mental health Page 31 of 52 difficulties also prompted a referral to the PMH Midwife. However, subsequently the PMH Midwife had very limited involvement with mother due to the difficulties in engagement for her ante-natal care. This resulted in a missed opportunity to undertake further assessment, planning and consideration of the need for a robust multi-agency plan. An assertive outreach approach to support mother in engaging with the Specialist Midwife might have assisted at this point. 103. In September 2016 when mother missed the first appointment, the Recovery Team Psychiatrist adopted an assertive outreach approach through the STR Worker, after which she attended the second appointment. The referral to CSC by the Psychiatrist was the first point at which a formal multi-agency plan was agreed. The Social Worker assessed the case as being at level 2. It was understood the Consultant Psychiatrist had developed a robust plan of care for mother and mother and Baby A’s needs could be met through effective joint working by Community Midwifery, HV and Mental Health Services. The post discharge plan was agreed between the screening Social Worker and the PMH Midwife during a telephone discussion. 104. The STR Worker was contacted by the Social Worker and understood the case was to be managed at level 2. The worker understood the Community Midwife and HV would monitor mother’s wellbeing and the Social Worker would coordinate a multi-agency meeting. The Social Worker had a telephone discussion with mother who agreed to accept all support offered. The development of this multi-agency plan was not informed by the professional opinions of the Community Midwife, HV and Psychiatrist. Given that the Community Midwife and HV would be the practitioners assessing and monitoring mother and Baby A at home after discharge, their opinions should have been sought. The provision of early help support, or a pre-discharge planning meeting could have avoided this situation. 105. At the point of discharge, information sharing issues then resulted in neither the Community Midwife or the HV having a good understanding of the agreed plan. Neither practitioner was aware of the need for a multi-agency meeting to coordinate the safeguarding planning or the risks relating to mother’s history of alcohol misuse. Given these challenges, the plan could not be effectively implemented, monitored or reviewed. 106. Although the multi-agency plan (see para 86) appeared robust, its appropriateness was compromised by mum’s long history of alcohol misuse and inconsistent access to mental health services not being fully understood. In addition, the perceptions by the PMH Midwife and the STR Worker that mother’s mental health was stable at the point of discharge added to the deficits of the assessment process. A robust EHAT assessment would have improved the collation of information which could have informed the decision-making process at the point of discharge. 107. In conclusion, this narrative of specific events has considered key events when more effective multi-agency planning could have been secured in the pre-birth and post-natal period. There was evidence that single agencies (Maternity and HV) undertook planning for their clinical intervention and there was some evidence of attempts by single agencies to work with the safeguarding concerns. However, the effectiveness of this work was disadvantaged by ineffective communication with front-line practitioners who were delivering the care, resulting in a lack of focus about the safeguarding plans required, and the risk of maternal mental health relapse resulting in possible increased alcohol use. 108. A multi-agency pre-birth protocol has been recently developed and was included on the LSCB website in April 2017. The focus of this is on the management of pre-birth concerns which have met the threshold for CSC intervention. Further guidance is required for multi-agency partners to support their assessment and intervention of early help in the pre-birth and post-natal period. Recommendation 1: The LSCB should ensure the multi-agency pre-birth protocol is revised and re-launched. It should include the multi-agency arrangements for early help as well as statutory intervention in pre-birth cases. This should encompass the pathways for intervention, multi-agency service offers as well as the learning and supervision requirements for front line practitioners. Page 32 of 52 4.3 TO WHAT DEGREE DID AGENCIES CHALLENGE EACH OTHER REGARDING THE EFFECTIVENESS OF THE RISK MANAGEMENT, PLANNING AND DECISION MAKING? 109. From 2009, there was a significant history of contacts or referrals being made to CSC due to concerns about domestic abuse, the impacts of mother’s difficulties on her children and about potential self-harm by Child M. There is no evidence that agencies making these referrals challenged the CSC decision making at any point. Mother was in receipt of Mental Health and GP Services at the point that she became pregnant with Baby A. She was seen by Mental Health Services at various points between the service becoming aware that she was pregnant and the date of the referral to CSC towards the end of September 2016. Mother was seen by a GP at the beginning of November 2015 and disclosed increasing low mood, a risk of self-harm and an increased alcohol consumption. The GP reviewed her medication and made an urgent referral to Mental Health Services which also advised of mother’s miscarriage three months previously. She was assessed by the Mental Health Assessment Team in the middle of November and admitted. 110. Mental Health Service information indicates ward staff contacted CSC the day after admission due to concerns about the possible negative impacts on her children. The concerns were regarding her alcohol intake and the children witnessing self-harm incidents. Mental health records noted feedback from CSC in that they had no concerns about the children as they lived with their fathers and this was accepted. However, Child M was living with her mother at this point and there was a shared care arrangement in place for Child N. There are inconsistencies in relation to this contact with the CSC chronology not referencing a contact on this date. Review of this contact has identified that expected practice within Mental Health Services would have been for a written referral to also have been submitted – this expectation has been reinforced by safeguarding leads. 111. In October 2013 Mental Health Services made a referral due to domestic abuse concerns and were advised that no action would be taken as mother was in a refuge and the children were living with their fathers. Therefore, the Mental Health Service information includes two occasions on which they received feedback from CSC that no action would be taken as the children were living with their fathers. This feedback was not challenged, nor the concerns escalated by Mental Health practitioners. 112. Following discharge from hospital in November 2015 and after limited engagement with DBT, mother was discharged back to the care of the GP and the Perinatal Midwifery Team in the middle of April 2016. In mid-May 2016, mother was referred again to Mental Health Services, medication was prescribed by a Psychiatrist at an assessment appointment and she was discharged back to the care of her GP and the Perinatal Midwifery Team. At this point, Baby A’s mother had been discharged by Mental Health Services twice in a one-month period, back to the care of her GP and the Perinatal Midwifery Team. The GP Practice received timely and detailed letters from Mental Health Service on both occasions. However, there was no direct communication between the partner agencies involved in her care on either occasion. Such communication would have provided opportunities to promote joint working, collate information and concerns, provide constructive challenge and to assess whether further action was required either to support mother or to safeguard her unborn baby. A hypothesis is likely that; due to differing Mental Health Teams 34 offering support at different points in her pregnancy, Maternity Service appointments being offered both for routine monitoring and with the PMH Midwife and GP contacts taking place, the totality of missed appointments and limited engagement was not fully understood. Silo working was seen in this case with each practitioner committed to doing their utmost to support mother but each working in isolation. Whilst Mental Health Services and the PMH Midwife were proactive in offering mother further appointments the information reviewed does not evidence she was challenged about her poor engagement with services, missed appointments or failure to consistently take prescribed medications until the appointment with the Recovery Team Psychiatrist towards the end of September 2016. The GP Practice learning summary notes that the importance of attending 34 Assessment, Home Treatment and Recovery Teams Page 33 of 52 appointments and complying with medications were reinforced with mother, particularly when she was seen during 2014. 113. Baby A’s mother received further support from the Mental Health Assessment Team between the end of June 2016 (22 weeks pregnant) and the beginning of August (27 weeks pregnant) at which point her mental health was assessed to be stable. This service ensured the Recovery Team would provide ongoing support prior to discharge. She was then seen by the Recovery Team Psychiatrist towards the end of September 2016, who advised her that a referral would be made to CSC. This Psychiatrist challenged mother about her engagement with services and made a good quality and detailed referral requesting a pre-birth assessment. The Social Worker who screened the referral did not contact the Psychiatrist to discuss the referral. During a conversation, the Social Worker advised she used professional discretion and communicated with the STR Worker whom she felt would be able to contribute information of added value as her key worker, to the level of information contained within the referral. In addition, the referral was not assessed to be under Section 47 as the child protection drop box had not been ticked on referral. It is not known whether the Psychiatrist would have challenged the plan agreed between the Social Worker, STR Worker and the PMH Midwife but a potential opportunity for challenge was missed at this point. It is expected practice the referrer is contacted by CSC; however, this may not always be a qualified Social Worker. The responder will be required to use professional discretion when deciding which practitioners are involved. This process is embedded in operational systems and its importance should be reinforced within Children’s Services. Learning Point 14: CSC procedures include a requirement for screening responder to communicate directly with a referrer. This direct communication ensures that the referrer’s perspective and level of concern are fully understood and can provide opportunity for challenge by either the referrer or the responder. These communications can prove difficult considering the high number of referrals screened, differing organisational systems and the availability of the referrer when contact is attempted. Referrers should anticipate being contacted and ensure their referral includes information required to assist a CSC responder in making contact. Within CSC, the importance of the referrer being contacted should be reinforced. 114. It is expected practice the responder ascertains whether an EHAT assessment has been completed and if one hasn’t the rationale for not completing one. There is no evidence that the screening Social Worker raised completion of a EHAT with the STR Worker or the PMH Midwife or provided challenge on a EHAT not having been completed. During discussion, the Social Worker advised it is common practice for agencies to refer cases without having completed an EHAT or provided early help support. A hypothesis offered by the Social Worker was the differing perceptions of what CSC can offer and some agencies are anxious about managing early help cases and want to pass the risk to CSC. The Social Worker advised her experience is that Midwives do not normally initiate a EHAT and refer pregnant women to CSC for a baby and family assessment. This perspective was supported by the data viewed and practitioner conversations held for this review. Currently around 40% of referrals received do not meet the threshold for intervention by CSC and a programme of work is already underway to manage this pressure. Workers who screen referrals provide a presentation at the multi-agency working together training on the work of the contact center and making effective referrals. Staff in the Contact Centre have a process in place to escalate any poor-quality referrals. However, it is expected practice that partner agencies have safeguarding leads with systems and processes in place to quality assure both contacts with and referrals made to CSC and the importance of these should be reinforced. Learning Point 15: Practitioners can contact CSC to discuss a case, however they should understand that such contact does not constitute making a formal referral. The referral process requires submission of a completed CSC service request form. Practitioners should seek advice about making a formal referral if CSC do not feel the case meets their service threshold on discussion. All agencies have safeguarding leads in place to provide support on contacts, making referrals and escalating cases if necessary and should have effective quality assurance processes in place for these practices. Page 34 of 52 115. The HV undertook a third home visit on the day prior to Baby A’s death in November 2016 and was very concerned about mother’s mental health. Following this visit, the HV raised the concerns with the STR Worker by telephone and there was evidence of challenge by the HV. Following a constructive discussion between the two practitioners an action plan was then agreed. 116. There were two occasions in the postnatal period on which mother disclosed drinking alcohol and this was not challenged. The first disclosure was made to the STR Worker on the day after mother and Baby A had been discharged from hospital. Mother disclosed having had a drink the previous evening (on the day of discharge) and that father had agreed to care for Baby A during the night. It is not known if mother disclosed why she had had a drink, but it may have been an indicator that she was feeling under pressure. Mother was expressing her breast milk to feed to Baby A by bottle at this point and therefore required advice on management of this in light of drinking alcohol. This would not be an expectation of the STR Worker’s role. However, had there been early help support in place or a pre-discharge planning meeting and ongoing communication between the involved practitioners, this disclosure may have been shared prompting further action. Mother disclosed drinking alcohol for a second time to the Community Midwife six days after discharge from hospital, saying that she had a drink for her birthday and father had agreed to care for Baby A. The record entry notes that mother was aware to discard her breast milk and that mother reported feeling a lot better. Practitioner feedback was that the Community Midwife understood this to be the first alcohol mother had drunk. 117. Had the Community Midwife been aware of mother’s disclosure at antenatal booking clinic of drinking 30 units of alcohol weekly and the disclosure to the STR Worker, it is likely that this disclosure would have been viewed as concerning and prompted further action. The Maternity Service learning summary notes that the booking clinic disclosure should have prompted further assessment of mother’s alcohol use and the offer of support by a specialist Midwife. The HV was not aware of either disclosure or of mother’s history of alcohol misuse resulting in this risk factor not informing her assessment or intervention. 118. In conclusion, there was very limited challenge between the involved agencies regarding the effectiveness of risk management, planning and decision making. Positive challenge was evident both when the Recovery Team Psychiatrist recognised potential risks to the unborn baby challenging mother prior to making the referral to CSC and when the HV contacted the STR Worker on the day prior to Baby A’s death. Had the HV been aware of mother’s two disclosures of drinking alcohol, this challenge could have been stronger given an identified increased risk which may also have prompted a more robust response from mental health services given their understanding of mother’s alcohol use history. Missed opportunities for challenge at earlier points in the timeframe have been highlighted. Overall, it appears that the level of risk and the full history was not understood by practitioners with involvement during the timeframe and this became particularly significant during the antenatal and postnatal periods. The provision of early help support could have facilitated the collation of multi-agency information to inform a thorough understanding of mother’s difficulties enabling robust risk assessment processes and inter-agency communication through which constructive challenge may have been made. 4.4 WERE THE RESPECTIVE STATUTORY DUTIES OF AGENCIES WORKING WITH THE INFANT, PARENTS AND FAMILY FULFILLED? 119. Statutory National Guidance, Working Together to Safeguard Children 35 (2013, 2015), references the critical importance of early help provision and clarifies the arrangements which should be in place. The St Helens Continuum of Need (EHAT Thresholds)36 references this guidance which requires 35 HM Government (2013) Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children. 36 St Helens Safeguarding Children Board (2014) The St Helens Continuum of Need (CAF Thresholds). Page 35 of 52 safeguarding boards to provide additional guidance on early help assessment processes. This should include the provision of services and the thresholds for referral into Children’s Services. This additional guidance is contained within St Helens Council Think Family documents37 and the St Helens CSC Thresholds of Need.38 120. In November 2014, an Ofsted inspection39 was undertaken in the Local Authority and a final report published in January 201540. The report highlighted two priority and immediate actions in relation to early help which Local Authority Children’s Services were required to address. Firstly, the full implementation of the early help strategy including all partners undertake common assessments and strengthen the role of lead professional for children and families with emerging vulnerabilities. Secondly, to ensure clear understanding and implementation of thresholds across the Continuum of Need so that children and young people receive the right help at the right time. A priority and immediate action required by the LSCB was; to strengthen the challenge and focus on partner agencies playing an active role in the delivery of early help provision, ensure that the threshold for early help is understood and embedded in practice by partner agencies. The Ofsted report noted that early help service changes were already underway. These included a Local Authority restructure of its Early Help Services and location of the Priority Families Programme alongside the Early Intervention Service in June 2014. The report also noted that the Continuum of Need had been revised and re-launched in May 2014. 121. The EHAT was introduced as part of Every Child Matters ‘Change for Children’ programme41 2004 and is a national shared holistic assessment and planning framework. The aims of the EHAT are to; help practitioners assess children and young people’s additional needs for services earlier and more effectively. develop a common understanding of those needs and to agree on a process for working together to meet those needs.42 Completion of an EHAT with family consent is the first step in the provision of early help support by all agencies working with children and families on identifying additional support needs. 122. The Continuum of Need provides the overarching framework for St. Helens and outlines indicators for instigating the EHAT assessment process. It currently doesn’t clarify practitioner expectations if a family refuses to engage in the EHAT process. Working Together 2013 (page 13, S10) and Working Together 2015 (Page 14, S10) state that “the lead professional should make a judgement as to whether, without help, the needs of the child will escalate. If so, a referral into Local Authority CSC may be necessary”. 123. The Think Family suite of documents template catalogue includes all the templates required by practitioners to provide early help using the EHAT and templates to obtain feedback from children, young people and parents/carers on the support provided. The Think Family procedure provides multi- 37 St Helens Council (2014) Think Family guidance documents. There are 5 documents- the Think Family Protocol, Think Family Brief Guide, Think Family Continuum of Need, Think Family Catalogue of Templates and the Think Family Procedure “Think Child, Think Adult, Think Family”. This was previously known as the child in need procedure. 38 St Helens Council (2014) St. Helens PSCYPS Thresholds of Need. 39 Ofsted inspection of services for children in need of help and protection, children looked after and care leavers and review of the effectiveness of the Local Safeguarding Children Board (2014). 40 Ofsted produces this report under its power to combine reports in accordance with Section 152 of the Education and Inspections Act 2006. This report includes the report of the inspection of Local Authority functions carried out under Section 136 of the Education and Inspection Act 2006 and the report of the review of the Local Safeguarding Children Board carried out under the Local Safeguarding Children Boards (Review) Regulations 2013. 41 Every Child Matters: Change for Children. 2004. HM Government. Every Child Matters: Change for Children set out the national framework for local change programmes aimed at building services around the needs of children and young people so that opportunities are maximised, and risks minimised. The framework highlights the fact that universal services which are provided to all children and young people have a crucial role to play in shifting the focus from dealing with the consequences of difficulties in children’s lives to preventing things from going wrong in the first place. ADD information about the programme 42 Children’s Workforce Development Council. (2010). Overcoming obstacles. Barriers affecting practitioners’ engagement with the CAF process and lead professional. Page 36 of 52 agency practitioners and managers with detailed guidance on the management of cases at levels 2 and 3 on the Continuum of Need. It includes the action required if an EHAT is refused how to initiate an EHAT, the management of family action meetings and family action plans. There is inconsistent wording in the thresholds diagrams within the Continuum of Need and the Think Family procedure. At the time of writing this report, the suite of Think Family documents was under review. 124. The St Helens Thresholds of Need references the 2014 Continuum of Need and Working Together 2013. This guidance clarifies the expectation that except for child protection (Section 47) referrals practitioners should have initiated a EHAT and provided support to the family prior to referring to CSC. 125. The Local Authority and LSCB have ensured that early help guidance has been developed with the Think Family documents providing a high level of detail on implementing early help processes. However, the guidance documents do not refer to the use of the EHAT process in cases of unborn babies or infants, when Midwifery and Mental Health Practitioners are involved. A hypothesis could be that adult focussed practitioners might not identify the guidance as being relevant to their role. Research findings 43 identifies that there are national barriers to the implementation of the EHAT process across all agencies working with children and families. These include some practitioner groups viewing the completion of a holistic assessment of a child as daunting. It can be hypothesised that practitioners working primarily with adults, including Maternity Services and Adult Mental Health Staff may well have such anxieties. 126. Given that there is a range of guidance required for this area of practice, it is important that it is collectively easily accessible, and that support is available to practitioners, particularly if they are completing an EHAT or adopting the lead professional role for the first time. Such practitioners, when working under pressure and within resource constraints, are likely to find the guidance and undertaking early help work extremely challenging without effective support. All agencies are required by guidance to identify and respond to early needs and therefore should have internal support arrangements in place for front line practitioners. 127. In addition to the early help guidance documents, the LSCB has a 7-minute briefing on the Continuum of Need on its website. The LSCB training includes Lead Practitioners in practice seminars and the Working Together training includes an early help presentation. Working Together notes that staff working in Maternity and Adult Mental Health services have critical roles in safeguarding and require sufficient training to attain the required competences. Whilst attendance at LSCB training by these practitioner groups can be challenging, midwives are generally well represented at such training. However, there is recent evidence of Health Practitioners including Midwives not attending booked LSCB training with staffing difficulties or work commitments being cited as the rationale. 128. The LSCB has an Early Help Strategy 2016-201944 and the recovery plan developed following the Ofsted Inspection has been implemented. The actions included; the provision of support for practitioners using the EHAT process through the establishment of a Partnership Co-ordinator post within the CSC First Response Team and development of early help outcomes for inclusion in the LSCB dataset. More recent developments have been the implementation of the EHAT system and the establishment of an Early Help Panel. The EHAT system enables the electronic completion of an EHAT, and recording of subsequent meetings and action plans. Work has been undertaken to streamline processes where possible. The CSC referral form clarifies where an EHAT has been completed this should be submitted through the EHAT ICS transfer process instead of completing the referral form to request a service from CSC. However, feedback from the learning event was there were 43 Children’s Workforce Development Council. (2010). Overcoming obstacles. Barriers affecting practitioner’s engagement with the CAF process and lead professional. 44 St Helens Safeguarding Children Board. Multi-agency Early Help Strategy for: Children, Young people and families in St Helens 2016-2019. Page 37 of 52 challenges for some agencies in using the EHAT system including the requirement to record the same information on both the EHAT and internal information management systems. 129. Despite the significant work undertaken to develop operational and strategic guidance to support front-line multi-agency practitioner understanding of their early help responsibilities, practitioners involved in this case did not discuss instigating the EHAT process with mother. This included the PMH Midwife and the STR Worker who both understood that the case was to be managed at level 2 in the post-natal period. The Continuum of Need clarifies that a EHAT is required for cases managed at level 2. Level 2 criteria entail a child having additional needs which can be met by universal services working together and accessing targeted and specialist services when needed. Whilst this case met the service provision criteria, the level 2 indicators within the Continuum Charts guidance do not reference cases involving parental mental health, substance misuse or domestic abuse concerns – these concerns are referenced in the level 3 and 4 Charts. 130. In April 2017, a LSCB multi-agency pre-birth protocol was included in the safeguarding procedures and is therefore not currently referenced within the early help guidance and resources. This guidance will support practitioners in determining how to manage concerns about the welfare of an unborn baby when there are complex maternal health and social issues. Section 2 includes “perinatal/mental illness or support needs that may present a risk to the unborn baby or indicate that their needs may not be met” as a parental risk factor. Practitioner conversations identified that this guidance has not yet been implemented within Maternity Services. Learning Point 16: Key issues that could have alerted involved practitioners to the need for a robust, coordinated response were the frequent missed appointments with all involved agencies, failures to accept interventions offered and the repeated failures to take prescribed medication. Whilst it is important to offer further appointments and support, consideration should also be given to the risks posed to an unborn baby by these issues and what further action is needed. Completion of an EHAT with parental consent facilitates holistic assessment and the provision of interagency early help support aimed at meeting identified needs and preventing escalation of the difficulties. Easily available and clear guidance on the early help responsibilities of all practitioners should be available to support them in this area of practice. Recommendation 2: The LSCB and Local Authority to ensure all early help guidance addresses the issues identified in this review process. The revised guidance documents should be re-launched and made collectively available. 131. As early help support including an EHAT assessment had not been offered to mother prior to the referral made to CSC in September 2016, the case did not meet the service thresholds detailed in the CSC Thresholds of Need. This guidance is clear that CSC provide a service for cases at Levels 3 and 4 on the Continuum of Need. Section 7 of this guidance clarifies that expected practice prior to a referral for support at Level 3 being made is that an EHAT has been completed with parental consent and support services have been offered. A referral to CSC becomes appropriate where support offered through the EHAT processes at Level 2 has not met the child’s needs or where support has been refused and a referral to CSC has been deemed necessary. Discussion at panel identified that the Partnership Co-ordinator posts are now proving effective in supporting practitioners in completing an EHAT or undertaking the lead professional role for the first time and that this resource has been increased. Research findings 45 identifies practitioner feedback in that such support is highly valuable, especially for those new to the lead professional role. 45 Easton, C., Morris, M. and Gee, G. (2010). LARC2: Integrated Children’s Services and the CAF Process. Slough: NFER Page 38 of 52 Recommendation 3: The LSCB to seek assurance that partner agencies have in place a robust early help offer and the required systems and processes in place to enable effective early help work including in cases involving unborn children. 132. CSC had significant previous involvement with the family. Between May 2007 and December 2014, there were 13 contacts recorded on the CSC system. Within the timeframe of the review there was 1 contact recorded on the CSC system in relation to mother’s difficulties prior to the Psychiatrist’s referral in September 2016. This contact was made by the hospital in December 2014 and related to mother having self-harmed and being under the influence of alcohol. The recorded outcome was for a children and family assessment, however information reviewed has not identified that an assessment was undertaken. 133. Discussion with the Social Worker identified the last contact on the system prior to the Psychiatrist’s referral was in December 2014. However, as discussed previously there was an inconsistency in information. Mental Health Service records noted CSC were contacted in November 2015 after mother had been admitted to hospital and received feedback there were no concerns as the children were living with their fathers. It has not proved possible to locate this contact within CSC systems and the inconsistency remains unresolved. It can be hypothesised however, that not having access to the information (November 2015) would have affected decision making as it appeared that no concerns had been raised in 21 months as opposed to 10 months. 134. In April 2013, CSC completed a core assessment which included participation by the fathers of both Child M and Child N. Mental Health Services made a referral in October 2013, which was not progressed further as the children were living with their fathers. Practitioner feedback highlighted that contacts or referrals to CSC about parental issues when children are not residing with that parent are challenging to manage. There are consent issues to consider and as in this case, mother’s consent to share information about her mental health issues would be required before contact could be made with a father. It is likely the outcome of the April 2013 core assessment informed the CSC decision making on the referral received in October 2013. 135. Evidence received indicates that mother had contact with her children when they lived with their fathers and the core assessment (April 2013) concluded they might return to mother’s care once she secured accommodation. The review has not been able to confirm that management of the referral received in October 2013 or the contact recorded in November 2015 by Mental Health Services included full consideration of the current care arrangements and possible impacts of mother’s contact with her children. Learning Point 17: Referrals received about children living in shared care arrangements can be complex to manage. It is important that a safeguarding investigation clarifies what the current care arrangements are, whether they are permanent, what contact a child is having with the parent about whom concerns have been raised and whether that contact poses a risk. In order for CSC to be able to do this, referrers should ensure that a clear understanding of the care and contact arrangements and whether the parent has consented to the referral are included on the service request form. Partner agencies should ensure this through their internal quality assurance processes. CSC should assure itself and the LSCB that this practice is standard when assessing such referrals. 136. The Recovery Team Psychiatrist who assessed mother for the first time towards the end of September 2016, clearly identified safeguarding concerns for the unborn baby and advised mother that a referral to CSC was going to be made. This referral was detailed and requested that CSC undertake a pre-birth assessment. Mother was distressed and left the consultation abruptly. The Psychiatrist arranged for mother to have further contact with Mental Health Services to clarify and reinforce the concerns. Page 39 of 52 Good Practice 18: The Psychiatrist ensured that mother was contacted after she left the consultation abruptly by a Nurse to provide her with reassurance. 137. The Social Worker who screened this referral assessed the case should be managed at level 2 on the Continuum of Need by the agencies already involved working collectively. The Psychiatrist had provided an expert opinion on mother’s mental health difficulties and the likelihood of relapse, however the PMH Midwife and the STR Worker were positive about mother’s current mental health. Discussion between the Social Worker and the Psychiatrist could have provided further clarity for the Social Worker on the level of risk. Early help could have been offered to mother and if refused or proved ineffective, the Social Worker may well have assessed the case at a higher level of need and meeting the threshold for CSC. 138. There is no evidence to indicate the need for an earlier safeguarding referral for the unborn baby was considered by practitioners. Maternity Services documented early concerns due to mother’s mental health difficulties and completed a ANCC form. However, these concerns did not then prompt further planning, assessment or intervention to provide early help support to mother. Mental Health Services and the GP Practice were aware at an early stage of mother’s pregnancy and had a good understanding of mental health and alcohol misuse history and could have considered making an earlier referral to CSC. It appears likely that practitioners were assured by mother’s presentation, her verbally expressed concern for her unborn baby and her agreements to follow advice. Her long-term history became lost. This type of compliance is frequently seen in complex safeguarding cases. 139. There was a negative impact on the provision of mental health care as mother disengaged from the Psychiatrist due to the referral to CSC being made. Planning through early help support or having made an earlier referral to CSC may have provided earlier opportunity to engage mother and may have avoided this distress at a late stage in her pregnancy. 140. Safe Sleep advice was provided the Community Midwife and the HV in accordance with internal guidance and Merseyside’s Child Death Overview Panel (hereinafter known as CDOP) multi-agency safe sleeping guidance (2015). 46 This guidance was re-launched in 2017.47 The multi-agency guidance includes an assessment tool which facilitates discussion on all risk factors and development of an action plan. Information received does not indicate that parental responses to the advice provided raised any concerns for practitioners or that practitioners observed any concerns at home visits such as inappropriate sleeping arrangements or a smoky atmosphere within the home. 141. Mother had several sudden infant death syndrome risk factors (hereinafter referred to as SIDS). These included two disclosures of drinking alcohol in the postnatal period, medication for mental health difficulties, disclosures of feeling very tired and smoking. The GP Practice understood mother to have reduced the number of cigarettes smoked whilst pregnant and recorded she had reduced this to four cigarettes daily in May 2016. Mother disclosed she smoked at the antenatal booking clinic in March 2016 and a referral was made appropriately to smoking cessation services. However no reference has been made to mother receiving support from this service. The review process has not identified if father also smoked. It was known he drank alcohol but that this was not problematic to him. Risk factors also for Baby A were her prematurity and the fact that she was less than 12 weeks old. 142. Practitioners who provided safe sleep advice were not aware of the potential risk of mother’s alcohol misuse history. She had disclosed binge drinking to the GP and to Mental Health Practitioners prior to becoming pregnant. She had also disclosed drinking 30 units of alcohol weekly to Maternity Services at antenatal booking, but this information had been “lost”. No evidence of mother drinking during pregnancy was identified and, when asked, she said that she was not drinking and had reduced her 46 Merseyside CDOP. (2015). Multi-Agency Safe Sleeping Guidance. 47 Merseyside CDOP. (2017). Multi-Agency Safe Sleeping Guidance. Page 40 of 52 smoking due to concerns for her unborn baby. Not being aware of this important risk factor impacted particularly negatively in the postnatal period on the assessment of overall risk and provision of advice by the Community Midwife and HV. 143. Research findings evidence that the number of SIDS appear to have now stabilised as opposed to continuing to decline. The incidence is higher for young mothers with risk factors living in deprived areas of the UK than in the general population and efforts to reduce the rate within this group have had relatively little effect.48 Research findings49 evidence increasing levels of poverty thus potentially increasing the numbers of vulnerable families requiring support. Providing safe sleep advice where there are known risk factors is an extremely challenging area of practice which the development of multi-agency guidance by CDOPs have attempted to address. 144. A recent small scale qualitative research project has concluded that this group of mothers don’t engage consistently when safe sleep advice is provided through a traditional, didactic information-giving model.50 The findings indicate these mothers require an understanding not just of the messages but why they are important and a discussion tailored to their individual circumstances and beliefs which also enables gentle challenge of their own instinctive views as required to support them in making safer decisions in caring for their baby. 145. Further recent research51 identified that mothers with babies at higher risk of SIDS demonstrated reduced knowledge about the specific risk factors and that a targeted campaign of higher risk mothers is warranted. A rethink of the traditional models of health promotion through conversations to allow new innovations to engage families is also suggested. Recommendation 4: The LSCB should seek assurance from CDOP and Public Health that the current provision of safe sleep advice to families with SIDS risk factors has been reviewed and options for more effective interventions explored considering recent research findings. 146. In conclusion, significant challenges have been identified in relation to involved agencies meeting their statutory responsibility to safeguard the unborn baby through the provision of early help support or by identifying and acting to protect the unborn baby from likely or actual significant harm. Maternity Services identified that mother’s mental health posed a risk and an antenatal ANCC form was shared to inform the GP and HV, however the service didn’t undertake further assessment or offer early help support. A referral was made appropriately to the PMH Midwife; however, mother did not attend any appointments with this practitioner. 147. As concerns were raised about mother’s mental health during her pregnancy, she was referred appropriately to Mental Health Services by her GP and the PMH Midwife resulting in assessments and offers of psychological therapy. Unfortunately, mother’s engagement with support offered was limited with missed appointments and disclosures of non-compliance with prescribed medication. During the antenatal period, mother’s lack of engagement was not perceived to pose a safeguarding risk to the unborn baby until the appointment with the Recovery Team Psychiatrist. 148. Mother’s misuse of alcohol was not considered as a risk factor during her pregnancy. She disclosed drinking 30 units of alcohol weekly at antenatal booking clinic, however the information was not recorded on the ANCC or safeguarding documentation so didn’t inform future planning. Mental Health 48 Anna Pease, Jenny Ingram, Peter S Blair, Peter J Fleming. (2017) Factors influencing maternal decision-making for the infant sleep. environment in families at higher risk of SIDS: a qualitative study BMJ Paediatrics Open Accessed- 07.09.17. 49 ADCS. (2016). Safeguarding Pressures Phase 5. The Association of Directors of Children’s Services Ltd. 50 Anna Pease, Jenny Ingram, Peter S Blair, Peter J Fleming. (2017) Factors influencing maternal decision-making for the infant sleep environment in families at higher risk of SIDS: a qualitative study BMJ Paediatrics Open Accessed- 07.09.17. 51 Anna Pease, Jenny Ingram, Peter S Blair, Peter J Fleming. (2017) Mothers’ knowledge and attitudes to sudden infant death syndrome risk reduction messages: results from a UK survey. ADC Online. Accessed 07.09.17. Page 41 of 52 Services and the GP Practice were aware of mother’s history of binge drinking but accepted mother’s assurances that she didn’t drink when pregnant. No evidence of mother having had a drink was identified during the pregnancy. 149. It is likely that Maternity Services staff did not fully understand the challenges for mother of living with a BPD and relied on Mental Health Services to address those needs. Multi-agency early intervention would have provided opportunities for discussions about mother’s mental health difficulties, how they might impact on her wellbeing and how to best meet her needs. Practitioner feedback has highlighted the screening Social Worker may also not have had a good understanding. At the point of the referral to CSC, including information on how this diagnosis might affect mother’s parenting capacity could have supported decision making. Learning Point 19: Practitioners require an understanding of how a diagnosis of BPD might impact on parenting capacity. The expertise of Mental Health Service Practitioners both within individual cases and through the provision of multi-agency training can promote such understanding. 4.5 WERE THERE ORGANISATIONAL OR CONTEXTUAL OBSTACLES OR DIFFICULTIES IN THIS CASE THAT PREVENTED AGENCIES FROM FULFILLING THEIR DUTIES? 150. In September 2016, the HV Service transferred from a NHS Foundation Trust to the Foundation Trust already providing the Mental Health Services to mother. During conversations the HV highlighted significant challenges in contacting the STR Worker when there were substantial concerns about mother’s mental health, on the day prior to the incident. She was unable to contact the STR Worker by telephone, and was advised her call couldn’t be held. Therefore an email was sent to try to make contact. The situation was further complicated by a lack of administrative support to answer calls in the HV base main office at that time. The HV had to make several calls before being able to discuss her concerns with the STR Worker at around 4.30pm. 151. The NHS Foundation Trust providing the Mental Health and HV Services had recently undergone organisational change following successful tender bids to provide several additional services and was renamed to reflect these changes in April 2017. This organisation is implementing a new integrated electronic recording and information sharing system across the organisation. It is anticipated that this will be operational at the end of 2017. This change should facilitate improved joint working and information sharing in safeguarding cases involving both Mental Health and Community Health Practitioners, including HVs and School Nurses. Further workstreams are currently underway to facilitate greater integrated working within the new organisation. 152. The services actively involved in the delivery of care to mother in the postnatal period; Community Midwifery, HV and Mental Health Services were each utilising different electronic recording systems, in addition to which there were challenges posed by ineffective information sharing prior to Baby A and mother being discharged from hospital. 153. The Community Midwife was not aware of mother’s disclosure around her alcohol use at the booking appointment and reported not being made aware of the requirement for a meeting at mother’s home prior to discharging the family into the care of the HV. The Maternity Service learning summary notes the information sharing processes where there are safeguarding concerns at discharge have already changed. 154. A maternity paediatric liaison communication form was completed on the day of discharge to update the HV. This requested an early HV visit, clarified that the Community Midwife would provide regular care up to 28 days post-delivery and that CSC were involved for support only. It did not reference the agreed plan of care. This form was sent by fax to the HV Team and was received the next day. Page 42 of 52 However, it was not filed in the records or seen by the HV prior to the new birth visit 4 days after discharge. Learning Point 20: Effective assessment and planning require access to all available information systems prior to contacts with children and families. The HV Service should ensure the systems and processes in place enable the timely inclusion of new information, particularly that related to vulnerability and risk issues. 155. At that visit, mother advised the HV that she was taking her medication for her mental health difficulties and that she felt better. Due to mother’s mental health issues, the fact that Baby A had been born prematurely and the feeding issues discussed, the HV undertook a second home visit 12 days later followed by a third visit on the day prior to Baby A’s death. 156. Both practitioners (Community Midwife and HV) were visiting the home without understanding the full situation or the agreed plan. Early help support, or a pre-discharge meeting would have avoided these difficulties and facilitated full discussion on the implementation of the plan including agreement on roles (including that of the STR Worker as a support worker) and responsibilities. The meeting would also have established communication processes between the three key practitioners involved in the post-natal period which would have facilitated the sharing of identified concerns. The review process has not identified any such communication between the practitioners aside from the telephone contact between the HV and the STR Worker on the day prior to Baby A’s death. 157. The GP Practice was involved in the antenatal period and utilising a different electronic system. Aside from receipt of the ANCC form, there was no communication between the GP Practice and Maternity Services in the antenatal period. The Practice did not have a regular Midwife who provided antenatal care at the surgery and advised that communication processes between these two services require improvement. Whilst Community Midwives provide antenatal care in GP Practices and record information electronically whilst there, this information cannot be viewed by the GP Practice. 158. Information from Mental Health Services to GP Practices is by letter with these normally being received about a week after appointments. The GP Practice learning summary noted that such letters were regularly received, provided detailed information and enabled a good understanding from the Mental Health Service perspective. 159. Whilst mother’s care was provided primarily by Maternity and Mental Health Services in the antenatal period, she was seen by practitioners from three different Mental Health teams (Assessment, Home Treatment and Recovery) during a period of 8 months. Maternity Service Practitioners included a range of professionals from; antenatal unit, delivery suite practitioners, post-natal ward and the PMH Midwife. The number of practitioners involved at different points over short time frame made it challenging for any one of these practitioners to fully assess mother’s needs and understand the overall picture. The limitations in involvement must also have made it extremely difficult for any one of them to establish a purposeful, working relationship with mother, particularly considering her frequent missed appointments and limited engagement, in relation to Mental Health Services, resulted in repeated discharges and re-referrals. 160. Research findings52 evidence that accurate assessment and a practitioner being able to establish a relationship with a service user which is both empathetic and purposeful are the two main factors which effect positive change. At the point of the referral being made to CSC, the Psychiatrist adopted an assertive outreach approach through involving the STR Worker. It can be hypothesised that earlier adoption of such an approach might have supported the earlier establishment of a working relationship which would have informed assessment processes. 52 McKeown, K. (2000). What works in Family Support with Vulnerable Families. Dublin: Dept. of Health and Children. Page 43 of 52 161. The Maternity Service learning summary notes that the missed appointments with that service should have prompted further action in accordance with the trust’s non-attendance policy (hereinafter known as DNA) and recommended a policy review to ensure it is fully clear, particularly where appointments at specialist clinics are not attended. Learning Point 21: Research findings53 evidence that parents with mental health problems offered services often didn’t access them and missed appointments. Health Practitioners sometimes step back in cases where engagement is poor but loss of support to the parent may in turn impact on the wellbeing or safety of the child. When parents with mental health problems don’t engage, practitioners should consider whether an assessment of the child is required. Recommendation 5: LSCB to seek assurance that DNA policies contain clear guidance on the actions to be taken when adults with caring responsibilities (including those for unborn babies) fail to engage with services dealing with health issues that can adversely impact on parenting capacity. Key services requiring such clear guidance include Adult Mental Health, Substance Misuse and Maternity Services. 162. The Maternity and Mental Health Service learning summaries note a lack of management oversight and practitioners did not receive support through supervision. There was no Named Midwife in post at that time, therefore the organisational safeguarding leadership would have been compromised. The Maternity Service learning summary notes this post has now been recruited to and an action plan is in place to ensure that Specialist Midwives receive regular safeguarding supervision on complex cases. The Mental Health learning summary also noted that the STR Worker’s role in this case was not formally agreed at a multi-disciplinary team meeting and formalised in the resultant care plan. Actions are underway to resolve this issue. 163. The LSCB did not have a multi-agency pre-birth protocol in place whilst this case was ongoing which could have supported practitioners in their decision making. This protocol has since been developed and included on the LSCB website in April 2017. 164. Safe sleep advice was provided by Maternity Service Practitioners including the Community Midwife and by the HV in accordance with internal guidance and the CDOP safe sleeping guidance, launched initially in 2015. This guidance has been updated and re-launched in 2017. The Mental Health learning summary includes a recommendation to ensure that Mental Health and Learning Disability practitioners working with families are aware of the key messages and can convey these to parents/carers. 165. Discussion with the Social Worker who screened the referral made by the Psychiatrist provided an insight into the challenges faced given the high number of referrals received and the fact that audit findings evidenced practitioners having only around 20 minutes to screen each one. 166. The Mental Health learning summary noted planned organisational change which will support future Mental Health service practice with pregnant women with serious mental health problems. Funding has been provided for the development of the Perinatal Mental Health Services through which local teams will support women during their pregnancy and for the first year after they have given birth. 167. The Psychiatrist at the learning event noted that previously there had been regular joint meetings held between Mental and Community Health Practitioners, facilitated by Mental Health Services which had been positively evaluated. The Mental Health learning summary includes an action to reinstate these meetings. 53 NSPCC Parents with a mental health problem: learning from case reviews. Accessed 29.08.17 Page 44 of 52 168. In conclusion, practitioners were challenged by organisational and contextual issues whilst providing care and meeting their statutory responsibilities towards mother and Baby A. In the ante-natal period, the lack of management oversight and supervision within Maternity and Mental Health Services resulted in missed opportunities to review the support provided, ensure a child focus, discuss mother’s limited engagement, consider other possible actions including early help support and challenge practitioner opinion through reflection on the case. Mental Health Services are delivered by teams with specific remits and patients who fail to attend appointments are discharged back to their General Practitioner as per practice policy. In complex cases where patients frequently disengage and are re-referred, it is then challenging for any practitioner to secure an effective working relationship. Specialist Midwifery roles can enable continuity of care by that service, however mother did not attend these appointments and the response to this was not sufficiently robust. 169. At the point of discharge, the lack of either early help provision or the co-ordination of a pre-discharge planning meeting, accompanied by poor information sharing processes impacted negatively on the care the Community Midwife and HV could provide in the post-natal period. Important risk information was not shared and neither practitioner was involved in the discharge plan decision making. Recommendation 8: The LSCB should seek to understand the systems issues and barriers which impact on effective information sharing both within and between partner agencies. 170. Throughout the timeframe, practitioners were working within differing electronic recording systems with frontline practitioners not having a full and thorough understanding of mother’s history and challenges. The situation was further complicated by the absence of multi-agency pre-birth guidance at that time. Page 45 of 52 SECTION 5: CONCLUSION 171. The review has considered whether the death of Baby A could have been predicted or prevented. Table 1 provides an analysis of the interrelating risk factors. 172. Table 1: Analysis of interacting risk factors (focusing on factors known at the time of the event in November 2016)54 BACKGROUND HAZARDS KNOWN AT THE TIME SITUATIONAL HAZARDS KNOWN AT THE TIME Maternal substance misuse (alcohol, cannabis, cocaine). Maternal mental health challenges, BPD, obsessive compulsive disorder, anxiety, low mood, depression. Maternal poor compliance with medication, treatment and therapy> no sustained improvement. Maternal history: domestic abuse, child protection concerns – no assessment of capacity to change. Deterioration in mental health prior to event. Father works full time. Incidents of family violence (maternal). Unstable adult partnership relationships. Maternal low to medium presentation BPD. Maternal low to medium risk in presenting mental health behaviours. Maternal experience of an unsettled baby vomiting all feeds back in conflict with professional opinion of settled baby. In early stages of renewed relationship between parents: previous history father struggled with mother’s mental health. No evidence of safety planning re alcohol use. Midwifery ANCC documented, no further planning or intervention. Maternal: multiple mental health behavioural issues. 13 contacts a with CSC (7-year period). 2 previous core assessments. Non-compliance. Specialist mental health support not escalated when maternal mental health deteriorated. Hidden or not appreciated Paternal alcohol intake minimised. 2 incidents of maternal alcohol intake. Conflicting opinion on Baby A’s presentation. No evidence of maternal parenting capacity. Joint parenting capacity (mother and father) not understood. STRENGTHS/PROTECTIVE FACTORS KNOWN AT THE TIME DANGERS KNOWN AT THE TIME Positive relationships between adults with parental responsibility. Adults focussed on needs of the children. Supportive extended family network. Mother child focussed when stable. Safer sleeping advice given. Maternal positive relationship with adult practitioners (MH, HV and Midwifery). Expert Psychiatrist report detailing risks of exacerbation of alcohol intake in the post-natal period. Interpretation of compliance issues. Maternal mental health unstable in pregnancy. Hidden or not appreciated Relationship between mother and maternal grandma could be volatile. Evidence of Maternal Grandmother alcohol and cannabis use. Some evidence of alcohol misuse in paternal family. 173. The review has identified the LSCB cannot currently be assured that multi-agency partnerships work cohesively and effectively with infants, children and their families to provide early help and protection where there is a history of a parental personality disorder/mental health issues and parental substance 54 Acknowledgement to Ball K (NSPCC) for the use of the Analysis of interrelating risk factors methodology, SCR repository. Page 46 of 52 misuse. It has focused on the provision of early help in relation to a pregnant woman, who had two children within complex family dynamics. She had significant mental health, substance misuse and social issues and agencies struggled to secure her consistent engagement. 174. The first key area of learning relates to early help provision. There was significant health service intervention with Baby A’s mother during the antenatal period and all practitioners did their utmost to support her. However, no consideration was given to working under the Early Help / EHAT frameworks. This would have provided more opportunity to provide multi-agency early help support or to plan other action to safeguard the unborn baby prior to a referral being made to CSC at a very late stage in the pregnancy. 175. CSC had previously taken the lead in providing early help support within the Local Authority Area and there was a perception within some agencies that this remained the responsibility of the Local Authority through CSC. The statutory responsibility to monitor the provision of early help is a function of the Local Authority. However, all multi-agency partners have a responsibility to provide support through an effective early help offer. This includes early assessment, planning and intervention where there may be additional needs for an unborn baby. All agencies should be clear about their responsibility and their service offer within the early help framework. Critically the key universal services involved in the antenatal period are health providers who need to ensure they have the systems and processes in place to identify additional needs, assess the level of need and intervene appropriately. The causes underlying the lack of early help support in this case are multi-factorial and have been identified and analysed within the review. 176. Removing a baby at birth for child protection reasons impacts on attachment and bonding. But allowing a baby to be discharged from hospital to a family who are unable to provide appropriate care and protection can result in significant harm to, or even the death of, the baby. The importance of good, clear early or statutory pre-birth assessment is critical. Joint assessment of adults who are carers is essential to understanding both strengths and weaknesses. 177. An initial practice challenge is that the pre-birth process should be given equal weighting to the statutory child safeguarding systems. Pre-birth early help is crucial to inform the pre-birth statutory assessment process, normally undertaken at 20-24 weeks of pregnancy. However, this is a late stage to begin a complex assessment. To complete a good assessment, it is important to focus on parental engagement (both parents) and make use of the duration of the pregnancy to work with the family and with the professional network around them. It is here that the role of the Midwife/HV/GP is crucial as they can form a supportive relationship with the mother to enable her to recognise the importance of ensuring the baby is safe. Engagement with a family does not need to mean the Social Worker must see the mother throughout the pregnancy. It could mean that the Social Worker overviews the case, working closely with the front-line professionals throughout the pregnancy and post birth period. 178. The second key area of learning relates to assessment of parenting capacity. Mother’s complex history and how it might impact on her parenting capacity was not fully understood. The need for additional support services for her children who had lived within a context of domestic abuse and witnessed mother self-harming at times was not identified. The relationship between Baby A’s parents was not well understood and their joint parenting capacity wasn’t assessed. Whilst services including CSC undertook assessments, these weren’t informed by all available information. Mental Health Services and the General Practice held key risk information in relation to mother. Whilst there was some communication between agencies, there was no robust multi-agency communication or collation of all the known information. 179. A further key area of learning is in relation to the provision on safe sleep advice. This was given in accordance with single and multi-agency guidance and practitioners felt that mother understood the advice given and would follow this. Providing this advice and ensuring this results in the desired behaviours with parents where there are known SIDS risk factors is very challenging. Recent research Page 47 of 52 findings have identified the need to further develop this area of practice. The key issue being that how can we change parental behaviours, who have been given the information and appear to understand its content when caring for infants. Frequently parental behaviour in such cases is strongly influenced by complex factors such as alcohol misuse, drug misuse, mental illness and other significant social challenges. 180. The review finds that there were complex, interacting factors leading up to the death of Baby A, as is frequently documented in infant deaths in similar circumstances. Within the timeline there was not one identifiable factor that led to the death or one point in the timeline at which, had different action been taken, the death could have been prevented. The risk could have been predictable had there been robust multi-agency information sharing to inform the risk assessment, planning and intervention in the antenatal and neonatal periods. Page 48 of 52 SECTION 6: RECOMMENDATIONS 1. The LSCB should ensure the multi-agency pre-birth protocol is revised and re-launched. It should include the multi-agency arrangements for early help as well as statutory intervention in pre-birth cases. This should encompass the pathways for intervention, multi-agency service offers and the learning and supervision requirements for front line practitioners. 2. The LSCB and Local Authority to ensure all early help guidance addresses the issues identified in this review process. The revised guidance documents should be re-launched and made collectively available. 3. The LSCB to seek assurance that partner agencies have in place a robust early help offer and the required systems and processes in place to enable effective early help work including in cases involving unborn children. 4. The LSCB should seek assurance from CDOP and Public Health that the current provision of safe sleep advice to families with SIDS risk factors has been reviewed and options for more effective interventions explored considering recent research findings. 5. LSCB to seek assurance that DNA policies contain clear guidance on the actions to be taken when adults with caring responsibilities (including those for unborn babies) fail to engage with services dealing with health issues that can adversely impact on parenting capacity. Key services requiring such clear guidance include Adult Mental Health, Substance Misuse and Maternity Services. 6. The LSCB to consider how General Practitioner Practices can be supported in increasing their involvement within multi-agency safeguarding work. 7. The LSCB should seek assurance that all partner agencies have recording practice standards in place which include the use of both robust chronologies and impact analysis. 8. The LSCB should seek to understand the system issues and barriers which impact on effective information sharing both within and between partner agencies. Page 49 of 52 APPENDIX 1: COLLATED LEARNING POINTS & GOOD PRACTICE 1. Learning Point: Pregnancy and post-delivery is a critical time when at least 1:5 women will experience a deterioration in their mental health. Women with a history of mental ill-health are at significant risk of a deterioration therefore practitioners delivering care should be aware of how individual women may present and the triggers to activate a deterioration. The use of healthcare passports 55 is a way of enhancing understanding and communication between the woman, her family and practitioners/services. 2. Learning Point: Monitoring and assessing growth of new-born, pre-term infants is a core activity to ensure optimal growth. There is an expectation that all new-born infants are weighed, and the weight is then plotted on a growth chart which enables accurate interpretation of the data. All infants have growth charts in their parent held Child Health records, to support growth monitoring processes. Maternity and HV Services should ensure that growth assessment and monitoring are in line with the expected practice standards. 3. Good Practice: Education and the School Nursing Service were very responsive following the death of Baby A in providing Child M and Child O with bereavement support, in seeking expert help and ensuring follow up. 4. Good Practice: In 2006/07, whilst there was evidence of the challenges in managing the thresholds of child concern between multi-agency partners, there was positive evidence that the common assessment framework was being implemented in practice. It is positive that at that time the HV Service used this process to plan and provide a range of services to support mother and Child N. 5. Good Practice: In 2013, there was a cohesive response by the Police and multi-agency partners to the incidents of domestic abuse which included safety planning and the use of specialist domestic abuse services for mother. 6. Learning Point: There is a practice expectation that all relevant multi-agency professionals are contacted for information during a core assessment however in this instance key professionals were not involved. This should be embedded in practice and is not a recent expectation. The Local Authority should lead work on ensuring this area of practice is strengthened. 7. Learning Point: In complex family units, it is crucial the safeguarding investigation undertaken by CSC gathers information in respect of all the children in the nuclear and extended sibling group to build a jigsaw in respect of the impact of an event on all the children involved. All agencies should contribute to effective information sharing to enable CSC to effectively lead the investigation. All agencies should be assured their role in this process is robust. 8. Learning Point: GP Practices have ongoing responsibility for the health and wellbeing of their practice population, they have the potential to be a hub of information. Currently the review was informed that practices do not receive information directly from CSC, Midwifery or Education. Therefore, the information they hold on families is incomplete. There has been local work to strengthen their role in multi-agency safeguarding arrangements but improved information sharing needs to be a continual focus to ensure the full participation of GP practices in safeguarding arrangements. 9. Learning Point: The maternity ANCC form is used to share information between Health Practitioners when there are safeguarding concerns. It is a system that has been in place for many years and has 55 A healthcare passport is a communication/information leaflet designed originally to facilitate and improve work with adults with learning difficulties in a NHS setting. Its scope can be extended for service users in other situations. Page 50 of 52 recently (July 2017) been reviewed as a part of the standard operating process. It could be used to trigger the early help assessment tool (hereinafter known as the EHAT) in the pre-birth period. Early assessment, planning and intervention could then be used to inform the statutory social work assessment in either pre-birth or neo-natal period. 10. Good Practice: The Midwifery Service was proactive and person-centred in recognising mother’s deterioration and expediting her appointment to the same day, for review and assessment by Home Treatment Team Mental Health Services. 11. Learning Point: The effective dissemination of safeguarding care plans to front line practitioners involved in the provision of care to new born infants and their mothers is crucial if infants are to be safeguarded. Frontline practitioners did not hold crucial information to support their intervention. The information cascade system failed in this case. All multi-agency workers including unqualified Mental Health Workers should have access to supervision and case monitoring processes. 12. Learning Point: The historic information was mainly documented in a narrative form and little information was identified pertaining to the needs of the children, impacts on them or any effective analysis of the outcomes of intervention on the children. Can the LSCB and its partner agencies be assured that practice has improved and the outcomes of intervention with families in crisis are documented to support future intervention?. 13. Learning Point: The development of chronologies of significant events should be embedded in practice. This is an expectation of safeguarding practice, but the evidence reviewed does not demonstrate their use in supporting the assessment of parenting capacity and parental motivation to change. The use of safeguarding chronologies should be strengthened in single and multi-agency practice to more accurately understand the history. 14. Learning Point: CSC procedures include a requirement for screening responder to communicate directly with a referrer. This direct communication ensures that the referrer’s perspective and level of concern are fully understood and can provide opportunity for challenge by either the referrer or the responder. These communications can prove difficult considering the high number of referrals screened, differing organisational systems and the availability of the referrer when contact is attempted. Referrers should anticipate being contacted and ensure their referral includes information required to assist a CSC responder in making contact. Within CSC, the importance of the referrer being contacted should be reinforced. 15. Learning Point: Practitioners can contact CSC to discuss a case, however they should understand that such contact does not constitute making a formal referral. The referral process requires submission of a completed CSC service request form. Practitioners should seek advice about making a formal referral if CSC do not feel the case meets their service threshold on discussion. All agencies have safeguarding leads in place to provide support on contacts, making referrals and escalating cases if necessary and should have effective quality assurance processes in place for these practices. 16. Learning Point: Key issues that could have alerted involved practitioners to the need for a robust, coordinated response were the frequent missed appointments with all involved agencies, failures to accept interventions offered and the repeated failures to take prescribed medication. Whilst it is important to offer further appointments and support, consideration should also be given to the risks posed to an unborn baby by these issues and what further action is needed. Completion of an EHAT with parental consent facilitates holistic assessment and the provision of interagency early help support aimed at meeting identified needs and preventing escalation of the difficulties. Easily available and clear guidance on the early help responsibilities of all practitioners should be available to support them in this area of practice. Page 51 of 52 17. Learning Point: Referrals received about children living in shared care arrangements can be complex to manage. It is important that a safeguarding investigation clarifies what the current care arrangements are, whether they are permanent, what contact a child is having with the parent about whom concerns have been raised and whether that contact poses a risk. In order for CSC to be able to do this, referrers should ensure that a clear understanding of the care and contact arrangements and whether the parent has consented to the referral are included on the service request form. Partner agencies should ensure this through their internal quality assurance processes. CSC should assure itself and the LSCB that this practice is standard when assessing such referrals. 18. Good Practice: The Psychiatrist ensured that mother was contacted after she left the consultation abruptly by a Nurse to provide her with reassurance. 19. Learning Point: Practitioners require an understanding of how a diagnosis of BPD might impact on parenting capacity. The expertise of Mental Health Service Practitioners both within individual cases and through the provision of multi-agency training can promote such understanding. 20. Learning Point: Effective assessment and planning require access to all available information systems prior to contacts with children and families. The HV Service should ensure the systems and processes in place enable the timely inclusion of new information, particularly that related to vulnerability and risk issues. 21. Learning Point: Research findings56 evidence that parents with mental health problems offered services often didn’t access them and missed appointments. Health Practitioners sometimes step back in cases where engagement is poor but loss of support to the parent may in turn impact on the wellbeing or safety of the child. When parents with mental health problems don’t engage, practitioners should consider whether an assessment of the child is required. 56 NSPCC Parents with a mental health problem: learning from case reviews. Accessed 29.08.17 Page 52 of 52 APPENDIX 2: BIBLIOGRAPHY. 1. Calder, M.C. (2003) Unborn Children: A Framework for Assessment and Intervention. In: Calder, M.C. and Hackett, S., eds. Assessment in Child Care Using and Developing Frameworks for Practice. Dorset: Russell House Publishing 2. Calder M., Hackett., et al (2013) Assessment in Child Care- Using and Developing Frameworks for Practice. 2nd ed, Russell House Publishing 3. Children’s Workforce Development Council. (2010). Overcoming Obstacles. Barriers affecting practitioner’s engagement with the CAF process and lead professional. 4. Corner, R. (1997) Pre-Birth Risk Assessment in Child Protection. Social Work Monographs, Norwich: University of East Anglia 5. Easton, C., Morris, M. and Gee, G. (2010). LARC2: Integrated Children’s Services and the CAF Process. Slough: NFER 6. Hart, D. (2010) Assessment Prior to Birth. In: Horwath, J., ed. The Child’s World, Assessing Children in Need. London: Jessica Kingsley Publishers 7. HM Government (2013) Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children. 8. HM Government (2015) Working Together to Safeguard Children- a guide to inter-agency working to safeguard and promote the welfare of Children. Crown Copyright. 9. Hodson A., (2012) How research on pre-birth assessments should affect practice. Community Care 30.8.2012. Downloaded comunitycare.co.uk 27.8.17 10. McKeown, K. (2000). What works in Family Support with Vulnerable Families. Dublin: Dept. of Health and Children. 11. Merseyside CDOP. (2015). Multi-Agency Safe Sleeping Guidance. 12. Merseyside CDOP. (2017). Multi-Agency Safe Sleeping Guidance. 13. NSPCC Parents with a mental health problem: learning from case reviews. Accessed 29.08.17 14. Ofsted (2011) Messages from Serious Case Reviews. 15. Anna Pease, Jenny Ingram, Peter S Blair, Peter J Fleming. (2017) Factors influencing maternal decision-making for the infant sleep environment in families at higher risk of SIDS: a qualitative study BMJ Paediatrics Open Accessed- 07.09.17. 16. Anna Pease, Jenny Ingram, Peter S Blair, Peter J Fleming. (2017) Mothers’ knowledge and attitudes to sudden infant death syndrome risk reduction messages: results from a UK survey. ADC Online. Accessed 07.09.17. 17. RCPCH (2009) Using the new UK-World Health Organization 0-4 years growth charts. DoH. 18. SCIE Learning Together to Safeguard Children: a systems model for serious case reviews. 19. St Helens Council (2014) St. Helens CSC Thresholds 20. St Helens Council (2014) Think Family guidance documents. There are 5 documents- the Think Family Protocol, Think Family Brief Guide, Think Family Continuum of Need, Think Family Catalogue of Templates and the Think Family Procedure “Think Child, Think Adult, Think Family”. This was previously known as the ‘child in need procedure’. 21. St Helens Safeguarding Children Board (2014) The St Helens Continuum of Need (CAF Thresholds) 22. St Helens Safeguarding Children Board. Multi-agency Early Help Strategy for: Children, Young people and families in St Helens 2016-2019. 23. Welsh Government (2012) Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Model. |
NC52706 | Significant head injuries to a 2-week-old boy in Autumn 2018. The injuries were suspected to be non-accidental. Thomas was alone in a room with his brother when the injury occurred. Learning themes include: early help; supporting adults with experience of adverse childhood experiences (ACES) and trauma; the impact of domestic abuse on children; abusive head trauma; safer sleep for infants; and identifying and supporting learning difficulties of parents and carers. Recommendations are embedded in the learning points, which include: the safeguarding children partnership should require all partners to evidence their organisational focus and response in relation to the Domestic Abuse Act 2021's requirement to recognise children who see, hear or experience the effects of domestic abuse as victims in their own right; the partnership should re-promote the local area's pre-birth protocol across all partners including the examples of pre-birth strengths and concerns to ensure all practitioners have a sound awareness of when and how to consider its use; the partnership should consider how professionals across the partnership are supporting parents and carers with learning disabilities and learning difficulties, what resources are available and whether further awareness raising and promotion regarding responding well to people with learning disabilities and difficulties is required; and the partnership should request assurance from members and subgroups that housing related challenges for families remain a focus across the partnership, including all professionals becoming more aware of the cumulative risks to children which housing issues can bring.
| Title: Serious case review: overview report: Child LS (Thomas). LSCB: Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership Author: Amanda Clarke Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SeriousCase Review l Overview Report: Child LS (Thomas)Author: Amanda Clarke Date: September 2022 Publication Date: 7th November 2022Page 2 of 21 Contents 1. The Reason for the Serious Case Review .................................................... 3 2. The Children and their Family ........................................................................ 3 3. Legal Framework and Methodology for the Review ............................... 4 4. Overview of What Happened, Key Circumstances and Background .. 5 5. Key Themes of the Review .............................................................................. 6 6. Good Practice .................................................................................................... 15 7. Conclusion/What Needs to Happen .......................................................... 15 8. Learning Points ................................................................................................. 16 9. References .......................................................................................................... 16 Appendix A ................................................................................................................... 17 Appendix B .................................................................................................................. 19 Page 3 of 21 1. The Reason for the Serious Case Review 1.1 In autumn 2018 Child LS (to be known as Thomas) was born. Two weeks later Thomas was found with a serious head injury at home. His parents (to be known as Mother and Father in the review) were both present as was his half sibling aged three (to be known as Liam in the review). The parents both said Thomas was alone in a room with Liam when he became injured. Serious injuries were found to Thomas’ skull and brain and a non-accidental cause suspected. Fortunately, Thomas survived but the injuries sustained have left him visually impaired. 1.2 A serious case review (SCR)1 referral was made to the local Safeguarding Children Board (now Safeguarding Children Partnership). It was concluded that the criteria for a SCR was met. An independent author (to be known as the Author) was commissioned to work with a multi-agency panel of local senior professionals (the Panel) to identify any learning from the circumstances to improve arrangements to safeguard and promote the welfare of children. 2. The Children and their Family 2.1 Thomas and Liam no longer reside with Mother and Father. The names used in the overview report will be used to protect the true identity of the children. The children, Mother and Father were all white British and spoke English. Name to be used in the review Age at significant incident Thomas 2 weeks Half Sibling Liam 3 years Mother (to the children) Early 30s Father (to Thomas) Early 30s 1 Serious case reviews are now known as child safeguarding practice reviews, Working Together to safeguard children, Gov.UK July 2018 Page 4 of 21 3. Legal Framework and Methodology for the Review See appendix A for Information. 3.1 After consideration of criteria in Working Together to Safeguard Children July 2018 (the guidance in use at the time) and after Panel members had been identified, the first meeting of the Panel and Author took place in May 2019. 3.2 The Author is an independent safeguarding advisor with no connections to the local area or any of the organisations involved in the review. Her career history includes working as an investigator within police public protection and conducting inspections and audits for the NSPCC. She currently chairs a Safeguarding Adults Board and is independent chair and scrutineer of a Safeguarding Children Partnership. She also provides safeguarding advice and support for a Diocese in the Midlands. She has authored several case reviews and domestic homicide reviews. 3.3 At the time of the first Panel meeting a criminal investigation and family court proceedings were ongoing involving both parents. These formal processes continued for a substantial period of time and were further delayed by the Covid 19 pandemic. The opportunity to hold a practitioners’ event for professionals who had offered support to the family was considered by the Panel at the first meeting in 2019. Plans commenced for a practitioners’ event, but this was postponed due to the parallel proceedings. At the point of the review resuming in Spring 2021 it was decided by the Panel that the substantial period of time elapsed since the significant incident made it not possible for the practitioners’ event to be reinstated. Some staff had changed roles or left. A Panel meeting had been held in February 2020 to ensure emerging learning themes from the review were identified including any urgent action required as it was clear then the SCR would not be completed in expected timescales, without the further delay caused by the impact of the Covid 19 pandemic. Meeting the parents as part of the review was delayed in the early stages due to them both being integral to the criminal investigation. When the Panel reconvened in 2021 it was agreed to contact Mother and Father after such a delay would be inappropriate. Family court processes were still continuing at that time regarding the future of the children. The Panel were informed the couple had separated and Mother had moved to a different area of the UK. A decision was made that the Panel would re-examine the experience of Thomas and his family, identifying key learning themes to be highlighted in an overview report and demonstrating the current position for the local area in terms of safeguarding, three years after the significant incident. The decision to proceed in this way was considered proportionate under the circumstances. Page 5 of 21 3.5 The terms of reference for the review were developed at the first panel meeting and are attached at Appendix B. The timeframe for the review was agreed as December 2016 to November 2018; the start and end dates were when significant episodes occurred in the family. The Panel members and the Author were clear that other relevant incidents relating to the children and family occurring prior to the timeframe must also be considered. Non recent events in the lives of families are often significant and can impact upon and shape what occurs in the future. 4. Overview of What Happened, Key Circumstances and Background 4.1 Mother had lived with her grandmother throughout much of her life. Records indicate Mother may have been abused as a very young child by another relative. Mother had learning difficulties and a history of other vulnerabilities including some substance and alcohol misuse, housing problems and debt. She had her first child as a very young adult. This child lived permanently with his father and was not part of the review. Another child, the sibling of Thomas, (known as Liam) was born in 2015. Team around the family (TAF) support was ongoing with regular engagement from Mother and sometimes Liam’s father (who was a different man to the first child’s father). The TAF support closed in spring 2017. When the relationship between Liam’s father and Mother ended, Mothers relationship with Father (of Thomas) is thought to have commenced. This was believed to be in late 2017. A domestic abuse incident occurred between Mother and Father in early 2018 in the presence of Liam who was a toddler at the time. Both adults received minor injuries but refused to make complaints to the police. Referrals were made to children’s social care regarding the domestic abuse and the impact on the child (Liam) who was present. An assessment was undertaken then the case was closed. Just prior to the domestic abuse incident Mother had asked for early help support but contact to commence the early help had not taken place. Mum was struggling emotionally due to her grandmother’s recent death and needed help with housing and finances. It transpired that around this time Mother became pregnant with Thomas. The pregnancy was eventually ‘booked’ (reported formally) in spring 2018 at around 12 weeks. Mother did not attend all antenatal appointments throughout the pregnancy but was seen intermittently. She continued the relationship with Father, sometimes they lived together at the same address but sometimes not. Housing and risk of homelessness continued to be a problem for Mother and Liam. They often stayed at different temporary addresses with little stability. Early help support was offered to the family in spring 2018. Mother was seen by a family support worker but eventually, due to a number of missed appointments the support was closed. Page 6 of 21 A re-referral for early help was made later in the pregnancy with two visits taking place prior to the birth of Thomas in autumn 2018. After the birth and discharge from hospital Mother and Thomas were seen by community midwifery and by early help support practitioners. Mother’s housing situation and sleeping arrangements for herself, and the children continued to be problematic. The midwife last saw Mother with both children the day before the significant incident. A plan had been made to visit jointly with the health visitor but sadly Thomas was injured before the contact took place. He was two weeks old when the incident leading to the severe head and brain injuries took place. Thomas has now been adopted and is said to be happy and settled, with his complex health needs being managed well. 5. Key Themes of the Review When the Panel reconvened in 2021 key themes from the review timeframe were identified as follows (in no order of priority): • Early Help • Supporting Adults with Experience of Adverse Childhood Experiences (ACEs) and Trauma • Impact of Domestic Abuse on Children • Abusive Head Trauma • Safer Sleep for Infants • Identifying and Supporting Learning Difficulties of Parents and Carers. Early Help Records show that Mother whilst in touch with the health visitor for Liam agreed to a referral for early help support in early 2018. This was just prior to the pregnancy with Thomas being known. At the time she had multiple needs including housing and debt, bereavement and was also asking for help with nursery for Liam and with parenting generally. These needs were in addition to her earlier adverse experiences. Several attempts by the support worker from the Children and Wellbeing Service (commonly known as the Early Help Service) to make contact with Mother were unsuccessful. A first joint visit with the health visitor eventually occurred five weeks after the referral. The domestic abuse incident in which Liam was present had occurred ten days before the early help service face to face contact. It is positive that weekly visits were made to Mother and Liam by the support worker during the following month, advice and signposting was provided for both parent and child, including support attempted relating to domestic abuse, see below. Page 7 of 21 Despite initial engagement with early help, Mother was then not seen for a period of six weeks regardless of the efforts of the support worker. Mother was pregnant at this point and was in intermittent contact with other health professionals for the pregnancy. The early help support was closed due to Mother’s perceived non-engagement, with a re-referral in summer 2018 from the health visitor. Mother’s needs were identified then as “pregnant and at risk of homelessness”. Mother and Liam were seen twice by the early help support worker prior to Thomas being born and once after the birth before Thomas was injured. Other contacts are on record as attempted. The significant focus for Mother in terms of early help support offered during that period was on housing. Some focus on Liam was evident in recording from visits including observations and guidance regarding nursery placements. The support workers involved appeared to be offering assistance for a wide range of issues, under difficult circumstances including trying to locate Mother who frequently had to change her living arrangements. However, a formal plan of support with agreed actions and intended outcomes was not evident. Support appeared offered on an adhoc basis with focus on Mother’s priority needs first. The Author was told in the Children and Family Wellbeing Service since the remodelling in early 2021, when the Family Safeguarding Model2 came into place, the service has introduced new practice standards and a new quality assurance framework. This is providing evidence that outcomes are improving as a result. Supporting Adults with Experience of Adverse Childhood Experiences (ACEs) and Trauma From what is recorded about Mother’s own childhood and transition into adulthood it is clear her life included ACEs3, as detailed in the overview of the case above. Different professionals were aware of some or all of Mother’s ACEs, there was evidence of ACEs being identified and recorded, (albeit not specifically using ACE terminology) and some support was offered. What was less evident was the consideration of the impact of the ACEs on Mother as an adult and a parent, and any consequential impact on her children. 2 Family Safeguarding works with the whole family using a strengths-based approach to identify families' strengths, needs and any changes to be made. The aim is to “support parents to become better equipped to meet the demands of parenting so families can stay together safely”. 3 Adverse childhood experiences (ACEs) are stressful or traumatic events that happen in childhood and can affect people as adults Page 8 of 21 Since the review timeframe the knowledge and awareness of ACEs and their impact has improved extensively. Information relating to trauma4 is also now more widely available. Mother’s documented history demonstrated some aspects of substantial trauma. The local area has taken a proactive approach to improve responses to ACEs. A group of frontline practitioners have developed a resource5 to inform practitioners about what ACEs are, their immediate effects and how they can affect children in the short-term and throughout their lives. A more trauma informed workforce is the aspiration for the whole partnership and wider geographical area. Senior leaders have committed to a pledge of investing in the development of trauma informed practice. This includes encouraging the understanding of human experiences of the children, families and communities in the area, responding to these experiences and addressing the causes rather than just the presenting behaviours. A local network is facilitating multi-disciplinary workshops aimed at different professional groups ranging from basic awareness, information for frontline staff and briefings for managers and leaders. The Child and Family Wellbeing Service are in the process of facilitating full day training/awareness sessions for all staff within the service in the local area. The Author was told the impact of the training will be examined. Impact of Domestic Abuse on Children Liam, in early 2018 whilst a toddler, was present and witnessed a domestic abuse incident between his Mother and the Father of Thomas. Police attending the incident recorded Liam’s unusual response, in that he appeared outwardly unaffected suggesting this may have been a regular occurrence in the household. No formal complaints were made by either adult, with both alleged to have assaulted the other. The level of need applied initially was Level 46, with a child being recognised as at risk of significant harm. It is believed that Mother had not yet conceived Thomas at the time of the reported domestic abuse incident. Pre birth assessment is explored below. A child and family assessment took place regarding Liam, but Father was not part of the assessment due to Mother claiming at the time the relationship was over. A manager’s case note suggested Father should have been included however this was not acted upon. Checks of Father had been undertaken when the referral was received with no recorded relevant history. 4 Trauma is a term for a wider set of experiences or events that can happen at any time of life and includes some of the adversities in childhood known as ACEs. Trauma describes the psychological impact of experiencing or witnessing a physically or emotionally harmful or life-threatening event. It may be a single incident or prolonged or repeating experiences. 5 Resource- “The little book of ACEs” 6 Local Area Continuum of Need and Thresholds Guidance, June 2016 Page 9 of 21 After the assessment the case was stepped down to a lower level of need (Level 2- evidence of some unmet needs/ low risk). A request for early help support (regarding housing issues) was already in progress prior to the domestic abuse incident. The health visitor having received notification of the incident 3 weeks after it occurred informed the support worker, who was not aware of the abusive incident and who at the time had not yet been able to make contact with Mother. There is considerable research relating to the negative impact and cumulative harm on children living in households where domestic abuse is present. In Sowing the Seeds- children’s experience of domestic abuse and criminality7, the importance of focusing on children is highlighted and it is recommended “identifying children who live in households with domestic abuse as victims in their own right”. The Domestic Abuse Act, April 2021 explicitly recognises children as victims if they see, hear or experience the effects of abuse. It is therefore imperative that all professionals are aware and respond accordingly to children as set out in the Domestic Abuse Act, when assessing risk and need, or when planning interventions. The Author was told the response to domestic abuse in the local area in terms of information sharing and families receiving appropriate support was much improved. Domestic abuse was one of the key priorities of the Partnership area, alongside neglect, with three domestic abuse tactical groups covering the three areas of the wider Partnership. A Multi-Agency Safeguarding Hub (MASH) approach is constantly evolving, resulting in more efficient ways of working with partners to identify cases (such as this one) and enable an earlier response. The local safeguarding children partnership’s current training programme offers a multi-agency course with a specific focus on children affected by domestic abuse. Training has improved within the Child and Family Wellbeing Service with more support workers across the districts trained in the Freedom8 Programme. This was not the position in 2018 and whilst some support was provided to Mother as part of the Early Help Offer, this was sporadic with limited impact. There are also plans now for the Child and Family Wellbeing Service to appoint a number of specialist domestic abuse workers. 7 Sowing the Seeds- Dr Elaine Wedlock, Dr Julian Molina for the Victims’ Commissioner (England and Wales), April 2020 8 The Freedom Programme is a domestic violence programme primarily designed for women as victims of domestic violence, since research shows that the vast majority of cases of serious abuse are male on female. The programme examines the roles played by attitudes and beliefs on the actions of perpetrators and the responses of victims and survivors. Page 10 of 21 Learning Point 1 The Safeguarding Children Partnership should require all partners to evidence their organisational focus and response in relation to the Domestic Abuse Act 2021’s requirement to recognise children who see, hear or experience the effects of domestic abuse as victims in their own right. Pre-Birth Assessment The pregnancy leading to the birth of Thomas became known to services in Spring 2018 when Mother was seen by community midwifery. She was assessed as being around 12 weeks pregnant. Mother told the midwife about the domestic abuse by Father, who she described as her ‘previous partner’. After this contact, Mother did not attend two appointments and at almost 20 weeks pregnant, she was seen with Father and Liam. At this appointment she denied any involvement with ‘Social Services’. There was no evidence of routine enquiry9 being undertaken despite the disclosure of domestic abuse at the first appointment. It is unclear if this was due to the presence of Father at the 20 week appointment. At this point, with Mother halfway through the pregnancy, there appears no consideration of a pre-birth assessment. Two routine, no access visits by the health visitor followed. When eventually Mother was seen, additional concerns were noted, including debt, homelessness, difficulty coping with Liam as a toddler and Mother’s possible learning difficulties. The health visitor made a request for support to the Child and Family Wellbeing Service but notably the previous domestic abuse was not mentioned. A different support worker was allocated in 2018 and it is unclear whether the different worker was aware of the previous domestic abuse incident. Some telephone contact had occurred between the worker and Father when he answered Mother’s phone but there was limited professional curiosity attempted with Mother about the relationship when Mother was eventually seen. Father did not stay during the contact therefore there was opportunity for further exploration with Mother about the couple’s history. Other pressing concerns during the visit, such as pending eviction and possible bleeding related to the pregnancy were managed well. There is no evidence in any agency records that a pre-birth assessment was considered regarding Thomas. A multi-agency pre-birth protocol was in place at the time in the partnership area, updated and re-published in 2021. This provides clear guidance regarding when a pre-birth assessment should be 9 The routine enquiry is an opportunity for health professionals to sensitively enquire with a woman about her experience of domestic abuse both present and past, regardless of whether there are indicators or suspicions of abuse. Should a response be received that domestic abuse is a concern then further safeguarding advice and/ or action must be taken. During pregnancy advice and action must include risks to the unborn child/ new baby as well as the mother being assessed- Domestic Abuse: A resource for health professionals, March 2017 Page 11 of 21 considered, stating “requests for a multi-agency pre-birth assessment should be made as soon as concerns for the safety of the unborn child become apparent in the pregnancy”. The updated protocol still includes helpful examples of pre-birth strengths and concerns. A number of the concerns relating to the position for Mother at the time were included in the protocol examples available when Mother was pregnant, but it is not known why a request for further assessment of the family’s situation was not instigated. Learning point 2 The Safeguarding Children Partnership should re-promote the local area’s pre-birth protocol across all partners including the examples of pre-birth strengths and concerns to ensure all practitioners have a sound awareness of when and how to consider its use. Routine enquiry and seeing women alone was scrutinised in the maternity themed review which followed this case, with assurance provided (see in Abusive Head Trauma below). Abusive Head Trauma Thomas was injured when he was less than one month old. Children under 1 have been consistently a high proportion of subjects of serious incident reports and serious case reviews10. Abusive head trauma was a suspected cause for Thomas’ injury. Often referred to as ‘shaken baby syndrome’ abusive head trauma can cause catastrophic injuries or death. The condition occurs most commonly in children younger than two years of age with an estimated prevalence of 1: 3000 in babies younger than six months11. Many local safeguarding children partnerships have introduced education programmes for parents and carers of babies, and for professionals supporting them, to raise awareness about appropriate responses to crying babies, which is when abusive head trauma can often occur. ICON12 an evidence based; multi-agency programmes is now in use across the safeguarding children partnership area where the incident occurred. In the absence of the ICON programme being implemented in 2018 there was still an expectation that routine advice relating to safe handling of babies would be provided to expectant parents. There is no specific evidence that this guidance was provided during the pregnancy. It is acknowledged that Mother, did not or was not able to attend all appointments, or meet with professionals who were trying to support her. Therefore, opportunities to provide the information to help prevent abusive head trauma were less 10 Child Safeguarding Practice Review Panel Annual Report, 2018-19. 11 CORE-INFO Head and spinal injuries in children, NSPCC and Cardiff University, May 2014. 12 ICON: I-infant crying is normal and will stop, C- comfort methods can soothe, and the crying will stop, O- ok to walk away if the baby is safe and the crying will stop, N- never shake or hurt a baby, iconcope.org Page 12 of 21 than with some other families. Immediately prior to the birth and in the first weeks after Thomas was born Mother’s housing situation worsened and the chances to share important advice were minimal. Mother’s understanding and ability to retain advice was never properly assessed, see below, meaning that advice, if provided may not have been fully understood. It is noted that Mother disclosed being dyslexic and not being able to read. The local area has arranged for the ICON advice leaflet in easy read version to be added to the Partnership website. This is helpful to some people with language and literacy issues but other parents who cannot read or have difficulties understanding certain information may still find accessing the guidance is a challenge. It is not known which carer, was responsible for causing the head injury to Thomas or under what circumstances or context. With case recording not evidencing Mother as receiving any advice or support regarding safe handling and responding to crying babies it is less likely that Father received any similar guidance. Research suggests that around 70% of babies who are shaken are shaken by men13. Any education and prevention programme should include male parents and carers even those who are hard to reach as in this family’s case. The local area’s ICON materials are currently for anyone in a caring role so targeted at parents/ carers, but dependent on the service delivery of messages as to how fathers are included. There is increasing awareness of the need to involve fathers including in preventative messaging. The Child Safeguarding Practice Review Panel’s National Review – The Myth of Invisible Men, September 2021 has been a catalyst for the local partnership to try to strengthen work relating to males. The Author was told in the local NHS Foundation Trust Hospital a themed review14 took place which included Thomas as his case was one of 4 similar cases having occurred over a short period of time in 2018. A detailed action plan was developed which included a focus on domestic abuse, routine enquiry and seeing women alone, and strengthening safeguarding supervision. Weekly audits were completed as part of the identified actions. Assurance was provided to the (then) local Safeguarding Children Board in February 2020 that actions had been completed to address the areas of focus identified in the themed review. Safer Sleep for Infants As has been described the living arrangements for Mother and Liam were complicated and appeared to worsen during the pregnancy and after Thomas was born. Mother would have been under considerable 13 Demographics of Abusive Head Trauma in the Commonwealth of Pennsylvania, Kesler et al, 2008 14 Maternity review of 4 cases of non-accidental injuries to babies in 2018, February 2019 Page 13 of 21 pressure which is demonstrated by her speaking to professionals about her worries regarding housing and related debt. This was Mother’s own priority need and often over shadowed other support which professionals tried to provide, including safer sleep advice for infants. Moving between temporary addresses presents difficulties for children, in particular with regard to safe sleep settings for babies and younger children. Mother described that she and Liam, a toddler at the time, were sometimes sleeping on sofas at the different locations where they stayed. Once Thomas was born there was still a lack of clarity as to what was a permanent address for the family. It was unclear whether Mother was in possession of required equipment to facilitate a safe sleep setting for a newborn each time she stayed at a different address, albeit a moses basket was later noted as being in use. Records show health visiting advice regarding swaddling and overheating. Specific safe sleep guidance was provided intermittently but Mother was observed as ‘agitated’ and therefore possibly not receptive to the information provided. Due to the frequency of appointments not attended by Mother during the antenatal period other opportunities to share routine advice had not always occurred. The position with Father and his contact/involvement with professionals was explored above. Father received no guidance relating to safer sleep for infants. It was positive that multi-disciplinary discussions took place regarding the concerns for the family’s living arrangements especially after Thomas was born. Conversations are recorded including queries related to equipment and furniture. Professionals recognised the stress that the housing position for the family created. The Author was told there has been much attention and progress across the local partnership area regarding support for parents and carers relating to safer sleep for infants. Evidence of the work includes a drive on public facing campaigns; introduction of safer sleep assessment tool; a multi-agency initiative by the police who on visiting a family home. If any safer sleep concerns are identified they will refer via MASH to the health visiting service. Whilst the significant incident for Thomas did not relate to safer sleep provision there were identified risks for him due to the context in which he and his family were having to live and sleep. Clear guidance repeated consistently in a method which takes account of any additional needs and circumstances of the parents should be a priority for all professionals to share with families who they are trying to support. The local safer sleep assessment tool was described as now being accessible, for parents with additional needs and where English is not the first language. Page 14 of 21 Identifying and Supporting Learning Difficulties of Parents and Carers Information submitted through the timeline of the review suggested Mother had a learning difficulty15. Several times in recording it was noted that learning difficulties were present or suspected for Mother but evidence of specific action taken, or evidence of adjustments being made or additional support being offered was limited. Around the pregnancy for Liam Mother was recorded as saying she could not read or spell and this was repeated in early help support provided in the first year after Liam was born. Mother continued to be open about her learning needs when pregnant with Thomas and particularly when asking for help regarding her housing situation. Dyslexia was disclosed by Mother twice prior to Thomas being born and records also show Mother saying she had had a statement of special educational needs. There is no record in the timeframe of Mother having a diagnosed learning disability. The Working Together with Parents Network has updated the ‘Good Practice Guidance of working with parents with a learning disability16’. The updated guidance supports professionals working with parents with learning difficulties and learning disabilities, and their children. It is “not just for professionals involved in child protection proceedings but contains useful information for anyone working with a family affected by parental learning disability”. The Guidance suggests good practice in working with parents which includes accessible information and communication, support designed to meet the needs of parents and children based on assessment of their needs and strengths, and access to independent advocacy. It is not sufficient to simply record an observation that a parent or carer has a learning difficulty or disability. Adults, particularly those with caring responsibilities for others and who have additional needs identified should receive appropriate support which takes account of their wishes and feelings, and of other known circumstances. Learning point 3 The Safeguarding Children Partnership should consider how professionals across the partnership are supporting parents and carers with learning disabilities and learning difficulties, what resources are available and whether further awareness raising and promotion regarding responding well to people with learning disabilities and difficulties is required. 15 A learning disability is different from a learning difficulty as a learning difficulty does not affect general intellect. There are many types of learning difficulty, some more well-known are dyslexia, ADHD, dyspraxia. A person can have one or a combination. Learning difficulties can exist on a scale, as with learning disabilities, from mild to severe. A person can have both a learning disability and learning difficulty. www.mencap.org.uk 16 The Good Practice Guidance was updated in July 2021, the original guidance being published in 2007 by the Department of Health and the Department for Education and Skills. Page 15 of 21 6. Good Practice It is clear many professionals and services worked hard to support Mother, Liam and Thomas. Good practice is highlighted when practitioners or a team or department are considered to have excelled ‘over and above’ what is expected of them and their service. The Panel and Author when examining all agency involvement felt that the following good practice should be noted: In 2017 when a health visitor discussed Clare’s Law17 with Mother regarding her new relationship. In 2018 there was good liaison between community midwifery and health visiting after Thomas was born regarding concerns for Mother’s living arrangements. In 2016 the GP requested Mother attend an appointment to talk over two attendances in quick succession for Liam at Accident and Emergency. The GP notes showed an appropriate focus on safeguarding for the child and after exploration no safeguarding issues identified. 7. Conclusion/What Needs to Happen Thomas suffered a significant head injury within the first month of his life. He was living with his Mother, Father and brother Liam at the time. The actual cause of the injury was never discovered despite extensive enquiries, but abusive head trauma was strongly suspected. It is known children under 1 are the most likely age group to die through abuse or neglect 18. In this case Thomas was very seriously harmed but survived the abuse. Mother and Father’s relationship was quite new, and a domestic abuse incident had occurred in Liam’s presence just prior to the pregnancy (for Thomas) being known. As well as the concerns regarding domestic abuse Mother had experienced other trauma in her life including suspected child sexual abuse and bereavement. Housing difficulties and debt were continuing problems for her and the children throughout the time frame of the review. The review has focused on key themes but recognises other concerning aspects in the lives of the family to be significant including housing and housing related issues. The Author was told housing was a feature in another local review “Millie, April 2022” and as a consequence has been a focus for the Partnership. The strategic partners were keen to ensure this learning was not lost and therefore asked that an additional learning point for the Safeguarding Children Partnership be added (see below). The longer term impact on children of housing challenges for families and related debt should not be under-estimated with 17 The Domestic Violence Disclosure Scheme (also known as Clare’s Law) enables the police to disclose information to a victim or potential victim of domestic abuse about their partner’s or ex- partner’s previous abusive or violent offending, Domestic Violence Disclosure Scheme Factsheet updated 31 January 2022, www.gov.uk 18 Child deaths by abuse and neglect, NSPCC Statistics briefing, September 2020 Page 16 of 21 homelessness and housing difficulties often associated with neglect, as the basic requirements for a child/children to live and thrive are not being consistently met. The delay in the review has been explained and is unfortunate. This meant the involvement of family members was not possible, but it is positive to know that Thomas appears to now be happy and thriving. The original terms of reference were re-examined to ensure key lines of enquiry identified at the start of the process had been explored. Reviewing practice, whenever this occurs, will always provide an opportunity to reflect on ways in which services can be developed and further enhanced, or to examine improvements already in place. As a result of the significant incident which occurred in the life of Thomas, learning points have been agreed by the Panel based on analysis and findings from the case and taking account of the current position for the local area. These are repeated below for consideration and action by the local Safeguarding Children Partnership. 8. Learning Points • The Safeguarding Children Partnership should require all partners to evidence their organisational focus and response in relation to the Domestic Abuse Act 2021’s requirement to recognise children who see, hear or experience the effects of domestic abuse as victims in their own right. • The Safeguarding Children Partnership should re-promote the local area’s pre-birth protocol across all partners including the examples of pre-birth strengths and concerns to ensure all practitioners have a sound awareness of when and how to consider its use. • The Safeguarding Children Partnership should consider how professionals across the partnership are supporting parents and carers with learning disabilities and learning difficulties, what resources are available and whether further awareness raising and promotion regarding responding well to people with learning disabilities and difficulties is required. • The Safeguarding Children Partnership should request assurance from members/ subgroups that housing related challenges for families remain a focus across the Partnership, including all professionals becoming more aware of the cumulative risks to children which housing issues can bring. 9. References • Working together to safeguard children, Gov.UK July 2018 • The Little Book of ACEs, local resource • Local Area Continuum of Need and Thresholds Guidance, June 2016 Page 17 of 21 • Sowing the Seeds- Dr Elaine Wedlock, Dr Julian Molina for the Victims’ Commissioner (England and Wales), April 2020 • The Domestic Abuse Act 2021 • Local area multi-agency pre-birth protocol 2021 • Child Safeguarding Practice Review Panel annual report, 2018-19 • CORE-INFO Head and spinal injuries in children, NSPCC and Cardiff University, May 2014 • ICON, iconcope.org • Demographics of Abusive Head Trauma in the Commonwealth of Pennsylvania, Kesler et al, 2008 • Maternity review of 4 cases of non-accidental injuries to babies in 2018, Local NHS trust, February 2019 • www.mencap.org.uk • Good Practice Guidance of working with parents with a learning disability, The Working Together with Parents Network, July 2021 • Domestic Violence Disclosure Scheme Factsheet, www.gov.uk updated 31 January 2022 • Child deaths by abuse and neglect, NSPCC Statistics briefing, September 2020 • Millie, April 2022 Serious Case Review. Appendix A Legal Framework Purpose of Child Safeguarding Practice Reviews, Working Together 2018 The purpose of reviews of serious child safeguarding cases, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children. Learning is relevant locally, but it has a wider importance for all practitioners working with children and families and for the government and policy makers. Reviews should seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose. Serious child safeguarding cases are those in which: • abuse or neglect of a child is known or suspected and • the child has died or been seriously harmed. Serious harm includes (but is not limited to) serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development. It should also cover impairment of physical health. This is not an exhaustive list. When making decisions, judgment should be exercised in Page 18 of 21 cases where impairment is likely to be long-term, even if this is not immediately certain. Even if a child recovers, including from a one-off incident, serious harm may still have occurred. 16C(1) of the Children Act 2004 (as amended by the Children and Social Work Act 2017) states: Where a local authority in England knows or suspects that a child has been abused or neglected, the local authority must notify the Child Safeguarding Practice Review Panel if – (a) the child dies or is seriously harmed in the local authority’s area, or (b) while normally resident in the local authority’s area, the child dies or is seriously harmed outside England. Safeguarding partners must make arrangements to identify serious child safeguarding cases which raise issues of importance in relation to the area and commission and oversee the review of those cases, where they consider it appropriate for a review to be undertaken. When a serious incident becomes known to the safeguarding partners, they must consider whether the case meets the criteria for a local review. The criteria which the local safeguarding partners must take into account include whether the case: • highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified • highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children • highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children • is one which the Child Safeguarding Practice Review Panel have considered and concluded a local review may be more appropriate. Safeguarding partners should also have regard to the following circumstances: • where the safeguarding partners have cause for concern about the actions of a single agency • where there has been no agency involvement, and this gives the safeguarding partners cause for concern • where more than one local authority, police area or clinical commissioning group is involved, including in cases where families have moved around • where the case may raise issues relating to safeguarding or promoting the welfare of children in institutional settings. Page 19 of 21 Appendix B Terms of Reference- Child LS Introduction This Review is being commissioned by the Chair of Lancashire Local Safeguarding Children Board (LSCB) in accordance with Working Together to Safeguard Children (2018) Transitional Guidance. A multi-agency panel established by Lancashire LSCB will conduct the review and report progress to the Board through its Chair. Membership will include an independent Lead Reviewer (Author) and representatives from key agencies with involvement. Timeframe for the Review The review will cover the timeframe of 01/12/2016 to 09/11/2018. Any significant incident relevant to the case but prior to the start date of the timeframe should be included in the timeline completed by each agency. Subject(s) of the Review T XXX – DOB: 2018 xx (Sibling) – DOB: 2015 Significant Others (Mother) – DOB: 1989 (Father of T) – DOB: 1987 The purpose of the review is to: • Determine whether decisions and actions in the case comply with the policy and procedures of named services and the LSCB; • Examine the effectiveness of service provision, information sharing and working relationships between agencies and within agencies, including case handovers/ transfers and joint working opportunities; • Explore the consideration and use of early help processes, and whether this was effective; • Determine the extent to which decisions and actions were focussed on the subject child/ children; • Analyse whether risks to the unborn child were assessed sufficiently including consideration of use of the pre- birth protocol; • Examine the quality of assessments relating to the child/children and to the parenting capacity/ ability to protect of all possible carers within the family; Page 20 of 21 • Determine the extent to which professionals identified domestic abuse and what actions were taken to share information about domestic abuse, to support the family and identify risks to the children; • Explore whether additional risk factors within the family including parental mental ill health, new relationships, substance misuse and housing issues were consistently and appropriately considered; • Explore how professionals responded to non-attendance at appointments and non-engagement generally and how this was professionally challenged; • Examine to what extent safe handling advice and support was provided and reinforced to all carers; • Explore whether opportunities to scrutinise and support the development and lived experience of older infants were taken, including safer sleep, safety in the home and responses to/ management of minor injuries; • Were responses to adults with learning disabilities appropriate and was consideration given to the literacy skills of all carers when providing information or making requests; • Establish any learning from the case about the way in which local professionals and agencies work together to safeguard children; • Identify any actions required by the LSCB to promote learning to support and improve systems and practice. Tasks specific to the review panel: 1. To set the time frame for the review, see above; 2. Agencies that have been involved with the child and family will provide information of significant contacts by preparing an agency timeline with a focus on the purpose and scope of the review, see above; 3. Other agencies/services may be asked to provide a timeline following review of the information provided; 4. Agency timelines will include analysis of relevant context, issues or events, and an indication of any conclusions reached. Information about action already undertaken or recommendations for future improvements in systems or practice may be included if appropriate. A case summary may include any relevant additional background information from significant events outside the timeframe for the review; 5. Agency timelines will be merged to create a composite timeline and used by the Panel to undertake an initial analysis of the case and form hypotheses of themes; 6. A full and accurate genogram of the subject family will be prepared for the panel and to assist the learning event; Page 21 of 21 7. The Panel, through the Chair and Lead Reviewer will seek contributions to the review from appropriate family members and provide feedback to the relevant family members at the conclusion of the review process; 8. The Panel will plan with the Lead Reviewer a learning event for practitioners to include identifying attendees and the arrangements for preparing and supporting them prior to the learning event and feedback following the event; 9. The learning event will explore hypotheses, draw out themes, good practice and key learning from the case including any recommendations for the development or improvement to systems or practice; 10. The Panel will receive and consider the draft SCR report prepared by the Lead Reviewer, to ensure that the terms of reference for the review have been met, initial hypotheses addressed, and any additional learning is identified and included in the final report; 11. The Panel will agree conclusions from the review and identify considerations for learning/ recommendations and make arrangements with the Lead reviewer for presentation to the LSCB for consideration and agreement; 12. The Panel will plan for feedback to be provided to the family and the practitioners in attendance at the learning event and share the contents of the report following the conclusion of the review, and before publication; 13. The Panel will take account of any criminal investigations or proceedings related to the case; 14. The Chair of the LSCB will be responsible for making all public comment and responses to media interest concerning the review until the process is completed. It is anticipated that there will be no public disclosure of information other than the SCR report for publication. SCR Overview Report – Child LS-August 2022 |
NC52280 | Neglect of a 2-year-old boy in 2018. Child AG presented at hospital severely malnourished and with fractures of varying ages. Learning includes: issues around the assessment of risk and impact of domestic abuse on the mother and children; issues around how the parents' learning difficulties were understood in relation their parenting; issues concerning how child neglect is understood by practitioners and the ability of services to identify and recognise malnutrition; assessments by medical practitioners should not take precedence over concerns raised by other professionals within a safeguarding network; not all professionals being competent in working with and understanding the culture of a Traveller family. Recommendations include: review the ability of partners to deliver the neglect strategy; equip practitioners with the confidence and skills to work with clients from diverse cultural backgrounds, including Gypsy, Traveller and Roma communities; local health agencies review the effectiveness of faltering child growth management.
| Title: Report of the serious case review regarding Child AG. LSCB: Norfolk Safeguarding Children Partnership Author: Ann Duncan Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Report of the Serious Case Review regarding Child AG. Author: Ann Duncan 2 PUBLICATION: Sept 2020 Contents Circumstances that led to this SCR Page 3 Methodology and Terms of Reference Page 4-5 Brief Summary of the Case Page 5-11 Areas of Practice Learning Page 11- 26 Areas of Good Practice Page 26 Conclusion and Recommendations Page 27- 28 Appendix 1: Methodology and Terms of Reference Page 29-31 Appendix 2: NSCB Thematic Learning Framework from SCRs Page 32 Appendix 3: Learning Event Page 33 Appendix 4: Acronyms Page 34 3 1. Circumstances that led to this Serious Case Review 1.1. In September 2018 Child AG1, then aged two and a half, presented at hospital severely malnourished and neglected. At the time of this presentation AG was in the care of his mother and father. Child AG is the fourth child in a sibling group of six. The case had been managed under a Section 472 of the Children Act but had recently been stepped down to be managed under a Child In Need Plan (Section 17). There had been previous concerns about the family including neglect and domestic abuse. A skeletal survey was completed on the 02.10.18 to investigate possible bone disease. As a result of this it was identified that there were bi-lateral humerus3 fractures of varying ages; there was no evidence of bone disease. The X-rays also confirmed malnutrition over time. 1.2. AG’s siblings were taken in to Police Protection on the 03.10.18 and placed in foster care. Police investigations and Care proceedings were still in progress at the time of writing this report. 1.3. The case was considered by the Serious Case Review Group (SCRG) on the 08.10.18 and it was agreed that the case met the criteria for a Serious Case Review (SCR), that is: • A child has suffered significant harm • Abuse or neglect of a child is known or suspected • There is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.4. The independent chair of Norfolk Safeguarding Children Board (NSCB) accepted the recommendation to conduct a SCR on the 10.10.18, in line with Chapter 4, Working Together4 1 To protect children’s anonymity all the children are referred to using the male pronoun. 2 The Local Authority have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, 3 The humerus is a long bone in the upper arm. It is located between the shoulder and the elbow. 4 Working Together to Safeguard Children, HM GOVT 2015. This SCR was commissioned while LSCB was still in statute. 4 1.5. At the time of Child AG’s presentation and subsequent diagnosis of malnourishment over time, and healing fractures (of varying age) to the arms, there were a number of agencies involved with the family. 2. Methodology and Terms of Reference. 2.1. Full details of the review process are included in Appendix 1. In summary, an independent lead reviewer worked alongside a review team, composed of senior managers, and facilitated by the NSCB Business Manager. The purpose of the SCR was to review the involvement of the agencies involved with the family to understand how professionals had understood the cause and nature of the family’s difficulties, and how effectively professionals had responded. The focus of the review was to learn about how the local safeguarding systems are operating and if any changes may be required as a result of the wider lessons from this case. The SCR considered the work of the following agencies: ▪ Local Authority Services (including: Children’s Services, Early Years, Community and Environmental Services) ▪ Education ▪ Womans Refuge ▪ Health agencies (including: Community Services, Midwifery Services, Acute and Community Paediatric Services, General Practice) ▪ Housing ▪ Norfolk Constabulary ▪ Services provided by neighbouring county. 2.2. The timeframe for the review was from March 2016, when Child AG was born, to the 30 September 2018, after AG had presented at the hospital suffering from malnutrition and healing fractures to his upper arm. 2.3. The Serious Case Review Panel identified specific lines of enquiry grouped against: expected standards and procedures, and cultural competence in the context of working with families from a travelling community, with a particular focus on the recognition of neglect and malnutrition (see Appendix 1) 5 2.4. The SCR was also asked to use the NSCB’s Thematic Learning Framework (see Appendix 2) and to consider learning that has already been identified within a number of recent Norfolk reviews. 2.5. Contribution of Family members. The involvement of key family members in a review can provide particularly helpful insight into the experience of receiving or seeking services. At the time of writing this report it has not been possible to meet with family members due to ongoing criminal proceedings. 3. Brief Summary of the Case. 3.1. Background: The family left their home in a neighbouring county citing that they no longer felt safe in their own home due to experiencing violence and intimidation from their neighbours which included reports of being shot at using a BB gun.5 The family felt victimised because ‘they were from a traveller background’. The family had been provided with a travel warrant6 by the housing department and travelled to a town in Norfolk where it was reported that a maternal aunt lived. The family’s application of homelessness was turned down by the borough council as the view from the police and housing department in the county they had left was that the family could safely return to their home. The family were deemed to have made themselves intentionally homeless.7 At the time the family moved they were receiving support from Early Help Services, General Practice and the Health Visiting service.8 AG had been born prematurely at 31 weeks’ gestation and spent a period of time in Special Care Baby Unit (SCBU). Following discharge AG was not taken for any follow-up appointments with the consultant paediatrician despite re-referrals made by the GP. AG’s younger sibling was also born prematurely at 35 weeks’ gestation and again had failed to be brought for a consultant paediatric follow-up9. 3.2. The mother contacted a Womans Refuge from a local railway station stating that she was fleeing domestic violence with her five children and had nowhere to go. The mother and her five children were accommodated at the refuge on the same day. A 5 A type of air gun designed to shoot metallic projectiles called BB’s. 6 With an explanation that the family were owed a duty of housing elsewhere- housing authorities must ensure that suitable accommodation is available for the applicant and their household, until the duty is brought to an end, usually through the offer of a settled home. 7 Section 119 of the 1996 Housing Act https://www.gov.uk>Housing,local 8 Universal plus service which meant that the family received a higher level of support from the service. 9 NICE guidance-developmental follow-up of children and young people born pre-term. 6 worker at the refuge noted that the mother presented as vulnerable, struggled to process information, had problems reading and writing and identified that she may have some level of learning difficulties. The mother left the refuge early in the morning with the children and arrived back late. It was discovered that not all of the children returned to the refuge each evening and when challenged the mother stated that they were at their aunt’s house. We now know that the family were visiting the father in nearby woods where he was living in a tent and two of the children stayed with the father overnight to help and support the mother who found it difficult to look after five children under the age of five. 3.3. Following a referral to Children’s Services (from the refuge and police) in early November 2017 a decision was made to undertake a Social Work Assessment (SWA) under Section1710 - to explore areas of developmental need and parenting capacity. The parenting capacity assessment was never completed, the decision was taken that this would be completed when the family were permanently housed (it has not been possible to determine why this decision was made but will be reviewed under the quality of the CPP). During the assessment period the eldest sibling made a disclosure of physical abuse by the father to a teacher. A strategy discussion took place and it was agreed by all agencies that the threshold for an Initial Child Protection Conference (ICPC) had been met. All five children were made subject to a Child Protection Plan (CPP) under the category of neglect. The parents did not attend the ICPC. The assessment was completed by SW1 and then allocated to SW2 (male). At the time the Family Intervention and Social Work Assessment Team were separate but have since joined together. 3.4. Following the ICPC appointments were made for AG and his younger sibling to be seen by the community paediatrician for developmental assessments as there had been no follow up from the point of discharge from the SCBU where the children were born (nearly two years and one year respectively). The HV identified that the parents had failed to take AG and his sibling for five appointments during a six-week period (December 2017-January 2018). When AG was examined by a paediatrician in the middle of February 2018 following identification of bruises by the HV on a home visit, the doctor recorded: 10 Children Act 1989. States that it is the general duty of every local authority to safeguard and promote the welfare of children. An assessment is undertaken to decide whether the child is in need. 7 • that the parents had clear explanations for the bruising and concluded that there was no evidence of non-accidental injury. • The doctor described AG as a ‘sick little boy who is weak” and to be followed up in the community due to developmental delay thought to be due to his prematurity. At the time there was no CP alert on AG’s records as when the notification had been received from CS following the ICPC, Medical Records were unable to find a matching patient; they registered a new patient and the alert was not put on. This is a systems failure and the NSCP will require assurance that this has been rectified for any future cases. 3.5. The mother and her five children left the refuge in early February 2018 and moved into a caravan with their father on a traveller site. The issue of domestic abuse had been attributed as a false statement in order to be accepted into the refuge and the violence experienced was by their previous neighbours. There were concerns about the environment and cramped conditions. The three older siblings were not attending school or nursery (they had not been seen since the end of January). The mother was pregnant due to deliver in September 2018. 3.6. Child AG was seen by a paediatrician (the same paediatrician who had examined AG when bruises were identified by the HV) in February 2018 for examination and assessment (the outstanding assessment from ICPC and the first Paediatric assessment following discharge from the SCBU). The outcome of the medical examination was that AG was delayed in more than one area of development and that this was due to his prematurity and low birth weight. It is accepted that children who prematurely may present with developmental delays and an allowance is given to children up to the age of two years. AG’s weight and height were recorded as on the 0.4th centile.11 The paediatrician recommended that the GP refer AG for Speech and Language, growth monitoring by the HV and referral to the Child Development Centre. 3.7. Team Manager 1(TM1) visited the family in early March 2018 on a pre-arranged visit because SW2 was unable to get to work due to the adverse weather. TM1 attempted to find Bed and Breakfast accommodation for the family over the weekend so that they could be in warmer surroundings - there was none available. TM1 recorded that “AG is clearly a very vulnerable child and his needs could become quickly lost in the 9. UK World Health Organisation growth charts: [email protected] 8 home” The case was transferred back to SW1 following the departure of SW2.The review case conference on the 20.03.18 was held; the children remained subject to a plan. Over the next two months the professionals continued to work with the family. The records of the visits continued to describe the cramped and overcrowded caravan and ongoing concerns about AG’s development, particularly gross motor skills and fluctuating weight. The parents were also challenged by the HV about watching inappropriate films that the children might find frightening - the parents stated that the children were always asleep. The community midwife made a referral to the Multi-agency Safeguarding Hub (MASH) following the booking appointment. 3.8. At a home visit in early May by the HV it was recorded that AG still had visible marks on his spine and scratch marks on the left-hand side below the rib-cage. AG was reported to have gained some weight but was still on the 0.4th centile. AG was reviewed the next day by a community paediatrician, the outcome of the assessment was that AG’s development was progressing slowly and his weight was still on the 0.4th centile. A referral was made to the physiotherapy service due to stiffness in the legs and he was to be reviewed in six-months. This information was shared with GP but not with SW1. Three days later at the core meeting the mother stated that she felt that HV1 was always watching AG and questioning bruises and abrasions that had been sustained. The mother also stated that she should be able to watch her films when the children were asleep; the HV reiterated the importance of ensuring that the children were asleep. SW1 stated that the children had not voiced that they had been frightened by any films that they might have seen (it is not known how this information was obtained by SW1) 3.9. The Eden Team12 conducted their initial risk assessment on mother’s sixth pregnancy using Signs of Safety and a plan was put in place. A joint visit was to be conducted by HV1 and the Community Midwife (CM) by 28 weeks’ gestation and a pre-birth risk assessment to be completed. HV made a home visit; AG’s weight had dropped by 1kg from when he was seen by paediatrician. The HV discussed this with the team leader and was advised to weigh again in two weeks. At the core meeting held in early June AG’s fluctuating weight was shared. The view from professionals was that good progress had been made with the child protection process, the parents had engaged well with professionals to significantly reduce the risks to the children. The outcome of this meeting was that SW1 was to consider whether the review child protection 12 Specialist team of midwives working with vulnerable women during pregnancy. 9 conference could be brought forward and step the children down to a Child In Need Plan (CIN). The HV weighed AG in the middle of June in three different parts of the caravan - the range was 8.1- 8.5 Kg; the plan was to weigh again in a further two weeks. The HV weighed AG again in early July and it was recorded as 8.8Kg. AG was observed eating a packet of crisps (this was the third time). Both parents reported that AG eats well, mother enquired whether she should give AG ‘build up’ drinks, HV advised mother to discuss with GP. 3.10. A pre-birth meeting between Children’s Services and health took place in the middle of July, it was confirmed that CS had rejected the proposal of obtaining the family a new trailer but were supportive of providing a deposit. Due to the size of the family many of the landlords were unwilling to take them on. There had been a suggestion that the family may have to be split up in order to obtain housing an option that the family quite rightly did not want. All professionals in attendance at this meeting were aware that the housing issue would need to be rectified prior to the birth of the baby (due in September). 3.11. AG was seen by the physiotherapist; the assessment was recorded in hand held notes only. It was noted that AG had a bruise on his left cheek (he had been crawling near the caravan door and had fallen) and sores around the nappy line. The mother stated that AG had been seen by the GP for the severe nappy rash and had been given cream. SW1 was informed about the presentation and explanations given by AG’s mother. (over the next two months AG missed four physiotherapy appointments and a hip X-ray). 3.12. At the Core meeting held on 23.07.18 it was noted that the attendance of the three older siblings at school and nursery, had fallen from the middle of June. (The children do not return to school after the summer holidays) AG’s fluctuation in weight was discussed and mother was advised to take AG to the GP. 3.13. In mid-August 2018 the sixth baby was born prematurely at 34 weeks’ gestation; the baby was fit for discharge on the same day. Over the next few days the midwives became increasingly concerned about the sleeping arrangements for the new baby in the caravan and specifically about the risks posed in the over-crowded caravan. Housing were unable to provide any temporary accommodation over the Bank Holiday weekend but SW1 was confident that the family would be offered something on Tuesday. The Safety Plan was not supported by the Eden Team Midwife; she had 10 discussed with her line manager who supported the challenge made to CS. There continued to be disagreement between the midwifery service and CS about the safety and suitability of the home environment. SW1 disagreed with the midwifery view and the HV felt that the home conditions were as safe as they could be. The case was now being managed by TM3 who discussed with Head of Social Work (HoSW). TM3 sent SW1 and an Early Help Family Focus Practitioner who was experienced in using The Graded Care Profile (GCP) to have ‘a fresh pair of eyes’ on the living conditions. The outcome of the visit was that the living conditions were suitable although the GCP was not completed. A written copy of the Safety Plan was given to the parents. 3.14. As well as concern about the sleeping arrangements the Eden Team Midwife was concerned about AG’s condition and described him as ‘malnourished’. The HV visited the following day after discussion with SW1 who informed the HV that midwifery had raised concerns about housing and the presentation of the other children. AG was weighed and had lost 1.2Kg from the last visit (05.07.18). The HV noted that AG looked “slender with ribs visible”; the mother reported that AG continued to eat well and had not been ill during this period. The mother was advised to take AG to the GP that day. The GP was aware of the concerns surrounding AG’s health and development. The mother did take AG to see the GP- the outcome was that “baby was well in himself” and to be seen by the dietician next week. HV informed SW1 about the weight loss. 3.15. The relationship between the Eden Team midwife and SW1 continued to be strained and SW1 was accused by the midwife of colluding with the family. The planned meeting between Head of Social Work and Health Safeguarding did not take place but a telephone conversation did. This failed to resolve the difference of opinion between the midwife and SW1 in how the case was being managed and that the concerns about AG remained in that he was “malnourished”. 3.16. During the first week in September 2018 the mother did not engage with the midwifery service in the same way. HV1 contacted the mother to arrange a joint visit with the midwife. Initially the mother refused as she stated that she thought that they were” judgemental” and had concerns about AG. The mother agreed to a joint visit on 10.09.18. At this point the family were accommodated into a larger trailer, for one week only. 11 3.17. The physiotherapist discussed safeguarding concerns with the Named Nurse during a supervision session on the 11.09.18. The concerns arose from the initial assessment in July 2018 when AG had sores around the top of the nappy area, a nappy rash and was reported to be dirty. The mother had failed to bring AG to subsequent appointments with the physiotherapist. The Named Nurse suggested that AG needed to have a planned paediatric medical. The Named Nurse and physiotherapist attended the review conference the following day. 3.18. The review child protection conference was held; the decision to step the children down to a Child In Need Plan was unanimous as they were no longer at risk of significant harm, however, Child AG was to have a child protection medical (see paragraph 3.17). The mother requested another health visitor as she was unhappy about the questioning about food in relation to AG. Four days after the conference the family moved into temporary accommodation. 3.19. AG attended for the booked Child Protection Medical, the medical problems were as follows: • Marasmic Kwashiorkor (severe malnourishment with oedema) • faltering growth, • gross motor delay of unclear cause, • severe nappy rash, • severe constipation (faecal impaction), • de-pigmentation of unclear cause, • Vitamin D deficiency and • Iron deficiency anaemia. AG was admitted on to the ward, the mother refused to allow photographs to be taken as “it is against her religion”; photographs were subsequently taken after the Strategy meeting. The mother signed the safety plan which stated that AG would remain in hospital until the doctors deemed him to be medically fit and if the parents attempted to remove AG then Police Protection (PP) would be obtained to keep AG safe. A strategy discussion took place. The plan was for a joint Section 47 investigation to commence. All of AG’s siblings were to undergo child protection medicals. The family and all children were seen at the temporary housing by the police and CS - there 12 were no grounds for PP. The case was re-allocated to SW3. The child protection medicals carried out on AG’s siblings did not identify any concerns. 3.20. The skeletal X-ray on AG identified healing fractures of varying ages to the upper arm. AG’s five siblings were removed under Police Protection and placed with foster carers. 4. Areas of Practice Learning 4.1. Introduction This section of the Review assesses the quality of multi-agency practice at the key points that are considered to provide the most significant learning. In doing so, the Review considers the information that was known, or could have been known, at the time of the events alongside the individual agency practice standards. Where there is information about why practice may not have met required standards, this is explained. By understanding why things happened in the way that they did, rather than simply what happened, the SCR is seeking to achieve a greater depth of learning about safeguarding systems within Norfolk, and beyond this individual case. The review focuses on six areas of practice learning; however, the areas overlap and impact on each other and demonstrate the complexity of what is happening at a given time. Child AG and his siblings were being seen regularly as part of the child protection plan and the plan was being implemented. At the ICPC the areas of concern and risks were clearly identified and a plan put in place to reduce the risk of significant harm to the children. The CPP was realistic in meeting the needs of the children, the focus for the plan was to support the parents in meeting the needs of the children to include parenting and supervision, ensuring that AG and his sibling attended all medical appointments and assessments and that the children attended school and nursery on a daily basis. The plan also identified the need to support the family in gaining suitable accommodation that would provide a safe environment for the children to live in. The statutory visits both announced and unannounced took place and the core meetings were held monthly. What is evident over the nine months that the children were subject to a plan under the category of neglect, is that the entries become more descriptive with little analysis or impact on what this means for the lived experience of the children. The fact that the children were living and continued to live in over-crowded and challenging conditions seemed to be accepted by all professionals with the exception 13 of the midwife. The professionals appear to have been desensitised to the ongoing and chronic neglect of the children and the concerning weight loss of AG. The child protection procedures that the NSCB and its member agencies had put in place, in adherence to Working Together 2015, had been implemented in the way they had envisaged throughout the involvement with the family. With some important exceptions, agencies coordinated their work, shared information and came together to implement the child protection plan. There was a systematic approach to evaluating risks using the Signs of Safety approach. Despite generally robust systems being in place, there were some gaps in practice which need to be considered in order to learn from them. For the purpose of gaining a better understanding of how and why, the learning has been separated out into six areas, however, they do overlap with one another and should not be viewed in isolation. 4.2. How did the safeguarding network assess the risk and impact on the mother and children of the reported domestic abuse from: the father, extended family and neighbours? 4.2.1. Research13 shows that domestic abuse is a significant health issue for the Gypsy & Traveller community. A recent study estimated that between 60% – 80% of women from travelling communities experience domestic abuse during their lives, compared to 25% of the female population generally. While many incidents of domestic abuse are perpetrated by husbands and intimate partners, other family members may be perpetrators of domestic abuse. Domestic abuse is accepted as normal for many women. Trapped by culture, poor literacy and education, distrust of the police and social services, and fear of separation from family and friends, Gypsy and Travellers are far less likely to report an incident or to seek help. Domestic abuse, often physical violence, impacts upon the victim’s mental health and upon their children. 4.2.2. The refuge was concerned about the vulnerability of the mother and recognised that she had some learning difficulties. The mother also spoke about an incident whereby the father had thrown a puppy against a wall to kill it. The mother later denied the domestic abuse and stated that she had made it up, and that her partner was not and 13 Firsttlight.org.uk 14 never had been violent towards her. Following the disclosure of physical abuse made by AG’s eldest sibling, both parents denied this. They stated that they would never hit their children and the mother said she would never ‘stay with someone who hit her or the children’. The parents expressed a view that AG’s sibling was always making up stories. The workers in the refuge were concerned that the mother continued to visit the father with the children following the alleged incident even though she had been told not to do so. The mother stated that she would be unable to manage the care of all the children without his support. 4.2.3. At the Initial Child Protection Conference, the risks were clearly identified including: concern about how open the parents were being about their relationship, the reporting and then retraction of domestic abuse, the possible controlling (financial) and abusive behaviour of the father towards the mother, domestic violence within the extended family and the violence from the neighbours. One of AG’s siblings described dad as ‘angry’ and mum and dad as ‘sad’. 4.2.4. The professionals in the network seemed to either accept the explanation given by the parents that they had made domestic abuse up to secure a place of safety for the children, or minimise it. There had been no reported domestic abuse incidents to the police since the family’s arrival in Norfolk, this does not mean that there weren’t any. 4.2.5. Professional authority comes from a position of confidence and competency in their understanding of the situation and associated risks. The Signs of Safety14 is a strength based and safety focused approach to child protection work and is grounded in partnership and collaboration. Risks must be assessed from the perspective of the child in a dynamic and ongoing cycle; “Assessments are a continuing process and not an event.”15 The professionals that worked with the family had a varying understanding of how to work with travellers, poor knowledge of cultural beliefs and lifestyle. For some professionals this was the first case that they had worked with traveller families. The visits and interaction with the family became overly focused on recording what they had observed rather than analysing and assessing the impact of the situation in relation to the safety of the children. 14 A solution focused, strength-based approach to social work practice which can be applied across the child protection system developed in Western Australia in the 1990’s. 15 Working Together 2018. 15 4.2.6. In this case the professionals lost sight of the domestic abuse and violence that had been reported and became focused on the housing situation; the view being that if the family had secure and appropriate housing then “everything would be alright.” 4.2.7. We now know that there was a serious incident in January 2019 (outside the timeline) which resulted in a Multi- Agency Risk Assessment Conference (MARAC). This is a meeting where statutory and voluntary agency representatives share information about high risk victims of domestic abuse in order to produce a co-ordinated action plan to increase victim safety. The father had slapped the mother on the face using a combat / hunting knife before prodding her under the chin. The father then did this with a wheel brace. 4.2.8. The professionals working in the safeguarding network are reliant on there being an open and honest relationship with the family that they are working with. If this trust and partnership working breaks down the danger is that there is no clear understanding of what is happening within the family, the possible increased risks or the lived experience for the children. 4.2.9. The conclusion of the review team was: there was a confusing picture and understanding of the domestic abuse within the family. The challenge for professionals is to obtain a deeper understanding of relationship dynamics. Assessments which concentrate largely on the source of current risk can miss the more hidden latent and complex indicators that might place children at risk of emotional and physical harm. There was a lack of professional curiosity and domestic abuse was downplayed possibly due to their traveller background and an unconscious bias of cultural norms from the professionals working with the family. Staff require a better understanding of traveller culture in order to feel less threatened and scared about working with this community. (see section 4.7.) 4.3. How well was the impact of the parents’ learning difficulty understood in relation to how they parented their children? 4.3.1. It is well documented that children maybe at increased risk where a parent/ carer has a learning need/disability. Professionals need to carefully consider the implications of relying on individual parents to follow through on advice or recommendations, bearing in mind that they may be unwilling or unable to do so. Professionals should consider 16 whether the failure of the individual to follow through on advice or recommendations is an additional level of concern. 4.3.2. There is substantial evidence concerning the range of problems that can impair parental capacity to meet the needs of children16 including: mental illness, problem drug and alcohol misuse, learning disability and intimate partner violence. Research also indicates that where parents were themselves abused or neglected in childhood there is an increased risk of maltreating their own children.17 It has been suggested that the more severe abuse or neglect experienced by parents in childhood, the more difficult it is to resolve losses and traumas, and the greater risk that parents will maltreat their own children.18 4.3.3. The extent of both parents’ learning disability/difficulty were never fully understood by the professional network. Although it was recognised that the parents found it difficult to understand what the professionals were concerned about, there was little evidence to demonstrate that professionals had considered any other means of communicating effectively with them. The parents left their home in a neighbouring county and moved to Norfolk without any housing provision; they had an expectation that they could turn up and a house would be provided. Both parents had literacy problems and yet there was an over reliance on giving the parents written instructions or copies of plans without checking whether they understood the content. The mother was very clear that when Children’s Services had asked her not to have contact with the father following the disclosure of domestic abuse she would continue to meet with him as she could not manage the five children on her own. The parents also had trouble understanding the concerns of the professionals when it was discovered that the children were sleeping overnight in a tent in November and December. 4.3.4. Professionals, especially those in targeted services, routinely work with adults who are distressed and needy, who have been damaged by their trauma and history. Professionals have to strike a balance between being supportive and positive towards the family in the steps that they have taken, but must maintain “healthy scepticism” and “respectful uncertainty.”19 In this case the mother continued to require a level of support in order to meet the needs of her children. 16 Cleaver et al, 2011; Brown and Ward, 2012. 17 Reder et al 2003; Dixon et al,2005. 18 Howe 2005 19 Laming 2003. 17 4.3.5. The conclusion of the review team was that it was unclear whether the multi-agency network fully understood the impact of the parents’ literacy and learning needs in order to care for and meet the needs of their children. As a consequence of this the parents did not have a level of insight about the concerns that were being raised by the professionals working with them or have a clear understanding of the expectations and outcomes that were required. The importance of constructive challenge and clear and simple communication using a variety of methods is a key learning point from this SCR. 4.4. How is ‘neglect ’understood and particularly the ability of services to identify and recognise malnutrition? 4.4.1. Neglect is defined in Working Together to Safeguard Children 201820 as “the persistent failure to meet a child’s basic physical, emotional and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. When the child is born, neglect may involve the parents or carers failing to: • Provide adequate food, clothing and shelter (including exclusion from home or abandonment); • Protect the child from physical and emotional harm or danger; • Ensure adequate supervision (including the use of inadequate care-givers); or • Ensure access to appropriate medical care or treatment Child AG and his siblings were all subject to a Child Protection Plan under the category of neglect. NSCB has endorsed the use of the Graded Care Profile (GCP) as the assessment tool that should be used at the earliest opportunity in all cases where neglect has been identified. The GCP was the tool identified and agreed as part of the Neglect Strategy that all partners working in the safeguarding arena in Norfolk signed up to. The tool should be used for assessment, planning, intervention and review. It provides a measure of the care of the child across all areas of need, showing both strengths and weaknesses. Improvement and/or deterioration can be tracked across the period of intervention. It allows professionals to target work as it 20 SCR commissioned under Working Together 2015 but definition is the same. 18 highlights areas in which the child’s needs are, and are not, being met. It may also help parents/carers who may have experienced neglect themselves to understand why such behaviours are harmful.21 The GCP was not used in this case, had it been it may have helped all the professionals to have an objective measure of what real progress was being made, if any. The Neglect Steering Group has identified this as an issue and has conducted focus groups and a small multiagency neglect audit.22 The sample in the audit was too small to draw meaningful conclusions but it is clear that more work needs to be done in promoting and using this tool across all agencies. When working with cases of neglect it is important that professionals focus on the needs of the children and not the parents/carers. Neglect is cumulative and not a result of one single incident. Assessment is critical in identifying the risks and determining whether the parents have the ability to change and importantly sustain the change required to reduce the risk of significant harm over time. There is a danger when categorising children experiencing neglect, that less attention is directed to the neglect itself or the associated risks that children may face. Neglect does not always achieve the same priority as other forms of abuse. 4.4.2. In this case there was concern about: • the three older siblings attending education (school and nursery) on a regular basis, • the parents keeping the paediatric appointments for AG and his younger sibling, • the developmental delay and faltering growth of AG, • the cramped and overcrowded housing conditions. AG was described as “a vulnerable child and his needs could become quickly lost in the home”. The professionals did not seem to consider whether AG was parented differently to his siblings or if he was being ‘scapegoated’ – although in the initial assessment it was identified that “the mother found it difficult to show a high level of emotional warmth towards AG”. The potential signs of abuse/neglect observed by the professionals who visited the family at home were largely left unchallenged, the view was that the parents were doing as well as expected in the circumstances that they 21 NSCB multiagency safeguarding arrangements, policies and procedures. 22 Audit conducted in March 2019 to act as a baseline to inform practice and develop a work plan for the Neglect Steering Group (limited to four cases and not all agencies were represented in the audit). 19 were living in and if some permanent accommodation could be found then this would help, especially in giving more space for the younger children to play in. What was absent from the plan was how the impact of the environment in which they lived was having a detrimental impact on their development and attainment, and how the cumulative effect was assessed and a contingency plan put in place to affect change. AG’s younger sibling who was also born prematurely was reaching his milestones and weighed more than AG who was a year older. The urgency of AG being reviewed by a paediatrician seemed to diminish over time and then when reviewed, the doctor did not seem overly concerned, although AG was described as a “sick little boy who is weak” (see 4.5). This seemed to be accepted without challenge or curiosity about what this meant in relation to the care and management of AG. 4.4.3. AG was described as being a small, thin child who was often observed either sitting on his mother’s lap covered in a blanket or in the bottom of a double buggy. AG was unable to fully weight bear or walk unaided and had reduced movements in the lower limbs. We now know that this was due to muscle wasting due to insufficient food being taken in to allow normal growth and development. There had been concern about AG’s weight and his general development. The health visitor regularly weighed AG, the Parent Held Record (Red Book) was not always available to record on the centile chart, although the weight was plotted on the electronic records. His weight had crossed more than two major centile spaces downwards and this should have prompted further exploration as to the cause, and to investigate or rule out any organic cause for faltering growth as well as considering whether there were any difficulties in the interaction between the child and the parents. The professionals relied on what the mother told them about what food AG ate, he was not observed eating anything other than bags of crisps. It might have been helpful to have asked the parents to keep a simple food diary to review the daily intake of nutrients and the calorific value. 4.4.4. Despite the core meetings discussing AG’s fluctuating weight it was difficult to get a sense of whether this was of concern to the wider network or if the significance and impact on AG’s development and growth was fully understood. Poor growth in infancy is associated with high childhood morbidity and mortality. This means that a child’s growth is an important indicator of health and wellbeing. The professionals were aware that AG was seen and weighed regularly, the weight went up and down and the explanation given was it was due to AG’s prematurity and developmental delay. AG’s centile chart was never brought to the meetings by the HV and the other professionals did not challenge as to why this was not available. This meant that there 20 was no visual overview of AG’s weight, this would have provided a very concerning picture. The parent(s) attended the core meetings: there were no professional meetings without the parents. Professionals should consider meeting together without the family in certain circumstances in order to allow an opportunity for mutual challenge without the risk of displaying different views or opinions in front of the parents. The process whereby a client splits a network into friendly and helpful people and others who are rejected needs to be guarded against The reluctance to meet as a professional group is possibly being driven by “nothing about me without me.”23 Professionals need to strike a balance between having an open and transparent working relationship with parents but have an opportunity to meet and discuss concerns before sharing with the parents. 4.4.5. The first professional to draw attention to AG’s weight with the term ‘malnourished’ when describing AG was the Eden Team Midwife who reported her concerns along with the risk to the new baby in cramped and overcrowded housing. Was this because AG was being seen ‘with a fresh pair of eyes’ and without the history of fluctuating weight and the opinion of the paediatrician? This will be further discussed under supervision and management oversight (see 4.6) 4.4.6. One of the Social Work Team Managers (TM3) told the SCR that when she saw the photographs of AG it was obvious that “something was wrong”. It is unclear why other professionals missed this (with the exception of the midwife). Was the network overly reassured by the fact that AG had been seen and examined by paediatricians and the family GP who did not seem worried? Research suggests that medical dominance in health care has resulted in the work of other healthcare professionals being largely requested and supervised by doctors through control of referral systems.24 The paediatrician queried why the HV had requested an assessment for AG, and then when the HV requested to know the outcome was told to wait for the report (overlaps with 4.5). This is not acceptable in the MAS arena and needs to be addressed urgently. 4.4.7. The conclusion of the review team was that there needs to be robust use of centile charts particularly in cases where there has been ongoing concern about growth and 23 Liberating the NHS: No decision about me, without me (DH 2012) 24 Churchmann JJ, Doherty C (2010) 21 development over a period of time. Professionals need to be aware of the signs of under nutrition which include: • weight loss • loss of fat and muscle mass • dry hair and skin. Despite NSCB (now NSCP) sign up to the Neglect Strategy and neglect identified as a priority, the multiagency leadership has not been consistently demonstrated. It was disappointing that despite the children being subject to a plan under the category of neglect the GCP tool was not used in this case. The use of the GCP in Norfolk is low with practitioners stating that it is another layer of assessment and is time consuming to complete. At the Learning Event professionals identified that the GCP is not used as an intervention tool and at times is muddled up with the Signs of Safety model that was introduced at the same time. The compliance of using the GCP is an issue across the country and is not specific to Norfolk. Work has been carried out in other areas of the country that use the GCP as an empowering tool which focus the assessment of neglect in the relevant domain25. 4.5. When a paediatrician gives a positive medical view in relation to a child’s presentation, as happened in this case, this should not necessarily override or take precedence over the concerns raised by the other professionals working in the safeguarding network. 4.5.1. Child AG had never been seen by a paediatrician following his birth at 31 weeks’ gestation and subsequent discharge from the SCBU. The parents had consistently failed to bring the child for an assessment and review despite numerous appointments and confirmation that they would do so. The first consultation was a Child Protection Medical for a bruise on AG’s cheek and at the base of the spine just above the nappy line. The view of the doctor was that the injuries were consistent with the history given by the mother. Although the doctor described AG as ‘sick and weak’ there was no further challenge of what this meant for AG. As a result of this a Strategy meeting that had been considered prior to the assessment was no longer required. At the next medical assessment, the view from the doctor was that AG was developmentally delayed and this was most likely due to prematurity. A referral was made for AG to be reviewed at The Child Development Centre in three months’ time. Did this lead the 25 Graded Care Profile Structured Judgement Tool developed by Jane Wiffin in Hertfordshire, May 2019. 22 professional network to be optimistic about AG’s condition? There are many factors,26 which lead professionals to adhere to a supportive and helpful plan, where there is sometimes unwarranted optimism about outcomes. As a consequence, professionals sometimes find it difficult to change course. Supervision becomes paramount to ensure that professionals are supported and challenged (see 4.7) In this case there was concern about AG’s developmental delay and fluctuating weight (loss and gain) but after the examinations by the Paediatricians there was a subtle change in the urgency of the case. The HV was directed to continue weighing and monitoring AG’s weight, which was done and recorded on the electronic system. It is difficult to understand why the sea-saw effect when the weight was plotted on the centile chart was not shared with the core group or escalated back to the paediatrician. The core meetings became an exchange of information, descriptive narratives and continuation of the plan with no evidence of challenge or analysis. This may be due in part to the fact that if a professional is reporting from a position of expertise and gives a rationale as to why this is happening it becomes more difficult for other professionals to feel able to seek further explanations. Training on providing skills to professionals to feel confident to challenge one another should be commissioned by NSCP. 4.5.2. The conclusion of the review team was that the significance of a medical opinion/ diagnosis appears to carry more weight within the safeguarding network. This was first highlighted in the Climbié27 enquiry where professionals accepted a diagnosis despite a lack of evidence to support this. The fact that AG had been seen and examined by two paediatricians in a relatively short period of time may have falsely influenced the other professionals that AG’s faltering growth was not as significant. The SCR was also told that there is generally a lack of challenge within meetings across agencies as there is a perception that other members of the team lack the knowledge and authority to challenge professionals speaking from a position of expertise. Clearly work needs to be undertaken by NSCP to ensure that all agencies feel that they can ask and challenge anyone within the network and that they will not be met with defensiveness. 26 Reder et al (1993) 27 https://www.gov.uk › government › publications › the-Victoria-Climbié-inq... 23 4.6. Supervision and management oversight are critical in managing and supporting professionals working with uncertainty; why did this not happen effectively in this case? 4.6.1. Much has been written on the benefits to both the individual and the organisation when regular supervision is given and received. Good supervision is fundamental to good practice in providing: support, challenge and reflection, particularly when practitioners are working with high levels of uncertainty and complex, chaotic and challenging circumstances. Whilst all of the agencies recognise the value of supervision and provide protected time for their staff it does not always take place. 4.6.2. The SCR was told that this case was well known within the different agencies as both SW1 and HV frequently discussed the case with colleagues and managers sometimes on a daily basis, using peer support and ad-hoc supervision which was not recorded. This discussion was helped by the co-location of Children’s Services and health staff in the same building. The view was that because this case was well known that the case was being managed effectively and the management team had oversight. What became clear during the conversations with the frontline practitioners and managers was that this case did not benefit from regular protected supervision. At the time there were a number of changes within Children’s Services in this locality which resulted in the case being overseen by three different team managers. The workloads were high and it was evident that it had been difficult to engage SW1 in structured supervision. This was also true for health and one of the supervisors described the daily exchange as “white noise” and reflected that maybe the full concerns about AG and his family had not been fully understood. Cambridge Community Services have identified the non-recording of ad-hoc supervision as a problem within the local area at the time and have subsequently introduced new guidance to capture and record these discussions. 4.6.3. The Eden Team Midwife was tenacious in her pursuit of raising her concerns about the sleeping arrangements for the new baby and her concern over AG. Through numerous telephone exchanges and written documentation outlying her concerns, nothing changed. The professional network split with the SW and HV on one side and midwifery on the other. The consequence of this was that the relationship that the midwives had with the mother changed and it became more difficult to work with the family. This was further exacerbated when the SW was accused by the Eden Team Midwife of colluding with the family. 24 4.6.4. The exchange happened over a bank holiday weekend, at the start of the next working week a telephone conversation took place between the Head of Social Work and Health Safeguarding Manager that did not resolve the difference of professional opinion. Problematic multi-agency working continues to result in lost opportunities for protecting children from harm; the ability to clearly identify the needs and risks within the family becomes more difficult28 4.6.5. The physiotherapist raised concerns during Safeguarding supervision about AG. The physiotherapist had been concerned from the beginning of July 2018 due to sores around the nappy area and that AG was dirty. The mother had also failed to bring AG for the follow-up appointments, the mother stating that she “cannot get there.” Recent research29 into health agency “Did not Attend” policies has shown inconsistency and that they can, at times, be a systemic defensive response by agencies to help manage large workloads. Non-compliance with appointments may be a parent’s choice but it may not be in the child’s best interest. Repeated cancellations and re-scheduling of appointments for children should be treated with curiosity. A shift away from using the term did not attend (DNA) to was not brought (WNB) would help maintain a focus on the child’s ongoing vulnerability and independence, and the carer’s responsibilities to prioritise the child’s needs. The concerns were shared with SW1 and they both attended the CPC the following day. The unanimous view of the professionals was that the risks could be safely managed under a Child In Need Plan but that AG was to have a Child Protection Medical. It is difficult to understand why the decision to ‘step down’ the case was not deferred until after the outcome of the CPM was known. 4.6.6. The SCR was told that the social work caseloads in this part of the county were higher than the recommended level and include a large volume of child protection work. At the time there were a number of agency workers employed in this area. The recruitment process was often carried out using the telephone. There was no formal induction or introduction to the values of the organisation. In this case SW1 was given a list of cases on the first day of working and some computer training and then “cracked on” with the work. 28 Triennial Analysis of SCR Research in Practice/University of East Anglia/Warwick. 24. Munro, Eileen (2012) Review Children and young people’s missed health care appointments: reconceptualising ‘Did Not Attend’ to ‘Was Nor Brought’- a review of the evidence of practice Journal of Research in Nursing,17(2). pp193-194.ISSN 1744-9871 and Lisa Arai, Terence Stephenson &Helen Roberts; the unseen child and safeguarding: ‘Did not attend’ guidelines in the NHS; Archives of Disease in Childhood. March 2015: http//adc.bmi.com/content/2015/03/16/archdischild-2014-30729 25 4.6.7. The conclusion of the review team was that this particular locality within Norfolk has a high level of deprivation and need. It can at times feel isolated from the rest of the county. The importance of restorative as well as safeguarding supervision becomes paramount in providing protected time and space to support the professionals working in this challenging environment. Ad-hoc supervision must be recorded and must not replace the rigour of planned supervision. Supervision should also explore and record what the lived experience is for the children. This case was the type that should have been taken to Joint Supervision project. The view of the panel was that there is an expectation that the current initiative for joint supervision will be reported back as part of the Multi Agency Safeguarding Arrangements (MASA) Plan by January 2020. 4.7. The family identified themselves as travellers; was the professional network competent in working and understanding the culture and beliefs of a traveller family? 4.7.1. For many professionals, working with Gypsies and Travellers for the first time means working within a new culture and context. This can be challenging and difficult to navigate and it is normal to have questions. For this reason, a level of cultural competence is important, or at very least, maintaining an open and inquisitive mind. Cultural competence is defined as the ability of providers and organisations to effectively deliver services that meet people’s social, cultural and linguistic needs. “Professionals need to be aware of their own prejudices and bias and ensure that it does not influence the care they give.” 4.7.2. The SCR was told that there was generally a lack of knowledge around travellers as well as some level of fear of traveller communities. Some of the professionals working with the family were unaware of services working with this community. Work is currently being carried out to look at upskilling workers around traveller communities and including knowledge of safeguarding practice. 4.7.3. The review team were curious as to why a male social worker had been allocated to work with the mother and children as Travellers may not accept male workers, as women and children should not be in the company of men that are not family. SW2 only worked with the family for a short period of time (about one month) and therefore the possible impact on this case was considered to be low. TM1 when asked about the allocation was clear that it was done because SW2 had capacity, that 26 consideration had not be given to whether this would pose a problem and it was not done with the view to work more closely with the father. It is surprising that SW2 had not considered whether there may be any impact or difficulties working with a family with six children. It was evident that there was no awareness from him that woman and female children should not be in the company of men who are not immediate family. This is of concern and needs to be addressed urgently. 4.7.4. The conclusion of the review team was that there was a gap in the knowledge and understanding of the culture and beliefs within the travelling community. At the same time, it must also be recognised that there are many interpretations and variations within the Roma Gypsy and Traveller community and that professionals need to be aware and confident in their knowledge and understanding in order to have a meaningful dialogue. The Gypsy and Traveller service should review their record keeping and safeguarding knowledge of the workers within the service. Specific training about working with the Gypsy and Traveller Community should be commissioned with immediate effect for the wider workforce and should consider working with One Voice30 and the Gypsy and Traveller community to gain a better insight into their culture and beliefs. 5. Learning Event for frontline staff and managers A Learning Event was held for key staff and managers at the end of September 2019 to share the key findings from the case and identify any additional learning. The full details of the event can be seen in Appendix 3. The Learning Event was an holistic process which allowed staff to reflect and challenge one another in both a positive and safe environment. The independent reviewer would like to acknowledge the honesty and contributions that all attendees made in difficult and emotional circumstances. The learning that emerged was: 30 Community based charity working with individuals, families and groups from the Gypsy, Traveller and Roma community across East Anglia in a supportive advocacy and community development role. [email protected] 27 ➢ The significance of children not in education is not always acknowledged by the wider safeguarding network ➢ Understanding the significance of faltering growth and the use of centile charts ➢ Early Years and Education are in a unique position in that they see the child and parents on a daily basis however they are not always invited to meetings. ➢ The thresholds the police use to assess neglect are currently under review as it is felt that the accepted level is too low. ➢ The need to identify whether the refuge will provide safety for a woman from the traveller community fleeing violence. Checks need to be done that there are no other travellers within the refuge as information can be shared very quickly within the community. The children that accompany the woman may not always be their own. ➢ Recognising that professionals will have different conversations with men and women in the traveller community. ➢ There is a gap with adult service representation within the safeguarding network. ➢ A joint supervision pilot, the numbers attending are small and the reason for non-attendance is time constraints. The model of the sessions may need to be reviewed in order to get engagement from all the agencies involved. 6. Areas of Good Practice. ➢ The tenacity of the midwife in raising her concerns of the risks posed to the new baby and the identification of AG’s condition. The midwife continued to do this on a daily basis and was not put off despite the concerns being downplayed. The record keeping was exemplary and provided a chronology of the unfolding events over a period of a few days. ➢ The physiotherapist brought the case to supervision because of the concerns about AG’s condition at the first assessment and the fact that AG “was not brought” did not attend for five follow-up appointments. This supervision session resulted in the Named Nurse for Safeguarding (acute) and physiotherapist attending the case conference and identifying the need for AG to have a child protection medical. ➢ The work done by the Woman’s Refuge in identifying the vulnerabilities of the mother and the complexity of the family. They worked to support as well as challenge the mother prior to the mother leaving the refuge. 28 7. Conclusion It is difficult to understand how a child who was receiving services from a number of agencies in Norfolk was diagnosed with severe malnourishment in 2018. Whilst undertaking this SCR it became apparent that there was a superficial level of understanding of the family dynamics and relationships including domestic abuse, learning difficulties and whether the parents understood why the professionals working with them were concerned. Following the initial child protection conference, the risks and areas to focus on were clearly identified. Over time the focus shifted to housing with the belief that everything else would fall into place if the family were found suitable housing. Despite the fact that AG was weighed regularly and seen by paediatricians there was little evidence of consideration of faltering growth and the impact on the development of AG. In this case the view of the medical/ health professional was accepted, as they were perceived to be the experts. When clarification or explanation was sought it was re-buffed. This is clearly not a healthy environment in which to work and professionals and managers need to support and challenge one another in order to gain a better understanding of the situation and lived experience for the child. The importance of good supervision becomes paramount in ensuring that the focus of the case does not drift and that there are clear measurable outcomes to ensure that there is no case drift and that management has oversight of the case. 8. Recommendations. The strategic leadership of NSCP should review the effectiveness and ability of all partners to deliver the neglect strategy and identify any barriers that may prevent this. NSCP as part of workforce development plan, identify and equip all staff with the confidence and skills to enable them to work with clients from cultural and diverse backgrounds, including the Gypsy, Traveller and Roma communities, and the competency to challenge other professionals in a non- confrontational manner. Health agencies to review the effectiveness of the management of faltering growth and how it is shared with all agencies. Children’s Social Care to provide assurance that Child Protection Plans are realistic and meeting the needs of children that reflect the current position of the risks to the children and are effectively reviewed over time. 29 Appendix:1 Terms of Reference Methodology Statutory guidance within Working Together requires Local Safeguarding Children Boards to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews. The guidance establishes the purpose as follows: Reviews are not ends in themselves. The purpose of these reviews is to identify improvements, which are needed, and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action, which lead to sustainable improvements, and the prevention of death, serious injury or harm to children. (Working Together, 2013:66) . The statutory guidance requires reviews to consider: “what happened in a case, and why, and what action will be taken”. In particular, case reviews should be conducted in a way which: ➢ recognises the complex circumstances in which professionals work together to safeguard children; ➢ seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; ➢ seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; ➢ is transparent about the way data is collected and analysed; and, ➢ makes use of relevant research and case evidence to inform the findings In order to meet these requirements, the model adopted in undertaking this review uses a ‘systems approach’, which draws significantly on the work undertaken by Professor Munro31 and SCIE [Social Care Institute for Excellence]. A ‘systems approach’ to learning recognises the limitations inherent in simply identifying what may have gone wrong and who might be ‘to blame’. Instead it is designed to identify which factors in the wider work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. The purpose therefore is to move beyond the individual case to a greater understanding of safeguarding practice more widely. The SCR was conducted in parallel with ongoing criminal investigations. 31 Social Care Institute for Excellence (Fish et al, 2008) 30 The Panel has worked with the police to agree meetings with individuals directly involved with the case. Police have been provided lists of individuals from the separate agencies and the outline of the conversations. Notes were taken but not shared with the individuals or Panel, but held centrally by the NSCB Business Unit and shared with the Lead Reviewer only. Specific issues to consider in the review of this case. • Expected standards and procedures • Cultural competence in the context of working with families from the travelling community Expected Standards and Procedures • Were existing identified risks to AG and her siblings understood and managed at the correct threshold, and in the correct way? • Was there a shared understanding of the CPP and CIN plan with clear contingency plans for stepping up, stepping down and /or escalation? • How effective were the multi-agency CIN meetings and was there ‘case drift’? • How was the concerning presentation and overall deterioration in Child AG's welfare understood, in particular: faltering growth, malnutrition, developmental delay, physical injuries and neglect? Were the needs of all the children considered? • Was the issue of domestic abuse sufficiently explored, including the impact on the children, and were the risks managed appropriately? Cultural competence in the context of working with families from the travelling community • To what extent did the cultural background of the family impact on the way that professionals managed this case, and responded to the family? Did professionals consider social isolation and transient lifestyle? • To what degree did agencies have a shared understanding of the parents’ non-compliance and was this acted on jointly? • Was the possible impact of the mothers learning disability / literacy explored sufficiently? Was she able to understand what was required in order to meet the needs of her children, in particular AG, and how to protect the children? • Due to the family’s poor housing and cramped conditions did professionals (perhaps) apply different thresholds than the norm? An independent lead reviewer worked alongside a review team (Panel), and composed of 31 senior managers, and facilitated by an independent chairperson. The review team met on 5 occasions and considered the following documentation: • A merged chronology • Child Protection Plans • Core Group Minutes • Child Protection Medical Report • Access to records from Liquid Logic (Children’s Services) • MARAC Minutes (post time line) • Individual Conversations with 18 front-line clinicians and managers • MASA Plan The author of this SCR, Ann Duncan was commissioned by NSCB to write the overview report, she was independent of the case and all agencies involved. The Review Team was comprised of the Independent Lead Reviewer, and the following senior managers/senior professional leads who were independent of the case: . Job title / Role Organisation Detective Inspector Norfolk Constabulary Head of Quality Assurance & Effectiveness Norfolk County Council Children’s Services Deputy Designated Nurse for Safeguarding Children Great Yarmouth and Waveney Clinical Commissioning Group Safeguarding Advisor for Schools Norfolk County Council Education Services Named Nurse for Safeguarding Children Cambridge Community Services NHS Trust Early Years Improvement & Inclusion Officer Norfolk County Council Children’s Services Head of Neonatal, Children and Young People Services James Pagett University NHS Trust Strategic Director Great Yarmouth Borough Council Head of Support and Development Norfolk County Council Community and Environmental Services Named Nurse Hertfordshire Community NHS Trust Representing Hertfordshire Safeguarding Partnership Business Manager Norfolk Safeguarding Partnership Board Ann Duncan Independent Lead Reviewer 32 Appendix 2: NSCB Thematic Learning Framework from SCRs The NSCB Thematic Learning Framework has been developed to enable us to think about the recurring issues and barriers to effective working together. The framework was introduced to Board in December 2015 and has subsequently been tested with partners within Norfolk, through the Public Protection Forum (PPF), with the support of partnership board business managers, as well as nationally. The thematic learning framework, focuses on four key learning areas: 1. Professional curiosity – how can the Board encourage and support appropriate curiosity with families, and between professionals? 2. Information Sharing and Fora for discussion – how can the Board ensure that we use opportunities for discussion effectively, include all relevant parties, act promptly and clearly; and share information well? 3. Collaborative Working, Decision making and Planning – how can the Board improve timely and collaborative planning and get strong and shared decisions? 4. Leadership: Ownership, Accountability and Management Grip – how does the Board give effective leadership and champion better safeguarding, locating clear accountability? At the heart of all learning is the child or young person, and sitting underneath everything we do is the recognition that safeguarding requires people at all levels to manage risk and uncertainty. 33 Appendix 3: Learning Event. Case AG Practitioners Event 26 September 2019 Registration at 9.00am – 4.00pm Venue: Great Yarmouth Race Course, NR30 4AU Agenda Welcome and Introductions Outline of Learning Event Norfolk SCR activity and background Outline of Serious Case Review Process Whole group consideration of timeline Whole group consideration of research questions Identification of gaps/additional information required Identification of learning & recommendations 34 Appendix 4: Acronyms CIN Child In Need CPC Child Protection Conference CPP Child Protection Plan GP Family Doctor/General Practitioner GCP Graded Care Profile HV Health Visitor HoSW Head of Social Work ICPC Initial Child Protection Conference MARAC Multi Agency Risk Assessment Conference MASA Multi Agency Safeguarding Arrangements NSCB Norfolk Safeguarding Children Board NSCP Norfolk Safeguarding Children Partnership SCR Serious Case Review SCRG Serious Case Review Group SW Social Worker SWA Social Work Assessment TL Team Leader TM Team Manager |
NC046647 | Death of a 3.5-month-old on 14 January 2013 from a non-accidental brain injury, consistent with shaking. Father was found guilty of manslaughter. Mother was acquitted of causing or allowing the death. Evidence of possible physical abuse of T's older sibling who had a 'Child in Need' status. Both parents had been known to professionals since childhood. Parents relationship started when Ts father was 20-years-old and mother was 13-years-old. Charges against the father for sexual activity with a child were dropped due to lack of evidence. Father was a prolific offender and a drug user with a known history of domestic violence including an assault on mother when pregnant. T's mother had a history of violent behaviour. Review highlights that the case was never seen as a child protection issue and that learning from previous case reviews was not embedded in practice. Uses the SCIE systems methodology to explore themes such as child sexual exploitation (CSE); the need to "Think family"; disguised and non-compliance; and domestic abuse. Recommendations include: regular multi-agency meetings to consider possible victims and perpetrators of CSE; the introduction of integrated chronologies; training for safeguarding leads on learning from previous local case reviews; advanced domestic abuse training for all social workers and child protection staff; a new protocol for the use of parent partnership agreements to ensure they are realistic; and the need for all assessments to be evidence-based. Also summarises good practice.
| Title: Serious case review: Child T: overview report. LSCB: Bristol Safeguarding Children Board Author: Joanna Nicolas Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Overview Report Relating to Child T Date: 22nd April, 2015 Ethnic Origin: White British Author: Joanna Nicolas. Independent child protection consultant. 2 Contents Part One Page 1. Introduction 3 1.1 Circumstances leading to this serious case review (SCR) 3 1.2 The Child Death Overview Process 3 1.3 Current criminal investigations, care proceedings and coroner’s inquiries 4 1.4 Terms of Reference (TOR) of the review 4 1.5 Methodology 4 1.6 Contributors to the review 5 1.7 The scope of the serious case review 7 2. The Facts 8 2.1 The Family 8 2.2 Genogram 9 2.3 Ethnic, cultural and other equalities issues 9 2.4 Information about the parents/carers, extended family and home 9 circumstances of the children 2.5 Summary of significant events 11 3. Themes and analysis 3.1 Child sexual exploitation 20 3.2 Levels and means of intervention 27 3.3 “Think family” 32 3.4 The use of partnership agreements 34 3.5 Disguised compliance 36 3.6 Domestic abuse 39 3.7 Summary of good practice 44 4. Conclusion 45 Appendix One – Explanation of acronyms used in the report and glossary of terms Appendix Two – Genogram 3 Part One About the author I have been a social worker for 19 years, having gained the relevant Diploma in social work from the University of North London in 1995, and have worked in social care for 22 years. Most of my work has been in child protection. Since 2008 I have worked as an independent child protection consultant and trainer and have undertaken a number of serious case reviews, usually as the overview author but also an IMR author. I am also an accredited lead reviewer in the Social Care Institute for Excellence (SCIE) “Learning Together” systems approach to case reviews and have, to date, been involved in four systems reviews. (I was involved in the Government’s South West pilot of “Learning Together” reviews, alongside Bristol in 2011). As well as undertaking consultancy work I also develop and deliver child protection training and am a published author. 1. Introduction 1.1 Circumstances leading to this serious case review Child T was admitted to the Bristol Children’s Hospital on 11th January 2013 with an acute collapse. Child T tragically died at 02.19 hours on 14th January 2013. CT scan revealed significant subdural and subarachnoid haemorrhages with hypoxic brain injury. Child T had some bruising on the ear and arms and extensive retinal haemorrhages. There have been no medical conditions discovered to account for these injuries so far and it is the opinion of all professionals involved that the most likely cause of Child T’s death is non-accidental injury, probably due to a shaking injury. The case was requested to be considered for a serious case review by the Community Paediatrician on call the weekend that Child T was admitted to hospital. The request was formally sent on 18th January 2013 and considered by the Serious Case Review Sub-Group on Monday 28th January 2013. It was considered that the circumstances of the child’s death fully met the criteria for a serious case review, as set out in Chapter 8 of Working Together to Safeguard Children, 2010. 1.2 The Child Death Overview Process From 1st April, 2008 Child Death Review processes became mandatory for Local Safeguarding Children’s Boards in England. The processes to be followed are outlined within Working Together to Safeguard Children (2013). This process will work with this serious case review. 1.3 Criminal investigations, care proceedings and coroner’s inquiries 4 1.3.1 All parallel proceedings have now concluded. 1.3.2 The Crown Prosecution Service (CPS) and coroner were informed of the SCR process. The independent chair of the SCR Panel liaised with the Senior Investigating Officer. It was the role of the Detective Inspector on the SCR Panel to ensure that any information relevant to the criminal proceedings, which arose from the serious case review process, be identified as such. No relevant information was identified. 1.3.3 The main body of the serious case review was concluded in December, 2013. Publication was delayed due to the requirement to wait until the conclusion of the criminal trial. 1.3.4 In December, 2013 Mr Z was found guilty of the manslaughter of his child, Child T. Ms A was acquitted of the charge of causing or allowing the death of a child. 1.4 Terms of Reference (TOR) of the review 1.4.1 In addition to the general requirements set out in chapter 8, Working Together to Safeguard Children, 2010 the serious case review and Individual Management Reviews (IMRs) were specifically asked to consider in respect of Child T:- TOR 2.1 In relation to this case was there a failure by agencies in working with this family in not recognising evidence of risk of significant harm? If such evidence exists, was this shared and/or acted upon in an appropriate and timely manner? TOR 2.2 In relation to the parents (and anyone who had care of Child T) are there any relevant medical, mental health, substance misuse (including alcohol) issues, previous convictions, intelligence and/or domestic violence or any children from previous relationships where these issues would apply? TOR 2.3 Did any agency working with this family fail to recognise previous evidence of risk of significant harm or need? Where such evidence exists was it shared and/or acted upon in an appropriate and timely manner? TOR 2.4 Do any issues emerge in relation to the safeguarding or management of risk in relation to domestic violence or abuse? 1.5 Methodology 1.5.1 The decision to undertake this serious case review was made at a time when the publication of the new statutory guidance, Working Together to Safeguard Children was imminent. The updated statutory guidance was to be informed by Professor Eileen Munro’s report1 to Government, published in May, 2011 Her recommendation regarding serious case 1 The Munro Review of Child Protection: Final Report. A child-centred system. http://www.official-documents.gov.uk/document/cm80/8062/8062.pdf 5 reviews was that Local Safeguarding Children Boards (LSCBs) should use systems methodology when undertaking serious case reviews and, “Over the coming year, work with the sector to develop national resources to: • provide accredited, skilled and independent reviewers to jointly work with LSCBs on each SCR; • promote the development of a variety of systems-based methodologies to learn from practice; • initiate the development of a typology of the problems that contribute to adverse outcomes to facilitate national learning”. 1.5.2 Professor Munro specifically recommended using the systems model developed by the Social Care Institute for Excellence (SCIE). Subsequently the Government funded a pilot using this methodology, and Bristol was part of the South West pilot. This was in 2011. 1.5.3 In November 2012 the draft Working Together was published and this stated that LSCBs should use systems methodology when reviewing serious cases. However as this was only in draft form in January 2013 when the decision was made to undertake an SCR in respect of Child T the Independent Chair was clear that the methodology set out in chapter 8 of Working Together, 2010 must be used, as that was the current statutory guidance. This decision followed robust discussion amongst the SCR sub-group and it was agreed that within that framework an element of systems learning would be included. (BSCB had undertaken two previous SCRs in the past three years and wanted to ensure they maximised the learning potential from this review). 1.5.4 To that effect the IMRs were completed with guidance from myself, the overview author and the SCIE systems methodology was explained to the SCR Panel and the IMR authors. The IMR authors interviewed the key professionals from their agencies, who had been involved with the family and were still working with the organisation. Once the IMRs had been completed there followed two meetings with the IMR authors and the SCR Panel. The first meeting was to consider significant events in the chronology, events which may have led to events taking a different turn, if they had been responded to differently. From that I deduced some themes arising from this case. The second meeting was to go through those themes and agree the final themes for analysis. 1.5.5 It should be noted that although SCIE has been mentioned, because it was recommended by Professor Eileen Munro and the author is an accredited SCIE lead reviewer, this is not a SCIE review. 1.6 Contributors to the review The Family Child T – 3 ½ months at the time of death 6 Child U, sibling – Under two at the time of the death of Child T Mother – 18 at the time of death of Child T Father – 24 at the time of death of Child T 1.6.1 The parents of Child T were made aware of the SCR in writing and were invited to make their own contributions to the review. Neither parent responded to the letter sent to them initially. Following the conclusion of the criminal trial the parents were contacted again, as were the maternal grandparents and paternal grandmother. It is good practice to involve families in serious case reviews, wherever possible. Our learning should come from families, as well as professionals however this resulted in further delay. In February, 2014 I met with Child T’s mother, Ms A and Child T’s maternal grandmother. In April, 2014 I met with Child T’s paternal grandmother. Their views are woven throughout the report. Mr Z has declined to contribute to the serious case review. The Professionals 1.6.2 The SCR Panel is made up of the following members:- Deborah Jeremiah Independent Chair SCR Panel Service Manager, Safeguarding and Quality Assurance, Bristol Children and Young Peoples Service (CYPS) Consultant Community Paediatrician from North Bristol Trust acting for the Clinical Commissioning Group Designated Nurse for Safeguarding, NHS Bristol Clinical Commissioning Group DCI, Avon & Somerset Constabulary, Bristol Public Protection Unit (PPU) Service Manager, NSPCC Crime reduction project officer Manager, Safer Bristol. Community Safety Partnership Service Manager East/ Central, CYPS, Bristol City Council Team Manager, Barnardo’s Against Sexual Exploitation (BASE)/Safe Choices, Barnardo’s 1.6.2 A Health Overview Report (HOR) was provided by Bristol Clinical Commissioning Group (CCG) 1.6.3 IMRs were provided by the following agencies:- North Bristol NHS Trust 7 Avon and Somerset Constabulary Avon and Wiltshire Mental Health Partnership Trust (AWP) Avon and Somerset Probation Trust CYPS, Children’s Social Care University Hospitals Bristol NHS Foundation Trust (UHB) Bristol Youth Offending Team (YOT) Learning Partnership West (LPW) Bristol Drugs Project (BDP) Next Link Domestic Abuse Services CYPS, Early Years: Children’s Centre General Practice/Primary Care The school attended by Ms A, the mother The IMR authors were all invited to the two meetings, referred to in 1.5.4, and there was good representation of agencies at each of the two meetings. 1.7 The scope of this Serious Case Review This serious case review is about Child T. Consideration will be given to relevant criminal history, intelligence, matters of medical history, education and social functioning of Child T's parents and where appropriate extended family members who were significant to Child T in order to provide some context of the life of Child T. The SCR Panel will not be prescriptive as to the range of records and time-frames to be considered by the IMR authors in their reports. Their professional judgement should be exercised in order to locate relevant information and outline the pertinent factors to include in their IMRs. However, the SCR Panel would expect the minimum to include all agency involvement prior to the birth of Child T and their sibling Child U and the commencement of their parents’ relationship in 2007 until Child T’s death on 14 January 2013. Consideration should be given to a thorough evaluation of records held regarding the histories of Mr Z and Ms A, Child T's Parents and Ms H the Maternal Grandmother. 1.8 Documents read by the overview author include:- • Bristol City Council Ofsted Inspection of Safeguarding and Looked After Children, April, 2010 8 • Bristol City Council Ofsted Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board, December, 2014 • “The sexual exploitation of children: it couldn’t happen here, could it?” Ofsted’s thematic review of child sexual exploitation, which included eight local authorities, including Bristol • Previous BSCB serious case reviews, including Child Z, 2009, Child M, 2011 and Child K, 2012 • MARAC Self-Assessment – Bristol (North and South). CAADA, 2012 • Bristol Safeguarding Children Board Serious Case Review Process • BSCB Joint Safeguarding Children Protocol. Children and Families Living with Substance Misuse. Safer Bristol • BSCB Joint Practice Guidance for Children’s Services and Adult Substance Misuse Services. Children and Families living with substance Misuse. Safer Bristol • Minutes of strategy discussions held on 16.1.12 and 3.7.12 • The partnership agreements drawn up on 16.1.12, 28.6.12, 26.7.12 and 30.11.12 • MARAC meeting minutes dated 20.1.11 and 17.11.11 • Barnardo’s Against Sexual Exploitation (BASE) fact sheet • Bristol BASE Annual Impact Results Report. March, 2013 • Engaging Fathers in Child Protection. An audit of Bristol policies and 20 child protection cases. Family Rights Group. May, 2012 and subsequent action plan, November, 2012. 2. The Facts 2.1 The Family 2.1.1 The immediate family consisted of the Mother, Ms A, the Father, Mr Z, the older child, Child U and the younger child, Child T. Ms A and Mr Z were known to have been together since Ms A was aged 13 and Mr Z aged 20, five years at the time of Child T’s death. It will never be known how much of those five years Ms A and Mr Z were together, for reasons which will become apparent as you read this review. The professionals were under the impression that the couple were not together for much of the five years. The family describes a different scenario, that being that the couple were rarely apart. 2.1.2 The extended family members, who had involvement with the family and with whom the agencies had some involvement, consisted of the Maternal Grandmother (MGM), Ms H, the Maternal Grandfather (MGF), Mr G and the Paternal Grandmother, Ms E. 2.1.3 In addition to this Mr Z had two other known relationships, both prior to and possibly during his relationship with Ms A. 9 2.2 Genogram A genogram of the family is Appendix Two. 2.3 Ethnic, cultural and other equalities issues 2.3.1 Ms A and Mr Z are both White British. There are cultural and equalities issues which will be considered in the analysis of this review. Those issues were assumptions made about the type of families and children who live in particular areas of Bristol and about Ms A and Mr Z generally. (See 3.1.11 and 2.6.15). There were also assumptions made about Ms H and Ms A being able to read sufficiently to receive written material, without any evidence that this had been confirmed. (See 2.6.6). Again, this will be examined in the analysis of this review. 2.3.2 There is no mention of any of the family members being affiliated to any particular religion and the family members interviewed made no mention of religion. 2.4 Information about the parents/carers, extended family and home circumstances of the children The Mother – Ms A 2.4.1 The first concerns expressed by any agency were by the school in September, 2006, when Ms A was 12. The concerns were about her attendance, which was starting to drop. Prior to that her attendance had been excellent and she was described as “Well presented” in school. Ms A first became known to social care in April, 2007. The police had attended a domestic incident involving Ms A’s parents. Ms A and her sister had witnessed the incident. 2.4.2 As Ms A’s childhood progressed there were on-going concerns. She had a difficult relationship with her mother, with Ms A accusing her mother of physical abuse on more than one occasion. There was little reference to her father’s involvement. She had periods of exclusion from school, was alleged to have physically assaulted another pupil, her disruptive behaviour increased, her attendance kept dropping and eventually it was decided she would be better suited to attend a vocational course at a college, at the age of 13 years and six months. It was around this time that Ms A’s parents were separating and Ms A said it was this that led to her behaviour deteriorating. She described being very upset by their separation. There were also further recorded incidents of domestic abuse between Ms A’s parents during this time and there was known to be excessive alcohol use. 2.4.3 Ms A was known to have started a sexual relationship with Mr Z when she was 13 and Mr Z was 20. Reference was also made to her drinking alcohol at this time. By the age of 14 Ms A had fallen out with her mother, was disappearing for days on end, according to her mother and was found living in a tent with Mr Z. Ms H described taking Ms A to social care 10 when she was 14 and handing her over, telling them to deal with her because she could not anymore 2.4.4 The rest of her childhood remained chaotic. She went to stay with a family friend but that then broke down and she returned home. In 2010 she was thought to be sleeping rough again and was offered bed and breakfast accommodation. She became pregnant with Child U when she was 16 and Mr Z moved in with her. 2.4.5 The relationship between Ms A and Mr Z was known to be abusive from November, 2011, when Ms A was in her second trimester of her pregnancy with Child U. The Father – Mr Z 2.4.6 Very little was known about Mr Z’s childhood, except that from the age of fifteen he became a prolific offender, until the criminal trial. What came from the trial was that Mr Z had one to one support from the age of two, in nursery, and he was not allowed to stay in nursery during lunchtimes because his behaviour was so disruptive. His mother, Ms E, confirmed this. She said that this continued when he went to school but his attendance at school was very poor. We would not have expected the workers working with the family to have had this level of detail about the family history. Murder inquiries allow for a level of investigation that is neither realistic, nor practicable in child protection work. Ms E did not engage with the school and he was only in secondary school for a short period before he dropped out completely. (It has not been possible to be more specific about Mr Z’s school attendance because there was no mention of his schooling in the IMRs. The timeline under consideration did not go back as far as Mr Z’s time at school. What is relevant and concerning is that the professionals working with Mr Z and his different partners and his children did not know about his history). This information has not been disputed. 2.4.7 In conversation Ms E did not express concern about Mr Z’s behaviour, or lack of school attendance. When Mr Z was a child Ms E only spoke of one contact with professionals. She described asking the GP once if he thought her son had Attention Deficit Hyperactive Disorder (ADHD). Ms E said the doctor said he did not have ADHD and that was the end of it. 2.4.8 Between 2003 and 2007 Mr Z was the subject of 86 police reports, including dealing drugs and theft. None of these involved violent crime. There were some offences of assault and causing actual bodily harm, including assaulting a police officer in 2005, when he was 17. 2.4.9 Mr Z’s offending behaviour decreased from 2007 and most of his contact with the police from that point was to do with child abduction and domestic abuse, although there continued to be some theft and criminal damage. 2.4.10 The first known domestic abuse incident between Mr Z and a female, an ex-partner, Ms X, was in 2006. From that time there were many recorded incidents of domestic abuse 11 between Mr Z and the three females he was/had been in relationships with. The first mention of Mr Z’s mother was a domestic abuse incident between Mr Z and his mother, Ms E. Mr Z was the alleged perpetrator. He was 19 at that time. 2.4.11 The first reference to Mr Z and street drugs was in 2006, when he was arrested for dealing Class A drugs. At that time it was alleged he was also using Class A drugs. In 2009 Mr Z told his GP he was addicted to crack cocaine and heroin and had been using intravenously for two years. There continued to be issues of Mr Z and street drug use throughout the rest of the period under review, with his mother requesting the GP’s help in November, 2012. Home Circumstances 2.4.12 From the time of their births until Child T’s death, in January, 2013, the children lived with their mother. As stated in 2.1.1 we will never know how much of that time Mr Z was also living in the home, however Ms A says he was there most of the time. She described being unable to keep him away. For much of that time he was not supposed to be having contact with Ms A and yet we now know he was. 2.4.13 During the periods Mr Z was accepted to be staying/living with Ms A he mostly presented to professionals as being supportive. It was recorded on occasions that he had a good bond with the children and he was keen to be a better father. Ms A’s view of this was that he did not care for the children but that he knew what to say to professionals. 2.4.14 There were no particular concerns expressed by professionals about the cleanliness of the home, or the physical care of the children. There was no record of electricity running out, or food cupboards being bare. There was a concern that the parents were using Child U’s bedroom for storage of items, which meant Child U was sleeping on the sofa in the front room. A family member had bought Child U a bed in October, 2012 but Ms A and Mr Z wanted to keep it until Christmas because Child U’s bedroom was not ready. There was also a concern that when Child T was born Ms A did not have a double pram, which meant she was unable to leave the house with the children, unless there was another adult and another baby carrier, although she and Mr Z had recently spent money on non-essential items. 2.5 Summary of significant events (Although all of the events listed below are considered significant, it must be accepted that some have only become significant with the benefit of hindsight and the knowledge of the tragedy that took place). There is purposefully limited information in this review about Mr Z’s previous known partners, Ms X and Ms W. The information included is relevant and necessary because it demonstrates a pattern of behaviour by Mr Z but is limited because the focus of this serious case review is Child T and Child T’s life and family. 12 2.5.1 On 20.2.06 Mr Z was first accused of domestic abuse. He was prosecuted for punching his ex-partner, Ms X, in the face and for criminal damage. 2.5.2 On 1.6.06 Mr Z was prosecuted for the incident set out in 2.5.1 and found guilty. He was also found guilty of a further assault on Ms X. This time he punched her, pushed her over and smashed her mobile telephone. He was given a 12 month Community Order and 100 hours of unpaid work. Ms X was under 16 at the time. 2.5.3 On 15.11.06 police enforcement action was taken against Mr Z for dealing Class A drugs. He was also thought to be a user. 2.5.4 On 1.2.07 there was an alleged domestic abuse incident between Mr Z and Ms W. there was no further action by police as the incident was not officially recorded. Ms W was under 16 at the time of the alleged incident and was seven weeks pregnant with Mr Z’s child. 2.5.5 In March, 2007 there were two incidents with Ms A in school. On 7.3.07 she refused to comply with school rules and sanctions and was excluded for one day. On 28.3.07 she physically assaulted another student and was excluded for another day. On 19.6.07 the school made a referral to social care because of concerns of neglect of Ms A and her sibling. Social care told the school they would make a referral to a family support service. (This family support service was one of the three services that had been commissioned by Bristol City Council to undertake the early intervention work in the three social care localities, at that time. The expectation was that they would undertake the assessment under the Common Assessment Framework (CAF)). This family support service has no record a referral was ever made. There were further assaults on other students on 11.10.07, 23.11.07, 3.12.07 and 16.1.08. These assaults included punching in the head on one occasion and in the eye on another. These resulted in further exclusions. 2.5.6 On 8.4.07 police attended the first domestic abuse incident between Ms H and Mr G. They were sent literature about domestic abuse. (See 2.3.1). In the next few months a number of further domestic incidents were reported. During this time Ms A alleged she was being physically abused by Ms H. In April, 2007 social care referred the family to a specialist domestic abuse service. In June, 2007 their records show there should be a referral to the specialist domestic abuse service and the family support service, again the referral to the family support service was never made. During this period Ms A’s behaviour and attendance at school deteriorated and Ms H accused Ms A of stealing jewellery from her “To fund her cocaine habit”. Although there was no evidence of a drug habit, Ms A was said to have an extensive knowledge of street drugs at 12 years old and said she frequented crack/heroin houses. (This information came from the initial assessment completed by the social worker at that time). As a result of this allegation there was a strategy discussion held between police and social care. Social care undertook an initial assessment. The outcome of which 13 was for the family support service to continue to support the family. (This was a misapprehension as the family support service had never worked with the family). 2.5.7 On 10.7.07 Ms W alleged Mr Z punched her in the stomach. She was seven months pregnant at the time. Mr Z was arrested for common assault and given a police caution. 2.5.8 On 21.8.07 there was an alleged domestic abuse incident between Mr Z and his mother, Ms E. There was a further alleged incident between them four months later. At the time Ms E said Mr Z grabbed her around her throat. Mr Z was charged with criminal damage to the property but the Crown Prosecution Service advised no further action regarding the domestic abuse because Ms E wanted to drop the charges and Mr Z said she had assaulted him first. 2.5.9 In the autumn of 2007 Ms W’s child, Child V was born. Mr Z was present at the birth. Ms W was under 17 at the time of Child V’s birth. 2.5.10 On 3.10.07 Mr Z agreed to counselling, as part of a partnership agreement between Ms W, Mr Z and social care. It was noted by social care that Mr Z could not read. Mr Z expressed remorse about his previous behaviour and told social care he wanted help on “Low self-esteem and anger management”. Three weeks later Ms W told social care her relationship with Mr Z was over because she suspected he had been using crack cocaine and he allegedly pushed her in the street and tried to snatch the baby, Child V. 2.5.11 On 18.1.08 Mr Z was remanded in custody for stealing a car and related offences. 2.5.12 On 1.5.08 Ms H reported to the police that Ms A, aged 13, was in a sexual relationship with Mr Z, aged 20, she was also known to be drinking alcohol. As a result of this a strategy discussion was held between the police and social care. The police arrested Mr Z for abduction and served him with an abduction notice. Mr Z gave a “No comment” interview and the case was closed as an undetected crime due to insufficient evidence. Ms A had been unwilling to give a police interview. She said she had been going out with Mr Z for a few months and had not been pressured into having sex. Ms A told the police she would like to live with her father but all her friends are near where her mother lives. 2.5.13 On 21.6.08 There was an alleged assault of Ms W by Mr Z. He was said to have grabbed her, punched her in the mouth and pulled her around by her hair. 2.5.14 On 14.8.08 Ms A, Ms H and Mr Z were arrested for being in a series of assaults and damage against four other persons. Mr Z admitted one offence and was cautioned for common assault on 5.11.08. The victim declined to pursue a prosecution and as there was insufficient evidence the case against Ms A and Ms H was dropped. After this incident Ms A’s father, Mr G contacted the police expressing his concerns about his daughter. Social care was advised. There was no further action. 14 2.5.15 On 29.8.08 Ms A and Mr Z were stopped by the police looking into gardens at 00.50. Ms A was 14 at the time. When the officers were asked about this, as part of this review the police IMR states “Young people out at that time of the night was not unusual, or out of the ordinary, in that area”, hence they did not consider taking her home, or offering her a lift and did not consider it was necessary to report the event to any other specialist department, for example the police child protection unit”. There was no further action. 2.5.16 On 2.1.09 Ms H told social care that Ms A continually went off with Mr Z, not returning home for days. Ms H also said that Ms A had tried to make her (Ms H) miscarry by kicking her in the stomach. Social care informed the police. Mr Z was in breach of his abduction order. Mr Z was arrested for abduction of a child and sexual activity with a child, Ms A. Mr Z was bailed and one of the conditions of his bail was not to contact Ms A. At this time Mr Z was also in breach of his court bail regarding an impending prosecution for driving whilst disqualified. Mr Z was sentenced to 40 weeks in a young offenders’ institution for driving whilst disqualified. The charges for abduction of a child and sexual activity with a child were dropped because Ms A would not give evidence and the police did not think it would meet the CPS threshold. Social care did not take any action because they had previously referred to a specialist support service. They did give the family information about The Bristol Barnardo’s Against Sexual Exploitation (BASE) project but did not refer to the project. Around this time during an argument between Ms H and Ms A, Ms A broke a mirror and cut her wrists. The police attended with paramedics. The injury was superficial. Social care was informed. There was no further action. 2.5.17 On 25.9.09 Ms H’s partner at the time contacted 999 saying that Ms A had been drinking heavily. Ms A was taken to hospital. She said she had gone out drinking with a friend and someone had put an ecstasy tablet in her drink. She was 15 at the time. Social care was informed. They wrote to Ms A’s parents advising them it was often at this age that children start take part in risk-taking activities and to contact their local social care office if they wanted support and advice. There was no further action. 2.5.18 On 7.10.09 Ms H informed the police that her daughter, Ms A was missing, following an argument. Ms A was found to be living in a tent with Mr Z, in the garden of the address Ms H had given the police. Social care was informed and contacted Connexions. Connexions was a service that offered information, support, guidance and activities to young people. Social care requested that Connexions undertake a CAF. Connexions sought advice from the local CAF co-ordinator and told social care they could do a joint CAF however on 16.10.09 social care informed Connexions that they were closing the case and would not be involved in a CAF. No CAF was undertaken. Ten days later the Connexions worker was advised that Ms A had been sleeping rough for the last week and had been sleeping in fields because her mother had asked her to leave the house. A strategy discussion was held between police and social care. The police took no further action because Ms A had previously refused to give evidence against Mr Z. (See 2.6.16). Social care allocated the case. 15 2.5.19 On 5.11.09 Mr Z was arrested for stealing a bicycle. He tested positive to a Class A drug. On 27.11.09 Mr Z informed his GP that he was a crack cocaine and heroin addict and had been using intravenously for two years. Mr Z was put on a Methadone prescription. During this period Mr Z was arrested five times for theft of items. He stopped collecting his Methadone script in April, 2010. In November, 2012 Mr Z’s mother contacted the GP saying her son wanted help with his drug addiction. (In our meeting Ms E said that Mr Z had only ever used cannabis. He had never used Class A drugs). She was told her son should contact the GP, which he never did. 2.5.20 On 30.11.09 Ms A was arrested for assaulting a friend she was with and stealing her coat. There was insufficient evidence to proceed. Ms A denied the charges. Two days later the police receive intelligence that Ms A was in possession of heroin and was injecting regularly. The police did not share this information with social care. The Police Child Abuse Investigation Team (CAIT) was not aware of this information. The police system has now changed and the CAIT would have sight of all information that comes in to the police regarding a child. Ms A was 15 at that time. 2.5.21 On 16.1.10 Ms A was arrested for assault, following an argument in the street. There were others involved but the case was dropped due to lack of evidence. 2.5.22 In September, 2010 Ms A became pregnant with Child U. She was 16. Mr Z was the father. Shortly after this she was placed in Bed and Breakfast accommodation. Mr Z moved in with Ms A. 2.5.23 The first known domestic abuse incident between Mr Z and Ms A took place on 1.1.11. She was a known to be in the first trimester of her pregnancy. Mr Z allegedly pulled Ms A around by her hair, punched her in the eye and hit her with a bicycle chain. It was Ms A’s father who informed the police. Mr Z was arrested as a result of the statement made by Ms A’s father, and charged with common assault. Ms A was unwilling to support the prosecution, make a statement or have photographs taken. She also refused Victim Support. Ms A said that Mr Z had only hit her with a shower bottle. Mr Z was remanded to 3.1.11, then released on bail. One of the bail conditions was that he was not to contact Ms A. Two days later Ms A attended hospital with lower abdominal pain, back pain and vomiting. She was admitted to the ward and was seen to have a cigarette burn on the back of her hand and bruising on her outer thigh. The following day Ms H visited her daughter. When she arrived Mr Z was also visiting Ms A. The hospital was unaware of his recent arrest and bail conditions. He was escorted from the hospital. 2.5.24 As a result of the incident set out in 2.5.23 Ms A was made the subject of a Multi-Agency Risk Assessment Conference (MARAC), a way of working with victims of domestic abuse. In court Mr Z pleaded not guilty and Ms A continued to decline to give evidence. The case was discontinued at court. 16 2.5.25 On 28.1.11 Ms A moved to a new address. Mr Z also moved to the same address. 2.5.26 In the spring/summer of 2011 Child U was born. Social care was not informed prior to, or post the birth. Neither the midwives, nor the health visitors had any concerns about Child U. 2.5.27 On 28.9.11 police were informed of a domestic incident between Mr Z and Ms A. Ms A had allegedly telephoned a family member saying she was too scared to go home because Mr Z was threatening her. She said he had hit her that morning. Mr Z was arrested for common assault. Ms A told the police she had been violent too. There was no further police action. This information was shared with social care and the health. 2.5.28 On 2.10.11 a neighbour reported to the police that she could hear Ms A being “Beaten up” by her partner and there was a baby in the house. The police attended. Both Mr Z and Ms A said they had been having an argument but did not want to take it further and there was no further action. Social care was not informed. 2.5.29 On 6.10.11 a housing officer made a referral to Next Link, a domestic abuse service. Next Link contacted Ms A who told them that Mr Z had moved out. Ms A told the Next Link worker that previously Mr Z had hit her with a bicycle chain (Which until this point she had denied). She also said he had strangled her and had shaken Child U, an allegation she later retracted. Child U was four months old at this time. Ms A also said that the housing officer had made a referral to social care regarding the incident with Child U. This was not the case but Next Link did make a referral to social care. Ms A agreed to support from Next Link but declined the Freedom Programme, a programme for victims of domestic abuse. There was no further action regarding the alleged shaking of Child U and when questioned later Ms A said she meant Mr Z had looked as though he would shake Child U. Next Link referred to MARAC and Ms A was discussed at a meeting held on 17.11.11. Ms A had informed Next Link that Mr Z only had supervised contact with Child U, which was supervised by his mother, Ms E. At the MARAC meeting the social worker said that Ms A was keen to access the Freedom Programme (She had declined this with Next Link) and Mr Z was keen to access SPLITZ, the community programme for perpetrators of domestic abuse. 2.5.30 Six days later on 23.11.11 Mr Z was present when the health visitor undertook a home visit. Ms A said he was staying two nights a week. The health visitor was aware of the MARAC meeting but did not inform social care that Mr Z was back in the family home. 2.5.31 On 13.1.12 there was a further domestic abuse incident between Mr Z and Ms A. Ms A had been at a party and Mr Z had “Dragged her out of the house”. The police attended and arrested Ms A for assault. Mr Z refused to give a statement and Ms A was released without charge. The MARAC co-ordinator was informed and a strategy discussion between police and social care took place. It was agreed social care would undertake a child protection investigation under s.47, Children Act, 1989 to see if Child U was suffering 17 significant harm as a result of the domestic abuse. Ms A was recognised as a child in this strategy discussion but it was decided that no specific services needed for Ms A “As she will be supported by services to Child U”. Ms A denied still being in a relationship with Mr Z. The first partnership agreement was drawn up between social care and Ms A. and signed on 16.1.12. Ms A agreed that Mr Z would not visit the family home and would only have contact with Child U supervised by his family. Social care was clear they would take further steps to safeguard Child U if the agreement was breached. 2.5.32 On 28.2.12 Ms A moved home. She advised professionals she was no longer in a relationship with Mr Z. A week later, on 8.3.12 Ms A was confirmed as 12 weeks pregnant with Child T. Child U was under one at the time. Ms A talked of having a termination. She told the GP Mr Z was not the father. Maternity records in April, 2012 show Mr Z as the father. 2.5.33 On 27.6.12 a neighbour, supported by their local children’s centre, made a referral to social care. They said Mr Z had been living with Ms A all along. They hear Ms A screaming and swearing at Child U, Mr Z is physically abusive towards Ms A and the home smells of cannabis. The following day social care visited the home, early in the morning and unannounced. Initially Ms A denied Mr Z was living in the home but then he appeared and admitted he was. A second partnership agreement was drawn up between social care, Ms A and Mr Z. Mr Z agreed not to live in the family home and Ms A agreed not to smoke cannabis, or shout at Child U. Mr Z agreed he would only have contact with Child U supervised by his mother (There was no known contact between social care and Ms E). Both parents agreed that any domestic abuse or risk of domestic abuse would be reported to the police. Ms A also agreed to engage with the children’s centre, the health visitor, the teen pregnancy midwife, the community midwife services and social care. A strategy discussion was held between police and social care. It was agreed social care would undertake a child protection investigation and would proceed straight to an initial child protection conference if the agreement was breached. 2.5.34 On 4.7.12 Mr Z and Ms A told the social worker that they had been together for the last five months, except for a brief split after the domestic abuse incident in January. Both parents denied shouting at Child U. There followed a third partnership agreement with social care. Social care accepted that Mr Z was living with Ms A. This agreement was similar to the partnership agreement of the previous month but this one stated that neither parent would shout at Child U and that both parents would engage with all of the services. It continued to say that Ms A would not smoke cannabis. Once again the agreement said that social care would proceed to an initial child protection conference if the agreement was breached. Social care now viewed Child U as a Child in Need (CIN). A multi-agency CIN meeting was held. 2.5.35 On 16.8.12 Child U was seen by the health visitor to have a bruise on the right side of the forehead. Ms A was unable to explain how the injury had occurred. Child U was under 18 18 months old at the time. No further action was taken. (It was during this period that Ms A was supported by the family support service. The support was for a 12 week period and took the form of weekly visits by a family support worker. 2.5.36 On 21.9.12 Child T was born. The family did not have a double pram, so Ms A was not able to leave the home with both children. The family had limited money and had prioritised buying non-essential items. 2.5.37 On 4.10.12 social care undertook a home visit. The home was thought to smell of cannabis. Child U had a bruise on his forehead. Ms A said this happened because the child head-banged. Child U also had two facial scratches. Ms A said they were self-inflicted. An appointment was made for two weeks’ time. No medical advice was sought regarding the regular administration of Calpol. The following day Mr Z was arrested for cannabis possession. Three weeks later he was arrested for burglary and tested positive to a Class A drug. 2.5.38. On 9.11.12 Child U was seen by the health visitor to have a graze on the forehead and scratches to the nose. Ms A said Child U had fallen over. No further action was taken. Four days later Ms H visited social care’s local office because she was so worried about her grandchildren. She told the social worker that another family member had observed Mr Z a few days earlier throw a talc bottle at Ms A which had hit Child T, who was three weeks old at that time, leaving a mark. She alleged that Mr Z used heroin and Ms A gave him money. Mr Z admitted to smoking heroin but only at his mother’s house. Ms H also said that recently Ms A and Mr Z had been out with the children, in two prams but Mr Z had stolen a bicycle and left Ms A with the two prams. Ms H said she had now bought a double pram for Ms A. When these concerns were discussed with Mr Z and Ms A, during a home visit by the social worker, Mr Z initially denied using heroin but when Ms A said later in the conversation that he only smoked heroin at his mother’s, Mr Z did not deny that. Ms A said she smoked cannabis. Ms A’s view at that time was that Ms H was vindictive; she had never approved of Mr Z and was just trying to cause trouble. All other allegations were denied. Social care decided to carry on working with the family under CIN status, although only one meeting had been held. It was decided a core assessment would be undertaken. A core assessment was started and was completed shortly before Child T’s death. A CIN meeting had been arranged. This had been due to take place shortly after 14.1.13, the date of Child T’s death. 2.5.39 Eight days later on 21.11.12 the graze on Child U’s forehead was seen to be healing. A yellow bruise was seen next to it. (Despite popular belief, medics cannot accurately age a bruise from the colour of it2). Ms A was not asked about the bruise and no further action was taken. 2 Can you age bruises accurately in children? A systematic review S Maguire, M K Mann, J Sibert, A Kemp 19 2.5.40 On 23.11.12 Ms E contacted the GP asking for help with Mr Z’s drug problem. Ms E told the GP that he was willing to engage with the GP. The next day there was a domestic abuse incident between Mr Z and Ms A. Mr Z forced entry to the property. Ms A alleged Mr Z hit her with a metal dog chain, kicked her and threw a cold drink over her and Child U. Ms A told the police that she had told Mr Z their relationship was over. She said that when she was pregnant he had kicked her and punched her in the stomach and the violence is now getting worse because of his drug problems. Ms A said that he “Is extremely controlling and will flip out if I am late and out longer than I say. He does not want me to see anyone. He controls my phone and where it is. He has kicked the dog and uses heroin and crack cocaine”. Mr Z was arrested. He admitted the criminal damage but denied hitting Ms A with a chain. He said he had thrown her to the floor in self-defence because Ms A had punched him. He was charged with criminal damage but on the advice of the CPS there was insufficient evidence to charge him with assault. He was remanded in custody because his mother refused to have him at her home. He was given a Community Order and a Restraining Order, one of the conditions being that he must not contact Ms A or go near their family home. The Restraining Order was for six months, so would expire on 29.5.13. The police made a referral to MARAC, social care, Next Link and the health Safeguarding Children Team. 2.5.41 On 29.11.12 Mr Z told the Criminal Justice Intervention Team (CJIT) that he smoked three to four spliffs of cannabis every day and he snorted cocaine at the weekends. He said he lived between his girlfriends and his stepfather’s. He also told CJIT that Ms A smoked cannabis, drinks alcohol and snorted cocaine at the weekends too. CJIT contacted social care. The next day Ms A told social care during a telephone call that she had bruises on her neck and arms from play-fighting with Mr Z. Later on 30.11.12 social care visited Ms A. She was not asked to show the bruises. A fourth partnership agreement was drawn up between Ms A and social care. This agreement stated that Mr Z would not reside at, or visit, the family home and that Ms A would contact the police immediately if he tried to contact her. Ms A also agreed that Mr Z would have no contact with the children. That Ms A would engage with the children’s centre Freedom Programme and with Northern Arc, the Next Link domestic abuse service. The agreement also said that Ms A would be in and available for all appointments. There was also mention of finding a child-minder. The agreement stated that “Failure to comply with the terms of this agreement may be referred to the court if court proceedings are commenced in respect of the children. Parents may wish to seek legal advice”. 2.5.42 On 13.12.12 Child U was seen by the health visitor with a graze to the forehead, a red mark and a pin-prick size bruise on the cheek. Ms A could not explain how the injuries had occurred. Child U was under two at this point. 2.5.43 On 7.12.12 there was a pre-MARAC panel. The action plan was for Next Link to try to engage with Ms A and to encourage links with the children centre. Next Link was to refer 20 back to MARAC, if necessary. Next Link closed the case on 27.12.12 after numerous attempts had been unable to contact Ms A. They had not left a message because they were unsure whether it was safe to do so. Next Link did not inform any other agencies that they were closing the case. Also on 19.12.12 social care agreed to undertake a Child in Need (CIN) review. A Child in Need meeting was arranged for 24.1.13. 2.5.44 On 20.12.12 Ms A told the GP she was two weeks pregnant and wanted a termination. Ms A told social care and the worker who took the call noted that they should ring Ms A over Christmas because of their worry about Ms A. The next contact by social care with Ms A was not until 7.1.13. 2.5.45 On 11.1.13 Child T was taken to the hospital. Child T died three days later. Part Two 3. Themes and analysis In the analysis the points raised in the terms of reference (See 1.4) will be addressed. There is no comment on individual IMRs but following the reading and critical analysis of the IMRs and the two subsequent meetings with the IMR authors and the SCR Panel, the following themes have been identified and agreed. These themes have been discussed in great detail at the meetings and practice will be analysed, in order to maximise our understanding of how agencies work individually and together in Bristol and to consider how we can best improve our practice. 3.1 Child sexual exploitation National Context The definition of child sexual exploitation is “Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive 'something' (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. Child sexual exploitation can occur through the use of technology without the child's immediate recognition; for example being persuaded to post sexual images on the Internet/mobile phones without immediate payment or gain. In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person's limited availability of choice resulting from their social/economic and/or emotional vulnerability”. This definition of child sexual exploitation was created by the UK National Working Group for Sexually Exploited Children and Young People and is used in statutory guidance for England. 21 Since 2007 there has become an increasing awareness of child sexual exploitation, reporting of child sexual exploitation and convictions but our understanding of the scale of the problem and the way in which victims are groomed are evolving all the time In the last three years there have been a number of high profiles child sexual exploitation cases, including Rochdale, Rotherham and Oxford. These cases have all involved gangs grooming victims. There has also been the case of child sexual exploitation in Torbay, which involved individuals grooming a number of victims, as well as the historic alleged child sexual exploitation perpetrated by Jimmy Savile and others. Serious case reviews have been published and in Rotherham there was an independent inquiry. All of these cases have attracted a considerable amount of press interest and have raised the profile of child sexual exploitation. LSCBs have responded by developing policies and procedures and screening tools, to ensure they are addressing this type of sexual abuse and protecting the children in their areas. Many have also put on training for staff, to increase their understanding of what the issues are and to look at how we deal with child sexual exploitation. Ofsted has recently published a thematic inspection of child sexual exploitation across eight local authorities “The sexual exploitation of children: it couldn’t happen here, could it?”3 which included Bristol. The main findings of the inspection demonstrate that we still have a long way to go, in terms of effective multi-agency responses to victims of child sexual exploitation. One of the main challenges for professionals across the country is that while we might identify a child who is particularly vulnerable to child sexual exploitation, or identify that a particular child is being groomed, if that child, or young person, does not see themselves as a victim, how do we work effectively with that child? Educating young people is important but we can only work with an adolescent if they will work with us. We cannot “Do to” young people as we can “Do to” children. We can make decisions about young people but if the young person does not agree, they may vote with their feet. That is the dilemma for all LSCBs, including Bristol. There is also an increasing body of research that makes it clear that going into care is not necessarily the answer, particularly with older children. One of the vulnerability factors for child sexual exploitation is being in care. The Association of Directors of Children’s Services published a position statement earlier this year “What is care for: Alternative models of care for adolescents4. This document considers alternative ways of working with vulnerable adolescents, including family therapy. Local Context 3 http://www.ofsted.gov.uk/sites/default/files/documents/surveys-and-good-practice/t/The%20sexual%20exploitation%20of%20children%20it%20couldn%E2%80%99t%20happen%20here%2C%20could%20it.pdf 4http://www.adcs.org.uk/download/position-statements/2013/ADCS_position_statement_What_Is_Care_For_April_2013.pdf 22 Since the death of Child T there have been two trials involving perpetrators of child sexual exploitation, following the police operation, Operation Brooke, which started in the Spring of 2013. In the first trial, in the Spring of this year, six men were convicted of child sexual exploitation offences. The second trial began in October, 2014. Following this, a further seven men were convicted of child sexual exploitation offences. The Bristol BASE (Barnardo’s Against Sexual Exploitation) service was established in 1997. The service aims to oversee direct support to 100 Bristol children each year and offers consultation and the use of resources to many more cases. In addition training is provided through the LCSB and 4YP, a public health team for young people in Bristol, to promote awareness and early identification of cases across the workforce. Bristol BASE support males and females, up to the age of 18, who are abused through sexual exploitation. Increasingly due to limited capacity at the service the referrals allocated at Bristol BASE need to demonstrate clear evidence of sexual exploitation or be at immediate risk of being so. Allocated cases usually have a child protection social worker coordinating the case or the child may be in the care of the Local Authority. Due to limited capacity Bristol BASE would rarely work with a case that is deemed to be at a SAF level but works closely with lower threshold services, in particular Brook Advisory Service, to ensure ‘preventative’ cases are not overlooked. Factors which commonly feature in the children supported at BASE include; - Relationships with older/risky adult(s) - High risk taking sexual behaviour - Repeat and acute missing episodes - Family breakdown/being in care - Past abuse - Trafficking (internally and externally to the UK) - Problematic substance misuse - Significant emotional/mental health concerns, attachment difficulties and marked learning needs - Risky internet use - Gang involvement/drug running”5 BSCB is part of the South West Safeguarding and Child Protection Group (SWSCPG). This group provides policies and procedures for the South West of England. There is a “Children Facing Exploitation”6 procedure and a draft “Safeguarding Children and Young People at Risk of Sexual Exploitation” procedure. BSCB also has its own “Safeguarding Children and Young People at Risk of Sexual Exploitation – Practice Guidance and Procedure”7 5 Bristol BASE. Background information. 6 http://www.online-procedures.co.uk/swcpp/contents/guidance-child-protection/sexual-abuse-and-sexual-exploitation/children-facing-sexual-exploitation 7http://www.bristol.gov.uk/sites/default/files/documents/children_and_young_people/child_health_and_welfare/CSE%20guidance.v1_08.pdf 23 BSCB has a Child Sexual Exploitation sub group to ensure that all agencies co-ordinate and work together effectively to support young people who are at risk of exploitation and to work to prevent sexual exploitation occurring. Membership of the group comprises the Police, Health, Youth Services, Barnardo’s BASE, CYPS, Brook and Bristol Sexual Health Service. Bristol has four different components of the MARAC. Two of these were particularly relevant to child sexual exploitation during the period under review. There is the Sexual Violence MARAC and the Perpetrators MARAC. These are not exclusively related to child sexual exploitation but deal with referrals for victims and perpetrators where identified. The Sexual Violence MARAC no longer considers cases of child sexual exploitation. A multi-agency meeting is held where a management plan is discussed and agreed to manage the issue in question. The actions are then reviewed as part of a formal process in the style of the Multi-Agency Public Protection Arrangements (MAPPA) meeting. Avon and Somerset Constabulary reports they are utilising multi-agency relationships developed particularly during Operation Brooke to ensure that a joined up approach is adopted by partners to identify and safeguard children from child sexual exploitation and to identify and target perpetrators. Bristol City Council has recently had an Ofsted inspection of services for children in need of help and protection, children looked after and care leavers, which included a review of the effectiveness of the Local Safeguarding Children Board. They have also been part of a thematic inspection of child sexual exploitation by Ofsted of eight local authorities. Bristol’s individual Ofsted inspection8 has highlighted that “Although there is an increased level of awareness of child sexual exploitation, more needs to be done to consolidate this area of work. There is no overarching strategic plan to tackle child sexual exploitation. Although a wide range of help and support is available, services are not well co-ordinated and practice is inconsistent”. The same issues were raised around children who go missing. The report does also say “A wide range of voluntary sector, local authority and partnership services is available to victims of child sexual exploitation, and these are having a positive impact in reducing risk to children and young people” and “The most recent audit on child sexual exploitation is much improved in quality. It draws up themes for improvement and a clear plan of multi-agency action. This includes developing a multi-agency child sexual exploitation strategy and reconvening high level multi-agency meetings about children at risk of child sexual exploitation. Early help was also considered in the inspection. The report concluded that “Early help services for children and families are now well targeted and coordinated so that they receive the help and support they need at the right time”. 8 http://www.ofsted.gov.uk/sites/default/files/documents/local_authority_reports/bristol_city/051_Single%20inspection%20of%20LA%20children%27s%20services%20and%20review%20of%20the%20LSCB%20as%20pdf.pdf 24 3.1.1 When we analyse the death of a child we have to look back. Is there any time in the adults’ lives where, if they had taken a different course, this tragedy may have been prevented? What roles did the professionals in their lives play and how can we learn from this and improve our practice? 3.1.2 During the Summer Term at school A, when Ms A was 12, the police were attending domestic incidents at home and there were other concerns about what was happening in the home. This was the term that Ms A’s attendance started dropping significantly and when she was in school her behaviour was often challenging – on more than one occasion she spent the day running round the school all day, avoiding teachers and lessons. The school’s response to this was to exclude her on two occasions that term, each time for two days. (The previous term they had excluded her twice, for one day each time). They also made a referral to social care that term. 3.1.3 When a 12 year old is experiencing troubles at home and that manifests itself in her behaviour what will make that child even more vulnerable is excluding her. The challenge for the school is that they have 30 other children in the class that they have to educate and one of the options they have to consider is exclusion of the disruptive child. This particular school had over 1,000 pupils and a child who will not attend lessons and is running around the school all day is very disruptive to the other children, not just in their class. Ms A had also previously assaulted another child in the school, the previous term. Ms A was remembered by staff at the school as being violent and aggressive. She was also described as “A sad young lady, who had great potential”. 3.1.4 The Department for Education (DfE) issues statutory guidance around pupil exclusion9. The guidance makes it clear that schools have a duty of care to a child and they must consider the child’s safety when s/he leaves the school. The school must also notify the local authority that they have excluded the child. These notifications are collated and analysed on a six-weekly basis. The department that deals with this does not have access to social care’s data base. There are examples of good working practices between the Behaviour and Inclusion Team and social care however this tends to be at the crisis end of the work we do, not the preventative. Bristol City Council also has local guidance on school exclusions10. In order for a school to know whether there are concerns in the home there needs to be communication with other agencies. Because the school thought social care had made a referral to another agency, the family support service, to undertake a CAF they thought work was being done. The school’s IMR has acknowledged that schools need to be pro-active and follow up referrals. 9http://media.education.gov.uk/assets/files/pdf/s/the%20school%20discipline%20pupil%20exclusions%20and%20reviewsengland%20regulations%202012.pdf 10 http://www.bristol.gov.uk/page/children-and-young-people/school-exclusions 25 3.1.5 If the CAF had been in place one would have hoped that all the agencies would have been asked to contribute and then the school would have known more about the home situation and how vulnerable Ms A was. 3.1.6 It is clear from the members of staff interviewed as part of this process that there were teachers who demonstrated great commitment, and a considerable amount of time, to Ms A. Her head of year had daily contact with her. She also had support from a learning mentor and the assistant head of year. However the school excluded Ms A eight times, for a total of thirteen days, during a ten month period. 3.1.7 Research and practice shows certain groups of children and young people are at higher risk of being sexually exploited through street grooming. Some of these risk factors include:- children with prior experience of emotional abuse or neglect, adolescents or pre-adolescents, girls (boys are also at risk but current research suggests a greater number of victims are girls), children not in education through exclusion, children who use drugs and alcohol, children going missing, children from families or communities with offending behaviours, children living in poverty or deprivation11. Ms A was witnessing domestic abuse, included within the definition of emotional abuse of a child, there were concerns of neglect and other troubles in the home. There was also one known incident of self-harm and Ms A was arrested for assault, for the first time, aged 15. One would hope that now Ms A would be considered in the context of child sexual exploitation. 3.1.8 Social care has acknowledged in their IMR that Ms A’s case should have been seen as child protection, when she was in a relationship with Mr Z. Their IMR states “Children’s social care has developed considerably since the events described in this review. Furthermore the Children’s Change program is redesigning services to strengthen the ‘Early Help’ Offer and ensure more secure pathways through services and as set out in the “local context”, this is proving to be effective. 3.1.9 The police have also made considerable changes since the time Ms A was a child, as have other agencies. There are now specialist investigation teams within the Public Protection Unit and specialist officers will have oversight of all incidents involving children. 3.1.10 Torbay Safeguarding Children Board’s sexual exploitation serious case review12 concerned individuals who were grooming girls. One of the findings from that review was that “Early intervention may have reduced the offender’s progression to becoming abusers”. In a recent BSCB Quality sub group audit it was recognised that there needs to be better co-ordination of child abduction notices. In this case the police IMR has addressed the need to respond more robustly to child abduction notices. 11http://www.nspcc.org.uk/Inform/resourcesforprofessionals/sexualabuse/identifying_sexually_exploited_children_wda85119.html 12 http://www.torbay.gov.uk/c26executivesummary.pdf 26 3.1.11 It is also concerning that when Ms A and Mr Z were stop searched at 00.50 in August, 2008, when Ms A was 14, the officers did not consider taking her home, or informing the police child protection team because it was not unusual for young people to be out at that time, in that area. 3.1.12 Nothing was done to explore Mr Z’s history, other than his involvement with the police. For a child to be receiving one to one support at the age of two, and having to go home at lunchtimes because they are so disruptive, is unusual and Mr Z’s history, beyond his police record, should have been explored further at this point, in order to effectively assess the level of risk to Ms A. Later in the report there is reference to Mr Z’s learning difficulties, particularly his communication and understanding difficulties. The police may have been able to deal with him more effectively if they had understood this. This was not explored or understood at the time and may have impacted on his ability to understand why he was being told to keep away from Ms A. Lessons to be Learned and Recommendations to BSCB. (The recommendations are made in the context of the two recent Ofsted reports referenced in this review). Lesson One Too often we have seen from child sexual exploitation serious case reviews that professional intervention comes too late and risk indicators of additional vulnerabilities are not responded to. In this case a child who was excluded from school and was beyond parental control was left to her own devices during the days she was excluded. The most effective way to keep any child safe is for all the agencies to talk to each other about what their concerns are, and how they are dealing with the child, within the framework of the law. This needs to happen when concerns first arise, not just when the work becomes crisis intervention. The most effective way we can work to prevent the sexual exploitation is to recognise and respond to risk indicators. Recommendation One When a school excludes a child, as well as following the current required procedure the school must check if that child is open to social care, or if there is a SAF (Single assessment framework) in place. If the child is open to social care, the school must inform them each time they exclude the child. If there is a SAF in place, the school must inform the lead professional. Lesson Two The most effective way of working with young people is to educate them, so that they make safe and right choices for themselves. There needs to be greater awareness of young people, and their parents, across Bristol about child sexual exploitation and particularly the 27 grooming process. Recommendation Two BSCB commissions the drama “Chelsea’s Choice13” to be offered annually to all Year 8 children and their parents. Chelsea’s Choice is a 30 minute drama in which a sexual exploitation case is played out. It is an extremely powerful production, which brings in all the issues and clearly shows children what is really happening. (Teachers will also see the production and this will bring added benefit because it will raise awareness amongst professionals). Lesson Three There needs to be a multi-agency approach to individuals who are known to be in sexual relationships with children and about whom there are concerns, as well as children at risk of sexual exploitation, so the two can be brought together and potential patterns can be identified early on. Assessments need to include the full history of both alleged perpetrators and victims, in order to consider levels of risk. Recommendation Three Relevant BSCB partners develop regular multi-agency meetings. The purpose of these meetings will be to consider possible victims and perpetrators of child sexual exploitation, including their histories from each of the relevant agencies, as well as the locations of alleged offences. The rest of this review will focus on Mr Z and Ms A as the parents of Child U and Child T 3.2 Levels and means of intervention National Context Throughout the period under review the statutory guidance was “Working Together to Safeguard Children, 2010”. The guidance sets out clearly “Where there are concerns that a child may be a possible child in need, and in particular where there are concerns about a child being harmed” advice should be sought”. “Working Together, 2010” also highlights the particular vulnerability of children exposed to domestic abuse, both pre and post-birth. “Working Together to Safeguard Children, 2013” sets out clearly who should be involved in strategy discussions: - “social care, the police, health and other bodies such as the referring agency”. The research carried out by Brandon et al, on behalf of the Department for Education, over the last eight years has highlighted the increased risk to children where there are issues around parental substance misuse and domestic abuse, as well as the increased 13http://www.justwhistle.org.uk/index.php/home/members 28 vulnerability of a child under one and the greater likelihood of a child being the subject of a serious case review if the mother is under 2114. As well as Brandon’s research there is a considerable body of research which highlights these additional risks. Domestic abuse and substance misuse, along with mental ill-health are often referred to as the “Toxic trio” because of the increased risk to the child in the home when there is one, or more of these factors. There was also the publication of the Advisory Council on the Misuse of Drugs 2011 report “Hidden Harm”15 which focused on the children of problem drug users. There has been a national drive, in view of this increasing body of research, to highlight the risks to children, whose parents are dealing with issues around domestic abuse, substance misuse and mental ill-health. (In 86% of all serious case reviews between 2009-2011 one, or more, of those issues was involved). Local Context BSCB has undertaken three serious case reviews in the last seven years which have involved young children. Child Z died in July, 2007 from ingesting Methadone and Morphine, Child M drowned in a pond in June, 2010 and Child K died in August, 2011 from ingesting Methadone. BSCB published the updated “Joint Safeguarding Children Protocol. Children and Families Living with Substance Misuse” and the “Joint Practice Guidance for Children’s Services and Adult Substance Misuse Services” in November, 2012. In addition to this BSCB also has the “Domestic Abuse/Violence” Protocol, as well as “Keeping Your Child Safe if You Use Drugs and Alcohol”. In common with other local authorities, in Bristol there are two types of strategy discussion that are held. The telephone strategy discussion, when the matter requires urgent attention. This will involve the police, social care and the community paediatrician. If the matter is not so urgent there will be a “sit-down” meeting held, when all those involved will be invited. If it is the former there has been much discussion about how other professionals working with the family are given information about the strategy discussion. There has also been an issue with the community paediatricians taking minutes of the discussion. These minutes may differ to the minutes taken by social care. This all requires greater clarity. A strategy discussion is held when there is reasonable cause to suspect a child is suffering, or is likely to suffer significant harm. It is the responsibility of social care to convene the strategy discussion and they will formally minute it. 14http://webarchive.nationalarchives.gov.uk/20130401151715/https://www.education.gov.uk/publications/eOrderingDownload/DFE%20-%20RR226%20Report.pdf 15 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/120620/hidden-harm-full.pdf 29 3.2.1 One of the perplexities of this case is that it was never seen as child protection, either by other agencies, or by social care. It is usual to see cases across children’s services where the other agencies are “Banging on the door” of social care. Those agencies believe very strongly that a case is child protection and social care does not agree and thinks the child is not suffering significant harm and is therefore not in need of protection. What is extremely unusual is to see a case where no agency thinks the children are suffering significant harm, despite clear evidence that they are witnessing domestic abuse and there is substance misuse and possible evidence of physical abuse. 3.2.2 What is also extremely perplexing is that Child U was born two months prior to the death of Child K, the BSCB serious case review referred to above. Professor Munro, in her final report16 describes the usual reaction following the high profile death of a child, such as the death of Peter Connelly, “Waves of anxiety travel through the system when there is a high profile death, leading to more referrals being made. Social workers, in turn, can be driven by anxiety into applying to remove children from their birth family at a lower level of risk”. Prior to the death of Child T, in Bristol there had been three child deaths, which had led to serious case reviews, within a four year period. It would therefore be natural to assume that the anxieties of all professionals would be heightened and the threshold level for intervention would be lower. 3.2.3 Despite much discussion with IMR authors, SCR Panel members and analysis of the IMRs it has not been possible to conclude why this case was not seen as child protection, either by the other agencies, or by social care. Between January, 2010 and December, 2012 numbers of children on child protection plans increased by 25%, children with child in need plans by 6% and Looked After Children by 11%. This demonstrates an increasing awareness of risks to children and yet we are still no nearer to understanding why this case was not seen as child protection when the SCR Panel, the IMR authors and myself are all absolutely clear that this was a child protection case. Everything seemed to be minimised – the horrific domestic abuse, drug-taking and the injuries to the children, including the incident on 6.10.11 when Ms A said that Mr Z had shaken Child U. She later retracted that statement, as she often did but Child U should have been seen immediately by a paediatrician. There seems to have been inertia amongst staff from other agencies, who were not reporting high levels of concern to social care, despite the high level of risk. It may have been that there was a false sense of security amongst agencies, that if there is social work involvement they will know when to escalate. There may have been a feeling that social care would have had the whole picture. This feeling can abdicate professionals of their role to challenge and scrutinise the safeguarding process. 16https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/175391/Munro-Review.pdf 30 3.2.4 There were several findings from the previous three serious case reviews which should have resonated with workers in this case. From Child K SCR “In-depth parenting assessments of drug-using parents are essential”. In the Child M SCR it was described as “Striking that neither CAF, child in need or child protection processes were put in place”. In the Baby Z SCR “For those families who do not come within the threshold of child protection concerns, the co-ordinating processes between adult and child focused services do not seem to be in place, as they are when child protection processes have been invoked. Baby Z’s name was never on the child protection register so he was not receiving a co-ordinated service. The issue of whether Baby Z was a child at risk or not would matter less if BSCB had a more co-ordinated response to children in need, particularly those whose parents are involved in illegal drug taking”. That SCR also found that “Child in need cases are not as well co-ordinated as they could be”. One of the recommendations was “BSCB need to develop systems to co-ordinate children in need cases”. Baby Z died in 2007. Child M, recommendation 6 of the SCR says that BSCB should ensure the involvement of parents/carers in child in need meetings, as well as other agencies, in multi-agency meetings to achieve improved outcomes for children”. In this case, even when the children were deemed to be children in need there was only evidence of one multi-agency children in need meeting and this meeting did not include all the agencies involved with the family, especially the father. 3.2.5 There is reference in many of the IMRs recommendations to address this lack of action, within their own agencies. There also needs to be a multi-agency response. Lesson Four It is essential that there is a clear process in place for minuting strategy discussions in Bristol and the dissemination of those minutes across partner agencies and that health are invited to take part in all strategy discussions, in line with the statutory guidance. It is also essential that workers across all adults and children’s services understand the increased risk to a child when there is domestic abuse in the home and substance misuse. An extremely effective tool for assessing risk is an integrated chronology. Currently in Bristol the only time an integrated chronology is completed is when a serious case review is being undertaken, which usually means a child has died, or suffered significant injuries. The integrated chronology is stark, is evidence of increasing risk, or an improving situation and is factual. It provides clarity in usually complex, and sometimes chaotic, families. Recommendation Four a) BSCB agrees the process for minuting strategy discussions in Bristol and the timely dissemination of those minutes across all partner agencies, including the GPS of both the mother and the father. In addition to this BSCB must satisfy itself that health colleagues are invited to contribute to all strategy discussions. 31 b) BSCB introduces the use of chronologies across all partner agencies. When a child is the subject of a SAF, a child in need plan, or a child protection plan there must always be an integrated chronology and it will be the responsibility of the lead professional to integrate the chronology and ensure it is kept up to date. Lesson Five The fact that the numbers of children on child protection plans and children in need plans and Looked After Children in Bristol have increased over recent years does demonstrate an increasing awareness of risks to children and yet this case could not be more concerning, in terms of a lack of recognition of risk indicators, inertia amongst workers in agencies other than social care and a seeming lack of understanding about their own accountability. It is equally concerning that social care did not recognise the significance of the risk indicators. It also cannot be overlooked that some of the critical lesson to be learned from serious case reviews in Bristol do not seem to have been learned by those working on the frontline, or their supervisors. (Although the recent Ofsted report stated “Learning from serious case reviews and multi-agency training has led to improvements in front line practice”). The most significant factor of this serious case review remains that this case was not seen, by any agency, as child protection. Recommendation Five 5a) BSCB brings together all of the recommendations from the three previous serious case reviews, and this one, into one training day, which will be delivered to the designated safeguarding leads across all partner agencies. It will then be their responsibility to disseminate the information across their agency. This will ensure that all the messages are heard. 5b) The training set out in 5a must emphasise to all agencies their accountability, responsibilities and ownership and significance of the information they hold. Although not relevant in this case, all agencies should be reminded of the escalation policy. 3.3 “Think family” National Context The issue of the role of men in children’s lives is a familiar feature in serious case reviews17 The focus is too often only on the primary carer, usually the mother and we ignore the sometimes shadowy figure of the father, or other men in the mother’s/children’s lives. Assessments of risk are done with insufficient knowledge about the men in the family. 17 Brandon et al 2008, 2009 32 “There is a need for public services to engage with both mother and father except where there is a clear risk to the child …” Children’s Plan, Department for Children, Schools and Families, 2007. From that time and leading up to 2009 there was an increasing awareness of the need to think about the family as a whole and not just the children. The Government at the time described itself as being committed to a national programme of reform and culture change and introduced the “Think Family Toolkit”18. The intention of the toolkit was to “improve the identification and support of adults experiencing problems who are parents or carers; and to co-ordinate the support that is provided by different agencies to each family, especially those experiencing significant problems”. Since 2009 the national agenda has very much been for all professionals, working across adult and children’s services, to think about the family as a whole. In 2011 Professor Munro’s report highlighted how important it is that all professionals in contact with a family are mindful of children who are vulnerable to abuse or neglect. Local Context The agenda of Bristol Safeguarding Children Board and Bristol Safeguarding Adults Board’s annual conference, in May, 2011 was “Think Family”. Bristol’s children and young people’s plan 2011-2014 sets out wide-ranging objectives for how the needs of children in Bristol should be addressed based on a thorough needs analysis. The document refers to parents throughout and not specifically to fathers or mothers. Bristol has a Parenting and Family Support Strategy, this refers to families throughout and not specifically to fathers, or mothers. The Fatherhood Institute, in partnership with Family Rights Group, was funded in 2012 by the Department for Education’s Voluntary and Community Sector Grant to support local authority safeguarding services to engage more effectively with fathers and other men in families. This project built on previous work led by Family Rights Group called the Fathers Matters Projects. This work addresses a need referenced in the Munro Review Final Report, and builds on the growing understanding about how to engage better with fathers where there are child welfare and safety concerns. This project encompasses work with six local authorities, including Bristol, to develop and test a broad package of sustainable resources, consultancy and training, aimed at building stronger local safeguarding strategies, policies, procedures and practice for engaging with, assessing and supporting men both as risks and resources in the lives of their children. As a result of this work and the subsequent report by the Family Rights Group, BSCB has developed an action plan, based on the recommendations of the report. The action plan 18http://webarchive.nationalarchives.gov.uk/20130401151715/https://www.education.gov.uk/publications/eOrderingDownload/Think-Family.pdf 33 was finalised in November, 2011 and the work is on-going. These recommendations include:- • All policies relevant to child protection should explicitly address the needs of Fathers and underpin the development of father-inclusive practice. • There should be an expectation that all fathers, whether they are in contact with the child or not currently, should be interviewed by a social worker who is completing a core assessment. • More consideration needs to be paid to inviting fathers to child protection conferences. • The father’s involvement with the child together with both his risks and strengths should be discussed at all child protection conferences. • Contact details for fathers need to be rigorously inputted and updated. • The importance of the role of fathers in a child’s life to continue to be discussed and raised as an issue. The recent Ofsted inspection noted that although “Recent practice is much improved and there are many examples of good assessments. The quality of social work assessments is not consistently good enough”. 3.3.1 As has been said elsewhere in this report little was known about Mr Z, other than his criminal record. During the criminal trial into the death of Child T Mr Z was the subject of a number of psychological and psychiatric assessments. These assessments were inconclusive, some stated that he had learning disabilities, others learning difficulties. What was agreed upon was that he had a level of learning difficulty and this was particularly around communication and understanding and he had an extremely low IQ. He also had difficulties reading and writing. During Child T’s life professionals were asking him to sign the partnership agreements and it must now be questionable whether he even understood what was being asked of him. Again, assumptions were made without further exploration. 3.3.2 When there is not a SAF, child in need plan, or child protection plan in place it is even more essential that each and every professional working with any individual thinks about any child, or adult, who might be affected by the issue the adult themselves is dealing with. 3.3.3 As set out in 3.2 much work has been done to raise awareness of the risk to a child if a parent is misusing substances. The emphasis in Bristol has been on parents on a Methadone programme because of the deaths of Child Z and Child K. In this case Mr Z was only on a Methadone programme for five months, in 2009-2010. The first information that he was a Class A drug user was in 2006 and there continued to be information / evidence he was using Class A drugs until November, 2011. There are two possible hypotheses for why this was not seen as a concern, both in terms of his relationships with young girls and then as a father. Either it was because professionals were not sharing information with each other about his drug use because often it could not be proved – unlike when someone is on a Methadone programme, or because for much of the time Mr Z was not supposed to be 34 having contact with Ms A and the children and therefore the risk his lifestyle posed was underestimated. Lesson Six It is essential that all professionals working across adults and children’s services think of the family as a whole and what risks are posed to the children by the lifestyles and circumstances of the adults who are caring for them. In order to do this effectively they need to know the history of each individual and explore any significant issues. Recommendation Six As it was a concern in the Child Z SCR and Child K SCR, Recommendation Five, above will ensure that professionals are reminded of the necessity to “Think Family”. In addition to this professionals will need to be reminded that they must be confident that they have sufficient information about all those around the child so that assessments are evidence-based. 3.4 The use of partnership agreements National Context The concept of partnership agreements, also known as written agreements, between parents and social care have evolved over time and are not framed by legislation or statutory guidance. They are usually used by social care as a way of providing clarity for what social care expect of the family and what the likely consequences will be if the family do not adhere to the partnership agreement. If the agreement is broken the consequences, which should have been clearly spelt out, should then ensue. Because of the level of concerns that there are when partnership agreements are used the consequence will usually be that the local authority will seek legal advice. N.B It is important to note that this is only my experience of partnership agreements, having worked across different local authorities, as there is no official reference to these agreements. Local Context Partnership agreements are used routinely by social care in Bristol. 3.4.1 In the Child K SCR concern was expressed about the use of partnership agreements, in that they were not adhered to and there were no consequences. The same is true of this 35 SCR. In total there were four partnership agreements drawn up, two between social care and Ms A and two between both parents and social care. No other agency was aware of the agreement. The first three times were within a six month period, each time the agreement was broken and there were no consequences. The fourth time was six weeks prior to the death of Child T. It was only confirmed that agreement had been broken following Child T’s death. 3.4.2 Each of the family members interviewed made reference to the partnership agreements. Ms A’s view was that “All social care were interested in were the partnership agreements and going to groups”. She said she signed the agreements because what choice did she have? In her words, “Either I signed them and kept the kids, or I didn’t and they would take my kids”. She also said that as she signed each one she knew she would never be able to adhere to the agreement because there was no way she could keep Mr Z away from her property. We now know from the criminal trial that Mr Z has limited reading abilities, so there remains a question, did he know what he was signing? We have not been able to explore that with Mr Z because of his unwillingness to engage with this process. Ms A’s view is he could not read them but signed them to “Get social workers off our back”. 3.4.3 Social care have addressed the need to tighten up these agreements and the use of them in their IMR but there is also a multi-agency aspect. Lesson Seven When social care draw up a partnership agreement with parents it is essential the agreement is realistic and practicable and that all of the agencies who are working with the family are aware of that agreement and the contents of it. This provides a safeguard, particularly if the child is not on any plan because it will raise awareness with other professionals as to what the concerns are and will also make clear their responsibility if they receive information that is relevant to the agreement. Recommendation Seven BSCB will draw up a “Partnership with Parents” Protocol and disseminate it across all partner agencies, including GPs. The protocol must include the need to advise all agencies working with the child, including the father and the mother’s GPs, if different, and will include the responsibility of all agencies to inform social care if they believe the agreement has been broken. The protocol will also emphasise that agreements must be realistic and practicable and advice will be sought from relevant partner agencies to ensure this happens. (Particular attention must be paid when there is thought, or known, to be domestic abuse in the relationship when the victim may be under the control of her partner). 3.5 Disguised and Non-compliance 36 National Context The term “Disguised compliance” was coined by Peter Reder, Sylvia Duncan and Moira Gray who outlined this type of behaviour in their book “Beyond blame: child abuse tragedies revisited”19 Defined by the NSPCC, “Disguised compliance involves a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention.”20 In their bi-annual analysis of serious case reviews Brandon et al state ““Apparent or disguised cooperation from parents often prevented or delayed understanding of the severity of harm to the child and cases drifted. Where parents engineered the focus away from allegations of harm, children went unseen and unheard.”21 In Lord Laming’s report to the Government following the death of Peter Connelly he wrote “Professionals were over-optimistic, they need to exercise “respectful uncertainty”22 It should be noted that disguised compliance is not something that families that we work with do and we do not. Disguised compliance is a natural response, whether it be tidying our home before a professional comes round, or being economical with the truth with our doctor about how much we smoke, weigh, drink etc. We, as professionals, say to families “Be open and honest with us” but sometimes the family is and we become so concerned about what is happening that the local authority applies to the court to remove the child. It is a natural response to hide the truth, if the family thinks there will be negative consequences. What professionals have to get better at is looking at facts and evidence, not what is said. Local Context BSCB has guidance on the use of Multi Agency Professionals Meetings The purpose of the guidance is to support all practitioners in the use of meetings especially where there are issues of professional disagreement or concerns regarding disguised compliance or parents who are avoiding engagement with one or more agencies. BSCB has put on training around working with disguised compliance and reluctant parents. This is currently under review but will be on-going. This training includes action learning sets. A core component of the BSCB business plan 2013-2014 is to build a more confident workforce. The business plan was in the process of being developed and was not available 19Beyond blame: child abuse tragedies revisited. Peter Reder, Sylvia Duncan and Moira Gray. 1993 20 NSPCC Safeguarding Information Service, 2010 21 Analysing child deaths and serious injury through abuse and neglect. What can we learn. A biennial analysis of serious case reviews 2003 – 2005. Brandon, M. et al.(2008a) 22The Protection of Children in England: A Progress Report . Lord Laming 2009 37 at the time of writing this review. The recent Ofsted inspection has noted that “Lessons learned from serious case reviews help to shape practice. For example in cases seen by inspectors where ‘disguised compliance’ was an issue, this was effectively identified and acted upon as part of the assessment and planning process”. 3.5.1 Ms A did not want to lose her children and so she was not honest with professionals about her situation. From her perspective social care were “The enemy” and she could not be honest with them. Ms A said she did want to tell some professionals that she liked what was going on, including her health visitor and the student social worker working with her but she was too afraid. She felt that all social care ever said was “If you do not go to groups and keep to the partnership agreements we will go to court and ask the court to take your children away from you”. She felt that that was all they cared about and to her mind no one ever offered her practical solutions about how she could keep herself and her children safe. 3.5.2 In October, 2007 Mr Z agreed to counselling, as part of a partnership agreement between himself, Ms W, the mother of his first child and social care. The counselling never happened. At that time he expressed remorse to social care about his previous behaviour and he told social care that he wanted help with “Low self-esteem and anger management”. 3.5.3 In October, 2011 Mr Z told social care he wanted to access the community programme for perpetrators of domestic abuse. It never happened. (The programme requires a self-referral and a commitment and honesty by the perpetrator of his/her behaviour). 3.5.4 In June, 2012 as part of the partnership agreement Mr Z agreed to only have contact with Child U supervised by his mother and agreed to not live with Ms A. Not only did he remain in the family home but also there is no evidence that social care spoke to Ms E about the proposed arrangement. There was no assessment of Ms E as a suitable person to supervise the contact. 3.5.5 In July, 2012 Mr Z agreed to engage with all of the services named by social care. There was very little engagement with these services. 3.5.6 In the two partnership agreements between social care and Ms A she agreed to not allow Mr Z to visit the family home and there were different requirements around the children’s contact with their father. None of these were kept to. (There is an issue around whether it is realistic to make partnership agreements with someone who is a victim of domestic abuse which has been addressed in 3.4.2 and will be considered further in 3.6). Ms A also agreed to attend the Freedom Programme, for victims of domestic abuse but failed to do so. It is not clear that anyone thought about who would look after the children if she 38 were to attend the programme. There was talk of a child minder by social care but that never materialised. (Peter Connelly’s mother attended a parenting course, as a requirement of the child protection plan and it was never known where her children were while she attended the course). Ms A said in interview that she found groups intimidating and she did not want to talk about her circumstances in front of other people, she was also afraid of the consequences, if professionals knew what was happening in the home. 3.5.7 Following the alleged incident involving Mr Z throwing a bottle of talc, which was meant to hit Ms A but actually hit Child T, Ms H went to social care to inform them of that and her other concerns, as set out in 2.6.38. Ms H said she had not witnessed the incident but another family member had. Ms A and Mr Z’s response to this was to assure professionals that Ms H was just causing trouble and that was accepted. Social care did not attempt to speak to the family member who had witnessed the alleged incident. It appears that Ms H was not seen as credible, because of the family’s history and her troubled relationship with her daughter. Ms A and Mr Z successfully deflected professionals from doing a full investigation. (The social care IMR acknowledges that the incident should have been investigated) 3.5.8 There is little evidence that professionals considered the facts, as opposed to what was being said by the parents and it is here that an integrated chronology plays a useful part (See Recommendation Four). 3.5.9 Disguised and non-compliance is another reason why effective supervision is essential. It should be part of the checks and balances that should be happening along the way when any agency is working with a family. There is little evidence that supervision was effective in this case. This was also a finding of the Child K SCR and the Child Z SCR. Lesson Eight Although it is positive that Ofsted noted good practice in this area there is always work to be done across the workforce looking at the extremely complex area of disguised and non-compliance and how there needs to be effective oversight. It is essential that workers look at evidence, not what is said by families and consider the deeper analysis as to what is the impact on the child of a family not engaging with a particular service. Is there a negative impact, or not? There may not be. It should not be seen as a positive if families engage and attend appointments and a negative if they do not. If a family engages it may only be superficial because they know professionals put great stock on that. It always has to go back to “What is the impact on the child?” and “What is the evidence?” As stated above, the integrated chronology will help with this. Recommendation Eight As this has been an issue in previous serious case reviews in Bristol, this will be covered by Recommendation Five. 39 3.6 Domestic abuse National Context There has been an ever-increasing understanding of the impact of domestic abuse on children over the last 10-15 years. Across all police forces now the police have to consider the risks to the children if they attend a domestic incident and there are children in the home. In 2002 the definition of emotional abuse of a child was broadened to include “Witnessing, or hearing, the abuse of another”. The number of children on child protection plans because of the domestic abuse element of emotional abuse has increased over the years and there is increasing research about the impact of domestic abuse on the unborn baby and the potential impact on the development of the baby’s brain23. There is also research that shows that domestic abuse is likely to start, or if it is there already, increase when a woman becomes pregnant24. Domestic abuse is still predominantly male to female. On average two women die every week in this country as a result of domestic abuse25. Although violence perpetrated by women is on the increase, generally26, it remains rare for a woman to kill a man. What is discussed much less is when there is violence on both sides of a relationship. Violence perpetrated by women is still seen as much less acceptable, culturally, than it is with men and our responses may be less clear if the female is violent too. Local Context Bristol has a domestic abuse forum, known as Bristol Against Violence and Abuse, a domestic violence and abuse, prevention tool kit, a domestic violence and abuse policy. Bristol has a Violence and Abuse Against Women and Girls and Domestic and Sexual Violence Against Men Strategy (2012-2015). This work is governed by the Domestic and 23http://www.cyc-net.org/features/viewpoints/c-domesticviolence.html 24http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2126542/pdf/9158458.pdf 25 http://www.womensaid.org.uk/domestic-violence-articles.asp?section=00010001002200410001&itemid=1280 26 http://www.independent.co.uk/news/uk/girls-get-violent-1345290.html 40 Sexual Abuse Strategy Group and supported by a specific Joint Commissioning Group and a Prevention Group. The MARAC process in Bristol has four strands, two of which are mentioned above. In addition to those Bristol holds two MARAC meetings each month to discuss and action plan for victims of domestic violence and abuse who are at high risk of harm. These processes are governed by the MARAC Steering Group. Since October 2011, pre-MARAC meetings have also been held to deal with the high volume of referrals received. A range of local guidance is available for professionals working with families experiencing domestic violence and abuse including the Early Years Domestic Violence toolkit, guidance for schools, learning difficulties and domestic violence toolkit, safeguarding children living with domestic violence and abuse, talking to children about domestic violence and abuse. There is also guidance for health professionals and midwives - Domestic violence in pregnancy. The recent Ofsted inspection noted that “Although a domestic abuse protocol has now been developed, there is not yet a shared understanding of risk in such cases between the police and children’s social care”. It goes on to say “Domestic abuse is the most commonly recorded risk factor in children in need and child protection cases. From April to June 2014, 777 open social work cases had domestic abuse as a significant risk factor. Work with families where there is domestic abuse, is closely aligned to other interventions in, for example, drug and alcohol misuse and mental ill health. Of the cases involving domestic abuse, 485 also involved substance misuse and 437 alcohol misuse, while in 510 cases, parents were identified as having some level of mental health need. Multi-agency risk assessment conferences (MARAC) ensure that high-risk domestic abuse cases are managed well and services effectively engage families”. 3.6.1 There are four elements to consider here. The first is was it realistic to expect Ms A to agree to have no contact with Mr Z when she was a victim of domestic abuse? Secondly, would the response have been different if Ms A had been seen purely as the victim and not as a perpetrator too? (There was a comment by one worker that the couple were “Both as bad as each other”, as if one being abusive negated the other, when of course the opposite is true). Thirdly, was there a good enough understanding of Mr Z’s history of domestic abuse, with some of the main workers involved with Child U and Child T and fourthly, did workers have a good enough understanding of risk factors around domestic abuse? 3.6.2 The fact that the relationship between Ms A and Mr Z kept resuming, even when there were partnership agreements in place and MS A had told social care she would not see Mr Z clearly demonstrated that she was either unwilling to separate from him, or she was more frightened of him than she was of social care, or he was in control of her and that was why their relationship kept resuming. There is no evidence that that was explored with Ms A. (In interview Ms A said it was the latter). In 3.5.5 the question is asked “Is it realistic to expect a woman who is a victim of domestic abuse to keep away from her partner?” As always, that 41 will depend on many factors but we should not assume, which happened in this case, that by professionals telling Ms A she must not have contact with Mr Z, that would happen – particularly as the evidence was their relationship kept resuming. (Interviewing a mother in another recent serious case review elsewhere, the mother said “I did not know who to be more frightened of – him or social services”). 3.6.3 In interview the maternal grandmother, Ms H, described her anxiety about her grandchildren and also her child, Ms A. It is not unusual for grandparents in domestic abuse cases to describe the fragility of their situation. They may be worried about their child and their grandchildren but they are also worried their children will prevent them from seeing their grandchildren if they ask too many questions, or go to the authorities. In this case Mrs H said she always knew when Mr Z was around because she would not hear from her daughter. 3.6.4 In interview Ms H said she contacted social care on a number of occasions following the visit she made to them in November, 2012. She said no one ever returned her calls. There is no record of those calls. In interview Ms H acknowledged that social care will receive malicious and false allegations her expectation is not that all are accepted, rather that they are investigated. Ms H is correct. All allegations should be investigated and decisions should not be made on assumptions. If the allegation regarding the talc bottle had been followed up and had been found to be true, that would have increased Ms H’s credibility with social care and she would have felt that they listened to her concerns and took them seriously, rather than feeling that they thought she was a trouble-maker. 3.6.5 Ms A had a history of violence. She had physically assaulted other pupils in school as a child and was first reprimanded by the police for physical assault when she was 13. She was arrested a further three times between August, 2008 and January, 2011. There is no evidence that the fact that Ms A was known to be violent did impact on how professionals responded but what was not demonstrated was an understanding of the increased level of risk to the children if both partners are violent, particularly when there are drugs and alcohol are involved. Although alcohol is not a trigger for violence it can act as a disinhibitor. 3.6.6 There is nothing in any of the IMRs about Mr Z’s childhood, except the police IMR referring to his offending and one reference in the social care IMR to an Acceptable Behaviour Contract when he was 13. As set out earlier in the report it is only through the criminal trial that we have learnt about his educational history. None of the professionals working with Ms A as a child, or Mr Z and Ms A as parents had looked into his history, to the extent that would be considered reasonable, other than his criminal record. He was using Class A drugs by the age of 18, was a prolific offender by the age of 19, his ability to read or write is limited and he has been using violence against others since he was young. (There was also little known about Mr Z’s mother, Ms E, although social care had concluded she could supervise Mr Z’s contact with Child U, at one point and little about Mr G, or Mr H). It is 42 a frequent finding of serious case reviews that little is known about the family history but family history is vital. 3.6.7 It cannot be ignored that Mr Z was given a custodial sentence for stealing a car and related offences but was not sent to prison for offences that most people would consider much more serious – child abduction and domestic abuse. It has not been possible to involve the courts in this serious case review but should be considered in the future. The message to the perpetrator is very clear – stealing cars is more serious than child abduction, or domestic abuse. There was horrific domestic abuse in this case and it seemed to be minimised, not only by Ms A and Mr Z but also by professionals. 3.6.8 There was not a clear understanding across all agencies of what a Pre-MARAC meeting is. In this case there was a Pre-MARAC meeting on 7th December, 2012. It is essential that all agencies understand the processes in place to protect children and vulnerable adults. 3.6.9 The first recorded incident of domestic abuse occurred when Ms A became pregnant with Child U. As stated above violence in an abusive relationship is more likely to start when a woman becomes pregnant. Ms A told social care, on 20th December, 2012 that she was pregnant. Although the worker noted that social care were worried about Ms A and she should be contacted over the Christmas period, a time of difficulty for many vulnerable people, no contact was made with her until 7th January. This meant that Ms A, who had told social care she had very little contact with her mother at that time due to their relationship difficulties received no support over the difficult period of Christmas and New Year and yet she may have been at greater risk of physical violence from Mr Z, due to her pregnancy and this would have implications for the children too. There is no acknowledgement of the risk factors increasing, or assessment of risk over this time. Lesson Nine Domestic abuse needs to be seen within the context of child protection, particularly when a woman is pregnant, or there is a baby in the home. As stated above, it is not clear why this case was never seen as child protection, or whether thinking was clouded because Ms A could also be violent. It is also essential that we have realistic expectations of victims of domestic abuse; otherwise we may be prolonging the danger to the child and the victim. As part of any assessment of risk and looking at the balance of probabilities there is much research about the links between a boy witnessing domestic abuse and going on to be a perpetrator and girls witnessing domestic abuse and entering abusive relationships. This research should have been considered. Ms A witnessed domestic abuse as a child. Recommendation Nine Advanced domestic abuse training should be mandatory for all social workers and frontline 43 staff working in child protection. The advanced training needs to include the use of written agreements with mothers who are victims of domestic abuse, the complexities of both partners being perpetrators as well as information about the increased risk of violence when a woman is pregnant, or there is a baby under one in the home. Currently BSCB delivers basic and advanced domestic abuse training. BSCB needs to satisfy itself that the course content, of both courses, is fit for purpose. (Ofsted’s comment on BSCB training was “The Board plans to implement an evaluation of the impact of training on improving practice but does not yet rigorously evaluate the impact of training. Work is underway to achieve this”). In cases when social care is involved and it is known there is domestic abuse BSCB should consider the proposal that a domestic abuse advisor will be attached to the case. Their role would be to consider the plan that is put in place, whether it is realistic and to advise the other professionals on all the issues around domestic abuse. Lesson Ten It is essential that all agencies understand the processes put in place to protect children and vulnerable adults. Recommendation Ten BSCB to draw up and circulate a list and statement of purpose of all the meetings that are held about children who are supported through SAFs, child in need plans, child protection plans. In addition to this BSCB to draw up and circulate a list and statement of purpose of the four different components of the MARAC meetings, the pre MARAC, the MARAC, the sexual violence MARAC and the perpetrator MARAC. Lesson Eleven Professionals may make judgements about family members, including extended family, based on assumptions and misinformation. In this case an assumption appears to have been made that the maternal grandmother was an unreliable source of information, possibly due to previous involvement with social care. If the alleged incident with the talc bottle had been followed up and the extended family member who witnessed the alleged incident interviewed, maybe professionals would have drawn a different conclusion and may have taken further steps to protect Child U and Child T. (It was only two weeks later that there was evidence of the domestic violence escalating). At the very least it would have helped to build a picture of the violence in the home. Equally assumptions were made about Mr Z without sufficient knowledge of his history, his abilities or his learning difficulties. It is essential that all decisions are evidence-based and all allegations are followed up. Recommendation Eleven This recommendation repeats Recommendation Six. Professionals need to be reminded of the need to ensure that assessments are evidence-based. In addition to this BSCB needs to send out a clear message to all professionals that allegations of child maltreatment must be 44 followed up. General Lesson One of the themes of the specific lessons and recommendations of this serious case review is the concern that some recommendations from previous serious case reviews have not been embedded in practice. This has been addressed by Recommendation Five. In order for the lessons of this serious case review to be learned and embedded in practice there must be buy-in from across all partner agencies of BSCB. General Recommendation The work that is generated from the recommendations of this serious case review must be shared amongst all BSCB members. This will ensure maximum shared learning across the Board. 3.7 Summary of good practice 3.7.1 Although it seems insensitive talking of good practice when a child has died, it is important that we learn from the poor practice and also acknowledge and learn from the good practice. 3.7.2 There is evidence of commitment and dedication by some of the school staff. The decision to move Ms A from School A to College A was made in the best interests of the child. The view was that her progress at school was hampered by the number of family members at the school and the disruptive influence they had on her. The school also did not want to permanently exclude Ms A but felt that would be inevitable if she remained there. They felt Ms A would be more likely to achieve if she was away from her family members and was doing a vocational course. 3.7.3 The GP tried several times to contact Ms A to have her contraceptive fitted after Child T was born. 3.7.4 The pregnancy advisory service nurses carried on supporting other health professionals after Ms A turned 18, which was beyond their remit but they were concerned about Ms A’s vulnerability and the safeguarding concerns. 3.7.5 The Children Centre supported the neighbour to make a referral to social care when she was concerned about what she was hearing from the flat. 3.7.6 A Children’s Centre worker offered to go in on her day off to look after the children, so Ms A could attend a clinic without them. 3.7.7 The health visitor tried three times to introduce Ms A to the Children’s Centre 45 3.7.8 The Teenage Pregnancy Midwife took Ms A groceries on one visit because she was worried about her. 3.7.9 The social worker did an early morning visit to Ms A, having been given information that Mr Z was living there, at a time when he was not supposed to be there. During the visit Ms A repeatedly denied that Mr Z was living there but the social worker persevered and insisted on seeing every room in the home. At this point Mr Z appeared. 4. Conclusion 4.1 Many of the findings of this serious case review are similar to the findings of the previous three serious case reviews in Bristol. Whilst acknowledging that, it is also important to consider what we can learn from this case. Blaming individuals, or organisations, achieves nothing, accountability is vital. Although there have been concerns about some individuals’ practice it has not been to the extent that it was considered disciplinary action needed to be taken. I agree with that decision. There are examples of good practice but as always there is much that we can do to improve our practice and I hope that the recommendations set out in this review will do exactly that. 46 Appendix One – Explanation of acronyms used in the report Acronyms ADHD – Attention Deficit Hyperactivity Disorder AWP – Avon and Wiltshire Mental Health Partnership Trust BASE – Barnardo’s Against Sexual Exploitation BDP – Bristol Drugs Project BSCB – Bristol Safeguarding Children Board CAF – Common Assessment Framework. The CAF was offered to children who have additional needs to those being met by universal services. The practitioner assesses needs using the CAF. The CAF has now been replaced in Bristol with the Single Assessment Framework (SAF) CAIT – Police Child Abuse Investigation Team CCG – Clinical Commissioning Group CIN – Children in Need. Under Section 17 (10) of the Children Act 1989, a child is a Child in Need if: - He/she is unlikely to achieve or maintain, or have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him/her of services by a local authority; - His/her health or development is likely to be significantly impaired, or further impaired, without the provision for him/her of such services; or - He/she is a Disabled Child. Child Protection – Section 47(1) of the Children Act 1989 states that: Where a local authority have reasonable cause to suspect that a child who lives, or is found, in the area and is suffering, or is likely to suffer, significant harm, the authority shall make such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child's welfare. CJIT – Criminal Justice Intervention Team CPS – Crown Prosecution Service DfE – Department for Education HOR – Health overview report IMR – Individual management review. Under Working Together to Safeguard Children, 2010 as part of the serious case review process each agency has to produce an individual management review, which feeds into the serious case review. LPW – Learning Partnership West LSCB – Local Safeguarding Children Board MAPPA – Multi-Agency Public Protection Arrangements MARAC – Multi-Agency Risk Assessment Conference 47 MGF – Maternal grandfather MGM – Maternal grandmother PGM – Paternal grandmother PPU – Public Protection Unit UHB – University Hospital Bristol SAF – Single Assessment Framework. The Single Assessment Framework has replaced the Common assessment framework in Bristol and is now being used in all areas of the city, including Early Help, Bristol Youth Links and the council's Family Intervention Teams. SCIE – Social Care Institute for Excellence SCR – Serious case review SWSCPG – South West Safeguarding Child Protection Group TOR – Terms of reference. Under Working Together to Safeguard Children, 2010 as part of the serious case review process there had to be terms of reference YOT – Youth Offending Team 48 Appendix Two – Genogram Child U Child T Ms A Mr Z Ms H Mr G Ms E Mr V Ms W Ms Y Ms X Ms K 49 |
NC049230 | Child CC aged 14, and her mother Adult S, were unlawfully killed by Adult R in June 2015. Adult R, who was Child CC's father and Adult S's husband, committed suicide before the bodies were found. Contacts with police prior to the event included a domestic abuse incident in 2012 resulting in a police visit to the home. Child CC had health problems including a gastric ulcer and 'leaky gut syndrome'. Apart from this she seemed happy, confident and popular at school. Both Adult R and Adult S were in debt and had County Court Judgements against them. This is a joint Domestic Homicide Review (DHR) and Serious Case Review (SCR). Analysis includes: private health services have been reluctant to share information; police did not enquire about the presence of children when called to the domestic abuse incident; some missed opportunities were noted in dealing with the same incident. Recommendations include: police to analyse their response to domestic abuse incidents; community interventions using the concept of co-production to be trialled; the independent school to integrate domestic awareness in safeguarding domestic abuse; HM Government to develop statutory guidance to include private medical care and oblige them to take part in DHR process.
| Title: Domestic homicide review and serious case review: Adult S and Child CC: overview report. LSCB: Surrey Safeguarding Children Board Author: Jessica Donnellan Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL i DOMESTIC HOMICIDE REVIEW & SERIOUS CASE REVIEW Elmbridge Community Safety Partnership & Surrey Safeguarding Children Board Adult S and Child CC OVERVIEW REPORT Author: Jessica Donnellan August 2016 RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL ii Contents 1. INTRODUCTION ..................................................................................................... 3 1.1 Details of the incident .............................................................................................. 4 1.2 The review ............................................................................................................... 4 1.3 Terms of Reference ................................................................................................. 6 1.4 Parallel and related processes ................................................................................. 6 1.5 Panel membership ................................................................................................... 7 1.6 Independence .......................................................................................................... 7 1.7 Methodology ............................................................................................................ 8 1.8 Contact with family and friends ................................................................................ 9 1.9 Equalities ................................................................................................................. 9 2. The Facts.............................................................................................................. 10 2.1 The killings of Adult S & Child CC .......................................................................... 10 2.2 The perpetrator’s suicide ....................................................................................... 10 2.3 Coroner’s Inquest .................................................................................................. 12 2.4 Information relating to Adult S ................................................................................ 12 2.5 Information relating to Adult R ................................................................................ 12 2.6 Information relating to Child CC ............................................................................. 13 2.7 Child CC’s health ................................................................................................... 14 2.8 Surrey Police ......................................................................................................... 14 2.9 Independent Secondary School ............................................................................. 17 2.10 Local GP Surgery Adult S ...................................................................................... 18 2.11 Local GP Surgery Child CC ................................................................................... 18 2.12 Private Hospital - Adult S ....................................................................................... 19 2.13 Private Hospital - Child CC .................................................................................... 19 3. Analysis ............................................................................................................... 20 3.1 Domestic Violence / Abuse Definition .................................................................... 20 3.2 The Coordinated Community Response (CCR) ..................................................... 20 3.3 Surrey Police ......................................................................................................... 21 3.4 Independent Secondary School ............................................................................. 27 3.5 Local GP Surgery Adult S ...................................................................................... 28 3.6 Local GP Surgery Child CC ................................................................................... 28 3.7 Private Hospital - Adult S ....................................................................................... 28 3.8 Private Hospital - Child CC .................................................................................... 29 4. Conclusions and Recommendations ................................................................. 30 4.1 Preventability ......................................................................................................... 30 4.2 Conclusions ........................................................................................................... 30 4.3 Partnership Arrangements ..................................................................................... 31 4.4 Surrey Police ......................................................................................................... 31 4.5 Independent Secondary School ............................................................................. 32 4.6 NHS General Practice in local Borough ................................................................. 32 RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL iii 4.7 National Recommendations ................................................................................... 32 Bibliography.................................................................................................................. 34 Appendix 1: Co-production .......................................................................................... 35 Appendix 2: Terms of Reference ................................................................................. 38 1. INTRODUCTION RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 4 1.1 Details of the incident 1.1.1 On 24 June 2015 a business associate of Adult S, contacted Surrey Police concerned for Adult S’s welfare as she had not seen her since 18 June 2015. She informed the call taker that Adult S had a 14-year-old daughter, Child CC. She stated that she had contacted a number of other companies that Adult S worked with but no-one had heard from her. Police advised her to visit the family home at the weekend to see if they had returned home or to speak to neighbours. 1.1.2 At 08:34 on 29 June 2015 a friend of Adult R, contacted Surrey Police from his home in France. He explained that Adult R had taken his own life in France and that he was concerned for Adult S and Child CC as Adult R had indicated that he had killed them both and had left them deceased at home in Surrey. 1.1.3 At 09:37 on 29 June 2015 Surrey Police attended the family’s home address and discovered the bodies of Adult S and Child CC. 1.1.4 On 23 November 2015 HM Coroner for Surrey returned verdicts of unlawful killing in respect of Adult S and Child CC. The cause of Adult S’s death was strangulation and the cause of Child CC’s death was suffocation. 1.1.5 The panel would like to express its sincere condolences to the family of Adult S and Child CC for their losses. 1.2 The review 1.2.1 Surrey Police notified the local Community Safety Partnership on 2nd July 2015 that the case should be considered as a DHR. The local Community Safety Partnership decided to conduct a DHR on 9th July 2015, notified the Home Office on 13th July 2015 and commissioned Standing Together against Domestic Violence to provide a chair and report writer for this process. 1.2.2 This Domestic Homicide Review (DHR) was commissioned by the local Community Safety Partnership in accordance with the Revised Statutory Guidance for the conduct of Domestic Homicide Reviews published by the Home Office in March 2013. 1.2.3 The Strategic Case Review Group (SCRG) of the Surrey Safeguarding Children Board (SSCB) received a referral for Serious Case Review (SCR) and considered the case on 27 July 2015. Additional information was requested from agencies RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 5 and the case was considered again on 30 September 2015. The group agreed that the case meets the criteria for a proportionate SCR, in accordance with the Working Together 2015 statutory guidance. The Independent Chair agreed a joined DHR/SCR process for this case. The Office for Standards in Education, Children’s Services and Skills (Ofsted), Department for Education (DfE) and the SCR National Panel were notified on 29 October 2015. 1.2.4 Surrey Police notified the local Community Safety Partnership on 2nd July 2015 that the case should be considered as a DHR. The local Community Safety Partnership decided to conduct a DHR on 9th July 2015, notified the Home Office on 13th July 2015 and commissioned Standing Together against Domestic Violence to provide a chair and report writer for this process. 1.2.5 The purpose of this review is to: a. Establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims. b. Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result. c. Apply those lessons to service responses including changes to policies and procedures as appropriate. d. Prevent domestic homicides and improve service responses for all domestic violence victims and their children through improved intra and inter-agency working. e. Meet the requirements for Serious Case review with regard to Child CC and specifically to: Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 6 Improve intra- and inter-agency working and better safeguard and promote the welfare of children. 1.2.6 The review process does not take the place of the criminal or coroners’ court nor does it take the form of any disciplinary process within any of the agencies involved. 1.2.7 Due to complexities with the availability of the Chair and Panel members, the first panel meeting was held on 01 October 2015. A subsequent meeting was held on 15 December 2015 where the independent management reviews (IMRs) and other information was considered. The draft report was reviewed at a meeting on 10 May 2016 with a final meeting of the panel on the 27 June 2016. The SCRG also considered the draft report on 27 May 2016 and the final report on 27 July 2016. 1.2.8 Once published, the final report will be shared with the governance boards and committees of participating statutory and voluntary agencies. Prior to publication, the report will be shared with DfE, OFSTED and SCR National Panel as per SCR process. The report will also be published on the SSCB website. 1.3 Terms of Reference 1.3.1 The full terms of reference are included in Appendix 2. 1.3.2 The review looked at the involvement of statutory and voluntary agencies with Adult S, Adult R and Child CC during the period of 01 June 2010 to 29 June 2015. Agencies were asked to summarise their involvement before 01 June 2015. 1.3.3 IMRs were completed by the Independent Secondary School and Surrey Police as they were the only agencies to have substantial involvement with either Adult S or Child CC. 1.4 Parallel and related processes 1.4.1 Inquest. On 23 November 2015 HM Coroner for Surrey returned verdicts of unlawful killing in respect of Adult S and Child CC. The cause of Adult S’s death was strangulation and the cause of Child CC’s death was suffocation. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 7 1.4.2 Criminal prosecution. As Adult R took his own life there is no opportunity to prosecute him for any offence. The investigation by Surrey Police into the death of Adult S and Child CC resulted in a clear conclusion that Adult R was the perpetrator of both killings. 1.4.3 Serious Case Review. The Surrey Safeguarding Children Board were represented on the DHR panel from the outset. As Child CC was 14 at the time of her death the issue of a serious case review (SCR) was considered at length. As the circumstances of Child CC’s death relate directly to those of Adult S it was felt that this report should include any issues in relation to the death of Child CC as a joint SCR process. Every attempt has been made to include the voice of Child CC within this process and discover any relevant learning. It was therefore agreed by the Panel that the Terms of Reference for this review would include both Adult S and Child CC. 1.5 Panel membership 1.5.1 The panel consisted of representatives from the following agencies: a. Independent Secondary School b. Surrey Police c. Surrey Safeguarding Children’s Board d. Local Community Safety Partnership e. Local CCG f. Local GP Surgery g. Local Citizens Advice Bureau / Local Domestic Abuse Outreach Service h. Surrey Safeguarding Adults i. Standing Together Against Domestic Violence 1.6 Independence 1.6.1 The Chair of the Review was Anthony Wills, an associate of Standing Together against Domestic Violence which is an organisation dedicated to developing and delivering a Coordinated Community Response to domestic abuse through multi-RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 8 agency partnerships. Anthony has conducted domestic abuse partnership reviews for the Home Office as part of the Standing Together team that created the Home Office guidance on domestic violence partnerships, ‘In Search of Excellence’ (Wills et al, 2013). He was also Chief Executive of Standing Together from 2006 to 2013. He has undertaken the Home Office accredited training for DHR Chairs and also worked as a police officer for 30 years, concluding his service as a Chief Superintendent. He has no connection with the local Community Safety Partnership or the agencies involved in this review. 1.6.2 The Overview Report Writer was Jessica Donnellan, the Senior Projects Coordinator at Standing Together against Domestic Violence. Jessica has over ten years’ experience working in the domestic violence and abuse sector. Jessica has no connection with the local Borough or any of the agencies involved in this case. 1.7 Methodology 1.7.1 Following an initial scoping exercise by the local Borough Council and their partners it was established that very limited contact had taken place with Adult S and/or Child CC. The review sought information from these agencies and most were represented on the panel. 1.7.2 IMRs were provided by: a. Surrey Police b. Independent Secondary School 1.7.3 Additional information sought and reviewed by the panel included patient records from: a. Local GP Surgery b. Private Hospital 1.7.4 The Chairs would like to thank all those who contributed their time, cooperation and patience to this review. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 9 1.8 Contact with family and friends 1.8.1 The Chair sought contact with Adult S and Child CC’s families through the Surrey Police Family Liaison Officer (FLO). Contact with Adult R’s family was sought via the Investigating Officer in the case. 1.8.2 All close relatives were contacted by the FLO and written to separately by Standing Together. One relative initially accepted the offer of a meeting to discuss the review but then cancelled that meeting. Subsequent attempts to arrange a new date have not been successful. 1.8.3 A work colleague of Adult S was contacted but declined to participate. The personal assistant for the family did agree to meet with the DHR Chair and overview report writer and provided some useful background information. 1.8.4 The panel considered speaking to Child CC’s close friends from school. They had provided extensive and detailed statements to the police which were very helpful in establishing some understanding of Child CC’s character. The panel decided, after some debate, that a further meeting with them would be unnecessary as they had been so informative and they would have been repeating what had clearly been a painful process. 1.9 Equalities 1.9.1 Adult S was a 47-year-old heterosexual white British woman. Her relationship with Adult R began whilst they were at school and they married in Barbados in 1999, although the marriage was not registered in the UK. 1.9.2 Child CC was a 14-year-old white British young woman. 1.9.3 The nine protected characteristics of the Equality Act 2010 (age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation) were considered and with the possible exception of sex and marriage are not considered relevant. The characteristics of sex and marriage are considered further below. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 10 2. The Facts 2.1 The killings of Adult S & Child CC 2.1.1 On 17 June 2015, Adult S’s mother had been with Adult S at the family home for most of the day. It is understood that the mother left the house just before 20:00 to walk to the bus stop to catch a bus back to her house. 2.1.2 At around 20:05 on that day Adult S’s niece went to the family home with her boyfriend to collect some belongings. Adult R answered the door and appeared to the niece to be behaving normally. Adult R told her and her boyfriend that Adult S was in the bath. They then both left at 20:20 when Adult R said that he was going to collect Child CC from a rehearsal at school. 2.1.3 At 20:31, Adult R’s vehicle was seen on an automated number plate recognition (ANPR) camera on route to Child CC’s school. 2.1.4 Child CC was collected by Adult R from the school sometime between 20:30 and 20:40. 2.1.5 Cell site and phone records show Adult S called Adult R’s phone at 20:41 with the call emanating from the location of the family home. 2.1.6 Adult R’s vehicle was seen again on an ANPR camera at 20:55 heading back towards the family home from Child CC’s school. 2.1.7 Adult R killed Adult S and Child CC at some point after he and Child CC returned home, between 21:00 on 17 June 2015 and the early hours of 18 June 2015. Adult R had placed the bodies of Adult S and Child CC side by side in a bed and their bodies lay undiscovered until 09:37 on 29th June 2015 2.1.8 The post-mortem found that Adult S died as a result of compression to her neck and the probable cause of Child CC’s death was suffocation. 2.2 The perpetrator’s suicide 2.2.1 At 22.38 on 17 June 2015 Adult R made an on-line Eurostar reservation to travel to Calais. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 11 2.2.2 At 00:58 on 18 June 2015 Adult R sent an email to Child CC’s school tutor stating that there had been a family tragedy and that Child CC would not be in school until 29th June 2015. 2.2.3 At 04:36 Adult R’s vehicle was seen on an ANPR camera driving on the M25. 2.2.4 At 06:20 Adult R caught the Eurotunnel to Calais. From here, Adult R proceeded to Lille where he met a French national with whom he had been having an extra-marital affair since April 2015. 2.2.5 Adult R was observed by her on this day to have a number of scratches on his face, neck and chest and a large bruise on his arm. She later described to Police that Adult R ‘was not his usual self’. 2.2.6 They spent nine days together travelling between Paris, Cannes and Nice until she returned to Lille on 27 June 2015. That same day, Adult R contacted a friend in Turkey and asked to meet with him as he was ‘in trouble’. This friend flew to France that day and met with Adult R at a flat owned by him (the friend) in Aix en Provence. 2.2.7 That evening, Adult R told him that he had killed Adult S and Child CC, falsely claiming that he had done so in a car accident. He advised Adult R that he should go to the Police and Adult R agreed to hand himself in the following day. 2.2.8 During the morning of 28 June 2015, he became concerned that Adult R had been in the bathroom for some time. He called the Police, who forced entry into the bathroom and found Adult R deceased on the bathroom floor in a pool of blood. 2.2.9 The French post mortem concluded that Adult R died from self-inflicted injuries, primarily from a large wound to his neck. He had two stab wounds and cuts to the inside of his arms. 2.2.10 At 08:34 on 29 June 2015 the friend contacted Surrey Police to advise of Adult R’s suicide and to register his concern for the welfare of Adult S and Child CC following Adult R’s disclosure that he had killed them. 2.2.11 At 09:37 Police attended the family home and discovered the bodies of Adult S and Child CC. 2.2.12 At 09:49 on 29 June 2015, the Independent Secondary School contacted Surrey Police to report significant concern that Child CC had not returned to school as RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 12 Adult R had outlined she would in his email of 18th June 2015. The school was informed that Surrey Police were attending the family’s address. 2.3 Coroner’s Inquest 2.3.1 On 23 November 2015 Her Majesty’s Coroner for Surrey returned verdicts of unlawful killing in respect of Adult S and Child CC. 2.4 Information relating to Adult S 2.4.1 Adult S was 47 years old at the time she was killed. Adult S had been in a relationship with Adult R since they were at school. They married in 1999 in Barbados, although the marriage was not registered in the UK. Child CC, their only child, was born in May 2001. 2.4.2 Adult S apparently did not socialise much outside of her immediate family: mother, brother, niece and nephew. Her father had died in May 2014. 2.4.3 Adult S was self-employed and she and Adult R worked in corporate hospitality. Together, they had traded under several companies. 2.4.4 Adult S had accumulated significant debt and at the time of her murder was the subject of several County Court Judgements amounting to very large sums of money. The payment of Adult S and Adult R’s joint mortgage was due on 18 June 2015, the date of the deaths. 2.5 Information relating to Adult R 2.5.1 Adult R was 50 years old at the time he took Adult S and Child CC’s lives, as well as his own. Adult R had a small number of friends but was rarely in contact with his surviving family members: a brother and sister. 2.5.2 Adult R has been described by an employee as an out-going and charismatic man. 2.5.3 Adult R had also accumulated significant debts at the time of the murders and was also subject of several County Court Judgements. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 13 2.6 Information relating to Child CC 2.6.1 Child CC was 14 years old at the time she was killed. 2.6.2 Staff at Child CC’s school describe her as ‘a lovely, kind and caring girl’. Child CC was performing well in school, was fully involved in school life and had good friends there. 2.6.3 During the course of the police investigation, some of Child CC’s friends were interviewed by police. They describe Child CC as popular, thoughtful, funny and “crazy”. She was a peacemaker, attentive to those who were upset and skilled in cheering everyone up. Child CC had recently cut her hair and donated it to the Little Princess Trust, to be made into a wig for young people with cancer. 2.6.4 Child CC was also ‘very arty’: she loved acting, singing, making films, taking photos, playing the piano, ice skating and YouTube. She attended an extra-curricular drama school and aspired to be seen as an actor, especially by her parents. 2.6.5 Outside of school, Child CC was usually busy with her family. She often spoke with her friends about her maternal grandmother, who she saw often. When friends visited or stayed at Child CC’s house, which they did regularly, they would spend a lot of time in Child CC’s bedroom and had to talk quietly or listen to music or films through headphones as Adult S and Adult R ‘did not like noise’. 2.6.6 Child CC’s friends and staff at her school describe Adult S and Adult R as being protective, sometimes over-protective, of Child CC. 2.6.7 On the evening of 17th June 2015, Child CC had performed a piece of prose which she had written as part of the Independent Secondary School Prose Festival. Review Panel members had the opportunity to read this piece of her work. Although, in order to protect Child CC’s privacy, the Panel took the decision not to publish this piece of work in this report, it is of note that Panel members were moved by the maturity, talent and humanity that it captures of this bright young woman. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 14 2.7 Child CC’s health 2.7.1 Child CC was known to suffer with gastric problems. The school records reflect an awareness of a gastric ulcer problem and an associated prescription for proton pump inhibitor (PPI) medication. Police interviews with Child CC’s friends reveal: ‘Child CC couldn’t eat certain foods and took tablets daily before and after food […] the side effects of the tablets were not very good and Child CC hated all the blood tests she used to have.’ 2.7.2 Child CC’s friends were aware of a diagnosis of “leaky gut syndrome” (LGS). They knew that Child CC ‘hated it and didn’t like people knowing about it’. Recently Child CC had felt that the problem had been getting worse and her friends were aware that the symptoms could be very disabling: ‘...it often made her feel really poorly and some days she couldn’t even walk without being in pain.’ 2.7.3 One of Child CC’s friends had the impression that ‘the doctors didn’t actually know what was wrong with Child CC.’ 2.8 Surrey Police 2.8.1 During the 1980s Adult R was known by a different name and was convicted for burglary, theft and vehicle related offences. He served a term of detention in youth custody, when he was about 18 years old. At some point after this episode, Adult R changed his name and there are no records on either the Police National Computer (PNC)1 or the Police National Database (PND)2 to indicate Adult R was suspected or known to have committed any further offences. 1 The Police National Computer (PNC): The PNC is a national database of information available to all police forces and law enforcement agencies. The PNC holds details of personal descriptions, bail conditions, convictions, custodial history, wanted or missing reports, warning markers, pending prosecutions, disqualified driver records, cautions, drink drive related offences, reprimands, formal warnings. The PNC holds details of people who are, or were, of interest to UK law enforcement agencies because they: have convictions for criminal offences, are subject to the legal process, for example waiting to appear at court, are wanted, have certain court orders made against them, are missing or have been found, have absconded (escaped) from specified institutions, are disqualified from driving by a court, have a driver record held at the Driver and Vehicle Licensing Agency (DVLA), hold a firearm certificate. 2 The Police National Database (PND) is available to all police forces and wider criminal justice agencies throughout the United Kingdom, allowing the police service to share local information and intelligence on a national basis. The PND supports delivery of three strategic benefits which are to safeguard children and vulnerable people, to counter terrorism, and to prevent and disrupt serious and organised crime. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 15 2.8.2 There is no trace of Adult S on PNC or PND. 2.8.3 During the period under review, Adult S and Adult R came into contact with Surrey Police on four occasions: on 05 September 2010 when Adult S reported that Adult R had been the victim of a road rage incident; on 18 December 2014 and 03 March 2015 when a vehicle registered to Adult S was recorded by speed cameras driving at excess speed; and on 31 July 2012 when Adult S telephoned Police in relation to domestic abuse. 2.8.4 The contacts relating to road rage and speeding have been analysed and are not believed to hold any relevance to this review. 2.8.5 At 20:17 on 31 July 2012 Adult S contacted Surrey Police for advice in relation to on-going ‘domestic issues’ with Adult R. Adult S spoke with a male call taker at Surrey Police Contact Centre and enquired how she could stop Adult R from returning to their home. Adult S stated that they argue constantly and that Adult R had been physically violent towards her in the past. 2.8.6 The call taker established with Adult S that she had not reported any previous incidents of domestic abuse to Police and that she and Adult R jointly owned their home. The call taker then advised Adult S that there was nothing Police could do to stop Adult R entering the property. 2.8.7 Records state that Adult S became ‘upset’ and ‘refused to be seen by the police’. Adult S explained to the call taker that she had friends in the area who would help her and she then terminated the call. 2.8.8 As the call taker was unable to obtain further information, a decision was made, in liaison with a supervisor and in line with Force policy, to pass the incident to the Force Control Room for police deployment. A police unit arrived at the home address at 21:44 nearly 90 minutes after the original call. There had been no police units available to attend prior to this due to a number of higher priority incidents. 2.8.9 The female police officer in attendance spoke with Adult R at the address who stated that he knew Adult S had called the police but he had not expected police to come to their home. Adult R stated that he had argued with Adult S earlier in the day but declined to provide any further details. 2.8.10 Adult R stated that he was packing to leave and also indicated that he would be speaking to his solicitor in relation to the police attendance. Adult R stated that RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 16 Adult S was not at the address. Adult R provided Adult S’s phone number so that the police officer could call Adult S. This call took place out of earshot of Adult R. 2.8.11 Records of this phone call note that Adult S was ‘angry’ that police had attended the address and that she intended to make a complaint as she had been seeking advice only and that the police presence had ‘made things ten times worse’. The police officer advised Adult S of Surrey Police procedures in respect of reports of domestic incidents, including positive action3, and how to make a formal complaint to the force. 2.8.12 Following the incident the attending police officer created a non-crime domestic incident report on the Crime Information System. The incident report additionally indicates that a male Acting Police Sergeant also made a phone call to Adult S with the intention of explaining the police procedures and to offer police assistance and specialist support services. 2.8.13 However, records note that Adult S ‘did not take kindly’ to the Acting Police Sergeant’s call and said she would be making a formal complaint about him. There is no record to indicate that the intention to explain police procedures and offer police assistance and specialist support services was realised. 2.8.14 A Domestic Abuse, Stalking and Honour based Violence (DASH) risk indicator checklist was not completed. Surrey Police describe the reasons for this as ‘lack of cooperation and minimal information provided by Adult S and Adult R’. 2.8.15 The incident report was reviewed first by a Police Sergeant and then by a Public Protection Investigation Unit (PPIU) Supervisor who concurred with the attending officer that the standard risk grading4 was appropriate. The Detective Sergeant determined that police should attempt no further contact with Adult S, reasoning that ‘she had made it quite clear that she did not want police assistance’. The incident was filed and no further action taken. 3 Positive action: In every report of a crime officers must take positive action with the perpetrator including arrest where necessary. Officers in charge of an investigation will take positive action, normally meaning an arrest, at every report of breach of police/court bail, court injunction or non-molestation order to protect the victim and ensure that the courts become aware of the behaviour and actions of the perpetrator. Where possible this should include a charge and remand into custody for placing before a court. 4 Standard Risk Grading: The assessor uses the information from the risk identification interview with the victim to help them grade the level of risk as standard, medium, or high. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 17 2.9 Independent Secondary School 2.9.1 Child CC joined the Independent Junior School in November 2008. 2.9.2 School medical notes show that in June 2009, the school was alerted that Child CC may be suffering a ‘suspected severe disease’. In September 2010 the school nurse administered PPI medication to Child CC for a gastric ulcer. Communication with the school relating to Child CC’s health needs was initiated by Adult R via email. 2.9.3 In 2011, the school were made aware of two incidents where Child CC had been hospitalised: On 07 March 2011 Child CC was admitted overnight to the Private Hospital with abdominal pain and vomiting; on 04 September 2011 Child CC was admitted to a local Hospital with pneumonia. Adult R emailed the school to inform them of both of these incidents and there were supporting medical notes that were shared. 2.9.4 In April 2014, the school’s medical records indicate that Child CC continued to receive treatment for Leaky Gut Syndrome (LGS). 2.9.5 In July 2014 Adult S expressed concern that school staff were not adequately monitoring Child CC’s food intake and preventing her from eating foods that were restricted in the management of her LGS. School staff noted that Adult S’s behaviour seemed disproportionate to the incident. 2.9.6 In May 2015 Child CC’s care plan was updated through a collaboration with the school nurse, Adult S and Child CC. It noted medications for allergies and hay fever and ‘moderation in food’ for the LGS. 2.9.7 At 00:58 on Thursday 18 June 2015 Adult R sent an email to Child CC’s school tutor stating that there had been a family tragedy and that Child CC would not be in school until 29th June 2015. 2.9.8 Adult R’s email was forwarded by Child CC’s tutor to the Head of Year and Deputy Head who then sent it to the Headmistress. Telephone messages and emails were sent to both Adult R and Adult S. 2.9.9 On Friday 26 June 2015 the school telephoned Adult S’s mother and brother to ask them to let Child CC know about a play rehearsal she was due to attend on RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 18 Sunday 28 June 2015. The mother and brother advised that they were not aware of a family tragedy. 2.9.10 Child CC was not present at the play rehearsal on 28 June 2015. An email exchange between the Headmistress, Head of Year and Deputy Head followed this absence, expressing concern. It was agreed that they would meet on Monday 29 June 2015 at 08:40 if Child CC was not in school. 2.9.11 On 29 June 2015, the school called Adult S’s mother and brother to share their concern for Child CC and advised that they were going to call the police. 2.9.12 At 09:49 on 29 June 2015, the Independent Secondary School contacted Surrey Police to report significant concern for Child CC and her family. The school were advised that police were already attending the address. 2.10 Local GP Surgery Adult S 2.10.1 Adult S attended the GP practice with suspected urinary tract infections in September 2012, November 2013 and May 2014. On each occasion medication was prescribed but no further investigations were instigated which could have led to a consideration of other factors, e.g. the possibility of domestic abuse as an issue in Adult S’s life. 2.10.2 In April 2013 and May 2015 Adult S did not respond to written reminders for smear tests and in March 2014 Adult S did not attend for a scheduled mammogram. 2.11 Local GP Surgery Child CC 2.11.1 During 2013 and 2014, Child CC presented at the GP surgery on two occasions with injuries. On each occasion the injuries seemed to be accompanied by credible causal explanations: in February 2013 she presented with a knee injury sustained through skiing and in September 2013 she presented with a superficial injury of her foot sustained through wearing shoes that were too tight. 2.11.2 In June 2014 Child CC presented at a walk-in centre with a bruised hand which was recorded as being sustained whilst playing with a dog. 2.11.3 There are no other records that indicate that Child CC may have been at risk of harm through domestic abuse. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 19 2.12 Private Hospital - Adult S 2.12.1 Adult S had no contact with the Private Hospital during the timeframe under review. However, she had one outpatient consultation in November 2007 and one in April 2008. Although the reasons behind these consultations are not known, no tests or investigations were requested following either. 2.12.2 The resistance of the Private Hospital to engage with this review in a meaningful way is noteworthy. 2.13 Private Hospital - Child CC 2.13.1 During the timeframe under review Child CC had four contacts with the Private Hospital: in January 2011 she had an outpatient appointment with an adult chest physician, in March 2011 she was a general paediatric inpatient overnight, in September 2012 she had a paediatric outpatient appointment with an allergist and in November 2012 she had a paediatric outpatient appointment with a general paediatrician. Prior to this, dating back to July 2001, Child CC had a further eight paediatric outpatient appointments at the Private Hospital. 2.13.2 The sparse information provided to this Review by the Private Hospital does not provide adequate context or detail to understand these interactions. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 20 3. Analysis 3.1 Domestic Violence / Abuse Definition 3.1.1 The government definition of domestic violence and abuse is: Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological; physical; sexual; financial; and emotional. Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour. Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim. 3.2 The Coordinated Community Response (CCR) 3.2.1 The CCR model recognises that no single agency can successfully resolve the inherent complexities of domestic abuse if acting alone. Whilst practice in agencies undoubtedly benefits from internal policies and procedures, without effective coordination of activities between agencies, responses are less effective and domestic abuse survivors will remain at risk of falling through the gaps in the system. 3.2.2 The inconsistent engagement of relevant health services with this review is therefore of deep concern to this Panel and, indeed, the wider local Community Safety Partnership. The consequent lack of information and analysis perpetuates our ignorance of potential problems, barriers and gaps and likely leaves unsafe practices unidentified and unresolved. The fundamental purpose of this review, to contribute to the prevention of further domestic homicides and improve responses for all domestic violence victims and their children, cannot therefore be fully realised. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 21 3.2.3 The engagement and support of Surrey Police with this review has been commendable. It is imperative to recognise that the absence of information from relevant health services places upon Surrey Police a disproportionate burden in that they have been required to think about responding to domestic abuse in isolation from other services. This is contrary to the fundamental principle of collaboration which lies at the heart of the CCR. They have also been the one agency that had significant information about this case leading to a microscopic examination of their practice whilst others (particularly Health) have remained immune from examination, guidance or criticism. There is a danger that the inability to properly examine agencies that should or have been involved in these cases leads to an unbalanced outcome for all agencies. 3.3 Surrey Police 3.3.1 Advice giving. Through this review process, Surrey Police have identified that they gave inaccurate information to Adult S during the Contact Centre call. The information given was that there was nothing the police could do to stop Adult R from entering the family home. Positively, Surrey Police’s own analysis has led to the identification of options available to victims in such circumstances: within the policing remit it has been identified that a removal of Adult R could have been actioned in order to prevent a breach of the peace; outside of the policing remit, it has been identified that Adult S could have sought to secure civil legal orders (e.g. occupation order5). The latter requires police to sign-post or refer victims on to other agencies, such as a family solicitor or specialist domestic abuse support service. The imperative to actively operate in partnership with other agencies in order to respond effectively to the multi-faceted risks and needs that arise from domestic abuse has been outlined in the section above (section 3.2) entitled The Coordinated Community Response (CCR). 3.3.2 It is pertinent to note that this initial interaction between Adult S and Surrey Police began a deteriorating relationship between them that would worsen with each further contact (in a very short space of time) and eventually result in a breakdown 5 Occupation Order: An occupation order is an order issued by the court which sets out who has the right to stay, return or be excluded from a family home. An occupation order doesn't change the financial shares in a home. It is usually a short-term measure and the length of time that it lasts will depend on circumstances. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 22 in meaningful communication. The opportunities to provide Adult S with sound advice about her options and safety were lost. It also made any likelihood of holding Adult R to account for any potential offences impossible. 3.3.3 This highlights the need for Contact Centre staff to be equipped to undertake these crucial initial responses to vulnerable victims with accurate and up-to-date information relating to domestic abuse as well as a clear pathway to support agencies outside of, and independent from the criminal justice remit. Recommendations (5 and 6) to reflect these needs are made in this Report. 3.3.4 Escalation within police frameworks: The escalation of the terminated call between Adult S and the Contact Centre, via a supervisor to the Force Control Room for police deployment, is not only a demonstration of compliance with domestic abuse procedures, but also an example of best practice. There was a deficit of information to establish whether there was a risk to life, risk of serious injury, or whether any party required medical attention so the decision to deploy a police officer to attend Adult S’s address was critical. 3.3.5 Escalation of risk of harm posed by Adult R to Adult S: When the deployed police officer arrived at the family home, it became evident that Adult S was not present. It was not established whether Adult S had fled the address to stay with the ‘friends in the area that would help her’ who she had mentioned previously. It is important to acknowledge that these circumstances may have indicated to police a separation between Adult S and Adult R. Separation, which can happen in many forms from emotional to physical and temporary to permanent, is a known predictor of escalation. This was a missed opportunity to establish whether Adult S’s absence from the home and Adult R’s imminent departure, was likely to trigger an escalation in Adult R’s abusive behaviour and increase the risk of harm to Adult S. (It is also true that Adult R could have been considered to be controlling the interface between the police and Adult S which may have been another indicator of a further risk factor.) 3.3.6 One study of domestic homicides in London (Richards, 2003) revealed that separation was a factor in 76% of intimate partner homicides. This is one of the factors that has led to the widespread employment of the DASH risk assessment, used by Surrey Police, to help staff identify risk and inform safety plans. It is therefore a great shame that such a form was not at least partially completed in RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 23 this case. As an example of relevance to this case the form includes the following question to guide enquiry around separation: Have you separated/tried to separate from Adult R within the past year? Yes/No. Include comments. 3.3.7 During the subsequent telephone conversation that took place between the police officer in attendance at the family home and Adult S, three issues were present in the conversations. Firstly, that Adult S seemed ‘angry’ that police had attended the address, to which the police officer responded with an explanation about Surrey Police procedures, including positive action. Secondly, that Adult S intended to make a complaint, to which the police officer responded with information about the force’s formal complaints procedure. Thirdly that Adult S considered the police response as having ‘made things ten times worse’, to which there was no response from the police officer. 3.3.8 Adult S was giving a clear indication of escalation. Within the context of an abusive relationship, we know that escalation, both in frequency and severity of incidents, is a reliable indicator that the victim is at risk of significant further harm from the perpetrator’s behaviour. Indeed, Surrey Police’s DASH risk assessment guides enquiry around escalation as follows: Is the abuse happening more often? Yes/No. Include comments. Is the abuse getting worse? Yes/No. Include comments. 3.3.9 In this case, the risks associated with escalation, as well as those associated with possible separation are not considered by the police. It is clear that the dynamic that had evolved between Adult S and those representing Surrey Police was unproductive by this stage and rendered any further assessment of risk impossible, whether within the structured DASH format or more informally. However, the failure to consider the known risks continued through two further levels of supervision: that of the Acting Police Sergeant and the Public Protection Investigation Unit Supervisor. 3.3.10 Surrey Police express confidence that additional domestic abuse training for response officers has greatly improved their approach in this domain. A RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 24 recommendation (8) is made in this Report in relation to the monitoring and evaluation of this assertion. A further recommendation (7) is made in this Report to reflect the need for enhanced domestic abuse risk identification training for supervisors. 3.3.11 Although the action of the Acting Police Sergeant in making a further call to Adult S to attempt to offer help is commendable, it ultimately did not achieve any reduction in the known risks. At both these supervisory stages, it is critical to consider how to activate support from services within the wider community network, such as specialist domestic abuse support services, whose independence, skills and knowledge may be able to engage survivors when the police cannot. This is another example of the importance of a CCR. 3.3.12 The Panel acknowledges the potential merit in creating a referral pathway from Surrey Police to the local Domestic Abuse Outreach Service in cases where Police have not been able to complete a DASH and, subsequently, do not have any adequate information on which to categorise the level of risk to the victim (i.e. standard / medium / high). The panel equally acknowledges the barriers associated with making such referrals without the consent of the victim as well as the resource implications that accompany the inevitable increase in demand on Domestic Abuse Outreach services. A recommendation (4) for the CSP to undertake a cost-benefit analysis of implementing this additional pathway is made in this Report. It may be that action is agreed on the basis that an inability to complete a risk assessment automatically suggests it is a high risk case leading to the appropriate referral. 3.3.13 Child Protection: Although the police had contact with Adult R on one occasion (deployed police officer) and with Adult S on three occasions (Contact Centre, deployed police officer, Acting Police Sergeant) during this incident, neither party was asked whether they had any children. This meant that Child CC’s presence within the home was not identified and that any associated risks to her or needs arising from the domestic abuse were not assessed. 3.3.14 Through the process of this review, Surrey Police have identified that this information should have been established. Had this happened, Surrey Police RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 25 would then have taken steps to see Child CC and completed a 39/24 form6. This latter procedure would have led to other agencies, including Surrey Children’s Services and possibly the Independent Secondary School, being made aware of the domestic abuse and given opportunities to intervene early or offer help to Child CC and Adult S. Surrey Children’s Services would then have been in a position to consider action to safeguard Child CC and explore Adult R’s role within the family and as a perpetrator of abuse. However, the Panel believes it unlikely that any intervention would have taken place as the circumstances would not have met the threshold for Children’s Services action. If relevant and proportionate information from the 39/24 form had been shared with the school, they may have discussed life at home with Child CC, which could have led to disclosures or greater understanding of the context to Child CC’s life. 3.3.15 The Panel notes the value of sharing relevant and proportionate information from the 39/24 form with appropriate agencies including schools, and Surrey Police are indeed pursuing the best practice Operation Encompass7 model of information sharing with schools. A recommendation (3) relating to improved dissemination of information from Police regarding vulnerable people is made in this Report. 3.3.16 Surrey Police express confidence that the procedures relating to the identification and safety of children are now, almost four years later, embedded within practice and undertaken as a matter of course. A recommendation (8) relating to the monitoring and evaluation of this is made in this Report. 3.3.17 The “one chance” rule: It is striking how little contact Adult S had with services during the timeframe under review. We have found little material to inform what services could do to build better bridges to reduce this kind of distance between Adult S, and other survivors like her, and those who have the power and duty to help. Adult S’s isolation from support only serves to frame the police response to her exclusive reach for help as vitally important. This unique episode in Adult S’s 6 39/24 form: Used by Surrey Police to report contact with a child or vulnerable adult. Completed by an attending officer and forwarded to the relevant PPIU for review, any further action, and shared with Surrey County Council Contact Centre. Since April 2011, all completed 39/24s are forwarded to the Surrey Police Central Referral Unit (CRU) for review and sharing with partner agencies. 7 Operation Encompass: Operation Encompass was created so that by 9.00am on the next school day, a ‘Key Adult” will be informed that the child or young person has been involved in or witnessed a domestic incident. This knowledge, given to schools through Operation Encompass, allows the provision of immediate early intervention through ‘overt' or 'silent support’, depending upon the needs and wishes of the child. We believe that this kind of early intervention is every child’s right. (http://www.operationencompass.org/) RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 26 life offered the police something akin to the “one chance” rule associated with Forced Marriage and Honour-Based Violence: All professionals working with suspected or actual victims of forced marriage and honour based violence need to be aware of the “one chance” rule. That is, they may only have one opportunity to speak to a victim or potential victim and may possibly only have one chance to save a life. As a result, all professionals working within statutory agencies need to be aware of their responsibilities and obligations when they are faced with forced marriage cases. If the victim is allowed to leave without the appropriate support and advice being offered, that one chance might be wasted. (HM Government, 2014, p.16) 3.3.18 There is a clear parallel with the unfulfilled potential of Adult S’s sole domestic-abuse-related interaction with the police to act as a conduit to information, help and safety. There are two inter-related learnings to be found, not only for the police but for any agency to whom Adult S may have made that unique approach for help, within the domains of co-production and the coordinated community response. 3.3.19 Co-production: Co-production is concerned with ‘enlisting people as co-producers of public services’ (Stephens et al, 2008, p.1): Professionals need their clients as much as the clients need professionals. In practice, the consumer model of public services – where professional systems deliver services to grateful and passive clients – misses out what is most effective about their ‘delivery’: the equally important role played by those on the receiving end, without which, doctors are almost powerless to heal, just as teachers are powerless to teach and police to prevent crime (Stephens et al, 2008, p.8). 3.3.20 At the core of the model is a definition of clients as assets and an understanding that where this is ignored, both sides are destined to fail. 3.3.21 The police relationship with Adult S seemed not to value, or at least undervalued Adult S as a co-producer of safety and justice. This is most visible in the language used by police to record Adult S’s behaviour (see Appendix 1 for examples) and may point to an opportunity to develop a model of co-production.RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 27 3.3.22 A recommendation (2) is made in this Report for the Community Safety Partnership to consider ways in which to utilise co-production to improve practice with victims / survivors of domestic abuse. 3.3.23 The Coordinated Community Response (CCR). The police response to Adult S’s approach for help did not realise its’ potential to activate other parts of a wider system to respond to the needs that arose from Adult R’s abuse of Adult S. A critical opportunity to offer or refer Adult S to a specialist domestic abuse support service, in this case the local Domestic Abuse Outreach Service, was missed. 3.3.24 A recommendation (4) is made in this Report for the CSP to undertake a cost-benefit analysis to establish the viability of implementing an additional referral pathway between police and Domestic Abuse Outreach services in cases where the DASH risk assessment system has not been successfully completed. 3.4 Independent Secondary School 3.4.1 Throughout the six and a half years that that Child CC attended the Independent Junior and Secondary Schools, the schools received no obvious evidence to alert them to the possibility that Child CC was living in a household where there was domestic abuse. This has given rise to the recommendations (9 and 10) in this report for the Independent Secondary School to consider more active ways in which the school can encourage and initiate dialogue around domestic abuse and publicise ways that children and young people can make disclosures. 3.4.2 The Independent Secondary School would have had the opportunity to draw potential links between Child CC’s health complaints and witnessing domestic abuse at home, had they received the relevant and proportionate information from the 39/24 form from police following the incident of 31st July 2012. 3.4.3 Following Adult R’s email to the Independent Secondary School on 18th June 2015 which advised that Child CC would be absent from school for a period of seven school days due to a ‘family tragedy’, the Independent Secondary School complied with their Child Protection and Attendance policies. 3.4.4 It is a matter of some conjecture whether GHS would have alerted police at an earlier stage of Child CC’s absence, if they had been in possession of the 39/24 form and consequently aware of Adult R’s abusive behaviour. Further conjecture RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 28 arises as to whether the police would have been able to locate Adult R within the ten-day window before his suicide and bring him to justice. 3.5 Local GP Surgery Adult S 3.5.1 Repeat presentation with UTIs could reasonably trigger a process of opportune enquiry around domestic abuse. There is an appetite for the IRIS8 (Identification and Referral to Improve Safety) programme to be rolled out in the local Borough and a recommendation (11) is made in this Report to reflect that. 3.6 Local GP Surgery Child CC 3.6.1 There is no evidence to indicate that the GP practice could have responded differently with the presentations that Child CC made. 3.7 Private Hospital - Adult S 3.7.1 The Panel expressed concern about the diagnosis of Child CC with LGS as it is not widely recognised by medical professionals as a legitimate illness. The Panel questioned whether the symptoms Child CC was experiencing could have been psychosomatic, caused by the stress of living in an abusive household. 3.7.2 Without further information from the healthcare provider, it is impossible to establish what enquiry took place by the diagnosing physician or how eagerly Adult R may have pursued a diagnosis of LGS, either to distract those around Child CC from drawing links between her poor health and an abusive home life, or to deny to himself, Adult S and Child CC the impact of his abusive behaviour on Child CC’s wellbeing. 3.7.3 It is woefully inadequate that the Private Hospital has not provided sufficient information to support this Review. A recommendation (13) is made in this report for the Home Office to hold private health care providers accountable to both the domestic homicide and serious case review process. 8 http://www.irisdomesticviolence.org.uk/iris/ RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 29 3.8 Private Hospital - Child CC 3.8.1 The sparse information provided to this Review by the Private Hospital does not provide adequate context or detail to identify whether Child CC disclosed any information that could have reasonably triggered enquiry around domestic abuse. 3.8.2 The fragmentation that occurs in the narrative of Child CC’s contact between private and NHS health services is notable. A recommendation is made in this report (14) for NHS England to respond to the gaps that emerge between care providers and threaten the safety of adult and child survivors of domestic abuse. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 30 4. Conclusions and Recommendations 4.1 Preventability 4.1.1 The precise nature of domestic violence and abuse is well known to those agencies who so regularly deal with victims, their children and perpetrators. The evidence of many DHRs is that opportunities nearly always exist where a different approach could have led to opportunities being grasped where the fatal outcome could have been averted. In this sense this is true in this case and, if preventability is defined in its widest sense, there is a possibility that the deaths of Adult S and Child CC could have been prevented. 4.1.2 This case highlights how fleeting and limited such opportunities can be. There should be no avoiding of the fact that in some way the police, the school and the GP practice in this case can now enhance their practice to consider whether domestic violence is present, what level of risk is posed and what action can be taken to mitigate that risk and support the vulnerable. This is the true benefit of DHRs and the recommendations will lead to a more responsive, aware and effective practice within a Coordinated Community Response. 4.1.3 With this in mind this case also illustrates the difficulty of predicting such events. The time lapse between the one report of domestic abuse and the deaths shows how difficult it is to assess the outcome of abusive relationships. On the evidence available it cannot be said that these killings were predictable, although that must never obscure the fact that such abuse is almost always accompanied by the dynamic of escalation and that the abuse or violence will worsen. 4.2 Conclusions 4.2.1 There is a paucity of information about the true nature of the relationship between Adult R, Adult S and Child CC. Whilst it is known that Adult S had reported domestic abuse in 2012 and that they were in financial difficulties, there is very little evidence on which to base strong and detailed conclusions. This, though, is often the nature of domestic relationships which are abusive. It is for this reason that the level of intervention and the expertise necessary to deal with such matters is the subject of much consideration, training, policy and practice. It is only through RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 31 agencies working together, in a Coordinated Community Response, that such improvements can be achieved. 4.2.2 According to the policies of the time (especially in the case of the police in 2012) this case was dealt with in a “standard” way. This is a vast improvement from earlier times but this review amply demonstrates that development is still necessary. The recommendations below are designed to build upon changes that have been instituted and become commonplace and also take the agencies to the next level where the prevalence of domestic violence or abuse and its nature are addressed more comprehensively and with the improved understanding of its dynamics. 4.3 Partnership Arrangements 4.3.1 Recommendation 1 - CSP analyse their existing response to domestic abuse and seek to develop a more complete and enhanced approach to this issue through the mechanism of a Coordinated Community Response to domestic abuse. 4.3.2 Recommendation 2 – Develop and trial individual and community interventions using the concept of co-production, to enhance the borough’s response to victims of domestic abuse. 4.3.3 Recommendation 3 – Ensure that the agreed intention of providing Police information about vulnerable people to relevant agencies, including schools is promulgated with urgency. 4.3.4 Recommendation 4 – Undertake a cost-benefit analysis to establish the viability of implementing an additional referral pathway between police and Domestic Abuse Outreach services in cases where the DASH risk assessment system has not been successfully completed. 4.4 Surrey Police 4.4.1 Recommendation 5 – Deliver training for Contact Centre staff to ensure a sound grasp of the dynamics of domestic violence and to equip them with the skills and information necessary to respond appropriately to victims of domestic abuse. 4.4.2 Recommendation 6 – Develop for all frontline staff (including staff in contact centres and control rooms) clear referral pathways to specialist domestic abuse support services and related agencies. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 32 4.4.3 Recommendation 7 – Provide enhanced risk identification and awareness training to ensure Public Protection Unit supervisors have adequately informed oversight of domestic abuse cases. 4.4.4 Recommendation 8 – Surrey Police to use this DHR process and the development from the recommendations to audit its policies and practice to ensure the developments are embedded in practice (within 6 months of publication of the report). 4.5 Independent Secondary School 4.5.1 Recommendation 9 – Integrate domestic abuse awareness into safeguarding training for all staff (and ensure those staff already trained in safeguarding receive this training). 4.5.2 Recommendation 10 – Integrate the Spiralling9 toolkit into PSHE (personal, social, health and economic) education. 4.6 NHS General Practice in the local Borough 4.6.1 Recommendation 11 – Request the Joint Commissioning Board to commission the IRIS programme within the area. 4.7 National Recommendations 4.7.1 The CSP should be informed of the outcome of the following recommendations which go beyond a purely local remit. 4.7.2 Recommendation 12 – Debt advisory services to develop a system where those individuals with County Court Judgements (or similar) relating to debt are provided with information about domestic abuse support services and support to assist in the resolution of the case. 4.7.3 Recommendation 13 – HM Government to develop the statutory guidance for DHRs to specifically include private medical care and oblige such organisations to participate in the DHR process. 9 https://www.tamesidesafeguardingchildren.org.uk/resources/materials/toolsandresources/spiralling/spiralling_toolkit.pdf RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 33 4.7.4 Recommendation 14 - NHS England to respond to the gaps that emerge between private and national health care providers which may threaten the safety of adult and child survivors of domestic abuse. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 34 Bibliography ANON. Multi-agency practice guidelines: Handling cases of Forced Marriage [online]. HM Government, 2014 [viewed March 2016]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/322307/HMG_MULTI_AGENCY_PRACTICE_GUIDELINES_v1_180614_FINAL.pdf RICHARDS, L. Findings from the Multi-agency Domestic Violence Murder Reviews in London [online]. Metropolitan Police, 2003 [viewed March 2016]. Available from: http://www.dashriskchecklist.co.uk/uploads/Findings%20from%20the%20Domestic%20Homicide%20Reviews.pdf STEPHENS, L., J. RYAN-COLLINS and D. BOYLE. Co-production: A Manifesto for growing the core economy [online]. New Economics Foundation, 2008 [viewed March 2016]. Available from: http://b.3cdn.net/nefoundation/5abec531b2a775dc8d_qjm6bqzpt.pdf WILLS, A., N. JACOBS, B. MONTIQUE and L. CROOM. In Search of Excellence: A Guide to Effective Domestic Violence Partnerships [online]. Standing Together against Domestic Violence, 2013 [viewed March 2016]. Available from: http://www.standingtogether.org.uk/sites/default/files/docs/In_Search_of_Excellence.pdf RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 35 Appendix 1: Co-production Table of examples to show how the application of the values of co-production can support improved risk identification and response. Terminology used in police recording Interpretation problems Co-productive reframe Potential positive impact of re-framing interaction ‘Adult S asked the call taker for advice regarding on-going domestic issues with her husband’. The term used here does not reflect the motivation for Adult S’s approach for help: the abusive nature of the behaviour Adult S had been subjected to from Adult R. Nor does it reflect the severity of abuse that Adult S disclosed, which included physical violence. Adult S was taking initiative to seek help in relation to domestic abuse from her husband. This record cites Adult S as an active agent in the interaction and reflects that abusive nature of Adult R’s behaviour has been heard by the police. ‘Adult S became upset’. This behaviour seems to be measured against the expectation that Adult S will be ‘grateful and passive’. It is not received as expression of distress from which police can understand important messages about risks to Adult S. Adult S’s behaviour seemed to me to be communicating a distress [specify behaviours e.g. crying, shouting, silent etc.] due to the absence of options to help her be safe from her husband’s abusive behaviour. This record focuses on the value of the messages that Adult S’s behaviour conveys to police about the risks she is facing. It recognises the contribution that police have made to her distress, in that they are unable to offer help. It cites Adult R’s behaviour as the root cause of Adult S’s distress. It also makes clear that further action is required by police to make links to others who can help. ‘Adult S was angry that police had attended the address’. This behaviour seems to be measured against the expectation that Adult S will be ‘grateful and passive’. It is not Adult S’s behaviour seemed to me to be communicating a distress [specify behaviours e.g. crying, This record focuses on the value of the messages that Adult S’s behaviour conveys to RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 36 received as expression of distress from which police can understand important messages about risks to Adult S. shouting, silent etc.] due to the escalation in risk to her safety that the police presence at the house had caused. police about the risks she is facing. It recognises the contribution that police have made to her distress. It also makes clear that further action is required by police to work with Adult S, and perhaps others, to respond to the escalated risk. ‘Adult S stated that […] police presence had made things ten times worse.’ The recording of this information is important but there is an absence of a call for further investigation and action. Adult S’s assessment of the circumstances is one of significantly increased risk. It seems that we have exhausted the possibilities of engaging effectively with Adult S to understand what is needed to manage this increased risk. We need to consider which other agencies would be able to help/intervene here. This record accepts Adult S as the expert in assessing the risks posed to her by Adult R. It acknowledges the limits of the police role but highlights that other agencies may be able to step-in to respond to the increased risks. It is clear that further action is required by police to activate a multi-agency response. ‘Adult S did not take kindly to the call’. This behaviour seems to be measured against the expectation that Adult S will be ‘grateful and passive’. It is not received as expression of distress from which police can understand important messages about risks to Adult S. Adult S’s behaviour seemed to me to be communicating a continued distress [specify behaviours e.g. crying, shouting, silent etc.] due to the escalation in risk to her safety that the police intervention had caused. This record focuses on the value of the messages that Adult S’s behaviour conveys to police about the risks she is facing. It recognises the contribution that police have made to her distress. It also makes clear that further action is required by police to work with Adult S, and perhaps others, to respond to the escalated risk. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 37 ‘Adult S refused to be seen by the police’. The essence of ‘refusal’ is to not being willing. However, in the context of an abusive relationship it is far more likely that Adult S did not feel able. Adult S is extremely fearful of the consequences of engaging with the police at this time. This barrier appears to me to be unsurmountable. This re-balances the power dynamic between Adult S and police. It acknowledges the level of fear that Adult S is experiencing. It necessitates action to identify those services who may be able to overcome the barrier that the police are facing. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 38 Appendix 2: Terms of Reference Terms of Reference for the joint Domestic Homicide & Serious Case Review for Adult S and Child CC This Domestic Homicide Review is being completed to consider agency involvement with Adult S, Child CC and Adult R following the deaths of Adult S and Child CC on the 18th June 2015. The Domestic Homicide Review is being conducted in accordance with Section 9(3) of the Domestic Violence Crime and Victims Act 2004. A serious case review ran jointly to ensure fair consideration of these events on Child CC. Purpose - DHR 1. Domestic Homicide Reviews (DHRs) place a statutory responsibility on organisations to share information. Information shared for the purpose of the DHR will remain confidential to the panel, until the panel agree what information should be shared in the final report when published. 2. To review the involvement of each individual agency, statutory and non-statutory, with Adult S and Adult R during the relevant period of time: 1st June 2010 – 29th June 2015. 3. To summarise agency involvement prior to 29th June 2015. 4. To establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to identify and respond to disclosures of domestic abuse. 5. To identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and as a consequence. 6. To improve inter-agency working and better safeguard adults experiencing domestic abuse and not to seek to apportion blame to individuals or agencies. 7. To commission a suitably experienced and independent person to: a. chair the Domestic Homicide Review Panel; b. incorporate the SCR process c. co-ordinate the review process; d. quality assure the approach and challenge agencies where necessary; and e. produce the Overview Report and Executive Summary by critically analysing each agency involvement in the context of the established terms of reference. 8. To conduct the process as swiftly as possible, to comply with any disclosure requirements, panel deadlines and timely responses to queries. 9. On completion present the full report to the local Community Safety Partnership. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 39 Purpose – SCR 10. Meet the requirements for Serious Case review with regard to Child CC and specifically to: a. Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; b. Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and c. Improve intra- and inter-agency working and better safeguard and promote the welfare of children. Membership 11. It is critical to the effectiveness of the meeting and the DHR that the correct management representatives attend the panel meetings. Your agency representative must have knowledge of the matter, the influence to obtain material efficiently and can comment on the analysis of evidence and recommendations that emerge. 12. The following agencies are to be invited to particpate: a. Clinical Commissioning Groups (formerly known as Primary Care Trusts) b. General Practitioner for the victim and alleged perpetrator c. Local domestic violence specialist service provider e.g. IDVA d. Education services e. Children’s services f. Adult services g. Health Authorities h. Substance misuse services i. Housing services j. Local Authority k. Local Mental Health Trust l. Police (Borough Commander or representative, Critical Incident Advisory Team officer, Family Liaison Officer and the Senior Investigating Officer) m. Prison Service n. Probation Service o. Victim Support (including Homicide case worker) RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 40 13. Where the need for an independent expert arises, for example, a representative from a specialist BME women’s organisation, the chair will liaise with and if appropriate ask the organisation to join the panel. 14. If there are other investigations or inquests into the death, the panel will agree to either: a. run the review in parallel to the other investigations, or b. conduct a coordinated or jointly commissioned review - where a separate investigation will result in duplication of activities. Collating evidence 15. Each agency to search all their records outside the identified time periods to ensure no relevant information was omitted, and secure all relevant records. 16. Each agency must provide a chronology of their involvement with Adult S, Child CC and Adult R during the relevant time period. 17. Each agency is to prepare an Individual Management Review (IMR), which: a. sets out the facts of their involvement with Adult S, Child CC and/or Adult R; b. critically analyses the service they provided in line with the specific terms of reference; c. identifies any recommendations for practice or policy in relation to their agency, and d. considers issues of agency activity in other boroughs and reviews the impact in this specific case. 18. Agencies that have had no contact should attempt to develop an understanding of why this is the case and how procedures could be changed within the partnership which could have brought Adult S, Child CC or Adult R into contact with their agency. Analysis of findings 19. In order to critically analyse the incident and the agencies’ responses to the family, this review should specifically consider the following six points: a) Analyse the communication, procedures and discussions, which took place between agencies. b) Analyse the co-operation between different agencies involved with the victim, alleged perpetrator, and wider family. c) Analyse the opportunity for agencies to identify and assess domestic abuse risk. d) Analyse agency responses to any identification of domestic abuse issues. e) Analyse organisations access to specialist domestic abuse agencies. f) Analyse the training available to the agencies involved on domestic abuse issues. RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 41 Liaison with the victim’s and alleged perpetrator’s family 20. We aim to sensitively involve the family of the victim in the review, identifying the most appropriate method and route of contact. 21. We also aim to explore the possibility of contact with any of the alleged perpetrator’s family who may be able to add value to this process. 22. The chair will lead on family engagement with the support of relevant Panel members, including coordination of family liaison to reduce the emotional hurt caused to the family by being contacted by a number of agencies and having to repeat information. 23. Coordinate with any other review process concerned with the child of the victim and alleged perpetrator. Development of an action plan 24. Individual agencies will take responsibility to establish clear action plans for agency implementation as a consequence of any recommendations in their IMRs. The Overview Report will set out the requirements in relation to reporting on action plan progress to the Community Safety Partnership: for agencies to report to the CSP on their action plans within six months of the Review being completed. 25. Community Safety Partnership to establish a multi-agency action plan as a consequence of the recommendations arising out of the Overview Report, for submission to the Home Office along with the Overview Report and Executive Summary. 26. SSCB Serious Case Review Group to act on the recommendations arising out of the report in relation to Child CC. Media handling 27. Any enquiries from the media and family should be forwarded to the chair who will liaise with the CSP. Panel members are asked not to comment if requested. The chair will make no comment apart from stating that a review is underway and will report in due course. 28. The CSP is responsible for the final publication of the report and for all feedback to staff, family members and the media. Confidentiality 29. All information discussed is strictly confidential and must not be disclosed to third parties without the agreement of the responsible agency’s representative. That is, no RESTRICTED – NOT FOR ONWARD TRANSMISSION FINAL 42 material that states or discusses activity relating to specific agencies can be disclosed without the prior consent of those agencies. 30. All agency representatives are personally responsible for the safe keeping of all documentation that they possess in relation to this DHR and for the secure retention and disposal of that information in a confidential manner. 31. It is recommended that all members of the Review Panel set up a secure email system, e.g. registering for criminal justice secure mail, nhs.net, gsi.gov.uk, pnn or GCSX. Confidential information must not be sent through any other email system. Documents can be password protected. Disclosure 32. Disclosure of facts or sensitive information may be a concern for some agencies. We manage the review safely and appropriately so that problems do not arise and by not delaying the review process we achieve outcomes in a timely fashion, which can help to safeguard others. Copyright © 2015 Standing Together Against Domestic Violence. All rights reserved. |
NC52285 | Death of a 21-month-old girl in November 2017 as a result of brain injuries following physical abuse by the partner of the child's special guardian. The perpetrator was found guilty of murder and sentenced to a minimum term of 20 years in prison. Learning includes: the importance of a close family relationship for the child with the special guardian; the importance of wider family support for the arrangement; management of contact; the importance of understanding a special guardianship order (SGO) as at the adoption end of permanence. Makes no recommendations but identifies learning points with actions: enough time should be given to assess the integration of a child placed within a family, the care of that child and the impact on all members of the family before a final SGO is made; organisations need to reflect on how the impact of a change of social worker and team in the middle of proceedings and planning can be mitigated to keep the needs of the child at the centre; there is an absence of guidance on what action to take when a child is presented with concerning bruising for frontline professionals; an absence of appropriate challenge and professional curiosity, particularly around apparently open reporting.
| Title: Serious case review: BSCB 2017-18/02. LSCB: Birmingham Safeguarding Children Board Author: Hilary Corrick Ranger Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review BSCB 2017-18/02 Lead Reviewer: Hilary Corrick RangerPublished 5th October 2021 CONTENTS Number Description 1 Introduction and Summary 2 Decision to hold a Serious Case Review 3 Process 4 Scope of the Serious Case Review 5 Key issues to be addressed within the Serious Case Review 6 Methodology 7 LILLY’S STORY 8 Key Issues 8.1 Quality and robustness of practice and of assessment and challenge during Special Guardianship Order 9 Quality of post court decision making, support and oversight 10 Quality of monitoring by universal services 11 Indicators of concern identified or missed 12 Nursery 13 GPs 14 Birmingham Children’s Hospital 15 Operational, organisational and strategic context of safeguarding provision 15.1 Birmingham Children’s Trust: Children’s Social Care 16 Cafcass 17 Court service 18 Birmingham Community Healthcare NHS Foundation Trust 19 Birmingham South and Central Clinical Commissioning Group: GPs 20 Birmingham Children's Hospital 21 Probation 22 National, regional or local policy issues 23 Close family relationship, family support and contact 24 SGO and adoption 25 Court timescales 26 Views of professionals 27 Views of family members 28 Analysis and Conclusions 29 Finally 30 Learning Points 31 Postscript Appendix 1 Abbreviations and acronyms Appendix 2 Relevant other Serious Case Review’s and research 1. INTRODUCTION and SUMMARY 1.1 Lilly was born on 21st February 2016. She was White British and the third child of her mother. Her two older siblings were cared for by her maternal grandmother. 1.2 Lilly was very ill after her birth and remained in hospital until the 15th March 2016 when she was placed by the Courts into the care of her maternal grandmother under a Child Arrangement Order (CAO) and Interim Supervision Order (ISO). By the 7th July 2016 Lilly had moved to live with her special guardian (a relative of the family) as her maternal grandmother was finding it difficult to manage her care in addition to her other caring responsibilities. A Special Guardianship Order (SGO) was made in favour of the special guardian on the 5th September 2016. 1.3 An ambulance and police were called to the home address of Lilly on the 19th November 2017. A person visiting the address, the partner of the special guardian, had found Lilly unresponsive. On arrival at hospital her condition was critical, and she was taken to the Paediatric Intensive Care Unit (PICU) where her prognosis was described as life threatening. A CT head scan was undertaken which showed the presence of subdural bleeding and there were clear signs of raised intracranial pressure. Lilly underwent two emergency brain surgery operations to save her life and reduce the swelling to her brain. She remained on life support until her death on the evening of the 22nd November 2017. These injuries were described as non-accidental. West Midlands Police conducted an investigation into the circumstances surrounding the death of this child, as a result of which the special guardian’s partner was charged with her murder. He was convicted and sentenced on 26th March 2021 to a minimum term of 20 years in prison. 2. Decision to hold a Serious Case Review (SCR) 2.1 When a child dies and abuse or neglect is either known or suspected the Local Safeguarding Children Board is required to undertake a Serious Case Review (SCR). At the SCR Sub-Group on the 8th December 2017, it was established that the case met the criteria for an SCR. The Independent Chair of the Birmingham Safeguarding Children Board (BSCB) ratified the decision to commission an SCR on the 21st December 2017. 3. Process 3.1 BSCB commissioned Hilary Corrick Ranger as the author of the review. She has over forty years’ experience of social care services, the majority with services for children and families as a practitioner and senior manager in local and national government. She has a professional social work qualification and is registered with Social Work England (SWE). She works as an independent consultant within Local Authority children and adult services, as well as the health economy and the voluntary sector. The main focus of her work is safeguarding. She has undertaken case reviews and provided overview reports to several LSCBs. She has not worked for any of the services contributing to this SCR. 3.2 A Review Team was established to provide oversight, guidance, advice and support to the independent author. The Review Team consisted of safeguarding experts with no direct responsibility or management links to the case, from: • Children’s Social Care; • West Midlands Police; • Children and Families Court Advisory Service (Cafcass); • Birmingham South and Central Clinical Commissioning Group (CCG). 4. Scope of the SCR 4.1 The Review Team agreed that the SCR should focus on the period from Lilly’s birth on the 22nd February 2016 until her death on the 21st November 2017. 4.2 The SCR would not consider in detail Lilly’s birth family nor the extended family network and agency contact with them unless there were issues which were directly pertinent to the key issues to be addressed by the SCR. 4.3 Each of the agencies that had contact with the family was requested to complete a Key Events Chronology and an Information Report based on their records and files relating to the case, identifying emerging learning and action that would be taken to implement any improvements to practice. Agencies were expected to analyse their agency’s involvement with the case professionally and critically. 4.4 Key Event Chronologies and Information Reports were requested from the following agencies: • Children’s Social Care; • Cafcass; • Early Years; • Mental Health; • Birmingham Children’s Hospital • Heart of England NHS Foundation Trust Hospital; • Probation; • Birmingham Community Healthcare NHS Foundation Trust; • West Midlands Police; • Birmingham South and Central CCG. 4.5 Other agencies, Change, Grow, Live (Reach Out Recovery Drug Service) and West Midlands Ambulance Service, submitted Information Reports but these were not directly relevant to the review. 5. Key issues to be addressed within the SCR. 5.1 It was agreed the review would focus on the following key issues: 5.2 The quality of practice, supervision and management oversight and support of those multi-agency professionals involved with the case during that period and in particular: a. The quality and robustness of assessments, reports to court, care planning and court decision-making processes; b. The degree to which information about the individual making an application for an SGO was evaluated, assessed, challenged and analysed during the proceedings. 5.3 The quality of post court decision-making, support and oversight processes put in place to support and monitor the SGO placement. 5.4 The degree to which universal services were engaged in providing ongoing monitoring of the placement and whether they demonstrated appropriate rigour and professional curiosity about the nature of the household. 5.5 Whether any concerns, or indicators of concern were raised, identified or, with hindsight, missed in relation to the special guardian’s care of Lilly following the placement, up to and including her death, by any agency, universal or specialist, in contact with the family in which she was living. 5.6 The operational, organisational and strategic context within which multi-agency children’s safeguarding activity (including the court service) was taking place at the time of the court case and the degree to which this context affected front-line practice and decision-making. 5.7 Whether there are any key national, regional or local policy issues arising from the use of an SGO in the circumstances that need to be addressed. 6. Methodology 6.1 The Review Team analysed the Information Reports and the integrated Key Events chronology. They considered the professional systems and individual agency pressures. 6.2 A Professionals’ Learning Event shared knowledge between agencies and individual professionals who knew Lilly and the special guardian and her family, and discussed the key issues and what could have been done differently. 6.3 The Independent Author had hoped to meet with members of Lilly’s family, with a member of the Review Team at an early stage of the Review, and listen to their thoughts about what happened to Lilly. Unfortunately, the police investigations and legal processes delayed this for a significant period, but meetings have now taken place with Lilly’s mother, her maternal grandmother and her special guardian. 7. LILLY’S STORY 7.1 Lilly was 21 months old when she died. The nursery she attended described her as a happy and healthy little girl who was meeting all her milestones. In court a family member, on behalf of the family, said she was loving, cheeky and a perfect little girl. She was mostly shy and cautious around new people, but it would never take long before she was dancing around with her arms in the air. When we met her mother and maternal grandmother, they described her dancing when they saw her shortly before her death. 7.2 She was born on 21st February 2016 at Good Hope Hospital, then part of the Heart of England Foundation Trust, now part of University Hospitals Birmingham NHS Foundation Trust. Her mother had received no antenatal care, and came to the hospital with vaginal bleeding. She admitted to chronic substance misuse before and during her pregnancy (crack cocaine and heroin). 7.3 Lilly was ill following her birth with complications associated with prematurity and substance misuse. On the day she was born she was transferred to the Neonatal Unit at Birmingham Heartlands Hospital and the Special Care Baby Unit. 7.4 Lilly’s mother informed the hospital midwives that she had two older children who were in the care of her mother (maternal grandmother). She discharged herself from hospital against medical advice on the day of Lilly’s birth. 7.5 A referral to Children’s Social Care was made by the midwives on the same day, in line with Safeguarding Children’s Policy. A Strategy meeting was held by the Multi-Agency Safeguarding Hub (MASH) the day after Lilly’s birth. It was decided that Section 47 enquiries were not required and responsibility was transferred to the area safeguarding team to undertake an assessment. 7.6 The assessment was opened the same day with a view to: • Ensure that support was available to the mother; • Ascertain the mother’s wishes for Lilly; • Consider her capacity to change; • Liaise with health services and ensure a discharge planning meeting is held for Lilly; • Liaise with maternal grandmother, who had offered to care for Lilly; • Establish if the mother wished to have Lilly returned to her, in which case immediate legal advice to be sought. 7.7 On the 25th February the mother told the social worker that she wished to care for Lilly herself; a Legal Planning Meeting was held on 1st March as a result, where it was agreed that: • The legal threshold for removal was met; • Family members and other connected persons were to be assessed as carers for Lilly; • Lilly to be placed in specialist foster care on discharge from hospital; • A detailed and robust parenting assessment of the mother to be completed. 7.8. On 2nd March the social worker spoke to the special guardian about the mother’s wish for her to become the carer for Lilly. On the 10th and 11th March the social worker explained to the mother, maternal grandmother and the special guardian that the Local Authority planned to place Lilly in foster care when she was discharged from hospital. 7.9 14th March: the Court hearing. Both the mother and maternal grandmother opposed the Local Authority plan for an Interim Care Order (ICO) and for Lilly to be placed with foster carers. A Cafcass Children’s Guardian was appointed for Lilly. The Local Authority was asked to consider further the Special Guardianship Order assessment which had been undertaken of maternal grandmother to be the carer for Lilly’s siblings, and the support plan, for the Court to consider the following day. 7.10 At the Court hearing on the 15th March a Child Arrangement Order (CAO) was made, placing Lilly in the care of maternal grandmother, with an Interim Supervision Order to the Local Authority. The Local Authority did not object, and the Cafcass Children’s Guardian supported the plan. Lilly was discharged from hospital on 17th March, to the care of maternal grandmother. Both maternal grandmother and the special guardian, put themselves forward as long-term carers for Lilly. 7.11 The assessment of maternal grandmother, filed at Court on 29th March, did not support the long-term placement of Lilly with her maternal grandmother, as it was felt she would be unable to meet the long-term care needs of three children, and the placement of Lilly would undermine the care of her siblings. 7.12 The viability assessment of the special guardian was positive and a full assessment was to be undertaken by the Special Guardianship Team. She had visited Lilly in hospital and in the home of maternal grandmother. Lilly stayed with her in early April when maternal grandmother went on a short holiday. There was frequent contact during the assessment period, including overnight stays. 7.13 A “new birth assessment” was made by the health visitor at the local Primary Care Centre on 1st April. Maternal grandmother was invited to take Lilly to the Well Baby Clinic for her 6 week assessment on 12th April. 7.14 The Children’s Social Care assessment of Lilly was completed on 5th April, with a recommendation that Lilly be placed with maternal grandmother on an interim basis while the Court concluded her long-term care and permanency. The possibility of reunification with her mother was kept open, although doubt was expressed about the mother’s ability to make the changes necessary within Lilly’s timescales. The long-term future for Lilly was an SGO with the special guardian with a parallel plan for adoption if the assessment should not be positive. 7.15 A Child in Need (CIN) meeting was held in late April, confirming the above plan. Both the mother and special guardian were present, as well as the social worker and the health visitor. Following the CIN meeting the case was transferred to a different social work team. 7.16 Records suggest that Lilly was staying with the special guardian on 1st June, but an unannounced visit to maternal grandmother on 22nd June suggested she was still there. The likelihood is that she was being cared for by both the special guardian and maternal grandmother. 7.17 The special guardian presented very well and demonstrated structure in her life. She had had difficulties as a teenager but had addressed these and returned to education. The care of her children was to a high standard and reports from their school were positive. She had considerable support from her mother, who lived nearby. 7.18 The SG assessment, recommending that the special guardian be made the special guardian for Lilly, was completed on 29th June, and the assessor closed the case. A CIN meeting on 30th June recommended that Lilly move to live with the special guardian. She did so on 7th July. 7.19 On 14th July a CAO was made for Lilly to live with the special guardian. 7.20 The final court hearing took place on 5th September, when an SGO was made to the special guardian. Discussion took place considering the possibility of a Supervision Order alongside the plan, but the special guardian argued, as did the Cafcass Children’s Guardian, that support would be provided by the Local Authority through the SGO support plan and the CIN plan.1 7.21 Lilly attended the Well Baby Clinic for the special guardian’s area. 7.22 On the 18th November a support worker from the SG team was allocated to the special guardian. The support worker made contact with the special guardian on 30th November, but there seems to have been no response and the case was closed by the team on 7th December. 7.23 Supervision notes from 25th January 2017 in the children’s social work team suggest that visits were taking place to see Lilly and the special guardian, but no records exist, and the case was closed to the service on 22nd March 2017. 1 A Supervision Order gives the Local Authority the legal power to monitor the child’s needs and progress. The Local Authority has the responsibility to “advise, assist and befriend” the child. In practice this means the Local Authority gives help and support to the family as a whole. The person with authority for the child, such as the Special Guardian, is required to give details of the child’s address and allow the Local Authority social worker reasonable contact with the child. In this case, it would have given the Local Authority more formal authority to pursue the Child in Need plan for a specified period. 7.24 There was little post-placement support, either from universal services (health visiting) or specialist services either through a CIN plan or an SG support plan, but Lilly appears to have settled well and happily into the special guardian’s family. The nursery she attended from April 2017 described her as a happy, well cared for child who was meeting all her milestones. 7.25 The convicted perpetrator was the father of the special guardian’s first child, but at the time of the SG assessment she told the assessor that she had not had contact with him since she became pregnant, and he had had no contact with this child, at the time of the SG assessment. 7.26 He had a long history of mental health problems and struggled to find a consistent service. At one point he was referred for ADHD services but there was a year’s waiting list and in the event he never accessed the service. 7.27 He also had a history of violence: he first became known to West Midlands Police in 1999 as a result of committing offences as a juvenile. Some of these involved assaults committed at school. From 2005 to 2016 he committed a number of domestic abuse offences, including assaults against two previous partners, and family members. He also committed violent offences against members of the public. 7.28 On 24th March 2017 a previous partner dialled 999 and reported to police that he was ‘smashing up’ her house, and that she was outside whilst he was inside with their child. She stated that they had had an argument in relation to contact with their child. This was identified as a domestic abuse incident and graded medium risk by means of the Domestic Abuse Safeguarding Risk Assessment (DASH). 7.29 He was arrested for assault and criminal damage. He was bailed with conditions not to contact this partner or attend her property, and to appear at Birmingham Magistrates Court. 7.30 The report was reviewed by a Public Protection Unit (PPU) officer within Birmingham MASH. It was forwarded for joint screening by the Children’s Advice and Support Service (CASS), with the recommendation that a family assessment was required. 7.31 He appeared before Birmingham Magistrates Court on 3rd July 2017. He was found guilty of battery and criminal damage and sentenced to a 12 month Community Order with two requirements: a Rehabilitation Activity Requirement and Building Better Relationships (BBR), a domestic abuse perpetrators’ group work programme. A restraining order was also issued. 7.32 The Probation Service began to supervise him on the 12th July 2017. He was known to present a “medium” risk to his former partner but the risk to their child was assessed as low. 7.33 He attended as required for the most part. Where he did not, enforcement action was taken in the form of warning letters, in line with Probation’s procedures. 7.34 The BBR programme pre-work was completed as required by the Probation Officer (PO) on 28th July. On 14th August he attended a one day session facilitated by an officer and a peer mentor entitled Transition and Hope where he participated well. On 20th September he was seen by the Programmes Tutor for pre-group session 1 of the BBR. At this meeting he disclosed that he was in a new relationship with a woman who he used to see when he was younger. The record is comprehensive and details that this new partner, who is unnamed, has three young children. At an earlier stage in his order, he signed a statement of understanding which informs participants of BBR that victims will be contacted, that new relationships should be disclosed so that new partners can also be contacted by the Women’s Support Worker (WSW). 7.35 Although this information was recorded, the information was not individually communicated to the Probation Officer, as required by procedures, nor copied in to the WSW, so that information about the risks posed by him was not shared with the special guardian or Children’s Social Care. Had this information been shared with Children’s Social Care it is likely that a Strategy meeting would have been held and a Section 47 investigation undertaken. 7.36 In October 2017 the special guardian expressed concern to the nursery about the number of bruises sustained by Lilly. On 2nd October Lilly was referred by the GP to Birmingham Children’s Hospital (BCH) with unexplained bruising. She was said to have been vomiting the previous day. She was seen by a triage nurse, a junior doctor and a consultant paediatrician. A diagnosis was made of a rash, possibly as a consequence of a virus. The special guardian was requested to return on the following day for a thorough examination of the child and blood tests. Following that visit the consultant paediatrician concluded that there were no safeguarding concerns. 7.37 On 30th October the special guardian told the nursery she had seen new bruises on Lilly on the Saturday. She had not seen the bruises on Friday but had put Lilly to bed as soon as they got home from nursery. The nursery said there had been no incidents on the Friday but agreed to keep a record of marks or bruises on body maps. 7.38 On 14th November the special guardian took Lilly to the GP as she was concerned that she appeared to bruise easily, was bruised in odd places, and did not appear to react to pain. The GP later telephoned the PAIRS advice line (Paediatric Advice and Integrated Referral Service). This service is staffed by consultants. The GP talked to a consultant paediatrician, who noted that no safeguarding concerns had been identified when she was seen at BCH on the 2nd and 3rd October. An “urgent” appointment for 21st November was made. 7.39 On 19th November Lilly was found unresponsive by the special guardian’s partner, the convicted perpetrator, who called an ambulance. On arrival at hospital her condition was found to be critical and despite two emergency brain operations and life support, Lilly died on the evening of 22nd November 2017. 7.40 The Sentencing Remarks of the judge in the trial of the perpetrator makes it clear that the perpetrator was an accomplished liar and manipulator and was persistently able to convince the special guardian that he was not responsible for Lilly’s injuries, despite her concern and possible suspicions. 8 KEY ISSUES 8.1 The quality and robustness of assessments, reports to court, care planning and court decision making processes and the degree to which information about the individual making application for an SGO was evaluated, assessed, challenged and analysed during the proceedings. 8.2 A referral was appropriately made to Children’s Social Care as soon as Lilly was born and a strategy meeting held the following day. A decision was made at that meeting that the case would be dealt with under Section 17 of the Children Act 1989 by Children’s Social Care as single agency. The case was allocated to a social worker in the area safeguarding team and an assessment of Lilly commenced with detailed instructions, including the need to ascertain the mother’s wishes for her child and her capacity to care for Lilly, and a viability assessment of maternal grandmother’s ability to care for Lilly. 8.3 It was appropriate to deal with the case under Section 17 as Lilly was in a place of safety and at the time her mother was not proposing to remove her; however the decision not to undertake a Section 47 investigation meant there was no independent perspective on the care planning that followed. 8.4 When the mother expressed her desire to care for Lilly herself, on 25th February, a Legal Planning Meeting was appropriately held on 1st March, and the Court process was put in train. The assessment of Lilly was completed on 5th April and signed off by the team manager on 10th April, within the required timescales. The assessment summarised Lilly’s family situation well and detailed her health and progress while in hospital though there is no information about her health after discharge. 8.5 There is no reference in the assessment to a possible impact on Lilly’s emotional development of her having been in hospital for the first three weeks of her life. 8.6 The assessment of Lilly was completed to a good standard. The team manager showed a good knowledge of Lilly’s circumstances and the issues, and demonstrated oversight of the work. The plan for Lilly was not finally settled at this time. It was rightly concluded that she needed long term care arrangements settled as soon as possible and the actions required of Lilly’s parents for them to assume care of her were detailed. 8.7 The plan at the conclusion of the assessment, when Lilly was seven weeks old, was that her parents should take steps to demonstrate their capacity to provide her with a safe and secure home. 8.8 This does not seem to have been realistic: Lilly’s mother had said that she wanted Lilly to live with her and visited her in hospital, but she had only attended one planned contact since Lilly’s discharge. Further she had not engaged with drug treatment services or sought help for depression which she said she had experienced for ten years. Lilly’s father was also dependent on drugs. Lilly’s parents continued to live with each other and there was no indication that her mother planned to secure her own home to further her aspiration to care for her daughter. 8.9 While it was right to encourage and support Lilly’s parents to resolve their difficulties and find stability in their lives there was no basis for believing that this could be achieved in timescales compatible with Lilly’s needs. Clear plans for permanent care by others should have been in train at this point. It is probable that had Lilly been in Local Authority care with no prospect of a placement within her family, planning for adoption would have been pursued by this time. 8.10 Enquiries were made with maternal grandmother who was caring for Lilly’s siblings; she offered to care for Lilly also. The team manager instructed that the suitability of this arrangement be assessed. 8.11 On 2nd March, in preparation for Court, the social worker contacted maternal grandmother and told her that the Local Authority intended to initiate care proceedings and asked her if she would be willing to care for Lilly while assessments in relation to her permanent care were completed. Maternal grandmother said she did not want Lilly to be placed in the care of the Local Authority and agreed that she would care for Lilly on an interim basis. This discussion was contrary to the view of the Legal Planning Meeting held the previous day, when the advice was that Lilly be placed in foster care on an Interim Care Order, while assessments of parents and family members were carried out. 8.12 On 7th March the social worker completed the social work evidence template (SWET) for the Court proceedings, including the assessment of Lilly and her needs. The first option was for Lilly to be placed with her parents, the second was for her to be placed with family members and the third was adoption. Factors in favour and against each option were set out. 8.13 The Local Authority’s preferred plan at this stage was for Lilly to be placed in foster care while an updated assessment of her parents and proposed family members took place. Placement with members of the extended family was not recommended in advance of assessments being completed. 8.14 At the first court hearing on 14th March both the mother and maternal grandmother opposed the plan to place Lilly in Local Authority care. The Court directed the Local Authority to consider further the SGO assessment of maternal grandmother which had been completed the previous year when she was awarded care of Lilly’s siblings. 8.15 The Cafcass Children’s Guardian was appointed at this hearing. She had read the key papers and was aware that Children’s Services were seeking an Interim Care Order (ICO) and planned to place Lilly in Local Authority foster care. She met the mother, maternal grandmother and special guardian at the first hearing. Maternal grandmother and special guardian told the Court that the family had met and believed that Lilly should remain in the family and that the special guardian would be best placed to care for her. However, she had not been assessed. The Cafcass Children’s Guardian’s view was that Lilly should be placed on an ICO with maternal grandmother as a Connected Person’s foster carer. 8.16 The Local Authority’s policy was that a Connected Person required a full assessment before a child was placed with them as it was difficult to remove a child from the care of a relative even if the assessment was negative. 8.17 The social worker visited maternal grandmother in the evening of the first Court hearing and made a good range of enquiries and observations, talking to Lilly’s two siblings and seeing school attendance certificates. Maternal grandmother said she routinely provided day care for two other children. There were no immediate safeguarding concerns for Lilly in the care of her maternal grandmother but there remained questions about the contact she had with Lilly’s mother and what support she needed and would have from other family members while caring for three children. 8.18 A CAO with an Interim Supervision Order (ISO) was made to maternal grandmother. The Local Authority did not oppose the CAO although it was not their preferred plan for Lilly. An ICO would have given Parental Responsibility to the Local Authority whereas the CAO and ISO allowed the family to decide between themselves the arrangements for Lilly’s care. 8.19 The social worker completed viability assessments of maternal grandmother and of the special guardian and filed these in Court as directed on 29th March 2016. A full assessment of maternal grandmother as a Special Guardian to Lilly was not recommended. The assessment was good and balanced with strong analysis of the strengths and vulnerabilities of this care arrangement in the long term. Had this been available for the first Court hearing it would have given strength to the Local Authority view that an ICO and placement with Local Authority foster carers while assessments were completed was the best plan for Lilly’s long-term care. 8.20 The viability assessment of the special guardian was positive and led to a full SG assessment by an SG assessor. 8.21 The Cafcass Children’s Guardian also assessed the needs of Lilly, her mother’s ability to care for her and met with and observed maternal grandmother’s and special guardian’s care of Lilly. By the end of April she was aware that the special guardian was already probably Lilly’s primary carer. As Lilly was placed with maternal grandmother on a CAO this was a decision that maternal grandmother was able to make, though it is not clear that the Local Authority was aware that the balance of care had moved to the special guardian. 8.22 A positive assessment of the special guardian for Lilly was received and placed before the Court on 14th July 2016. The assessment did identify some vulnerabilities, and the Cafcass Children’s Guardian explored these further with the special guardian on two further visits. 8.23 The assessment was as thorough as it could be, within the time constraints set by the Court timescale (see Paragraph 9.7). The assessment was completed using the Connected Persons Form C assessment framework which requires checks and references in line with fostering regulations. There were six interviews at the special guardian’s home, three interviews with personal referees, a health assessment, seen and signed off by the agency medical adviser, and other agency checks. The assessor spoke to each of the applicant’s children and observed them with Lilly. The assessor felt that the applicant was quite open, and that she had got to know her well in the course of the assessment. 8.24 There were significant positives in the assessment: • The applicant had received counselling following a difficult childhood which she said had involved abuse, and a period of alienation from her mother. Counselling had enabled her to rebuild her relationship with her mother; • Although she left school early she had studied as an adult and was waiting to take up a university place; • The care of her children was observed to be of a high standard and the schools the children attended spoke highly of her as a parent. • She had protected herself and her children when a partner became violent. 8.25 However, there were areas of the assessment which could have been explored in more detail: • A decision was made not to interview any of her former partners. It was only thought to have been feasible to interview the second partner, who had been violent, and permission was given by a senior manager that this was not necessary. In fact, there seems to have been no reason why this former partner, who was the father of the eldest child and the subsequently convicted perpetrator, should not have been seen, although the relationship was thought to have finished some ten years before. • There was no real exploration of the applicant’s relationship history, and a lack of professional curiosity about the links between her childhood and adolescent difficulties and her apparent difficulty in sustaining a long term relationship. • There was a failure to explore the extended family dynamics in which Lilly’s mother, maternal grandmother, the applicant and Lilly lived and which would impact on Lilly’s life as she grew up. There was little discussion on how contact by Lilly’s mother might be managed. • It was known that the applicant’s mother, who lived nearby and was the special guardian’s main source of support, had a child with difficulties for whom she was caring, and there was no discussion about the limits on the support she could provide, nor the amount of support which the applicant provided to her mother. 8.26 A fuller assessment would probably have precluded her approval as a foster carer or adopter (see paragraph 29.1). Nevertheless, she was a close relation of Lilly, was the choice of Lilly’s mother and maternal grandmother and would ensure that Lilly grew up within her own extended family and culture. 8.27 The initial assessment of maternal grandmother and special guardian, followed by the SG assessment, met the court timescales for completion within 26 weeks, but gave no time for reflection or monitoring of the placement prior to a final decision. 9 The quality of post court decision making, support and oversight processes put in place to support and monitor the SGO placement. 9.1 The post court support and oversight processes were based on the care planning processes described in detail in the previous section. The CIN planning process and the SGO Support Plan were the two mechanisms in place at the time the SGO was made and these were intended to continue for at least three months after the making of the Order. 9.2 The first CIN meeting was held in late April, when Lilly’s mother, special guardian, the health visitor and social worker were present and the plan clarified the detail of where Lilly would live and who would care for her in the long term. An ISO was in place alongside the CAO from the point of Lilly’s placement with maternal grandmother until the SGO was made. Social workers were unclear about their separate responsibilities within this role and the ISO plan used the framework for an Interim Care Plan. However the role was carried out within the CIN plan, which itself was part of the care planning process, and seen by Children’s Social Care as driven by the Court processes. 9.3 The original team and social worker changed after the first CIN meeting and some of the care planning impetus was lost, as is often the case. The next CIN meeting is recorded as having taken place on 30th June, although there is no detail available about this meeting, and it would seem the health visitor was not invited. The meeting was, therefore, just the social worker and the family. The social worker and her manager have said that the care planning was driven by the Court processes. 9.4 The SG Support Plan, about which the Cafcass Children’s Guardian had some concerns, was made more robust prior to the final hearing. The CIN plan was intended to be in place for three months post order and would focus on the needs of the child. The SG Support Plan would be in place for six months post order. It relied upon the special guardian taking up the offer of support, which she did not do. 9.5 There is no provision for formal oversight of children placed through SGOs, although many Local Authorities provide training and regular support to SGs, subject to their accessing it. 9.6 However, on 19 May 2016 Mr Justice Keenan, Family Division Lead Judge for the Midland Circuit circulated a letter by e-mail to Directors of Children’s Services. Following this on 19 July 2016 he held a meeting with the Chairs of the Local Family Justice Boards and in August circulated a further, clarifying letter to Directors of Children’s Services. The letters are both wide ranging but SGOs feature prominently in both and he stated: “It is imperative that these are considered to be at the adoption end of the spectrum and not, as I fear they are now, at the CAO end of the spectrum… A SGO should not be made, absent compelling and cogent reasons, until the child has lived for an appreciable period with the prospective special guardians.” 9.7 Compliance with this would have required time to embed and it does not appear to have been considered at the conclusion of proceedings for Lilly. The Local Authority was required to commit to a plan within a month of placement (because of the legal requirement to conclude care proceedings within twenty-six weeks) and in the SGO support plan the Local Authority was offering three months’ support of Lilly through a CIN plan, to be extended if required or requested. 9.8 Following Mr Justice Keenan’s letter, in Birmingham it has been the expectation that, following a positive assessment of a prospective SG for a child who is the subject of an ICO, the Local Authority will approve the carer as a Connected Person foster carer and the child will be made the subject of a Care Order for a trial placement of around twelve months. If this is successful, the matter will be returned to Court for revocation of the Care Order and the making of a SGO. By the time the meeting with the local Family Justice Board Chair’s and clarifying advice was circulated (August 2016) Lilly was already placed with the special guardian. 9.9 However there remains no agreed route to a trial period with a prospective SG when the child has been the subject of a CAO during care proceedings. 9.10 Lilly was placed with the special guardian in July, shortly before the school holidays. At the time she was the subject of a CAO to the special guardian and an ISO. The SG assessment was complete, and although Lilly would have been seen at Court hearings on 14th July and 5th September (final hearing) there is no evidence of visits by the social worker until 7th September. 9.11 It would seem that the Cafcass Children’s Guardian visited and saw Lilly with the special guardian on 6th July, 12th July and 26th August, although no record of these visits are available, the information gathered having been used for the Guardian’s final report to the Court. 9.12 The support plan for Lilly was that the social worker would continue to visit monthly after the Order was made, and hold regular CIN meetings. A CIN plan is intended to offer support to enable a parent or carer to best meet the child’s needs. Its success depends on the engagement of the carer. At the same time a SG Support Team worker would be allocated, who would offer support to the special guardian and her needs. 9.13 Although supervision of the social worker in January 2017 noted that “visits taking place; Lilly doing well; special guardian engaged” there is no actual record of any visits or of any CIN meetings after the SGO was made. No health visitor was involved in any meetings after April. The case was closed on 22nd March 2017. In other words there is no firm evidence of any visits after the 20th October from Children’s Social Care. There was contact recorded from the social worker by email and telephone about the larger car which the special guardian wished to purchase to transport her now larger family, and the financial support she sought from Children’s Services. 9.14 A SG Team support worker was allocated on 18th November 2016. The worker contacted the social worker on the 30th November for advice about specific support for the special guardian. The case was closed by this team on 7th December as there was no response by the special guardian to telephone calls and offers of help. 9.15 Both the case holding team and the SG Support Team should have been monitoring whether support was taken up. The lack of recorded visits and meetings should have been picked up by data monitoring and highlighted to managers. Had CIN meetings, home visits, support visits taken place practitioners might have had a proper sense of what life was like for Lilly within this family. 10 The degree to which universal services were engaged in providing ongoing monitoring of the placement and whether they demonstrated appropriate rigour and professional curiosity about the nature of the household. 10.1 In terms of health visiting services, as a child subject to an SGO, Lilly should have received additional monitoring and support. In fact, the health visitor from maternal grandmother’s local clinic, who had been part of the original CIN, contacted the social worker on 26th July to be told that Lilly had moved to the special guardian and had a new social worker. On 13th September Lilly was taken to the special guardian’s local Well Baby clinic for the first time. At this time Lilly was not identified as a child new to the caseload and no assessment of her needs took place during her placement with the special guardian. This was the last recorded contact with Lilly by the health visiting service. 10.2 The Community Child Health Services (health visiting) was aware that Lilly was subject to an SGO, and that her neonatal health was seriously compromised: this information was held within the system. There was poor communication to this service by Children’s Social Care but in fact the information was already with the service. Not only did the service not offer any monitoring or oversight of the placement, there was no enhanced service to a child with potential additional health and social needs, information that was available from the safeguarding nurse in the original MASH meeting. It is not clear whether there was any routine referral from Heartlands Hospital to Community Child Health Services when Lilly was discharged from hospital, although there appears to be a system for this. 11 Whether any concerns or indicators of concern were raised, identified or, with hindsight, missed in relation to the SG’s care of Lilly following the placement, up to and including her death, by any agency, universal or specialist in contact with the family in which she was living. 11.1 As can be seen above there was little contact by Children’s Social Care or health visiting services with the special guardian or Lilly after the SGO was made, and none during 2017. However, Lilly attended a nursery on a daily basis during term time from March 2017. She was also seen seven times at the GP surgery, and three times at the Emergency Department of Birmingham Children’s Hospital. 11.2 Bruises and other injuries were brought by the special guardian to the attention of professionals on several occasions, including at the ED: she presented as a worried parent. It is possible that she was suspicious of her partner and hoping for confirmation or reassurance. It is also possible that she was concerned that there was a medical cause for the bruising. 11.3 Disguised compliance is the term used to describe a carer giving the appearance of cooperating with services, while in fact failing to do so. Disguised reporting, where a carer reports injuries as of unknown origin when in fact they are aware of how they happened, could have been a feature in this case. 12 Nursery 12.1 On 28th April the nursery recorded an injury to Lilly at the nursery; up to 23rd October there were 13 reports of minor injuries sustained at the nursery. 12.2 On 2nd October 2017 there was a conversation with the special guardian about bruises observed by her on Lilly: bruising on her back possibly caused by lying on her jumper; bruises in her ears from a hard building block. She told the nursery she was taking Lilly to the GP. 12.3 On 30th October, a Monday, there was a telephone conversation with the special guardian about new bruises she had noticed on Saturday, having put Lilly straight to bed on the Friday after nursery: bruises on the ears and under her chin. The nursery officer said there had been no incidents on the Friday but agreed to keep a record of marks or bruises on body maps. They reassured the special guardian and accepted her explanations. Later that day a bruise was noticed on Lilly’s bottom when her nappy was changed. 12.4 A bruise was noted on the back of her head on 31st October. 12.5 On 1st November there was a meeting with the special guardian at the nursery. She described Lilly’s early history and stated that she had been seen at the BCH. The nursery was told that blood tests were normal. The special guardian queried whether Lilly felt pain. The nursery agreed to complete the first of 10 body maps on Lilly. This one showed 16 marks including the bruising on her back and the bruise on the back of her head. 12.6 There is no evidence of challenge to the special guardian’s narrative or explanations. For example, the nursery was aware that Lilly did in fact feel pain when she hurt herself at nursery. The nursery held no discussion with the Children’s Advisory and Support Service (CASS) for advice, as they took the special guardian’s words at face value. The Information Report identifies a lack of professional curiosity in the nursery. 13 GPs 13.1 Lilly had been in receipt of a Birmingham Primary Care Medical Service from August 2016, following her placement with the special guardian until her death. Staff at the medical centre were aware that Lilly was cared for firstly by her maternal grandmother and then by her relative, the special guardian. They received the Court documents and this was indicated within the medical record. 13.2 Lilly was seen in person at the surgery 7 times in the course of her life. This was for gastro-enteritis (August 2016); an upper respiratory tract infection (November 2016, twice); vaccinations (April 2017); chickenpox (May 2017); bruising and blanching spots (2nd October 2017); and further “easy bruising” (14th November 2017). 13.3 There were two key episodes in which Lilly was in contact with the GP service. The first of these was on the 2nd October 2017 when Lilly was brought to the surgery by the special guardian with non-specific blanching2 spots on either side of her back and bruising on the inner ear. The GP noted a recent viral infection and made an urgent referral, with a letter, to A&E at BCH for further investigations, including blood tests. The letter included a query about child protection, and the GP told the special guardian that safeguarding issues might be raised. He telephoned BCH to inform them that the child was 2 Blanching means that when a spot or mark is pressed it disappears. Eg, The “glass test” used to check for the rash seen in meningitis. It is usually reassuring if the rash disappears. coming, and he later telephoned the special guardian to ensure that she had attended. When he learned that no blood tests had been undertaken he arranged for these to be done as an outpatient. 13.4 Nevertheless the GP did not seek advice from the safeguarding lead within the practice and nor did he make a referral to Children’s Social Care. He thought that safeguarding issues would be addressed at BCH, and in any case he was aware that the symptoms could have a medical cause. 13.5 Later on the 2nd October the special guardian telephoned the GP and told him she had been recalled to the hospital the following day. On 3rd October there was a further telephone contact between a locum consultant paediatrician at BCH and the surgery, stating that the paediatrician had done the blood test and that he had no safeguarding concerns. This was confirmed in a letter dictated by the consultant the following day. 13.6 The second key episode is 14th November. The special guardian telephoned the surgery on 1st November with continuing concern about Lilly’s “easy bruising”. The (different) GP reviewed the notes and asked for Lilly to be seen by the health visitor (this did not happen) and herself on the 14th November. 13.7 The GP took a very thorough history and sought advice by calling the advice line at BCH PAIRS (see paragraph 7.38) and discussed concerns regarding unexplained bruising and apparent presentation of Lilly being unable to feel pain. The consultant arranged an appointment for the following week. 13.8 In both cases there were sufficient clinical grounds for the GP to take prompt action to arrange urgent paediatric medical opinion, and both GPs did this. However the simultaneous need for effective safeguarding was not fully recognised or acted upon. This was partly because the first GP was working under out-dated safeguarding procedures and assumed the hospital would explore safeguarding issues, and the second GP was reassured by the opinion of the BCH Consultant that there were no safeguarding concerns. 14 Birmingham Children’s Hospital 14.1 Following the referral by the GP Lilly was seen at the Clinical Decision Unit on the 2nd October. She presented as unwell and vomiting and the referral was for unexplained bruising to her left ear and back. She was seen by the triage nurse, who noted the bruising and classified her as low priority. She was then seen by a junior doctor who assessed the marks as “non-blanching rash”. She was then seen by a consultant paediatrician who made a diagnosis of “multiple petechial3 rash/viral illness”, and discharged her. His notes document that he did consider non-accidental injury in respect of the marks but made a final diagnosis of rash. He later contacted the special guardian and asked her to return with Lilly the following day. 3 Petechiae are pin prick sized bruises. 14.2 The consultant paediatrician did not contact the safeguarding team at the hospital, but on the 3rd October undertook a very thorough examination of Lilly, with a chaperone present. He said this was as thorough as a safeguarding examination would have been, and was undertaken to ensure that there were no safeguarding concerns. He also arranged for blood tests to be taken. 14.3 It is unusual to call a child back in this way and suggests that the consultant paediatrician may have been uneasy about the case. At the professionals’ meeting he was unclear why he had recalled her. He agreed it was a missed opportunity to have a discussion with the BCH Child Protection Team but felt that his own examination on 3rd October was the “equivalent of a child protection medical”. He recorded “no safeguarding concerns” both in the medical notes and in the letter sent to the GP. These notes were used when the GP contacted the on-call paediatrician through PAIRS. 14.4 The safeguarding lead at BCH has clarified that there would have been an expectation to discuss the child with the safeguarding team if she were being recalled for an examination. They emphasised the need to be clear, when bringing a child back, whether this is a child protection medical or not. In this instance the consultant paediatrician had not undertaken lateral checks and had deviated from the established process. 15 The operational, organisational and strategic context within which multi-agency children’s safeguarding activity (including the court service) was taking place at the time of the court case and the degree to which this context affected front-line practice and decision-making. 15.1 Children’s Social Care 15.2 The two teams who had responsibility for Lilly were both fully staffed and stable (and continue to be). All workers with responsibility for Lilly had been in post for at least nine months at the time. 15.3 There had been some changes in the remit of the children’s teams responsible for Lilly and workloads were high: all staff members were working to capacity. In terms of Lilly’s second social worker she reported a workload which was not unmanageable but which required prioritisation decisions – and given that she had not been involved in the original decision making for Lilly, and that case planning was seen to be driven by the Court, inevitably Lilly’s case was perhaps seen as lower priority. All staff interviewed said that workloads have now reduced and are more manageable. 15.4 Processes within Children’s Social Care meant that Lilly had a change of social worker following the original CIN meeting in April 2016. The original social worker knew all the key players in the case and there was a lack of impetus following that case transfer, especially given the high case load of the second social worker and the view that the plan was in place and driven by the court. 15.5 All social workers said that their managers were available, supportive and gave effective supervision, though for Lilly’s second social worker this frequently had to be cancelled due to other work demands. In fact, it is hard to agree that supervision was effective if it was frequently cancelled, and there is no recorded evidence that supervision was checking that the plan was being followed, nor of reflective and analytical discussion. Pressures have apparently abated and monthly supervision is now in place. 15.6 The Ofsted report on Birmingham (October 2016, i.e. immediately following Lilly’s SGO) followed soon after the SCR on a Birmingham child subject to an SGO. The report stated “The Local Authority has taken robust action to ensure, following a recent child death, that the circumstances of children subject to a special guardianship order (SGO) have been reviewed to ensure their welfare. Current assessments to place young people under SGOs with carers are now of satisfactory quality." 15.7 "The Local Authority took practical and decisive action to review and improve the welfare of children living with special guardians and connected persons following the death of a child in 2015. Detailed reviews of children who were subject to proceedings for special guardianship orders, and those who had been placed with special guardians over the preceding two years, were undertaken. Appropriate follow-up action was taken when relevant to promote individual children’s welfare. The Local Authority has added substantial resources to develop the assessment and support service for SGOs and connected persons to ensure that these placements are timely, safe and supported for children. SGO and connected persons assessments are now of a good quality. Furthermore, the Local Authority is in the process of identifying and contacting all special guardians to explain its offer of support." In relation to this case, this assessment by Ofsted may well have been accurate, but any review did not throw up concerns. 15.8 These changes were underway at the time of Lilly’s placement and the assessment of the special guardian. Further changes were taking place in line with the letters from Mr Justice Keenan referred to in paragraph 9.6 but were not embedded at the time decisions for Lilly were taking place. Post SGO support (referred to in the Ofsted report) was only implemented in April 2016 so was at an early stage when this SGO was made. And indeed, planning for Lilly was made more difficult for the Local Authority given her legal status which effectively gave control to the family. 15.9 Birmingham Children’s Services was assessed as inadequate by Ofsted in October 2016 and it is therefore likely to have been the case that advice and guidance were slow to be picked up and acted upon. Nevertheless, in a well-functioning Local Authority there would be an expectation that a director receiving such a strongly worded communication from Mr Justice Keenan, would immediately ask staff to identify what SGOs were ongoing and seek reassurance that each child had been placed with their carers for long enough to assess. 15.10 In fact, following the death of a young child subject to an SGO in 2015, Children’s Services had reviewed all children subject to SGOs and those in proceedings, and had developed assessment processes and post-order services which were significantly better than many other authorities. 15.11 Within Children’s Services it is clear that there was a lack of clarity between the roles of the child’s social worker and the SG Support Team. 16. Cafcass 16.1 Both the Cafcass Children’s Guardian and her manager had been in their posts for over ten years: this suggests a stable team and service, although at the time the team manager had no practice supervisors to support her, unlike other areas in the organisation, which meant that her time was stretched for supervision. 16.2 There was a failure by the Cafcass worker to record her visits to Lilly and the special guardian, merely including them in her assessment. This does not seem to have been picked up in supervision, nor by any practice-monitoring system. 16.3 There was an issue around Birmingham failing to give prior warning to Cafcass of pending applications, which made work difficult to plan. 16.4 There is some evidence in the Information Report of a lack of dialogue and understanding between Birmingham Children’s Services and Cafcass about Birmingham’s policies and procedures. For example, Birmingham did not approve family carers as Connected Persons foster carers prior to a detailed assessment, in line with the Fostering Regulations 2015; in some Local Authorities children could be placed with relatives approved as Connected Persons foster carers while subject to an ICO. Cafcass felt this arrangement worked well for children; the view of Birmingham was that this often pre-empted a poor assessment. 17. Court service 17.1 The legal proceedings regarding the care of Lilly took place before magistrates: a Family Court Judge might have had a more robust approach to the SGO, in line with the advice of Mr Justice Keenan. 17.2 Court timescales meant that the viability assessments of maternal grandmother and the special guardian, as well as the full assessment of the special guardian had to be completed within 26 weeks, giving no time to monitor and assess the special guardian’s care of Lilly in the longer term. The DfE Special Guardianship Review (Dec 2015) identified a national issue about assessments being carried out “very quickly to meet court timelines”. 18. Community Health Care: Health Visiting Service 18.1 Because the electronic birth notification records recorded Lilly’s address as that of her mother at the time of her birth, the notification was forwarded to the Health Visiting Team based on her postcode. Subsequently there was a failure to notify the local health visiting service for maternal grandmother when Lilly was discharged to her care under a new health visiting team. 18.2 The Rio electronic patient system was new in January 2016, and staff took time to receive training on its use, and to become familiar with it. 18.3 The health visiting service was engaged with Lilly when she was placed with maternal grandmother as she attended the Well Baby clinic for Lilly to be weighed, and a health visitor attended the first CIN meeting. However, she was not told of the following CIN meeting, and when she pursued this, she found that the case had been transferred to a different social worker and team and that Lilly was now placed with the special guardian within a different health visiting area. 18.4 Lilly was taken by the special guardian to her local Well Baby clinic on 13th September 2016 soon after the making of the SGO. However, she was not identified as a child new to the area and therefore the Rio system did not generate triggers for normal checks. 18.5 The health visiting service for the special guardian moved their office base in September 2016, around the time that the SGO was made. This required the transfer of all paper records to the new base. It also detached the health visiting team from the GPs at the Medical Centre, meaning there was little face to face contact and informal exchange of information. It was also probably the reason why Lilly was not seen as requested by the GP prior to her appointment on the 14th November. Regular meetings are now taking place between the GPs and health visitors and these are audited. 18.6 A change in bordering arrangements at this time resulted in the relevant health visiting service receiving over 1000 records from a bordering team, with a requirement to contact all the families being transferred. There was significant sickness within the team and the senior nurse had left. No additional staff resources were available to support the team. There is no doubt that this affected the service provided to Lilly and the special guardian. 19. Birmingham South and Central CCG: GPs 19.1 GPs who have been in practice for many years may still be practicing according to the way they had previously been trained. Level 2 training includes the need for children with suspicious bruising to be referred to social care. All GPs have to be trained to level 3 in safeguarding. The report from the CCG states that level 3 safeguarding training covers a huge amount of material and it is hard to remain up to date with each area. In addition, training has not previously covered some of these areas in detail such as how to risk assess and manage a child with bruising in the surgery. There is no local brief guidance for GPs to help them make decisions regarding a bruised child within the time pressure that they face. 19.2 All GPs who saw Lilly were up to date with CP training. However, the reality is that bruising can be presented in a complex context that is not dealt with in the training. It can be tricky to know whether to refer a child for medical investigations first in order to rule out medical causes of bruises or other symptoms, before referring to social care; or to do things in reverse order, or simultaneously. The previous practice was to refer to the hospital where a paediatrician would be better placed to make the differential diagnosis. 19.3 This GP was weighing up upsetting a family already anxious about their child’s symptoms by referring them to social care, versus getting a medical opinion but missing an opportunity to safeguard a child. A telephone call to CASS for discussion is possible within working hours and could have been made when Lilly was seen on 2nd October. It was not done because the GP did not perceive CASS to be a source of advice or help due to unhelpful historic interactions with social care and its reputation for being slow to respond. There is an expectation that GPs are able to have difficult conversations with patients and parents in an appropriate way. GPs are encouraged to develop positive relationships with CASS and Children’s Services through their safeguarding leads. 19.4 Health visitors are no longer present on site with GPs and have to be contacted by telephone, making it harder for GPs to discuss informal concerns with them rapidly. There is now, since 2018, a duty and advice line available. 19.5 There is another child on the practice list with congenital insensitivity to pain. The existence of this syndrome was in the GP’s mind when assessing Lilly on 14th November and the GP felt it provided a possible explanation for the set of symptoms presented. 20. Birmingham Children’s Hospital 20.1 It is evident from the Information Report that all the doctors working in the Emergency Department at BCH, apart from the on-call consultant, had received Level 3 Child Protection training. This includes the original Consultant Paediatrician and the Junior doctor, both of whom were locums who have since left the hospital. It is reassuring to note that all locum medical staff have the required child protection training. Nevertheless, it is possible that their locum situation meant a lack of familiarity with key processes which were possibly more embedded for permanent staff. 20.2 The expected procedure was that the consultant would consult with the lead safeguarding consultant, and the safeguarding team. This did not happen. 20.2 The Emergency Department at BCH is extremely busy during winter months including October and November 2017. The Emergency Department managers had raised the issue of workload and capacity with the Trust Board. 21. Probation 21.1 The Programmes Tutor in the Probation Service became aware that the convicted perpetrator had a new partner, the special guardian, who had children, in September 2017. Although the information was recorded on the case notes by her, procedures required that she inform the Probation Officer verbally (by telephone or in a face to face meeting) and confirm this information in an email. That email is duplicated by the system and copied to the Woman’s Support Worker (WSW). In this case she did not inform the probation officer or the WSW. 21.2 The probation officer relies on the system working, so although in ideal circumstances, they would read the case notes and hence would have picked up the information and made the relevant referral to the WSW themselves, that did not happen in this instance. The probation officer was responsible for 60 cases at the time, so was unable to prioritise reading all the case notes. 21.3 Had the probation officer and WSW been made aware of the new information the response would have been a referral to the Multi-Agency Safeguarding Hub (MASH) with information on the new partner, the special guardian, and contact by the WSW with the special guardian to make her aware of the identified risks potentially posed to partners and children by the perpetrator. 21.4 The Probation Service guidance and process is clear. From this case, the Service has identified that the process is not sufficiently robust. A review is to be undertaken by the service to determine whether a change to the process is required. 21.5 Indeed, this omission may well have had very serious consequences for Lilly, and may be the single omission that could have made a difference. 22. Whether there are any key national, regional or local policy issues arising from the use of an SGO in the circumstances that need to be addressed. 22.1 The key issues for this case that arise from local and national research, and relevant SCRs (see Appendix 3 for a full analysis) are as follows: • The importance of a close family relationship for the child with the special guardian; • The importance of wider family support for the arrangement; • The management of contact; • The importance of understanding an SGO as at the adoption end of permanence; • The pressure of court timescales. 23. Close family relationship, family support and contact 23.1 It is clear that, in the event of her not being able to care for Lilly herself, the mother favoured her placement with either maternal grandmother or the special guardian. Lilly and the special guardian were related and in many ways the special guardian and Lilly’s mother had grown up as sisters. 23.2 The Court was informed by both the special guardian and maternal grandmother that “the family” wished the special guardian to care for Lilly. There is no evidence of a family meeting or Family Group Conference being held. 23.3 There was no analysis in the assessment of the special guardian that the wider family dynamics were explored, nor that there was a detailed discussion of how contact might be managed, although this was part of the support plan. 24. SGO and adoption 24.1 The statement by Mr Justice Keenan (paragraph 9.6) is very relevant to the issue of the permanence spectrum, placing SGOs firmly at the adoption end. This is particularly relevant because SG applicants have often made their application in a rush faced with a difficult family situation, and subject to emotional pressure from family members. Adopters have generally reflected about their decision for a long period of time before making the decision to apply. They then are subject to an intense period of training and assessment. While SGs are assessed there simply is not sufficient time for the necessary depth of reflection, analysis or training to take place. 25. Court timescales 25.1 A Research in Practice deep dive study for the DfE (2015) identified a number of concerns around the use of SGOs within the context of care proceedings, including challenges in completing assessments within the court’s timeframe and a disconnect between the views of the Local Authority and the court on the most appropriate order for the child. 25.2 As a result the DfE commissioned a qualitative case file study for children who have been the subject of SGOs with a particular emphasis on investigating the impact of the 26 week time limit and court judgments such as Re B-S, the 2013 judgment that adoption without consent was only permissible where “nothing else will do”. This has been interpreted by local authorities (and some courts), as placement within the wider family at all costs. This study looked in depth at 50 SGO cases from 5 Local Authorities and concluded that the timescales for completing assessments of potential SGs are squeezed following the revised PLO and the expectation that cases will be completed within 26 weeks. There was concern about the rigour of assessments and the support provided to SGs in comparison to the assessment processes and support services for adopters and foster carers, whose children may have similar needs. 25.3 There was a perception that, since Re B-S, Courts had lower thresholds for approving SGs, focusing on “good enough” here and now, while local authorities were looking further into the child’s future. There was a level of tension identified between Courts and Local Authorities. Certainly there is evidence in the case of Lilly that the Local Authority wished for Lilly to be placed with foster carers while in depth assessments of maternal grandmother and the special guardian took place but were aware of the Court’s view and succumbed to it without testing it. 25.4 In December 2014 Justice Munby clarified the implications of his Re: B-S judgement: "I wish to emphasise, with as much force as possible, that Re B-S was not intended to change and has not changed the law. Where adoption is in the child’s best interests, Local Authorities must not shy away from seeking, nor Courts from making, care orders with a plan for adoption, placement orders and adoption orders. The fact is that there are occasions when nothing but adoption will do, and it is essential in such cases that a child’s welfare should not be compromised by keeping them within their family at all costs." Re R (A Child) [2014] EWCA Civ 1625 https://www.judiciary.uk/wp-content/uploads/2014/12/re-r-a-child.pdf 26. VIEWS OF PROFESSIONALS 26.1 A workshop was held for professionals and their managers who had been involved in the care of Lilly. There were 22 participants all of whom contributed in a thoughtful manner. The first part of the meeting members worked in small multi-agency groups, considering the key SCR issues. During the second half only those professionals involved in the last two months of Lilly’s life took part and the events of those weeks were analysed together. This conversation is incorporated into the main body of the report. The small group notes can be found in Appendix 1. 26.2 Some significant thoughts from the workshop: • Once the Court made the decision to place Lilly within the family it was difficult to propose an alternative plan, eg. foster care, unless there had been evidence of significant harm. The first order set the agenda; • The Local Authority did not seek a change from magistrates to a designated judge: identified it as a “simple” case; • Robustness of assessments: lack of analysis regarding former partners; lack of information about the mother’s relationships within the family; • The SG Team and support process were new at the time; • Unfortunate that the SGO assessor left after the assessment because she could have provided post SGO support; • Lack of professional curiosity about previous partners, mental health history and family relationships; • Comparison of adoption and SGO assessment and post placement regulation and support. 26.3 Ultimately the consensus was that even if the assessment had been more in depth and explored previous partners, or the health visiting service had identified Lilly as a child with additional support needs, it is likely the court would have made the same order. 27. VIEWS OF FAMILY MEMBERS 27.1 There was a significant delay in meeting with family members because the police investigation was very complex requiring specialist advice which was in short supply and hard to access. The whole investigation and court process took nearly 4 years. 27.2 Once the police investigation and court case were complete the reviewer and a Review Team Member met with the mother and her mother, the maternal grandmother, and later, the special guardian. 27.3 There was no attempt to make contact with the father of Lilly, since there was no evidence from any of the reports that he had been involved in planning for Lilly’s care, or in her life. 27.4 The meetings with family members took place nearly 4 years after Lilly’s death. The body of this report was written early in 2018, soon after Lilly’s death, and uses contemporaneous records. The mother and maternal grandmother 27.5 The mother told us that she is now off drugs and no longer with Lilly’s father. She stopped using drugs after the death of Lilly, and has been rebuilding her life and her relationship with her children. She told us that she believes that she could have cared for Lilly from when she was born, but even if she was not able to, her mother could have cared for Lilly. That was what she wanted at the time. She never wanted the special guardian to care for Lilly. 27.6 She believes that the assessment of the special guardian was inadequate because the family knew that although the special guardian was a good mother, she always got involved with violent men and when she had a boyfriend, she could only focus on him. 27.7 The mother told us that “Social Services” (CSC) lied when they said that she had failed to sustain contact with Lilly during the time of the Court hearing. 27.8 Her mother, maternal grandmother, agreed with her daughter that she should have been allowed to care for Lilly. They both blame CSC for the death of Lilly. The decision not to allow either the mother or maternal grandmother to have the long-term care of Lilly they believe came from CSC. Had she been placed with maternal grandmother she would still be alive today. 27.9 They also believe that CSC should have continued to monitor and supervise the care of Lilly while she was with the special guardian. In fact, they wish to make a national recommendation, to form part of the outcome of this review, that all children subject to an SGO should be monitored and supervised for at least 3 years post the Order. 27.10 Both the mother and maternal grandmother are grief stricken. Although a Family Liaison Officer (FLO) has supported them since Lilly’s death, they do not feel that they have had adequate support. Mother’s other children, who are cared for by maternal grandmother under SGOs, have been very distressed by the death of their sister. The elder child suffers with anxiety as a result and this has been made worse by the pandemic. This child has not had adequate help. 27.11 As a result of our meeting, the FLO contacted the mother about financial support for the funeral and other issues. 27.12 The whole family has been torn apart by the death of Lilly, and the prolonged police investigation and court processes. The special guardian’s children are in foster carer, subject to Care Orders and as yet, maternal grandmother has been unable to have direct contact with them. The mother and maternal grandmother have had no contact with the special guardian since Lilly’s death. 27.13 Both the mother and grandmother requested that when the SCR is published that Lilly’s name be retained within the report and a pseudonym not used. The special guardian 27.14 The special guardian wept throughout our meeting. She told us that she blames herself completely for the death of Lilly: that she should have been more suspicious of her then partner, should not have taken his word, should not have allowed him to babysit for Lilly, should have seen the pattern in the bruises. 27.15 At the time she thought the bruises were the result of Lilly’s early addiction to heroin, and had expected that someone would explain to her what the health implications were of that. 27.16 She blames “Social Services” (CSC) for Lilly’s death because of her lack of support from them. She told us she had had no support from CSC, despite being told there would be courses – First Aid for example – available to her. She did not refuse help, was not out for visits or appointments, as claimed by the Special Guardianship Support Team. 27.17 She believes CSC should have kept in touch, should have monitored the care of Lilly. In fact, like the mother and maternal grandmother, she believes that supervision of SGOs should be made mandatory. 27.18 She also blames the police for not informing her about her then partners convictions. In fact, Probation (see Section 21) had a duty to inform her. She said, that had she known, she would have immediately taken steps to distance herself from him. 27.19 She blames all the other agencies – nursery, GPs, hospital – for failing to ask safeguarding questions. She had expected them, but none came. 27.20 The special guardian has been unable to return to University since Lilly’s death. She has also been unable to access her house, which was viewed as a crime scene. Her children are in care and she has been staying with friends and family. 27.21 Because she was seen as “person of interest” she did not receive any support from the Police Family Liaison Team or Victim Support. 27.22 As a result of our meeting the special guardian’s house and property have been returned to her. 27.23 The above views of family members do not represent the findings of this SCR. 27.24 This recommendation was requested by the family: In line with current Government Regulations, there was no on-going monitoring of the care of Lilly once she ceased to be a Child in Need. The Government should consider requiring local authorities to monitor the care of a child subject to an SGO for three years after the making of an Order, in line with Regulation 3 of the 2017 Special Guardianship Guidance, which requires local authorities to provide support services to special guardians. 28. ANALYSIS AND CONCLUSIONS 28.1 Care planning and assessment • The Local Authority could have sought a referral of the case to the oversight of a District Judge, rather than a Lay Bench, or the Gatekeeping Judge could have made this decision. • The SGO assessment of the special guardian could have considered her mental health history in more detail and made enquiries of previous partners. It could also have explored the family dynamics more closely. There could have been more challenge, both by the assessor and the Cafcass Children’s Guardian. Nevertheless the assessment was thorough, and even if more time had been spent and these matters considered it is unlikely that the Court would not have made the order. • The Court could have reflected on the letter from Mr Justice Keenan before it made the decision to direct the Local Authority to re-consider placement with the maternal grandmother. • Family Court Advisers (Cafcass) need to ensure better understanding of the new Fostering Regulations 2015 as they relate to Connected Persons. • Had a Supervision Order been in place there would have been a requirement for the special guardian to inform the Local Authority about her new partner. Good practice • The social work evidence template, with an assessment of Lilly’s needs, the options available for her care, and the factors in favour of and opposed to each option, was thorough and well evidenced, and necessarily completed expeditiously. • The SG assessment of the special guardian had to be completed in a very short time because of court timescales. Nevertheless, within those constraints, it was extremely thorough and thoughtful. 28.2 Post placement support and universal services • There was a systemic failure to ensure that Lilly was integrated into community health services, specifically health visiting, and to ensure that she was identified as a child with a challenging neo-natal history, cared for within an SGO, and therefore entitled to Universal Plus services. • Support through the SGO Support Plan and the CIN plan was totally inadequate, despite a new SGO Support Team being in place and Cafcass insisting on a more rigorous support plan before the SGO was made. • The nursery, which had most contact with Lilly on a day to day basis, failed to demonstrate professional detachment, curiosity and challenge, especially when injuries were brought to their attention. 28.3. Indicators of concern • The special guardian herself was concerned about the bruises seen on Lilly and brought them to the notice of professionals on a number of occasions, and indeed the GPs and the hospital paediatrician investigated these concerns. • There were no indicators of concern seen about the special guardian’s lifestyle or behaviour during her care of Lilly. It is possible that the consultant paediatrician when he recalled her to the BCH, and the GPs when they followed up Lilly’s visits to the surgery were perplexed by the injuries, or perhaps they were reacting to some unusual cues from the special guardian’s behaviour but those who attended the professionals’ meeting could not think what they might be. It might be that they were aware of disguised reporting (see paragraph 11.3). Nevertheless, it might be that the special guardian was concerned about her partner’s care of Lilly and was hoping that other professionals would pursue investigations. • None of the services in touch with the special guardian during the period of bruising: the nursery, GPs, the hospital – asked safeguarding questions. This was contrary to the guidance for all those agencies. • The Probation Service was concerned about the perpetrator’s involvement with a partner with children. There was a serious error of communication which resulted in the special guardian not being made aware of his history of violence towards partners, and Children’s Social Care not being made aware of this relationship, which would certainly have resulted in a Strategy discussion had it been known. 28.4 However • All the evidence suggested that the special guardian had used counselling appropriately to move on from a difficult past. She had returned to education and had begun a university degree. She was demonstrably a good and protective mother to her own children. Given Lilly’s mother’s wish that she should care for Lilly and the Court’s view, post Re B-S, it is unlikely that any court would have made a different decision. • It is evident that systems have been tightened in Community Health and that the SGO Team and advice from Mr Justice Keenan are now embedded in Children’s Social Care procedures. Recommendations in the Information Reports from agencies are all relevant and address issues of omission and commission in the relevant services. • There are national issues which need to be taken forward and these are reflected in the Learning Points from this report. 29. FINALLY 29.1 Had the special guardian applied to be an adopter or foster carer for Lilly, it is likely that her application would have been refused. Her vulnerabilities would have been explored in more depth and her position as a single mother of three young children, with no support from any of the fathers, would have precluded her at an early stage. 29.2 She did however, have a relationship with Lilly from soon after her birth and she was the choice of the mother and the wider family to care for Lilly. Her assessment was as thorough as it could have been given the demands of Court timescales, and there was no evidence to suggest that there would be a tragic outcome of the placement. 29.3 Support was not provided by the SGO Support Team within Children’s Social Care because the special guardian failed to take up the offer: this could have raised alarm bells or led to more robust action. Support could have been offered at a later date, perhaps on a regular basis. 29.4 The GPs, hospital doctors and nursery staff were all aware that Lilly had sustained bruises on several occasions and none of them sought safeguarding advice from CASS or from their own safeguarding teams as directed in their own procedures. 29.5 The Probation Service failed to follow their own procedures when they became aware that convicted perpetrator had developed a relationship with a woman with children. Had they done so, Children’s Social Care would have been alerted and safeguarding processes put in place. 30. LEARNING POINTS 30.1 Enough time should always be given to assess the integration of a child placed within a family, the care of that child and the impact on all members of the family, before a final SGO is made, including consideration of wider family dynamics and the impact of an additional child on children within the household. In this case, the making of an Interim Care Order, followed by a Connected Person fostering assessment prior to the making of an SGO, would have provided sufficient time to make a fully informed assessment. 30.2 In this case, the post placement support network was not clear, and a multi-agency pathway, with a named lead agency, and clear expectations of each agency, would have been helpful. 30.3 There appears to have been a negative impact on service provision during a period of organisational changes in the Health Visiting service, coupled with high levels of sickness. This resulted in referrals not being made and missed opportunities for the child to be seen by a Health Visitor. 30.4 A change of social worker and team in the middle of proceedings and planning was unhelpful in this case. Organisations need to reflect on how the impact of such transfers can be mitigated to keep the needs of the child at the centre. 30.5 The GP and the nursery were unsure of what action to take when the child presented with concerning bruising. The review identified that there was an absence of guidance for frontline professionals in this important area. 30.6 There was an absence of appropriate challenge and professional curiosity, particularly around apparently open reporting. 30.7 There was evidence that the Probation Officers within the Community Rehabilitation Company had unacceptably high caseloads, which contributed to a failure to share information in this case. 31. POSTSCRIPT 31.1 All agencies involved in this case have completed action plans in respect of the learning points identified, as well as the issues identified in their own analysis. These have been monitored by the BSCB. 31.2 The CCG has set up a duty advice line for health professionals which provides advice and supervision from Designated Nurses with access to Designated Doctors if needed. 31.3 There is now a simple guide for health professionals about bruising, and several training sessions have been run for GPs. 31.4 All carers who have an SGO granted in Birmingham are now offered support via the SGO Support Team for a minimum of six months post order with an allocated social worker. In addition, if they have current or previous Trust involvement they will also be subject to a CIN plan for a minimum of three months post order. CIN meetings will ensure that all professionals are informed of the SGO and that the support is in place. The SGO Support Plan can be updated if required at the end of the 6-month period. The SGO Support Plan will be reviewed on an annual basis. Special Guardians will have access to advice and guidance at any point. They will also have access to continued training, support groups and dedicated support to assist with the child’s education. 31.5 Since the sad death of this child the local judiciary and the Local Authority have taken steps to ensure that children who achieve permanence through special guardianship receive the appropriate levels of support and supervision following the Order. In many instances a Care Order with a view to the making of a Special Guardianship Order is the judicial preferred way. Many children thrive into adulthood through Special Guardianship and it is important that the judiciary do not dismiss the idea of special guardianship in the first instance as a result of this sad event. Appendix 1: Abbreviations and acronyms Acronym Description A&E Accident and Emergency ADHD Attention Deficit Hyperactivity Disorder BBR Building Better Relationships BCC Birmingham City Council BCH Birmingham Children’s Hospital BSCB Birmingham Safeguarding Children Board Cafcass Children and Families Court Advisory Service CAO Child Arrangement Order CASS Children’s Advice and Support Service CCG Birmingham South and Central Clinical Commissioning Group CIN Child in Need CT scan Computerised Tomography scan DASH Domestic Abuse Safeguarding Risk Assessment DfE Department for Education FLO Family Liaison Officer GP General Practitioner HCPC Health and Care Professions Council HV Health Visitor ICO Interim Care Order IRO Independent Reviewing Officer ISO Interim Supervision Order LPM Legal Planning Meeting MASH Multi-Agency Safeguarding Hub PICU Paediatric Intensive Care Unit PO Probation Officer PPU Public Protection Unit PT Programmes Tutor SCR Serious Case Review SG Special Guardian SGO Special Guardianship Order SN Statistical Neighbour SW Social Worker SWET Social Work Evidence Template TM Team Manager WSW Women’s Support Worker Appendix 2: RELEVANT OTHER SCRs and RESEARCH 1. Research into SGOs: 1.1 The Children’s Services Information Report includes a review of research related to SGOs which notes: • Possible higher rates of disruption of SGOs than of adoption orders, and SGO disruptions taking place more quickly and when children are younger; • Recent increase in use of SGOs, especially for babies, indicating that SGOs are not solely being used as originally intended, for older children placed with family, friends or foster carers. 1.2 Other key points from research include: • Different levels of support for special guardians across LAs – for instance, 55% of LAs have a support group for special guardians (DfE, 2017) – and general agreement that support is not good enough (DfE, 2014b; DfE, 2015). • Varying use of SGOs across LAs (DfE, 2014a). • Varying approaches to the approval of special guardians (DfE, 2014b; DfE, 2015). • Use of SGOs “overwhelmingly for children in or on the edge of the care system” (DfE, 2014a). • Special guardians feeling under-prepared and sometimes pressured to accept an SGO (DfE, 2014a). • The importance of family support for special guardians. “Social workers should therefore be mindful of the need to assess the strength of these networks and, wherever possible, help guardians to strengthen them before cases are closed.” (DfE, 2014a) • “expediency may lead to all placement options not being fully explored” (DfE, 2015) • “making SGOs quickly, before relationships have been properly tested may carry some future risk” (DfE, 2015). • Some special guardians approved who are only just “good enough”: “More fragile SGO assessments are being sanctioned by the court. You have done the assessment, and think it’s just good enough to look after the child; the threshold is just good enough. It's because of the emphasis on Re B-S and a focus on placing with kinship, which is explored first. Under normal circumstances the carer probably wouldn't make it, but we are forced to really look at why we are ruling out a relative. More fragile SGO placements are being made rather than adoption (Manager).” (DfE, 2014b) • Professor Judith Harwin et al looked at trends in the making of Supervision Orders with Special Guardianship Orders between 2007 and 2015 and found a sharp increase in the making of Special Guardianship Orders compared to Placement Orders since 2012/13 and by 2014/15 the proportions and numbers of the 2 orders were converging. There was a particular increase in the use of SGOs for children under 1 year old so by 2015 they comprised 30% of permanency orders for children in that age group. • Clarity around financial support is a particular issue (Ombudsman, 2018). 1.3 Note that guidance and research has since 2014 strongly recommended that SGOs should not be made until the placement has been monitored for a trial period: “Time for preparation is accepted as good practice in fostering and adoption. Adoption orders are not made without a prescribed period of monitored ‘settling in’. No equivalent provision exists for SG, in large part because it was assumed that SGOs would be made for children living in settled homes and with already established relationships with their carers. However, this is not always the case. A sizeable minority of children in our survey (17 per cent) only moved to live with their guardian at the time of the SGO and, as we have seen, one-quarter of cases arose in the context of care proceedings. The potential of SG to build on existing relationships is an important strength. Where a close relationship is lacking, however, greater caution should be exercised, as strength of the pre-existing bond between child and carer was a key predictor of later disruption …. In these circumstances, therefore, there is an argument for relationships to be first tested (perhaps under fostering regulations) before a move to SG is made.” (DfE, 2014a) 1.5 “Wade and colleagues suggest that making SGOs quickly, before relationships have been properly tested may carry some future risk and that ‘a period of time in which these relationships can be tested before moving to a final order is to be recommended’ (Wade et al, 2014: 234). At the very least, where there is no long-term relationship between the child and the special guardian there should be provision for a period of preparation and settling in prior to the order being made, similar to that which is routinely available for adopters.” (DfE, 2015) 1.6 Since the original draft of this report, there have been several significant reports on SGOs. These have continued to report that: Most children in SG placements are safe, cared for and make good developmental progress. Educational outcomes are better than those of children looked after. SGOs mostly result in stable placements, with a lower breakdown rate than that of adoptions. Outcomes are better when the child and carer have a strong pre-existing relationship (Nuffield Foundation, 2019). Older children are more at risk of placement breakdown (Centre for Child and Family Justice Research, 2019). Children are likely to have a higher level of need than their peers who are not the subject of SGOs, but the data are difficult to unpick as they include children who have been adopted (average Strengths and Difficulties score of 19 for children receiving support from the Adoption and Special Guardianship Support Fund compared to 8 for all children in the population – DfE 2021). There is regional variation in the number / rate of SGOs made, and in the proportion where a supervision order is also made (70% of SGOs made in the North had an attached supervision order, compared to 30% in the South) (CCFJR, 2019). The quality of assessments for prospective special guardians, and of support plans, are inconsistent and often poor (Family Justice Council, 2020; Family Rights Group, 2020). Court timescales are not long enough for comprehensive assessments (FRG, 2020; CCFJR, 2019). The framework and forms for the assessment are overly focussed on the prospective special guardians rather than the needs of the child (CCFJR, 2019). Some professionals report "a significantly lower standard of assessment for family members compared to other placement options such as adoption or fostering ... [and] a general assumption that special guardianship placements do not require the same rigour and depth of information on the child, their history and future needs and the fit between those needs and the prospective special guardian’s parenting capacity and resources as is required in adoption or fostering" (FRG, 2020). Assessments do not consistently include full exploration with the prospective SG of their past and current personal and family experiences" (FJC, 2020). The amendments made to the legislation following the 2015 DfE report have had little impact (FJC, 2020). One research report found that 10 of 50 reviewed SG arrangements were not likely to meet the child’s long-term needs, particularly where the prospective SGs had health or social problems or where children had experienced abuse or had complex difficulties (Cafcass 2015 report quoted in FRG, 2020). Family Group Conferences are not routinely held when planning for the child (CCFJR reports 37%). Children on whom SGOs are made are often (CCFJR found 31%) not placed with the prospective special guardian until after the order has been made, so the placement is untried: the CCJFR highlights that “it is only through the testing of placement that the support needs of the SGO carers/placement becomes clear”. Support for special guardians is not good enough. SGs are not always given all the information they need to make the decision to become a special guardian or to care for the child effectively (NF, 2019). Assessments are effectively one-way and do not offer prospective SGs the opportunity to understand the challenges of the task (Family Rights Group, 2020). Few SGs are offered training (CCFJR, 2019). Support is often short-term (NF, 2019). Financial support is unclear and inadequate (NF, 2019). Where support is provided as part of a supervision order, the frequency of visits and of child in need reviews varies considerably, and the quality of CiN reviews is often poor (CCFJR, 2019). There is some evidence that special guardians may be more likely than other people to have had difficulties in their lives. The Centre for Child and Family Justice Research (2019) found that 14% had previously experienced domestic violence, 13% had a history of mental health problems, 20% had current physical health issues, 20% had current financial difficulties, 23% had conflict within the extended family and 25% had housing difficulties (the latter unclear whether it relates to overcrowding post-placement). Comparable data on this for the whole population are not available, however. Special guardians also report that their mental and physical health, and financial situation, are badly affected by the court process, difficulties with contact, managing the child’s needs and what they often find an intrusive and unsupportive experience with social workers (CCFJR, 2019). There is not enough evidence-based information about what works. The Family Rights Group (2020) identifies a lack of research into professional doubts about placements, how these are addressed and whether they are associated with poorer outcomes; one research project found that, where practitioners had concerns, "most of the specific concerns identified did not materialise, while the issues which did arise had not usually been predicted". The report also notes that we have very little information about children’s experiences of SGOs; the Nuffield Foundation (2019) finds the same and adds that we do not have a good understanding of what works in managing contact. The Centre for Child and Family Justice Research (2019) notes that some local authorities have put in place or are considering particular approaches to SGOs (for example: work on disguised compliance; framing post-SGO support around a child protection planning model) but these are not yet evidence-based. 2 References: Centre for Child and Family Justice Research (2019) The contribution of supervision orders and special guardianship to children’s lives and family justice https://www.cfj-lancaster.org.uk/files/documents/SO_SGO_report.pdf DfE (2014a) Investigating special guardianship https://www.gov.uk/government/publications/investigating-special-guardianship DfE (2014b) Impact of the Family Justice Reforms on Front-line Practice Phase Two: Special Guardianship Orders: Research report https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/450252/RR478B_-_Family_justice_review_special_guardianship_orders.pdf.pdf DfE (2015) Special guardianship: qualitative case file analysis https://www.gov.uk/government/publications/special-guardianship-qualitative-case-file-analysis DfE (2017) Children’s Services Omnibus: Wave 1 Research Report https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/634696/DfE-CSO-Wave_1_Final_Report.pdf DfE (2021) Adoption support fund: baseline survey of families https://www.gov.uk/government/publications/adoption-support-fund-baseline-survey-of-families Family Rights Group (2020) Two decades of UK research on kinship care: an overview https://frg.org.uk/wp-content/uploads/2020/12/Overview-research-kinship-care.pdf Family Justice Council (2020) Recommendations to achieve best practice in the child protection and family justice systems: Special guardianship orders https://www.judiciary.uk/wp-content/uploads/2020/06/PLWG-SGO-Final-Report-1.pdf Harwin, Judith et al (nd) Supervision Orders and Special Guardianship http://www.nuffieldfoundation.org/supervision-orders-and-special-guardianship Nuffield Foundation (2019) Special guardianship: a review of the English research studies https://www.nuffieldfjo.org.uk/wp-content/uploads/2021/05/Nuffield-FJO_Special-guardianship_English-research-studies_final.pdf Ofsted (2014) Children and Family Court Advisory and Support Service Advisory (Cafcass): Inspection of Cafcass as a national organisation https://reports.ofsted.gov.uk/sites/default/files/documents/cafcass-reports/national_report_2014/Cafcass%20national%20inspection%20report%202014.pdf Ombudsman (2018) Firm foundations: complaints about council support and advice for special guardians https://www.lgo.org.uk/assets/attach/4320/FR%20-%20SGO%20-%20FINAL.pdf 3 SGOs in Birmingham: Data: 3.1 The only data available relating to the numbers of SGOs made in Birmingham are on children looked after who left care because an SGO was made: Year Number of children ceasing to be looked after - SGOs made to former foster carers Number of children ceasing to be looked after - SGOs made to carers other than former foster carers Total SGOs made for children looked after Total children leaving care % SGOs 2013/14 32 30 62 758 8% 2014/15 17 42 59 764 8% 2015/16 18 46 64 887 7% 2016/17 6 6 12 724 2% From 2017/18 this was broken down differently in published data: Year SGO made to … Total children leaving care % SGOs Former FC, not Connected Person Former FC, is Connected Person Not former FC, not Connected Person Not former FC, is Connected Person Total SGOs 2017/18 suppressed suppressed 6 in total 8-14 689 1-2% 2018/19 suppressed suppressed suppressed 8 11-20 661 2-3% 2019/20 suppressed 7 0 6 14-17 681 2% The DfE suppresses any figures higher than zero but lower than 5. This means we have very patchy data for the last three years. 3.2 % of children leaving care on SGOs for Birmingham, Statistical Neighbours, West Midlands and England 2013 2014 2015 2016 2017 Birmingham 7% 8% 8% 7% 2% Derby 4% 4% 6% 12% 7% Enfield 7% 5% 5% 6% 16% Luton 7% 10% 19% 17% 13% Manchester 11% 5% 6% 11% 11% Nottingham 11% 18% 15% 8% 5% Sandwell 7% 6% 14% 9% 7% Slough 10% 15% 6% 17% 14% Walsall 8% 13% 15% 13% 15% Waltham Forest 8% 11% 9% 11% 17% Wolverhampton 9% 11% 6% 9% 5% Statistical Neighbours 8.2% 9.8% 10.1% 11.3% 11% West Midlands 9% 10% 11% 10% 7% England 10% 11% 11% 12% 12% (https://www.gov.uk/government/collections/statistics-looked-after-children) 2019 2020 Former FC – not Connected Person Former FC – Connected Person Not former FC – Connected Person Former FC – not Connected Person Former FC – Connected Person Not former FC – Connected Person Birmingham - - 1% - 1% 1% Bradford 0% 8% - 0% 10% 3% Derby - - - - - - Enfield - - 6% - 6% 9% Luton 15% 0% 4% - 6% 6% Manchester 2% 12% 5% - 9% 4% Nottingham - 3% - - 6% - Sandwell - 4% 0% - 8% 0% Walsall - 11% 3% 5% 9% - Waltham Forest - 4% - - 6% 4% Wolverhampton 8% 0% 4% 6% - - Statistical Neighbours 6.25 5.25 3.67 3.67 7.50 4.33 West Midlands 2% 6% 1% 1% 7% 1% England 1% 8% 4% 1% 7% 4% (Source: Local Authority Interactive Tool – 2018 not published) 3.3 These figures show the number of SGOs in Birmingham as very consistent between 2011 and 2016, dropping sharply from the end of 2015/16, possibly as part of changing local policy in response to the death of Shi-Anne Downer in September 2015. They have never risen to the number / proportion that they were since that time. 3.4 The % of children leaving care on SGOs is consistently lower in Birmingham from 2013 onwards than in the region and its SN group. This pattern is striking – children in Birmingham are generally not leaving care on SGOs at the rate of other LAs. We cannot tell from the data here whether that means they are less likely to leave care or less likely to achieve permanence. 3.5 The Cafcass report notes the following figures for Birmingham: % of children removed from parents and placed with family on SGOs or CAOs by BCCS: 2013 it was 26.7%; 2014 it was 24.2%; 2015 20.8% 2016 21.3%. BCC has a higher %ge of SGO/CAOs than neighbouring Las: 2016 Dudley had 11.2%, Sandwell 5.8%, Walsall 13.1%. These figures suggest that Birmingham has a significantly higher rate of SGO and CAO than its neighbouring authorities. 3.6 It has not proved possible to verify this data from government statistics, and it may be that there is a particularly high level of CAOs in Birmingham which would account for the discrepancy. 4. SGOs in Serious Case Reviews 4.1 In addition to the SCR published by Birmingham LSCB on Shi-Anne Downer in February 2017 (https://www.cscb-new.co.uk/wp-content/uploads/2017/04/Birmingham-SCR-BSCB-2015-162.pdf), there are a number of recently-published SCRs involving young children placed with relatives on SGOs. Those where the circumstances and findings may be relevant are: 4.2 “Bonnie”, Devon (published 2016): a two-year-old who was the subject of an SGO to her grandmother, and was subsequently sexually abused by her grandfather. The report notes, among other findings, that: • predictive analysis of risk must include the history of family relationships and events to identify unresolved risks rather than submit to a rule of optimism; • there is a need for vigilance against the potential for disguised compliance. (https://library.nspcc.org.uk/HeritageScripts/Hapi.dll/search2?searchTerm0=C5975&_ga=2.170254051.213636357.1530108306-392135669.1530108306) 4.3 Child J, Nottingham (published 2017): a seven-year-old who died following injuries caused by her aunt and grandmother, having been the subject of an SGO to her aunt as a five-year-old. The report notes, among other findings, that: • SGO and FAO support plans must include details about how support will be delivered; they must have clear outcomes, aims, timescales and monitoring arrangements, and should be multi-agency; • supervision must ensure that professionals are able to reflect on fixed views they may hold about children and their carers, and how confirmatory bias may be affecting their views. {https://library.nspcc.org.uk/HeritageScripts/Hapi.dll/search2?searchTerm0=C6460&_ga=2.112055367.213636357.1530108306-392135669.1530108306) 4.4 Children A and B, Oxfordshire (published 2017): two children aged under five who were the subject of an SGO to a distant relative, and subsequently sexually and physically abused by the relative's husband. The issues in this SCR do not strongly reflect those in the current SCR, as the Oxfordshire case involved complex legal proceedings and the children had disabilities and complex needs. However, the SCR author’s statement “Overall the desire for the placement to be successful inappropriately affected child protection processes” may have some relevance. (http://www.oscb.org.uk/case-reviews) 4.5 The murder of 18-month-old Elsie Scully-Hicks by her adoptive father (https://www.theguardian.com/uk-news/2017/nov/07/matthew-scully-hicks-jailed-for-life-daughter-elsie) may also have some relevance to this SCR. A child practice review was undertaken by Cardiff and Vale of Glamorgan Regional Safeguarding Children Board. The report (2018) noted that “paediatricians are key professionals in recognising the possibility of injuries being caused deliberately”. The board went on to recommend that “a child placed for adoption, who presents at hospital with an injury, should be overseen by a paediatrician with safeguarding experience and training” This recommendation could usefully be extended to SGOs. 4.6 Child LH, Lewisham and Harrow (published 2019): child aged four who was placed with extended family on an SGO and abused. Learning relevant to this SCR includes: inadequate background checks during SG assessment; lack of independent scrutiny of SG assessments; lack of an SGO support plan. Recommendations include: training on governance of different placement types; review of SGO processes; SGO assessments and support plans to be presented to the permanency panel. http://www.harrowscb.co.uk/wp-content/uploads/2019/09/Child-LH-LewishamHarrow-Overview-Report-for-Publication-4.7.19.pdf 4.7 Family M, Surrey (published 2020): six children placed with extended family on SGOs, where they were abused. Learning relevant to this SCR includes: “view that placement with family is best, without critical thinking”; failures to share information between agencies; inadequate assessment relying on self-reported information. Recommendations include increased focus on voice and lived experience of the child; improved supervision. https://www.surreyscp.org.uk/wp-content/uploads/2021/04/Family-M-SCR-2018-Final.pdf 4.8 Megan, Gloucestershire (published 2020): child aged six who was placed with extended family on an SGO and abused. Learning relevant to this SCR includes: inadequate assessment; not hearing the voice of the child; not recognising signs of abuse; professional optimism and lack of curiosity. Recommendations include pathway for SGO application where the prospective SG does not have an existing relationship with the child – placements in this situation always to be interim kinship care; use of family group conferences; better information sharing between agencies; training on disguised compliance. https://www.gscb.org.uk/media/2097918/0215-scr-megan.pdf 4.9 Child O, local safeguarding practice review, Bexley (published 2021): child aged four placed with extended family on SGO, accidentally swallowed drugs when alone with his mother (this situation being contrary to the SGO agreement). Learning relevant to this SCR includes: quality of the support plan and of actual support; domestic abuse; management oversight. Recommendations include training for staff on governance of different placement types. https://bexleysafeguardingpartnership.co.uk/wp-content/uploads/2021/04/Child-O-Report-SHIELD-Final.pdf |
NC52428 | Child sexual abuse in the context of child sexual exploitation and trafficking of a 14-year-old child over a significant period of time. The abuse was perpetrated by males ranging from older adolescents to adult men, who were known either to Child 9's mother or some of her relatives. Learning includes: frequent local movement around education providers is an indicator of risk; the use of victim blaming language is careless and should be avoided to ensure the presenting behaviour is seen as a representation of the child's distress; there should be no delay in monitoring and information sharing when vulnerable children who live in a cross boundary area are subject to elective home education or are missing education; practitioners in urgent care centres should always be prepared to "think the unthinkable", and finding the time to secure communication with a child alone should be a central focus; the use of hypothesis in safeguarding assessment and planning is crucial; attendance and active participation in child protection meetings should be a priority for services to ensure effective information sharing. Recommendations include: highlights the ongoing development needs of the multiagency workforce when working with children who have escalating and complex safeguarding needs, working with troubled children, hypothesis in safeguarding work, reflective supervision and the use of victim blaming language in safeguarding work; ensure that responsive restorative services are available for children who are victims of rape and sexual assault; examine issues and demonstrate improvements around children missing education and children subject to elective home education.
| Serious Case Review No: 2022/C9524 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. LOCAL AUTHORITY 1 SAFEGUARDING CHILDREN PARTNERSHIP Child 9 Local Safeguarding Child Practice Review (LSCPR) Full Document: Final Version 3rd April 2022 Independent Reviewer: Jane Carwardine This LSCPR has been fully anonymised to protect the identity of Child 9 and involved practitioners. It will be published on the NSPCC repository only. An executive summary is available. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 2 of 28 CONTENT PAGE SECTION SUB SECTION PAGE CONTENT 2 A Current Pen Portrait 1 3 Methodology 1.1 3 The LSCPR Process 1.2 4 Participation 1.3 5 Parallel Enquiries 2 5 Background to the LSCPR. 2.1 5 The Family Unit 2.2 5 Family Dynamics 2.3 5 The Incident 3 6 A Summary of Child 9’s Life Experiences 3.1 6 Historic Events Pre-Dating the LSCPR Timeline 3.2 9 Child 9: Events from 1st May 2018 to 7th February 2019 whilst resident in Local Authority 2. 3.3 16 Child 9: Events from 7th February to 11th December 2019 whilst resident in Local Authority 1. 4 22 Conclusion 5 24 Recommendations 6 25 Appendices 25 1. Abbreviations Used 25 2. Reviewers Biography 26 3. Rapid Review Panel 27 4. Case Review Panel Membership 28 5. Agency and Practitioner Participation CHILD 9 – A PEN PORTRAIT 1. Throughout the review process Child 9 was resident in a secure placement outside the boundaries of local authority 1(LA1), whilst remaining under the care of LA1. She remained subject to an interim care order with welfare decisions made under the inherent jurisdiction1 of the family court of protection; through an order made under the Deprivation of Liberty Safeguards2 (DOLS) and under Section 25 of the Children Act 1989 3 in order to maintain her safety. Practitioners in contact with Child 9 described her as polite, lovely and liked to be well presented. She enjoyed good health which was monitored through the school nursing service and general practitioner (GP) services. She regularly accessed urgent care centres for advice regarding minor ailments. When in class she behaved well and was keen to complete her work. The behavioural challenges relating to her distress mostly occurred outside of the classroom e.g., in the playground. They were frequently linked to the use of social media by Child 9 and other children. She could be cautious and reluctant to engage with practitioners until they had been able to gain her trust. The review has been informed Child 9 is currently making positive progress and is always keen to accommodate new experiences and activities. She enjoys experiencing new foods, trips to the theme parks, is motivated by boxing activities where she also is a supporter of younger children and is engaging well educationally. 1 The inherent jurisdiction means a residual jurisdiction to make decisions for people who need it when there is no other framework 2 DOLS ensures people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty. Arrangements are assessed to check they are necessary and in the persons best interest. Downloaded SCIE 4.12.21 These orders can be used to detain children in homes when alternative suitable accommodation cannot be found. 3 Section 25 of the Children Act 1989 provides for the placement of looked after children in secure accommodation for the purpose of restricting their liberty LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 3 of 28 SECTION 1: METHODOLOGY 1.1 The LSCPR Process 2. Until early 2018, Child 9 lived in local authority 2 (LA2) when she moved to LA1 with her maternal great grandma (MGGM) and maternal great uncle (MGU). Education provision was provided in LA1. Policing was provided by three different police forces, across neighbouring boundaries. Children’s social care (CSC) and health provision (walk in centres, general practitioner and school nursing) were accessed by the family across both local authority areas. Two regional sexual assault referral centres (SARC)4 had contact with Child 9. In the Spring 2018, Child 9 lived intermittently for short periods with her mother in local authority 3 (LA3), she was not known to services in that area. The Safeguarding Children Partnership (SCP) in LA1 took the lead responsibility for coordinating this review process and ensured robust participation from LA2. 3. In November 2020, a child safeguarding incident notification was submitted to the National Panel, following concerns Child 9 had been subject to sexual abuse committed in the context of child sexual exploitation and trafficking. In December 2020, a senior management multiagency case review group (see appendix 3) was convened to undertake a rapid review.5 The group unanimously agreed the criteria to undertake a local safeguarding child practice review (LSCPR)6 was met due to the longevity of child sexual abuse and exploitation whilst her case was open to multiagency services and subject to child protection planning. 4. The following key lines of enquiry (KLOE) were identified; KLOE 1 The effectiveness of multiagency local authority cross boundary partnership working. KLOE 2 Supporting the risks for children with complex safeguarding needs who become subject to elective home education. KLOE 3 Understanding the workforce challenges when working with “disguised” compliance. KLOE 4 Maintaining a focus on the child at risk of child sexual abuse. KLOE 5 Securing effective, responsive, child focused, multiagency planning arrangements. KLOE 6 Escalation and de-escalation in CSE/CSA case management. Additional KLOE identified during the analysis of information were to be highlighted by the independent reviewer. The review was to reflect multiagency improvements made since the rapid review and highlight potential gaps in multiagency practice when working with children and young people and their families who are at risk of child sexual abuse and child sexual exploitation whilst receiving services across local authority boundaries. 5. The National Panel agreed the criteria to undertake a LSCPR was met. There was a delay in initiating and completing the review due to; challenges in securing relevant information, agency capacity to respond to the review process due to the impact of the Covid-19 pandemic and latterly the independent reviewer’s unplanned absence from the workplace. The methodology planned was the 4 SARC centres (SARC) offer medical, practical and emotional support to anyone who has been sexually assaulted or raped regardless of age or gender or whether the victim reports the incident to the police or not. SARC services can deliver services to both recent and non recent victims. SARC services can support police and forensic investigations. Some services offers a paediatric SARC service staffed by paediatricians, paediatric nurses, and other staff. These services are jointly commissioned by NHS England, CCG’s, Local Authorities and the Criminal Justice System Downloaded NHS England, Service Spec 30, 24.2.22 5 Guidance is found in Working Together to Safeguard Children (2018) and advice published from the national panel “joint communication from the Child Safeguarding Practice Review Panel and the DFE. 6 Described in Chapter 4, Working Together to Safeguard Children. Published 2018. HM Government. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 4 of 28 systems approach,7 using elements from the Welsh model.8 The review was asked to summarise key learning from historic events. The timeline for information gathering regarding key events was from 1st May 2018 to 11th December 2019, having been extended during the review process to include the period when Child 9 was subject to elective home education (EHE). A multiagency chronology was formulated using information from agency records. Further attempts were made to secure additional evidence as gaps in information became evident. Significant attempts have been made to ensure the completeness of the information however it should be acknowledged the data may not be complete. 6. On the 29th April 2021, following the appointment of an independent lead reviewer (appendix 2) working alongside the SCP business unit (LA1), an initial case review panel virtual meeting was convened (see appendix 4). The governance of the review was provided through the case review panel, who met virtually on four occasions. The initial draft review was shared with the case review panel in early December 2021, with the final version shared for ratification and final ammendments in early March 2022. The SCP (LA1) ratified the review on the 14th March 2022 and further plans were made to share with the SCP (LA2). The learning will be shared with the practitioners/agencies who participated in the review process and will be disseminated to the wider multiagency workforce. The anonymised review will only be published on the NSPCC repository in order to maintain Child 9’s anonymity. Relevant agencies will be asked for their responses and improvements to the review’s findings. 7. In September 2019, children services (LA2) were assessed inadequate during an Ofsted Inspection.9 The services have been subject to improvement planning, scrutinised by an improvement board, working in partnership with the Department for Education. In July 2021, improvements were evidenced during a follow-up focussed visit by Ofsted.10 In January 2017, children services (LA1) were assessed good overall during an Ofsted Inspection.11 Since March 2019, three focussed visits have taken place and the authority has undertaken ongoing improvement planning. During their involvement with Child 9, both local authority children’s service departments experienced workforce capacity challenges which impacted negatively on the delivery of services. Both areas have improvement plans in place which are intended to stabilise and develop the workforce. Creating a stable workforce is a national issue for local authority children’s service departments. 1.2 Participation 8. Child 9 has been required to participate in interviews as a potential witness in the criminal proceedings. She has been informed of this review by her key worker, however, did not feel able to participate due to feeling overwhelmed at the time. The participation of Child 9’s family members could not be secured due to ongoing criminal proceedings. They have been informed of the review by the SCP (LA1) business unit. 9. It was hoped to secure the participation of involved multiagency practitioners, line/senior managers and relevant others across the local authority areas’ multiagency provider and commissioning organisations, in order to enhance the knowledge gained from the written information. In June 2021, a virtual practitioner learning event was facilitated. Optimal attendance at this event could not be secured as many practitioners had left their respective employers and could not be located. Additional virtual practitioner conversations were convened between August and October 2021 (see appendix 5), but very few conversations were possible with practitioners who had worked directly with Child 9 and her family as many were no longer in employment locally. 7 SCIE Learning Together to Safeguard Children: A Systems Model For Serious Case Reviews. 8 Welsh Government (2012) Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Model. 9 LA2 , Inspection of Children’s Services, September 2019. Downloaded files.ofsted.gov.uk 6.1.22 10 Focussed Visit to LA2 Children’s Services, July 21, Ofsted. Downloaded files.ofsted.gov.uk 6.1.22 11 Ofsted, LA1 Children’s Services Inspection, focused visits downloaded files.ofsted.gov.uk 6.1.22 LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 5 of 28 1.3 Parallel Enquiries 10. Parallel enquiries have been considered to avoid potential conflict of interest. At the time of writing there were ongoing criminal proceedings which impacted on the participation of the victim and family members. Agencies were requested to share incident investigations arising from this case however, none were disclosed during the review process. SECTION 2: BACKGROUND TO THE LSCPR 2.1 The Family Unit FAMILY MEMBER AGE* RESIDENCY Child 9 14 yrs 6mths Resident with MGGM and MGU in LA2 till early 2018 then moved into LA1. Maternal Great Grandma (MGGM) 68 yrs Held parental responsibility and a residency order for Child 9 from birth. Grandma (MGM) 49 yrs Lived separately and in same locality as Child 9, MGU and MGGM until early 2018. Maternal Great Uncle (MGU) 41 yrs Resident with MGGM and Child 9. Mother 30 yrs Lived in LA3 with her 4 children who are Child 9’s half siblings. Minimal contact. (*age at the time Child 9 became a child looked after in December 2019) 2.2 Family Dynamics 11. From around 8 weeks of age Child 9 lived in a complex family network, primarily residing with MGGM who held a residency order and parental responsibility. MGU was resident with MGGM and MGM lived in a nearby locality. MGU, MGGM and MGM jointly provided care to Child 9. It is understood this decision was taken by the family who thought Child 9’s mother was too young to provide Child 9 with adequate care around the time of her birth. More recent maternal disclosures identified there were “bonding” issues after Child 9 was born. Her father’s identity is not known to the review. Her mother lived 40 miles away (LA3), with her four children who are not included in this review. There is evidence Child 9 had gained recent contact with her mother and half siblings through social media, with no significant prior contact. The contact ceased in July 2018, following an incident when Child 9 was allegedly sexually assaulted by a male whilst staying with her mother. This incident will be discussed later in this review. 2.3 The Incident 12. In September 2018, following an initial child protection conference (LA2) Child 9 became subject to planning under the category of emotional abuse. It has not been possible to determine why the category of emotional abuse was used, as prior to the conference her social worker had recommended the category should be child sexual abuse. Whilst Child 9 was subject to child protection planning there was insufficient focus on Child 9 as a child at risk of child sexual abuse/exploitation. Analytically reflective practice was not evidenced with more focus on front facing practice which lacked the required level of reflective analysis. There then appeared to be a delay in case transfer to LA1 when the family re-located and a further delay in case allocation to a key social worker following transfer. The focus on managing Child 9’s risks as a victim of child sexual abuse/ exploitation was confused with her case de-escalated from specialist child exploitation teams despite the known risks and professional concern. There was a later a delay in the instigation of legal proceedings prior to her being removed into care under a care order. Throughout the period under review there was insufficient focus on the assessment of parental capacity or parental motivation to LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 6 of 28 maintain Child 9’s safety despite considerable evidence of her carer’s behaviours in relation to disguised/non- compliance to the planning in place. 13. In December 2019, Child 9 then aged 14yrs 6mths, had been able to form a trusting relationship with a secondary school 2 teacher. This enabled her to disclose to the teacher that between July 2018 and December 2019 she had been a victim of child sexual abuse by various adults visiting the home. Child 9 had told her trusted carers (MGGM, MGU) about an incident who dismissed the disclosure saying, “he was only playing with her.” She disclosed offender 2 had lived in the family home during part of that period. He shared a bed with her and she alleged offender 2 had repeatedly sexually abused her during that time. MGM had suggested offender 2 should hide and his property be out of sight when the social worker visited. Child 9 was removed into local authority care in December 2019 and placed with a foster carer. However, she regularly went missing and was found in substantial risk situations. Sometimes she was found with family members and reported she had been asked to change her evidence. Child 9 was then placed in a secure placement by LA1 in an attempt to maintain her safety. 14. Whilst in the care of the local authority Child 9 continued to make disclosures reflective of her traumatic experiences related to child sexual abuse and exploitation, perpetrated over a significant period of time. The abuse was committed by males ranging in age from older teenagers to adult men. The men were known either to her mother, MGU or MGGM and it is now hypothesised they used their familial relationship with Child 9 to facilitate her abuse. There was a general lack of professional curiosity and ready acceptance of Child 9’s denials without deeper investigation and analysis. There was suggestive evidence of the use of victim blaming language12 throughout documentation when referring to Child 9. This may have contributed to her distressed behaviours as she was regularly perceived as a challenging child rather than a child who was experiencing the trauma of child sexual/emotional abuse on a regular basis. Her behaviours became the focus of initial management strategies. There was insufficient evidence her distressed behaviours was explored, with limited focus on therapeutic support to manage the psychological aftermath of the trauma she was enduring. There was limited curiosity into the impact of family, environmental factors and parenting capacity on Child 9 despite the known historical concerns about family functioning and the longevity of Child 9’s distressed behaviours. SECTION 3: A SUMMARY OF CHILD 9’S LIFE EXPERIENCES 15. This section will provide a narrative, analysis and learning related to the most significant events in Child 9’s life. Service improvements made following the rapid review will be highlighted. The timeline reviewed was from when Child 9 commenced elective home education (1st May 2018) to when she became a child looked after (11th December 2019). This timeline was extended to incorporate a period of elective home education. Relevant historical information pre-dating the timeline of the review is also included as this provides some insight into Child 9’s early life experiences when early help may have been an opportunity to secure improved outcomes for Child 9. 3.1 Historic Events Pre-Dating the LSCPR Timeline 16. Primary Education: Child 9 attended at least four primary schools in the same locality (LA1), moving between the schools on several occasions. It is not understood why MGGM decided to move her around education providers so frequently. This behaviour should have been seen as an indicator of risk related to parental avoidant behaviour. It could have triggered an early help assessment. (LP1) Research shows moving schools multiple times has a devastating impact on academic attainment, the development of social relationships and a child’s emotional wellbeing. This movement also created safeguarding challenges for education being able to keep a focus on Child 9 welfare. 12 Victim blaming Language is terminology that could imply the child is complicit or responsible for their abuse. Appropriate language should always be used to ensure the child is referred to in a way that does not place the blame on the child i.e., challenging behaviours could be seen as distressed behaviours which may be reflective of a child’s everyday experience. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 7 of 28 Learning Point 1: Legally parents/carers can choose to move their child around education providers however, Child 9’s frequent local movement was an unusual pattern of parental behaviour. Research13 14 highlights the negative outcomes of this type of behaviour pattern for children which should be linked to parental avoidant behaviours. It is an indicator of risk which should be understood. It is important this cohort of children are identified to enable an early multiagency response, thereby ensuring an early assessment inclusive of parental capacity and family and environmental factors is undertaken. A key question for consideration is : Can local education provision identify and maintain a focus on the cohort of children who move around local education provision in order to safeguard their welfare? 17. Early Safeguarding Concerns: There had been historical child in need15 involvement by CSC (LA2) due to the distressed behaviours Child 9’s presented whilst in school. During primary education, it was known she was active on social media, potentially making profiles of others, had watched inappropriate online videos which used violent and threatening language, had been brought up in a violent home and used sexualised language inappropriate for her age. In March 2017, the school acted appropriately raising another safeguarding alert with CSC (LA2). The contact did not convert to a referral which would have provided an opportunity for further multiagency information gathering and assessment. A plan was formulated which included direct work in school, support via an early help assessment tool (EHAT),16 support to MGGM and a referral to the school nursing service. There is no evidence of the outcome of this intervention as the early help assessment could not be located. Given the known history this was a missed opportunity to undertake a more comprehensive children and families assessment by CSC(LA2) . (LP2) Learning Point 2: In 2017, there was a missed opportunity following a contact with CSC (LA2) to undertake a more comprehensive assessment of Child 9’s welfare. The contact did not convert to a referral despite the known historical indicators of risk. The outcomes of contacts that do not convert of a referral are now monitored through quality effectiveness measures in the area. There is no evidence the early help plan developed as a result of the contact, was effectively coordinated or its outcome demonstrated. Early help provision (LA2) has developed since that time with improved leadership, strategic oversight and performance monitoring. The area (LA2) offers early help support for their children to schools across the boundary (LA1). (Good Practice) 18. Victim Blaming Terminology: Primary education reported “academically she had done quite well, with mathematics being her greatest challenge.” The use of victim blaming language was documented “Child 9 could be lovely in class however also loved to be involved in gossip”. Her primary school suggested “this brought out the worst in Child 9.” The use of such language in written documentation should be avoided when working with children, to ensure the presenting behaviour is seen as a representation of the child’s distress. The documentation created a hypothesis of a challenging rather than distressed child who was subject to family violence and was experiencing a range of adverse childhood events on a regular basis. This created a missed opportunity to explore the traumatic events she may have been experiencing at that time. (LP3) Learning Point 3: Multiagency documentation regularly evidenced the use of victim blaming language. The use of such language is careless and should be avoided to ensure the presenting behaviour is seen as a representation of the child’s distress. The documentation created a hypothesis 13 Rodda M et al (2013) Between the cracks, July RSA Action, and Research Centre. Downloaded thersa.org 1.1.22 14 Downloaded sec-ed.co.uk 1.1.22. The alarming impact that moving school; frequently can have on students. 15 A child in need is a child assessed to need additional support from a local authority to meet their potential. Section 17 of the Children Act 1989 places a general duty on all local authorities to “safeguard and promote the welfare of children within their area who are in need. Downloaded scie.org.uk 11.11.21 16 EHAT is a tool used for gathering information and a standard approach in assessment for the identification of early help needs. Its intention is to support practitioners to gather and understand information about the needs and strengths of children and their families. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 8 of 28 of a child being challenging/troublesome rather than distressed. This created a missed opportunity for practitioners to explore her adverse experiences and may have inhibited Child 9 from disclosing her experiences at an earlier stage. The use of victim blaming language is subject to audit by CSC in both areas and practice standards have been developed. The NHS provider organisation (LA1) responsible for school nursing has also developed a training programme. Whilst some agencies have made improvements this is not evident across all multiagency partnerships. Further multiagency workforce development would ensure the complexity and risks of victim blaming language are fully understood. All agencies should consider improvements that minimise the use of victim blaming language through development opportunities and quality effectiveness measures. 19. Distressed vs Challenging Behaviour: In September 2017, on entry to secondary school 1, Child 9’s distressed behaviours continued to be a cause for concern. During September and October three incidents were recorded related to her involvement in the use of social media. In one of the incidents, she had been threatened with “rape” by another student, however she retracted this allegation. In another she sent a student a photograph depicting self-harming behaviours whilst also threatening to kill herself. There is no evidence of intervention to assess the risks relating to threats to kill. In the last incident it is alleged she threatened a fight with another student. Secondary school 1 put behaviour modification interventions in place within a few weeks of Child 9 commencing the school, in line with expected practice. MGGM was always kept informed and considered to be supportive. In January 2018, Child 9’s distressed behaviours continued to escalate; she was placed on an individual behaviour plan17 (IBP) and a period of exclusion. The impacts of exclusion will be discussed later in this review. At this point, the discussions were positive, reinforcing the idea of IBP as a supportive mechanism for helping to modify/improve behaviour. In April 2018, following an incident resulting in a 2-day exclusion, incidents involving Child 9 continued to escalate. This prompted a meeting with MGGM to discuss the possibility of Child 9 going into an education respite placement or escalating her IBP to a pastoral support programme18 (PSP) which is considered a more serious level of monitoring. The focus of the work with Child 9 was about helping her to contain her behaviours within the school environment. There is no evidence that individual work was undertaken with Child 9 to explore deeper understanding of her distressed behaviours or to support her emotional wellbeing. (LP4) Learning Point 4: The focus of the work with Child 9 pre-dating the review’s timeline was to contain her behaviours within the school environment through differing education behaviour modification programs and exclusion processes. There is no historical evidence of individual work with Child 9 to gain a deeper understanding of the root cause of her distressed behaviours, to support her emotional wellbeing, to gain a greater understanding of her experience of being parenting or her family and environment factors. When children are showing recurring distressed behaviours providing the right environment for a child to develop trust to be able to disclose her feelings should be the priority for intervention. 20. In conclusion; the historical information provided an indication of the range of difficulties Child 9 had to navigate throughout her primary/secondary education and within her home life. Her behavioural responses were reflective of a distressed and vulnerable child; however, the predominant hypothesis presented was that of a troublesome child with challenging behaviour. Her emotional distress and threats to end her life were not effectively managed or supported through multiagency working. Differing interventions including exclusion from education focused on the management of her behaviour in school rather than creating an understanding of her safeguarding needs as a child with complex health and social needs. A hypothesis should have been tested that Child 9 was growing up with vulnerability and risks that she had to accommodate on a daily basis. The historical indicators of 17 An individual behaviour plan a document that helps all staff to have a consistent approach to behaviour with a child enabling them to achieve the most from their education. 18 A pastoral support programme is a school based process intended to support a child if school based strategies have not been successful. The aim being to involve everyone in the shared challenge of improving a child’s behaviour and social skills and ensuring social and educational inclusion. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 9 of 28 risk regarding family and environmental factors/parental avoidant behaviours were known, however an appropriate multiagency early response was not sufficiently evidenced. There are significant challenges for education providers when balancing the needs of individual children alongside the safety of the school population. The work is complex and multifaceted. However, at the core of this work it is always necessary to undertake an accurate early help assessment not only of the child’s needs but inclusive of the parenting capacity, family functioning and environmental factors. Greater emphasis should be placed on enabling the child to develop the confidence to trust to be able to share their worries and anxieties and may support greater understanding of the child’s journey through everyday life. 3.2 Child 9: Events 1st May 2018 to 7th February 2019 whilst resident in Local Authority 2. 21. Elective Home Education (EHE): On the 1st May 2018, Child 9 left secondary school 1 to become subject to EHE. MGGM later suggested to education practitioners a secondary school 1 practitioner had actively encouraged her to home school, otherwise Child 9 would have to attend a pupil referral unit. During the rapid review process there were concerns expressed that “off rolling”19 may have occurred which is against the expectations of practice guidance. During a conversation with a deputy headteacher (secondary school 1), as part of the review process it was confirmed MGGM had presented a formal handwritten letter. This was thought to be in her own handwriting, outlining her intention to withdraw Child 9 to home educate. The practitioner suggested the school thought MGGM had been assisted in writing the letter due to its use of formal language. Access to proformas to support EHE are easily accessible on the internet. At the time the school was shocked at MGGM’s decision and outlined their concerns. The school highlighted the responsible local authority team would make checks about the EHE offer. Child 9 remained subject to EHE until joining secondary school 2 on the 5th November 2018. The review has not been able to explore this incident with MGGM to gain deeper understanding of her decision making. 22. The education inclusion team20 (LA1) was informed of the decision by secondary school 1. The reviewer’s conversation as part of this review, highlighted an inadvertent error had been made during the notification process. LA2’s EHE team should have been notified rather than LA1’s team, as Child 9’s resident address was a LA2 postcode. It was wrongly thought to be a LA1 postcode. On the 18th July, 11 weeks later, Child 9’s case was transferred to LA2’s education welfare team by LA1. The reason for the delay in processing the information remains unclear. The education inclusion service (LA1) has been subject to improvement strategies to identify children who may be subject to “off rolling” and to EHE. The improvements include an electronic notification system, a flagging system to identify children with safeguarding needs and weekly off roll checks through a commissioned provider. The improvements should be monitored to ensure there is no delay in monitoring and information sharing when vulnerable children who live in a cross boundary area and are subject to EHE or are missing education. (LP5) 23. During conversations it was identified the teams with responsibility for children subject to EHE in both areas work closely with their local education providers. They have systems to identify and minimise the risk of “off rolling” and to support children subject to EHE. The school is expected to inform the responsible council team according to the child’s postcode address. The education database also creates alerts when a child is removed from a school roll which initiates follow up by the relevant team. In addition, LA2 have more recently collaborated with neighbouring local authorities the implementation of the STAR standard. This has been developed to support cross boundary information sharing when children are identified as having safeguarding needs and leave school at transition points or mid-term. (Good Practice) Currently not all local authority areas link into this standard which could be a future consideration for LA1 if the standard is evaluated positively. During 19 Off rolling is the practice of removing a pupil from the school roll without using permanent exclusion, when the removal is primarily in the best interest of the school. This includes pressuring a parent to remove their child from the school role. 20 LA1 has an educational inclusion team which is responsible for the support of children and their families who are subject to elective home education. The service also supports children and their families with special educational needs and disabilities. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 10 of 28 practitioner conversations it was highlighted that timely cross boundary information sharing about children not in school could sometimes be delayed due to the processing of information through LA1’s multiagency safeguarding hub onwards to the relevant team. It was suggested having the opportunity for direct verbal communication between the two cross boundary teams would enhance timely information sharing. Learning Point 5: In May 2018, there was a 11-week delay in sharing a EHE notification between the two local authorities. Both areas have introduced failsafe systems to identify vulnerable children subject to EHE and have made improvements to their systems. These systems should be monitored to ensure they remain effective in notifications across local authority boundaries. Contributory factors related to information remaining un-processed (LA1), challenges in securing cross boundary communication between the teams with responsibility for EHE and a simple misunderstanding of postcodes. LA2 have supported the recent implementation of the Star standard 21 and if proven effective could support information sharing across local authority boundaries. These issues should be a consideration to strengthen the current system. 24. Attendance Urgent Care: On the 1st June 2018, Child 9 attended an urgent care centre (LA2), accompanied by MGGM, with a history of intermittent vaginal bleeding during the preceding months, which had recently worsened. MGGM advised Child 9 was anxious and in her opinion the bleeding was normal menstrual bleeding. Child 9 and MGGM denied she was sexually active or there was a risk of pregnancy. The practitioners advised them a gynaecological examination was out of the remit of the service. Child 9 and MGGM were given follow-up advice and the general practitioner was notified. The urgent care centre followed expected practice in referring Child 9 back to her GP. The assessment being there was no indication for screening or onward referral regarding sexual health issues or safeguarding concerns. The service has clear guidance22 on how practitioners should respond when a child under 13 years attends the service and workforce development has been provided. The review has been unable to ascertain whether Child 9 was spoken to alone or in MGGM’s presence, which is a key factor to support a potential disclosure. Her type of presentation accompanied by parental carer is not unusual in urgent care centre settings and would not have triggered further enquiry relating to child sexual abuse. However, with hindsight we know at this time Child 9’s daily life was unsettled, chaotic and with the likelihood of child sexual abuse a significant risk. Providing opportunity for Child 9 to discuss her health issues alone without her MGGM could have supported her opportunity to disclose her situation. (LP 6) Learning Point 6: Child 9 and MGGM accessed urgent care centres across the local authority areas on a number of occasions. In June 2018, Child 9 attended a centre (LA2), accompanied by MGGM, with a history of intermittent vaginal bleeding. She was under 13 years and her presentation could have prompted professional inquisitiveness into her everyday life experience, which with hindsight we know was unsettled and chaotic. The review has been unable to ascertain whether Child 9 was spoken to alone or only in MGGM’s presence, who we now know exhibited “disguised compliance” behaviours. The opportunity for a child to speak alone and the recognition of parental disguised compliance is a key factor to support potential disclosure. During that and other urgent care attendances the focus on her safeguarding risks was not evident within the review process. When working with children the early identification of child sexual abuse requires all health practitioners to assess the risk of abuse in order to instigate a prompt referral to the police and CSC. Practitioners in urgent care centres should always be prepared to “think the unthinkable” when working with children and parents, to enable the early identification of children at risk of child sexual abuse and exploitation. Finding the time to secure communication with a child alone should always be a central focus. 21 The STAR standard (2021) is a recent initiative agreed by several local authorities to transfer safeguarding information across local authority boundaries when children leave a school roll 22 LA2 SCP procedures, Underage Sexual Activity, downloaded sthelens.proceeduresonline.com LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 11 of 28 25. Safeguarding Referral: In recognition of the concerns for Child 9’s welfare the education welfare (EWO) team manager (LA2) responded promptly to the EHE notification. It was a priority to ascertain Child 9’s whereabouts. MGGM and mother were contacted on the same day and a visit was arranged to assess her welfare, including the EHE offer. (Good Practice). It was clarified Child 9 had gone missing ten days previously to live with her mother, 40 miles away (LA3) and she no longer resided with MGGM. Child 9 had intermittently travelled alone to and from LA3 to sometimes stay with MGM. At the time MGGM and mother suggested Child 9 had gone missing due to; MGU always being drunk which caused family arguments and Child 9 had witnessed inappropriate language. Child 9 verbalised to her mother she did not want to reside with MGGM and MGU, who she said treated her badly. MGGM reported she had made a referral to CSC (LA2) a few days earlier and was awaiting a response. There was no record of MGGM’s referral. 26. On the 18th July, the day following notification, the EWO team manager (LA2) made a safeguarding referral to CSC (LA2). The referral clearly summarised the concerns and risks, suggesting further assessment was undertaken including exploration of Child 9’s wishes, feelings and care arrangements. (Good Practice) Following the referral MGGM contacted the school nursing service who was proactive in undertaking further EHE checks and this contributed to positive information sharing with CSC. (Good Practice).The referral was accepted with a plan to progress to a child and family assessment. The information shared by MGGM and MGM was conflicting as to Child 9’s domicile and the family circumstances leading to Child 9 going missing. 27. Child Sexual Abuse Disclosure: On the 10th August 2018, Child 9 and MGGM attended the GP’s surgery, requesting a pregnancy test. She disclosed sometime between 8th and 15th July 2018, whilst visiting her mother (LA3) she had been sexually abused/raped by a 15 year old male (offender 1). Offender 1 was alleged to be her mother’s friend; they were in a relationship. Information highlighted her mother knew of the incident and had stated Child 9 was “lying and the boy is lovely”. The incident was reported to have occurred after she had been given alcohol and tablets and whilst recovering from the effects of a hangover. The GP followed practice guidelines and made a safeguarding alert. Child protection processes were followed and Child 9 was medically examined at SARC 1.23 The outcome was indicative she had experienced child sexual abuse. Police Force 1 led the criminal investigation, as the incident had occurred in LA3. Child 9 was offered access to short and long term support by a local rape and sexual abuse support centre.24 The GP was informed of this provision should Child 9 request access in the future. Subsequently Child 9 did not access the provision. Child 9 thought at that time she was fine and did not want any support “as she could speak to her family”. On the 25th September, CSC (LA2) were advised by Police Force 1 no further action would be taken and the criminal case would be pended. CSC (LA2) received further information of intimidatory behaviour as a result of this incident towards Child 9 and her family by friends and the family of offender 1. Child 9 was distressed as a result of this intimidation. There is no evidence of further action taken to support Child 9. 28. In line with expected practice a strategy meeting was coordinated and a plan to undertake section 47 enquiries to ensure Child 9 was safeguarded. The outcome of the initial enquiries were; Child 9 would continue to live with MGGM and MGU, a child and family assessment would be undertaken and an initial child protection case conference (ICPCC) would be convened. The family were asked not to allow Child 9 to spend time alone with MGU. Intelligence was being investigated regarding MGU and inappropriate behaviours that could pose a risk to Child 9. In addition, Police Force 2 were investigating an allegation of a sexual assault that occurred in May 2018, against MGM by MGU. Child 9 denied MGU had ever done anything to her when asked by MGGM. It is not known whether Child 9 was ever spoken to alone by a social worker assessing these issues. MGGM did not believe MGU was a risk, although she agreed not to allow MGU unsupervised access or to provide care to Child 9. MGGM was advised should Child 9 go missing this should always be reported. 23 The service offers a paediatric SARC service staffed by paediatricians, paediatric nurses, and other staff. 24 Provided by a registered charity that aims to provide crucial specialist support, independent advocacy, counselling, help and information for those affected by rape, sexual assault/or abuse> downloaded 12th January 2022. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 12 of 28 29. The safety plan regarding MGU’s contact with Child 9 was unrealistic given MGU and MGGM lived together in a two bedroomed property, with Child 9 sharing a bedroom with MGGM. Practitioners involved should have been “thinking the unthinkable” due to intelligence about the family’s potentially dysfunctional relationships. Practitioners should have heightened their curiosity regarding family functioning, rather than accepting MGGM’s agreement at face value. There had been discrepant messages verbalised by Child 9 regarding the familial relationships and MGGM had stated she did not believe MGU to be a threat despite the ongoing investigations Therefore, it should have been hypothesised until proven otherwise she was unlikely to follow the safety plan which in reality was not realistic. (LP7) Learning Point 7: The use of hypothesis in safeguarding assessment and planning work is crucial. Reflective practice supports practitioners analysis about a child’s experiences rather than accepting what is presented at face value. Practitioners should have been “thinking the unthinkable” due to the information received about the family’s dysfunctional relationships and Child 9’s discrepant messages in respect of her relationships rather than the acceptance of MGGM’s agreements at face value. 30. Child Protection Process (LA2): The social work report prepared for the ICPCC was comprehensive. It described Child 9 and MGGM as having “a good relationship” and Child 9 as a happy and confident child who took pride in her appearance. It highlighted key areas of concern related to family functioning and identified risk factors regarding MGGM’s capacity to provide care in the long term to Child 9. The report identified concerns relating to EHE and the lack of concern expressed by MGGM when she went missing or exhibited distressed behaviours. It recommended Child 9 should become subject to child protection planning under the category of sexual abuse. 31. On the 6th September, ICPCC members unanimously decided Child 9 should be made subject to child protection planning under the category of emotional abuse. It is unclear why a decision was taken to change the category despite the social worker recommendations and Child 9’s recent sexual assault experience. CSC (LA2) as part of its improvement programme has completed an audit of child protection planning categories and undertaken development with conference chairs to ensure understanding of the nature of concern is clear within case conferences. Multiagency conference members also have a responsibility to reflect on the information presented during a conference, however there was no evidence of dissent or constructive challenge by conference members. (LP8) In line with expected practice the core group membership was identified and an initial protection plan was formulated. The child protection plan was; inclusive of safety planning, recommended the involvement of a family intervention worker, strategies to support MGGM should Child 9 go missing, suggested further risk assessment of MGU and management of Child 9’s general health. 32. The child & family assessment was completed in line with expected practice. CSC(LA2) allocated two practitioners to undertake family intervention work, one working with MGGM and the second with Child 9 (Good Practice). The intervention methodology used was the triple p positive parenting programme25. The whole course could not be delivered as a number of sessions were cancelled by MGGM. However, during a practitioner conversation, it was highlighted the practitioners were not concerned about MGGM’s intention to keep Child 9 safe and that MGGM did everything asked of her. It was difficult to secure Child 9’s engagement, she was shy and reluctant to work with the practitioners. The work undertaken was based around managing the risks relating to missing episodes. 25 The Triple P Positive Parenting Program is a parenting and family support system designed to prevent as well as treat behavioural and emotional problems in children and teenagers. It is delivered to parents of children up to 12 years with a teen program for older children downloaded https://www.triplep.net 3.2.22 LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 13 of 28 33. Subsequent review and core group meetings were convened in line with the local child protection pathway. However multiagency representation was not always sufficiently evidenced in the meetings. This would have impacted negatively on information sharing, case analysis and communication as Child 9’s situation became more complex. Attendance and active participation in child protection meetings should always be a priority for universal services when working with children with complex and escalating safeguarding needs. The core elements of the plan were developed during the core groups, however, there was insufficient focus on the counselling for Child 9 following her allegation of rape which should have been a central consideration to reduce the risk of post-traumatic stress disorder. She later disclosed that from July 2018 she was regularly subjected to child sexual abuse at home by family friends, counselling or therapy may have provided the environment for an earlier disclosure. (LP8) Learning Point 8: During the ICPCC it is unclear why the decision was taken Child 9 should become subject to child protection planning under the category of emotional abuse when there was dominant evidence to support child sexual abuse. This resulted in less focus on planning support to aid her psychological recovery following her allegation of rape. The focus on her traumatic experience of child sexual abuse started to become obscured. Children’s services (LA2) have made improvements; undertaking audit and development work to ensure conference chairs categorise cases accurately. Multiagency partners also have a responsibility to reflect on information presented during child protection meetings and should confidently challenge decisions made. There was no evidence of reflective practice or challenge by multiagency partners. Attendance at child protection meetings (core groups and review case conference) across both areas was not always reflective of services involved with Child 9 and her family. The reason for non-attendance is unclear. However, these meetings are the forums to coordinate multiagency planning and ensure interventions for children who are subject to child protection planning are demonstrating better outcomes for children. Attendance and active participation should always be a priority for services to ensure effective information sharing when working with vulnerable children whose daily experience can rapidly change. Improvements in attendance and participation by multiagency practitioners should be monitored. 34. Re-entry into Secondary Education: In November 2018, Child 9 re-commenced mainstream secondary education in secondary school 2. Within a few days she had begun to exhibit distressed behaviours which were described as “manipulative” and she began to truant school. (LP3) Despite MGGM’s agreement with CSC (LA2) there was evidence Child 9 was being picked up from school by MGU and this should have been recognised as evidence of non-compliance to the safety planning. CSC (LA2) also received an anonymous contact detailing an incident involving Chid 9 when an adult, thought to be a family member was seen “shouting, swearing and aggression to a child” Additional concerns were expressed with the referrer saying “ MGU drink drives with the child”. (LP10) 35. Escalating Safeguarding Risk: In the weeks following the ICPCC the escalating risks for Child 9 were documented in agency records. Shortly after the conference, Child 9 went missing for two nights. The police found her at the home of a 17 yr old male (offender 2), who lived with his mother. At the time there was insufficient evidence of professional inquisitiveness or challenge, given the age difference. (LP9) Child 9 wanted to stay another night, which was agreed by MGGM. This agreement should have heightened professional curiosity in respect of MGGM’s parenting capacity and Child 9’s safety. There was no evidence of professional enquiry regarding MGGM’s ability to manage the risks or understanding gathered in respect of her motivation in allowing Child 9 to stay another night. (LP10) Child 9 disclosed “she had been stressed” following the recent sexual assault incident and needed some ”head space” from her family. She disclosed taking two overdoses but had no desire to self-harm. Further specialist assessment was not sought nor were interventions provided to assess or support Child 9’s emotional wellbeing. (LP8) In subsequent child protection meetings her association with offender 2 was regularly referred to as a relationship which detracted the focus on Child 9 as a victim of child sexual abuse. The use of victim blaming language has previously been highlighted in this review (LP3) LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 14 of 28 Learning Point 9 : During her initial missing from home incident the police found Child 9 at the home of a 17yr old male (offender 2), who lived with his mother. Their association was initially queried and their denial of a sexual relationship accepted. There was insufficient evidence of professional curiosity regarding their sleeping arrangements, or the power imbalance given the age difference at the time or during later professional discussions. Learning Point 10: In September 2018, Child 9 went missing from home. When found she wanted to stay for a third night, which was agreed by MGGM. This decision was not in the spirit of the safety planning and should have heightened professional curiosity in respect of MGGM’s parenting capacity. There was no evidence of professional enquiry to understand MGGM’s motivation in allowing Child 9 to stay another night. This was a missed opportunity to reflect on MGGM’s behaviours as being reflective of disguised compliance behaviours. Practitioners should always recognise that disguised compliance may be a hypothesis in safeguarding case work and remain cautiously optimistic until parenting capacity is robustly assessed. 36. In September 2018, following the initial missing from home incident a referral was made to the missing and child sexual exploitation service (LA2) 26 to provide Child 9 with keep safe intervention. The return interview was convened (13 days later) and Child 9 reported she felt safe whilst missing. Ongoing keep safe work was undertaken, a needs assessment completed 9 weeks later. She was assessed to be at “moderate risk” and it was documented she was feeling overwhelmed by the professional involvement. On completion of the assessment professional concerns were expressed by the police and the social worker that Child 9 was not being honest about the relationship with offender 2 due to the age gap. On the 5th January it was assessed Child 9 was at medium risk during another child exploitation meeting (LA2) with a plan to share relevant information with the safeguarding team (LA1) as Child 9 had moved to the area. 37. In December 2018 during the review case conference, it was documented some practitioners raised concerns that Child 9 was at risk of child sexual exploitation. The documentation again described her being in a “relationship” with offender 2 rather than using language to describe her as a victim of child sexual abuse. Further information was requested in respect of offender 2 due to concerns about his behaviour towards Child 9. 38. On the 16th January 2019, during a child exploitation review combined core group meeting Child 9’s risk of child exploitation was changed to low. There was no further evidence of Child 9 going missing. Child 9’s truancy from education was discussed and the police were investigating allegations against Child 9 in relation to sending malicious texts and bullying. There were concerns MGGM may not be reporting all missing episodes and health records identified multiple concerns for Child 9’s welfare but suggested there was “no real evidence” of exploitation. There was repeated evidence of the use of victim blaming language being used by practitioners. Descriptions such as “manipulative,” “in a relationship with an 18 year old male” were observed in records. This language detracted from Child 9 being seen as a victim of child sexual abuse or at risk of child exploitation. (LP3) A decision was taken her case would not to be formally transferred to the child exploitation team (LA1). An action was taken the social worker would ensure the child exploitation team (LA1) were aware of the work that had been undertaken in LA2 as further monitoring may be necessary. 39. The decision to de-escalate her risk of CSE at this time is not understandable. It was not based on a robust reflective analysis of the risks she faced, the intelligence known or MGGM’s capacity to maintain her safety but simplistically on the number of disclosed missing from home episodes. LA2 has improvement planning in place to provide assurance this situation is not replicated. This will again be discussed later in the review. (LP14) 26 LA2’s Missing and Child Sexual Exploitation Service that works alongside young people, their families and the police to find out what has caused them to run away and prevent them from running away again in the future downloaded 28th January 2022. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 15 of 28 40. Case Transfer to LA1: During the Autumn 2018, MGGM began bidding for houses across the border (LA1) due to relationship problems in the community. The police were investigating two community incidents relating to alleged inappropriate behaviours by MGU. On the 19th December 2018, it was known the family had moved, although CSC (LA2) had not been formally notified by MGGM. On the 29th December, at the core group a plan was to make transfer case request and it was noted Child 9 was happy in her new home. The case was formally closed in August 2019. 41. In January 2019, prior to the case transfer, Police Force 2 began an investigation due to an allegation of bullying against Child 9 by another child in the school. A crime was recorded against Child 9 and the matter referred to the neighbourhood unit who made follow up visits. On 29th January, the school received social media information from other pupils, who had seen photographs which provided intelligence Child 9 was in a sexual relationship with offender 2 and might be pregnant. This notification was managed by Police Force 2. Comprehensive police checks occurred including a discussion with Child 9 and MGGM who denied being pregnant or in a relationship with offender 2. A strategy meeting was not convened which would have been expected practice. This incident was referred through to the CSE team (LA1) but not heard till after the transfer in ICPCC. The SW manager (LA1) was present and agreed the allocated social worker would explore the CSE concerns. However, the case remained unallocated to a social worker due to workforce capacity for around three months. 42. In conclusion; the period between 1st May 2018 to 7th February 2019 must have been a challenging time for Child 9. She had commenced secondary school 1, however her distressed behaviours were difficult to manage as education tried to balance her needs with the associated risks to the school population. Planning was underway to support her in education however MGGM chose to remove her under the pretext of EHE. There were EHE monitoring systems in place however the two failsafe notification mechanisms were not sufficiently responsive or effective across local authority boundaries to be able to assure agencies of the education plans for Child 9. 43. The level of adult supervision for Child 9 was of concern. Child 9 was free to move around the community and across local authority boundaries for eleven weeks. She is now known to have stayed at differing family homes whilst travelling alone to and from the differing local authorities. MGGM was known to be struggling to provide care for her on a daily basis and Child 9 had discussed some of her adverse family experiences. There was a positive safeguarding response by the EWO manager (LA2) which effectively triggered multiagency child protection processes. During her EHE period Child 9 was in contact with her birth mother, was a victim of rape whilst staying with her mother in LA3 and was then a victim of intimidation by the perpetrator’s relatives after she reported the incident. There was no criminal prosecution in respect of these incidents and her mother did not believe her. During professional contact with Child 9 a hypothesis emerged that her family was supportive so she did not require the support of SARC services. This was accepted at face value rather than gathering greater understanding of the child’s daily experience. Safety planning with MGGM could not be effective as MGGM would say what she believed practitioners needed to hear. An example being she agreed for MGU not to be in contact with Child 9 but she did not believe MGU was a risk. MGU started picking Child 9 up from school. There is no evidence this was ever challenged. The preference was to believe information given at face value by family members rather than gaining a deeper understanding of family functioning or the adults’ capacity to provide Child 9 with a safe environment. 44. Once the child protection process (LA2) were triggered a robust children and family assessment was completed which accurately highlighted Child 9’s risks of sexual abuse and the family’s capacity to keep Child 9 safe. The child protection meetings were coordinated according to expected guidance, however, over time there was significant limitations in how the case was managed. Attendance at core group meetings by multiagency practitioners was not consistent. Ongoing reflective analysis/constructive challenge by multiagency practitioners was not evidenced within case-management supervision or within subsequent child protection meetings. There were indicators of the CSE/CSA risks Child 9 faced yet she remained registered under the category of emotional abuse. There was limited focus on her risks of sexual abuse. The planning process followed was unclear, plans were developed but it is unclear how the outcomes were evaluated. A growing body of LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 16 of 28 information was available but “the “jig saw” was not put together so the risks were ineffectively managed at all levels. Child 9 and MGGM were invited to and attended the relevant meetings. It was known that MGGM demonstrated behaviours related to “disguised compliance” but it is unclear whether Child 9 was ever spoken to alone or whether she was at the centre of the planning process. Once the family had decided to move areas Child 9 had thought this would mean they would not be subject to the same level of scrutiny. In practice when they moved this seemed to happen and despite the indicators of risk her case was de-escalated by the specialist CSE team. During the transfer period the social worker was unable to secure management oversight as risk incidents were arising. CSC (LA2) has now implemented improvements to assure case management scrutiny. 45. Throughout this period there was documentary evidence of the use of “victim blaming” language which may have contributed to Child 9 being perceived as challenging rather than a troubled young person at risk of abuse. There were workforce capacity issues and service transformation which may have impacted on practitioners capacity to respond effectively at that time. 3.3 Child 9: Events 7th February to 11th December 2019 whilst resident in Local Authority 1. 46. LA1 Child Protection Processes: On the 7th February documentation clarified the transfer-in ICPCC was convened in line with expected timelines, however, it was not clearly documented when the agreement to accept the case was agreed. The concerns relating to Child 9 as a victim of child sexual exploitation, including the possible un-assessed risk of pregnancy and MGGM’s ability to keep Child 9 safe were all discussed. Her association with offender 2 was considered, although victim blaming language continued to be used when referring to her association with offender 2 as a “relationship”. This underplayed the risks relating to child sexual abuse. (LP3) CSC (LA1) now undertakes a monthly record audit to check the quality of practice and the use of inappropriate language. A decision was taken to register Child 9 under the category of emotional abuse and her case was not transferred to the local CSE multiagency team. CSC (LA1) has re-issued guidance around the management of case transfer to support responsiveness and improvements in case management. The outcome of audit measures demonstrate an upward trend in improvements. 47. Core group meetings were convened but initially not always in line with practice guidance. This improved following the allocation of the key social worker, around 3 months after transfer. Practitioner participation at core groups was not always reflective of service involvement for example; police, CSE and child and mental health (CAMHS) practitioners were not in attendance. (LP8) There was positive evidence of participation by school nursing and education. During the initial core group meeting it was recognised Child 9 would benefit from support of SARC services. Secondary school 2 made a referral to the regional SARC service 2, which was a different service to the one Child 9 had previously accessed. The use of victim blaming language was again documented within some core groups which may have detracted from Child 9’s being perceived as victim child sexual abuse. (LP3) In June, the documentation highlights practitioner concerns which were escalated to the newly allocated social worker after MGGM and Child 9 had left the core group. The specific nature of these concerns is not clearly documented and conversations with involved practitioners has not been possible. During a core group (September) there were concerns MGGM was not adhering to elements of the safety plan. All these concerns should have prompted practitioners to focus on greater understanding of MGGM’s capacity/motivation to keep Child 9 safe and provided the opportunity for case escalation through agency supervision processes or by legal services. 48. The delay in case allocation and ineffective multiagency participation impacted negatively on case coordination, interagency communications, information sharing and risk management as Child 9’s situation became more complex. At the time there were significant workforce capacity issues in CSC (LA1). Improvement planning is ongoing to create a stable workforce. New quality effectiveness systems have been developed throughout CSC inclusive of the conference chair’s unit to provide assurance of improvements in case oversight when children are subject to child protection planning. Performance monitoring measures should become embedded in governance arrangements to ensure children who transfer in and are subject to child protection planning are responsively allocated a key LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 17 of 28 social worker and that case oversight remains a focus to ensure optimal outcomes during and following case transfers. (LP11). Learning Point 11: When Child 9’s case was transferred to LA1 there was a delay in case allocation by CSC and ineffective multiagency participation impacted negatively on case coordination, interagency communications, information sharing and risk management at a time her situation was becoming more complex. Significant workforce capacity issues in CSC (LA1) was a factor. Improvement planning is ongoing to create a stable workforce. New quality effectiveness systems have been developed throughout CSC, with the conference chairs unit provides assurance of improvements in case oversight when children are subject to child protection planning. Performance monitoring measures should become embedded into ongoing governance arrangements to ensure children who transfer in and are subject to child protection planning are responsively allocated a key social worker and that case oversight remains a focus to ensure optimal outcomes. 49. Subsequent review case conferences were coordinated in line with practice guidelines. The decision was taken that Child 9 should remain subject to planning under the category of neglect. It remains not understandable why this category was used when there were significant indicators, she was a victim of child sexual abuse. She had been referred to the local CSE team and offender 2 had been served with an abduction notice to prevent him being in contact with Child 9 by the time the initial conference took place. Police Force 1 were not represented. Police attendance at case conferences was at that time dependent on the outcome of risk assessments undertaken locally by case management teams CAMHS had undertaken an assessment due to concerns for Child 9’s mental health, agreeing the plan for her to be supported by regional SARC services, however the service also was not represented. Multiagency participation was not representative of the service involvement. As part of quality effectiveness improvement measures the function of conference chairs should be reviewed to ensure there is adequate opportunity for case reflection in relation to the categorisation of abuse and planning to secure optimal outcomes. There was no evidence of multiagency discussion/challenge related the categorisation of registration. Conference attendees should always actively participate in discussions, actively reflect on the information presented and be prepared to constructively challenge decisions made during the conference process. This practice expectation has not been evidenced during this review. (LP8) 50. In the months following the case transfer there was evidence of Child 9’s and MGGM’s participation in child protection meetings although it is unclear how they were involved in the subsequent planning. GMP coordinated regular CSE DGM meetings to share relevant intelligence to which some practitioners where invited. However, the review has identified there are significant challenges in ensuring all involved practitioners are able to participate in the range of meetings held or have access to the information shared. The commitment to attend meetings remains a challenge for many multiagency practitioners due to a complexity of reasons including workload capacity. This remains an area for improvement. 51. Exclusion from School: In early 2019, following two periods of education exclusion, Child 9 was referred for additional targeted educational provision.27 The key issues identified were; relationships with peers, engagement in learning and adhering to staff instructions. Following a lesson observation, a pastoral support programme was initiated working with Child 9 on a weekly basis. Included in this programme were 6 sessions of Change Your Mind 28 intervention. Child 9 engaged well and was able to use the techniques learned whilst in school. She expressed; her desire to have a better life in school, demonstrated self-awareness but at times struggled to regulate her responses. As the school year progressed the adverse incidents decreased, better attendance in lessons was noted and her relationships with peers improved. Effectively the intervention had ceased by the autumn term and 27 Targeted Education Support Service is specialist, qualified, experienced teachers and educational practitioners who work with schools to support children and young people when learning, emotional or mental health are causing concern. The service is bought in bi local education providers. 28 Change your Mind intervention is a type of cognitive behavioural therapy. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 18 of 28 her case was closed to the pastoral support programme. This intervention appeared to have contributed to achieving positive outcomes for Child 9. (Good Practice) 52. The recognition of the need to maintain Child 9 in education through the use of alternative strategies was positive intervention. Research 29 has identified exclusion as an adverse approach for vulnerable children and potentially increases the risk of child sexual abuse and exploitation due to children having more unsupervised time within communities. (LP12) If education is considering exclusion, this practice should be avoided. There should be robust multiagency engagement to discuss alternative solutions, including opportunities to support the young person’s emotional welfare as well as interventions to reduce the risk. Learning Point 12 : Exclusion30 has been shown to have a negative impact on a child’s emotional wellbeing, can further isolate a troubled child, creating opportunities to increase the risk of CSE/CSA. Child 9 was subject to exclusion in both secondary schools, however during these periods we now also know she was also at significant risk of harm due to child sexual abuse/exploitation. If education is considering exclusion, this practice should be avoided. There should be robust multiagency engagement to discuss alternative solutions, including opportunities to support the young person’s emotional welfare as well as interventions to reduce the risk. 53. Missing From Home: One day in April, Child 9 was seen by education practitioners going towards the area (LA2) where offender 2 resided, rather than being in school. She had been reported missing by MGGM. Following the missing episode and in line with expected practice Police Force 3 had served a child abduction warning on offender 2 and informed Police Force 2 who created an intelligence record in line with expected practice. There was evidence of valuable information sharing between the school and the Police Force 2 and across boundaries with Police Force 3 at this time. The attending police recognised Child 9’s distress linked to the trauma of the previous sexual assault and made a CAMHS referral the same day. (Good Practice) CAMHS was responsive offering a same day appointment but Child 9 could not attend. Safety planning was undertaken with MGGM and a home visit undertaken to complete an initial mental health assessment the following day 54. During the mental health assessment Child 9’s distress was well documented. She discussed the trauma following the rape incident, her challenges in education causing her to have suicidal thoughts and her self-harming behaviours. The outcome of the assessment was that the impact of sexual harm due to the sexual assault was the key factor in Child 9’s unhappiness. The plan to support her through SARC 2 was thought to be the best intervention. (Good Practice) This plan was discussed and agreed with MGGM who agreed to support Child 9. At this time CAMHS referred Child 9 onwards to the local young people’s advocacy service . It is unclear why Child 9 was not enabled to access the support that had been previously offered by SARC 1 which will be discussed in the next section of this report. 55. Provision of SARC Services: In February 2019, Child 9 had been known to SARC 1 services and a few months later she was referred for the support by SARC 2 services. SARC 1 had made arrangements for Child 9 to access the provision should it be needed in the aftermath of the sexual assault she had experienced in August 2018. These arrangements had been shared with her GP. However, the family then moved to LA1 and changed GP practice. It is unclear whether involved practitioners or the core group knew about the previous offer of SARC 1 service provision or whether the referral was made to the SARC 2 services as that was the provision normally accessed by children locally. The review process has not been able to secure conversations with the services. 56. The core group and the CAMHS practitioner assessed SARC 2 services would provide the most beneficial provision to support Child 9. CAMHS had withdrawn in the period believing the SARC 2 services would be a responsive provision. In October 2019, secondary school 2 followed up the 29 NCMD (Oct 21) Suicide in Children and Young People, Data from April 2019 to March 2020. 30 NCMD (Oct 21) Suicide in Children and Young People, Data from April 2019 to March 2020. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 19 of 28 progress regarding the SARC referral. The delay in offering provision was due to the capacity within the service which was then undertaking other child sexual exploitation work. An initial contact was offered at the end of November 2019. Child 9 had said she did not want MGGM to accompany her so the allocated social worker agreed to go with her. However, for reasons unknown to the review the social worker could not accompany Child 9 on the day. She was accompanied by MGGM. Child 9 and MGGM stated the situation had improved and Child 9 declined counselling. It is not known whether the counsellor alone saw Child 9. There was a subsequent delay in the counsellor contacting the allocated social worker to discuss concerns arising during the appointment. The counsellor was told by the social worker MGGM “puts pressure on Child 9 to not accept counselling”. However, by this time Child 9 had become a looked after child. Documentation suggests during communications victim blaming language was used again referencing Child 9 being in a “relationship” with an 18 year old male. For reasons unknown this referral/contact was not scanned electronically onto the SARC 2 system as would be an expectation of practice. 57. The provision of regional SARC services includes therapeutic support to enable the recovery of children who are victims of child sexual abuse. The SARC 2 regional service could not be sufficiently responsive to be able to support Child 9 in her recovery. This provision may have provided an opportunity for Child 9 to gain trust and disclose her ongoing experiences of CSA/CSE. A key question for the partnership should be ; Do local children who victims of CSA/CSE have access to specialist therapeutic provision to support their recovery and can this service be sufficiently responsive to meet their needs. The review process has not been able to secure conversations with the service to assure the accessibility of this provision for local children The accessibility and effectiveness of this provision in providing therapeutic support for local children should be assured (LP13) Learning Point 13: The provision of regional SARC services includes therapeutic support to enable the recovery of children who are victims of child sexual abuse. The regional service was not sufficiently responsive to be able to support Child 9 in her recovery as a victim of CSA and rape. This provision may have provided an opportunity to disclose her ongoing experiences of CSA/CSE. The review process has not been able to secure conversations to assure the accessibility of this provision. This accessibility and effectiveness of this provision in the provision of therapeutic support for local children should be assured. 58. Child 9- The Escalation/De-escalation of CSE Risk: As previously discussed Child 9’s case had been de-escalated by LA2’s CSE team prior to the case transfer as it had been assessed Child 9’s risks related to CSE had reduced; the main factor being less reported missing from home episodes. (para 38) In February 2019, during a local GMP CSE meeting (CSE DGM) a child protection social work manager was in attendance who agreed Child 9’s child protection social worker (CPSW) would share information with LA1’s CSE multiagency team. The CPSW would then manage the CSE risks highlighted by her secondary school (January 2019) in respect to ongoing contact with offender 2. There was a delay in allocating her case to CPSW however the CSE DGM meetings continued to review the intelligence in respect of offender 2, highlighting the risks in relation to Child 9. 59. In April, following a CSE DGM meeting her case was opened by the multiagency CSE team (LA1), with a meeting scheduled for May 2019 to plan intervention. There were concerns at that time offender 2 was breaking the terms of the abduction notice in regard to his contact with Child 9. The GMP CSE DGM meetings were effective in tracking and recording the outcome of the CSE risk assessments and her risk was set at medium. Information sharing was effective by Police Force 2 with multiagency partners and the case conference process. Her case was de-escalated from s CSE team (LA1) in August 2019 as the score31 placed her at low risk of CSE; she engaged well within sessions and her knowledge base was thought to have increased. The work was home based despite previous 31 The Phoenix Project uses a child sexual exploitation measurement tool used across Greater Manchester to support a collaboration of 3rd sector and the public sector partners in their risk assessments when working with young people at risk of CSE. The project is led by GMP. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 20 of 28 suggestions that it should be undertaken away from home and MGGM’s influence. Child 9’s CSE worker did not attend the core group meetings which were relevant to the child protection planning especially around CSE. At that time whilst a CSE worker was assigned to the case, the allocated CPSW was managed by a different service which may have impacted on the focus related to CSE. Practice has now changed with a social worker being co-located within the CSE team (LA1) thereby providing improved scrutiny of cases that are also subject to child protection planning. 60. In June 2019, offender 2 engaged in malicious communication with Child 9; making attempts to contact her, demanding the return of gifts. When Child 9 asked offender 2 not to make contact, the offender made threats against her so she informed the police. Further intelligence provided evidence offender 2 had shared an inappropriate photograph with one of Child 9’s peers. This issues were shared effectively with relevant multiagency practitioners and partnerships. (Good Practice) In July 2019, Police Force 2 received further intelligence from Police Force 3 linking Child 9 to an incident. It was alleged Child 9 had taken two young girls (aged 13yrs and 15yrs) to meet offender 2. The 13yr old girl was alleged to have been sexually abused, through intercourse, by offender 2. The intelligence indicated offender 2 and Child 9 were in regular contact. A strategy meeting was coordinated. In September 2019, additional intelligence was received from Police Force 3 to confirm offender 2 remained in contact with Child 9. The use of victim blaming language was again used as this contact was determined to be a “relationship” which detracted from Child 9 being seen as a victim of child sexual abuse. A delayed strategy meeting was coordinated (9 days). There was some confusion as to whether her case was re-referred or accepted into the local CSE team. However, the outcome was that Child 9’s case was not allocated by the CSE team for further assessment or intervention. 61. Child 9’s case was de-escalated by the CSE team (LA1) despite significant intelligence offender 2 was making contact with Child 9. A notice had been served on offender 2 in an attempt to disrupt his association with Child 9. The CSE worker was not linked into the child protection multiagency planning arrangements and whilst Police Force 2 provided information they were not in attendance at crucial child protection meetings. The de-escalation decision appears to have been based on Child 9’s willingness to engage in the work programme and her understanding of the issue rather than deeper reflective analysis of the risks she faced from a potential offender and MGGM’s failure to safeguard. Since this case has been highlighted an improvement plan has been developed to improve the effectiveness when working with children at risk of CSE. The improvements include; • A review of the step up / step down pathway arrangements and the development of practice standards relating to CSE • The development of whole service transition arrangements and re-structure of the service • The development of thematic performance clinics to review children subject to CSE monitoring. • A regional audit review and learning group are undertaking a multi- agency audit around CSA to consider learning and development themes arising The partnership should be assured the planning is sufficient to secure optimum outcomes for children at risk of CSE. (LP14) Learning Point 14: In both local authority areas Child 9’s case was de-escalated by the local CSE teams despite significant intelligence in relation to offender 2’s behaviours and his intention to sexually abuse Child 9 under the pretext of a “relationship,” The decision was not based on a deeper reflective analysis of the risks Child 9 faced or her MGGM’s capacity to protect her but on simplistic indicators such as the number of missing from home episodes or her engagement in intervention. Since this case has been highlighted improvement plans have been developed and their implementation is ongoing to assure effectiveness when working with children at risk of CSE. The partnerships in both local authority areas should be assured the planning is sufficient to secure optimum outcomes for children at risk of CSE. 62. Escalation into Legal Proceedings: Following Child 9’s disclosure in school in December 2019 the police, education and CPSW were responsive and followed due process in respect to the referral. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 21 of 28 The key CPSW informed education practitioners a police protection order (PPO) could be secured and would discuss this with the appropriate manager. There is no evidence a PPO was secured and Child 9 was placed in foster care under a Section 20 order. 32 However, Child 9 went missing from her foster placement within 4 days of arriving. She then stayed with MGM and then with MGGM. A few days later Child 9 returned to her foster carer The CPSW tried to secure a court slot to instigate care proceedings but there were significant delays due to the holiday period. During January 2020, Child 9’s family members continued to make contact urging her to “change her statement” and by shouting at her. 63. At the time management oversight of the case was not robust and the CPSW was unable to escalate the case to assure Child 9’s safety which resulted in ongoing intimidation by family members. As part of the improvement planning there is now more robust management scrutiny of such cases to ensure more responsive case escalation into legal proceedings. Assurance should be provided that practice guidance has been reviewed and provides a clear pathway to follow when case escalation into legal proceedings is required (LP15) Learning Point 15: Case escalation into legal proceedings was not supported through management case supervision in children’s social care. As part of the improvement planning there is now more robust management scrutiny of such cases to ensure and support more responsive case escalation into legal proceedings. Assurance should be provided that practice guidance has been reviewed and provides a clear pathway to follow when case escalation into legal proceedings is required 64. In conclusion; In February 2019 Child 9’s risks of child sexual exploitation and her carers ability to keep her safe were known. Despite this during the ICPCC she was registered under the category of emotional abuse and her case was not formally transferred to the local CSE multiagency team. The delay in allocating a key social worker may have impacted on the coordination of core groups. Two review case conferences were coordinated in line with practice guidelines. It is not understandable the category of emotional abuse was assigned when she was a clearly a victim of child sexual abuse. Multiagency representation within these meetings was not always representative of service involvement and although practitioner concerns were highlighted case escalation during agency case management supervision was not evidenced. 65. Child 9’s and MGGM’s participation in child protection meetings was evidenced although it is unclear how they were involved in the subsequent planning. It was known that MGGM ‘s actions did not always equate to the plans she had agreed to follow. Following two periods of education exclusion, Child 9 was referred for additional educational provision. This intervention appeared to have contributed to achieving positive outcomes for Child 9. The recognition of the need to maintain Child 9 in education through the use of alternative strategies was positive intervention. Research has identified exclusion as an adverse approach for vulnerable children and potentially increases the risk of child sexual abuse and exploitation. 66. In April, Child 9 went missing and was found at the home of offender 2. Police Force 3 served a child abduction notice on offender 2. Police Force 3 also made a CAMHS referral the same day. Safety planning was undertaken with MGGM and a home visit undertaken to complete an initial mental health assessment the following day. During the assessment Child 9’s distress was well documented and included trauma following the rape, suicidal thoughts and self-harming behaviours. The impact of sexual harm due to the sexual assault was the key factor in Child 9’s unhappiness. The plan to offer her support through SARC 2, was thought to be the best intervention. It is unclear whether involved practitioners knew about the previous offer of support from SARC 1. Unfortunately, due to the limited capacity the service did not offer an appointment until November 2019. The accessibility and effectiveness of this provision in providing therapeutic support for local children should be assured. 32 Section 20 of the Children Act 1989 provides the local authority with the power to provide accommodation for children without a court order when they do not have somewhere suitable to live. It is known as voluntary accommodation because the parents must agree to the child being accommodated LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 22 of 28 Whilst her case was opened to the local CSE team and she was assessed as medium risk of CSE her case was de-escalated after a brief period of intervention. This was despite the Police Force 2 intelligence that offender 2 remained a risk. Requests to re-open her case to the CSE team later in the year were not effective. 67. Throughout this period the use of victim blaming language was used. Following Child 9’s disclosure in school in December 2019 the police, education and social worker were responsive. A police protection order was not secured and Child 9 was placed in foster care under a Section 20 order. At the time management oversight of the case was not robust and the social worker appeared unable to escalate the case to assure Child 9’s safety which resulted in ongoing intimidation by family members towards her. 68. During this period there were significant challenges in CSC (LA1) in maintaining a stable workforce with sufficient capacity to undertake the range of work. The area has introduced a range of quality effective measures since the rapid review to assure improvements are made in response to the issues this review has highlighted. SECTION 4: CONCLUSION This section will provide an overview of the principal issues for discussion. 69. The multiagency response to support children with complex safeguarding needs who are living with the risk of CSE/CSA on a daily basis is both challenging and complex in front line practice. The commitment, passion, motivation of multiagency practitioners to influence the outcomes for Child 9 was evident. However, the review has identified significant practice and system challenges when supporting children like Child 9 within the current systems and pathways. These challenges are not unique to this case and are understood locally and nationally. Evolving improvement plans are in place across both local authority areas to drive long term and sustainable change. 70. The review has highlighted a number areas of good practice within multiagency working arrangements; LA2’s early help offer is accessible to schools in LA1 when children from LA2 are on the school role, the implementation in LA2 of the Star protocol to track children with safeguarding needs who leave school is a positive innovation, the inquisitiveness and responsiveness demonstrated by EWO service (LA2) in locating Child 9, the inquisitiveness and enquiry about Child 9 demonstrated by the school nursing service (LA2), the allocation of a worker to Child 9 by the family intervention service (LA2), the targeted education intervention provided by secondary school 2, information sharing with multiagency practitioners by the police forces, police force 3 recognition and response to Child 9’s mental distress and the core groups(LA1) attempts to secure trauma based support for Child 9 through SARC services, 71. It is positive the review process has identified many areas of effective communication and information sharing between multiagency services across the local authority areas. This was demonstrated in health, the police and children’s social care. There is also evidence that during the case transfer relevant information was shared so the risks were understood at that time but the delay in the allocation of a CPSW created challenges in securing the ongoing flow on information as Child 9’s case became more complex. 72. The use of victim blaming language was evidenced throughout the timeline of the review. This helped to create the hypothesis that Child 9 had an older boyfriend rather than she was trying to manage the risks of child sexual abuse and exploitation. Her distressed behaviours were not openly recognised as an outcome of her daily journey through life and adverse childhood experience. The inadvertent hypothesis developed was that of a challenging, troublesome child rather than a troubled child. The use of victim blaming language is complex but should be avoided. This is a workforce development need. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 23 of 28 73. The review has highlighted the risks for children who have to manage difficult family lives on a daily basis and are missing from education. The review heard that in front line practice this is an increasing challenge which has been exacerbated by the COVID pandemic. Therefore, a key question for the partnership is are agencies able to keep track and support these children in the longer term until desired outcomes are achieved. Whilst the review has highlighted there are systems in place to monitor children subject to EHE, these were not sufficiently effective (LA1) at the time. Improvement plans are in place locally however the partnership should be assured of their effectiveness. 74. A consistent theme has emerged during the review process in that there was limited evidence of reflective practice in the multiagency work undertaken or child protection processes. There was a growing body of information indicative of the CSA/CSE risks Child 9 faced yet her situation was remained categorised as emotional abuse. Her situation was not effectively analysed or understood during the child protection processes or within front line practice. The preference being to manage issues and plan on a “front facing” basis. Contextual safeguarding enables practitioners to consider a range of hypothesis and the push and pull factors impacting on Child 9 and is a development need. Multiagency case management supervision and scrutiny was not sufficiently robust at that time. The review has been informed that there were challenges in securing a stable workforce and service transformations underway which may have impacted on the opportunity to reflect. Improvements are ongoing. 75. During the assimilation of information there was a range of information known about the family and suspicions about the adults “disguised compliance” behaviours. The review process has identified professional concerns about the adults but not been able to determine how the risks were assessed or how the adults would be challenged. This is a development need for the workforce. 76. It is not understandable why Child 9’s case was de-escalated from the CSE team in both local authority areas. The intelligence made available to this review indicates the CSE risks she had to manage on a daily basis were known at the time. The decisions made to de-escalate were based on a lack of reported missing events despite the suspicion MGGM was not reporting events and that Child 9 had sufficiently engaged in the CSE work. The decisions did not seem to include the intelligence known about offender 2. CSE service improvements have been made across both local authority areas, with regional multiagency CSE review also underway to drive further improvements 77. The review has identified that once Child 9 gained trust she engaged effectively in therapy. It is of concern that her access to sexual assault therapy was delayed. Earlier therapy with Child 9 might have supported an earlier disclosure. The partnership should be assured that restorative work with child victims of rape/sexual assault is accessible for local children. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 24 of 28 SECTION 5: RECOMMENDATIONS 1. The partnership should seek assurance from partners that the learning and recommendations have been responded to and evidence demonstrates improvement to local practice. Improvement plans have currently been shared by children’s services and the safeguarding units (LA1, LA2), Police Force 2, NHS trust (LA1) and secondary school 2. 2. This review has highlighted the multiagency workforce’s ongoing development needs; when working with children who have escalating and complex safeguarding needs, working with troubled children, hypothesis in safeguarding work, reflective supervision and the use of victim blaming language in safeguarding work. 3. The safeguarding children partnership should seek assurance that responsive restorative services are available for children who are victims of rape and sexual assault. 4. Both local authority areas have both introduced governance arrangements to assure improvements in child protection processes. These systems are not embedded so there needs to remain a focus on implementing the improvements. 5. There is a growing concerns for children missing education and children subject to EHE. These issues should be subject to ongoing scrutiny that demonstrate improvements. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 25 of 28 APPENDIX 1: ABBREVIATIONS USED CAMHS Child and Mental Health Services CSA Child Sexual Abuse CSC Children Social Care CSE Child Sexual Exploitation DOLS Deprivation of Liberty Safeguards EHAT Early Help Assessment Tool EHE Elective Home Education EWO Education Welfare Officer GP General Practitioner Services IBP Individual Behaviour Plan ICPCC Initial Child Protection Case Conference KLOE Key Lines of Enquiry LSCPR Local Child Safeguarding Practice Review MGGM Maternal Great Grandma MGM Maternal Grandma MGU Maternal Great Uncle PSP Pastoral Support Programme SARC Sexual Assault and Referral Centres SCP Safeguarding Children Partnership SW Social Worker APPENDIX 2 : INDEPENDENT REVIEWERS BIOGRAPHY Jane Carwardine has worked as an independent safeguarding consultant (children/adult) since April 2015, completing around 25 reviews (serious case reviews, concise practice reviews, thematic reviews, RCPCH invited service reviews). She holds an MA in Child Care Law and Practice (Keele) and a BA Honours in Health Studies (Bolton). Her practitioner background is nursing (nurse, health visitor and midwife now lapsed) with over 42 years NHS experience. She has undertaken a range of NHS strategic, provider and commissioning management roles. Jane had 15 years dedicated specialist safeguarding experience prior to her current role, in a variety of NHS leadership roles. These roles included; senior and line management, named nurse, designated nurse for safeguarding (including adults and children) and head of safeguarding. Examples of previous safeguarding activity includes; supporting the completion of serious case reviews, multiagency safeguarding development leadership, the delivery of safeguarding learning events, safeguarding assurance work with the workforce and exec boards, complex case management scrutiny, the development of multiagency teams, development of reflective supervision systems, development organisational safeguarding advisory teams, membership on safeguarding boards, chairing multiagency safeguarding sub-groups and providing advice to a range of strategic boards. Jane has worked intensively to improve the quality effectiveness of the case review process. She has not been employed by any organisation aligned to this review and has previously undertaken independent consultancy work for each of the local authorities involved. LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 26 of 28 APPENDIX 3: RAPID REVIEW PANEL Organisation Representative Local Authority 1: Safeguarding Children Partnership • Business Manager, (Chair) • Learning and Improvement Officer • Business Support Manager (minutes) Police Force 2 • Detective Constable, Serious Case Review Unit Police Force 3 • Detective Chief Inspector Healthcare NHS Trust • Named Nurse for Safeguarding Children • Safeguarding Children Specialist Nurse Local Authority 2 • Head of Service Safeguarding and Quality Assurance • Education Welfare Service Representative • Head of Service, Social Work Assessment Service Teaching Hospitals NHS Trust • Named Nurse Safeguarding Children Local Authority 1: CCG • Deputy Designated Nurse Local Authority 1 • Service Lead, Practice Improvement & Quality Assurance, Children’s Services • Targeted Education Support Service Representative Local Authority 1: Secondary School 2 • Assistant Headteacher, Inclusion and Welfare Local Authority 1: NHS Trust • Head of Safeguarding • Specialist Nurse, Children’s Safeguarding LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 27 of 28 APPENDIX 4: MEMBERSHIP OF CASE REVIEW PANEL Organisation Representative Independent Reviewer • Lead Reviewer and Chair Local Authority 1: Safeguarding Children Partnership • Business Manager • Business Support Manager/Assistant • Learning and Improvement Officer Police Force 2 • Detective Sergeant Police Force 3 • Detective Chief Inspector Healthcare NHS Trust • Safeguarding Children Specialist Nurse Local Authority 2: NHS Trust • Named Nurse Safeguarding Children Local Authority 2: CCG • Designated Nurse for LAC Local Authority 2 • Safeguarding Coordinator • Head of Service, Social Work Assessment Service • Head of Children & Partnership Work • Head of Service Safeguarding and Quality Assurance Local Authority 1: CCG • Designated Nurse Safeguarding Children & Children Looked After Local Authority 1 • Service Lead, Practice Improvement and Quality Assurance, Children’s Services • Interim Service Manager, CSC Local Authority 1: Education • Assistant Headteacher, Inclusion and Welfare, Secondary School 2 • Targeted Education Support Service Representative Local Authority 1: NHS Trust • Specialist Complex Safeguarding Nurse LSCPR CHILD 9: FINAL VERSION (3/4/22): COPYRIGHT LOCAL AUTHORITY 1 SCP Page 28 of 28 APPENDIX 5 : PARTICIPATION Organisation Representative Police Force 2 • Detective Officer, LA1 Complex Safeguarding Team Local Authority 2: CCG • Designated Nurse for Safeguarding and LAC Local Authority 2 • Head of Children & Partnership Work • Safeguarding Coordinator • Safeguarding Children in Education • Family Intervention Worker • Head of Service, Social Work Assessment Service • Head of Service Safeguarding and Quality Assurance • Head of EWO service • Safeguarding Coordinator, Children’s Safeguarding Unit Local Authority 1: CCG • Designated Nurse Safeguarding Children & Children Looked After • Practice Manager. Local Authority 1 • Service Manager, Multiagency Safeguarding Team & Complex Safeguarding • Head of EWO service • Service Manager, Inclusion • Independent Reviewing Officer • Social Worker, Advanced Child Exploitation Worker, Complex Safeguarding Team • CSE Team • IRO CSC Local Authority 1: Education • Deputy Headteacher, Secondary School 1 • Teacher Targeted Education Support Service Teacher, Secondary School 2. |
NC52786 | Focuses on Charlie's life between October 2019 and February 2022, when Charlie was a child and transitioning to adult services. Charlie was diagnosed with high functioning autism and generalised anxiety disorder.. Learning is embedded in the recommendations.commendations include: all partners should ensure that their staff and teams are aware of the diversity of organisations in relevant agencies and partner organisations, moving away from generic terms such as local authority or health; review the current training on child sexual abuse, ensuring that when professionals are working with a disabled children who are the victims of or witness of sexual abuse the course highlights the increased risk these children are living with due to a broad range of disability; ensure their workers are aware of the vulnerabilities of children who have a disability and are electively mute or non-verbal; assurance that disguised compliance and being able to recognise this early and as well as being aware of what actions to take when sporadic and reluctant or disguised compliance is suspected in embedded in training; monitor attendance at child protection conferences to ensure conferences are quorate with sufficient agencies present to enable safe decisions to be made, escalation should be made immediately; and ensure where there is a medical diagnosis offered as an explanation for the presenting features of neglect, all aspects of the child's health and wellbeing should continue to be considered to avoid the potential for diagnostic overshadowing.
| Title: Child safeguarding practice review: Charlie: review report. LSCB: Pan-Dorset Safeguarding Children Partnership Author: Robin Harper-Coulson Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child Safeguarding Practice Review Charlie REVIEW REPORT Agreed by the Pan-Dorset Safeguarding Children Partnership on 1st February 2023, Published 23rd May 2023 2 Contents 1 Introduction to the case and summary of the learning Page 2 2 Process Page 2 3 Family structure Page 3 4 Background before the scoped period Page 3 5 Key episodes Page 4 6 Analysis by theme and learning Page 8 7 Conclusion and Recommendations Page 26 1 Introduction to the case and summary of the learning from this review 1.1 This Child Safeguarding Practice Review (CSPR) is in respect of an 18-year-old adult to be known as Charlie. Charlie was diagnosed with High Functioning Autism1 and ‘‘likely’’ to meet the Generalised Anxiety Disorder2 criteria in March 2015 by a Private Psychologist. Although this review focuses on Charlie’s life between October 2019 - February 2022 when Charlie was a child and transitioning to adult services, it will also provide a background of information known before the scoped period. 1.2 The learning identified from this review includes: • Children and young people who have a primary diagnosis of autism who also have significant and complex care needs • Children and young people transitioning from children to adult-focused services. • Legal Planning for children and young people with disabilities and complex needs. • Children and young people who display a rapid deterioration in interaction with others. 2 Process 2.1 The Pan Dorset Safeguarding Children Partnership (PDSCP) recognised the potential to learn lessons from this review regarding the way that agencies work together to safeguard children3. It was agreed that this CSPR would be undertaken using a systems theory methodology, which engages frontline staff and their managers in reviewing cases and focuses on why those involved acted as they did at the time avoiding hindsight bias. Agency reports are completed where agencies have the opportunity to consider and analyse their practice and any systemic issues. They provide details of the learning from the case within their agency. Then practitioners, managers and agency safeguarding leads come together for learning events. All agency reports are shared in advance and the perspectives and opinions of all those involved at the time are discussed and valued at the events4. Further interviews were arranged when issues requiring clarification were identified. 1 High-functioning autism generally refers to autistic people who have significantly developed language and independent living skills. What is high-functioning autism? Medical News Today reviewed by N Greene, PsyD — By Z Villines — Updated on October 31, 2021 2 Generalized anxiety disorder is a persistent state of heightened anxiety and apprehension characterized by excessive worrying, fear, and dread. Generalized Anxiety Disorder in Children and Adolescents. By J Elia, MD, Nemours/A.I. DuPont Hospital for Children Last full review/revision Apr 2021| Content last modified Sep 2022 3 The Chair of the PDSCP agreed the CSPR following a Rapid Review and advice from the National Panel, the lead reviewer was appointed, the terms of reference were agreed, agency reports were requested, and two events were held to engage with staff in October and November 2022. The reviewer is Robin Harper-Coulson, an independent safeguarding consultant. He is independent of PDSCP and its partner agencies. 4 The same group then came together again to study and debate the first draft of the CSPR report. Later drafts are also commented on by all of those involved and making a vital contribution to the learning and conclusions of the review 3 2.2 It was agreed that the CSPR would consider in detail the period from October 2019 up until February 2022. Detailed family information will not be disclosed in this report5, only the information that is relevant to the learning established during this review. 2.3 Family engagement is required within the systems model of review. However, in this review, this was not initially seen as appropriate due to ongoing legal intervention. This situation changed following advice from Adult Social Care and Mother was informed of the review and invited to contribute to its findings. However, the legal processes may delay publication. It is important that this learning can be embedded before publication. Following advice from organisations involved in the case the planned conversations with Charlie did not take place, as Charlie was assessed as not having capacity and may have been distressed by any planned attempts at communicating. 2.4 The PDSCP Business Manager and reviewer met with Charlie’s Mother and she was reassured PDSCP were providing confidentiality to her family by protecting Charlie’s and the family’s identity. She was also able to share her views on Charlie and wanted the reader to be aware that Charlie was a young adult with a logical mind, interests and a good sense of humour, not just a case or subject. Charlie, she believes has very controlling behaviour and has mental health needs, although the focus has been primarily on Charlie’s learning needs. Mother also commented that Charlie does not cope well with change and this is why the late deterioration occurred moving from primary to secondary education. 3 Family structure 3.1 The relevant family members in this review are: Family member To be referred to as: Subject child Charlie Mother of Charlie Mother Father of Charlie Father Siblings of Charlie Siblings 3.2 To protect the families and Charlie’s identity a non-binary name has been used as an alias, with titles used for the family relationships and no geographical locations identified within the Bournemouth, Christchurch and Poole (BCP) boundaries. 4 The background before the scoped period 4.1 Concerns were first raised about Charlie’s presentation at the age of eleven by Education following a Professionals Meeting. Charlie had been absent from school due to laryngitis for two weeks. It is reported by Education that Charlie returned to primary education following a rapid deterioration with a noticeable change in Charlie’s presentation. When meeting Mother at the school gate, Charlie’s behaviour changed to not verbalising words and being unable to walk and needing their Mother to assist walking. Charlie was observed placing themselves in one of Mother’s child-minding pushchairs as they were having difficulty walking. The discrepancies between the school’s assessment of Charlie and to Mother’s assessment of Charlie were striking. Discussions with the Local Authority Designated Officer (LADO) took place due to Mother being a child minder. Mother shortly after closed her child-minding business. At this time an early help assessment should have been considered. 4.2 When Charlie moved to High School on a part-time basis, they noted no significant concerns. This was contrary to what Mother was reporting regarding Charlie’s presentation and behaviour at home. Charlie was seen by a Paediatric Neurologist in 2016 for an MRI and this confirmed that no neurological 5 Statutory Guidance expects full publication of CSPR reports, unless there are serious reasons why this would not be appropriate, If they consider it inappropriate to publish the report, they must publish any information about the improvements that could be made following the review. 4 abnormality was found, although there were some changes these were not seen as of consequence. The MRI was repeated in 2019 and the same findings were reported. 4.3 In 2016, a professionals meeting took place and it was reported that Charlie was being neglected and had regressed in their behaviour and started to show traits of obsessive-compulsive disorder (OCD) and ritualistic behaviour. Charlie was said to be soiling at home, but the school saw no evidence of this. Charlie’s Mother appeared not to be utilising the support on offer and was said to be encouraging dependency of Charlie on herself. It was reported that Charlie’s Mother was not supporting Charlie to attend education. Charlie was reported in school as softly spoken and described as timid; however, Charlie was able to engage with peers and teachers and move independently around the school. 4.4 Charlie's mother commented that one key area that she believed would have improved the service's involvement with Charlie, was the knowledge professionals had about autism and how to best manage this. She was very clear that Charlie had shutdowns where this lack of knowledge in her view caused a misinterpretation of her actions and Charlie’s development. 4.5 In February 2017 reports of extensive historical domestic abuse by Father against Mother were made. Father had assaulted Mother after consuming large amounts of alcohol. Charlie and their siblings were made the subject of CP plans. Mother commented that this had an impact on Charlie’s functioning, with comments at the time such as Daddy’s drunk and Daddy’s noisy. Mother said Charlie was scared by the noise. Mother undertook the Freedom Programme6, and stated she should have left Charlie’s father much earlier. 4.6 On 1 April 2019, the BCP Councils merged into a single Unitary Authority. Followed within 6 months by a merger of the two NHS Trusts that managed Poole Hospital and the Royal Bournemouth and Christchurch Hospitals forming University Hospitals Dorset NHS Foundation Trust (UHD). These complex re-organisations and restructuring of services Charlie was accessing were described by the professionals at the learning event as significant to the learning for this review. 5 Key episodes 5.1 The time under review has been divided into three ‘key episodes’. These are periods of intervention that are judged to be significant to understanding the work undertaken with a child and family. 5.2 As the episodes are key from a practice perspective rather than to the history of the child, they will not form a complete history, but will summarise the relevant activities that occurred, and are a brief outline of the information that informed the review. Key episodes7 1. From 30 June 2019, before re-referral to 20 April 2020 when the Hospital-based residential assessment unit8 (Residential Unit 1) closed because of the Covid-19 pandemic 2. From the 21 April 2020 when a Review Child Protection Conference was held, Charlie continued to remain on a Child Protection Plan, to the 28 April 2021 agreement to apply to the Court of Protection (CoP) 3. From 30 July 2021 application to the CoP and subsequent delays until February 2022, when Charlie was admitted to the hospital 6 https://www.freedomprogramme.co.uk/ The Freedom Programme examines the roles played by attitudes and beliefs on the actions of abusive men and the responses of victims and survivors. The aim is to help them to make sense of and understand what has happened to them, instead of the whole experience just feeling like a horrible mess. The Freedom Programme also describes in detail how children are affected by being exposed to this kind of abuse and very importantly how their lives are improved when the abuse is removed. 7 The impact of covid will be a theme throughout 8 Residential Unit 1 provides a homely and welcoming environment in order to support, care and manage children’s physical, psychological, educational and social needs from the ages of 0 to 16 years. 5 Key episode 1: (30 June 2019, before re-referral to 20 April 2020 when the Hospital-based residential assessment unit (Residential Unit 1) closed because of the Covid-19 pandemic) 5.1 On 19 June 2019, an interagency referral was made to Children’s Social Care (CSC) by the Child and Adolescent Mental Health Services (CAMHS) within Dorset Healthcare University NHS Foundation Trust (DHCUT)9 due to concerns about Charlie’s declining presentation. By August 2019 the situation had deteriorated to Charlie receiving personal care from their Mother whilst asleep. CAMHS professionals wanted to assess Charlie’s needs away from the family home in Residential Unit 1 as it had in-house services such as psychiatrists, psychologists, clinical staff, and education provisions, Mother did not consent to this move as she believed that this would neither meet Charlie’s needs or interests. In September 2019 Special educational needs and disabilities (SEND) team recorded that Mother agreed for Charlie to be admitted to Residential Unit 1 for assessment. Within 3 days SEND received a request to Electively Home Educate (EHE) Charlie from Mother. CAMHS advised they could not support the request to EHE Charlie, as EHE would add further pressure to the family. The admission to Residential Unit 1 did not progress as Mother did not want Charlie to be admitted to Residential Unit 1. She commented she wanted to try CSC interventions first. There should have been a consideration of early help at this stage to provide support to Charlie, siblings and family. 5.2 On 1 December 2019, a BCP CSC Practice Audit was undertaken which identified that there was a delay in the case being allocated. On 24 December the case was transferred to an SW in the CHAD10 team. The SW’s role was specific to supporting Charlie and the family with Charlie’s disability-related needs and supporting the transition to Residential Unit 1. Mother stated she did not consider the placement necessary. The CHAD SW visited the family home for the first time on 9 January 2020 and escalated concerns immediately, including that Charlie would spend days in the lounge under a blanket, Charlie was not attending school or having social interactions, and sitting in soiled clothes. Charlie was reliant on Mother and had not been out of the family home since August 2019. 5.3 In January 2020, the Police received allegations of sexual abuse from siblings in different Police areas. This led to an Initial Child Protection Conference (ICPC) and the arrest of the Father. The criminal action threshold for the prosecution was not met so there was no further Police action. Father moved out of the family home and Mother later disclosed further historic domestic violence and did not exclude the possibility of Charlie being sexually abused by father. A CHAD Family Practitioner (FP), started working with Charlie and the family (two or three times weekly) to build relationships and seek to support Charlie to engage to seek an understanding of Charlie’s wishes and feelings. There was unanimous agreement that Charlie should be placed on a CPP under the category of Neglect, as there were concerns that Charlie‘s lifestyle is limited and they are not getting the social interaction or personal care that is required. There was recognition from the Independent Reviewing Officer (IRO) that an ‘effort has been made to try and capture the child’s lived experience but that this has been difficult due to the level of communication and the child’s presentation. Capturing the child’s voice has proved to be difficult in this situation’. Charlie’s Parents did not attend this conference, but received the minutes. Some key professionals from UHD were also not in attendance, including Safeguarding Children NHS Team named professionals and the Consultant Paediatrician but received the minutes. 5.4 On 7 February 2020 CAMHS team was clear that Charlie’s needs were beyond what could be met in the community. This was agreed upon by the Dorset Clinical Commissioning Group (CCG), however, due to the Covid-19 pandemic Residential Unit, 1 closed. As such, Charlie did not enter Residential Unit 1, remaining in their Mother’s care until 1 February 2022. 5.5 The Covid-19 pandemic had an impact on visiting and establishing the safety of vulnerable children and 9 Dorset HealthCare is responsible for all mental health services and many physical health services in Dorset, delivering both hospital and community-based care. We are the biggest provider of healthcare in Dorset, and our services continually evolve and develop to meet the needs of the local community. 10 https://www.bcppartnershipacademy.co.uk/our-teams/child-health-disability-team 6 young people. BCP introduced a protocol that vulnerable children and young people living in the community who are either Children in Need or have a CPP must be seen by their SW every week. The CHAD SW and FP continued to visit Charlie at home wearing PPE. Garden visits took place with Mother by the SW and CAMHS worker to reinforce the strategies recommended by CAMHS. On occasions Mother considered that she may be Covid-19 positive a visit took place on the doorstep and Charlie was able to mobilise, as Mother refused entry to the property despite workers wearing gloves, masks, aprons and visors. Some virtual visits also took place. Charlie was seen under the blanket during these when Mother would remove the blanket briefly. Key episode 2: (21 April 2020 Review Child Protection Conference (RCPC) was held, Charlie continued to remain on a Child Protection Plan (CPP), to 28 April 2021 agreement to apply to CoP. 6.1 The RCPC was held on 21 April 2020. Charlie remained on a CPP. There was a focus on Residential Unit 1 reopening and for the funding to be in place, alongside Charlie’s basic health needs, hygiene, and the plan to seek an assessment away from the family home in a specialised unit. 6.2 A joint home visit was made by the CHAD SW and CAMHS on 22 May 2020. They spoke with Mother regarding behavioural strategies that needed to be employed to make Charlie aware of the day/night by pulling the curtains in the morning, using Picture Exchange Communication Systems (PECS) to indicate a choice, visual timetables and calendars. The expectation was these needed to be used routinely and consistently to achieve any progress. These strategies had been put in place when CAMHS first became involved but were strengthened through this visit. The CHAD FP’s role was extended to support Mother in implementing the autism strategies for Charlie in the home. Mother refused entry to the home due to fear of COVID-19 infection although workers were wearing gloves, masks, visors and aprons. 6.3 Charlie was not brought to attend the pre-assessment at Residential Unit 1 on 9 June 2020. Mother informed the Duty SW that Charlie was not prepared for the assessment. Mother declined support from the CHAD Duty SW to take Charlie out, and refused to allow Charlie to be seen. Later on, the same day, a joint home visit was undertaken by CAMHS and the CHAD SW. Charlie came to the doorway and appeared to walk with a slightly bent spine, communicating by making noises and gestures rather than words, appearing slightly cross-eyed and appearing underweight. The workers were unable to assess Charlie’s capacity to make decisions due to refused access by Mother, whom the professionals believed was acting in a hostile manner. A further Strategy Meeting was held at Dorset MASH. There were multi-agency concerns around parental engagement, non-compliance with CPP, the presenting health and wellbeing of Charlie and the lack of progress and opportunities for Charlie and the wellbeing of Charlie’s carers. A s.47 enquiry was agreed with a Health assessment at UHD. A further health assessment at UHD was arranged for 22 June 2020, but Charlie was unable to attend this appointment safely. Charlie was distressed, kicking, hitting, and shouting and the SW decided to halt the attempt. At this point, the SW requested CAMHS undertook a physical health assessment of Charlie as this was a requirement from CSC Legal Advisors. CAMHS explained the reasons were not able to undertake a safeguarding health assessment as their medical knowledge and expertise were predominately within mental health needs and they would have not been able to undertake a safeguarding health assessment. CAMHS, signposted CSC to the appropriate process for this, so that any medical assessment would be suitable for legal proceedings. The family's GP visited to undertake an observation of Charlie’s health two days later and the advice was that there was no reason to indicate Charlie was unwell organically. 6.4 In July 2020 Mother gave consent to prepare for adulthood (PfA) referral, having previously refused this many times. The CHAD FP offered to support her with advice in the home and a log was to be kept daily. Mother was informed that Social Care would begin Legal proceedings if consistency was not shown. Mother’s views were the behavioural strategies provided did not meet Charlie’s specific needs or understanding and that as an example, taking photographs of food didn’t support Charlie to make a choice, but Charlie would attempt to eat the photograph. In August 2020 autism-experienced 7 carers from an independent care agency (ICA) started going into the family home. The carers were arranged as Mother had indicated that she would agree to Charlie being changed out of soiled clothes. Mother undertook all the care herself. Mother refused to leave the house for some respite while leaving carers to look after Charlie. 6.5 On 27 August 2020, Public Law Outline11 (PLO) proceedings were started due lack of progress with the CP plan and Charlie’s care not being managed in the home. Later on, 14 September 2021, CSC instructed a Consultant Chartered Clinical Psychologist (CCCP) to undertake a psychological assessment of Charlie and Mother. 6.6 By September 2020 there was a high volume of professionals attending the family home offering the following support, Weekly Child Protection Monitoring Visits by CHAD Social Workers, 3 x times per week support for behaviours from CHAD FP, Home Tutoring Monday – Friday mornings, CAMHS reviews, Carers from an Independent Care Agency (ICA) attending Monday- Friday, afternoons and Parenting Assessor visiting 1-2 times per week. In December 2020, Mother requested a break from the ICA carers for the Christmas celebrations. Mother refused to have this reinstated until 1 June 2021. CAMHS were requested to provide an itemisation of all strategies and advice supplied to the Mother and Father during the time of involvement. Mother stated to CAMHS she had only tried these strategies once. 6.7 The CCCP, on 21 January 2021 completed reports on both Mother and Charlie as part of the PLO process. This was delayed as a result of the CCCP’s personal health. Later in January, the CHAD SW made a referral to CAMHS ID (Intellectual Disability Team) as Charlie was identified by CCCP’s assessment to have lower cognitive ability than previously assessed and therefore CAMHS ID threshold was met. 6.8 Charlie moved on 2 February 2021 to an area on the landing and refused to move or stand up. A core group meeting was held on 8 February 2021 and the PLO process was closed, due to no threshold for removal, as Mother was cooperating with the Child Protection Plan (CPP). Charlie remained on a CCP alongside CSC searching for skilled autism carers to work with Charlie and potentially offer respite care. A Mental Capacity Assessment was discussed and the means of assessing capacity by using autism strategies. Guidance was provided by BCP Legal team about an application to the Court of Protection. Key episode 3: From 30 July 2021 application to CoP and subsequent delays until February 2022, when Charlie was admitted to the hospital 7.1 A Letter before proceedings was issued to Mother on 19 July 2021. With an initial hearing before the CoP on 31 August 2021. The CCCP was instructed to provide a further assessment of Charlie as an addendum to the original assessment. The CHAD team, CAMHS ID and PfA team were meeting or communicating daily about the progress of the case and Charlie’s welfare during the delays in the CoP, due to the Covid-19 pandemic. Charlie’s mother explained that CSC and ASC did provide some support to her during this period through Acceptance and Commitment Therapy (ACT)12. She believed that this was supporting her and was making a difference and the therapist wanted to continue. However, BCP had only funded six sessions and this came to an end. 7.2 On 22 September 2021, the CoP ordered a ‘Round the Table meeting’ to seek to agree on a care plan for Charlie. Mother remained of the opinion that Charlie should reside at home in her care which conflicted with the professionals’ views, this was supported by Charlie’s Official Solicitor. The CCCP amended report did not support a move for Charlie to residential care and recommended therapeutic services in the community. The Final contested hearing was set for 20 December 2021. Some key professionals were not available for this date, so it was re-scheduled. The Judge recommended that 11 The Public Law Outline (PLO) sets out the duties that local authorities have when taking a case to court 12 https://www.talkingchange.nhs.uk/acceptance-commitment-therapy-act The aim of ACT is to maximise your potential for a rich, full and meaningful life. Developing mindfulness skills to deal with painful thoughts and feelings effectively – in such a way that they have much less impact and influence. 8 Mother consider a 12-week assessment period at Residential Unit 213. 7.3 On 16 January 2022, Mother instructed her solicitor to accept the placement at Residential Unit 2 but requested that the hearing the following day continued. This CoP hearing was condensed into one morning as a result of Mothers agreement to residential care. Charlie was made the subject of an order to reside at Residential Unit 2 from February 2022, Charlie at an RCPC became a child in care under the Children Act 1989, Section 20. On the same day, Charlie moved to Residential Unit 2 in a supported move. On 4 February 2022 Residential Unit 2 informed CSC of concerns that Charlie was refusing to eat or drink. They further sought medical advice from the GP who advised to weigh Charlie’s incontinence pads, with ongoing advice sought on 10 February 2022, a Nurse Practitioner attended Residential Unit 2 to assess Charlie and recommended hospital admittance. On 11 February 2022, Charlie was admitted to University Hospital Southampton (UHS) needing acute care as a result of malnutrition and dehydration supported by carers from residential Unit 2. 8 Analysis by theme and learning Theme Monitoring the progress of plans and quality of practice Legal Intervention application and progress Organisational culture and leadership for good outcomes Escalation, Dissent, and raising concerns Understanding Professional Roles and responsibilities Diagnostic Overshadowing Response to potential Sexual Abuse and Trauma The child’s voice Reluctant and Sporadic Compliance 8.1 Monitoring the progress of plans and quality of practice. 8.2 All conferences took place within the required timescales. However, there was a significant turnover of Child Protection Conference Chairpersons (CPCC) following the merger of BCP into a Unitary Authority, the Ofsted inspection on 6 December 2021.14 This impacted the morale of the IRO service with many CPCCs leaving and difficulties in recruiting. In Charlie’s life, this meant there were two CPCCs during the timescale of the key episodes. 8.3 Critical thinking and challenge were absent at the beginning of the child protection process and the impact of domestic abuse on Charlie and alleged sexual abuse by Charlie’s siblings was not considered in depth especially given that Charlie has additional needs15. 8.4 The Father was absent in the CP process and this limited professional views of the Father despite there being allegations of historical domestic abuse and Charlie’s siblings alleging that they were sexually abused by their Father. Although no further action was taken by the Police due to lack of evidence, the CPCC did not raise the need for an updated risk assessment to be undertaken of Father and also Mother to look at her ability to protect, although these were undertaken by the CHAD SW. Domestic abuse 13 Residential Unit 2 supports men and women of various ages with severe learning disabilities, autism and associated complex needs. 14 Inspection of Bournemouth, Christchurch and Poole local authority children’s services https://files.ofsted.gov.uk/v1/file/50177455 15 Franklin, A., Bradley, L. and Brady, G. (2019) ‘Effectiveness of services for sexually abused children and young people. Report 3: Perspectives of service users with learning difficulties or experience of care’ comments on the invisibility of disabled children and young people within child sexual abuse services. Services in this study reported not receiving referrals for young people with learning disabilities/difficulties, despite the fact that they know that they face greater risk of sexual abuse. 9 work was offered to Mother, but there is no evidence of any work being offered or undertaken with Father who was the perpetrator. No consideration was given as to whether Mother’s over-protectiveness was to protect Charlie from the Father. This was eventually identified as a concern by the second CPCC although much later in the child protection process16. 8.5 Not all child protection conferences were quorate but went ahead. Parents did not attend some of the meetings and there is no evidence of any follow-up by the chair with other agencies or parents. Mid-point reviews were also absent from the file. Having these meetings would have aided the CPCC to have a clearer oversight of Charlie and the progress of work. 8.6 The focus of support and services provided by agencies seemed to focus mainly on Charlie’s abilities being the focus of service provision. This meant that Charlie’s abilities became the issue rather than concerns such as Mother’s behaviour and allegations of historical domestic/sexual abuse against Father which seemed to fade into the background. The obstacles and concerns that mother was presenting were not fully addressed and mother appeared to be keeping professionals at arm’s length, meaning access to Charlie and professionals’ ability to assess and build a relationship with Charlie was difficult. The absence of Charlie’s voice in assessments and the CP process meant there was an unassessed risk. This response to changing risk is something that should have been challenged earlier on by the first CPCC who should also have considered the history of this family and the length of time children’s services had been involved with no positive impact or outcome for Charlie as a result. 8.7 Legal advice should have been recommended earlier on by the CPCC. There were many opportunities for both CPCCs to escalate their concerns (Pan-Dorset Multi-agency Escalation Policy) due to the lack of progression and change for Charlie. This was reviewed by the Senior leadership involvement in a case discussion which agreed with the current plan and pursued the legal intervention within the CoP. It also declined a suggestion to seek a bespoke placement to care for, promote Charlie’s welfare and enable a medical assessment. 8.8 CPPs were too optimistic and, in some areas, superficial, with limited contingency planning. The plans did not tackle the lack of change for Charlie. A CPP should not continue for two years especially when a child or young person has already been subject to a plan before. Additional to the drift and delay due to Covid-19, there was further drift and delay in this case that could have been avoided. 8.9 The impact of Covid-19 did play a part and the first placement that had been identified for Charlie was unable to provide this care due to closing due to Covid-19. The Placement Commissioning Service were searching locally, regionally and nationally for a suitable placement that could meet Charlie’s needs without success. RCPCs should have taken place more frequently in Charlie’s case. However, the fact that this has to happen should indicate to the CPCC that further action needs to be taken to safeguard Charlie. 8.10 There is no evidence of the CPCC being told of Mother or Father’s employment as a person in a position of trust. BCP LADO has no evidence of any contact being made to discuss Mother’s position of trust as a child minder. The CHAD team were contacted by the IRO service in May 2022 to notify them of Father’s assault conviction. The CHAD team worked with the adult’s allegations officer, but this was communicated to the LADO, as the Father may have also had contact with children and young people within that position of trust. 8.11 Both CPCCs, in their minutes, refer to Charlie’s Mother as wanting what is best for Charlie. Whilst there is a need for all professionals to highlight the positives to a parent as well as what needs to change, there is also a need to be open and honest with a parent whose actions continue to raise concerns and impact their child. From reading the minutes of the meetings, sporadic and reluctant compliance was present and there were occasions when Mother appeared to control situations. For example, when 16 The Social Care Institute of Excellence (SCIE) addresses ‘Men and male caregivers’ in their Working Together with Parents e-learning module 3. They highlight a number of different but connected issues emerging from reviews in relation to men in families: • the dearth of information about men in most serious case reviews • the failure to take men into account in an assessment • rigid or fixed thinking about men as ‘all good’ or ‘all bad’ • the threat posed by men to workers 10 she refused visits to take place due to professionals having to wear masks which she said would cause Charlie distress. Mother also asked for the child in-care meeting to be incorporated within another professional meeting which was agreed upon by the social work team without consultation with the IRO or CPCC. Mother believes that the professional network did not want to work with her or listen to what she was saying. 8.12 Parents did not always attend CPCC’s, at the ICPC neither parent attended which was the same for the last CP conference. Father’s views were sought, but he should have been offered separate time from Mother to attend the conferences. There is ongoing work to improve the response to working with Fathers, and ‘Practice Fundamentals’ development sessions are now arranged in working with Fathers. 8.13 The second CPCC did a case allocation review, although this was around 6 weeks after the case was allocated. The review did identify the seriousness of matters and noted that legal proceedings should already have been initiated and Charlie should have been removed from Mother’s care. The CPCC identified that throughout the involvement of children’s services and health, no in-depth assessments or mental health assessments had been completed with Mother. 8.14 There have been significant changes in the IRO service since February 2022. The new Service Manager for IRO, CPC and LADO has implemented a service improvement plan concerning the Ofsted inspection report, subsequent focussed and monitoring visits. The improvements include, ▪ CPCCs have been reminded of the need for conferences to be quorate and include relevant key people who are significant in the child’s life and who will help progress the child protection process. ▪ There has been a change made to the case management system (Mosaic) so that the IRO and CPCC footprint and recording of mid-point reviews can be monitored more robustly by managers. ▪ Work with the IRO service has been undertaken around mid-point reviews and the need for these to take place. Practice learning is discussed in team meetings and good examples are given as well as learning. ▪ IRO team managers are now required to use data in supervision with an IRO and review any child or young person who has been the subject of a CP plan for more than 9 months. IROs and CPCCs are requested to use the formal Multi-Agency Escalation Policy to raise concerns about drift or delay. Any cases of concern are brought to the attention of the IRO service manager in weekly management meetings. ▪ It is not clear from the file if there was any consideration given to a consultation with LADO given parents were both at some point in a position of trust or if this was discussed with parents. Although referred to adult services, the BCP LADO has no records of any consultation in respect of Mother and only in May became aware of Father’s position of trust and his assault conviction. ▪ Weekly monitoring is in place with IROs and CPCCs to further monitor visits to children, mid-point reviews and referrals/allocation of an advocate in a child’s life. ▪ The first CPCCs should have been more robust in the CP process and considered the history of the family when making recommendations at the ICPC. The LA seeking legal advice should have been recommended earlier at the first RCPC. The plan should not have continued for two years when no change or improvement for Charlie had been evidenced. Charlie’s CP plan needed to be more robust with clear timescales and meaningful and realistic actions that should have been managed better by the CPCCs and other professionals. 8.15 There is learning for CPCC’s managers also around tracking CP cases where a child is on a repeat CPP or this has continued beyond the 9-month RCPC. At the point of reallocation, the IRO manager who was tasked with reallocating the previous CPCC cases should have identified the delay and lack of 11 change for Charlie and instructed the new CPCC to raise a Multi-Agency Escalation. This should also have been raised with the IRO /CP service. 8.16 The CPCC’s footprints on Charlie’s file were limited. There is other email evidence of the second CPCC liaising with the social work team and raising his concerns. These emails were not on Charlie’s file. A Multi-Agency Escalation should have been formally raised on numerous occasions by any multi-agency partner. In particular when Charlie’s placement at Residential Unit 1 did not go ahead, when the situation for Charlie did not improve by the first RCPC (given that Charlie had been on a CP plan before) and when there was a delay in the application to the CoP and Charlie remained at home in mother’s care. 8.17 The CPCCs did not identify or appropriately challenge the obstructions that Mother was presenting, or the sporadic and reluctant compliance by Mother. Their view of Mother was too optimistic and at times, not based on the reality of the situation for Charlie. Concerns around Father, domestic abuse and sexual abuse were not fully assessed or recognised which meant that the trauma likely to have been experienced by Charlie was not addressed. Covid-19 added to the difficulties in engaging with Charlie and Mother. Mother’s behaviour was at times rationalised due to circumstances such as Covid-19. Information from Mother was sometimes accepted by the CPCCs and other professionals rather than investigating further. 8.18 Charlie’s Mother’s views of the case review progress were that the decision-making meetings were poor, with a lot of being spoken at rather than with. The chairperson tried to listen, but she believed the outcome was a foregone conclusion. 8.19 Learning: Monitoring the progress of plans and quality of practice 1. There needs to be an improved approach by professionals when it is identified that the person who we are working with is in a position of trust. 2. On occasions, case conferences were held which were not quorate. Some apologies were received in relation to members of the CPP being Covid positive or impacted on by the raised levels of working during the pandemic. To determine quoracy, there should be sufficient agencies present to enable safe decisions to be made. Conferences were mainly attended by children’s services and other agencies were absent, such as police and health. In Charlie’s case, all relevant health services, both Mental Health and Physical Health must attend CP conferences, which was not always the case. 3. There is a need to update or review risk assessments if there is a change in circumstances, risks or needs. 4. Both CPCCs or any other professional did not escalate this through the Multi-Agency Escalation Policy due to the lack of progression and change for Charlie. Child protection plans were too optimistic and, in some areas, superficial and there were limited contingency plans. The CP did not tackle the lack of change for Charlie. 5. A CP plan should not continue for two years especially when a child or young person has already been subject to a plan before. There was drift and delay in this case that could have been avoided. 6. CPCCs should further develop knowledge of reluctant and sporadic compliance and should be able to recognise this early on and as well as being aware of what actions to take when this is suspected. Work around professional curiosity should also be undertaken. 7. Father’s views were sought, but he should have been offered separate time from Mother to attend the conferences. 12 Legal Intervention application and progress 9.1 Many professionals at the learning event voiced their concerns about why a legal intervention was not pursued in Charlie’s case. They highlighted the lack of change in Charlie’s circumstances and the timescales of intervention. 9.2 On 24 June 2020 at a Care and Resource Panel Review meeting, BCP Legal services advised that CSC would rarely make applications for 16-year-olds, but believed this should be considered. It was agreed that the threshold for PLO and a Care Order was met. It was also agreed highlighted that CSC could apply for a Child Assessment Order if Mother did not agree to CSC’s care plan under PLO. 9.3 This was followed up by the CHAD SW on 30 June 2020 when she received Legal Services which advised the threshold for PLO was not met. This was at odds with the previous legal advice 9.4 This was identified by Ofsted in November 2020 focused visit to BCP Children’s Services on 13 October 2020, which stated “The failure of managers to provide appropriate oversight of the pre-proceedings Single Agency Recommendations, Monitoring the progress of plans and quality of practice Children’s Social Care: 1. CSC will provide assurance to the BCP PDSCP that disguised compliance and being able to recognise this early and as well as being aware of what actions to take when sporadic and reluctant or disguised compliance is suspected is embedded in training. 2. CSC will monitor attendance at CP Conferences to ensure conferences are quorate with sufficient agencies present to enable safe decisions to be made, escalation should be made immediately to the senior management and assurance should be made to the BCP - PDSCP when sharing the annual report of the IRO, Safeguarding and LADO annual report. 3. CSC will be aware of the need to meet with parents separately when there are disputes, or when one partner is a risk to the other, assurance should be made to the BCP - PDSCP when sharing the annual report of the IRO, Safeguarding and LADO annual report. 4. CSC will share their IRO/LADO annual report with the BCP – PDSCP setting out the progress of CCP, the functioning of the IRO Service and any quality issues. 5. CSC should ensure that the guidance Standards for Enabling Participation of Children and Young People in Child Protection Conferences, is followed in CPCs. All Acute Health Services 1. All acute services will review the role of Safeguarding Professional’s and their role in attending and providing their expertise and knowledge to child protection conferences. 2. Once this review is undertaken oversight and assurance should be provided to the PDSCP. Multi-agency Recommendations Recommendation 1: All Organisations and professionals must follow the PDSCP Policy on Child Protection Conferences Procedures, including guidance about when to attend Child Protection Conferences as set out in the Policy. The PDSCP must send the guidance to agencies to distribute and link it to the learning to give context for the rationale. Recommendation 2: The PDSCP must develop a seven-minute guide to ensure that the role of the LADO is understood by all partner organisations and relevant organisations. The PDSCP should ensure the LADOs functions are built into existing multi-agency training. This should also include information regarding working with adults who may be parents or carers who are involved with children’s services and who are in a position of trust. . 13 stage of the Public Law Outline (PLO) results in children remaining for too long in unsafe situations”.17 9.5 This situation has improved since November 2020 in the most recent monitoring visit undertaken on 4 and 5 October 2022, Ofsted identified “When risks escalate to the point of using the pre-proceedings process under the Public Law Outline (PLO), work is carried out under the clear and organised oversight of a service manager who understands the work and children’s needs very well. A clear and closely maintained tracker is used to monitor progress for children effectively”18. 9.6 The Professional Meeting agreed that a court application for a Child Assessment Order19 would be fruitless. For the following reasons: • Residential Unit 1 did not believe they can complete it in timescale, and other provisions were not admitting new patients due to Covid-19. • CAMHS stated its role was mental health rather the physical health, so could not provide a safeguarding health assessment that was appropriate for Court. • The order can only be granted for 7 days, and it was believed that any assessment would take longer, due to Charlie’s needs • Although many options were considered no other provision was identified that could undertake the health assessment. 9.7 In August 2020 BCP issued a Letter Before Proceedings under the PLO, highlighting their concerns and what Mother could do to improve things, setting out the concerns that the LA has about Charlie and the things that have been done to try to help the family. The PLO was reviewed monthly following the issuing of the letter. 9.8 At a Legal Gateway meeting on 29 January 2021, the significant delay in the legal process was due to CCCP’s report being overdue due to illness and the parenting assessor being off due to ill health. The parenting assessment was significantly delayed as the assessor wanted sight of the CCCP’s report before concluding her report. This was not sent to the parenting assessor until January 2021. 9.9 The CCCP’s assessment did not assist in legal planning for Charlie as the recommendations made had been tried in the past. The assessment made no suggestions of how the recommendation of respite and community-based services could be achieved given Charlie has not left the family home for 2 years. This was challenged by the Legal Service’s asking the CCCP to respond to further questions to assist in planning for Charlie. 9.10 At this time Charlie was 17 in 6 weeks and therefore the opportunity to seek an Interim Care Order (ICO) was lost. Also, without a recommendation of removal from home in the CCCP’s assessment, it would be very unlikely to secure removal and an ICO at home would serve no purpose for Charlie. 9.11 It was agreed that the case needed to remain in PLO until the CCCP replied to our further questions and the parenting assessment was complete20. The CHAD team continued to seek an assessment unit that would agree to assess Charlie identified and then make an application for an Assessment Order. Without this provision identified the CHAD team continued to work with Mother to identify a respite provision and support Charlie to access this provision through a transition to the PfA Team. 9.12 On 8 February 2021, the PLO was discontinued. By this time Charlie had been on PLO Pre-Proceedings since August 2020, this should not go on longer than 16 weeks.21 This was a significant delay in the 17 https://files.ofsted.gov.uk/v1/file/50156980 18 https://files.ofsted.gov.uk/v1/file/50197985 19 Child Assessment Orders, Section 43 is the opening section of Part V of the Children Act 1989, entitled "Protection of Children". 20 Recently published Best practice guidance: Support for and work with families prior to court proceedings March 2021, Public Law Working Group suggests that “the purpose of the PLO pre proceedings process is to be a genuine opportunity to work closely with families by offering help and support to address their recognised needs in a bid to negate the need to issue care proceedings”. 21 In 2014, the revised PLO was published (Family Procedure Rules, Practice Direction 12A). Revised statutory guidance (DfE, 2014) 14 progress of the PLO Pre-Proceedings work. Charlie remained subject to a CPP and The Multi-Agency team continued to work with Mother and Siblings for the best outcomes for Charlie. 9.13 On 27 April 2021 at a Local Area Protocol meeting held under the Care, Education and Treatment Reviews (CETR) process. Mother commented that she believed Charlie had deteriorated since the family had lost a lot of support. This view was disputed by professionals and further legal advice was requested. The legal advice confirmed there was sufficient evidence to make a welfare application to the CoP. CHAD and Adult Services Transitions Team SWs met to complete the Transition plan for the CoP, with parallel planning continuing with BCP legal for welfare application to the CoP. 9.14 At a legal meeting in June 2021, the following actions were agreed upon, to source a residential placement/suitable placement, including a transition plan to move Charlie from the landing to the identified placement, Also a care plan will be provided that can be lodged with the CoP setting out how Charlie will be cared for. Also, the present statement will be updated to set out the reasons why the application is being made and to encompass the views of the health professionals as to why an acute hospital or admission to a psychiatric unit is not appropriate. If no placement has been identified within 7 days an application will be made to the CoP to authorise the present deprivation of liberty. 9.15 The CCCP’s report was completed by 12 September 2021. He stated that he questioned why Mother could not continue to provide care in the family home, if she was compliant and he did not support the move. Given this Mother submitted her statement saying she would not consider a trial period at Residential Unit 2. 9.16 A round table meeting was held at the direction of the court on 22 September 2021 to respond to some questions from Mother and the Official Solicitor. Further information was requested from the CCCP and to prevent further delay, he was invited to the meeting. The CoP hearing was held on 5 October 2021. The Judge suggested a trial period at Residential Unit 2. Mother agreed to a placement but not at Residential Unit 2. 9.17 A full hearing was listed for 20 December 2021, but the Judge did not have any availability and the final hearing did not go ahead until 17 January 2022 in the CoP. The Judge instructed the move from the family home to Residential Unit 2, which was planned and took place on 1 February 2022. 9.18 There was a significant delay in the legal intervention and progress of Charlie’s case, The initial advice from BCP legal service was that the threshold for PLO and ICO was made on 24 June 2020. Charlie finally moved into residential Unit 2 shortly after 17 January 2022, which was a period of 1 year and 30 weeks. This delay was for a variety of reasons. Changing legal advice from BCP Legal Services, delays caused by long-term sickness to the parenting assessor and the CCCP. Then following these delays in the CoP due to Covid-19 and capacity issues. 9.23 Learning: Legal Intervention, application and progress 9.19 Cases for 16 and 17-year-olds that lack capacity should not be dealt with using The Children Act 1989 legislation and processes, they should be directed to The Court of Protection. 9.20 Delays in the progress of the legal case impacted Charlie’s deterioration and access to full-time carers. 9.21 The minimal level of knowledge concerning the CoP and PLO in services that work for children and their families identified within written records, discussion and templates for this CSPR is significant. 9.22 The Practice Guidance Safeguarding Disabled Children was published in 2009 this guidance is significantly out of date. Although legislation is in place through Children and Families Act 2014 Part 3. It does not give the guidance required for this vulnerable group of children and young people. which included a pre-proceedings flow chart, starting with the initial referral of the family to children’s social care. This flow chart, for the first time, included a suggested time limit on the formal pre-proceedings process of 12-16 weeks (Annex A, DfE, 2014). 15 9.23 Furthermore, the Pan-Dorset Safeguarding Children Partnership (SCP) Policies and Procedures Manual Safeguarding Disabled Children section also requires improvement to ensure it provides in-depth guidance to all professionals and volunteers when working with this group of children and young people, including the Legal aspects of capacity and consent in children and young people with a disability. 9.24 The impact Covid had on the progress of the CoP timescales also was significant. The Judge tried to reduce delay through the round-the-table meeting and invited the CCCP to this meeting to gain the required information to complete their report. 9.25 The CCCP’s report commissioned by BCP repeated already attempted interventions that had not been successful earlier in Charlie’s life and did not consider available resources. 10.0. Organisational culture and leadership for good outcomes 10.1 During the learning event, the participants highlighted the move to a Unitary Authority named BCP Council and the merger of two Health Trusts into the University Dorset NHS Foundation Trust, with both restructured organisations embarking on a programme of integration and transformation. 10.2 The learning event participants spoke about the retention of staff during this time in BCP CSC as low with many senior managers, Social Workers leaving BCP. Also, following the publication of the Ofsted Inspection, Monitoring and focussed visits recruitment of experienced local professionals into teams was exceedingly difficult. The learning event said that children were being left too long in places of risk and opportunities to seek management guidance and/or support were limited due to this turnover and restructure of BCP CSC. Single Agency Recommendations Children’s Social Care 6. The Director of Children’s Services in BCP should ensure that the PLO processes are being conducted within 16 weeks and that delays and risks are addressed immediately. BCP Legal Team 1 The BCP Legal Team should develop guidance on PLO pre-proceedings and the use of PLO and the application to the Court of Protection for 16- and 17-year-old vulnerable young people. This should be presented to the PDSCP and Children’s services so this guidance is available for partners and Social Workers through the PDSCP website and the children’s service manual, so that there is a better understanding of a process which becomes integral to many safeguarding cases in which partners are involved. 2 The BCP Legal team should monitor the timescales for PLO Pre-proceedings work, ensuring this remains within the 16-week timescale. Multi Agency Recommendations Recommendation 3: The PDSCP should write to HM Government highlighting that the Practice Guidance Safeguarding Disabled Children was published in 2009. This guidance is significantly out of date. Although legislation is in place through Children and Families Act 2014 Part 3 does not give the guidance required for this vulnerable group of children and young people. Recommendation 4: The PDSCP should ensure the Pan-Dorset Safeguarding Children Partnership (SCP) Policies and Procedures Manual Safeguarding Disabled Children section is reviewed with the support of Tri.x in light of this CSPR to ensure it provides in-depth guidance to all professionals and volunteers when working with this group of children and young people. This should include the legal aspects of capacity and consent in children and young people with a disability and diagnostic overshadowing to ensure that safeguarding concerns do not become invisible due to the child's disability. 16 10.3 In the most recent monitoring visit undertaken on 4 and 5 October 2022, it was identified that “Child protection conference decisions are inconsistent. While high staff turnover has played a part in this, the absence of a sufficiently robust frontline management approach in this area has had a greater impact. The subsequent child protection plans are either generic or place too much emphasis on actions and tasks rather than impact and change”22. 10.4 The CHAD team explained at the time of Charlie’s allocation to their team, Charlie did not meet their threshold criteria, but due to them knowing Charlie and no other team was available, they felt under pressure to take on the case. 10.5 CAMHS also stated that they were going to close their oversight of the case as Charlie did not meet their criteria, but retained case responsibility as they were unsure who would take on the case if they closed it. Closing the case was also at odds with the Thrive Model23 in working with difficult complex cases. 10.10 Learning: Organisational culture and leadership for good outcomes 10.11 At the learning event, it was discussed that there were two centres for medical assessments for children in Dorset, one with criteria of up to 16 and the other under 18 which provides a different level of service provision in Dorset/BCP area. These differences in accessibility and service provision should be reviewed by the DICB working with the Acute NHS Trusts in the area. 10.12 Since the CSC inspection, there have been significant improvements in management identified by Ofsted in the Monitoring Visit on the 4 and 5 October 2022, highlighting • Concerted effort to put right structures in place to make the improvements necessary • Children’s Services Senior Management Team understands areas for improvement/ Corporate support to continue under current financial pressures • More timely decisions and actions • Sensible and sustainable plan in place to provide better quality services for children • Making steady progress – we are where Ofsted expect the service to be at this stage • Quality of SW is improving – however more to do before children receive consistently good services. • Staff are increasingly confident at tackling risk for the most vulnerable 22 https://files.ofsted.gov.uk/v1/file/50197985 23 THRIVE is an integrated, person-centred and needs-led approach to delivering mental health services for children, young people and families which conceptualises need in five categories or needs based groups: Single Agency Recommendations Children’s Social Care 7. The Director of Children’s Services in BCP should continue to share the BCP Improvement Plan with the PDSCP for information. NHS Dorset Integrated Care Board (DICB) 1. DICB should lead a review of safeguarding paediatric services in their area working in partnership with all Health Trusts that provide safeguarding paediatric services. To ensure all Health Trusts in the Dorset and BCP areas that provide safeguarding paediatric services are deployed effectively to meet service requirements and local health needs across the area they serve. 17 11.0 Escalation, Dissent, and raising concerns 11,1 At the learning event and in their single agency report template the participants and authors mentioned the Pan-Dorset Multi-agency Escalation Policy numerous times. However, during the Key Episodes, this was never implemented. The Policy drafted in 2019 remains current and the view was that it was to be used to escalate concerns about CSC, rather than between any safeguarding partner. The policy is clear that is to set expectations and pathways for managing differences of professional opinions in the child’s best interest. It has a focus on resolving multiagency safeguarding challenges, and the policy can be used between any agencies working to safeguard children. 11.2 The policy sets out the principles of professional challenge and escalation. Stating the use of professional challenge and escalation is expected and promoted in multiagency working to enable children (including young people) to be safeguarded effectively. The child’s welfare and safety are paramount. The Pan-Dorset Multi-Agency Safeguarding Policies and Procedures Manual provides detail of expected practice and this should be referenced by practitioners in their challenges and escalations. 11.3 The lack of use of escalation, and dissent in core groups and CP conferences is clear as were professional differences of opinions in the learning event and individual interviews. The use of the escalation process was seen to be negative by the professionals involved in the case, rather than in progressing the case by providing an opportunity to promote the child’s welfare. 11.4 There was a lack of challenge by the first CP chair and partly by the second CP chair who both should have applied the Multi-agency Escalation Policy process due to there being no change for Charlie and no professional being able to find out what life was like for Charlie. The fact that there was no change for Charlie for the length of the CP plan was enough for the Multi-agency Escalation Policy process to be implemented at many stages of the process. Also, during the CP conferences, there were no incidents of dissent where an agency does not agree with a decision or recommendation made at a child protection conference, their professional dissent will be recorded in the record of the conference 11.5 There were numerous examples where the use of the Pan-Dorset Multi-agency Escalation Policy was considered but not implemented by professionals These examples included the Police decision not to interview Charlie either as a potential victim of or witness to sexual abuse, lack of progress in the case, difficulties in information sharing, professional disagreement about a referral to ID CAMHS, delay in legal intervention, and the commissioning of a medical assessment of Charlie. 11.6 Learning: Escalation, Dissent, and raising concerns 11.7 The Pan-Dorset Multi-agency Escalation Policy and dissent process were not well understood by the multi-agency partners involved in this case or its role in promoting the welfare of children. This was further identified in the PDSCP CSPR “Iris 2021”, In the learning event the feedback from the professionals involved in the case was it was a mechanism to raise concerns or a complaint process about CSC. Following “Iris 2021 para 25 Page 50” assurance was provided that “Dorset Council has added that it has further strengthened its escalation policy since the summer of 2020” This CSPR recommends that the PDSCP ensures that this policy in now understood by partners. Multi-Agency Recommendation Recommendation 5: The PDSCP should develop a seven-minute guide on the Pan-Dorset Multi-agency Escalation Policy and ensure training and supervision includes the use of the guide to confirm that all partners understand, are well versed and empowered to use this Policy. 18 12.0 Understanding Professional Roles and responsibilities 12.1 In the single agency templates and learning event, many professionals and agencies used generic titles for organisations such as “Health” “Local Authority” and “Children’s Social Care” without understanding the multiple professional teams specialising in specific arenas in that organisation24. 12.2 An example of this is the use of the term “health” when recording case details involving CAMHS. It was clear that CAMHS was identified as the responsible “Health” agency and CHAD as the “Local Authority”. 12.3 A named person from UHD at the CPRC to agree with Charlie’s admission into the hospital for a medical assessment could have supported the discussion about a potential safeguarding paediatric assessment before the day of admission and may have avoided a subsequent refusal to accept the admission as there was no medical emergency. 12.4 The health assessment given Charlie’s needs was undertaken later in the case by University Hospital Southampton (UHS). They describe it as a complex situation, where ethics and the law were unclear. Charlie had to be given a general anaesthetic to gain Charlie’s height and weight. Careful planning should have been agreed upon at the case conference or strategy discussion to agree on a way forward to gain this medical assessment. 12.5 Following this refusal of admission as it was not in Charlie’s best interests the Family GP attempted to assess Charlie in the family home. However, Charlie became distressed and began kicking and grabbing Mother's hair. It was agreed at a health focussed meeting, which included the UHD staff, Paediatric safeguarding consultants and the GP agreed that Charlie did not need to be admitted into Hospital and the health assessment could be undertaken in the community. It is not clear if CSC were involved in this meeting. However, the GP reported that Charlie had good muscle tone as Charlie was able to kick out at him from below the blankets. 12.6 The role of the acute medical specialists and paediatricians, in this case, working alongside CAMHS should have been in place and although invited to CP conferences did not attend and minutes were sent as requested. 12.7 CSC was identified by professionals at the learning event as being responsible for the delay in seeking legal intervention in Charlie’s case. This was not the case as legal intervention was pursued through legal advice and the threshold was not met due to the Mothers engagement with services and the CCCP’s report which suggested community-based respite care and community-based services rather than a move to residential care. 12.8 Learning: Understanding Professional Roles and responsibilities 12.9 The need for a Child to have a safeguarding health assessment, in this case, was significant, CSC stated they were concerned about Charlie’s health, lack of mobility, not being changed from soiled clothing until asleep and how this impacted skin integrity. They also required information about weight and hydration, as this was unknown. 12.10 Although CAMHS were the consistent health partners and supported Charlie’s case., there was a need for them to be supported by Acute Services from UHD. It is important that a child who has been placed on a CPP for neglect with the potential to have been the victim or witness to sexual abuse be able to access a safeguarding health assessment. 12.11 So that organisations, agencies and practitioners collaborate effectively, it is vital that everyone working with children and families, including those who work with parents/carers, understands the 24 This was also identified in an earlier CSPR ”River May 2022” in which at Para 5.14 This review has highlighted that some practitioners required a greater and deeper understanding about the roles and responsibilities of colleagues in other agencies or with other client groups (adults or children). 19 role they should play and the role of other practitioners. They should be aware of and comply with, the published arrangements set out by the PDSCP. Working Together 201825 This was identified in the PDSCP CSPR “River May 22” and this review also identifies the need for professionals to be aware of each other roles and legal and statutory responsibilities. 13.0 Diagnostic Overshadowing. 13.1 Charlie’s complex needs impacted the progress of this case. The focus seemed to be on Charlie and ASD being the problem rather than the situation where Charlie may have been the subject or witness to Sexual abuse or domestic violence and was placed on a CPP for Neglect for two years. 13.2 Stalker et al, 2015 highlight how practitioners can lose sight of the child (and abuse) due to overly focused attention on impairment. As they state: "signs of abuse could be attributed to aspects of a child's impairment and thus go unrecognized. This applied to both physical signs such as injury and changes in a child's behaviour denoting distress”.26 13.3 The Pre-Assessment meeting at Residential Unit 1 was attended by Mother, but not Charlie who was reported to have refused to come. The majority of the assessment was from Mother’s information as Charlie was not present. The Clinic letter summarised that the professionals who assessed Charlie did not feel able to decide on whether Charlie could come in for admission as they needed to understand Charlie’s response to being in the environment. 13.4 The Police in the learning event stated that they had not interviewed Charlie as communication was not possible and it may have caused Charlie distress. Police Dorset have an intermediatory service to assist children and young people with their communication and involvement with the criminal justice system. But access to this provision is not timely. We know from recent research that “Access to justice via thorough police investigations and criminal proceedings was rarely an outcome for disabled children and young people. They were often perceived as unreliable witnesses especially if they had communication needs. Disablism appeared to affect practice, with little evidence that access needs were met or 25 Working Together 2018 Introduction para 17 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf 26 9. Stalker, K., Taylor, J., Fry, D. and Stewart, A. (2015). "A study of disabled children and child protection in Scotland—A hidden group?" Children and Youth Services Review 56: 126-134 Single Agency Recommendations NHS Dorset Integrated Care Board (DICB) 2. The DICB should lead a review of the agreed safeguarding paediatric pathway to ensure that children with disabilities / complex presentations who live in the BCP area who require a health assessment due to concerns about their welfare due to alleged or potential abuse are able to access medical health assessments. This pathway should be presented to the PDSCP for ratification and entered into the PDSCP Multi-Agency Procedures. 3. The DICB review will also consider the policy of no home visits, or ambulance support for safeguarding paediatric investigations. The review needs to consider if this policy needs to change to include flexible support for cases where it involves children with disabilities to ensure they can access these services Multi-Agency Recommendations Recommendation 6: All partners should ensure that their staff and teams are aware of the diversity of organisations in relevant agencies and partner organisations, moving away from generic terms such as Local Authority or Health. This recommendation was also made in the Local Child Safeguarding Practice Review “River” 2022. The BCP - PDSCP should coordinate the development a briefing document to explain the role and responsibilities of agencies and organisations. Existing PDSCP training should provide the opportunity to discuss individual roles and responsibilities to break down stereotypes and myths. 20 adjustments made”.27 13.5 At the meeting called to discuss this admission and subsequent lack of admission, there were concerns about how Charlie would react and present in a busy ward and uncertainties on how Charlie may be distressed by the hospital environment due to Charlie’s ASD needs, also worries about inflicting further trauma. As we now know Charlie was hospitalised in 2022, seriously ill. It was reported that Charlie did well while on the sideward at UHS, although this was a challenge for the hospital staff. 13.6 In 2020, in discussions with UHD safeguarding paediatricians, the CHAD SW was told that safeguarding paediatricians do not complete house visits, an ambulance won’t be offered for transport, and sedation won’t be offered. If the child can be brought in, they will undertake an assessment, otherwise, they can’t provide a service. The case then became Primary Care and the GP's responsibility with limitations in what services and assessments they can undertake. 13.7 The focus of support and services provided by various agencies seemed to focus mainly on Charlie being the difficulty. It felt that Charlie became the issue rather than concerns such as Mother’s behaviour and allegations of historical domestic/sexual abuse against Father which seemed to fade into the background. This was at odds with CAMHS's view that diagnostic overshadowing appears to have been a factor from other agencies outside of CAMHS who over-relied on CAMHS to provide support for Charlie’s needs, despite them being clear they had exhausted all their pathways. 13.8 In Charlie’s records by UHD on 11 June 2021; CSC requested for Charlie to have a medical assessment (including blood tests, weight, and skin check) to exclude underlying medical causes for the behavioural deterioration. The GP wanted to discuss this, having spoken to adult medicine who did not feel that admission to an acute hospital for basic medical assessment was appropriate or in Charlie’s best interests. The UHD staff agreed that there needs to be further discussion with all parties regarding how Charlie can be supported currently and how any basic assessment of health can be undertaken, agreeing that Charlie will need significant mental health/behavioural support to be able to tolerate examination etc. but disagreeing that there is a need for a 'child protection medical' - as per the acute medical team, as bringing Charlie into the hospital would be very difficult. 13.9 Learning: Diagnostic Overshadowing 13.10 A full health assessment was requested on numerous occasions, by BCP Legal Team, and at the CAMHS CETR (Care, Education and Treatment Review meeting) 13.11 Concerning admission into UHD. UHD may need to review that some rooms are available and suitably adapted to admit children with special needs for emergency treatment. The latest research shows increasing numbers of children are now born on the ASD spectrum28. These children will get ill and are at an increased risk of abuse due to their disabilities. 13.12 Concerning UHD safeguarding paediatric services and medicals, the policy of no home visits, or ambulance support. UHD needs to consider if this policy needs to be reviewed to consider flexible support for cases where it involves children with disabilities to ensure they can access these services. 13.13 CAMHS stated “The physical deterioration and wellbeing of Charlie was recognised. Had a medical review taken place sooner Charlie may not have required admission to the hospital following the transfer to Residential Unit 2”. This was supported by UHS medical team who explained the BMI level and dehydration levels would not have occurred in the short timescale that Charlie was resident in Residential Unit 2. 27 UK Social Work Practice in Safeguarding Disabled Children and Young People A qualitative systematic review June 2022 Franklin et al. 28 Roman-Urrestarazu, R et al. Association of Race/Ethnicity and Social Disadvantage With Autism Prevalence in 7 Million School Children in England. JAMA Paediatrics; 29 March 2021; DOI: 10.1001/jamapediatrics.2021.0054 https://www.ncl.ac.uk/press/articles/archive/2021/03/autismratesincrease/ 21 14 Response to potential Sexual Abuse and Trauma 14.1 Charlie’s siblings made separate allegations of sexual abuse against their Father. The siblings and Mother commented that they could not rule out Charlie also being abused. Charlie was not interviewed by the Police at this time and this would be in Charlie's best interests due to ASD and concerns about distress. The CAMHS professional felt this was a mistake and raised her concerns but did not formally challenge this decision. The use of the Pan Dorset Escalation Policy would have enabled decisions to be reviewed and provided an opportunity for Charlie’s voice to be heard. Charlie was not offered a paediatric safeguarding medical. 14.2 The s.47 threshold was met, and Father was arrested. The actions from this meeting included formal police interviews for the siblings and safety plans made. Father moved out of the family home following his arrest and never returned, Police took no further action due to lack of evidence. Father met with the social worker in February 2020 to deny all allegations and following this he made the decision not to have any further communication with children’s social care, stating clearly in his email “I do not want to be included in your updates/meetings etc”. 14.3 Although no further action was taken by the Police due to lack of evidence, the CP chair did not raise the need for a thorough risk assessment to be undertaken of Father and also Mother to look at her ability to protect. Domestic abuse work was offered to Mother, but there is no evidence of any work being offered or undertaken with father who was the perpetrator. There was a lack of acknowledgement of the impact domestic abuse and possible sexual abuse had on Charlie. No consideration was given as to whether Mother’s over-protectiveness was to protect Charlie from Father. Single Agency Recommendations NHS Dorset Integrated Care Board (DICB) 1. DICB should lead a review of safeguarding paediatric services in their area working in partnership with all Health Trusts that provide safeguarding paediatric services. To ensure all Health Trusts in the Dorset and BCP areas that provide safeguarding paediatric services are deployed effectively to meet service requirements and local health needs across the area they serve. 2. The DICB should lead a review of the agreed safeguarding paediatric pathway to ensure that children with disabilities / complex presentations who live in the BCP area who require a health assessment due to concerns about their welfare due to alleged or potential abuse are able to access medical health assessments. This pathway should be presented to the PDSCP for ratification and entered into the PDSCP Multi-Agency Procedures. 3. The DICB review will also consider the policy of no home visits, or ambulance support for safeguarding paediatric investigations. The review needs to consider if this policy needs to change to include flexible support for cases where it involves children with disabilities to ensure they can access these services. Dorset Police 1. Dorset Police should provide assurance to the PDSCP that children with disabilities in Dorset that need to have an intermediatory to assist their communication and involvement with the criminal justice system are offered this service to ensure that their access needs were met or adjustments made. Children’s Social Care 8. CSC should ensure where there is a medical diagnosis offered as an explanation for the presenting features of neglect, all aspects of the child’s health and well-being should continue to be considered to avoid the potential for diagnostic overshadowing. 22 14.4 The research and evidence around child sexual abuse (CSA) and the symptoms and behaviours that a child may exhibit are well documented. Behavioural concerns include bladder and bowel changes, mutism, and eating disorders to name just a few. These three concerns are documented clearly within the records for Charlie. 14.5 Studies also indicate that disabled children’s risk of abuse varies according to impairment type, with having a mental or learning disability, communication impairment or behavioural difficulty being more strongly associated with maltreatment (Sullivan and Knutson, 2000; Spencer et al, 2006; Jones et al, 2012). Young people with learning disabilities have also been identified as at increased risk of sexual abuse (Spencer et al, 2006). 14.6 The focus of support and services provided by various agencies seemed to focus mainly on Charlie being the difficulty. It felt that Charlie became the issue rather than concerns such as Mother’s behaviour and allegations of historical domestic/sexual abuse against Father which seemed to fade into the background. 14.7 Learning: Response to potential sexual abuse and trauma 14.8 Many professionals do not understand that children with disabilities may be victims of sexual abuse. Often, signs and indicators of potential sexual abuse in children with disabilities go unrecognised or are dismissed as being part of their disability. Often the Thresholds document or Pan Dorset Continuum of Need does not provide clear guidance on children with disabilities. Professionals need to understand what the disability means for the child and their usual functioning. How does this impact their communication and sensory needs, how does this impact how they respond and make sense of information? They may be displaying signs that result from their condition, but this needs to be properly assessed rather than assumed. 14.9 There was a wide range of expertise available to multi-agency professionals to help them understand Charlie’s needs, and communication style and to advise on the best way of maximising this. Charlie was non-verbal, but signs and indictors that are not expressed verbally could be considered. This needs to be a core requirement of strategy meetings/discussions regarding children with some form of disability so that those needs are discussed. The Centre of Expertise on Child Sexual Abuse has developed Signs and Indicators: A template for identifying and recording concerns of child sexual abuse. 29 This template may assist in the identification of non-verbal signs and indictors for children and young people who have suffered child sexual abuse. 14.10 The Police need to consider the use of Registered intermediaries for any child, but particular consideration should be given when the child is young or disabled. Officers must take into account the use of an intermediary when planning interviews with children. 29 https://www.csacentre.org.uk/documents/signs-and-indicators-a-template-for-identifying-and-recording-concerns-of-child-sexual-abuse1/ Multi-Agency Recommendations Recommendation 7: The PDSCP should signpost in the PDSCP procedural Manual, the Centre of Expertise on Child Sexual Abuse’s Signs and Indicators: A template for identifying and recording concerns of child sexual abuse. This template may assist in the identification of non-verbal signs and indicators for children and young people who have suffered child sexual abuse. Recommendation 8: The BCP - PDSCP should review the current training in Child Sexual Abuse. Ensuring that when professionals are working with a disabled children who are the victims of or witness of sexual abuse the course highlights the increased risk these children are living with due to a broad range of disability. 23 15 The child’s voice 15.1 Charlie has been the subject of two CPP’s and a brief period of being a looked-after child before Charlie’s 18th birthday. At one meeting there were 18 professionals from different agencies and still no one could engage fully with or find out what life was like for Charlie. The CPCC’s should have made it their priority to speak with and find ways to engage Charlie. 15.2 The voice of Charlie in the child protection process was absent. There is no evidence that either CPCC made attempts to visit Charlie or communicate via other ways. There were comments about Charlie playing video games so the chair could have attempted to use technology to initiate contact with Charlie which would have been a start to building a relationship. The lack of Charlie’s voice in the CP process meant there was unassessed risk and gaps in assessments which meant the CP process was not safeguarding Charlie. Charlie was allocated an advocate but there is no evidence of the CPCC speaking with the advocate or Charlie’s views being represented in the CP process by an advocate. 15.3 On 14 January 2020, the CHAD FP, started working with Charlie and the family (two or three times weekly) to build relationships and attempt to get Charlie to engage to seek an understanding of Charlie’s wishes and feelings. 15.4 There was recognition from the IRO that “effort has been made to try and capture the child’s lived experience, but that this has been difficult due to the level of communication and the child’s presentation. Capturing the child’s voice has proved to be difficult in this situation”. However, the IRO stated that “Other agencies were helpful in the conference and were able to offer some insight into what Charlie’s life is like and the risks and concerns currently in place, particularly professionals from CAMHS”. 15.5 Charlie’s needs were reviewed regularly by CAMHS, and actions were added which were based on professional knowledge and experience. Charlie was unable to verbalise words but was able to demonstrate displeasure by shhhing, shouting and kicking. At times it was not possible to communicate directly with Charlie in any meaningful way, or indeed gain access to even have sight of Charlie. 15.6 The CCCP commented. “Charlie offered only very infrequent, sporadic eye contact which could be described as fleeting, with no social interest shown in me”. The psychologist was also asked whether Charlie was Gillick Competent, responding no, explaining Charlie’s understanding is that the overall test of Gillick competency is one of a child being able to give consent if they fully understand the (medical) treatment that is proposed and if a child has sufficient understanding and intelligence to understand fully what is proposed. Charlie does not have this full and sufficient understanding of any changes that might be proposed for intervention. He went on to state, even if one would apply the Mental Capacity Act 1987 and 2005 test of mental capacity, Charlie would not be likely to be seen as having sufficient mental capacity to independently take decisions. Issues around advantages, disadvantages and potential long-term implications are not likely to be understood and processed with good understanding. Charlie is not likely to understand risks, implications and any consequences that may arise from any decision. 15.7 Learning: The child’s voice 15.8 Following the CCCP’s view of Charlie’s ability to consent, give views and independently make decisions. Charlie’s ability to contribute information about needs and wishes also seems fraught with difficulties. It is clear from the IRO's comments that professionals all attempted to communicate with Charlie with very limited or no success. The FP from the CHAD team who had developed a relationship with Charlie was allowed to press buttons to restart videos or reset the device, commenting he believed that Charlie was not able to contribute and provide professionals with a view of needs and wishes. 15.9 However, since the case improvements have been made and weekly monitoring is in place with IROs to further monitor visits to children, mid-point reviews and referrals/allocation of an advocate in a child’s life. 15.10 Further learning regarding the numbers of professionals involved and Mother being used as a proxy for Charlie’s, views and perspectives is highlighted by Taylor et al, (2016) “talk of losing sight of the 24 child due to perceptions that the number of services that would potentially be involved with disabled children was highlighted as a safety net. They argue that this must not lead to complacency in safeguarding practice. This reliance on others for protecting disabled children was also seen to extend to reliance upon parents or carers to understand what the child was communicating, or even using them as a proxy for the child’s perspective, which in some cases could render the child vulnerable”30. 16 Reluctant and Sporadic Compliance 16.1 Mother's views on processes and actions changed repeatedly and how this impacted on Charlie’s care was remarked on through the learning event and the organisation's single agency reports for this review. There were many instances when this occurred. This in many reviews is often termed disguised compliance. In this case, the Mothers choices were not hidden and were often clearly verbally shared. Organisations and individual workers explained how this impacted the progress of the plan and in many situations delayed progress. Mother also provided a different response to individual professionals changing her opinion regularly. An example of this is the work of the DHCUT Bladder and Continence service. This service worked closely with Mother and Charlie, providing support and strategies to mum for Charlie from May 2019. They were very flexible in their approach and Mother was supported to communicate with the service and was able to request continence supplies and pads. During a home visit by CAMHS in October 2020 Mother commented that she had no support with continence issues and had no ‘supplies’ to manage this. Records reviewed show that the Bladder and Continence Service had spoken with Mother on 24 September 2020. 16.2 On 9 June 2020, Charlie was booked for a pre-assessment appointment at Residential Unit 1, but Mother went on her own as she felt that Charlie was not ready. Mother refused the support of the CHAD Duty Social Worker to support getting Charlie to Residential Unit 1 and refused to allow access to Charlie. Mother attended the Residential Unit 1 pre-assessment appointment on her own, meaning the clinicians were not able to see and assess Charlie. In response to this, a strategy meeting was held on 12 June 2020. A further meeting took place in which it was identified that Residential Unit 1 was not able to meet Charlie's needs. 16.3 A review of the PLO was held on 29 October 2020 with an agreement that a final meeting would be held in December when the expert report was received. At this stage, Mother was informed that she had not adopted CAMHS recommendations or embedded them in her approach to Charlie and that a lot of things seemed to have got in the way of her achieving this e.g., tiredness, lateness, and wanting to make sure Charlie had food; or lack of confidence in the CAMHS approach. Mother objected to this, saying symbols had been used a lot. 30 Taylor, J., et al. (2016). "Disabled Children and the Child Protection System: A Cause for Concern." Child Abuse Review 25(1): 60-73 Multi-Agency Recommendation 9: All relevant agencies should ensure their workers are aware of the vulnerabilities of children who have a disability and are electively mute or non-verbal. Recommendation 10: The BCP- PDSCP should develop an easy-to-follow guide based on the Centre of Expertise on Child Sexual Abuse template https://www.csacentre.org.uk/documents/signs-and-indicators-a-template-for-identifying-and-recording-concerns-of-child-sexual-abuse1/ setting out how electively mute or non-verbal children can communicate through written information, changes to their behaviour or through interaction with objects. This should be assessed alongside the behaviours of others providing care for the child. The BCP- PDSCP should seek assurance that this is embedded into practice through supervision and training 25 16.5 Learning: Reluctant and Sporadic Compliance • It is uncertain if Mother compliance was due to distinct choices, to disrupt the care planning for Charlie or was due to the stress and fatigue caused by the demands and fatigue of caring for a child with complex needs. • Initial Child Protection Conference report of 30 January 2020 comments “Historically Mother has and continues to feel accused by the professionals of being a bad mother and in some way contributing to her child’s presentations. This makes her quite distrusting of professionals and wary of their intentions, questions, comments and advice.” • Given the need to understand and respond to the reluctant and sporadic compliance, it is important the professional at the Core group and CP Conference involved maintain a robust multi-agency chronology, recording evidence about what is happening and sharing this with involved professionals. This was also a recommendation from a previous review “Ashley” 202031. 17 Conclusion and recommendations 17.1 Charlie has a diagnosis with High Functioning Autism and ‘‘likely’’ to meet the Generalised Anxiety Disorder and was in Mother’s Care. Charlie had been known to CSC since in 2015. There was reported domestic abuse in February 2017 which was found to be extensive historical domestic abuse by Father against Mother. In January 2020 Charlie’s sibling disclosed being sexually abused by Father which started from the age of 4 or 5. Another older Sibling also disclosed being sexually abused. More historical domestic abuse was reported by mother after this. Mother did not exclude the possibility of Charlie being sexually abused by father. Throughout CSC involvement, Mother did not engage fully and obstructed professionals from undertaking assessments which meant that Charlie did not receive the required support and services. The legal intervention was started under the PLO and high-level intervention was put in place. This was in place for a period of 1 year and 30 weeks, with Charlie, eventually moving into a specialist unit as an adult after intervention by the CoP. 17.2 The context of the case includes a structural re-organisation of three Local Authority areas into a single Unitary Authority. Also, the merger of two Health Trusts to a single Trust system. 17.3 The Covid-19 pandemic impacted the progress of the case due to the closure of services, lockdown, shielding, restrictions on new admissions and delays in legal processes. Although BCP CSC put into place processes for children on CPP to be seen weekly in person. The response to Covid-19 allowed parents who are hard to engage with to avoid professional contact. In this case professional rigor and persistence were required so that Charlie’s needs continued to be met despite the challenges of working during a pandemic. 17.4 Good Practice 17.5 Good practice has also been identified in this case both in the agency reports and during discussions with the professionals involved in the case. They include: 31Pan Dorset Safeguarding Children Partnership, Local Child Safeguarding Learning Review, Ashley 2020 June 2022 Recommendation j. The Pan Dorset Safeguarding Children Partnership should develop a multiagency chronology template and protocol for use in certain circumstances to support informed decision making by all partner safeguarding agencies when working with complex situations Multi-Agency Recommendation Recommendation 11: The BCP - PDSCP will provide a multi-agency chronology template and protocol to review children where they have been subject to a child protection plan on a number of occasions and have complex needs. This will be in line with the multi-agency chronology template and protocol under development by PDSCP following the Learning Review "Ashley" 2020. 26 • CAMHS provided consistent support to promote Charlie’s welfare and needs. They were a constant support and at times lead agency when the case was closed to CSC. • UHS from the start of admission demonstrated good working together with adult and children services within the hospital. Charlie was treated within adult environments as initially it was deemed more clinically appropriate. A wide range of professionals all worked together to meet all of Charlie’s needs, and all recognised Charlie’s status as a child. This teamwork then provide support until Charlie was 18 years of age and transitioned into sole adult hospital care. The safeguarding team within UHS have a dedicated Transition Safeguarding service. This enabled and supported a consistency of care and communication for Charlie as the transition to adult services occurred at 18. • Residential Unit 2 regular communication was maintained throughout and up to the admission to the hospital and this was done with a very detailed plan. During the emergency hospital admission Residential Unit 2 provided a carer to work with Charlie in UHS to provide consistent care. • This family have had the opportunity to have continuity of care within the GP practice. They all have access to GPs that know them well. The GPs provided late visits and good multi-agency working. • The timeliness of CP conferences was good, and all conferences took place within the required timescales. • There was excellent joint working between the CSC CHAD Team and the ASC PfA Social workers and teams, at the point of case transition and beyond. • The second CP chair raised concerns with the social worker and team manager about the delays in the CoP process via email and Charlie remaining at home. • There was extensive agency involvement and various expert assessments were undertaken. • Full MDT approach to decision making and preparing for adulthood led by Children’s Social Care and excellent joint working with adult and children’s services. • The best possible solutions could not be achieved using The Children Act 1989, therefore processes within The Mental Health Act 1983 and The Mental Capacity Act 2005 were explored, resulting in a Court of Protection hearing. • CSC tried to gain access to a range of provisions – initially Residential Unit 1, then Residential Unit 2, seeking provisions that could provide Charlie with a medical assessment. • The SEND team sought a resolution regarding education by providing a home education service for Charlie in the home environment. Multi-Agency Recommendation for linked to identified learning Recommendation 12: The PDSCP should write to the Department of Education and Ofsted about the challenge in finding placements for children with ASD, and the need for flexible bespoke packages of accommodation, care and support for these children that are based on the child’s needs and are not provision-led. They should be specifically asked to review the registration requirement for bespoke placements to ensure they can provide support in a timely way. Recommendation 13 The issues raised in this CSPR relating to Covid-19 should be presented to the National Covid Inquiry by the PDSCP. 27 18 Appendices Appendix 1 Multi-agency Recommendations. Recommendation 1: All Organisations and professionals must follow the PDSCP Policy on Child Protection Conferences Procedures, including guidance about when to attend Child Protection Conferences as set out in the Policy. The PDSCP must send the guidance to agencies to distribute and link it to the learning to give context for the rationale. Recommendation 2: The PDSCP must develop a seven-minute guide to ensure that the role of the LADO is understood by all partner organisations and relevant organisations. The PDSCP should ensure the LADOs functions are built into existing multi-agency training. This should also include information regarding working with adults who may be parents or carers who are involved with children’s services and who are in a position of trust. Recommendation 3: The PDSCP should write to HM Government highlighting that the Practice Guidance Safeguarding Disabled Children was published in 2009. This guidance is significantly out of date. Although legislation is in place through Children and Families Act 2014 Part 3 does not give the guidance required for this vulnerable group of children and young people. Recommendation 4: The PDSCP should ensure the Pan-Dorset Safeguarding Children Partnership (SCP) Policies and Procedures Manual Safeguarding Disabled Children section is reviewed with the support of Tri.x in light of this CSPR to ensure it provides in-depth guidance to all professionals and volunteers when working with this group of children and young people. This should include the legal aspects of capacity and consent in children and young people with a disability and diagnostic overshadowing to ensure that safeguarding concerns do not become invisible due to the child's disability. Recommendation 5: The PDSCP should develop a seven-minute guide on the Pan-Dorset Multi-agency Escalation Policy and ensure training and supervision includes the use of the guide to confirm that all partners understand, are well versed and empowered to use this Policy. Recommendation 6: All partners should ensure that their staff and teams are aware of the diversity of organisations in relevant agencies and partner organisations, moving away from generic terms such as Local Authority or Health. This recommendation was also made in the Local Child Safeguarding Practice Review “River” 2022. The BCP - PDSCP should coordinate the development a briefing document to explain the role and responsibilities of agencies and organisations. Existing PDSCP training should provide the opportunity to discuss individual roles and responsibilities to break down stereotypes and myths. Recommendation 7: The PDSCP should signpost in the PDSCP procedural Manual, the Centre of Expertise on Child Sexual Abuse’s Signs and Indicators: A template for identifying and recording concerns of child sexual abuse. This template may assist in the identification of non-verbal signs and indicators for children and young people who have suffered child sexual abuse. Recommendation 8: The BCP - PDSCP should review the current training in Child Sexual Abuse. Ensuring that when professionals are working with a disabled children who are the victims of or witness of sexual abuse the course highlights the increased risk these children are living with due to a broad range of disability. Recommendation 9: All relevant agencies should ensure their workers are aware of the vulnerabilities of children who have a disability and are electively mute or non-verbal. 28 Recommendation 10: The BCP- PDSCP should develop an easy-to-follow guide based on the Centre of Expertise on Child Sexual Abuse template https://www.csacentre.org.uk/documents/signs-and-indicators-a-template-for-identifying-and-recording-concerns-of-child-sexual-abuse1/ setting out how electively mute or non-verbal children can communicate through written information, changes to their behaviour or through interaction with objects. This should be assessed alongside the behaviours of others providing care for the child. The BCP- PDSCP should seek assurance that this is embedded into practice through supervision and training Recommendation 11: The BCP - PDSCP will provide a multi-agency chronology template and protocol to review children where they have been subject to a child protection plan on a number of occasions and have complex needs. This will be in line with the multi-agency chronology template and protocol under development by PDSCP following the Learning Review "Ashley" 2020. Recommendation 12: The PDSCP should write to the Department of Education and Ofsted about the challenge in finding placements for children with ASD, and the need for flexible bespoke packages of accommodation, care and support for these children that are based on the child’s needs and are not provision-led. They should be specifically asked to review the registration requirement for bespoke placements to ensure they can provide support in a timely way. Recommendation 13 The issues raised in this CSPR relating to Covid-19 should be presented to the National Covid Inquiry by the PDSCP. Appendix 2 Single Agency Recommendations: Children’s Social Care: 1. CSC will provide assurance to the BCP PDSCP that disguised compliance and being able to recognise this early and as well as being aware of what actions to take when sporadic and reluctant or disguised compliance is suspected in embedded in training. 2. CSC will monitor attendance at CP Conferences to ensure conferences are quorate with sufficient agencies present to enable safe decisions to be made, escalation should be made immediately to the senior management and assurance should be made to the BCP - PDSCP when sharing the annual report of the IRO, Safeguarding and LADO annual report. 3. CSC will be aware of the need to meet with parents separately when there are disputes, or when one partner is a risk to the other, assurance should be made to the BCP - PDSCP when sharing the annual report of the IRO, Safeguarding and LADO annual report. 4. CSC will share their IRO/LADO annual report with the BCP – PDSCP setting out the progress of CCP, the functioning of the IRO Service and any quality issues. 5. CSC should ensure that the guidance Standards for Enabling Participation of Children and Young People in Child Protection Conferences, is followed in CPCs. 6. The Director of Children’s Services in BCP should ensure that the PLO processes are being conducted within 16 weeks and that delays and risks are addressed immediately. 7. The Director of Children’s Services in BCP should continue to share the BCP Improvement Plan with the PDSCP for information. 8. CSC should ensure where there is a medical diagnosis offered as an explanation for the presenting features of neglect, all aspects of the child’s health and well-being should continue to be considered to avoid the potential for diagnostic overshadowing. BCP Legal Team 1 The BCP Legal Team should develop guidance on PLO pre-proceedings and the use of PLO and the application to the Court of Protection for 16- and 17-year-old vulnerable young people. This should be presented to the PDSCP and Children’s services so this guidance is available for partners and Social 29 Workers through the PDSCP website and the children’s service manual, so that there is a better understanding of a process which becomes integral to many safeguarding cases in which partners are involved. 2 The BCP Legal team should monitor the timescales for PLO Pre-proceedings work, ensuring this remains within the 16-week timescale. NHS Dorset Integrated Care Board (DICB) 1. DICB should lead a review of safeguarding paediatric services in their area working in partnership with all Health Trusts that provide safeguarding paediatric services. To ensure all Health Trusts in the Dorset and BCP areas that provide safeguarding paediatric services are deployed effectively to meet service requirements and local health needs across the area they serve. 2. The DICB should lead a review of the agreed safeguarding paediatric pathway to ensure that children with disabilities / complex presentations who live in the BCP area who require a health assessment due to concerns about their welfare due to alleged or potential abuse are able to access medical health assessments. This pathway should be presented to the PDSCP for ratification and entered into the PDSCP Multi-Agency Procedures. 3. The DICB review will also consider the policy of no home visits, or ambulance support for safeguarding paediatric investigations. The review needs to consider if this policy needs to change to include flexible support for cases where it involves children with disabilities to ensure they can access these services. University Dorset NHS Foundation Trust 1. UHD should review the availability and if necessary, undertake the adaption of a number of treatment rooms so they are suitably adapted to admit children with special needs for emergency treatment or health assessments. All Acute Health Services 1. All acute services will review the role of Safeguarding Professional’s and their role in attending and providing their expertise and knowledge to child protection conferences. 2. Once this review is undertaken oversight and assurance should be provided to the PDSCP. Dorset Police 1. Dorset Police should provide assurance to the PDSCP that children with disabilities in Dorset that need to have an intermediatory to assist their communication and involvement with the criminal justice system are offered this service to ensure that their access needs were met or adjustments made. |
NC043785 | Serious injury of a baby girl in February 2010, consistent with her having been shaken on two occasions separated by a period to 2-3 weeks. Father was convicted of inflicting grievous bodily harm with intent and both parents were convicted of child cruelty. At the time of the incident Infant W was the subject of a Child Protection Plan. Mother was known to children's services from the age of 9 and had been a looked after child from her early teenage years. Father was well known to a number of agencies in connection with abuse and neglect within his family, a problematic education, youth offending and homelessness. Shortly before the incident, Infant W moved to a guest house with her father; an interim arrangement pending supported independent accommodation becoming available. Identifies lessons for learning, including: blurring of professional boundaries in respect to working simultaneously in the best interests of the mother as a looked after child and Infant W; support provision for teenage parents; the role of fathers; and professional knowledge of legislation and powers. Recommendations include: practice guidance for children's services where both parents and their children are prospective service users; local Teenage Pregnancy Strategy reflecting the support needs of fathers; and Oxfordshire Safeguarding Children Board publishing a lay person's guide to the legislative framework within which professionals operate to safeguard children.
| EXECUTIVE SUMMARY SERIOUS CASE REVIEW IN RESPECT OF A CHILD Infant W Chris Few September 2012 INTRODUCTION 1.1 The Local Safeguarding Children Board Regulations, 2006 require Local Safeguarding Children Boards to undertake reviews of serious cases. Working Together to Safeguard Children (2010) provides statutory guidance on the criteria for holding such reviews and on how they should be conducted. 1.2 A Local Safeguarding Children Board should consider whether to conduct a Serious Case Review whenever a child sustains a potentially life threatening injury or serious and permanent impairment of physical and or mental health and development through abuse or neglect and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children. 1.3 The purpose of a Serious Case Review is to: Establish what lessons are lessons to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and Improve inter-agency working and better safeguard and promote the welfare of children. 1.4 On 10 June 2010 the Secretary of State for Education issued amended guidance that all Serious Case Reviews commenced from that date should be published in full. That guidance was not however retrospective and this review was accordingly completed on the basis that only an executive summary will be published. 2 Summary of circumstances leading to the Review 2.1 In February 2010 Infant W was admitted to the local Hospital requiring resuscitation. Investigations identified that her condition was the result of brain and other injuries which are consistent with her having been shaken. 2.2 Infant W was discharged from hospital in February 2010 but it is believed she will have long term health issues as a consequence of her injuries. She is the subject of an Interim Care Order and is currently in a Local Authority foster placement. 2.3 At the time she sustained her injuries Infant W was the subject of a Child Protection Plan, intended to address concerns regarding the parenting ability of her parents. 2.4 The Serious Case Review sub-group of Oxfordshire Safeguarding Children Board (OSCB) considered the circumstances of Infant W’s injuries on 18 February 2010 and recommended that a Serious Case Review be undertaken. That recommendation was endorsed by the Independent Chair of the OSCB on 25 February 2010. 3 Terms of Reference 3.1 Draft Terms of Reference for this Review were developed by the Serious Case Review sub-group of the OSCB. These were subsequently reviewed and amended by the Serious Case Review Panel in light of information gathered during the Review. 3.2 The Review focused on Infant W. Her parents’ status as children was however acknowledged and considered at all stages of the Review process. 3.3 The primary focus of the Review was from June 2008, when Infant W’s mother was accommodated in a Local Authority Children’s Home, until 48 hours after Infant W’s admission to hospital in February 2010. Significant events in the childhood of both parents were also taken into account in order to provide some understanding of their backgrounds and the development of their relationship. 3.4 Within the Terms of Reference a number of specific issues to be addressed were identified: Were race, religion, language, linguistic and cultural needs met during the intervention with the family, by all agencies; to include learning disabilities and or any mental health issues Were the assessments and support to the two teenage parents and family members sufficient, taking into account their backgrounds, risk factors and situation Were there recorded references to the grandparents of Infant W suffering domestic abuse, mental ill health or misusing substances, and any such records relating for Infant W’s parents Was pre-birth assessment and planning undertaken in a timely way, did Infant W’s premature delivery have a significant impact on this and did services respond appropriately, in line with contingency plans Were Infant W’s parents’ pre/post birth mental health needs adequately identified and addressed What factors influenced a change in planning from a supervised mother and baby placement to Infant W living in a guest house with her father Were Infant W’s needs central to the assessment and planning process Was the impact of the Infant W’s parents’ volatile relationship sufficiently considered in planning and service delivery If up to date medical information had been available at a Review Child Protection Conference in February 2010 would the decision and plan have been markedly different. 3.5 In addressing these questions the Review also considered the specific issues identified at paragraph 8.39 of Working Together to Safeguard Children, 2010. 4 Serious Case Review Panel 4.1 The Serious Case Review Panel was chaired by Andrea Hickman, Independent Chair of the Oxfordshire Safeguarding Children Board. 4.2 Chris Few, an independent consultant, was appointed to write the Overview Report at the outset of the Serious Case Review. He had previously conducted an agency management review for Oxfordshire County Council Education Services and authored the Overview Report of another Serious Case Review in Oxfordshire but otherwise has no personal or professional connection with any agency in the County. 4.3 Other members of the Serious Case Review Panel were: Lead Solicitor - Oxfordshire County Council Superintendent - Thames Valley Police Designated Nurse - Oxfordshire Primary Care Trust Lead Officer Safeguarding - Oxfordshire County Council Children, Young People and Families Service Assistant Delivery Director – Connexions Interim Service Manager - Youth Offending Service Business Manager - Oxfordshire Safeguarding Children Board. 5 Review process 5.1 The Serious Case Review Panel met on seven occasions to consider the agency management reviews and progress the Serious Case Review. 5.2 The Panel agreed that meeting with family members was important to gain a full understanding of their situation as children and new parents; and of Infant W’s life prior to her being injured. The parents had however been arrested and were on bail whilst the circumstances of Infant W’s injury were investigated. It was recognised that interviewing the parents prematurely could interfere with the integrity of that investigation and any consequent prosecution. A decision on the timing of an offer to meet with the Independent Author and for completion of the Review was therefore deferred. 5.3 In this connection an extended timescale for the Review was agreed by the Serious Case Review Panel and notified to the Government Office for the South East (GOSE) and subsequently Ofsted. 5.4 Action was taken during the Serious Case Review process to ensure that identified learning was implemented at the earliest opportunity. 5.5 The Serious Case Review Overview Report was presented to, and accepted by, the Oxfordshire Safeguarding Children Board on 20 September 2012. 6 Contributions to the Review 6.1 Individual Management Reviews (IMRs) were received from: Community Health Oxfordshire Connexions Oxford Radcliffe Hospitals NHS Trust Oxfordshire County Council – Children, Young People and Families Service Oxfordshire County Council - Education Services Oxfordshire County Council - Legal Services Thames Valley Police Oxfordshire Youth Offending Service. 6.2 In addition to the Individual Management Reviews, an Overview of the health agencies’ involvement was prepared by the Designated Nurse for Oxfordshire PCT in accordance with Working Together to Safeguard Children 2010. 6.3 These were supplemented by: Relevant research and inspection reports Policy and guidance documents Copies of documents, meeting records and communications Judgements of the High Court of Justice Correspondence with individuals and agencies to confirm and clarify information. 7 Family engagement 7.1 The parents of Infant W were notified that this Serious Case Review was being conducted and the process was explained in a face to face meeting with Infant W’s Social Worker. 7.2 Following their conviction, letters were hand delivered to both parents inviting them to contribute to the Review. Unfortunately neither wished to do so. The Review therefore had to be concluded without their perspective on the events prior to Infant W being injured. 7.3 It is intended that the findings of the Review will be shared with family members prior to publication of the Executive Summary. SUMMARY OF EVENTS SURROUNDING THE INJURY OF Infant W 8.1 Infant W and her parents are white British and from English speaking families. 8.2 Infant W’s mother, who was under 18 in February 2010, had been known to Children’s Social Care from the age of nine in connection with care arrangements following the death of her mother. From her early teenage years she had been a Looked After Child in the care of Oxfordshire County Council and shortly after became a Looked After Child in a Local Authority residential home. She had had contact with a number of other agencies in Oxfordshire, mainly in relation to her Looked After Child status, going missing from care and absence from education. 8.3 Infant W’s father was under 18 years of age in February 2010. From pre-school age onwards he had had extensive involvement with a number of agencies in Oxfordshire. This was in connection with abuse and neglect within his family, a problematic education, offending behaviour during his teenage years and homelessness. 8.4 Assessment of Infant W’s future needs and planning for her care commenced during her mother’s pregnancy. Professional plans centred on Infant W and her mother being accommodated in a mother and baby foster placement. No placement that was suitable and acceptable to the parents was however identified and, following her birth, Infant W was cared for by her father at the home of his father and stepmother. 8.5 When Infant W was aged four weeks she was made subject of a Child Protection Plan, intended to address concerns regarding the parenting ability of her parents. 8.6 The family accommodation arrangement for Infant W and her father ended and they moved to a guest house shortly before the admission to the Local Hospital. This was an interim arrangement pending supported independent accommodation becoming available. Throughout this period Infant W was visited daily by her mother, although her father was the main caregiver. 8.7 In February 2010 Infant W was admitted to the local Hospital requiring resuscitation. Investigations identified that her condition was the result of brain and other injuries consistent with her having been shaken on two occasions separated by a period of 2-3 weeks. 8.8 Infant W was discharged from hospital in February 2010 but it is believed she will have long term health issues as a consequence of her injuries. She is currently in care of the Local Authority. 8.9 On 24 July 2012 Infant W’s parents were convicted at Oxford Crown Court of offences committed against Infant W; her father of two counts of inflicting grievous bodily harm with intent, and both parents one count of child cruelty. Both were sentenced on 28 August 2012 with Infant W’s father receiving three years in a Young Offenders Institution and her mother a 6 month community sentence. LEARNING FROM THE REVIEW 9.1 The Serious Case Review identified a number of key themes which, along with the need for greater professional knowledge of legislation and associated powers, constitute the learning from this review: Blurred practice boundaries Assessment quality Core Group effectiveness Support provision for teenage parents The role of fathers. 9.2 Whilst expressed individually these themes are in many ways interdependent and all contributed to professional involvement with the family being less effective than it should have been. 9.3 These themes echo the recurring issues in professional responses to vulnerable babies and their families identified in the 2011 Ofsted analysis of Serious Case Reviews1, including those concerning babies under one year old2. 1 Ages of Concern: learning lessons from serious case reviews (110080), Ofsted, 2011. 2 Babies under one year old comprised 210 (35%) of the 602 children subject of serious case reviews during this period. 10 Blurred practice boundaries 10.1 Blurring of practice boundaries arising from professionals, particularly within Children’s Social Care, attempting to work in the best interests of Infant W’s mother as a looked after Child and simultaneously in the best interests of Infant W were evident throughout the period under review. 10.2 Early in the pregnancy of Infant W’s mother it was decided that her own Social Worker would undertake the pre-birth assessment in respect of her unborn child. As the pregnancy progressed the mother’s own overwhelming level of need and inconsistency with professionals led to the focus on Infant W’s interests being largely eclipsed. Following Infant W’s birth, adoption of the main carer role by her father introduced a further set of competing needs, adding to the distraction away from a primary focus on Infant W. 10.3 Further difficulty arose when the views of and decisions made by Infant W’s mother as a (prospective) parent conflicted with the plans seen as necessary by Children’s Social Care in exercising their role as her corporate parents. This manifested as moves towards using child protection processes in respect of Infant W and sanctions which would impact on the parenting role of Infant W’s mother as a means of securing her compliance. This questionable practice was met with resistance and disengagement. 10.4 To address these issues the Review made two recommendations: 10.5 That Children’s Social Care, in consultation with partner agencies, should produce professional practice guidance for situations where both parents and their (unborn) children are (prospective) service users and in particular where corporate parenting responsibilities exist. This should enable professional networks to identify case specific practice boundaries and arrangements for coordinating work across these. 10.6 That Children’s Social Care should ensure that needs and service provision for parents and their children, where both are service users, are assessed and managed by separate Social Workers. This applies equally to the assessment and any consequent processes in respect of unborn babies. 10.7 Initial and Review Child Protection Conferences held in respect of Infant W were chaired by the Independent Reviewing Officer responsible for her mother. This undermined the independence of the chair, and thereby the objectivity of the conferences. The chair’s familiarity with information relevant to the conferences also led to this not being comprehensively elicited from attendees to inform decision making. The most serious consequence of this was an over emphasis in Child Protection Plans on issues connected with the parents, to the detriment of measures focussing primarily on the protection and welfare of Infant W. 10.8 In relation to this issue the Review recommended: 10.9 That Children’s Social Care ensure that Child Protection Conferences in relation to the children of a Looked After Child are not chaired by the Independent Reviewing Officer responsible for the parent, who should contribute to the conference as an attendee or through provision of a report. 11 Assessment quality 11.1 It was apparent from the start of the pregnancy of Infant W’s mother that, consequent to the support needs of the parents, their baby would be a Child in Need. The primary assessment tool for planning services to support the parenting of Infant W was therefore a pre-birth assessment. This assessment process was deficient in a number of respects. 11.2 The assessment was not commenced until 21 weeks after Infant W’s mother was confirmed to be pregnant and then completed only five days prior to the birth of Infant W. The potential for plans arising from the assessment to be effectively implemented was therefore seriously undermined. 11.3 The pre-birth assessment was conducted by a Social Worker who had no experience of such assessments and compiled on a computerised Initial Assessment format. This undermined the depth of analysis and the quality of the subsequent planning processes. 11.4 There was a narrow focus on a mother and baby foster placement as the preferred option for Infant W’s care and insufficient consideration of the role of her father within assessment and planning processes. The assessment did not consider any of the other potential care options or provide contingency plans against the possibility that a suitable mother and baby placement would be either unavailable or unacceptable to Infant W’s parents. 11.5 During her pregnancy Infant W’s mother was subject of a number of parallel planning processes. There is no indication that these processes were effectively coordinated with each other or the pre-birth assessment beyond the involvement of the same professionals in a number of the different strands. A number of key professionals were not engaged in contributing to the assessment. 11.6 Subsequent Children’s Social Care assessments were also flawed and lacked responsiveness to changed circumstances and new information. 11.7 Assessment quality in the case of Infant W was suggested by the staff interviews undertaken to be a wider concern. This was addressed by a recommendation of the Children’s Social Care IMR. However, taking into account that deficiencies in the assessments were not identified or addressed by Children’s Social Care management, the Review recommended: 11.8 That Children’s Social Care ensure that rigorous and continuous arrangements for monitoring the quality of assessments are in place and that there is regular exception reporting of both this monitoring activity and its findings to the Director for Children’s Services. The outcomes of this process should be included within the Oxfordshire Safeguarding Children Board performance framework. 12 Core Group effectiveness 12.1 The Core Group has a key role in development and implementation of an effective Child Protection Plan. In this case the Core Group did not fulfil this function and a numbers of deficiencies in its operation were evident: Poor organisation and coordination Lack of engagement by agencies other than Children’s Social Care Poor communication and information sharing Lack of progress monitoring Absence of challenge regarding the effectiveness of the Core Group 12.2 Action has been taken in Oxfordshire to improve Core Group effectiveness consequent to a previous Serious Case Review (Children D, E, F & G 2009). The deficiencies in this case occurred however after the action plan arising from the earlier review had at least started to be implemented. Investigating the underlying causes of this difficultly would therefore be appropriate; alongside the existing audit, training and practice guidance developments. 12.3 Adopting this approach, the Review recommended: 12.4 That the Oxfordshire Safeguarding Children Board commission its QAA subgroup to engage with professionals across all relevant agencies, identify barriers to effective Core Group engagement and operation, and report on ways to address these. 13 Support provision for teenage parents 13.1 The Health Overview Report identified that while maternity provision for Infant W’s mother followed the Oxford Radcliffe Hospitals NHS Trust Teenage Pregnancy Pathway (2005) this actually mitigated against effective information sharing and cooperation between those providing midwifery care and other professionals. 13.2 It is therefore appropriate that both this Teenage Pregnancy Pathway and the wider Oxfordshire Teenage Pregnancy Strategy have been reviewed and updated, as part of the Oxfordshire Children and Young People’s Trust “Narrowing the Gaps” agenda, to provide an holistic package of care which includes: Access to Healthy Start Contraception and Sexual Health advice Support for parenting (Including the Family Nurse Partnership) Targeted support through the Healthy Child Programme Support for employment, education or training Strong partnerships between services e.g. Maternity, Universal Services, Children’s Centres, Connexions. 13.3 In the above circumstances the Review made no recommendation in respect of services to teenage parents. 14 The role of fathers 14.1 Infant W’s father was not mentioned once in any of the midwifery pre-birth documentation. The situation was somewhat better within Children’s Social Care where his need to be involved in Infant W’s life was recognised. Infant W’s father was not however considered as having an equal parental role to her mother, reflecting a cultural professional mindset in which the father was seen as almost irrelevant, or at best incidental, to Infant W’s parenting. 14.2 As a consequence the potential for the unborn baby to be cared for within her father’s extended family was never effectively explored. The parents’ decision that Infant W’s father would undertake the primary carer role therefore seemed to come as a complete surprise to professionals; resulting in an unplanned, uncoordinated and rushed response. 14.3 Within this the most serious deficit was that prior to Infant W’s discharge from hospital her father had had no education or support to prepare him for a role in the care of his baby. 14.4 Even subsequently, the primary carer role of Infant W’s father was seen as a substitute arrangement until her mother could assume that role. Thus resulted, for example, in the primary birth visit of the Health Visitor being undertaken at a Children’s Centre, rather than at the father’s address. 14.5 Whilst a father adopting a primary carer role for a newborn child is undoubtedly unusual it is not unique; and even in situations where the mother provides the majority of care many fathers play a significant role in parenting their children. It is therefore important that professional practice recognises this and ensures that both parents are supported in the role that they undertake. 14.6 Addressing an entrenched mindset is not easy. It may however be influenced by the strategic and practice framework within which professionals work. In this regard the Review recommended: 14.7 That the Oxfordshire Health and Wellbeing Board should ensure that the Teenage Pregnancy Strategy appropriately reflects and addresses the support needs of fathers and other male caregivers. 14.8 That the Oxfordshire Safeguarding Children Board and its partner agencies include within their training provision relating to the assessment of children and their families an emphasis on including information regarding, and planning for the involvement of, men within the family. 14.9 That the QAA sub group of the Oxfordshire Safeguarding Children Board include within their arrangements for monitoring and reporting on the quality of assessments and other practice, consideration of how effectively the presence and role of fathers and males within families has been addressed. 15 Other Learning - Professional knowledge of legislation and powers 15.1 Whilst not impacting on the outcome of events there were a number of occasions during the period covered by this Review where Police, Health Trust and Children’s Social Care professionals demonstrated a less than robust knowledge of the law within which they were operating. This related particularly to the legal status of and parental responsibility for children; and the powers available to professionals to intervene to safeguard a child. 15.2 The Review recommended: 15.3 That the Oxfordshire Safeguarding Children Board commission and include on their website a comprehensive lay person’s guide to the legislative framework within which professionals operate when safeguarding children. 16 Learning from the Individual Management Reviews 16.1 The IMRs which contributed to this Review identified and made recommendations in relation to a number of other areas where services should be improved. In some cases the background circumstances fall outside the scope of this Review. The learning is nonetheless important. These include: Provision of education services to Looked After Children and young people with Special Educational Needs Coordination and engagement of education support and youth offending services with child protection arrangements Provision of primary health care services to Looked After Children Midwifery and Health Visiting provision for vulnerable children and families Engagement of escalation procedures by health professionals Case recording practices Provision of IAG3 (Connexions) services to vulnerable young people Assessment and management of infants at hospital emergency departments Return interviews for missing children, and particularly those in residential care Police attendance at Child Protection Conferences Arrangements for provision of legal advice to Social Workers, including in relation to pregnant teenagers who are looked after or known to Children’s Social Care Safeguarding children awareness by ambulance service personnel. 17 Areas of Good Practice 17.1 A number of professionals demonstrated commendable commitment and perseverance in providing services to both of Infant W’s parents, often in the face of disengagement and resistance. These included, in particular, a Youth Offending Service Intensive Support and Supervision Officer and a Housing Support worker engaged with Infant W’s father as well as a Specialist Nurse for Looked After Children and a Community Midwife for Infant W’s mother. 17.2 Conducting Looked After Child Reviews, and associated health reviews, is not a statutory requirement for children in private fostering arrangements. That these processes were utilised for Infant W’s mother when in such an arrangement that was supported by the Local Authority is however considered to be safe and effective practice. CONCLUSION 18.1 The events leading to this Serious Case Review comprise a sad story of two damaged and vulnerable young people who came together in an intense but apparently enduring relationship and had a child together. 18.2 All indications are that Infant W’s mother and father were both loving and committed parents. There was at no point prior to Infant W’s presentation at hospital in February 2010 any suggestion that either parent intended to deliberately harm their child. 18.3 Even with the benefit of the hindsight applied by this Serious Case Review process and the parallel Family Court and criminal proceedings there is no indication that there was an intention to cause Infant W serious harm. It is typical that injuries of the type sustained by Infant W result from a momentary loss of control when the person responsible is alone, stressed, tired, frustrated and unable to cope with the persistent demands of a crying baby. That the perpetrator loves and cares for the child is immaterial. 18.4 It could and should however have been identified that the circumstances into which she was born and in which she was cared for created an environment in which there was a significant potential for such a sudden reaction or outburst by either parent to cause her physical harm. The age of Infant W’s parents, their troubled histories, unresolved issues of loss, inadequate living arrangements and social isolation could all be seen as increasing the stresses that would be placed on them. 3 Information, Advice and Guidance. 18.5 Recognising this risk of physical harm would not have changed the underlying approach of the assessments and plans made; to support Infant W’s mother and father to effectively and safely parent Infant W in a suitable environment. It would certainly have been unreasonable to expect this to have led professionals to conclude that Infant W should be removed from her parents care, or provided the basis for doing so. It should however have properly increased the focus of plans, in their development and implementation, on the safety of Infant W; whilst ensuing that the parents were robustly supported in their parenting and highlighted the need for appropriate respite arrangements. RECOMMENDATIONS 19.1 The Review made nine recommendations as outlined in sections 10-15 above. 19.2 The implementation of recommendations from both the Individual Management Reports and the Overview Report are the subject of action plans developed by the Oxfordshire Safeguarding Children Board. Progress with these is reported to that Board via the Quality Assurance and Audit subgroup. |
NC52300 | Sexual and emotional abuse of two female siblings over a number of years up to October 2017.Learning: need to/for: listen to the child and keeping their views central in practice; recognise and respond to abuse and/or neglect, including in adolescents; focus on child safety and welfare; have and use a formal escalation policy; reflect on changing facts and circumstances as well as accumulating evidence rather than family socio-economic status and act accordingly; consider using the multi-agency approach; base thresholds on assessment; single assessment with sufficient content for analysis; professional challenge especially dealing with strong opinions and/or fixed thinking; identification frameworks; child led and focused approach; deal effectively with disclosures of abuse; address domestic abuse; safeguarding training for GPs. Makes no specific recommendations but suggests embedding learning from the review into policy, practice and procedure.
| Title: Serious case review Claire and Anne summary report. LSCB: North Tyneside Safeguarding Children Board Author: Richard Burrows Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Claire and Anne Summary Report Report Author: Richard Burrows Independent Chair - North Tyneside Safeguarding Children Board and Chair of the Case Review Panel 1. Introduction 1.1 NTSCB commissioned a Serious Case Review (SCR) in relation to Claire and Anne on 23 October 2017 in accordance with Working Together 2015. 1.2 The review process brings together senior representatives from all the agencies who had been involved with the family. This ensures there is an accurate chronology of events and therefore as clear a view as possible of what agencies and their practitioners did and the extent to which multi-agency working resulted in Claire and Anne being protected and ensuring that their needs were met. 1.3 The review report concludes that these arrangements fell short over a period of time and failed to recognise and respond to the direct disclosure the children made to a number of agencies and professionals. 1.4 The review report completed by the Independent Reviewer has helped to shape and contribute to establishing learning. However the Case Review Panel and subsequently the LSCB felt that this did not ultimately provide learning that was easily accessible or that fully reflected local expectations given partners commitment to transparency, challenge and continuous learning and improvement. 1.5 As a result this summary report seeks to focus the learning and sits alongside the review report. The Case Review Panel took account of 2 the more recent developments resulting from the establishment of the new National Panel and in particular their guidance for a “good” report. 1.6 The overall purpose of this report is to demonstrate and set out how as a partnership we intend to respond to the learning in the report so that we can meet the expectations identified by Anne during the review. 1.7 The SCR report and this summary were subject to scrutiny by the Case Review Panel and the LSCB and were endorsed by the latter on 29 October 2019. 1.8 Initially the review was focused on the lived experience of Claire but as the review progressed her older sister Anne was also included. Anne has contributed significantly to the review and is concerned that the learning from her and her sister’s experience should be taken seriously and acted upon. 2. Brief overview of what happened, key circumstances, context and significant learning themes (for further details please see main report) 2.1 In 2017 Claire disclosed to a teacher that she had been sexually assaulted by her father. She was immediately safeguarded and a police enquiry commenced. The SCR was commenced when significant concerns emerged about the emotional harm, neglect and threats of physical abuse that Claire had experienced within the family setting. Claire had not made any previous allegations of sexual abuse but had, along with her sister, been involved with a number of agencies and joint working processes over several years. 2.2 Claire presented at an early stage and at various times with indicators that suggested neglect. This was correctly recognised and acted on by the school but did not result in consideration by Children’s Social Care that the threshold for child protection had been met. It did result in the offer of early help involvement in the form of parenting support. 2.3 This intervention continued for some time, and despite new information and events coming to light, the needs, vulnerabilities and risks each child faced were not felt to meet the threshold for a more formal multi-agency approach. The type of support offered and the way in which this was delivered meant that there was insufficient focus on the paramountcy of the children’s safety and welfare. Claire and Anne’s voices were not always fully heard by Children’s Social Care, the GP 3 and the wider system. Their needs, vulnerability and the harm they were suffering were not sufficiently recognised. 2.4 The school that the sisters attended were tenacious in repeatedly raising concerns based on their observations of Claire and Anne, what they were saying and their knowledge of the family. Staff found it difficult to accept the decisions by Children’s Social Care not to consider the information and concerns through the child protection process. The school was in another Local Authority area and neither they, or North Tyneside, had a specific formal escalation process at this time. 2.5 When Anne was 16 years old, she was empowered, through her involvement with a local women and girl’s centre, to challenge the response that she was offered by Children’s Social Care. Legal advice was sought by the Centre, on Anne’s behalf and as a result of the subsequent solicitors’ letter, an assessment was completed, and Anne was accommodated. However, this event did not alter the approach to the family. 2.6 Following Claire’s disclosure of sexual assault child protection procedures were initiated, and the subsequent plan ensured that Claire was safeguarded. In 2018 the girl’s father was charged and convicted of the sexual abuse of Claire, Anne and others. 2.7 It is of note that the Review Panel sought assurance from the Local Authority that it was taking into account the emerging facts and learning from the review in terms of the ongoing protection of Claire and the longer term plan. The Local Authority conducted two internal reviews in response to the issues raised by the Panel. The Panel continued to have a level of concern that the local authority was not fully reflecting on the learning arising from the review. 2.8 Throughout the review period, all family members had regular contact with their GP practice. The GPs who saw the children and parents were therefore in a good position to form a view about the family and act in the best interests of each child. However, the GPs and the GP who had most frequent contact, were not significantly involved in or aware of the multi- agency early help intervention. This and other factors meant there was not always a focus on potential safeguarding concerns as a result of contact with the parents and Claire and Anne. The GP appears to have identified with the parents needs and wishes. 2.9 The decision to continue to provide the family with parenting support was with hindsight a poor one. This intervention, though well 4 intentioned, was not well matched with the unfolding circumstances and events. There were a number of reasons for this. In part it appears for the period of the review the parenting support service did not appear to be particularly integrated with other services and wider multi-agency safeguarding arrangements. This was compounded by the fact that there appears to have been a poor level of recording, supervision and review. The potential for such circumstances to arise with regard to present arrangements need to be considered by Safeguarding Partners and agencies. 2.10 The decision may have also been unduly influenced by perceptions that because the children attended a private school and the family appeared to be middle class that focusing on supporting the parents was proportionate initially. However as noted subsequent information sharing and events did not result in any successful efforts to re-focus intervention or consider intervention on the basis of child protection procedures. 2.11 Although schools followed procedures, the learning from the Review identifies that the multi-agency arrangements and therefore the agencies involved collectively failed Claire and Anne and as a result each child suffered different forms of abuse and harm. There was a failure at a statutory and pre statutory level to build an understanding of the children’s needs, how the family functioned and to be able to place the presenting symptoms and events into a multi-agency process that focused on the potential risks that each child faced. The operation of thresholds to meet levels of needs, and ensure safeguarding concerns identified, were not effective. Whilst an early help response may initially have been justified, the basis for this does not appear to have been grounded in any kind of assessment. 2.12 A number of agencies, for example the GP, CAMHS, had an accumulation of evidence and Children’s Social Care response did not recognise the importance of accumulative evidence when concerns were referred, and new events and information came to light. The apparent reluctance to commit to a single assessment process meant in effect that it was not until mid-way through the review period, that all concerned were able to benefit from structured and informed assessment. Even when this was the case the assessment appears to have lacked sufficient content to support effective analysis. As a result, it did not significantly raise challenges and alternatives, which in the light of what was known, meant that the thinking about the girls and the family remained “fixed”. 5 2.13 The application of frameworks that help identify and understand neglect, emotional harm and domestic abuse would have led to more questions being asked and the testing out of potential hypotheses. Instead it appears that the collective effort accepted and to some extent maintained a view that working to support the parents would make things better for the children. 2.14 For many years the underlying principles for understanding families, parental conflict and the potential impact these can have on the wellbeing and safety of children have been embedded in policy, practice and procedure. It is therefore important that the learning identified by this review has a measurable impact on current and future practice at all levels. 2.15 There appears to be an over reliance on two occasions on the sharing of personal opinion by practitioners. These in effect sided with the views of the parents and were influential in maintaining the status quo, i.e. that the children’s needs and safety could best be met with this level of support and type of approach, and perhaps inhibiting alternative views being formed and approaches being adopted. Specifically, both the Parenting Support worker and one of the GPs, compromised the safety of the children. The ways in which Children’s Social Care interpreted and applied “thresholds” did not act as a potential ‘check and balance” to the influence individual views had. The quality of social work assessment also means that there was insufficient challenge and a limited understanding of the information that was available. 2.16 The purpose of assessment, planning and review arrangements is to ensure that the available information and the work of different agencies results in a coherent and clear view of the family as a whole and the needs, vulnerabilities and risk that the children face. At all stages the evidence suggests that there were opportunities for this to have considered the available information and demonstrate how the available frameworks for recognising abuse, harm and exploitation may have helped to alter the overall approach. 2.17 Whilst there can be justification for any overall approach, there are a number of factors that suggest that opportunities were missed. For example, significant learning from the Review is the importance of listening to what children and young people tell us and keeping their views central to our work. Both girls were clear and consistent in describing their lived experience within the family home. Claire spoke about being frightened of her fathers’ anger, had violent nightmares about father killing her and had thoughts of killing herself with a knife. 6 Anne spoke of her unhappiness, her low mood and suicidal thoughts which she linked to what was happening at home over a prolonged timescale. In different ways, both Claire and Anne consistently shared their concerns and fears with a number of agencies and practitioners. It is important to note that the schools were able to recognise this, but ultimately were reliant on the judgments of others despite their efforts to bring these concerns to light. The “voice of each child” was not given sufficient priority, in part because the view remained that supporting the parents was the priority. 2.18 There is documented evidence that both children made direct disclosures as to the emotional abuse and neglect they were experiencing on number of occasions to a range of professionals at different points during the review period. 2.19 This learning indicates there was not always an effective response to what children tell others, directly and through their behaviours, about their wellbeing and safety. The learning also indicates that although within the school settings their voice was heard, the way in which multi agency arrangements are intended to operate did not result in a timely or a proportionate response in terms of safeguarding. This raises an issue that if this case is representative, that agencies and multi-agency arrangements were, or are not sufficiently focused on listening to and recognising the potential importance of what children tell us, directly and through their presentation. 2.20 It may also suggest that the arrangements and pathways for responding to, recognising and prioritising concerns and shared information would have been more effective if the Children’s Social Care response was more focused on the child protection threshold and fuller assessment of needs and risks focused on the children. The action partners take in respect of this will need to reflect their understanding of what can prevent practitioners and systems from achieving a “child led and focused approach” especially given the significant investment partners have made in recent years. 3 The findings 3.1 It is clear from the evidence that Claire and Anne were not effectively safeguarded and their views about their own lives and experiences were not always listened to or acted on by some agencies. The work of safeguarding is complex, and inevitably this means that there is never one influential factor on practice, but a number of interacting factors. 7 This was the case here. These different factors are the six Findings of the SCR outlined below and discussed in detail in the SCR Report. 3.2 Finding 1. Listening to the voice of the child and dealing effectively with children and young people’s disclosures of abuse and harm 2. The importance of identifying and addressing the Emotional Abuse of children and young people 3. Fixed professional thinking in this case influenced the analysis of the needs and circumstances of Claire and Anne 4. Domestic abuse not addressed as a concern 5. The importance of addressing the neglect of children and adolescents 6. Multi-agency working 3.3 The Board and safeguarding partners are therefore resolved to act on the learning identified to include the following, 3.4 The new Multi-Agency Safeguarding Arrangements that came into operation from the 29th September 2019 will set as a priority a review of the Threshold and Levels of Need guidance. There are two reasons for this, firstly as the learning from the review indicates in this instance the guidance did not create opportunities to hear and see what the children were telling people alongside the information that was already available. Secondly, although arrangements for early help and the ways in which information, contacts and referrals has changed, we need to be sure that there is sufficient capacity and depth of understanding to ensure that risk, need and vulnerability is responded to in an appropriate and proportionate way, and that we do not become “fixed” in our thinking and therefore the way we respond. 3.5 We rely on practitioners and organisations at all levels across North Tyneside to be able to recognise and raise any concerns they have about children they are in contact with. Our thresholds, guidance, multi agency training and other measures all seek to inform and support when and how they should do this and what they might expect and may be expected from them. This means that a non statutory response such as early help is often one of the ways in which risk, need and vulnerability can be explored and managed. However we do need to be sure that those who take part in this kind of response have the necessary resources including knowledge and skills. Also, that this level of approach is informed by assessment that takes into account 8 the frameworks that can help recognise the reality of the child’s lived experience. We therefore need to be sure that the standards of assessment, supervision and case management are robust and consistent at all levels of intervention and across all settings. This should promote and allow for the forming of a better understanding of children’s situations, that take into account and reference what we know about neglect, domestic abuse, emotional and sexual harm as well as how we understand families and their dynamics. 3.6 We have recognised for some time that the quality of our early help and statutory assessments can always be improved, and there continues to be a range of measures in place to achieve this. We also know that the pressures and complexity of demands placed on systems as a whole and therefore the practitioners and managers we rely on to ensure these work effectively, can serve to counter best efforts on occasions. As a result of this review we will take a fresh look at how we can be assured that people have the necessary skills, knowledge, support and space to be able to strengthen how they work together, and which addresses the key factors identified in 3.5 3.7 We also need to be sure that we do not allow situations that result in children experiencing avoidable harm and abuse. We also need to be sure that when there are conflicting judgments and opinions that there are arrangements for and a robust culture to ensure that individuals and agencies are able to recognise and raise concerns that the best interests of children are not being addressed. This needs to include the recognition that there can be times when individuals, who may or may not represent the view of their agency, may be acting contrary to their professional standards and codes of conduct. 3.8 This suggests that there needs to be a focus on shared and single agency/professional codes of conduct and how these compliment established multi agency policies and procedures. We know that working with families where there are concerns for the safety and or wellbeing of children, is not a binary process i.e. a question of accepting for example the views of a parent instead of those of a child, but we need to be sure that there is sufficient challenge built into how we deal with each other and specific challenge when it may appear a line is being crossed. We will therefore explore ways in which we can inform and support practitioners to always act in the best interests of children. 3.9 Although we felt confident that our respective practice and approach to being child centred and that collectively we heard and acted on what children told us was reliable and embedded, we accept that there is 9 more we can and should do. Some of the system wide measures that are already in place such as Signs of Safety are enabling us to further develop this especially in order to focus on protection and the need to take appropriate steps. We can draw on our experiences of how we do this with children who are Looked After, as well as remembering that these arrangements need to draw on and contribute to protective measures for other children who may remain in the family. 3.10 It is clear that we will also need to identify specific measures and approaches, to further support and increase confidence in the value of challenge and escalation when one party feels that their view is not being heard or is inappropriate. We will therefore review and revise our current approach to “escalation” and what we term “professional” conversations to ensure that these reflect the learning from this review and are better embedded as a constituent part of joint working arrangements. 3.11 We have commissioned from our Case Review Group a detailed action plan which will identify achievable and measurable actions to act on the learning and improvements we have identified above. These will be subject to regular review and scrutiny by the Partnership and will form a part of the annual independent scrutiny report. |
NC52806 | Death of a 4-month-old-boy in Spring 2022. A post-mortem found that Rowan died from Sudden Unexpected Infant Death Syndrome. His parents were children themselves at the time of Rowan's birth. Mother was 13 and father was 14-years-old. Learning themes include: the importance of parenting and pre-birth assessments; recognising that the parents were themselves children and the support offered to young parents; child protection planning; and professional advice on safe sleeping. Recommendations to the partnership include: ensure all practitioners read the briefing 'Learning from Pre-Birth Assessments'; if a vulnerable baby is living in the care of grandparents (with or without the presence of their parent), an assessment of their parenting capabilities and skills should be a pre-requisite before any such placement is made, especially if the child is subject to a child protection plan; when parents are children themselves, their needs and wellbeing should be recognised, and considered a priority, together with that of the need to safeguard their child; explore the possibility of young, teenage mothers being offered the services of the perinatal mental health team when it is evident that their health and wellbeing is at risk; GP practices should be informed when a child is subject to a child in need plan, to ensure that relevant safeguarding information is shared; seek assurance that the framework concerning safe sleeping is embedded for use by practitioners and that it includes a requirement that professionals visiting the home ask to see where a baby is sleeping.
| Title: Child safeguarding practice review: Child “Rowan”. LSCB: Surrey Safeguarding Children Partnership Author: Moira Murray Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 35 Final 17 July 2023 CONFIDENTIAL Surrey Safeguarding Children Partnership Child Safeguarding Practice Review Child “ROWAN” Lead Reviewer Moira Murray March 2023 Page 2 of 35 Final 17 July 2023 TABLE OF CONTENTS 1. Introduction: Background Information to the Review .................................................................... 3 2. Terms of Reference, Methodology and Scope ................................................................................ 4 3. Key lines of enquiry .......................................................................................................................... 4 4. Involvement of family members in the review ................................................................................ 5 5. Background History: including information outside the time period for the review ...................... 6 6. Rowan’s lived experience in the family environment ................................................................... 10 7. Key Lines of Enquiry ....................................................................................................................... 13 7.1 What was the quality of assessments of Mother and Father as children who were in need of help and protection? ..................................................................................................................... 13 7.2 What was the quality of support for Rowan’s mother and father as young parents? Did their needs and vulnerabilities overshadow professionals understanding of his needs as a child in need of protection? .................................................................................................................................... 16 7.3 How was Father’s capacity as a young father assessed and supported? .............................. 19 7.4 How well was the parenting capacity of both these parents and their wider families understood, assessed and supported? .............................................................................................. 21 7.5 How effective was the multi-agency work in providing and reinforcing safer sleeping advice? ............................................................................................................................................... 23 8 Findings and Lessons Learned ........................................................................................................ 25 8.1 The importance of parenting assessments, including pre-birth assessments ....................... 25 8.2 Recognising that the parents were themselves children ....................................................... 26 8.3 Support to young parents ...................................................................................................... 27 8.4 Child Protection Planning....................................................................................................... 28 8.5 Professional Advice on Safe Sleeping .................................................................................... 28 8.6 Risk-factors identified in the Out of Routine Report and presenting Issues in this case ........... 28 9. Good Practice ................................................................................................................................. 29 10. Conclusions ................................................................................................................................ 29 11. Recommendations ..................................................................................................................... 30 Appendix 1 ............................................................................................................................................. 32 Terms of Reference ................................................................................................................................ 32 Page 3 of 35 Final 17 July 2023 1. Introduction: Background Information to the Review 1.1 Rowan was found unresponsive by his mother at home in his cot in a morning in Spring 2022. He was four months old. Mother said that on the previous evening she had fed Rowan and placed him on his back in his cot, although he preferred to sleep on his front. Mother reported that this was the first occasion that Rowan had been put in his cot at night to sleep, as they usually co-slept. Fearing that Rowan might wake up, Mother remained awake until 00:30 and then fell asleep. On waking the next morning, Mother was concerned that Rowan had not woken for his feed and found him unresponsive, lying face down in his cot. 1.2 An ambulance was called, and CPR was administered until Paramedics arrived. Sadly, the Advanced Paramedic who attended the home, determined that there was no chance of Rowan being successfully resuscitated. Mother accompanied Rowan to hospital where he was pronounced deceased. 1.3 At the time of his death, Rowan was subject to a Child Protection Plan, under the category of Physical Abuse. This was because of the contextual safeguarding risks associated with his father, which resulted in threats being made to Mother and her family. Surrey County Council initiated Care Proceedings in respect of Rowan, with an Interim Supervision Order being sought. Because of the young age of the parents, the Public Law Outline was determined not appropriate and in accordance with case law guidance, it was proposed that the matter be dealt with by a High Court Judge. 1.4 Both parents were children themselves at the time of Rowan’s birth. Mother was 13 and Father was 14 years old. Mother had been subject to a Child Protection Plan prior to Rowan’s birth. Father lived outside Surrey and there were concerns about physical abuse in the home as well as his association with youth violence. Because of these concerns, both Father and his sibling were subject to Child Protection plans at the time Rowan was born. Statutory agencies in the local authority where Father and Paternal Grandmother lived considered them to be at risk of harm. 1.5 At the time of death, Rowan and Mother were living in the home of Maternal Grandmother, together with three of Mother’s five siblings. Mother’s family had been known to Surrey statutory agencies since 2014 due to concerns about domestic abuse, Maternal Grandmother’s aggressive behaviour towards her children, and the violent behaviours of Mother’s older siblings. 1.6 A post-mortem found that Rowan died as a result of Sudden Unexpected Infant Death Syndrome (SUDIS). 1.7 Given the involvement of agencies with both families, consideration was given by Surrey Safeguarding Children Partnership (SSCP) as to whether the case met the Page 4 of 35 Final 17 July 2023 criteria for a Child Safeguarding Practice Review under Working Together to Safeguard Children, 2018. It was decided at a Rapid Review meeting on 13 May 2022 that the case met the criteria for a Local Child Safeguarding Practice Review, which was commissioned on 1 August 2022. 2. Terms of Reference, Methodology and Scope 2.1 Full details of the terms of reference and methodology for the review can be found in Appendix 1, as can details of the agencies involved, and the Lead Reviewer. 2.2 An online, multi-disciplinary Reflective Learning Workshop for practitioners was held in January 2023. Thirty two professionals attended the event, representing all of the agencies involved with the families. Discussion and reflection of the practice issues arising from the review proved extremely helpful to the Lead Reviewer and are reflected in this report. The Lead Reviewer would like to thank all those who attended the event and to the Surrey Safeguarding Partnership Team for organising and contributing to its success. 2.3 The time period for the review is from January 2021, when Mother came to the attention of services following a domestic abuse incident perpetrated against Maternal Grandmother by Maternal Grandfather and her older sibling, until the date of Rowan’s death. Additional information relevant to the review, but outside the time period has been included in this report. 3. Key lines of enquiry 3.1 What was the quality of assessments of the parents as vulnerable children who were in need of help and protection? 3.1.1 What was the quality of the pre-birth assessment: assessment is a live and on-going process; each assessment should reflect the specific characteristics of each child within their family and community context; this includes drawing upon relevant family history and family functioning; as well as the risk factors for Sudden and Unexpected Death in Infancy identified in the Child Safeguarding Practice Review Panel’s Out Of Routine report published in 2020. 3.1.2 Did assessments focus sufficiently on the needs of Rowan as a child who needed to be safeguarded. 3.2 What was the quality of support for Rowan’s mother and father as young parents? Page 5 of 35 Final 17 July 2023 3.2.1 The Rapid Review noted that when parents have a range of vulnerabilities, these must be addressed, whilst maintaining focus on the child. In this case, did the needs and vulnerabilities of Rowan’s very young parents overshadow professionals’ understanding of his needs as a child in need of protection? 3.2.2 How was Father’s capacity as a young father assessed and supported? The role of fathers: Father was the focus of significant concern; however, it is less clear regarding the work that was done to support him as a parent, including joint work with both sides of Rowan’s family. This should be considered against the findings and recommendations of the Child Safeguarding Practice Review Panel’s report, the Myth of Invisible Men, published in September 2021. 3.2.3 How well was the parenting capacity of both these parents and their wider families understood, assessed and supported? The risk to Mother and Father were known, however, there needed to be a greater focus on how these risks impacted on their ability to act as consistently good enough parents for Rowan. Related to this was the need for a clear assessment of the impact of the vulnerabilities of the Maternal and Paternal Grandparents for Rowan. 3.3. How effective was the multi-agency work in providing and reinforcing safer sleeping advice? 3.3.1 As identified in the Surrey SUDI thematic review and the Child Safeguarding Practice Review Panel’s Out of Routine report, this case highlights the need for all agencies to play a role in communicating safer sleep advice and safe sleep assessment to form part of all child and family assessments. 4 Involvement of family members in the review 4.1 Both Mother and Father were invited to contribute to the review, but this has not proved possible. Paternal Grandmother was also invited to meet with the Lead Reviewer, and although initially indicating that she would like to do so, a meeting did not materialise. 4.2 The Lead Reviewer and a Nurse from the Child Death Overview Panel met with the Maternal Grandparents at their home in January 2023. The Lead Reviewer would like to thank the Maternal Grandparents for agreeing to meet with us to discuss the tragic death of their grandson and to express their views on their experience of agency involvement during the time period of the review. Their views have informed the review and are referenced in this report. Page 6 of 35 Final 17 July 2023 5 Background History: including information outside the time period for the review 5.1 Rowan was of White and Black British heritage, and lived with Mother, Maternal Grandmother and Mother’s siblings. At the time of his death, Father and Paternal Grandmother were not in contact with Rowan following an argument in early January 2022, which had resulted in Father allegedly pushing Mother whilst she was holding Rowan. 5.2 Mother’s family had been known to Surrey Children's Services since March 2014, with input from Early Help and Social Care. Following an incident of domestic abuse between Maternal Grandparents in January 2021, a child protection investigation was initiated. During the three months between January and March 2021, Mother was thrown out of the family home on several occasions by Maternal Grandmother and was sent to stay with her paternal grandparents. Such action on the part of Maternal Grandmother was to be repeated during the time Mother was pregnant and was said by her older siblings to be a pattern of behaviour exhibited by Maternal Grandmother, which they had also experienced. At this time, Mother was 12 years old, and her parents knew that she was involved in a relationship with a boy (Father) from another area, although they said they were not aware that the relationship was sexual. 5.3 Since September 2020, Mother had been permanently excluded from mainstream school, following a physical assault on another pupil and a member of teaching staff, and had been attending a Short Stay School. The Short Stay School provided education to those children who were unable to attend a mainstream school because they had been permanently excluded or were experiencing emotional or behavioural difficulties. This was not a permanent placement and Mother was expected to return to mainstream education. During the period of national lockdown because of the Covid Pandemic, Mother would have had a place available at the Short Stay School. 5.4 During the time period of the review, five Child and Family Assessments were undertaken concerning Mother and her siblings. Safeguarding concerns about the younger children being subject to physical violence, domestic abuse, Maternal Grandmother’s mental health, the impact of the Maternal Grandparents separation and Mother being ‘beyond parental control’ emerged during the assessments. In addition, it became known that Mother, aged 12, was sexually active, when she consulted the GP Surgery as to whether she might be pregnant in mid-March 2021. During the consultation, which she attended alone, Mother disclosed that she had been involved with a 13 year old boy for eight months. The GP provided sexual health and contraception advice, and as it was too early to ascertain whether Mother was pregnant, advised a pregnancy test should be done in one week’s time. The GP made a safeguarding referral to Children’s Services, and informed Maternal Grandmother of the situation. Page 7 of 35 Final 17 July 2023 5.5 As a result, a strategy discussion was convened to consider Mother’s ability to consent to sexual activity and to investigate whether sexual offences were being committed by Father. A Police investigation was undertaken, and a decision made that given the nature of the relationship and the closeness in age, a criminal prosecution was unlikely to succeed. Mother was placed on a Child in Need plan at the end of March 2021. It is noted that Child in Need Plans are not routinely shared with GP Practices, although a policy was in place at the time, which stated that they should be made aware. Thus, the GP did not know of this decision or the background information leading to it. This issue is discussed in the Findings and Lessons Learned section of this report at para 8.4.2. 5.6 In April 2021, a Strategy Discussion was held in relation to Father, after his arrest for possession of a firearm. Father had been out of school for over 18 months. Father and his sibling were both subject to Child Protection Plans under the category of physical abuse. This was as a result of an escalation of arguments between Paternal Grandmother and Father over the Christmas period in 2020, leading to Paternal Grandmother physically assaulting Father, for which she was arrested. It was also the case that Father was at risk because of his involvement in Gang and County Lines activity and being at risk of Child Criminal Exploitation (CCE). 5.7 In May 2021, Mother was placed on a Child Protection Plan under the category of Neglect, until January 2022. In June 2021, Maternal Grandmother informed Children’s Services that Mother was pregnant, and had booked an appointment for a termination of pregnancy. Information provided to the review states it was Maternal Grandmother who wished for Mother to have a termination, but that Mother was unsure. There was uncertainty as to when Mother may have become pregnant, but confirmation of the pregnancy was passed to a Social Worker who at the time was covering the case on behalf of the allocated Social Worker. 5.8 A Strategy Discussion held in mid-June 2021, shared information that Mother was visiting and staying with Father, who because of threats of violence had been moved out of area with Paternal Grandmother and his family. It was agreed that the threshold was met for a single Section 47 child protection investigation to be commenced in respect of Mother. 5.9 By the beginning of July 2021, Mother confirmed that she had decided to keep the baby, and the first antenatal appointment was booked at the hospital. Mother was under the care of Willows1, a specialist midwifery team working with young mothers. Maternal Grandmother attended the appointment and stated she would be supportive. This was despite her initial reaction to the news, which according to Mother was that she would not support her as she had children of her own. (Source: Combined Chronology Education entry). 1 Willows has now been disbanded Page 8 of 35 Final 17 July 2023 5.10 The Midwifery Team was aware that Mother was on a Child Protection plan and made a safeguarding referral to Children’s Services. A referral was also made by the Health Visiting Service to the Family Nurse Partnership (FNP). It was not until early September 2021 that a first visit was successfully made by the Family Nurse to Mother, who welcomed FNP engagement. 5.11 Following confirmation of the pregnancy, Mother’s allocated Social Worker was commissioned to undertake a Pre-birth Assessment. At the time, the current Surrey Pre-birth Assessment Policy was not in place, which states that such an assessment should be undertaken by a Social Worker from the Family Safeguarding Team (FST). 5.12 When the Pre-birth Assessment had been completed (the assessment was allocated to the Social Worker for the family on 20 July 2021 and information was still being collated on 8 December 2021. Source: Combined Chronology) it was planned that the case would progress to a Strategy Discussion and with an Initial Child Protection Conference convened concerning the unborn baby. During her pregnancy, in accordance with Child Protection Procedures, Mother was visited regularly by her Social Worker. The home situation was considered to be stable with Maternal Grandmother offering support with fewer arguments taking place between the Maternal Grandparents. It would appear that Maternal Grandfather was still a member of the household, at this time, although following arguments with Maternal Grandmother, he was often requested to leave. Mother continued to be on roll at the Short Stay School during her pregnancy, with a place being held for her at a mainstream school after the baby was born. 5.13 In early August 2021, Mother and her family moved to different accommodation believed to be because of risks presented by gang members associated with Father. Later that month following management oversight by the Independent Reviewing Officer (IRO) the pre-birth assessment was reallocated to a Social Worker in the FST, with a recommendation that a Strategy Discussion be convened within 48 hours. A Strategy Discussion took place in early September 2021, with a recommendation for an ICPC in respect of the unborn baby. 5.14 During September Father was threatened with violent assault from gang members and went missing for 2 days. This caused the ICPC in relation to the unborn baby to be postponed due to Mother’s anxiety for Father’s welfare. On his return, Father had sustained an injury to his hand and he and his family continued to receive threats of violence. At the beginning of October 2021, a Strategy Discussion was convened. Father remained allocated to the Adolescent Team in Children’s Services, but was open to the Child Criminal Exploitation Police Team as a consequence of the risks posed to him by his involvement in youth violence. Father continued to be associated with gang culture, and he and his family were once again moved to a safe place. Page 9 of 35 Final 17 July 2023 5.15 In October 2021, unborn Rowan was made subject to Child Protection Plan, under the category of Physical Abuse. This was on the basis of Father’s continued association with criminal gang activity and the risk posed to Mother, her family and the unborn baby. The plan was for Maternal Grandmother to supervise any contact between Mother and Father. Mother’s school attendance at this time continued to be 100%, she was attending antenatal appointments with the support of Maternal Grandmother and was engaging with the FNP. 5.16 In mid-November Father was arrested for suspicion of knife point robbery, which was to result in no further action. In early December 2021, Father, Paternal Grandmother and other members of the family moved to permanent accommodation, out of area, which was funded by Children's Services. 5.17 The review has been informed that information was still being gathered in December 2021 for a Pre-birth Assessment. Rowan was born in December 2021. Maternal Grandmother was in attendance at the birth. Rowan remained in hospital for a further period because of jaundice. Whilst in hospital Mother had tested positive for Covid. On his discharge, both Mother and Rowan resided with Maternal Grandmother, and were under the care of Community Midwives and the FNP. Health and Children’s Services professionals continued to visit the family home at this time, and throughout the Pandemic. As part of the discharge plan, support was offered by Maternal Grandmother. The Maternal Grandparents home was considered appropriate for the needs of Rowan and Mother. 5.18 Mother’s care of Rowan was considered to be good. He was gaining weight and Mother kept appointments with the FNP. Safer sleeping information was reiterated by the Community Midwife and the Family Nurse, but it is known that Mother co-slept with Rowan. On the advice of the midwife, Mother and Maternal Grandmother attended hospital A&E in late December 2021 with concerns about a lump on Rowan’s head. This proved to have resulted from his forceps delivery, and the injury had not been noted on his discharge notes to the Community Midwives. 5.19 It is not clear to the review as to how much contact Father had with Rowan, following his birth. When we met with the Maternal Grandparents, we were told that Father was at the hospital when Mother was in labour but once she was diagnosed with Covid he was required to leave. Father did have some limited contact with his son when Mother and baby returned home from hospital. It is known that in early January 2022 there was an incident involving both parents with an alleged physical assault by Father towards Mother whilst she was holding Rowan. Police and Children’s Services were informed, resulting in a Strategy Discussion and Section 47 investigation. Paternal Grandmother made allegations that Maternal Grandmother smoked cannabis and drank alcohol, which she claimed Maternal Grandmother gave to Mother and Father. These allegations were denied by Maternal Grandmother, and following an investigation by Children’s Services, no evidence could be found to substantiate such allegations. Following this incident, Children’s Services attempted to facilitate contact Page 10 of 35 Final 17 July 2023 between Father and Rowan, but it appears from this point onwards contact ceased. 5.20 Mother was no longer subject to a Child Protection Plan, as at a Review Child Protection Conference in December 2021 a unanimous decision was made by professionals that the case should be stepped down to one of Child in Need. In early February 2022, a Legal Gateway Meeting was held in respect of Rowan, and a second meeting took place later that month. In mid-February, Maternal Grandmother informed Children’s Services that she no longer wished to be responsible for Mother and Rowan’s care and suggested that Maternal Grandfather should take responsibility, which he refused to do. Children’s Services agreed to find a foster placement for Mother and Rowan. However, when Mother said she wished to live with Maternal Grandfather, arrangements were put in place to assess the feasibility of this proposal. By the end of February 2022, it was evident that such an arrangement would not work, and when Maternal Grandmother said that Mother and Rowan could remain in the family home, an agreement was put in place between Mother, Maternal Grandmother and Children’s Services as to the expectations for the care provided to Rowan. It was made clear that if the agreement was not adhered to, Rowan would be removed. 5.21 During March and early April, arrangements were being made for Mother to return to fulltime education. Rowan was thriving and considered to be making good progress. Efforts were being made to arrange supervised contact between Father and Rowan, although concerns continued about his gang association and issues had been raised as to whether he was a victim of modern slavery. The Maternal Grandparents agreed to attend relationship counselling and attempts were made to reduce their significant rent arrears. 5.22 In April 2022, Surrey County Council delivered letters to both parents of their intention to issue to Care Proceedings in respect of Rowan. An application was listed for a hearing in April, but sadly, Rowan died before the hearing. 6 Rowan’s lived experience in the family environment 6.1 Rowan was a baby born to parents who were themselves children, both of whom experienced emotional trauma and had witnessed and suffered physical violence. In the case of Father, it was evident that his involvement with gang related violence and criminality resulted in risk of serious harm to himself, Mother, Rowan and extended family members. This in turn meant that attachment to his son could not develop due to the severe restrictions in place concerning Father’s contact with Rowan, because of the risk posed by his behaviour. 6.2 Mother came from a home where there was marital discord, domestic abuse, and physical harm and neglect. She was on occasions told to leave by Maternal Grandmother. Because of aggressive outbursts at her mainstream school, Mother was permanently excluded, but it is to her credit and that of the staff at the Short Page 11 of 35 Final 17 July 2023 Stay School that she began to fully engage in education, achieving 100% attendance prior to Rowan’s birth. 6.3 Mother became sexually active from a very young age, and it is evident that she and Father were involved in a sexual relationship when she was 12 and he was 13 years old. According to his expected date of delivery, Rowan was born 4 weeks prematurely, however, there is some uncertainty as to the date of his conception. Although Maternal Grandmother appeared to try and influence Mother’s decision as to whether she should continue with the pregnancy, Mother decided that she would. 6.4 During her pregnancy, Mother regularly attended antenatal appointments and once engagement with the FNP was established, a good relationship developed with the Family Nurse. Rowan’s birth weight was 3080g (6lbs 12 oz) and he continued to gain weight appropriately. Although Rowan had not been vaccinated during his short life, Mother’s care of him was assessed as being appropriate and she was seen to be a caring and loving mother. Her concern for Rowan’s wellbeing was demonstrated by her pointing out the lump on his head to the Community Midwife, which was found to be caused by his forceps delivery. Mother and maternal Grandmother acted immediately on the Midwife’s advice and took Rowan to A&E. 6.5 Rowan was a wanted and loved child, whose care professionals considered good. His lived experience, however, was that of a child born to extremely young parents, who were dependent on the support offered by Maternal Grandmother who was caring for her other children, whose mental health was volatile, and who consistently used cannabis to ‘self-medicate’ her mood. In addition, the added pressures and risks to both families brought about by Father’s involvement in youth violence meant there was a lack of stability in the home environment in which Rowan was living. 6.6 When the Lead Reviewer met with the Maternal Grandparents they were able to provide some insight into Rowan’s lived experience. He was described as a beautiful, smiley baby, who fed and slept well. He was much loved by Mother and all the family. He was described as a ‘strong baby’ who could ‘roll over.’ He did co-sleep with Mother, but Maternal Grandmother said that this began because there were problems with the heating at their previous address where Rowan lived when he was first brought home from hospital. 6.7 Maternal Grandmother described how under the terms of the Child Protection Plan she was required to support and supervise her daughter’s care of Rowan. According to both Maternal Grandparents, in essence this meant that Mother and Rowan could not leave the family home unaccompanied because of concerns about the threat presented by Father’s involvement with gang related violence. The Maternal Grandparents also alleged that Father was threatening Mother, and that the family was in fear of him and his associates. Their relationship with Paternal Grandmother was described as difficult, and according to Maternal Page 12 of 35 Final 17 July 2023 Grandmother, Paternal Grandmother had only limited contact with her grandson and had never held him. Following Father’s alleged aggressive behaviour towards Mother in January 2022 whilst she was holding Rowan, he had not been allowed to have unsupervised contact with his son. 6.8 When asked about their experience of agency involvement, both Maternal Grandparents expressed concern about a lack of communication with them as a family, as well as a lack of communication between agencies, especially Children’s Services and Police. They felt that there could have been more liaison between these two agencies concerning the risk presented by Father, which in turn should have been communicated to them. From a review of Child Protection Conference minutes and from other documentation provided to the Review, this appears not to be the case. 6.9 Maternal Grandmother considered there was little support offered either by the FNP or Children’s Services to her or Mother. She also stated that Children’s Services had said that Mother and Rowan would be split up in different foster placements if they no longer resided with her. This view contradicts the information supplied to the review by these agencies. Maternal Grandmother did praise the support, care and concern consistently shown to Mother by the Senior Pastoral Worker, Short Stay School. 6.10 It was not possible to speak with Mother, to confirm the views expressed by Maternal Grandmother, and the above account is a reflection of the Maternal Grandparents discussion with the Lead Reviewer. Maternal Grandmother went on to describe how Mother’s pregnancy was normal but following a 16 hour labour Rowan’s birth was traumatic, requiring a forceps delivery. Maternal Grandmother also stated that Mother experienced discrimination from some maternity staff on the post-natal ward due to her age. Because of the treatment she experienced Maternal Grandmother complained to the Unit Matron on her daughter’s behalf and received an apology. Maternal Grandmother did praise the Teenage Pregnancy Lead, who showed empathy and understanding towards Mother. Maternal Grandmother said that not only was she with Mother when she gave birth to Rowan, she stayed on the ward with her for four days. 6.11 Maternal Grandmother wanted to emphasise that despite her young age, the care given by Mother to Rowan could not be faulted and his death was devasting for her. 6.12 Although there was a cot for Rowan in Mother’s room, she was co-sleeping with him, until the night before he was found unresponsive the following morning. On several occasions, both the Community Midwife and the Family Nurse discussed with Mother the risks of co-sleeping and provided her with information about the dangers of doing so. Mother was also given advice as to how Rowan needed to be placed on his back to sleep. Page 13 of 35 Final 17 July 2023 6.13 The information provided to the Child Death Overview Panel, following Rowan’s death, resonates with the risk factors associated with Sudden Infant Death, as manifest in the Child Safeguarding Practice Review Panel Report ‘Out of Routine’ published in July 2020, concerning Sudden Unexpected Death in Infancy (SUDI).2 The report found that almost all of the 14 tragic incidents of sudden unexpected death (SUDI) in infancy examined included risk factors such as co-sleeping, domestic abuse, mental ill health, secondary smoking, and substance misuse. Whilst Mother was seen to be a loving and caring parent to Rowan, it is apparent that some of the findings of the ‘Out of Routine’ Report concerning the risk factors prevalent in the sudden unexpected death of an infant did feature in Rowan’s home environment. 6.14 The report is one which Surrey Safeguarding Children Partnership has taken seriously and has implemented measures to improve outcomes for infants at risk of sudden unexpected death. 7 Key Lines of Enquiry 7.1 What was the quality of assessments of Mother and Father as children who were in need of help and protection? 7.1.1 As is evident from the narrative section of this report, Mother’s family had been known to statutory agencies during the period under review and for several years previously. 7.1.2 Information provided by Surrey Police to the review states that between January 2021 and April 2022 Police had direct contact with Mother’s family on twenty one separate occasions. The primary source of these contacts arose from relationship breakdowns between Maternal Grandparents and conflict between Maternal Grandmother and her older children, especially Mother when she became involved in a sexual relationship with Father, with the added stress of the threat of violence towards Mother from criminal gangs. Police involvement with the family was shared with other agencies at numerous Strategy Discussions and Child Protection meetings. 7.1.3 Mother experienced periods of rejection by Maternal Grandmother, said to be because of her behaviour, at several times resulting in her being ejected from the family home and living instead with Maternal Grandfather’s parents. Such incidents happened when Mother was 12 and 13 years old, including one occasion in March 2021 when she was thrown out of the house at midnight, in her pyjamas, was collected by Maternal Grandfather and driven to his parents’ home. On another occasion, when aged 12, Mother was known to be out of the home, not returning until 11:30pm during a period of lockdown. 2 https://www.gov.uk/government/publications/safeguarding-children-at-risk-from-sudden-unexpected-infant-death Page 14 of 35 Final 17 July 2023 7.1.4 During the period under review, there were five Child and Family Assessments. In relation to Mother, the first assessment in March 2021 discovered that the Maternal Grandparents had recently separated, there were concerns that Mother was ‘beyond parental control’ and that she was sexually active. Maternal Grandmother maintained that as part of a safety plan Mother and Father were not left alone and at that time Mother had been sent to live with her grandparents after being ‘disrespectful.’ The Maternal Grandparents said they were worried about Mother’s sexual activity but had not acted to ensure that she was provided with sexual health advice or long acting reversable contraception. Clearly the arrangements put in place by the Maternal Grandparents to ensure that Mother and Father were not left alone were unsuccessful, given that Mother spoke to the Social Worker during the assessment visit about having sex, going to the GP for a pregnancy test and being worried about the test being positive. Mother also disclosed her ambivalence about what to do if she was pregnant. (Source: Children's Services report to the review). 7.1.5 It is apparent that Mother was seeking help to discuss her situation and could have been referred to a professional for advice and guidance as to her choices. The author of the Children’s Services report asks the question as to whether there may have been a role for the School Nursing Service to assist at this time. This suggestion is one with which the Lead Reviewer agrees. Also, it was known that Mother had visited the GP to discuss her fears about pregnancy and the GP had acted with concern and compassion. The outcome of the assessment was for Mother to be placed on a Child in Need plan. There is no indication, however that consideration was given to proactively seeking professional support to assist Mother with her relationship with Maternal Grandmother, her sexual activity and the fear that she may be pregnant. She was 12 years old when she became sexually active, and as such should have been considered a vulnerable child, living in a home environment which was not sympathetic to her health and wellbeing. 7.1.6 Mother’s ongoing association with Father resulted in a Child Exploitation Risk Assessment being undertaken in late April 2021, which resulted in Father being seen as a risk to Mother. The Children and Family Assessment was updated, and a Strategy Discussion considered that Mother may be pregnant and questioned the capacity of Maternal Grandmother to put in place effective boundaries and effective parenting. During this time, Mother had been ‘kicked out’ of the family home by Maternal Grandmother and sent to stay with grandparents in another part of the country. In addition, on one occasion Maternal Grandfather and Mother presented as homeless. No information has been provided to the review to indicate that there was any assessment made of the impact of Maternal Grandmother’s rejection of her daughter, or action taken to ameliorate the situation, apart from a referral to Talking Teens, a parenting course for parents of teenagers. 7.1.7 The risk of significant harm to Mother culminated in her being placed on a Child Protection Plan in May 2021. Further assessments followed, during her pregnancy and prior to Rowan’s birth. The author of the Children’s Services report supplied to the review reaches the conclusion that “the ongoing assessment and support Page 15 of 35 Final 17 July 2023 planning for Mother demonstrated a thorough and strength based approach to understanding and improving her lived experience.” Whilst the report goes on to state that Mother’s allocated workers knew her well and had built a good relationship with her, which helped to advocate for and support her in the midst of a ‘sometimes chaotic and rejecting relationship with Maternal Grandmother’, there is little information to evidence what this support consisted of and what improved outcomes were achieved. 7.1.8 Mother became pregnant when she was possibly still 12 or just 13 years old. Annual statistics gathered by the Census 2021 for England and Wales concerning conception rates by age groups including women aged under 18 years in 2020, show that the rate of teenage pregnancy had been decreasing, especially in the under 16 age range: “There was a 16% decrease in the under-16 age group conception rates, from 2.5 conceptions per 1,000 women aged 13 to 15 years in 2019 to 2.1 in 2020. This is the largest annual decrease seen since 2016.”3 7.1.9 These figures show that Mother is in a very small minority of children who conceived a child, although the figures do not indicate how many went on to give birth. For professionals working with these young parents, the impact of Mother becoming pregnant and giving birth to Rowan needed to be seen first and foremost in the context of both parents being children. Support by health professionals during Mother’s pregnancy and postnatally was manifest in the GP Surgery who continued to maintain Mother and Rowan as patients at the Practice after they had moved out of area, the Young Mums Midwifery Team, the FNP and the Community Midwives. In addition, Children’s Services were involved given that Mother, Father and subsequently Rowan were subject to Child Protection Procedures. However, the voice of Mother and indeed Father is not apparent in the information provided to the review. 7.1.10 It is clear that Mother wished to continue with her pregnancy despite Maternal Grandmother’s opposition. The review has received no information to indicate that she received guidance or counselling to make an informed decision as to the choice she made. When the Lead Reviewer met with Maternal Grandparents, Maternal Grandmother expressed her concern and frustration that Mother was allowed to make her own decision as to whether she should continue with the pregnancy, given she was only 13 years of age. We briefly discussed the concept of Gillick Competency4 and Maternal Grandmother contrasted this with the right of Mother to make her own decisions, compared with the action taken by Surrey County Council to invoke care 3https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/conceptionandfertilityrates/bulletins/conceptionstatistics/2020 4 Gillick competency is often used in a wider context [to that of Fraser Guidance] to help assess whether a child has the maturity to make their own decisions and to understand the implications of those decisions. https://learning.nspcc.org.uk/child-protection-system/gillick-competence-fraser-guidelines#skip-to-content Page 16 of 35 Final 17 July 2023 proceedings, given that both parents were considered children themselves and too young to care for a baby. Maternal Grandmother said she failed to understand how Mother could be treated as ‘an adult’ in certain circumstances and as a child in others. 7.1.11 Recent research5 shows that the brain continues to develop through childhood and adolescence, even into the late 20s and 30s in some brain regions. White matter increases, grey matter decreases. These changes are thought to be caused by important neurodevelopmental processes that enable the brain to be moulded and influenced by the environment. When a risk is taken the brain’s positive reward system gets activated. In adolescents, that activation is higher during risk taking than in adults. It is important for professionals to be aware of research findings concerning the workings of the adolescent brain if an informed understanding is to be developed and maintained of the additional risk posed to young parents themselves and, more importantly to their babies and children. 7.1.12 These findings are particularly relevant to Rowan’s parents, as not only were they both extremely young, their engagement in a sexual relationship without use of contraception, as well as Father’s involvement in gang activity and its consequences for his safety and that of Mother and Rowan epitomize the influence of environment on adolescent brain development. Mother lived in an unstable family home situation, where frequent parental discord was prevalent, physical violence, unpredictable rejective and abusive behaviour by Maternal Grandmother, regular cannabis use, difficulties with school and a previous history of self-harming behaviours. 7.2 What was the quality of support for Rowan’s mother and father as young parents? Did their needs and vulnerabilities overshadow professionals understanding of his needs as a child in need of protection? 7.2.1 Mother’s support before and after the birth of Rowan came from a variety of professionals. When she transferred to the Short Stay School, she received continuous support and advice from the Senior Pastoral Worker who saw her in school and at home and intervened in times of crisis. The Senior Pastoral Worker was able to engage with the Maternal Grandparents to ensure that Mother needs were recognised and addressed as far as was possible, whilst at the same time maintaining Mother’s trust. The Senior Pastoral Worker liaised with Social Workers allocated to Mother and Rowan, and as the Designated Safeguarding Lead acted appropriately, immediately bringing to their attention safeguarding concerns. Because Mother’s pregnancy had not been confirmed and she was anxious as to whether she was pregnant, it was the Senior Pastoral Worker who discussed with the School Nurse whether it was possible for Mother to undertake a pregnancy test at school. She was advised that under Gillick Competence this could be offered, and the test was carried out at school. 5 Blakemore Sarah-Jayne Inventing Ourselves: The Secret Life of the Teenage Brain, 2018 Page 17 of 35 Final 17 July 2023 7.2.2 In July 2021, Mother told the Senior Pastoral Worker that she wished to visit a Mother and Baby Unit. This request was passed on to Mother’s Social Worker but seemingly the visit did not materialise. At that time Mother also had a Targeted Youth Support Worker. Once her pregnancy was confirmed and she was booked into the hospital, Mother was under the care of the Teenage Pregnancy Unit. The Safeguarding Midwife made an appropriate referral to Children’s Services. During the antenatal period Maternal Grandmother supported her daughter with antenatal clinic visits, scans and was with her during labour and when Rowan was born. 7.2.3 Support was also offered to Mother by the FNP, the Community Midwifery Team and Social Workers allocated to the family and Rowan. Once engagement with the Family Nurse was established, a good relationship developed with Mother and Rowan’s development was appropriately monitored, he was recorded as gaining weight and reaching milestones. During the visits by the Family Nurse, no evidence was apparent that Mother was smoking or using alcohol, although Maternal Grandmother stated that she (Maternal Grandmother) used cannabis for ‘medicinal use’. 7.2.4 The Family Nurse was concerned when she visited in late January 2022 that Mother was at increased risk of postnatal depression and social isolation due to not being permitted to leave her home unsupervised and planned to closely monitor this at future contacts. It was also noted that Rowan had not been brought to his scheduled hip scan appointment, which Maternal Grandmother said she would rebook. Additionally, Mother did not attend her six week check with the GP, nor did she take Rowan for his immunisations appointment. The Family Nurse reinforced the importance of doing so, and for Mother to seek contraception advice. She also discussed safer sleeping arrangements, which is detailed below at Section 7.5. 7.2.5 The Family Nurse became increasingly concerned about Mother’s emotional wellbeing after the incident involving alleged abusive behaviour by Father at the beginning of January 2022. A decision was made by statutory agencies that Father should not have unsupervised contact with Mother or Rowan, and resulted in maternal Grandmother removing Mother’s mobile phone. This action caused Mother to feel angry and isolated as not only could she not make contact with Father, she could not contact or see her friends. Maternal Grandmother was also expressing her desire for Mother to move to her father’s home (Great Grandfather) in another county. During a visit in late February 2022, the Family Nurse described Mother’s mood as ‘flat’ and her feeling increasingly isolated due to having no mobile phone. However, Mother’s interaction with Rowan was described as loving and affectionate. Mother reiterated several times that she did not consider Father to be a risk to Rowan. After the visit, the Family Nurse learned from Maternal Grandmother that she had discovered that Mother had been in contact with Father via a laptop and as a result she had removed all devices from Mother and had changed the passwords. 7.2.6 Following this visit, it was good practice on the part of the Family Nurse to contact the GP requesting to discuss Mother’s emotional health as her mood assessment had indicated low mood and anxiety. It is evident that the Family Nurse persevered to establish a positive relationship with Mother (and Maternal Grandmother), and closely Page 18 of 35 Final 17 July 2023 monitored Rowan’s development and Mother’s interaction with her baby. She showed good awareness of the impact of removing a teenager’s mobile phone and what this meant in terms of Mother feeling isolated, which could in turn lead to the development of postnatal depression. It should be noted that in the past Mother came to rely on Father and Paternal Grandmother, when the situation became difficult at home, and at times was allowed to stay at their home. Thus, for her to be denied contact with him, however well-intentioned Children’s Services and Maternal Grandmother’s actions may have been, meant in reality Mother was left cut off from the father of her child and a person she loved. 7.2.7 Events already documented in this report, exemplify how Maternal Grandmother’s behaviour towards her daughter was a reflection of her reaction to her children as they got older, resulting in them being forced out of the family home. Such a pattern of behaviour was confirmed by one of Mother’s older siblings who expressed fears for Mother’s safety to Children’s Services, explaining that Maternal Grandmother’s actions in requiring Mother to leave the family home was an experience which all three older siblings had been subjected to. In addition, on numerous occasions, Maternal Grandmother left the family home, taking the two younger children with her and went to stay with her father, leaving the older children, including Mother, dependent on her estranged husband to care for them. 7.2.8 Mother’s attendance at mainstream school was characterized by aggressive behaviour, resulting in frequent suspensions, and culminated in permanent exclusion when she was 12 years old. Mother was also subject to serious bullying on social media from other students, which increased her vulnerability. It was not until she arrived at the Short Stay School that Mother began to engage more fully in secondary education and was described by the Senior Pastoral Worker and Deputy Designated Safeguarding Lead (DDSL) at the school as “a lovely bright girl with ambition for her life with Rowan not to be the same as her mother’s.” The Short Stay School informed the review that “not enough weight had been given to the impact Maternal Grandmother’s inconsistent parenting has had on Mother. Whilst acknowledging that Maternal Grandmother could be very supportive sometimes, however at other times when for example she had thrown Mother ou,t this has had a very negative impact on Mother.” 7.2.9 It is also important to note that it was when Mother was due to return to school after the birth of Rowan that Maternal Grandmother stated her unwillingness/inability to care for her grandson and requested that Mother leave. It was at this point that Children’s Services began to seek a foster placement for Mother and baby. Maternal Grandmother then changed her mind and allowed them to remain in the family home. 7.2.10 It is acknowledged that the account given to the Lead Reviewer by Maternal Grandmother differs to the information provided to the review by agencies. Having read documentation related to the Strategy Meeting held in February 2022, in relation to Maternal Grandmother saying that she was no longer willing to support Mother and Rowan living with her, it is evident that there was no suggestion that Mother and Rowan would be in placed in separate foster homes. The Chair of the meeting was Page 19 of 35 Final 17 July 2023 recorded as stating that a request for a foster placement had been made, and it had been stipulated that ‘they must not be separated.’ 7.2.11 The anxiety caused to Mother, then aged 13, and the resulting vulnerability of both her and her baby, caused by the uncertainty and precariousness of where she and Rowan would live, cannot be underestimated. The incident in February 2022, presented Children’s Services with an opportunity to remove Mother and Rowan to a safe environment where explorative work could have been undertaken with Mother to reflect on her own childhood experiences of parental rejection. It could have also enabled her to care for her baby in an atmosphere of stability, where she could enjoy being a child, as well as a mother, by continuing her education and receiving continued support to improve her own parenting skills. 7.2.12 It is evident that Rowan was considered vulnerable, both prior to and after his birth, as reflected in recognition by statutory agencies of the need for him to be subject to a Child Protection Plan. Indeed, the fact that Mother was seen as a child in need of protection, and then as a Child in Need herself is an indication that her baby could also be considered to be at risk of significant harm, heightened by Father’s involvement in youth violence. The decision of the Child Protection ICPC and subsequent Review Conferences that Maternal Grandmother would be an appropriate person to protect and support Mother and Rowan required a more rigorous assessment than appears to have taken place. 7.2.13 Given the incidents of domestic abuse, Maternal Grandmother’s own mental health needs, her volatile behaviour towards Mother and her siblings, her parental responsibilities towards her younger children, and the requirements to support Mother and Rowan, it was over optimistic that Maternal Grandmother could fulfil the requirements of the Child Protection Plan. The family history of safeguarding concerns was known to those agencies involved in the child protection process relating to Rowan. The Senior Pastoral Worker and DSL for the Short Stay School, who was closely involved with Mother and Maternal Grandmother expressed her concerns about the expectations placed on Maternal Grandmother, given the numerous incidents which had occurred, resulting in Mother being thrown out of the house. 7.2.14 The incident in February 2022, when Mother and her baby were requested to leave, provided statutory agencies with an opportunity to remove both Mother and Rowan from an unstable environment and to place them together in foster care. Unfortunately, once Maternal Grandmother changed her mind and said that her daughter and grandson could remain, the placement was not pursued, which was a lost opportunity to hear Mother’s voice in her own right and to make suitable provision for her needs and those of Rowan. 7.3 How was Father’s capacity as a young father assessed and supported? 7.3.1 Father’s experience of childhood had featured physical abuse from Paternal Grandmother, (Police Officers had been called on 13 occasions in a 13 month period Page 20 of 35 Final 17 July 2023 because of conflict between Father and Parental Grandmother), lack of school attendance for over 18 months, involvement in criminal activity, resulting in him being assaulted and at serious risk of significant harm from rival gangs. 7.3.2 The University of Bristol's research findings on violence in teenage relationships6 undertaken between 2005 – 2009 clearly show that physical, sexual and emotional forms of teenage partner violence constitute a major child welfare issue. Such research resonates with Father’s increasingly volatile behaviour, and his limited threshold for impulsive, aggressive behaviour, as illustrated when he was arrested for being in possession of a firearm and for allegedly being involved in a robbery at knife point. Most concerningly he allegedly pushed Mother when she was holding Rowan, which led to a curtailment of contact with her and his son. 7.3.3 It is also important to note that Father was considered to have difficulties with his emotional regulation and expressive language and had been assessed by a Speech and Language Therapist. It was recommended that Father “receives a follow up, in depth assessment of his language skills to establish support needs for educational settings. Professionals should be mindful of checking his understanding of information by asking him to explain in his own words what he has understood.” (Source: Combined Chronology). This assessment of Father was part of the Youth Offending Service Speech and Language Team’s specialist caseload and was undertaken to ensure that Father would receive follow-up assessment and input as required. It was part of the service offered to any young person referred to the Youth Offending Service on a Youth Offending Order, as was the case for Father at that time. It is not known to the review as to whether any further assessment and input took place, given the family moved out of area. 7.3.4 It is evident that the Children’s Services Adolescent Team responsible for Father did their utmost to engage with him and Paternal Grandmother and attempted to protect him and his family from the significant harm they faced because of his involvement in youth violence. Little is known to the review about Father’s interaction with his son; as due to the risk presented by his association with gang members and the very real threat to his safety and possibly that of Mother and Rowan, his feelings towards his child and the situation he found himself in were not known to the practitioners attempting to engage him. 7.3.5 The Terms of Reference for the review request that consideration should be given to the ‘The Myth of Invisible Men’7, the third review commissioned by the National Panel focusing on the circumstances of babies under one year old who had been killed by their fathers or other males in a caring role. Rowan was found to have died a result of 6 Conducted by Christine Barter (Senior Research Fellow 2005-present), Professor David Berridge (Professor 2005-present), Dr Melanie McCarry (Research Associate/Lecturer 2004-2013), Ms Marsha Wood (Research Associate 2003-present) and Ms Kathy Evans (Research Associate 2006-2009). 7https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1017944/The_myth_of_invisible_men_safeguarding_children_under_1_from_non-accidental_injury_caused_by_male_carers.pdf Page 21 of 35 Final 17 July 2023 SIDS, and there is no suggestion that either parent was responsible for his tragic death. The findings of the National Panel review concerning background information of the men involved in the study resonate to some extent with the circumstances of Rowan’s father. 7.3.6 It is, however, crucial to recognise in this case, Father was himself a child. The findings relevant to this review are as follows: • There was a history of adverse childhood experiences • Substance misuse (Father was known to use cannabis) • Problems with anger and frustration • Fathers were too often ‘excluded’ from child protection assessments and work with families • Men are often only ‘partially seen’ and subject to ‘shallow’ assessments – it is unclear as to whether Father was involved in any pre-birth/parental assessments • Failures to seek information proactively – it could be said that an opportunity was missed by practitioners in Surrey to communicate earlier with colleagues working with Father in the local authority where he lived • Fathers/men’s role in families are often not understood – it is difficult for this review to comment on the role of Father in case, because of his lack of contact with Rowan • The importance of practitioners acknowledging and exploring how ethnicity, race, and racism affect parenting, and a need to understand every individual within the context of their own histories, backgrounds and culture. 7.3.7 The above considerations, including the research findings referenced above, highlight the need for professionals working with young teenage parents to not only focus on the child protection needs of the infant, but to also recognise the complexities of their own experience of parenting, the influence of their lived environment on behaviour and most importantly that the parents are children themselves. This is not always easy, given the difficulty, which is so often encountered when attempting to engage with young people. However, if these fundamental principles are not embedded in professional practice the risk to the babies and children of young parents is severely heightened and can lead to tragic consequences. 7.4 How well was the parenting capacity of both these parents and their wider families understood, assessed and supported? 7.4.1 The review has been informed, and practitioners attending the Reflective Learning Workshop confirmed that Mother had a loving, caring relationship with her son. Rowan was well looked after, he gained weight and was a thriving, happy, healthy baby. Mother was however 13 years old when she gave birth and just 14 when Rowan died. To consider her parenting capacity, the necessity to take into account that she was a child herself, only just entering adolescence, was paramount. Those practitioners involved with Mother did understand this and commented that they Page 22 of 35 Final 17 July 2023 were surprised at how devoted she was and how well Rowan was looked after. Yet, because she was only 13 years old, Mother had to rely on support, advice and material assistance from the Maternal Grandparents. 7.4.2 This report has detailed the history of safeguarding concerns, the volatility of the Maternal Grandparents own relationship, which impacted their approach to parenting, and the involvement of statutory agencies over a period of seven years at the time of Rowan’s birth. Given this history, the reliance by agencies on Maternal Grandmother to undertake responsibility for supervising the care of her grandson, the contact between Mother and Father, whilst continuing to parent Mother and her younger siblings was over ambitious. Agencies were aware of the difficult relationship between Mother and Maternal Grandmother, of the precarious situation concerning the family facing homelessness due to rent arrears and of the two younger children being subject to Child Protection plans because of physical abuse by Maternal Grandfather. 7.4.3 Yet, despite knowing this information, the outcome of the Initial Child Protection Conference was that Maternal Grandmother could be considered appropriate to offer protective oversight of Mother and Rowan. From information provided to the review there appears to have been little consideration given to seeking Mother’s views as to whether she wished to pursue alternatives to returning to the family home after Rowan’s birth. It is known that whilst pregnant she discussed the prospect of going to a Mother and Baby Unit with the Senior Pastoral Worker, but this does not seem to have been pursued. Similarly, there was an opportunity for Mother and Rowan to go to a foster placement, but once Maternal Grandmother changed her mind and said her daughter and grandson could stay at the family home, consideration of this option was discontinued. 7.4.4 It is evident that greater thought should have been given by agencies to alternative placements for Mother and Rowan. Maternal Grandmother was seen as the ‘go to option’ and whilst in principle families should be kept together wherever possible, the underlying factors of poor parenting capacity of the Maternal Grandparents required greater professional scrutiny before making such a decision. 7.4.5 As has already been discussed, Father did not feature in the care of Rowan. The pre-birth assessment was completed by the Social Worker allocated to Mother and there were concerns about the quality of this assessment. Father was not involved in any parenting assessment. Practitioners involved with him have told the review that he was pleased to be a father and loved his son. However, his contact and interaction with Rowan was limited because of his involvement with youth violence and gang related crime. Communication for arrangements for supervised contact between Father and Rowan were required go via Paternal Grandmother. At the Practitioners Event, it was said that Paternal Grandmother did not allow such arrangements to be made, as she was of the view that contact did not require supervision. Practitioners discussed how much the restrictions on Page 23 of 35 Final 17 July 2023 visiting and appointments impacted on relationship building between Father and Rowan, which was considered to be significant. 7.4.6 Father was fearful for his safety, as was Paternal Grandmother. The seriousness of risk to life faced by Father and his family was manifest in the action taken by the local authority to permanently rehouse them out of area. Given this situation, it was difficult, if not impossible, for Father to be engaged with the care of Rowan. It was further compounded following his alleged outburst towards Mother at the beginning of January 2022, which resulted in Father having no contact with Rowan prior to his death. However, the turmoil and distress experienced by Father following this incident is captured by the author of the Children’s Services report provided to the review, and highlights his own vulnerability as a child: “The reports of him having to get out of Mother’s house on 2 January 2022 paint a picture of a boy who was also caught up in the domestic abuse incident, trying to leave the house and crying in the street and needing to be collected by a family member. He had stayed overnight against the safety planning agreed with Mother and Maternal Grandmother. A more controlled and measured introduction to his son, supported by Surrey County Council and [his local authority] may have prevented this extended visit from taking place at a time when family life was already heightened, and alcohol was likely to be consumed during the New Year celebrations.” 7.4.7 Little is known of the views of Paternal Grandmother concerning her involvement with her grandson. What is apparent is that the relationship between the Maternal and Paternal Grandparents was difficult with assertions made on both sides concerning inappropriate behaviours. Following the incident in January 2022, Paternal Grandmother raised concerns about how Rowan was being parented. It is unfortunate that Paternal Grandmother has chosen not to meet with the Lead Review, as her views could have been further explored, and included in this report. 7.4.8 It is also known that Paternal Grandmother was deeply worried and was said to be overwhelmed by anxiety about her son’s safety and his involvement with youth violence. At the Practitioners Event on 5 January 2023, those who knew Paternal Grandmother and who had engaged with her said that she was very positive about having a grandson and openly expressed the view that she and Father wished to be more involved. However, given her concerns for Father’s safety, Paternal Grandmother struggled to engage with services to try and resolve the situation and this in turn limited Father’s engagement with services. It is unfortunate that Paternal Grandmother was unable to engage with the review, as her views would have been valuable in informing this report. 7.5 How effective was the multi-agency work in providing and reinforcing safer sleeping advice? Page 24 of 35 Final 17 July 2023 7.5.1 One of the recommendations from the ‘Out of Routine’8 report produced by the National Child Practice Safeguarding Review Panel, July 2020 was that: “the Department of Health and Social Care works with key stakeholders to develop shared tools and processes to support front-line professionals from all agencies in working with families with children at risk to promote safer sleeping as part of wider initiatives around infant safety, health and wellbeing”. 7.5.2 A similar recommendation was identified in the SUDI thematic review undertaken by Surrey Safeguarding Children Partnership, with learning disseminated by the Partnership in the publication of a 7 minute briefing in November 2021. It is unclear as to how this learning was embedded in Partner Agencies, for whilst it is apparent from report provided to the review detailing the involvement of the FNP that the Family Nurse reiterated the importance of safe sleeping, it is evident that this was not the case from the review of Social Care records. The author of the Children’s Services report makes the point that Maternal Grandmother was overseeing the care of Rowan but he was sleeping in the same room as Mother, thus it was not clear who had the final say over co-sleeping or the positioning of baby in his cot. It is not evident from Children’s Services casefile records that this key area of parenting was explored with Mother or Maternal Grandmother. Risk assessments were not evident on the casefile to determine the factors that increased the risk of SUDI to Rowan, which may have prompted wider discussion and safety planning as part of the child protection process. 7.5.3 The Lead Reviewer agrees with the Children’s Services report author that there is a need to consider all the risks to vulnerable children and not just those of a child protection nature. As previously indicated in this review, Rowan would have been considered at higher risk of SUDI due to the factors in his family and environment at the time. Whilst it may be difficult for practitioners to explain to parents and carers that their baby is at risk of SUDI, a previous Child Safeguarding Practice Review9 undertaken by the Surrey Partnership has highlighted that speaking to parents in plain language about the risks of unsafe sleeping arrangements is important and welcomed. 7.5.4 The report of FNP involvement with Rowan states that safe sleeping and sudden infant death were discussed with Mother at the new birth visit on 5 January 2022. Maternal Grandmother was in the next bedroom as she had tested positive for Covid. These issues were discussed again during two visits in January 2022, when Mother told the Family Nurse that Rowan slept on his tummy. The Family Nurse reinforced the importance of him sleeping on his back and the associated risk of sudden infant death syndrome for Rowan sleeping on his front. Maternal 8 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf 9 CSPR Acer Page 25 of 35 Final 17 July 2023 Grandmother was seemingly only in attendance during one visit in January 2022, for some of the time. 7.5.5 It was known by the Family Nurse that Maternal Grandmother was using cannabis to ‘help her sleep’ and the Family Nurse sought confirmation from Maternal Grandmother that she had signed a safety plan drawn up by the Social Worker confirming she was not using cannabis around Rowan. When the Family Nurse visited the home in 7.5.6 Ashford and St Peters Hospital and West Middlesex March 2022, Mother and Rowan were present, but Maternal Grandmother was only in attendance towards the end of the contact. During this visit, Rowan was ‘sleeping in his cot with cot contents observed by the Family Nurse. Safer sleeping was discussed with [Mother] advising that the cot is clear during the night and when Rowan is alone in his cot with correct feet positioning.’ 7.5.7 From the above account it is clear that the Family Nurse was diligent in ensuring that Mother was told of the risks of SUDI and the need for Rowan to be in a safe sleeping position. What is not clear is whether Maternal Grandmother was present when this advice was being given. Maternal Grandmother had overall caring responsibilities for Rowan, however, it was known to agencies that she was using cannabis at night to ‘help her sleep.’ This raises the question of whether Maternal Grandmother would have woken up if an issue had arisen with the care of Rowan, and if she had, would she have been capable of reacting appropriately to ensure his wellbeing. By entering into an agreement with Maternal Grandmother that she would not use cannabis in the presence of Rowan, Children’s Services acknowledged that she was using an illegal substance whilst being responsible for the care of her grandson. If such an agreement had referred to the use of alcohol, it would not have been considered appropriate. The need for practitioners to be aware of the effects that cannabis use can have on the capability of parents/carers to look after children appropriately is a finding of virtually every Child Safeguarding Practice Review, and is a lesson learned from this review. 7.5.8 In addition, it needs to be acknowledged that practitioners can advise parents of the risks to infants of unsafe sleeping arrangements, but it is the decision of the parent as to whether such advice is followed. Sadly, in the case of Rowan the advice of the Family Nurse was not followed. 8 Findings and Lessons Learned 8.1 The importance of parenting assessments, including pre-birth assessments 8.1.1 The pre-birth assessment of Rowan was completed; however, the assessment should have been assigned to a Social Worker, who was not already involved with the family. Page 26 of 35 Final 17 July 2023 Given that Rowan’s parents were possibly some of the youngest parents that agencies involved with them had encountered, it was crucial that a thorough pre-birth assessment was undertaken if the unborn child was to be protected. This was even more pressing because of the known child protection concerns for both Mother and Father. The pre-birth assessment should have been assigned to a social worker who was not already involved with Mother’s family, and this did not happen. A Social Worker was allocated to Rowan, but this practitioner did not complete the assessment. 8.1.2 Changes have been put in place by Surrey Safeguarding Children Partnership to improve practice concerning pre-birth assessments since Rowan’s birth. This is manifest in the 7 Minute Briefing: Learning from Pre-Birth Assessments, January 2022, as well as other policies and procedures10 which have been implemented. The 7 Minute Briefing sets out the learning from an audit of pre-birth assessments undertaken in 2021, the areas of practice requiring development and provides clear guidance as to timeframes and action required for pre-birth assessments. Such revisions to policy and procedure are welcomed by the review, and should be recommended reading (or revisiting) for those practitioners involved in this case. Recommendation 1(a) 8.1.3 Given that it was agreed at the ICPC prior to Rowan birth that Maternal Grandmother would have overall responsibility for his care, an assessment of her parenting skills should have been undertaken. It seems that the decision to place Rowan on a Child Protection Plan was influenced by the risk presented by Father’s involvement in youth violence. There is little evidence that Maternal Grandmother’s parenting capacity was assessed. This was a missed opportunity, given the history of relationship breakdown between the Maternal Grandparents, between Mother and Maternal Grandmother, and the fact that Mother and the younger children were made subject to Child Protection Plans in May 2021. It would have also provided an opportunity to explore arrangements for Rowan’s day to day care. Recommendation 1(b) 8.2 Recognising that the parents were themselves children 8.2.1 The need to protect Rowan from significant harm was of paramount importance. However, it was also important for all those involved with Mother and Father to recognise that they were themselves children and extremely young. It is possible that for Father, his involvement in youth offending and connection with gang criminality, became the main concern for those practitioners involved with him and his family, and the fact that he had fathered a child as a child, was a secondary concern. Clearly, the risk presented to Father’s life was considered to be very real, but his vulnerability as a child is discernible in the description of his distress following the incident of alleged domestic abuse in January 2022. 10 5.20 SSCP: Pre-birth Child Protection Procedure (revised October 2022); Pre-birth assessment and intervention timeline; Pre-Birth Policy: under 16 year olds, 16-18 year olds, LAC and Care Leavers Page 27 of 35 Final 17 July 2023 8.2.2 To become pregnant at 12 and give birth to Rowan at 13 years old was a traumatic experience for Mother. The birth itself was lengthy and difficult and resulted in a forceps delivery. Although the GP had referred her to the Perinatal Mental Health Team in October 2021 to address Mother’s anxieties about the threat posed by Father’s involvement with gangs and how she would cope as such a young mother, the referral was rejected due to her age and a referral to CAMHS was suggested. The GP report submitted to the review stated that no correspondence could be found relating to a subsequent referral to CAMHS. 8.2.3 Maternal Grandmother has stated that Mother faced discrimination whilst in hospital after giving birth to Rowan. The Lead Reviewer has seen no evidence to support this, and it may be something which needs further exploration outside the remit of this Child Safeguarding Practice Review. However, given Mother’s age it is understandable that she may have felt under scrutiny whilst in hospital, and such feelings could have compounded her experience of abusive telephone calls and messages on social media whilst pregnant. 8.2.4 That Mother had aspirations to continue her education are apparent from her desire to return to school, which she did briefly on a part-time basis after Rowan’s birth. This decision can be linked to the support, care and understanding offered to her by the Senior Pastoral Worker and the teaching staff at the Short Stay School. The tragic death of Rowan interrupted not only Mother’s education but severely impacted her childhood. Recommendation 2. 8.3 Support to young parents 8.3.1 Not only were both parents very young, they were also subject to child protection procedures, as was Rowan, during their short period of parenthood. The need for support from professionals was engrained in the child protection process and this was evident during the time frame of this review. Mother was well supported by the Family Nurse Practitioner, her Social Worker, the GP and the Senior Pastoral Worker. She could have benefitted from intervention from the Perinatal Mental Health Team, but this was not available. Recommendation 3. 8.3.2 Mother’s main support came from Maternal Grandmother. This report has highlighted that such support was inconsistent and was dependent on Maternal Grandmother’s frame of mind and the state of relations between her and her daughter. The issues raised by the decision to task Maternal Grandmother with the responsibility of the overall care of Rowan and to ensure that no contact, supervised or unsupervised could take place between the parents have been already addressed in this report. Of further consideration is the effect on Mother’s mental health and wellbeing of the removal of her phone and other means of communication, in addition to not being permitted to see friends outside the home unsupervised. The Family Nurse recorded her concerns about Mother’s low mood and general anxiety, and appropriately brought this to the attention of the GP. Such actions instigated by Children’s Services and implemented by Maternal Grandmother placed an unrealistic expectation on a 13 year old, and Page 28 of 35 Final 17 July 2023 needed careful consideration as to the consequences of leaving Mother feeling isolated, as well as the impact on her relationship with Maternal Grandmother. The need to take account of the needs of young parents who are children is a lesson arising from this review, as reflected in Recommendation 2. 8.4 Child Protection Planning 8.4.1 The importance of taking full account of family history and consideration of the consequences of requiring a family member to take responsibility for ensuring a safe environment and supervise the care of an infant cannot be overestimated. It can be concluded that given Mother’s family history and the dynamics of her relationship with Maternal Grandmother, there was misplaced optimism on the part of practitioners that the specifications of the Child Protection Plan would succeed. Child Protection planning was needed from the outset and should have been the focus of the pre-birth assessment, which proved not to be the case, and is a lesson learned. Recommendation 1(b) 8.4.2 In addition, the review has noted that GPs are not routinely informed of when a child is subject to a Child in Need Plan. This practice is considered to be a gap in information sharing and should be reconsidered by the Partnership. Recommendation 4. 8.5 Professional Advice on Safe Sleeping 8.5.1 The review has evidenced that frequent advice was given to Mother, and possibly Maternal Grandmother by the Family Nurse about the importance of safe sleeping to avoid risk of harm to infants. It is apparent that although such advice was given, Mother and Maternal Grandmother did not necessarily follow it. One of the issues discussed at the Practitioners Event was that whilst such information is delivered to parents by professionals, documentary evidence by midwives and health visitors when undertaking home visits, as to where a baby is actually sleeping can be missing. Whilst in this case the Family Nurse did see where Rowan was sleeping, the importance of all professionals asking to see where a baby sleeps is crucial and could potentially save lives. Recommendation 5(b) 8.6 Risk-factors identified in the Out of Routine Report and presenting Issues in this case 8.6.1 It is apparent that the risk-factors identified in the Out of Routine report resonate with the presenting issues in this case. One of the most important findings of the Report, was that the risk of SUDI should not be seen in isolation from other risks present in the home environment. Of equal importance, as has already been discussed was the need to not see assessment of the risk of SUDI as solely the responsibility of health professionals. Practitioners in all agencies working with children at risk, need to develop an evidence-based understanding of the decisions parents make in relation to their child/ren’s sleeping environment and where there are concerns, consideration given to what could be put in place to achieve change. Page 29 of 35 Final 17 July 2023 8.6.2 The need to develop a framework for practitioners from partner agencies working with families where young infants are at risk because of unsafe sleeping arrangements, as stated at Recommendation 3 of the Out of Routine Report, was a finding of the previous review undertaken by Surrey Child Safeguarding Partnership referenced at para 3.4.3 and is a finding of this review. See Recommendation 5(a) 9. Good Practice 9.1 The GP Practice offered exceptional care to Mother and showed good awareness of Safeguarding Children. 9.2 The Short Stay School provided a safe, caring environment for Mother that continued during her pregnancy and after Rowan’s birth. The duty of care shown by the Senior Pastoral Worker and DSL was exceptional. 9.3 The Family Nurse was exemplary in her care and support to Mother and Rowan. 9.4 Community Midwives, the Family Nurse and Children's Services continued to visit the family during the Covid Pandemic. 9.5 The local authority responsible for Father did their utmost to engage him and to ameliorate the risk of significant harm, culminating in the funding of a permanent move for the family out of area. 10. Conclusions 10.1 This review is one which unusually focuses on the death of a baby born to extremely young parents. It has considered the impact on and outcomes for parents who themselves are children, and how their needs, as well as those of their baby have to be taken into consideration by professionals involved in child protection procedures. The dangers faced by children involved in youth violence and gang criminal activity have also been addressed, as have the risks posed to vulnerable babies of Sudden Unexpected Death in Infancy. 10.2 This report has shown there was good professional practice by many of those practitioners involved with this family and in this context, it is perhaps worth considering a comment arising from the Practitioners Event when concluding this review. Those attending the Event recognised the death of Rowan was a tragedy, but it was suggested that it was not as a result of any one individual or professional practice. This assertion is one with which the Lead Reviewer agrees. Rowan was a much loved, healthy and well cared for baby, by a mother who was still a child herself. The impact of such a loss on a such young parents is incalculable. 10.3 It needs to be recognised that the positive support Mother received from the Short Stay School was a model of what can be achieved when children are on the brink of Page 30 of 35 Final 17 July 2023 exclusion from mainstream education. It enabled her to develop aspirations to have a different life for her and her son. It is to be hoped that Mother will be able to renew and re-engage at some point with some of those visions for herself. 11. Recommendations The following recommendations are for consideration by Surrey Safeguarding Children Partnership (SSCP). Recommendation 1: (a) The SSCP to disseminate the 7 Minute Briefing: Learning from Pre-Birth Assessments, January 2022, with a requirement that it is recommended reading for all practitioners working with parents and children. (b) If a vulnerable baby is living in the care of grandparents (with or without the presence of their parent), an assessment of their parenting capabilities and skills should be a pre-requisite before any such placement is made; especially if the child is subject to a Child Protection Plan, which is reliant on the care offered by the grandparents. Recommendation 2: Partner agencies are to be reminded that when parents are children themselves, their needs and wellbeing should be recognised, and considered a priority, together with that of the need to safeguard their child. Recommendation 3 Consideration should be given to exploring the possibility of young, teenage mothers being offered the services of the Perinatal Mental Health Team when it is evident that their health and wellbeing is at risk, and sufficient support for their mental health cannot be provided by the services of the FNP (Family Nurse Partnership). Recommendation 4 As required by existing SSCP policy, GP Practices should be informed when a child is subject to a Child in Need Plan, to ensure that information relevant to safeguarding is shared. Recommendation 5 (a) The SSCP to seek reassurance that the framework concerning safe sleeping is embedded for use by practitioners working with families where young infants are at risk because of unsafe sleeping arrangements. (b) Such a framework should include a requirement that professionals visiting the home should ask to see where a baby is sleeping to seek assurance that the arrangement is safe. Page 31 of 35 Final 17 July 2023 Page 32 of 35 Final 17 July 2023 Appendix 1 Terms of Reference SCOPE OF THE REVIEW Time Period to be Considered by the Review: 1 January 2021 when Mother came to the attention of services following a domestic abuse incident at the family home until the date of Rowan’s death. Relevant historical information related to Rowan’s parents can be included as background information in the form of a summary, highlighting significant events and key practice episodes. Key Lines of Enquiry to be Addressed by the Review: The case has identified the following areas of key lines of inquiry: 1. What was the quality of assessments of Mother and Father as vulnerable children who were in need of help and protection? ▪ What was the quality of the pre-birth assessment: assessment is a live and on-going process; each assessment should reflect the specific characteristics of each child within their family and community context; this includes drawing upon relevant family history and family functioning; as well as the risk factors for Sudden and Unexpected Death in Infancy identified in the Child Safeguarding Practice Review Panel’s Out Of Routine report published in 2020. ▪ Did assessments focus sufficiently on the needs of Rowan as a child who needed to be safeguarded? 2. What was the quality of support for Rowan’s mother and father as young parents? ▪ The Rapid Review noted that when parents have a range of vulnerabilities, these must be addressed, whilst maintaining focus on the child. In this case, did the needs and vulnerabilities of Rowan’s very young parents overshadow professionals’ understanding of his needs as a child in need of protection? ▪ How was Father’s capacity as a young father assessed and supported? The role of fathers: Father was the focus of significant concern; however, it is less clear regarding the work that was done to support him as a parent, including joint work with both sides of Rowan’s family. This should be considered against the findings and recommendations of the Child Safeguarding Practice Review Panel’s report, the Myth of Invisible Men, published in September 2021. ▪ How well was the parenting capacity of both these parents and their wider families understood, assessed and supported? The risks to Mother and Father were known, however, there needed to be a Page 33 of 35 Final 17 July 2023 greater focus on how these risks impacted on their ability to act as consistently good enough parents for Rowan. Related to this was the need for a clear assessment of the impact of the vulnerabilities of the Maternal and Paternal Grandparents for baby Rowan. 3. How effective was the multi-agency work in providing and reinforcing safer sleeping advice? ▪ As identified in the Surrey SUDI thematic review of and the Child Safeguarding Practice Review Panel’s Out of Routine report, this case highlights the need for all agencies to play a role in communicating safer sleep advice and safe sleep assessment to form part of all child and family assessments. PLANS TO INVOLVE CHILDREN AND FAMILY MEMBERS The Parents and the Paternal and Maternal Grandparents and relevant extended family will be invited to participate in the review process. METHODOLOGY Throughout the review process the well-being of the workforce will be a priority – the review panel will be mindful of staff well-being throughout The review will include individual agency reports and chronology of key practice episodes from relevant agencies and services including: • Surrey County Council Children’s Social Care • A London Borough Children’s Social Care • Surrey County Council Education Department • Ashford and St Peters Hospital • West Middlesex Hospital • The Midwifery Service • Community Health Teams • Surrey Police and the Metropolitan Police The review process will be collaborative which means the Independent Review author and the Panel will listen to and involve practitioners. LEGAL CONSIDERATIONS Parallel Investigations: There are no parallel investigations related to the death of this child. Legal Advice: Page 34 of 35 Final 17 July 2023 Legal advice will be provided to the Panel by Surrey County Council Legal Department who will act on the behalf of the SSCP. OTHER CONSIDERATIONS The impact of COVID-19 was discussed at the Rapid Review and not felt to be significant to practice and system learning. The Lead Reviewer Moira Murray has been an independent reviewer since 2010 and has undertaken numerous SCRs, Learning Reviews and Safeguarding Children Practice Reviews. She has been involved in safeguarding audits for the NHS, the voluntary sector and local authorities, and co-authored HM Government Safeguarding Disabled Children Practice Guidance, 2009 whilst Head of Safeguarding at the Children’s Society. Moira was a non-executive board member of the Independent Safeguarding Authority for 5 years, and was Safeguarding Manager for Children and Vulnerable Adults, London 2012 Olympic and Paralympic Games. She has also undertaken a review for the Foreign & Commonwealth Office, reviewed safeguarding at the BBC post Jimmy Savile and undertaken safeguarding reviews of Premier League Football. Page 35 of 35 Final 17 July 2023 |
NC52698 | Explores the death or serious injury to 17 under 2-year-olds in Kent to identify key themes that help us understand when and why harm occurs, and what practice can safeguard young children from harm. Recommendations include: seek clarification on current Health Visiting operating standards around face-to-face visits; Early Help assessments and plans to be shared with involved multi-agency partners (with family consent); the positive practice audit to be published and shared as a standalone report, as a reminder that familiar, expected, basic practice works, and avoid a sense of needing to wait for learning from individual LCSPRs to be published before seeking to change or improve practice; the need for universal services to be more inquisitive and alert to less obvious risks has been clearly identified, particularly when considering the inherent physical vulnerabilities of children under 2-years-old; that practitioners, against human instinct, must be prepared to think the worst - even where there are not clear 'red flags'; and professionals need to understand that significant harm occurs to children in families where risk is not obvious, where universal services may be the only ones engaged, and to consider whether there is one more question which might help identify an obscured risk.
| Title: Harm to Under 2s in Kent. LSCB: Kent Safeguarding Children Multi-Agency Partnership Author: Lenni Frampton, Trudi Godfrey and Laura Wright Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 | P a g e Harm to Under 2s in Kent May 2022 Each bumblebee represents one of the children considered in this report. Authors: Lenni Frampton – Practice Review Manager, KSCMP Trudi Godfrey – System Performance Analyst, KSCMP Laura Wright - Learning & Development and Policy Advisor, KSCMP Date: 13/05/22 2 | P a g e Contents Page 1. Executive Summary 3 2. Introduction 5 3. Analysis of Serious Incident Notifications 6 4. Non-Accidental Injury Practice Event 13 5. Positive Practice Audit 18 6. What does this tell us? 23 7. Conclusion and Recommendations 26 3 | P a g e 1. Executive Summary This study builds on the previous KSCMP Non-Accidental Injury (NAI) deep dive study undertaken in 2021, with a broader scope to consider significant harm of all under 2s notified to KSCMP in a 3-year period. Through case analysis, identifying positive practice in similar cases, and engaging directly with professionals, the aim has been to identify key themes that help us understand when and why harm occurs, and what practice can safeguard young children from harm. There were 19 children aged under 2 who were seriously injured or died in the period considered, and whilst only 17 of these were included in the analysis (explained in section 3.1), we have reflected all of these children in the illustration on the cover of this report. The majority of the cases analysed related to harm as a result of NAI, with a smaller number of children harmed through co-sleeping and neglect. Analysis of the cases showed that the majority of children were harmed at age 3-months or under. This is congruent with research underpinning the ICON programme, that harm to babies is often inflicted due to a loss of control during periods of infant crying. It may also be reflective of the physical vulnerability and dependency of young babies. Of note is the fairly even split between only children and those with siblings – i.e. neither group appears more likely to be harmed than the other. Children who experienced NAI were more likely to be in families where there were not obvious risk factors and who were only open to universal services. In these cases it appeared that individual parental resilience levels had been surpassed. In contrast, children who were harmed through co-sleeping and neglect were mostly in families where a number of visible risk factors were present, and professionals were more likely to already be involved and concerned. Although signs of neglect or concern were apparent to professionals quite early on, they may be harder to reverse, or fail to be fully understood by professionals given the complex nature of the families. There is also evidence in both cohorts that Covid-19 had impacted on appointments with the family, which might have led to some missed opportunities for further identification of concerns. Practitioners, when presented with case scenarios, identified risks and concerns for children; they also identified the actions they felt should be undertaken to effectively safeguard. They reflected openly on the challenges in practice which could prevent those measures from being put in place in reality. What became clear was that despite their passion, increasing demand for services is impacting on the ability to deliver beyond what is absolutely required as well as on their capacity for multi-agency working. Additional challenges include confusion and anxiety around submitting Requests for Support and Support Levels Guidance (thresholds), conducting difficult conversations, and variations in practice across the county. In identifying positive practice, it became clear that basic practice is what works. There is no need for new innovation, but a need for a more ‘back to basics’ approach. Through the study three specific practice themes emerged: 1. Early identification and referral 2. Consideration of family history 4 | P a g e 3. Assessing the impact of parental issues on risk to the child. Early preventative work should be seen as the role of all universal services, not only KCC Early Help once the Tier 3 threshold is met. To reduce missed opportunities and ensure the right support is given at the earliest point, families need to be engaged and understood before concerns become very visible. Understanding in all services that harm occurs in families which do not necessarily present as ‘risky’ is needed and practitioners must be prepared to think the worst, including in families which exhibit less obvious warning signs. This report makes five specific recommendations, although the authors also urge reflection on the broader themes identified. Recommendation 1. Kent and Medway CCG to present an update on the roll-out of the ICON programme and provision of future training in Kent. 2. KSCMP Executive to seek clarification on current Health Visiting operating standards around face-to-face visits. 3. The Kent Support Levels Guidance course be reviewed to ensure it adequately covers terminology in the SLG and details on completing a Request for Support. Delivery of the course to be reviewed to address consistency and provision issues. 4. Early Help assessments and plans to be shared with involved multi-agency partners (with family consent). 5. The positive practice audit to be published and shared as a standalone report, as a reminder that familiar, expected, basic practice works, and to avoid a sense of needing to wait for learning from individual LCSPRs to be published before seeking to change or improve practice. 5 | P a g e 2. Introduction In October 2021 the Kent Safeguarding Children Multi-Agency Partnership (KSCMP) Business Team undertook a deep dive study into the surge of Serious Incident Notifications (SINs) related to the Non-Accidental Injury (NAI) of babies in August and September 2021. The study outlined the key themes and factors of the cases; however, it was acknowledged that it considered a small sample group, and that further SINs related to NAI had been received which were outside the scope of the inquiry. It was therefore recommended and agreed that a broader study be conducted, to consider all SINs related to harm in the under 2s in Kent in over a three-year period. This report encompasses three areas of work undertaken as part of this study: 1) Analysis of the SIN data for all Under 2s in Kent between 1st March 2019 and 31st March 2022. 2) A Positive Practice Audit of cases which shared characteristics with the six cases from the previous NAI deep dive. 3) A NAI Practice Event held in March 2022 with practitioners. We would like to acknowledge the scale of harm considered in this report. We identified 19 children aged 2 or under who had been subject of a SIN to the KSCMP over the period considered. Of these 19 children, 5 children had sadly died, whilst others had sustained serious and/or life changing injuries. We hope this study will help to develop understanding of the issues and of tools that can be effectively employed to reduce the risk of this harm occurring again in the future. We also acknowledge that since 31st March 2022, further SINs related to NAI have been received by the KSCMP. It is not proposed that this study be re-visited to encompass these newer cases. However, learning identified during the individual rapid reviews or subsequent Local Child Safeguarding Practice Reviews (LCSPRs) will continue to be taken forward by the KSCMP. 6 | P a g e 3. Analysis of Serious Incident Notifications 3.1 Serious Incident Notifications The scope of this review was to consider incidents relating to children aged 2 and under over the period 1st March 2019 to 31st March 2022 and which had been notified to the KSCMP. In this report the term Serious Incident Notification (SIN) refers to cases considered either through statutory or local frameworks. There were 19 notifications relating to children aged under 2 over this period. One of these children had died as a result of a medical issue and was only notified due to being a child looked after by the local authority. To add to this, one child had died as a result of choking in an early years setting. Due to the specific natures of those notifications, they were removed from the cohort addressed in this study, leaving 17 cases for analysis. 3.2 Methodology This study focuses on 62 indicators across 17 cases of serious harm in the under 2’s. There were varying levels of detail recorded in each case that the authors were able to draw upon. As a result, the following methodology has been used to make comparisons across indicators. Where there were fewer than 17 cases which had information recorded for that indicator, the base number would be the number of children who had information recorded. For example, KSCMP has information relating to mother’s mental health for 11 children out of the 15 children that the information was available for, so the proportion of cases where this was a known factor was 11/15 = 73.3%. This was felt to be a more comparable measure than always having the base number as 17, if there was no information given related to the indicator (and so was ‘unknown’) or if the indicator was not applicable. The same method of calculating proportion has been used throughout this analysis to allow us to look for themes and make comparisons across indicators. This approach was also helpful when breaking down the sample of 17 into an NAI cohort (13 children) and a co-sleeping/neglect cohort (4 children). Overarching themes relating to the 17 cases are discussed, alongside comparisons between the NAI and co-sleeping/neglect cohort. We recognise that all of these are small sample sizes from which to draw comparisons, but the co-sleeping/neglect group is a particularly small group. 7 | P a g e 3.3 Data analysis 3.3.1 Cohort demographics Only two of the children were aged over 9 months at the time they were injured or died, with the majority being aged under 3-months. This is congruent with general understanding, and principles behind programmes such as ICON1, that the majority of abusive injuries caused to infants are as a result of a loss of control when a baby’s crying becomes too much. The infant crying curve2 suggests that babies begin to cry less from around 3 months onwards. Recommendation 1. Kent and Medway CCG to present an update on the roll-out of the ICON programme and provision of future training in Kent. District No. District No. Folkestone & Hythe 3 Canterbury 1 Thanet 3 Dover 1 Ashford 2 Tonbridge and Malling 1 Dartford 2 Gravesham 0 Maidstone 2 Sevenoaks 0 Swale 2 Tunbridge Wells 0 The geographic spread of the children, based on their home address at the time of the incident, is relatively even. Only 2 of the children had parents that were both ‘young parents’ (aged 21 or under) and a further child had one young parent. 1 https://iconcope.org/for-professionals/ 2 http://purplecrying.info/sub-pages/crying/why-does-my-baby-cry-so-much.php 8 | P a g e In 35% of cases the child had no siblings, and in a further 30% the child had only one sibling; however this included a child who was a twin. Therefore 41% of cases involved a ‘first born’ child. When looking only at the 12 NAI children for whom it is known whether or not they had siblings, 50% were first born. Overall then, there is not a clear set of evidence to show whether a first born, or single child is any more or less likely to be harmed than a child with siblings. 3.3.2 Characteristics The graphic below gives an overview of which of the 62 indicators were prevalent across the entire under 2’s cohort considered. The indicators include a range of family context issues (such as parental mental health concerns or poor living conditions) and practice themes identified in review of the individual cases (such as missed opportunities and incomplete records). A particular note should be made in regard to the Family known to ICS indicator. This does not mean that the individual child was open, or even known to KCC Integrated Children Services at the time of the incident but includes families where a sibling or parent has been known to ICS. A separate indicator was included for children open to ICS at the time of the incident, and another for children who had previously been open to ICS prior to the incident. Only 29% of the whole cohort were open to ICS at the time of incident, whilst 44% had previously been open. There was significant divergence between the two cohorts, explored in the respective sections below. No. of siblings No. of cases 0 6 1 5 2 2 3 2 6 1 Unknown 1 9 | P a g e 3.3.4 NAI characteristics None of the children in this cohort died, however 3 sustained life changing or serious injuries, including one child who is not expected to live beyond early childhood. In the NAI cohort of 13 children, 92% were under 9 months and 69% were aged 3 months or under. As indicated in section 3.3.1, this is in-line with expectations and is most likely linked to the stress of a young infant, and in particular, babies crying. In the indicators above, there are some significant changes to the indicators most present for the whole cohort of under 2s. Less of the families in this cohort were known to ICS prior to the incident of NAI and there were less ‘missed opportunities’ identified – although these remain in the ‘majority’ or cases category. However, a small increase was observed in the percentage of cases where there was evidence 10 | P a g e the family should have been referred to ICS (this may be due to the lower percentage already known). There was also a small increase in the number of children where there had been a previous Children and Families (C&F) assessment. In this cohort only 23% of children were open to ICS at the time of the incident, and 33% had previously been open to ICS. A shown, maternal mental health issues and the impact of under recognised cannabis use remained static, although there was also a decrease in parental substance misuse in this cohort. Indications of parental Adverse Childhood Experiences (ACEs) increased in proportion within this cohort, moving up to being present in the majority of cases. Paternal mental health concerns increased in proportion, whilst the theme of invisible males within case work was slightly less present. The Covid-19 impact on appointments was less apparent in this cohort, which also potentially accounts for the increase in family homes being physically seen by professionals. It is of note that poor living conditions is not reflected in 50% or more of the NAI cohort, whilst this was a greater factor in the entire under 2s cohort. 3.3.5 Neglect & Co-sleeping characteristics In this cohort, 3 of the children died, all as a result of co-sleeping; in 2 cases neglect was also a factor in the child’s death. Three quarters of these children were aged 3 months and under at the time of the incident. It might have been expected to see a larger spread of ages in this cohort, given the broader nature of harm, which is not necessarily linked to crying infants, however there are some additional considerations. For example, taking into consideration that this is a very small sample size. Very young babies are more dependent on their needs being met by their parents and carers and are less physically robust to withstanding neglectful conditions or co-sleeping. 11 | P a g e It is significant that there were six factors which appeared in all of the co-sleeping and neglect cases, illustrated below. The graphic below further shows the indicators present in the majority of cases in this cohort. Parental substance misuse and cannabis presence in the household was a consistent feature, which is likely to be a contributing factor towards neglect and is a known risk factor in co-sleeping deaths. It could be speculated whether there is also correlation between the poor living conditions and the Covid-19 impact on appointments (potentially meaning that more appointments were telephone based rather than in person), although below it is noted that 75% of the family homes had been seen by a professional. Parental ACEs were also noted for all the children in this cohort, potentially highlighting the impact of unaddressed childhood trauma on parenting capacity as an adult. Moreover, additional points of note presenting in this cohort are that potential signs of neglect or at least unpreparedness that may be indicative of a chaotic lifestyle and often are seen in early pregnancy, with three quarters of the mothers booking late for pregnancy-related health services. Missed appointments were also a common feature both pre and post birth. There are also more obvious risk factors evident for this cohort. For instance, parents with a criminal history or a history of violence, and 12 | P a g e elder siblings who were already in care or resident elsewhere (with limited or controlled contact arrangements) were over-represented in this group. Concerns were further noted about sleep safety in 75% of the cases, and despite this being noted and safer sleep advice being given in all of those cases, these were the 3 children that died as a result of co-sleeping or co-sleeping and neglect. Half of the children were open to ICS at the time of the incident. Furthermore, in this cohort there was an increased proportion of children previously having been open to ICS and evidence that the family should have been (re)referred to ICS. This latter issue may be linked with evidence which shows assessments failed to take into account the family and child’s history appropriately in 75% of the cases examined. If this had been achieved, then possibly the requisite referral would have been made. Recommendation 2. KSCMP Executive to seek clarification on current Health Visiting operating standards around face-to-face appointments. 13 | P a g e 4. Non-accidental Injury Practice Event 4.1 Purpose and structure In March 2022 an NAI Practice Event was held to measure impact and changes in practice and attitudes, to understand whether current working practice would lead to a better identification of risks relating to children already at risk of NAI. The event was structured in two parts. The first saw attendees split into five groups (with equal multi-agency distribution). These groups were provided with a different anonymised case example of the circumstances of one of the cases included in this study and asked to identify: 1) What are the risk factors or characteristics you are concerned about, and rank them in order of concern? 2) What further information do you need? 3) What action or support do you feel is needed? The second exercise saw the groups tasked with identifying what policies and procedures they were aware of that would be relevant to the scenario they discussed, and identifying what barriers exist to them being used in practice. 4.2 Attendance The event was advertised through KSCMP communication channels, with spaces capped at 25 and distributed as evenly as possible across services. In total 52 professionals registered their interest to attend, the spread of multi-agency representation of the requests can be seen below. Agency/Service No. registered Agency/Service No. registered Kent Police 14 KCC Children’s Social Care 11 East Kent Hospital University Foundation Trust 3 KCC Early Help 4 Kent Community Health Foundation Trust 3 KCC Disabled Children’s Services 1 Kent and Medway NHS CCG 1 KCC Public Health 1 Maidstone & Tonbridge Wells Trust 3 Voluntary and Community Sector organisations 1 The Education People 1 14 | P a g e Of the 25 places allocated, 20 professionals attended the event including: Safeguarding Children Nurses, Midwives, Social Workers, Early Help Workers, Children Centre Managers, Child Protection Investigators, and Safeguarding Advisors. Representation of attendees is shown below. Agency/Service No. registered Agency/Service No. registered Kent Police 6 KCC Children’s Social Care 3 East Kent Hospital University Foundation Trust 2 KCC Early Help 3 Kent Community Health Foundation Trust 3 The Education People 1 Maidstone & Tonbridge Wells Trust 2 KSCMP would like to thank the professionals who attended and engaged in the event. All attendees approached exercises openly and engaged in honest reflection and discussion. The format was based on a previous practice event linked to an individual practice review case and will continue to be considered for future learning opportunities. 4.3 Case scenario feedback This exercise allowed for a ‘mirror on the system’ to see whether the prevalent risk factors that had been identified in the previous NAI deep-dive study would be identified by multi-agency practitioners, and what the likely response to the scenarios of the 5 children presented would be. It was also hoped that this would enable us to gain a better understanding of what the key differences were between the 5 children that had been referred and were known to services and those who were not known prior to the NAI occurring. In all 5 cases professionals identified parental mental health (of one or both parents) as a risk factor which featured high in the risk order for all groups. In 3 cases professionals identified the history of the family and previous involvement as a relevant risk factor, although this was not overwhelmingly identified as a high-risk factor. In 3 cases substance misuse was identified as the second most concerning factor, however this was often not in the sense of the impact it may have on parenting more broadly. Domestic abuse was identified in 2 cases, in one as the most concerning factor, but much less a risk factor in another. A lack of, or lack of knowledge of, wider family support was also identified in 2 cases at the lower end of the risk spectrum, as was professional optimism. In 2 cases professionals speculated whether the parents may have had ACEs which impacted their parenting capability. In all 5 of the cases professionals identified a need for further information sharing – either sharing risk information, or to obtain a better understanding what other multi-agency information existed, in order to inform the assessment of risk. Only two of the groups specifically stated that a multi-agency response would be needed, whereas 15 | P a g e others indicated that further information was needed in order to understand whether there was a need for this. In one case professionals were very clear that whilst if all the information was shared there should be a multi-agency response to the risk to the child, that it was more likely that single agencies would hold information individually and so a multi-agency response would not be triggered. It was interesting that professionals noted this likelihood, as this was exactly what had happened in that case in reality. What was overwhelmingly apparent was that as impartial observers presented with the case scenarios, professionals quickly identified a range of risk factors and the need for multi-agency information sharing/discussions, which had not always been identified in the reality of the cases considered. A certain degree of ‘hindsight bias’ might have affected this, as the professionals were aware that the scenarios they were considering had resulted in the NAI to a child; this may have led them to search more for the potential risk factors. 4.4 Challenges to offering effective support and safeguarding The second exercise encouraged professionals to share the challenges and barriers that exist in practice, that may inhibit the pro-active multi-agency working they had identified as being necessary in exercise one. The challenges identified mostly fell into four areas. 4.4.1 Referrals and thresholds Challenges were identified in the referral making process, such as the language used in the request for support (RfS) form which does not necessarily resonate with multi-agency practitioners; an anxiety amongst practitioners leading them to include inappropriate or irrelevant information into the RfS form; and a lack of understanding about consent and information sharing. It was highlighted by professionals that the wording in the RfS form makes a significant impact on the outcome- more so, in some instance, than the actual circumstances of the child. Some also suggested that there have been examples of schools holding safeguarding concerns internally and not making referrals, meaning the full risk picture for a child is not understood. To add to this, some agencies highlighted that their limited window of contact with a child or family poses a challenge to them identifying safeguarding concerns and making appropriate onward referrals. Professionals also discussed the Kent Support Levels Guidance (SLG) and its application. It was commented that the SLG is worded in a way that is primarily suited to older children, making it difficult to apply to situations involving infants. Professionals also spoke of a perception that over time there has been an increase of thresholds for service provision and an increased tolerance of poor or risky situations for children. There was a consensus that the complexity of cases allocated to Early Help has increased, which previously would have been considered via a multi-agency strategy meeting and held within Children’s Social Care. 16 | P a g e A recent LCSPR published by Northamptonshire Safeguarding Children Partnership3 noted similar perceptions of staff had led to referrals not being made: “However, when the Serious Incident Investigator explored… their rationale for not referring Child Au to the MASH sooner, two of the Health Visitors shared their belief that if they submitted a referral to MASH it would not be accepted. This decision was apparently influenced by their previous experience of referrals being rejected on more than one occasion, a view that was generally shared with members of their team. As the Serious Incident Investigator points out: “this assumption is concerning as it potentially has the ability to create a ‘culture’ within a service that prevents practitioners from submitting timely referrals and this will impact on the welfare of the children at risk.”.” Recommendation 3. The Kent Support Levels Guidance course be reviewed to ensure it adequately covers terminology in the SLG and details on completing a Request for Support. Delivery of the course to be reviewed to address consistency and provision issues. The outcomes of referrals into the Front Door were also discussed. Professionals highlighted that in their experience there can be delays in arranging joint visits out of hours. A further concern, also highlighted in wider practice events, was that those submitting RfS are not always informed of the outcome of the referral. 4.4.2 Organisational capacity There was acknowledgement that most, if not all, services are currently experiencing challenges in terms of organisational capacity. Demand on services has risen, particularly as a result of the Covid-19 pandemic, and demand versus capacity seems to have led to less multi-agency working. The demands have also led to high caseloads across a range of services, which professionals felt had on occasion impacted on their ability to adequately assess risk, in order to manage workloads. It was also felt that safeguarding is not a priority for every organisation or service, particularly as they have become more stretched. One specific development was highlighted regarding high caseloads. As a result of the NAI notification spike in 2021, Integrated Children’s Services introduced a policy that children who were opened to Children’s Social Care for a pre-birth assessment would not be closed until the case had been reassessed and the baby was at least 3-months old. Professionals praised the intention behind this change to safeguard very young babies. However, there was an indication that in practice this has led to some social workers holding cases which are deemed lower risk by their supervisors, and therefore not being counted in their overall case numbers when new cases are allocated. Nonetheless, the Social Worker is still required to conduct the requisite visits and assessments but their time is stretched across an increased number of cases. 3 http://www.northamptonshirescb.org.uk/about-northamptonshire-safeguarding-children-partnership/scr/child-au-child-safeguarding-practice-review/ paragraph 4.2.20 17 | P a g e 4.4.3 Working with families Professionals identified difficulties in holding challenging conversations with parents about safeguarding concerns. For some services they are operating in settings which are inappropriate to discuss concerns (due to a lack of privacy for example). It was acknowledged that practitioners can often be anxious about damaging relationships by addressing concerns or making a RfS, and sometimes staff lack confidence to have difficult conversations with families. It was also highlighted that not all practitioners are confident in navigating parent vs. child rights as to the appropriate course of action, and that there remains a stigma attached to making referrals to Children’s Social Care with both families and professionals. 4.4.4 Multi-agency working A lack of understanding of each other’s roles and responsibilities was highlighted as a key challenge in multi-agency working, alongside a sense that the environment is ‘policy and procedure rich but action poor’. Professionals highlighted that there is also a variation in practices and expectations between different districts across the county, which for some services spanning multiple areas can be confusing and lead to a sense of inconsistency. The nature of the health and education economies and the number of different organisations that make up each, with varying areas of responsibilities, was similarly highlighted to be confusing and difficult to navigate. Two specific points were raised as being a challenge, firstly the removal of the ‘link worker’ role which was responsible for coordinating multi-agency involvement with a child and family. The second was Early Help assessments and plans not being shared with other multi-agency professionals involved with the child/family. The latter did appear to have some variance depending on area of the county or individual worker, but the majority of professionals indicated that this does not happen routinely in their experience. Recommendation 4. Early Help assessments and plans to be shared with involved multi-agency partners (with family consent). 4.4.5 Single issues Two further single issues were identified by professionals as challenges relevant to NAI. 1) Lack of understanding and assessment of parental cannabis use, in particular how cannabis use interfaces and potentially amplifies other issues (a point raised in the Child Safeguarding Practice Review Panel report on safeguarding children under 1 from non-accidental injury caused by male carers4). This was identified both as an issue in assessments, but also a broader concern in the child protection landscape, as even when an individual 4 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1017944/The_myth_of_invisible_men_safeguarding_children_under_1_from_non-accidental_injury_caused_by_male_carers.pdf 18 | P a g e assessment does fully incorporate this, it is not consistently accepted and recognised within the family court framework. 2) Professionals also acknowledged challenges in fully understanding male carers and fathers within services and assessments. Health colleagues specifically noted a challenge in that fathers’ records cannot necessarily be linked to their children’s, as the national spine only allows for a link to mothers. 19 | P a g e 5. Positive Practice Audit 5.1 Context Following the deep-dive study into NAI in the under 1’s in September 2021, the Executive Board endorsed a recommendation to pursue a positive practice review of cases sharing similar risk characteristics, but which had ended with positive outcomes.5 The aim of the audit was to identify what has worked well to enable effective safeguarding so that good practice can be shared across the Partnership, allowing us to build on what is already working well. 5.2 Case identification In January 2022, the KSCMP Business Team presented to DivMT in Kent’s Integrated Children’s Services (ICS), requesting the identification of cases matching the risk profile of the original 6 in the NAI deep dive as closely as possible. These characteristics included: • Parental mental health issues • Parental substance misuse issues, including during pregnancy • Cannabis use in the household • Premature birth And of significant interest but less importance: • Family history of ICS involvement • Deprivation/financial issues • Housing issues • Parental Adverse Childhood Experience’s (ACE’s) • Older sibling in care or living elsewhere Each of the 4 districts were tasked with identifying 3 cases and providing their Liberi ID numbers to the KSCMP Business Team, with a view to the 6 most closely matched being selected for the positive practice audit. The 6 selected demonstrated 6 or more of the 9 identified characteristics at the time a Children and Families assessment (C&F) was undertaken for the unborn (therefore ‘premature birth’ was removed as a characteristic and substance misuse concerns/maternal use during pregnancy were separated). The final 6 were represented by the districts as follows: These cases were then reviewed in a desk-top exercise using records available on Liberi. 5 ‘Positive outcomes’ meaning the children were appropriately safeguarded, with no direction regarding how that may have been achieved e.g. accommodated by the Local Authority, or family supported and case stepped down to Early Help services due to decreased risk. ICS District No. of cases in report North 2 South 1 East 1 West 2 20 | P a g e 5.3 Positive Practice – key themes From the desk-top review of Liberi records, the following key themes were noted in relation to these cases: Agency checks These cases demonstrated clear evidence of multi-agency checks for the purpose of informing the Children and Families (C&F) assessments. It was evident that the checks were used to establish a picture of the families’ circumstances over time and to corroborate details shared by the families themselves. This enabled a more holistic assessment of risk, and reduced reliance on ‘face value’ parental accounts. C&F Assessment (pre-birth) As noted above, assessments evidenced the gathering and corroboration of information from multi-agency partners. They also analysed this information in the context of what was already known about the families and whether current circumstances resembled previously observed patterns or indicated new risks. Assessments tended to explore family and wider support networks, as well as associated risks. They thought beyond immediate family and/or the household, to consider others who were likely to be relevant to the babies’ lives. Some assessments drew links between current circumstances and behaviours, and the risk of Sudden Unexplained Death in Infancy (SUDI)6. This demonstrates foresight and an understanding of safeguarding issues relevant to the local and national landscape. Referrals to Family Group Conferencing Service In all 6 cases, a referral had been made to the Family Group Conferencing (FGC)7 service. Whilst the impact of FGC support on safeguarding is less easy to gauge as part of this review, what can be assumed is that the professionals in these cases were mindful to consider and explore existing and sustainable support networks to help safeguard the subject children. This resonates with the ‘Think Family’ approach in Health and the AWARE principle adopted by Kent Police. Further information and relevance to Kent Local Child Safeguarding Practice Reviews can be found in KSCMP’s Family Context and Professional Curiosity 5-minute fact sheet8. Case notes Some excellent practice in relation to case recording was observed, with particular case notes modelling how it is possible to capture the lived experience and voice of 6 The National Child Safeguarding Practice Review Panel undertook a thematic review into SUDI which can be found online. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf 7 Family Group Conferences - Kent County Council 8 Family-context-and-professional-curiosity-final.pdf (kscmp.org.uk) 21 | P a g e a child. Some offered insight into the relationship between the social worker and the children in the families. For example, in one case note, the social worker described how the baby became unsettled and was handed to her by the mother as she went to prepare a feed. The social worker described her interaction with the baby, including how the baby looked, how she may have been feeling, and the behaviours that led her to believe that. An absence of this type of relationship being reflected in case notes has been highlighted as an issue of concern in historic case reviews locally and nationally, such as that of Peter Connelly9. Supervision Each of the Liberi profiles evidenced supervision and oversight by senior managers. This enabled progression to be tracked and support for the social workers to plan next steps. One social worker commented “supervision enabled me to reflect. It was always open and non-judgemental and helped me to recognise what my own limitations might be in relation to the case.” The views of the social workers are explored in more detail in the next section. 5.4 Positive Practice – feedback from professionals Alongside the desk-top review of available records, efforts were made to contact the allocated social workers who completed the C&F assessments for the unborn babies10. They were invited to engage in semi-structured discussions over MS Teams to share their views on what worked well to ensure the effective safeguarding of these children. The KSCMP are very grateful to these social workers who willingly offered their time and valuable insight to assist with this report. The key themes arising from these discussions are detailed below. Early Request for Support via the Front Door Several of the social workers commented that the Request for Support submitted via Kent’s Front Door service occurred at the very early stages of pregnancy. This enabled the time required to establish a relationship with the families, gather relevant information for assessment, complete chronologies, initiate any relevant proceedings well in advance of birth, and front-load support so there was adequate time to measure impact prior to birth. Exploring the family support network Social workers commented that from the outset they wanted to understand who was going to be relevant in the lives of these babies. This may have been in a supportive role that provided practical and emotional help for the parents, or more directly as potential care-givers for the babies themselves. Also of note was the importance of understanding who was relevant to the lifestyle of the parents, and if these individuals would likely pose risk if in contact with the babies. 9 Haringey serious case reviews: child A - GOV.UK (www.gov.uk) 10 5 of the 6 identified social workers contributed to this report, with the 6th being on maternity leave. 22 | P a g e Relationship building It was felt that some of the most important and meaningful visits were for ‘a cup of tea and a catch up’ rather than a targeted intervention. It was noted that capacity does not always allow for this, however, when it does, it helps establish a positive and trusting working relationship that can subsequently support better safeguarding. It was commented that this helped to break-down some parents’ preconceptions about working with professionals and made them feel more comfortable about engaging in subsequent processes. Multi-agency responsibility for co-owned and created support plans Those interviewed commented on the support provided by wider colleagues (namely Health, Education, Housing, Probation and Substance Misuse services) in assessing risk, creating plans and communicating effectively in relation to any observed changes in the family’s presentation or circumstances. One social worker described a multi-agency exercise involving ICS, the school and Health Visitor, where Mother’s history was discussed and triggers for increased risk of harm identified. Behaviours that might indicate Mother was struggling were noted, meaning that when her presentation did in fact change, it was quickly picked up and communicated to the wider professional network, leading to an immediate multi-agency response. Several commented they felt those in the professional network took equal responsibility and accountability for safeguarding, which meant that concerns were responded to promptly and proactively across the board and were not left solely for Children’s Social Care to address. Creative and practical support Two of the social workers commented they created visual aids and timetables for parents who might otherwise have struggled to structure their time or remember and keep to appointments. Although quite a basic task, they were confident this facilitated positive engagement and could be used as a tool to measure what parents were proactively engaging with (e.g. by crossing off days on the calendar or adding their own images to the timetable). 5.5 Observations and analysis In all the cases considered for this positive practice review, the family had a history of involvement with ICS. This is significant for 2 reasons: firstly, when a Request for Support was submitted to the Front Door the history of involvement would have indicated the significance of current concerns, lending to appropriate triage. Secondly, once allocated to a social worker, the historical records helped to establish patterns of behaviour over time, avoiding current concerns being considered in isolation, and lending to effective forward planning. It is important to contrast this with breadth of NAI cases the KSCMP is currently reviewing, which includes several where the family had not had a history of ICS involvement, having only been supported under a universal offer. With this in mind, 23 | P a g e consideration should be given to how the positive practice identified in this report can be shared and embedded in universal services, such as midwifery and health visiting, to facilitate the identification of safeguarding concerns that require a RFS at an early stage. What has been noted to have worked well in these cases will come as no surprise to safeguarding professionals. Multi-agency collaboration, good quality assessment and case-recording, management supervision, building meaningful relationships with families and offering creative and practical support are basic requirements that most would likely highlight as essential for effective safeguarding. What it might indicate for the Partnership, is a need to ‘get back to basics’ following the interruption caused by the pandemic to ‘business as usual.’ Recommendation 5. The positive practice audit to be published and shared as a standalone report, as a reminder that familiar, expected, basic practice works, and to avoid a sense of needing to wait for learning from individual LCSPRs to be published before seeking to change or improve practice. 24 | P a g e 6. What does this tell us? The purpose of this study was to identify key factors which may assist in identifying children most at risk of harm and understand what practice is likely to make most impact in safeguarding the under 2s. Analysis of the cases which have been referred, engagement with professionals, and reviewing positive practice have all provided different lenses on these issues. The findings indicated through these activities are outlined in this section. 6.1 Differing context of harm A picture has emerged of different circumstances and appearance of risk between the cohort of children who were harmed because of NAI, and those harmed as a result of co-sleeping and neglect. For children harmed through NAI it appears that there were less obvious warning signs of risks which would be apparent to practitioners on a surface level. It appeared that parents in those cases had reached a point where their resilience was stretched beyond capacity, and then in those moments of stress (potentially related to infant crying) a loss of control followed resulting in abusive injury to a young infant. These are not necessarily the families where safeguarding concerns are immediately evident, and the exhaustion of resilience would only be realised through thorough exploration of the individual family’s context and support measures. It is less about specific factors putting a child at risk in these cases, but rather a general amalgamation of factors which outweigh the parental threshold for coping. These are families who are more likely to only be open to universal services, which means the emphasis has to be on those services to think beyond a surface picture presenting with no major risks. In most of the cases it seemed that everything looked fine, until the NAI occurred, however with hindsight it can be seen that a few further questions might have opened a window to individual struggles and challenges. This should not just be seen as a lack of ‘professional curiosity’ however. There is a need to acknowledge that, in the context of NAI, ‘risky’ families are not easy to identify. As such there is a need for universal services working with parents, families and babies to explore beyond face value, and for a focus on early prevention to begin in those services at ‘Tier 1’. It is important that the role of universal services in preventative work is recognised, and that safeguarding of young babies is not just seen as the responsibility of ICS once a threshold for Early Help or Social Care has been met. By engaging in that preventative work, it will also be possible to detect escalating risk that may put a child under threat at an earlier time. For the children and families in the co-sleeping and neglect cohort, risk was more visible and from an earlier point in time. Late pregnancy booking is already recognised as a potential risk factor, and was evident in this study, as was this broadening into a pattern of missed appointments following birth. It appears the tone of laxity for the children in this cohort was established from the outset of their lives, with concerns about not following safety guidance (such as safer sleep guidance) noted. These were families where there were also a range of other clear risk factors which were obvious to professionals (such as substance misuse and parental 25 | P a g e violence). Families were more likely to be receiving enhanced services above universal and professionals were already concerned about the safeguarding of the child. This, however, possibly presents a complicated and ‘busy’ family picture for professionals, in which it may be difficult to determine pressing or escalating risk amongst the level of ‘noise’ in the case. 6.2 Practice themes Three specific practice themes emerged which could make a difference in safeguarding children from harm in the future. 1. Early identification and referral It was noted in the data analysis that most children harmed through NAI were not known to ICS, but in a high proportion missed opportunities were identified in hindsight where they should have been referred either to ICS or have received an enhanced service provision (for example, from Health Visiting). Early identification of need is clearly important, and agencies need to understand this not just in the context of provision of KCC Early Help services. Where there are needs which do require assessment or support from ICS, good engagement with universal services will enable prompt referrals. 2. Consideration of family history In the cohort of children harmed through co-sleeping and neglect, it was noted that assessments often did not thoroughly consider the family history and the context this provides for a risk to children. Patterns of un-sustained change, or cycles of repeated concerns are relevant considerations to assessments of current need and in establishing realistic expectations of progress. When previous change has not been sustained, it is important that professionals consider what evidence there is that short-term change presented a) actually exists, and b) will continue. There were also examples in both cohorts of older children having been removed from the care of a parent due to previous concerns. However this was not considered in terms of what this might suggest about the capability of safe parenting of the current child. 3. Assessing the impact of parental issues on risk to child A range of indicators present in both cohorts related to parental issues. Mental health concerns featured fairly frequently, alongside substance misuse and other concerns. Whilst mental health issues do not equate to a parent being unable to safely care for their child, it is necessary to assess the impact of parental issues on risk presented to the child. In one case a father reported significantly deteriorating mental health, which was identified as requiring a priority response. The relevant referral was made for support to the father, and whilst the young baby was listed as a protective factor for the father, it was not recognised that the deterioration in his mental health could have posed a risk to the baby. Where parental concerns exist it is right that they are identified and support given as appropriate, but this must also be reflected when assessing the risks for the child. 26 | P a g e 6.3 Moving forward In the positive practice audit, it was clear that the things which are working well are familiar basic concepts. They do not represent new ways of working and would likely be what professionals would describe as expected practice. This primarily revolves around good coordinated multi-agency working and taking time to build relationships with families. Whilst these are not new or revolutionary ideas, what is clear is that this work needs to be taking place sooner, not only once the family is in a clear position of risk. What has been clear throughout this study is that professionals from all services are passionate about their work. Nonetheless, the demands on services cause challenges as the desire to safeguard children and do the best for them, is impacted by the capacity individual workers have to be really interested in individual cases and delve into detail with families when they are affected by time constraints. This can result in professionals resorting to achieving what is required to ‘tick off’ a task, rather than allowing for natural inquisitiveness to be followed and a richer, more accurate picture to be understood. 27 | P a g e 7. Conclusion and Recommendations At the outset of this report, we acknowledged the number of young children being considered in this study who had been seriously injured or died. It is right as we draw conclusions to also acknowledge the commitment to safeguarding children that exists across the range of Kent practitioners from various agencies and the very difficult contexts in which they are often working. Throughout the study our objective has been to identify where practical change can be made to support multi-agency working, and to hear directly from practitioners the challenges that exist to enacting effective practice. It is also useful to acknowledge existing Partnership work that is underway or planned, which will provide further learning and support to address the issues raised in this study. As part of the KSCMP multi-agency audit programme, for example, an audit will shortly be commencing regarding Front Door and Requests for Support. Separately, and resulting from the deep dive study in 2021, the KSCMP Independent Scrutineer will be undertaking a review of multi-agency expectations and requirements of engagement with fathers to help us better understand broader family involvement. Five recommendations have been made throughout the report, which are collated below: Recommendation 1. Kent and Medway CCG to present an update on the roll-out of the ICON programme and provision of future training in Kent. 2. KSCMP Executive to seek clarification on current Health Visiting operating standards around face-to-face visits. 3. The Kent Support Levels Guidance course be reviewed to ensure it adequately covers terminology in the SLG and completing a Request for Support. Delivery of the course to be reviewed to address consistency and provision issues. 4. Early Help assessments and plans to be shared with involved multi-agency partners (with family consent). 5. The positive practice audit to be published and shared as a standalone report, as a reminder that familiar, expected, basic practice works, and avoid a sense of needing to wait for learning from individual LCSPRs to be published before seeking to change or improve practice. In addition to the specific recommendations, the need for universal services to be more inquisitive and alert to less obvious risks has been clearly identified, particularly when considering the inherent physical vulnerabilities of children under 2. It is on this point in particular that the authors would encourage the KSCMP Executive to reflect and discuss. This does require a shift in mindset of what a ‘risky family’ looks like and it is clear most of the children harmed who were considered in this study were not necessarily those where there were existing concerns about safety. This study has also been a reminder that practitioners, against human instinct, must be prepared to think the worst – even where there are not clear ‘red flags’. Professionals in all services need to understand that significant harm occurs to children in families where risk is not obvious, where universal services may be the 28 | P a g e only ones engaged, and to consider whether there is one more question which might help identify an obscured risk. Experience shows us that people do not volunteer information unless they are specifically asked and one more question might be just enough to prevent the tragedies seen with the children considered in this study from occurring again. |
NC049603 | Death of 22-month-old Child O at the hands of their mother who also killed herself in summer 2014. A post-mortem concluded mother and child died of carbon monoxide poisoning. Parents were separated, and mother and Child O had since moved to a number of areas around the country. At the time of their death in Lancashire, they were not known to any statutory or other agencies within the county. Father had made an application for contact with Child O and a Cafcass children's guardian was working with the family. Mother had made unsubstantiated allegations to Devon and Cornwall police of domestic violence and sexual abuse against Child O's father. The coroner's inquest concluded there was no substance to the mother's belief that she was being pursued by Child O's father and he had acted appropriately throughout. Mother had a history of possible post-natal depression and personality problems; and giving misleading information to statutory services to conceal the whereabouts of herself and Child O. Findings include: there were organisational weaknesses in the approach to working constructively and proactively with fathers; professionals need to be encouraged to balance respect for women who talk about domestic abuse with appropriate scepticism and curiosity where allegations are denied. Makes multi-agency recommendations including developing knowledge and awareness of the nature of homicide in the context of parental conflict.
| Title: Serious case review: Child O LSCB: Lancashire Safeguarding Children Board Author: Sian Griffiths Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Lancashire Safeguarding Children Board SERIOUS CASE REVIEW CHILD O Date of Serious Incident: August 2014 In order to protect the identity of individuals this report has been anonymised. The subject of this review is herein referred to as Child O. Independent Reviewer: Sian Griffiths Independent Chair: Jane Booth Date: March 2016 This report has been commissioned by: Lancashire Safeguarding Children Board 2 Chair's foreword This Serious Case Review has considered the complex circumstances around Child O's life and death. The Lancashire Safeguarding Children Board has taken responsibility for the completion of the review as the death took place in Lancashire but neither the child nor the mother were known to agencies in this area. The child had previously lived in a number of areas and we have worked with four other Safeguarding Children Boards – Devon, Hampshire, Norfolk and Southampton – in order to complete this review. The findings and issues for consideration from the review have been endorsed by Lancashire Safeguarding Children Board and have been forwarded to the four other Boards for their endorsement. Child O died at the hands of their mother who also committed suicide. She had taken great steps to hide Child O and herself from public and professional view. Experience and research both tell us that the circumstances around Child O's death are extremely rare. This child's death was a tragedy and our sympathies go out to Child O's father and extended family. The review has enabled agencies and professionals to look at their actions to see if there was anything that could be done in future to further improve working between agencies and safeguarding for children. It has identified some areas where agency practice can be improved. It is acknowledged that, whilst different actions might have resulted in Child O being traced earlier, there is a real possibility that this would have resulted in another move and ultimately the same outcome. Regretfully one of the agencies involved, Cafcass, has indicated that it does not feel able to endorse the overview report. This is the first time that Cafcass has not endorsed a Serious Case Review overview report and the first time the Lancashire Safeguarding Children Board has been unable to secure unanimous sign off a Serious Case Review by all agencies. Considerable efforts have been made to reach an agreed position and Cafcass has not taken this decision lightly. Cafcass has however drawn on the findings from their own internal review in to the circumstances of this tragedy and has identified an action which addresses supervision arrangements. Family members have contributed to the review and been kept informed of its progress. Their contribution has helped inform the learning from this review. Lancashire Safeguarding Children Board and the independent reviewer would like to thank them for their contribution which we know has not been easy due to their loss. Jane Booth, Independent Chair of the review 3 CONTENTS 1. Introduction: 1.1 The circumstances leading to this Serious Case Review Page 4 1.2 Family Composition Page 5 1.3 Methodology Page 5 1.4 Contribution of family members Page 8 2. Summary of the case and agencies involvement Page 10 3. Appraisal of Practice and Analysis Page 18 3.1 Introduction Page 18 3.2 Working with fathers Page 18 3.3 Domestic abuse. Disclosure or allegation? Page 23 3.4 Recognition of risk to the child Page 27 3.5 Communication across agencies and geographical boundaries Page 32 4. Concluding Comments Page Page 34 5. Recommendations for the Boards Page Page 36 6. Appendix A: LSCB Actions Page Page 38 7. Appendix B: Individual Agency Actions Page Page 55 8. Bibliography Page Page 58 4 1. INTRODUCTION 1.1 The circumstances that led to this Review 1.1.1 In the summer of 2014 twenty-two month old Child O and mother were found dead in the garage of a house in Lancashire after concerns about them had been raised by neighbours. The post mortem report concluded that both mother and child had died from carbon monoxide poisoning. Neither the mother nor Child O were known to any statutory or other agencies within Lancashire. Child O had been reported to Devon and Cornwall police as missing in October 2013, had been located but had then moved again. The mother was using an assumed name and the only person who appeared to be aware of where they were living was Child O’s maternal grandfather. 1.1.2 The subsequent inquest, which took place during the course of this review, concluded that Child O’s death was an unlawful killing, in that Child O's mother had poisoned her child with carbon monoxide. The inquest also ruled that Child O's mother had taken her own life by self-administering carbon monoxide. The inquest, which heard comprehensive evidence from both professionals and family members, saw written information suggesting that the mother had been fleeing domestic violence from the father of Child O and also heard similar allegations from the maternal grandfather. However, the Coroner concluded that there was no substance to the mother’s belief that she was being pursued by the father. Nor did the coroner find that Child O’s father had manipulated the Police, Family Court System or Children’s Services, but indeed that he had acted appropriately throughout. 1.1.3 The case of Child O was referred to the Lancashire Safeguarding Children Board on 14th August 2014. Due to the involvement of several Safeguarding Children’s Boards and following discussion with the Department for Education, the Independent Chair of Lancashire Safeguarding Children Board formally made a decision to undertake a Serious Case Review on 26th November. Child O’s case had met the criteria for a Serious Case Review as identified in Working Together to Safeguard Children 20131, in that there was information that: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.1.4 The initial completion date for the Review was to have been the end of May 2015. However, due to the complexities of establishing which 1 Working Together: HM Govt 2013 5 agencies in which parts of the country had been involved with Child O and their family, it became clear that it would not be possible to meet this date. The Review was therefore completed by September 2015. 1.1.5 A Police investigation had been undertaken on behalf of the Coroner. 1.2 Family Composition The family members referred to in this review are as follows: • Subject – Child O • Father • Paternal grandfather • Paternal grandmother • Mother • Maternal grandfather • Maternal grandmother 1.3 Methodology 1.3.1. Statutory guidance within Working Together requires Local Safeguarding Children Boards to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews. The guidance establishes the purpose as follows: Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together, 2013:66) 1.3.2. The statutory guidance requires reviews to consider: “what happened in a case, and why, and what action will be taken”. In particular, case reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and 6 • makes use of relevant research and case evidence to inform the findings. 1.3.3. From the outset of this Review it was established that that there would be limitations regarding information gathering. In particular the Review Team were aware that this could have an impact on achieving an understanding of why things took place, rather than simply what happened. Child O and mother lived in a number of different locations around the country, ultimately moving to Lancashire where they had no contact with any social care or health agencies. Four other Safeguarding Children Boards needed to be involved in the Review as a result: • Devon Safeguarding Children Board • Hampshire Safeguarding Children Board • Norfolk Safeguarding Children Board • Southampton Safeguarding Children Board. Staff and services in the different authorities, which are geographically very widely spread, generally had very short periods of contact with the family, and most of that contact took place in 2013. As a result the capacity of the practitioners involved to add anything significant to this Review in addition to their written records was very limited. 1.3.4. The methodology used for this Review was however underpinned by the principles outlined in Working Together, including the need to use a systems approach. The author of this report is familiar with a systems based methodology. In particular this approach recognises the limitations inherent in simply identifying what may have gone wrong and who might be ‘to blame’. Instead it is intended to identify which factors in the wider work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. A central purpose therefore is to move beyond the individual case to a greater understanding of safeguarding practice more widely. 1.3.5. The Review was chaired by Jane Booth, who is also the Independent Chair of Lancashire Safeguarding Board. Ms Booth met the criteria of independence given that Child O was never known to services in Lancashire. The Author of the Review is Sian Griffiths who has significant experience in undertaking Serious Case Reviews and is an Accredited SCIE Learning Together Reviewer2. The author is independent of all the agencies involved. 1.3.6. The chair and author worked with a core Review Team from relevant agencies in Lancashire. The four other Safeguarding Boards were asked to consider sending a representative to the Review Team meetings, but predominantly felt unable to do so, given the limited nature of their involvement with the family and the resource implications of travelling to Lancashire for meetings. Contact with the four Boards was 2 This Review has not been undertaken as a SCIE Learning Together Review 7 undertaken by the Chair of the Review and opportunities for comment and reflection on the draft report were built in. 1.3.7. Attendance at the Review team was made up of Senior Safeguarding representatives from the following agencies: � Cafcass � NHS Chorley and South Ribble Clinical Commissioning Group � Lancashire Constabulary � Lancashire Children’s Social Care � Northern, Eastern and Western Devon Clinical Commissioning Group (Designated Doctor) The Norfolk Safeguarding Children Board Manager also attended on one occasion. 1.3.8. The review process included • Consideration of chronologies and learning summaries produced by 14 key agencies. • 4 meetings of the Review team. • Meetings with the family of Child O. • Access to the Lancashire Police investigation file • Attendance by Lancashire SCB representative at the Inquest for Child O and mother • Access to the Family Court files 1.3.9. The following agencies provided chronologies and Agency Reflection and Learning Reports: � Cafcass � Devon Family Solutions (Mediation) � Devon GP (Teign Estuary Medical Group) � Devon Virgin Care (health visiting services) � Devon and Cornwall Constabulary � Devon Children’s Social Work � Southampton City Primary Care Trust and North Hampshire Primary Care Trust � Hampshire Hospitals NHS Foundation Trust � University Hospital Southampton NHS Foundation Trust � Hampshire Constabulary � Southampton City Council Children and Family Services � Hampshire Children’s Services � Norfolk Children’s Services � Norfolk Constabulary 1.3.10. The timeframe under consideration for this Review was: 8 14th February 2012 – 13th August 2014 The starting point was chosen as this was the point that the mother informed the father that she was pregnant with Child O. The date of Child O’s death marks the end point. 1.3.11. The Terms of Reference identified four key issues for consideration within the Review, however these were not intended to limit any other learning that might emerge: 1. What knowledge or information did agencies have about the family, including any that indicated mother might be a risk to Child O? 2. What services were offered to mother, father and Child O and were they accessible and sympathetic? 3. What information did family and friends have that might have indicated mother was a risk to Child O? 4. What learning is there for agencies in this case? 1.4 Contribution of family members 1.4.1. The involvement of key family members in a Review can provide particularly helpful insights into the experience of receiving or seeking services. The Independent Author met with the father and his family as well as with the maternal grandparents early in the process of undertaking the Review. Their main concerns are summarised here, but also where relevant to the purpose of this Review more detailed contributions are woven into the report. 1.4.2. Child O’s father and extended family: Child O’s father and partner, his paternal grandparents and paternal aunt contributed significantly to this review, both in providing written information and in meeting with the author. The first meeting took place with all the family, a second meeting just with Child O’s father and his partner. 1.4.3. Child O’s father and his family feel significantly let down by a system which they felt should have recognised that Child O might be at risk, not necessarily of such a tragic outcome, but at least of the possibility of emotional harm. They considered that there were points at which individual agencies should have been more concerned about the mother’s behaviour and could have responded more effectively. For the father and his family there were three particularly significant concerns: • the apparent lack of urgency during the Family Court Process. 9 • the response of Devon and Cornwall Police when Child O was reported as missing. • failings of communication between the various agencies. A strong thread throughout their concerns was their sense that the significance of Child O’s father’s role was inadequately recognised and the allegations made by the mother were too easily accepted. As such they felt there was an inherent bias towards him as a father. 1.4.4. The impact on Child O’s father and his family has been profound. Child O’s father had not seen his child since he was 5 months old and had no knowledge of his whereabouts for the remainder of his life. The mother of Child O would not allow any contact with the father’s family, meaning that they never met their first grandchild and nephew. Child O’s father was also faced with serious allegations from Child O’s mother which could have been life-changing, but these were ultimately identified by the police as unfounded. 1.4.5. Child O’s maternal grandfather: Child O’s grandfather met with the author on one occasion. The grandfather’s main focus of concern was his belief at the time that his daughter was fleeing serious domestic abuse and that her life was at risk. He described this need to believe what his daughter told him as taking priority over any other requirements, including court orders, and he confirmed his continued belief that he was justified in his actions. 1.4.6. Child O’s grandfather did not raise particular issues about the responses of the various agencies other than in relation to Devon and Cornwall Police. He was highly critical of the police for what he considers to be their failure to respond to his daughter’s allegations of domestic abuse. He also questioned the degree to which the police’s actions in July 2014 impacted on his daughter’s state of mind. 1.4.7. Child O’s maternal grandmother: Child O’s grandmother, accompanied by a friend, met with the author on one occasion. Child O’s grandmother’s level of distress throughout the meeting was acute and despite her desire to contribute it was evident that this would be difficult for her to achieve. Child O’s grandmother provided background information about her daughter’s early life. However, as she had never met her grandchild, nor had any contact with her daughter during Child O’s lifetime, she was not in a position to comment on the services provided to them. 1.4.8. Child O: Whilst it is Child O who is at the heart of this review, there are few sources of information to draw on in order to gain a detailed picture of their personality, or experience of their own life. Child O was only known to professionals in the very early months of their life and that contact was of a routine nature. Child O was not able to have any contact with their father after the age of 5 months, so for Child O's paternal family their knowledge of Child O for much of Child O's life has 10 been limited to a few photos and videos provided by the maternal grandfather following Child O's death. Maternal grandfather described Child O as absolutely normal and adorable, and said that the child was learning to talk and running around. The available information about Child O's care by his mother would suggest nothing other than a thriving child who was physically well cared for. It is evident however that Child O's world was limited to relationships with mother and maternal grandfather. While this would have been likely to lead to concerns about Child O's development as they grew older, given Child O's age it is fair to assume that this had yet to have a significant impact. 2 SUMMARY OF THE CASE AND AGENCIES’ INVOLVEMENT WITH THE FAMILY The following is a chronological summary of what is now known about the family and their involvement with agencies. The summary will identify what was or was not known to the relevant agencies at the time the events were taking place. 2.1. Ante-natal period: The parents of Child O met in early 2012 in Southampton. Neither, at that point, had any previous involvement with safeguarding services. The mother of Child O had at some point prior to their meeting changed her name, but this was not then known to the father. The mother’s initial description to the father of her own family was that she had been brought up by her grandmother and had no contact with her parents for most of her life, which is now known not to be the case. 2.2. The couple had only been in a relationship for a period of months when the mother told the father she was pregnant. This was not only an unplanned pregnancy, but unexpected, as the father states that he had been told by the mother that she was unable to conceive. The first relevant contact with services was when the mother visited her GP in Southampton in February 2012 and confirmed that she was pregnant. She booked with the midwife for her ante-natal care shortly afterwards. During the booking appointment, which she attended alone, the mother spoke of general anxiety but declined any help from health services. She did not raise any issues about domestic abuse, nor were there any safeguarding concerns identified. 2.3. During her pregnancy the mother attended at her GP’s with a range of symptoms and in June 2012 she was referred by her GP to IAPT (Increased Access to Psychological Therapies3) for stress related problems. No record has been provided as to whether the mother accessed this service. The couple moved to Basingstoke in August 2012 3 IAPT: NHS programme of psychological therapy treatments for people suffering from depression or anxiety disorders. 11 and mother registered with a new GP the following month. Again the mother made no reference to domestic abuse. 2.4. October 2012 Birth of Child O. Child O was born at North Hampshire Hospital in October 2012. There was no information of concern identified in the hospital records. Although the staff in the hospital noted that there was some evidence of maternal low mood, this was not highlighted as being unusual. However, the father’s experience gave him greater cause for concern, including the mother’s quite insistent refusal to allow anyone else to touch the baby. He was also concerned at the mother’s insistence on discharging herself the day she had given birth due to her dislike of hospitals but contrary to medical advice. Child O became ill with congenital pneumonia necessitating a return to hospital the following day and care in the neo-natal unit for a number of days. 2.5. A few days after their return home, the midwife recorded that the mother was feeling stressed and ‘needed time alone with Child O to bond following disruptive beginnings’. The Health Visitor (HV1) also noted that the atmosphere in the home was very tense and that the mother talked about stress, although she did not expand on this. The father, who was visibly upset, told HV1 that the problem was the mother’s relationship with his parents to whom he was close. The mother reported having no family of her own and would not allow father’s family to visit new-born Child O. HV1 noted that she would follow the family up for a Mood Assessment at 6 weeks, rather than waiting for the more standard next visit in 8 weeks. 2.6. The following day HV1 spoke to the GP because of her concerns including that the father had visited her at her office, again very upset. He stated that he increasingly felt he did not really know the mother and that she had been dishonest about a number of things, including her relationship with her family. The Health Visitor sought advice from the GP and they noted a joint concern about the possibility of the mother having mental health problems. Information from the father was that the relationship was now breaking down and he was becoming increasingly worried about the mother’s extreme over-protectiveness of Child O, which effectively excluded him from having any meaningful care of the child, as well as worries about whether she had been lying to him about her personal history and family. 2.7. A couple of days after the father’s visit to HV1, Mother contacted the health visiting service to cancel her next appointment as she was planning to leave the area. HV1 was on annual leave but the duty Health Visitor (HV2) recognised the significance of this given the recorded concerns regarding mental health and arranged to meet her later that day. HV2 noted that the mother’s mood was low, but she had no concerns about her care of Child O. The mother presented as distressed about the ending of the relationship with the father, but stated that he was not abusive or controlling, simply that he did not understand how she felt. HV2 encouraged her to see her GP and consider medication to 12 help her stabilise her mood, which she did the following day and was duly prescribed with a low dose anti-depressant. Follow up appointments with both GP and HV2 were planned for the following week. 2.8. In mid-November the mother phoned the police following what she described as a ‘heated argument’ with the father, who had then left the house. Police attended, spoke to both parents and recorded no offences. It was agreed that the parents would stay in separate rooms until Mother was able to move out in the next couple of days. A DASH risk assessment4 was undertaken and concluded there was a standard risk, the details were passed to Victim Support and a Child at Risk form was sent to Children’s Social Care as a matter of routine. 2.9. November 2012: Mother and Child O move to Devon The following day the father made a referral to Hampshire Children Services, raising concerns about mother’s mental health. Children’s Services made enquiries with HV1 and recorded that mother had post-natal depression, had been abandoned by her father as a child, but had ‘good family support’ in place. A duty Social Worker telephoned the mother who stated she would be moving to Devon the next day and did not want the father to know her new address. When both the father and maternal grandmother subsequently contacted Children’s Services they were informed that the mother had moved to Devon and that they would need to contact Devon Children’s Services if they had further concerns. The father also contacted HV1 who explained that she would provide a verbal handover to the new Health Visitor and GP once the mother and Child O were registered. Both Children’s Services and HV1 advised him to seek legal advice. 2.10. Hampshire Children’s Services informed Devon Children’s Services by fax that the mother and Child O had moved to Devon and that the mother did not want her new address disclosed to Child O’s father. It was further stated that there had been no concerns raised by the Health Visitor and the only referral they had received was from the father who was concerned about the mother’s mental health and wanted this to be checked. The manager reviewing the referral concluded that there was no reason for further action as the issues described by the father did not reach the threshold for Safeguarding concerns and information from Hampshire Children’s Services were ‘clear that there were no concerns held by health in the originating area’. The mother later phoned Devon Children’s Services unhappy that they had become involved and stating that the father had been abusive to her. 2.11. HV2 from Hampshire telephoned the mother to check if she had registered with a GP, and confirmed that Child O was registered with Teignmouth Medical Centre. HV2 also spoke to the new Health Visitor, who had already sent out an appointment. The Devon Health Visitor 4 CAADA-DASH RIC : Nationally used risk assessment for domestic abuse. 13 recorded that there were concerns around post-natal anxiety and conflict in the parental relationship. 2.12. Period living in Devon, November 2012 to Summer 2013: Child O and his mother remained in Devon until some point in the summer or early autumn of 2013. Her address there was known both to the father, who was aware of it from information that the mother had left behind, and to primary health services. At this time Child O and his mother were living with maternal grandfather in a property owned by him. The mother was registered with the same GP as Child O and stated that she had left her previous address because the father had been abusive. She denied having post-natal depression. 2.13. A similar conversation took place with the Devon Health Visitor (DHV), who noted that the mother had ‘fled’ domestic abuse but had also said that this had never been physical. A referral was made by the DHV to unspecified ‘domestic violence services’. Child O’s mother again denied any post-natal depression and stated she was not on any medication. Nevertheless, information that the mother was prescribed with anti-depressants whilst in Hampshire was recorded within the Devon health visiting records. Child O was subsequently seen by the GP for the routine 8 week baby check and routine vaccinations. He was initially identified as Universal Partnership Plus by the Health Visitor, meaning that the family would have some extra support, though this was soon afterwards reduced to the Universal service provided to all children. Child O was seen on 11 occasions by the health visiting team. 2.14. Child O’s father made contact with the mother in Devon and it was agreed that he could have contact with Child O supervised by the mother in a restaurant in Devon. This proved unsuccessful and as a result in April 2013 the father arranged for them to take part in mediation at Devon Family Solutions. Two mediation sessions took place but were unsuccessful in achieving any agreement. The father had suggested a contact centre which would provide supervision, but the mother was unwilling to agree. Although the Mother requested that they remain in separate rooms during the second mediation appointment, there was no information recorded that suggested any concern about risks to the mother. Instead this was understood by the mediation service to be because the mother felt more comfortable being in a separate room. 2.15. Following the failed attempt at mediation Child O’s father made an application to the Family Court under private law to resolve the dispute between them. During this period the mother contacted her GP asking for Child O’s name to be changed by removing the father’s surname. It would appear that this was actioned by the GP. 2.16. Whilst living in Devon, Child O’s mother contacted the police on 3 occasions with allegations about the father. On the first occasion she stated that he had called her pretending to be from a doctor’s surgery in order to obtain information. She also said he had contacted the surgery 14 claiming to be from the hospital. There was no evidence to support this allegation. This was recorded by the police as a ‘non crime domestic incident’ and a DASH assessment undertaken, which identified it as ‘standard risk’. On the second occasion she reported receiving an abusive letter from his parents. The Police Officer did review the letter and did not consider the letter to be threatening or offensive and again recorded this as a non-crime domestic incident on the basis of what the mother had told them. Lastly in April 2013 the mother reported that during a contact meeting the father had made a threat to her life and had also sent her a sympathy card. Again this was recorded as a non-crime domestic incident, but given that the mother appeared to be very frightened, the DASH risk assessment on this occasion was recorded as medium. The Police Officer spoke to the father who was noted to be polite and understanding, but denied the allegations. The father reported to this Review that the officer had told him he had not actually seen the sympathy card and felt frustrated at what therefore appeared to him to be an unquestioning acceptance of the mother’s allegations. 2.17. Summer 2013: Father’s application to the Family Court: In late summer of 2013 father applied to the Family Proceedings Court in Torquay under private law proceedings5. He had not had any contact with Child O since March 2013. The application was forwarded to Cafcass who, in line with their normal practice, undertook safeguarding checks with Children’s Services and checks with the police regarding any criminal convictions, which confirmed that neither party had convictions. A Cafcass officer in the team responsible for undertaking the initial pre-court checks, spoke to the father by telephone, and was informed of his concerns, including that the mother had changed her name in the past. In the absence of a phone number for mother Cafcass e-mailed her to ask her to make contact with them, but she did not do so. 2.18. During the same period and in response to a request from the father, the Devon Health Visitor was advised by her Child Protection Supervisor that she should pass on information to him about Child O’s progress as it was understood he had parental responsibility, though not to disclose the mother’s address. Child O’s mother was unhappy that the GP had disclosed which town she lived in, although, this was in fact already known to the father. Child O's mother stated that she would now move away ‘to maintain her and Child O’s safety’. 2.19. The first Family Court hearing was in late September 2013. Cafcass had forwarded the outcome of their safeguarding checks to the court. The father attended the hearing, but the mother did not. The mother did not attend any of the subsequent hearings at the Family Court. Another court date was set for November when the further necessary safeguarding checks would be produced by Cafcass. 5 Applications to Family Court regarding parental disputes over children under the Children Act 1989 15 2.20. At the end of October 2013 Child O’s father contacted Devon Police to report that Child O and mother were missing. This followed the return of court papers, sent to the mother, which had been marked that she was no longer at that address. The father had also been concerned as a result of previous comments that the mother had made suggesting she might move to Spain. During the autumn the mother missed appointments with the Health Visitor, including taking Child O for their 1st year assessment in November 2013. 2.21. The Police immediately initiated a Missing Person enquiry in relation to Child O and mother, assessing the case as Medium Risk. They spoke to maternal grandfather who said that he had not seen his daughter and grandchild for two months since they moved to Spain, but did provide an e-mail address. Mother subsequently contacted them to state that she and the child were safe and well, but she refused to tell them where they were living. There is no independent information to suggest that they had in fact moved to Spain. In early December Devon police identified that Child O and Mother were living at an address in Norfolk. Contact was made by Devon with Norfolk Police who agreed to visit in order to undertake a ‘safe and well’ check, which took place first thing the following morning. Two officers attended, they saw both Child O and mother and concluded that there were no immediate concerns regarding Child O’s welfare. Child O was described as clean, cheerful and engaging and the home environment was immaculate. Child O’s mother was very unhappy about having been traced and was not willing to provide any details in order for a Risk Assessment to be undertaken nor to provide a contact phone number. She was advised that she should inform maternal grandfather or her solicitor if she intended to leave the country. 2.22. The information was fed back to Devon and Cornwall police. The Norfolk officers completed a Domestic Incident Report, which was recorded as medium risk, and the information was shared with Norfolk Children’s Social Care Multi-Agency Safeguarding Hub (MASH) in line with normal practice. Later that day maternal grandfather contacted Devon and Cornwall police asking for a further visit from the police in Norfolk as Mother wished to make a statement regarding a history of sexual and physical abuse and attempts to kill. 2.23. A Police Officer from the MASH visited Child O’s mother 4 days later and spent several hours with her. The mother made serious allegations of domestic violence and rape against father. She also alleged that he had in the past told her of a sexual relationship with a young person which, because of the nature of his employment, would need to be investigated by the local authority in Southampton. This investigation is commonly known as a LADO investigation, as it is undertaken by a Local Authority Designated Officer. The mother also said that she was in fear of her life as the father had threatened to kill her if she ‘took Child O from him’. Mother was not willing to make a formal statement in relation to any of 16 the allegations, but agreed that she could be referred to the IDVA (Independent Domestic Violence Advisor). 2.24. The Police Officer referred the relevant allegations to the Norfolk LADO officer who telephoned her equivalent in Southampton with the information. Norfolk Police also e-mailed the information to Devon and Cornwall, so that they could inform Hampshire Police. However, no LADO investigation was initiated in Southampton. This will be explored further in Section 3. The Police Officer followed up her visit by e-mailing the mother on two occasions to ask if she had thought further about making a formal complaint, but got no response. The IDVA contacted the mother twice offering support but also gained no response. Whilst it was not known to the agencies at the time, the mother and Child O left this address some time in January 2014 and moved to a house owned by her father’s family in Lancashire where she and Child O remained until their deaths. 2.25. A total of 11 Family Court hearings took place between September 2013 and Child O’s death as summarised in the table below. The mother did not attend any of these hearings. 24.07.13 Application to the Family Court for contact by Father. 23.09.13 Family Proceedings Court, first hearing. Mother did not attend, adjourned for further safeguarding checks and listed for a Review Hearing in November. 01.10.13 Proceedings transferred to Plymouth County Court. 04.11.13 Family Court Hearing (County Court): Court informed that Child O now registered as missing. Prohibited Steps Order made to prevent the mother leaving the Country. Order for DWP6 to provide the mother’s address. 26.11.13 Family Court Hearing (County Court): The mother did not attend and a further hearing listed for January. 21.01.14 Family Court Hearing. (County Court): An address for the mother had been provided by the DWP. Section 77 report ordered from Cafcass. The address provided was her address in Devon, at which she was no longer living. 14.04.14 Cafcass file the Section 7 report with the Court. Attempts to contact Mother had been unsuccessful. 29.04.14 Family Court (County Court): Child O made a Party to proceedings and the Cafcass officer appointed as the Children’s Guardian.8 Case adjourned to be heard by a Circuit Judge on 30.04.14 6 DWP: Department of Work and Pensions 7 Section 7 Report. A report required under Section 7 of The Children Act 1989, regarding the welfare of the child and making recommendations. 8 A Child can be made a party to private Family Court Proceedings in their own right under Rule 16.4 of the Family Proceedings Rules 2010. A CAFCASS officer is appointed as Guardian within the proceedings and the Child will be legally represented through the Children’s Guardian. 17 30.04.14 Family Court hearing (Circuit Judge): Parental Responsibility Order made to Father. Various orders made to trace Mother and a Penal notice attached9. 22.05.15 Family Court hearing (Circuit Judge): New Order for disclosure of information re whereabouts of Child O from CSA. Case transferred to High Court. 16.07.14 Hearing in the High Court. Order to Child Support Agency (CSA) to disclose all information regarding mother by 18/07/15 or CSA director would be ordered to attend court. Location order made. 25.07.14 Hearing in the High Court. Adjourned due to Mother not having been served with Order 31.07.14 Hearing in the High Court. Adjourned to be listed before the same judge, the first week in September 2.26. Various unsuccessful attempts were made during the Family Court process to locate Child O and mother, including contacting the Department for Work and Pensions and the Child Support Agency. A court order made in April 2014 was intended to include an order to the police to disclose Child O’s whereabouts. The court order however was wrongly drafted and had to be redrafted in May 2014. It is not clear why the order was not served on the police after that point but it was not, and information therefore not identified about the mother’s address in Norfolk. 2.27. In July 2014 Child O’s case was transferred to the High Court which then enabled a Location Order10 to be put in place. This Order, which has powers of entry and arrest, is executed by a Court Officer, known as the Tipstaff, who acts either in person, or requests the police to act on their behalf. The Tipstaff contacted Devon and Cornwall police in mid July 2014 in order to locate and serve the court order on the mother, on the basis of her original Devon address, which had been provided both by the CSA and the DWP. Devon Police visited the address and subsequently informed Tipstaff that mother was not there and this was maternal grandfather’s address. On 8th August 2014 Tipstaff requested that the police visit maternal grandfather’s address twice daily in an effort to make contact with him. On two occasions maternal grandfather was spoken to by phone and gave dates when he would be available to be seen, but due to internal errors the police did not attend on those dates. 2.28. On 13th August 2014 Child O and mother were found in the garage of the house in Lancashire. 2.29. As a result of Lancashire Police’s investigation regarding the deaths, it was identified that the original LADO referral in December 2013 had not led to an investigation. This was taken up with the Southampton LADO. 9 A Penal Notice can be attached to a family court order, meaning that failure to comply with the order can result in a period of imprisonment. 10 Location Order is an order under the child Abduction and Custody Act 1985 18 However given the comprehensive nature of Lancashire Police’s investigation with its clear conclusions that there was no evidence to support Mother’s allegations against Father and conversely that there was evidence corroborating the view that Mother had lied on a number of significant occasions, it was agreed that there was no evidence to justify initiating a LADO investigation. 3 APPRAISAL OF PRACTICE AND ANALYSIS 3.1 Introduction 3.1.1. This Section will consider the principal areas for learning which have emerged during the Review and in the course of doing so will also appraise significant episodes of practice that have been identified both by the Review team and by family members. It begins with two areas for learning which help contribute to our understanding of what is the most central issue for the Review: the capacity of systems to identify and respond to potential risk to the child. 3.1.2. Individual agencies have acknowledged that there were some, largely minor, mistakes made during their contact with Child O and his family and have responded to these appropriately. Where these have no significant bearing on the outcome for Child O and do not contribute to wider learning, these have not been re-examined within this analysis. With hindsight however, we can also see aspects of practice across a number of agencies that would benefit from a re-evaluation, irrespective of the impact they are likely to have had on the outcome for Child O. The key findings from this Review are therefore predominantly about wider cross agency culture and practice. 3.1.3. It is not the remit of this Review to analyse in detail the practice of the Family Courts, however, the analysis does reflect on the relationship between the Family Court and the multi-agency safeguarding system. The information contained within this Review is of relevance to the Family court and could provide valuable learning within that arena. A recommendation has therefore been made to ensure the Review is shared with the family court. (Recommendation 6). 3.1.4. The analysis will conclude by considering whether the risk to Child O could have been anticipated and what implications this has for future practice. 3.2 Working with fathers 19 “despite recognition of the benefits of father inclusive health and family services, services are still heavily weighted in favour of mothers, and appear slow to change.”11 3.2.1. The role that the father was able to play in his child’s life was manipulated by the mother, who, we can see with hindsight, worked over an extended period to exclude him from Child O’s life. That she was able to do this so effectively appears, to some degree, to have been unwittingly supported by professional assumptions and attitudes about the father’s role and it appears that her actions were rarely actively challenged. Given the limitations on this Review our understanding of the professionals’ response to the father is based predominantly on written records combined with what we know about engagement with fathers from research. It is important to note that the Review has not identified explicit, confirmed evidence of individual bias or negative views towards the father by professionals. However, the routine practices and culture within agencies often did not appear to support an active engagement with fathers. 3.2.2. The father describes a level of controlling behaviour by the mother, beginning during pregnancy, which prevented Child O from having a normal relationship with their father and with the extended paternal family. Much of this described behaviour took place within the family setting and was not visible to health or other agencies. The father describes this behaviour taking place in the hospital immediately following Child O’s birth. Nevertheless, the mother’s actions are not identified in professional records or memories as having been a particular cause for concern. This is not to say that the father was wrong in his view; some of the behaviour that he has described to this Review is certainly concerning. However, given the information available it is not possible to judge now whether the fact that this has not been noted by professionals represents a failure to recognise the impact on the relationship between father and child, or was a reasonable response at the time in a busy maternity unit familiar with anxious parents. 3.2.3. What is apparent from their records is that when the father raised his concerns with the Health Visitors, they took his concerns seriously and identified the possibility of Post-natal depression. The health visiting service shared their concerns with the GP which led to the mother being prescribed a low dose of anti-depressants. During the short period of their involvement with the family, the health visitors demonstrated that they were involving and listening to both parents. 3.2.4. At other points in Child O’s life there is some evidence that processes and routine practice tended to assume that the mother, who had immediate care of Child O, was ‘the parent’. Examples of this include the acceptance by the GP of the Mother’s decision to remove the 11 The Burdett Report June 2014: 20 father’s surname from Child O’s surname. A parent can only change a child’s name legally with the agreement of everyone with parental responsibility or with a court order. The implications of removing the father’s name did not appear to be recognised and there is no evidence that this was questioned or challenged. After the move to Devon, there is no evidence of attempts being made by the health visiting service to actively contact or involve the father. The need for training and support of Health Visitors in this regard has been identified nationally as an area for development. Evidence from research supports the view that improvements to practice can be achieved.12 Also, in February 2014 in response to a solicitor’s letter the GP surgery were only willing to confirm that Child O was registered with them and the date they had seen the child, as the mother had requested that no information should be given about the child to Child O’s father. Child O’s father had Parental Responsibility and this had been confirmed by the Health Visitor, which raises a question as to why he was not considered to be entitled to full information about his child. 3.2.5. The father felt that he and his family were frequently not taken seriously enough by professionals and believes this was a result of his role as a father. In particular he described a poor experience of Cafcass’ involvement. He did not feel listened to or properly consulted, for example he specifically told the Children’s Guardian that Mother was not at the address in Devon, and was left highly frustrated that letters continued to be sent to this address, which, it appears, was the only address held by the court, and therefore by Cafcass, at that time. He felt the Children’s Guardian was at times dismissive of his concerns and that he was given minimal opportunity to speak to the officer either before or during court hearings, including not receiving responses to his phone messages. The Children’s Guardian has been interviewed by Cafcass as part of this Review and “believes … was sympathetic to the situation and was clear with the father about their role”. The degree of the mismatch between the father’s description of his experience and the Cafcass officer’s perception is striking, but ultimately it is not something about which this report can make a judgement. 3.2.6. What is undisputed is that the Children’s Guardian made a decision not to interview the father while undertaking the Section 7 report for the Court and it is evident that this has impacted significantly not least on the perception of fairness, irrespective of the rationale. The Children’s Guardian began the enquiries by trying to speak to the mother and meet the child, sending three letters, the last by recorded delivery and visiting the address on the day of the court hearing. On failing to make contact with the mother the Children’s Guardian decided not to meet the father, instead undertaking a short telephone interview. The Review has been told that one reason for this was because of the distance that the father would have had to travel to a meeting, although this does not appear to have been offered to him as a choice. The Children’s Guardian also 12 Osborne, M (2014) 21 decided not to look at the file of papers when the father asked for these to be viewed. Cafcass considers that this was a reasonable decision as the father was in a position to place this information with the court. The Review questions this. It cannot be concluded that if there had been a meeting with the father it would have changed the outcome for Child O, but it might have shifted the perception of the case and, for example, led to a stronger advice to the court about the need for an urgent response. 3.2.7. Cafcass have acknowledged that a more ‘cautious’ approach would have been to meet the father earlier in the process. Cafcass practice standards do not define whether or how parties should be interviewed, this is a matter for professional judgement. The Cafcass report identifies that the Children’s Guardian had developed a mindset about Child O’s case, as one of a ‘mother not seeking to be found as she did not want her child to have a relationship with their father’. It concludes that she had not been robust enough in her planning. Cafcass has assured this Review that there was no suggestion in discussion with the practitioner that the Children’s Guardian’s thinking had been influenced by assumptions about the different roles of mothers and fathers. 3.2.8. In response to questions about whether there might be anything further to learn about the organisation’s approach to working with fathers, Cafcass has provided information from two National Audits of practice (April 2013 and November 2014) and the Ofsted National Inspection (April 2014). This latter report concluded that Cafcass ‘consistently worked well with families to ensure children are safe’. None of these audits identified poor practice in relation to working with fathers and Cafcass as a result feels satisfied that attitudes to fathers are not a cause of concern within their practice nationally. This Review has therefore sought further information about the specific context in which the Children’s Guardian was working in order to better understand how such practice decisions are made. However, the information provided was unable to answer the key question as to why the Children’s Guardian adopted a particular approach. On this basis the Review cannot share Cafcass’ confidence that it can exclude the possibility that an individual or cultural response to fathers’ roles may have impacted on the management of this case. 3.2.9. The application of supervision and support available to the individual practitioner is of concern in this case. There is now a strong body of knowledge within social care13 that errors in human thinking are an inevitable feature of complex assessment. ‘Critical challenge by others is needed to help social workers catch … biases and correct them – hence the importance of supervision.’14 In the case of Child O there is no evidence that reflective supervision or other systems which might 13 Munro 2011 (and others.) 14 Munro 2011 (p93) 22 have challenged a particular mindset, and acted as a safeguard, took place. 3.2.10. The Cafcass Operating Framework identifies that individual performance management and reflective supervision take place within quarterly ‘performance and learning review meetings’ whose focus is ‘based around how learning has been applied and embedded in work from one quarter to the next’. Supervision in relation to current work with individual children and families, is based on a model of ‘situational supervision’ which takes place ‘at the point of need’. The frequency of this supervision is flexible and reliant on the individual practitioner or manager identifying the need for individual case supervision. The Cafcass Operating Framework states in relation to Rule 16.4 cases (where a child is made a party to the proceedings in their own right), such as Child O: ‘Case review/case consultation/management oversight should occur at appropriate intervals to ensure the case is on track and not drifting15. However, there is no evidence of any agreement as to what the ‘appropriate interval’ would have been in this case, and no supervision is recorded as having taken place. No information has been provided to this review evidencing that this was unique to this case or that there is a system in place to avoid this happening again. 3.2.11. It is the judgement of the author and the Review team (with the exception of Cafcass) that this highlights a gap in the Cafcass approach to case supervision. Cafcass states that it ‘aims to be in line with the direction of travel set out in Eileen Munro’s Review of Child Protection’’. A significant theme of the Munro review was to reverse a trend whereby social workers had become deskilled by an excessively bureaucratic approach, overly focussed on process and regulation. This aspiration is reflected in Cafcass’ approach to professional development which is based on the concept of ‘self-regulation’. However, what is also clearly identified by Munro is the crucial role played by employing organisations, as well as by individual practitioners, relating to supervision and reflection in order to ensure safe practice. Munro identifies that effective safeguarding practice requires a proactive approach by services and includes ‘arrangements for frequent case supervision for practitioners to reflect on service effectiveness and case decision-making, separate from arrangements for individual pastoral care and professional development16. The most recent OFSTED inspection, which was based on 7 of Cafcass’ 17 Service Areas, judged that ‘quality assurance is effective in most cases’. Nevertheless, in the absence of more robust processes regarding the supervision of individual cases, Cafcass cannot be fully assured that it has fulfilled its obligation to support and challenge practice in order to ensure the best outcomes for children. An agency specific recommendation is therefore made as follows: 15 CAFCASS (para 4.32) 16 Munro (p111) 23 Recommendation 1: That Cafcass consider how it can ensure that its supervision systems are sufficiently comprehensive in order to identify those cases where there may be an unrecognised safeguarding risk to the child. Following the completion of this Overview Report, CAFCASS forwarded an alternative recommendation which has been included in Appendix B. 3.2.12. The role of fathers is an all too familiar an issue in SCRs17, frequently in relation to fathers who seem to be ‘invisible’ or may be threatening or dangerous. SCRs and research more widely have also highlighted the failure to recognise that fathers can bring positive resources to their children’s lives. Child O’s separation from their father was fundamentally a result of the actions of their mother and maternal grandfather. However, what Child O's experience again reflects is the often subtle mindset within health and social care which can view the mother, who is generally the day to day carer, as having more ‘rights’ and significance in the child’s life and involvement with the father as ‘optional or undesirable’18 3.2.13. Changing the approach of agencies and professionals to fathers is a complex task that requires not simply new policies or procedures, but a shift in skills and culture and the development of a ‘father inclusive service’. Five Safeguarding Children Boards have played a part in this review; within each of these Boards and their partner agencies there is likely to be a wide spectrum of practice and culture in working with fathers. Whilst there are plenty of training courses and other tools that this Review could highlight, these will only be of value in the context of a positive organisational culture towards the role of fathers. 3.2.14. It is the conclusion of this report that there is evidence to suggest organisational weaknesses in the approach to working constructively and proactively with fathers. The recommendation of this report therefore is: Recommendation 2: The Safeguarding Boards to satisfy themselves that they and their partner agencies have in place a proactive strategic approach to working with fathers and a means to assess the impact on the outcomes for children. 3.3 Domestic abuse – disclosure or allegation? 3.3.1. Child O’s mother made a number of allegations of domestic abuse to a range of services, initially asserting that there were no issues of domestic abuse, later describing low level conflict and emotional abuse 17 OFSTED The voice of the child: learning lessons from serious case reviews, 2011 18 Osborn, M (July 2014) 24 and specifically stating that the abuse was never physical, but developing over time into very serious allegations. The evidence in this case is that professionals generally worked to established practice guidelines regarding listening to, respecting, recording and offering support when approached by the mother. Health services routinely asked the mother about domestic abuse and followed up any information the mother supplied which might suggest cause for concern. Advice and information was provided to the mother about support services. 3.3.2. Maternal grandfather has been very critical of the response of Devon and Cornwall police to his daughter’s contact with them. However, given the nature of the allegations, as outlined in Section 2, this Review has concluded that the response of Devon and Cornwall Police was within expected standards. Officers used the national Risk Assessment tool and applied appropriate professional judgement in reaching the decision that the risk was ‘standard’, which is defined as “current evidence does not indicate a likelihood of causing serious harm”. There is no reason to consider that this was anything other than a reasonable conclusion, based on the available information and the use of well-established tools supporting professional judgement. 3.3.3. When very serious allegations of domestic abuse, both physical and sexual were made to Police in Norfolk, the Police Officer, who was trained and experienced in sexual abuse and domestic abuse, worked hard to gain the mother’s trust. She was not restricted by resources and referred the mother to appropriate support. Without the mother being willing to make any formal complaint regarding historical allegations, the police could not reasonably be expected to take any further action. What is of concern however, is the multi-agency management of the LADO referral and this will be considered separately in 3.5. 3.3.4. The primary focus of learning for this Review is not about improving practice relating to agencies’ work with women who have experienced domestic abuse. Instead, what is of concern here is services’ capacity to recognise those much smaller number of occasions19 when what is being revealed is an unevidenced allegation, possibly a false allegation made tactically to manage the response of professionals and court proceedings. That there are a small group of women who are willing to make false allegations about domestic abuse, is not an unknown phenomenon, particularly in the family courts. However, it is not an issue that receives frequent attention in the wider health and social care world; it is little accounted for in service and individual practice and can be an unfamiliar, even uncomfortable, concept for many professionals. For the family, the impression was given, whether or not it reflected what professionals actually thought, that father had already been 19 See for example, CPS 2013 25 judged. What resulted was a perception of bias, in the words of Child O’s paternal grandmother: ‘they just put him in this box: he was a man, he had to be violent and he was none of those things.” 3.3.5. Although the father’s distress at being contacted by the police about false allegations is entirely understandable, reasonable judgements were made about the absence of criminal offences and no action was taken other than ‘giving words of advice’, which in itself understandably added to the father’s sense of frustration. Nevertheless, it is difficult to avoid the conclusion that services had not given serious consideration to the possibility that the allegations might be malicious and therefore whether this might lead them to take different actions or consider the potential implications for Child O. Illustrative examples include: • The language of agency records effectively shifts from allegation to presumed fact, such as recordings that the mother has ‘fled’ domestic abuse. • The use of the words ‘disclosures’, rather than ‘allegations’ in many records, which subtly reflects an acceptance of what the service has been told. • Decisions by health and social care services not to pass on information about Child O in response to the mother’s wishes. 3.3.6. One particular example of the way current systems to assess domestic abuse can have unintended consequences and could impact unhelpfully on professionals’ judgement is the use of risk assessment tools. Police officers appropriately used the CAADA DASH RIC, a tool which is used nationally to identify risk in relation to domestic abuse. The risk factors that form the basis of the assessment are statistically evidentially sound. However, what the assessment does not explicitly recognise is that the actual information provided to the assessor may not itself be based on objective evidence. On one occasion the risk assessment identified 9 high risk factors, moving the risk assessment from standard to medium risk. However, each one of those risk factors was totally reliant on self-reporting by the mother and therefore open to manipulation. 3.3.7. Given what is known about the often hidden nature of domestic abuse and the difficulty in obtaining evidence, the use of this tool is both legitimate and highly valuable. Seven women a month are killed by a current or former partner and on average high-risk victims live with domestic abuse for 2.6 years before getting help.20 The consequences of not taking domestic abuse allegations seriously can therefore be extremely dangerous. However, what this case highlights is that there are always limitations to any risk assessment tool when considering 20 http://www.safelives.org.uk 26 individual cases. These limitations can go unrecognised and the proper focus on identifying genuine domestic abuse may not always be adequately balanced alongside professional curiosity about absent or contradictory information. This review does not seek to argue that tools such as the CAADA-DASH RIC should not be used, but that they should be considered within the full context of the case. What is needed is a proper awareness of the evidential base of the assessment and consideration of the need for any further investigation before judgements or decisions are made in relation to the alleged perpetrator. 3.3.8. The allegations against the father did however remain exactly that: allegations which had not been proven. There is no actual evidence that the allegations in themselves led directly to Services preventing him from having contact with Child O, which was throughout Child O’s life within the control of the mother. It is the case however that decisions not to disclose the mother’s address, had the result of preventing the father from knowing the whereabouts of his child. Some of the professionals however, rightly advised the father to seek legal advice which he subsequently did, leading him to his application through the family court system. 3.3.9. From the outset of the Family Court Proceedings it was known that the father denied there had been domestic abuse and told Cafcass and the court that the mother had made false allegations about him. There is no direct evidence that the Children’s Guardian’s decision making was a result of believing the mother rather than the father. Up until the point that the case was transferred to the High Court, the approach taken both by Cafcass and the court followed a course whereby the allegations of domestic abuse and the failure of the mother to attend the proceedings were the main focus of actions. As such, it could again be argued that the mother’s perspective effectively determined the actions of professionals. The mother was absent and yet completely in control up until the very final weeks of Child O’s life. 3.3.10. Managing intransigent behaviour of either or both parents is commonplace in Private Law Proceedings, and it is well recognised that the actions of one parent can significantly frustrate the attempts of the Court to achieve the best outcome for the child. Whilst there can be no easy assumption that it would have changed the outcome, Child O’s father could have provided information about the pattern of the mother’s behaviour, which might have painted a different picture, than that being created by the mother. The request for a Section 7 report presented an opportunity to begin gathering information from the father rather than simply waiting until the mother was located, with the implication that her views were more important. Irrespective of any impact that might reasonably have been expected in this case, this offers important learning for future work. 3.3.11. The paradox highlighted by Child O’s case is that whilst there is evidence that agencies generally met required standards in responding 27 to domestic abuse, what appeared to be missing was a recognition that in certain circumstances allegations can be used as a weapon to deny a child a relationship with a father and to create a smokescreen with professionals. We are therefore left with a question about the unintended consequences of the major shift in understanding and policy regarding domestic abuse that has taken place in recent years and its overwhelming focus on believing the woman’s reporting of what has happened. 3.3.12. It is therefore the conclusion of this review that there is an identified need for professionals to be encouraged and supported to balance respect for women who talk to them about domestic abuse, with appropriate scepticism and curiosity where allegations are denied. This is particularly important where there is no independent evidence and where a child is at the centre of a parental dispute. The following recommendation is made as a result: Recommendation 3: The Safeguarding Boards to assure themselves that their Domestic Abuse strategies and practice supports services and staff to respond effectively to the needs of victims whilst remaining aware of the possibility of false allegations in a minority of cases. 3.4 Recognition of potential risk to the child 3.4.1. What is striking at a number of points during the involvement of agencies was the lack of explicit focus on how Child O might be experiencing their circumstances and whether those circumstances might raise safeguarding concerns. It has been difficult to identify evidence that agencies reflected on whether Child O's circumstances following the parents’ separation might in themselves be an indicator of a safeguarding concern. In May 2014, the County Court judge did ask the Cafcass officer to alert Torbay Children’s Services of the Court proceedings, but it would appear that this was, albeit a perfectly sensible sharing of information, not in itself a safeguarding alert. 3.4.2. Child O was referred to Children’s Services within the first two weeks of their life, by father. The response was that the referral would not reach the threshold for a safeguarding assessment, and this is not in itself being challenged. Referrals to Children’s Services continue to be very high and the initial process of establishing whether a referral should trigger a fuller assessment is by necessity based on the immediate seriousness of the issues being raised. Children’s Services did make contact with the Health Visitor, reviewed the police report, which gave no cause for concern and spoke to the father in person, but at this point the mother moved to Devon. As such normal standards of practice were followed by Hampshire Children’s services in forwarding the information to Devon. 28 3.4.3. The information having been received by Devon Children’s Services, led to a similar conclusion which was recorded as being that the concerns did not reach safeguarding thresholds, which again is a justifiable position. What is of some concern is that the rationale as fed back to the Mother was that ‘the concerns had not been substantiated’. In the absence of an assessment it is not clear how such a conclusion could have been reached. It is also of concern that information faxed by Hampshire Children’s Services to Devon, stated that there had been no interventions or concerns raised by the health visiting service. As a result Devon recorded that ‘it is clear there were no concerns held by health in the originating area’. Whilst the possibility of post-natal depression without other features of concern could not be expected to trigger a safeguarding assessment, this was nevertheless a relevant piece of information that should have been given to Devon and recorded for future reference. 3.4.4. On receiving the application to the Family Court, Cafcass’ standard process is to undertake basic safeguarding checks including telephone contact with each parent. These checks did not identify anything of immediate safeguarding concern for Child O. The next point for Cafcass at which an assessment of any risk to the child would be considered was the request for a Section 7 report and comment has already been made about the gap in this assessment of not speaking to the father. The Cafcass officer has acknowledged that the possibility of a safeguarding concern was never part of their thinking and this did not change throughout the court proceedings, even when the decision was made that the child should be separately represented and therefore take a more central role in the proceedings. Information provided by Cafcass also stated that the father “had not raised significant safeguarding concerns, although he did express anxiety about Mother’s mental health or possible post-natal depression”. It is important to recognise that a concern about mental health does not in itself indicate that there will be safeguarding risks to a child. However, any parental mental health problem, particularly depression, should be considered in relation to a child’s welfare, not least in the context of a child of this age whose whereabouts were unknown. 3.4.5. Although Child O was reported as missing to Devon and Cornwall Police by their father, this appeared to have limited subsequent impact on professional perceptions regarding any safeguarding risk to him. Child O was not brought to their first year health review and in the absence of any explanation, this should have caused greater concern. The health visiting response was to write to the Mother but take no further action, assuming that the mother was happy with Child O's development and inviting her to make contact if she had any concerns. The health visiting service has acknowledged that there should have been a more pro-active attempt to identify whether mother and child had left the area and consideration of a national safeguarding alert. This has led to an individual agency recommendation. 29 3.4.6. Devon and Cornwall police have analysed in some detail their response to Child O being reported as missing. While the investigation was immediately initiated and ultimately succeeded in locating Child O and mother, it is also acknowledged by the police that there was a period of a few days when the investigation drifted. The father’s experience was that he had to push for an active response, for example by using the local press. Nevertheless within a fortnight the police had reason to believe that Child O and mother might be in Norfolk and this information was passed to the Norfolk Police. Within 5 weeks her location was identified. Although Father has some very understandable concerns regarding the categorisation of Child O on being missing as medium risk, on the basis of the information the police had this could not be considered an inappropriate categorisation. Medium risk ‘requires an active and measured response by police and other agencies’ and there is clear evidence of proper activity by the police during the investigation. The categories relating to risk are clearly defined with High Risk being defined as follows: “risk posed is immediate and there are substantial grounds for believing that the subject is in danger”21. This is reflected in national statistics which identify that only 13% of cases are assessed as High Risk22. No child that is reported missing can be graded as standard risk. On receiving the information from Devon about Child O and mother’s whereabouts, Norfolk police responded immediately, succeeding in meeting with them both the following morning. 3.4.7. What however did represent a failure in the multi-agency approach, including the role of the Family Court, is that the information about the mother’s Norfolk address was never shared with any other agencies because of the mother’s apparent concern about being discovered by the father. The Family Court was made aware in January 2014 that the police had located mother (although by this point it is likely that she had already moved and was therefore now missing again). In late April the Court made an order to seek the information from the police, although this order could not be served as it had been badly drafted. It was subsequently redrafted, although it is unclear why a further attempt was not made to serve it, nor why it was not actively pursued by any of the professionals involved, including the Children’s Guardian who had taken the view that it was the court’s role to ‘manage the situation’. The role of the Family Court itself is not for this Review to analyse, but from a multi-agency safeguarding perspective this was effectively a lost opportunity to identify that Child O and mother were missing again and to re-open a police missing person investigation 3.4.8. From a problem solving perspective there was a significant period once Child O and mother were registered as missing, when the actions available to agencies were inevitably focussed on the adults. What is difficult to identify, prior to the move to the High Court, is evidence of a conscious recognition that this was not just a parental dispute, but a 21 ACOP Guidance on the Management, Recording and Investigation of Missing Persons, 2010 22 UK Missing Persons Bureau: Missing Persons Data and Analysis 2012/13 30 missing child who had not, as far as anyone was aware, been seen by any independent professional for a significant period. Viewed from a safeguarding perspective the pace of the Family Court proceedings with its repeated attempts to gain the mother’s attendance, lacked apparent urgency prior to the transfer to the High Court. The requirement for Cafcass to undertake a Section 7 report unavoidably takes a period of several weeks, however it is of concern that in the absence of any response by the mother over a two month period no urgent action was taken to contact the court and therefore minimise further delay. 3.4.9. Family Courts, particularly the High Court, are very familiar with the concept of Child Abduction. However the definition and received understanding of child abduction assumes a child abducted, often by a non-resident parent and taken abroad. What appears to be much rarer is a resident parent going missing with the child in this country, and as a result, there is no tailored, established process to ensure an urgent response in such circumstances. One feature of particular concern that has been identified is the very limited budget available via public funding to the Children’s Guardian to appoint investigators to trace a child. The father’s income meant that he had no access to legal representation and he was also asked to contribute to the costs of appointing investigators. Whilst this father had some limited funds available, this was experienced by him as highly insensitive and unjust and again failed to take into account that his child was in fact missing. It is not within the power of this Review to require a change to Government policy in relation to Legal Aid funding, however, there is no doubt that the absence of financial support to the non-resident parent in these circumstances could have a significant impact on the outcome for a child. 3.4.10. The issue of Mother’s mental health remains unresolved and it is not the role of this report to take a view on whether she was suffering from any mental health condition or personality disorder. Maternal grandmother has asked whether the point at which her daughter changed her name might have marked a fundamental personality change, but it is impossible to comment on this. Medical information has provided some evidence of historical emotional vulnerability, including a referral to psychology services, although this information would not have been available to Cafcass or Children’s Services at the time. There is no previous history of any mental ill health problems and neither of the mother’s parents’ identified mental health concerns during her childhood or adolescence. 3.4.11. There was nevertheless information which was available about potential post-natal depression and the possibility of emotional or personality problems. This included substantial information held by the father, some of which was supported in health records, regarding over-protectiveness, as well as contradictory information provided by the mother about her own background and family relationships which 31 impacted on her view of Child O’s paternal family. This included quite extreme behaviour such as an unwillingness to allow the father’s family or friends to have any information about the pregnancy or Child O’s birth. Given that the mother was understood to be happy about the pregnancy and to welcome the father’s commitment to their relationship and child, this might suggest something more complex and worrying was in fact taking place. 3.4.12. All the information available to agencies was that the mother’s physical care of Child O was very good. Child O’s father never raised concerns in this regard and when professionals saw the child there was a consistent picture of a visibly well cared for child. The Norfolk Police Officer who met with the mother in December 2013 following her allegations described the home as “immaculate” and that Child O “seemed loved and well cared for”. Although she also noted some concern about the longer term impact on Child O of such a reclusive lifestyle. On the information available to professionals it would have been a significant leap to conclude that Child O met the threshold for emotional abuse which is defined in Working Together as : “The persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects of the child’s emotional development.”23 3.4.13. Child O’s case however does pose a question regarding the state of our current knowledge about the potential for emotional harm to children where physical abuse or neglect are not apparent. Whilst there was very limited information available and no serious criticism of individuals intended here, at what point should professionals consider that issues such as maternal over-protectiveness, control and exclusion of the father and inconsistent engagement with primary services such as health, might be safeguarding issues? 3.4.14. Child O’s father has raised a question as to whether there should be a greater degree of contact by statutory agencies with pre-school age children, to provide better protection in such circumstances. Whilst this is a legitimate question given the experience of this family, universal services for children are designed to balance the legitimate need for safeguarding with the equally legitimate requirement for minimal unnecessary intervention by the state in family life. It is also the case that increasing routine contact with statutory services, for example more frequent health contacts, would be unlikely to impact on a parent determined on a particular course of action. This is a question that was considered seriously by the Review team and has been considered in other Serious Case Reviews, but as identified in the SCR regarding Hamzah Khan: ‘it is realistically impossible to guarantee that a child will not remain hidden from universal or specialist services ….under current statutory arrangements’24 23 Working Together 2015 (p92) 24 Bradford Safeguarding Children Board, Nov 2013 32 3.4.15. It is not the contention of this Review that given the limited involvement of individual professionals, and particularly the lack of access to the mother and Child O, professionals could have anticipated that the concerns outlined above were indicators of such a significant risk. Identifying the nature of the risk that is now known the mother posed to Child O, would have been extremely difficult if not impossible. However, greater knowledge about child killings (filicide) in the context of parental conflict could only have helped the agencies and professionals involved with Child O to better understand what risks he might face. Recent research by O’Hagan has identified that the exercise, and then loss, of parental control is a significant feature of filicide25. Even with the gaps in our knowledge about the mother’s motivation, what is absolutely clear is that she was determined to maintain control over her care of Child O even if this meant taking extreme steps, the most extreme when it may have appeared to her that she might be about to lose that control. 3.4.16. The numbers of parents who kill their children in the context of parental separation are very low, an average of 4 taking place each year26. A review of information held by Cafcass has identified that on average there are 2 such incidences a year where the family is known to that agency and that predominantly the perpetrator is male. The limited data about this type of homicide means that it is extremely difficult for agencies and practitioners to identify whether a particular individual presents as a serious risk. 3.4.17. The numbers of children who die in these circumstances are small both in total and as a proportion of the number of child deaths arising from abuse or neglect.27 However the numbers also remain stubbornly consistent from year to year and statistically any one of the 5 Board areas could be faced with a child death of this nature within the foreseeable future. It is therefore the finding of this review that whilst recognising the difficulties in identifying which children might be at risk, nevertheless the repeating nature of such deaths requires an active response by agencies. Two recommendations are therefore made: Recommendation 4: The Safeguarding Boards to consider a plan of work designed to develop knowledge and awareness amongst partner agencies of the nature of homicide in the context of parental conflict. Recommendation 5: That Lancashire SCB, as lead for this SCR, request a thematic review of SCRs relating to homicide and suicide held in the NSPCC repository. 25 O’Hagan (2014 p194) 26 O’Hagan 27 There is no single source which identifies the number of child killings. However, information from the NSPCC and Ofsted would suggest that this is between 50 and 200 annually. See NSPCC March 2014 33 3.5 Communication across agencies and geographical borders 3.5.1. On a number of occasions there were problems with the way that agencies communicated information, particularly when this involved agencies in different geographical locations. This included the information from the original health visitor in Hampshire being missed for reasons that remain unclear and therefore not being passed on either to Children’s Services or to Cafcass. It should however be noted that the Hampshire Health Visiting service did meet practice standards in passing on information to their counterparts in Devon and following up with the mother to check that she had registered with a GP. Small gaps in information sharing are commonly a feature of Serious Case Reviews28, particularly across geographical boundaries, and can have an impact on the course of a case disproportionate to the original error. The broad issue of achieving consistent, effective communication across complex systems and multiple agencies, is well recognised as a continuing difficulty within safeguarding and as such is not subject to a recommendation in this Review. 3.5.2. There is one gap in communication that could potentially have impacted on subsequent professional actions and requires more detailed appraisal. When particular allegations were made by the mother to Norfolk Police these were referred to the Norfolk LADO for further action. These were serious allegations about inappropriate relationships with young people in the father’s professional life. As has been noted in Section 2, this was not actioned in Southampton until after Child O’s death. Two factors led to this significant failing. 3.5.3. Firstly the Southampton LADO did not record the telephone conversation she had received from Norfolk, a conversation which from memory she believes took place on her personal mobile phone on Christmas Eve. She also believes she had been expecting written information from the police. Southampton Family Services have acknowledged that this was a significant mistake, but identified that it took place in the context of organisational problems which meant that the LADO was also working as a Conference Chair, in effect undertaking two roles which impacted on her capacity to cover all the work. There is a clear lesson here for Southampton Family Services regarding the importance of ensuring that adequate resources are given to the LADO role, given the potentially serious consequences of not pursuing an investigation 3.5.4. The second problem was that the information held by the police was not passed on to the Southampton LADO. Norfolk Police made a decision to pass their information to Devon and Cornwall Police, given the mother’s apparent belief that someone in Hampshire Police might inform the father of her whereabouts. The intention was that Devon 28 Brandon et al, 2011 (p30) 34 and Cornwall would pass it on to Hampshire, thereby ‘cloaking’ the original source of the information. However, Devon and Cornwall Police did not agree to this course of action and the information was never transferred. Both police forces evidently believed that they had fulfilled their duties in sharing the information but the outcome belied that belief. As a result, Devon Police and Norfolk Constabulary have each responded with an individual agency recommendation. 3.5.5. The significance of this failure to effectively share information is that an investigation into serious allegations did not take place. For Child O, the initiating of the LADO investigation in December 2013 might have been able to contribute further information to the collective understanding of the mother’s actions and the implications for Child O. The father’s view is that this could have had a significant impact and in his words “it would have been a hideous way to get there, but I wish they had done it…if they had investigated then they could have found out it was false and Child O might still be alive”. Whether or not a LADO investigation would have affected the outcome, the impact on the family of knowing that this did not take place, when it should have done, has added to their sense of trauma. That the investigation did not take place in a timely way fell crucially short of good agency practice. 4 CONCLUDING COMMENTS 4.1. The purpose of a Serious Case Review is to learn from the case in order that improvements to practice can be put in place so as to help families in the future. The learning from this case does not lend itself to simple solutions, nor is the learning particularly specific to one authority. 4.2. It should be acknowledged that it is possible, though would not have been easily achieved, that different actions could have resulted in Child O being traced earlier. However, given all that we know about the mother’s determination not to be found, and her access to the financial and practical support that allowed her to stay hidden, there is a real possibility that this would have resulted in another move and ultimately the same outcome. 4.3. As has already been noted, both Lancashire Police and the Coroner concluded that there was no evidence to support the allegations of domestic violence made against Child O’s father. Conversely there was evidence that Child O’s mother and maternal grandfather provided misleading information to the statutory services in order to conceal Child O and the mother’s whereabouts. The information provided to this Review is entirely consistent with the Coroner and Police’s conclusions. 35 Child O’s mother left a suicide note stating that her intent was to prevent Child O being harmed by someone who was hunting them down. What is clear from all the information available is that no-one, other than her own father, knew where she was living until after her death and there was no information at the time of her death to suggest that the father had located her. 4.4. The death of Child O and mother took place in circumstances which both experience and research would tell us are extremely rare29. Whilst the explanation given by the grandfather and the mother in the notes she left was that this was a response to fear of the father, such a fear appears to be highly irrational, or possibly not a genuinely held fear. The suicide note’s strangely calm tone and reference to their pending deaths being “the only way I can keep my child happy and safe” indicates a disturbing logic that mother believed Child O’s death by her hand was acceptable, in stark contrast to the harm she suggests others intended. The deaths of Child O and their mother were carefully planned, rather than impulsive, underlining a sense that the mother was controlling all aspects of Child O’s existence. 4.5. Current knowledge, and therefore capacity to identify the risk of homicide and suicide following separation is still comparatively limited. The most well-known model used to explain this phenomenon, developed by Philip Resnick in 1969, has for many years been used to provide explanations for motivation in these cases. Currently, it is to some degree being reviewed and there also is recognition that there is a lack of knowledge about mothers who kill in these circumstances. The most recent research from O’Hagan acknowledges that it is extremely difficult to provide useful information to practitioners to help with the recognition of risk. However, given the repeat nature of the resulting child deaths it is incumbent on services to improve their knowledge and better prepare professionals in the future. Improving collective understanding of the degree of control and planning that is often identified after these events is particularly important, given what we know about Child O’s experience and the message from research that “most….are wholly dependent upon an exceptionally high degree of premeditation on the part of the perpetrator.30 5 RECOMMENDATIONS FOR THE BOARDS a. This Serious Case Review was undertaken following the tragic death of Child O in a very unusual set of circumstances which themselves only increased the trauma for Child O’s remaining parent. In examining the involvement of the various agencies it has been possible to identify points of practice where mistakes have been made or where practice 29 See Berry et al 30 O’Hagan, (p100) 36 could be improved, although these largely do not lend themselves to simple recommendations with SMART outcomes. More significantly it has highlighted some vulnerable aspects of safeguarding practice that apply to a larger or greater extent across agencies and cannot be considered unique to particular individuals or agencies. There is the potential for significant learning to be gained from Child O’s death, irrespective of the extent or quality of agency involvement in this individual case. Lancashire Safeguarding Children Board, which had no involvement with Child O during their life, has already acknowledged that there will be learning for safeguarding agencies within Lancashire. b. As a result the recommendations are not specific to groups of agencies or individual boards. It is also hoped Child O and their family’s experience will contribute to the national body of knowledge particularly regarding the death of children in such circumstances. c. A number of the contributing agencies identified learning specific to their agency and their resulting recommendations are attached as Appendix A. d. The multi-agency recommendations are as follows: Recommendation 1: That Cafcass consider how it can ensure that its supervision systems are sufficiently comprehensive in order to identify those cases where there may be an unrecognised safeguarding risk to the child. NB: Cafcass have not accepted this recommendation and therefore not provided an action plan Recommendation 2: The Safeguarding Boards to satisfy themselves that they and their partner agencies have in place a proactive strategic approach to working with fathers and a means to assess the impact on the outcomes for children Recommendation 3: The Safeguarding Boards to assure themselves that their Domestic Abuse strategies and practice supports services and staff to respond effectively to the needs of victims whilst remaining aware of the possibility of false allegations in a minority of cases. Recommendation 4: The Safeguarding Boards to consider a plan of work designed to develop knowledge and awareness amongst partner agencies of the nature of homicide in the context of parental conflict. Recommendation 5: That Lancashire Safeguarding Children Board ensure that this report is shared with the Family Court and discussions take place with the judiciary as to how learning from SCRs relevant to the Family courts can be shared. 37 APPENDIX A: LSCB ACTIONS Devon Safeguarding Children Board Action Plan Recommendation 2: The Safeguarding Boards to satisfy themselves that they and their partner agencies have in place a proactive strategic approach to working with fathers and a means to assess the impact on the outcomes for children. Lessons learned Key Actions Evidence Key Outcome Lead Officer Target date by which actions will be completed Actual completion date RAG status Embed the participation and involvement of fathers in all stages of the assessment and planning and review process Single and Multi-Agency Case audit to be undertaken to evaluate participation and involvement of fathers and the Think Family protocol Evidence of the following within case files: Use of genograms Evidence of father’s views within assessments Fathers being invited to attend at meetings Evidence of assessed exclusion to also be evidenced All practitioners to evidence that they have contacted the father and facilitated his participation in their work with the family unless it has been assessed that it is unsafe to do so. In such cases the reasons for exclusion should be clearly given and recorded. Safeguarding Leads May 2016 38 Recommendation 3: The Safeguarding Boards to assure themselves that their Domestic Abuse strategies and practice supports services and staff to respond effectively to the needs of victims whilst remaining aware of the possibility of false allegations in a minority of cases. Assumptions regarding Domestic Abuse should not be made Professional challenge and curiosity should be maintained Careful use of language when an allegation remains as such (allegation vs disclosure) To use this case in training and disseminate learning through the DSCB “magazine” and on the DSCB website Inclusion in training packages (Domestic Abuse, learning from Serious Case Reviews) Attendance at training Supervision records Case audit (MACA) Accurate and non-prejudicial case management. All practitioners should be aware of the complexities of domestic violence/abuse and the potential for it to be used as a smokescreen. All practitioners should consider their use of language particularly avoiding escalation of terms in the absence of confirmation/evidence of behaviours. Maintain “respectful disbelief/professional scepticism/professional curiosity” To understand that Filicide is rare but Workforce Development Lead for the DSCB January 2016 (subject to SCR being published) 39 more common in conflict situations For Domestic Abuse Strategy to be in place For Domestic Abuse Strategy to support services and staff to respond effectively to the needs of victims whilst remaining aware of the possibility of false allegations in a minority of cases Director of Public Health April 2016 Recommendation 4: The Safeguarding Boards to consider a plan of work designed to develop knowledge and awareness amongst partner agencies of the nature of homicide in the context of parental conflict. Filicide is rare but more common in conflict situations Use this case as an example to promote understanding of Filicide. Disseminate learning through the “magazine” and on LSCB website Filicide to be included in LSCB training programme Increase understanding and knowledge of filicide amongst practitioners using this case as an example. For there to be no further cases of preventable Filicide Workforce Development Lead for the DSCB January 2016 (depending on publication date) 40 Hampshire Safeguarding Children Board: Recognising the range of carer’s behaviours which may ultimately lead to harm or compromise a child’s development Use case in training to illustrate the risks of “overprotective” behaviours/disguised compliance and how this links to emotional abuse. Training packages Supervision records For Practitioners to recognise behaviours which may ultimately lead to harm or compromise a child’s development. Workforce Development Lead for the DSCB January 2016 for current Domestic Abuse training (depending on publication date) April 2016 (for new training) Lessons learned Key Actions Evidence Key Outcome Lead Officer Target date by which actions will be completed Actual completion date RAG status 1 Recommendation 2 – to ensure that agencies / professionals have a proactive approach to engaging with and working with Fathers. HSCB to review its multi-agency training to ensure that professionals know how to, and the benefit of, engaging fathers and male carers in case work and discussions. Training courses include how to engage fathers / carers and why it is important to hear from everyone who can help them understand the needs of a child. Professionals will be able to - identify important males in children’s lives - understand the roles that fathers / men play in the lives of at-risk children - make accurate assessments of risk and Workforce Development Group March 2016 41 HSCB and SSCB to work with Pan-Hampshire colleagues to update the relevant 4LSCB policies to highlight the importance of engaging fathers / male carers. Policies will be updated and published online. challenge any inappropriate behaviour if necessary - support men in strengthening the positive contribution they can make to the child’s well-being. 4LSCB Procedures Group March 2016 2 Recommendation 3- Domestic Abuse strategies enable staff to respond effectively to the needs of victims whilst remaining aware of potential false allegations HSCB and SSCB will oversee the review and update of the ‘Joint Working Protocol’ which outlines how professionals will respond to issues relating to domestic abuse, and ensure that it includes information relating to the potential for false allegations. The protocol will be updated and relaunched to include the learning from the Child O review Professionals will be able to support victims of domestic abuse but will also be able to consider the possibility for false allegations which may mask real risk factors for vulnerable children. Hampshire County Council Mental Health Commissioning Manager Review in progress and due to be completed by March 2016. 3 HSCB to include the key points from this recommendation in the next cohort of ‘Lessons Learnt’ briefings for professionals across the county. Relevant points to be worked into case studies used in workshops to highlight potential risk factors to front line staff Workforce Development Group March 2016 42 4 Recommendation 4 – to improve awareness of the nature of homicide in the context of parental conflict. HSCB to include the key points from this recommendation in the next cohort of ‘Lessons Learnt’ briefings for professionals across the county. Relevant points to be worked into case studies used in workshops to highlight potential risk factors to front line staff Professionals understand that in some - extreme and on-going – cases of parental conflict there can be an increased risk of homicide or serious harm to children. Workforce Development Group March 2016 5 HSCB to review its multi-agency training to ensure that professionals are aware of the risk of homicide in cases involving parental conflict. WDG will explore how training courses can be updated to include the potential, and extreme, risk of homicide in ongoing parental conflict. Workforce Development Group March 2016 43 Lancashire Safeguarding Children Board Action Plan Lessons learned Key Actions Evidence Key Outcome Lead Officer Target date by which actions will be completed Actual completion date RAG status 1 Recommendation 2 – to ensure that agencies / professionals have a proactive approach to engaging with and working with Fathers. LSCB to review its multi-agency training to ensure that professionals know how to, and the benefit of, engaging fathers and male carers in case work and discussions. Training courses include how to engage fathers / carers and why it is important to hear from everyone who can help them understand the needs of a child. Professionals will be able to - identify important males in children’s lives - understand the roles that fathers / men play in the lives of at-risk children - make accurate assessments of risk Learning and Development Sub Group March 2016 2 Recommendation 3- Domestic Abuse strategies enable staff to respond effectively to the needs of victims whilst remaining aware of potential false allegations LSCB to include the key points from this recommendation in the Child O learning brief Relevant points to be worked into case studies used in workshops to highlight potential risk factors to front line staff Professionals will be able to support victims of domestic abuse but will also be able to consider the possibility for false allegations which may mask real risk factors for vulnerable children. Learning & Development sub group March 2016 44 3 Recommendation 4 – to improve awareness of the nature of homicide in the context of parental conflict. LSCB to include the key points from this recommendation in the Child O learning brief Relevant points to be worked into case studies used in workshops to highlight potential risk factors to front line staff Professionals understand that in some - extreme and on-going – cases of parental conflict there can be an increased risk of homicide or serious harm to children. Learning & Development sub group March 2016 4 LSCB to review its multi-agency training to ensure that professionals are aware of the risk of homicide in cases involving parental conflict. L&D Sub group will explore how training courses can be updated to include the potential, and extreme, risk of homicide in ongoing parental conflict. Learning & Development sub group July 2016 45 Southampton LSCB Action Plan Lessons learned Key Actions Evidence Key Outcome Lead Officer Target date by which actions will be completed Actual completion date RAG status 1 The Safeguarding Boards to satisfy themselves that they and their partner agencies have in place a proactive strategic approach to working with fathers and a means to assess the impact on the outcomes for children. LSCB Team to arrange a Wednesday Workshop on ‘Working with Fathers’. LSCB and HSCB to work with Pan-Hampshire colleagues to update the relevant 4LSCB policies to highlight the importance of engaging fathers / male carers. Workshop takes place Policies will be updated and published online. Increase professional knowledge on this issue LSCB Team 4LSCB Procedures Group April 16 April 2016 2 The Safeguarding Boards to assure themselves that their Domestic Abuse strategies and practice LSCB and HSCB will oversee the review and update of the The protocol will be updated and relaunched to include the learning Professionals will be able to support victims of domestic abuse but will also be able to consider 4LSCB Procedures Group April 2016 46 supports services and staff to respond effectively to the needs of victims whilst remaining aware of the possibility of false allegations in a minority of cases. ‘Joint Working Protocol’ which outlines how professionals will respond to issues relating to domestic abuse, and ensure that it includes information relating to the potential for false allegations. Raise awareness of existing Domestic Abuse training for professionals Learning and Development Group to ensure that training is available on responding effectively to the needs of victims of Domestic Abuse which acknowledges from the Child O review Featured in LSCB Communications Training on this issue will be identified the possibility for false allegations which may mask real risk factors for vulnerable children. An increase in the take up of DV training Professionals will feel confident in responding to and working with victims of Domestic Abuse and know where they can receive training on this issue. LSCB Team Chair of Learning and Development Group LSCB March 2016 February 2016 47 the possibility of false allegations within existing training. 3 The Safeguarding Boards to consider a plan of work designed to develop knowledge and awareness amongst partner agencies of the nature of homicide in the context of parental conflict. Learning and Development Group to review training opportunities with regard to homicide in parent conflict. Training on this issue will be identified or developed Professionals will have a greater understanding and awareness of the nature of homicide in the context of parental conflict. Chair of Learning and Development Group LSCB April 2016 4 Identified by the Southampton LSCB Practice and Policy Group to ensure that agencies have a clear response and process when they are no longer able to track families. Practice and Policy Group assurance documented in minutes. All agencies and the LSCB will be clear on the process for tracking ‘lost families’ Chair of Practice and Policy Group LSCB April 2016 Southampton LSCB to seek assurance of CAFCASS processes via Section 11 reports Section 11 forms and feedback Regular data and reports from CAFCASS to LSCB Southampton LSCB to be assured of CAFCASS processes and systems to Safeguard Children Chair of Monitoring and Evaluation Group LSCB Chair of LSCB December 2015 Green 48 Southampton Children and Families Service Lessons learned Key Actions Evidence Key Outcome Lead Officer Target date by which actions will be completed Actual completion date RAG status 4 It is important that the LADO is clear as to the source of the referral or contact and that there is a narrative thread that runs through the recording. This has already been implemented. All referrals that relate to another authority should be noted for audit purposes. All referrals to LADO are recorded, even if it is a misdirection for another authority. All conversations are recoded on the LADAO database Audit of LADO data base All communications to and from LADO are recorded Principle Social Worker September 2015 June 2015 49 Southampton CCG/NHS England (Wessex Local Area Team) - Southampton Primary Care Team Lessons learned Key Actions Evidence Key Outcome Lead Officer Target date by which actions will be completed Actual completion date RAG status 5 Within a GP practice, where there are known risks and vulnerabilities associated with an individual patient, it is fundamental that this information is shared utilising uniform READ codes (RCGP 2009) as stipulated by the DES (2006) Include a question on the use of the agreed READ codes in annual audit (RCGP template) Review and analyse audit post return (Oct 2015) Escalate poor compliance with READ codes to Local Area Team and performance teams Annual Southampton GP audit includes question on READ code use within practice Analysis of audit provides areas of poor compliance which when escalated, results in joint action by LAT and lead professionals with further monitoring as part of agree action planning Ascertain the level of READ code usage within individual Southampton GP practices to ensure that identified adult risk and vulnerability factors are shared Named GP / Designated Nurse / LAT Dec 2015 Green 6 During all engagements with individuals who present with mental health issue, “Spot check” of READ codes to be undertaken with individual GP practices Further audit of READ codes to identify adult risk / vulnerabilities is documented within Monitor the use of read codes/patient records to ensure that READ code for adult risk and vulnerability Named GP / Designated Nurse / LAT May 2016 Amber 50 emotional distress, learning disabilities, or a drugs and alcohol misuse, assessment should be made with regard to parenting capacity Potential parental risk (JWP) factors need to be READ coded in children’s notes to increase awareness of the potential risk “Spot check” to include review of parental notes for evidence of further enquiry and / or assessment of parenting consideration “Spot check” to include review of children’s notes for translation of appropriate READ codes associated with parental risks / vulnerabilities individual patient record Consideration of parental role and where applicable, risk / vulnerabilities are transferred to READ codes on child’s (children’s) record factors is documented and associated READ codes assigned to Child (ren) record 7 People who experience domestic violence and abuse must be offered evidenced-based treatment and support IRIS referrals made by Southampton GPs are monitored and analysed against the known demographics and reporting of DVA Monthly reporting by IRIS provides details of GP referrals per month comparable to referrals from other services within the multi-agency Patients who attend a consultation with their GP and disclose information / provide indicators of domestic abuse, are referred to a specialist service for support and advice All GPs / Named GP / Designated Nurse Sept 2015 Sept 2015 Green 51 8 All pregnant females attending GP consultations in Southampton should be seen alone and specifically asked about mental illness and domestic violence and abuse. An audit of antenatal referral forms by Southampton GPs will be audited for review timely and appropriate sharing of information specifically related to mental health and domestic abuse Antenatal audit identifies percentage of antenatal forms which include information of mental health / domestic abuse Audit identifies GP practices where information of mental health / domestic abuse has not been shared with midwifery service via the antenatal form Frontline practitioners must ensure they are able to recognise and respond to the indicators of domestic abuse and understand how it impacts upon parenting / caring capacity (babies, children and young people) Safeguarding Lead Midwifery / Named GP / Designated Nurse May 2016 Amber 52 University Hospital Southampton Midwifery Services Action Plan Updated 24.8.15 Lessons learned Key Actions Evidence Key Outcome Lead Officer Target date by which actions will be completed Actual completion date RAG status 9 When a mother changes her booking from PAH it is important that records of A/N care are retained by the hospital. It is also important for the mother to take her A/N handheld records with her to her new provider to share her A/N care thus far . The maternity records guideline does not reflect this and needs to be reviewed Review Maternity Records Guideline Raise awareness When a woman changes maternity services provider she should be given a copy of her handheld maternity records to take with to her new location, a copy of the handheld records should also be retained with her maternity records at PAH Maternity Records Guidelines updated to reflect learning from SCR child O Maternity records will be available for future reference Quality Assurance Manager October 2015 November 2015 December 2015 October 2015 First action is Green 2 actions are Amber 10 When pregnant women leave the area this fact needs to be recorded centrally on the Electronic Documents (E Docs) system and the Raise awareness Midwives should inform HICSS Maternity Manager by E mail of the details when a pregnant woman Maternity Records Guidelines updated to reflect learning from SCR child O Electronic records will be kept up to date HICSS Maternity Manger October 2015 January 2016 Green 53 pregnancy suspended on the hospital computer system. ( the pregnancy cannot be ended on the system until the outcome is known) moves area this E mail can then be saved to the E Docs system and the pregnancy can be suspended. 54 APPENDIX B: INDIVIDUAL AGENCY ACTIONS and RECOMMENDATIONS This section contains recommendations made by agencies in response to their internal reviews. Cafcass A recommendation will be made to the Head of Service, for individual coaching to be commissioned from the National Improvement Service to ensure that the learning from this review is fully embedded for the individual FCA involved. The following additional recommendation was forwarded to the LSCB after completion of the Overview Report: In private law cases Work after First Hearing, if one party or more is persistently not engaging with the FCA/court process, situational supervision should be sought to determine what actions need to be taken to safeguard the child and/or ensure the court is informed. Integrated Children’s Services 1) Good Record keeping and analysis of concerns will be monitored through management and safeguarding supervision and audited both by internal annual VCL records audit / ICS annual safeguarding audit and external Multi-agency case audit ensuring quality assurance is in place. Analysis training will be rolled out across ICS to all service areas, this is currently in an action plan for a local SCR. Retention period for clinic sheets will be reviewed by the Public Health Nursing service with advice from the Information Governance team to ensure data is retained and stored as per DOH guidance. This will be monitored through audit and internal service inspection. 2) GP and Health Visitor liaison is now firmly embedded in practice, each GP practice has a link Health Visitor who meets regularly with the GPs. Consideration needs to be given to how information shared at these meetings is recorded and fed back to the named Health Visitor for the family by the Public Health Nursing Service for ICS. 3) A systems review of the process where families have left the area or are believed to be missing, including a review of ICS DNA Policy, to be completed by the Public Health Nursing Service to ensure guidance is current and will result in a prompt response with safeguarding concerns fully explored. This process is to be monitored through supervision and case file audit. 4) A review of the process for issuing missing child alerts to take place between the Named Nurses for ICS and the designated professionals for safeguarding children in Devon CCG to ensure a robust system is in place. 55 Devon and Cornwall Police Recommendation 1: This review and others has highlighted the requirement for this agency to consider the current levels of knowledge and understanding among front line staff including supervisors around the DASH risk assessment process. Women’s Aid has been commissioned to carry out a gap analysis in respect of training requirements. Findings from this work will inform the development and commissioning of DASH training for police officers. Progress on this recommendation will be monitored through the force domestic abuse improvement plan and is currently captured in Covalent (Recommendation 2014DHRC02-01) which is the tracking system used by this force to monitor recommendations arising from Serious Case Review and Domestic Homicide Review. It is recommended that audits are conducted across the force area post implementation to identify any weaknesses in practice and ensure these are redressed through supervision and monitoring. The force may also wish to consider Peer review as an effective mechanism to review and audit practice. Recommendation 2: The review of the use of COMPACT shows a number of uncompleted tasks, which have in some cases been completed but incorrectly recorded on the narrative. This has caused issues in the review and management of the enquiry and has detrimentally impacted upon the expediency and efficiency of the investigation. It is recommended that supervisors intrusively monitor investigations to ensure the system is utilised as intended and actions are generated and resulted correctly within the tasking system. Findings from this review should be disseminated to portfolio lead and Missing Persons Intervention Managers. Recommendation 3: Enquiries conducted through this review indicates that significant information has not been shared across all relevant police forces. This agency should consider regular refresher training for staff working in specialist Public Protection roles to ensure they have a good operational understanding of their responsibilities in recording and disseminating information. Norfolk Constabulary Ensure significant information is shared across relevant police forces in a timely manner and the fact that the information shared is recorded on relevant systems Southampton and Hampshire PCTs 1. Include monitoring of the agreed READ codes in annual audit (RCGP template) and escalate poor compliance to LAT and performance teams (Responsibility Designated and Named professionals) 2. READ coding of risks and vulnerabilities in adults to be spot checked after self-reporting with annual safeguarding audit. Spot checks supported by LAT / performance teams. (Responsibility Designated and Named professionals with support LAT) to include if enquiry and / or 56 assessment of parenting consideration evident in parent’s notes and associated risks / vulnerabilities translated to appropriate READ codes in children’s noes. 3. The number of referrals of IRIS team in Southampton is monitored and analysed against the known demographics and reporting of DVA. The antenatal referral forms will be audited to review timely and appropriate sharing of information. 4. In Hampshire where women can self-refer for antenatal care (not see GP first) an audit and assurance process needs to be undertaken to ensure booking assessment covers all aspect of the NICE guidance (Designated professionals). Southampton City Council Children and Families Service It is important that the LADO is clear as to the source of the referral or contact and that there is a narrative thread that runs through the recording. This has already been implemented. All referrals that relate to another authority should be noted for audit purposes. University Hospitals Southampton NHS Foundation Trust 1. When a mother changes her booking from PAH it is important that records of A/N care are retained by the hospital. It is also important for the mother to take her A/N handheld records with her to her new provider to share her A/N care thus far. The maternity records guideline does not reflect this and needs to be reviewed 2. When pregnant women leave the area this fact needs to be recorded centrally on the Electronic Documents (E Docs) system and the pregnancy suspended on the hospital computer system. (the pregnancy cannot be ended on the system until the outcome is known) 57 BIBLIOGRAPHY Berry et al: Parents who commit suicide after killing their children. Family Law (June 2013) Brandon, M et al A study of recommendations arising from serious case reviews 2009-2010 (Sept 2011) Burdett Report: Evaluation of a Training Programme and Toolkit to assist Health Visitors and Community Practitioners to Engage with Fathers as Part of the Healthy Child Initiative: A developmental study using action research. June 2014 Cafcass: Operating Framework http://www.cafcass.gov.uk/media/212819/cafcass_operating_framework.pdf CPS: Charging perverting the course of justice and wasting police time in cases involving allegedly false rape and domestic violence allegations (March 2013) Munro, E (2011) The Munro Review of Child Protection: Final Report A child-centred system NSPCC (March 2014) Child killings in England and Wales. O’Hagan, K (2014) Filicide-Suicide. The Killing of Children in the context of separation, divorce and custody disputes. Osborn, M: Working with Fathers to safeguard children, Fatherhood institute Journal, July 2014 Lancashire Safeguarding Children Board Child L SCR Learning Briefing: March 2016. 1 CHILD O Serious Case Review March 2016 Welcome to this Child O Serious Case Review Learning Briefing published by Lancashire Safeguarding Children Board. The full review report is available at this link: http://www.lancashiresafeguarding.org.uk/media/13787/lscb-child-o-overview-report-with-foreword-march-2016.pdf Background This was a review which encompassed five LSCBs, as the mother and child had been moving around all the authorities. It is possible to speculate on the mother's motivation for all the moves, but we do not know it. It is likely that the moves were prompted by the fear of being found by either the child's father or the authorities. In August 2014, the mother killed Child O and then herself. It was a tragic and highly unusual incident. At the time of death, Child O was 22 months old. The court process related to father's application for contact with Child O. Mother had removed herself and Child O from cohabiting with father when Child O was a tiny baby. Whilst the couple were together, she had made one allegation of domestic abuse (recorded by Police as 'domestic dispute'). Police had attended and recorded a verbal argument. Once she had left, she stayed hidden from all agencies, moving around the country. Later, after the separation she made other serious allegations, but had been unable to offer any evidence when the Police investigated. The family thus had very limited involvement with professionals. The only agency involved at the time of Child O's death was Cafcass. There were a small number of findings which required a response. Broadly the issues identified were: Working with fathers: The importance of working proactively with fathers was emphasised. It is possible that assumptions regarding the role of fathers affected professionals in this case. Practice questions: Have I made assumptions about the role of fathers? Have I heard the views of fathers? Ensuring that the impact on children is taken into account in assessment and decision-making: LSCB Learning briefing Lancashire Safeguarding Children Board Child L SCR Learning Briefing: March 2016. 2 It appeared that the child was lost in the parental dispute and that decisions did not sufficiently consider the outcomes for the child. Practice questions: Do I know what a day in the life of this child is like? Have I considered the impact on this child of my decisions? Dealing with allegations of domestic abuse: In this case, the mother told professionals of increasing levels of domestic abuse, describing abuse of increasing severity as time went on. However, there are significant concerns that this was untrue. Practice questions: How do we make sure we respond appropriately to allegations of domestic abuse? Do we ever question whether domestic abuse allegations are true? Homicide in the context of parental conflict: This is an issue which is the subject of new research. Practice questions: do we know the research on homicide in the context of parental conflict? Are we aware of the warning signs? For further information please refer to 1. LSCB safeguarding procedures http://panlancashirescb.proceduresonline.com/index.htm 2. Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively https://www.nice.org.uk/guidance/ph50 Finding Out More about Serious Case Reviews: Lancashire Safeguarding Children Board continues to run Briefing Sessions about the findings from Serious Case Reviews and they are updated on a regular basis. There will be more about the learning from Serious Case Reviews completed in Lancashire and helpful practical advice to take back into your practice. Check the LSCB website for upcoming dates. Contact the LSCB: LSCB, Room 503/504, East Cliff Offices, JDO, Preston, PR1 3JT 01772 530283 / 01772 530329 |
NC048978 | Death of Child L aged 14 found hanging in her home in February 2016. A coroner's verdict found the cause of death to be 'death by misadventure'. Child L had attempted suicide on two occasions in the previous two years by taking overdoses and had a history of self harming from the age of seven. She had witnessed persistent domestic abuse from an early age. Maternal history of alcohol misuse led to mother's ill health including frequent seizures. Child L's grandmother, identified as a protective factor, was also seriously ill. Child L had contact with Child and Adolescent Mental Health Services (CAMHS) and Children's Social Care (CSC). A common assessment framework (CAF) and a Child in Need assessment were completed. Learning includes: keeping the focus on the child at risk when dealing with resistant parents or assessing parental capacity; critical thinking skills are necessary when assessing families with complex dysfunction; remaining attuned to the presence of unknown men. The recommendation is made that all children assessed as medium to high risk through self-harm or suicide are referred directly to CSC to coordinate multi-agency working.
| Title: Serious case review report: Child L. LSCB: Rochdale Borough Safeguarding Children Board Author: Rochdale Borough Safeguarding Children Board Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child L Final Report 11 Sept 2017 1 Serious Case Review Report Child L This report will be published in line with statutory guidance. In order to preserve the anonymity the author has: Used initials to represent people Avoided the exact use of dates Child L Final Report 11 Sept 2017 2 Contents 1. Introduction 2. Decision Making Process 3. Scope and Terms of Reference 4. Overview of what was known to Agencies 5. Analysis 6. Learning from the Review 7. Recommendations Anonymisation Key Designation Referred to as: Subject Child Child L Mother of subject child ML Father of subject child FL Social Worker SW1 Practice manager Children’s Social Care PM1 Child Adolescent Mental Health Service (CAMHS) Practitioner MHP Alcohol Practitioner AP School Safeguarding Officer SSO Family Support Worker FSW Hospital 1 – Fairfield General Hospital 2 – Oldham Royal Hospital 3 – North Manchester Hospital 4 – Rochdale Infirmary Hospital 5 - Tameside General Child L Final Report 11 Sept 2017 3 1. Introduction 1.1 This Serious Case Review (SCR) concerns a child who died aged 14 years after she was found hanging at her family home. A Coroner’s inquest was held in August 2017. After careful consideration of evidence from all the agencies referenced in this report a verdict was reached that the cause of death for Child L was ‘death by misadventure’. 1.2 On the evening leading up to the incident, family members had believed she had gone to her bedroom to listen to music. At the time of her death, following an attempted overdose approximately six months previously, Child L was actively known to Children’s Social Care, Early Help and Schools RBC, and the Child and Adolescent Mental Health Service as a Child in Need. 1.3 Child L lived with her mother (ML) and siblings in a family that had a closely connected relationship with their Maternal Grandmother (MGM). Child L was a bright and capable child, she approached her school life with enthusiasm and had a firm friendship group. She enjoyed typical teenage culture and was noted to be especially happy to be attending a pop concert. 1.4 As a young child, Child L was exposed to serious and persistent domestic abuse and the separation of her parents. Child L worried a great deal about her mother’s physical health related to high levels of drinking and about the impact of this on her mother’s emotional availability to her. Child L’s relationship with MGM was experienced by her as compensating for some of the limitation she felt in relation to ML, and her world no doubt became a scarier place when MGM became terminally ill. 2. Decision Making Process and Methodology 2.1.1 The determination as to whether a Serious Case Review was indicated was considered by the Serious Case Review Consideration Panel, who made a recommendation that a Serious Case Review should be convened on the basis that the criteria as listed in Schedule 5 of the Local Safeguarding Children Boards Regulations was met, namely 5(2,1,b,i) that a child has died, and 5 (2,1,b, ii). Child L Final Report 11 Sept 2017 4 Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. This was endorsed by the Chair of Rochdale Safeguarding Children Board. 2.2 The Serious Case Review commenced in June 2016. The Review was overseen by a Review Panel of senior officers from participating agencies and an Independent Chair. An Independent reviewer was appointed to facilitate the progress of the Review and write an overview report. 2.3 Each agency involved with Child L provided a chronology of key contacts and activities in order to establish who did what and when. The accuracy of CAMHs contribution was compromised by the paucity of agency recordings in relation to this case and this presented some challenges in understanding how all of the agency activities unfolded and interacted. 2.4 The independent reviewer along with a representative from the Review Panel met with all of the key practitioners referred to in this report, including staff who had moved to new employers. This assisted greatly in understanding the perspective of individual practitioners and to some extent in reaching an analysis of how organisational systems and individual points of judgements impacted on Child L’s journey through services. 2.5 The Independent Reviewer also met with ML and FL, their contributions at a time of grief and confusion were greatly appreciated and valued in helping to understand the family dynamics that Child L lived within. 3. Scope and Terms of Reference 3.1 The timeframe for the Review was January 2015 to February 2016; this took into account all known contacts for Child L with child welfare agencies beyond universal services and provided a picture of her life through her schooling. 3.2 The Panel overseeing the Review agreed that in order to avoid a narrow and pre-determined focus from the start, detailed Terms of Reference would not be established in favour of allowing the issues of significance to flow from the unfolding consideration and analysis of multi-agency activities. To this end, each agency was Child L Final Report 11 Sept 2017 5 asked to complete a self-analysis of the interventions that they perceived as key and provide the following: commentary on each episode against policy, protocol, practice standards or compliance criteria; an analysis of strengths and vulnerabilities of process and practice; identification where gaps in safeguarding systems are exposed; proposals for single agency learning and how this will be embedded from this review. 3.3 The meetings with practitioners enabled the Review to gain an understanding of what influenced their practice, decisions, and communications on both an inter and intra- agency basis. Practitioners were invited and encouraged to provide an appraisal of practice and an honest reflection of the context and conditions in which they were working. 4. Overview of what was known to Agencies 4.1 In the first seven years of Child L’s life, ten incidents of domestic abuse occurred that incurred a police response. The majority of the incidents included acts of violence which resulted in injuries to ML by FL and damage to the family home. Police records indicate that MGM was concerned about ML’s drinking in 2011. 4.2 In 2015 Child L completed school Year 9 with 95% attendance and a very positive report with regard to attitude to work. Child L was a capable student on track to achieve pass grades in GCSE subjects. Occasional unexplained absences were followed up expediently by the school attendance officer. 4.3 During the school summer holiday of 2015, the following significant events occurred: police attended the family home in relation to an argument between Child L and ML. Police information indicates that a referral was made to Children’s Social Care, however, there is no record of this within Children’s Social Care; ML attended an Urgent Care Centre with regard to a head injury sustained three weeks earlier. ML stated that she was having intermittent seizures, before Child L Final Report 11 Sept 2017 6 leaving without a consultation and declining to return when contacted by telephone. ML was noted to have bruises and had been drinking alcohol. September to October half term 4.4 Child L returned to school at the beginning of Year 10. Two weeks into term, Child L was taken to the Urgent Care Centre at approximately 10pm by ambulance accompanied by MGM. Child L had telephoned a friend stating that she had taken 30 tablets, the friend told her mother who then contacted ML. Child L was seen by a Locum Doctor who recorded her mood as low with suicidal thoughts. Child L was noted to have self-laceration marks to her arms and stated that she had self-harmed since the age of 12 years caused by distressing issues which included her parents separating due to domestic abuse, MGM undergoing treatment for a serious illness and that a best friend had moved away. The ambulance service contacted police, and, after speaking with Child L at the Urgent Care Centre the police made a referral to Children’s Social Care. Child L was admitted to hospital, and consequently transferred to a hospital (2) which had a children’s ward. The transfer protocol required Child L to be further triaged through the hospital (2) Accident and Emergency. 4.5 The following day, Child L was assessed by a nurse trained practitioner, MHP from the Child and Adolescent Mental Health Team. ML and MGM were present when the assessment was conducted, Child L presented as tired and weepy and the assessment noted the following significant information about Child L and the family: Child L had a history of superficial self-harm since age 7 years; ML had problematic alcohol use; Child L felt she could not discuss her worries with ML believing that ML would become annoyed; Child L had been told not to talk to professionals as the family had contact with Children’s Social Care several years previously which angered ML; Child L was enjoying school, had friendships, ate and slept well. The assessment concluded that: Child L Final Report 11 Sept 2017 7 the overdose was an impulsive act in the context of an argument with friends and complicated family relationships; Child L was reluctant to talk in front of ML and MGM and that there was little positive interaction between Child L and ML; there was no evidence of clinical depression; safeguarding risk factors included parental mental health and alcohol misuse and domestic abuse with no services currently involved; Child L was high risk. The MHP formulated a care plan which included safety advice given to Child L’s carers, a follow up appointment in 7 days, information sharing with Child L’s school and consultation with Children’s Social Care regarding subsequent interventions. Child L was discharged to the care of ML. 4.6 A referral was received at the multi-agency safeguarding service (MASS). The referral from police indicated that Child L was experiencing hormonal changes and struggling to cope with associated moods, was feeling sad about her parent’s relationship and took approximately 25 tablets of ibuprofen and paracetamol. The referral was screened by the MASS and directed to the Early Help Service. An Early Help MASS support officer contacted Child L’s school who agreed that they would initiate a Common Assessment Framework (CAF)1 but if ML was not co-operative, then the case would be referred to Children’s Social Care for social work allocation. 4.7 To progress the CAF, MHP and the School Safeguarding Officer, SSO, arranged a visit to the family home. Although aware of the visit, ML was not at home to receive the professionals. This was also the scheduled date of the seven day follow up visit by MHP, ML indicated however that this could not be facilitated because the family were moving home that day. The professionals noted however that there was no 1 The CAF (Common Assessment Framework) is a way of offering early help to children and young people. Health services, schools and children’s services all work together to support the parents and child and prevent problems at an early stage. The CAF is voluntary; An assessment will be undertaken to find out needs and decide on what help is needed. CAF is a shared assessment One person, called a lead professional, keeps the family informed and co-ordinates the support Child L Final Report 11 Sept 2017 8 indication at the home that the family were moving and the SSO emailed the MASS support officer to inform that ML had declined a CAF. The SSO advised that ML had denied drinking alcohol despite staff regularly noting the smell, that she had attended only two out of eight meetings arranged by the younger children’s school and was experiencing vacancies linked to epilepsy. After further consultation with the MASS manager, the case was opened to Social Worker SW1 for assessment. 4.8 E-mail correspondence between MHP and SSO indicated that a one to one session was held between MHP when Child L was tearful and reluctant to discuss concerns openly. Child L reported being unable to talk with ML or MGM about what troubled her and referenced about 27 house moves. MHP indicated that Child L would benefit from 1:1 support in school and that she would monitor the ‘flat mood’. MHP stated that Child L denied any current thoughts to harm herself, but ‘could not guarantee that [Child L] was not considering this again’. 4.9 Two weeks after the overdose incident SW1 met with ML in the family home and Child L in school. Child L told SW1 that nothing had changed at home, and that her relationship with ML was not a positive one. Child L reported that she worried about ML’s health which was deteriorating because she was not getting the medical attention that she needed. Child L reported irregular contact with FL but the presence of some good friends. 4.10 Approximately one week later a Child In Need2 meeting took place with SW1, SSO and a Pastoral Officer from school, ML and MGM were present with apologies by the School Nurse. MHP sent an email to SW1 prior to the meeting stating that she had seen Child L on two occasions, summarising that Child L was very tearful, fearful of talking about what was going on in the family and that ML had a boyfriend with whom she was out a lot. Child L reported that ML was using alcohol and cannabis and minimising Child L’s difficulties. MHP reported that Child L still had fleeting suicidal thoughts, mostly when alone stating ‘…This is worrying as Child L is 2 A Child in Need is defined under the Children Act 1989 as a child who is unlikely to reach. or maintain a satisfactory level of health or development, or their health or development. will be significantly impaired, without the provision of services, or the child is disabled Child L Final Report 11 Sept 2017 9 secretive, no one knew what she is thinking, and I am worried that one day she will do something again’. 4.11 The following day ML was taken by ambulance to hospital (3). She reported that she had five seizures during the day before leaving without seeing a Doctor. That same day SW1 had telephoned ML to arrange a visit, ML said that she would not be available for four weeks because she was moving house. SW1 discussed the response with a Practice Manager who advised that an unannounced visit should be made. SW1 visited the home the following day, when MGM advised that ML was not home and was too unwell to meet with SW1. 4.12 SW1 made an appointment for one week later which she proceeded with despite ML protesting that she was not happy with the need to complete an assessment and would not co-operate with any professionals. MGM was present when SW1 arrived at the home and indicated that they did not need any support. The home was described as having a strong smell of stale alcohol and being very untidy. When SW1 challenged this position is respect of Child L, both ML and MGM indicated that there was ‘nothing wrong with Child L’, that her behaviour was attention seeking which they were dealing with as family. SW1 indicated that refusal to engage in an assessment would result in a Child Protection Plan3 because the concerns were significant. On the advice of the Practice Manager 1 (PM1), SW1 re-iterated this position in a letter. 4.13 SW1 met with Child L in school one week later. Child L reported feeling low and that the relationship with ML was not good. Child L felt blamed by ML for Social Services being involved and this was making her feel bad. SW1 subsequently spoke with MHP and MHP recorded that SW1 was ‘looking to step the case up to child protection’ and also that Child L remained high risk as ML was not meeting the needs of her children. 4.14 The next day, ML attended the GP surgery reporting 4 seizures in the day. ML was taken to hospital (3) by ambulance. She was treated and advised to attend for follow 3 Where a Child Protection Conference determines that a child is at continuing risk of Significant Harm, a multi-agency Child Protection Plan is formulated to protect the child. A Core Group of professionals, including the Lead Social Worker, are responsible for keeping the Child Protection Plan up to date and co-ordinating inter-agency activities within it. Child L Final Report 11 Sept 2017 10 up with the GP. The hospital Accident and Emergency report to the GP concluded that ML was experiencing seizures and was alcohol dependent. 4.15 A further visit to the home was made by SW1 the following day and Child L’s older sibling indicated that ML was at MGM’s home. SW1 went to the home of MGM where ML stated that she had been in hospital due to seizures. At this visit it was recorded that both agreed to co-operate with a Child in Need plan. 4.16 The next home visit by SW1 was just after half term holiday. ML, MGM and Child L’s younger sibling were present. It was noted that the family were residing with MGM due to ML’s health. SW1 was satisfied that MGM was a protective factor but that the problems were likely to be evident once the children returned to mother’s sole care. October to December 4.17 A second Child in Need meeting was held, attended by SW1 and SSO, a primary school representative and School Nurse. ML and MGM reported that they believed the meeting to be the following day, and MHP was not in attendance due to ‘unforeseen circumstances’. Child L’s school attendance had dropped to 83% and she was described as looking ‘a bit lost and unhappy’. Although generally well presented, her appearance was described as dishevelled on occasion. It was agreed that SW1 would complete a Child and Family assessment and that a Graded Care Profile4 would be completed by a Family Support Worker (FSW). 4.18 Two days after the meeting, SW1 discussed this case in supervision and it was agreed that a Strategy Meeting would be initiated if engagement from ML could not be secured. ML was not available for the next home visit but was available at the following attempt where she described as ‘engaging’. One week after this (mid November 2015), the Child and Family assessment was completed. It concluded that ML was now willing to engage with the Child in Need process, however, the family was lacking stability due to housing issues, and concerns for the children’s emotional needs as ML was chaotic at present. The assessment noted that the children had 4 The Graded Care Profile (GCP) is an assessment tool designed to help practitioners identify when a child is at risk of neglect. Child L Final Report 11 Sept 2017 11 spoken of ML’s alcohol use and how this is affecting them but that she was engaging with the GP for support. The Manager signed off the assessment indicating that a ‘robust’ Child in Need plan was needed with an escalation to child protection if ML disengaged. 4.19 Child L attended the school health Drop-In clinic with the School Nurse. The School Nurse thought Child L appeared happier although she reported things to be ‘about the same’. 4.20 Upon completion of the Child and Family Assessment, SW1 contacted MHP. MHP advised that she was continuing to meet Child L in school, described her as having low mood and indicated she would see her weekly. SW1 requested that a family therapy approach was introduced to enable Child L to build up the relationship with ML. SW1 also made a home visit with the FSW to introduce the graded Care Profile. ML was found to be under the influence of alcohol with MGM and a boyfriend also present. 4.21 At the end of November, SW1 made a home visit with ML and all the children present. The home was observed to be more organised, the children’s bedrooms and food stores were observed as appropriate. Written records show generally a much more positive image was gained. It is now known that Child L was absent from school without explanation that day and later in the evening ML attended the Urgent Care Centre with chest pain that was said to have been present all day. ML was admitted to hospital (4) for two days and an Alcohol Withdrawal Pathway was progressed. This included a referral to a specialist Alcohol Practitioners (AP). 4.22 A Child In Need meeting was planned and took place whilst ML was in hospital. The meeting was attended by SW1, SSO, and MGM. MGM indicated that Child L was seeking attention, and was ‘playing up’ when indicating concern for ML. 4.23 In early December MHP met with Child L. Child L was noted as looking tired , not sleeping well, mood up and down, and became very tearful saying things were not going well at home. Child L disclosed the following information: concern about ML’s health and substance misuse indicating that she (ML) was currently living with MGM due to her ill health; Child L Final Report 11 Sept 2017 12 worries about looking after ML on occasions and being fearful of a seizure in case she went to sleep and did not wake up; that Child L was living at home with an older sibling aged 19, and that it was cold with no heating or food; that ML and her partner smoke cannabis and drink alcohol and ML gets angry when she is intoxicated; that Child L was staying with friends often and had taken a further overdose (2-4 tablets) at the end of October during the half term school break. Child L had eventually told MGM who told her to tell MHP; that Child L had hidden some tablets following the previous overdose and was having frequent fleeting suicidal thoughts with no intent. She also said however that when things get bad at home she will ‘just do it’; that Child L had self-harmed on one occasion in early October. Child L told MHP that she wanted to be ‘somewhere where she feels looked after’, because ML could not do this and Child L ‘didn’t want her life to be like this anymore’. The recording noted that MHP would request a meeting with SW1 and Child L. MHP shared the information by e-mail with SSO. A telephone discussion is recorded by SW1 with MHP sharing this information and the social workers undertook a joint visit with Child L five days later 4.24 Prior to the visit to Child L, ML told the AP in a telephone call to arrange an appointment that she had been alcohol free for 11 days and was feeling positive. Child L told SW1 and MHP that she was staying frequently with a friend who had a flat or at another friend’s family home as well as having food at MGM’s home as the freezer in the home was broken and the house was cold. Child L talked about how ML and a boyfriend were smoking cannabis in the house and that when drunk, ML would say mean things to her and she at times tells ML that she wants to kill herself. Child L said that nothing had changed in her family and that she did not feel safe. Child L presented as angry with ML because she was not doing anything to address the problems, Child L stated that she had had enough. MHP expressed concern about Child L’s friendships could place her additional risk due to knowledge of a young person that she was associating with. The recording of Child L Final Report 11 Sept 2017 13 the visit stated that SW1 intended to discuss the concerns with a manager and possibly a strategy discussion would be held to agree a multi-agency decision on the way forward. 4.25 The next day, the FSW visited the home to complete the Graded Care Profile. ML told the FSW that Child L chooses to stay where she wants to which she considered to be ‘fine at her age’. The FSW noted that ML minimised the concerns that the children had about her health, reporting that she now had a counsellor and had been referred to a high level support team. ML continued to assert that Child L’s behaviour was attention seeking. An e-mail to the SSO from MHP indicated that Child L was seen the following day by SWC and was considered to be more settled and that Child L may have ‘an underlying depressive illness’. MHP wrote to ML advising that she intended to continue working with Child L, reiterating safety advice to lock away sharp objects and medication. MHP also wrote to the GP outlining the concerns and noting that Child L risk remains high. 4.26 SW1 discussed the concerns about Child L with a manager 6 days after the visit with Child L. It was agreed that SW1 should meet with ML to discuss the concerns and to request access to her GP records, and that ML should be asked to ensure that Child L should stay in the family home rather than different friends’ houses. A decision was made to continue with a Child in Need Plan rather than escalate to a higher threshold of intervention. The next attempted home visit was made 8 days later, 2 days before Christmas. 4.27 In the week prior to Christmas, ML had a telephone conversation with the AP whereby she stated that she was alcohol free and did not want any further contact until the New Year. SW1 also contacted the AP and was told that there was a concern that the seizures reported by ML were alcohol related and that she had agreed to access high level support in the New Year. SW1 invited the AP to join a planned Child in Need meeting in January. 4.28 ML refused to allow SW1 into the family home when the next home visit was made. ML complained that SW1 had spoken to the AP and asked for food vouchers that she indicated the FSW had promised. No further contact occurred prior to the Christmas holiday. Child L Final Report 11 Sept 2017 14 4.29 Between Christmas and New Year, Child L was taken to hospital (4) by ML after being found in a local field intoxicated. Accident and Emergency Consultant was aware that Child L had previously attempted overdose and was open to the CAMHS service. Child L was observed apologising to ML stating that she ‘did not want to die’. Child L was admitted to hospital (5). The hospital informed Children’s Social Care EDT, CAMHS and a referral was made to an Alcohol Nurse linked to young people. This referral resulted in a letter to Child L and ML advising of alcohol services for young people. Child L was discharged the following day without further CAMHs assessment. Emergency Duty social workers made contact with MHP prior to undertaking a home visit following Child L’s discharge. The social workers noted the home to be cluttered and smelling of cigarette smoke, whilst they were present an object was thrown at the window and ML contacted police. Child L was recorded as feeling ‘unwell but okay’. MHP recalled making a telephone call to Child L over this period but it is unclear when and there is no written record. January 2016 onwards 4.30 When services resumed after the Christmas holiday, MHP sent an e-mail to SW1 asking ‘are we any further forwards with things’. MHP met with Child L in school and she indicated this was not a self-harm issue. Child L reported no improvements at home had occurred but denied any feelings of suicide or deliberate self-harm. MHP discussed with Child L behavioural therapy options but Child L did not want to consider this approach. The FSW saw Child L in school the same day, Child L told her that boys had bought alcohol and although she knew she was getting too drunk, she carried on any way and also smoked some cannabis. Child L said it was a stupid thing to do and it wouldn’t happen again. Child L talked of feeling ‘left out’ at home. 4.31 SW1 visited ML who agreed to attend a forthcoming Child In Need Meeting and advised that MGM was having tests in relation to as serious illness. The Child in Need meeting was held in the second week of the New Year and attended by SW1, ML, FSW, SSO, primary school, School Nurse and AP. The meeting discussed the following issues: concern that Child L was given alcohol by a group of boys was a concern in respect of CSE; Child L Final Report 11 Sept 2017 15 Child L’s school attendance had increased to 97%, although attainment was slipping; the impact of ML’s alcohol misuse on her parenting capacity; ML stated she had stopped drinking since November and was willing to accept the alcohol withdrawal pathway; that the graded care profile does not indicate neglect. (This was completed for younger sibling only not Child L). 4.32 Subsequent to this meeting, ML did not attend the next two scheduled appointments with AP. After the second failed appointment, the AP contacted ML who indicated that she would ring within 2 weeks if she intended to continue with the service. ML made no further contact and the case was closed. 4.33 SW1 met with Child L who said that she had not seen MHP since before Christmas MHP states a visit took place on 4th January that was not recorded) and that they would like to continue to see FSW. Child L indicated that she could no longer confide in MGM because of her poor health and a diagnosis of serious illness. ML told SW1 that she intended to meet with the AP two day later however this did not happen. SW1 praised ML for engaging with professionals and stated that if this continues the case could be managed at a CAF level. 4.34 At the end of January, SW1 discussed the case in supervision and reported improvements in ML’s engagement and that she was accessing alcohol services. It was noted that although concerns remained for Child L, services were now in place including the FSW. The record indicates that the manager noted this case may move to a CAF at the next meeting. 4.35 MHP saw Child L in school at the beginning of February. Child L was continuing to spend much time at the home of friends, reporting that there was no heating at home and ML was still drinking and smoking cannabis. Child L reported having to bring ML home from a local park where she was intoxicated and sat in mud. A home visit one week later by FSW found the home to be ‘a mess’, and when challenged about this ML admitted to drinking and smoking cannabis. ML had a burn to her leg sustained when she fell asleep drunk in front of the fire, and she said she had brought a male home the previous night which upset the children. Alerted to the Child L Final Report 11 Sept 2017 16 deteriorating conditions by FSW, SW1 visited ML later in the day and suggested a referral to a Family Group Conference5. This was the last visit to the family home prior to the incident which caused Child L’s death nine days later. 4.36 ML did not attend an arranged appointment with the School Nurse to complete a health assessment for all of the children. The School Nurse advised SW1 that ML had not attended. 4.37 In the week prior to Child L’s death, a meeting took place with MHP where she considered Child L to be in a good mood, excited about going to a music concert. MHP discussed the forthcoming half term holiday, recognising school holidays were generally a more difficult time for Child L. A Safety Plan was re-iterated of contacting CAMHS, staying with friends, or attending Accident and Emergency if needed. 4.38 During February 2016, there was deterioration in Child L’s attendance to 89% and deterioration in attainment. A Child in Need Meeting was planned for after the half term holiday. SW1 discussed the case in supervision the day prior to Child L’s death. The discussion concluded that if ML can engage with alcohol services, than the case could be stepped down to CAF. 5. Analysis 5.1 The period of multi-agency interventions for this review essentially cover a six month period from September 2015 to February 2016 with the first point of intervention being in relation to an attempted overdose when Child L was aged 14 years and 5 months. Suicidal behaviour is a complex phenomenon that occurs along a continuum that progresses from suicidal thoughts, to planning and attempting suicide through to a worst case scenario of fatality. Children who talked to ChildLine (NSPCC 1999) about feeling suicidal were generally facing turmoil relating to a range of problems which had left them feeling desperate and unable to cope. It was noted that the common characteristic of such children were loneliness, low self-esteem and a belief that nobody cared about how they were feeling. 5 Family Group Conferences are decision-making meetings which bring children and families and their wider support networks together to jointly find solutions to the difficulties the family are experiencing. Child L Final Report 11 Sept 2017 17 5.2 An overdose attempt by such a young person is a shocking and frightening situation for most families, with access to professional help and support being valued and welcomed. The response to the attempted overdose demonstrated a timely approach to assessing the risk that Child L was exposed to underpinned by the use of a Trust Approved Risk Assessment (TARA) which addresses past history and current situation to identify factors that increase risk and factors that decrease risk. Although Child L was assessed as suitable for discharge, she was also identified as high risk and therefore in need of a risk management plan. ML and MGM were present throughout the assessment of Child L, MHP noted a dismissive attitude toward Child L which was severely impacting her emotional distress and need for support and re-assurance. Child L was seen alone, but it must have been very difficult for her talk about her family worries whilst her two main care givers were close to hand but she was able to say that she felt an absence of emotional care and shared that she was concerned about ML’s drinking. Child L also stated that she had a history of self-harm from Year 7, suggesting longer term pain and distress indicative of an underlying issue and insecure attachment. Attachment theory argues that children are biologically programed to form an emotional bond with their caregiver and that an attachment figure will act as physical security and comfort to the child. An insecure attachment style can develop when the primary care giver is inconsistent in responding to the child in times of need so predisposing the child to become either preoccupied with maintaining contact or disengaging with the care giver. Insecure attachment styles impede socioemotional development and the development of coping strategies and problem solving skills. The observations of the parent-child interaction during the assessment suggested that the emotional difficulties of Child L needed to be explored in the context of the familial relationships that were impacting detrimentally on her resulting in a risk of significant harm. 5.3 The TARA assessment was limited in completion, with the factors that decreased and increased risk insufficiently developed. The Safety Plan referenced a need to consult with Children’s Social Care, however, it is apparent that based on her assessment or risk and the factors impacting upon this, MHP should have made a formal referral to Child L Final Report 11 Sept 2017 18 Children’s Social Care but instead accepted working with the SSO without challenging whether the case sat appropriately within the early help service. A referral directly to Children’s Social Care would have enabled a more informed focus on risk at the early stages of intervention. The relationship between CAMHS and Children’s Social Care did not develop as a multi-agency partnership. Communication was limited to approximately five telephone calls or e-mails and one joint visit in December when Child L presented as very distressed about her living situation. The CAMHS service were not present at any of the three Child in Need meetings and had no shared Child in Need plan. Exploration of the activity undertaken by CAMHS has been hampered by an absence of contemporaneous recording, but from meeting with MHP it is evident that she was extremely concerned about Child L and expressed frustration that ‘something should have been done’. 5.4 The voice of Child L is evident throughout agency records, to name but a few, there are many examples of her telling people how she was feeling and what she needed as follows: September 2015 during CAMHS assessment Child L indicated that she could not discuss her worries with ML and that she was fearful about her mums physical health; September 2015 Child L told SW1 at their first meeting that nothing at home had changed following the overdose and that she did not feel close to anyone in her family but wished that that she had a better relationship with her mother; October 2015 Child L told the School Nurse that she ‘felt the same’ when asked how she was; December 2015, Child L told SW1 and MHP that the home had no heating or food, she was staying away with friends for comfort and that she wanted to ‘be somewhere where she feels looked after’ and didn’t want her life ‘to be like this anymore’; MHP recalls that Child L told SW1 that she wanted to move out of the house and that SW1 agreed to look into it; January 2016, Child L told FSW that ML was drinking and this was causing problems; Child L Final Report 11 Sept 2017 19 February 2016 Child L was tearful when meeting with MHP, again explaining home conditions as very poor without heating and ML drinking heavily; February 2016. Child L advised the FSW that she was removing herself from the family home to protect herself from situations that make her feel low and anxious. The extent to which her voice was heard and acted upon is questionable. 5.5 Child L is clear throughout the period of intervention that the ability of ML to meet her needs was compromised because of an alcohol dependency. Whilst this resulted in the Child in Need plan seeking to address ML’s dependent drinking, the manner in how this occurred was naïve. There is a significant discrepancy in recording and recall by MHP and SW1 in relation to whether Child L was offered assurance that consideration would be given to exploring alternative living arrangements. It was striking that the view of SW1 presented as somewhat out of step with the reality of this case when she described the death of Child L as a shock because she believed that the multi-agency plan was making progress. Given Child L’s descriptions of family life and how it was impacting on her emotional wellbeing, exploring the possibility of alternative care arrangements would seem like a reasonable course to follow. 5.6 SW1 was of the view that the family was assisted by the presence of MGM and that she provided an additionally protective factor. It is noted however that this view was not based on any particular assessment of MGM and in fact, very little was known about her history of parenting. ML reported during the course of this Review that MGM also had a problematic relationship with alcohol and that she herself had been exposed to high levels of domestic violence fuelled by alcohol. In this context there is a question about MGM’s ability to recognise risk, or challenge her daughter’s problematic drinking. 5.7 The Practice Manager who provided support and supervision to SW1 advised that to the best of his recall, the possibility of Child L moving away from the family home had never been discussed with him. Six days after the joint visit by SW1 and MHP when MHP states this was referenced as an option, SW1 had supervision with the Practice Manager. The records state that there were concerns about Child L’s Child L Final Report 11 Sept 2017 20 ‘emotional wellbeing and the chaos in the household’ but the advice went on to say that SW1 should advise ML that in order for Child L to settle at home, ML was responsible for ensuring that Child L was sleeping in her own home rather than friends and family. This approach completely misunderstood the reasons why Child L was staying away from the family home and effectively dismissed one of her coping strategies that decreased risk and increased her resilience. Following the overdose in September, there was reference to CAMHs developing a Safety Plan however, this approach was not shared across agencies or reviewed as part of the Child in Need meetings. Similarly, whilst a Child in Need Plan was developed by Children’s Social Care, this was not effectively shared with partner agencies or systematically reviewed against the objectives and intended outcomes. Had this have happened, it would have been evident that the issues that impacted on Child L in September remained unchanged in the subsequent three multi-agency meetings. 5.8 From the outset of intervention, ML and to a lesser extent MGM indicated clearly that they believed Child L’s behaviour to be attention seeking and adopted a ‘no nonsense’ approach. For Child L this simply re-enforced her sense of worthlessness and hopelessness. The potential for support from child welfare agencies was also difficult for Child L to pursue as she had clearly been warned off from bringing ‘social services’ into the family’s business. There are various references in agency records that indicate that Child L was concerned about being disloyal as this would break the family code. In the meeting with ML during this Review she presented as clearly presented a sense of strong family values that created an ‘us against the world’ mentality. She perceived that professionals only ever worked against her, and although she accepted her drinking impacted on Child L, she excused her addiction for a host of reasons. 5.9 The reluctance of ML to engage with agencies was apparent throughout this case, and this is why it is surprising that the Child and Family assessment concluded that ML was willing to work with the Department after an ongoing resistance and only one visit where she allowed SW1 to visit as planned. This is a clear example of what Brandon et al (2012) Learning from Serious Case Reviews describes as the rule of optimism that exists within social work and other helping professions. The rule of Child L Final Report 11 Sept 2017 21 optimism originates from a desire to make a positive difference to the life of people that professionals work with and the need to believe in what they are doing. When at play, the rule of optimism can blind practitioners to what is really going on by believing that what they are seeing is progress through the filtering or minimising of areas of concern. The third Child in Need meeting set out a plan for ML to work with AP and without any real reason to be confident about this, the professionals simply anticipated that the intervention would work without considering the consequences of it not doing so. 5.10 SW1 was a practitioner of one years’ experience and needed consistent management support and challenge to apply a critical thinking style to a very complex case. ML would undoubtedly have been a very difficult client to work with, she was alcohol dependent, likeable and vacillated between aggressive and pitiful behaviour that would have invoked a range of complex emotional responses in any worker. It is in situations like this where high quality reflective supervision can make a difference in recognising the presence of that the rule of optimism and the tendency for practitioners to give parents too many chances whilst paving the way to adverse outcomes for children. The social work supervision was an opportunity to spot the indicators of disguised compliance and ensure a continued focus on the impact of no change on Child L. 5.11 Although three multi-agency Child in Need meetings took place, there was a view amongst the professionals that attended that there was a greater focus on the younger sibling of Child L for whom previously there had been a CAF intervention. The decision to use the Graded Care Profile as a tool to assess neglect if executed well could have provided an opportunity to focus of the effects of neglect on Child L. Although not clear to multi-agency professionals at the time, it is now known that the profile was only completed on the younger child and not Child L. So although in the weeks running up to Child L’s death part of the rationale for considering stepping the intervention to down to a CAF level was that the Graded Care Profile did not indicate neglect, this did not address the unique neds of Child L. Research shows that practitioners are often more willing to intervene to protect younger children however when this scenario was discussed with SW1 and the Practice Manager, Child L Final Report 11 Sept 2017 22 both indicated that the organisational culture at the time strongly supported the need to act to protect older children, particularly in the light of learning from local and national enquiries. 5.12 The impact of alcohol abuse on children is one that is often underestimated and may be influenced by the fact that alcohol is a legal substance. Any attempts to engage parents in treatment is based on a uniquely personal motivation cycle and voluntary engagement with services who have a predominantly adult focus. ML told the Independent Reviewer that she needed two cans of strong lager simply to stop her shaking upon waking each morning and there are numerous indicators that she was drinking very heavily. The FSW told the Independent Reviewer that it was best to see ML in the mornings because she would be obviously under the influence of alcohol later in the day which made her less capable and amenable to work with. The school told the Independent Review that both ML and sometimes MGM smelt of alcohol, a comment that was echoed by the school nurse. It was telling to the Review Team that on one occasion ML incurred a significant burn by falling asleep too close to a source of heating. It appears that the working arrangements with ML around the effects of her drinking would have masked the professionals understating of the impact on Child L. Working with parents with addictions can be very frustrating, broken promises and agreements are common and that is why the Child in Need process, when implemented systemically within a multi-agency structure, directs professionals to maintain the child as the focus of concern. 5.13 Overcoming long standing addiction is a major achievement for anybody and becoming alcohol free after many years requires a carefully planned series of interventions that would include medication to stabilise the physical cravings, counselling to gain an understanding of the underlying factors of the addiction alongside a planned and medically supervised detoxification. Sadly for the addicted individual, even If all those stages are successful the hardest work of remaining alcohol free then begins. Alcohol dependency is much more than a physical dependence so even when physical dependence is addressed the risk of relapse remains high. Whilst the Child in Need plan directed ML to engage with the AP, there was a gross naivety that this is what she would do, let alone an absence of an Child L Final Report 11 Sept 2017 23 assessment of her capacity and desire for change. In the meeting the Independent Reviewer ML gave no indication that she accepted the need to cease drinking at that time and offered many reasons why she could not do this. One can only conclude that the management oversight of this case was poor within Children’s Social Care, constancy of proposed weave between threshold applications should have been seen as a clear indicator that ML was not achieving consistent engagement. 5.14 This position raises the question of the possibility of challenge from other agencies in the partnership. MHP in her meeting with the Independent Reviewer expressed frustrations about how Children’s Social Care responded to Child L’s needs and this led to a discussion about why a robust challenge was not made on behalf of Child L at the point MHP believed her needs were not being met. The CAMHs Lead advised the Lead Reviewer that MHP is an experienced practitioner who was considered to have a good understanding of risk. MHP advised that she believed that Child L was at a high degree or risk, and that from December onwards she was expecting that Child L would be offered accommodation as a looked after child. When this did not happen, MHP believed that requesting an update from SW1 constituted a challenge and said that she was unaware of the Escalation Policy overseen by the LSCB. MHP did say that she left a message for the Practice Manager although there is no record of this in either agency. MHP spoke of her access to professional supervision and support and reported that she had two separate supervisors which she found confusing. MHP said that she did have good access to daily management advice through the duty arrangements. The concern about the mental health Of Child L were rooted in the context of welfare concerns that needed to be addressed, and to this end it was critical that Children’s Social Care and CAMHs formed an effective partnership for Child L. The CAMHS Lead advised that the supervisory arrangements were made clear to staff, with a Clinical Supervisor for clinical discussion and a management supervision to address issues personal to the supervisee. Discussion of cases through supervision however relied on practitioners identifying the case for discussion, and the Trust records indicate that this case was not discussed within the supervision framework although it should have been. It is acknowledged that MHP was operating a high case load, but had a tendency to readily seek new work. In Child L Final Report 11 Sept 2017 24 public facing professions, it is not uncommon for ‘busy-ness’, or too much ‘doing’ to get in the way of, or become a substitute for high level thinking time. In order to effectively exercise professional judgement, professionals must be confident to challenge against the grain of other people’s thinking in meaningful manner. Analysis of Serious Case Reviews tell us that it is common for there to be disagreement in safeguarding between those involved but that to lead to safe outcomes it needs to be openly acknowledged and addressed. Respectful and assertive challenge based on the desire for positive outcomes can stimulate and motivate other professionals, it is not uncommon in Serious Case Reviews for practitioners to wish they had challenged more as they reflect on practice and to accept the need to take affirmative action with the intention of protecting a child when respectful challenge is not working. 5.15 There can be no doubt of the impact that Child L’s death has had on the CAMHS practitioner and the painful reflections that she has undertaken. The Practitioner was able to share that CAMHS and CSC worked quite separately indicating that Child in Need meetings needed to have a greater priority in CAMHS. MHP stated that she now realises that raising her concerns practitioner to practitioner provided insufficient challenge, and that there was too much reliance and confidence that ML would change when she was not able to. 5.16 The last visit to the home on Child L was conducted by FSW ten days before her death. The FSW was alarmed to see a rapid deterioration in home conditions and that ML was not coping and admitting that she had resorted to drinking and using cannabis. It was also noted that ML had placed the children at risk by bringing an unknown drinking partner into the family home overnight. This did not result in any direct consultation with Child L, and no further direct multi-agency work was undertaken prior to her death. SW1 advised that she was unable to make a visit to the family home because she was on a rota to provide duty cover all week, although this increased concern should undoubtedly have invoked an agency response. The Review can find no understandable reason as to why this information did not result in affirmative action, in particular as the AP had already shared that ML had not engaged with the alcohol service. The Review was advised by FSW that on occasion ML was racist in her language and manner to SW1, and it was interesting to note that Child L Final Report 11 Sept 2017 25 this was not recorded in any of the supervision discussions. Discussion with SW1 on this matter revealed that she saw coping with racism as part of the job, and that her coping mechanism was essentially to disregard its presence and ‘not take it personally’. SW1 commented that this was acknowledged and challenged by FSW however, it is significant to note that the resistance to acknowledging racism may also have the effect of minimising its impact. 5.17 The final conversation between the Practice Manager and SW1 occurred the day before the death of Child L. The records of this conversation indicate that there is knowledge that ML is drinking heavily, that MGM’s presence as a support to the children is reduced because of a serious illness. The agreement then that because the family were settled in their own home and that the home conditions have been generally good enough, the case could be stepped down to CAF if ML engages with alcohol services (even though it was known she had not) is dismissive of the purpose of the intervention over five months. It is noticeable that this key management advice was given outside of a formal supervision session and lacked analysis or understandable rationale. 5.18 There is a sense that practitioners over empathised with ML who saw the illness of MGM as an excusable reason for drinking. I would suggest that ML would find many reasons to excuse her drinking, it was having a profound impact on Child L and ML needed to experience frequent challenge so as not to collude with her and break down her distorted image. Although the AP from an adult facing perspective felt she could do little more than close the contact after ML did not engage, she did advise SW1 of this so that the impact could be considered as part of the ongoing assessment of risk for the children. The AP recollected her experience of attending the Child in Need meeting, which she described as very informal without access to a written plan and no minutes being made available. It should be noted that Child L was neither advised of or introduced to organisations that provide specific emotional support to children who are affected by alcohol such as Al-a-Teen or Nacoa (national association for children of alcoholics) , and that potentially access to such support could have helped Child L feel less lonely. Nacoa runs a helpline which can provide support at a time of crisis through the relative anonymity of a telephone call. Child L Child L Final Report 11 Sept 2017 26 clearly felt different to her peers staring a ‘just want a mother like other people have’. 5.19 The Review was keen to explore the position of FL in Child L’s life. SW1 acknowledged that she did little to achieve engagement with FL because in her view, and that of MHP, Child L did not see her father as part of her life. When meeting with the Independent Reviewer, FL agreed that he did not see Child L often but that he did see her consistently. FL is upset that he was not told of the risk to Child L and reports that he could also have provided a good deal of contextual information about ML and her drinking habits. FL advised that he had served a prison sentence for domestic violence against ML, and that he very rarely went to the family home fearful that if ML ‘kicked off’ he would be held responsible. FL advised that it was he who purchased the ticket for the pop concert that Child L enjoyed. FL presented as distressed during the meeting, and questioned if he had understood the difficulties she was in whether he could have provided a solution to her living arrangements. The tendency to exclude men and develop fixed thinking about what they can offer a child is commonly identified in Serious Case Reviews. 6. Learning from the Review 6.1 The use of existing multi-agency structures and processes is significant to responding to the needs of children who present a risk of suicide and self-harm. In particular, the use of a shared multi-agency plan with a focus on risk and resilience is critical to maintaining a focus on the child and achieving best outcomes. The analysis of this case demonstrates an inherent weakness in the approach to multi-agency working. SW1 as Lead Professional understood the need to approach the case using a model of multi-agency working, however, the practice fell short of achieving a consistent and cohesive team around the child and there was an absence of a meaningful Child in Need plan, a shared assessment of risk or identification of the resilience factors that could be built upon for Child L. There is often a misunderstanding in practitioners mind that work that falls under a threshold of Child in Need has less status than work that is identified within the child Child L Final Report 11 Sept 2017 27 protection arena and this can be reflected in the engagement of professionals. Children subject to Child in Need fall under the statutory requirements of Section 17 Children Act 1989, and professional must approach this with the same vigour as child protection work within Section 47 of the same act. The Child in Need meetings with key practitioners absent led to a more limited appreciation of risk as well as an absence of challenge on behalf of Child L. 6.2 Working with resistant parents to achieve change through partnership provides significant challenges for single and multi-agency working and it is the duty of professionals to remain clearly focussed on the impact of any ongoing risk of harm to each individual child. It is not uncommon for multi-agency professional to experience a level of resistance from families when there is a requirement for change. Working through the barriers of resistance is a common task that is achieved for the majority of families who come to the attention of additional welfare services but can be time consuming. The challenge for the multi-agency partnership is to establish whether sufficient change can be achieved within a timescale that reflects the needs of the child. The analysis of the case shows an insufficient focus on how the child was coping an experiencing parenting whilst agencies were trying to engage ML in a process of change. Child L told several professionals how she was feeling, how the experiencing of parenting affected her and this went unheard. Every child is unique and the impact of parenting will be different based upon their individual relationships and levels of resilience. Child L told professionals she could not cope within her home environment and that this led her to take an overdose. Her attempts to find alternative living solutions were misinterpreted as her not conforming rather than her only means of achieving a degree of control over the issues she found very difficult to cope with. 6.3 The assessment of parental capacity for change must be central to any multi-agency plan of intervention. The complexity of assessing the potential and actuality of Child L Final Report 11 Sept 2017 28 change in a parent with an alcohol/ substance addiction should be factored into children’s plans alongside an explicit understanding of the impact on the child. Examination of this case reveals little indication of change on the part of ML, save an occasional statement of intent. The case management approach showed a very limited understanding of the reality of alcohol dependency and an over optimistic acceptance what ML’s reluctant acceptance to see an alcohol counsellor would mean. The level of oversight and support that both Child L and ML needed in the weeks and months leading up to Child L’s death was not fully appreciated, there was a passivity on behalf of professionals that did not achieve the level of challenge and questioning that was required to ensure that Child L was sufficiently safe. This is evidenced by an undeveloped Child in Need plan, with an insufficient focus on identifying the impact on Child L should change not be achieved to enhance her welfare. Critical to this case was an understanding of the psychology of alcohol dependence, there was strong evidence that ML was unable to cease drinking over a prolonged period, yet a belief that this could be achieved over a short period of time by the application of external pressure and expectation. The outcome of the third Child in Need meeting effectively placed unchecked trust in ML that she could and would use the support of an alcohol practitioners to gain control over her drinking despite all indicators of behaviour suggesting otherwise. 6.4 The role of management oversight is critical to helping practitioners achieve safe outcomes when working with resistance to change in long standing and deep rooted family dysfunction. This reports suggests that both SW1 and MHP were at times struggling with how to respond to the issues this case presented, with SW1 maintaining a belief that ML could adapt and change her parenting once she had control over alcohol, and MHP believing that Child L should be offered alternative care. MHP was however unable to use organisational management processes to support the need for challenge to Children’s Social Care, and the management systems did not pick up the need to do so. MHP, although an experienced practitioner, had little understanding of how to challenge on behalf of a child and reported no knowledge of the LSCB procedures. Child L Final Report 11 Sept 2017 29 SW1, a social worker in her first year of independent practice needed a much more challenging management approach, one which offered reflective thinking time to take a step back and review what was known, what research in practice reminds us and how to use of all this information to reach a judgement about what Child L needed. 6.5 Critical thinking skills are necessary when undertaking complex family assessments and the use of such skills must be embedded in organisational culture and practice. Powerful thinking requires powerful questioning which does not always lead to comfortable answers. All practitioners are affected by inherent biases and we have to mitigate against the possibility of wilful blindness when faced with seemingly intractable scenarios. Developing critical thinking skills is of the utmost importance for safeguarding partners and we are reminded of this through successive national enquiries and reviews. It is crucial therefore that organisations pro-actively dedicate some time to think about how their cultures and processes support and encourage this kind of thinking in the sure knowledge that for practitioners it may be a lot easier to ‘go with the flow’ and not think outside of presenting issues. 6.6 Multi-agency professionals must remain alert and attuned to the role of men in families, avoid a recognised tendency for fixed thinking and adopt and exploratory and inclusive approach. It is striking that FL was neither informed nor consulted about the position of Child L, it is suggested that this is because Child L did not introduce her father as a source of potential support. From the professional’s perspective, it is possible that they were influenced by the knowledge that FL had been convicted and indeed served a prison sentence in relation to the assault of ML some years previously. ML had a right to know of the concerns about his children and Child L gave SW1 a contact number for him; whether he could offer support in terms of building resilience should have been explored. The failure to include men and in particular an absent father in assessments of families is almost a cliché, and the need to do so in order to understand a child’s whole circumstances must be continually re-enforced. Child L Final Report 11 Sept 2017 30 6.7 Maintaining good records of agency contacts and interventions is necessary to achieve chronologies which help practitioners and agencies analyse risk robustly, ensure that assessments take account of all known information and patterns and review the impact of their work. The standard of record keeping in CAMHs fell much short of agency standards. Whilst this has caused difficulties for this review, what is of greater concern is that this deficit had not been identified through usual management approaches and audits. Whilst contemporaneous records in Children’s Social Care were not in themselves a matter of concern, there was concern about the availability of minutes from Child in Need meetings. Whilst it is not necessarily the sole responsibility of the social worker to minute the meeting (and in this instance one meeting was minuted by the school), it is the responsibility for Children’s Social Care as the lead agency to ensure this is achieved. Minutes of such meetings should be used to structure the review of actions in subsequent meetings. The absence of multiagency agreements will lead agencies to reach their own, maybe conflicting interpretations, of what was achieved. 7. Conclusion 7.1 This case is a particularly sad death of a child in circumstances where she was known to be distressed and that this distress had previously manifested itself in an overdose. It is evident from the first intervention that Child L felt very alone with worries that she perceived her peers did not have, and that speaking of the worries about her family outside of her family was a very difficult thing to do. 7.2 There is great discomfort for the two key agencies involved in assessing risk to Child L who have both accepted that more could and should have been done to support and listen to her. 7.3 The findings from this Review lead to some significant considerations for the Board as follows: Child L Final Report 11 Sept 2017 31 Is there confidence that learning from previous reviews in respect of the challenges of assessing parental capacity for change has been embedded What can be done to support agencies to build on a culture of respectful uncertainly and embed critical thinking styles across the organisation Are multi-agency practitioners sufficiently equipped to understand the nature of substance abuse by parents and the impact on children How can the voice of the child become more prominent in the application of threshold criteria How can the partnership agencies demonstrate strengthened management oversight for children at risk of harm How are the processes which support multi-agency working maintained for all children across the spectrum of need 7.4 The Serious Case Review Panel considered how children at risk of self-harm and suicide could be better anchored into multi-agency structures which provide a high level analysis of risk and determine a multi-agency approach to support. To this end, it is recommended as a matter of urgency that all children assessed to be at medium or high risk of harm through self-harm or suicide are referred by the assessing agency directly to Children’s Social Care who will then coordinate a multi-agency professionals meeting, which could be a strategy meeting when significant harm or risk of significant harm is identified |
NC046141 | Death of a 14-year-old black boy in September 2012, as the result of a fatal stab wound to the heart. Child M was stabbed by another teenager, following an altercation. Child S was found guilty of murder and sentenced to life imprisonment, to serve a minimum of 14-years; the Judge referred to the incident as a "revenge killing". At the time of the incident, Child M had been missing from home for nine weeks; family was not known to children's social care prior to Child M's going missing. Child M attended college a week after he was first reported missing. Police and children's social care were informed and told that Child M did not want to return home as he was scared he would be beaten by his stepfather; neither agency visited the college nor investigated this disclosure and Child M was allowed to leave college without confirmed arrangements for his care. Identifies issues including: difficulties between Child M and mother; and Child M's wishes distracting professionals from considering the risk to Child M as a missing child. Identifies key learning, including: passive response from police and children's social care to a missing 14-year-old child; passive attitude of police to communicating with parents; and insufficient involvement of mother's partner in assessments. Makes various recommendations covering: professional challenge and escalation; communication between schools and colleges and other agencies during school/college holidays; and whether child protection services received by older children are robust and the extent to which gender and ethnicity effect them.
| Title: Overview report in respect of Child M: a 14 year-old teenager. LSCB: Croydon Safeguarding Children Board Author: Ghislaine Miller Date of publication: [2015] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Confidential Croydon Safeguarding Children Board Serious Case Review under Working Together 2010 Overview Report In respect of Child M: a 14 year-old teenager October 2014 Confidential 2 CONTENTS Page EXECUTIVE SUMMARY 3-6 OVERVIEW REPORT 1. Introduction, Terms of Reference and Serious Case Review process 7-10 3. Family and Professional Context 11-12 4. History of Professional Involvement 12-24 5. Child M’s Journey 25 6. Analysis of Practice 26-33 7. Key Learning Points and Emerging Themes 33-37 8. Conclusions 37-38 9. Overview Report Recommendations 39-40 10. Individual Management Review Recommendations 40-41 Confidential 3 EXECUTIVE SUMMARY 1.1 1.2 1.3 1.4 1.5 1.6 1.7 This Serious Case Review (SCR) concerns the tragic death by stabbing of Child M: a 14-year old black teenager from Croydon. He was stabbed whilst travelling on the bus, and was stabbed by another black teenager, following an “altercation”. It is not known what the argument was about, but Child M was found to have a small amount of drugs on his person at the time of the autopsy. It would be speculative to draw any conclusions from this. CHILD M came from Rwanda to the UK with his mother when he was 14 months old. His mother claimed asylum for herself and her son, and they were later granted indefinite leave to remain and later naturalised as British Citizens. UKBA records confirm that Child M’s father also arrived in the UK that day. Child M lived for several years with both his parents, but they later separated. At the time of his death, CHILD M was living with his mother, Mrs P, her partner, Mr Q and his stepbrother, Child N. He still maintained contact with his father, Mr T, who re-married and has a young child from that marriage, Child O. At the time of his death, Child M had been missing from home for nine weeks, and it is this period that the SCR is focussed on. Prior to being reported missing in the summer of 2012 Child M was not known to Children’s Social Care (CSC). Child M was known to the Police and had been stopped and searched by them on several occasions during the previous eighteen months, but on each occasion “nothing was found” (quote from Police IMR). During the three year period prior to his death he had been involved in five incidents that the Police attended, where he was part of a group of youths involved in fights with other groups of youths. On one occasion the group assaulted a 14-year old boy. On each occasion no charges were brought and there was no further action by the Police. Child M was best known outside his family and friends, by staff at the college he attended in another London Borough and was described as “ likeable and very sociable, but on occasions engaged in silly “off task” behaviour. He made friends quickly and was throughout his time at college, a popular pupil”. Child M left home on a Friday evening in July 2012, following an argument with his mother. This was partly provoked by the fact that she, MRS P, had been to a meeting at the college the evening before (concerning his on-going lateness in getting to college in the mornings) and had locked him out of the house as a punishment. She did not return home until 10pm, which he reported to college staff the next day (Friday) as it had made him Confidential 4 angry and upset. He returned home after college that day, but ran away that evening. This was the last time his family saw him alive. 1.8 1.9 1.10 1.11 1.12 1.13 Once reported missing, the three agencies involved in the case were Education (in the borough where Child M attended college), CSC (Croydon) and the Police. All three agencies have provided Individual Management Reviews (IMRs) that outline their involvement. A pivotal issue in this SCR is that Child M was seen on one occasion by College staff, a week after he had been reported missing from home. He went into College as it was the last day of term, and was there from 9.30 in the morning until the College closed at 2pm. Although there was telephone communication between these three key agencies, there is a divergence of view in the three IMRS about what happened and what was said that morning. This is analysed in the full report. Crucially, neither the Police nor CSC sent a member of staff to the college that morning to talk to Child M (he had threatened to run away if they did) and the College (on the advice of the duty social worker in CSC) made a contingency plan that he would go and stay with a relative and CSC would pick up the case from there. In reality no contact had been made with the relative to agree this plan, Child M’s parents were not involved or informed, and at 2pm when the College closed Child M left the premises and was not seen again. PARALLEL PROCEEDINGS Post Mortem and Coroner’s Enquiry: a Home Office Forensic Pathologist carried out a post mortem examination in September 2012. It is of note that during the examination, a small amount drugs was found. The provisional finding about the cause of death was a fatal stab wound to the heart. The inquest was opened later that month, but was adjourned pending the outcome of the criminal proceedings. Criminal Proceedings: Child S was found guilty of murder and has been sentenced to life imprisonment (to serve a minimum of 14 years). The Judge referred to it as a “revenge killing”. Independent Police Complaints Commission: This SCR was commissioned in October 2012 and was due to be completed in April 2013. However, the process was put on hold, as Child M’s mother, Mrs P, made an official complaint to the Independent Police Complaints Commission (IPCC) about their response to Child M being missing. The Police Officers involved were interviewed as part of the complaints process but could not be interviewed by the Police IMR author for this SCR until the Confidential 5 1.14 1.15 1.16 complaint had been fully dealt with. The SCR process resumed at the end of May 2014, with a reconvened meeting of the Serious Case Review Panel (SCRP). The outcome of the complaints investigation is described more in paragraph 1.19 of the Overview Report CONCLUSION It is not known where Child M lived whilst he was missing from home, but there were several sightings of him, and on each of these occasions, he reportedly looked clean and well cared for. The terms of reference state that he was involved in drug related gang activity and was ”harboured” by a gang. No evidence has been provided during the SCR to support this view. The members of the SCRP and the Overview Author are of the view that there has been no evidence to suggest that Child M’s death might have been predicted or prevented. Although Child M was missing from home at the time of his death, there is no evidence to suggest that his death was related to the fact that he was missing from home. RECOMMENDATIONS 1.17 1.18 Missing Children There is evidence that, despite protocols already being in place, that what is absent, is a real understanding of what can trigger a young person running away and how agencies can respond proactively, including keeping the family informed. The recent APPG1 report from the Joint Inquiry into children who go missing and the recent Ofsted report2 on Missing Children could be used to enhance learning and improve multi-agency practice in this area. Recommendation 1 It is recommended that Croydon LSCB monitor compliance with the recently implemented Missing from Home, Care and Education Procedure (January 2014) to ensure a more robust response from all agencies when children go missing and that the LSCB ensure information is gathered regularly about children in Croydon who are at risk of going missing, and aim to reduce those numbers (Outcome: Children who go missing regularly are addressed as a higher priority by all agencies, reducing the number and frequency of such episodes). 1 Report from the Joint Enquiry Into Children Who Go Missing from Care: APPG for Runaway and Missing Children and Adults and the APPG for looked after Children and Care Leavers. June 2012 2 Missing Children, Ofsted, February 2013. Reference no: 120364 Confidential 6 1.19 1.20 1.21 1.22 Professional Challenge and the Use of Escalation There is evidence of poor inter-agency communication and information sharing. It is important that agencies understand and use existing escalation procedures in order to resolve matters effectively. Recommendation 2 Agencies are to re-assure the LSCB that the current multi agency escalation procedures are understood and used appropriately. (Outcome: staff feel more confident that they are able to raise concerns about the actions of other agencies or staff in their own agencies in order to resolve matters of divergence effectively). Including Male Partners in Assessments There is evidence of a lack of professional curiosity about the role of Mr Q in this “re-constituted” family and the quality of the relationship between him and Chid M. He was not included in the Initial Assessment and should have been. Recommendation 3 The LSCB QA and Performance Sub-Committee to ensure agencies understand the importance of including male partners in assessments. (Outcome: to ensure that all those involved in the “parenting” of children or who are part of a family network, are included in assessments) 1.23 Communication Between schools/colleges and other agencies during school/college holidays. This SCR has identified the need to ensure follow through of any safeguarding concern or missing child concern that occurs just before holiday periods. There should be someone with responsibility for making sure that referrals and concerns generated by colleges have been received and acted upon. 1.24 Recommendation 4 The LSCB to be notified and assured by schools and Colleges that there are appropriate arrangements in place to ensure that all have a single point of contact (SPOC) during school holiday periods that is shared with a senior manager in Police, CSC and Health. Conversely, that these other agencies have a SPOC whose details are shared with schools/colleges. 1.25 1.26 Older children who go missing from home This case has highlighted an underlying assumption by professionals that a seemingly competent and confident 14 year old can look after themself during a 6 week holiday period. This begs the question of how we view the risks of gang and drug involvement and knife crime involving predominantly to young black males in areas of London. Recommendation 5 The LSCB to commission a review of whether services received by older children who go missing are sufficiently robust and to what extent gender and ethnicity plays a part. Confidential 7 OVERVIEW REPORT SECTION 1: INTRODUCTION 1.1 Croydon LSCB commissioned this Serious Case Review (SCR) following the death of Child M in September 2012, aged 14 years and 7 months. On the previous evening he had been travelling on a bus in Lewisham with friends, when there was an “altercation” with another young person, Child R, then aged 15 years and 4 months. Child R’s friends, who were also on the bus, telephoned his older brother, Child S, who was travelling on the bus immediately behind. It is understood Child S got off the bus he was travelling on, and jumped onto the bus the other young people were on. He was witnessed running upstairs on the bus, stabbing Child M in the chest, and then running downstairs, leaving the bus and running away. Child M ran downstairs after him, but collapsed on the bus, at the exit. 1.2 Professionals from the Fire Service were first on the scene, and attempted CPR, gave oxygen and electric shock. The Helicopter Emergency Service (HEMS) were called at 9.42pm and arrived 21 minutes later to find Child M in cardiac arrest. An emergency thoracotomy was performed at the site of the stabbing and he was transferred by helicopter to Kings College Hospital, arriving there at 10.56pm. He was transferred to the Cardiac Theatre, but died in theatre at 3.23am the following morning. Both parents were at the hospital at the time of his death. 1.3 Child M had been reported to the Police as a missing person by his mother, Mrs P, on Saturday 14 July 2012, so at the time of his death he had been missing for 9 weeks. The Missing Person Report was closed by the Police on 20 July 2012, when Child M attended college, and was deemed by the Police to be in a Place of Safety. Later that day, the duty social worker, advised Mrs P to telephone the Police to report that Child M was still missing. Mrs P did not make this telephone call until the evening of 6 August. A second Missing Person report (MISPER) and a MERLIN were completed by the Police on this day (6th August 2014). 1.4 There had been no previous involvement with Children’s Social Care (CSC), but as a result of Child M being missing, the CSC Business Support Officer, was contacted on 20 July 2012, by both an officer from the Police Missing Persons Unit and a member of staff from the College where Child M was a student. The latter resulted in a referral to CSC and the case becoming open to CSC, although Child M was not seen at any point because he was missing. 1.5 The last professionals to see Child M, apart from those involved on the day of his death, were the staff at the College, as he attended on 20 July 2012, which was the last day of term. Confidential 8 Serious Case Review Process 1.6 The case was referred to the Croydon Standing Serious Case Review Panel (SCRP) and was considered at the meeting on 28 September 2012. It was decided that the criteria for conducting a Serious Case Review (SCR) were met, in accordance with paragraph 8.12 of Working Together 2010 and that a recommendation should be made to the LSCB Chair that a SCR be conducted. The LSCB Chair endorsed the recommendation of the SCRP on the same day, 28 September 2012 and the Department for Education was also notified the same day. Terms of Reference 1.7 Terms of reference for the review were initially drawn up by the Standing SCRP and were agreed at the first SCRP for this particular case on 17 October 2012. The terms of reference were amended following the second SCRP meeting on 17 December 2012. These amendments involved corrections to some family background details. 1.8 The terms of reference are those outlined in Working Together 2010, with two additional specific questions to be addressed, namely: Child M was a young person who was believed to be gang involved and who was missing for a significant time. Did local agencies respond appropriately to the risks to which he was subject? Child M was a black boy who was involved in gangs and very vulnerable. Was there evidence to suggest that his ethnicity and gender affected the quality of services that he was offered? (Author’s Note: Terms of reference should raise issues to be considered and explored during the SCR process. These two issues as they are written in the terms of reference, suggest that they are based on facts about Child M’s involvement in gangs. However, it is the view of the Overview Author and the SCRP is that they are unfounded. In hindsight these two points could have been more carefully worded at the start of the SCR process) 1.9 The agreed timescale for the review was 1 July 2012 up to and including the death of Child M on 16 September 2012. 1.10 Ghislaine Miller, Independent Consultant and Director of Ghislaine Miller Consultancy Ltd. was commissioned as Overview Author and attended all SCRP meetings with a remit to question, understand and challenge. 1.11 The Overview Author has an MA in Social Work and an Advanced Award in Social Work. She has significant experience in the work of Local Safeguarding Children Boards and Serious Case Reviews and is an accredited Overview Author, accredited in October 2010 by the Tavistock Consultancy, London Safeguarding Children Board and Department for Education. The author is also a trained Lead Reviewer, trainer and mentor Confidential 9 1.12 for the Social Care Institute for Excellence (SCIE) Learning Together model of systems based case reviews. The author is independent, with no prior knowledge of or involvement in this case. Laura Eades, Independent Consultant and Director of Eadeskersewell Strategic Ltd, was appointed as Independent Chair of the SCRP. Panel Membership 1.13 Laura Eades, Independent Chair Representative: Croydon Borough Police Service Manager, ICD, Croydon CSC Designated Nurse, Child Protection Team Manager, Croydon Youth Offending Team Secondary Consultant, College Improvement Service, Croydon LSCB Education representative from the borough in which Child M attended College CSCB Business Manager CSCB Administrator 1.14 IMR reports were commissioned from the following organisations: Children’s Social Care, Croydon Education and Colleges, Croydon College which Child M attended in another borough Croydon Health Services (A&E, college nursing, health visiting and community and acute services) NHS Croydon (GP) Kings College Hospital (letter) London Ambulance Service (LAS) (letter) United Kingdom Border Agency (UKBA) (letter) Fire Service (letter) Children’s Social Care, Lewisham 1.15 The SCRP met on 6 occasions from 17 October 2012 onwards. The original agreed submission date was 30 April 2013. However, a decision was made to put the process on hold in March 2013, as Child M’s mother, Mrs P, had made a complaint to the Independent Police Complaints Commission (IPCC), This meant that the officers who needed to be interviewed for the Police could not be seen until after the IPCC had dealt with the case. The SCR process was resumed in May 2014. 1.16 There has been an emphasis on learning lessons from this Serious Case Review, as well as quality assurance. This has been built into the process through: IMR authors presenting their reports to members of the SCRP on 17 December 2012. This enabled panel members to ask questions regarding omissions, discrepancies in information and provided an opportunity for emerging issues to be discussed. This discussion Confidential 10 provided an early opportunity to identify lessons for learning that could be used to improve practice, with an emphasis on early implementation of that learning. The IMR reports have been quality assured by the SCRP. Further work (for example clarification, further exploration of particular issues, ensuring that the recommendations flowed from the analysis and were SMART) was requested by the SCRP on some reports. This additional work was completed within the requested deadlines. Parallel Processes 1.17 1.18 1.19 1.20 1.21 Criminal Proceedings: The criminal proceedings in relation to Child S have been concluded. He was found guilty of murder and sentenced to life in prison (minimum of 14 years). The judge described it as a “revenge killing”. Post Mortem and Coroner’s Enquiry: a Home Office Forensic Pathologist carried out a post mortem examination of Child M in September 2012. A small amount drugs was found during this examination. The provisional finding about the cause of death was a fatal stab wound to the heart. The inquest was opened on 25 September 2012, but was adjourned pending the outcome of the criminal proceedings. Independent Police Complaints Commission The IPCC process commenced on 9 October 2012 and the Investigating Officers report was completed on 18 September 2013. Mrs P lodged an appeal that same day. The report in relation to the appeal was signed off on 24 February 2014. The complaints made by Mrs P were: A Police Officer had been rude to her (upheld) Failure by the Missing Person Unit to keep the family updated on progress (upheld) Not enough enquiries were made with the college to obtain addresses for friends (upheld) A photograph of Child M, provided by the family to the Police was not passed on to the Missing Person Unit as promised (upheld) Involving the Family An appointment was made for the Overview Author and Independent Chair to visit Mrs P, but she was not at home. She had previously been written to twice but did not respond. The LSCB Business Manager and Overview Author visited Child M’s father, Mr T, at home in January 2013. A follow up visit was made in February 2013. Attempts have been made to contact both parents and the family relative on completion of this report, to discuss the outcome and findings of the SCR. However, to date, it has not been possible to contact them at the addresses or on the telephone numbers previously given. 11 SECTION 2: FAMILY AND PROFESSIONAL CONTEXT 2.1 2.2 2.3 Family Context Family Composition Name Age at the time of Ethnicity Child M’s death Living at Mrs P’s Home Mrs P (Child M’s Mother) 39 Black/African (Rwandan) Mr Q (Mrs P’s partner) n/k White British Child M 14 Black/African (Rwandan) Child N (half-sibling) 5 Black/African (Rwandan/Polish Living at Mr T’s Home Mr T (Child M’s Father) 53 Black/African Mr T’s wife n/k Black/African Child O (Mr and Mrs T’s child) 4 Black/African Child M and his mother, Mrs P came to the UK from Rwanda in April 1999. Child M would have been 14 months old at this time, and his mother 24 years of age. She claimed asylum for them both. They were granted Indefinite Leave to Remain in April 2004. Child M was naturalised as a British Citizen in September 2005. Mrs P has told professionals that she was not having a relationship with Child M’s father when she became pregnant, and that he came to the UK some time after her. Clarification was sought from the UKBA on the detail of Mr T’s arrival in the UK and they have confirmed that he arrived in the UK on the same day as Mrs P and Child M. When Child M was due to start secondary college in September 2009 Child M’s parents had separated but had discussions about Child M’s education. They agreed that he would attend the College local to where his father lived as this would provide continuity as he had attended primary school in that area. They agreed that Child M would live with his father on College days during term time, and Mr T described how he would take Child M back home to his mother’s on Fridays. 12 2.4 2.5 2.6 2.7 2.8 2.9 Mr T could not remember when this arrangement ended, but College records indicate that on 17 March 2011 he went to the College in response to a letter about Child M’s punctuality and confirmed that Child M was now living with his mother on a full time basis. When asked what triggered Child M’s move back to his mother’s Mr T said that is “what she wanted” and shrugged his shoulders. In 2007 Mr T’s wife had arrived in the UK from Uganda, along with his now 23-year old son from a previous relationship. In March 2008, his wife gave birth to Child O. Child M lived with his father, two half siblings and stepmother on college days between September 2009 and 2011. In August 2007, Mrs P gave birth to Child N, who is of dual heritage and is Child M’s half sibling. (The SCRP later made a referral to Children’s Social Care because of concerns about Child N. An Initial Assessment was carried out and “identified some areas of potential safeguarding concerns” (CSC IMR report) for Child M and Child N. The Police were involved in 2 domestic abuse incidents in July and August 2007, when Mrs P alleged that Mr Q had assaulted her. The Police took no action but gave advice to both parties. The Police considered that the first alleged incident was a “malicious” report on the part of Mrs P. There is also evidence that Mrs P was living in a refuge between June 2003 and August 2004, and the Police were involved in 2 incidents where she alleged assault and racial abuse by 2 other residents who were of Kosovan nationality. No further action was taken. Mr Q has no previous convictions. There is evidence that he has suffered from depression in the past. Mr T has no previous convictions. Mrs P has one conviction for assault in relation to an incident in September 2011, where she allegedly tried to stab a male neighbour. She refused to accept a caution and was found guilty of Common Assault at South London Magistrates Court in February 2012. She was given a conditional discharge. CSC would have been sent a MERLIN in relation to this incident. Mr T told the Overview author that he got on well with Mrs P and with Mr Q, saying of him, “I completely applaud him and admire him”. Professional Context 2.10 Children’s Services: An Ofsted inspection of safeguarding and looked after children services took place in May 2012. The overall outcome was adequate but there were some areas for improvement, including arrangements in the Intake Team, supervision and management oversight. 2.11 Police: Child M’s mother, Mrs P, made a formal complaint to the IPCC in relation to the two Missing Person reports. The impact of this has been that the Police IMR is based on written records and no interviews could take place with the Police Officers involved in this case until the complaint process was completed hence the delay in completion of the SCR. 13 SECTION 3: THE HISTORY OF PROFESSIONAL INVOLVEMENT (1 July to 16 September 2012) 3.1 3.2 3.3 3.4 The Education IMR outlined that Child M “was an able pupil who was not achieving his full potential though he had an improved behaviour record. The significant issue continued to be his lateness”. Child M’s mother was invited to the college on Thursday 12 July 2012 to discuss this with the Head of Year. Mrs P and Mr Q attended the meeting. The Head of Year described Child M as “generally polite, co-operative and honest: an intelligent student who had the potential to do well in his studies”. Mrs P expressed her concern about where Child M went to after College every day, not returning home until late. She told the Head of Year that when Child M refused to get up for College in the mornings she “bit’ him. The Head of Year was not sure whether Mrs P said that she ‘bit” Child M or “beat” him. There is no evidence that she sought to clarify this with Mrs P at the time, and the IMR author reported that in interview the Head of Year said she “was concerned about the nature of the comments made but was unable to follow this up fully with Child M”. (Author’s Note: it would have been good practice to have probed further about what Mrs P was saying in order to assess if there were any child protection issues that needed following up. Mr Q could have been asked by the HOY to clarify what it was that Mrs P was saying, but there is no reference in the College IMR to his part in the discussions). The following day at College, Friday 13 July 2012, Child M was reported (by the HoY in interview) to be “very unhappy”. He told her his mother was “very unfair on him”. For example, she had told him to be home by 6.30pm the previous evening, but his mother was at the meeting at the College she did not arrive home until 10pm, and as he had no keys to the house (Mrs P had taken them from him as a punishment) he had to wait in the garden. Child M told the HoY that this happened often and that was the reason why he did not go home on time. He described that he and his mother would have arguments about this, but that she did not physically chastise him. At the end of the day the Head of Year e-mailed the Child Protection Designated Teacher (CPDT) to raise her concerns about Child M. On the evening of Friday 13th July 2012 Child M ran away from home where he lived with his mother, Mrs P (then aged 37), and his half sibling Child N (then aged almost 5). Mrs P told various professionals that her partner, Mr Q, did not live with her (and he does have a different address in another part of London according to Police records), but the impression is that he did spend quite a bit of time in the household, and was referred to by various people as Child M’s step-father. 3.5 Child M’s birth father, Mr T, who lives in another part of London, told the Overview Author that on the evening of Friday 13th July 2012, at about 9.30pm, Child M’s ‘step-dad” Mr Q, had telephoned him, to say that Child M 14 was being “unruly”, and could he go to the house and either pick Child M up and take him back to his house, or help “try and resolve whatever there was (going on) between the two of the them” (Mr Q and Child M). Mr T said he got on well with Mr Q, and felt he was asking for his help to sort Child M out, and he knew how difficult Child M could be as a typical teenager. Mr T told the Overview Author that he was in another part of London at the time he took this call and told Mr Q that he would get there as soon as he could. 3.6 Mr T said that by the time he arrived at the house “Child M had bolted”. Mr Q had locked the front door to prevent Child M running away, but Child N said that he escaped out of a ground floor window overlooking the garden. 3.7 Mr T said he waited at the house for a while, and tried calling Child M on his mobile telephone, but the phone was closed. He said Child M had never run away from home before, so they were not sure what to do. Mr T suggested that they waited until the morning before they telephoned the Police, in case Child M returned of his own accord later that night. 3.8 3.9 3.10 3.11 3.12 The following morning. 14 July 2012 Mr T, Mrs P and Mr Q started calling the telephone numbers of any friends of Child M, to see if anyone knew where he was. Mr T and Mr Q also went looking for Child M in the Charlton, Woolwich areas of London. Whilst out looking, they met up with a relative of the family, who knew Child M well. This relative helped them look for Child M that day. Mrs P contacted the Police at 1.45pm that afternoon, 14 July 2012, to report Child M missing. The Police MERLIN record states that Child M had last been seen at 9 am that morning (this is at odds with what Mr T has reported). The MISPER also stated that Mrs P had said Child M and Mr Q had had an argument the night before. She said Child M’s behaviour had changed over the previous few months, but even so, he had never gone missing before. The initial risk assessment made by the Police at this point was that Child M was a ‘medium” risk in view of his age. (Medium Risk is defined as “the risk posed is likely to place the subject in danger or they are a threat to themselves or others”.) This MERLIN Missing Person Report (MMPR) was reviewed by the Croydon Police Public Protection desk and forwarded to Children’s Social Care (CSC) on Sunday 15 July 2012. On Monday 16 July 2012, Mrs P, Mr T and the relative all went together to College. Mr T said they went there to see if Child M had gone into College that day and also with the intention of asking staff at the College to speak to Child M’s friends and see if anyone’s knew where he might be. When they arrived there they discovered that Child M was not in College. The Education IMR states that they were at the College all morning. It is recorded that that Mrs P reported that she had “disciplined” Child M the previous evening after she had returned from the meeting at the college. Whilst at the College Mr T said they spoke to one of Child M’s friends who 15 3.13 3.14 3.15 3.16 3.17 said they had seen him on the night of Friday 13th July when Child M had gone to his house to pick up a games console. Another pupil said he had seen Child M “in passing” in the Eltham area of London on the morning of Sunday 15th July. Before the parents had gone to the College that morning their relative had been able to access Child M’s Facebook account and saw that someone called Friend 3 had sent Child M a message on Saturday 14 July, to which Child M had replied. When they went to the college on Monday 16 July, the parents discovered that Friend 3 was a girl in the year above Child M. The Education IMR reported “it emerged through talking to Child M’s friends that he had gone to a friend’s house at midnight on Friday 13 July, and that he had been seen by another friend in Middle Park on Sunday 15 July”. Friend 3 was spoken to and she confirmed that she was in contact with Child M on Facebook, and was sending him “messages of concern”. She thought he was staying with male friend in Charlton. He was not student at College and she did not know his name. The Education IMR states that they passed this information to the Schools Liaison Police Officer, but the police have no record of this. According to Mr T, after they left the College that day, they went to Woolwich Police station. The relative had said that although Child M had already been reported missing to Eltham Police, they knew that Child M used to “hang out” in Woolwich, so thought it would be a good idea to go to the Police Station there. Mrs P had a photograph of Child M with her. The Police Officer they saw at the station said, in response to seeing the photograph, that Child M looked familiar and that he thought he recognised him and had seen him previously in Woolwich (not from being in trouble, but from “hanging out’ there). The Woolwich Police Officer telephoned a Police Officer at Croydon Police Station, and they confirmed that a Missing Persons report had been made previously. They tried to give the Woolwich Police Officer the photograph of Child M, but he would not take it and said they needed to take it to the Croydon Police Station. Mr T said he went back to Croydon Police Station on Wednesday 18 July 2012 to take the photo. There is no record of this in the Police chronology. Mr T said that he also went back to the College on Thursday 19th July 2012, as Child M had posted some messages on Facebook (that their relative was able to access) to say that he was going into College that day. However, when Child M’s father spoke to one of the staff at college that morning they said that Child M was not in college and in fact all the class were out on a college trip. (Author’s Note: This is reported in the Education IMR. That evening Child M again posted a message on Facebook to say that he was staying at a friend’s house and had already arrived there. This was so that he could go into college from there the following day, Friday 20 July, which was the last day of college term). According to the Police chronology, also on 19 July 2012, a Police Officer contacted Mr Q. It is not clear if this was via a telephone call or face to 16 3.18 3.19 3.20 3.21 face. Mr Q said he believed Child M was in the Charlton area. In the Police chronology it is quoted as, “he has no concerns. His mother also sent a message on Facebook saying they were both sorry, he should come home as they will not put him into care”. On Friday 20 July 2012, Child M did go into college. The Education IMR reported that he was “well presented, clean and tidy and there were no external indicators to suggest any concern about his physical welfare… he was sharp and articulate and he was asked to remain in the office, which he did for the duration of the day”. The atmosphere in college was described as relaxed and cheerful as the college was due to close at 2pm. Child M went to his tutor room during the course of the day to share the doughnuts brought in for the group by his form tutor”. (Author’s note: an over optimistic statement about Child M. By this time he had been missing from home for a week. There should have been a risk assessment at this point) The Head of Year contacted the Child Protection Designated Teacher (CPDT) and it was agreed that the Police and CSC would be contacted. She told Child M that she needed to contact CSC and the Police and he was “very agitated” about this and “made it very clear to all the professionals involved (by this time the HoY was joined by the CPDT who had been “off-site for a large part of the day”, and the Deputy CPDT) that he would not go home and that if CSC or the Police were contacted he would “run”. The Deputy Head of Year telephoned the Police and spoke to the Police Constable from the Sexual Exploitation and Missing Person Unit (SEMPO). It is not clear when the SEMPO took over the investigation. It is not recorded what time this telephone call was made. The Deputy Head of Year said that Child M had “turned up” at College that morning and “he appeared agitated, but confirmed he was safe and well”. He told her that he had spent the previous night with Friend 3. The Police IMR records that the Deputy Head of Year told the Police Officer that “Child M was frightened of going home and physical abuse was mentioned”. There is no further detail of this information on the Police report. The Education IMR gives a different account of this situation and states “Child M was agitated about the decision (to contact the Police). His main concern was that he would be sent to Africa and he made no reference to being worried that he might be at risk if he returned home”. (Author’s Note: the Police report in their IMR that the College mentioned Child M’s fear of going home and “physical abuse was mentioned”. Sadly, it does not go into further detail. The Education IMR author states that Child M made no mention of being afraid of going home and the fear of being physically abused. This is a clear divergence of view. The nub of the matter is that if Child M did express concern to the HOY about being afraid of going home, this should have formed the basis of considering a child protection referral to CSC. There is no record that the College shared the comments Mrs P had made about biting/beating Child M. This could also 17 3.22 3.23 3.24 have been included in the referral to CSC, as it is another incident of concern that needed assessing. When Child M spoke to the HOY on 13 July, he said that his mother shouted a lot, but that she had never chastised him physically). The Police PC advised the Deputy Head of Year to make a referral to Croydon CSC. It is reported in the Education IMR that the Police Officer said that, as Child M had been found safe and well that there was no longer a role for the Police. It was at this point that the Police closed the MERLIN. (Author’s Note: it would have been expected practice for the Police to attend the College to see Child M and conduct an interview with Child M before closing the Missing Persons Report. This view is upheld by the IPCC on 2 grounds a) Their Standard Operating procedures are clear that there must be a de-brief with a missing person who has been found before the case is closed and b) given the comments, albeit vague, about possible physical abuse, a Police officer should have gone out to the college to speak to Child M about this. The College did challenge the Police, which is good practice, but the Police were clear they would not go out to the college. (Author’s Note: Given the comments the Police said the Head of Year made about Child M being afraid of going home, it would have been good practice for the Police and CSC to have a Strategy Discussion at this point to jointly agree a plan. Some members of the SCRP and the Overview Author are of the view that this was an urgent situation that needed a quick response, with either the Police, a social worker, or both, going to see Child M at the College, given that he had been missing from home for a week. Although he was deemed “safe” at College, it was the last day of term and the College was due to close for the summer in a few hours. However, the Police are clear that with 15 children going missing every day in the Croydon area, they would not have had the resources to go out to the College. They were particularly under resourced at this time, because the Olympics were taking place and several Police Officers had been taken off normal duties. The duty social worker (social worker 3) also made it clear that she was not in a position to go out to the College (which was outside the Croydon area). The impact of these decisions by the Police and CSC was that responsibility was handed the back to the College to make a plan, and this put them in a very difficult position, with the added pressure of them closing in a few hours and Child M threatening to run away.) The Police advised the College to contact Child M’s parents to let them know he was safe and well, but because Child M was “adamant” that he “wanted nothing to do with his parents, and was threatening to leave” the College did not contact them. (Author’s Note: While listening to the voice of the child is important, there is evidence that that Child M and his views were driving events at College on the morning of 20 July. This seems to have distracted professionals at the College from considering whether, as a 14-year-old child missing from home, he was likely to be vulnerable and at risk). 18 3.25 3.26 3.27 3.28 The Police PC then telephoned CSC and spoke to the Business Support Officer to alert her to the fact that someone from the College would be telephoning to make a referral about Child M. It is not clear whether or not the Police Officer told the Business Support Officer that Child M by this time been reported missing for a week, and that he had turned up at College where he had made an allegation of possible abuse. At this point the Police closed the Merlin Missing Person Report. The SENCO at College (who was also the Deputy Designated Child Protection Teacher) then telephoned CSC and was put through to the duty social worker, SW3. He explained to her that Child M had been reported missing since 14 July 2012, and that Child M, had arrived at College that day, 20 July 2012, and “said that he had been staying with various friends”. The CSC IMR reports that social worker 3 recorded that the SENCO said Child M had disclosed that there had been arguments at home and that he did not wish to return, “as he was afraid that he would be beaten by his stepfather, Mr Q”. The SENCO was also reported by the duty social worker (social worker 3) to have said that there had been no previous concerns about Child M at college, he “had presented as well cared for and clean”. The SENCO gave contact details for Child M’s father, Mr T. The duty social worker asked the SENCO to find out further information from Child M about when he was last hit and where, and where he was currently staying (Author’s Note: it was the role of the social worker to go out to the College and ask these questions as part of her assessment of the situation) .The social worker also advised him to let Mrs P know that Child M was at College. (Author’s Note: This is the second instance where the College view diverges from that of another agency: on this occasion it is CSC. The Education IMR author states that Child M did not mention being afraid of returning home because of possible physical abuse by Mr Q) The Education IMR recorded that the SENCO ( who was also the Deputy CPDT) “sought advice” from CSC and “it was agreed that the College would try to work with Child M in order to find alternative safe accommodation for that night. They identified, in discussion with Child M, a relative who had been to the College on 16 July as a possible alternative carer. Child M thought this relative might be able to mediate between him and his mother. Child M said he didn’t know the relative’s address but gave College staff the telephone number. They tried to keep Child M with them whilst they telephoned the relative. (Author’s Note: there is no record that the relative was contacted and spoken to, and agreed to the plan of having Child M to stay.) A member of staff offered to take Child M to his relative’s house, but he refused and threatened to run away. The Deputy Head of Year told Child M that he appeared to be “blackmailing” the staff and he agreed. Child M “did eventually compromise and agreed in principle to being dropped off near to the relative’s house. CSC was contacted for “advice and “their view was that, given the circumstances, that the best course of action would be to let Child M go on the understanding that he would make his own way to his relative’s house. Child M left the College at 2pm when 19 3.29 3.30 3.31 3.32 3.33 3.34 all the other pupils left for the summer break. The Education IMR report said that Mrs P telephoned the College later that day and was told that Child M had agreed to make his way to the relative’s and “she appeared to be happy with the plan”. Shortly after this (and probably in response to the telephone call she had received from the SENCO) Mrs P telephoned the duty social worker. She explained that Child M’s behaviour had deteriorated of late since he began to “associate with the wrong peer group”. She said her boyfriend Mr Q, did not live with them, and said that he and Child M had a good relationship, and that Mr Q never hit Child M. The duty social worker (social worker 3) advised Mrs P to contact the Police and report Child M as still being missing. The duty social worker (social worker 3) then tried to telephone the College, but there was no response. The CSC IMR recorded that, “this was the last day of term and there was no further contact between CSC and the college until early September 2012. No written referral appears to have been made by the College to CSC”. (Author’s Note: it is striking that communication with the College came to an abrupt halt on that afternoon on the last day of college. It is surprising that there was no point of contact for professionals from other agencies until the new term started. There was no contingency plan in place by the College for following up on Child M). During the meeting with the Overview Author, Mr T described how he had tried to call Child M’s mobile that day (20th July), but it was still closed. He telephoned the College after 9am and asked the person who answered whether Child M had turned up at college that day. He was told that “no, Child M has not come into college” and “the person who is dealing with it is not in”. He was asked to call back later. It has not been possible to establish whom he spoke to that day. He telephoned again 30 minutes later (he said that Child M’s mother was not able to call, as she was taking an exam that day). The person who answered the telephone told him that “the case was no longer with them” and that if he wanted any more information he should contact the Police Missing Person Unit, and he was given the telephone number. He said that he immediately telephoned Police PC, as he thought perhaps Child M had been found and was dead. He was told that the case was “no longer with them” and that he should contact CSC. He was given the general CSC telephone number, but not the name of who to ask for. He said he telephoned the number but it “rang and rang and then the line went dead”. Mr T described that he felt the professionals involved were treating Child M as a “commodity”. He got the impression that “Child M was somewhere, but they didn’t know where he was”. He said that he “just wanted to be re-assured that Child M was alive and well…the anxiety you are going through is not measured in days, hours, minutes, but in seconds….” 20 3.35 Mr T said that Mrs P then telephoned him, to ask what was happening and he updated her. She said that, as she was in Croydon, she would go to the CSC offices. CSC records state that she telephoned the duty social worker but did not go into the office. 3.36 Mr T said that someone from the college telephoned him at 3pm and told him “We have had Child M with us here. He says he doesn’t want to go to his Mum’s, and he doesn’t want to go to yours. He says he wants to go to a relative’s house”. The person said they had “let Child M go”. Mr T told the Overview Author that he felt as though he was “being treated with suspicion” and wondered if there was an “arrangement” with the relative. He tried to telephone the relative but their telephone was closed as they were at work. 3.37 On 6 August 2012 Mrs P telephoned the Police at 10.26pm to say that her son was still missing. She was informed that the MISPER had been closed on 20 July when Child M went into college. A new MERLIN and MISPER were completed. 3.38 3.39 3.40 3.41 3.42 On 7 August 2012 the Police contacted Team Leader 1 at CSC to ascertain the outcome of the their involvement with Child M on 20 July 2012. Team Leader 1 stated “there had been no formal allegation made by Child M. CSC had contacted his mother who said there was no abuse at home and that Mr Q does not reside with her. Child M has no allocated social worker”’. SW1 telephoned the police later that day to say she was the allocated social worker for the case. The Police spoke to Mrs P that same day, and she said that she had gone to college to pick Child M up but was told he had left at 1.30pm and was staying with the relative. The Police also checked local hospitals that day and the following day, but there was no trace of Child M. A CSC diary note by Team Leader 1 on 7 August 2012 recorded a decision to undertake an Initial Assessment, as a result of the contact from the Police and the SENCO. On 10 August 2012 a social worker from CSC contacted the Police to share information they (CSC) had been given through an anonymous telephone call. The caller said Child M had run away because he was late for College and his mother had threatened to put him into care. Child M knew the caller’s son and told him (the son) he was living in a “crack den’ in Lewisham. On 10 August 2012 a social worker from CSC commenced the Initial Assessment by visiting Mrs P at home. Child N was at home and was also seen. Later that evening Mrs P went to Greenwich Police Station to say that her son was still missing. She was told that the matter was still under investigation and someone would contact her on Monday. (Author’s Note: 21 3.43 3.44 3.45 3.46 3.47 3.48 3.49 the Initial Assessment was opened on Child M only.) On 13 August Mr Q contacted the Police and gave them the address of the relative, where it was thought Child M might be staying. (Author’s Note: the Police did not follow this up). On the same day, 13 August, the social worker had supervision with her team leader: it was stated that Child M had gone missing following a row with his mother during which she had threatened to send him back to Rwanda, to stay with his maternal grandmother. It was agreed that a Strategy Meeting would be convened. On 15 August 2012 the social worker, SW1, telephoned Mrs P. Mrs P told her that Mr T had telephoned her to say that Child M had been spotted in Woolwich a few days previously. Mrs P had passed this information on to the Police, but there had been no response from them. Later that afternoon, Mr T went to the social work office and spoke to the social worker, SW1. He said that Child M had been spotted in Greenwich on a couple of occasions, and that he also had evidence through Facebook entries that Child M had stayed with Friend 3 (a female friend from college) on 19 July 2012, the night before he went into College and was last seen. Mr T told the social worker that Mrs P had been making allegations about him; saying he had kidnapped Child M, but he was trying to stay calm, and he wanted to tell the social worker his side of the story. On 16 August Mrs P contacted the Police, to say that she thought Child M had run away because she had threatened to send him back to Rwanda because his behaviour was getting worse. She also told the police “she believes that he may have gotten involved with gangs and that they are using him to sell drugs, due to age, in the Woolwich area.” (Author’s Note: this was not followed up by the Police). On 20 August 2012 the relative contacted the Police to say they had last heard from Child M about three weeks before when he had asked if he could stay. They told the Police they would try and contact him again on Facebook. On 20 August CSC completed the Initial Assessment and a Core Assessment was triggered. That afternoon Police PC contacted the social worker to say that she could not make the Strategy Meeting planned for that afternoon, but “could make Friday.” On 22 August, the mother of a friend of Child M telephoned the Police to say that she thought Child M was being used by a local gang to sell crack cocaine for them. The Police recorded that “Greenwich officer will familiarise herself with report and explore how they can pro-actively patrol the area to find Child M”. 22 3.50 3.51 3.52 3.53 3.54 3.55 On Friday 24 August 2012 a Strategy Meeting took place and was attended by Police PC. This was nearly 6 weeks after Child M had been reported missing and 9 days after the Police had opened a new MISPER and the social worker had agreed with her team leader that a Strategy Meeting was necessary. (Author’s Note: It is concerning that there was such a delay in convening a Strategy Meeting. This suggests that there was little sense of urgency.) It was noted (in the Police chronology) that the outcome of the Strategy Meeting was that “once found Child M would be assessed by CSC and placed in s20 accommodation if necessary; that CSC will try and get more information from his family and will try and contact Child M on Facebook; the Police would continue their enquiries and would contact the College for details of Child M’ friends; and that the Police would circulate Child M’s image and a briefing note to Lewisham and Gangs Unit.” On 28 August a CSC manager’s decision note was recorded “Child M still missing. Core Assessment to be completed although he has not been seen. Case can then be put forward for C&A team. Copy of the assessment to be sent to the family.” (Author’s Note: What was the purpose of undertaking a Core Assessment? It suggests that matters were being procedurally driven, and that the options available were to close the case or proceed to a Core Assessment. This would then allow the case to be transferred from the duty team, to a long- term team, and this is what subsequently happened. These were system driven decisions.) On 30 August 2012 the relative spoke to the Police and said they had been in touch with Child M on 28 August and he said that he did not want to return home as “Mum and dad stress him out”. The Police informed the social worker of this conversation, and also advised the relative to contact Child M and tell him that if he would go to their house then a social worker would go there and assess him and that if he did not want to return home, then that would be discussed with him. The main concern was that he returned safe and well. The relative did try to say this to Child M during a telephone conversation, but he said the credit on his phone had run out and he was cut off. On 31 August a Missing from Home Strategy Meeting was held, attended by Police PC, Team Leader 3 and SW1. The case was referred to the “Missing Panel” on 3 September 2012. This Missing from Home Strategy Meeting took place 18 days after he was reported missing for the second time. On 4 September 2012 a social worker did a Child in Need visit to the family home and spoke alone to Child N. She then spoke to Mrs P who gave her family background information, but also said that she felt “Mr T and his partner were trying to get Child M back into their care to try and get status in the UK”. 23 3.56 3.57 3.58 3.59 3.60 3.61 3.62 On 5 September 2012 a Missing Person Panel was held. It was agreed that the case would be transferred to one of the longer-term teams in CSC, and that checks would be done with Greenwich CSC where the family previously lived. The social worker had completed a detailed report and later recorded in her diary notes ”It is hoped Child M will re-surface once College re-opens”. (Author’s Note: This meeting should have been held sooner. There is an assumption running through that case that Child M will turn up when he is ready, and this is reinforced by the social worker’s comment. From what people knew of Child M from second hand information was that he appeared to be very much in control. However, this seems to have masked the need to consider his vulnerability and conduct a risk assessment). On the same day, 5 September 2012, the Head of Safeguarding in CSC sent a memo to the Director-Social Care and Family Support and the Executive Director, Children, Families and Learning, informing them that Child M was missing and that the Panel had agreed the following action: that publicity will be pursued; that friends from College would be contacted, the Police would access his Facebook account; Police to liaise with other local forces; and case to return to Panel in October. The following day, the case was transferred to Pembroke Team in CSC and the allocated social worker became SW2. A manager’s note on the electronic system that day stated that the social worker was to complete a Core Assessment. On 6 September 2012, Mrs P telephoned the SW1, to say that Child M’s Friend 3 had told her that Child M might go into college on Monday 10 September. Mrs P wanted to let CSC know that they could “act this time due to the confusion last time” (i.e. no-one going to the college when Child M had been there on 20 July 2012). Mrs P was given the details of the new social worker. On 7 September 2012 the Police contacted the College. The Deputy Head spoke to Friend 3, who confirmed that she had spoken to Child M “most days during the summer break”. The Police then spoke to SW1 to update her on this. A message was later left for the Police, stating that the new social worker was SW2. The Police then left her a message “stressing that Child M could possibly be in college on 10 September 2012 and that this was an opportunity regarding his welfare and placement”. On 10 September 2012. The social worker, SW2, contacted the College but Child M had not turned up. Mrs P telephoned social worker 2 that afternoon and was told the Child M had not gone into college. On 12 September 2012 the Police were contacted by a missing person charity that said they would do poster and web-based appeals. 24 3.63 3.64 3.65 3.66 3.67 On 13 September the relative contacted the Police to say that Child M had been in contact on Facebook, and said he would go round to their house that day. Social worker 2 was updated on this by the Police and said she would liaise with her team leader about what action was to be taken. The relative had also contacted the Missing Person Unit to provide them with this information, and they then contacted social worker 2 and repeated what the Police had already said. Social worker 2 then telephoned the relative herself at 1.50pm. The relative said they did not know what time Child M was going to visit. He was waiting for a lift from a friend. Social worker 2 asked the relative to tell Child M that CSC was worried about him. The relative said this was not possible as they were the only person who had managed to keep Child M’s confidence. The relative was happy for Child M to come and stay with them. They said “Mrs P is in denial as to the real reason as to why Child M had run away. She was protecting her partner instead of Child M”. (Author’s Note: this relative was involved in helping the parents look for Child M from the outset, passed on information to the College, Police and CSC, but was not interviewed by any of the agencies and was not asked to contribute to the Core Assessment. This is concerning. A clear statement is made that suggests that Child M was at risk from Mr Q, but this was not followed up. Mr Q was not interviewed by social worker 1 as part of the Initial or Core Assessment and this is concerning.) On 14 September 2012 social worker 2 and her team leader discussed the matter of Child M possibly staying with the relative. It was agreed they would do a joint visit to discuss this with Mrs P and then with Mr T the following week and that they would also have a professionals meeting that week (beginning 17 September 2012). On the evening of 15 September 2012 Child M was stabbed on the bus. He died in hospital the early hours of the morning on 16 September 2012. 4.1 SECTION 4: Child M’s journey - what was daily life like for him? How did professionals perceive him and engage with him? The only information we have about Child M has come from his parents and those professionals from the College who knew him. What comes across about him from the conversation between Mrs P and the College at the parent’s evening on 13 July 2012 is that they saw two different sides of behaviour. The College saw a young person who was “likeable and very sociable, but on occasions engaged in silly “off task” behaviour. He made friends quickly and was throughout his time at the college a popular pupil.” The only problem the College was concerned about was his lateness: a 25 4.2 4.3 4.4 4.5 problem that had been going on for some time. “Child M was often off task. not fulfilling his potential: he had been placed on report, and failed it. However, Child M was not identified as a pupil with significant difficulties and did not require any specific pastoral support”. The Deputy Head of Year described him as a “generally polite, co-operative, and honest and intelligent student who had the potential to do well”. There is evidence, from when the Deputy Head of Year who met Mrs P and Mr Q on the evening on 13 July 2012, what the former observed and noted was that Mrs P had a very negative view of her son; that his behaviour had deteriorated, he would not get out of bed in the morning and that he did not come straight home from College at night and would not tell her where he had been. There is evidence from what Child M told the Deputy Head of Year the next day at College, that Child M was insightful about his relationship with his mother. He said they argued a lot, “which meant that she shouted and he listened’”. There is also evidence that he had a good relationship with his birth father Mr T, but less evidence about his relationship with his mother’s partner, Mr Q. There is some evidence that he was embarrassed or ashamed that his mother’s partner was White British and that he was being teased about this at College. There is also some implied evidence that he did not get on well with Mr Q and was afraid of him (the relative implied that Mrs P was “covering up” for Mr Q, see paragraph 3.65). Nothing is known about Child M’s relationship with Child N or Child O, despite Initial Assessments being carried out by social worker 1. From the two meetings the Overview Author had with Mr T, he was obviously very proud of his son and thought him as a typical teenager, who sometimes fell out with the family. In this case, the family he lived with was his mother, Mrs P, half-brother and Mr Q, who we still know nothing about. Perhaps Mr T was able to have a good relationship with his son, because he was not part of the immediate family/household, and he showed a degree of objectivity about the situation? In putting together the pieces of information that we do have, an impression emerges of a 14 year-old (who was tall and looked older than his age) who was getting increasingly “worldly wise” and “streetwise”, who wanted to impress his friends and was getting fed up with the pressure of the arguments at home. He was clearly able to make and maintain friendships and viewed his friendships and College positively. It seems clear that an argument did take place after Mrs P and Mr Q returned home from College after 10.00 pm on 12 July 2012, and although the full details are not known, it included threats by Mrs P of sending Child M back to Rwanda or having him taken into care. Child M was also frustrated and angry with his mother because he had been locked out of the house all evening and had to wait in the garden until she came home (she had taken away his house keys as a punishment). Whatever happened was enough to trigger Child M to jump out of the window and run away the following evening. What does not appear to have been taken into account is the level of 26 4.6 4.7 5.1 5.2 violence in the family: there had been two reported incidents of domestic violence between Mrs P and Mr Q; Mrs P had previously been found guilty of Common Assault (trying to stab a neighbour following a dispute); and Child M had been questioned by the police on several occasions (he was part of a group who on one occasion assaulted a 14 year-old. No charges were brought). Another matter that does not seem to have been considered is the quality of the attachments Child M had with the different members of the family He came to the UK with his mother and spent many years living with her. He also spent time living with his father. It is significant that in 2007 his stepmother gave birth to Child O and his mother gave birth to Child N. At this time his mother, Mrs P, was also in a relationship with Mr Q and there is evidence that domestic violence was a feature of this relationship. It may be that Child M felt displaced from both households with these changing dynamics. There is also evidence that he was not comfortable living in a dual heritage household and that he was being teased at College about this (Mr Q is White British, and Child N is of dual heritage). SECTION 5: ANALYSIS OF PRACTICE This section identifies some Key Practice Episodes and analyses the quality of professional practice. KEY PRACTICE EPISODE 1: Mrs P and Mr Q attended College on 12 July 2012, Child M attends College on 13th and is Reported Missing from Home on 14 July 2012 Mrs P and Mr Q had attended the parents evening at the college on 12 July 2012 and Mrs P was negative in her attitude towards Child M. She said that would get angry with him when he would not get up in the mornings and would ‘bite” or “beat” him. These comments should have been explored further and consideration given to making a referral to CSC. It is interesting to note that Mr Q was with Mrs P at the meeting, but is not referred to at all when these discussions were taking place. He could have been helpful in clarifying what it was that Mrs P was saying, but there is no suggestion that this was considered, or what part he played in the discussions, if any. He appears to be invisible: it is almost as if he was not there. The focus is solely on Mrs P. It would be interesting to know why this was so: was it because he was not Child M’s father and did not have Parental Responsibility, or was it that the Mrs P dominated the conversation? We have not been able to answer the why question, as the member of staff from the College is currently unavailable. However, this incident does raise the question of how well equipped and confident professionals are to communicate with parents under such difficult circumstances. On 14 July 2012, Mrs P reported Child M as missing, to the Police. She told the Police Officer that Child M had left home after an argument with Mr 27 5.3 5.4 Q. A Police MERLIN Missing Person Report (MMPR) was completed and Child M deemed to be of medium risk. This was not properly reviewed during the 9 weeks he was missing. There is a view (IPCC appeal report) that if further information had been taken into consideration he would have been deemed high risk (the allegation recorded by the Police of the possibility of physical abuse by Mr Q and the suggestion, made through an anonymous telephone call to CSC that Child M was “living in a crack den” and was being used to traffic drugs) A recent change to Police policy deemed all young people under 18 to be at medium risk. The MMPR was reviewed by the Croydon Public Protection Desk (CPPD) on 15 July 2012 and then forwarded by e-mail to CSC. It was discovered on 16 July 2012 that Child M’s name had been misspelt on the records so as the IMR highlighted “It is unclear in the early contacts with the family if the personal details recorded, including the family name, were checked. Based on the (mis) spelling of his last name, research carried out internally and externally showed Child M was not known to the Police. Consequently, early opportunities to access information about Child M and his associates retained on Police systems were therefore missed and potential lines of enquiry not identified” The Police have recognised this error and made an appropriate IMR recommendation in relation to this. KEY PRACTICE EPISODE 2: Child M went to college on 20 July 2012. In appraising the practice of professionals involved on this day (the College, the Police and CSC) it is the Overview Author’s view that it fell below the standard that would have been expected as laid down in the inter-agency procedures. The communication trail between those involved was quite complex, but the net result was that Child M, who had been missing for a week by this time, was in College all day. Both the Police and CSC were made aware of this, but neither went to the college to investigate his alleged disclosure to a member of staff that he had run away because of arguments at home and “did not want to return as he was afraid that he would be beaten by his step-father”. It is the Overview Author’s view that one or both agencies should have attended to undertake a single/joint section 47 enquiry based on Child M’s disclosure to the DHOY, and this should have been agreed between them beforehand via a telephone Strategy Discussion. The Education IMR states that Child M did not made such a disclosure; but both CSC and the Police IMRs record that this was the information that was given to them by the College. Even without the disclosure by Child M, the Police should have gone to the College to speak to Child M, as a missing child who had been found, before closing the case. This view is upheld by the IPCC. The professionals at the College (the CPDT, the Head) appear to 28 have been confused about their safeguarding responsibilities, in not notifying CSC straightaway that Child M was in College, and it seems they were somewhat misguided in their response to the situation. Although they did listen to what Child M had to say and did engage with him, they did not recognise that he was a child possibly at risk of significant harm and act accordingly by considering notifying CSC and the parents straightaway that he was in College, in compliance with Working Together 2010 and the inter-agency child protection procedures. It is of concern that Child M was allowed to leave the College that day without being interviewed by the Police or a social worker. There is evidence of an over-reliance by staff at the college who were involved with him on the last day of term, on what Child M said, taking it at face value, rather than recognising his vulnerability and the underlying risks. They should have carried out a risk assessment and the matter should have been escalated at this point by involving the Head of the College and contacting a senior manager in CSC and the Police. There is also evidence that both the Police and CSC were clear they did not intend to go to the college to interview Child M and this left professionals at the College in a very difficult position. CSC was notified about Child M being missing by the Police on 20 July 2012 (and they had been sent the MMPR by the Police on 15 July 2012). They attempted to telephone the College on the afternoon of July 20th, but there was no response. No consideration had been given to going to the College with the Police in the morning, or asking the Police to go, as Child M had been missing for a week. On 20 July the Police closed the missing person MERLIN as, in their view, Child M was no longer missing, as he was at College: a place of safety. In the view of the Overview Author, this was an error of judgement, possibly influenced by the fact that it was the last day of term and they were due to close in a few hours. It is the Overview Author’s view that a Police Officer should have gone to the College to undertake a section 47 enquiry either as a single agency, or with a social worker. As it was there was an over-reliance on the view of the professionals at the College, who appear to have had an over optimistic view of Child M, and they believed that when he left College that day he would go to the relative’s house, but he did not. It is the Overview Author’s view that the Police Missing Person Report was closed prematurely. The decision by CSC not to send a social worker to the College may have been influenced by the fact that Child M was at College in another borough, some considerable distance from Croydon. One option would have been to contact CSC in this borough and ask them to send a duty worker to the College. The Police’s decision not to go to the College was probably influenced by the fact that it is normal practice not to go out on such visits. 15 children go missing every day in Croydon and the Police 29 3 Inspection of safeguarding and looked after children services, London Borough of Croydon, May 2012, published 28 June 2012. 4 Inspection of safeguarding and looked after children services, London Borough of Croydon, May 2012, published 28 June 2012, paragraph 17. have stated that they do not have the capacity to follow up matters in this way. This is a significant issue, as the IPCC report is clear that a Police Officer should have gone to College that day and returned Child M to his parents care. 5.5 5.6 5.7 5.8 KEY PRACTICE EPISODE 3: CSC Allocated a Social Worker to complete an Initial Assessment A social worker was not allocated this case to undertake an initial assessment until 7 August 2012; 2 weeks after the referral came in from the Police and the College. This is practice that falls below the standard required. The CSC IMR author identified ”From reviewing the case records and from a discussion with the social worker it appears that the case remained unallocated for 2 weeks as information received on the duty desk was not entered appropriately onto the system…This was not work-flowed (i.e. did not follow the normal process for progressing cases). I only noticed this when I was reviewing new contact”. The fact that the case was allocated on 7 August 2012 was only because it was triggered by 2 additional contacts by the Police that day: firstly, a MERLIN report was received that stated that Mrs P was unhappy that the Police had closed the case on 20 July 2012 on the basis of Child M going into College that day, and secondly, a Police Officer had telephoned CSC to ask if the case had been allocated, and said that Mrs P was filing a compliant against the Police as “nothing had been done regarding her missing child”. The CSC IMR author has attributed this problem to “human error”, “possibly due to the lack of familiarity of uploading information onto Croydon ICS system, on the part of a locum social worker receiving the initial referral”. A CSC IMR recommendation has been made in relation to this (see section 9). However, this is an issue that has been raised in another SCR in Croydon, (Child X) when in July 2011 there was said to be a problem with the Intake Service with a “a backlog of contacts and referrals, with 200 or more that had not been looked at”. The team leader at that time stated, “the system was not robust and the management oversight was poor due to the number of processes a contact went through before it came to the attention of the duty manager.” This is also an issue that was highlighted during the Ofsted Inspection of Safeguarding and Looked After Children Services3 which although it rated overall effectiveness of the safeguarding services as adequate did note “there is more progress to be made, for example with the quality of assessments and the management of contacts and referrals to the service”. 4 The CSC IMR author for the Child X SCR has recently stated “However, 30 5 Understanding serious case reviews and their Impact: a biennial analysis of serious case reviews, 2005-2007, Marion Brandon et al, 2009. 5.9 5.10 5.11 there has now been a significant change in how contacts and referrals are dealt with in the Intake Service which is ensuring that there are timely and appropriate responses. One of the most significant changes is a Screening Team Leader overseeing all contacts and ensuring cases are dealt with promptly and commensurate to the seriousness of the situation. The service is now in the process of implementing a Multi-Agency safeguarding Hub (MASH) in line with other London Boroughs”. (CSC IMR author, Child X SCR, March 2013). Key Practice Episode 4: Social Worker Visit to the Family on 10 August 2012 and Completion of an Initial Assessment. The social worker 1 made a visit to Mrs P on 10 August 2012 during which she spoke to Child N alone. According to the CSC IMR author no child protection concerns were raised and Mrs P “came across as a concerned and caring mother”. She did tell the social worker that Child M “had struggled with Mr Q’s ethnicity (White British) and was being teased at college, with his friends saying that he ‘would become English” and “joking that he will be staying in on a Sunday to eat a roast dinner”. She thought that Child M running away was prompted by an argument they had had the evening before (he ran away), when she was angry with him always being late home from College and was worried about his deteriorating behaviour which she attributed to him being involved with a boy’s gang in Woolwich, and was afraid he was involved in carrying and selling drugs. The Initial Assessment (opened in Child M’s name, not Child N) was completed and signed off within the expected timescale of 10 working days. However, in appraising practice, it was, in the Overview Author’s view, a major omission that Mr Q was not seen and interviewed as part of the assessment, or during any subsequent visits, given the allegations Child M is said (by the Police and CSC) to have made to college staff about Mr Q hitting him and that Child M was afraid of him. The lack of inclusion of men who are involved in the parenting of children in assessments has been highlighted in previous SCRs: “ A number of issues emerged including the dearth of information about men in most serious case reviews. Failure to take fathers and other men connected to the families into account in assessments”.5 The Police had records of 2 domestic abuse incidents between Mrs P and Mr Q, but it is not known if CSC became aware of this when they made routine enquiries as part of the Initial Assessment (the MERLINS should have been uploaded on to ICS). 31 5.12 5.13 5.14 5.15 Key Practice Episode 5: The Strategy Meeting on 24 August 2012 and Missing from Home Strategy Meeting on 31 August 2012. On Friday 24 August 2012 a Strategy Meeting took place and was attended by Police PC. It was noted (in the Police chronology) that “once found Child M would be assessed by CSC and placed in s20 accommodation if necessary; that CSC will try and get more information from his family and will try and contact Child M on Facebook; the Police would continue their enquiries and would contact the College for details of Child M’ friends; and that the Police would circulate Child M’s image and a briefing note to Lewisham and Gangs Unit.” The meeting had originally been arranged for 21 August 2012 but was re-arranged because of the unavailability of Police PC, the Police Officer from the Sexual Exploitation and Missing Person Unit. The only agencies who were represented at the meeting were CSC and the Police. There was no one from education there as it was still the College holidays. There is no CSC entry on the integrated chronology about the meeting or any minutes of the meeting available. This falls short of expected practice. There was at this time a comprehensive Croydon procedure entitled “Safeguarding Children Missing from Care & Home” endorsed by the LSCB in August 2011, which states that a Strategy Meeting should be convened within 7 days of the young person going missing and that “where a child/young person is missing for more than 7 days the child/young person’s social worker, in consultation with the CQASS and the Service Manager for the Operational team, should arrange a further Strategy Meeting. (Author’s Note: This procedure has now been superceded by the Children Missing from Home, Care and Education Procedure, January 2014. Under this a Strategy Meeting would need to be convened within 5 working days of the child going missing). The meeting should include all the key people, including foster carer/residential staff/parents, Police, Council’s press office, legal services etc. to decide whether any other action should be taken. Consideration should also be given to invite a representative from the National Missing Person’s Helpline (see contact details in Section 8.1). The Operational Manager in the Children’s Quality Assurance & Safeguarding Service (CQASS) should chair the meeting. The purpose of this meeting is to ensure that all appropriate action is being taken to locate the child and to consider what further action needs to be taken. The Service Manager and Head of Service must be updated weekly by the Operational Manager on all missing children and informed of progress against the action plan. The Head of Service must update the Directors of Social Work and Youth Inclusion on a weekly basis. If the child/young person is still missing after 7 days, two weekly (or, as required) meetings 32 6 “Safeguarding Children Missing from Care & Home”, Croydon LSCB, August 2011 5.16 5.17 5.18 5.19 should be held. The Social Care Service Manager, following every meeting must provide a written briefing for Director: Development and Care who will brief the Executive Director. The Executive Director will brief the Lead Member for Children and Young People”6. In appraising practice, the procedure that was in place at the time Child M was missing was not complied with, as the Strategy Meeting was not held within 7 days of the young person being reported missing. Child M had been reported missing on 14 July 2012, and the first Strategy Meeting took place just under 6 weeks later, on 24 August 2012. It is not clear who chaired the meeting and whether or not there are minutes of the meeting. The actions of the meeting recorded in paragraph 5.1.13 above have been taken from the Police chronology. There was a Missing Person Strategy meeting held on 31 August 2012. Key Practice Episode 6: Missing Person Panel 5 September 2012 The case was discussed at the Missing Person Panel on 5 September 2012 and this did comply with procedures. However, the minutes of the meeting record Child M as being missing since 7 August 2012 and this is incorrect as he had been missing since 13 July 2012 and reported missing to the Police on 14 July 2012. Following this meeting, the Divisional Director and the Executive Director were notified in writing by the Head of Children’s Quality Assurance and Safeguarding Service, and the mistaken date was rectified in this memo, which stated that Child M had been missing for 7 weeks and “ was considered to be at risk of being exploited and becoming involved in criminal activity, as Police intelligence suggested that he was involved with the Woolwich Boys Gang”. Actions from the meeting included the case being transferred to a longer- term team, and a Core Assessment being completed. It is the Overview Author’s view that this approach was reactive and process driven. It is baffling that the Police were not challenged by the College and CSC about the complacent approach being taken to trying to find Child M. There seems to have been an assumption by all that he would be alright and would “turn up” when he wanted to”. Key Practice Episode 7: Police and CSC contact with the relative On 30 August 2012 the relative spoke to the Police and said that they had been in touch with Child M on 28 August who said that he did not want to return home as “Mum and dad stress him out”. The Police informed the social worker of this conversation, and also advised the relative to contact 33 7 Missing Children, Ofsted, February 2013. Reference no: 120364 5.20 6.1 6.2 6.3 Child M and tell him that if he would go to the relative’s house then a social worker would go there and assess him and that if he did not want to return home, then that would be discussed with him. The main concern was that he returned safe and well. The relative did try to say this to Child M during a telephone conversation, but he said the credit on Child M’s phone had run out and he was cut off. There was good liaison between CSC, the Police and the relative at this point. However, something more proactive could have been done: the relative could have been used to find Child M and been part of the multi-agency team trying to make sue he was safe and well, and provide him with accommodation. It was a missed opportunity that the relative was not involved in the Initial Assessment or seen by the Police as a key line of enquiry. SECTION 6: KEY LEARNING POINTS AND EMERGING THEMES A Child Missing from Home But a Passive Attitude on the Part of Professionals There has been a recent thematic inspection by Ofsted on Missing Children,7 based on tracking 105 cases of missing children from a range of local authorities. The issues it addresses include the quality of inter-agency working and communication (most notably Police, CSC and Education), strategic systems in place, and perceptions and attitudes towards children who run away. The report tries to identify the reasons why children run away: “The complex and often varied reasons identified on a national basis why children go missing were reflected in the nature of the cases seen by inspectors. Children’s histories included inadequate parenting, past or current abuse, bullying and domestic violence. Some children who were looked after had experienced several placement moves. Children who went missing were subjected to considerable associated risk, most often from sexual exploitation, drug and alcohol abuse, and becoming the victim or perpetrator of crime”. It also identified that: “Running away or going missing was often symptomatic of wider problems and in turn, was likely to exacerbate and add to those difficulties. “Push” and “Pull” factors were evident: some children sometimes ran to a situation that presented risks to them whilst some ran away from something or someone. Push and Pull factors were often both apparent in cases”. 34 8 Working Together to Safeguard Children, Department for Education, 2010 6.4 6.5 6.6 6.7 6.8 From the evidence we now have about Child M, and with the benefit of hindsight, it is possible to speculate that he was running away from the arguments at home and was worried that his mother’s threats to send him back to Rwanda or have him taken into care might turn into reality. There is also a suggestion that he was afraid of Mr Q and of being beaten by him. There is also a sense that Child M knew what he was doing and there was an allure to whatever it was that he was running to. During the morning that he spent in College on 20 July 2012 a clear description is portrayed of a young person who knew exactly what he was doing and he was seen as totally in control of that situation and was the one with the power: telling staff that he would run away if the Police or CSC were contacted. The Deputy Head of Year remarked that it was as though he was “blackmailing” them and he agreed. However, he was still a 14-year-old child who had been reported missing and he was potentially exposing himself to risk and danger. The Ofsted report refers to the “tenacious partnership working” needed across agencies to safeguard children at risk of going missing. One of the lessons for learning from this case is that, in the Overview Author’s view, there was no evidence of such tenacity. There is evidence that, for reasons unknown, both the Police and CSC professionals were passive in their responses to a 14 year-old boy missing from home. A picture emerges of the parents frantically looking for Child M in the local area in the days immediately after he ran away, but this response was not matched by a similar response from the Police. There is little evidence of them actively searching for him, and the fact that they had mis-spelt his name on the MERLIN report meant that any opportunity to make connections with any other boys in the neighbourhood, or with local gangs, was lost. There was quite a lot of evidence that he was good friends with Friend 3, and that he had stayed with her on the19 July 2012 and that ”she was in contact with him throughout most of the summer” but there is no evidence that they interviewed her in connection with their enquiries. This was a missed opportunity. If she had been interviewed early on, she could have played a key role in contacting Child M. The response of both the Police and the social worker when contacted by the college on 20 July 2012 fell below the standard expected by Working Together 20108 and the local Missing Children procedures, which state that the Police should take the lead on missing children enquiries. This was a line of enquiry that should have been pursued rigorously, given that Child M had been missing for a week by this time. The response of the Police to the College is concerning: that as Child M was at College then de facto he was safe and well, and there was no further role for them, so they closed the missing person report. There is a sense that professionals (the Police and CSC) were complacent 35 9 Report from the Joint Enquiry Into Children Who Go Missing from Care: APPG for Runaway and Missing Children and Adults and the APPG for looked after Children and Care Leavers. June 2012. 6.9 6.10 about Child M being missing and there is evidence that they assumed he would “turn up” at some point. Although the Police had assessed him as being at medium risk, there is no sense that any of the professionals viewed him as a vulnerable young person, but rather as a streetwise young man who knew exactly what he was doing, that he was probably staying with friends and would contact his family when he was ready to do so. The Ofsted inspection and a recent APPG Enquiry9 both raised concerns about some professionals’ attitudes towards children who go missing and the prevailing culture of (poor) child protection responses to older children. One social worker commented: “some behaviours of an older child are seen by agencies as expressing a choice, but this doesn’t consider the risks that the young person is placing himself /herself in.” This resonates with professional practice in this case. Inter-Agency Communication and Divergence of Views The events of 20 July 2012 when Child M went into College on the last day of term portray a pattern of communication between professionals from the Police, College, CSC and the family that was not effective in protecting Child M from the risk of significant harm. He was 14 years old and had been missing from home for a week, and despite the various communications that took place that morning, Child M left College unaccompanied at 2pm that day, and was not seen alive again. In that sense, the practice of all the professionals involved fell short of what would have been expected, and the ineffectiveness of the communication that took place had a negative impact on outcomes for Child M. There was a lack of curiosity in following up possible lines of enquiry. For example: the anonymous telephone call (paragraph 3.41) was not responded to Mr Q telephoned the Police to give them the relative’s telephone number, but the relative was not contacted Mrs P called the police to say Child M had been spotted in Woolwich (paragraph 3.44), but this was not followed up 6.11 Communication with the Parents Similarly, there was a passive attitude by the Police in keeping the parents up to date with their missing child enquiries. There is a strong evidence that it was Mrs P and Mr T who were chasing the Police for information and updates, and this view is endorsed in the findings from the Independent Police Complaints Commission report 36 6.12 6.13 The communication between the College and the parents during this period was limited to the parents going to College on 12 July 2012 and then responding to the parents request to go into college for the day to talk to Child M’s friends, to see if anyone had any information, which was helpful. Their responses to the parent’s telephone calls to the college on 20 July 2012 were less than helpful, in failing to provide them with basic information about Child M’s welfare (see paragraph 3.32). It is of note that all communication came to an abrupt halt when College closed at lunchtime on Friday 20 July 2012, with the exception of a telephone call made by the Police to the College at 3pm, to which there was no response. The parents and the relative were driving the search for Child M and feeding information to the Police, College and CSC, but the energy and drive they invested in this was not matched in the response from the professionals who were passive and complacent and thought Child M would turn up when he was ready. They saw him as a young man who was in control of his life, who was doing what he wanted, and they overlooked the fact that he was only 14, and still a child. Generally the communication between CSC and the family was of the standard expected once the case had been allocated. After Child M’s death Mrs P telephoned the social worker and thanked her for her support. Professional Challenge 6.14 Professionals at the College were clearly unhappy and dissatisfied with the response they received from the Police and to some extent CSC on 20 July 2012. They did challenge the Police about their decision not to come to the College. It would have been good practice if the matter had been escalated that day by the Head of College to a senior officer in the Police and a senior manager in CSC. 6.15 Involving Male Partners in Assessments It is crucial that male partners who are involved in the dynamics of family functioning are included in assessments. It is concerning that Mr Q was not seen and interviewed by the social workers as part of the different assessments. 6.16 6.17 The Initial Assessment was signed off by a manager when there was no evidence of Mr Q being involved, despite the fact that he was a significant figure within the family dynamics and there was a suggestion that Child M was afraid of him and was being teased by his peers because of his mother’s relationship with a white man. There is evidence that there was insufficient management oversight in the Intake Team as there was a 2-week delay in processing the referral from the College about Child M being missing. The matter only came to light when the Police made contact to see if the case had been allocated. 37 6.18 The Missing Person procedure states that a Strategy Meeting should be held within 7 days of the child going missing. Child M had been missing nearly 6 weeks when the first Strategy Meeting took place. It is concerning that this was not picked up in supervision. SECTION 7: CONCLUSIONS What Might Have Been Done to Ensure Better Outcomes for Child M? 7.1 7.2 If the Police had been more pro-active in following up lines of enquiry they may have been able to gather more information about where Child M was staying during the 9 weeks he was missing and thereby locate him. By all accounts, on the few occasions he was seen, he looked clean and well kept, and there was soft intelligence that he was staying at someone’s house. There was no suggestion that he was “sleeping rough”. Friend 3 said that she had been in touch with him on Facebook “most of the summer”. There is evidence from the Police Independent Police Complaints Commission report that the Police were not proactive in following possible lines of enquiry, such as speaking to Friend 3 or the relative, or trying to trace Child M through the use of his Oyster Card, mobile telephone or Blackberry. Instead, in the view of the IPCC, the Police were reactive; responding to contacts from M’s parents. Professionals should have responded differently on 20 July 2012 when Child M went into College, and either the Police and/or the social worker should have gone to the College to talk to Child M and conduct a section 47 enquiry if necessary. The IPCC report states that a social worker should have gone out to the College to speak to Child M and should have contacted the Police if Child M did make allegations of abuse, so that they could attend the College as well. The IPCC (appeal) report expresses the view that “the Police should have returned Mrs P’s son to her on that day (20th July) he attended College and this may have altered the outcome” 7.3 Could his Death Have Been Predicted or Prevented? There is some suggestion that Child M was involved in a local gang and was being used to carry drugs, but no evidence has come to light during this SCR to confirm that. There is no explanation for the “altercation” that took place on the bus on the evening of 15 September 2012 and ended with Child M being murdered. If Child M had been found during the weeks after he ran away from home, it may be that he would have disclosed what he was “up to” and a risk assessment could have been completed. It may be that he was living a high-risk life style, but that remains supposition. 38 10 Brandon. M. et al. New Learning from Serious Case Reviews: a two year report for 2009- 2011, DfE-RR226 7.4 7.5 8.1 8.2 There is no evidence to suggest that his death might have been predicted or prevented. There is no evidence to prove that Child M was involved in gang activity. However, there is “soft intelligence” via messages to professionals from his friends that he was involved in some activity selling drugs and this was related to gang activity. The autopsy discovered that Child M was in possession of a small amount of drugs, but it is not possible to know whether this was for his own use or for sale. There is no evidence to suggest that his ethnicity and gender affected the quality of services that he and his family were offered. The family have a view that their race and his gender did affect the services they received. The social worker told the Overview Author that they compared the response they received when Child M went missing to the response that was given to a very high profile case of a young white girl who went missing in the same area at around the same time. There has been no evidence to support this throughout this SCR. SECTION 8: OVERVIEW REPORT RECOMMENDATIONS: “SCR recommendations are still very numerous and the endeavour to make them specific, achievable and measurable has resulted in a further proliferation of concrete and procedural tasks to be followed through. Part of the issue may lie with the skills and knowledge of those conducting the reviews but also with the need to distinguish between learning lessons and making recommendations. The best learning from serious case reviews may come from the process of carrying out the review”.10 Missing Children There is evidence that, despite protocols already being in place, that what is absent, is a real understanding of what can trigger a young person running away and how agencies can respond proactively, including keeping the family informed. The recent APPG report from the Joint Inquiry into children who go missing and the recent Ofsted report on Missing Children could be used to enhance learning and improve multi-agency practice in this area. Recommendation 1 It is recommended that Croydon LSCB monitor compliance with the recently implemented Missing from Home, Care and Education Procedure (January 2014) to ensure a more robust response from all agencies when children go missing and that the LSCB ensure information is gathered regularly about children in Croydon who are at risk of going missing, and aim to reduce those numbers (Outcome: Children who go missing regularly are addressed as a higher priority by all agencies, reducing the number and frequency of such 39 8.3 8.4 8.5 8.6 8.7 8.8 8.9 8.10 episodes). Professional Challenge and the Use of Escalation There is evidence of poor inter-agency communication and information sharing. It is important that agencies understand and use existing escalation procedures in order to resolve matters effectively. Recommendation 2 Agencies to re-assure the LSCB that the current escalation procedures are understood and used appropriately. (Outcome: staff feel more confident that they are able to raise concerns about the actions of other agencies or staff in their own agencies in order to resolve matters of divergence effectively). Including Male Partners in Assessments There is evidence of a lack of professional curiosity about the role of Mr Q in this “re-constituted” family and the quality of the relationship between him and Chid M. He was not included in the Initial Assessment and should have been. Recommendation 3 The LSCB QA and Performance Sub-Committee to ensure agencies understand the importance of including male partners in assessments. (Outcome: to ensure that all those involved in the “parenting” of children or who are part of a family network, are included in assessments) Communication Between schools/colleges and other agencies during school/college holidays. This serious case review has identified the need to ensure follow through of any safeguarding concern or missing child concern that occurs just before holiday periods. There should be someone with responsibility for making sure that referrals and concerns generated by colleges have been received and acted upon. Recommendation 4 The LSCB to be notified and assured by schools and colleges that there are appropriate arrangements in place to ensure that all have a single point of contact during school holiday periods that is shared with a senior manager in Police, CSC and Health. Conversely, these other agencies need to have a SPOC whose details are shared with schools/colleges. Child protection and older children. This case has highlighted underlying assumption by professionals that a seemingly competent and confident 14 year-old can make their own way over a 6 week holiday period. This begs the question of how we view the risks of gang and drug involvement and knife crime to predominantly young males and sadly to young black males in areas of London. Recommendation 5 The LSCB to commission a review of whether services received by older 40 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 children who go missing are sufficiently robust and to what extent gender and ethnicity plays a part. SECTION 9: SINGLE AGENCY (IMR) RECOMMENDATIONS POLICE It is recommended that the Croydon Senior Leadership Team remind staff of the requirement to enter all details, such as family names, accurately onto MPS computer systems in support of National and MPS Recording Standards. It is recommended that the Croydon Senior Leadership Team remind staff of the requirement to complete detailed MERLIN/PAC reports at the conclusion of MISPER investigations so that appropriate information is shared with partner agencies. It is recommended that the Croydon Senior Leadership Team remind staff of the importance of completing and recording detailed research on a missing person prior to carrying out a risk assessment to ensure all available information can be considered for the risk assessment. It is recommended that the Croydon Senior Leadership Team remind staff investigating and supervising missing person investigations that any information that may impact on the current risk assessment is reviewed and the risk assessment re-assessed. The MERLIN record should reflect any rationale for the decisions made. CSC Practitioners (including locum social workers) need to be fully aware of the process for appropriately entering data onto IVCS to ensure that cases are not lost and are brought to the immediate attention of the Intake Team Manager. Appropriate ICT training needs to be provided before any practitioner undertakes work on duty. Where there are men involved in families, whether in the role of fathers or partners, due consideration needs to be given to their involvement/participation in any assessment process concerning the protection of children. The Croydon LSCB to ensure that all agencies adhere to agreed procedures concerning Missing Children and Children Affected by Gang Activity. Key messages from this review to be incorporated into safeguarding children training. 41 9.9 9.10 NHS CROYDON To update and brief staff of the wider learning from this Serious Case Review specifically issues relating to missing children and gang activity. To ensure Independent contractors are aware and follow guidelines and policies when dealing with child missing and safeguarding children affected by gang activity EDUCATION 9.11 The college to ensure that when dealing with young people where there is no indication that they are at risk of significant harm, parents with parental responsibility are appropriately involved in any decision making regarding referrals to social care agencies. 9.12 Ensure that when decisions are made in phone discussions that agencies use e-mail communication to confirm what has been agreed. |
NC52372 | Death of unborn baby due to suicide of mother, who was 37 weeks pregnant, in April 2019. Mother found hanged and taken to hospital; following emergency caesarean the baby was stillborn. Mother known to substance misuse services, police, community housing, and wider family was known to education services. Midwife placed mother on pathway for substance misusing mothers; social work assessment pending at time of death. Maternal history of attempted overdose, drug abuse, previous partner violence and missed appointments. Ethnicity or nationality is not stated. Does not specify any learning but finds significant evidence of strong practice, particularly in relation to prompt follow up when the mother did not attend or could not be contacted, by the midwife, social worker and housing officer. Recommendations include: substance misuse midwifery team should consider informing women on the substance misuse pathway that a positive toxicology result will lead to a referral to social care at the point of testing; conduct a review analysing current referral processes and pathways.
| Title: Serious case review: SC17 Unborn Baby A: review report. LSCB: Solihull Local Safeguarding Children Board Author: David Peplow Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Solihull Local Safeguarding Children Board Serious Case Review SC17 Unborn Baby A Review Report Independent Author: David Peplow 2 CONTENTS Page 1.Introduction to the case review 3 2. Process for conducting this review 3 3. Relevant case history 4 4. Analysis 6 5. Conclusion 7 6. Recommendations 7 3 1. INTRODUCTION TO THE CASE REVIEW 1.1. On 1st April 2019 a young woman was found hanged at her own home. She was 28 years old and 37 weeks pregnant. Emergency services attended as a priority and she was transferred to hospital. Efforts were made to resuscitate her and a caesarean section was carried out. The baby was stillborn and the mother died. 1.2. The hospital’s safeguarding matron made contact with children’s social care and a decision was made that a rapid review, in accordance with the transitional arrangements for Local Safeguarding Children Boards (LSCB), should take place. Relevant notifications and requests to agencies were made on 10th April 2019 and the review took place on 29th April 2019. 1.3. In considering if the case should be notified and considered under this process, Solihull partners had regard to the Infant Life (Preservation) Act 1929 which says amongst other things “… any person who, with intent to destroy the life of a child capable of being born alive, by any wilful act causes a child to die before it has an existence independent of its mother, shall be guilty of felony, to wit, of child destruction…” 1.4. The rapid review members concluded that the criteria for a serious case review as defined by Working Together 2015 was met in that, abuse or neglect was known or suspected and a child had died. (A child as defined in the above mentioned Infant Life Preservation Act 1929). The LSCB Chair agreed with this decision and the National Panel were notified. 2. PROCESS FOR CONDUCTING THIS REVIEW 2.1. Whilst some agencies had worked with the mother there was very limited learning. This was all identified during the rapid review process and any additional work would not reveal further learning. It was felt that the process that had taken place was proportionate and work on the identified actions could start. 2.2. The rapid review was not conducted with a view to publication, nor was it carried out by anyone who was “independent of the case under review and of the organisations whose actions are being reviewed”. In that regard the review is not compliant with Working Together 2015. 2.3. Following correspondence with the National Panel it was agreed that the Independent Chair could use the rapid review as the basis for a publishable report that would then achieve the requirements for a serious case review. 2.4. It was decided that publication should await the result of the coroner’s inquest and finalisation of the action against the recommendation. The inquest concluded in mid August 2019 and found that the mother’s death was by suicide. 4 3. RELEVANT CASE HISTORY 3.1. University Hospitals Birmingham. 3.1.1. In October 2018 mother had an antenatal appointment with a midwife. She appeared to be open in disclosing her history. This included talking about cocaine use, an intentional overdose and self-harming in 2012 and 2005 respectively. A referral to mental health services was offered but declined. 3.1.2. A few days later some checks were made to establish what partner agencies may know. There had been an incident in the South West, the reporting author from the hospital comments that this was an omission. 3.1.3. In early November there was an antenatal appointment where a sample was taken to analyse for drugs. A wide range of issues was discussed including smoking and previous medical history. A referral was made to the specialist substance misuse midwifery team. A few days later the drugs screening test was reported as Nothing Abnormal Discovered (NAD) meaning no drugs were detected. 3.1.4. The first substance misuse clinic appointment was missed but as the recent sample provided was negative, the follow up was to send out another appointment. 3.1.5. On 12th December 2018 mother was seen in the substance misuse clinic. A further sample was obtained for drug testing; this was negative when the result was reported later. A plan was put in place to maintain the specialist monitoring. Mother declined a referral to drug misuse services. There was a conversation about making a referral to children’s services and it was said that the midwife would talk to mother before making a referral. 3.1.6. On 21st December the substance misuse midwife had a conversation with children’s social care. Overall it was agreed that the midwifery plan to conduct drug tests was sufficient but there should be a referral if required. 3.1.7. At the next substance misuse clinic mother reported that she was not smoking or drinking alcohol and had not used drugs. She reported having had a conversation with a social worker; this was as a result of the conversation between services as above. A further sample was taken for drugs testing. A week later on 13th February 2019 it was reported that the test showed cocaine use. 3.1.8. This information (drug use) was conveyed to the community midwife and it was also said that the substance misuse midwife was to contact mother to discuss a referral to children’s services. Mother made contact a few days later seeking to rearrange an appointment; during the conversation she denied using cocaine. 3.1.9. On 14th March 2019 midwifery made a referral to the Multi Agency Safeguarding Hub (MASH). The response was for a social worker to carry out an assessment detailed in section 3.2 below. 5 3.1.10. Appointments were continuing at the substance misuse clinic. One took place the day after the mother met with a social worker. Whilst at the clinic remorse was expressed and the midwife offered and discussed a referral to Solihull Integrated Addiction Services. Mother was left to think about this. 3.1.11. On 1st April 2019 the hospital obstetric services were alerted to mother being brought to hospital by ambulance having been found suspended. 3.2. Children’s Social Work Services 3.2.1. The first contact with Social Care was on 10th December 2018 by midwifery services. There was a disclosure from mother that prior to knowing she was pregnant she was taking cocaine. There was an agreement between CSWS and midwifery that midwifery service would monitor the situation monitor and there would be no further action by CSWS. 3.2.2. On 14th March 2019 CSWS received another referral from midwifery as mother had tested positive for cocaine. The MASH screened the case on 18th March and the mother was allocated a Social Worker on 20th March. 3.2.3. The Social Worker met with the mother on 21st March; at the meeting the mother denied using drugs and disputed the test results. She spoke about a previous relationship which was abusive and compared this with her current relationship with the baby’s father which was described as ‘perfect’, going on to say there were no drugs, no alcohol and no domestic abuse. Mother said she was looking forward to her life with her partner (baby’s father). 3.2.4. On 25th March there was another positive drugs test this indicated drugs had been used in the previous 72 hours. 3.2.5. The Social Worker had a planned appointment with her on the 28th March 2019 mother did not attend. This was followed up with an unannounced visit to the property. The mother was not at the property but a woman present there advised the Social Worker that mother was at her boyfriend’s property. Social Worker attended the boyfriend’s property but once again was told by the boyfriend that she was not in. They subsequently spoke on the phone and an appointment was made for the morning of 1st April 2019. 3.2.6. On the morning of the appointment mother contacted the Social Worker and moved the appointment to the afternoon. She did not attend. 3.2.7. On 3rd April CSWS were informed by the hospital safeguarding matron that mother had died. 3.3. West Midlands Police. 3.3.1. The police hold very little information. The mother had been a victim of domestic abuse with a different partner, which was about two years earlier. There were no recent police incidents other than the critical event leading to the review. 6 3.3.2. The police system held a warning marker that was ten years old that mother might self-harm. There was no other information as to how this had originated available to the review. 3.3.3. The police were part of the MASH process following a referral received in March 2019 concerning mother’s drug use. 3.4. Solihull Community Housing. 3.4.1. Mother had failed to attend her first appointment on 24th Jan 2019 and then made contacted a few days later. She did not disclose anything in relation to drugs or alcohol. Solihull Community Housing was actively trying to find accommodation for her. 3.5. Birmingham and Solihull Clinical Commissioning Group. 3.5.1. Very limited information was held. All the midwifery contacts are appropriately recorded within the GP records. 3.6. Education. 3.6.1. Education services had knowledge of the extended family some of whom were in the same household as mother. 3.7. Other agencies. 3.7.1. Requests for information were made to the following agencies all of which held no information: Birmingham and Solihull Mental Health Foundation Trust, Coventry and Warwick Partnership Trust, The National Probation Service, South Warwickshire NHS Foundation Trust, CAFCASS, The Community Rehabilitation Company. 4. ANALYSIS 4.1. The midwifery team identified the maternal history of drug use and an earlier deliberate overdose. An appropriate offer was made for a referral to mental health services but was declined. 4.2. The mother was correctly placed on the pathway for substance misusing mothers. This was appropriate and it identified that there was continued substance use in pregnancy based on the results of samples taken for drugs screening. 4.3. There were some episodes of failures to attend appointments with the substance misuse midwives and these resulted in follow up appointments being offered and in mother being contacted to re-engage her. This was successful in that there was re-engagement. 4.4. In March 2019 there was a referral to children’s social care due to a positive drug test (cocaine). This information was available in mid-February and it could have been more promptly shared with social care, however this was delayed as the specialist substance misuse midwife was attempting to contact mother to discuss the need for referral, something she had told mother she would do before a referral. 7 4.5. Attempts to discuss the referral were initially unsuccessful and the substance misuse midwife eventually got a call back from mother on the 14th March 2019. The specialist midwife felt that she was acting within guidance in discussing the referral and obtaining consent for it with mother. The delay this caused was significant and exposure of an unborn infant to cocaine could result in significant harm. This is addressed by recommendation 1. 4.6. There is no record of a referral to Solihull Integrated Addiction Services following the positive drugs test. Mother had previously declined such a referral (see 3.1.5 above) when it was offered by the specialist midwife when her drugs test was negative. However, because the referral was not made between February and March the mother did not receive any form of specialist support to help her stop using cocaine. This is addressed by recommendation 2. 4.7. The MASH response to the concerns identified by professionals was adequate and proportionate. There is evidence of positive partnership working between children services and midwifery. 4.8. The timeliness of the response to the concerns identified on the 14th March 2019 was what would have been expected. The case screened on the 18th March and allocated to a social worker on the 20th March 2019. The social worker’s visit to mother was completed within 24 hours of case allocation. 4.9. The social worker made appropriate decisions and several attempts to maintain contact with the mother in order to progress the social work assessment. 5. CONCLUSION 5.1. The review panel found there was significant evidence of strong practice, particularly in relation to prompt follow up when the mother did not attend or could not be contacted, by the midwife, social worker and housing officer. Practitioners worked hard to retain strong engagement and provide a thorough service. 5.2. The mother was placed on the pathway for substance misusing mothers, which was appropriate, and this identified that there was continued substance use in pregnancy based on toxicology results. It was also noted that throughout mother was reassuring practitioners that she was not subject of abuse or exploitation by anyone, and she was in a stable and safe relationship with the child’s father. There was no evidence available to partners to the contrary. 5.3. The only indicator of an increased risk to her and her child’s wellbeing was the positive test for cocaine. The mother did disclose a previous suicide attempt and was offered mental health referrals in pregnancy but declined to take up this service. 6. RECOMMENDATIONS 6.1. The substance misuse midwifery team should consider with immediate effect the ‘up front’ conversation with women on the substance misuse pathway, that a positive toxicology result will result in a referral to social care. 6.2. The MASH manager, SIAS manager and the midwifery manager to meet to conduct a review analysing current referral processes and pathways. |
NC50683 | Serious harm of a 15-year-old girl throughout her childhood. Child Z was taken into care in 2015. She had been on a child protection plan since before birth in 2000. Throughout Child Z's life she was considered to be at risk because of: concerns about parents' capacity to meet the physical, emotional and educational needs of their children; lack of boundaries, including sexual boundaries, within the family; father's mental health and an unwillingness to engage with services. Ethnicity or nationality is not stated. Learning includes: the importance of preserving accessible case records to inform current practice; mental health practitioners should ensure there are robust arrangements to take into account the risks to other family members, especially children when an adult is discharged from a service; police to ensure that custody staff take into account the risks for children when setting bail; ensure that all partner agencies ensure that all relevant agencies are involved in child protection discussions. Makes a number of recommendations including: partner agencies ensure that pathways for escalating child protection issues are maintained until the issue is resolved and ensuring that there are accessible services to children and young people who are victims of abuse or neglect.
| Title: Child Z: serious case review: case summary, review findings, recommendations and responses. LSCB: Central Bedfordshire Safeguarding Children Board Author: Central Bedfordshire Safeguarding Children Board Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child Z – Serious Case Review Case Summary, Review Findings, Recommendations and Responses 1. The case for this Serious Case Review Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases. A serious case is defined as one where: • abuse or neglect of a child is known or suspected; and • the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. • Statutory guidance specifies that ‘seriously harmed’ includes, but is not limited to, cases where the child has sustained • A life-threatening injury • Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development. A SCR was first considered with regard to Child Z and her family in May 2014 following a referral to the Central Bedfordshire Safeguarding Children Board (CBSCB) highlighting a number of concerns about the practice of agencies involved with the family. Whilst it was initially concluded that the case did not meet the threshold for a Serious Case Review, revised guidance on this threshold and the disclosure of further information through the family court proceedings led to a further referral to the CBSCB, requesting that a Serious Case Review be commissioned. The CBSCB Case Review Group re-considered the case in March 2015, and took the view that Z appeared to have suffered serious harm and recommended that a Serious Case Review should be commissioned. Alan Caton OBE, Independent Chair of the CBSCB, decided that Z appeared to have been seriously harmed through neglect and possible sexual abuse as a result of failings of multi-agency working whilst being subject to a Child Protection Plan; and accordingly decided that this Serious Case Review should be undertaken. 2 2. The purpose of the Serious Case Review The terms of reference for this review were to: • Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children • Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result • Recognise good practice and improve intra and inter-agency working and better safeguard and promote the welfare of children. The Review considered in detail the period from 1 September 1999, when it was first known to agencies that Z’s mother was pregnant with Z to 5 February 2015. Summary information regarding significant events outside of this period was also considered. 3. Contributors to the Serious Case Review Reports on the involvement of various organisations with Child Z and her family were provided to inform the review. Specifically, the following bodies provided reports; • Action for Children • Bedfordshire Clinical Commissioning Group (on behalf of NHS England in respect of primary care services) • Bedfordshire Police • CAFCASS • Central Bedfordshire Council - Access and Inclusion • Central Bedfordshire Council - Adult Social Care 3 • Central Bedfordshire Council - Children’s Social Care • Central Bedfordshire Council - Legal Services • East London NHS Foundation Trust • Middle School attended by Z • Secondary School attended by Z • South Essex Partnership University NHS Foundation Trust. 4. A Summary of this Case The Serious Case Review examined the history of the troubled childhood of Child Z, who was known to agencies and subject to a Child Protection Plan since before birth in 2000. Z’s mother has learning difficulties and had a history of being in a relationship which involved domestic violence prior to her involvement with Z’s father. There is also history that suggests that she struggled with parenting, with her children from this previous relationship being considered to be at risk of neglect. Z’s father was ultimately sectioned under sectioned under mental health legislation in August 2014. From his childhood, Z’s father demonstrated poor social skills and later reported that he had been a victim of repeated sexual abuse as a child. The review established that Z’s father had a series of interventions with mental health services. It also established that on numerous occasions, concerns about his inappropriate sexual behaviour, particularly in relation to children, were raised with various agencies. Despite this and the fact that at various points in Chid Z's life child protection investigations, conferences, strategy meetings and full plans were put in place, the lack of co-operation by her parents, ill-informed decision making by professionals and a failure to restrict this father's access to children, led to the conclusion that Child Z was seriously harmed. 4 5. Key findings of the Review By the time that Z was born there were already well-founded concerns that Z would be at risk of significant harm. The risks identified during the period that Z was on the Child Protection Register between February and June in 2000 ( which remained relevant throughout the period under review) were: a. Parental capacity to meet the physical, emotional and educational needs of their children b. Lack of boundaries, including sexual boundaries, within the family c. Father’s mental health d. An unwillingness to engage with services. At no point subsequently were there grounds to conclude that the risk of serious harm to Z had been eliminated. Rather, there continued to be a number of events which highlighted risks to the child’s safety, wellbeing and development. Accordingly, it was predictable that Z would suffer serious harm unless effective action was taken to either significantly reduce the risks to which she was exposed while in the care of parents or to remove Z from that situation. Over the 15 year period that Z was known to agencies there were a number of opportunities to do this but these were not taken. The review concluded that there were four critical areas where opportunities were missed: - In Child Protection planning and implementation between 1999 and 2000, at which point the protection plans were discontinued without proper consideration of the risks. - In failing to recognise and respond to the father's mental health issues and the impact of these on the children. - In the inadequate response to repeated concerns that were about sexual activity and potential sexual abuse that were reported to the police and other agencies. - In later child protection processes between 2010 and 2014, which were not effectively implemented until the point at which child Z was taken into care. 5 The review panel has looked at all the factors that have contributed to these issues, which range from the decision of the former Bedfordshire County Council children's social care service to relinquish responsibility for safeguarding Child Z in 2000 through to the impact of accessibility of records , organisational restructuring and IT developments. The review has investigated each of these factors in detail and made a series of twelve recommendations for action. These relate to training, procedures and guidance, record keeping, mental health services for children who are victims of abuse, enhanced collaboration between professionals involved in child protection. The recommendations are listed in detail below, together with the actions that have been taken in response to them by various organisations. Central Bedfordshire Safeguarding Children Board – Response to the SCR for Child Z Learning from the Serious Case Review (Recommendation) Action that has been taken since the start of the review and the impact of those measures Continuing work to make children safer and improve the quality of services 1. That the CBSCB review and re-launch their procedures and guidance in respect of sexual activity involving children CBSCB has reviewed and updated its Under Age Sexual Activity Chapter and this was included within its online procedures in May 2016. The LSCB has also reviewed and refreshed its Child Sexual Exploitation (CSE) guidance and CSE Risk Assessment Tool. No additional points. 2. That the CBSCB considers whether the training and resources provided for front line practitioners across all agencies adequately equips them to recognise and respond to neglect and emotional abuse, particularly in resistant families, including trigger points for the escalation of intervention. Since 2013, the overall quality of the service to vulnerable children has improved. This has been indicated by a significant rise in the percentage of Children’s Services case file audits that conclude that the service provided is good or outstanding – in 2013, most were judged to be inadequate or requiring improvement whilst in 2016 80% are judged good or outstanding. A pilot of the Graded Care Profile (a tool for assessing neglect) has been successfully tested in Regular case file auditing, and using the learning and improvement opportunities from this activity, is well embedded and ongoing with children’s Services Operations in Central Bedfordshire Council. An audit on the use of the Graded Care Profile is due to be undertaken during the October 2017. 6 Learning from the Serious Case Review (Recommendation) Action that has been taken since the start of the review and the impact of those measures Continuing work to make children safer and improve the quality of services one Children’s Services Operations locality in Central Bedfordshire. The Graded Care Profile supports practitioners in being clear about when the care of children is inadequate, assisting authoritative challenge and support to families. Multi-agency partners such as South Essex Partnership Trust (SEPT) have also taken part with in the Graded Care Profile Pilot. The Graded Care Profile is now being rolled out further across Social Work and Early Help Teams. CBSCB currently provides multi-agency training in relation to resistant families. A review carried out in relation to the impact of this training highlighted impact in relation to three key areas - messages taken into practice, strengthened child centred practice and specific examples of enhanced team practice. A strong legacy from the training is a heightened awareness of the need to “think family”, maintain a high level of professional curiosity about the ‘real life’ experience of children in the family and strengthen collaboration with other professional colleagues and agencies. CBSCB offers an E-learning Course on the topic of Neglect, which is available to all staff from all agencies across Central Bedfordshire and is free to access. All practitioners and managers in Children’s Services Operations will begin training in Motivational Interviewing, to enhance their skills in assessing and engaging with families who are resistant to change. Training began in September 2016, and most staff and managers have had training and briefings. This learning programme is ongoing. 7 Learning from the Serious Case Review (Recommendation) Action that has been taken since the start of the review and the impact of those measures Continuing work to make children safer and improve the quality of services In addition the CBSCB has completed a multi-agency audit in relation to neglect cases to identify any further multi-agency learning and training needs and since November 2016 has been delivering a face to face training course ‘Understanding the impact of abuse and neglect on children’ On the 30th March 2017 a Pan Bedfordshire LSCB Conference focusing on tackling Neglect was held with 340 practitioners attending. 3. That all partner agencies ensure that the importance of preserving accessible case records to inform current practice when recommissioning or restructuring services and when implementing IT developments is embedded in their organisational memory. Within Children’s Services Operations any transitional arrangements are carefully assessed in terms of risk at regular Mosaic (electronic case records system) Optimisation meetings. This means that the full history of a family is available for Children’s Services Operations staff. Within Health Services this is addressed via contractual arrangements from the Bedfordshire Clinical Commissioning Group with its contracts with the service providers. Following the Serious Case Review health providers within Bedfordshire have completed the Goddard Checklist which includes clarity around preserving records. SEPT has confirmed there is a policy in place to retain child records for 25 years in accordance No additional points. 8 Learning from the Serious Case Review (Recommendation) Action that has been taken since the start of the review and the impact of those measures Continuing work to make children safer and improve the quality of services with NHS Information Standards. ELFT has transferred all patient records from April 2015 onto its electronic patient records system (RiO). ELFT’s Health Records Policy includes a section on the Goddard Enquiry. The Goddard Enquiry: This is an enquiry that was set up after investigations in 2012 and 2013 into the activities of Jimmy Saville. Dame Lowell Goddard was appointed chair in September 2014 however the enquiry faltered several times. Professor Alexis Jay OBE has taken over as Chair and set out a plan of action for the Committee through to the end of 2018. All that is being said of the future is that it is hoped to make serious progress by the end of 2020. A letter was sent to all CEOs of Trusts in July 2015 stating that until The Goddard Enquiry had finished its deliberations Trusts were to put the destruction of records in any format on hold. The enquiry’s remit broadens as it progresses and it is felt that it will necessarily include adults of today and tomorrow who were children at the time that the enquiry began. Accordingly archiving of all documentation to our contracted secure storage facilities may continue but the deletion of those records is on hold. 9 Learning from the Serious Case Review (Recommendation) Action that has been taken since the start of the review and the impact of those measures Continuing work to make children safer and improve the quality of services Within the Police all records are kept electronically and retained in accordance with the Management of Police Information and CPIA disclosure rules. There is a specific plan in place to ensure records are retained, although legacy systems might become harder to access in the future, but this is a risk around general software/hardware development. There is a very low risk of not accessing these records in the future. 4. That Bedfordshire Police ensure that their custody staff, when setting bail conditions for individuals who may pose a risk to children, take into account all children to which person has access and if applicable coordinate this with other processes addressing risk to the children. Custody Sergeants have been reminded of their responsibilities to consider all children that may be at risk. Beds Police Custody Sergeants make bail decisions based on the advice of investigating officers and by conducting a risk assessment considering all available information. Where Custody staff are made aware of risks the conditions set will be designed to mitigate that risk. Custody Inspectors will be asked to consider appropriate conditions during regular Custody Record audits. In relation to the recent Bail Act changes, Bedfordshire Police has given guidance to staff that the presumption against bail for most cases will not count in relation to child safeguarding cases. This is to ensure the limited protection available through the imposition of bail conditions is not lost. 5. That commissioners and providers of CAMHS NHS Bedfordshire Clinical Commissioning Group, ELFT and CAMHS will work in partnership with 10 Learning from the Serious Case Review (Recommendation) Action that has been taken since the start of the review and the impact of those measures Continuing work to make children safer and improve the quality of services ensure that appropriate and accessible services are available to children and young people who are victims of abuse or neglect. through their commissioning arrangements with East London Foundation Trust who provide the CAMHS Service has addressed this issue. A new structure has been implemented and a Single Point of Access (SPOA) has been put in place to develop a consistent and clinically led screening process and triage for all CAMHS referrals. Waiting times within Bedfordshire have been reduced and a new 7 day week crisis service has also been commissioned. ELFT staff have attended training regarding child sexual exploitation. In addition there is now a dedicated Looked After Children Service Team within the CAMHS service. CHUMS, Bedfordshire Open Door, Sorted and Relate to create an integrated SPOA for CAMHS services. 6. That CBC ensures that all of their Social Care and Legal Services staff are aware of their responsibilities in respect of legal planning and able to effectively interface with each other. All staff and managers in Children’s Services Operations and Legal Services have been briefed on the learning from this SCR, including clarity around the respective roles of each service. Cases in formal pre-proceedings process are jointly reviewed by Consultant Social Worker and Legal Services Manager. This learning will continue to be regularly revisited and tested in routine case file audits of Children’s Services case files. 7. That the CBSCB and CBC include within their training provision information on differing standards of proof in criminal and civil Newly qualified social workers are provided with learning sessions by experienced team managers and the Legal Services Manager on legal work. This issue will be revisited in the ongoing staff learning sessions facilitated by the Consultant Social Workers. 11 Learning from the Serious Case Review (Recommendation) Action that has been taken since the start of the review and the impact of those measures Continuing work to make children safer and improve the quality of services proceedings and the relationship of these to child protection practice. This includes addressing the differing standards of proof in criminal and civil proceedings and the relationship of these to child protection practice. All managers have briefed staff on the learning from their SCR including this issue. The burden of proof is included within the current CBSCB module two training. The burden of proof has also been included within the single agency training for SEPT staff and is reinforced through supervision. 8. All partner agencies should ensure that their pathways for escalating child protection issues, including those from routine audit processes, ensure that senior manager oversight and supervision is maintained until the issue is fully resolved. Within Children’s Services Operations all managers have been briefed on the learning from this SCR in terms of the need for evidenced follow through to make sure that concerns about child protection issues are resolved. SEPT has clear internal structure to escalate concerns supported by LSCB escalation protocol. SEPT’s 0-19 Team Service have also strengthened processes for Team Leader oversight, supported by caseload monitoring tool, and supervision. In relation to the Police the current escalation policy has been reviewed and is still appropriate and but needs to be consistently used. Therefore guidance has been sent to all senior managers in the Public Protection departments within the The Audit Manager and Head of Professional Standards for Children’s Services Operations provides oversight and challenge to monitoring progress and outcomes when child protection issues are raised in routine audits. 12 Learning from the Serious Case Review (Recommendation) Action that has been taken since the start of the review and the impact of those measures Continuing work to make children safer and improve the quality of services Police. ELFT have confirmed that escalation pathways within their organisation are in place. 9. That the CBSCB sponsor a multi-agency task and finish group to develop and embed a ‘Think Family Approach’ across children’s and adult services when working with parents with mental health difficulties. In particular this should include robust arrangements for the assessment of risk to children from parents and carers with mental health difficulties including when an adult is discharged from a service. The need for a Think Family Approach (children and adult services) task and finish group has been identified from this SCR and Child A. This is in respect of making sure that there is effective communication and decision making for the children of parents with mental health difficulties and possible or known learning difficulties. The Principal Social Workers for Adult Social Care and Children’s Services Operations now have an established dialogue to develop processes to improve collaborative working and trouble shoot when problems are emerging that may be detrimental to the welfare and safety of children. Task and Finish Groups have been completed to improve collaborative working between ELFT, CBC Adult Social Care and Children’s Services Operations. The Pan Bedfordshire Protocol between Children’s Services and Adult Mental Health Services is currently being updated. 10. That the CBSCB consider whether their procedures and the practice of partner agencies adequately ensure that all relevant agencies are engaged in strategy discussions and where appropriate remain engaged with child protection investigations. The recent (March 2016) Joint Targeted Area Inspection (JTAI) provided a detailed independent regulatory review of decision making in the Access and Referral Service for Children’s Services Operations and concluded that the service provided to families was of a good quality. The inspection concluded that information sharing; multi-agency analysis and threshold decisions in strategy discussions were sound. There was good awareness and competence in understanding the issues of child sexual abuse (signs and symptoms), in particular, but not exclusively, in respect of Central Bedfordshire Council Children’s Services Operations contributes actively to ongoing Pan Bedfordshire service development around child sexual abuse and neglect. Central Bedfordshire has proceeded with an updated and more effective chid sexual exploitation risk assessment tool, as agreed during the March 2016 JTAI inspection. 13 Learning from the Serious Case Review (Recommendation) Action that has been taken since the start of the review and the impact of those measures Continuing work to make children safer and improve the quality of services child sexual exploitation. ‘The single point of access safeguarding hub and social care assessment teams effectively provide a timely response to the range of problems that children and young people experience. In particular, children and young people generally receive high quality services at the first point of contact with children’s social care.’ Ofsted, the Care Quality Commission (CQC), HMI Constabulary (HMIC) and HMI Probation (HMI Probation) May 2016 In relation to SEPT, safeguarding policy and procedures, training and supervision inform and reinforce staff of their responsibility to full participate in strategy and child protection conferences both ICPC & RCPC. Recent inspections/audit has acknowledged SEPT professional participation at these meetings. In addition the CBSCB has developed and implemented a Policy and Procedure Group to oversee the reviewing and updating of its online procedures. The procedure for Child Protection Enquiries has been reviewed. 11. That CBC should ensure that all Child Protection Plans are stand-alone documents which include all of the actions required by the The Chairs of Child Protection Case Conferences and all managers in Children’s Services Operations are clear that all Child Protection Plans are stand The Chairs of Child Protection Case Conferences introduced a Strengthening Families approach to Child Protection Case Conferences in the last 14 Learning from the Serious Case Review (Recommendation) Action that has been taken since the start of the review and the impact of those measures Continuing work to make children safer and improve the quality of services professional network and the family concerned, along with clear milestones and contingency arrangements for lack of progress with the plan. alone documents. They have been reminded of the risk of confusion for the professional network and family if there are multiple documents. They are also clear that all plans need to be outcomes, impact and child focused. quarter of 2016. This has meant that Child Protection Case Conferences, and the plans created, will provide high support and high challenge to families and professionals by being really explicit about what people are worried about, what needs to change, by when, what the signs might be if the plan is not working, and what will happen if it is evident that the welfare and safety of the children is not being secured. Feedback from surveyed professionals and parents has indicated high satisfaction rates with the Strengthening Families approach to Child Protection Case Conferences in CBC. 12. That the CBSCB disseminate the learning from this Review to staff across the partnership. CBSCB in conjunction with the two other LSCBs in Bedfordshire provide multi-agency briefing events on a quarterly basis for front line practitioners in to share the learning from Serious Case Reviews. LCSB Training courses are also updated as necessary following case reviews with any appropriate learning. Learning is also disseminated through newsletters and briefing documents. To continue the dissemination of learning from case reviews. |
NC50836 | Death of an infant boy under 1-year-old in April 2017 due to drowning. Child I was left unattended whilst bathing with his sibling (IS). IS and unborn sibling subsequently made subjects of a child protection plan. No criminal charges were brought. Police described home conditions as neglectful. Mother (IM) and father (IF) both asylum seekers to the UK from Southern Africa. IM had previously been admitted to hospital and detained by police under the Mental Health Act. IM had three unsuccessful pregnancies between March 2013 and April 2014. IF was known to police for domestic abuse and disclosed to GP he was suffering from stress at work; later lost his job. Mother and father are of black African heritage. Learning includes: housing providers may have indications that families with young children are struggling and may benefit from support; family might have benefited if greater consideration was given to social factors including ethnicity, apparent isolation, historical mental health concerns and status as asylum seekers; ensure good communication between GP and maternity services, sharing information on previous parental mental health and details of previous pregnancy complications. Recommendations include: seek assurance from health providers that social and medical risk factors in pregnant women are communicated to maternity services by GPs; seek assurance from the police that when responding to domestic abuse all relevant information is shared with partner agencies; seek assurances from housing commissioners that staff making home visits receive suitable training in recognising and responding to concerns about vulnerable adults and children.
| Title: Serious case review: Child I. LSCB: Hertfordshire Safeguarding Children Board Author: Russell Wate Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 | P a g e SERIOUS CASE REVIEW CHILD I Independent Author: Dr Russell Wate QPM January 2019 2 | P a g e TABLE OF CONTENTS Page no. 1. Introduction 3 2. About the Author 3 3. Terms of reference / Scope 4 4. Methodology 4 5. The family 5 6. Contact with the family 5 7. Background 6 8. Birth of IS and Child I 7 9. Analysis of involvement 10 10. Learning from this case 13 11. Recommendations 15 3 | P a g e 1. Introduction 1.1 This Serious Case Review (SCR) was commissioned by the Hertfordshire Safeguarding Children Board following the death of the subject of the review, CHILD I. At the time of his death CHILD I was under one year old. 1.2 On the day of his death in April 2017 CHILD I was left in the bath with his older brother (who was under two years old) by his mother while she looked for clothing and started to prepare breakfast. On her return she found CHILD I lying in the bath. The SCR has received different accounts as to his exact position and it is not certain how long the children were left for. The children’s father was in the vicinity but says that he did not know that anything untoward had happened until the mother returned and screamed in distress. 1.3 The mother removed CHILD I from the bath and emergency services were called. CHILD I was taken to the local hospital where extensive resuscitation was undertaken. Despite these best endeavours medical staff were unable to save CHILD I. 1.4 The police described the conditions in the home as neglectful (further details are given in paragraph 8.21 – 8.22). This caused immediate concern as to the ability of the parents to care for CHILD I’s sibling. Child I’s sibling and an unborn baby were subsequently made the subject of a child protection plan. No criminal charges were brought as taking account of the circumstances as a whole Hertfordshire Police decided that this would not be in the public interest. 1.5 A referral was made to the Hertfordshire Safeguarding Children Board. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) defines a serious case as being one where: (a) abuse or neglect of a child is known or suspected; and (b) either - (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. In this case CHILD I had died and the SCR panel believed that the children had been living in neglectful circumstances. 1.6 On 5 July 2017 the Hertfordshire Safeguarding Children Board Panel made a recommendation to their Independent Chair that a Serious Case Review should be undertaken in this case. The Chair agreed with this recommendation. 2. About the Author 2.1 The Hertfordshire Safeguarding Children Board commissioned an independent author to carry out the review. The review is supplied by RJW Associates and the lead reviewer is Dr Russell Wate QPM. He is a retired senior police detective, who is very experienced in the investigation of homicide and child death and child 4 | P a g e neglect issues. He has contributed to several national reviews, inspections and inquiries, as well as being nationally experienced in all aspects of safeguarding children. He has carried out many SCRs and is also an independent chair of two LSCBs. He has no connection with and has never worked in Hertfordshire. 3. Terms of reference / Scope including time-frame to be covered 3.1 The subject of the review is CHILD I (under one year old). 3.2 The focus and key issues that this review sought to address were as follows: To review the circumstances leading to the death of CHILD I and establish what lessons are to be learned from the case about the way in which local professionals and organisations worked individually and together To establish what lessons are learned to safeguard and promote the welfare of children and by doing so act upon these lessons swiftly, identifying the need for change where appropriate 4. Methodology 4.1 Working Together 2015 allows Local Safeguarding Children Boards (LSCBs) to determine their own processes for review. The Case Review Group of the Hertfordshire Safeguarding Children Board formed a panel to manage the review process. The panel was independently chaired and consisted of senior managers and safeguarding specialists from agencies from the area. The role of the panel was to assist the independent author and reviewer in considering what lessons could be learned and developing recommendations to improve policy and practice to better safeguard children. The panel details: Keith Ibbetson, Independent Chair Russell Wate, Independent Author Safeguarding Boards Manager, HSCB Detective Chief Inspector, Hertfordshire Constabulary Named Doctor, West Herts Hospital Trust Designated Nurse Safeguarding, East & North Herts CCG and Herts Valleys CCG Head of Family Services Commissioning, Herts County Council Named Nurse Safeguarding Children, Herts Community NHS Trust Consultant Safeguarding Nurse (Named Nurse) Herts Partnership Foundation Trust Strategic Project Manager, Borough Council Senior ASB & Fraud Officer, Community Housing Trust 5 | P a g e 4.2 After understanding which agencies had been involved with the family, management reports and chronologies were requested from the below listed organisations. Where possible report authors spoke to staff within their organisation who were involved in the case. Hertfordshire Constabulary West Hertfordshire Hospitals NHS Trust Borough Council General Practitioner Hertfordshire Community Trust Hertfordshire Partnership Foundation Trust Community Housing Trust 4.3 The methodology applied to this review has been a “blended methodology” utilising the rigour of a chronology and management reports from each agency, with the review author’s analysis. The review was then supplemented by a thorough practitioner workshop. It is good practice for an Overview Report to have input from professionals who have been involved in the case so as to test out the material gathered and to try and answer the ‘why’ questions. In this review it was particularly helpful, and helped to add context, content and richness to both the report and also the learning. The review author also spoke to both the mother and father, gaining their unique perspective. 5. The family 5.1 The mother and father are of black African heritage having both originally come from Southern Africa. At the time of CHILD I’s death, they had two children and the mother IM was pregnant with their third child who has now been born. Father of Child I IF Mother of Child I IM Sibling of Child I IS Under 2* Subject Child I CHILD I Under 1* Sibling of Child I IS2 Unborn* *Age at time of CHILD I’s death 6. Contact with the family 6.1 It is essential where possible that reviews obtain the views of family members. As part of this review IM and IF were seen and given the opportunity to express their views on CHILD I’s death and their family circumstances that led up to it. Understandably they found talking about CHILD I difficult. The parents are understandably distressed that they are having to discuss their loss again after almost a year and feel that, although they will never get over losing the baby, they 6 | P a g e need to move on and that they feel these processes are impacting upon them emotionally. To the extent to which they were able to convey them to the reviewer their views are reflected throughout this review. 7. Background 7.1 The mother IM arrived in the UK in 2002, as an asylum seeker from Southern Africa. IM reported suffering traumatic experiences whilst living in Southern Africa. They were of immense significance to her but to protect her privacy they are not described in more detail here. She lived with an aunt in another area in the UK until November 2003 before moving to Hertfordshire. 7.2 IM resided in hostel accommodation and in 2003 there are indications that she suffered some mental health illness. She was admitted to hospital and later being detained by police under s136 of the Mental Health Act.1 7.3 During 2005, IM was involved in an appeal process regarding her immigration status, and at this time enrolled on a college course to train as a mental health nurse. 7.4 In 2007, it is recorded that IM’s disorder had resolved and after a phone consultation she was removed from her GP’s ‘severe mental illness register’ of patient’s subject to mental health care plans. IM was still regarded by the GP practice as someone who needed checking for her mental health but not on their register. This consultation was carried out on the phone. It is known that IM had failed to attend two appointments in 2006.2 7.5 In 2008, it was documented in the GP records that IM had felt well and stable for some time. She had finished her initial college course and was due to attend University. IM stated that she was continuing with her medication, but the GP records do not support this as her last prescription had been in 2006. 7.6 It would appear that IM wished to have no further contact with psychiatric services after this point. The GP surgery sent letters to IM in 2008 and 2009 inviting her to the surgery for a mental health review but received no response. It was suggested at the practitioner learning event by a GP that where a person is suffering from mental health issues, it is important to ask consent for a family member or friends details to be given so that in the event of no contact there is someone else to contact to ensure they are no mental health issues that need addressing. This was 1 At the time mental health legislation gave the police the power to remove a person who appeared to be suffering from a mental disorder from a place to which the public had access and take the person to a place of safety. These powers have subsequently been extended by Section 80 of the Policing and Crime Act 2017. 2 It is not possible to provide more detail of these episodes because the mental health records were destroyed in a fire and cannot be accessed. 7 | P a g e seen by the review author and agreed by others at the practitioner event as good practice, as was the sending of the letters in the first place. 7.7 In 2011, the GP had a further telephone consultation with IM and reported conducting a ‘mental health review’. 7.8 IM and IF are not married. IF had also entered the UK as an asylum seeker from the same African country. The first records for IF are in 2004 when he registered with his GP. There are few records of contact from agencies with IF after this time. Several years before becoming a parent he had been arrested for offences of dishonesty and was charged with sexual offences, but not convicted. 7.9 In March 2013, September 2013 and April 2014 IM became pregnant, but on each occasion lost the unborn baby at various stages of pregnancy. The second of these pregnancies resulted in IM giving birth to a baby who survived only very briefly. When IM presented for the last of these pregnancies at 4 weeks she was told to self-refer to maternity services. 7.10 IM and IF attended what is described in records as a small African church in North East London. It is located more than 20 miles from the family home. 8. Birth of IS and CHILD I 8.1 In early January 2015, IM attended her GP, pregnant with IS. A referral was made to maternity services, but details of her mental health history and the outcomes of her previous pregnancies were not included in the referral. 8.2 IS was born prematurely at 26 weeks in April 2015, at a hospital in another area with IM having been transferred there from their local hospital. IS remained in various hospital neonatal units until finally being discharged in mid-August 2015. 8.3 Throughout 2015, IM was being dealt with by the Housing Department for unpaid Council Tax resulting with a summons being issued in August 2015. In June a letter was sent by the Housing Department for Breach of Tenancy due to an untidy garden. 8.4 IM presented as pregnant with CHILD I in October 2015. Again, when the GP referral to hospital maternity services was made there was no mention of the previous mental health issues or the previous difficult pregnancies. 8.5 In October 2015 a home visit was made by the local children’s centre to discuss what services they were able to offer. This is common practice and there is no record to indicate that this was because of any professional concern. 8.6 In October 2015, the police attended a domestic dispute at the family home. A neighbour reported hearing shouting and screaming coming from ‘the flat upstairs’ in which a child also resided. The police found IF to be drunk and in a fracas on the 8 | P a g e doorstep he assaulted two police officers and was arrested. The officers attending had concerns over the new-born child because they found no food that they believed was of a decent quality for the child and the address was dirty and unhygienic. There is no information on what risk assessment was made because of this incident and IM was pregnant at this time and had a young child. Despite identifying and recording these concerns and categorising the event as a non-crime low risk domestic incident the officers involved made no referral to the local authority. It has not been possible to establish why this oversight occurred. IF was subsequently convicted of assaulting the two officers. 8.7 In late October 2015, IM failed to attend a clinic baby check appointment but shortly after did attend a local baby massage group. This was the only session that she did attend but it does demonstrate contact with some of the local community support that was available. 8.8 In November and December 2015 IM attended two further baby clinic appointments with IS before informing staff that she would be travelling to Southern Africa in December 2015 to visit family. 8.9 In February 2016 IM failed to attend a neo-natal appointment for IS, a letter was sent to the GP to highlight the non-attendance. Two days later IM did attend a scan for her pregnancy which was normal. In March 2016, IM did attend the neo-natal clinic with IS and he was noted to be making good progress. 8.10 In April 2016 CHILD I was born at 37 weeks of pregnancy, the following day IM was discharged to the care of the community midwife. At the time of CHILD I’s birth IS was one year of age. IM and CHILD I were seen by the community midwife until 10 days after the birth. There are no recorded concerns at this time over the care given to the children or the state of the family home. There had been a lot of antenatal care and appointments for IS due to their prematurity during which there were no concerns. 8.11 In May 2016, the Health Visitor (HV) made the first new birth visit. The examination of CHILD I was recorded as satisfactory. A broken window was noted and an explanation for this was given. The family said that they were to be re-housed due to a neighbour dispute. No Domestic Abuse screening took place due to IF being present throughout the visit. CHILD I was noted to be sleeping with IM as the cot needed to be assembled. Safe sleeping advice was given and two days later the HV visited again to ensure the cot was in place. 8.12 In May 2016, IF attended the GP surgery with hay fever he also, discussed being under stress. He stated that he had recently had a baby and that he had a lot of issues at work. He was advised to speak to his work HR department and union. There was no referral made for more specialist assessment in relation to the reported stress. 8.13 In June 2016 the HV saw IM with CHILD I and IS, on this occasion the Domestic Abuse screening questions were asked, and the answer given to each was ‘no’, 9 | P a g e indicating that there was no domestic abuse present. IM kept her GP appointment for routine immunisations. Health professionals had no knowledge of the police attendance at the domestic abuse incident. 8.14 In July 2016 the family moved to a new address in the same council area. In September 2016, IS attended a neo-natal clinic with CHILD I and IF, there were no concerns noted. 8.15 In September 2016, IM notified the GP that she would be travelling to Southern Africa, and she would be staying several months. 8.16 Although there are no records of exactly how long IM was out of the UK, or when she went, from discussion with the family for this review it is known that IM travelled with the children and IF remained at home. When she returned IF had lost his job and IM would state that this is the time that family conditions started to deteriorate. 8.17 In January 2017, IM booked with antenatal services as pregnant, this was a late booking as she was 22/23 weeks pregnant. The late booking was recognised, and information was shared with Children’s Services. There is no information to suggest that the GP was aware of this pregnancy previously. IM was booked a consultant appointment due to her previous complications in pregnancy. 8.18 At the beginning of February 2017, IS attended the neonatal clinic with IM, IF, and CHILD I. It was noted that he was making good progress and there were no concerns. 8.19 In March 2017, IS was not taken for his yearly check-up, a text reminder had been sent and the missed appointment was followed up with a phone call to IM, to which there was no response. A letter was sent to re-arrange the check for April 2017. 8.20 In mid-March and mid-April, IM attended a consultant appointment and community midwife clinic respectively for her current pregnancy where no concerns were noted. 8.21 In the morning in late April 2017 ambulance and police attended the home address on the report of a child in cardiac arrest. CHILD I’s mother reported that he was breathing, though this is not confirmed by the ambulance service records. CHILD I was conveyed to hospital where resuscitation continued. CHILD I died after approximately one hour. It is not possible to be certain how long the children had been in the bath. 8.22 The police noted the house was in a neglectful condition. The officer describes this as ‘The home has 2 bedrooms which identified that the home conditions were in a neglected state. There was evidence of mould to windows and walls. Limited food was in the home and nothing which would be suitable or appropriate for small children. One room had a bed and baby cot and it would appear that IM slept here with Child I. The cot was full of clothes and other items and did not appear to be used for Child I to sleep in. IF and IS were sleeping in the other room, there was no 10 | P a g e bed in this room and appeared they were sleeping on a duvet on the floor. The bedding appeared grubby; there was no cover on the duvet and no pillow. There were piles of clothes in both bedrooms. Soiled nappies were on the floor (and also in mother's bed room). In the kitchen there was an absence of any consumable food. The fridge was rusty with few items inside. It was dirty and unhygienic. Pots of food were on surfaces. It was generally unhygienic and in need of a clean.’ 8.23 The next day, a strategy discussion took place in relation to the accommodation of IS. The following day to this an initial information sharing and bereavement planning meeting was held, this was attended by professionals to discuss the case and next actions in accordance with the Hertfordshire Safeguarding Children Board multi-agency procedures3. A Home Visit by the Rapid Response Nurse took place in this case. The nurse also noted the neglectful conditions as described by the officer, but went further to say how in her professional view the house and garden were an unsafe environment for the children to be living in. 8.24 IM was pregnant at the time with Child IS2. 9. Analysis of involvement 9.1 IM was pregnant every year between 2013 and 2017. She miscarried on the first three occasions, once very late in the pregnancy. IS was born prematurely and was in hospital for several months at hospitals in Luton and Cambridge. IM travelled by bus almost daily to visit him. CHILD I was then born less than a year after his sibling. This understandably made this a difficult and stressful period for both IM and IF. However, when IM and her children were seen by professionals the evidence was that IM prioritised her child’s needs effectively. 9.2 IM has a history of mental illness, this dated back to 2003 and she had received both in-patient and out-patient treatment up until around 2008, when she felt well and no longer sought support from mental health services. There is no evidence that IM’s mental health history had any impact on her ability to parent her children. There was though, no communication of the mental health history between the GP and maternity services. Knowledge of this history taken together with the repeated maternity problems that IM experienced may possibly have led to more support being offered to IM. As an example, in April 2014, when IM presented for the third of her unsuccessful pregnancies she was advised to ‘self-refer’ to maternity services, suggesting that her psychiatric and obstetric medical histories had not been fully considered. 9.3 At the SCR practitioner learning event there was a good discussion about the national and Hertfordshire encouraging ‘self-referral’ to maternity services, which can happen without the knowledge of the GP. It was felt that in the vast majority of 3 HSCB Rapid Response Protocol - http://hertsscb.proceduresonline.com/pdfs/cdr_rapid_response.pdf?zoom_highlight=rapid+response#search="rapid%20response" 11 | P a g e cases this worked out fine as the medical notes and patients were normally cross referred in due course. However, for a mother with high medical, social or psychiatric risks, advice to self-refer may not have been the best course of action. 9.4 Although there is an understandable desire not to stigmatise pregnant women with past medical history of mental health conditions, there are very strong reasons in this case for GPs to inform maternity services of this potential vulnerability. 9.5 IM and IF were struggling financially and proceedings were being taken against them for non-payment of council tax. Shortly after the birth of CHILD I, IF attended his GP for hay fever but did disclose that he was suffering from stress due to having a new baby and issues at work. When a review author met IF, he would seem a relatively private individual and his infrequent access to services would tend to support this as being his personality. It may have also been that he was not confident to talk to people he doesn’t know. This disclosure regarding stress may have been a ‘cry for help’ and he may have benefited from a referral for support to further explore his stress. The SCR practitioner learning event considered whether the mother might have been referred (for example for community based mental health support) in similar circumstances, so maybe this should have taken place for IF. 9.6 IM and IF did not have a geographically close family network on which to rely. They did seek and receive support from their church although at that time (early 2016) this was not on a regular basis. There is no evidence that the church was aware of the financial and practical difficulties facing the family as they were not always regularly in attendance there. IM visited Africa with the children in December 2016 and she told the SCR that when she returned she found IF had lost his job and it was from this time that the home conditions started to deteriorate. 9.7 As a family with two young children health practitioners made fairly regular home visits, but there were no recorded concerns about home conditions, so it is reasonable to assume that it was around this time the neglectful conditions witnessed by emergency staff in April started to prevail. The normal pattern of health visiting contact specifies a home visit at about 10 months to 1 year. The community health records state that a clinic appointment was given but that the children were not brought. This could have instigated a home visit but it is not clear if there was a plan to do this or not. 9.8 There was a pattern of some other missed health appointments, so consideration must be made to ‘Did not attend’ procedures, however, in this case, these were interspersed with attendances, so wouldn’t have given rise for concern for the children. An example of this where the whole family attended an appointment in February 2017 and IM attended appointments in March and April. It could not be said that the family were conspicuously trying to avoid services. On the face of it their fluctuating attendance gave no cause to concern professionals. 9.9 There is evidence that extended universal services were offered to the family with a visit made by the children centre. This may have been the catalyst for IM to access 12 | P a g e baby massage with CHILD I. Although IM only used this service on one occasion it does show that she was aware that there were services available to support her and the family. 9.10 The SCR has considered whether the family’s ethnicity and position as asylum seekers may have affected the parents’ ability to access services or the response of agencies. The family come from a country which has strong links with the UK and many migrants and asylum seekers. Many of its former residents thrive in the UK, making an important contribution to services such as the NHS. This couple did not thrive. The mother experienced mental health problems and appears to have been treated and supported successfully. However, her plans to work as a nurse did not come to fruition. Less is known about the father’s background and history. 9.11 Conversations with the family suggest that they were isolated from family and community support and even their links with their church were not frequent. They donated money to the church but its members were not aware in detail of their difficulties. They may have wanted to participate as full members and not appeared to have been dependent. Both parents spoke fluent English and lived in a part of Hertfordshire that has a substantial minority ethnic population, including many other Black African families with young children. 9.12 The family received specialist medical services in hospital and universal services in the community for IS. In both settings it will have appeared that the mother was focused on her children and coping with her son’s health difficulties. It appears that no additional efforts were made to encourage engagement in services that could have assisted. She went once to a baby massage session but no one asked why she stopped attending. On paper the father had a troubled history with the police, though he did not acknowledge this as a major consideration. The SCR has noted that his response to the police attending his house might have been influenced by his experience of government interventions in his life in his country of origin. 9.13 Whilst all of these factors may have been significant, as a family that largely received universal services and coped well, it is unlikely that any professional would have had the opportunity or felt the need to probe their significance more deeply . However, if a more comprehensive picture had been available someone might have explored these questions. 9.14 IM did state that she thought she would have benefitted from the parenting course earlier which she has undertaken since CHILD I’s death for her other children. She described the course as ‘awesome’ (a tribute to those that deliver this course, and good practice), but states that she would not have known how to access it, when either IS or CHILD I had been born. 9.15 There was evidence of one report of domestic abuse in the relationship with one incident being reported to the police in October 2015. At this time IM had a young baby (IS) recently released from hospital and she was pregnant with CHILD I. A neighbour had called the police after hearing shouting from the flat upstairs. When police attended IF assaulted two officers and was arrested. A line of enquiry that the 13 | P a g e review author was asked to consider by the SCR panel, was whether IF was violent and controlling. There is no clear evidence to suggest this following information to the review from agencies, the social work team currently working with the family and conversations with the family themselves. This possibility cannot however be entirely discounted. 9.16 The Police on attendance did have concerns about the state of the house and felt it was neglectful. They did plan to report this to Children’s Services but did not. Information now provided to the review is that there is in Hertfordshire (as elsewhere in the UK) a very large number of referrals are made about children in families where there have been domestic abuse concerns. Since 2015 systems have changed so that information about these referrals is passed to schools and health professionals as well as the local authority. Housing providers are not currently included in this arrangement and they lose the opportunity to visit families and provide services. 9.17 When a woman is pregnant there is a higher risk from domestic abuse. Information in this case was not shared with other agencies because of an oversight on the part of the officers. However, there is no indication that this is a wider problem in Hertfordshire and in fact the main challenge facing some agencies is processing and risk assessing the large number of referrals that are made. 9.18 The housing service had a high level of contact with the family primarily about the continuous failure to pay the rent. However, no home visits were made. Had this happened there may have been opportunities to identify the neglect that was building up after IF had lost his job and IM was pregnant again. Professional curiosity by thinking how the family coping with two very young children was when unable to pay the rent may have helped. 9.19 CHILD I did die from a drowning incident in his household bath. It is fully accepted by all including the review author that this was a tragic accident, and fully understand the family’s feelings that they are trying to cope with the impact of this. As part of the learning from this case there should be a re-emphasis to parents of young children of the dangers of leaving them unattended while bathing them. 10. Learning from this case 10.1 Although this was a family that were only known to universal services there are some indications that could be considered for future learning. Housing providers may have indications that give rise to concern that families with young children, are starting to struggle and may benefit from more support. In this case it is not clear whether any additional support would have been accepted by this family at the relevant and crucial time. Housing providers told the SCR that they often feel that important updates including safeguarding information are not shared with them. In this case they believed the family had one child and did not know about police contacts. The SCR was told that professionals in other agencies often do 14 | P a g e not know what housing providers can do to help vulnerable families. This is something the partnership could develop further. As an example, Housing providers and District and Borough Council Neighbourhood Officers who complete home visits and speak to tenants should always receive an agreed level of safeguarding training in identifying child neglect issues and ensuring that staff are aware of the relevant reporting mechanism. Housing officers should be encouraged to be more proactive in such matters. The SCR author has been told of an initiative that will hopefully improve this working together. Locally Police and housing providers attend a monthly meeting known as the Community Protection Group (for information sharing). This provides officers with an opportunity to discuss any cases and concerns (including safeguarding) in relation to particular cases and request information, advice or support from partners, agencies and or other services around the table. Any cases of concern which need on-going monitoring and multi-agency support are placed on Safety Net, accessible to all partners and agencies for input as part of the Community Protection Group. Health professionals do not attend the Community Protection Group meetings, however the importance of health’s attendance at these meetings is vital. The review has noted that the family might have benefited if greater consideration had been given to needs to a range of background social factors, for example the family’s ethnicity and apparent isolation, the mother’s historical mental health concerns and their status as asylum seekers, and how their cultural background and previous experiences might need to be taken into account by those providing services. Also, if these factors could leave them isolated within the community they live in. The family themselves stated they were just very private individuals and would not describe themselves as isolated or that their home life situation was grim. There needs to be good communication between GP and maternity services to ensure that information on issues such as previous parental mental health and details of previous pregnancy complications is shared at an early stage to allow for the appropriate support to be given. Health professionals referring for and providing antenatal care should give consideration to mothers who have suffered multiple miscarriages and then become pregnant, especially if pregnancies follow in quick succession. Prematurity will in this context in particular increase the stress felt by parents with a new baby. There is already wide cross agency sharing of domestic abuse information and the systems in place have been reviewed since the events described in this review. The review of the effectiveness of such systems should be continuous. 15 | P a g e In July 2017 following the death of Child I and the Rapid Response process that was instigated at the time of the death, a decision was made to commence a water-safety initiative. The health visiting teams across the county were asked to discuss and share the HSCB water safety leaflet at every child’s next developmental assessment for the next year. This will be extended for another year. The leaflet will be handed to all new mothers at new birth visits through to the age of 1 year. Health commissioners should establish how effective the recent Water Safety Initiative has been. 11. Recommendations The HSCB should seek confirmation that recommendations and areas of improvement identified by agencies in their own reviews have been implemented. Recommendation 1 The HSCB should seek assurance from health providers and commissioners that any social and medical risk factors in pregnant woman are communicated effectively to maternity services by GPs and that the growth in self-referral does not hinder this. Recommendation 2 The HSCB should seek assurance from the police that their procedure for responding to any incident of domestic abuse ensures in practice that all relevant information is shared with partner agencies through the current processes that exist. This includes the Domestic Abuse Investigation and Safeguarding Unit (DAISU) and where appropriate if the notification meets threshold this will also be undertaken via the Multi Agency Safeguarding Hub (MASH). Recommendation 3 The HSCB should seek assurance from housing commissioners that their own staff and those of housing providers, in particular those who make home visits, receive suitable training in recognising and responding to concerns about vulnerable adults and children. This should take account of the needs of families with small children who fall into arrears. |
NC52249 | Sudden unexplained death of a 5-month-old baby. An expert witness concluded that TSs death met the criteria for a sudden infant death syndrome, but no criminal charges were made. Learning includes: routine questions and assessments need to consider the relationship with all significant family members who are involved in the care of the child; social workers need to consider information held by all involved health professionals; professional curiosity about the childs lived experience including considering the impact of living between homes on babies; the Bruises and injuries in non-mobile children policy should be followed in all cases where a non-mobile child has injuries. Recommendations include: ask the Department of Education and Department of Health to consider adding to guidance about routine questioning and assessments in domestic abuse whether any household members are experiencing domestic abuse in the childs home; consider how partner agencies can influence a cultural change regarding the role of fathers and secondary carers in the family.
| Title: Child safeguarding practice review: TS. LSCB: Sandwell Children’s Safeguarding Partnership Author: Nicki Pettitt Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child Safeguarding Practice Review TS Lead Reviewer Nicki Pettitt 2 Contents 1 Introduction to the case and summary of the learning Page 2 2 Process Page 2 3 Family structure Page 3 4 Background prior to the scoped period Page 3 5 Analysis by key episode and identification of learning • Pregnancy and birth • Assessment and support • Emergency department attendance Page 4 6 Conclusion and Recommendations Page 13 1 Introduction to the case and summary of the learning from this review This review is in respect of a five-month-old baby to be known as TS1. TS lived with their2 parents at the time of their death. The family had no tenancy of their own and was staying with an extended family member when TS died. The cause of death remains unexplained after a thorough and appropriate investigation. An expert witness concluded3 that TS’s death meets the criteria for sudden infant death syndrome. There was evidence of a low level of parental neglect of TS’s basic needs for nutrition, hygiene and safety, and this may have contributed to a degree of underlying vulnerability and exposure to known environmental risk factors for SIDS. 1.2 The learning identified from this review is in relation to: • Domestic abuse through control • The need to equally consider fathers/partners • Parental mental health • Information sharing and professional communication • Professional curiosity about the child’s lived experience • The involvement of wider family members • Responding to injuries in immobile babies • Professional understanding of the systems that provide health services 2 Process 2.1 Following a rapid review process4 and consultation with the Child Safeguarding Practice Review Panel, the Sandwell Children’s Safeguarding Partnership (SCSP) identified that lessons could be learnt regarding the way that agencies work together to safeguard children and commissioned this local Child Safeguarding Practice Review. 2.2 It was agreed that the review would be undertaken using the Significant Incident Learning Process (SILP) methodology, which engages frontline staff and their managers in reviewing cases and focuses on why those involved acted as they did at the time, avoiding hindsight 1 It is important to protect the identity of the child and family; the pseudonym TS has been chosen for this review. 2 It was agreed that the review would not disclose the gender of TS. 3 An expert medical witness was consulted as part of the police investigation undertaken after the child’s death. 4 A rapid review is undertaken in order to ascertain whether a Local Child Safeguarding Practice Review is appropriate, or whether the case may raise issues which are complex or of national importance and if a national review may be appropriate. The decision is then made by the national Child Safeguarding Practice Review Panel. 3 bias or individual blame. Opportunities for improvement within systems for safeguarding children are identified and strengths are promoted5. 2.4 The review considered agency involvement with the family during the pregnancy, around the birth and until TS’s death. There was some relevant involvement with the parents prior to the pregnancy and this is summarised when relevant to later practice. Detailed personal family information will only be disclosed in this report where it is relevant to the learning established during the review. 2.5 Early family engagement is required in the SILP model of review. The lead reviewer6 spoke to both parents while undertaking the review7. They will be spoken to again prior to publication. Their views are included in the report where relevant. 3 Family structure 3.1 The relevant family members in this review are: Family member To be referred to as: Subject child TS Mother of TS Mother Father of TS Father Mother’s grandmother Great-grandmother (GGM) Father’s aunt Great-Aunt (GA) 3.2 Father had a child from another relationship, who was around six months old when TS was born. There was no known contact between Father and his older child8, who was not considered by this review. 3.3 Mother lived with her grandmother (GGM) during her pregnancy and immediately after the birth of TS. Father reported that he lived with his own family, but it appears he had no fixed address and lived between various family members. At the time of TS’s death Father was staying with his aunt (GA). 4 The background prior to the scoped period 4.1 Mother was adopted as a young child by her grandmother (GGM) due to concerns about the care she received from her own mother9. Professionals believed GGM suffered with anxiety and depression and that domestic abuse featured in GGM’s relationships. Mother told the review that the domestic abuse was prior to her living with her GGM and she did not witness this however. 4.2 There were concerns about neglect, domestic abuse and maternal mental ill health when Father was growing up. He was diagnosed with ADHD and assessed for Asperger’s, had 1:1 support in school, was known to CAMHS and was prescribed ADHD medication. Father was 5 As part of the model, agency reports are completed. This gives agencies the opportunity to consider and analyse their practice and any systemic issues, identifying learning from the case. Practitioners, front line managers and agency safeguarding leads come together at learning events5 to consider the case and identify learning. All agency reports are shared in advance and the perspectives and opinions of all those involved at the time are discussed and valued. 6 The lead reviewer is Nicki Pettitt. She is an experienced and accredited SILP reviewer and entirely independent of the Sandwell Children’s Safeguarding Partnership. 7 This was by telephone, as due to Covid-19 face-to-face meetings were not possible. 8 It appears that the mother of the baby had not allowed father any contact, but it is not clear why. 9 This appears to have been organised within the family and without the involvement of children’s social care. Mother reported to professionals that her siblings had been subject to care proceedings. 4 reportedly violent to his mother on one occasion, and spent time living with his father in another area of the country and with extended family locally. 4.3 Around a year prior to TS’s birth, Father was prescribed anti-depressants by his GP for ‘low mood’. There was no review of the medication and no record of how effective they were for Father or of repeat prescriptions being issued. 5 Analysis by key episode 5.1 Key episodes are periods of intervention that are deemed to be central to understanding the work undertaken with TS and their family. The episodes do not form a complete history but are key from a practice perspective and summarise the significant professional involvements that informed the review. 5.2 From the information gained within the agency reports, the discussions at the learning events and from speaking to family members, the following key episodes provide the analysis and enable the review to identify learning for the SCSP10. Key Episodes Pregnancy and birth Assessment and support post birth Emergency department attendance Pregnancy and birth 5.3 Both parents were in their late teens at the time of the pregnancy. The midwives involved do not appear to have been aware how long they had been together as it is not a standard question. GGM told the police at the time of the birth that Mother had become pregnant within the first two months of her relationship with Father. TS was Mother’s first child and Father’s second, although Father was clear with professionals that he had no contact with his older child as the relationship had broken down before the child was born11. 5.4 Mother had the involvement of a number of different community midwifes12 during the pregnancy and following TS’s birth and two health visitors. Routine questions were asked of Mother regarding domestic abuse, mental health, drinking, and substance misuse by those involved. NICE guidance13 states that the health visitor’s primary birth visit and the community midwives’ antenatal booking appointments should include an assessment of maternal and paternal mental health. During the antenatal booking appointment, Mother told the midwife who completed the booking that Father suffered from anxiety and depression, ADHD and Asperger’s. This was recorded on Badgernet14 but there is no evidence that it was explored further with Mother or Father, or discussed with and shared with other professionals, including Father’s GP. 5.5 Research shows that professionals are aware of the role that fathers play in supporting women with mental health problems, yet less is known about the importance of exploring and monitoring a father’s historic or present mental health when there is a new baby. One in 20 men experience depression during their partner’s pregnancy, and up to one in 10 new 10 Each learning point is linked to a recommendation in either this report or within the agency reports. 11 At the time father said he did not know the baby’s surname, date of birth or address. 12 The agency report notes that 11 different community midwives were involved. 13 NICE (2014a) Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance. 14 An online information system that is used in Sandwell to record midwifery patient information. It is not accessible to GPs however, and cannot be accessed by all hospitals outside of the borough, unless they have Badgernet themselves. Important information should be shared on a Cause for Concern form which is shared with the health professionals who are involved and are also copied to the relevant safeguarding leads. 5 fathers are believed to struggle with depression following the birth of their baby15. The lack of focus on fathers is partly due to the time constraints within appointments and the amount of information that needs to be covered by the midwife, the fact that fathers are not always present and because fathers are not seen as service users in their own right at this time. There can also be related perceived concerns about where to store any information provided by fathers, as it could potentially be a breach of data protection to store it on the pregnancy notes - although permission can be gained for this. As well as these practical issues, there is a general lack of awareness of father’s mental health as an issue. ‘The Dad Project’ is run by the NSPCC and shows how information, advice and support for fathers can be improved in order to promote their emotional wellbeing and help them to achieve better outcomes for their families. Many of the fathers involved in the project said that they felt isolated during the perinatal period as attention is understandably focused on their partner and new baby. New parenthood is a time of stress and sleeplessness, and both parents are going to be more susceptible to anxiety and a decline in emotional wellbeing. 5.6 Universal provision16 was planned following the health visitor’s antenatal visit, as no concerns were shared or known. Mother did not tell the health visitor about Father’s vulnerabilities, but it is possible that she assumed the midwife and health visitor would have shared information. Service users often make these understandable assumptions.17 Those involved also believed that Mother and the baby would be living with GGM and they had no concerns pre-birth. There is no evidence that any routine questions about domestic abuse or mental health were undertaken in regards to GGM herself, despite the plan for the baby to be living in her home and for her to be the main support to Mother and TS. This type of exploration is not common practice but can result in babies living in homes where there may be unknown vulnerabilities or risks. 5.7 Mother’s hospital care was provided by a hospital outside of Sandwell18. Mother had most contact with the community midwives and attended the hospital for blood testing and scans. There is no information sharing between the community and hospital services unless there are specific concerns. The system relies on community professionals recording on both the electronic system and the paper handheld notes, and an expectant mother bringing their handheld notes to appointments at the hospital and in the community. When this doesn’t happen, it can result in time being spent chasing information, as happened in this case when Mother did not have the correct scan paperwork. It can also result in ineffective information sharing. 5.8 During her attendance at maternity triage at the hospital, those involved were concerned about the behaviour they witnessed from Father towards Mother. It was described as controlling and potentially abusive. While it was discussed in-house, a Multi-Agency Referral Form (MARF)19 or a Cause for Concern20 was not completed until Mother was admitted to give birth around 2 months later. The 2017 Department of Health domestic abuse resource for professionals21 states that health practitioners are in a key position to identify domestic abuse and to initiate support and safety for victims. They show evidence that a large number of these victims had attended health settings prior to receiving specialist domestic abuse support services. 15 https://www.panda.org.au/info-support/how-is-dad-going 16 Level’s are set out by NHS England and outline what all families can expect from their health visiting service. Universal provision involves access to a health visitor, development checks, and information about parenting and immunisation. 17 The Children’s Commissioner for England. Family Perspectives on Safeguarding and Relationships with Children’s Services. June 2010 18 The NHS Constitution states that people living in England have the right to choose where to receive treatment. 19 https://westmidlands.procedures.org.uk/local-content/zgjN/multi-agency-referral-reporting-concerns-marf 20 a Cause for Concern Information Sharing Form is used to share information between Midwifery teams who share a Mother’s care because this confidential information cannot be documented on the Maternity Hand Held records. 21 https://www.gov.uk/government/publications/domestic-abuse-a-resource-for-health-professionals. 6 5.9 A Young Parent Maternity Support Worker (YPMSW) was allocated during the pregnancy as Mother was under 20 years. They undertook two visits at the request of Mother’s midwife. They gathered a lot of information about the family history and current circumstances, including concerns voiced by GGM that Father was controlling of Mother, and Mother’s report that she wished to have her own property because of difficulties in her relationship with GGM. Both of these concerns were recorded by the YPMSW on Badgernet but not proactively shared at the time with her supervisor. It is expected practice that information of this type is shared with other health professionals via a Cause for Concern, which the supervisor would likely have requested. 5.10 TS was born at 35 weeks22. There was a report from Mother of a domestic incident between Father and GGM just prior to TS’s birth. She told staff at the hospital that she had intervened in an argument and implied this had an impact on her blood pressure. They were right to be concerned about the report, they had also observed both GGM and Father being controlling towards Mother and Father being threatening and abusive to Mother and GGM. The Specialist Midwife for Vulnerable Women23 (SPMWVW) submitted a MARF to the Children’s Trust including information of concern, but which could have been more clearly written. Neither the MARF nor the information included in it was shared with the community midwifes who were due to visit on discharge, the GP, or the health visiting service and no Cause for Concern was completed. The midwife who undertook the first postnatal visit was aware there had been an emergency caesarean but not that there had been a dispute in the home prior to this, or that there were concerns about behaviours at the hospital. 5.11 The police were aware of this incident as GGM had made a complaint about the threats she stated Father had made to her. The incident was recorded as a public order offence rather than a domestic incident, so no DASH checklist24 was completed and there was no information sharing. Father was spoken to by police and no further action was taken. 5.12 There was a timely response to the MARF with a social worker visiting Mother and TS in hospital the same day, and also seeing Father. It was agreed that a single assessment would be completed and TS and Mother were discharged to GGM’s address when TS was three days old. Mother had been clear that she wished to live with GGM and not with Father and his family at this stage, although she denied any domestic abuse or controlling behaviours from Father. Mother and Father both shared their hope that they would get housing together and that they would be able to live as a family. 22 By caesarean section due to maternal eclampsia. 23 The hospital trust agency reports outline that there had been an email request for the involvement of the SPMWVW following the initial appointment at the hospital, but this was not actioned, with the SPMWVW stating no email had been received. 24 A risk identification, assessment and management model for Domestic Abuse, Stalking and Honour Based Violence 25 Including a mother’s partner, even when they are not the parent of the child. Learning: • All assessments undertaken by any professional need to consider both parents25. • The mental health and emotional wellbeing of the father should be considered alongside the mother’s, as this can have an impact on their care of a baby. • When vulnerabilities are evident, assessments need to consider information on a parent’s backgrounds and history, including their mental health over time and their own experience of being parented. • Routine questions and any assessment need to consider the parental relationship and the relationship of the parent/s with other significant family members who are involved in the day-to-day care of the child. 7 Assessment Support post birth 5.13 When TS and Mother returned home they received support from Sandwell community midwives. A discharge letter from the hospital was included in Mother’s hand-held notes, but did not have any details of the MARF, just a note at the bottom of the form saying ‘SS and SW to visit at home’ on the form, meaning ‘social services / social work involvement’. Those working in the community in Sandwell stated they would not necessarily understand what ‘SS’ means, and that they would expect the letter to specifically include that a MARF had been completed. The midwives working in the community were not aware of the MARF or that a social worker was undertaking an assessment. However, to see ‘SS and SW to visit at home’ written on the discharge letter potentially should have sparked professional curiosity and a question could have been asked. 5.14 After discharge the visiting community midwife was concerned that TS may be jaundiced. It is likely the concerns about this health concern dominated this post-birth visit and that the opportunity to discuss the birth, and the concerning events that preceded it, were lost. In the visits following the birth, Mother was asked about her mental health, but there was no recorded consideration of how Father was at this time. 5.15 When the health visitor carried out a new birth visit, Mother and GGM told her about the domestic incident between Father and GGM prior to the birth of TS, and about the MARF sent by the hospital to the Children’s Trust. The health visitor gained permission to speak to the Children’s Trust about this, but there is no evidence this happened at this time. During this visit Mother also reported that she was suffering from anxiety but claimed she was effectively using distraction techniques to manage this. There is no evidence this information was explored further or shared with other professionals including the midwives who were visiting regularly, or that consideration was given to whether additional intervention was required, possibly via the GP. The health visitor confirmed at the visit that a Universal service continued to be suitable for the family, despite Mother’s reported anxiety, the shared difficulties in the relationship between GGM and Father, and the involvement of a social worker. This was because the family appeared to be open about the issues and were happy to accept support from the health visitor. It was not until around a month later that this was revised to Universal Plus, due to the baby’s slow weight gain. 5.16 In 2017 the Royal College of Obstetricians and Gynaecologists conducted a survey Maternal Mental Health – Women’s Voices26 which explored women’s experience of perinatal mental health. It established that women were not readily comfortable talking to healthcare 26 https://www.rcog.org.uk/globalassets/documents/patients/information/maternalmental-healthwomens-voices.pdf • Assessments need to consider other stresses, such as the impact of poverty or housing / living circumstances. • Any significant information shared by a parent or family member should be checked with other agencies / professionals, and shared appropriately. Professionals should not assume that other professionals have been told, as service users often believe that information sharing between professionals is more effective that it actually is. • There are enormous expectations of professionals involved at the time of and immediately following a baby’s birth and limited time to complete all required tasks. • Cause for Concern forms should be completed to ensure information is shared between health professionals. This is particularly important when part of the system does not have access to Badgernet. 8 professionals about their mental wellbeing. The most common reasons given were concerns about the perceived stigma of mental ill health and having it recorded, and a belief that healthcare professionals would not be able to help. It was also established that a relationship needs to have developed in order for a woman to be able to confide in the professional27. In this case Mother did not have a consistent midwife, which may have made it difficult for her to speak about how she was feeling. While it is important to ascertain as soon as possible if mental health is a concern in an expectant mother, the issue potentially needs to be on the agenda at all contacts, not just the first, so that relationships can develop and in case things change. The issue was readdressed with Mother by the health visitor when she undertook an emotional health assessment at GGM’s home when TS was four months old. No concerns were identified or disclosed by Mother. 5.17 When TS was five days old the midwife had concerns about the baby’s weight. It is expected that newborn babies will lose some weight in the first week following their birth. A five percent weight loss is considered normal for a formula-fed newborn like TS. Most babies should regain this lost weight after two weeks. At birth TS was 2.8 kg, their weight dropped to 2.3 kg after seven days, then dropped to 2.25 kg the following week. This is a weight loss of 21%. Mother had stated that she was living between Father’s mother’s address and GGM’s home, so there was an exploration about whether the feeds were being made up correctly at both addresses. There was no robust consideration of or information sharing about these living arrangements however, and no record that Mother was robustly questioned about how she was managing this arrangement. 5.18 TS was initially referred by the Community Midwife28 to the Paediatric Assessment Unit (PAU) at the hospital where TS was born, due to weight loss. TS was assessed by the Paediatric doctors and discharged later the same day, with a plan for the Community Midwifery team to monitor weight and feeding. They were unaware of the social work assessment that was being completed or of the MARF that had been submitted previously by staff at the same hospital, as it had not been filed on TS’s notes. Adhering to the Trust’s safeguarding children policy, PAU staff checked the Child Protection Information Sharing (CPIS) system to see whether TS was known, however only those children subject to a child protection plan or in care are flagged and therefore there was no alert to staff that TS had an allocated social worker or was the subject of a social work assessment. 5.19 A week later the ongoing concerns about TS’s weight led to them being admitted to hospital for two days for investigation and monitoring. On discharge the hospital contacted the health visitor for information and shared that they had to prompt Mother to wake for feeds during the night, and that on occasion parents had to be reminded to feed TS despite having an alarm set on their mobile phones. Mother and GGM informed ward staff that a social worker was involved. At discharge, the ward contacted the social worker29 and updated her on the situation but did not record why there was social work involvement with TS. The hospital has identified as part of this review that the liaison with the health visitor and social worker should have occurred at the point of admission rather than at the end of TS’s stay. This would have enabled more effective information sharing and ensured that TS’s medical condition was not treated in isolation to social factors. The opportunity for a helpful discussion between hospital staff, the health visitor and the social worker around the support 27 The NICE guidance states that mental health questions are posed at the primary visit, which means that there has been no chance for a relationship to have developed. 28 This was an appropriate referral in accordance with NICE Guidance 2017 on Faltering growth: recognition and management of faltering growth in children 29 There is no evidence of any contact from the hospital in the social work records. This appears to be a record keeping issue as the social worker remembers the call. 9 the family required, possible parenting capacity issues and potential reasons for their faltering growth should also have been taken. 5.20 TS gained weight while in hospital (83 grams within 48 hours) and was discharged home with additional visits to be provided by the community midwifery service. The hospital shared the discharge plan with the community midwifery team by telephone. The health visitor was also informed. This was good practice. This additional community midwifery support continued until TS reached their birth weight, which took just over a month. The family believes the weight was incorrectly recorded at birth, but those involved at the time insist this was not the case. 5.21 There were no other concerns about TS, who presented well and was otherwise meeting developmental milestones. While the weight drop led to a short period in hospital it did not trigger the policy for weight loss which includes referral to a paediatrician and the safeguarding nurse, as TS did not drop two centile points or more at any stage. However, as a medical reason was not found for TS’s faltering growth, there should have been consideration of other social and environmental reasons, including parenting capacity. From the documentation it is not evident that this was pursued or planned. There was no evidence that the hospital safeguarding team were notified of this admission. There was no record made by the hospital staff of how TS presented generally while an inpatient, or of their experience of being parented by Mother and Father, including their interaction with TS and each other. The only thing recorded was that they sometimes needed to be reminded to feed the baby. 5.22 GGM shared concerns with the health visitor about the relationship between Mother and Father and her own difficulties with Father on three separate occasions, including her concern about Mother and TS spending time at the paternal grandmother’s address, which GGM considered unsuitable. The health visitor contacted the social worker about these concerns on one occasion30 and shared GGM’s concerns. The social worker confirmed she was undertaking a single assessment as a result of the verbal altercation which had occurred between GGM and Father prior to TS’s birth. The social worker also stated that there was ‘no order in place’ to prevent Mother from going to stay with Father, and that she had made a written agreement with Mother and Father that he would not visit them at GGM’s home. 5.23 Following TS’s discharge from hospital having put on weight, the midwives continued to visit. GGM shared concerns with one of the midwives about family relationships. The midwife then spoke to a community midwife colleague who had also visited the family to establish if there were any historic concerns that might lead to a MARF needing to be completed. None were known. At this point the community midwifery service was working in complete isolation, unaware that a single assessment was being completed and that the hospital midwives had submitted a MARF the previous month. An attempt was made by a midwife to check if the family was known to the Children’s Trust, but the IT system was down at the time. They then sent an email to ask for the information, but there is no evidence that there was any reply from Sandwell Children’s Trust. GGM confirmed to a visiting midwife around two weeks later that a social worker was involved and they spoke to the allocated worker who said the case was about to close. The opportunity to share the case history and consider any concerns and vulnerabilities was not taken. There is also no evidence that the different midwives involved each day shared information adequately. Issues identified at previous visits were 30 On another occasion the health visitor suggested to GGM that she speak directly to the social worker herself. 10 not always addressed at the next visit when another midwife saw the family. This includes the management of TS’s weight loss (and paediatrician advice that a feeding diary be maintained by Mother), clarifying where Mother and TS were living, and the difficult family relationships. 5.24 When TS was two months old Father went to see his GP and reported he was suffering with ‘mood swings and anger outbursts’ and that he had a new baby. He was prescribed antidepressants. There was no communication with any other professionals involved, including with TS’s GP. (Mother and baby were registered at a different GP surgery.) There is no evidence that the impact of this presentation was considered in relation to the baby, or that the child or the parent’s GPs were contacted as part of the single assessment (with their consent). If contact had occurred, the GP would have been aware of the concerns about the parental relationship, and the assessment would have considered Father’s reported mood swings and anger outbursts. 5.25 The only other professionals aware of Father’s reported mental health issues were the community midwife team as reported by Mother while she was pregnant, although it is unclear how many of the individual midwives were aware as the information was recorded but records cannot be read on every case by every midwife undertaking visits to a family. As they did not do checks with Father’s GP or the community midwives at the start, this potentially important information was not considered in the social work assessment. There is a common misperception by social workers that speaking to a health professional will ensure they will be aware of all the necessary information to undertake the assessment. They are not always aware of the complexity of health provision and that there is no guarantee that health professionals are communicating with each other. Social workers need to be aware that if they are completing an assessment on a newborn baby, they need to ensure that they have information from, and provide information to, the GP for child and parents31, the health visitor, the community and the hospital midwifery services. A similar finding was found in the Sandwell Serious Case Review NS that was undertaken shortly before this review, where comprehensive checks were not undertaken across health agencies. 5.26 The single assessment that was started following the MARF from the hospital was very focused on the relationship between GGM and Father, along with whether domestic abuse was a feature of the relationship between Mother and Father. There is no evidence that the concerns about TS’s weight loss were considered during the assessment, or that there was any consideration of potentially important information in regards to this that was held by health colleagues. During their assessment the social worker observed aspects of controlling behaviour from Father to Mother. She recorded that Father dominated the conversations and that Mother was quiet and did not express her wishes, even when the social worker asked Father to allow Mother to speak. Father did state that his ADHD and Asperger’s impacted on his social skills, and it was acknowledged that this may have been a feature of the behaviour observed. No checks were made regarding his diagnosis. The parents consistently denied that domestic abuse was an issue and it was acknowledged that there were no allegations that there was any physical domestic abuse. 5.27 There were counter allegations from Father about GGM during the Single Assessment. He told the social worker that he did not want his family to live with GGM due to what he described as her controlling behaviour and her mental health issues. This was recorded but not explored with the family or other professionals. The single assessment concluded that a referral to Black Country Women’s Aid was required. A written agreement was also put in place which required Father not to visit GGM's home and that if he did, she and Mother 31 With consent 11 were required to contact the Police. This requirement was not shared with other agencies. There is no evidence of any focus on TS’s weight loss or the impact on the baby of contact with Father needing to be outside of GGM’s home. The referral to Women’s Aid was never made, and there was a gap of around seven weeks between the last contact with the family and the case closing to the social worker without any further contact32. 5.28 The use of written agreements in domestic abuse cases is questionable practice. The National Director for Social Care at Ofsted said following a thematic Joint Targeted Area Inspection (JATI) in 2018 that written agreements in domestic abuse cases can be ‘tantamount to victim blaming’, and are at best ineffective. The JATI showed that written agreements should only be used if they are ‘underpinned by thorough assessment that is clear about risk and protective factors of all relevant adults and family members’, and that there must be ‘clarity on how the written agreement will be monitored and reviewed in accordance with multi-agency plans and how this will inform the assessment of risk and action taken’. This was not the case for TS, although the content and quality of the agreement cannot be considered by the review as no copy was downloaded onto the child’s social work record. The 2020 Annual Report of the Child Safeguarding Practice Review Panel33 reinforces the concerns about using such agreements in cases of domestic abuse. It states that ‘at best written agreements had little or no protective effect, and at worst provided false reassurance that this would keep children safe’. In this case the plan that Father should be excluded from GGM’s home, while Mother continued her relationship with him and while he wanted to be a parent to TS, means that they would have to find somewhere else for TS to see theirfather. No consideration was given to what this might mean for TS. 5.29 Grandmother had shared that the result was that Mother and TS were spending significant amounts of time with Father, which concerned GGM. Where Father was actually living was not sufficiently explored. As Father was not to visit GGM’s home, he was rarely seen with the baby by any professional, although the social worker had undertaken a visit to paternal grandmother’s home and saw both parents and TS there. 5.30 When TS was five weeks old, Mother called the police to say that GGM was preventing her from taking TS to see Father. Police attended after a short delay due to capacity issues. They saw TS who was fine. They confirmed that there was no legal reason why Mother could not take TS to visit Father but did not record what GGM’s concerns were. A notification was shared with the Children’s Trust and the case was listed for joint screening. The Social Worker telephoned Mother the same day to discuss the notification and was reassured that things had settled down. 5.31 During this key episode health professionals responsible for TS were working with the family in regard to the baby’s weight, the GP was working with Father about his mood swings, and CSC had concerns about domestic abuse and the competing controlling influences and relationships in the family. At no stage were these issues considered together. GGM continued to share her concerns with the health visitor about Mother and Father’s relationship following the decision to close the single assessment. It was also established during a visit when TS was around 10 weeks old that while the baby was putting on weight, they had dropped a centile. There was still no clear idea about how many days and nights a week TS was spending at GGM’s home and how many at Father’s accommodation. 32 The procedures states that visits to TS should have been continued at a minimum of every 14 days in line with all children considered to be a child in need. 33 The Child Safeguarding Practice Review Panel Annual Report - Patterns in practice, key messages, and 2020 work programme, published March 2020. 12 Understanding a child’s lived experience is an important part of any assessment and any support being provided. Professionals need to put themselves in that child’s shoes and think ‘what is life like for this child right now?’ The understanding of the child’s world should then be incorporated into the work undertaken with a family. This is not possible if there is a lack of clarity about where the child lives. 5.32 Because all of the community health professionals visited Mother and TS at GGM’s home, and Father was not welcome there, none of the professionals saw Father with TS on a regular basis. This was a significant omission bearing in mind the social worker’s concerns about the parental relationship, Father’s own acknowledgement that he was suffering with mood swings and anger issues, and GGM’s allegations. The opportunity to discuss with Father how he was finding caring for TS by undertaking a visit at his accommodation was not taken. Learning: • Health systems are complex and professionals not working in the NHS may not understand this. This has an impact on the seeking and sharing of information. • When undertaking a single assessment on a new baby, social workers need to ensure they consider information held by all of the health professionals involved. 34 This includes the GP for the baby and both parents35, the hospital midwifery team, the community midwifery team and the health visitor. This should include asking who else is involved. • When a baby loses weight or does not put on weight as expected, social and environment issues always need to be considered as well as potential medical explanations, and a multi-agency response provided. • If it emerges that a baby is living between homes, professionals need to consider the impact this will have on the baby, particularly when issues develop such as poor weight gain. Consideration should also be given to visiting all homes. • Written agreements can provide false assurance and should only be used in very specific circumstances. Emergency department attendance 5.33 TS was taken to the A&E department of the local hospital by both parents when four months old. They reported that TS had fallen out of their pushchair when getting off a bus, sustaining a head injury. Processes were not followed in A&E, with the parents’ explanation immediately being accepted. No information was shared or sought from the Safeguarding Designated or Named Doctor or the paediatrician on call. No Paediatric Liaison form was completed, which would have resulted in the safeguarding team being aware of TS’s attendance at A&E and the health visitor being informed. The policy for when an injury is sustained by a child who is not yet mobile was not followed36. 5.34 During the triage process in A&E both parents were asked if they had ever had a social worker, and they said they had not. This was not checked. Those who know them state that they come across as confident and caring parents, which may have led to a lack of professional curiosity about the family. 5.35 The health visitor saw Mother and TS a few days afterwards. She was not aware of the A&E attendance and the parents did not share the information, so it was not discussed. The health visitor was leaving her role and a new health visitor was to be allocated. There was a 34 It might be agreed that the health visitor speaks to the GP/s and provides this information to the social worker 35 With consent 36 This is covered within Level 3 safeguarding training for health professionals 13 verbal handover of the case to the new health visitor, including a discussion about the slow weight gain and the case now being deemed ‘universal plus’. 5.36 TS’s GP received a notification about the A&E attendance but did not question the response and the fact that the correct procedures had not been followed with regards to an injury in a non-mobile baby. There was no consideration of inviting the baby in to be seen by the GP, as would be good practice, and the information was not shared with the health visiting service who were likely to be the only professionals with any ongoing involvement. 5.37 Information sharing has been identified as an issue across the professional involvement in this case. Poor information exchange between agencies at critical points was present in 40% (215) of all rapid reviews considered by the Child Safeguarding Practice Review Panel, as stated in their annual report 2018-1937. For TS, there was more communication than is reflected in the case records, but evidence of good information sharing was often lacking. The identified gaps include; the hospital not sharing information about their concerns and the MARF with the community health professionals who had an ongoing involvement; the MARF not being filed onto the child’s and Mother’s hospital records - so this would not be available in later admissions; the community midwifery service not informing the health visiting service about the weight loss, jaundice and readmission to hospital; the health visitor not pursuing the information she had from the family about the issues prior to the birth and the subsequent MARF with the Children’s Trust until after GGM shared further concerns; the information known to the health visitor about GGM’s concerns were not shared with the midwifery service; the GP did not share information about Father’s mental health with the health visitor; the single assessment did not include communication and lateral checks with the GPs or midwifery service; despite the existence of a Communication and Handover policy between midwives and health visitors this was not utilised in this case and no information was shared; the reported domestic incident about GGM not allowing Mother to take TS to see their father when TS was 5 weeks old was not shared with health professionals; and the A&E attendance was not shared with any professional other than the GP. 5.38 A week after the health visitor had seen Mother and TS at GGM’s home, Father called 999 from his aunt’s home where Mother and TS were staying. TS was taken to hospital but died following an apparent cardiac arrest. The Sudden Unexplained Death of an Infant or Child (SUDIC) protocol was commenced, and the professional response to their death was well managed. It was not established until following TS death that Mother, Father and TS were residing at the home of Father’s aunt. There were serious concerns about the state of the home, which was not judged to be appropriate for a young baby. It is noted that Father had always implied to professionals that he lived with his mother, and this was confirmed by the social worker who visited him there while undertaking the single assessment. Learning: • The Bruises and Injuries in Non-Mobile Children Policy should be followed in all cases where a non-mobile child has injuries. Conclusion and recommendations 6.1 TS died while in the care of both parents at an address that professionals were not aware of and had not visited. Risk factors were evident but not well communicated between the professionals involved. Father had known mental health and anger control issues. There were well reported relationship difficulties between Father and Mother’s grandmother. 37 The Child Safeguarding Practice Review Panel Annual Report - Patterns in practice, key messages, and 2020 work programme, published March 2020. 14 Professionals were concerned that there was domestic abuse through control of Mother by Father and potentially GGM. There had been concerns about TS not gaining weight and an incident where they received injuries. (Although the police have since told the review that with the help of CCTV footage they believe these injuries to be accidental.) Due to limited professional curiosity, a lack of reflective practice, inconsistent information sharing, and concerns being seen in isolation, there was little understanding of TS’s lived experience and an insufficiently co-ordinated response to their needs. 6.2 The Child Safeguarding Practice Review Panel stated in their annual report 2018-19 that partner agencies need to ‘move beyond the legislative and procedural, to the technological and the behavioural, and forensically explore how we can develop our multi-agency and multi-disciplinary practice in routine ways, and at critical points, which strengthens information sharing, risk assessment and decision making.’ They also state that ‘whilst technological solutions are a critical component, we also need to think in terms of human factors. Complexity of practice requires sophisticated conversation, hard wired into the DNA of our child protection practitioners. How do we help people talk to each other within a context of high-risk, high-volume and limited resource, often when practitioners are fearful of reprisals from families, employers and society at large?’ This case, like many others nationally, shows that this remains one of the main challenges for safeguarding partnerships and professionals. 6.3 The Triennial Review 2014-2017, published in March 2020, found that there continues to be a “dearth of information” in practice, about men. ‘The primary focus of health professionals and social workers continues to be on the needs, circumstances and perspectives of the mother. This is the case even in established relationships, when the mother’s partner has a major role in looking after the children. Such a lack of professional curiosity in fathers and partners not only potentially leaves women and children vulnerable, it can also leave fathers feeling alienated and forgotten, and their role in bringing up the children dismissed. Services need to find ways to become more male friendly if they are to encourage the involvement of men in the lives of their children.’ This review found that improvements in considering the history and involvement of Father were required. He was effectively excluded from much of the professional contact with the family. 6.4 Good practice38 was indentified during this process and there has been good co-operation and engagement from agencies with the review process, which has been important in identifying the learning. 6.5 It is recognised that actions have already been taken in relation to some of the individual agencies identified learning in this case, and that changes have been made which will be outlined in the SCSP’s response to this review. For example, a West Midlands Police force-wide message has been circulated to remind staff of the domestic abuse policy, the definition of a domestic incident, and what constitutes a family member39, reinforcing the message that domestic incidents are to be accurately recorded to enable effective prosecution, safeguarding and signposting as appropriate. A briefing note has been shared with health visitors regarding the need to visit families at any other addresses where they are living. Work is also under way regarding improved involvement of fathers, improving professionals’ networks when there are pre-birth concerns (following SCR case KS) and by the relaunch of an improved Bruises and Injuries in Non-Mobile Children Policy. 38 Including the identification of coercive behaviour by the hospital midwife and the social worker, both of whom spoke to Mother alone about this. The GP encouraged immunisations and allowed parents to make an informed choice when Father expressed concerns. The hospital midwives spent time with Mother to find out her wishes about where she wanted to live with TS on discharge from hospital. Actions taken by the community midwives in relation to the monitoring of TS’s weight and jaundice. 39 Family members are defined as mother, father, son, daughter, brother, sister, grandparents, whether directly related, in-laws or step. 15 6.6 The agency reports have made recommendations which have also largely been completed by the conclusion of the review. Some of the learning identified within this report will have been addressed by the single agency actions plans, which are being monitored by the SCSP. They include recommendations regarding the need for GPs to ensure that they request a face-to-face assessment in the surgery following an A&E notification of injuries sustained to a non-ambulatory child, ensuring that hospital staff use the policy around non-medical management of faltering growth, and that a health care needs assessment must carried out by the health visitor where safeguarding concerns are evident and babies are moving or living between address. 6.7 Other local case reviews have been completed with similar learning and recommendations. This review has considered these and not repeated recommendations. 6.8 The review requires that further recommendations for the safeguarding partnership are made, to ensure that any areas identified as being of particular concern that are not included in the single agency plans, or which require an all agency or interagency action, are addressed. Question 1 for the SCSP to consider: In light of the learning from this case and the findings of the Child Safeguarding Practice Review Panel in their annual report 2018-19 (see 6.2 above), how can the partnership ensure that information sharing is improved, both using technological solutions and by ensuring that professionals talk to each other and collaborate so that that all information is known? Recommendation 1: The SCSP should ask the Department of Education and Department of Health to consider adding to guidance about both routine questioning and assessments in domestic abuse the need to consider whether any household members beyond the parents are experiencing domestic abuse in the child’s home. Recommendation 2: The SCSP to ask its partner agencies to provide the opportunity for professionals to learn from research to inform practice. The areas required, as highlighted by this review, are: • The use and validity of written agreements or contracts in cases of domestic abuse • The importance of equally involving fathers/partners in all areas of work • Domestic abuse through coercion and control, including outside of intimate relationships • Trauma informed practice and the impact of adverse childhood experience on parenting • The importance of non-medical professionals understanding the systems that provide health services • The need to follow procedures when there is an injury in a non-mobile baby Recommendation 3: The SCSP to consider how they can influence a cultural change across partner agencies, regarding the role of fathers and secondary carers in families. This should include consideration of the barriers and what works well. |
NC048257 | Serious harm caused by the medical and nutritional neglect of Child R, aged 3 years and 9 months. His parents were arrested for neglect in October 2015 but released without charges. His siblings, Child A and Child B, were taken into care. Child R had short gut syndrome following complications of a premature birth and bowel surgery. He received nutritional support administered by his mother at home. The family received support from a large number of health practitioners. Child A was subject to a child protection plan under the category of neglect for 3 months. Following a referral from medical staff and an initial assessment, a Team around the Child process was recommended but the family declined a Common Assessment Framework (CAF) process and services from tenancy and family support workers. Concerns included: homelessness, a limited support network, substance misuse and strained relationships with professionals. Both parents were looked after and had a number of different placements. Findings include: not recognising R as a child with a disability resulted in a missed opportunity to assess his needs and provide early help services; practitioners had insufficient understanding of the parents' backgrounds and experiences and how these affected their attitudes towards disability, health and social services; the lack of a multi-agency approach with an allocated lead professional led to poor co-ordination of services and impeded information sharing. Recommendations include: Section 85 notifications of prolonged admissions to hospital of a child with a disability or complex chronic health condition should lead to an assessment of need by the local authority; health partners should arrange multi-agency participation at discharge planning meetings for children with complex health needs or a disability and a lead professional should be allocated to the family as soon as possible.
| Title: Child R: serious case review: final report. LSCB: Salford Safeguarding Children Board Author: Nicki Walker-Hall Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child R Serious Case Review Final Report SCR Child R Final Report 22 March 2017 Page 1 Contents EXECUTIVE SUMMARY 2 1 INTRODUCTION 7 1.1 Initiation of Serious Case Review 7 1.2 Agencies and Local Authorities involved 7 1.3 Structure of the report 10 2 CONTEXT 11 2.1 Summary of what happened 11 2.2 The Family 13 2.3 Short gut Syndrome 15 3 NARRATIVE AND APPRAISAL OF PRACTICE 18 3.1 Introduction 18 3.2 Key events 18 4 ANALYSIS OF THE KEY ISSUES 41 4.1 Introduction 41 4.2 How do we better understand the needs of children with disabilities as a multi-agency group? 42 4.3 How can we create stronger multi-agency systems to identify and intervene in situations of neglect, particularly if we are working across borough boundaries? 43 4.4 Parental engagement appears to be minimal. Were the parent’s needs overlooked? What counselling and support is available for parents with a disabled child? 44 4.5 How can practitioners work together in a manner which takes account of a family’s needs, yet keeps children’s needs as the focus of intervention 45 4.6 What are the challenges to identifying matters of neglect when working with complex health situations across many health providers? 46 4.7 Should only one parent be trained to administer Parenteral Nutrition feeds? 48 4.8 Given the complexity of the case, was consideration given to appointing a Lead Professional at a sufficiently early point? Was consideration given as to which practitioner was the most appropriate Lead Professional? Was there confusion about the existence of or identity of the Lead Professional and the functions of the role? 50 4.9 Was consideration given to holding a Team Around the Family (TAF) meeting to formulate plans and implement them? 50 4.10 Is there evidence of escalation of concerns by any of the practitioners who felt at points that child protection processes should have been initiated? Was there over reliance on medical consensus in initiating child protection procedures? 52 5 FINDINGS& RECOMMENDATIONS 54 5.1 Introduction 54 5.2 Findings and associated recommendations 54 5.3 Common Assessment Framework 57 5.4 There lacked a multi-agency network around the family 57 5.5 The lack of an allocated Lead Professional impacted both on the co-ordination and delivery of services causing difficulties for both parents, children and professionals 57 6 CONCLUSIONS 60 Glossary of Terms & Abbreviations 61 Appendix 1: SAAR Recommendations 62 Appendix 2: Panel Membership 64 SCR Child R Final Report 22 March 2017 Page 2 EXECUTIVE SUMMARY Initiation of Serious Case Review This review was initiated by Salford Safeguarding Children Board as a result of concerns Child R had been seriously harmed through neglect of his nutritional and medical needs. Both Adult A and Adult B were arrested but have since been released with no charge. The children There are three children within the family; practitioners and the parents confirm good relationships with each other and their parents. Child A and Child B were aged eight and six when Child R presented in a moribund condition, both were in primary education. In school Child A presented as a confident outgoing child who was protective of her quieter, shy sibling, Child B. There were intermittent concerns regarding the two children’s attendance at school, which at times dipped below the acceptable level. Highlighting this to the parents brought about improvements. Child R had Short Bowel Syndrome. The condition affects absorption of water, vitamins, minerals, protein, fat, calories, and other nutrients from food which can put patients at risk of malnutrition, diarrhoea and dehydration. As a result, Child R required on-going additional nutritional support in the form of tube feeds into his abdomen and a central feeding line into a large vein. Child R also had some developmental delay associated with prematurity. Child R was described by practitioners as a lovely boy, quietly spoken, always appearing happy. The parents describe Child A as a ‘wanna-be’ celebrity who can be loud and outspoken in contrast to Child B who they describe as laid back, shy with new people, but very bright and intelligent. The two are said to alternately fight like cat and dog then cling to each other. Child R is the joker of the family who is polite, well mannered, generally quiet and calm but can be boisterous. Summary of Case The period covered by this review is the 45 months from the premature birth of Child R, in January 2012 to the date the parents were arrested for neglect in October 2015. During this period, life for the family, and in particular Adult B, changed significantly. Child R’s diagnosis of prematurity and intraventricular haemorrhages required careful monitoring of development and this, coupled with Short Bowel Syndrome, led to extended periods in hospital; initially NICU, then PICU and then on children’s wards at local and tertiary hospitals. Child R needed a series of surgical procedures, on-going treatments and nutritional support. SCR Child R Final Report 22 March 2017 Page 3 Child R’s complex health needs meant they required continued support from a large number of health practitioners, both in the community and from five hospitals. During this time Adult B took on responsibility for all Child R’s additional needs, remaining with, or visiting daily, whilst Child R was hospitalised. Adult B performed many of Child R’s cares whilst, at the same time, continuing to be seen as the head of the household by the professionals involved with the family Adult A, a constant in the family, took on a more active role with Child A and Child B taking them to and from school and facilitating their contact with Child R and Adult B throughout Child R’s hospitalisation. Adult A declined to be involved in Child R’s additional medical cares. The reason for this was not known to the professionals involved with the family. Adult A indicated to the lead reviewer this was due to fear. The family were supported by Adult A’s mother who would care for Child A and Child B whilst the couple were at hospital with Child R. Relevance to wider context of safeguarding children with disabilities This review has unearthed an interesting difference in practitioner’s perceptions around what constitutes disability versus a child with complex health needs, and therefore which services may be required. The Disability Discrimination Act 2005 (DDA) defines a disabled person as someone who has “a physical or mental impairment which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities.” According to the DDA ‘substantial’ means ‘more than minor or trivial’ and ‘long-term’ means that it ‘has lasted or is likely to last more than a year’. Applying this definition to Child R it is clear that he has a disability. Research concludes,1Different agencies may use a variety of definitions of disability and the terminology used is the subject of much debate between professionals as outlined in the DCSF research report Disabled Children: Numbers, Characteristics and Local Service Provision (2008). These differences in the use of terminology may result in a loss of focus on the welfare of the child. The research found the key issue was not what definition of disability had been used but the impact of abuse or neglect on a child’s health and development, and consideration of how best to safeguard and promote the child’s welfare. In Salford, Children with Disabilities would be assessed by the Children with Disabilities team and appropriate services offered in line with current guidance2. 1 Murray, M. & Osborne, C. (2009) Safeguarding Disabled Children: Practice Guidance. DCSF: Nottingham 2 0 to 25 SEND code of practice: a guide for health professionals Advice for clinical commissioning groups, health professionals and local authorities (February 2016) SCR Child R Final Report 22 March 2017 Page 4 Safeguarding concerns for disabled children can arise in a number of ways. One way, as in this case, arises from parents being seemingly unwilling or unable to follow medical and allied health professional advice and with consequent potential impacts on the child’s health and/or development. On occasion Adult B would either challenge the decisions of the professionals or disregard their advice but not to a point where practitioners felt concerned that Child R’s welfare was not being safeguarding until October 2015. Practitioners at the local tertiary hospital were aware that the family were reportedly suing the Trust and according to both parents and practitioners this appeared to have a negative impact on relationships. Summary of Findings The incident that led to the requirement for this review, could not have been predicted by the professionals working with the family. In the period prior to the incident no concerns of a safeguarding nature had been raised by any of the professionals working with the family. There is no certainty that any of the findings below would have made any difference or prevented the incident from occurring. The lack of recognition of Child R as a child with a disability meant there was never an assessment as such. An opportunity to provide early help services was lost when no action, other than to place Child R’s name on the disability register was taken, following S85 notification of Child R’s prolonged hospitalisation. In order to provide the right support to any family with a child with disability or complex health needs it is important to understand the parent’s needs. Practitioners had insufficient understanding of how the parent’s backgrounds and experiences impacted on their views about disability, health and, in particular, social services. In part, due to Adult A and Adult B’s backgrounds, they were unlikely to invite involvement of certain professionals into their family and even less likely to identify when they were struggling to juggle all their responsibilities. Aspects of Adult B’s manner, coupled with legal action the couple were taking against a health Trust, at times impeded the professionals working with the family. Adult B indicated to the lead reviewer an awareness that when feeling anxious they spoke quickly, and in a tone, others may perceive as threatening. The challenge for professionals is to find ways to work effectively in these circumstances and with those that do not readily agree or accept the advice given. Throughout the period under review there were a number of occasions when professionals considered the use of CAF would be beneficial for the family, both to assess the whole family’s needs and provide the appropriate early help services and support. Parents belief that the CAF was a social worker led process allied to Child Protection led to them declining the offers. SCR Child R Final Report 22 March 2017 Page 5 The lack of multi-agency approach and in particular the lack of an allocated Lead Professional led to a lack of co-ordination of services and appointments, and impeded information sharing within and between services. Professionals energies were spent on following up on missed appointments and on no access visits, rearranging them, rather than on direct outcome focussed interventions. This also impeded consideration of whether these factors were evidence of non-compliance or neglect. Seemingly low level concerns are difficult to assess as a single agency and in isolation, making the use of supervision and multi-agency approaches essential. Recommendations 1. All health professionals when taking initial histories should, in addition to obtaining the child’s medical history, explore a family’s previous experiences of health, as well as the family composition, the support network available for the family and parent/s and other needs of the family in relation to housing, monetary needs, health needs etc. when needed. 2. The SSCB in conjunction with the Regional network and its partners needs to ensure all its procedures and training includes complex health issues when relating to disability. 3. All Section 85 notifications of prolonged admissions to hospital of a child with a disability or with a complex chronic health condition should lead to an assessment of need by the Local Authority. 4. The SSCB health partners need to ensure multiagency participation is an explicit requirement at discharge planning meetings where a child has complex health needs or a disability. This involvement must commence early on so a Lead Professional is allocated to the child and family at the earliest point. 5. The SSCB partners need to develop pathways for counselling and support provision and ensure the level of service meets the population need and the needs of parents and carers of children with complex health needs and/or disabilities across Salford. 6. SSCB to ensure that policies set an expectation that professionals working with complex child health cases and those where there are barriers to open dialogue and challenge discuss this in safeguarding supervision and ensure concerns are shared with lead professionals, and that CAF guidance provides consistent advice that links to the ‘threshold of need’ and ‘Uncooperative families’ Greater Manchester policy. 7. A system needs to develop whereby Health Visitors working with children with complex needs/disabilities, who have school age siblings, are required to inform the appropriate school nurse. 8. Children Services to consider how CAFASS assessments can be shared across relevant partner agencies and with parents. SCR Child R Final Report 22 March 2017 Page 6 9. It should become routine practice that the children’s social care representative in attendance at the strategy meeting informs the Lead Professional regarding serious incidents in order they can inform all the professionals involved. See Recommendation 12&13. 10. Local Authority to review the current practice regarding children living in hospital provision (Section 85 notifications) and provide an assurance report to the SSCB regarding how robust the process is. 11. SSCB health partners to agree a process to ensure all children with ongoing complex health and developmental needs are referred to Community Paediatricians before discharge from secondary/tertiary hospitals. 12. Salford SCB to agree with member agencies a consistent process for identifying the Lead Professional and the responsibility for the various functions of the Lead Professional. 13. The SSCB with the support of the Police, to develop multi-agency guidance for staff on their engagement with parents during criminal investigations e.g. the. do’s and don’ts of discussions regarding their situation. What will the LSCB do in response to this? The LSCB and partner agencies have prepared SMART action plans which describe the actions that are planned to strengthen practice in response to the findings and recommendations of this serious case review. SCR Child R Final Report 22 March 2017 Page 7 1 INTRODUCTION 1.1 Initiation of Serious Case Review 1.1.1 This review was initiated by Salford Local Safeguarding Children Board following concerns that Child R had been seriously harmed; there was prima-facie evidence of medical and nutritional neglect. Two older children within the family were taken into Local Authority Care following the arrest of their parents. 1.1.2 Child R had short gut syndrome following complications of a premature birth, (necrotising enterocolitis) and bowel surgery. As a result, Child R had problems related to poor absorption of water, vitamins, minerals, protein, fat, calories, and other nutrients from food. 1.1.3 Child R was receiving additional nutritional support through a combination of Parenteral Nutrition (PN) and gastrostomy feeds which were being administered by Adult B within the family home. 1.2 Agencies and local authorities involved 1.2.1 Due to the complex needs of Child R there were different health agencies involved in his care. These agencies spanned across the boundaries of Manchester and Salford. 1.2.2 The following is a list of the agencies involved with the family and the services they offered. Where abbreviations have been identified these will be used throughout the report to denote the organisation the author is referring to: Salford Royal NHS Foundation Trust (for provider services) Speech and Language Therapy Team Occupational Therapy and Physiotherapy Health Visiting Diana Nursing Team Community Paediatrician School Nursing GP Services, NHS Salford, Clinical Commissioning Group Central Manchester Foundation Trust (CMFT) Neonatal Team Speech and Language Consultant Gastroenterologist Gastroenterology Specialist Nurse ENT Sleep Studies North West Ambulance Service Greater Manchester Police Education Starting Life Well Service Higher Broughton Nursery Oakland’s Nursery SCR Child R Final Report 22 March 2017 Page 8 Marlborough Road Primary School Salford City Council (Children’s Services) Emergency Duty Team Duty and Assessment Education Welfare Service Looked After Children Housing Salix Homes Housing Options In addition, a summary of involvement was requested from: 1. Abbott Nutrition 2. Calea UK Ltd Company which provided the PN machine 1.2.3 This has been a systems review, focusing on the strengths and weaknesses of the multi-agency system in supporting families and safeguarding children with complex health needs. 1.2.4 The review was managed by a review panel (see appendix 2), consisting of senior managers of the involved agencies, working with the independent Lead Reviewer. In recognition of the complex health issues for child R, the Salford Safeguarding Children Board chair, Simon Westwood, appointed an experienced Lead Reviewer from a health background (Nicki Walker-Hall). 1.2.5 The membership of the panel was agreed at the beginning of the process to include representation of the main agencies involved, and/or of those that commission their services. 1.2.6 The Case Review and Audit Sub-group and the screening panel decided the key focus points for the review and highlighted the following lines of enquiry for consideration: How can we understand the needs of children with disabilities as a multi-agency group better? How can we create stronger multi-agency systems to identify and intervene in situations of neglect, particularly if we are working across borough boundaries? Parental engagement appears to be minimal. Were the parent’s needs overlooked? What counselling and support is available for parents with a disabled child? How can practitioners work together in a manner that takes account of a family’s needs, yet keeps children’s needs as the focus of intervention? What are the challenges to identifying matters of neglect when working with complex health situations across many health providers? Should only one parent be trained to administer PN feeds? Given the complexity of the case, was consideration given to appointing a lead professional at a sufficiently early point? Was consideration given as to which practitioner was the most appropriate lead professional? Was there confusion about the existence of, or identity of, the lead professional and the functions of the role? SCR Child R Final Report 22 March 2017 Page 9 Was consideration given to holding a team around the family meeting to formulate plans and implement them? Is there evidence of escalation of concerns by any of the practitioners who felt at points that child protection processes should have been initiated? Was there over reliance on a medical consensus in initiating child protection procedures? 1.2.7 The process used included: Chronologies from all involved agencies Single Agency Analysis Reports (SAARs) from all involved agencies Panel challenge of the SAARs Resubmission of revised SAARs Individual and various group practitioner and management sessions to maximise learning for those involved with the family at the time, both in the SAAR stage and in the 'overview' phase of the review. Staff participation was good, showing commitment to learning; this participation increased understanding of the situation at the time, the reasons for actions (or non-actions) and decisions. Feedback from the learning events has been incorporated into this report throughout. The Lead Reviewer was given access to documents that formed part of the criminal investigation and legal process. Timeline Screening Panel 23rd November 2015 1st Serious Case Review Panel- 26th February 2016 o Submission of 1st iteration SAARs – 31st March 2016 2nd Serious Case Review Panel – 15th April 2016 SCR Briefing session – 29th April 2016 Learning Event – 17th May 2016 3rd Serious Case Review Panel – 20th May 2016 o 2nd Learning Event – 24th June 2016 4th Serious Case Review Panel- 27th June 2016 o Submission of 2nd iteration SAARs – 7 July 2016 o Submission of 1st draft Overview Report – 25th July 2016 5th Serious Case Review Panel – 3rd August 2016 o Submission of 2nd draft overview report – 9th September 2016 6th Serious Case Review Panel – 23rd September 2016 o Submission of 3rd draft overview report – 4th November 2016 7th Serious Case Review Panel – 11th November o Submission of final overview report – 5th December 2016 8th Serious Case Review Panel and Case Review and Audit Subgroup Presentation –9th December 2016 SSCB Presentation – 19th December 2016 Send SCR to Ofsted, DfE and the national panel – March 2017 Publish SCR and Board Action Plan– March 2017 Annual SSCB Learning from Case Reviews Event –March 2017 SCR Child R Final Report 22 March 2017 Page 10 The timeframe from the outset did promote compliance with statutory timescales. 1.2.8 The timeline has been impacted by some of the parallel processes – please see section below. Parallel Processes 1.2.9 The pace of this review was impacted by two parallel processes, the first being the criminal proceedings against the parents and the second the care proceedings in respect of all three children within the family. Family participation 1.2.10 Adult A and Adult B wished to be fully involved with the review once the criminal processes had been completed. The lead reviewer, on the third appointment, met with both parents separately and together on one occasion, time was limited but the parents were able to provide their own views and experiences which has enriched the review . An invitation was extended to Adult A’s mother, unfortunately illness prevented her involvement. Limitations 1.2.11 The lead reviewer would have welcomed an opportunity to speak to Adult A’s mother, believing this would have provided insight and a different perspective on the impact of Child R’s illness on the whole family and the functioning of the family unit. 1.3 Structure of the report 1.3.1 The report is structured as follows: Chapter 2 provides a summary of the overall context: o a summary of what happened o details of family members and a description of what was known about the children in the family, in particular Child R o An explanation of Short Bowel Syndrome Chapter 3 describes what happened from the perspective of those involved at the time, including both professionals and family, explains the rationale for actions and decisions and appraises the practice Chapter 4 provides an analysis of the themes emerging from the practice in this case: o chapter 4 considers the facts of the Chid R's health needs o chapter 5 explains the impact of complex health needs/disability on this family o chapter 6 discusses the professional and organisational practice Chapter 5 provides the conclusions, overall findings and recommendations SCR Child R Final Report 22 March 2017 Page 11 2 CONTEXT 2.1 Summary of what happened Parental background 2.1.1 This family had previous involvement with, and knowledge of, Local Authority Social Care. Both parents previously resided in a neighbouring authority and had themselves been cared for within the Looked After Children system for many years; drug and alcohol addiction were features of their parent’s lives. They explained, to the lead reviewer, that they had a number of placements both with foster carers and in care homes and met whilst residing in the same care home. Some placements were happy, some were not and broke down and some ended due to closure of the care home. The couple felt they had a mixed experience of Social Workers, some were good others were poor and didn’t relate. Adult B became pregnant with their first child (Child A) aged 15. The couple felt the support offered following the conception of Child A was poor, both financially and in terms of a placement offered which they felt unsuitable. Adult A was initially resistant to claim benefits wanting to earn a wage however eventually both Adult A and Adult B found themselves reliant on benefits. Background prior to period under review 2.1.2 The parents had two older children prior to the period under review. Child A was born in 2006 and Child B in 2008. Child A was subject to a short period (3 months) on a Child Protection plan under the category of neglect in the same neighbouring authority, until a support plan could be put in place. At that time an assessment indicated there had been concerns that the couples’ chaotic lifestyle, including drugs and alcohol, was impacting on Child A; additionally, it was reported the couple had no good role models themselves. The couple report whilst drugs and alcohol were an issue in the environment they had been placed, the couples use of drugs and alcohol was reported to be untrue, it has seemingly remained on their records and is referred to whenever there is a new contact, causing them upset. Child A was removed from the child protection plan after the couple had shown a high level of care and commitment to Child A. Adult B recalls attending a number of parenting courses which she enjoyed. The week following Child B’s birth all Children’s Services involvement in respect of Adult B ceased as she was transferred to Barnardo’s after care services early. 2.1.3 Following Child B’s birth there were no identified professional concerns about either child’s care. The only notable involvement with acute illness and secondary health services was when Child B was treated for meningococcal sepsis aged 13 months. SCR Child R Final Report 22 March 2017 Page 12 2.1.4 The family had settled in the Salford area by the time Child R was born. The couple moved their family into a privately rented home in Salford; the couple wanted a better life for their children and saw this as a path to achieving this. Practitioners attending the learning events perceived the family were all living together with the exception of housing who thought Adult B was a single parent as her name was the only name on the housing application; the couple indicated their relationship has been a constant. 2.1.5 There was no indication to professionals that the family had any additional support other than Adult A’s mother in caring for their children. The couple confirm a very limited support network, Adult B referring to Adult A’s mother as her ‘best friend’. Period under review 2.1.6 The period covered by this serious case review begins from the date of the premature birth of Child R, in January 2012 to the date the parents were arrested for neglect in October 2015. 2.1.7 During this period the life of the family, and particularly Adult B, changed significantly not only with adjustment from being a family of four, to a family of five, but in taking on a significant care role for Child R following diagnosis of Short Bowel Syndrome. This diagnosis meant Child R’s health care needs were complex and required extensive multi-disciplinary health input from primary, secondary and tertiary services across five hospitals and three geographical areas. 2.1.8 Child R spent the majority of his first year in hospital, Adult B spent significant amounts of time at hospital caring for Child R. It is common for there to be a significant period of emotional and practical adjustment for parents in these circumstances and additionally this affects all members of the family. 2.1.9 Thereafter Child R was admitted on multiple occasions with complications relating to the diagnosis of short gut syndrome and central line infections. Child R's complex health needs meant at other times, the family had numerous contacts with health practitioners, both in the community and from the hospitals involved, who offered care, monitoring, advice and support. 2.1.10 Adult B was perceived by professionals at the learning events to have responsibility both for the domestic sphere, and also for Child R’s additional care needs. This involved monitoring Child R’s health and wellbeing and performing many activities normally undertaken by qualified nurses in the hospital setting, for example, administering intravenous (IV) antibiotics and parenteral nutrition as well as gastrostomy feeding. Although Adult A was believed by health professionals to be an integral part of the family Adult A declined, for reasons unknown to the professionals involved, to actively participate in Child R’s additional care needs; it was also noted Adult A didn’t intervene when Child A and Child B were distracting Adult B whilst undertaking Child R’s cares in the home. SCR Child R Final Report 22 March 2017 Page 13 2.1.11 In March 2012 Child A and Child B witnessed a domestic violence incident between Adult B’s sister and her partner. This was reported to Salford Children’s Social Care but there is no indication an assessment was done. 2.1.12 In May 2012 there were concerns when Adult B removed Child B from one hospital and transported the child to another hospital, where Child R was being cared for, against medical advice. This incident led to a Child Protection referral and completion of an initial assessment. The social worker recommended the Team around the Child process and services were offered to the family (tenancy support worker and family support worker) but these were declined. The assessment concluded that the level of concern did not meet the threshold for further intervention; Adult B indicated they were keen to take support from the school family support worker and the social worker agreed to facilitate contact 2.1.13 In October 2015 Child R was admitted in a moribund condition and diagnosed with dehydration, severe acidosis and hyperosmolar non-ketotic coma due to high blood sugars, raised blood sodium levels, acute kidney problems, developing subsequent fungal infection. A scan of the head identified sub-dural haemorrhages on both sides of Child R’s brain. 2.1.14 As results of tests were received and Child R’s blood glucose and sodium levels returned to normal quickly, safeguarding concerns were raised. This was coupled with Adult B commenting on home conditions and an inability to safely administer Parenteral Nutrition, Adult B’s anxious and seemingly aggressive behaviours, and the loss of a pump that administered Child R’s parenteral nutrition. Hospital staff referred the case to Children’s Social Care and the Police for investigation four days after admission. 2.1.15 The Police commenced their investigations and the following day both parents were arrested. 2.2 The Family 2.2.1 The parents are White British having lived in or around the Salford/Manchester area for all their lives. 2.2.2 Table 1 shows the family composition living in the household in Salford. Additional support was provided by Adult A’s mother. Adult B’s father features within this review only in so far as Adult B put herself forward as a potential carer for his child, her half-sister when there were Child Protection concerns. TABLE 1 Term used in report Relationships Age in October 2015 Child A Eldest child 8 years Child B 2nd eldest child 6 years Child R Subject of the review 3 years 9 months SCR Child R Final Report 22 March 2017 Page 14 The children 2.2.3 There are three children in the family and those practitioners who had opportunity, observed that they had good relationships with each other and with their parents. The eldest children were 5 and 3 when Child R was born. 2.2.4 The two older children had no additional health or educational needs; both were in mainstream primary education, attending the same school. Child R had developmental issues relating to prematurity and Short Bowel Syndrome as a result of bowel resection affecting his gut absorption (see section 2.3). 2.2.5 Practitioners described Child A as a pre-pubescent, confident child who liked dressing up, but often wearing inappropriate shoes. Parents indicated she can be loud and at times outspoken with a desire to become a singer. Child A was said to be very protective of Child B who was described as quite sombre, much the quieter of the two, seemingly shy, and in the professionals’ opinion, insecure and needy of adult attention. Parents describe her as more ‘laid back’, bright and intelligent. The pair are said by parents to alternately fight like ‘cat and dog’ or ‘cling’ to each other. 2.2.6 Child R had recently commenced at nursery school and was described as a lovely boy, quietly spoken, always appearing happy. He engaged well with practitioners involved in his care, and liked to be able to see Adult B. Other children took to him well and he made good progress at nursery. Health staff stated that he engaged with therapy and was often giggling and happy. Parents describe him as ‘the joker of the pack’, polite and well mannered. Family Dynamics 2.2.7 The couple appeared to professionals to have very separate roles with the children with Adult B seemingly at the helm. Adult A had a clear role in transporting the older children to and from school. Any additional input into schooling was however Adult B’s domain. This appeared less marked for the couple themselves. 2.2.8 Hospital staff were under the impression that Adult B provided the majority of care for both Child R and their siblings, although Adult A was present at some hospital admissions and facilitated visits from Child A and Child B. Adult B was described as good with and encouraging of Child R. Adult A indicated they took on normal parenting duties with all the children but left medical care to Adult B. 2.2.9 Professionals involved with the family were aware that Adult A’s mother was involved with the family and on occasion Adult A was reported to have gone to live with her. Housing also believed Adult A’s mother was supportive, Adult B having requested to be housed near to her for that reason. The couple indicated their relationship was solid and constant. Adult A Father of all the children 27 years Adult B Mother of all the children 25 years SCR Child R Final Report 22 March 2017 Page 15 2.2.10 There was some contact with Adult B’s father who, it is stated, used drugs and alcohol and whose child Adult B had considered caring for during a particularly concerning period. 2.3 Short Bowel Syndrome Nature of the condition 2.3.1 Short Bowel Syndrome, or SBS, is a rare, life-threatening gastrointestinal disorder in which patients are unable to maintain nutrient and fluid balances with a normal diet.345 2.3.2 SBS generally occurs when a large portion of the small intestine has been removed by surgery for a variety of reasons, resulting in the loss of intestinal absorptive capacity but can also occur when the intestine loses the ability to function properly as a result of other disorders. 2.3.3 This means that patients can no longer absorb enough fluids and nutrients from liquids and food they digest to maintain good health. This is known as malabsorption, and can put patients at risk of malnutrition, diarrhoea and dehydration. 2.3.4 SBS can have a negative impact on a patient's quality of life because it restricts or alters their lifestyles. However, with the right treatment and disease management, these restrictions can be attenuated.6 Potential Problems 2.3.5 The complications of short gut syndrome may include: Malnutrition peptic ulcers—sores on the lining of the stomach or duodenum caused by too much gastric acid kidney stones—solid pieces of material that form in the kidneys small intestinal bacterial overgrowth—a condition in which abnormally large numbers of bacteria grow in the small intestine Care 2.3.6 Treatment for short gut syndrome is based on the patient's nutritional needs. Treatment may include: nutritional support medications surgery 3 Hofstetter S, Stern L, Willet J. Key issues in addressing the clinical and humanistic burden of short bowel syndrome in the US. Curr Med Res Opin 2013;29(5):495–504. 4 Jeppesen PB. Spectrum of short bowel syndrome in adults: intestinal insufficiency to intestinal failure. JPEN J Parenter Enteral Nutr 2014;38(1 Suppl):8S–13S. 5 O'Keefe SJ, Buchman AL, Fishbein TM, et al. Short bowel syndrome and intestinal failure: consensus definitions and overview. Clin Gastroenterol Hepatol 2006;4(1):6–10. 6 Kelly DG, Tappenden KA, Winkler MF. Short bowel syndrome: highlights of patient management, quality of life, and survival. JPEN J Parenter Enteral Nutr 2014;38(4):427–37. SCR Child R Final Report 22 March 2017 Page 16 intestinal transplant 2.3.7 The main treatment for short gut syndrome is nutritional support, which may include the following: Oral rehydration. Children should drink oral rehydration solutions—special drinks that contain salts and minerals to prevent dehydration—such as Pedialyte, Naturalyte, Infalyte, and CeraLyte, which are available on prescription. Parenteral nutrition. This treatment delivers fluids, electrolytes, and liquid vitamins and minerals into the bloodstream through an intravenous (IV) tube—a tube placed into a central vein. Health care providers give parenteral nutrition to people who cannot or should not get their nutrition or enough fluids through eating. Enteral nutrition. This treatment delivers liquid food to the stomach or small intestine through a feeding tube a small, soft, plastic tube placed through the nose or mouth into the stomach, or a tube/button placed on the tummy which enters directly into the stomach. Gallstones—small, pebble like substances that develop in the gallbladder—are a complication of enteral nutrition. Vitamin and mineral supplements. A person may need to take vitamin and mineral supplements during or after parenteral or enteral nutrition. Special diet. A health care provider can recommend a specific diet plan for the patient that may include o small, frequent feeds o avoiding foods that can cause diarrhoea, such as foods high in sugar, protein, and fibre o avoiding high-fat foods 2.3.8 A health care provider may prescribe medications to treat short gut syndrome, including: antibiotics to prevent bacterial overgrowth H2 blockers/proton pump inhibitors to treat too much gastric acid secretion choleric agents to improve bile flow and prevent liver disease bile-salt binders to decrease diarrhoea anti-secretin agents to reduce gastric acid in the intestine hypomotility agents to increase the time it takes food to travel through the intestines, leading to increased nutrient absorption growth hormones to improve growth if there is associated growth hormone deficiency teduglutide to improve intestinal absorption 2.3.9 The goal of surgery is to increase the small intestine's ability to absorb nutrients. Approximately half of the patients with short gut syndrome need surgery.2 Surgery used to treat short gut syndrome includes procedures that prevent blockage and preserve the length of the small intestine narrow any dilated segment of the small intestine slow the time it takes for food to travel through the small intestine lengthen the small intestine 2.3.10 Long-term treatment and recovery, which for some may take years, depends in part on SCR Child R Final Report 22 March 2017 Page 17 what sections of the small intestine were removed how much of the intestine is damaged how well the muscles of the intestine work how well the remaining small intestine adapts over time The role for parents 2.3.11 Parents often take on an extended role when caring for children with complex health needs/disabilities. Much of the extended role encroaches into what is commonly understood to be a nursing role with parents undertaking tasks usually assigned to qualified nurses in the hospital. Parents are trained and supported to undertake this role. 2.3.12 The basics of feeding can be quite onerous, with parents being encouraged to learn how to administer feeds either directly into the stomach via a tube, or intravenously or both (as in Child R’s case). Some of the pleasure and intimacy usually associated with infant feeding is lost and feeds can become more of a task. Feeding can be either continuous or more frequent than usual, and can be time consuming, as feeds may require increased preparation and tubes require care pre and post feeding. 2.3.13 The change in role from parent to parent/carer has the added dimension of putting the parent in control of much of their child’s nursing care. Parents of children with complex ongoing health needs are often viewed as the expert in their child’s needs and care in a way that would not be expected of parents whose child had a general or acute illness. 2.3.14 Parents of children with complex health needs/disability often report increased tiredness, in part due to their caring responsibilities with increased numbers of routine check-ups and appointments for review and for treatment, but also as a result of the emotional toll associated with their caring role. 2.3.15 The increased care needs can result in a reduction of opportunities for parents to socialise and to stay involved with friends and remain active in their communities. This can result in isolation and loneliness. 2.3.16 It is not uncommon for parents to go through the grieving process, particularly if their child is not developing and progressing as they had anticipated. 2.3.17 Caring for children with complex health needs/disability can cause strain within the most stable of relationships, and if there are existing relationship difficulties or inequalities these often become amplified. SCR Child R Final Report 22 March 2017 Page 18 3 NARRATIVE AND APPRAISAL OF PRACTICE 3.1 Introduction 3.1.1 The period under review covers the date from the premature birth of Child R, in January 2012 to the date the parents were arrested in October 2015. 3.1.2 In order to gain an understanding of the circumstances that led up to this point, the time period under review has been divided into a series of manageable episodes. Crucially, not all the activity that was focussed on Child R and his family on an ongoing basis is explicitly listed so it is important to keep in mind the significant amount of professional activity/energy that was being concentrated on the family 3.1.3 This chapter explains what happened, with a 'comment' box providing an appraisal of practice for each key practice episode. 3.2 Key Events 1 January 2012 – September 2012 Birth of Child R to discharge 3.2.1 Child R was born in January 2012 at 29 weeks’ gestation weighing 1665gms and requiring resuscitation. Initially Child R was admitted to the neonatal unit at Hospital 1 with prematurity, suspected sepsis and respiratory disease of the newborn and found to have a Grade 2 Intraventricular Haemorrhages (bleeds on the brain). 3.2.2 Whilst Child R’s care was administered during this period within secondary and tertiary care, primary care services were made aware of his birth; the allocated Health Visitor conducting a primary visit to introduce herself to the parents at the hospital. 3.2.3 Other services and professionals involved with the family, in particular Child A and Child B’s school, were less aware of the circumstances surrounding Child R’s premature birth and subsequent health issues. Child R’s birth coincided with a temporary increase in absenteeism of Child A and Child B. 3.2.4 Within two weeks of birth, Child R developed necrotising enterocolitis (NEC) which is the most common surgical emergency in newborn babies and tends to affect more babies born prematurely than those born full-term. NEC is a serious, life threatening illness in which tissues in the intestine (gut) become inflamed and start to die. This can lead to a perforation (hole), which allows the contents of the intestine to leak into the abdomen. Child R initially underwent emergency bowel surgery and had a resection of his small intestine causing the short gut and formation of duodenostomy. 3.2.5 Child R received specialist neonatal care until late March when he was discharged to a children’s ward for on-going treatment of his short gut syndrome. Child R had further planned bowel surgery as part of the treatment of his condition in March and April. SCR Child R Final Report 22 March 2017 Page 19 3.2.6 Due to being unable to absorb nutrients in his small bowel, Child R required Parenteral Nutrition for feeding. Child R also required additional feeds and fluids via a tube into the stomach. Adult B underwent extensive training to administer both of these feeds and his prescribed regime. His regime changed periodically in response to regular weight monitoring and blood tests. Child R was also prescribed dioralyte for times when he was unable to tolerate solids and needed additional hydration. 3.2.7 During Child R’s admission the couple were experiencing housing issues; their landlord indicated he was pursuing court action with a hearing scheduled in April 2012. 3.2.8 Adult B sought help from Housing Options. A homelessness application was triggered and forms were sent to Adult B for signing. No referral was made to Children’s Services by Housing Options, as no concerns were identified and there were services in place in relation to Child R’s needs. The neonatal unit were aware of the issue but also did not identify a need to refer to any other services. 3.2.9 The HV made a further visit to Child R and in recognition of his complex health needs weighted his care needs as level 3. Comment: In these early weeks there were signs that the family had a number of competing priorities. A sick child, hospitalised for a number of weeks is well recognised as a strain on families. Adult B became the main carer for Child R frequently staying overnight or visiting daily and beginning a programme of training in order to be able to care for Child R’s nutrition, after his discharge. The plan of care was not marked as completed in its entirety, however Adult B was assessed as competent. Hospital staff, aware of the couples housing issues, provided supporting letters to housing. However, they were unaware Adult B was applying for housing individually, believing the family members were all residing together as a single family unit. The Health Visitor weighted Child R’s needs at level 3 in recognition of the complexity of his health needs. This decision indicates an increased level of input would be required, Child A and Child B’s childhoods undoubtedly changed following Child R’s birth, however little is known about the impact on Child A and B and no information is noted to have been shared between health visiting and school nursing. Except for housing, all the professionals involved in Child R’s care were predominantly focussed on his complex health needs. Completion of a CAF at this point may have provided a more holistic view of the family and their individual needs See section 5.2 3.2.10 Child A and Child B witnessed a domestic violence incident involving Adult B’s sister and partner whilst in their care; the couples’ children were known to Children’s Social Care however Child A and Child B were not considered as at risk, so no further action was taken. SCR Child R Final Report 22 March 2017 Page 20 Comment: The circumstances around this incident are largely unknown. The incident did not involve the children’s parents, what we don’t know was how frequently Adult B’s sister was caring for Child A and Child B. There was no communication regarding this incident with school nursing, education or the Children’s Centre, so there was no opportunity to assess or address any emotional impact. This opportunity for an assessment had the potential to bring to light any difficulties the couple were facing in meeting all their children’s needs. This has been addressed and recognised in the recent JTAI inspection. The Board initiated and supported a pilot project to share domestic abuse notifications with schools. This will be embedded into the Tackling Domestic Abuse Board (TDAB) and therefore no recommendation is made. 3.2.11 In mid-April, homelessness full duty was awarded. Adult B, Child A and Child B were to be placed in Bed and Breakfast accommodation; parents indicated the landlord allowed them to remain at the address until suitable accommodation was sourced. 3.2.12 School became aware of the housing issues when Child A and B were absent from the school. Adult B agreed to complete a CAF with school. In the meantime, Child B became unwell with shortness of breath and was admitted to Hospital 3 A&E. Adult B took Child B, against medical advice to Hospital 2 where Child B was admitted for the evening. Hospital 3, concerned, referred the incident to Children’s Services and the case was opened by Children’s Services for an initial assessment. School were advised by Children’s Services; the CAF they were planning was not necessary in view of the initial assessment. The initial assessment concluded that the risk of a repeat of the situation was small. The general concerns regarding the parents’ ability to cope with their current circumstances were noted, as was the parents’ refusal for support from a Tenancy Support Worker and TAC. It was recorded that the level of concern did not meet the threshold for further intervention and thus the case was closed. Comment: The information used to inform the initial assessment came mainly from health sources and Adult B, and was focused on the incident. That a core assessment might be helpful was not considered. There appears to have been no discussion with Housing and it is not clear whom, within the school, the social worker spoke with or what information was shared. Adult A and Adult B informed the lead reviewer they understood CAF/TAC to be social work lead and part of child protection, and as such, not something they would willingly embrace because of their previous experiences. At the time Adult B expressed an interest in knowing more about the school Family Support Worker and whether they were able to support the family in getting the children to school. The social worker indicated this would be progressed when the Family Support Worker returned from leave, however there is nothing to indicate this was communicated with the school nor that it was followed through. Feedback to the school would have allowed the staff to offer support in an alternative way the couple may have found more acceptable and offered an opportunity to assess and deliver support to the family. A SCR Child R Final Report 22 March 2017 Page 21 step down process to TAC is now in place. 3.2.13 Housing Options continued their support of the family in respect of housing. 3.2.14 Hospital 2 sent summaries of Child R’s treatment to all the health professionals, in line with the recommendations of the Initial Assessment, who were to have on-going involvement with Child R. The summaries identified that Child R would be discharged on Parenteral Nutrition (PN) and a bowel expansion programme. 3.2.15 In June 2012 a pre-discharge planning meeting was held. The GP, Housing and the Community Paediatrician were not present. Physiotherapy and Occupational Therapy indicated Child R had developmental delay and that he would benefit from on-going developmental advice in the community. The following week Child A and Child B were absent from school, Child A was said to have Chickenpox. Two weeks later Child R was transferred to PICU with a fever and deterioration in his condition; he remained there for an extensive period with a diagnosis of sepsis. Child R had a further brief admission to PICU with a suspected line infection. Absenteeism relating to housing and transport issues continued for Child A and B. 3.2.16 In August 2012 Child R had further planned bowel surgery; the hospital continued to prepare for Child R’s discharge which took place in early September. Comment: The pre-discharge planning meeting was an opportunity to bring all professionals within primary, secondary and tertiary care together and was good practice. This meeting provided an opportunity to allocate a Lead Professional but this did not happen. It is unfortunate that there was a delay in discharge. This meant there was a considerable time between the original discharge planning meeting and discharge. During this time there had been many difficulties for the family with regards to housing and absenteeism relating to transport issues. Adult A indicated a 40-minute walk for the children to and from school was impacting. A multi-agency meeting at this point could well have influenced both the discharge date and the package of care and support offered. 3.2.17 Child R’s weight was 5.1kg <0.4th centile, he was in receipt of PN and oral feeds of formula milk. Within 3 days of discharge Child R was re-admitted to Hospital. Adult B noticed he had a sunken fontanelle and felt Child R looked dehydrated and acted appropriately on her concerns Comment: Adult B demonstrated she was able to recognise Child R’s change in condition and took appropriate action in returning him to Hospital. There is no discharge letter in the GP records pertaining to this admission. An audit has not demonstrated this as a systemic issue. 3.2.18 Two days later Adult B’s tenancy commenced. SCR Child R Final Report 22 March 2017 Page 22 October 2012 – December 2012: Child R has two central line infections 3.2.19 During this period Child R continued to receive care from primary, secondary and tertiary services and underwent further planned bowel surgery, he also had a developmental assessment by the physiotherapist and occupational therapist. There were two admissions with line sepsis in this period. The first resulted in a 5-day stay before discharge with Intravenous Antibiotics to be administered by Adult B after discharge. The second admission was due to bronchiolitis. 3.2.20 Admissions led to a missed appointment with the Health Visitor. 3.2.21 The family’s change of address impacted a referral to the speech and language therapy feeding team and a developmental assessment by the physiotherapist. 3.2.22 The Specialist Paediatric Nurse requested the Health Visitor monitor Child R’s weight and refer Child R to the Community Paediatrician. 3.2.23 During this period housing issues continue as satisfactory payments were not being made. Adult B is notified that a Notice of Seeking Possession would be served the following week if no arrangements to pay were made. 3.2.24 Adult B was proactive in informing SPN PN of seeking GP assistance as Child R had a cough and cold. Child R had an OT/PT initial assessment and a further appointment was made. Comment: It appears that at this point there is a lack of co-ordination of roles, appointments and assessments. Professionals are working in silos and lack of information sharing was causing unnecessary work load. The sharing of basic demographic details may have prevented missed appointments and wasted home visits. There remain additional stressors for the family that health professionals were unaware of. CAF, if better understood and agreed by the family, could have increased understanding of the family’s circumstances and brought about a holistic approach promoting information sharing and a co-ordinated plan of support that would be reviewed and would have led to the allocation of a Lead Professional. Adult B reported to the lead reviewer that she was discouraged from seeking GP assistance and instructed by the SPN PN to direct all health concerns to secondary and tertiary hospitals. Adult B indicated she felt she was given considerable authority at this time to take bloods and administer antibiotics and that a multi-agency plan would have helped. SCR Child R Final Report 22 March 2017 Page 23 Jan 2013 – March 2013: This period includes two contacts to Children’s Services. 3.2.25 During the next three months, there continued to be confusion and a pattern of missed appointments in the community with the physiotherapist. Sometimes when appointments were missed, it was because Child R was in hospital, however on one occasion, Adult B stated Child R had been in hospital, which was not true. The community nursery nurse referred Child R to the community paediatrician some two months following initial request. Child R continued to attend short gut clinic; there were no concerns regarding his progress. Wt 6.3kg 3.2.26 Issues with non-payment of rent continued with attempts by the income officer to speak to Adult B. 3.2.27 During this period Child A had 1-day absenteeism for a temperature and Child B had routine growth measurement in school 3.2.28 In February Child R was seen in the gastroenterology clinic, the following day he was admitted via A&E. Child R had become unwell with a raised temperature whilst having his PN via a central line. A central line infection (3) was suspected and IV antibiotics commenced. Child R was discharged 5 days later – wt 6.7kg 3.2.29 During this admission Child R failed to attend his 1st SALT appointment; he was discharged, as per policy at the time and the referrer advised. Comment: Adult B appeared to be prioritising appointments with the Hospital Consultant relating directly to Child R’s Short Bowel Syndrome, whilst appointments with community health care professionals are more frequently missed. Without clear communication lines, the Hospital staff formed a view that Adult B was compliant however the picture is not the same for other services. CAF and TAC process with an identified Lead Professional could have promoted information sharing and a co-ordinated plan of support that was reviewed. 3.2.30 There were concerns that Child B possibly had 2 bruises/nappy type rash. The school rang CS for advice as they couldn’t contact Adult B. The family had changed address without informing the school. There’s no record of this contact at CS however school indicate they were advised to speak to the parents which they did. Adult A took Child B to school the following day, Child B was checked in Adult A’s presence, and no bruising or rash were present. Comment: The actions or inactions around this concern have been difficult to analyse. School staff were right to contact Children’s Services for advice; the lack of recording of this contact within Children’s Services means the reviewer is unable to establish whether practice was in line with policy at that time. It is difficult to establish the advice given and the processes followed which may have been anywhere from entirely appropriate through to warranting a medical opinion. However, this lack of recording is concerning. Whilst SCR Child R Final Report 22 March 2017 Page 24 children’s services have been assessed by various agencies and reported as having good systems in place for safeguarding it should be checked to ensure advice given to professionals is routinely recorded. 3.2.31 During this period a number of requests came from one medical professional to another, the GP was requested by the hospital, to prescribe long term treatment for decontamination of the gut and the Neonatologist requested the GP conduct a neurodevelopmental assessment. Over the following months there was infrequent ordering of these treatments by the family indicating possible non-compliance and no evidence the GP carried out a neurodevelopmental assessment or made a referral for a Paediatrician to complete this. Comment: Within GP surgeries there have long been systems for monitoring the over ordering of medications however there is no system to monitor under prescribing of medication essential for patients to maintain or achieve optimal health. The responsibility for this now lies with the allocated GP. This information could then feed into other assessments/review processes i.e. CAF. Adult A and Adult B indicated much of the medication was prescribed by the tertiary hospitals. 3.2.32 The GP is informed by Adult B that Child R has a further SALT appointment; they have been promised a co-ordinator but this has not happened. 3.2.33 Child R has a further admission for a temperature due to a line infection (4) and not having had his Bowels Opened. 3.2.34 The GP was requested to increase Child R’s dose of Ursodeoxycholic acid; this did not happen. Comment: The lack of a Lead Professional to co-ordinate all the requests and information means there are a lot of requests for primary care from secondary and tertiary care services with little evidence of a positive effect. Hospital 2 were clear within their SAAR that there is a firm arrangement that GPs act as the single point for all information to go to and will cascade that information. The GP needs to be clearly notified that he/she needs to cascade the information. There is a lack of clarity as to whether that was fully understood by the GP practice involved or the hospital. Whilst the GP was notified of action such as prescription continuation or alteration, the GP was not notified of all the prescriptions issued by the hospital. There is a need for providers to notify GP’s of actions to be undertaken such as prescription continuation or alteration, cascading information to relevant specialities and making onward referrals. Child R has had four line infections at this stage. It is clear that parental competence was in the mind of the gastroenterology specialist nurse who was supporting Adult B and assessing, if not documenting, her technique however, there is a lack of clarity about what will trigger parental competence to be formally rechecked. SCR Child R Final Report 22 March 2017 Page 25 April 2013 – June 2013 3.2.35 During this period there were a number of different appointments with various professionals. The mixed picture of compliance continues with Child R being seen by the physiotherapist at home who encountered a no access visit on another occasion, when Adult A stated Adult B had gone to the GP and forgotten, despite a text reminder. On another occasion Child R was presented for a Physiotherapy review of gross motor skills – it was felt he no longer needed specialist seating. 3.2.36 Child R was not taken to a community paediatrician appointment; Adult B citing non receipt of appointment. 3.2.37 The children’s community nursing team discharged Child R in consultation with SPN as no input was deemed to be required. At that time Child R was undergoing a trial of no PN 1 night per week; dioralyte was prescribed to support hydration. The HV was active with the family and carried out weight checks pre and post two separate nights off PN and was informed by Adult B she had been assessed as still competent in her care of Child R. 3.2.38 The GP responded immediately to a request from gastroenterology for increase in prescribed dose of Ursodeoxycholic acid. 3.2.39 During this period the HV made multiple no access visits whist Child R was in hospital. On the first occasion Child R attended A&E with a temperature and was later admitted with a further line infection (5) Bloods were suggestive of sepsis and blood results indicated low sodium; thus Child R was re-admitted for central line removal and for gastrostomy. On the second occasion Child R was attending an Ophthalmic review for a possible intermittent squint; Child R was for further review in September 2013. There was a further no access visit for the HV with no apparent reason given. 3.2.40 Housing issues continue with Adult B being informed of their intent to recover possession of the property if there was no contact within 7 days. Adult B made contact and was informed an income officer would be in touch. Adult B later rang housing to advise an arranged home visit would be difficult as Child R was in Hospital; arrangements were made to pay the arrears. July 2013 – September 2013 3.2.41 The Health Visitor offered to refer Child R to portage, Adult B declined this on the basis that there was input from other services. Child R had four admissions during this period: The first was planned for a PEG7 insertion in early July; The second with low sodium and weight loss; sodium chloride was prescribed. 7 Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a PEG tube is passed into a patient's stomach through the abdominal wall SCR Child R Final Report 22 March 2017 Page 26 Child R had a further admission with central line sepsis wt 8.1 kg. Child R was further admitted with vomiting for 3 days 3.2.42 On the day of Child R’s PEG insertion Child A and B were absent from school with no reason given. Child A and Child B were also absent four days later. 3.2.43 Following PEG insertion, the Diana team become involved. Adult B was carrying out all Child R’s cares having been taught in hospital, and so was advised to contact the CCN if any input was required. 3.2.44 The Physiotherapist visited Adult B who reported Child R had not received an appointment with the Paediatrician yet. During one admission Child R missed a physiotherapy appointment which was followed up by the physiotherapist; Hospital 2 informed of impending discharge. 3.2.45 During this period` the housing Income officer left a message for Adult B regards non-compliance with a rent arrears agreement. The message was ignored and a further letter sent. 3.2.46 Child R had a change to diet to help with bowel frequency and aid weight gain; gluten free products were prescribed. Child R’s regime was changed to 5 nights’ parenteral nutrition plus milk per week, his weight was 7.86kg off PN. 3.2.47 The SPN PN re referred Child R for SALT. There was no HV involvement during this period. Comment: During this period there is evidence that Adult B was struggling to manage all her responsibilities and as a result the two older children’s schooling was impacted and the family’s housing placed in jeopardy. The professionals involved deemed Adult B to be competent in the care of Child R, however there was little evidence, that the impact of her caring role was being assessed. The onus was placed on Adult B to request help rather than a more helpful coordinated response e.g. a reactive rather than proactive service. An offer of CAF and a multi-agency response at this point may have been helpful despite previous refusal. October 2013 – December 2013 3.2.48 There were a number of activities relating to housing during this period. Housing issued a Notice of Seeking Possession for rent arrears; however, they continued to take care of the property, carrying out three visits where they conducted repairs to a door lock and leaking toilet, made safe a ceiling in the kitchen, repaired a bathroom light and boiler, and plastered the kitchen ceiling. Adult B called to speak to the income officer; the call was returned but contact was not successful. SCR Child R Final Report 22 March 2017 Page 27 3.2.49 Adult B sought advice from the SPN PN as Child R was not coping with alternate night feeds. Adult B felt Child R was dehydrated by the afternoon. The SPN PN agreed to attend and review Child R the following week. 3.2.50 Child R had two further admissions with line infections. On a further occasion Child R attended with a temperature and vomiting. Adult B initially refused admission however returned later. 3.2.51 Child A was absent from school for 1 day with vomiting 3.2.52 Child R had another brief 1-day admission with a raised temperature weight 9.3kg and attended a hospital appointment for weight check and hub change. 3.2.53 The Physiotherapist visited Adult B and agreed to re-refer Child R to the community Paediatrician with regard to gross motor delay. Adult B indicated she was happy with Child R’s progress. Adult B was reportedly keen at this point for local services to be co-ordinated. Comment: Adult B indicated she felt there was a need for better co-ordination of care. This provided staff with an opportunity to further discuss and initiate a multi-agency response via CAF, TAC and allocate a Lead Professional. There are a number of reasons why there can be a discrepancy between parents and professionals view on a child’s progress. In part this may be due to parents’ expectations, particularly with a sick or preterm child, but it can be difficult for any parent to remain objective around their own child’s development. Professionals are not just looking for a child to progress, they are looking for a child to reach recognised milestones in their development. January 2014 – March 2014 3.2.54 The tenancy officer made a home visit to discuss medical waste removal some fifteen months post initial discharge. 3.2.55 Child R attended a follow up appointment with the paediatric surgeon and dietician with plans to review in one month; medication was increased. 3.2.56 Child R had a failed appointment with the physiotherapist and had an emergency admission with vomiting and a two-week history of a virus; Adult B had not sought GP advice. Adult B wanted to take Child R home without completing treatment and voiced concern about the care provided, however the Consultant made it clear, Child R needed to stay and complete treatment for a line infection and the consequences of not doing so. Child A was absent through illness however Child B was absent as Adult B indicated there was no one to take Child B to school as Child R was in hospital. It is not clear why Adult A or Adult A’s mother could not do this. School advised Adult B to ask school to transport if there was a problem the following day. SCR Child R Final Report 22 March 2017 Page 28 3.2.57 Adult B requested the HV weigh Child R. The named HV had left, and the case had yet to be reallocated. In response to Adult B’s request for Child R to be weighed, the nursery nurse made a home visit, Adult B expressed concern as Child R had lost weight. The following day Child R was admitted with seizures and low blood sugar – Child A and B were late for school as a result. 3.2.58 The physiotherapist completed a home review; Child R was making good progress. 3.2.59 In February Child R was admitted to PICU for a stricture release and bowel lengthening procedure. The physiotherapist kept in contact throughout admission. The Community Paediatricians appointment could not be attended due to Child R’s hospitalisation. SALT took a decision to discharge until Child R was discharged by Hospital and left it to the hospital to re-refer. Abbot attempted to contact Adult B to check if their equipment was still required and to discuss deliveries. There were no discharge letters sent or pre discharge meetings. 3.2.60 Adult B agreed for an application to be made for a deduction of benefits, this was successful and there were no further issues with arrears. 3.2.61 Child R was discharged from Ophthalmology due to two failed appointments. 3.2.62 In March the Paediatric surgeon and dietician reviewed Child R who was reported to be tired during the day following a night off PN. Adult B was advised to give Child R x 2 sachets of dioralyte. Child R’s weight was 9.6kg. Bloods were taken and showed low potassium; as a result, Child R was admitted. Child A and B had a 1-day unauthorised absence. Comment: It is not fully understood how Adult B was managing at this point, she had expressed a desire for co-ordination which hadn’t resulted in a change of strategy. The consultant acted appropriately when explaining likely consequences of Adult B removing Child R thus promoting the need of the child whilst considering the best outcomes for Child R. Adult B’s desire to take Child R home at a point staff felt would be detrimental to his health, could have been borne out of difficulties in managing all her responsibilities and in particular getting Child A and Child B to school. The decision of SALT to discharge Child R was in accordance with policy at that time, however this then placed responsibility for re-referral on other professionals and open to oversight. Policy has now changed and this would not be the practice now. April 2014 – June 2014 3.2.63 The physiotherapist remained active conducting a home review; Child R was progressing and Adult B was reportedly pleased. On the same day Child R missed an appointment with the community Paediatrician; his neuro developmental assessment remained outstanding. Adult B was to be advised by the physiotherapist of a referral to the Starting Life Well service for an early support key worker. SCR Child R Final Report 22 March 2017 Page 29 3.2.64 Child A and B continued to have a number of school absences, once for 2 days with no reason/explanation given and on another occasion with a tummy bug. 3.2.65 Child R had a dietician review. Adult B was advised to recommence bolus gastrostomy feeds as Child R had lost weight – 9.36kg. 3.2.66 Child R had two further admissions for line infections, on the first his weight had increased to 10.2kg, during the second the Community Paediatricians appointment was missed again. The physiotherapist was advised to complete a CAF; no safeguarding concerns were noted. 3.2.67 3 months after Adult B’s request for a Health Visitor to weigh Child R a HV was allocated. At this point Child R has had no 9-month developmental check or 2-year developmental check as per the Healthy Child Programme. 3.2.68 SPN PN conducted a home visit to review Adult B’s care of Child R’s line following numerous admissions with line infections. The visit was followed up with a letter to both parents detailing the advice given. 3.2.69 The physiotherapist visited the home and was informed Adult B was suing the surgical team. Adult B was tired and unwell, thought to be due to constant visits, CAF was discussed and the initial questions completed. The CAF was completed 5 days later with a plan to check it with the family. Child A and B were absent from school; it was reported their uniforms were ruined in the washer. Comment: As a result of repeat admissions and in part due to the lack of allocated Health Visitor Child R has missed his routine developmental assessments as well as his neuro developmental assessments. This is a concern as without these assessments it is difficult to judge whether he was receiving the appropriate level of support and care to ensure he reached his optimum potential. An appropriate single agency recommendation has been made to manage vacant caseloads and address this issue. July 2014 – September 2014 3.2.70 The physiotherapist referred Child R to ENT for snoring, Child R is reviewed and referred for a sleep study. 3.2.71 Child R failed to attend a community paediatricians’ appointment; on this occasion he was not in hospital. 3.2.72 Child A and B have two short periods of absence during this period, the first without any reason given and the second with head lice. 3.2.73 Child R was seen by the gastroenterologist and dietician wt 11.05kg. PN was reduced to 4 x a week with 6 concentrated feeds. Child R was to have a trial of inhaler for his breathing SCR Child R Final Report 22 March 2017 Page 30 3.2.74 Child R was seen by the gastroenterologist and dietician wt 11.05kg. PN was reduced to 4 x a week with 6 concentrated feeds. Child R was to have a trial of inhaler for his breathing. 3.2.75 The Dianna CCN noted Child R had a dirty PEG end and made arrangements for it to be changed. The following visit was a no access visit. 3.2.76 The Physiotherapist visited to complete the CAF. Child R was noted to be climbing and walking with a push along toy. Following on from the CAF the physiotherapist and support worker carried out a joint home visit. Adult B raised concerns regards Child R’s slow progress with mobility. The dietician was said to be concerned Child R remained on a sloppy diet and was not having finger foods, a decision was made to await the result of sleep studies, Adult B was yet to visit B Hub regarding a nursery placement. It was felt Child R would benefit from play/nursery. All professionals known to be involved were notified of the support workers role as designated key worker. 3.2.77 Feed pump training was arranged for Adult B. Child R’s Peg end breaks. Child R’s ophthalmology appointment was attended with a plan for on-going review. 3.2.78 Following the allocation of a key worker there was a flurry of activity, the key worker visited the home and discussed nursery placement. A visit arranged for September was attended and Adult B agreed to the placement. A professionals meeting was held, a plan for introduction visits to nursery was formed and a referral for feeding team input made. A 2-year funding application was completed and agreed. Child R was seen by a senior registrar in community paediatrics. Developmental delay was noted and a plan formulated for coordinated care with education and therapies. Child R was referred to the child development forum. A travel voucher application was completed. 3.2.79 Child R had a further admission with a central line infection – his weight was 10.3 kg; this admission delayed Child R’s sleep study and attendance at nursery with the key worker. October 2014 – December 2014 3.2.80 The Physiotherapist continued to visit Adult B at home. Adult B reported the sleep study was complete. Child R was referred for a feeding assessment. 3.2.81 The Key worker started to co-ordinate Child R’s care. The CCNs attended nursery to deliver gastrostomy and Hickman line training; Child R was not yet attending and his placement was on hold until after half term so training was cancelled. Adult B subsequently declined the nursery placement stating it was too far; an alternate nursery placement was sought. 3.2.82 Adult B’s competence to take bloods, administer PN and IV antibiotics was assessed by SPNPN. Child R was re-referred to SALT by SPN PN this equates to an eight month delay. SCR Child R Final Report 22 March 2017 Page 31 3.2.83 Child R was reviewed by gastroenterology. The ENT sleep study was reported normal. Child R was said to choke on food so a further SALT referral was made to the feeding team. 3.2.84 Adult B reported Child R was tired and dehydrated by his third night off PN, and was advised to give dioralyte on the 3rd night. Child R’s medication was increased to control stool frequency. It appears Metronidazole may not have been being given frequently enough. On one occasion Child R had a floppy episode following TPN, he was reviewed and his regime changed. 3.2.85 There are a number of days when Child A and Child B were absent from school during this period Child A had 3 days’ absence and Child B had 5 days’ absence, on occasions no reason was given. 3.2.86 Child R was seen in Paediatric clinic but missed his SALT appointment. At a dietetic review he appeared to have lost weight, his stools had increased in volume (more watery). A further change was made to his diet. 3.2.87 There was one missed and one rearranged appointment with key worker. 3.2.88 Child R was seen by ENT and referred to SALT for video fluoroscopy due to choking. 3.2.89 At the child development forum meeting, Child R’s needs were discussed and plans made for support. No actions were identified for the HV at this point. 3.2.90 Adult B attended a viewing of nursery 2 with a plan for Child R to commence in January. The physiotherapist continued to visit regularly and carried out a successful opportunistic visit, Child R was reported unwell. Child R was later admitted with a raised temperature, believed to be an Upper Respiratory Tract Infection (URTI), and given antibiotics. January 2015 – March 2015 3.2.91 Adult B indicated she would like Child R to start nursery. As a result, a transition meeting was arranged. The meeting took place and as a result the key worker made telephone calls to try and kick start nursery attendance and staff training. 3.2.92 Child A and Child B continued to have occasional one day absences from school. 3.2.93 A family service planning meeting was held. Child R was not gaining weight despite TPN 3 nights a week and bolus feeds alternate days. Child R was having frequent stools and reflux; Child R was referred to pre-school Occupational Therapy for assessment of support for functionality. 3.2.94 Child R had a planned admission for bloods, weight and dietary review. Weight 11.05kg, gut de-contamination continued. 3.2.95 A routine home visit was made by the SPN PN. 3.2.96 Child R had a Gastroenterology admission for growth assessment (weight 11.1kg) and bloods. SCR Child R Final Report 22 March 2017 Page 32 3.2.97 The key worker reminded Adult B re a SALT appointment Adult B later stated SALT advised her Child R could swallow normally but could not chew normally. Adult B was given advice and an arrangement was made for Child R to be reviewed 2 months later. 3.2.98 Child R started nursery, his attendance was sporadic but he was settling well. Staff received training. Child R then missed two weeks of nursery sessions, Adult B stated he was unwell when off his PN, and not well enough to attend. 3.2.99 The housing repair inspector attended to inspect damp and black mould in the dining room and bedrooms and a shower hose. As a result, a vent was replaced. April 2015 – June 2015 3.2.100 The Occupational Therapist made a home visit and completed an assessment of functional needs, discussing the suitability of the accommodation, adaptations and housing options. Adult B was given advice on progressing Child R’s gross motor skills. 3.2.101 Several attempts were made to train staff at the nursery re delivering gravity feeds and use of the pump. These attempts were thwarted by the children’s illness and Adult B indicated Child R’s charger wasn’t working. Also training regards management of Child R’s central line was affected. Child R was seen by the dietician and had gained weight. Adult B was starting to encourage chewing. Child R was again absent from nursery for three weeks – Adult B reported being really busy. 3.2.102 Housing carried out a number of repairs to the external doors, shower and fitted new kitchen units and work tops 3.2.103 Child R was seen by SALT; there was a debate between hospital and community regarding the need for video fluoroscopy, a decision was made that it was not required. 3.2.104 Child R had a planned ward admission for weight and bloods. 3.2.105 The key worker discussed Child R’s attendance at nursery with Adult B. Adult B reported difficulties with her father and his partner which she had been sorting. Social workers were involved and it was possible Adult B might become the carer for their children at some point. The key worker contacted the OT and SALT. 3.2.106 Child R returned to nursery after Easter. 3.2.107 The ophthalmology nurse followed up Child R’s non-attendance at two appointments. 3.2.108 Child A and B were absent for 1 day no reason was given. A referral was made to EWO regarding their attendance. The parents were invited to panel but did not attend, later the children’s attendance improved. 3.2.109 Child R failed to attend a feeding review but was seen in Gastroenterology clinic and said to be making good progress; eating well, walking, having 2 bolus feeds per day and PN. A letter was sent to all the health professionals involved. Metronidazole needed to be administered two weeks on and two weeks off. SCR Child R Final Report 22 March 2017 Page 33 Comment: It appears Metronidazole was not being prescribed by the GP frequently enough to be administered as prescribed –there were a number of months when no prescriptions were issued. It is known that some prescriptions were being issued from secondary/tertiary care so it has been difficult to establish if there is evidence of non-compliance by the parents. An appropriate recommendation has been made to address this issue. Parents indicate prescriptions were also being given by the Hospital; it remains unclear whether Child R was receiving all his medication 3.2.110 Child R failed to attend a community paediatric appointment; the key professional had been put off from visiting by Adult B because of this appointment. It is not clear if the key professional was informed. Adult B was sent a reminder regarding an appointment with SALT by key worker but still did not attend. 3.2.111 Adult B attended a family service planning meeting which was later uploaded as a CAF review. Adult B reported illness had affected Child R’s nursery attendance although she had not sought any assistance. Adult B requested an OT assessment at home. It is unclear why as this had recently been done but may have related to concerns Adult B raised regarding the outdoor and garden areas being unsafe. There was a plan for physiotherapy to review Child R’s mobility. The OT arranged a review at the home but there was no one in, the key worker was informed; the nursery visit completed. 3.2.112 SALT emailed the key worker with regards to the importance of the family engaging. Comment: There is evidence that Adult B is either struggling to keep on top of all the responsibilities or non-compliant at this time. Discussion regarding Adult B acting as carer for a half sibling would likely have be an additional strain. It is not known if this was considered within Children’s Services assessments as it pertains to a child who is not part of this review however Adult B informed the Lead Reviewer this child was subsequently placed with its mother. July 2015 – September 2015 3.2.113 Prior to the summer holidays Child R’s nursery attendance picked up for a couple of weeks, this was followed by 4 weeks of non-attendance. Adult B reported to nursery Child R was unwell with conjunctivitis and a temperature and possible line infection which may need readmission. 3.2.114 Nursery tried to accommodate Adult B’s request for afternoon sessions following Adult B reporting difficulties in taking Child R when Child A and Child B were off school. 3.2.115 A further orthoptist appointment was missed so Child R was discharged. The GP was informed of this. 3.2.116 Child R had a routine admission for bloods and weight 11.9kg SCR Child R Final Report 22 March 2017 Page 34 3.2.117 Over the summer appointments were missed with the Occupational Therapist (the OT informs the key worker), the Physiotherapist and Community Paediatrics who discharged Child R. On hearing this the key worker informed Community Paediatrics she was trying to coordinate appointments. These missed appointments were not as a result of ill health necessitating admissions. 3.2.118 Child R attended gastroenterology for routine admission bloods and nutritional assessment; his weight had increased to 12.2kg 3.2.119 Occupational therapy and Physiotherapy carried out an assessment. There had been no emergency admissions for a year and Child R was progressing. The assessment indicated there were no concerns regarding the home conditions, Child R was walking holding a rail. Both Child R and Adult B were reported happy. Adult B was making the garden safe. One sibling was present. After the assessment Occupational therapy discharged Child R with a plan. On the same day Child R missed a SALT appointment; the keyworker and paediatrician were informed. The key worker followed this up with Adult B who said she was unaware she had missed so many appointments. Joint appointments were to be arranged between SALT and the community paediatrician with reminders from the key worker. Comment: There is evidence that the key worker is proactively starting to co-ordinate appointments from a variety of services, this would have been made easier if she had had full knowledge of all the professionals involved. At this point non-attendance was being shared with the key worker but there was no explicit consideration by any of the professionals involved that this might constitute neglect on Adult B’s part. Trust 1 have made an appropriate recommendation regarding training on the use of Graded Care Profile and neglect. 3.2.120 Child R was allocated a new HV as the previous HV had left; failure to attend paediatric appointments was noted. This allocation was after a prolonged period of no HV input. 3.2.121 Child R had a further routine admission for bloods, weight and urine. Child R was reported to be vomiting; domperidone was restarted, however of positive note, his weight had increased to 12.4kg, Child R was noted to have signs and symptoms that may indicate inflamed kidneys and referred for ultrasound. 3.2.122 The referral for a developmental assessment was not accepted by the community paediatrician as there was no family consent received with the referral. 3.2.123 The key worker followed up Child R’s discharge from community paediatrics with Adult B and as a result a joint paediatric/feeding team appointment was made. SCR Child R Final Report 22 March 2017 Page 35 October 2015 3.2.124 In the weeks before the critical incident Child R attended the joint appointment. Child R was noted to be sociable and smiling. A further family service plan meeting was planned for November; they were awaiting an Educational Health care plan. There was ongoing involvement with SALT, gastroenterology and dietetic support with a plan for follow up by the community paediatrician in six months. The GP was not aware the worker from the Starting Life Well service was the Key Professional. 3.2.125 On the 12.10.15, Child R was admitted to PICU via A&E following a 999 call from Adult B, with collapse, seizures and respiratory distress. Ambulance staff stated Adult B questioned everything they did and on informing her that they needed to use an airway to assist breathing, Adult B stated, she didn’t think it was required. There was a short delay in transferring Child R to Hospital because Adult B argued, she wished him to be transferred to Hospital 2. Ambulance staff felt his condition warranted transfer to the nearest hospital, Hospital 1. Once in Hospital Adult B was noted to be anxious, aggressive, angry and loud with erratic behaviour. Comment: It is not uncommon to see out of character behaviours in times of great stress however ambulance staff indicated Adult B did not seem to understand how sick Child R was, hence arguing about which Hospital to go to. Parents of children with long term conditions are always told that in emergency situations their child will need to go to the nearest Hospital. This was also notified by the gastroenterology team in a letter to the parents previously. 3.2.126 Child R’s blood electrolytes were out of the normal range; glucose was high (80) and sodium levels were also high (177), on admission. Child R was diagnosed with dehydration, severe acidosis and hyperosmolar non-ketotic coma due to high blood sugars, raised sodium levels, acute kidney problems from a fungal infection and subdural haemorrhages were found on both sides of Child R’s brain. Adult B indicated there had been a pump failure. Child R was intubated, ventilated and sedated. A decision was made that the pump failure needed to be investigated. 3.2.127 During information gathering Adult B informed staff Adult A was an alcoholic. On the 15.10.15 Adult B commented to staff about home conditions and her own ability to safely administer PN. Comment: This is the first time Adult B raised concerns regarding her ability to care safely for Child R’s PN. It was also the first time Adult B indicated there were any issues with Adult A. On discussion with Adult B she believes she was referring to her father and not Adult A. SCR Child R Final Report 22 March 2017 Page 36 3.2.128 An attempt to allow Child R to breath independently subsequently was unsuccessful leading to him require resuscitation and being placed on the ventilator again. 3.2.129 Concerns regarding the missing pump and Adult B’s comments led to the case being escalated on the unit and a referral being made to hospital safeguarding as per hospital procedures. As a result, the hospital safeguarding paediatrician and nurse met with Adult B and took a detailed history. 3.2.130 The following is the history obtained: Adult A and Adult B had gone out leaving the children in the care of maternal uncle. The couple returned home at 0100. As Adult B had been drinking Adult B decided not to give Child R PN. Child R was reported well the next day and said to be eating well. That evening Adult B connected the PN as usual. At 2am Child R woke crying, Adult B changed him and noted the pump wasn’t working. The gastrostomy feed was said to be running normally. At 5am Child R woke with a pain in his head but settled back to sleep. At 8am, Adult B got up leaving Child R to sleep, when Adult B checked on him later he was lying on his side, unresponsive, foaming from the mouth with his eyes staring. Adult B called an ambulance and whilst waiting, reported Child R had a shaking episode. 3.2.131 That evening, following the meeting the safeguarding team referred the case to the Police and Children’s Social Care, some 4 days after admission. The school nurse was informed but didn’t communicate this to the school. All the health professionals known, by the staff, to be involved in Child R’s care were informed. Comment: The reason for delay to children’s social care from the time of admission becomes understandable when the whole picture is analysed. Dehydration and altered electrolytes are not an uncommon event in children with short gut syndrome, although not generally to the degree in Child R’s case. The paediatric team initially thought Child R’s condition was as a result of his medical condition. Concerns gathered momentum as he was not displaying abnormal fluid loss e.g. no diarrhoea or vomiting, and as blood and x-ray results were received. Adult B’s behaviours gave cause for concern; she was anxious, aggressive and not happy with the level of sedation wanting Child R to be extubated. Clear explanation from nursing and medical staff did not improve her behaviours, she continued to be very angry, loud and erratic. Adult B states this is a response she exhibits when stressed. When the PN pump was missing and Adult B indicated difficulties in administering PN safely the level of concern increased. The safeguarding team acted swiftly upon hearing the rising concerns, using the meeting with Adult B to order thinking and gain a better understanding of events leading up to Child R’s admission. It could be argued an earlier referral and first interview by the police is preferable, but it is important to understand that the first course of medical support is to make the child better. As it was Child R was in a place of safety and with SCR Child R Final Report 22 March 2017 Page 37 the emerging information, the situation became clearer and appropriate safeguarding actions were taken. NB It remains important to consider all the children in a family are safeguarded. 3.2.132 A strategy meeting was held the following morning; those present were a social worker, police, paediatrician, and two PICU nurses. No nursery, school or community staff were invited. Comment: There is no agreed process for cascading information from the acute hospital through to other agencies unless a case is already being dealt with within TAC/CiN/CP arenas The lack of multi-agency approach to this case meant that the Hospital staff did not have contact details for non- health staff involved with the family. This is of particular significance for the key worker who by this point, had established a professional but friendly relationship with Adult B and who was placed in a difficult situation. The nature of a strategy meeting means it is not unusual to not have all professionals represented initially however it is vital that all professionals are informed at the earliest point of the concerns. Communicating with all the professionals working with the family should have been part of the plan following this meeting. This would normally fall to the allocated social worker/chair; however, the case did not have an allocated social worker at this point. In the absence of an allocated social worker this should have been an explicit task to be allocated. (see section 5.2 Lead Professional) 3.2.133 The Intensivist at the strategy meeting, (not the allocated Paediatrician), concluded that Child R had not had adequate levels of hydration, that his condition had continued for a prolonged period of time; and that his high glucose was likely to have been caused by a substance which had not yet been identified. 3.2.134 The same Intensivist indicated the bleed on Child R’s brain was an old bleed that required further investigation. The hospital had requested the PN machine be brought in so the data collected on the machine could be analysed, Adult B stated whilst bringing it in, it had accidentally been left in a taxi. Comment: In cases of unexpected death there are clear Rapid Response (CDOP) procedures. These procedures cover cases where a child has died and there are CP concerns or concerns requiring criminal investigation. This raises the question as to whether the parents should have been asked to bring the PN machine in i.e. contamination of evidence etc. however, in this situation it is difficult to see how, at point of admission, staff could have foreseen Child Protection concerns and acted any differently. 3.2.135 Those present were informed Adult A and Adult B were to be arrested. SCR Child R Final Report 22 March 2017 Page 38 3.2.136 Adult B and Adult A were later arrested in front of Child A and Child B. Adult B later contacted the Starting Life Well key worker distressed. The key worker was subsequently advised not to make further contact with the family by managers. 3.2.137 Children’s Services placed Child A and Child B with foster carers subject to a Police Protection Order as no suitable adult was found within the family initially. The same day Adult A was interviewed. Adult A indicated he left everything to Adult B. 3.2.138 Adult B was later interviewed by the police. 3.2.139 The following day the nursery made a routine contact to Adult B for an update and learned of the couples’ arrest. 3.2.140 The case was allocated to another social worker two days after the initial strategy meeting who organised the second strategy meeting and made plans to contact other universal services. It is clear this does not happen prior to the second strategy meeting. 3.2.141 A second strategy meeting takes place with hospital staff, police and social worker. 3.2.142 The paediatrician present at this meeting has a different opinion to the intensivist present at the previous meeting, as to the length of dehydration - 4 days not 10, and thinks that the bleed on the brain may have a medical cause rather than a physical cause. The police push for a consensus of the paediatrician and intensivist in relation to the bleeds on Child R’s brain. The feeding pump was found at Adult E’s home It was thought it had been left with Child A and Child B’s bags during the panic of dropping them off and was now believed a genuine mistake. Comment: The request for consensus of opinion is not unusual. Between strategy meeting 1 and 2 the presenting information changes as the pump, that was worryingly missing, is found but also the Clinician’s stance changes. It is not unusual for different Paediatricians/Paediatric staff to have different opinions based on their knowledge and experience, also the passage of time and presentation of new information means clinicians will review and revise their opinions as more test results and information are received, and dependent on the speed of recovery of the child. For social workers and the police, this can be particularly problematic, as they are trying to build a clear picture of the concerns, likely causes and gain clarity on whether there are grounds for concern, a criminal case or potential prosecution. A medical professional can only give information or raise concerns when they have information that justifies their suspicions, thus safeguarding can only progress when all concerns are justified. Within the learning event it became clear that within the hospital records the Doctors were ordering their thinking and writing down the possible causes for the symptoms they were seeing. It would be good practice for all the possible causes to be shared in full with the social workers and police when safeguarding, as a cause of the clinical presentation, is considered. In this case an intensivist and a Paediatrician, who was also a Tertiary Safeguarding Lead and involved for their specific expertise, worked together. As information emerged it informed further decisions and lead to the Safeguarding referral. SCR Child R Final Report 22 March 2017 Page 39 3.2.143 On 20.10.15 school were informed by SW 2, that Child A and Child B had been placed in care. Child R was extubated. 3.2.144 On the 21.10.15 Child A and Child B undergo safeguarding medicals; no concerning factors were found although both children were found to be overweight (BMI’s were high). This can be an indicator of neglect. 3.2.145 On the 22.10.15 the first legal planning meeting was held. 3.2.146 On the 23.10.15 there was an update regarding the position. The feed pump had been analysed. Feeds had not been administered as prescribed over the previous 2 weeks with a deficit of 2533 mls. Child R went 36-40 hours without PN then Adult B pumped the fluid through at an increased rate. The brain haemorrhages could have been present for weeks, months or even years; there was no cause of the haemorrhages identified. The Police opinion was there was clear neglect and proposed a challenge interview, to be held on 05.11.15. SCR Child R Final Report 22 March 2017 Page 40 4 ANALYSIS OF THE KEY ISSUES 4.1 Introduction 4.1.1 Child R’s health is a significant factor within this review and as such it is crucial to remain mindful of this as we analyse the key issues. Child R’s health issues arose as a result of his medical diagnosis (see section 2.3). In addition, Child R had the added element of prematurity, adding to the complex picture. 4.1.2 Adult A and Adult B’s experiences of complex health issues/disability prior to Child R’s admission were limited, neither had significant health care issues meaning their experiences of hospitals was limited. Adult A informed the Lead Reviewer he had experienced the cot death of his younger sibling. Their first experience of acute hospital admissions in their family was following the admission of Child B with meningococcal sepsis aged 15 months. 4.1.3 Adult B was seen by the professionals as Child R’s carer, with Adult A taking a less active role. The reasons for this stance were not known to, or explored by, professionals. Adult A informed the Lead Reviewer loss of his sibling, the size of Child R, concerns Child R might die and the tubes frightened him to a point that he backed away from that aspect of Child R’s care. Recommendation 1: All health professionals when taking initial histories should, in addition to obtaining the child’s medical history explore a family’s previous experiences of health, as well as the family composition, the support network available for the family and parent/s and other needs of the family in relation to housing, monetary needs, health needs etc. when needed. 4.1.4 Child R’s prematurity and Short Gut Syndrome led to a prolonged stay in hospital of eight months and required careful management from a number of different health professionals, both within the hospital and, post discharge, in the community also. Child R’s prematurity, meant there was a need to carefully review and monitor his development. It is usual practice that this is done by both primary and secondary care staff. 4.1.5 Child R’s short gut syndrome meant he was unable to maintain nutrient and fluid balances with a normal diet. Bowel surgery had left Child R with a loss of intestinal absorptive capacity meaning he could not absorb enough fluids and nutrients from liquids and food to maintain good health. The risks associated with this are malnutrition, diarrhoea and dehydration and these were the issues being addressed by the health professionals. 4.1.6 Child R was prescribed medications to treat his short gut syndrome including antibiotics and anti-fungals. Some prescribing was done within the Hospital and some by the GP. SCR Child R Final Report 22 March 2017 Page 41 4.1.7 Child R also underwent further surgery to prevent blockage and preserve the length of his small intestine as well as a gastrostomy and PEG insertion to provide a route to deliver nutrition. 4.1.8 This following sections will address the key focus points posed for this review. 4.2 How do we better understand the needs of children with disabilities as a multi-agency group? 4.2.1 In order to better understand the needs of children with disabilities the multi-agency group first need to recognise when a child has a disability. 4.2.2 If a child has been diagnosed with an illness, disability or sensory impairment that needs additional support for them to live their daily lives, they might be described as having “complex needs”. This could certainly apply to Child R whose care needs, in the main, related to nutrition, feeding, weight gain and development. 4.2.3 Practitioners at the learning events had differing opinions as to whether Child R fitted the criteria for complex needs or that of a disabled child. 4.2.4 A definition of disability is as follows: Disability is an impairment that may be physical, cognitive, intellectual, mental, sensory, developmental or some combination of these that results in restrictions on an individual's ability to participate in what is considered "normal" in their everyday society. A disability may be present from birth or occur during a person's lifetime. 4.2.5 Approximately a fifth of those in attendance indicated they thought Child R was disabled, a fifth believed he was ‘normal’ (this was largely practitioners working with Child A and Child B) and three fifths viewed him as a child with complex health needs and not disabled. There was no consensus of opinion. This is likely because they did not have all the information on the needs of the child and family. 4.2.6 The requirement for daily Parenteral Nutrition is one of the markers that defines someone with short gut syndrome as disabled. So in effect Child R had both complex health needs and a disability. 4.2.7 The way a child is perceived by professionals is important and becomes relevant when we consider that all are disabled children are considered ‘Children in Need’ under the Children Act8. This brings with it a duty to work within the legislative framework making it much clearer that when a parent does not engage or for example, consent to a CAF the child’s needs as potentially a Child in Need must be given the highest consideration. 8 Children Act 1989 SCR Child R Final Report 22 March 2017 Page 42 4.2.8 Child R spent his first eight months in hospital. In line with the Children Act the Health Authority seemingly notified the Local Authority, when Child R had been living in healthcare accommodation for three months. The action the Local Authority took on receipt of this notification, was to note it on the Child Disability Register. There is no indication that an assessment of need was considered or carried out at this time. Children with long-term illness and impairment are 'children in need' under the Act and as such are entitled to an assessment of need. Good practice suggests appropriate services and support should be offered to meet any needs identified at the earliest opportunity. Recommendation 2: The SSCB in conjunction with the Regional network and its partners needs to ensure all its procedures and training includes complex health issues when relating to disability. Recommendation 3: All Section 85 notifications of prolonged admissions to hospital of a child with a disability or with a complex chronic health condition should lead to an assessment of need by the Local Authority. (see section 5.1.6). 4.3 How can we create stronger multi-agency systems to identify and intervene in situations of neglect, particularly if we are working across borough boundaries? 4.3.1 In this case neglect was not given sufficient consideration by any of the professionals involved with Child A, Child B or Child R. There was a mixed picture of compliance with appointments with Adult B seemingly prioritising some appointments above others. Until the allocation of a key worker, professionals were unwittingly making appointments that overlapped each other and in effect making it difficult for Adult B to be fully compliant. That said parents do need to notify the professional of appointment clashes. Whilst the unification of patient centre system in Salford Royal Foundation Trust means all Salford Health Appointments are on one system and can be viewed by the Trusts’ employees, thus making it possible to be more accommodating, there remain issues to co-ordinate appointments offered by other organisations e.g. housing and tertiary services. 4.3.2 When individual staff members raised concerns that their appointments were not being attended, others were not experiencing the same issue and therefore the level of concern never reached a threshold where any one individual felt the need to escalate or refer Child R as a Child in Need. SCR Child R Final Report 22 March 2017 Page 43 4.3.3 There was a degree of sympathetic understanding applied by the professionals involved, regarding the pressures on Adult B in her caring role. Whilst this is commendable this unwittingly took the professional focus from Child R’s needs to the parents, and led to a child with known medical and developmental problems missing routine developmental checks. As a consequence, a proactive approach with involvement of early support services to ensure Child R reached his potential was replaced with a reactive approach. 4.3.4 This is not a new phenomenon and has been a finding in serious case reviews over the last decade. 4.3.5 There remains a need for appropriate communication between various agencies—e.g. tertiary services with primary and secondary services, appropriate notification of actions required e.g. GP was expected to take actions but was not specifically informed what was required. 4.3.6 Recommendation 4: SSCB health partners need to ensure multiagency participation is an explicit requirement at discharge planning meetings where a child has complex health needs or a disability. This involvement must commence early from the onset of condition so a Lead Professional is allocated to the child and family at the earliest point. 4.4 Parental engagement appears to be minimal. Were the parent’s needs overlooked? What counselling and support is available for parents with a disabled child? 4.4.1 This couple were not unusual in not being forthcoming about their relationship, family circumstances and needs. They were also not unusual in their division of responsibilities for child care where there is often one parent who is more active/proactive than the other. Adult A abdicated significant responsibility for Child R’s additional cares to Adult B and whilst involved in Child A and Child B’s lives it was not fully understood how ‘hands on’ Adult A was in their day to day cares other than his role in taking and fetching them from school. Adult A indicated to the lead reviewer he perceived himself to have a normal parenting role with all the children. 4.4.2 In terms of Adult B there is a mixed picture with regards to engagement, ranging from Gastroenterology Services who saw Adult B as very engaged, through to SALT and the Community Paediatrician who experienced very poor engagement. This mixed picture related in part to Adult B prioritising Child R’s significant medical health needs and not perceiving Child R as having any significant additional developmental needs. There were additional issues with non-receipt of appointments due to a systems issue and changes in address. SCR Child R Final Report 22 March 2017 Page 44 4.4.3 The parent’s experiences of Local Authority care and the Child Protection system influenced their willingness to seek additional support or engage fully in assessment processes. Adult B told the lead reviewer she had an overriding desire to prove herself as a ‘good parent’. This, coupled with Adult B’s desire to prove herself capable without Children’s Social Care involvement, ultimately presented barriers to the couple having their own needs met. 4.4.4 The support group ‘Small Bowel Friends’ for those with small bowel syndrome was offered but rejected by Adult B. Adult B indicated they perceived they were discouraged from writing a full account of their experiences, which were not wholly positive, and thus chose to communicate on a social networking site with other parents of children with the condition. 4.4.5 Counselling and support services, professionals report, are not plentiful across Salford with no specific service for parents. All counselling is reported to be of a generic nature accessed via the GP. In this case, neither was sought by Adult B during the review period. At times when Adult B did indicate she was struggling, professionals appeared to relate this mainly to the practicalities of caring for Child R rather than the emotional and physical toll of her caring role. The lack of services served to prevent professionals considering this as an option. Recommendation 5: The SSCB partners need to develop pathways for counselling and support provision and ensure the level of service meets the population need and the needs of parents and carers of children with complex health needs and/or disabilities across Salford. 4.5 How can practitioners work together in a manner which takes account of a family’s needs, yet keeps children’s needs as the focus of intervention? 4.5.1 This case is not unique and raises many of the common professional dilemmas faced by practitioners supporting a family where there is a child with complex health needs. There is the tension about whether to focus primarily on providing support to the family, so the parents are better able to care for their children or move into more assertive intervention. 4.5.2 In this case, the lack of a multi-agency co-ordinated approach inhibited practitioners from working together, and prevented them from identifying concerns and focusing on the needs of the family and most importantly on the needs of Child R. It is not unusual for one agency to have a higher degree of involvement with a child than another, and in these cases professionals can be unwittingly channelled into thinking only in terms of their agency’s remit; in this case health. SCR Child R Final Report 22 March 2017 Page 45 4.5.3 In the longer term, this is not in the best interests of the child, therefore it is essential that a multi-agency approach becomes standard practice from point of diagnosis so all the child and family’s needs can be identified and strategies put in place to address them 4.5.4 For some of the professionals, and for the parents, there was the back drop of the parents bringing legal action against a health Trust This undoubtedly affected the working relationships between professionals and the parents creating a barrier to open dialogue and a reluctance to challenge on the professional’s part. This did not lead to consideration of the need for discussion in safeguarding supervision. 4.5.5 Adult B initially refused a CAF and would challenge professionals when she did not agree with a proposed treatment or intervention. In such circumstances the tensions for professionals is between supporting the parents to help them understand the need to follow health advice, balanced with a need to safeguard the child's welfare. Whilst professionals strive to accomplish both, the balance between support for the parents and protection of the child can be difficult. 4.5.6 In this case, there was little consideration as to whether the overall care provided to Child R might be deemed as neglectful of their medical or developmental needs. It can be difficult for professionals to judge this when a parent is seen to do their best to provide their children with a good standard of care and attention. 4.5.7 Safeguarding concerns for disabled children can arise in a number of ways. One way, as in this case, arises from parents being unwilling or unable to follow medical and allied health professional advice and there are consequent potential impacts on the children’s health and/or development. This can occur when children are receiving a good standard of care in other aspects of their lives. There were indicators that Adult B was not managing and latterly she requested better co-ordination of appointments to make it more manageable. A multi-agency approach would have met that need and ensured all professionals shared their concerns; had they been, the focus may have moved and led professionals to consider moving into explicit child protection processes. 4.6 What are the challenges to identifying matters of neglect when working with complex health situations across many health providers? 4.6.1 There are many challenges to identifying neglect when working with complex health cases across many health providers. One of the biggest challenges is around communication. Maintaining communication across disciplines when electronic systems are not compatible and individuals cannot readily access other professional’s records, whilst essential, is challenging. This becomes increasingly complicated as patients are referred on to new services and discharged from others. SCR Child R Final Report 22 March 2017 Page 46 4.6.2 Only by having a single point of contact, (in effect a Lead Professional) trained to understand the indicators of neglect of sufficient seniority to act with authority, which holds all the information for a child, can professionals have a degree of assurance that issues of neglect can be identified (see section 4.8). In this case there was no Lead Professional. 4.6.3 Medical staff at Hospital 3 believed that there was an agreement that the GP should be the person who receive all the information pertaining to a child’s treatment and admissions and take action. In part this is correct and guidance for doctors9 indicates “you must consider the safety and welfare of children and young people, whether or not you routinely see them as patients.” Whilst GP’s hold the comprehensive medical records and take action if concerns emerge, it is essential that any actions required by tertiary providers of GP’s are clearly requested. 4.6.4 In this case there was very little direct contact between the GP and Child R (two appointments) however information in the form of discharge letters, notification of non-attendance and changes required to prescriptions was, on the whole, shared with the GP. There is no evidence that any one GP was reviewing the case and that non-attendance with other services was considered by the GP practice as an indicator of neglect or required them to take any action taken. The GP did however follow up non-attendance to an arranged appointment at the GP practice. 4.6.5 Changes to the National GP contract mean that all patients now have an accountable GP; for Child R allocation occurred in June 2015. Following allocation, Child R was not seen in the GP practice, however information was still being shared by the Hospital. 4.6.6 The lack of a system to identify that insufficient prescriptions were being requested by the parents for medication required by Child R to treat his condition, meant the GP did not recognise a further indicator of neglect, non-compliance with treatment. It is essential there is effective communication from hospitals to GPs when they give prescriptions, along with specific notifications of actions to be carried out by GP. There are many occasions currently, when GPs are not aware of prescriptions given by hospital services especially if children visit hospitals frequently as in this case, thus making it difficult for GPs to know when to prescribe. An appropriate single agency recommendation to address this has been made. 4.6.7 Whilst Hospital 3 were routinely sharing information with the GP other services were not. For example, the GP received no information from Health Visiting or School Nursing. In Salford now, there is communication between HV teams and GP surgeries on patients with complex needs, at the GP surgery meetings, where children’s needs and concerns can be discussed. The HV and SN’s are now part of one integrated team and whilst the SN’s do not meet with the GPs HV’s will take GPs concerns back to the SN’s. 9 GMC. Protecting Children and Young People: The responsibilities of all doctors (2012). SCR Child R Final Report 22 March 2017 Page 47 4.6.8 Another challenge is around roles and responsibilities. Within safeguarding there is clarity around individual practitioner’s responsibilities to safeguard a child, however when there are numerous professionals involved with a child, it is not unusual for that clarity to become blurred, as junior staff may defer to seniority in decision making and ‘group think’ can stop professionals acting appropriately. 4.6.9 Clarity about the roles, inclusion of safeguarding professionals to facilitate supervision to professionals involved in these complex cases, providing objectivity and challenge is essential. 4.6.10 In this case no supervision was sought by any of the professionals involved in the case and there was no involvement of health safeguarding professionals until after the significant event. Recommendation 6: SSCB to ensure that policies set an expectation that professionals working with complex child health cases and those where there are barriers to open dialogue and challenge discuss this in safeguarding supervision and ensure concerns are shared with lead professionals, and that CAF guidance provides consistent advice that links to the ‘threshold of need’ and ‘Uncooperative families’ Greater Manchester policy. 4.7 Should only one parent be trained to administer Parenteral Nutrition feeds? 4.7.1 Within the learning event there was much debate about this question. Practitioners who work within the specialism believed this was acceptable if not ideal. In this case Child R, at the point of discharge from hospital, was on PN five nights a week. This gave a degree of flexibility to Adult B regarding which nights she chose to administer this. 4.7.2 In effect, if Adult B was unwell or indeed planned to be away for a night, Child R could still receive his prescribed nutrition over the course of a week. 4.7.3 There are parents who administer PN who are single parents, and to say there needs to be more than one parent trained to administer it, would delay the discharge causing unnecessary prolonged hospitalisation. 4.7.4 The question would appear to centre around the support needs of the parent in order to be able to consistently and safely administer PN and also meet Child R’s wider needs. Best practice would be for two people to be trained, the second could be a grandparent or aunt or a sister or brother of the parent who is local as illness in the mother not requiring hospitalisation would compromise the safeguards for the child. Indeed, a requirement from the final court hearing-is to train Adult A. SCR Child R Final Report 22 March 2017 Page 48 4.7.5 In this case the issues were wider than administering PN. Feeding and weight gain were managed and monitored in the main by Adult B and the gastroenterology team. Child R received his nutrition in three ways. The first was orally through a combination oral rehydration often in the form of dioralyte, which provides the electrolytes required, and latterly through finger foods. Child R was not able to maintain growth and nutrition via oral feeds and so received a combination of parenteral nutrition (PN) with fluids, electrolytes, liquid vitamins and minerals going into the bloodstream through an intravenous (IV) tube or central line and enteral nutrition with food to the stomach through a feeding tube. Health care providers usually administer parenteral and enteral nutrition in the hospital setting; however, where this is required long term it is usual for family members to be trained to administer this; there was significant involvement with a specialist nurse who supported Adult B in both the hospital and community. 4.7.6 Adult B was consistently the main carer for Child R and was frequently resident and, if not, a daily visitor to Child R whilst he was in Hospital. Adult B had undergone training in order to be proficient in recognising any complications of Child R’s condition and in carrying out Child R’s cares. This role brings with it considerable responsibility and changes the dynamics of the parent child relationship. 4.7.7 Child R had numerous re-admissions following initial discharge. Some of these were for continuation of treatment through surgery and some were as emergencies when Adult B indicated a concern regarding Child R’s general wellbeing, predominantly when he was pyrexial. On no occasion were any of those admissions deemed unnecessary, which indicated to staff, that Adult B largely understood the circumstances which warranted admission. 4.7.8 On most of these occasions Child R was found to have a central line infection. Whilst line infections are a potential side effect with all intravenous lines; research shows, in patients receiving parenteral nutrition (PN), Candida albicans and non-albicans Candida and Malassezia furfur have been found to be common causes of IV line infection. Researchers looking at the incidence of line infections found that home intravenous therapy resulted in fewer infections than with hospital care, 10 and so such frequent line infections caused health professionals to be concerned regarding Adult B’s competence. Latterly this was checked in the family home and Adult B assessed as competent. 4.7.9 Adult B did not always agree with professionals on the best course of treatment for Child R and it was reported at the practitioners’ events, would challenge professionals, if she disagreed with a proposed course of action, on two occasions rejecting admission. There were some concerns regarding Adult B’s compliance with treatment within secondary/tertiary care although these were not documented or widely shared nor did professionals escalate any of their concerns. 10 Cunha, Burke A. "Intravenous line infections." Critical care clinics 14.2 (1998): 339-346. SCR Child R Final Report 22 March 2017 Page 49 4.7.10 All parents receive extensive training and assessments are made of both competence and the home environment. 4.7.11 In this case Adult B was deemed competent on all occasions this was assessed. There was an issue regarding maintaining an environment where Adult B could give her undivided attention to her task. Attempts made to address this included encouraging Adult A to keep Child A and Child B from the room whilst Adult B set up the PN. 4.7.12 Adult B’s knowledge of, and competence in, managing Child R’s TPN gave professional (both health and non-health) a positive impression and she was viewed not only as a parent but as an expert in Child R’s care. 4.7.13 These professionals did not know that there had been concerns that Adult B was prone to outbursts and could be confrontational in her challenge of professionals if she didn’t agree with what was proposed, raising her voice and invading personal space and that, at times this had impacted on treatment, for example only receiving two days of antibiotics when prescribed seven. When challenged, Adult B learned, but at that stage the treatment had already been missed. Adult B also formed strong opinions of professionals, questioning the competence of some. 4.8 Given the complexity of the case, was consideration given to appointing a Lead Professional at a sufficiently early point? Was consideration given as to which practitioner was the most appropriate Lead Professional? Was there confusion about the existence of or identity of the Lead Professional and the functions of the role? 4.8.1 In this case the simple answer to all the questions posed above is no. It is now clear that there was no Lead Professional at any point during the period under review. The community Physiotherapist took on some of the role of a Lead Professional between Child R’s discharge and September 2014 when, following completion of the CAF an Early support key worker from the Starting Life Well service was allocated. 4.8.2 The key worker attempted with some success to co-ordinate appointments and fulfil some of the functions of the Lead Professional. Indeed, there were some professionals who referred to the key worker as Lead Professional. The lack of a Lead Professional is a fundamental issue within this case and a key finding – see section 5. 4.9 Was consideration given to holding a Team Around the Family (TAF) meeting to formulate plans and implement them? 4.9.1 In this case no consideration was given to holding a team around the family meeting prior to the critical incident. There were a number of issues that could also have led to CAF and ultimately a TAF. Initial refusal of CAF appears to have impacted on professionals considering offering this again. SCR Child R Final Report 22 March 2017 Page 50 Housing issues 4.9.2 Housing had a rather different role with the family to any of the other professionals and a very different perception regarding the structure of the family. Housing’s information led them to believe that Adult B was a single parent of three children; they had no knowledge of Adult A. 4.9.3 The family were experiencing significant change in relation to housing during Child R’s initial hospitalisation with a requirement to vacate their home, declaring themselves homeless and then moving into bed and breakfast accommodation before moving to more permanent accommodation. Whilst staff on the ward were made aware of these issues initially, and wrote supporting letters providing information to housing that was helpful, there was no further communication between housing and other agencies with regard to the timing of these changes and rent arrears which continued for a further two years. 4.9.4 Following the critical incident Adult B indicated the conditions at the house were impacting on her ability to safely administer Child R’s PN, a concern that had not been voiced, to either health professionals or housing, previously. The full impact of the housing issues on the family and whether this inhibited Adult B from voicing concerns at an earlier stage remains unknown. School absenteeism 4.9.5 Child A and Child B had intermittent periods when their school attendance was of concern. The EWO became involved at these times, following their normal processes and procedures. It was reported by school that Child R’s health was known to be having some impact on his siblings’ school attendance but the parents’ failure to attend panel meetings, refusal of CAF and an improvement of the children’s attendance meant there was no recognised need for further intervention. Comment: Whilst there was discussion between School and EWO regarding Child R’s health impacting on Child A and Child B’s schooling, there was no discussion between the school and any health professional to look at preventative strategies should Child R’s health deteriorate. Recommendation 7: A system needs to develop whereby Health Visitors working with children with complex needs/disabilities, who have school age siblings, are required to inform the appropriate school nurse. SCR Child R Final Report 22 March 2017 Page 51 4.9.6 Following completion of a CAF and referral by the Physiotherapist, an Early Support key worker from the Starting Life Well service was allocated. Following this, family service planning meetings took place, looking specifically at Child R’s health needs. Whilst these meetings brought a degree of co-ordination to services in the community, there was no involvement of secondary and tertiary care professionals or the GP, inhibiting information flow and effective planning. This was not sufficiently recognised by those in attendance at that time. 4.9.7 The needs of the whole family were not explicitly discussed within these meetings however the meetings were in their infancy and there was a plan for a further meeting in November after the critical incident. 4.10 Is there evidence of escalation of concerns by any of the practitioners who felt at points that child protection processes should have been initiated? Was there over reliance on medical consensus in initiating child protection procedures? 4.10.1 In this case none of the practitioners involved considered there were sufficient concerns to initiate the use of child protection processes until after the critical incident. 4.10.2 CAF was considered by Child A and Child B’s school however, following advice from Children’s Social Care, as an initial assessment was being undertaken they were advised it was not necessary. Across Salford CAFASS Assessments are not being shared thus limiting professional’s abilities to challenge the assessment or escalate their concerns. Recommendation 8 Children Services to consider how CAFASS assessments can be shared across relevant partner agencies and with parents. 4.10.3 At the point of the critical incident the concerns were appropriately escalated to the named safeguarding professionals within the Trust. An appropriate response was made, leading to referral to Children’s Social Care and the Police. 4.10.4 Following on from the referral, the case followed a recognisable route into Child Protection investigation and legal processes. 4.10.5 In those first days, following admission, there was considerable activity for all the professionals involved directly in caring for Child R, his siblings and in the arrest of his parents. What is apparent, is the lack of central co-ordination, to ensure that all professionals involved with the family are notified at the earliest point. Comment: If there had been a Lead Professional this would likely have been their role however, SCR Child R Final Report 22 March 2017 Page 52 in the absence of a Lead professional, it remains imperative that notification is received immediately by professionals to prevent them from unwittingly contacting the family or being placed in compromising situations when contact is made. This would normally be addressed at the strategy meeting. An action plan would normally be agreed which should identify actions and practitioners responsible for these actions. Recommendation 9: It should become routine practice that the Children’s social care representative in attendance at the strategy meeting informs the Lead Professional regarding serious incidents in order they can inform all the professionals involved. Guidance needs to be developed to address this. See Recommendation 12 & 13. 4.10.6 In terms of offering protection to the children, there is no evidence that there was over reliance on medical consensus in initiating child protection procedures. The impact was seen when the Police were trying to progress the case and make decisions regarding the grounds for arrest. SCR Child R Final Report 22 March 2017 Page 53 5 FINDINGS & RECOMMENDATIONS 5.1 Introduction This chapter contains the overall conclusions and findings of this serious case review, with additional associated recommendations for the SSCB. The findings relate to what we have learnt about the strengths and weaknesses in multi-agency safeguarding systems. The findings of the recommendations of the individual agencies SARs are included as an appendix (see appendix 1). The SSCB has prepared a separate document with their responses to these findings and the plans to address the recommendations. 5.2 Findings and associated recommendations The complexity of Child R’s health needs overshadowed his developmental needs and inhibited staff from recognising Child R as a child with disabilities 5.2.1 The majority of the focus of both professionals and Adult B was on Child R’s health needs, whilst this is somewhat understandable, Child R’s developmental progress was infrequently assessed by Professionals. Adult B alternately was/wasn’t happy with his development. 5.2.2 Recognition should have followed notification to the LA of Child R’s prolonged stay in Hospital. Section 85 of the 1989 Children Act places a duty on local authorities to check on the safety and welfare of children living in hospital provision for any continuous period exceeding and/or likely to exceed 12 weeks. 5.2.3 The intention behind the legislation is to provide a ‘safety net’ for vulnerable children living away from home where the child is not accommodated under section 20 and where the child is not subject to the usual processes of care planning and review by and Independent Reviewing Officer. 5.2.4 The legislation is aimed particularly at ensuring the safety and support needs of disabled children and their families. It is well recognised that these children are at increased risk of significant harm within every category of abuse due to their increased level of dependency on others. The families of disabled children also experience enormous demands upon their parenting capacity in trying to meet a child’s additional needs. 5.2.5 The Children and Young Persons Act 2008 amends Schedule 2 Part 1 of the 1989 Children Act and clarifies the sort of services appropriate for ‘accommodated’ children away from home (Section 85) including financial help to promote contact, advice, counselling and help for children to holiday with their family as well as the provision of advocacy services. SCR Child R Final Report 22 March 2017 Page 54 Recommendation 10: Local Authority to review the current practice regarding children living in hospital provision (Section 85 notifications) and provide an assurance report to the SSCB regarding how robust the process is. 5.2.6 Secondary and tertiary health services delivered their services in an appropriate manner. There was however gaps between these services and those within primary care provision with some impact on the services offered by the Community Paediatrician, Health Visiting, the GP and Community Nursing. The reviewer learned that referrals to community services initiated by tertiary hospital staff are made through a cascade system. For example, the Health Visitor was tasked with making a referral to the local Community Paediatrician. This system adds another layer in the referral system and relies on individuals referring issues they have no ownership for, causing the reviewer to question whether this model is robust. The process between services in Salford is robust. GPs refer on the choose and book system, health visitors, school nurses, allied health professionals e.g. speech therapy, audiology etc. refer on the electronic referral form that is triaged on a daily or every other day basis in Paediatrics. In this case referral was delayed. 5.2.7 It is usual for Community Paediatricians to have a role in caring for a child with complex health needs and disabilities in the community so it is surprising that a referral to this service was not initiated by local health staff. Recommendation 11: SSCB health partners to agree a process to ensure all children with ongoing complex health and developmental needs are referred to community Paediatricians before discharge from secondary/tertiary hospitals with information of the child and the likely issues that may need supporting. 5.2.8 The Healthy Child Programme provides guidance to health visitors and school nurses who are commissioned to deliver their services in line with the programme. Child R was being seen by a Health Visitor fairly consistently over the first two years of life, and as a minimum should have had a nine month (recent guidance does not include this assessment as statutory) and a two-year developmental assessment as part of that programme. It has not been possible to establish what impacted the completion of these assessments, save to say they would have provided a baseline on which Child R’s progress could be measured over the following months, and thus ensure provision of information to influence service involvement and delivery. SCR Child R Final Report 22 March 2017 Page 55 5.3 Common Assessment Framework11 5.3.1 Consideration was given to the need for a CAF to be completed on a number of occasions and by different agencies. CAF is a voluntary process, hence in order for a CAF to be completed there needs to be consent from a parent. On occasions when this was muted, Adult B refused consent. Practitioners indicated, they believed that Adult A and Adult B’s experiences of being in care and of the involvement of child protection services when Child A was subject to a child protection plan, had impacted. Adult B confirmed a desire to prove she could care for her children without children’s services involvement. This, coupled with the parents’ belief this CAF was part of Child Protection, lay behind the lack of consent. 5.3.2 Without a CAF, a TAC could not be held. If the CAF had been completed it would likely have concluded that a multi-agency response was required, and a TAC would have been formed and a delivery plan agreed by the TAC members. 5.3.3 When CAF was refused there was no consideration of the likely impact of this refusal on Child R or the family, or consideration of the need to hold a multi professionals meeting. This is contrary to the SSCB current threshold of need guidance12 which states, ‘Where parents/carers are uncooperative with all agencies there is likely to be a lack of information leading to an incomplete picture of the child and his or her welfare. Under these circumstances the practitioners involved will hold a meeting to decide the level of concern and plan a response to promote the child’s welfare.’ Guidance can also be found in the Greater Manchester procedures13 and a Salford guide.14 This guide indicates that ‘When the CAF cannot be completed with the family. Consent can be overridden. If you feel there are safeguarding concerns and the child is at risk of significant harm or likely to be by trying to gain consent’. In contrast the working with resistant families flowchart15 makes no mention of professional meeting. It is important to recognise this family didn’t appear resistant to many professionals however this could have been picked up by a Lead Professional and the above procedures and guidance used in conjunction with the Greater Manchester uncooperative family’s policy. See Recommendation 12. 5.4 There lacked a multi-agency network around the family. 11A framework to help practitioners working with children, young people and families to assess children and young people’s additional needs for earlier, and more effective services, and develop a common understanding of those needs and how to work together to meet them. 12 http://www.partnersinsalford.org/sscb/Thresholds.htm 13http://greatermanchesterscb.proceduresonline.com/chapters/p_deal_uncooperative_fam.html?zoom_highlight=managing 14 http://www.salford.gov.uk/media/389141/caf-and-tac-q-and-a-sheet.pdf What happens if parents don’t consent? 15 www.salford.gov.uk/children-and-families/safeguarding-children/advice-for-professionals/caf-and-tac/lead-professional-and-chairing/ SCR Child R Final Report 22 March 2017 Page 56 5.4.1 This impacted on professionals, Child R and his family. Agencies and professional groups were working in silos, with limited awareness of Child R’s condition and care needs. Child A and Child B’s school had no knowledge of the complexity of Child R’s condition or the impact of this on the family. The lack of a multi-agency forum to share information limited professionals’ abilities to understand the issues and concerns, and reduced the potential for professionals to identify and act upon concerns. 5.4.2 It is clear that the lack of co-ordination across services meant there were numerous occasions when Child R’s appointments clashed and Adult B was in a position of prioritising which appointment to attend. 5.4.3 The impact of Child R’s health needs on Child A and Child B’s school attendance is noticeable when all the information is brought together. Multi-agency networking could have helped put in place a helpful support plan when Child R had planned admissions and reduce the impact on both parents and children. 5.4.4 Different recording systems in agencies posed an additional barrier to networking however the proposed introduction of Version 2 of the Salford integrated record is expected to alleviate some of the issues. 5.5 The lack of an allocated Lead Professional impacted both on the co-ordination and delivery of services causing difficulties for both parents, children and professionals 5.5.1 Whenever there are large numbers of professionals working together there will be difficulties in coordination and promoting a united response. The responsibility for co-ordination largely falls to the 'Lead Professional' however in this case this role was not allocated leading to the lack of communication between various teams who were individually supporting Child R. SCR Child R Final Report 22 March 2017 Page 57 5.5.2 Latterly, there was a 'key professional' in the form of an early support worker who fulfilled some of the functions of a Lead Professional role and brought about a greater degree of co-ordination. Whilst this was positive, confusion arose through a lack of understanding of the difference between the role of a key professional and a Lead Professional, and the limitations of having a non-health professional at the helm of such a health focussed case. 5.5.3 The lack of Lead Professional tied to the different understandings of the meaning of key worker is worth exploration. Within health, the term ‘Lead Professional’ is used to refer to the professional most involved in supporting the patient’s needs- this could be an allied professional or paediatric consultant (in charge of the patients’ health treatment, usually a medical consultant). In this case there were multiple consultants involved in Child R’s care however no overarching consultant ever held the case. This often falls, post discharge, to a Community Paediatrician; however, Child R was not referred to the Community Paediatrician until post discharge and because Child R was not brought to appointments the Community Paediatrician had no direct involvement in Child R’s care until later. 5.5.4 Within the wider multi-agency environment, the term has a specific meaning. The Lead Professional role16 is defined in government guidance as 'a set of functions to be carried out as part of the delivery of effective integrated support'. These functions are to: 'Act as a single point of contact for the child, young person or family' 'Co-ordinate the delivery of the actions agreed by the practitioners involved in the multi-agency TAC to ensure that children, young people and families receive an effective integrated service which is regularly reviewed: these actions will be based on the outcome of the common assessment and recorded in the CAF delivery plan' 'Reduce overlap and inconsistency in the services received by children, young people and their families ' 5.5.5 Salford’s’ CAF team have guidance available regarding the above.17 5.5.6 The parents did not recognise any one person as the Lead Professional. When Child R became unwell prior to emergency admission, Adult B took steps to provide the deficit from the missed PN but didn’t seek medical advice. Adult B indicated to the lead reviewer she had been told to do this on a previous occasion and so believed it the right action to take. There is evidence Adult B had been given clear instructions on what action to take if Child R was unwell by the Gastro team and indeed had previously followed this advice and accessed appropriate treatment. It remains unclear to the Lead Reviewer why Adult B did not follow the instructions given on this occasion; Adult B indicated she had never received a written plan. 16 The Team around the child (TAC) and the lead professional, Children's Workforce Development Council 17 http://www.salford.gov.uk/children-and-families/safeguarding-children/advice-for-professionals/caf-and-tac/lead-professional-and-chairing/ SCR Child R Final Report 22 March 2017 Page 58 5.5.7 Adult B was seen as somewhat obstructive of the Ambulance Service, dictating her wishes rather than following their recommendation. 5.5.8 Part of the multi-agency approach should be to outline strategies and provide a multi-agency plan of action of what to do when a child is unwell which is given to parents, reinforced frequently and monitored. This would ensure clear and consistent direction to parents with the potential to gain evidence of compliance/non-compliance building a picture and identifying cases of neglect. 5.5.9 The role of the Lead Professional is critical in such complex circumstances, but consideration needs to be given to how all the functions of a Lead Professional can be undertaken and who is best placed to fulfil this role. 5.5.10 Following Child R’s admission in a moribund state and the movement of the case into Child Protection and a criminal investigation the need for clarity amongst all the professionals involved in his care became even greater. Community staff, in particular, including non-health staff were not immediately formally informed of the situation, and in some cases, were informed by Adult B during routine contact, of their arrest. This placed professionals in an extremely difficult situation wanting to support the family whilst not compromising any on-going investigation. Recommendation 13: The SSCB, with the support of the Police and Children’s Social Care, to develop multi-agency guidance for staff on their engagement with parents during criminal investigations e.g. the. do’s and don’ts of discussions regarding their situation. Incidental Learning falling outside the Terms of Reference 5.5.11 Staff attending the practitioner events expressed concern that the parents were arrested in front of Child A and Child B. Adult A and Adult B confirmed this in interview with the Lead Reviewer, indicating they had been placed in handcuffs in front of the children and expressed their concerns regarding the trauma caused to the children and the ongoing negative impact this has had. The Police and the SSCB will take forward this learning. Recommendation 12 Salford SCB to agree with member agencies a consistent process for identifying the Lead Professional and the responsibility for the various functions of the Lead Professional. SCR Child R Final Report 22 March 2017 Page 59 6 CONCLUSIONS 6.1.1 Professionals who had been involved in Child R’s care or with his family expressed their shock on hearing of Child R’s moribund condition and on the arrest of his parents on suspicion of neglect. 6.1.2 Adult B was seen to have a very loving relationship with her children, Child R in particular was always happy to be with her. Adult B demonstrated her commitment to all her children even if at times, she was overstretched or unwilling to accept the support on offer. 6.1.3 Whilst there was nothing to suggest an incident of this nature was likely, issues regarding compliance with treatment had been previously identified. For a child who is as vulnerable as Child R, receiving optimal care is of the highest importance. 6.1.4 Adult B could be very challenging of professionals and it was known to some that she was suing a health Trust, and was documented to have challenged incorrectly the decisions of professionals when Child R was unwell. The impact of this on professionals has been difficult to establish. At the learning event attendees stated Adult B “sounded like a nurse,” and there was a ready acceptance of a degree of expertise both within community health practitioners and non-health professionals. It appears this affected professional interactions with Adult B impeding challenge and suggesting a different approach adopted to parents who are thought to be very informative about their child’s condition and management. 6.1.5 On the occasions Adult B was challenged about compliance issues, she demonstrated an ability to learn and modify her behaviours. As a result, no one with direct involvement and care of Child R, expected or predicted an incident of this kind. When Child R became unwell prior to emergency admission, Adult B undertook steps to provide the deficit from the missed PN, however, she did so without seeking medical advice. In addition, Adult B challenged the Ambulance Service over their care of Child R, dictating her wishes rather than following their recommendations and the advice given previously by the tertiary hospital. Had Adult B followed the instructions on actions to be taken if Child R was unwell, as on previous occasions, and sought advice, this situation may have either been averted. 6.1.6 The lack of recognition of Child R as disabled, prevented a more multi-agency, holistic approach to assessing and managing Child R within the context of his family. Allocation of a Lead Professional in such a case is essential. 6.1.7 The impact of the lack of an allocated Lead Professional and lack of multi-agency approach cannot be under estimated. In this case it led to a lack of co-ordination and clarity for both professionals and parents, and reduced opportunities for communication between professions and teams. A Lead Professional would have been well placed to reinforce the messages between Professionals and parents and challenge any compliance issues. SCR Child R Final Report 22 March 2017 Page 60 Glossary of Terms & Abbreviations A&E Accident and Emergency CAF Common Assessment Framework CCN Children’s Community Nurse CiN Child in Need CP Child Protection ENT Ear, Nose and Throat EWO Educational Welfare Officer GP General Practitioner HV Health Visitor IV Intra-venous LA Local Authority OT Occupational Therapist PEG Percutaneous endoscopic gastrostomy PICU Paediatric Intensive Care Unit PN Parenteral Nutrition PT Physiotherapist SALT Speech and Language Therapy SGS Short Gut Syndrome SPN Specialist Paediatric Nurse SSCB Salford Safeguarding Children Board TAC Team Around the Child TAF Team Around the Family TPN Total Parenteral Nutrition SCR Child R Final Report 22 March 2017 Page 61 Appendix 1: Single Agency Recommendations Salford Royal NHS Foundation Trust 1. Communication pathways will be developed between Nursing and Allied health Professionals. 2. A MARAM lead will be identified for both Universal and Targeted Services. 3. The development of one Electronic Patient Record (EPR) 4. All staff to continue to access safeguarding supervision. 5. All children will have been offered the core element within the Healthy Child Programme. 6. The rational for additional interventions within the core programme will be clearly documented in the records. 7. All relevant staff will be adept in the identification of when a family require a Common Assessment Framework (CAF) to be completed. 8. Weights are recorded in line with the Faltering Weight Guidelines. 9. Implement a “Management of a vacant caseload” policy. Central Manchester University Hospitals NHS Foundation Trust Royal Manchester Children’s Hospital. 1. From April 2016 CMFT to raise awareness through Level 3 Safeguarding Children Training that parents will not always disclose concerns or issues, however asking a parent how they are coping or if they need help may give them the opportunity to discuss any concerns. 2. From April 16 CMFT Level 3 Safeguarding training will include the need for ‘respectful uncertainty’ and consider the Lessons from previous serious case reviews nationally highlighting the ‘rule of optimism’ and professional dangerousness to increase awareness of this issue. 3. Improved documentation in relation to documenting conversations, presentation and the voice of the child will be included in the Record Keeping Audit planned for Quarter 4 in CMFT as part of the safeguarding work plan (Jan – Mar 17) 4. The CMFT Record Keeping Audit in Quarter 4 will include ensuring that all documentation from Specialist Practitioners is included in the main medical records. 5. Level 3 Safeguarding Training highlights the need for closer liaison with Community Practitioners when a child is admitted, in particular those children with a long term medical condition or disability, to ensure robust communication and information sharing and where appropriate there should be identification of a lead professional. This will be audited within the Safeguarding Record Keeping Audit in Quarter 4. NHS Salford Clinical Commissioning Group 1. Individual GP practices to review the management of cases involving children with complex needs ensuring that the individual child has a Lead Named Accountable GP. 2. Individual GP practices to ensure patient record flagging systems are in place for a complex case that has the potential to be reviewed by several GP’s in the same practice. This should include linking family members to children within the practice. 3. Individual GP practices to ensure electronic patient record flagging systems are in place for children who are not brought to appointments (DNA)with a process for review and follow up. This information to be underpinned by a GP Practice Policy for the Management of DNA in Children within Primary Care. 4. The process and system for review of patient medication requests and repeat prescription on GP systems needs to be reviewed so that repeat prescription requests including identifying under ordering of medication as well as over ordering can be identified. This should culminate in closer monitoring and review of medication. SCR Child R Final Report 22 March 2017 Page 62 5. Record keeping guidance within GP practice to be refreshed within the safeguarding children training in light of children with complex needs and also discussed at the local NHS Salford GP Safeguarding Leads Forum. 6. Training to be delivered around the lessons learned from this Serious Case Review in practice from a multi-agency perspective to inform current and future practice in Primary Care. This information will also be cascaded by the NHS Salford GP Safeguarding Leads Forum & CCG GP Newsletter. Salford City Council Children’s Services 1. Social Workers and Team Managers must prior to the closure of any case ensure that they identify the most appropriate lead professional i.e. Key Worker to co-ordinate proportionate work with families in need of services. This will in the initial stages be lead by the 0-25 pilot in West. Once this has been evidenced as a positive working model it will then be rolled out to all four areas across the city. 2. Further work from Service Managers in Team Meetings in respect of social workers and managers taking account of historic details and patterns within a Chronology of parents own experiences or episodes. This will inform decision making without being over reliant on the self-reporting of parents’ ability to manage without professional intervention. 3. Practice Managers within the Bridge who screen lower level referrals must consider the history prior to agreeing to the BRAG rating of a case before allocation or closure to services. Salford new system will support this but the Head of Service to arrange a training sessions for Practice managers where this issue can be discussed and shared. Educational Welfare Service 1. All Education Welfare officers will record all interventions and family details including full names of parents/carers and professionals and reflect clearly work undertaken 2. Support given to all Education Welfare Officers to ensure a consistent approach to recording interventions and actions 3. Managers to ensure that communications logs are kept up to date and are SMART 4. A clear indication of pupil attendance at the time of any significant event should be evident Starting Life Well Service 1. Outline the role of the Early Support Key Worker as lead professional to ensure that professionals are aware of what the role entails 2. Review of family service plan meetings to ensure that if at any stage CAF is required this is completed in tandem with the FSP meetings. Salix Homes 1. Officers should adopt a consistent way of collating and recording information. Information should be captured in one central place in the organisations Housing Management system and should include ‘global’ picture of what is known about the family. 2. Salix Homes should review and revise its vulnerable customer alert processes. This review should include better use of flags and alerts for front line staff 3. Salix Homes should use the learning from real life case studies with front line officers to raise awareness and reinforce their safeguarding SCR Child R Final Report 22 March 2017 Page 63 Appendix 2: Panel members The review panel consisted of the following members: AGENCY ROLE Lead Reviewer Greater Manchester Fire & Rescue Chair - Community Safety Manager CMFT Named Nurse: Safeguarding Children Duty & Assessment, Salford Children’s Services Service Manager Education Childcare Strategy Manager GMP Detective Sergeant Housing Options Service Manager Housing Choice and Support Manchester & Salford Legal Department Deputy Head of Legal Services North West Ambulance Service Safeguarding Practitioner Prevent Training Lead Public Health Assistant Director: Public Health Nursing Salford CCG Designated Doctor: Safeguarding Salford CCG Designated Nurse for Safeguarding Children and LAC Salford Children’s Services Business Manager, Education Welfare Service Salford Children’s Services Head of Integrated Social Work & Prevention Salford Children’s Services Interim Head of Safeguarding Salford Royal Foundation Trust Named Nurse Safeguarding Children Salix Homes Neighbourhood Manager SSCB Interim Business Manager SSCB Senior Business Support Officer SCR Child R Final Report 22 March 2017 Page 64 Practitioners involved in the SCR process The following practitioners were involved in individual and group meetings with the lead reviewers and other panel members: AGENCY ROLE CMFT Gastro Nurse Specialist NMP Nurse Specialist for Paediatric Home Parenteral Nutrition and Inflammatory Bowel Disease CMFT Department of Paediatric Medicine General Paediatric Consultant CMFT Paediatric Intensive Care Unit Matron CMFT Paediatric Dietician Paediatric Dietician CMFT Safeguarding Team Named Nurse: Safeguarding Education Starting Life Well Early Support Team Leader Education Primary School Safeguarding Officer Education Starting Life Well Early Support Designated Key Worker Education Nursery Nursery manager Education Nursery Children’s Centre Coordinator GMP Detective Sergeant GMP Detective Sergeant: Serious Case Review Team GMP Officer in Charge Housing Options Service Manager - Choice and Support Housing Provider Neighbourhood Officer Housing Provider MRI Consultant Gastroenterologist NHS Salford, Clinical Commissioning Group Specialist Nurse: Safeguarding Children Primary School Executive Head Teacher Salford Children’s Services Emergency Duty Team Social Worker Salford Children’s Services Education Welfare Service SCR Child R Final Report 22 March 2017 Page 65 Education Welfare Manager Salford Children’s Services Education Welfare Education Welfare Officer Salford Children’s Services Looked after Children Service Manager, Looked after Children Salford Children’s Services Duty and Assessment Duty and Assessment Team Manager Salford Royal NHS Foundation Trust Health Visiting HV Cluster Lead Salford Royal NHS Foundation Trust Diana Nursing Community Nurse. Salford Royal NHS Foundation Trust Community Paediatrics Community Paediatrician Salford Royal NHS Foundation Trust Occupational and Physio Therapy Physio Therapist Salford Royal NHS Foundation Trust Named Nurse Salford Royal NHS Foundation Trust Health Visiting Community Nursery Nurse Salford Royal NHS Foundation Trust Occupational and Physio Therapy Occupational Therapist Salford Royal NHS Foundation Trust Occupational and Physio Therapy Paediatric Occupational Therapist Salford Royal NHS Foundation Trust Speech and language Therapy Targeted Services Matron. Salford Royal NHS Foundation Trust Speech and Language Therapy Speech & Language Therapist Salford Royal NHS Foundation Trust Speech and Language Therapy Speech & Language Therapist Salford Royal NHS Foundation Trust Speech and Language Therapy Nurse and AHP Manager Targeted Services Salford Safeguarding Children Board Training Officer Salford Safeguarding Children Board Senior Business Support Officer Salford Safeguarding Children Board Training Coordinator Salford Safeguarding Children Board Interim Business Manager Salix Homes Neighbourhood Manager |
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